Eoin Psychopathology

Collishaw (2015) - Clinical diagnosis and treatment of child and adolescent psychiatric disorders increased over recent decades.

McElroy - Average number of symptoms reported higher in those born at the turn of the millennium, compared with those born in the 1990s, 1970s, and 1950s 

Wray (2012) - Traditionally, heritabilities have been estimated from families' info from specific hospital registers, but finding sufficient numbers of families can be difficult.

Flint (2014) - “Despite convincing evidence for a genetic contribution to disease susceptibility, there has been a dearth of substantive molecular genetic findings.” 

Researchers found that:

• 7.4% of total disease burden in 2010 attributed to mental health problems
• Depressive disorders accounted for 40.5% of this (approximately 3% of all burden)
• Genome-wide association studies – largely failed to identify specific genes associated with depression

Neuro

Pizzagalli et al. (2014) - Anhedonia has emerged as one of the most promising endophenotypes (hereditary bio-marker) of depression. Pizzagalli et al. summarised animal data indicating that "stress negatively affects mesocorticolimbic dopaminergic pathways critically implicated in incentive motivation and reinforcement learning." 

Keren et al. (2018) - Meta-analysis of 38 fMRI and 12 EEG studies. Consistent neural aberrations during reward processing in depression, blunted neural response to reward, may be more pronounced in under 18's. 

Social

Cromby (2013) - All experiences require biology, but it's reductionist to reduce experiences to JUST biology. 

Mandelli et al. (2015) - Meta-analysis 26 studies found emotional abuse showed the strongest association with depression. Other associations found were neglect, sexual abuse, domestic violence, and physical abuse.

McElroy - Those in lower SES classes (i.e. those with less income, education etc.) at greater risk of mental distress, but only in more recent generations. 

Caspi et al. (2013) - Serotonin transporter gene (5HTT) + Polymorphism (two short allelles). The specific combination of this and environmental stressors found to predict depression. 

Gender

Salk et al. (2017) - Women are twice as likely as men to meet the criteria for depression. Possible factors: 

• Biological (e.g. hormones – findings mixed)
• Social
  • Girls more likely to be abused
  • Women more likely to be exposed to chronic stress (e.g. caregiving)
  • Women tend to provide more social support to others facing stress; dubbed the ‘cost of caring’
  • Social roles – may intensify self-critical attitudes about appearance

Klerman et al. (1984) - Interpersonal psychotherapy: identifying key interpersonal problems, make decisions/develop strategies to solve these issues.

Cognitive therapy = Cognitive restructuring: Identifying and changing information processing biases

Jackobsen et al. (2017) - Several meta-analytic reviews find that SSRIs are an effective method of treatment for depression.

E Karyotaki (2016) - Combined therapy did produce better maintenance of recovery compared to pharmacotherapy alone at 6-months and 12-months+. 

Polythetic (sharing non-essential characteristics) nature of diagnoses

• Nine primary symptoms of MDD + Various sub-symptoms 
• Fried et al. (2015) - “This leads to roughly 1,000 unique combinations of symptoms that all qualify for a diagnosis of MDD, some of which do not share a single symptom.” 

Comorbidity = the presence of one or more additional conditions co-occurring with a primary condition.

Kessler et al. (2005) - Rule of 50% 

• Half of those who meet the diagnostic criteria for one disorder will also meet the diagnostic criteria for another disorder
• Half of those who qualify for two disorders will qualify for a third

Imperfect boundaries between disorders challenge the supposedly distinct nature of disorders.

To qualify for the diagnosis, an individual must exhibit five or more symptoms that cause significant distress/impairment, one of which must be either depressed mood or loss of interest/pleasure.

DSM-5 criteria for MDE examples:

• Depressed mood most of the day
• Anhedonia 
• Significant unintentional weight loss/gain
• Insomnia or sleeping too much
• Fatigue or energy loss

Depression is a very common and debilitating psychological disorder, with enormous individual and societal costs. 

