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Class:PSYCH 8412 - CORE PSYCHOPATHOLOGY
Subject:Psychology
University:Temple University
Term:Fall 2014
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ADHD: statistics and comorbidity HIGH comorbidity
80% of children oppositional defiant disorder
90% of adults are comorbid with mood disorders
boys:girls = 3:1
adults with ADHD 50% have problems as adults
inattention persists and hyperactivity, impulsivity declines
ADHD causes genetics
-familial component
-dopamine (ritalin inhibits this gene and increases DA)
-norepinepherine
-GABA
-serotonin
ADHD causes neurobiological contributions smaller brain volume (3-4% smaller than children without)
frontal cortex and basal ganglia
-inactivity
-abnormal development
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ADHD causes role of toxins allergens and food additives
-very small association of artificial food colors, additives, and pesticides

maternal smoking
-increases risk
-interacts with genetic predisposition
ADHD causes psychosocial factors negative feedback
-teachers
-peers
-adults
peer rejection
social isolation
low self-esteem
poor self-image
treatment of ADHD: biological goals are to reduce impulsivity and hyperactivity, and improve attention

stimulants effective for 70% (ritalin, adderall, etc)

other medications
-strattera: problems with not really helping attention, but just making the patient calmer, less disruptive to class)
-imipramine (antidepressant)
-clonidine (used for high blood pressure)
effects of ADHD biological medication treatments positive
-improve compliance
-decrease negative behaviors

negative
-do not affect learning and academic performance
-benefits are not lasting following discontinuation
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autism spectrum disorder is aka pervasive developmental disorder
pervasive=significant impairment across lifespan
autism spectrum disorder language, socialization, and cognitive problems
pervasive=significant impairment across lifespan
autism spectrum disorder DSM-5 combines autism, asperger's disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified
autism spectrum disorder DSM-5 clinical description 1. impairment in social communications and interactions across multiple contexts
2. restrictive, repetitive patterns of behavior, interests, or activities (at least 2 form list)
-repetitive motor movement, use of objects, etc
-insists on sameness and routines
-restricted, fixated interests that are abnormal in focus and intensity
-hyper or hyporeactiity to sensory input or unusual interest
3. symptoms must be present in early development
specifiers to indicate severity-w/ or w/o language or intellectual impairment (40-55% w intellectual disability)
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causes of autism: biological genetic influences
-family component: 5-10% risk of second child w/ autism and 20& risk for ASD
-polygenetic influences
-oxytocin receptor genes: bonding and social memory, lower levels of oxytocin

causes of autism: biological neurobiological influences amygdala
-larger at birth: higher anxiety, fear
-elevated cortisol
-neuronal damage over time
-fewer neurons in postmortem brains
treatment of autism children w autism cant or will not imitate: this has major consequences for learning language

psychosocial treatment
-behavioral approaches
early intervention is critical
problem: very time intensive
medical treatments are NOT effective
biological treatments target specific problems UNIQUE to individual
(decrease agitation w tranquilizers and SSRIs)
the verbal comprehension subtests (VCI) vocabulary and ocmprehension
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the perceptual reasoning subtests (PRI) block design, picture concepts, and matrix reasoning
the working memory subtests (WMI) digit span and arithmetic
the processing speed subtests (PSI) coding and symbol search
specific learning disorder actual vs expected achievement
not due to sensory deficits such as sight or hearing

can occur in any of these areas:
1. reading-inaccurate and slow reading, recognition (dyslexia), fluency, comprehension
2. math-difficulty w calculations and applying math knowledge
3. writing-written expression and spelling

begins during school ages years
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learning disorder causes genetic and neurobiological contributions
-some evidence of specific brain regions involved dependent on the type of learning problem

