Chapter 6: Dissociative disorders are characterized by severe disturbances or alterations of identity, memory, and consciousness. The primary symptom of dissociative amnesia is the inability to recall significant personal information, usually of a traumatic or stressful nature, in the absence of organic impairment. Dissociative fugue is an extremely rare subtype of dissociative amnesia in which individuals forget who they are and suddenly and unexpectedly travel away from their home. The key feature of depersonalization/derealization dis- order is a persistent feeling of unreality and detachment from one’s self or surroundings, often described as feeling like one is in a dream. Dissociative identity disorder (DID) is diagnosed when the patient presents with two or more distinct personality states, wherein various symptoms indicate a disruption in sense of self and sense of agency. According to the trauma model, DID results from a combination of (1) severe childhood trauma, including sexual, physical, and emotional abuse; and (2) particular personality traits that predispose the individual to employ dissociation as way of coping with that trauma. Although dissociation may initially be an adaptive way of coping with traumatic events, it becomes maladaptive when it is maintained as a habitual way of coping throughout adulthood. In contrast, proponents of the socio-cognitive model argue that DID is an iatrogenic condition that results from well-intentioned but misguided therapists inadvertently planting suggestions in the minds of their patients that they have multiple personalities. Highly hypnotizable patients may then develop the symptoms of DID as a learned social role. Individuals with somatic symptom and related disorders complain about bodily symptoms suggestive of medical illnesses, along with significant psychological distress and functional impairment. n conversion disorder, symptoms are observed in voluntary motor or sensory functions (e.g., paralysis or seizures) that suggest neurological or other medical etiologies, but these cannot be confirmed by medical tests. I Somatic symptom disorder involves one or more somatic symptoms (e.g., chronic pain, fatigue) that are distressing or cause significant disruption of daily life, accompanied by disproportionate concerns about seriousness, anxiety, and/or excessive time and energy devoted to health concerns; a diagnosed medical illness may or may not be present. People with illness anxiety disorder have long-standing fears, suspicions, or convictions about a serious disease, despite medical reassurance that the disease is not present. According to the integrative biopsychosocial model (Kirmayer & Looper, 2007), somatic symptom and related disorders result from a series of vicious cycles involving physiological, psychological, and social factors. Physiological factors include stress-related increases in cortisol, which can adversely affect immunity and produce feelings of fatigue, pain, and general malaise, causing individuals under stress to perceive themselves as having a physical illness. Psychological factors include excessive attention to and misattribution of bodily symptoms, somatic amplification, and high levels of health anxiety. Social factors include early childhood abuse and social learning comprising both positive and negative reinforcement of illness behaviours and the “sick role.” Establishing a co-operative therapeutic relationship between therapist and patient is a particular challenge and a vital first step in psychotherapy for somatic symptom and related disorders. I dentification and treatment of comorbid anxiety and depressive disorders is also important. Cognitive interventions for somatic symptom and related disorders involve restructuring dysfunctional thoughts, interpretations, and preoccupations relating to bodily symptoms and illness. Chapter 8: Mood Disorders – Summary Depressive disorders involve a change in mood to depression and include major depressive disorder (MDD) and dysthymia. Symptoms of MDD include persistent feelings of sad- ness, loss of interest in activities, loss of appetite or weight loss, insomnia, low energy, feelings of worthless- ness or guilt, difficulty concentrating or making decisions and suicidality. At least five of these symptoms must be present for at least two weeks, although episodes of MDD typically last for several months. Symptoms of persistent depression are chronic feelings of sadness that persist for at least two years, plus at least an additional two depressive symptoms. Bipolar disorders involve alternating periods of depression and mania and include bipolar I disorder (mania alternating with episodes of major depression), bipolar II disorder (hypomania alternating with episodes of major depression), and cyclothymia (hypomania alternating with minor episodes of depression). Mood disorders are caused by the interaction of psychological, environmental, and biological variables. Early psychodynamic views of depression saw it as stemming from an unresolved regression to the oral stage of development following a real or imagined loss. More recent psychodynamic theories have focused on disruptions of early parent–child attachment and the development of pathological adult relationships. Cognitive models stress the role of negative thinking patterns that derive from rigid and tightly connected negative schemas about the self, world, and future. Interpersonal models point to specific maladaptive behaviour patterns that depression-prone individuals engage in, ones that heighten risk for interpersonal conflicts and rejections to trigger depression. Life stress models propose that depression occurs when a stressful event in the environment triggers an underlying biological