Tends to affect females more commonly than males and can occur throughout the lifespan – most common in middle-adulthood.

Little progress has been made on understanding the genetic and neurochemical correlates of depression.

Greater understanding of the neurological correlates of depression.

Psychological and environmental factors such as childhood trauma, negative thinking, and emotion regulation strategies are strong predictors of depression.

Several empirically-supported treatments for depression exist

Psychosis – a broad term for clusters of symptoms (e.g., hallucinations, delusions). Schizophrenia is proposed to be a form of psychosis.

W.H.O. - described schizophrenia as a "severe mental disorder" vs. A.P.A. - described schizophrenia as a "chronic brain disorder".

Schizophrenia is characterized by the DSM-5 by: 

• Delusions 
• Hallucinations 
• Disorganized speech and behaviour
• Other symptoms that cause social or occupational dysfunction, e.g. blunted affect, emotional withdrawal 

Symptoms must be present for 6 months and include 1+ month of active symptoms. 

• Schizophreniform disorder = schizophrenia but shorter (lasts less than 6 months)
• Schizoaffective disorder = schizophrenia but moodier (schizophrenic symptoms AND depression/mania symptoms)

Simeone et al. (2015) - Schizophrenia affects males and females about equally. The median 12-month prevalence rate was 0.33%, whereas the median lifetime prevalence rate was 0.48%.

Research suggests that prevalence across studies appeared to vary by: 

• Study design
• Geographic region
• Time of assessment
• Study quality 

Buckley et al. (2008) found comorbidity with schizophrenia at:

• Depression 23–57% 
• PTSD 29%
• OCD 23%
• Substance abuse 47%

Hilker et al. (2018) - Studied 31,524 twin pairs. Researchers found a concordance rate of 33% in monozygotic twins and 7% in dizygotic twins for schizophrenia. 

The dopamine theory of schizophrenia - "excessive transmission of the neurotransmitter dopamine produces positive symptoms such as delusions, hallucinations, and disordered thinking."

Antipsychotics work primarily by blocking dopamine D2 receptors, thereby affecting dopamine transmission in the brain BUT are relatively ineffective at treating the negative symptoms and cognitive deficits of schizophrenia.

Rothman et al. (2003) - Excitatory neurotransmission in the brain is primarily glutamatergic, with glutamatergic neurons utilising between 60 and 80% of total brain metabolic activity.

Research has shown that - "The multiple areas of the brain involved in schizophrenia are connected by a circuit of brain cells that rely on glutamate to communicate." This suggests that either excess or insufficient glutamate activity may cause symptoms, partly through its interactions with other neurotransmitters like dopamine and GABA.

Morgan et al. (2009) - Established social risk factors:

• Depressive and other non‐psychotic experiences 
• Socioeconomic status 
• Social dysfunction 
• Being single 
• Unemployment 
• A lower level of education and IQ 
• Childhood trauma 

Shevlin et al. (2007) - In the case of cumulative trauma, odds ratios (OR) increased dramatically, e.g. from 2.53 for 1 type of trauma to 53.26 for 5 types of trauma. 

Harrow et al. (2012) - Patients not on antipsychotics were significantly less likely to be psychotic and experienced more periods of recovery. However, they also had more favourable risk and protective factors.

Guloksuz et al. (2018) - ‘Schizophrenia’ ignores evidence that psychosis expression is continuously distributed across the general population and can be better understood dimensionally than categorically.

Psychotic distress lies on a continuum - normality on one end and extreme distress/need for care on the other

Continuum categories:

Positive: Hallucinations, delusions etc.

Negative: Blunted affect, emotional withdrawal

Depression: low mood, guilt, tension

Disorganization: mannerisms and posturing

Mania: impulsivity, excitement etc. 

