Abnormal Final

Myths & Misconceptions: CAUSES ED

"EDs are caused by vanity & the media"

Myths & Misconceptions ED: SEVERITY

"EDs are not a serious illness" "EDs are not a serious mental illness"

Myths & Misconceptions TREATMENT: ED

"There are no effective treatments for ED" "Healthy weight means the ED is cured" "Treatment must be voluntary"

Feeding & Eating Disorders

"persistent disturbance of eating or eating related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychological functioning"

Age Hoarding Disorder

+ in older samples (studies av. age ≈ 50yrs) Studies suggest ONSET 11-15yrs, impairment by mid-30 May take decades to build up to a clinically sign problem Sxs worsen with every decade of life ( linked to difficulties discarding)

Substances related to psychosis

- Alcohol: Alcohol hallucinosis; Delirium tremens (DTs) is a rapid onset of confusion caused by withdrawal usually from alcohol, with hallucinations - Cannabis: can precipitate the onset of chronic schizophrenia, dose-response relationship for risk - PCP & Ketamine: also exacerbation of core psychotic & cognitive sxs in schizophrenia Other hallucinogens: psilocybin Sedative, hypnotic or anxiolytics: DTs also - Amphetamine & Cocaine: esp. paranoia

Suicidality Schizophrenia

- Individuals with schizophrenia have a 20% shorter life expectancy than the population at large - About 5% die by suicide, usually near the time of the illness onset - Suicide is more common when: Depression is present Intense psychotic sxs but few negative symptoms are present A 1st or 2nd degree relative has attempted or committed suicide Dissociative Disorder is present Concurrent Substance Use (though this finding has been inconsistent) Previous suicide attempts has occurred

Specific Phobia

- Marked fear or anxiety about a specific object or situation - Object or situation almost always elicits fear - Object or situation is actively avoided or endured with intense fear - The fear is out of proportion to the actual danger or context - The fear or avoidance is persistent: SIX+ MONTHS - Clinically significant distress or impairment NOT panic or agoraphobia, OCD, trauma (PTSD) separation anxiety disorder or social anxiety disorder

Ethnicity OCD

- Y-BOCS: NO sign diff across ethnicities - PI-WSUR: Southeast Asian & south Asian/East Indian sign HIGHER behaviors: poss more reporting, cos more distress

3 main eating disorders

1 Anorexia nervosa (AN) 2 Bulimia nervosa (BN) 3 Binge-eating (BED)

Psychosocial Treatments Schizophrenia

1 individual/family therapy (CBT, family therapy, psychoeducation 2 case management 3 assertive community treatment 4 social skills training 5 vocational training

Brief Psychotic Episode

1(+) of (#1, 2 or 3 obligatory) Delusions Hallucinations Disorganized speech Grossly disorganized or catatonic behavior Duration: minimum 1 day to less than 1 month, with full remission & return to pre-morbid functioning NOT MDD, Bipolar Disorder with psychotic features or schizophrenia, catatonia, drugs or meds Specify with or without a marked stressor: brief reactive psychosis With postpartum onset: during pregnancy or 4wks following birth With catatonia: if present Severity: rating of 0-4pts for each sxs Individuals typically experience emotional turmoil & overwhelming confusion Brief but may be severe with severe impairment necessitating supervision for basic everyday functions and to protect against the consequences of poor judgement, cognitive impairment & delusion inspired behavior Att! It is important to distinguish culturally-accepted beliefs & practices that may be particular to a specific culture, e.g., hearing voices during a religious ceremony For most individuals prognosis & outcome are excellent, despite high rates of relapse

Social & Sociocultural Factors Anxiety

1) Daily environmental stress 2) Traumatic events 3) Isolation & low perceived social support 4) Lack of power & status 5) Exposure to discrimination & prejudice 6) Acculturation: level of integration

Psychological Factors (cognitive vulnerabilities)

1) Negative appraisals: tendency to interpret events as negative, even when ambiguous (also rumination) 2) Anxiety sensitivity: tendency to interpret physiological body sensations as signs of danger 3) Low perceived control/low self-efficacy: low sense of control over events and capacity to cope

Highest for HIC, but on the rise in Low-Mid ICs, why?

1) Previous DSM less culturally sensitive = underestimation 2) More vaccines, more sanitation: more young people reaching age of onset

3 Phases Schizophrenia

1) Prodromal phase 2) Active phase 3) Residual phase

3 categories of phobias

1) Specific phobia 2) Social Anxiety Disorder 3) Agoraphobia

Myths & Misconceptions ED: DEMOGRAPHICS

1. "Eating disorders are very rare" 2. "EDs are just a teenage phase" 3. "Men don't get eating disorders" 4. "Men with ED tend to be gay" 5. "Eating disorders are a 'white' illness" 6. "Eating disorders are a Western illness"

Generalities Obsessive Disorders

1st time these disorders are grouped together & in their own section: much debated issue Common themes: obsessive thoughts & related behaviors Important relationship with anxiety Issue of insight: distorted beliefs vs. psychosis Chronic tic disorders remain separate in childhood disorders

Schizophrenia

2(+), present for a significant proportion of time during a 1-month period, or less if successfully treated (#1, 2 or 3 obligatory) Delusions Hallucinations Disorganized speech Grossly disorganized or catatonic behavior Negative symptoms For a significant portion of time since onset, functioning in 1(+) work, interpersonal relations or self-care, below before onset (in children/ados: below expected level for age) Continuous disturbance for 6+ months (1month minimum active phase, may be only neg sxs or 2(+) sxs in prodromal/residual phases) NOT schizoaffective, MDD, Bipolar disorder NOT drugs/substances or other medical condition IF ASD or Communication disorder in children: delusions, hallucinations & other sxs present for 1+months Specify (only if 1-year duration) 1st episode full criteria OR Multiple episodes: Current acute, current partial OR current full remission, e.g., Schizophrenia, 1st episode, currently in partial remission Continuous: majority of criteria most of the time with briefer periods of subthreshold sxs between Unspecified: no regular pattern With catatonia: if present Severity: rating of 0-4 pts for all sxs Does NOT come out nowhere with sudden onset It may seem like that because the prodromal phase was more subtle, patient was able to compensate, or diagnosed as depression Overall Schizophrenia is a heterogeneous disorder: diff constellations of signs & sxs across individuals Low insight: seen as a sxs itself, common predictor of non-compliance, higher relapse rates, worse prognosis