psychosocial contributions
-motivational factors reinforced by others
-socioeconomic status
-cultural expectations
-parental interactions
-expectancies
treatment of learning disorders • Educational Interventions
– Specific skills instructions 
• Vocabulary
• Discerning meaning 
• Fact finding 
– Strategy instruction Improve cognitive skills through 
• Decision making 
• Critical thinking
intellectual disability (ID) clinical description
1. below average intellectual functioning measures by standardized tests, IQ of 70 or below
2. adaptive problems in multiple areas
-communication, self care, home living, social, work, leisure, health
3. disorder of childhood present before age 18, previously coded on axis II
levels of intellectual disability
 Mild
– IQ = 50 or 55 to 70
• Moderate
– IQ = 35-40 to 50-55
• Severe
– IQs = 20-25 to 35-40
• Profound
– IQ = below 20-25
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american association of intellectual and developmental disabilities (AAIDD)
 Based on assistance required
• Intermittent
• Limited
• Extensive
• Pervasive
– Keeps the emphasis on what assistance is needed
intellectual disability: statistics
• Prevalence = 2% of general population
– 9 in 10 people with ID have mild impairment (IQ
50-70)
• Chronic course
• Highly variable individual prognosis
– Independence is possible for many individuals with
mild impairment when provided with appropriate
resources (e.g., skills training)
intellectual disability causes psychological and social dimensions
 Nearly 75% not associated with biological cause
– Mild levels, impairments
– Good adaptive skills
• Cultural-familial ID
– Abuse
– Neglect
– Social deprivation
intellectual disabilities enriched environment and the brain
More dendritic sprouting
• More LTP
• Stubbier dendrites
• More receptors
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causes of intellectual disorders environmental, prenatal, perinatal, postnatal
  Examples
– Fetal alcohol syndrome
– Exposure to other illness in the womb
– Lack of oxygen (anoxia) during birth
– Malnutrition
– Head injuries
– Childhood abuse
causes of intellectual disorders biological contributions
Genetic Influences
– Multiple genes
– Single genes
• Dominant, few because of evolution
• Recessive
– Phenylketonuria (PKU)
• Protein contains phenylalanine, an amino acid that is essential
for normal growth and development. People with PKU lack an
enzyme to properly metabolize phenylalanine. Very high levels
of phenylalanine in the blood can lead to irreversible brain and
nervous system damage
causes of intellectual disorders biological contributions
Chromosomal Influences
– Down syndrome: Extra 21st chromosome, Trisomy 21, Physical symptoms (Heart malformations), Increased prevalence of Alzheimer’s
After age 40-Risk increases with maternal age AND
paternal age
Fragile X syndrome
• Primarily affects males (no second X), Learning disabilities, Hyperactivity, Perseverative speech, Gaze avoidance, Large ears, testes, and head circumference
treatment of intellectual disability depending on severity
 Severe ID: Treatment similar to that for autism
spectrum disorder
– Mild ID: Treatment similar to that for learning
disorders
– Goals are similar across severity; level of assistance
differs
– Behavioral interventions teach:
• Basic skills (e.g., dressing, hygiene)
• Social skills
• Practical skills (e.g., paying bills)
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treatment of intellectual disability
 Common goals
– Participate in community life
– Benefit from education
– Hold a job or other productive pursuits (e.g.,
volunteering)
– Build meaningful relationships
prevention of developmental disorders
• Early intervention
– At-risk children, families
– Ex: Head Start Program: Educational, Medical, Social supports, Leads to IQ above 85 compared to those without educational intervention (all below 85)
• Genetic screening
– Detection and correction (e.g.,
genes therapy in the future
– Cell free DNA test (prenatal)
– Amniocentesis
somatic symptoms (previously somatoform disorders)
Combination of previous somatoform disorders, such as Somatization disorder and Pain Disorder
– Illness Anxiety Disorder
– Conversion Disorder (Functional Neurological Symptom Disorder)
somatic symptom disorder
• One or more somatic symptoms that are distressing or result in disruption of daily life
• Excessive thoughts, feelings, or behaviors related to somatic symptoms or health concerns with at least one of:
– Persistent thoughts about seriousness of symptoms
– High level of anxiety about symptoms
– Excessive time or energy devoted to symptoms
• Occurs for at least 6 months
– Specify if disorder is with predominant pain (previously pain
disorder)
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somatic symptom disorder statistics
• Statistics
– Previously somatization disorder and pain disorder, but 75% of hypochondriasis would fit into this diagnosis
– Prevalence unknown, but probably around 5-7%
– May be higher in females, but also unknown
– Onset at any age
• Peaks: adolescence, middle age, elderly
somatic symptom disorder causes
**The full time patient**
– Disorder of cognition or perception
• Focus on physical signs and sensations >increases
arousal>makes physical sensations more intense
• Faulty cognitions >anxiety>worsening of physical
symptoms
• Stroop
– Enhanced sensitivity to illness cues
• History of family illness or injury
• Neuroticism, anxiety and depression common
• Links to antisocial personality disorder for previous DSM-IV
category
– But no callousness or aggressiveness associated with somatization
– A weak behavioral inhibition system (BIS), which causes excessive:
• Impulsivity
• Novelty-seeking
• Provocative sexual behavior
• May be the same risk factor for APD but cultural and social factors
decide which way a person goes.
– Other factors
• Stressful life events
• Low SES and few years of education
• History of sexual abuse or childhood adversity
• Current chronic illness or psychological disorder
illness anxiety disorder (previously hypochondriasis)
• Preoccupation with having or acquiring a serious
illness
• Somatic symptoms are not present or are mild
in intensity. If a medical condition is present,
then the preoccupation is excessive
• There is a high level of anxiety about health
• Excessive health related behaviors (e.g. checking body
for signs of illness) or exhibits maladaptive avoidance
(e.g. missing doctor’s appointments)
• At least 6 months duration: Care-seeking type e.g. excessive doctor’s appointments or Care-avoidant type
illness anxiety disorder statistics
– Only 25% former hypochondriasis
– Prevalence Unknown, but about 1.3-10% from
surveys
– Hypochondriasis 1% to 14% of medical patients
• 6.7% median rate
– Female : Male = 1:1
– Comorbid anxiety & depressive disorders
– Onset at any age
• Peaks: adolescence, middle age, elderly, but increases with age
– Chronic course
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illness anxiety disorder causes
– Familial history of illness
• Genetics
• Modeling/learning
– Similar reports to family members
– Childhood abuse or illness
– Other factors
• Stressful life events
• High family disease incidence
• “Benefits” of illness
conversion disorder (functional neurological symptom disorder)
Popularized by Freud
– Anxiety from unconscious conflicts changed into physical
symptoms to find an expression!
• Clinical Description
– Physical malfunctioning: sensory-motor areas including blindness, paralysis, difficulty vocalizing
– Lack physical or organic pathology
– Lack awareness
– Intact functioning
• Visual tests study
conversion disorder DSM 5 criteria