or psychological diathesis. Biological models of the mood disorders have focused on the role of genetics, neurochemistry, and brain function and structure. Both major depression and bipolar disorder have a strong genetic component, and this may be mediated at least in part by the role of the serotonin transporter gene in heightening sensitivity to stressful life events (short allele vs long allele of 5-HTT study). Mood disorders are also associated with disruptions in serotonin, norepinephrine, and dopamine neurotransmission. Techniques that look at the function and structure of the brain have found decreased blood flow in certain cortical regions of the brain, as well as increased activity in limbic areas, such as the amygdala, when processing negative information. Psychological treatments for major depression include cognitive-behavioural therapy (CBT) and interpersonal psychotherapy (IPT). These emphasize the role of negative thinking patterns and improving interpersonal relationships and functioning through structured, collaborative, and time-limited therapy sessions. Biological treatments for major depression involve medications (monoamine oxidase inhibitors, tricyclics, and serotonin reuptake inhibitors) that increase the availability of one or more neurotransmitters. Other biological treatments include electroconvulsive therapy (ECT), trans magnetic stimulation (TMS), vagus nerve stimulation (VNS), and deep brain stimulation (DBS). All of these more invasive techniques have shown promise for severely and chronically depressed patients who do not respond to psychotherapy or medication. Biological treatments for bipolar disorder include lithium, anticonvulsant medication, or antipsychotic medication. Adjunctive psychological treatments have recently been developed to help improve remission rates and prevent relapse in bipolar disorder. These include family-focused therapy (FFT), interpersonal and social rhythm therapy (IPSRT), and cognitive therapy (CT). Chapter 9: Schizophrenia Spectrum and Other Psychotic Disorders – Summary Schizophrenia is a psychotic disorder that may affect both men and women in late adolescence and early adulthood. The disorder is complex and heterogeneous in its clinical presentation, course, and outcome. Approximately 50 percent of patients with schizophrenia improve over time and in response to treatment, but few achieve their social and occupational potential, and many require lifelong support and remain at risk for suicide. Direct and indirect social and health care costs of schizophrenia approach $7 billion a year in Canada, affecting almost 300,000 Canadians. Schizophrenia involves characteristic symptoms that must be present for diagnosis, including hallucinations, delusions, thought and language disorder, bizarre behaviour, and withdrawal. Positive and Negative Symptoms are present – positive being hallucinations, delusions, motor and grossly disorganized behaviour, speech inconsistencies. Negative symptoms include avolition, apathy, loss of motivation, anhedonia, diminished attention, and concentration. The diagnosis requires evidence of a decline in social and occupational functioning. Having psychotic symptoms for one day does not mean a person has schizophrenia; these symptoms (two or more) must persist for at least a month unless successfully treated. Mood disorders such as depression and other medical and developmental disorders may complicate the diagnosis of schizophrenia and must be ruled out. There is no objective test that confirms whether a person has schizophrenia. Disorders such as schizophrenia may result from many interacting biological and psychosocial influences rather than from a single cause or event. Biological and psychosocial processes may increase or decrease the probability that a vulnerable person develops schizophrenia. Most theorists argue that both a vulnerability, or diathesis, and environmental stress are required to cause schizophrenia. Having a parent with schizophrenia significantly increases the chances that a young person will develop the disorder. The influence of parents on the development of schizophrenia in their children is biological and genetic in nature. Many genes are implicated in schizophrenia, but their individual effects are very small. Epigenetic processes that turn genes on and off may be as important in causing schizophrenia as the genes themselves. Slow processing of information; poor coordination; and deficient attention, perception, and learning are characteristic of most people with schizophrenia. Abnormalities of the frontal and temporal lobes of the brain are among the most studied features of schizophrenia, but no single brain abnormality occurs in everyone with the disorder. Neuroscience research methods provide increasingly accurate and sophisticated information about the structure and physiology of the brain. The most frequently implicated neurochemical abnormality in schizophrenia involves the neurotransmitter dopamine. Chlorpromazine was the first effective antipsychotic medication used with schizophrenia patients, reducing the severity of positive and, to a lesser degree, negative symptoms. Newer generations of antipsychotic medications claim to provide therapeutic benefits with fewer side effects. Antipsychotic medications have little or no effect on the cognitive impairments associated with schizophrenia. Significant advances have been made in the application of psychological interventions, such as cognitivebehaviour therapy (CBT), family therapy, and cognitive remediation training. Cognitive remediation training has potential value for addressing cognitive impairment and may also reduce some symptoms and improve social functioning in people with schizophrenia. Early