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http://courses.ucsd.edu/frose/ps163
Assessment concepts
• Physical exam
○ Important because many physical ailments can cause or masquerade as psychological issues
i.e. hypothyroidism causing same symptoms as depression
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□ Ensure that they're at least baseline functional and try to assess i.e. vocabulary and education level
Sensorium
□ A person's awareness of the "here and now" - are they in the moment?
A&O x 3 (alert and oriented times three)
◊ Are they alert/Do they know where they are/what day it is/why they're there or who they are.
○ Psychological testing and projective tests
Projective tests
□ i.e. Rorschach tests
Subjective, easy to fake, easy to misdiagnose or extrapolate incorrectly, small standard set of slides
Objective tests
□ Series of questions with set options (true/false, 1-5) that get counted/scored and lead to a result
i.e. Myers-Briggs test
Objective intelligence tests
i.e. Weschler, Stanford-Binet
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Thursday 10/8
Thursday, October 08, 2009
3:38 PM
Neuropsychological Tests
Assess broad range of abilities
My Soup Lacks Many Hot Peas
○ Motor skills
e.g. right hand vs left hand dexterity
○ Sensory functioning
Ability to accurately sense various stimuli
○ Language
Language output, ability to speak and name objects, grammar,
understanding language, repetition (connection between reception
and production)
○ Memory
Both short term and long term
○ Higher brain functioning
Reasoning, interpretation, e.g. understanding proverbs
Example:
- Axis I
300.30 Obsessive-compulsive disorder
296.22 Major depressive disorder
- Axis II
301.7 Antisocial personality disorder
- Axis III
None
- Etc.
Reification
Stigmatization
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Tuesday 10/13
Tuesday, October 13, 2009
3:32 PM
Somatoform disorders
• Preoccupation with health, physical appearance and function
○ With no identifiable medical cause
• DSM-IV somatoform disorders
○ Hypochondriasis
Clinical description
□ Physical complaints; no clear cause
□ Severe anxiety over having a serious disease
□ Strong disease conviction
□ Not usually part of the pop culture display
□ Medical reassurance useless
Statistics
□ 1-3% prevalence
□ Affects men and women equally
Previously thought to be mostly female
□ Occurs across all age ranges
□ Onset can occur at any time
□ Chronic
Physical evaluation
□ Rule out actual physical problem
Diagnosis
□ Psychological evaluation
Rule out actual physical problem
□ Determine nature of complaints
Disease conviction
Illness conviction
Illness phobia
Anxiety disorder
Cultural difference (Koro, dhat, etc.)
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□ Cultural difference (Koro, dhat, etc.)
Causes
□ Cognitive perceptual distortions
Unpredictable and uncontrollable world
□ Overly attentive to physical sensations
□ Misinterpretation of sensations
□ Interpersonal influences
Trigger event
Family history of illness
Rewards of sick role
Integrative model of causes of hypochondriasis (graph)
□ Trigger (information, event, illness, image)
Perceived threat
◊ Apprehension
► Increased focus on body
► Increased physiological arousal
► Checking behavior and reassurance seeking
Preoccupation with perceived
alteration/abnormality of bodily
sensations/state
– Misinterpretation of body sensations
and/or signs as indicating severe illness
– BACK TO APPREHENSION
Treatment
□ Challenge illness-related misinterpretations
Collaborative empiricism to open dialogue
□ Substantial and sensitive reassurance
Humanist approach
□ Stress management and coping strategies
○ Somatization disorder
Clinical description
□ Extensive physical complaints before age 30
□ Marked impairment
□ Focus on symptoms, not illness
Symptoms must come from multiple systems within the body
i.e. be fairly unreasonable that someone could be suffering from
all of them legitimately
□ Symptoms become the person's identity
□ QUESTION FOR OFFICE HOURS: Someone internalizing symptoms
without having somatization disorder >30?
Statistics
□ Rare
□ Onset usually in adolescence
□ Mostly affects unmarried, low SES women
Not a lot of resources, most likely very stressed
Having complaints enables one to feel entitled and possibly get
financial support due to supposed illness
□ Runs a chronic course
Causes
□ Familial history of illness
□ Antisocial personality disorder
□ Weak behavioral inhibition system
Possible link to antisocial personality disorder?
