General Psychology An Introduction Chapter 13 Psychological Disorders

Chapter 13 Psychological Disorders 22 Anxiety and Related Disorders David Barlow Kristen Anxiety is a natural part of life and , at normal levels , helps us to function at our best . However , for people with anxiety disorders , anxiety is overwhelming and hard to control . Anxiety disorders develop out ofa blend of biological ( genetic ) and psychological factors that , when combined with stress , may lead to the development of ailments . Primary diagnoses include generalized anxiety disorder , panic disorder , specific phobia , social anxiety disorder ( social phobia ) post traumatic stress disorder , and disorder . In this module , we summarize the main clinical features ofthese disorders and discuss their similarities and differences with everyday experiences of anxiety . Learning Objectives Understand the relationship between anxiety and anxiety disorders . Identify key vulnerabilities for developing anxiety and related disorders . Identify main diagnostic features of specific disorders . Differentiate between disordered and functioning . Introduction What is anxiety ?

Most of us feel some anxiety almost every day of our lives . Maybe you have an important test coming up for school . Or maybe there that big game next Saturday , or that first date with someone new you are hoping to impress . Anxiety can be defined as a negative mood state that is accompanied by bodily symptoms such as increased heart rate ,

Anxiety and Related Disorders 381 muscle tension , a sense of unease , and apprehension about the future ( APA , 2013 Barlow , Anxiety is what motivates us to plan for the future , and in this sense , anxiety is , actually a good thing . It that nagging test , practice that game , or be , at our very best on that date . But some ) people experience anxiety so intensely ' I that itis ' I may become so overwhelmed and distracted by anxiety that they actually A I fail their test , fumble the ball , or spend the whole date fidgeting and avoiding While may experience some level of anxiety at one time eye Contact begins to interfere or another , those with anxiety disorders experience it consistently in the , life in a Way it and so it has a significantly negative impact on their is Considered a disorder quality oflife . Photo ) Anxiety and closely related disorders emerge from triple , a combination of biological , psychological , and specific factors that increase our risk for developing a disorder ( i , FEE ! iD ( 99 ?

VU ' refer to and predispose develop anxiety disorders . No single gene directly causes anxiety or panic , but our genes may make us more susceptible to anxiety and influence how our brains react to stress ( et , 2012 to the influences that our early experiences have on how we view the world . If we were confronted with unpredictable stressors or traumatic experiences at younger ages , we may come to view the world as unpredictable and uncontrollable , even dangerous ( is dangerous , maybe through witnessing our family reaction whenever anyone got sick , we may focus our anxiety on physical sensations . Ifwe learned that disapproval from others has negative , even dangerous consequences , such as being yelled at or severely punished for even the slightest offense , we might focus our anxiety on social evaluation . If we learn that the other shoe might drop at any moment , we may focus our anxiety on worries about the future . None of these vulnerabilities directly causes anxiety disorders on its , when all of these vulnerabilities are present , and we experience some triggering life stress , an anxiety disorder may be the result ( Barlow , 2002 Suarez et , 2009 ) In the next sections ,

Anxiety and Related Disorders 382 we will briefly explore each ofthe major anxiety based disorders , found in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders ( APA , 2013 ) Generalized Anxiety Disorder Most of us worry some ofthe time , and this worry can actually be useful in helping us to plan for the future or make sure we remember to do something important . Most of us can set aside when we need to focus on otherthings or stop a problem has passed . However , for someone with generalized anxiety disorder ( GAD ) these worries become difficult , or even impossible , to turn off . They may find themselves worrying excessively about a number of different things , both minor and catastrophic . Their worries also come with a host of other symptoms such as muscle tension , fatigue , agitation or restlessness , irritability , difficulties with sleep ( either falling asleep , staying asleep , or both ) or difficulty criteria specify that at least six months of excessive anxiety and worry of this type must be ongoing , happening more days than not for a good proportion of the day , to receive a diagnosis of GAD . About of the population has met criteria for GAD at some point during their lifetime ( Kessler , et , 2005 ) making it one of the most common anxiety disorders ( see Table ) Prevalence Lifetime Prevalence Prevalence by Median Age of Rates Rates Gender Onset Generalized Anxiety Disorder 67 female OCD . 55 female Panic Disorder . 67 female . 52 Social Anxiety . 50 female Phobia . 60 90 female Table Prevalence rates for major anxiety disorders . Kessler et al . 2005 ) Chiu , Walters ( 2005 ) Hughes , Nelson ( 1995 ) et al . 1996 ) What makes a person with GAD worry more than the average person ?

Research shows that individuals with GAD are more sensitive and vigilant toward possible threats than people who are ( 2001 Barlow , 2002 Bradley , White , Groom , de Bono , Anxiety and Related Disorders 383 as an unpredictable , uncontrollable , and even dangerous place . Some have suggested that people with GAD worry as a way to gain some control over these otherwise uncontrollable or unpredictable experiences and against uncertain outcomes ( mind , the person might feel like they are less vulnerable to an unexpected outcome , giving them the sense that they have some control over the situation ( Wells , 2002 ) Others have confronted with a stressful situation had less physiological arousal than those who worry , maybe because the worry distracted them in some way . The problem is , all of this what if ?

does get the person any closer to a solution or an answer and , in fact , might take them away from important things they should be paying attention to in the moment , such as finishing an important project . Many of the catastrophic outcomes people with GAD worry about are very unlikely to happen , so when the catastrophic event does materialize , the act of worrying gets reinforced ( daughter will get home safe from a night out and the daughter returns home without incident , the mother could easily attribute her daughter safe return to her successful vigil . What the mother has learned is that her daughter would have returned as safe if she had been focusing on the movie she was watching with her husband , rather than being preoccupied with worries . In this way , the cycle of worry is perpetuated , and , subsequently , people with GAD often miss out on many otherwise enjoyable events in their lives . Panic Disorder and Agoraphobia Have you ever gotten into a or been taken by surprise in some way ?

You may have felt a flood of physical sensations , such as a racing heart , shortness of breath , or tingling sensations . This alarm reaction is called the fight or flight response ( and is your body natural reaction to fear , preparing you to either fight or escape in response to threat or danger . It likely you were too concerned with these sensations , because you knew what was causing them . But imagine if this alarm reaction came out of the blue , for no apparent reason , or in a situation in which you did expect to be anxious or fearful . This is called an unexpected panic attack or a false alarm . Because there is no apparent reason or cue for the alarm reaction , you might react to the sensations with intense fear , maybe thinking you are having a heart attack , or going crazy , or even dying . You might begin to associate the physical sensations you felt during this attack with this fear and may start to go out of your way to avoid having those sensations again .

Anxiety and Related Disorders 384 Unexpected panic attacks such as these are at the heart of panic disorder ( However , to receive a diagnosis of , the person must not only have unexpected panic attacks but also must experience continued intense anxiety and avoidance related to the attack for at least one month , causing significant distress or interference in their lives . People with panic disorder tend to interpret even normal physical sensations Panic disorder condition that leaves sufferers with ii ! a catastrophic way , triggers acute anxiety that persists long after a specific panic attack has more anxiety and , more subsided . When this anxiety leads to deliberate avoidance of physical sensations , creating a vicious cycle of panic ( The person may begin to avoid a number of situations or activities that produce the same physiological arousal that was present during the beginnings ofa panic attack . For example , someone who experienced a racing a panic attack might avoid exercise or caffeine . Someone who experienced choking sensations might avoid wearing sweaters or necklaces . Avoidance of these internal bodily particular places and situations a person may be given a diagnosis . nate or somatic cues for panic has been termed interoceptive avoidance ( Barlow , 2007 The individual may also have experienced an overwhelming urge to escape during the unexpected panic can lead to a certain places situations where escape might not be not These situations become external cues for panic . If the person begins to avoid several places or situations , or still endures these situations but does so with a significant amount and anxiety , then the person also has agoraphobia ( Barlow , 2002 Barlow , 1988 Barlow , oftheir way to avoid situations , such as adding hours to a commute to avoid taking the train or only ordering to avoid having to enter a grocery store . In one tragic case seen by our clinic , a woman suffering from agoraphobia had not left her apartment for 20 years and had spent the past 10 years confined to one small area ofher apartment , away from the view of the outside . In some cases , agoraphobia develops in the absence of panic attacks and therefor is a separate disorder in . But agoraphobia often accompanies panic disorder . About ofthe population has met criteria for or agoraphobia lifetime ( Kessler ,

Anxiety and Related Disorders 385 cases of panic disorder , what was once an adaptive natural alarm reaction now becomes a learned , and much feared , false alarm . Specific Phobia The majority of us might have certain things we fear , such as bees , or needles , or heights ( But what if this fear is so consuming that you ca go out on a day , or get vaccines needed to go on a special trip , or visit your doctor in her new office on the floor ?

To meet criteria for a diagnosis phobia , there must be an irrational fear of a specific object or situation that substantially interferes with the person ability to function . For example , a patient at our clinic turned down a prestigious and coveted artist residency because it required spending time near a wooded area , bound to have insects . Another patient purposely left her house two hours early each morning so she could walk past her neighbors fenced yard before they let their dog out in the morning . The list of possible phobias is staggering , but four major of specific phobia are recognized ( type , situational type ( such as planes , elevators , or enclosed places ) natural environment type for events one may encounter in nature ( for example , heights , storms , and water ) and animal type . A fifth category other includes phobias that do not fit any of the four major ( for example , fears , vomiting , or contracting an illness ) Most phobic in the sympathetic nervous system and increased heart rate and blood pressure , maybe even a panic attack . However , people with type phobias usually experience a marked drop in heart rate and blood pressure and may even faint . In this way , those with phobias almost always differ . in their Elevators can be a trigger for sufferers of claustrophobia or physiological reaction from people with a age other types of phobia ( Barlow

Anxiety and Related Disorders 386 disorders in the United States , with of the population reporting a lifetime history of fears significant enough to be considered a phobia ( et , 2003 Kessler , Social Anxiety Disorder ( Social Phobia ) Many people consider themselves shy , and most people find social evaluation uncomfortable at best , or speech somewhat mortifying . Yet , small proportion ofthe population fear these types of situations significantly enough to merit a diagnosis of social anxiety disorder ( SAD ) APA , 2013 ) SAD is more than exaggerated shyness ( et , 2010 situations must be so strong that the person avoids them entirely , or if avoidance is not possible , the person endures them with a . Further , avoidance situations must get in the way ofthe person daily life , or seriously or occupational functioning . For example , a patient at our clinic compromised her perfect grade point average because she could not complete a required oral presentation in one of her classes , causing her to fail the course . Fears of negative evaluation might make someone repeatedly turn down invitations to social events or avoid having conversations with people , leading to greater and greater isolation . The specific social situations that trigger anxiety and fear range from interactions , such as starting or maintaining a conversation to situations , such as giving a speech or performing on stage to assertiveness , such as asking someone to change disruptive or undesirable behaviors . Fear evaluation might even extend to such things as using public restrooms , eating in a restaurant , filling out forms in a public place , or even reading on a train . Any type of situation that could potentially draw attention to the person can become a feared social situation . For example , one patient of ours went out of her way to avoid any situation in which she might have to use a public restroom that someone would hear her in the bathroom stall and think she was disgusting . If the fear is limited to situations , such as public speaking , a diagnosis of SAD performance only is assigned . What causes someone to fear social situations to such a large extent ?

The person may have learned growing up that social evaluation in particular can be dangerous , creating a specific psychological vulnerability to develop social anxiety ( Lieb et , 2000 punished them for even the smallest mistake , maybe even punishing them physically .

Anxiety and Related Disorders 387 Or , someone might have experienced a social trauma that had lasting effects , such as being bullied or humiliated . Interestingly , one group of researchers found that 92 of adults in their study sample with social phobia experienced severe teasing and bullying in childhood , compared with only 35 to 50 among people with other anxiety disorders ( Antony , might react so strongly to the anxiety provoked by a social situation that they have an unexpected panic attack . This panic attack then becomes associated ( conditioned response ) with the social situation , person to they are in that situation . This is not considered , however , because the person fear is more focused on social evaluation than having unexpected panic attacks , and the fear of having an attack is limited to social situations . As many as of the general population suffer from social phobia at some point in their lives ( most common , second only to specific phobia ( see Table ) Social trauma in childhood effects . Photo Photos ) Posttraumatic Stress Disorder With stories of war , natural disasters , and physical and sexual assault dominating the news , it is clear that trauma is a reality for many people . Many individual traumas that occur every day never even make the headlines , such as a car accident , domestic abuse , or the death of a loved one . Yet , while many people face traumatic events , not everyone who faces a trauma develops a disorder . Some , with the help friends , are ableto continue on with their lives ( For some , however , the months and years following a trauma are filled with intrusive reminders of the event , a sense of intense fear that another traumatic event might occur , or a sense and emotional numbing . They may engage in a host of behaviors intended to protect themselves from being vulnerable or unsafe , such as constantly scanning their surroundings to look for signs of potential danger , never sitting with their back to the door , or never allowing themselves to be anywhere alone . This lasting reaction to trauma is what characterizes posttraumatic stress disorder ( A diagnosis of begins with the traumatic event itself . An individual must have been

Anxiety and Related Disorders 388 exposed to an involves actual death , serious injury , or sexual violence . To receive a diagnosis of , exposure to the event must include either directly experiencing the event , witnessing the event happening to someone else , learning that the event occurred to a close relative or friend , or having repeated or extreme exposure to details of the event ( such as in the case of first responders ) The person subsequently the event through both intrusive memories and nightmares . Some memories may come back so vividly that the person feels like they are experiencing the event all over again , what is known as having a flashback . The individual may avoid anything that reminds them of the trauma , including conversations , places , or even specific types of people . They may feel emotionally numb or restricted in their ability to feel , which may interfere in their interpersonal relationships . The person may not be able to remember certain aspects of what happened during the event . They may feel a sense ofa foreshortened future , that they will never marry , have a family , or live a long , full life . They may be jumpy or easily startled , hypervigilant to their surroundings , and quick to anger . The prevalence of among the population as a whole is relatively low , with having experienced at some point in their life ( Kessler , was previously categorized as an Anxiety Disorder , in the most recent version of the ( APA , 2013 ) it has been reclassified under the more specific category and Disorders . A person with is particularly sensitive to both internal and external cues that serve as reminders experience . For example , as we saw in , the physical sensations of arousal present during the initial trauma can become threatening in and of themselves , becoming a powerful reminder of the event . Someone might avoid watching intense or emotional movies in order to prevent the experience of emotional arousal . Avoidance of conversations , reminders , or even ofthe experience also be an attempt to avoid triggering internal cues . External stimuli that were present during the trauma can also become strong triggers . For example , ifa woman is raped by a man wearing a red , she may develop a strong alarm reaction to the sight of red shirts , or perhaps even more indiscriminately to anything with a similar color red . A combat veteran who experienced a strong smell of gasoline during a roadside bomb attack may have an intense alarm reaction when pumping gas back at home . Individuals with a psychological viewing the world as uncontrollable and unpredictable may particularly struggle with the possibility future , unpredictable traumatic events , fueling their need for and avoidance , and perpetuating the symptoms of . Disorder

Anxiety and Related Disorders 389 Have you ever had a strange thought pop into your mind , such as picturing the stranger next to you naked ?