A. One or more symptoms of altered voluntary motor or sensory function
B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.
C. The symptom or deficit is not better explained by another medical or mental disorder
D. Clinically significant distress or impairment
conversion disorder statistics
 Unknown, but found in 5% of neurology patients
– Prevalence depends on setting
• Rare in mental health settings, but remember that people who seek
help for this are more likely to consult specialist (e.g., neurologist etc)
• Common in Neurology and Epilepsy clinic(s)
– Female > male
– Comorbid anxiety, depression, personality disorders, and
somatic symptom disorder
– Onset = throughout life
– Chronic, intermittent course
• Will disappear, then return in the same form w new stressor
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conversion disorder causes
• Family/Social/Cultural
– Difficult temperaments
– Childhood abuse and neglect/stressful life events
– Presence of neurological disease causing similar
symptoms
– Low SES
– Limited disease knowledge
• Patients tend to adopt symptoms from familiar diseases, These disorders are becoming less common as people are
learning more about health (internet)
– Family history of illness
conversion disorder causes and views
• Anno O.
• Freudian psychodynamic view
POSITIVE
– Trauma, conflict experience (can’t run)
(language disorders, neuralgia, paralysis, visual ippairment)
 Repression
– “Conversion” to physical symptoms
• Primary gain
NEGATIVE
– Attention and support
• Secondary gain
conversion disorder treatments
• Cognitive-behavioral interventions
– Initial reassurance, Stress-reduction, Reduce frequency of help-seeking behaviors
• SSRI treatment may help but side effect profile actually ends up
worsening symptoms.
• “Gatekeeper” physician, Reduce visits to numerous specialists
• Conditioning
– Reward positive health behaviors
– Punish problem behaviors
• Remove supportive consequences
body dysmorphic disorder
• Now in Obsessive Compulsive and Related Disorders
• Clinical Description
– Preoccupation with imagined defect in appearance
– Repeatitive behaviors (e.g. skin picking, mirror checking) or mental acts (e.g. comparisons with others) in response to appearance concerns
– Impaired function
• People will stop leaving their house, avoid mirrors, engage in
checking or compensating rituals (e.g. tanning), Social, Occupational
– Not concerns about weight or shape, as in eating disorders
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delisonal disorder: body dysmorphic disorder type
• Many are unable to realize, even for a second, that their ideas
are irrational (different than OCD). In DSM-5 specifier was
added for those with absent insight/delusional beliefs
body dysmorphic disorder causes
• Little scientific knowledge known about causes
• Serious: patients will alter their own appearance if they cannot afford surgery (staple gun; nip tuck; at home-lypo-suction)
• More commonly seen in plastic surgeon or dermatology clinics than in mental health settings.
• Cultural imperatives: Body size, Skin color (lightening)
• Similarities with OCD: Intrusive thoughts, Rituals, Age of onset and course
body dysmorphic disorder treatment
• Treatment (Similar to OCD)
– Medications (SSRIs)
– Exposure and response prevention
• Also
– 6-25% of cosmetic surgery clients have BDD
– Plastic surgery is often unhelpful
dissociative disorder
• A collection of disorders characterized by detachment from self or surroundings, usually in response to a traumatic event
• Types
– Depersonalization/derealization Disorder
– Dissociative Amnesia
– Dissociative Identity Disorder
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trauma/memory argument dissociative identity disorder
 Psychological stress disrupts personality, so individual becomes split off from consciousness
– Dissociation occurs to protect ego against traumatic stress
• Traumatic origins can be identified in most cases, dissociative amnesia but not always
• Associated with trauma, mostly incest, but entirely based on self-report
– Trauma is broadly defined
– No specificity
depersonalization/derealization disorder
• Clinical Description
– Presence of persistent depersonalization, derealization or both
– Reality remains intact
– Significant distress or impairment necessary for diagnosis
depersonalization
Feelings of unreality, detachment, or being an outside observer with respect to one’s own thoughts, feelings, body, actions, etc. (e.g. emotional numbing)
derealization
Experiences of unreality or detachment with respect to surroundings (e.g. dreamlike)
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depersonalization/derealization disorder causes
• Cognitive deficits
– Attention
– Short-term memory
– Spatial reasoning
• Flattened 3 dimension objects into 2 dimensions
– Easily distracted
• Decreased emotional response
depersonalization/derealization treatment
• Psychological treatments are unstudied
• Prozac appears ineffective
dissociative amnesia
– Inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with normal forgetting
– Psychogenic memory loss
• Not traced to organic etiology
– Specifier:
• With dissociative fugue: apparently purposeful travel or bewildered wandering that is associated with amnesia for identity or for other important autobiographical information
Rapid onset, tends to occur in adulthood
dissociative identity disorder (previously multiple personality disorder)
• Clinical Description
– Disruption of identity with 2 or more personality states (can be
described as possession in some cultures)
– Amnesia for every day events inconsistent with normal forgetting
– Adopt several new identities or “alters”: 2 to 100, Average = 15, Unique characteristics
– Host: The one that seeks help due to being overwhelmed. But, not the original identity!
– Switch: transition from one personality to another: Even changes in handedness have been shown to occur in 37% of patients
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dissociative identity disorder statistics
Statistics
– 1.5%
– Female: male = 9:1 (although some studies indicate ratios are more equal)
– Onset = childhood
– High comorbidity rates (more than 7 additional disorders on average)
• Axis I
• Axis II
– Lifelong, chronic course
paraphilias
Misplaced sexual attraction and arousal
– Focused on inappropriate people, or objects
– It is NOT a disorder unless the person feels distress
about their interest (not merely because of society
disapproval) and/or the sexual desire/behavior causes
another person’s distress, injury or distress (or involves
unwilling person or unable to give legal consent)
– Often multiple paraphilic patterns of arousal
– High comorbidity
• With anxiety, mood, and substance abuse disorders
paraphilias DSM 5 descriptions
fetishistic disorder
trasvestic disorder
voyeuristic disorder
exhibitionistic disorder
frotteuristic disorder
sexual sadism and masochism
pedophilia
fetishistic disorder
Non-living objects : inanimate object, source of tactile stimulation (rubber, hair, shoes)
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trasnvestic disorder cross dressing
voyeuristic disorder Witnessing unsuspecting undressing, naked, sexual 
exhibitionistic disorder Exposing self to unsuspecting others
frotteuristic disorder Rubbing or touching against non-consenting persons
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sexual sadism and masochism
• Inflict (sadism) or receive (masochism) humiliation and pain
– A minority of rapists may be extreme variants of sadism
– Has to involve nonconsenting person or involve distress
pedophilia children (can be of either sex) object of sexual attraction