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□ Possible link to antisocial personality disorder?
Some manipulative aspects involved
Treatment
□ Often very treatment resistant
□ Limit visits to doctor unless there is a (definitive) emergency
□ Assign "gatekeeper" physician
□ Behavioral approaches
Operant condition, etc.
Removing rewards for sick role behavior
Develop rewards for acting against symptoms
"Fix your own sandwich"
○ Conversion disorder
Clinical description
□ Physical malfunctioning without organic pathology
□ Typically sensory-motor areas
□ La belle indifference
"Oh. I can't walk. Huh."
In 1/3rd of patients
□ Retains most normal functions, but unaware
Not faking
e.g. "blindsight"
Statistics
□ Rare condition, chronic intermittent course
□ Females, onset in adolescence
Causes
□ Psychodynamic view
□ Trauma, conversion, and secondary gain
□ Detachment from the trauma and negative reinforcement
□ Trauma is too overwhelming, so is psychodynamically"converted" to
physical ailment
Treatment
□ Similar to somatization disorder
□ Attend to the trauma
□ Behavioral approaches
○ Pain disorder
○ Body dysmorphic disorder
Clinical description
□ Preoccupation with imagined defect
□ Fixation on or avoidance of mirrors
□ Suicidality
□ Ideas of reference
□ Paranoia
Statistics
□ Lifelong, chronic course
□ More common than previously thought
□ Seen equally in males and females, with onset usually in early 20s
□ Most remain single, and many seek out plastic surgeons
Causes
□ Unknown, tends to run in families
□ Related to OCD?
Treatment
SSRIs provide some relief
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□ SSRIs provide some relief
□ CBT
Cognitive Behavioral Therapy
□ Exposure and response prevention
□ Plastic surgery is often unhelpful
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Thursday 10/15
Thursday, October 15, 2009
3:34 PM
Dissociative Disorders
Compared to somatoform disorders; both involve possibilities for early trauma. What are the
similarities?
Two classes of disorders are thought to be maladaptive coping strategies for dealing with anxiety
One is pushing anxiety to a physical expression
The other is avoidance
○ Overview
Involve severe alterations or detachments in identity, memory, or consciousness
Depersonalization - Distortion in perception of reality
□ e.g. "out of body" experiences
Derealization - Losing a sense of the external world
□ e.g. others appear to be moving in slow motion, buildings appear shaped oddly
Variations of normal depersonalization and derealization experiences
□ Everyone experiences such things occasionally and mildly
e.g. time dilation effects in times of extreme stress like car crashes
"Highway hypnosis"
◊ COGS1: Also related to grouping of route information in brain?
Depersonalization Disorder
○ Overview and Defining Features
Severe and frightening feelings of unreality and detachment
Such feelings and experience dominate and interfere with life functioning
Primary problem involves depersonalization and derealization
○ Facts and Statistics
Comorbidity with anxiety and mood disorders is extremely high
Onset is typically around age 16
Usually runs a lifelong chronic course
○ Causes
Show cognitive deficits in attention, short-term memory, and spatial reasoning
Such persons are easily distracted
Cognitive deficits correspond with reports of tunnel vision and mind emptiness
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□ As person gets distances from the trauma, often memories of their old life and
eventually their old identity resolve on their own and both the amnesia and fugue
recede (often within hours or days).
Often an incident of adaptive amnesia to block out a traumatic event (e.g. rape) will usually
not repeat if a similar event occurs, but could if a dissimilar event does
QUESTION FOR OFFICE HOURS: What is the biological basis for amnesia?
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Alters often fight for dominance, don't like to be in the background
□ Book: First Person Plural, by Cameron West
Semiautobiographical
□ Sometimes alters are used for general life issues
e.g. an alter for eating and swallowing, one for dealing with anger, etc.