Or maybe you walked past a crooked picture on the wall and could resist straightening it . Most people have occasional strange thoughts and may even engage in some behaviors , especially when they are stressed ( Boyer , 2008 et the behaviors are done ( or not done ) without a second thought . For someone with compulsive disorder ( OCD ) however , these thoughts and compulsive behaviors don come and go . Instead , strange or unusual thoughts are taken to mean something much more important and real , maybe even something dangerous or frightening . The urge to engage in some behavior , such as straightening a picture , can become so intense that it is nearly impossible not to carry it out , or causes significant anxiety if it ca be carried out . Further , someone with OCD might become preoccupied with the possibility that the behavior carried out to completion and feel compelled to repeat the behavior again and again , maybe several times before they are satisfied . To receive a diagnosis of OCD , a person must experience obsessive thoughts compulsions that seem irrational or nonsensical , but that keep coming into their mind . Some examples of obsessions include doubting thoughts ( such as doubting a door is locked or an appliance is turned off ) thoughts of contamination ( such as thinking that touching almost anything might give you cancer ) or aggressive thoughts or images that are unprovoked or nonsensical . Compulsions may be carried out in an attempt to neutralize some of these thoughts , providing temporary relief from the anxiety the obsessions cause , or they may be nonsensical in and of themselves . Either way , compulsions are distinct in that they must be repetitive or excessive , the person feels driven to carry out the behavior , and the person feels a great deal ifthey ca engage in the behavior . Some examples behaviors are repetitive washing ( often in response to contamination obsessions ) repetitive checking ( locks , door handles , appliances often in response to doubting obsessions ) ordering and arranging things to ensure symmetry , or doing things according to a specific ritual or sequence ( such as getting dressed or ready for bed in a specific order ) To meet diagnostic criteria for OCD , engaging in obsessions compulsions up a ofthe person time , at hour per day , and must cause significant distress or impairment in functioning . About of the population has met criteria for OCD over the course of a lifetime ( Kessler , 2005 ) see Table ) Whereas OCD was previously categorized reclassified under the more specific category and Related Disorders . People with OCD often confuse having an intrusive thought with their potential for carrying out the thought . Whereas most people when they have a strange or frightening thought are able to let it go , a person with OCD may become stuck on the thought and be intensely afraid

Anxiety and Related Disorders 390 that they might somehow lose control and act on it . Or worse , they believe that having the thought is just as bad as doing it . This is called fusion . For example , one patient of ours was plagued by thoughts that she would cause harm to her young daughter . She experienced intrusive images of throwing hot coffee in her daughter face or pushing her face underwater when she was giving her a bath . Where does productive organization end and compulsive behavior begin ?

If These images were so terrifying to the patient that she would no longer allow herself any physical contact with her daughter and would leave her daughter in the care of a babysitter if her husband or another family was not available to supervise her . In reality , the last thing she wanted to do was harm her daughter , and she had no intention or desire to act on the aggressive thoughts and images , nor does anybody with OCD act on these thoughts , but these thoughts were so horrifying to her that she made every attempt to prevent herself from the potential of carrying them out , even if it meant not being able to hold , cradle , or cuddle her daughter . These are the types of struggles people with OCD face every day . the behavior consumes more than an hour per day and causes distress it can be considered OCD . Photo man ) Treatments for Anxiety and Related Disorders Many successful treatments for anxiety and related disorders have been developed over the years . Medications ( drugs and antidepressants ) have been found to be beneficial for disorders other than specific phobia , but relapse rates are high once medications are stopped ( et , 1998 et , 2005 ) and some classes of medications ( minor tranquilizers or ) can be habit forming . cognitive behavioral therapies ( are effective psychosocial treatments for anxiety disorders , and many show greater treatment effects than medication in the long term ( In . Patients are taught skills to help identify and change problematic thought processes , beliefs , and behaviors that tend to worsen symptoms of anxiety , and practice applying these skills to life situations through exposure exercises . Patients learn how the automatic appraisals or

Anxiety and Related Disorders aims to help patients recognize and change problematic thoughts and behaviors in situations . A person with a fear of elevators would be encouraged to practice exposure exercises that might involve approaching or riding elevators to attempt to overcome their anxiety . Photo 391 thoughts they have about a situation affect both how they feel and how they behave . Similarly , patients learn how engaging in certain behaviors , such as avoiding situations , tends to strengthen the belief that the situation is something to be feared . A key aspect of is exposure exercises , in which the patient learns to gradually approach situations they find fearful or distressing , in orderto challenge their beliefs and learn new , less fearful associations about these situations . Typically 50 to 80 of patients receiving drugs or initial response , with the effect of more durable . Newer developments in the treatment of anxiety , such as the use of certain medications to enhance learning during ( Otto et , anxiety and related disorders , so too will our treatments advance , with the hopes that for the many people suffering from these disorders , anxiety can once again become something useful and adaptive , rather than something debilitating .

Anxiety and Related Disorders 392 Outside Resources American Psychological Association ( APA ) National Institutes of Mental Health ( Web Anxiety and Depression Association of America ( Web Center for Anxiety and Related Disorders ( CARD ) Discussion Questions . Name and describe the three main vulnerabilities contributing to the development of anxiety and related disorders . Do you think these disorders could develop out of biological factors alone ?

Could these disorders develop out of learning experiences alone ?

Many of the symptoms in anxiety and related disorders overlap with experiences most people have . What features differentiate someone with a disorder versus someone without ?

What is an alarm reaction ?

If someone experiences an alarm reaction when they are about to give a speech in front of a room full of people , would you consider this a true alarm or a false alarm ?

Many people are shy . What differentiates someone who is shy from someone with social anxiety disorder ?

Do you think shyness should be considered an anxiety disorder ?

Is anxiety ever helpful ?

What about worry ?

Anxiety and Related Disorders 393 Vocabulary Agoraphobia A sort disorder distinguished by feelings that a place is uncomfortable or may be unsafe because it is significantly open or crowded . Anxiety A mood state characterized by negative affect , muscle tension , and physical arousal in which a person apprehensively anticipates future danger or misfortune . Biological vulnerability A specific genetic and neurobiological factor that might predispose someone to develop anxiety disorders . Conditioned response A learned reaction following classical conditioning , or the process by which an event that automatically elicits a response is repeatedly paired with another neutral stimulus ( conditioned stimulus ) resulting in the ability of the neutral stimulus to elicit the same response on its own . External cues Stimuli in the outside world that serve as triggers for anxiety or as reminders of past traumatic events . Fight or flight response A biological reaction to alarming stressors that prepares the body to resist or escape a threat . Flashback Sudden , intense of a previous event , usually . Generalized anxiety disorder ( GAD ) Excessive worry about everyday things that is at a level that is out of proportion to the specific causes of worry . Internal bodily or somatic cues Physical sensations that serve as triggers for anxiety or as reminders of past traumatic events . Interoceptive avoidance

Anxiety and Related Disorders 394 Avoidance of situations or activities that produce sensations of physical arousal similar to those occurring during a panic attack or intense fear response . disorder ( OCD ) A disorder characterized by the desire to engage in certain behaviors excessively or compulsively in hopes of reducing anxiety . Behaviors include things such as cleaning , repeatedly opening and closing doors , hoarding , and obsessing over certain thoughts . Panic disorder ( A condition marked by regular strong panic attacks , and which may include significant levels of worry about future attacks . Posttraumatic stress disorder ( A sense of intense fear , triggered by memories of a past traumatic event , that another traumatic event might occur . may include feelings of isolation and emotional numbing . Psychological vulnerabilities Influences that our early experiences have on how we view the world . Reinforced response Following the process of operant conditioning , the strengthening of a response following either the delivery of a desired consequence ( positive reinforcement ) or escape from an aversive consequence . SAD performance only Social anxiety disorder which is limited to certain situations that the sufferer perceives as requiring some type of performance . Social anxiety disorder ( SAD ) A condition marked by acute fear of social situations which lead to worry and diminished day to day functioning . Specific vulnerabilities How our experiences lead us to focus and channel our anxiety . fusion The tendency to overestimate the relationship between a thought and an action , such that one mistakenly believes a bad thought is the equivalent of a bad action .

Anxiety and Related Disorders 395 References APA . 2013 ) Diagnostic and statistical manual of mental disorders ( Washington , American Psychiatric Association . 2001 ) Cognitive theories of generalized anxiety disorder . Psychiatric Clinics of North America , 24 ( vi . Antony , Barlow , 2002 ) Specific phobias . In Barlow ( Ed . Anxiety and its disorders The nature and treatment of anxiety and panic ( New York , NY Press . Richter , van der , Cultural Clinical Psychology Study , Group . 2003 ) Phobic anxiety in 11 nations . Part I Dimensional constancy of the model . Behaviour Research and Therapy , 41 ( 461 . Bar ow , 2002 ) Anxiety and its disorders The nature and treatment of anxiety and panic ( New York Press . Bar ow , 2007 ) Mastery ofyour anxiety and panic ( New York , NY Oxford University Press . Bar ow , 1995 ) Specific and social phobias . In Kaplan . Comprehensive textbook VI ( Baltimore , Williams Wilkins . Bar ow , Allen , 2007 ) treatments for panic disorders , phobias , and generalized anxiety disorder . In . Nathan . to treatments that work ( New York , NY Oxford University Press . Bar ow , Allen , 2011 ) Unified Protocol for the Treatment of Emotional Disorders ( Workbook ) New York , NY Oxford University Press . Bar ow , Shear , Woods , 2000 ) therapy , or their combination for panic disorder A randomized controlled of the American Medical Association , 283 ( 19 ) Alden , Clark , Pine , Stein , 201 ) Social anxiety disorder questions and answers for the Depression , 27 ( doi , Hu , 1990 ) The effect of worry on cardiovascular response to phobic imagery . Behaviour Research and Therapy , 28 ( 2004 ) Avoidance theory of worry and generalized

Anxiety and Related Disorders 396 anxiety disorder . In . Turk . Generalized Anxiety Disorder Advances in research and practice ( New York , NY Press . Diaz , 999 ) The role of positive beliefs about worry in generalized anxiety disorder and its treatment . Clinical Psychology and , Boyer , 2008 ) Ritual behavior in obsessive and normal individuals Moderating anxiety and reorganizing the flow of action . Current Directions in Psychological Science , 17 ( Bradley , White , Groom , de Bono , 999 ) Attentional bias for emotional faces in generalized anxiety disorder . Psychology , 38 ( Brown , White , Barlow , 2005 ) A psychometric reanalysis ofthe Albany Panic and Phobia Questionnaire . Behaviour Research and Therapy , 43 , 1994 ) Differences in perceptions of parental and personal characteristics between generalized and social Disorders , Cannon , 1929 ) Bodily changes in pain , hunger , fear and rage . Oxford , UK . Barlow , 1998 ) The development of anxiety the role of control in the early environment . Psychological Bulletin , 124 ( Clark , 1996 ) Panic disorder From theory to therapy . In ( Ed . of cognitive therapy ( New York , NY Press . Clark , 1986 ) A cognitive approach to panic . Behaviour Research and Therapy , 24 ( Barlow , 988 ) A review ofthe relationship between panic and avoidance . Clinical Review , Barlow , 2008 ) Panic disorder and agoraphobia . New York , NY Press . Antony , Barlow , 2006 ) and phobias Therapist guide . New York , NY Oxford University Press . Edge , Hyde , Goldin , Gross , 2012 ) Neural mechanisms underlying sensitivity to acute stress . American journal , 169 ( doi , 1998 ) Generalized anxiety disorder a preliminary test of a conceptual model . Behaviour Research and Therapy , 36 ( 2009 ) Phenomenology of stress disorder and acute stress

Anxiety and Related Disorders 397 disorder . In Anthony Stein ( Oxford Handbook Anxiety and Related Disorders . New York , NY Oxford University Press . 2009 ) Obsessions and compulsions in the community prevalence , interference , seeking , developmental stability , and psychiatric , 166 ( doi , Stein , 2009 ) Heritability and genetics disorders . In . Antony . Stein ( Oxford handbook of anxiety and related disorders . New York , NY Oxford University Press . Gunnar , Fisher , A . 2006 ) Bringing basic research on early experience and stress neurobiology to bear on preventive interventions for neglected and maltreated children . Developmental Psychopathology , 18 ( 651 . Hope , Holt , Klein , 1998 ) Cognitive behavioral group therapy phenelzine therapy for social phobia outcome . Archives of General Psychiatry , 55 ( 12 ) 2009 ) Phenomenology of panic and phobic disorders . In Antony Stein ( Oxford handbook of anxiety and related disorders ( New York , NY Oxford University Press . Barlow , 997 ) How specific are specific phobias ?

journal of Behavior Therapy and Experimental Psychiatry , 28 ( Shelton , Amsterdam , Salomon , Gallop , 2005 ) Prevention of relapse following cognitive therapy medications in moderate to severe depression . Archives of General Psychiatry , 62 ( doi Kessler , Jin , 2005 ) Lifetime prevalence and of disorders in the National Survey Replication . Archives of General Psychiatry , 62 ( doi Kessler , Chiu , Walters , 2005 ) Prevalence , severity , and inthe National Replication . Archives of General Psychiatry , 62 ( doi Kessler , Chiu , Jin , A . Shear , 2006 ) epidemiology of panic attacks , panic disorder , and agoraphobia in the National Survey of General Psychiatry , 63 ( doi Kessler , Hughes , Nelson , 1995 ) Posttraumatic stress

Anxiety and Related Disorders 398 disorder in the National Survey . Archives of General Psychiatry , 52 ( 12 ) Lieb , Stein , 2000 ) Parental psychopathology , parenting styles , and the risk of social phobia in offspring a longitudinal community study . Archives of General Psychiatry , 57 ( Antony , Liss , 2003 ) Preliminary examination of the relationship between anxiety disorders in adults and history of teasing or bullying experiences . Cognitive Behavior Therapy , 32 ( doi Myers , Anthony , 1984 ) prevalence of psychiatric disorders in three communities . Archives of General Psychiatry , 41 , Ost , 1992 ) Blood and injection phobia background and cognitive , physiological , and behavioral Psychology , 101 ( Otto , Simon , Pollack , 2010 ) Efficacy of for enhancing response to therapy for panic disorder . Biological Psychiatry , 67 ( doi 01 Page , Martin , 1998 ) Testing a genetic structure of fears . of Medical Genetics , 81 ( 997 ) Recall in social phobia and panic disorder comparison of mother and offspring reports . Depress Anxiety , George , 1996 ) Social Phobia . In , Frances , Ross , First Davis ( Vol . Washington , American Psychiatric Association . Shear , Brown , Barlow , Money , Woods , A . 1997 ) collaborative panic disorder severity scale . American journal of Psychiatry 154 ( 11 ) Block , Young , 2009 ) Genetics disorders the complex road from to DNA . Depression , 26 ( 11 ) doi Suarez , Bennett , Barlow , 2009 ) Understanding anxiety disorders from a triple vulnerabilities framework . In . Antony . Stein ( Oxford Handbook of anxiety and related disorders ( New York , NY Oxford University Press . Wells , A . 2002 ) GAD , and mindfulness An information processing analysis .