HALLUCINATIONS SCHIZOPHRENIA SPECTRUM

A sensory perception that occurs without an external stimulus An experience that feels REAL, but only exists inside the mind May involve a single sense or multiple Auditory (hearing), visual (seeing), olfactory (smelling), tactile (touching) gustatory (tasting) Auditory are the most common type (voices) Can be negative or positive, can be very distressing Hallucinations at the time of falling asleep or waking are not considered pathological Insight: some individuals recognize that these perceptions are unreal, but some do not

phobic stimulus

A strong, persistent & unwarranted FEAR of a specific object or situation:

OCD: Diagnostic criteria (DSM-5, APA, 2013)

A. Presence of obsessions and/OR compulsions Obsessions 1) Thoughts, urges, images: intrusive, unwanted, causing anx or distress 2) Attempts to ignore or suppress them with another thought or action Compulsions 1) Repetitive behaviors, in response to an obsession or a rigid rule 2) Compulsion aimed at reducing anx, distress or a feared event BUT not realistic or clearly excessive Att! Children may not be able to explain their compulsions B. Obsessions /Compulsions are time consuming (1hr+/day) OR cause distress or impairment C. NOT due to a substance or medical condition D. NOT another disorder (anxiety (GAD), BDD, hoarding, trichotillomania (pure), stereotypic movement disorder, ED, gambling, illness anxiety disorder, impulse-control disorder, MDD, psychotic disorder or ASD) Specify: good or fair insight (thoughts definitely or probably not true); poor insight (probably true); absent insight (completely true) Tic-related: current or past history of a tic disorder

Anorexia Nervosa (AN)

A. Restriction, leading to significantly low weight (> normal or > minimally expected) B. Intense fear of gaining weight OR persistent behavior that interferes with weight gain, despite low weight C. Disturbance in body weight or shape perception, undue influence on self-evaluation OR persistent lack of recognition of the seriousness of low weight

Panic Attack Symptoms

Abrupt surge of intense fear or intense discomfort that peaks within minutes, including 4+ Palpitations, pounding heart, accelerated heart rate Sweating Trembling or shaking Shortness of breath Feelings of choking Chest pain or discomfort Nausea or abdominal distress Feeling dizzy, unsteady, lightheaded or faint Chills or heat sensations Paresthesias (numbness or tingling) Derealization (unreality) or depersonalization (outside oneself)

Biggest Change Schizophrenia to DSM-5

Added the word spectrum Schizophrenia

Ethnicity Schizophrenia

African Americans: 3-4x higher rates than Euro-Americans Latino American/Hispanics: 3x higher then Euro-Americans BUT pop studies of schizophrenia show similar prevalence across ethnicities, & no genetic evidence for diffs

Schizophrenia Comorbidity

Any anxiety disorder 3+ mental disorders

Age of Onset Schizophrenia

Average age 16-25yrs 1st ep. 18 in men & 25 in women Peaks: 20 in men & 25 women Women are more likely than men to experience onset later in life

Anxiety Disorders Associated Features

Avoidance: can be so severe people are house-bound, dependent on others for services & assistance for even their basic needs Abuse of alcohol & drugs (legal & illegal) as self-medication is common Somatic sxs are common even when not part of the criteria, e.g., GAD: sweating, nausea... Panic attacks are related to a higher rate of suicide ideation & attempts, and high levels of disability

Treatment OCD: Psychotherapy CBT / ERP

CBT & ERP (Exposure Response Prevention) 1st line for children & adults (also meds only for adults) As efficacious (reduction in sxs) as meds, some evidence: poss more than meds in children Primary focus: EXPOSURE, facing the fear, challenging the distorted thoughts & learning new coping strategies Att!: 30% drop-out, 80% of remaining improve, 20% do not = total 50% for whom treatment DOESN'T work Why? Distressing, comorbidity, severity, family factors (criticism, rejection...)

Treatment Anxiety

CBT: Exposure therapy & systematic desensitization Gradual exposure to increasingly feared stimuli Adding muscle relaxation to reduce anxiety In vivo (real) better than imaginal (imagined) exposure Panic: Interoceptive inducing bodily sensations & habituating Technology: virtual-reality exposure therapy = VRET VRET BETTER than imaginal exposure Flooding: intense, prolonged exposure to the phobic stimuli until anxiety recedes. Att! v. distressing CBT: Cognitive Restructuring Focus on distorted, unrealistic thoughts & emotions Interpretations of physical symptoms as 'normal' anx Redirecting attention away from the self Used in conjunction with behavioral techniques Emotion regulation strategies Hard to determine efficacy as usually mixed with beh' techniques for panic & phobia GAD & social anx: effective, esp. long-term effects Adjunct therapeutic interventions Relaxation, Mindfulness Focus on the here & now, breathing, muscle relaxation Mixed findings & long term efficacy unknown Acceptance & Commitment Therapy (ACT) Metacognitive skills and mindfulness Similar efficacy to traditional CBT or poss better 2012 meta-analysis Regular exercise Poss better than relaxation Medication 1st line of treatment for medium to severe anxiety SSRIs & SNRIs: esp. in panic disorder, GAD, SAD In phobia, can be used to reduce the distress of exposure therapy Side effects: see depression lecture Tricyclic antidepressants (TCA) & Benzodiazepines Older meds, only for non-responsiveness More complex side effects, including sedation, dependency

Chemical Brain Differences Schizophrenia

Chemical brain differences Dopamine hypothesis: excess dopamine High number of D2 receptors Dopamine increasing drugs (e.g., amphetamine, cocaine) can induce positive sxs Serotonin, glutamate & GABA also Support from 3 types of drugs 1) Phenothiazines 2) L-dopa 3) Amphetamines

Structural Brain Diffs Schizophrenia

Chronic progressive structural changes Decreased grey matter & white matter: temporal lobe (esp. language processing) & cingulate, frontal lobe, hippocampus Progressive ventricular enlargement

Psychological Factors Phobia

Classical Conditioning theory Observational Learning theory Negative information theory Cognitive-behavioral theory