□ Often a difficult diagnosis to come to
"When you hear hooves you think of horses, not zebras"
Controversial diagnosis
Don't want to throw the label around, as some people can suddenly start to
"develop" alters when given the diagnosis
Often mistaken for something else at first
○ Statistics
Average number of identities is close to 15
Ratio of females to males is high (9:1)
Onset is almost always in childhood
High comorbidity rates, with a lifelong chronic course
○ Causes
Almost all patients have histories of horrible, unspeakable, child abuse
Closely related to PTSD
Most are also highly suggestible
DID is viewed as a mechanism to escape from the impact of trauma
○ Treatment
Focus is on reintegration of identities
Aim is to identify and neutralize cues/triggers that provoke memories of trauma
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Tuesday 10/27
Tuesday, October 27, 2009
3:33 PM
Panic Disorder: Treatment
○ Psychological and Combined Treatments
Cognitive-behavior therapies are highly effective (PCT)
Combined treatments do well in the short term
□ SSRIs in particular, not so much the benzodiazepines
Best long-term outcome is with cognitive-behavior therapy alone
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□ Graduated or massed (e.g., flooding) imaginal exposure
e.g. violent video games?
□ Some try to recreate or alter the memories via hypnosis
Medical treatments
□ SSRIs are helpful
Wrapup
• Anxiety disorders represent some of the msot common forms of psychopathology
• From a normal to a disordered experience of anxiety and fear
○ Fear and anxiety persist to bodily or environmental non -dangerous cues
○ Symptoms and avoidance cause distress and impairment
○ Consideration of biological, psychological, experimental and social factors
• Psychological treatments are generally superior in the long-term
○ Most treatments involve exposure
○ Suggests that anxiety-related disorders share common processes
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Thursday 10/29
Thursday, October 29, 2009
3:34 PM
Post-Traumatic Stress Disorder
○ Requires exposure to an event resulting in extreme fear, helplessness, or horror
○ Re-experiencing that trauma
○ Avoidance of cues
○ Emotional numbing and/or arousal
○ Markedly interferes with one's ability to function
○ Symptoms > 1 month
Video on PTSD
Mood Disorders
○ Extremes in normal mood
Nature of depression
Nature of mania and hypomania
○ DSM-IV Depressive Disorders
Major depressive disorder
Dysthymic disorder
Double depression
○ DSM-IV Bipolar Disorders
○ Major Depressive Eposide
Depressed mood
Anhedonia
□ Inability to experience pleasure
Cognitive symptoms
Vegetative symptoms
□ Changes in eating; usually weight loss
□ Sometimes insomnia or hypersomnia
○ Major Depressive Disorder
Single episode
□ Major depressive episode that lasts for >= 2 weeks and interferes with normal functioning
Recurrent episodes
○ Dysthymia
Overview
□ Depressed mood for at least 2 years
□ Mild
□ Chronic
Statistics
□ Late onset - early 20s
□ Early onset - Before age 21, poorer prognosis
○ Double Depression
Overview
□ Major depressive episodes AND dysthymic disorder
□ Dysthymic disorder typically first
Statistics
□ Severe psychopathology
□ Poor outcome
□ Most difficult to treat
○ Bipolar I Disorder
Overview
□ Full manic episodes and major depression
Statistics
□ Average age on onset is 18 years
□ Chronic
Suicide is common
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□ Suicide is common
Bipolar I has the highest suicide risk
○ Bipolar II Disorder
Overview
□ Hypomanic episodes and major depression
Statistics
□ Average age on onset is 22 years
□ Only 10 to 13% of cases progress to bipolar I
Bipolar II is not as serious as bipolar I
Not considered to be a "bipolar I waiting to happen"; separate disorders
□ Chronic
○ Cyclothymic
Overview
□ Milder mania and depression
□ Pattern must last for at least 2 years
Statistics
□ High risk for developing bipolar I or II
□ Most are female
□ Average age on onset is early adolescence
○ The Bipolar Spectrum
The disorders cycle back and forth every few days, from normal > cyclothymic > bipolar II > bipolar I
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Tue. 11/03
Tuesday, November 03, 2009
3:33 PM
The Bipolar Spectrum
SIGECAPS
Sleep
○ Disturbance
○ Insomnia (typical)
○ Hypersomnia (atypical)
○ Early-morning wakening
Interest
○ Anhedonia
Guilt
Energy
Concentration
Appetite
○ Disturbance, sometimes anorexia or overeating
Psychomotor
○ How much effort someone subjectively feels it takes to do things
Suicide
○ Not just considered it, actually planned it out - i.e. not just calls for help
○ Important to try and build a contract - the client will call the doctor if they feel they're considering suicide too strongly
Bipolar disorders have a higher risk of suicide than the unipolar disorders. Why?