Anxiety and Related Disorders 399 Clinical Psychology Science and Practice , 23 Mood Disorders Anda Renee Thompson Everyone feels down or euphoric from time to time , but this is different from having a mood disorder such as major depressive disorder or bipolar disorder . Mood disorders are extended periods , euphoric , or irritable moods that in combination with other symptoms cause the person significant distress and interfere with his or her daily life , often resulting in social and occupational difficulties . In this module , we describe major mood disorders , including their symptom presentations , general prevalence rates , and how and why the rates of these disorders tend to vary by age , gender , and race . In addition , biological and environmental risk factors that have been implicated in the development and course of mood disorders , such as heritability and stressful life events , are reviewed . Finally , we provide an overview of treatments for mood disorders , covering treatments with demonstrated effectiveness , as well as new treatment options showing promise . Learning Objectives Describe the diagnostic criteria for mood disorders . Understand age , gender , and ethnic differences in prevalence rates of mood disorders . Identify common risk factors for mood disorders . Know effective treatments of mood disorders . The actress Brooke Shields published a memoir titled Down Came the Rain My Journey following the birth of her daughter . Despite the fact that about one in 20 women experience

Mood Disorders 401 depression birth ofa baby ( American Af , postpartum renamed depression to be veiled by stigma , owing in part to a widely held expectation that motherhood should be a time of . In an opinion piece in the New York Times , Shields revealed that entering motherhood was a profoundly overwhelming experience for her . She vividly describes experiencing a sense of doom and dread in response to her newborn baby . Because motherhood is conventionally thought of as a joyous event and not associated with sadness and hopelessness , responding to a newborn baby in this way can be shocking to the new mother as well as those close to her . It may also involve a great deal for the mother , making her reluctant to divulge her experience to others , including her doctors and family . Feelings of shame are not unique to depression . Stigma applies to other types of depressive and bipolar disorders and contributes to people not always receiving the necessary support and disorders . In fact , the World Health Organization ranks both major depressive disorder ( and bipolar disorder ( among the top . Further , and carry a high risk of depression following child birth afflicts about ofall suicide is estimated that 25 of mothers . An unfortunate social stigma regarding this form of people diagnosed with will attempt suicide at least once in their lifetimes ( Goodwin , 2007 ) depression compounds the problem forthe women who suffer its effects . Quinn What Are Mood Disorders ?

Mood Episodes Everyone experiences brief periods of sadness , irritability , or euphoria . This is different than having a mood disorder , such as or , which are characterized by a constellation of symptoms that causes people significant distress or impairs their everyday functioning . Major Depressive episode ( for at least two weeks and cause significant distress or impairment in functioning , such as interfering with work , school , or relationships . Core symptoms include feeling down or

Mood Disorders 402 depressed or experiencing or pleasure in things that one typically enjoys . According to the fifth edition ofthe Diagnostic Manual ( the criteria for an require five or more ofthe following nine symptoms , including one or both ofthe first two symptoms , for most of the day , nearly every day . depressed mood diminished interest or pleasure in almost all activities significant weight loss or gain or an increase or decrease in appetite insomnia or hypersomnia psychomotor agitation or retardation fatigue or loss of energy feeling worthless or excessive or inappropriate guilt diminished ability to concentrate or indecisiveness ! recurrent thoughts of death , suicidal ideation , or a suicide attempt These symptoms can not be caused by physiological effects ofa substance or a general medical condition ( hypothyroidism ) Manic or Hypomanic core criterion for a manic or hypomanic episode is a distinct period and persistently euphoric , expansive , or irritable mood and persistently increased activity or energy . The mood disturbance must be present for one week or longer in mania ( unless hospitalization is required ) or four days or longer in hypomania . Concurrently , at least three of the following symptoms must be present in the context of euphoric mood ( or at least four in the context of irritable mood ) inflated or grandiosity . increased activity or psychomotor agitation . reduced need for sleep . distractibility racing thoughts or flight of ideas increased talkativeness . excessive involvement in risky behaviors Manic episodes are distinguished from hypomanic episodes by their duration and associated

Mood Disorders 403 impairment whereas manic episodes must last one week and are defined by a significant impairment in functioning , hypomanic episodes are shorter and not necessarily accompanied by impairment in functioning . Mood Disorders Unipolar Mood major types of unipolar disorders described bythe ( APA , is defined by one or more , but no history of manic or hypomanic episodes . Criteria for are feeling depressed most ofthe day for more days than not , for at least two years . At least two of the following symptoms are also required to meet criteria for poor appetite or overeating insomnia or hypersomnia low energy or fatigue low poor concentration or difficulty making decisions ' feelings of hopelessness Like , these symptoms need to cause significant distress or impairment and can not be due to the effects of a substance or a general medical condition . To meet criteria for , a person can not be without more than two months ata time . has overlapping symptoms with . If someone meets criteria for an during a episode , the person will receive diagnoses of and . Bipolar Mood major types of are described by the ( Bipolar I Disorder ( I ) which was previously known as , is characterized by a single ( or recurrent ) manic episode . A depressive episode is not necessary but commonly present for the diagnosis Bipolar Disorder Bipolar disorders are characterized by cycles of high energy and characterized by single ( or recurrent ) depression .

Mood Disorders 404 hypomanic episodes and depressive episodes . Another type of is cyclothymic disorder , characterized by numerous and alternating periods of hypomania and depression , lasting at least two years . To qualify for cyclothymic disorder , the periods of depression can not meet full diagnostic criteria for an the person must experience symptoms at least half the time with no more than two consecutive months and the symptoms must cause significant distress or impairment . It is important to note that the was published in 2013 , and findings based the Updated manual Will be Both and manic episodes can be further described using the standardized tags based on the timing of , or her symptoms that presented below Was largely based On are occurring during , the mood episode , to diagnostic a similar , but not identical , conceptualization and inform treatment . Psychotic features is disorders drawn from the when the episodes are accompanied by del ( held ( APA , 2000 ) beliefs that are false ) or hallucinations ( perceptual disturbances that are not based in reality ) Seasonal pattern is when HOW Common Are Mood a mood episode occurs at the same time the year or two consecutive commonly in the all and ?

who Develops winter . onset when a mood episode hasan Mood Disorders ?

pregnancy the birth . Approximately of women who have a child experience an with onset ( APA , 2013 ) his is less and different from the baby blues or when women feel transient mood symptoms usually within 10 days birth , which are In a nationally representative sample , experienced by ( lifetime prevalence rate for is ( Kessler , jin , Depressive Disorders criteria for during their lifetime . The proportion of people who meet criteria for a disorder during a is approximately ( ARA ! Although the onset of can occur at any time throughout the lifespan , the average age of onset is , with the age of onset decreasing with people born more recently ( APA , widely . Recovery begins within three months for 40 of people with and within 12 months for 80 ( APA , 2013 ) tends to be a recurrent disorder with about 40 of

Mood Disorders 405 earlier age of onset predicts a worse course . About of people who experience an will later experience a manic episode ( thus no longer meeting criteria for but instead meeting them for I . Diagnoses of other disorders across the lifetime are common for people with 59 experience an anxiety disorder 32 experience an impulse control disorder , and 24 experience a substance use disorder ( Kessler , Wang , 2007 ) economic and social position based on income , education , and occupation . Higher prevalence rates of are associated with lower SES ( Robert , of SES , results from a nationally representative sample found that European Americans had a higher prevalence rate of than did African Americans and Hispanic Americans , whose rates were similar ( BYE ?

The course Americans is often more severe and less often treated than it is for European Americans , however ( Williams et , 2007 ) Native Americans have a higher prevalence rate found in all countries that have been examined , although the symptom presentation as well as prevalence rates vary across cultures ( Bipolar Disorders The lifetime prevalence rate of bipolar spectrum disorders in the general population is estimated at approximately , with I constituting about of this rate than do adults . Making matters worse , those who are diagnosed with Prevalence seem to estimates , however , are highly . dependent on the diagnostic Adolescents experience a higher incidence of bipolar spectrum disorders

Mood Disorders 406 procedures used ( interviews ) and whether or not forms of the disorder are included in the estimate . often with other psychiatric disorders . Approximately 65 of people with meet diagnostic criteria for at least one additional psychiatric disorder , most commonly anxiety disorders and substance use disorders ( study sample of more than adults from 11 countries , estimated the worldwide prevalence of at , with I constituting ofthis rate ( In this study , the prevalence of varied somewhat by country . Whereas the United States had the highest lifetime prevalence ( India had the lowest ( Variation in prevalence rates was not necessarily related to SES , as in the case , a country with a very low prevalence rate of ( With regard to ethnicity , data from studies not confounded by SES or inaccuracies in diagnosis are limited , but available reports suggest rates of among European Americans are similar to those found Americans ( and ( that although prevalence rates disorders were similar across ethnic groups , Hispanic Americans and African Americans with a mood disorder were more likely to remain persistently ill than European Americans ( Compared with European Americans with , African to be for ( and for schizophrenia ) Haas , Bauer , 2004 , Vega , Gara , Escobar , Misdiagnosis of can result in the of treatment or the utilization of inappropriate treatment , and thus profoundly impact the course of illness . As with , adolescence is known to be a significant risk period for mood symptoms start by adolescence in roughly half of cases ( Longitudinal studies diagnosed with adulthood experience a more pernicious course of illness relative to those with adult onset , including more episode recurrence , higher rates of , and profound social , occupational , and economic repercussions ( Buckley , Klein , 2002 ) The prevalence of is What Are Some of the Factors Implicated in the Development and Course of Mood Disorders ?

Mood Disorders 407 Mood disorders are complex disorders resulting from multiple factors . Causal explanations can be attempted at various levels , including biological and psychosocial levels . Below are several of the key factors that contribute to onset and course of mood disorders are highlighted . Depressive Disorders Research across family and twin studies has provided support that genetic factors are implicated in the development of . Twin studies suggest that familial influence on is mostly due to genetic effects and that mental effects ( romantic relationships ) play an important role , too . By contrast , the contribution of shared environmental effect by siblings is negligible ( Sullivan , The mode Of Romantic relationships can affect mood as in the case of divorce or the inheritance is not fully understood death ofa spouse . Photo although no single genetic variation has been found to increase the risk of significantly . Instead , several genetic variants and environmental factors most likely contribute to the risk for ( One environmental stressor that has received much support in relation to is stressful life events . In particular , severe stressful life that have consequences and involve loss of a significant relationship ( divorce ) or economic stability ( unemployment ) are strongly related to depression ( Stressful life events are more likely to predict the first than subsequent episodes ( Allen , 1999 ) In contrast , minor events may play a larger role in Depression research has not been limited to examining stressful life events . Much research , particularly brain imagining research using functional magnetic resonance imaging ( fMRI ) has centered on examining neural that allow multiple brain regions to perceive , generate , and encode information in concert . A of studies showed that when viewing negative stimuli ( picture of an angry

Mood Disorders 408 face , picture of a car accident ) compared with healthy control participants , participants with have greater activation in brain regions involved in stress response and reduced activation regions involved in positively motivated behaviors ( Other environmental factors related to increased risk for include experiencing early adversity ( childhood abuse or neglect , chronic stress ( poverty ) and interpersonal factors . For example , marital dissatisfaction predicts increases in depressive symptoms in both men and women . On the other hand , depressive symptoms also predict increases in marital dissatisfaction ( Research has found that people with generate some of their interpersonal stress ( People with whose relatives or spouses can be described as critical and emotionally have higher relapse rates than do those living with people who are less critical and emotionally ( People styles or their general ways of thinking , interpreting , and recalling information have also been examined in the etiology of ( People with a pessimistic style tend to make internal ( versus external ) global ( versus specific ) and stable ( versus unstable ) to negative events , serving as a vulnerability to developing . For example , someone who when he fails an exam thinks ( that heis stupid ( global ) and that do ( stable ) has a pessimistic attribution style . Several influential theories of depression incorporate ( Bipolar Disorders Although there have been important advances in research on the etiology , course , and treatment of , there remains a need to understand the mechanisms that contribute to episode onset and relapse . There is compelling evidence for biological causes of , which is to be highly heritable ( may be argued that a high rate of heritability demonstrates that is fundamentally a biological phenomenon . However , there is much variability in the course of both within a person across time and across people ( The triggers that determine how and when this genetic vulnerability is expressed are not yet understood however , there is evidence to suggest that psychosocial triggers may play an important role in risk ( 2008 et , 1998 ) In addition to the genetic contribution , biological explanations of have also focused on

Mood Disorders 409 brain function . Many of the studies using techniques to characterize have focused on the processing stimuli based on the idea that is fundamentally a disorder of emotion ( Findings show that regions of the brain thought to be involved in emotional processing and regulation are activated differently in people with relative to healthy ' However , there is little consensus as to whether a particular brain region becomes more or less active in response to an emotional stimulus among people with compared with healthy controls . Mixed findings are in part due to samples consisting of participants who are phases of illness at the time of testing ( manic , depressed , Sample sizes tend to be relatively small , making comparisons between difficult . Additionally , the use ofa standardized stimulus ( facial expression ) may not elicit a sufficiently strong response . Personally engaging stimuli , such as recalling a memory , may be more effective in inducing strong emotions ( Johnson , 2013 ) Within the psychosocial level , research has focused on the environmental contributors to . A series of studies show that environmental stressors , particularly severe stressors ( loss of a significant relationship ) can adversely impact the course of . People with have substantially increased risk of relapse ( Brown , 1990 ) and following a severe life stressor . Interestingly , positive life events can also adversely impact the course of . People with suffer more manic symptoms after life events involving attainment ofa desired goal ( Johnson et , 2008 ) Such findings suggest that people with may have a hypersensitivity to rewards . Evidence from the life stress literature has also suggested that people with mood disorders may have a circadian vulnerability that renders them sensitive to stressors that disrupt their sleep or rhythms . According to social theory ( Frank , 1988 Frank biological clock ( meal times ) can trigger episode relapse . Consistent with this theory , studies have shown that life events that involve a disruption in sleep and daily routines , such as overnight travel , can increase bipolar symptoms in people with ( et What Are Some of the Treatments for Mood Disorders ?