Psychotic experiences are a common psychological phenomenon experienced widely in the population

Psychotic distress lies on a continuum - normality on one end and extreme distress/need for care on the other

Anti-psychotic drugs have no demonstrated efficacy in ‘curing’ schizophrenia or any other psychotic disorder

There is an abundance of evidence for the role of psychosocial factors in the development of psychotic distress

Traumatic exposure during early development is a particularly potent factor for the onset of psychosis

Treating emotional/behavioural problems using psychological rather than biomedical means with a broad range of approaches and methods: Usually involves talking, but there are other techniques such as role-play or dance.

Not just individuals, also couples/families/groups whose members share similar problems (e.g. veterans).

Goal: increase a sense of well-being + reduce discomfort.

Approaches:

• Changing current behaviour patterns 
• Promoting different ways of thinking
• Others emphasize understanding of past issues
• Combination of both

Can be short-term with few meetings, or with many sessions over years

Origins

The ancient Greeks were the first to identify mental illness as a medical condition, rather than a sign of malevolent deities

Defence Mechanisms 

Projection – it’s not me it’s you

Displacement – child is beaten at home – bullies others at school 

Rationalisation – false reasons justify behaviour

Sublimation – e.g. take out aggression in other ways e.g. sports

Conversion – repressed feelings result in physical complaints

Regression reverting to a childlike state to avoid anxiety

Id – the primitive area of personality present from birth, mainly concerned with securing food, comfort and pleasure (pleasure principle)

Ego – the ‘civilised’ part of our consciousness; realistic awareness of self and of the world. Has evolved through contact with the external world, is determined by the individuals’ own experience

Superego – develops by age 3. The morality principle is the main basis of the superego, main function is to curb the id; concerned with conscience and moral judgement

Key assumption: lack of awareness of ‘unconscious feelings’ is a potential cause of problems in everyday life.

Strategy: help clients look more closely at the past to uncover repressed memories that may explain unconscious feelings

Limitations

Fonaghy (2000) - Psychoanalysis appears to be consistently helpful to patients with milder disorders and less consistently so for more severe groups.

The patient puts what they’ve learned into practice between sessions by doing “homework”

Techniques: identify cognitive distortions / maladaptive assumptions, test automatic thoughts

The therapist takes an active, problem-oriented, directive stance

The cognitive revolution in psychotherapy began in the 1950s/1960’s with Ellis (1957) and Beck (1959)

ABC Model of Psychopathology (Ellis)

A - Activating Event
B - Beliefs about Event
C - Consequences (emotional)

According to Ellis, rational beliefs lead to healthy emotional outcomes, whereas irrational beliefs lead to unhealthy emotional outcomes, including depression.

CBT is an umbrella term for various models - all focus on cognition, but different cognitions.

Beck (1959) - Negative Schemas = Information processing biases. Cognitive restructuring is focussed upon identifying and challenging negative thoughts about external events.

Behavioural Activation

• Identify routine, pleasurable and necessary (RNP) activities 
• Organise activities into a hierarchy with easier RNP activities to more difficult RNP activities
• Help patients plan in some ‘easy’ avoided activities keeping a balance from the three categories
• Implement and record the BA exercises
• Review and reflect on progress; collaboratively working towards solving any problems and deciding on further activities

Family therapy = umbrella term

Wender (1968) - Goal: to disrupt self-reinforcing cycles that maintain difficulties – turn vicious cycles into virtuous ones 

• Therapist’s major role is to change problem-maintaining sequences
• Emphasis on ‘action’, rather than ‘insight’
• Therefore the emphasis is on techniques, on how to change a situation – rather than trying to understand how a situation came to be

Cuijpers (2019) - conducted an overview of targets and outcomes of psychotherapies for mental disorders

Moderate-to-large effect sizes = Depression, Anxiety disorders (social anxiety disorder, panic disorder, generalized anxiety disorder), PTSD, OCD

Smaller effect sizes = Psychoses, Bipolar

Cuijpers (2013) 

• Differences small to non-existent for major depression, panic disorder and SAD
• Therapy > medication for OCD
• Medication > Therapy for chronic depression 

In a different meta-analysis found significant and clinically relevant improvement for depression, panic disorder, OCD

Research suggests psychotherapy is as efficacious as medication, best with a combination of medication and psychotherapy rather than solely biomedical means

Stone (1985) - Approximately 80,000 British troops treated for ‘shell shock’ after World War I, it was labelled an ‘illness’ rather than admitting that war itself is horrific. 