○ Research is mixed. Some think the suicide rate for bipolar II is higher than bipolar I.
Bipolar Disorders
Cyclothymic Disorder
Depression Mania
Melancholic Psychotic
Atypical Catatonic
Postpartum
Seasonal onset
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Additional Facts and Statistics
Lifetime Prevalence
About 7.8% of the US population
Sex Differences
MDD: 2:1 Women to Men
Bipolar disorders: 1:1
○ Most depressed persons are anxious, not all anxious persons are depressed
Genetic Influences
○ Strong familial inheritance patterns for both major depression and bipolar
○ Serotonin transporter gene (5-HTT) is ONE candidate
○ Depression in MDD and bipolar have same genetics
○ Mania has a separate genetic influence
Genetic Influences
Identical twins much more likely to also develop depression/bipolar than just fraternal twins
Neurobiological Influences
○ Neurotransmitter systems
Serotonin
□ Some people are questioning if serotonin actually plays as much a part as previously thought
Permissive hypothesis
○ The Endocrine System
Cortisol and Dexamethasone suppression test (DST)
○ Sleep and Circadian Rhythms
Sleep disturbance = hallmark
Learned Helplessness
○ Animal Research (Seligman and Maier, 1967)
○ Dogs learn to avoid shock by jumping a barrier.
○ Dogs who previously cannot control shock do not subsequently learn to avoid shock.
○ Instead, these dogs become "helpless".
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Triggered by negative life events. (e.g. "I must be the best at everything")
□ Cognitive Biases (Systematic Logical Errors)
Arbitrary Inference - The professor must think I'm stupid because I got a D.
Selective abstraction - I did poorly because I'm stupid.
Overgeneralization - I got a D. I'm going to flunk out of school.
Magnification & Minimization - That A was a fluke.
Personalization - The professor didn't call on me; he must think I'm dumb.
Absolutist Dichotomous Thinking - If I don't get an A, I'm a loser.
Should & Must Statements - I have to get the highest grade.
◊ Result: Depression
An Integrative Theory
○ Shared Biological Vulnerability
Overactive neurobiological response to stress
○ Exposure to Stress
Stress activates hormones that affect neurotransmitter systems
Stress turns on certain genes, affects circadian rhythms, awakens dormant psychological vulnerabilities (i.e., negative
thinking), contributes to sense of uncontrollability (i.e. helplessness), fosters a sense of helplessness and hopelessness
Social and Interpersonal Support are Moderators
Gene-Environment Interactions
○ Murphy et al. (2001)
Mice with altered 5-HTT susceptible to stress
○ Sumoi and colleagues, Bennet et al. (2002)
Macaques with 5-HTTs gene susceptible to stress AND show lower serotonin levels
○ Hariri et al. (2002)
Humans with 5-HTTs show INCREASED amygdala activation to fearful stimuli
○ Caspi et al. (2003)
Mood Disorders
Treatment: Tricyclic Medication
○ Widely used (e.g. Tofranil, Elavil)
○ Block Reuptake of Norephinephrine and Other Neurotransmitters
○ Takes 2 to 8 weeks for the therapuetic effects to be known
○ Negative side effects are common
○ May be lethal in excessive doses
Lithium
○ Lithium is a common salt
Primary drug of choice for bipolar disorders
○ Side effects may be severe
Dosage must be carefully monitored
○ Why lithium works remains unclear
Treats mania more than depressive symptoms
○ Common alternative: Depakote
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□ Results in temporary seizures
□ Usually 6 to 10 outpatient treatments are required
○ Side effects are few and include temporary short-term memory loss
Also formerly brain damage.