Psychological Factors OCD: Cognitive Models

Cognitive Deficits Models Organizational: categorization, unsupported theory Working Memory: deficits in WM, data suggests opposite, better memory for anx-related events Reality Monitoring: real vs imagined events, unsupported theory Cognitive inhibition: diffs forgetting anx thoughts, supported theory Most robust finding: less confidence (doubt) in their memory Biggest limitations: no specificity to OCD, can apply to other disorders, e.g., mood, anx, ED etc. also chicken-egg problem So overall: weak support for these models Cognitive-Behavioral Models Dysfunctional beliefs & interpretations of normal intrusive thoughts LEADS TO obsessions & compulsions when thoughts are interpreted as threatening & important Avoidance & compulsions are attempts to remove or prevent PROB: short-term gains, never ending cycle, cos no extinction & no change in core-beliefs Good support in older pops, but insufficient for young children

Etiology of BDD: Psychological Factors

Cognitive/interpersonal vulnerabilities Low self-esteem, high perfectionism (esp. concern over mistakes & doubt over actions) Social anxiety Chicken-egg problem: few studies of temporal patterns High comorbidity: 12-69% BDD+SAD; 5-12% SAD+BDD Conceptualized as variants of the same disorder in some cultures (e.g., Asia: Japan, China)

Anxiety Disorders Life Course

Community samples Subthreshold sxs, episodic course, periods remission GAD: waxing & waning Patient samples Chronic sxs, remission-relapse cycles GAD, panic, social anx: chronic, prolonged Diagnostic shifts: esp. depression & somatoform disorders (e.g., hypochondriasis, pain, BDD)

OCD Brain Differences

Cortico-Striato-Thalamic-Cortical (C-S-T-C) circuit abnormalities: hyperactive perfusion & metabolism aka: C-BG-T-C loop (Basal Ganglia), C-LS-C loop (part of Limbic system) Volume differences: Reduced areas: left ACC & OFC Increased areas: thalamus Increased size of the thalamus poss related to sxs severity Direct & indirect pathways Glutamate excitatory effects GABA inhibitory effects = opposing actions on the thalamus & effect on feedback loop to the frontal cortex Theorized imbalance in these pathways Different pathways, different functions Ventral cognitive pathway: context processing & inhibition Dorsal cognitive pathway: working memory Affective pathway: emotions

BMI criteria

Criteria: FUZZY "Definitely larger than most" "Discrete period" "Loss of control" "Inappropriate" Emotions: negative Not built into the criteria Disgust, shame, guilt Secrets Difference with Anorexia

Combined Treatment OCD

Current guidelines: 1st line for severe or nonresponders to monotherapy (adults & children) Superior efficacy than meds alone (medium to large effect size)

Body Dysmorphic Disorder (BDD)

DSM-5: in new OCRD section Reasoning: obsessive thoughts & compensatory behaviors, mirrors OCD response to treatment BDD & ED share similar features Poor body image Excessive worry about physical appearance Physical appearance strongly linked to self-worth Develop compulsive behaviors to reduce anxiety Can co-occur with ED Att! differential diagnosis with Gender dysphoria

Cannabis induced psychotic disorders

Danish study 535 patients, followed for 3+ years New psychotic episodes of any type: 77.2% Schizophrenia spectrum disorders : 44.5% Male gender & younger age: increased risk Patients: earlier onset schizophrenia (5-6yrs earlier) than control group (controls: first episode not cannabis related)

Obesity

Definition: BMI above 30 DSM-5 states: "a range of genetic, physiological, behavioral and environmental factors contribute to the development of obesity; thus it is NOT considered a mental disorder" Study: more than 25% of overweight/obese individuals engaged in binge-eating episodes

Recovery Schizophrenia

Despite the public stereotype of chronic severe schizophrenia this is NOT the outcome for the majority of patients (only for 25%) Due to other maintaining factors: lack of stable consistent environments including housing, poverty, unemployment; lack of access to treatment, lack of supervision for medication, social isolation, comorbid substance-dependence Long-term prognosis for those who receive treatment is good, the majority of individuals improve over time & lead meaningful satisfying lives May not be full return to premorbid functioning: quality of life, independence with support, employment & relationships Recovery as an evolving process: being "in recovery"

COGNITIVE SYMPTOMS SCHIZOPHRENIA SPECTRUM

Disorganized thinking, communication & speech Derailment or loose association Tangentiality Incoherance: so disorganized as to be incomprehensible Overinclusiveness: abnormal categorization (e.g., pear, lips, orange, banana, ear) Attention, memory, decision making also impaired = poor executive function (probs in the PFC), & social communication (perspective taking, other's emotions) Must be severe enough to impair effective communication

Functional Brain Differences Schizophrenia

Disrupted connectivity due to reduced dendritic complexity & synaptic density Deficits in working & long-term memory tasks Lower metabolic activity in the frontal lobes

Etiology: Biological factors HD

Distinct Fronto-limbic circuits Cingulate cortex: hyperactivation: decision making Ventromedial prefrontal cortex, & limbic structures: hyperactivation, related to object significance, information processing deficits Different than OCD Impairments: memory, planning, strategizing, decision making & problem solving, impulsivity, delayed gratification, behavioral disinhibition Dysfunctional beliefs: heightened sense of responsibility for objects, fears of waste, fears of losing information, need for control of belongings, intense emotional attachment to possessions Family studies: HD sxs common among 1st-degree relatives Twin studies: heritability 51%, so moderate genetic contribution, environmental factors also important Gene studies: genetic correlations (2016 study) between: Hoarding & obsessive-compulsive sxs (r = 0.41) Hoarding & tics (r = 0.35), Obsessive-compulsive sxs and tics (r = 0.37) So poss some shared genetic contributions, but so far unknown Animal studies: limbic areas (dopamine deficits), vmPFC lesions induce HD

DELUSIONS SCHIZOPHRENIA SPECTRUM

Distorted BELIEFS that are persistent, despite contrary evidence Bizarre delusions = implausible, not understandable for culturally-matched peers & not derived from ordinary life experiences Non-bizarre = plausible but delusional as contrary evidence exists Att: within the framework of the delusion the patient may try to maintain some form of 'logic' Insight: usually low insight into the irrational nature of the beliefs Intense emotions: fear, distress, anger Content of delusions can vary, common themes include: Persecutory delusions: belief that one is being harassed, surveilled, harmed by others (individuals or organizations) Referential delusions: belief that certain gestures, comments, environmental cues are directed at oneself Grandiose delusions: belief that one has exceptional abilities, powers, wealth or fame Control delusions: beliefs that others (people, animals, aliens, objects) are trying to control them Nihilistic delusions: beliefs that something catastrophic will occur Erotomanic delusions: falsely believing that an individual is in love with them