Sexual attraction to young children
– 90% of perpetrators are male
– Not aroused by adult women
• Victims are children or young adolescent
– Typically female
• Rationalized as “loving”
• Moral compensatory behavior (e.g., church)
paraphilia causes
– Associated with sexual and social problems and deficits
– Patterns of inappropriate arousal and fantasy
• May be learned early in life
– High sex drive, coupled with suppression of urges

 Deviant patterns of sexual arousal
– Desired sexual arousal to adult content
– Social skills deficits
– Have difficulties forming appropriate adult relationships
paraphilia psychosocial treatment
– Most are behavioral
– Target deviant and inappropriate sexual associations
– Covert sensitization – imagining aversive consequences
– Orgasmic reconditioning – masturbation plus appropriate stimuli
– Family/marital therapy – address interpersonal problems
– Coping and relapse prevention – self-control and risk management
– About 70% of cases show improvement
– Poorest outcomes:Sadistic rapists, Pedophiles, Multiple paraphilias
– Run a chronic course with high relapse rates
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paraphilia drug treatments
Medications: The equivalent of chemical castration
– Often used for dangerous sexual offenders
Types of available medications
•Cyproterone acetate: Anti-androgen, reduces testosterone, sexual urges and fantasy
Medroxyprogesterone acetate: Depo-provera, also reduces testosterone
•Triptorelin: A newer and more effective drug that inhibits gonadotropin secretion
• Efficacy of medication treatments
– Drugs work to greatly reduce sexual desire, fantasy, arousal
– Relapse rates are high with medication discontinuation
dissociative identity disorder causes
– Biological vulnerability
– Severe abuse/trauma history (97%)
• Links with PTSD
– Highly suggestible
• A diathesis or vulnerability that interacts with trauma to from DID
dissociative identity disorder treatment
– Reintegration of identities
– Reliving and reprocessing the trauma
– Identify and neutralize cues/triggers
– Visualization
– Coping
gender dysphoria (previously gender identity disorder and transsexualism)
Trapped in the body of the wrong sex
– Strong desire to be the desired sex e.g. appearance, behaviors, friends, sexual anatomy
– Goal is not sexual
• New gender may result in person being heterosexual or homosexual
– Rare: ~ 1 in 25,000 (.004%)
• Causes are unclear
– Gender identity develops between 18 months and 3 years of age
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gender dysphoria treatment
• Sex-reassignment as a treatment
– Psychologically evaluated
– Must live as opposite sex for 2 years 1st
– 75% report satisfaction with new identity
• Psychosocial treatment
– Realign psychological gender with biological sex
– Few large scale studies 
sexual dysfunction classifications
– Lifelong vs. acquired
• Acquired = after there has been normal sexual functioning
– Generalized vs. situational
• Situational = specific partners and/or times
– Psychological factors alone vs. Psychological factors combined with medical condition
• Latter = vascular, hormonal, or associated physical condition known to contribute to sexual dysfunction
– 43% of women and 31% of men suffer from sexual dysfunction
sexual desire disorders
Male hypoactive sexual desire disorder HSDD & Female Sexual Interest/Arousal Disorder
– Little or no interest in any type of sexual activity
– Significant distress about symptoms
– Accounts for half of all complaints at sexuality clinics
– Affects 22% of women and 5% of men
– Extreme fear, panic, or disgust: Related to physical or sexual contact
– Among males with this form of sexual aversion: 10% report panic attacks during attempted sexual activity
– PTSD or Panic Disorder may be present in most cases
sexual arousal disorders
• Male erectile disorder
– Difficulty achieving and maintaining an erection: Called “impotence”, Age related, Female sexual arousal disorder (removed fromDSM-5 and combined with desire disorders)
– Difficulty achieving and maintaining adequate lubrication: Called “frigidity” in the past, Age independent, Problem is not desire 
Associated features of sexual arousal disorders 
– Problem is arousal, not desire 
– Males are more troubled by the problem than females 
– Erectile problems are the main reason males seek help 
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genito-pelvic pain/penetration disorder
– Marked pain (pelvic or vaginal), fear or pain, or tensing or tightening of pelvic during intercourse
– Extreme pain during intercourse
• Affects 1% to 5% of men and about 10% to 15% of women
– Adequate sexual desire
– Adequate ability to attain arousal and orgasm
– Must rule out medical reasons for pain
sexual dysfunction biological contributions
• Biological contributions
– Physical disease, medical illness
• CNS problem can lead to decreased sensitivity in genital area =
arousal problems, Vascular disease = arousal problems
– Prescription medications
• Some blood pressure meds: arousal problems
• SSRIs: problems with sexual desire and / or sexual arousal
– Use and abuse of alcohol and other drugs
• Alcohol CNS suppressant
• Chronic use, testicular problems (men) infertility (women)
• Smoking associated with increased erectile dysfunction
erotophobia learned negative attitudes about sexuality
phenylketonuria PKU is a disease where the individual is born without an enzyme to metabolize phenylalanine, which is found in a lot of food. If this protein isn't metabolized, then it can become toxic to the brain and can cause severe cognitive problems, including intellectual disability. However, if the person doesn't eat any food with phenylalanine, then nothing happens to the individual
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borderline personality disorder
A pattern of instability in, self image, interpersonal relationships, and
affect, and marked impulsivity.
BPD causes
• Vulnerability to negative emotion
– High sensitivity, reactivity, and slow return to baseline
• Poor coping skills
– Inability to: manage social interactions, awareness of
relevant social stimuli, identify and label emotional
experiences, manage arousal
• Maladaptive responses to others expressions of
emotion
– Others responses often trigger emotional arousal 

BPD biological causes
• Prefrontal Cortex (PFC) needed for cognitive control appears
to be structurally intact but functionally dysregulated
– PET studies show hypoactivity in BPD patients during rest (e.g. Soloff)
• Limbic system (emotion) appears to be structurally and
functionally impaired in BPD
– Structural
• ↓ Volume hippocampus and amygdala (Driessen et al, 2000; Schmahl et al,
2003; Rusch et al., 2003)
– Functional
• Amygdala hyperactivity has been shown in BPD when responding to emotional words, pictures( Herpertz et al, 2001), and faces (Donegan et al,
2003)
dialectical behavior therapy (DBT)
• Developed by Marsha Linehan
• Underlying model: BPD = dysregulation
• DBT Combines CBT with eastern philosophy
– Dialectic: Truth is synthesis of a thesis and an antithesis
• Typical dose is one year of treatment
• Treatment Targets
– Suicidal and Life-Threatening Behavior
– Therapy Interfering Behavior
– Quality of Life Interfering Behavior
– Skills Training
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dialectical behavior therapy
• Outpatient Individual Psychotherapy
• Outpatient Group Skills Training
– Mindfulness
– Interpersonal Effectiveness
– Emotion Regulation
– Distress Tolerance
• Telephone Consultation
• Therapist support (for therapists)
narcossistic A pattern of grandiosity, need for admiration, and lack of empathy
narcissistic PD
 Associated Features:
– May attain significant achievement, but they rarely
accept them as “enough” or derive pleasure from
them
– Self-esteem, outwardly high, is actually quite fragile
with a need for constant attention and admiration
– Other PD are often common
– Adjustment Disorders are common
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List View: Terms & Definitions