Mood Disorders 410 Depressive Disorders There are many treatment options available for people with . First , a number of antidepressant medications are available , all of which target one or more of the neurotransmitters implicated in earliest antidepressant medications were monoamine oxidase inhibitors ( inhibit monoamine oxidase , an enzyme involved in deactivating dopamine , norepinephrine , and serotonin . Although effective in treating depression , can have serious side effects . Patients taking may develop dangerously high blood pressure if they take certain drugs ( antihistamines ) or eat foods containing A number of medications are effective in treating mood disorders . Meditation , exercise , counseling and other therapies also show effectiveness for some disorders . tyramine , an amino acid commonly found in foods such as aged cheeses , wine , and soy sauce . the class of antidepressant medications , block the reabsorption of norepinephrine , serotonin , or dopamine at synapses , resulting in their increased availability . are most effective for treating vegetative and somatic symptoms . Like , they have serious side effects , the most concerning of which is being cardiotoxic . Selective serotonin reuptake inhibitors ( and serotonin and norepinephrine reuptake inhibitors ( are the most recently introduced antidepressant medications . the most commonly prescribed antidepressant medication , block the reabsorption of serotonin , whereas block the reabsorption of serotonin and norepinephrine . and have fewer serious side effects than do and . In particular , theyare less cardiotoxic , less lethal in overdose , and produce fewer cognitive . They are not , however , without their own side effects , which include but are not limited to difficulty having orgasms , gastrointestinal issues , and insomnia . Other biological treatments for people with depression include electroconvulsive therapy ( transcranial magnetic stimulation ( and deep brain stimulation . involves inducing a seizure after a patient takes muscle relaxants and is under general anesthesia . is viable treatment for patients with severe depression or who show resistance to antidepressants although the mechanisms through which it works remain unknown . A common side effect is confusion and memory loss , usually (

Mood Disorders 411 ! Ve noninvasive technique administered while a patient is awake . Brief pulsating magnetic fields are delivered to the cortex , inducing electrical activity . has fewer side effects than ( and while outcome studies are mixed , there is evidence is a promising treatment for patients with who have shown resistance to other treatments ( Most recently , deep brain stimulation is being examined as a treatment option for patients who did not respond to more traditional treatments like those already described . Deep brain stimulation involves implanting an electrode in the brain . The electrode is connected to an implanted , which electrically stimulates that particular brain region . Although there is some evidence of its effectiveness ( additional research is needed . Several psychosocial treatments have received strong empirical support , meaning that independent investigations have achieved similarly positive high threshold for examining treatment outcomes . These treatments include but are not limited to behavior therapy , cognitive therapy , and interpersonal therapy . Behavior therapies focus on increasing the quality that are pleasant or help the patient achieve mastery . Cognitive therapies primarily focus on helping patients identify and change distorted automatic thoughts and assumptions ( therapies are based on the rationale , behaviors , and emotions affect and are affected by each other . Interpersonal Therapy for Depression focuses largely on improving interpersonal relationships by targeting problem areas , specifically unresolved grief , interpersonal role disputes , role transitions , and interpersonal deficits . Finally , there is also some support for the effectiveness of Psychodynamic Therapy for Depression ( The treatment focuses on a limited number of important issues , and the therapist tends to be more actively involved than in more traditional psychodynamic therapy . Bipolar Disorders Patients with are typically treated with pharmacotherapy . Antidepressants such as and are the primary choice for depression , whereas for , lithium is the first line treatment choice . This is because and have the potential to induce mania or hypomania in patients with . Lithium acts on several neurotransmitter systems in the brain through complex mechanisms , including reduction of excitatory ( dopamine and glutamate ) and increasing ( Lenox

Mood Disorders 412 Harvey , 2009 ) as well as physical symptoms such as nausea , tremor , weight however , medication noncompliance remains an ongoing concern in the treatment of patients with medications ( are also commonly used to treat patients with , either alone or in conjunction with lithium . There are several adjunctive treatment options for people with . Interpersonal and social rhythm therapy ( is a psychosocial intervention focused on addressing the mechanism of action posited in social theory to predispose patients who have to relapse , namely sleep disruption . A growing body of literature provides support for the central role of sleep in ( Consistent with this literature , aims to increase rhythmicity of patients lives and encourage vigilance in maintaining a stable rhythm . The therapist and patient work to develop and maintain a healthy balance and stimulation such that the patient does not become overly active ( by taking on too many projects ) or inactive ( by avoiding social contact ) The efficacy of has been demonstrated in that patients who received this treatment show reduced risk of episode recurrence and are more likely to remain well ( Frank et , 2005 ) Conclusion Everyone feels down or euphoric from time to time . For some people , these feelings can last for long periods of time and can also with other symptoms that , in combination , interfere with their everyday lives . When people experience an or a manic episode , they see the world differently . During an , people often feel hopeless about the future , and may even experience suicidal thoughts . During a manic episode , people often behave in ways risky or place them in danger . They may spend money excessively or have unprotected sex , often expressing deep shame over these decisions after the episode . and cause significant problems for people at school , at work , and in their relationships and affect people regardless , age , nationality , race , religion , or sexual orientation . Ifyou or someone you know is suffering from a mood disorder , it is important to seek help . Effective treatments are available and continually improving . Ifyou have an interest in mood disorders , there are many ways to contribute to their understanding , prevention , and treatment , whether by engaging in research or clinical work .

Mood Disorders 413 Outside Resources Books Recommended memoirs include A Memoir of Madness by William ( Noonday Demon An Atlas of Depression by Andrew Solomon ( and An Unquiet Mind A Memoir of Moods and Madness by Kay ( Web Visit the Association for Behavioral and Cognitive Therapies to find a list of the recommended therapists and treatments . Web Visit the Depression and Bipolar Support Alliance for educational information and social support options . Discussion Questions . What factors might explain the large gender difference in the prevalence rates of ?

Why might American ethnic experience more persistent than European Americans ?

Why might the age of onset for be decreasing over time ?

Why might overnight travel constitute a potential risk for a person with ?

What are some reasons positive life events may precede the occurrence of manic episode ?

Mood Disorders 414 Vocabulary Anhedonia Loss of interest or pleasure in activities one previously found enjoyable or rewarding . style The tendency by which a person the cause or meaning of behaviors or events . Chronic stress Discrete or related problematic events and conditions which persist over time and result in prolonged activation of the biological psychological stress response ( unemployment , ongoing health difficulties , marital discord ) Early adversity Single or multiple acute or chronic stressful events , which may be biological or psychological in nature ( poverty , abuse , childhood illness or injury ) occurring during childhood and resulting in a biological psychological stress response . Grandiosity Inflated or an exaggerated sense and ( believing one has special powers or superior abilities ) Hypersomnia Excessive daytime sleepiness , including difficulty staying awake or napping , or prolonged sleep episodes . Psychomotor agitation Increased motor activity associated with restlessness , including physical actions ( fidgeting , pacing , feet tapping , Psychomotor retardation A slowing of physical activities in which routine activities ( eating , brushing teeth ) are performed in an unusually slow manner . Social is German for time Social are environmental cues , such as meal times and interactions with other people , that entrain biological rhythms and thus cycle regularity .

Mood Disorders 415 Socioeconomic status ( SES ) A person economic and social position based on income , education , and occupation . Suicidal ideation Recurring thoughts about suicide , including considering or planning for suicide , or preoccupation with suicide .

Mood Disorders 416 References , 1978 ) Learned helplessness in humans Critique and reformulation . journal of Abnormal Psychology , 87 , doi , Alloy , 1989 ) Hopelessness depression subtype . Psychological Review , 96 , doi , Townsend , Cohen , 2008 ) Regional brain changes in bipolar I depression A functional magnetic resonance imaging study . Bipolar Disorders , 10 , doi American Psychiatric Association . 2013 ) Diagnostic and statistical manual disorders ( Washington , Author . American Psychiatric Association . 2000 ) Diagnostic and statistical manual disorders ( text ) Washington , Author . Beck , 1967 ) Depression Clinical , experimental , and theoretical aspects . New York , NY . Blazer , George , et al . 1985 ) Psychiatric disorders . A comparison . Archives of General Psychiatry , 42 , doi , Su , Williams , Kessler , 2006 ) Specifying differences in risk for psychiatric disorder in a US national sample . Psychological Medicine , 36 , doi , Su , Kessler , 2005 ) Lifetime risk and persistence of psychiatric disorders across ethnic groups in the United States . Psychological Medicine , 35 , doi Brown , Harris , 1989 ) Life events and illness . New York , NY Press . 1998 ) Expressed emotion and psychiatric relapse A analysis . Archives of General Psychiatry , 55 , doi , 2009 ) Understanding depression across cultures . In . Handbook ( New York , NY Press . Rudolph , 2009 ) The emerging sex difference in adolescent depression Interacting contributions of puberty and peer stress . Psychopathology , 21 , doi

Mood Disorders 417 Du , 2000 ) Optimizing lithium of Clinical Psychiatry , 61 ( Frank , 1988 ) Social and biological rhythms a unified approach to understanding the etiology of depression . Archives of General Psychiatry , 45 , doi , Brown , 1990 ) Life events and the course of bipolar disorder . of Psychiatry , 147 , Frank , Monk , Carter , et al . 1994 ) Interpersonal and social rhythm therapy for bipolar disorder Integrating interpersonal and behavioral approaches . Behavior Therapy , 17 , Frank , et al . 2005 ) outcomes for interpersonal and social rhythm therapy in individuals with bipolar I disorder . Archives Psychiatry , 62 , doi , Burgess , Goodwin , 2004 ) lithium systematic of randomized controlled 161 , doi , Hernandez , et al . 2007 ) Factors associated with stigma among caregivers of patients with bipolar disorder in the study . Psychiatric Services , 58 , doi Goodwin , 2007 ) illness Bipolar disorders and recurrent depression . New York , NY Oxford University Press . 2010 ) Cognition and depression Current status and future directions . Annual Review of Clinical Psychology , doi . Hamilton , Johnson , 2012 ) Functional of major depressive disorder A and new integration of baseline activation and neural response , 169 , 2005 ) Stress and depression . Annual Review of Clinical Psychology , Harvey , 2008 ) Sleep and Circadian Rhythms in Bipolar Disorder Seeking synchrony , harmony and regulation . of Psychiatry , 165 , doi . Goodwin , Grant , 2005 ) depressive disorder Results from the National Epidemiological Survey on Alcoholism and Related Psychiatry ,

Mood Disorders 418 Hassel , Almeida , Kerr , et al . 2008 ) Elevated striatal and decreased dorsolateral prefrontal cortical activity in response to emotional stimuli in bipolar disorder No associations with psychotropic medication load . Bipolar Disorders , 10 , doi , Johnson , 2013 ) Emotion in aging and bipolar disorder Similarities , differences and lessons for further research . Emotion Review , doi Johnson , 2005 ) Mania and in goal pursuit A review . Clinical Psychology Review , 25 , doi Johnson , White , et al . 2008 ) Life events as of mania and depression in bipolar I of Abnormal Psychology , 117 , doi Johnson , Meyer , Greenhouse , Miller , I . 999 ) Social support and the course of bipolar disorder . journal of Abnormal Psychology , 108 , doi Kessler , Jim , 2005 ) Lifetime prevalence and of disorders in the National Survey Replication . Archives of General Psychiatry , 62 , doi Kessler , Hwang , 2010 ) Age differences in the National Replication ( Psychological Medicine , 40 , doi Kessler , Wang , 2007 ) Prevalence , and service utilization for mood disorders in the United States at the beginning of the century . Annual Review of Clinical Psychology , doi , Haas , Bauer , A . 2004 ) Concurrent psychiatric diagnoses by age and race among persons with bipolar disorder . Psychiatric Services , 55 , doi , 2001 ) Comparative effects psychodynamic psychotherapy and therapy in depression A approach . Clinical Psychology Review , 27 , doi ( 99 ) Lennox , Jacob , Calder , 2004 ) Behavioural and responses to sad facial affect are attenuated in patients with mania . Psychological Medicine , 34 , doi Lenox , Hahn ( 2000 ) Overview ofthe mechanism of lithium in the brain

Mood Disorders 419 of Clinical Psychiatry , 61 ( 59 ) Keck , et al . 2003 ) Factors associated with suicide attempts in 648 patients with bipolar disorder in the Stanley Foundation Bipolar of Clinical Psychiatry , 64 , doi . Post , Keck , et al . 2007 ) The poor prognosis bipolar Pediatrics , 150 , doi , Allen , 1999 ) First onset versus recurrence of depression differential processes of psychosocial Psychology , 108 , doi , Buckley , Klein , 2002 ) Bipolar disorder in adolescence and young adulthood . Child Adolescent Psychiatric Clinics of North America , 11 , doi ( 02 ) 2010 ) Overview of genetics of major depressive disorder . Current Psychiatry Reports , 12 , doi , Robert , A . 2003 ) Socioeconomic inequalities in depression A . Epidemiology , 157 , doi , Frank , Anderson , Patterson , 998 ) Stressful life events and social rhythm disruption in the onset of manic and depressive bipolar episodes a preliminary investigation . Archives of General Psychiatry , 55 , doi , Kennedy , 2005 ) Deep brain stimulation for depression . Neuron , 45 , doi , Keck , et al . 2001 ) Axis I psychiatric and its relationship to historical illness variables in 288 patients with bipolar disorder . 158 , doi , Andrew , Sham , A . 2003 ) The heritability of bipolar affective disorder and the genetic relationship to unipolar depression . Archives of General Psychiatry , 60 , doi , Angst , et al . 2007 ) Lifetime and prevalence of bipolar spectrum disorder in the National

Mood Disorders 420 Survey replication . Archives of General Psychiatry , 64 , doi , Jin , He , Kessler , Lee , et al . 201 ) Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative . Archives of General Psychiatry , 68 , doi , Vega , Gara , Escobar , 2003 ) Diagnostic patterns in Latino , African American , and European American psychiatric patients . Archives of General Psychiatry , 60 , doi , 201 ) Recurrence in major depression analysis . Psychological Review , 118 , doi , 2005 ) Life stress , the hypothesis , and the recurrence of depression Considerations from a life stress perspective . Psychological Review , 112 , doi , 2009 ) The social environment and life stress in depression . In , New York , NY Press . Hilt , 2009 ) Gender differences in depression . In , Handbook ( New York , NY Press . 2004 ) implications of early onset in bipolar disorder data from the first 1000 participants in the systematic treatment enhancement program for bipolar disorder ( Biological Psychiatry , 55 , doi Rosa , Rosa , A . 2006 ) Comparison transcranial magnetic stimulation and electroconvulsive therapy in unipolar refractory depression a randomized , study . International journal of , doi , Harms , Wagner , 2005 ) Distinctive effects of repetitive transcranial magnetic stimulation and electroconvulsive therapy in major depression . of Psychiatry , 186 , Shields , 2005 ) Down Came the Rain Through Postpartum Depression . New York Hyperion . Sullivan , 2000 ) Genetic epidemiology of major depression

Mood Disorders 421 Review and . American journal of Psychiatry , 157 , doi , 2002 ) gender , race , SES , and birth on the Children Depression Inventory A Psychology , 111 , doi , A . 2009 ) Prospective associations between marital discord and depressive symptoms in and older adults . Psychology , doi , 2007 ) A prospective investigation of major depressive disorder and in abused and neglected children grown up . Archives Psychiatry , 64 , doi Williams , Neighbors , jackson , 2007 ) Prevalence and distribution depressive disorder in African Americans , Caribbean blacks , and whites Results from the National Survey ofAmerican Life . Archives of General Psychiatry , 64 , doi , Harvey , 2009 ) Effects on cognitive performance a of Clinical Psychiatry , 70 , doi

24 Dissociative Disorders van van der In psychopathology , dissociation happens when thoughts , feelings , and experiences of our consciousness and memory do not collaborate well with each other . This module provides an overview of dissociative disorders , including the definitions , its origins and competing theories , and their relation to traumatic experiences and sleep problems . Learning Objectives Define the basic terminology and historical origins of dissociative symptoms and dissociative disorders . Describe the posttraumatic model of dissociation and the model , and the controversies and debate between these competing theories . What is the innovative angle of the model ?