Diagnosis Schizophrenia

Duration: important to be able to specifically asses the timeframe of the disorder May be necessary to rely on 3rd-party observations particularly when extended prodromal phase Differential Assessing cognitive functioning Comorbidities: esp. depression, bipolar disorder, anxiety Drugs/substances: use, abuse, history Spectrum: there is much controversy surrounding the validity of these disorders, particularly because delusions & even hallucinations can appear on the context of several disorders not just schizophrenia

Treatment Schizophrenia

EARLY treatment: as soon as positive sxs appear No current cure: sxs management (Higher risk of relapse in those who terminate medications earlier after an active episode) Medications: 1st line of treatment for schizophrenia (Atypical antipsychotics (e.g., clozapine most effective)) Side effects: weight gain, nausea, elevated blood sugar & cholesterol which effects the heart Relapse: within 1-year. = 40% in those who are compliant

cognitive vulnerabilities schizophrenia

Early cognitive deficits in people who develop schizophrenia Possible signs of cognitive regression (decline in verbal ability) Patients: deficits in empathy & ToM - impact on interpersonal relations Distorted beliefs: misattributions, negative attitudes, low self-worth, hopelessness: esp related to neg sxs Hostile, negative, critical family environments = families high in Expressed Emotion (EE), can also be over-involved or intrusiveness Esp. related to onset & relapse But high emotional involvement may be a protective factor in some cultures (AA, LA vs. EA)

Generalized Anxiety Disorder

Excessive anxiety or worry, more days than not, for 6+ months, across situations Difficulty controlling the worry Accompanied by 3+ (some: more days than not), 1+ children Restlessness, feeling on edge, keyed-up Being easily fatigued Diff concentrating, mind going blank Irritability Muscle tension Sleep disturbance Clinically significant distress or impairment NOT a medical disorder or drugs (meds or street drugs) NOT another mental disorder (e.g., worry about panic attacks in panic disorder, worry about social evaluation in SAD, fears in OCD, separation anxiety, PTSD, weight gain in AN, BDD, hypochondriasis, or delusions) Children tend to worry excessively about their competence or performance, may be overly conforming, perfectionistic Adults tend to worry about more everyday things During the course of GAD the focus of the worry may shift

Etiology of BDD: Biological Factors

Family studies: 1st degree relatives 8% BDD & 7% ODC Genes: GABA in BDD, BDD + OCD BUT not in OCD alone Serotonin transporter (5-HTTPRL) - Att! few studies Neuroimaging: mixed findings, few studies Caudate nucleus: left shift & greater white matter volume Diff in visual processing & amygdala: focus on details? Functional: differences in info processing, incl. memory deficits, executive function, selective threat processing (anx), emotion interpretation (more anger): low PFC? High amygdala? Not enough studies

OCD Gender and Age

Females slightly more than males Males more in childhood May vary with types of obsessions Cleaning/contamination higher females Religious/sexual higher in males Males higher tic-disorder comorbidity Females higher ED comorbidity Sxs typically diminish or stay stable

Gender Schizophrenia

Gender ratio: 1.4 men : 1 women But shifts later in life, with more onset in later life (50-60yrs) for women, possible that estrogen provides some protection before menopause Women tend to display more emotional & psychotic symptoms (delusions, hallucinations) than men Men tend to have more disorganization, negative symptoms & social impairment Women tend to show a worsening of psychotic symptoms as they age

Gender/Age & Ethnicity Hoarding Disorder

Gender: mixed findings, poss due to focus on OCD samples Men > women: population samples Women > men: clinical samples Some studies: no differences Ethnicity: sparse findings, lack of studies HD exists across ethnicities Findings suggest: same or possibly slightly lower in AA, Hispanic & Asian populations Treatment response: very few data (samples 90%+ Euroamerican)

Sociocultural Factors Phobia

Gender: specific phobia (♀15.7% vs. ♂6.7%). Disgust? Culture: collectivistic cultures and SAD, e.g., China shaming as an educational practice Culture-bound syndrome: Japan Taijin Kyofusho, fear of embarrassing others, being offensive

PSYCHOMOTOR ABNORMALITIES SCHIZOPHRENIA SPECTRUM

Grossly disorganized, abnormal motor behavior Several manifestations Silliness: childlike behaviors, or agitation: disorganized erratic Catatonia: lack of responsiveness to the environment (verbal = mutism, motor = stupor), peculiar body movements or postures, strange gestures & grimaces, or a combination of all. Catatonic excitement = purposeless, excessive motor activity vs. Catatonic withdrawal = total lack of responsiveness Extreme withdrawal can be life-threatening when it last a significant period of time (lack of food & water)

Genetic Findings Schizophrenia

Heritability estimate varies from 41 to 87% Twin concordance: MZ 50%, DZ 17%: moderate genetic risk Family Studies: 5-17% risk in 1st degree relatives Gene studies: polygenicity, including up to 108 loci Distinct symptomatic subtypes of schizophrenia may be related to different polymorphism (combination of genes) C4 gene: role in synapse pruning, & increased C4 expression leads to reduced dendritic spines & a higher schizo risk Possible genetic overlap with ASD, ADHD, Bipolar disorder, MDD

Biological Factors - Phobia

Heritability: 31% twin concordance Functional brain studies (fMRI): Hypersensitive amygdala Preparedness - innate evolutionary fear, necessary for survival: maybe for some, impossible to test! Temperament - introverted, shy, anxious children, interaction with environment/social causes

BDD: Ethics & Stigma

High distress & behaviors: quality of life Cosmetic surgery: Include therapy? Financial cost Surgical risks Understudied disorder Not just vanity or narcissism Not just a female issue High rates of depression & suicide Treatment highly distressing