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 ADHD: statistics and comorbidityHIGH comorbidity
80% of children oppositional defiant disorder
90% of adults are comorbid with mood disorders
boys:girls = 3:1
 adults with ADHD50% have problems as adults
inattention persists and hyperactivity, impulsivity declines
 ADHD causes genetics
-familial component
-dopamine (ritalin inhibits this gene and increases DA)
-norepinepherine
-GABA
-serotonin
 ADHD causes neurobiological contributionssmaller brain volume (3-4% smaller than children without)
frontal cortex and basal ganglia
-inactivity
-abnormal development
 ADHD causes role of toxinsallergens and food additives
-very small association of artificial food colors, additives, and pesticides

maternal smoking
-increases risk
-interacts with genetic predisposition
 ADHD causes psychosocial factorsnegative feedback
-teachers
-peers
-adults
peer rejection
social isolation
low self-esteem
poor self-image
 treatment of ADHD: biologicalgoals are to reduce impulsivity and hyperactivity, and improve attention

stimulants effective for 70% (ritalin, adderall, etc)

other medications
-strattera: problems with not really helping attention, but just making the patient calmer, less disruptive to class)
-imipramine (antidepressant)
-clonidine (used for high blood pressure)
 effects of ADHD biological medication treatmentspositive
-improve compliance
-decrease negative behaviors

negative
-do not affect learning and academic performance
-benefits are not lasting following discontinuation
 autism spectrum disorder is akapervasive developmental disorder
pervasive=significant impairment across lifespan
 autism spectrum disorderlanguage, socialization, and cognitive problems
pervasive=significant impairment across lifespan
 autism spectrum disorder DSM-5combines autism, asperger's disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified
 autism spectrum disorder DSM-5 clinical description1. impairment in social communications and interactions across multiple contexts
2. restrictive, repetitive patterns of behavior, interests, or activities (at least 2 form list)
-repetitive motor movement, use of objects, etc
-insists on sameness and routines
-restricted, fixated interests that are abnormal in focus and intensity
-hyper or hyporeactiity to sensory input or unusual interest
3. symptoms must be present in early development
specifiers to indicate severity-w/ or w/o language or intellectual impairment (40-55% w intellectual disability)
 causes of autism: biologicalgenetic influences
-family component: 5-10% risk of second child w/ autism and 20& risk for ASD
-polygenetic influences
-oxytocin receptor genes: bonding and social memory, lower levels of oxytocin

 causes of autism: biological neurobiological influencesamygdala
-larger at birth: higher anxiety, fear
-elevated cortisol
-neuronal damage over time
-fewer neurons in postmortem brains
 treatment of autismchildren w autism cant or will not imitate: this has major consequences for learning language

psychosocial treatment
-behavioral approaches
early intervention is critical
problem: very time intensive
medical treatments are NOT effective
biological treatments target specific problems UNIQUE to individual
(decrease agitation w tranquilizers and SSRIs)
 the verbal comprehension subtests (VCI)vocabulary and ocmprehension
 the perceptual reasoning subtests (PRI)block design, picture concepts, and matrix reasoning
 the working memory subtests (WMI)digit span and arithmetic
 the processing speed subtests (PSI)coding and symbol search
 specific learning disorderactual vs expected achievement
not due to sensory deficits such as sight or hearing

can occur in any of these areas:
1. reading-inaccurate and slow reading, recognition (dyslexia), fluency, comprehension
2. math-difficulty w calculations and applying math knowledge
3. writing-written expression and spelling

begins during school ages years
 learning disorder causesgenetic and neurobiological contributions
-some evidence of specific brain regions involved dependent on the type of learning problem