○ Uncertain why ECT works and relapse is common
Psychosocial Treatments
○ Cognitive Therapy
Overwhelmingly shown to have the best talking-therapy response for depression
Addresses cognitive errors in thinking
Also includes behavioral components
○ Interpersonal Psychotherapy
Focuses on problematic interpersonal relationships
□ e.g. changing how you ask someone out to actually get results
○ Outcomes with psychological treatments are comparable to medications
Suicide: What to Do
○ Research shows that threats should be taken seriously
○ Do not be afraid to discuss the topic
○ Get assistance - don't accept responsibility
○ Consider hospitalization
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Thursday 10/05
Thursday, November 05, 2009
3:37 PM
Suicide: What to Do
○ Research shows that threats should be taken seriously
○ Do not be afraid to discuss the topic
○ Get assistance - don't accept responsibility
○ Consider hospitalization
Prevalence of Shizophrenia
○ Prevalence of 1% worldwide
2x Alzheimer's
5 x Multiple Sclerosis
6 x Insulin-dependent (Type I) Diabetes
60 x Muscular Dystrophy
○ Schizophrenia is generally chronic
Moderate-to-severe lifelong impairment
Life expectancy is slightly less than average
Equal gender distribution
□ Women - better long-term prognosis
□ Onset differs between men and women
Diagnosis: DSM IV
○ Symptoms (2 or more):
Delusions (content)
Hallucinations
Disorganized speech (form)
Disorganized or catatonic behavior
Negative symptoms (flat affect, etc.)
○ Social/occupational dysfunction
○ Duration: 6 months (1 month of symptoms)
○ Not caused by substances
○ Not schizoaffective/Mood disorder
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The "Positive" Symptoms
○ Active manifestations of abnormal behavior or distortions of normal behavior
○ Delusions - 90%
Somatic: "Snake living inside my abdomen"
Grandeur "Chosen by God"
Persecution: "'They' are monitoring me"
Manifestations: Thought broadcasting, ideas of reference, thought withdrawal
Schizophrenic symptoms
Schizoaffective Disorder
"Disorganized" Symptoms
○ Severe and excessive disruptions in:
Speech
□ Cognitive slippage - Illogical and incoherent speech
□ Tangentiality - "Going off on a tangent" and not answering a question directly
□ Loose associations or derailment - Taking conversation in unrelated directions
Affect
□ Inappropriate affect (e.g., crying when one should be laughing)
Behavior
□ Disruption in goal-directed behavior
□ Decline in routine daily functioning
□ Catatonia - Spectrum from wild agitation, waxy flexibility, to complete immobility
Disorganized Speech
"I have also killed my ex-wife, [name], in a 2.5 to 3.0 hours sex bout in Devon Pennsylvania in 1976, while two Pitcairns were
residing in my next room closet, hearing the event. Enclosed, please find my urology report, indicating that my male genitals ,
specifically my penis, are within normal size and that I'm capable of normal intercourse with any women, signed by Dr.
[name], a urologist and surgeon who performed a circumcision on me in 1982. Conclusions: I cannot be a nincompoop in a
physical sense (unless Society would feed me chemicals for my picture in the nincompoop book)."