Assessment: Interview measures HD

Hoarding Rating Scale-Interview (HRS-I, Tolin, Frost, & Steketee, 2010) 5-item brief interview, covering clutter, diff discarding, acquisition, distress, & impairment Score 14+ clinical, high sensitivity & specificity BUT not diagnostic for DSM-5 as does not assess specific reasons for hoarding & difficulty discarding Structured Int. for Hoarding Disorder (SIHD; Nordsletten et al., 2013) DSM-5 diagnostic criteria BUT not measure or quantify sxs severity & associated features

Assessment: Additional dimensions OCD

IMPAIRMENT essential for dxs & treatment goals Sheehan Disability Scale (SDS, Sheehan, 1983) Impairment in 1. work/school, 2. social & 3. family life Scores 0-10 on each domain, 5-10 = moderately-extremely impaired Good internal consistency & construct validity Child Obsessive-Compulsive Impact Scale - Revised (COIS-R, (Piacentini, et al., 2007) INSIGHT need for specifier Included items in the scales & interviews Limited insight - worse clinical prognosis & attenuated treatment response to exposure-based psychotherapy

Anxiety Stigma and Ethics

Isolation, avoidance: interpersonal functioning Families, intimate relationships, loneliness, distress Ability to work & function Panic attacks: frightening to self & others Often a chronic disorder: may take years to be recognized as significant by general practitioners Ethics of assessment: can go undiagnosed as anxiety sxs are often masked by depression Ethics of treatment: exposure therapy can be highly distressing

Animal Hoarding

Keeping lots of animals, no proper care, whilst denying this inability US: legal consequences only, animal cruelty laws: misdemeanor poss higher some states Consequences for health & safety of both animals & humans Usually specialize in one species, majority also hoard objects Excessive acquisition: 'mission-driven, rescuing' OR breeding May occur within the context of Diogenes syndrome - senile squalor syndrome (not in DSM but medical dxs): extreme self-neglect, squalid living conditions, social withdrawal & denial of problem May be a distinct syndrome or a specific subtype of HD

Prevalence Schizophrenia

Lifetime prev schizo: ≈ 1% US data diff to find Some evidence that urbanicity may be a prominent risk factor esp. for later onset

Prevalence Comorbidity OCD

Lifetime: 2.3% 12-month: 1.2% 28% reported obsessions or compulsions at some point On av. obsessions: 6h/day, compulsions: 4.5h/day 30% severe, 65% moderate sxs 65% severe role impairment Any anxiety disorder Any mood disorder Any impulse control disorder Any substance abuse disorder Any disorder

Biological Factors (Brain)

Limbic system (emotions) Amygdala Emotion memories, esp. danger 1) Stimulates the Hypothalamic-pituitary-adrenal (HPA) axis: releases cortisol for fight or flight 2) Hippocampus-Prefrontal cortex pathway: evaluate danger & dampen the amygdala & slow the HPA

Etiology of BDD: Environmental Factors

Maltreatment: abuse / neglect Few studies: retrospective, perceived self-reports only E.g.: 79% abuse / neglect; 40% severe maltreatment

Agoraphobia

Marked fear or anxiety about 2+ : Using public transport Being in open spaces Being in enclosed spaces Standing in line or being in a crowd Being outside of the home alone Individual fears or avoids situations because escape may be difficult or not available if panic sxs or other incapacitating or embarrassing sxs Situation almost always provokes fear or anxiety Situation is actively avoided, or require the presence of a companion or are endured with severe distress Fear or anxiety is disproportionate Is persistent: 6+ months Causes clinically significant distress OR impairment If another medical condition: fear, anxiety or avoidance is excessive NOT specific phobia, SAD, OCD, BDD, PTSD or fear of separation Note: agoraphobia + panic = 2 separate diagnoses now

Social Anxiety Disorder (Social Phobia)

Marked fear or anxiety in social situations where the person may be exposed to scrutiny by others (during social interactions, being observed, performing ) (children: with peers, not just adults) Fears of showing anxiety (blushing, sweating etc.)& being negatively evaluated (embarrassment, rejection) or embarrassing others Social situations almost always provoke fear or anxiety (children: crying, tantrums, freezing, clinging, shrinking or silence) Social situations are avoided or endured with intense distress Fear or anxiety is grossly disproportionate to the actual situation Fear, anxiety or avoidance persists: 6+ months

Etiology Environmental Factors HD

Material deprivation in childhood Elevated rates of traumatic events

BDD: Treatment

Medication - 1st line: SSRIs: more effective than non-SSRI, May need high doses Psychotherapy: CBT, esp. for dysfunctional thoughts, ERP / behavioral component esp. for those with high social avoidance, Insight affects motivation for treatment

Treatment HD

Meds = SSRIs: 50% less responsive than OCD (= 50% of 50%!) Therapy: CBT-ERP-HRT Habit Reversal Training (used for skin picking & trichotillomania) 3 techniques: 1) awareness training (identifying high-risk situations), 2) developing a competing response until the urge passes & 3) stimulus control (eliminating cues for pulling and picking) Therapy usually involves a mix of CBT-ERP-HRT HD shown lower response to ERP alone than OCD does No RCT to date that compare SSRIs to therapy in HD

Anxiety Disorders Suicidality

Meta-analysis 2016: 69 samples, < 800, 000 participants: clinical & gen population Anxiety symptoms were significant predictors of suicide ideation & attempts, but NOT actual death = increased risk

AN severity

Mild = 17-18.5 Moderate = 16-16.99 Severe = 15-15.99 Extreme = below 15

Stigma and Ethics OCD

Misconceptions: 'Not a big deal', 'a few quirks': Estimated av. obsessions: 6h/day, compulsions: 4.5h/day 'Just a few rituals': intrusive thoughts, highly distressing Sxs are ego-dystonic & anx provoking (fear of acting on thoughts) Individual Self-stigma: not 'normal', effects on self-worth, isolation, secrecy Anticipated stigma: fear of being judged, esp. with more unusual (violent, sexual) intrusive thoughts (even by family members) Only 29% receive specialized treatment & most wait 8-10yrs Barriers to treatment: Access to specialized services, cost, stigma (labeling/treatment) Fear of discrimination, at work, school, socially May be even more pronounced for multicultural communities Clinician: ethics Misdiagnosis? Comorbidity may mask OCD 'Invisible' sxs: may go undetected Rapport & alliance: sensitivity to social & economic reality