intervention, whereby medication and psychological therapies are provided before a person develops prolonged psychosis, has become a new and promising focus for clinical researchers. Integrated psychosocial and medical therapies offer the most hope for improving the lives of people with schizophrenia. Chapter 11 – Substance Related and Addictive Disorders DSM-5 sets out the criteria for substance intoxication and substance use disorders in the section called Substance-related and Addictive Disorders, which also includes gambling disorder. Alcohol is the world’s number one psychoactive sub- stance, with almost 80 percent of Canadians reporting drinking in the past year. Alcohol may result in positive feelings in the short term, but over time it acts as a depressant. Alcohol causes deficits in coordination, vigilance, and reaction time. These physical and psychological effects can result in negative consequences eco- nomically, socially, and medically. Treatment for alcohol use disorders includes abstinence-based treatments (AA, Minnesota model), pharmacotherapy medication (benzodiazepines, Naltrexone, Acamprosate, Antabuse), and psychological treatments (behavioural interventions, relapse prevention, marital and family therapy, brief interventions). One of the major problems in treating substance abusers is the phenomenon of polysubstance abuse. Research has demonstrated that concurrent dependence may be the rule rather than the exception. In the DSM-5, an individual can receive a diagnosis for each separate drug that is being abused. The use of tranquilizers (including barbiturates and benzodiazepines) is low in Canada. Barbiturates and benzodiazepines are considered depressants because they inhibit neurotransmitter activity in the CNS. The euphoria produced by small doses turns to poor motor coordination at higher doses and can prove fatal in too large a dose. Treatment usually involves pharmacological treatment (progressively smaller doses of the abused drug) in combination with psychological and educational programs. In 2015 it was estimated that 13 percent of Canadians over the age of 14 smoked cigarettes. Nicotine is a CNS stimulant. Lower dosages can interfere with thinking and problem solving and can cause extreme agitation and irritability along with mood changes. The small amount of nicotine present in a cigarette is not lethal and can increase alertness and improve mood. Treatments for smoking cessation include psychological (behavioural or cognitive) and pharmacological (nicotine replacement and prescription medication) interventions. Six percent of Canadians report having used amphetamines at least once in their life. Short-term effects of low dosages of amphetamines include increased alertness and ability to focus attention. This may lead to enhanced cognitive performance. Higher dosages, preferred by drug addicts, may produce feelings of exhilaration, but restlessness and anxiety may also be present. Prolonged use may lead to paranoia, toxic psychosis, periods of chronic fatigue, or a “crash” when the drugs wear off. n 2015 about 1.2 percent of Canadians reported having used cocaine or crack in the past year. The shortterm effects of cocaine appear soon after its ingestion and wear off very quickly. Crack is especially fastacting, and its effects may wear off in a few minutes. In small amounts, cocaine use in any form produces feelings of euphoria, well-being, and confidence. Continual use may result in mood swings, loss of interest in sex, weight loss, and insomnia. I Chapter 12 – Personality Disorders Personality disorders comprise maladaptive personality traits. All people have relatively consistent characteristics that make up their personality. Personality disorders are distinguished from normal personality traits by being rigid, maladaptive, and monolithic. People with person- ality disorders typically have many intact abilities but have impaired functioning (especially socially) because of their disorder. Personality disorders (i.e., psychopathy or APD) were first clearly described in the early nine- teenth century. The present set of personality disorders first appeared in DSM-III as Axis II, separate from the Axis I “clinical” disorders. While the same set of person- ality disorders is included in the DSM-5, the multi-axial system is no longer used in the current version of the DSM, and the personality disorders are now included in Section II of the manual. Personality disorders are more rigid and often more difficult to treat than are other major mental disorders. Other mental disorders (e.g., schizophrenia, bipolar disorder) are primarily considered to be egodystonic because they cause distress and are viewed as problem- atic by the individual sufferer. Personality disorders are often considered to be egosyntonic. In fact, most individuals diagnosed with personality disorders do not report experiencing any distress in interpersonal rela- tions or daily functioning (with exceptions, of course, e.g., borderline personality disorder, avoidant personality disorder). It is often the family and friends of an indi- vidual with a personality disorder who seek help for the individual, because those closest to the individual most often feel the effects of personality disorders. The DSM-5 lists 10 disorders, grouped into three clus- ters: odd and eccentric disorders (paranoid, schizoid, schizotypal); dramatic, emotional, or erratic disorders (antisocial, borderline, histrionic, narcissistic); and anxious and fearful disorders (avoidant, dependent, obsessive-compulsive). It also lists two other disorders: “Personality change due to another medical condition” and “other specified personality disorder and unspecified personality disorder.” Personality disorder diagnoses tend