How can the two models be combined into one conceptual scheme ?

Introduction Think about the last time you were daydreaming . Perhaps it was while you were driving or attending class . Some portion ofyour attention was on the activity at hand , but most ofyour conscious mind was wrapped up in fantasy . Now imagine that you could not control your daydreams . What if they intruded your waking consciousness unannounced , causing you to lose track of reality or experience the loss of time . Imagine how difficult it would be for you . This is similar to what people who suffer from dissociative disorders may experience . Ofthe

Dissociative Disorders 423 many disorders listed in the Diagnostic and Statistical Manual of Mental Disorders ( dissociative disorders rank as among the most puzzling and controversial . Dissociative disorders encompass an array of symptoms ranging from memory loss ( amnesia ) for autobiographical events , to changes in identity and the experience of everyday reality ( American Psychiatric Association , 2013 ) Is it real ?

Let start with a little history . Multiple personality disorder , or dissociative identity it is known to be a mere curiosity . This is a disorder in which people present with more than one personality . For example , at times they might act and identify as an adult while at other times they might identify and behave like a Dissociative disorders are often exaggerated when portrayed in television and The disorder was movies however , there is concrete evidence that people do suffer from these rarely diagnosed the disorders . Lopez 19805 . That when multiple personality disorder became an official diagnosis in the . From then on , the numbers of multiples increased rapidly . In the , there were hundreds of people diagnosed with multiple personality in every major city in the United States ( How could this epidemic be explained ?

One possible explanation might be the media attention that was given to the disorder . It all started with the book The Three Faces ( This book , and later the movie , was one of the first to speak of multiple personality disorder . However , it until years later , when the fictional as told to book of Sybil ( sier , became known worldwide , that the prototype ofwhat it was like to be a multiple personality was born . Sybil tells the story of how a the different personalities of her patient Sybil during a long course of treatment ( over office hours ! She was one ofthe first to relate multiple personality to childhood sexual abuse . Probably , this relation between childhood abuse and dissociation has fueled the increase of numbers of multiples from that

Dissociative Disorders 424 time on . It motivated therapists to actively seek for clues of childhood abuse in their dissociative patients . This suited well within the mindset of the 19805 , as childhood abuse was a sensitive issue then in psychology as well as in politics ( From then on , many movies and books were made on the subject of multiple personality , and nowadays , we see patients with dissociative identity disorder as guests visiting the Oprah show , as if they were our circus acts . Defining dissociation The defines dissociation as a disruption discontinuity in the normal integration , memory , identity , emotion , perception , body representation , motor control and behavior ( American Psychiatric Association , 2013 , 291 ) A distinction is often made State dissociation is viewed as a transient symptom , which lasts for a few minutes or hours ( dissociation during a traumatic event ) Trait dissociation is viewed as an integral aspect of personality . Dissociative symptoms occur in patients but also in the general population , like you and me . Therefore , dissociation has commonly been as ranging on a continuum , from manifestations of daydreaming to more severe disturbances typical of dissociative disorders ( 1986 ) The dissociative disorders include . Dissociative Amnesia ( extensive forgetting typically associated with highly aversive events ) Dissociative Fugue ( reversible amnesia for personal identity , involving unplanned travel or bewildered wandering . Dissociative fugue is not viewed as a separate disorder but is a feature of some , but not all , cases of dissociative amnesia ) Disorder ( feeling as though one is an outside observer of one body ) and . Dissociative Identity Disorder ( DID experiencing two or more distinct identities that recurrently take control over one behavior ) Although the concept of dissociation lacks a generally accepted definition , the Structural Clinical Interview for Dissociative Disorders ( assesses five symptom clusters that encompass key features of the dissociative disorders . These clusters are also found in the depersonalization ,

Dissociative Disorders 425 , dissociative amnesia , identity confusion , and ' identity alteration . Depersonalization refers to a feeling of detachment or estrangement from one self . Imagine that you are outside of your own body , looking at yourself from a distance as though you were looking at somebody else . Maybe you can also imagine what it would be like if you felt like a robot , deprived of all feelings . These are examples of depersonalization . is defined as an Have you ever said a word so many times that it no longer seemed real to you ?

is a similar experience , but one that applies to all of reality . alteration in the ofone surroundings so that a sense of reality of the external world is lost ( 101 ) Imagine that the world around you seems as if you are living in a movie , or looking through a fog . These are examples of , Dissociative amnesia does not refer to permanent memory loss , similar to the erasure of a computer disk , but rather to the hypothetical disconnection of memories from conscious inspection ( Thus , the memory is still there somewhere , but you can not reach it . Identity confusion is defined by as thoughts and feelings of uncertainty and conflict a person has related to his or her identity ( 2001 , 101 ) whereas identity Dissociative disorders are not as uncommon as you would expect . Several studies in a variety of patient groups show that dissociative disorders are prevalent in a range ( Ross , Studies generally find a much lower prevalence in the general population , with rates in the order ( Lee , Hunter , Richards , David , 2010 Lynn , 1995

Dissociative Disorders 426 , Importantly , dissociative symptoms are not limited to the dissociative disorders . Certain diagnostic groups , notably patients with borderline personality disorder , posttraumatic stress disorder ( disorder ( Held , Measuring dissociation The Dissociative Experiences Scale ( DES ) 1986 , 2000 report measure is a type of psychological test in which a person completes a survey or questionnaire with or without the help of an investigator . This scale measures dissociation with items such as ( a ) Some people sometimes have the experience of feeling as though they are standing next to themselves or watching themselves do something , and they actually see themselves as if they were looking at another person and ( Some people find that sometimes they are listening to someone talk , and they suddenly realize that they did not hear part or all of what was The DES is suitable only as a screening tool . When somebody scores a high level on this scale , this does not necessarily mean that he or she is suffering from a dissociative disorder . It does , however , give an indication to investigate the symptoms more extensively . This is usually done with a structured clinical interview , called the Structured Clinical Interview for Dissociative Disorders ( which is performed by an experienced clinician . With the publication of the new there has been an updated version of this instrument . Dissociation and Trauma The most widely held perspective on dissociative symptoms is that they reflect a defensive response to highly aversive events , mostly trauma experiences during the childhood years ( One prominent interpretation ofthe origins disorders is that they are the direct result of exposure to traumatic experiences . We will refer to this interpretation as the posttraumatic model ( According to the , dissociative symptoms can best be understood as mental strategies to cope with or avoid the impact of highly aversive experiences ( Spiegel et , 2011 ) In this view , individuals rely on dissociation to escape

Dissociative Disorders 427 defensive coping mechanism , response to minor stressors ( Yen , art , The idea that dissociation can serve a defensive function can be traced back to Pierre Janet ( one of the first scholars to link dissociation to psychological trauma ( Hacking , The casts the clinical observation that dissociative All of us have played games at times to escape reality . But for some people with . truly traumatic experiences , that reality they escape to can become the reality disorders are linked to a trauma history in straightforward causal terms , that is , one causes the other ( 1999 ) For example , they live in . Janine DID patients in their study all suffered from posttraumatic stress disorder and concluded that DID should be as an extreme form posttraumatic stress disorder ( et , 2006 ) Causality and evidence The empirical evidence that trauma dissociative symptoms is the subject of intense debate ( 2005 , 2010 , Lynn , 2010 ) Three limitations of the will be described below . First , the majority of studies reporting links between trauma and dissociation are based on designs . This means that the data are collected at one point in time . When analyzing this type , one can only state whether scoring high on a particular questionnaire ( for example , a trauma questionnaire ) is indicative of also scoring high on another questionnaire ( for example , the DES ) This makes it difficult to state if one thing led to another , and therefore ifthe relation between the two is causal . Thus , the data that these designs yield do not allow for strong causal claims ( 2002 ) Second , whether somebody has experienced a trauma is often established using a questionnaire that the person completes himself or herself . This is called a measure . Herein lies the problem . Individuals suffering from dissociative symptoms typically

Dissociative Disorders 428 have high fantasy proneness . This is a character trait to engage in extensive and vivid fantasizing . The tendency to fantasize a lot may increase the risk of exaggerating or understating experiences ( Third , high dissociative individuals report more cognitive failures than low dissociative individuals . Cognitive failures are everyday slips and lapses , such to notice signposts on the road , forgetting appointments , or bumping into people . This can be seen , in part , in the criteria for DID , in which people may have difficulty recalling everyday events as well as those that are traumatic . People who frequently make such slips and lapses often cognitive cues provided by others ( Schmidt , 2002 , distort , and thus limits conclusions that can be drawn from studies that rely solely on to investigate the link ( Most important , however , is that the does not tell us how trauma produces dissociative symptoms . Therefore , workers in the field have searched for other explanations . They proposed that due to their dreamlike character , dissociative symptoms such as , depersonalization , and absorption are associated with experiences . noted that experiences can explain the relation between highly aversive events and dissociative symptoms ( et , 2008 Watson , 2001 ) In the following paragraph , the relation between dissociation and sleep will be discussed . Dissociation and Sleep A little history Researchers ( have proposed that dissociative symptoms , such as absorption , and depersonalization originate from sleep . This idea is not entirely new . In the century , double consciousness ( or ) Those who have fallen asleep in class have likely experienced those dreams that moment or two where reality kind of blends in with your dreams . For a long time , scientists thought dissociative disorders were the historical precursor of dissociative simply this confusion and dreaming states . identity disorder ( DID formerly ' known as multiple personality

Dissociative Disorders 429 disorder ) was often described as somnambulism , which refers to a state of sleepwalking . Patients suffering from this disorder were referred to as ( Many scholars believed that these patients were switching between a normal state and a somnambulistic , a English this era , viewed dissociation as the uncoupling of normal consciousness , which would result in what he termed the dreamy state ( 1999 ) Interestingly , a century later , and the observing self serves as the basis of states , emphasizing its occurrence , especially in dreams . Likewise , Franklin ( considered dreamlike thoughts , the amnesia one usually has for dreams , and the lack oftime , place , and person during dreams to be strikingly similar to the amnesia DID patients often report for their traumas . Related , Barrett ( 19951 , described the similarity between dream characters and , with , movement , amnesia , and continuity with normal waking . The many similarities between dreaming states and dissociative symptoms are also a recurrent theme in the more recent clinical literature ( Bob , 2004 ) Sleep problems in patients with dissociative disorders Anecdotal evidence supports the idea that sleep disruptions are linked to dissociation . For example , in patients with depersonalization , symptoms are worst when they are tired ( abuse , experiences paralysis accompanied by raised levels symptoms ( Clancy , 2005 , Mulligan , 2008 ) Patients with mood disorders , anxiety disorders , schizophrenia , and borderline personality with relatively high levels of dissociative a rule exhibit sleep abnormalities . Recent research points to fairly specific relationships between certain sleep complaints ( insomnia , nightmares ) and certain forms of psychopathology ( depression , posttraumatic stress disorder ) Watson , 2009 ) Studying the relationship between dissociation and sleep In the general population , both dissociative symptoms and sleep problems are highly prevalent . For example , 29 percent ofAmerican adults report sleep problems ( National Sleep sleep not only in patients but also in the general population . In a pioneering study , Watson

Dissociative Disorders 430 ( showed that dissociative red by the linked to dreams , nightmares , recurrent dreams , and other unusual sleep phenomena . This relationship has been studied extensively ever since , leading to three important statements . First , Watson ( basic findings have been reproduced time and again . This means that the same results ( namely that dissociation and sleep problems are related ) have been found in lots of different studies , using different groups , and different materials . All lead to the conclusion that unusual sleep experiences and dissociative symptoms are linked . Second , the connection between sleep and dissociation is specific . It seems that unusual sleep phenomena that are difficult to control , including nightmares and waking dreams , are related to dissociative symptoms , but lucid that are only weakly related to dissociative symptoms . For example , dream recall frequency was related to dissociation ( Individuals who reported three or more nightmares over a period showed higher levels of dissociation compared to individuals reporting two nightmares or less ( Levin Fireman , 2002 ) and a relation was found between Third , the link is apparent not only in general population such as you and also in patient groups . Accordingly , one group of researchers reported nightmare disorder in 17 out of 30 DID patients ( They also found a prevalence of nocturnal dissociative episodes in patients with dissociative disorders ( Another study investigated a group of borderline personality disorder patients and found that 49 of them suffered from nightmare disorder . Moreover , the patients with nightmare disorder displayed higher levels than patients not suffering from nightmare disorder ( Cetin , 2008 ) Additionally , Ross to a group of psychiatric outpatients and a sample from the general population . To sum up , there seems to be a strong relationship between dissociative symptoms and unusual sleep experiences that is evident in a range of phenomena , including waking dreams , nightmares , and sleepwalking . Inducing and reducing sleep problems Sleep problems can be induced in healthy participants by keeping them awake for a long duration of time . This is called sleep deprivation . If dissociative symptoms are fueled by a labile cycle , then sleep loss would be expected to intensify dissociative symptoms .

Dissociative Disorders 431 Some evidence that this might work was already found in 2001 , when soldiers who underwent a Army survival training , which included sleep deprivation , showed increases in dissociative symptoms ( Other researchers conducted a 25 healthy volunteers during one day and one night loss . They found that dissociative symptoms increased substantially after one night of sleep loss ( 2007 ) unusual sleep experiences and dissociation in a patient group at a private clinic . They completed questionnaires upon arrival at the clinic and again when they departed eight weeks later . During their stay , they followed a strict program designed to improve sleep problems . And it worked ! In most patients , sleep quality was improved after eight weeks . We found a robust link between sleep experiences and dissociative symptoms and determined that sleep normalization was accompanied by a reduction in dissociative symptoms . An exciting interpretation of the link between dissociative symptoms and unusual sleep phenomena ( see also , may be this A disturbed cycle may lead to dissociative symptoms . However , we should be cautious . Although studies support a causal arrow sleep disruption to dissociative symptoms , the associations between sleep and dissociation may be more complex . For example , causal links may be , such that dissociative symptoms may lead to sleep problems and vice versa , and other psychopathology may interfere in the link between sleep and dissociative symptoms ( et , 2011 ) Implications and Conclusions The model offers a fresh and exciting perspective on dissociative symptoms . This model may seem remote from the . However , both models can be integrated in a single conceptual scheme in which I No longer are dissociative disorders an untreatable illness . With the new methods traumatic Childhood experiences developed by researchers , there is hope ( may lead disturbed sleep this debilitating disorder . Heidi Matt patterns , which may be the

Dissociative Disorders 432 final common pathway to dissociative symptoms . Accordingly , the model may explain both ( a ) how traumatic experiences disrupt the cycle and increase vulnerability to dissociative symptoms , and ( why dissociation , trauma , fantasy proneness , and cognitive failures overlap . Future studies can also discern what characteristic sleep disruptions in the cycle are most reliably related to dissociative disorders , and then establish training programs , including medication , to address these problems . This would constitute an entirely novel and exciting approach to the treatment of dissociative symptoms . In closing , the model can serve as a framework for studies that address a wide range questions about dissociative symptoms and disorders . We now have good reason to be confident that research on sleep and dissociative symptoms will inform psychiatry , clinical science , and psychotherapeutic practice in meaningful ways in the years to come .