psychosocial contributions
-motivational factors reinforced by others
-socioeconomic status
-cultural expectations
-parental interactions
-expectancies
 treatment of learning disorders• Educational Interventions
– Specific skills instructions 
• Vocabulary
• Discerning meaning 
• Fact finding 
– Strategy instruction Improve cognitive skills through 
• Decision making 
• Critical thinking
 intellectual disability (ID)clinical description
1. below average intellectual functioning measures by standardized tests, IQ of 70 or below
2. adaptive problems in multiple areas
-communication, self care, home living, social, work, leisure, health
3. disorder of childhood present before age 18, previously coded on axis II
 levels of intellectual disability
 Mild
– IQ = 50 or 55 to 70
• Moderate
– IQ = 35-40 to 50-55
• Severe
– IQs = 20-25 to 35-40
• Profound
– IQ = below 20-25
 american association of intellectual and developmental disabilities (AAIDD)
 Based on assistance required
• Intermittent
• Limited
• Extensive
• Pervasive
– Keeps the emphasis on what assistance is needed
 intellectual disability: statistics
• Prevalence = 2% of general population
– 9 in 10 people with ID have mild impairment (IQ
50-70)
• Chronic course
• Highly variable individual prognosis
– Independence is possible for many individuals with
mild impairment when provided with appropriate
resources (e.g., skills training)
 intellectual disability causes psychological and social dimensions
 Nearly 75% not associated with biological cause
– Mild levels, impairments
– Good adaptive skills
• Cultural-familial ID
– Abuse
– Neglect
– Social deprivation
 intellectual disabilities enriched environment and the brain
More dendritic sprouting
• More LTP
• Stubbier dendrites
• More receptors
 causes of intellectual disordersenvironmental, prenatal, perinatal, postnatal
  Examples
– Fetal alcohol syndrome
– Exposure to other illness in the womb
– Lack of oxygen (anoxia) during birth
– Malnutrition
– Head injuries
– Childhood abuse
 causes of intellectual disorders biological contributions
Genetic Influences
– Multiple genes
– Single genes
• Dominant, few because of evolution
• Recessive
– Phenylketonuria (PKU)
• Protein contains phenylalanine, an amino acid that is essential
for normal growth and development. People with PKU lack an
enzyme to properly metabolize phenylalanine. Very high levels
of phenylalanine in the blood can lead to irreversible brain and
nervous system damage
 causes of intellectual disorders biological contributions
Chromosomal Influences
– Down syndrome: Extra 21st chromosome, Trisomy 21, Physical symptoms (Heart malformations), Increased prevalence of Alzheimer’s
After age 40-Risk increases with maternal age AND
paternal age
Fragile X syndrome
• Primarily affects males (no second X), Learning disabilities, Hyperactivity, Perseverative speech, Gaze avoidance, Large ears, testes, and head circumference
 treatment of intellectual disability depending on severity
 Severe ID: Treatment similar to that for autism
spectrum disorder
– Mild ID: Treatment similar to that for learning
disorders
– Goals are similar across severity; level of assistance
differs
– Behavioral interventions teach:
• Basic skills (e.g., dressing, hygiene)
• Social skills
• Practical skills (e.g., paying bills)
 treatment of intellectual disability
 Common goals
– Participate in community life
– Benefit from education
– Hold a job or other productive pursuits (e.g.,
volunteering)
– Build meaningful relationships
 prevention of developmental disorders
• Early intervention
– At-risk children, families
– Ex: Head Start Program: Educational, Medical, Social supports, Leads to IQ above 85 compared to those without educational intervention (all below 85)
• Genetic screening
– Detection and correction (e.g.,
genes therapy in the future
– Cell free DNA test (prenatal)
– Amniocentesis
 somatic symptoms (previously somatoform disorders)
Combination of previous somatoform disorders, such as Somatization disorder and Pain Disorder
– Illness Anxiety Disorder
– Conversion Disorder (Functional Neurological Symptom Disorder)
 somatic symptom disorder
• One or more somatic symptoms that are distressing or result in disruption of daily life
• Excessive thoughts, feelings, or behaviors related to somatic symptoms or health concerns with at least one of:
– Persistent thoughts about seriousness of symptoms
– High level of anxiety about symptoms
– Excessive time or energy devoted to symptoms
• Occurs for at least 6 months
– Specify if disorder is with predominant pain (previously pain
disorder)
 somatic symptom disorder statistics
• Statistics
– Previously somatization disorder and pain disorder, but 75% of hypochondriasis would fit into this diagnosis
– Prevalence unknown, but probably around 5-7%
– May be higher in females, but also unknown
– Onset at any age
• Peaks: adolescence, middle age, elderly
 somatic symptom disorder causes
**The full time patient**
– Disorder of cognition or perception
• Focus on physical signs and sensations >increases
arousal>makes physical sensations more intense
• Faulty cognitions >anxiety>worsening of physical
symptoms
• Stroop
– Enhanced sensitivity to illness cues
• History of family illness or injury
• Neuroticism, anxiety and depression common
• Links to antisocial personality disorder for previous DSM-IV
category
– But no callousness or aggressiveness associated with somatization
– A weak behavioral inhibition system (BIS), which causes excessive:
• Impulsivity
• Novelty-seeking
• Provocative sexual behavior
• May be the same risk factor for APD but cultural and social factors
decide which way a person goes.
– Other factors
• Stressful life events
• Low SES and few years of education
• History of sexual abuse or childhood adversity
• Current chronic illness or psychological disorder
 illness anxiety disorder (previously hypochondriasis)
• Preoccupation with having or acquiring a serious
illness
• Somatic symptoms are not present or are mild
in intensity. If a medical condition is present,
then the preoccupation is excessive
• There is a high level of anxiety about health
• Excessive health related behaviors (e.g. checking body
for signs of illness) or exhibits maladaptive avoidance
(e.g. missing doctor’s appointments)
• At least 6 months duration: Care-seeking type e.g. excessive doctor’s appointments or Care-avoidant type
 illness anxiety disorder statistics
– Only 25% former hypochondriasis
– Prevalence Unknown, but about 1.3-10% from
surveys
– Hypochondriasis 1% to 14% of medical patients
• 6.7% median rate
– Female : Male = 1:1
– Comorbid anxiety & depressive disorders
– Onset at any age
• Peaks: adolescence, middle age, elderly, but increases with age
– Chronic course
 illness anxiety disorder causes
– Familial history of illness
• Genetics
• Modeling/learning
– Similar reports to family members
– Childhood abuse or illness
– Other factors
• Stressful life events
• High family disease incidence
• “Benefits” of illness
 conversion disorder (functional neurological symptom disorder)
Popularized by Freud
– Anxiety from unconscious conflicts changed into physical
symptoms to find an expression!
• Clinical Description
– Physical malfunctioning: sensory-motor areas including blindness, paralysis, difficulty vocalizing
– Lack physical or organic pathology
– Lack awareness
– Intact functioning
• Visual tests study