WW2 reignited interest in reactions to trauma, brought psychiatrists from all over the world to USA.

In 1952, the American Psychiatric Association published the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I). Included a diagnosis called “Gross Stress Reaction”, described as a condition that occurs:

• In response to an exceptional physical or mental stress, such as a natural catastrophe or battle
• Occurs in people who are otherwise “normal” (no previous diagnosis)
• Must subside in days to weeks (if not - another diagnosis should be made)

2nd edition of the DSM removed this diagnosis, then between 1968 and 1980 no official diagnosis for stress disorders was available. 

For DSM-III (APA, 1980), Posttraumatic Stress Disorder was first introduced - Political pressure from the Vietnam war/concentration camp survivors drove the inclusion of diagnosis.

PTSD included 17 symptoms across three clusters:

• Re-experiencing
• Avoidance & Emotional Numbing
• Hyperarousal

The DSM underwent several revisions after 1980: DSM-III-R (1987), DSM-IV (1994), and DSM-IV-TR (2000). The formulation of PTSD remained largely consistent across all revisions. 

Criteria A – E that are necessary for a diagnosis of PTSD according to the DSM-V:

• Traumatic exposure - Experience or witness a major traumatic event 
• Intrusions - Recurrent, involuntary, and intrusive memories
• Avoidance - Avoidance of thoughts, feelings, or of external reminders
• Alterations in cognition or mood - Memory loss, negative mood
• Arousal - Irritability, hypervigilance, startle response 

PTSD can only be diagnosed if these symptoms persist for 1 month following traumatic exposure. Symptoms must be associated with impairment in at least one area of life.

Bryant - meta-analyses have been conducted that identified consistent social, demographic, trauma-related, and biological correlates of PTSD, as well as effective treatments for PTSD, but the same analyses showed that the effect sizes of many of these variables vary dramatically.

ICD typically adopts a simpler approach to psychiatric diagnoses with 2 disorders:

• More useful in parts of the world where resources are limited - ICD (11) is used by all WHO Member States (117 countries) and is translated into 43 languages.
• Focuses on essential features of PTSD/CPTSD – more precise descriptions that are cross-culturally relevant.
• Reduces comorbidity rates (additional condition diagnoses) – avoids false diagnoses
• Cloitre et al. (2013) Overwhelming evidence supports the distinction between PTSD/CPTSD 

Posttraumatic Stress Disorder - Re-experiencing in the here and now, Active avoidance, Sense of Current Threat

Complex Posttraumatic Stress Disorder - " " AND Affective Dysregulation, Negative Self-Concept, Disturbances in Relationships

What factors predict the development of CPTSD rather than PTSD?

• Exposure to chronic trauma (Cloitre et al., 2013)
• Childhood traumatization (Karatzias et al., 2017; Murphy et al., 2016)
• Childhood sexual abuse, specifically (Hyland et al., 2017)
• Increased levels of functional impairment (Elklit et al., 2014)
• Unemployment status (Karatzias et al., 2017)

Benjet et al. (2016) - Representative surveys from 24 countries of traumatic event exposure. Low of 28.6% in Bulgaria, high of 84.6% in Ukraine.

The five most common traumas accounted for 51.9% of all exposures:

• The unexpected death of a loved one
• Witnessing death, a dead body or someone seriously injured
• Being mugged 
• Life-threatening automobile accidents
• Life-threatening illness or injury

Women significantly more likely than men to experience intimate partner sexual violence 

Men more likely than women to experience physical violence and accidents

Polyvictimization (refers to having experienced multiple victimizations) such as:

• Collective violence
• Caused/witnessed bodily harm
• Interpersonal violence
• Intimate partner/sexual violence
• Accident/injuries
• Other (e.g. death of a loved one)

Kessler et al. (1995) - Lifetime PTSD prevalence rates of 13.0-20.4% for women and 6.2-8.2% for men.