Dissociative Disorders 433 Outside Resources Book , 1973 ) Sybil . Chicago . Structured Clinical Interview for ( Web Video depicting the controversy regarding the existence of DID and show you some debate between and researchers on the topics of brain imaging , recovered memories , and false memories . Brain on command . Web Video depicting the controversy regarding the existence of DID and show you some debate between and researchers on the topics of brain imaging , recovered memories , and false memories . False memory syndrome . Web Video depicting the controversy regarding the existence of DID and show you some debate between and researchers on the topics of brain imaging , recovered memories , and false memories . Revisiting the memory wars . Web Video illustrating patients suffering from DID . a stereotype picture of the disorder , with the patients switching between personality states . Web Video illustrating patients suffering from DID . The woman with seven personalities . Discussion Questions . Why are dissociation and trauma related to each other ?

How is dissociation related to sleep problems ?

Are dissociative symptoms induced or merely increased by sleep disturbances ?

Do you have any ideas regarding treatment possibilities for dissociative disorders ?

Dissociative Disorders 434 . Does DID really exist ?

Dissociative Disorders 435 Vocabulary Amnesia The loss of memory . Anxiety disorder A group of diagnoses in the Diagnostic and Statistical Manual of Mental Disorders ( classification system where anxiety is central to the person . Typical symptoms include excessive rumination , worrying , uneasiness , apprehension , and fear about future uncertainties either based on real or imagined events . These symptoms may affect both physical and psychological health . The anxiety disorders are subdivided into panic disorder , specific phobia , social phobia , posttraumatic stress disorder , disorder , and generalized anxiety disorder . Borderline Personality Disorder This personality disorder is defined by a chronic pattern . This instability manifests itself in interpersonal relationships , mood , and behavior that can interfere with social functioning or work . It may also cause grave emotional distress . Cognitive failures Every day slips and lapses , also called . Consciousness The quality or state of being aware ofan external object or something within oneself . It has been defined as the ability to experience or to feel , wakefulness , having a sense of selfhood , and the executive control system ofthe mind . design Research method that involves observation ofall ofa population , or a representative subset , at one specific point in time . Defensive coping mechanism An unconscious process , which protects an individual from unacceptable or painful ideas , impulses , or memories . DES Dissociative Experiences Scale .

Dissociative Disorders 436 DID Dissociative identity disorder , formerly known as multiple personality disorder , is at the far end of the dissociative disorder spectrum . It is characterized by at least two distinct , and personality states . These personality states or alternately control a person behavior . The sufferer therefore experiences significant memory impairment for important information not explained by ordinary forgetfulness . Dissociation A disruption in the usually integrated function of consciousness , memory , identity , or perception of the environment . Fantasy proneness The tendency to extensive fantasizing or daydreaming . General population A sample of people representative of the average individual in our society . Insomnia A sleep disorder in which there is an inability to fall asleep or to stay asleep as long as desired . Symptoms also include waking up too early , experience many awakenings during the night , and not feeling rested during the day . Lucid dreams Any dream in which one is aware that one is dreaming . Mood disorder A group of diagnoses in the Diagnostic and Statistical Manual of Mental Disorders ( classification system where a disturbance in the person mood is the primary dysfunction . Mood disorders include major depressive disorder , bipolar disorder , and cyclothymic disorder . Nightmares An unpleasant dream that can cause a strong negative emotional response from the mind , typically fear or horror , but also despair , anxiety , and great sadness . The dream may contain situations of danger , discomfort , psychological or physical terror . Sufferers usually awaken in a state and may be unable to return to sleep for a prolonged period of time . Disorder This anxiety disorder is characterized by intrusive thoughts ( obsessions ) by repetitive

Dissociative Disorders 437 behaviors ( compulsions ) or both . Obsessions produce uneasiness , fear , or worry . Compulsions are then aimed at reducing the associated anxiety . Examples of compulsive behaviors include excessive washing or cleaning repeated checking extreme hoarding and nervous rituals , such as and offa certain number oftimes when entering a room . Intrusive thoughts are often sexual , violent , or religious in nature Prevalence The number of cases of a specific disorder present in a given population at a certain time . model of dissociation . Recurrent dreams The same dream narrative or is experienced over different occasions of sleep . Schizophrenia This mental disorder is characterized by a breakdown of thought processes and emotional responses . Symptoms include auditory hallucinations , paranoid or bizarre delusions , or disorganized speech and thinking . Sufferers from this disorder experience grave in their social functioning and in work . Structural Clinical Interview for Dissociative Disorders . measure of psychological test in which a person fills out a survey or questionnaire with or without the help ofan investigator . Sleep deprivation A sufficient lack of restorative sleep over a cumulative period so as to cause physical or psychiatric symptoms and affect routine performances of tasks . Sleep paralysis Sleep paralysis occurs when the normal paralysis during REM sleep manifests when falling asleep or awakening , often accompanied by hallucinations or a malevolent presence in the room . cycle rhythmic activity cycle , based on intervals , that is exhibited by many organisms .

Dissociative Disorders 438 State When a symptom is acute , or transient , lasting from a few minutes to a few hours . Trait When a symptom forms part ofthe personality or character . Trauma An event or situation that causes great distress and disruption , and that creates substantial , lasting damage to the psychological development of a person . Vivid dreams A dream that is very clear , where the individual can remember the dream in great detail .

Dissociative Disorders 439 References , Mulligan , 2008 ) Prevalence and correlates of sleep paralysis in adults reporting childhood sexual Disorders , 22 , 541 . Kara , Kiran , 2003 ) Clinical importance of nightmare disorder in patients with dissociative disorders . Psychiatry Clinical Neuroscience , 57 , Kara , Kiran , 2001 ) Characteristics of patients with nocturnal dissociative disorders . Sleep and Hypnosis , 131 134 . Allen , 1995 ) Dissociation and the vulnerability to psychotic experiences . journal of Nervous and Mental Disease , 183 , American Psychiatric Association . 2013 ) Diagnostic and statistical manual disorders . Washington , American Psychiatric Association . American Psychiatric Association . 2000 ) Diagnostic and statistical manual disorders ( text revision ) Washington , Author . 1966 ) Depersonalization and . In , Newman , general psychology ( New York , NY International Universities Press , Barrett , 1995 ) The dream character as a prototype for the multiple personality alter . Dissociation , 61 . Barrett , 1994 ) Dreaming as a normal model for multiple personality disorder . In . Lynn . Dissociation Clinical and ( New York , NY Press . 1986 ) Development , reliability , and validity of a dissociation scale . Journal of Nervous and Mental Disease , 174 , Bob , 2004 ) Dissociative processes , multiple personality , and dream functions . American journal of Psychotherapy , 58 , 201 ) Cognitive processes in dissociation Comment on et al . 2008 ) Psychological Bulletin , 136 , Brett , 1997 ) dissociative states and psychopathology in posttraumatic stress of Trauma and Stress , 10 , 2000 ) Psychoanalytic Inquiry , 20 ,

Dissociative Disorders 440 , Kaplan , Lipschitz , 2006 ) Prevalence disorders in psychiatric outpatients . of Psychiatry , 163 , Franklin , 1990 ) Dreamlike thought and dream mode processes in the formation of personalities in . Dissociation , 1999 ) Relations among psychological trauma , dissociative phenomena , and distress A review and integration . Clinical Psychology Review , 19 , Lynn , 2010 ) trauma , and and Reply to ( 2010 ) Psychological Bulletin , 136 , Lynn , 2008 ) Cognitive processes in dissociation An analysis of core theoretical assumptions . Psychological Bulletin , 134 , 647 . 2007 ) Acute dissociation after night of sleep Psychology , 116 , Hacking , I . 1995 ) Rewriting the soul Multiple personality and the sciences . Princeton , Princeton University Press . 2005 ) Dissociative Review Psychology , 10 , Watson , 2009 ) The structure of sleep complaints and its relation to depression and Psychology , 118 , Lee , Hunter , Richards , David , 2010 ) Prevalence and childhood antecedents of depersonalization syndrome in a UK birth cohort . Social Psychiatry and Psychiatric Epidemiology , in press ) Levin , Fireman , 2002 ) Nightmare prevalence , nightmare distress , and psychological disturbance . Sleep , 25 , 1967 ) Depersonalization and the dream . The Psychoanalytic , 36 , Clancy , A . 2005 ) Sleep paralysis in adults reporting repressed , recovered , or continuous memories of childhood sexual Anxiety Disorders , 19 , 602 . 999 ) The contribution of to an understanding . 156 , 2004 ) Dissociative symptoms are related to endorsement of vague trauma items . Comprehensive Psychiatry , 45 ,

Dissociative Disorders 441 , 2002 ) The causal link between trauma and dissociation A critical review . Behaviour Research and Therapy , 39 , Schmidt , 2002 ) Modeling the connection between trauma and dissociation in a student sample . Personality and Individual Differences , 32 , 2000 ) Dissociative experiences and interrogative suggestibility in college students . Personality and Individual Differences , 29 , a Campo , Hardy , 2005 ) Dissociation and fantasy proneness in psychiatric patients A preliminary study . Comprehensive Psychiatry , 46 , 181 185 . Wang , 2001 ) Symptoms of dissociation in humans experiencing acute , uncontrollable stress A prospective journal of Psychiatry , 158 , Sleep Foundation . 2005 ) 2005 Sleep in America poll . Washington Author . Lynn , 1995 ) Fantasy proneness , axis I psychopathology and Psychology , 104 , Ross , A . 2011 ) Possession experiences in Dissociative Identity Disorder A preliminary study . journal of Trauma Dissociation , 12 , Ross , Anderson , Norton , 1991 ) The frequency of Multiple Personality Disorder among . American journal of Psychiatry , 148 , Held , Hand , 2006 ) Dissociation and symptom dimensions of replication study . European Archives of Psychiatry and Clinical Neuroscience , 256 , Lynn , 1992 ) Dissociative experiences , psychopathology and adjustment , and child and adolescent maltreatment in female college students . journal Psychology , 101 , Sar , I . 2000 ) Frequency of dissociative disorders among psychiatric outpatients in Turkey . Comprehensive Psychiatry , 41 , 1973 ) Sybil . Chicago , IL . Cetin , 2008 ) Nightmare disorder , dream anxiety , and subjective sleep quality in patients with borderline personality disorder . Psychiatry and Clinical , 62 ,

Dissociative Disorders 442 , 2006 ) Feeling unreal Depersonalization disorder and the loss of the self . New York , NY Oxford University Press . Spiegel , Sar , Dell , 201 ) Dissociative disorders in . Depression , 28 , Vogel , 2007 ) Psychopathology and in severe mental illness The impact of trauma and posttraumatic stress symptoms . European Archives of Psychiatry and Clinical Neuroscience , 257 , 2001 ) The stranger in the mirror hidden epidemic . New York , NY Harper Collins Publishers , 1994 ) Structured Clinical Interview for Dissociative Disorders ( 96 ) Washington , American Psychiatric Press . 2005 ) Altered states of consciousness , dissociation , and dream recall . Perceptual Motor Skills , 100 , 1957 ) The Three Faces Eve . New York , NY . Sar , 1998 ) Frequency of dissociative disorders among psychiatric in a Turkish university clinic . American journal of Psychiatry , 155 , Van der Hart , Horst , 989 ) The dissociation theory of Traumatic Stress , Van der , Lynn , de , A . 2011 ) Sleep normalization and decrease in dissociative experiences Evaluation in an inpatient sample . journal Abnormal Psychology , Online First Publication , August 15 , doi , 2006 ) Hippocampal and in dissociative identity disorder . 163 , Watson , 2001 ) of the night Individual differences in experiences and their relation to dissociation and . journal of Abnormal Psychology , 110 , Wright , 1999 ) Measuring dissociation Comparison of alternative forms ofthe Dissociative Experiences Scale . of Psychology , 112 , Yu , Ross , Li , Dai , Zhang , Wang , Fang , Xiao , 2010 ) Dissociative disorders among Chinese diagnosed with schizophrenia . journal of Trauma and Dissociation , 11 ,

25 Schizophrenia Spectrum Disorders Deanna Schizophrenia and the other psychotic disorders are some of the most impairing forms of psychopathology , frequently associated with a profound negative effect on the individuals educational , occupational , and social function . Sadly , these disorders often manifest right at time ofthe transition from adolescence to , just as young people should be evolving into independent young adults . The spectrum of psychotic disorders includes schizophrenia , schizoaffective disorder , delusional disorder , personality disorder , disorder , brief psychotic disorder , as well as psychosis associated with substance use or medical conditions . In this module , we summarize the primary clinical features of these disorders , describe the known cognitive and neurobiological changes associated with schizophrenia , describe potential risk factors causes for the development of schizophrenia , and describe currently available treatments for schizophrenia . Learning Objectives Describe the signs and symptoms of schizophrenia and related psychotic disorders . Describe the most cognitive and neurobiological changes associated with schizophrenia . Describe the potential risk factors for the development of schizophrenia . Describe the controversies associated with clinical high risk approaches to identifying individuals at risk for the development of schizophrenia . Describe the treatments that work for some ofthe symptoms of schizophrenia .