Ethics & Stigma Psychotic Disorders

Misunderstandings about causation Underestimation of the genetic contribution Complete misattributions in some countries: supernatural causes Overestimation of the probability of violence The vast majority of individuals with schizophrenia are NOT violent Stigma & self-stigma: labelling, hospitalization Social isolation worsens the disorder Social contributors such as poverty & inaccessibility of healthcare and health supervision increase the severity for some which could be avoidable: increased suffering, stigmatization

Psychological Factors: Conditioning Model OCD

Mowrer's 2-stage theory of fear acquisition & maintenance (1960) Classical Conditioning (like phobia) Fear provoking trauma/event (UCS) is paired with a neutral object (CS) Then neutral object (situations, objects, thoughts, feelings ) becomes threatening (CR) and triggers fear and... Operant Conditioning Avoidance Behavior (compulsion) develops to reduce the anx, through negative reinforcement More it's used the more habitual it gets Long-term maladaptive as eliminates the poss of natural extinction Mixed support: low for onset, good for maintenance, low for multiple & shifting obsessions Basis for Exposure-Response Prevention (ERP) therapyP

Gene x Environment interactions Factors

NOT all short allele carriers show behavioral inhibition so environmental factors important triggers Early Life Stress Moderate-severe adversity experienced during childhood/adolescence Low maternal social support Maternal mental illness, esp. depression & anxiety

negative symptoms of schizophrenia

Negative refers to a lost beh' or emotion, something that existed before onset Inability or decreased ability to initiate actions or speech, express emotions, or feel pleasure Avolition: loss of ability to initiate or persist in goal-directed behavior Alogia: loss of meaningful speech Asociality: loss of interest in social relationships Anhedonia: loss of ability to experience pleasure from pos events Alexithymia & Flat Affect: loss of capacity to express emotions and to display emotions (facial expressions, voice intonation, gestures) Negative sxs are common & they account for a large proportion of the morbidity (degree of sickness) associated with schizophrenia

Changes in DSM-5 Obsessive Compulsive

No longer an anxiety disorder: own section (OCRDs)

Anxiety biggest change to DSM-5

No longer includes OCD & related disorders

Anxiety

Normal adaptive reaction: threat system, survival Fight or flight Spectrum: extreme anxiety, disproportionate to threat Cognitive & physical reactions Anticipatory & reactionary

Cross-Cultural OCD

OCD found across all cultures/countries Transcultural homogeneity: sociodemographics & core sxs SAME across cultural, ethnic, religious, geographic differences Most common: 1) contamination & washing, 2) doubt & checking But within a culture people may share common concerns, which may influence themes of obsessions/compulsions Religious themes, fear of violence, fear of illness (HIV)... 7 countries: Lifetime 1.9%-2.5%, 12-month prev 1.1%-1.8% Att! few data: Central Asia, Eastern Europe, & sub-Saharan Africa

OCD

Obsessions Recurrent & persistent thoughts, urges or images, intrusive or unwanted: autogeneous (no triggers) & reactive (triggered) Compulsions Repetitive behaviors or mental acts, driven to perform, in response to obsessions or rigid rules: rituals (overt/covert), neutralizing & avoidance (not sxs in DSM, but highly present) Additional dysfunctional beliefs: inflated responsibility, overestimation of threat, perfectionism, intolerance of uncertainty, overestimation of importance of thoughts Chronic life course with waxing & waning sxs

Environmental Factors OCD: PANDAS

PANDAS: Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (strep throat, scarlet fever etc) Age 3 to puberty, ados = v. rare but poss, adults unstudied Subtype of OCD, appears following an infection: body's autoimmune reaction BUT specific mechanism unknown Sxs: sudden, severe & EPISODIC (incl. tics, anx, irritability) Treatment: antibiotics (lab tests) + standard OCD treatments Debated entity, few studies, NO prospective population data

Screeners Anxiety

PHQ & GAD-7 (Spritzer et al., 2006): anxiety modules, sxs & severity PADIS (Batterham et al., 2015): panic sxs & severity Clinical Questionnaires BAI: Beck Anxiety Interview (Beck & Steer, 1990): somatic sxs (maps more onto panic), independent of depression MASQ: Mood & Anxiety Questionnaire (Clarke & Watson, 1991): tripartite model = sxs specific to dep, anx & common sxs

Panic Attack

Panic attack is NOT a mental disorder per se Can occur in the context of any anxiety disorder & other mental disorders Usually added as a 'specifier', e.g., PTSD with panic attacks For panic disorder the attacks are contained within the main criteria, therefore it is NOT added as a specifier The attacks are the CRITERIAL symptom

Treatment: Family Factors OCD

Parental Anxiety High parental anxiety more reassurance seeking & providing, compromises exposure Family accommodation to sxs Direct: family members complete aspects of the person's ritual Indirect: developed family avoidance of things hat may provoke obsessions & compulsions Less exposure & less experimentation during treatment esp. problematic for ERP & CBT Family involvement in treatment may be beneficial

Social Factors Phobia

Parenting: overprotection of fearful children, low autonomy support - interaction with temperament Family stress: negative family interactions, esp. SAD Bullying: has been shown to increase SAD

Hoarding Disorder Criteria

Persistent diff discarding possessions, regardless of value Related to perceived need to save items or distress at discarding them Results in accumulation of clutter & congestion of living areas, compromising normal use (if clear only due to a 3rd party, still meet) Significant distress or impairment (incl. maintaining safety) NOT another med condition (brain injury/ neurocognitive) NOT another mental health condition (OCD, MDD, Schizophrenia, ASD...) Specify: with excessive aquisition (not needed, no space, $ or free) Specify: insight absent or delusional ; poor ; good or fair

Hostility & Aggression Schizophrenia

Poss BUT the vast majority of patients with schizophrenia are nonviolent & are more frequently VICTIMIZED: 14x more likely than the general pop Spontaneous & random assault is VERY RARE Risk of violence is higher when comorbid substance use disorder, pre-morbid impulsivity or anti-social personality disorder (v. rare) Att! The prevalence of violence in Bipolar disorder (esp. during acute mania) is the same/more than in schizophrenia Same increased risks with comorbidities: substance use/abuse, impulsivity, personality disorders