to have lower reliability than those of other major mental disorders, and there is considerable comorbidity as well as overlap among these disorders. Further, many have argued that the diagnostic criteria reflect cultural and gender bias, although this is not conclusive. The essential feature of ASPD is a pervasive, ongoing disregard for the rights of others. Special diagnostic issues and confusion over prevalence and research out- comes arise because ASPD is similar in some respects to the related construct of psychopathy. The latter, as measured by PCL-R, focuses on core emotional and interpersonal processes as well as behaviour, whereas the DSM-5 criteria for ASPD are largely behavioural. Social and family factors have been cited as etiological factors for ASPD; there is some support for genetic factors as well. Studies have shown that psychopaths are at high risk for future violence and that treatment outcomes are generally poor. BPD is characterized by fluctuations in mood (emotional instability), an unstable sense of identity, instability in relationships, and behavioural instability (impulsivity). Diagnostic criteria are still debated for several disorders. Disruptions in the family of origin are the most common etiological explanation. Treatment for personality disorders in general is difficult to evaluate, because many patients never seek treatment. Among the main approaches used those rooted in cognitive- behavioural theory, though medications are also used. There are few well-controlled studies of any treatments for most of these disorders. Obsessive-compulsive personality disorder and the more commonly known obsessive-compulsive disorder are distinct constructs. OCD can be found in the Obsessive-Compulsive and Related Disorders section, whereas OCPD is listed under the Personality Disorders. These disorders can be distinguished by the symptoms displayed; due to these differences, OCD and OCPD require different interventions. Etiological explanations have focused on psychodynamics, attachment theory, cognitive-behavioural perspectives, and, most recently, biological factors such as genetics, neurotransmitters, or brain dysfunction. Unfortunately, the majority of the data are correlational. Of the 10 DSM-5 disorders, APD has received the bulk of research attention due to the harm caused by those with the disorder. The DSM-5 includes two chapters on the personality disorders, the first in Section II and the second in Section III. The criteria set forth in Section II are those that are currently being implemented. The chapter in Section III proposes drastic revisions to the personality disorders chapter, including abolishing four of the existing personality disorders (schizoid personality disorder, histrionic personality disorder, paranoid personality disorder, and dependent personality disorder), as well as adding a new diagnosis of personality disorder trait specified. The DSM-5 authors have also proposed to change the model used to diagnose personality disorders from categorical to a hybrid dimensional-categorical model. This shift will involve a completely new method for diagnosis, replacing the categorical method with a measure of self and interpersonal functioning, as well as a continuum of personality traits. It is unknown when this new model of assessing personality traits will be implemented but it will likely be included in revisions of the DSM-5. Chapter 17: Review of Therapies ECT can be an efficacious treatment of last resort for severely depressed individuals who have not responded to other treatments and are at suicidal risk. ECT is associated with short-term benefits, but these must be balanced with the possibility of cognitive impairment side-effects. Psychotropic drugs have proven to be effective in treating a wide range of disorders. Psychopharmacological treatment includes phenothiazines and second generation antipsychotics used to treat psychotic disorders; anxiolytics for some anxiety disorders and anxiety-related disorders; MAOIs, TCAs, SRRIs, and SNRIs for depression, some anxiety disorders, and some anxiety-related disorders; mood stabilizers for bipolar disorders; and stimulants for ADHD. Psychotherapy is offered by diverse mental health professionals using a variety of theoretical orientations. There are efficacious psychological treatments for many mental disorders. Psychodynamic approaches are based on the assumption that much of the client’s distress stems from patterns developed early in life and use both interpretive and supportive interventions. Humanistic-experiential approaches focus on emotional aspects of subjective experience, highlighting the impact of affect in the client’s current life situation. Cognitive-behavioural approaches focus on internal (thoughts, images, emotions, bodily sensations) and external (fear-arousing objects, interpersonal interac- tions) stimuli in shaping the client’s adaptive and maladaptive reactions. Individual therapy is the most common treatment modality. Couples therapy can be effective in treating relationship difficulties. Family therapy addresses the way that family patterns maintain or resolve problems. Group therapy is a cost-effective way to deliver services. Many efficacious psychological treatments can now be delivered at a distance via the internet, or via computer- ized self-help programs. Efficacy trials use highly controlled randomized clinical trials to establish that the treatment works. Effectiveness research examines whether the treatment can be just as useful when transported to a realworld context. Meta-analyses are an efficient way to synthesize results from diverse studies. Clinical practice guidelines are based on the best avail- able data and often use a stepped-care approach.