 conversion disorder DSM 5 criteria
A. One or more symptoms of altered voluntary motor or sensory function
B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.
C. The symptom or deficit is not better explained by another medical or mental disorder
D. Clinically significant distress or impairment
 conversion disorder statistics
 Unknown, but found in 5% of neurology patients
– Prevalence depends on setting
• Rare in mental health settings, but remember that people who seek
help for this are more likely to consult specialist (e.g., neurologist etc)
• Common in Neurology and Epilepsy clinic(s)
– Female > male
– Comorbid anxiety, depression, personality disorders, and
somatic symptom disorder
– Onset = throughout life
– Chronic, intermittent course
• Will disappear, then return in the same form w new stressor
 conversion disorder causes
• Family/Social/Cultural
– Difficult temperaments
– Childhood abuse and neglect/stressful life events
– Presence of neurological disease causing similar
symptoms
– Low SES
– Limited disease knowledge
• Patients tend to adopt symptoms from familiar diseases, These disorders are becoming less common as people are
learning more about health (internet)
– Family history of illness
 conversion disorder causes and views
• Anno O.
• Freudian psychodynamic view
POSITIVE
– Trauma, conflict experience (can’t run)
(language disorders, neuralgia, paralysis, visual ippairment)
 Repression
– “Conversion” to physical symptoms
• Primary gain
NEGATIVE
– Attention and support
• Secondary gain
 conversion disorder treatments
• Cognitive-behavioral interventions
– Initial reassurance, Stress-reduction, Reduce frequency of help-seeking behaviors
• SSRI treatment may help but side effect profile actually ends up
worsening symptoms.
• “Gatekeeper” physician, Reduce visits to numerous specialists
• Conditioning
– Reward positive health behaviors
– Punish problem behaviors
• Remove supportive consequences
 body dysmorphic disorder
• Now in Obsessive Compulsive and Related Disorders
• Clinical Description
– Preoccupation with imagined defect in appearance
– Repeatitive behaviors (e.g. skin picking, mirror checking) or mental acts (e.g. comparisons with others) in response to appearance concerns
– Impaired function
• People will stop leaving their house, avoid mirrors, engage in
checking or compensating rituals (e.g. tanning), Social, Occupational
– Not concerns about weight or shape, as in eating disorders
 delisonal disorder: body dysmorphic disorder type
• Many are unable to realize, even for a second, that their ideas
are irrational (different than OCD). In DSM-5 specifier was
added for those with absent insight/delusional beliefs
 body dysmorphic disorder causes
• Little scientific knowledge known about causes
• Serious: patients will alter their own appearance if they cannot afford surgery (staple gun; nip tuck; at home-lypo-suction)
• More commonly seen in plastic surgeon or dermatology clinics than in mental health settings.
• Cultural imperatives: Body size, Skin color (lightening)
• Similarities with OCD: Intrusive thoughts, Rituals, Age of onset and course
 body dysmorphic disorder treatment
• Treatment (Similar to OCD)
– Medications (SSRIs)
– Exposure and response prevention
• Also
– 6-25% of cosmetic surgery clients have BDD
– Plastic surgery is often unhelpful
 dissociative disorder
• A collection of disorders characterized by detachment from self or surroundings, usually in response to a traumatic event
• Types
– Depersonalization/derealization Disorder
– Dissociative Amnesia
– Dissociative Identity Disorder
 trauma/memory argument dissociative identity disorder
 Psychological stress disrupts personality, so individual becomes split off from consciousness
– Dissociation occurs to protect ego against traumatic stress
• Traumatic origins can be identified in most cases, dissociative amnesia but not always
• Associated with trauma, mostly incest, but entirely based on self-report
– Trauma is broadly defined
– No specificity
 depersonalization/derealization disorder
• Clinical Description
– Presence of persistent depersonalization, derealization or both
– Reality remains intact
– Significant distress or impairment necessary for diagnosis
 depersonalization
Feelings of unreality, detachment, or being an outside observer with respect to one’s own thoughts, feelings, body, actions, etc. (e.g. emotional numbing)
 derealization
Experiences of unreality or detachment with respect to surroundings (e.g. dreamlike)
 depersonalization/derealization disorder causes
• Cognitive deficits
– Attention
– Short-term memory
– Spatial reasoning
• Flattened 3 dimension objects into 2 dimensions
– Easily distracted
• Decreased emotional response
 depersonalization/derealization treatment
• Psychological treatments are unstudied
• Prozac appears ineffective
 dissociative amnesia
– Inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with normal forgetting
– Psychogenic memory loss
• Not traced to organic etiology
– Specifier:
• With dissociative fugue: apparently purposeful travel or bewildered wandering that is associated with amnesia for identity or for other important autobiographical information
Rapid onset, tends to occur in adulthood
 dissociative identity disorder (previously multiple personality disorder)
• Clinical Description
– Disruption of identity with 2 or more personality states (can be
described as possession in some cultures)
– Amnesia for every day events inconsistent with normal forgetting
– Adopt several new identities or “alters”: 2 to 100, Average = 15, Unique characteristics
– Host: The one that seeks help due to being overwhelmed. But, not the original identity!
– Switch: transition from one personality to another: Even changes in handedness have been shown to occur in 37% of patients
 dissociative identity disorder statistics
Statistics
– 1.5%
– Female: male = 9:1 (although some studies indicate ratios are more equal)
– Onset = childhood
– High comorbidity rates (more than 7 additional disorders on average)
• Axis I
• Axis II
– Lifelong, chronic course
 paraphilias
Misplaced sexual attraction and arousal
– Focused on inappropriate people, or objects
– It is NOT a disorder unless the person feels distress
about their interest (not merely because of society
disapproval) and/or the sexual desire/behavior causes
another person’s distress, injury or distress (or involves
unwilling person or unable to give legal consent)
– Often multiple paraphilic patterns of arousal
– High comorbidity
• With anxiety, mood, and substance abuse disorders
 paraphilias DSM 5 descriptions
fetishistic disorder
trasvestic disorder
voyeuristic disorder
exhibitionistic disorder
frotteuristic disorder
sexual sadism and masochism
pedophilia
 fetishistic disorder
Non-living objects : inanimate object, source of tactile stimulation (rubber, hair, shoes)
 trasnvestic disordercross dressing
 voyeuristic disorderWitnessing unsuspecting undressing, naked, sexual 
 exhibitionistic disorderExposing self to unsuspecting others
 frotteuristic disorderRubbing or touching against non-consenting persons
 sexual sadism and masochism
• Inflict (sadism) or receive (masochism) humiliation and pain
– A minority of rapists may be extreme variants of sadism
– Has to involve nonconsenting person or involve distress
 pedophiliachildren (can be of either sex) object of sexual attraction