Environmental Social Factors Schizophrenia

Prenatal & postnatal environments During pregnancy: stress, malnutrition, viral infections Obstetrical complications & low birth weight Older father: more genetic disruptions in semen Poverty: more prev in poorer neighborhoods (chicken-egg) STRESS: Trauma, neglect, abuse & bullying Negative life events: vulnerability & maintenance factor e.g., recent immigrants receive more diagnoses, but unclear whether this is clinician bias or higher rates due to the stress of migration/discrimination etc. Substance use / abuse: esp. alcohol & cannabis

BDD Diagnostic Criteria

Preoccupation with 1+ PERCEIVED defect or flaw in physical appearance, not visible/appear slight to others At some point, performance of repetitive behaviors (excessive checking/grooming, skin picking, reassurance seeking) or mental acts (comparing) in response to concerns Distress or impairment NOT weight focused (ED) Specifier: with muscle dysmorphia (even if also other areas) Specifier: good/fair insight (def or prob not true/may or may not be true) ; poor insight (probably true) ; absent/delusional beliefs (true)

Substance Induced Psychotic Disorder

Presence of one or both: delusions and/or hallucinations Physical evidence (lab finding, examination, history) of: Criteria A sxs started during or soon after intoxication/withdrawal The substance taken is capable of producing such sxs NOT an independent psychotic disorder NOT delirium (fever, acute intoxication) Causes distress or impairment Specify: onset during intoxication; onset during withdrawal Severity: rating of 0-4 for all sxs

Prevalence & Comorbidity HD

Prev: range 1.5-6% in pop samples Comorbidity: No gender diffs MDD: 51% ; ANX: GAD: 24.4%, Social Phobia: 23.5% ADHD: 40%, > inattentive OCD in HD: unclear due to dxs overlap: 1st study post-DSM-5: around 18%, 2x more men, prelim finding OCPD: higher only when incl. HD sxs

BDD: Demographics

Prevalence: 1-6% (DSM-5: 2.4%) gen pop Patients: dermatology 9-15%; cosmetic surgery 7-53% Psychiatric patients: 16% Gender: 2.5% females, 2.2% males Poss. female > male esp. ado, not enough studies Onset: adolescence mean 16-17yrs Subclinical sxs: 12-13yrs Elderly population: some continue into older age Course: gradual worsening, chronic course

Changes in DSM-5 Hoarding Disorder

Previously viewed as a SYMPTOM of OCD in DSM BUT not all hoarding meets OCD criteria Received Anxiety disorder NOS or no diagnosis! Only mentioned in DSM-IV: because of the Y-BOCS items

Binge Eating Disorder (BED)

Recurrent binge eating, characterized by: Definitely larger than most people, discrete period of time Sense of lack of control Binges are associated with 3 or more: Rapidly Uncomfortably full Not hungry Alone Disgusted / guilty Marked distress regarding binge eating At least 1 / week for 3 months No compensatory behaviors, no AN or BN Same severity as BN Previous DSM: BED was in EDNOS Binge criteria Same problems as in BN Emotions: negative Built into criteria Weight Healthy, overweight & obese individuals

Bulimia Nervosa (BN)

Recurrent binge eating, characterized by: Definitely larger than most people, discrete period of time Sense of lack of control Recurrent inappropriate compensatory behaviors Both occur at least 1 x week for 3 months Self-evaluation unduly influenced by shape/weight Is not AN Severity (based on # compensatory behaviors per week) Mild: 1-3 ; Moderate: 4-7 ; Severe: 8-13 ; Extreme: 14 + Previous DSM: needed 2 binges x week

Panic Disorder

Recurrent unexpected panic attacks (1+ full attacks) At least one of the panic attacks has been followed by 1+ month(s) of: Persistent concern or worry about additional attacks or their consequences (e.g., losing control, having a heart attack, going crazy) AND/OR A significant maladaptive change in behavior related to the attacks (e.g. avoidance or triggers) NOT from a substance or a medical condition NOT another mental disorder (e.g., SAD, specific phobia, OCD, PTSD, or separation anxiety disorder - all these can have the panic attacks specifier)

Diagnostic Interviews Anxiety

SCID: Structured Clinical Interview Schedule for DSM-5 ADIS: Anxiety and related disorders for DSM-5

Treatment: Medications OCD

SSRI's: also 1st line for adults, 2nd line for children Better than placebo BUT NOT more effective then CBT/ERT 20-40% sxs reduction, BUT usually some sxs remain & 50% show no response Tricyclic antidepressant: clomipramine, has shown similar efficacy but more side effects than SSRIs Atypical antipsychotics as adjuncts for severe low response cases, esp. with chronic tics Att! For 1/3rd, sxs remain clinical level Benefits of meds are lost when they are terminated

Assessment: Self-report measures HD

Saving Inventory-Revised (SI-R, Frost, Steketee & Grisham, 2004) 23-items, 3 subscales 1) difficulty discarding, 2) excessive clutter & 3) excessive acquisition Good psychometrics clinical & nonclinical pops. Score of 42+ indicates clinical severity Hoarding Rating Scale-Self Report (HRS-SR; Tolin et al., 2008) 5-item scale assessing clutter, diff discarding, acquisition, distress, & impairment BUT not perceived need to save items, reasons for difficulty discarding, or associated features, so NOT DIAGNOSTIC

Epidemiology: Cross-Cultural

Schizophrenia affects about 0.3-0.7% of people at some point in their life 21 million people worldwide as of 2011 (about 1/285 people) Prevalence & incidence vary across the world Lowest = Africa to highest = Japan & Oceania 544/100,000 for men & SE Europe 527/100,000 for women

Schizophrenia Spectrum includes

Schizotypal PD (pervasive, no delusions & hallucinations) Delusional Disorder (delusions only, 1 month) Brief Psychotic Disorder (full disorder but 1 month only) Schizophreniform disorder (full schizophrenia but less than 6mnths) Schizophrenia (schizophrenia for 6+ months, with 1+months active sxs) Schizoaffective Disorder (Mood + active sxs together & 2wks D/H alone) plus Substance-induced or due to a medical condition

OCD Brain Chemistry

Serotonin: hyposensitivity, increase with SSRIs Dopamine: hyperactivity in basal ganglia-thalamus pathway, reduce with antagonist, esp. for those with tics Glutamate: excitatory neurotransmitter, dysregulation in glutamate homeostasis Att!: ex juvantibus reasoning, i.e.: reasoning backwards from what helps Other neurochemicals are candidates for involvement: GABA, BDNF, substance P, Bradykinin and its receptor BDKRB2, and cholinergic & endogenous opioid systems