Schizophrenia Spectrum Disorders 444 The phenomenology of schizophrenia and related psychotic disorders Most of you have probably had the experience of walking down the street in a city and seeing a person you thought was acting oddly . They may have been dressed in an unusual way , perhaps disheveled or wearing an unusual collection of clothes , makeup , or jewelry that did not seem to fit any particular group or subculture . They may have been talking to themselves or yelling at someone you could not see . lfyou tried to speak to them , they may have been difficult to may have false beliefs about reality . Grim fOllOW Oi understand , or they may have acted paranoid or started telling a bizarre story about the people who were plotting against them . chances are that you have encountered an individual with schizophrenia or another type of psychotic disorder . lfyou have watched the Beautiful Mind or The Fisher King , you have also seen a portrayal of someone thought to have schizophrenia . Sadly , a few of the individuals who have committed some of the recently highly publicized mass murders may have had schizophrenia , though most people who commit such crimes do not have schizophrenia . It is also likely that you have met people with schizophrenia without ever knowing it , as they may suffer in silence or stay isolated to protect themselves from the horrors they see , hear , or believe are operating in the outside world . As these examples begin to illustrate , psychotic disorders involve many different types of symptoms , including delusions , hallucinations , disorganized speech and behavior , abnormal motor behavior ( including catatonia ) and negative symptoms such and blunted speech . Delusions are false beliefs that are often fixed , hard to change even when the person is presented with conflicting information , and are often culturally influenced in their content ( delusions cultures , delusions involving Allah in Muslim cultures ) They can be terrifying for the person , who may remain convinced that they are true even when loved ones and friends present them with clear information that they can not be

Schizophrenia Spectrum Disorders 445 true . There are many different types or themes to delusions . The most common delusions are persecutory and involve the individuals or groups are trying to hurt , harm , or plot person in some way . These can be people that the person knows ( people at work , the neighbors , family members ) or more abstract groups ( the FBI , the CIA , aliens , Other types of delusions include grandiose delusions , where the person believes that they have some special power or ability ( I am the new Buddha , I am a rock star ) referential delusions , where the person believes that events or objects in the environment have special meaning for them ( that song on the radio is being played specifically for me ) or other types of Under Abstract groups like the police or the government are commonly the focus of a schizophrenic persecutory delusions . Photo Tim Shields delusions where the person may believe that others are and actions , their thoughts are being broadcast aloud , or that others can read their mind ( or they can read other people minds ) When you see a person on the street talking to themselves or shouting at other people , they are experiencing hallucinations . These are perceptual experiences that occur even when there is no stimulus in the outside world generating the experiences . They can be auditory , visual , olfactory ( smell ) gustatory ( taste ) or somatic ( touch ) The most common hallucinations in psychosis ( at least in adults ) are auditory , and can involve one or more voices talking about the person , commenting on the person behavior , or giving them orders . The content ofthe hallucinations is frequently negative ( you are a loser , that drawing is stupid , you should go kill yourself ) and can be the voice of someone the person knows or a complete stranger . Sometimes the voices sound as if they are coming from outside the person head . Other times the voices seem to be coming from inside the person head , but are not experienced the same as the person inner thoughts or inner speech . Talking to someone with schizophrenia is sometimes difficult , as their speech may be difficult to follow , either because their answers do not clearly flow from your questions , or because one sentence does not logically follow from another . This is referred to as disorganized

Schizophrenia Spectrum Disorders 446 speech , and it can be present even when the person is writing . Disorganized behavior can include odd dress , odd makeup ( lipstick outlining a mouth for inch ) or unusual rituals ( repetitive hand gestures ) Abnormal motor behavior can include catatonia , which refers to a variety of behaviors that seem to reflect a reduction in responsiveness to the external environment . This can include holding unusual postures for long periods of time , failing to respond to verbal or motor prompts from another person , or excessive and seemingly purposeless motor activity . Some of the most debilitating symptoms of schizophrenia are difficult for others to see . These include what people refer to as negative symptoms or the absence of certain things we typically expect most people to have . For example , anhedonia or reflect a engage in social or recreational activities . These symptoms can manifest as a great amount of time spent in physical immobility . importantly , like anhedonia a lack anhedonia and do not in the kinds of social and recreational activities most others enjoy are seem to reflect a lack of enjoyment in pleasurable activities or events ( Cohen Moran , not as readily apparent to outside observers as the more obvious symptoms like disorganized speech or talk of hallucinations . Photo lack of showing emotions through facial expressions , gestures , and speech intonation , as well as a reduced amount of speech and increased pause frequency and duration . In many ways , the types of symptoms associated with psychosis are the most difficult for us to understand , as they may seem far outside the range of our normal experiences . Unlike depression or anxiety , many of us may not have had experiences that we think of as on the same continuum as psychosis . However , just like many ofthe described in this book , the types of psychotic symptoms that characterize disorders like schizophrenia are on a continuum with normal mental experiences . For example , work by Jim van Os in the Netherlands has shown that a surprisingly large percentage of the general population ( 10 ) experience symptoms , though many fewer have multiple

Schizophrenia Spectrum Disorders 447 experiences and not continue to experience these symptoms in the long run ( Kenya has also shown that a relatively high percentage of individuals experience one or more experiences ( at some point in their lives ( et , 2012 et Schizophrenia is the primary disorder that comes to mind when we discuss psychotic disorders ( see Table for diagnostic criteria ) though there are a number of other disorders Schizophrenia ( Lifetime prevalence about to , 2013 ) or more of the following for at least month hallucinations , delusions , disorganized speech , grossly disorganized or catatonic behavior , negative symptoms . Impairment in one or more areas of function ( social , occupational , educational ) for a period of time since the onset ofthe illness . Continuous signs of the illness for at least months ( this can include prodromal or residual symptoms , which are attenuated forms of the described above ) Disorder ( prevalence similar to APA , 2013 ) same symptoms of schizophrenia described above that are present least month but less than months . Disorder ( lifetime prevalence APA , 2013 ) A period of illness where the person has both the psychotic symptoms necessary to meet criteria for schizophrenia and major depression or manic episode . person experiences either delusions or hallucinations least weeks when they are not having a depressive or manic episode . The symptoms that meet criteria for depressive or manic episodes are present for over half of the illness duration . Delusional Disorder ( lifetime prevalence about APA , 2013 ) The presence of at least one delusion for at least a month . person has never met criteria for schizophrenia . The person function is not impaired outside the impact of the delusion . The duration of any depressive or manic episodes have been brief relative to the duration of the ( Brief Psychotic Disorder ( Lifetime prevalence undear , 2013 ) One or more of the following symptoms present for at least day but less than month delusions , hallucinations , disorganized speech , grossly disordered or catatonic behavior . Attenuated Psychotic Disorder ( In Section III of the APA , lifetime presence undear , 2013 ) One or more of the following symptoms in an attenuated delusions , hallucinations , or disorganized speech . The symptoms must have occurred at least once a week for the past month and must have started or gotten worse in the past year . symptoms must be severe enough to distress or disable the individual or to suggest to others that the person needs clinical help . person has never met the diagnostic criteria for a psychotic disorder , and the symptoms are not better attributed to another disorder , to substance use , or to a medical condition . Table Types of Psychotic Disorders ( Simplified from the Diagnostic and Statistical Manual Edition ( APA , 2013 )

Schizophrenia Spectrum Disorders 448 that share one or more features with schizophrenia . In the remainder ofthis module , we will use the terms psychosis and schizophrenia somewhat interchangeably , given that most of the research has focused on schizophrenia . In addition to schizophrenia ( see Table ) other psychotic disorders include disorder ( a briefer version of schizophrenia ) schizoaffective disorder ( a mixture and symptoms ) delusional disorder ( the experience delusions ) and brief psychotic disorder ( psychotic symptoms that last only a few days or weeks ) The Cognitive Neuroscience of Schizophrenia As described above , when we think of the core symptoms of psychotic disorders such as schizophrenia , we think of people who hear voices , see visions , and have false beliefs about reality ( delusions ) However , problems in cognitive function are also a critical aspect of psychotic disorders and of schizophrenia in particular . This emphasis on cognition in schizophrenia is in part due to the growing body of research suggesting that cognitive problems in schizophrenia are a major source of disability and loss of functional capacity ( The cognitive deficits that are present in schizophrenia are widespread and can include problems with episodic memory ( the ability to learn and retrieve new information or episodes in one life ) working memory ( the ability to maintain information over a short period oftime , such as 30 seconds ) and other tasks that require one to control or regulate one behavior ( 2012 Bora , also have difficulty with what is referred to as processing speed and are frequently slower than healthy individuals on almost all tasks . importantly , these cognitive deficits are present prior to the onset ofthe illness ( et , 2007 ) and are also present , albeit in a milder the development of psychosis , ratherthan being an outcome psychosis . Further , people with schizophrenia who have more severe cognitive problems also tend to have more severe negative symptoms and more disorganized speech and behavior ( Carter , el 10 ) In addition , people with more cognitive problems have worse Some people with schizophrenia also show deficits in what is referred to as social cognition ,

Schizophrenia Spectrum Disorders 449 though it is not clear whether such problems are separate from the cognitive problems described above or the result of them ( Hoe , includes problems with the recognition of emotional expressions on the faces of other individuals ( Walker , problems inferring the intentions of other people ( theory of mind ) Bora , with schizophrenia who have more problems with social cognition also tend to have more negative and Some with schizophrenia suffer from difficulty with social cognition . They may not be able to detect the meaning of facial expressions or Symptoms ( Venture ! Wood 84 , 2011 ) as well as world . community function ( The such as magnetic resonance imaging and positron emission tomography opened up the ability to try to understand the brain mechanisms of the symptoms of schizophrenia as well as the cognitive found in psychosis . For example , a number of studies have suggested that delusions in psychosis may be associated with problems in detection mechanisms supported by the ventral striatum ( Jensen Kapur , 2009 Jensen , 2008 Kapur , 2003 Kapur , that normally increase their activity when something important ( aka ) happens in the environment . Ifthese brain regions misfire , it mistakenly attribute importance to irrelevant or unconnected events . Further , there is good evidence that problems in working memory and cognitive control in schizophrenia are related to problems in the function of a region of the brain called the dorsolateral prefrontal cortex ( i , I , a , 999 ) These problems include changes in how the works when people are doing or tasks , and problems with brain region is connected to other brain regions important for working memory and cognitive control , including the posterior parietal cortex ( et , 2008 Kim et , 2003 et , 2003 ) the anterior

Schizophrenia Spectrum Disorders 450 ) In terms of understanding episodic memory problems in schizophrenia , many researchers have focused on medial temporal lobe deficits , with a specific focus on the hippocampus ( This is because there is much data from humans and animals showing that the hippocampus is important for the creation of new memories ( However , it has become increasingly clear that problems with the also make important contributions to episodic memory deficits in schizophrenia ( et , 2009 ) probably because this part ofthe brain is important for controlling our use of memory . In addition to problems with regions such as the and medial temporal lobes in schizophrenia described above , magnitude resonance studies have also identified changes in cellular architecture , white matter connectivity , and gray matter volume in a variety of regions that include the prefrontal and temporal cortices ( People with schizophrenia also show reduced overall brain volume , and reductions in brain volume as people get older may be larger in those with schizophrenia than in healthy people ( Taking antipsychotic medications or taking drugs such as marijuana , alcohol , and tobacco may cause some ofthese structural changes . However , these structural changes are not completely explained by medications or substance use alone . Further , both functional and structural brain changes are seen , again to a milder degree , in the relatives of people with schizophrenia ( Boos , Pol , 2007 et , suggests that that neural changes associated with schizophrenia are related to a genetic risk for this illness . Risk Factors for Developing Schizophrenia It is clear that there are important genetic contributions to the likelihood that someone will develop schizophrenia , with consistent evidence from family , twin , and adoption studies . il , However , there is no schizophrenia gene and it is likely that the genetic risk for schizophrenia reflects the summation of many different genes that each contribute something to the likelihood of developing psychosis ( Shields , disorder , which means that two different people with schizophrenia may each have very different symptoms ( one has hallucinations and delusions , the other has disorganized speech and negative symptoms ) This makes it even more challenging to identify specific genes associated with risk for psychosis . importantly , many studies also now suggest that at least some of the genes potentially associated with schizophrenia are also associated with other mental health conditions , including bipolar disorder , depression , and autism (

Schizophrenia Spectrum Disorders 451 Sanders , 2011 Kim , Trace , Sullivan , 2011 Owen et , 2010 Rutter , There are also a number of environmental factors that are associated with an increased risk schizophrenia . For example , problems during pregnancy such as increased stress , infection , malnutrition , diabetes have been associated with increased risk of schizophrenia . In addition , complications that occur at the time of birth and which cause hypoxia ( lack of oxygen ) are also associated with an increased risk for developing schizophrenia ( Cannon , Jones , Murray , fathers are also at a somewhat increased risk of developing schizophrenia . Further , using cannabis increases risk for developing psychosis , especially if you have other risk factors ( Murray , Di , is also higher for kids who grow up in urban settings ( March et , 2008 ) and for some There are a number of biological risk factors for der Vent schizophrenia including older fathers , complications BOth ofthese factors may reflect during and a family history of higher social and environmental stress in these schizophrenia . Photo settings . Unfortunately , none of these risk factors is specific enough to be particularly useful in a clinical setting , and most people with these risk factors do not develop schizophrenia . However , together they are beginning to give us clues as the factors that may lead someone to be at an increased risk for developing this disease . An important research area on risk for psychosis has been work with individuals who may be at clinical high risk . These are individuals who are showing attenuated ( milder ) symptoms of psychosis that have developed who are experiencing some distress associated with these symptoms . When people with these types of symptoms are followed over time , about 35 of them develop a psychotic disorder ( Cannon et , 2008 ) most

Schizophrenia Spectrum Disorders 452 individuals , a new category , called Attenuated Psychotic Syndrome , was added to Section III ( the section for disorders in need of further study ) of the ( see Table for symptoms ) APA , 201 ) However , adding this diagnostic category to the created a good have been worried that including risk states in the would create mental disorders where none exist , that these individuals are often already seeking treatment for other problems , and that it is not clear that we have good treatments to stop these individuals from developing to psychosis . However , the have been that there is evidence that individuals with symptoms develop psychosis at a much higher rate than , Psychotic Syndrome in Section III will spur important research that might have clinical benefits . Further , there is some evidence that treatments such as fatty acids and intensive family intervention may help reduce the development psychosis ( Cella , 2010 ) in people who have symptoms . Treatment of Schizophrenia The currently available treatments for schizophrenia leave much to be desired , and the search for more effective treatments for both the psychotic symptoms of schizophrenia ( hallucinations and delusions ) as well as cognitive deficits and negative symptoms is a highly active area of research . The first line of treatment for schizophrenia and other psychotic disorders is the use medications . There are two primary types medications , referred to as typical and The fact that typical antipsychotics helped some symptoms of schizophrenia was discovered more than 60 years ago ( are drugs that Share feature of being a strong block ofthe type dopamine receptor . Although these drugs can help reduce hallucinations , delusions , and disorganized speech , they do little to improve cognitive deficits or negative symptoms and can be associated with distressing motor side effects . The newer generation of antipsychotics is referred to as atypical antipsychotics . These drugs have more mixed mechanisms in terms ofthe receptor types that they influence , though most of them also influence receptors . These newer antipsychotics are not necessarily more helpful for schizophrenia but have fewer motor side effects . However , many of the atypical antipsychotics are associated with side effects referred to as the metabolic which and increased illness , diabetes , and mortality ( The evidence that cognitive deficits also contribute to functional impairment in schizophrenia has led to an increased search for treatments that might enhance cognitive function in

Schizophrenia Spectrum Disorders 453 schizophrenia . Unfortunately , as of yet , there are no pharmacological treatments that work consistently to improve cognition in schizophrenia , though many new types of drugs are currently under exploration . However , there is a type of psychological intervention , referred remediation , which has shown some evidence in schizophrenia . In particular , a version of this treatment called Cognitive Enhancement Therapy ( CET ) has been shown to improve cognition , functional outcome , social cognition , and to protect against gray matter loss ( et , 2009 , of new treatments such as Cognitive Enhancement Therapy provides some hope that we will be able to develop new and better approaches to improving the lives of individuals with this serious mental health condition and potentially even prevent it some day .