Sexual attraction to young children
– 90% of perpetrators are male
– Not aroused by adult women
• Victims are children or young adolescent
– Typically female
• Rationalized as “loving”
• Moral compensatory behavior (e.g., church)
 paraphilia causes
– Associated with sexual and social problems and deficits
– Patterns of inappropriate arousal and fantasy
• May be learned early in life
– High sex drive, coupled with suppression of urges

 Deviant patterns of sexual arousal
– Desired sexual arousal to adult content
– Social skills deficits
– Have difficulties forming appropriate adult relationships
 paraphilia psychosocial treatment
– Most are behavioral
– Target deviant and inappropriate sexual associations
– Covert sensitization – imagining aversive consequences
– Orgasmic reconditioning – masturbation plus appropriate stimuli
– Family/marital therapy – address interpersonal problems
– Coping and relapse prevention – self-control and risk management
– About 70% of cases show improvement
– Poorest outcomes:Sadistic rapists, Pedophiles, Multiple paraphilias
– Run a chronic course with high relapse rates
 paraphilia drug treatments
Medications: The equivalent of chemical castration
– Often used for dangerous sexual offenders
Types of available medications
•Cyproterone acetate: Anti-androgen, reduces testosterone, sexual urges and fantasy
Medroxyprogesterone acetate: Depo-provera, also reduces testosterone
•Triptorelin: A newer and more effective drug that inhibits gonadotropin secretion
• Efficacy of medication treatments
– Drugs work to greatly reduce sexual desire, fantasy, arousal
– Relapse rates are high with medication discontinuation
 dissociative identity disorder causes
– Biological vulnerability
– Severe abuse/trauma history (97%)
• Links with PTSD
– Highly suggestible
• A diathesis or vulnerability that interacts with trauma to from DID
 dissociative identity disorder treatment
– Reintegration of identities
– Reliving and reprocessing the trauma
– Identify and neutralize cues/triggers
– Visualization
– Coping
 gender dysphoria (previously gender identity disorder and transsexualism)
Trapped in the body of the wrong sex
– Strong desire to be the desired sex e.g. appearance, behaviors, friends, sexual anatomy
– Goal is not sexual
• New gender may result in person being heterosexual or homosexual
– Rare: ~ 1 in 25,000 (.004%)
• Causes are unclear
– Gender identity develops between 18 months and 3 years of age
 gender dysphoria treatment
• Sex-reassignment as a treatment
– Psychologically evaluated
– Must live as opposite sex for 2 years 1st
– 75% report satisfaction with new identity
• Psychosocial treatment
– Realign psychological gender with biological sex
– Few large scale studies 
 sexual dysfunction classifications
– Lifelong vs. acquired
• Acquired = after there has been normal sexual functioning
– Generalized vs. situational
• Situational = specific partners and/or times
– Psychological factors alone vs. Psychological factors combined with medical condition
• Latter = vascular, hormonal, or associated physical condition known to contribute to sexual dysfunction
– 43% of women and 31% of men suffer from sexual dysfunction
 sexual desire disorders
Male hypoactive sexual desire disorder HSDD & Female Sexual Interest/Arousal Disorder
– Little or no interest in any type of sexual activity
– Significant distress about symptoms
– Accounts for half of all complaints at sexuality clinics
– Affects 22% of women and 5% of men
– Extreme fear, panic, or disgust: Related to physical or sexual contact
– Among males with this form of sexual aversion: 10% report panic attacks during attempted sexual activity
– PTSD or Panic Disorder may be present in most cases
 sexual arousal disorders
• Male erectile disorder
– Difficulty achieving and maintaining an erection: Called “impotence”, Age related, Female sexual arousal disorder (removed fromDSM-5 and combined with desire disorders)
– Difficulty achieving and maintaining adequate lubrication: Called “frigidity” in the past, Age independent, Problem is not desire 
Associated features of sexual arousal disorders 
– Problem is arousal, not desire 
– Males are more troubled by the problem than females 
– Erectile problems are the main reason males seek help 
 genito-pelvic pain/penetration disorder
– Marked pain (pelvic or vaginal), fear or pain, or tensing or tightening of pelvic during intercourse
– Extreme pain during intercourse
• Affects 1% to 5% of men and about 10% to 15% of women
– Adequate sexual desire
– Adequate ability to attain arousal and orgasm
– Must rule out medical reasons for pain
 sexual dysfunction biological contributions
• Biological contributions
– Physical disease, medical illness
• CNS problem can lead to decreased sensitivity in genital area =
arousal problems, Vascular disease = arousal problems
– Prescription medications
• Some blood pressure meds: arousal problems
• SSRIs: problems with sexual desire and / or sexual arousal
– Use and abuse of alcohol and other drugs
• Alcohol CNS suppressant
• Chronic use, testicular problems (men) infertility (women)
• Smoking associated with increased erectile dysfunction
 erotophobialearned negative attitudes about sexuality
 phenylketonuriaPKU is a disease where the individual is born without an enzyme to metabolize phenylalanine, which is found in a lot of food. If this protein isn't metabolized, then it can become toxic to the brain and can cause severe cognitive problems, including intellectual disability. However, if the person doesn't eat any food with phenylalanine, then nothing happens to the individual
 borderline personality disorder
A pattern of instability in, self image, interpersonal relationships, and
affect, and marked impulsivity.
 BPD causes
• Vulnerability to negative emotion
– High sensitivity, reactivity, and slow return to baseline
• Poor coping skills
– Inability to: manage social interactions, awareness of
relevant social stimuli, identify and label emotional
experiences, manage arousal
• Maladaptive responses to others expressions of
emotion
– Others responses often trigger emotional arousal 

 BPD biological causes
• Prefrontal Cortex (PFC) needed for cognitive control appears
to be structurally intact but functionally dysregulated
– PET studies show hypoactivity in BPD patients during rest (e.g. Soloff)
• Limbic system (emotion) appears to be structurally and
functionally impaired in BPD
– Structural
• ↓ Volume hippocampus and amygdala (Driessen et al, 2000; Schmahl et al,
2003; Rusch et al., 2003)
– Functional
• Amygdala hyperactivity has been shown in BPD when responding to emotional words, pictures( Herpertz et al, 2001), and faces (Donegan et al,
2003)
 dialectical behavior therapy (DBT)
• Developed by Marsha Linehan
• Underlying model: BPD = dysregulation
• DBT Combines CBT with eastern philosophy
– Dialectic: Truth is synthesis of a thesis and an antithesis
• Typical dose is one year of treatment
• Treatment Targets
– Suicidal and Life-Threatening Behavior
– Therapy Interfering Behavior
– Quality of Life Interfering Behavior
– Skills Training
 dialectical behavior therapy
• Outpatient Individual Psychotherapy
• Outpatient Group Skills Training
– Mindfulness
– Interpersonal Effectiveness
– Emotion Regulation
– Distress Tolerance
• Telephone Consultation
• Therapist support (for therapists)
 narcossisticA pattern of grandiosity, need for admiration, and lack of empathy
 narcissistic PD
 Associated Features:
– May attain significant achievement, but they rarely
accept them as “enough” or derive pleasure from
them
– Self-esteem, outwardly high, is actually quite fragile
with a need for constant attention and admiration
– Other PD are often common
– Adjustment Disorders are common
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