Assessment Schizophrenia

Several scales: positive-negative sxs, but given the low insight in schizophrenia may be underestimates Mostly used within the context of research Most assessments are made by clinicians during an acute active phase using clinical interviews like the SCID PLUS: focus on overall clinical presentation: history, impairment, life style, substance-use/abuse Reliance on third-party reporters, preferably family members or individuals who live with the patient Scales/tests may be given to RULE OUT other disorders & physical causes

Content of Hoarder

Shopper Hoarder Specialized Hoarder Food Hoarder Garbage Hoarder Paper/recycling Hoarder

Stigma & Ethics OCD

Stand alone disorders vs. sxs of OCD Misconceptions in the general public Length of time until treatment Serious health & safety concerns for self, family, pets, neighbors Possible losing home: eviction Clutter impacting home quality of life: self & family members Financial impact: never ending cost of stuff Treatment, esp. discarding is highly distressing (accumulating ego-syntonic, discarding ego-dystonic) Underlying beliefs, emotions & trauma Focus on quality of life for self, family (incl. pets)

Environmental Factors OCD: Stress & Trauma

Stressors & ONSET: single events (11%) & chronic stressors (19%) BUT some mixed findings Stressors & SEVERITY: poss association but few studies Traumatic events PTSD & OCD associated, may increase likelihood of older onset Trauma (no PTSD) & OCD associated BUT few studies Acute TBI, some evidence of OCD sxs onset (case reports only) Att!: retrospective data, need prospective population based studies

Assessment: Interviews OCD

Structured Clinical Interview Schedule for DSM-5 (SCID-5) Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5) Structured interview: current anxiety, mood, OCD, trauma, related disorders, & differential dxs amongst these disorders Strong psychometric properties, shows excellent discrimination & can reliably produce an OCD diagnosis

Anxiety: Assessment & Diagnosis

Tends to be under-diagnosed, why? Masked by depression Difficult to verbalize emotions Not enough time & attention paid to mental health by GPs Stigma: embarrassment, shame Solutions? Repeated visits, GP training, use of screening measures, checking for both depression & anxiety

BMI "the good, the bad & the ugly"

The good Standardized adults Quick & easy Across professionals The bad Focus on weight Body frames & composition The ugly Access to insurance Masks some health problems Alternatives? Body fat %, waist-to-height ratio, waist-to-hip ratio

Generalities Psychotic Disorders SCHIZOPHRENIA SPECTRUM

These disorders are built up using blocks of symptoms Positive symptoms (added thought or behavior): delusions, hallucinations, cognitive symptoms & psychomotor abnormalities Negative symptoms: loss of actions, speech & emotions PLUS specific time frames The severity of symptoms has been shown to be a reliable predictor of prognosis, and impairment These disorders are intensely distressing to patients and to their families

Etiology: Genetics OCD

Twins: MZ twins 80-87%, DZ twins 47-50%, no separation studies Family studies: 4-6x higher risk of lifetime OCD in 1st-degree relatives, may be higher in child onset families: 4-8x risk (spouses/partners) - assortative mating & social homogamy Gene linkage studies: polygenicity but only suggestive effects Candidate gene studies: specific variants or risk Increased Serotonin transporter (SERT) & glutamatergic transporter functioning

BDD: Obsessions & Behaviors

Ugly, unattractive, abnormal or deformed Too big, too small, out of proportion, unsymmetrical One or many body areas Most common: skin, hair, nose Any body area, lifetime 5-7 body parts BEH: Comparing, checking/avoidance, grooming, camouflaging, exercising/weight-lifting/steroids, tanning, skin lightening, cosmetic surgery Time-consuming: 3-8hrs per day Intrusive, distressing & diff to control

Ranges BMI

Underweight = below 18.5 Healthy weight = 18.5 to 25 Overweight = 25 to 30 Obese = above 30

Cross-Cultural Hoarding Disorders

Universal phenomenon, sxs found in Africa, Asia, and SAmerica BUT few non-Western studies & most only in the context of OCD HD in OCD (Y-BOCS): India, Japan, Turkey & Brazil: 11-49%, lower for hoarding specific measure: India & Brazil 10-17% Phenomenological diffs?: mixed findings but possibly if so, WHY? $, space, culture (idioms of distress)

Biological Factors (genetic)

Variations in serotonin transporter genes (5-HTTLPR) Implicated in ANXIETY & DEPRESSION A polymorphic (difference in shape) genetic mutation: length of alleles (2 parts of each gene), can have 2 short, 2 long or one of each, with 2 SHORT alleles: Reduction in serotonin activity Increased inhibition (fear & anxiety behaviors) = GENETIC VULNERABILITY to more amygdala reactivity, creates a predisposition, i.e., higher likelihood, MUST be triggered by the environment

Assessment: Clinician-rated OCD

Yale-Brown Obsessive Compulsive Scale (Y-BOCS, Goodman et al., 1989) Most common, 54 common obsessions/compulsions, by theme Sxs for the previous week across 5 dimensions: (1) time/frequency, (2) interference, (3) distress, (4) resistance, and (5) degree of control The 'gold standard ' for OCD severity & good psychometric properties 2 criticisms: 1) poss low discrimination with depression, 2) inconsistent factor structure across several studies Y-BOCS-II (Goodman et al., 2004) developed to address these criticisms There is a self-report version of the Y-BOCS (adults, youth & children)

Hoarding Disorder

aka Compulsive Hoarding: excessive, impulsive, pathological Chronic need to accumulate & distress about discarding Primary Hoarding: the main disorder Secondary Hoarding: developmental, neurological, psychiatric conditions Results in clutter & chaotic environment, may be UNSAFE vs. Stockpiling: accumulating a reserve supply, organized, purposeful, usually without clutter, distress or impairment vs. Collecting: organized, targeted, systematic, usually without clutter, distress, or impairment Insight: may be poor with impairment apparent only to others

BDD comorbidity

major depression social phobia anorexia bullimia Suicidality Ideation: average 58% Attempts per year: average 2.6%

BDD: Ethnicity/Diversity & Cross-Cultural

sexual minority women highest Often associated with other disorders, some considered culture bound syndromes (e.g., Japan: shubo-kyofu)