Symptoms of Schizophrenia
Positive (Type I) Negative (Type II) Disorganized
Thematic Delusions Avolition (Apathy) Grossly Bizarre Behavior
Thematic Hallucinations Alogia (Povert of Speech/Content) Incoherent hallucinations or delusions
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Bizarre Behavior Anhedonia Disorganized Affect
"Good" intellect Flat Affect Disorganized Speech
Asociality
Better Prognosis Poor Prognosis Poor Prognosis
Lenzenweger, Dworkin & Wethington (1991)
Subtypes of Schizophrenia
○ Paranoid Type
Intact cognitive skills and affect, and do not show disorganized behavior
Hallucinations and delusions thematic (e.g., grandeur or persecution)
Probably matches up to Type I
Means more thematic hallucinations rather than just paranoia
○ Disorganized Type
Marked disruptions in speech, behavior, affect
Fragmented hallucinations and delusions
Develops early, tends to be chronic, lacks periods of remissions
○ Catatonic Type
Unusual motor responses and odd mannerisms (e.g. echolalia, echopraxia)
? Need for consistency
Tends to be severe and quite rare
○ Undifferentiated Type
Symptoms, but don't meet criteria for another type
○ Residual Type
One past episode of schizophrenia
Continue to display less extreme residual symptoms (e.g., odd beliefs)
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Tue. 11/10
Tuesday, November 10, 2009
3:31 PM
Subtypes of Schizophrenia
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Tue. 11/17
Tuesday, November 17, 2009
3:31 PM
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Thu. 11/19
Thursday, November 19, 2009
3:39 PM
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Thu. 12/03
Thursday, December 03, 2009
3:40 PM
Cluster B: Borderline PD
○ Clinical Features
Unstable moods and relationships
Very poor boundaries
□ Egocentric and impulsive
□ Acts as if world revolves around them
Impulsivity, fear of abandonment, coupled with a very poor self-image
Self-mutilation and suicidal gestures
Most common personality disorder in psychiatric settings
High comorbidity
○ The Causes
Runs in families - genetics?
Early trauma and abuse
○ Treatment Options
Many doctors shy away from borderline patients due to aforementioned boundary issues
Few good treatment outcome studies
Antidepressant medications provide some short-term relief
Dialectical behavior therapy is the most promising psychosocial approach
□ Developed by Marshall Lyneham out of sexual abuse literature
□ Form of CBT designed to address interpersonal skills
Cluster B: Histrionic PD
○ Clinical features
Overly dramatic, sensational, and sexually provocative
Need to be the center of attention
Perceived as shallow
○ The causes
Unknown
Female variant of antisocial personality disorder?
○ Treatment options
Few good treatment outcome studies
Treatment focuses on attention seeking and long-term negative consequences
Targets may also include problematic interpersonal behaviors
Little evidence that treatment is effective
Cluster B: Narcissistic PD
○ Clinical Features
Exaggerated and unreasonable sense of self-importance
□ Differences with histrionics
Histrionics try to run out and "grab" attention
Narcissist just naturally expects it
Preoccupation with receiving attention
Lack of empathy
Highly sensitive to criticism
Envious and arrogant
□ Envious because they feel that they're naturally more deserving than all others
○ The Causes
Early failure to learn empathy as a child
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Early failure to learn empathy as a child
Sociological view - a product of the "me" generation?
○ Treatment Options
Extremely limited treatment research
Treatment focuses on grandiosity, lack of empathy, unrealistic thinking
Treatment may also address co-occurring depression
Little evidence that treatment is effective
Cluster C: Avoidant PD
○ Overview and clinical features
Extreme sensitivity to the opinions of others
Highly avoidant of most interpersonal relationships
Are interpersonally anxious and fearful of rejection
○ The causes
Numerous factors have been proposed
Early development - A difficult temperament produces early rejection
○ Treatment options
Several well-controlled treatment outcome studies exist
Treatment is similar to that used for social phobia
Treatment targets include social skills and anxiety
Cluster C: Dependent PD
○ Clinical features
Excessive reliance on others to make major and minor life decisions
Fear of abandonment
Clingy and submissive
○ The causes
Still largely unclear
Early disruptions in learning independence
○ Treatment options
Research on treatment efficacy is lacking
Therapy typically progresses gradually
Treatment targets include skills that foster independence
Cluster C: Obsessive-Compulsive PD
○ Clinical features
Excessive and rigid fixation on doing things the right way
Highly perfectionistic, orderly, and emotionally shallow
Obsessions and compulsions are rare
○ The causes
Are largely unknown
○ Treatment options
Data supporting treatment are limited
Treatment may address fears related to the need for orderliness
Other targets include rumination, procrastination, and feelings of inadequacy
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100Q, 50 COMPREHENSIVE 50 NOT
BRING SCANTRON
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Study notes
Monday, December 07, 2009
12:52 PM Chapter 11 Personality Disorders
Chapter 10
Check p.398 for benzo + addiction (anxiety) Schizoid PD p.439
Neuroleptics p.488
Essentials of Abnormal Psych
4th Edition
V. Mark Durand
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