Schizophrenia Spectrum Disorders 454 Outside Resources Book Ben Behind His Voices One family journal from the chaos of schizophrenia to hope ( 2011 ) and . Book Conquering Schizophrenia A father , his son , and a medical breakthrough ( 1997 ) Peter . Book Henry Demons Living with schizophrenia , a father and son story ( 201 ) Henry and Patrick . Scribner Macmillan . Book My Mother Keeper A daughter memoir up in the shadow ( 1997 ) Tara Elgin . William Morrow Book Recovered , Not Cured Ajourney through schizophrenia ( 2005 ) Richard . Allen and . Book The Center Can not Hold through madness ( 2008 ) Hyperion . Book The Quiet Room out of the torment of madness ( 1996 ) Lori Schiller . Grand Central Publishing . Book Welcome Silence My triumph over schizophrenia ( 2003 ) Carol North . Publishing . Web National Alliance for the Mentally III . This is an excellent site for learning more about advocacy for individuals with major mental illnesses such as schizophrenia . Web National Institute of Mental Health . This website has information on schizophrenia research . Web Schizophrenia Research Forum . This is an excellent website that contains a broad array of information about current research on schizophrenia . Discussion Questions

Schizophrenia Spectrum Disorders 455 . Describe the major differences between the major psychotic disorders . How would one be able to tell when an individual is delusional versus having ?

variation been taken into account when assessing psychotic symptoms ?

Why are cognitive important to understanding schizophrenia ?

Why has the inclusion of a new diagnosis ( Attenuated Psychotic Syndrome ) in Section III ofthe created controversy ?

What are some ofthe factors associated with increased risk for developing schizophrenia ?

If we know whether or not someone has these risk factors , how well can we tell whether they will develop schizophrenia ?

What brain changes are most consistent in schizophrenia ?

Do antipsychotic medications work well for all symptoms of schizophrenia ?

If not , which symptoms respond better to antipsychotic medications ?

Are there any treatments besides antipsychotic medications that help any ofthe symptoms of schizophrenia ?

If so , what are they ?

Schizophrenia Spectrum Disorders 456 Vocabulary Alogia A reduction in the amount increased pausing before the initiation . A reduction in the drive or ability to take the steps or engage in actions necessary to obtain the potentially positive outcome . Catatonia Behaviors that seem to reflect a reduction in responsiveness to the external environment . This can include holding unusual postures for long periods oftime , respond to verbal or motor prompts from another person , or excessive and seemingly purposeless motor activity . Delusions False beliefs that are often fixed , hard to change even in the presence of conflicting information , and often culturally influenced in their content . Diagnostic criteria The specific criteria used to determine whether an individual has a specific type of psychiatric disorder . Commonly used diagnostic criteria are included in the Diagnostic and Statistical Manual of Mental Disorder , Edition ( and the Internal Classification of Disorders , Version ( Disorganized behavior Behavior or dress that is outside the norm for almost all . This would include odd dress , odd makeup ( lipstick mouth inch ) or unusual ( repetitive hand gestures ) Disorganized speech Speech that is difficult to follow , either because answers do not clearly follow questions or because one sentence does not logically follow from another . Dopamine A neurotransmitter in the brain that is thought to play an important role in regulating the function of other neurotransmitters .

Schizophrenia Spectrum Disorders 457 Episodic memory The ability to learn and retrieve new information or episodes in one life . Flat affect A reduction in the display of emotions through facial expressions , gestures , and speech intonation . Functional capacity The ability to engage in ( cook , clean , bathe ) work , attend school , engage in social relationships . Hallucinations Perceptual experiences that occur even when there is no stimulus in the outside world generating the experiences . They can be auditory , visual , olfactory ( smell ) gustatory ( taste ) or somatic ( touch ) Magnetic resonance imaging A set of techniques that uses strong magnets to measure either the structure ofthe brain ( gray matter and white matter ) or how the brain functions when a person performs cognitive tasks ( working memory or episodic memory ) or other types of tasks . Processes that influence how the brain develops either in utero or as the child is growing up . Positron emission tomography A technique that uses to measure the distribution of different neurotransmitter receptors in the brain or to measure how much of a certain type of neurotransmitter is released when a person is given a specific type of drug or does a particularly cognitive task . Processing speed The speed with which an individual can perceive auditory or visual information and respond to it . Psychopathology Illnesses or disorders that involve psychological or psychiatric symptoms . Working memory The ability to maintain information over a short period of time , such as 30 seconds or less .

Schizophrenia Spectrum Disorders 458 References APA . 2013 ) Diagnostic and statistical manual of mental disorders , Fifth Edition ( Washington , American Psychiatric Association . 201 ) Cognition in schizophrenia Core psychological and neural mechanisms . Trends in Cognitive Science , 16 , Dowd , 2010 ) Goal representations and motivational drive in schizophrenia The role interactions . Schizophrenia Bulletin , 36 ( 91 doi , Carter , Cohen , 2003 ) Context processing deficit in schizophrenia Diagnostic specificity , course , and relationships to clinical of Abnormal Psychology , 112 , Carter , Noll , Cohen , 1999 ) Prefrontal cortex and context processing in patients with schizophrenia . Schizophrenia Research , 36 ( Frances , A . 201 ) Diagnostic inflation Causes and a suggested cure . of Nervous and Mental Disease , 200 ( doi Boos , Pol , 2007 ) Brain volumes in relatives of patients with schizophrenia A Psychiatry , 64 ( Bora , Seal , Wood , 2011 ) Neuroanatomical abnormalities in schizophrenia A multimodal and analysis . Schizophrenia Research , 127 ( doi . Bora , Cognitive functioning in schizophrenia , schizoaffective disorder and affective psychoses study . The Psychiatry The journal Science , 195 ( doi Bora , Theory of mind impairment in schizophrenia analysis . Schizophrenia Research , 109 ( doi , van der Ven , A . 2011 ) A of the risk for psychotic disorders among and immigrants . Psychological Medicine , 41 ( doi Bowie , Leung , McClure , Patterson , Harvey , 2008 ) Predicting schizophrenia patients behavior with specific neuropsychological and functional capacity res . Biological Psychiatry , 63 ( doi

Schizophrenia Spectrum Disorders 459 Bowie , Patterson , Harvey , 2006 ) of functional performance in schizophrenia subjects Correlations with cognition , functional capacity , and symptoms . The American journal of Psychiatry , 163 ( doi , van , van Baal , Pol , 2008 ) Heritability of changes in brain volume over time in twin pairs discordant for schizophrenia . Archives of General Psychiatry , 65 ( 11 ) doi Cannon , Jones , Murray , 2002 ) Obstetric complications and schizophrenia Historical and review . The , 159 ( Cannon , Woods , Walker , 2008 ) Prediction of psychosis in youth at high clinical risk A longitudinal study in North America . Archives of General Psychiatry , 65 ( Carpenter , Davis , 2012 ) Another view of the history of antipsychotic drug discovery and development . Molecular Psychiatry , 17 ( 12 ) doi , Murray , Di , 2011 ) Cannabis use in young people The ( 11 ) Cohen , Minor , 2010 ) Emotional experience in patients with schizophrenia revisited of laboratory studies . Schizophrenia Bulletin , 36 ( doi , Honey , Fletcher , 2007 ) From prediction error to psychosis Ketamine as a pharmacological model of of , 21 ( Honey , Shanks , Fletcher , 2006 ) Frontal responses during learning predict vulnerability to the effects of ketamine Linking cognition , brain activity , and psychosis . Archives of General Psychiatry , 63 ( doi , Murray , Honey , Shanks , Robbins , Fletcher , Disrupted signal in psychosis Evidence for an associative account . Brain , 130 ( doi , Murray , Honey , Shanks , Robbins , Fletcher , Disrupted signal in psychosis Evidence for an associative

Schizophrenia Spectrum Disorders 460 account . Brain , 130 ( doi 73 73 , Simons , van Os , 2009 ) Are psychotic psychopathology and orthogonal ?

A systematic review of their associations . Psychological Bulletin , 135 ( doi , 2010 ) durability of . Schizophrenia Research , 120 ( doi ( 10 ) Montrose , 2009 ) Cognitive enhancement therapy for schizophrenia effects of a randomized controlled trial . Serv , 60 ( 11 ) doi , Cho , Prasad , 201 ) effects against gray matter loss in early schizophrenia Results from a randomized controlled trial . Archives of General Psychiatry , 67 ( doi , 2010 ) Mechanisms improvement in a trial enhancement therapy for early schizophrenia . doi 71 0001 765 01 , Penn , van Os , 201 ) The relationship between and social cognition with functional outcomes in schizophrenia A . Neuroscience and Reviews , 35 ( doi , Clare , 2005 ) A of cognitive deficits in adults with a diagnosis of schizophrenia . Neuropsychology Review , 15 ( doi Fletcher , Frith , 1995 ) Brain systems for encoding and retrieval of memory An in vivo study in humans . Brain , 118 , Forbes , Carrick , 2009 ) Working memory in schizophrenia A . Psychological Medicine , 39 ( doi , Yung , 2012 ) Should attenuated psychosis syndrome be included in ?

Lancet , 379 ( 9816 ) doi ( 11 ) Schizophrenia Spectrum Disorders 461 , McGuire , 2012 ) Mapping prodromal psychosis A critical review of studies . European Psychiatry The journal of the Association of European Psychiatrists , 27 ( doi , Perez , McGuire , 2007 ) correlates of vulnerability to psychosis A systematic review and . Neuroscience and Reviews , 31 ( Sanders , 2011 ) Genetics of schizophrenia New findings and challenges . Annual Review of Genomics and Human Genetics . doi , I . Shields , 1967 ) A polygenic theory of schizophrenia . Proceedings of the National Academy of Sciences of the United States of America , 58 ( Green , 2006 ) Cognitive functional outcome in schizophrenia and bipolar disorder . of Clinical Psychiatry , 67 , discussion . 2010 ) Hippocampal pathology in schizophrenia . Current Topics in Behavioral , Hoe , Green , 2012 ) The causal relationships between , social cognition , and functional outcome over time in schizophrenia A latent difference score approach . Psychological Medicine , doi , 2006 ) Durability and mechanism of effects of cognitive enhancement therapy . Psychiatric Services , 57 ( 12 ) doi Jensen , Kapur , 2009 ) Salience and psychosis Moving from theory to practise . Psychological Medicine , 39 ( doi Jensen , Smith , Kapur , 2008 ) The formation of abnormal associations in schizophrenia Neural and behavioral evidence . Official Publication of the American College of , 33 ( doi Kapur , 2003 ) Psychosis as a state of aberrant salience A framework linking biology , phenomenology , and pharmacology in schizophrenia . 160 ( Li , 2005 ) From dopamine to salience to biology , pharmacology and phenomenology of psychosis . Schizophrenia Research , 79 ( doi , van , Cannon ,

Schizophrenia Spectrum Disorders 462 ( 2008 ) Diffusion tensor imaging of the superior longitudinal fasciculus and working memory in schizophrenia . Biological Psychiatry , 63 ( Kerr , 1993 ) Emotion perception in schizophrenia Specific deficit evidence poor performance ?

102 ( 31 . Kim , Kwon , Park , Youn , Kang , Kim , Lee , 2003 ) Functional disconnection between the prefrontal and parietal cortices during working memory processing in schizophrenia A 150 PET 923 . Kim , Trace , Sullivan , 2011 ) Schizophrenia genetics Where next ?

Schizophrenia Bulletin , 37 ( doi , Martin , 2010 ) Facial emotion perception in schizophrenia A review . Schizophrenia Bulletin , 36 ( doi , Moran , 2008 ) Emotional response deficits in schizophrenia Insights from affective science . Schizophrenia Bulletin , 34 ( Stroup , Perkins , 2005 ) Effectiveness of antipsychotic drugs in patients with chronic schizophrenia . The New England journal of Medicine , 353 ( 12 ) doi , Strauss , Cohen , 2012 ) Looking at the other side of the coin A analysis of emotional arousal in people with schizophrenia . Schizophrenia Research , 142 ( doi , Alamo , Shen , 2005 ) History of the discovery and clinical introduction of chlorpromazine . Annals of Clinical Psychiatry Official journal of the American Academy of Clinical Psychiatrists , 17 ( 35 . Morrison , di , Murray , 2008 ) What is the mechanism whereby cannabis use increases risk of psychosis ?

Research , 14 ( doi , III , 2009 ) Imaging genetic liability to schizophrenia Systematic review of FMRI studies of patients relatives . Schizophrenia Bulletin , 35 ( amah , Constantino , 2012 ) A survey of psychosis risk symptoms in Kenya . Comprehensive Psychiatry , 53 ( doi arch , Hatch , Morgan , 2008 )

Schizophrenia Spectrum Disorders 463 Psychosis and place . Reviews , 30 , doi , Goff , 2009 ) in schizophrenia A review . Neuropsychology , 23 ( doi , Egan , 2001 ) Evidence for abnormal cortical functional connectivity during working memory in schizophrenia . 158 , 2011 ) of paternal age and schizophrenia risk in male versus female offspring . Schizophrenia Bulletin , 37 ( doi , Laird , Carter , 2009 ) of 41 functional studies of executive function in schizophrenia . Archives of General Psychiatry , 66 ( doi , Clark , Honey , Fletcher , 2008 ) Substantia tegmental reward prediction error disruption in psychosis . Molecular Psychiatry , 13 ( 2012 ) Prevalence and characteristics of experiences in youth . Psychiatry Research , 196 ( doi , Green , Ventura , 2011 ) ofwork outcome in schizophrenia . Schizophrenia Bulletin , 37 , doi , Wood , 201 ) Are there progressive brain changes in schizophrenia ?

A of structural magnetic resonance imaging studies . Biological Psychiatry , 70 ( doi . Owen , 2010 ) Suggestion of roles for both common and rare risk variants in studies of schizophrenia . Archives of General Psychiatry , 67 ( doi , Cella , 2010 ) trials in people at ultra high risk of psychosis a review of treatment effectiveness . Schizophrenia Research , 123 ( doi , Laird , Gonzales , 2009 ) Prefrontal activation deficits during episodic memory in schizophrenia . American journal , 166 (

Schizophrenia Spectrum Disorders 464 , 2012 ) Working memory related brain network connectivity in individuals with schizophrenia and their siblings . Frontiers in Human Neuroscience , doi Rutter , 2006 ) and in psychopathology between childhood and adult life . journal of Child Psychology and Psychiatry , Disciplines , 47 ( doi , 2003 ) Altered effective connectivity during working memory performance in schizophrenia and modeling . 19 ( 763 . Macdonald , Carter , 2006 ) Cognitive deficits in unaffected degree relatives of schizophrenia patients A review of putative . Schizophrenia Bulletin , 32 ( Squire , 1992 ) Memory and the hippocampus A synthesis from findings with rats , monkeys , and humans . Psychological Review , 99 , Sullivan , 2003 ) Schizophrenia as a complex trait Evidence from a of twin studies . Archives General Psychiatry , 60 ( 12 ) Ventura , Thames , A . 2009 ) Symptoms as mediators of the relationship between and functional outcome in schizophrenia a . Schizophrenia Research , 113 ( doi . Ventura , Thames , Wood , 2010 ) Disorganization and reality distortion in schizophrenia a relationship between positive symptoms and deficits . Schizophrenia Research , 121 ( doi Ventura , Wood , 2011 ) Symptom domains and functioning can help differentiate social cognitive processes in schizophrenia A analysis . Schizophrenia Bulletin . doi , van Os , 2002 ) Psychotic symptoms in populations and the continuum of psychosis . Schizophrenia Research , 54 ( van , a Campo , 2008 ) Social cognition and as independent domains in psychosis . Schizophrenia Research , 103 ( doi