Pre-trauma Risk Factors

Gressier et al. (2013) - Short allele (5-HTTL PR S aka the gene that codes for the serotonin transporter) associated with PTSD. However, only associated with highly traumatic events.

Logue et al. (2018) - Smaller hippocampus in those with PTSD. However, cause or consequence? Unethical to traumatise participants so can only study brain structure after traumatic exposure.

Pineles et al. (2017) - Females twice as likely to be diagnosed. Men and women have different emotional, cognitive, and neurobiological risks for PTSD 

Brewin et al. (2000) - 

• Younger age at trauma
• Prior psychiatric disorder 
• Family history of psychiatric disorder 
• Social factors 

Peri-trauma Risk Factors

Trauma type

• Extreme interpersonal violence
• Sexual violence
• Witnessing atrocities

Trickey et al. (2012) - Perceived life threat 

Eisen & Lynn, 2001; Morgan et al. 2001; Rocha-Rego et al. 2009 - Peri-traumatic dissociation consistently found to be a risk factor for the development of PTSD.

Peritraumatic dissociation is defined as a complex array of reactions at the time of the trauma that include depersonalization, derealization, dissociative amnesia, out-of-body experiences, emotional numbness, and altered time perception.

Post-trama Risk Factors

Bryant & Guthrie (2005) - Negative cognitive styles, e.g. catastrophic thinking  

• Ehlers & Clark, (2000) - Cognitive models of trauma response propose that an individual's assessment of a traumatic event and capacity to respond to the experience is crucial in how that individual adapts to the experience 

Hyman et al. (2003) - Lack of social support. 

• 172 adult females reported Childhood Sexual Abuse (CSA). Regression analysis indicated that social support significantly buffered PTSD development. 

Ullman et al. (2016) - Re-victimisation = Revictimized women had greater PTSD symptoms and more negative social reactions.

Hoskins et al.

• Data from 21 studies (n = 3932) compared SSRI’s v. placebo
• SSRIs were found to perform better than placebo but the effect size was very small
• Inferior to effect for trauma-focused psychological interventions

Benzodiazepines act as a sedative – slowing down the body’s functions – and are used for both sleeping problems and anxiety. They work by increasing the effect of a brain chemical called GABA (gamma-aminobutyric acid). GABA reduces brain activity in the areas of the brain responsible for:

• rational thought
• memory
• emotions
• essential functions, such as breathing

BZDs are ineffective for PTSD treatment and prevention, and risks associated with their use tend to outweigh potential short-term benefits as they may result in long term dependence/addiction.

Trauma-Focused Cognitive Behavioural Therapy (TF-CBT)

• Sensitive to the unique problems resulting from abuse, violence, or grief
• Typically 8 to 25 sessions
• Cognitive behavioural techniques are used to help modify distorted or unhelpful thinking and negative reactions and behaviours
• Family therapy techniques often implemented (e.g. with non-abusive parents)

EMDR

After the clinician has determined which memory to target first, he asks the client to hold different aspects of that event or thought in mind and to use his eyes to track the therapist’s hand as it moves back and forth across the client’s field of vision

Believed to be connected with the biological mechanisms involved in Rapid Eye Movement (REM) sleep, internal associations arise and the clients begin to process the memory and disturbing feelings

A recent review found:

• No difference in efficacy between TF-CBT and EMDR
• TF-CBT and EMDR were more effective than other psychotherapies
• Effective for children, adolescents, and adults
• Recommended as the treatments of choice by guidelines such as those published by the United Kingdom’s National Institute of Health and Clinical Excellence (NICE)