Chapter 6: Dissociative Disorders

-Changes, disturbances, or breakdowns in identity, memory or consciousness that affect the

ability to maintain an integrated sense of self.

Dissociative Identity Disorder

A) Disruption of identity characterized by two or more distinct personality states, which
may be described in some cultures as an experience of possession

The disruption in identity involves marked discontinuity in sense of self and sense of
agency, accompanied by related alterations in affect, behavior, consciousness,
memory, perception, cognition, and/or sensory-motor functioning

These signs and symptoms may be observed by others or reported by the individual

B) Recurrent gaps in the recall of everyday events, important personal information, and/or
traumatic events that are inconsistent with ordinary forgetting
C) The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning
D) The disturbance is not a normal part of a broadly accepted cultural or religious practice
Note: In children, the symptoms are not better explained by imaginary playmates or
other fantasy play
E) The symptoms are not attributable to the physiological effects of a substance (e.g.
blackouts or chaotic behavior during alcohol intoxication) or another medical condition
(e.g. complex partial seizures)

-Fragmentation: body divides traits and feelings, and group them into smaller sections,
keeping some of them hidden until a safe space for expression is provided
-Alters: separate identities
Trauma response

Dissociative Amnesia
A) An inability to recall important autobiographical information, usually of a traumatic
or stressful nature, that is inconsistent with ordinary forgetting
Note: Dissociative amnesia most often consists of localized or selective amnesia for a
specific event or events; or generalized amnesia for identity and life history
B) The symptoms causes clinically significant distress or impairment in social, occupational,
or other important areas of functioning
 C) The disturbance is not attributable to the physiological effects of a substance (e.g.
alcohol or other drug of abuse, a medication) or a neurological or other medical condition
(.g. Partial complex seizures, transient global amnesia, sequelae of a closed head
injury/traumatic brain injury, other neurological conditions).
D) The disturbance is not better explained by dissociative identity disorder, posttraumatic
stress disorder, acute stress disorder, somatic symptom disorder, or major or mild
neurocognitive disorder

-Specify if:
-With dissociative fugue: Apparently purposeful travel or bewildered wandering
that is associated with amnesia for identity or for other important autobiographical information.
Subtypes:
-Localized: Inability to recall events related to a period of time
-Selective:Can remember some but not all for the period of time
-Generalized: Failure to recall one’s entire life
-Continuous: Failure to recall successive events
-Systematized: Categories (family, one person)

Depersonalization/ Derealization Disorder

A) The presence persistent or recurrent experiences of depersonalization, derealization, or
both:
Depersonalization: Experiences of unreality, detachment, or being an outside observer
with respect to one’s thoughts feelings, sensations, body, or actions (e.g. perceptual
alterations, distorted sense of time, unreal or absent self, emotional and/ or physical
numbing)

Derealization: Experiences of unreality or detachment with respect to surroundings (e.g.

individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually
distorted)

B) During the depersonalization or derealization experiences, reality testing remains intact.

C) The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning
D) The disturbance is not attributable to the physiological effects of a substance (e.g. a drug
of abuse, medication) or another medical condition (e.g. seizures)
E) The disturbance is not better explained by another mental disorder, such as
schizophrenia, panic disorder, major depressive disorder, acute stress disorder,
posttraumatic stress disorder, or another dissociative disorder
Theories (how did these happen)
-Psychodynamic: Removing self from troubling memories/ unacceptable impulses by blotting
them out of consciousness

-Biological: Research demonstrates structural brain differences between patients with

dissociative identity disorder and health controls

-Learning/ Cognitive: Learning not to think about troubling behaviors/ thoughts that leads to guilt
or shame (negative reinforced by removal via dissociation)

Treatment
-Treatment aimed at reintegration of parts and personality, working with reinforcement, and
some drug treatment

Somatic Symptoms Disorder

A) One or more somatic symptoms that are distressing or result in significant disruption of
daily life
B) Excessive thoughts, feelings, or behaviors related to the somatic symptoms or
associated health concerns as manifested by at least one of the following:
-Disproportionate and persistent thoughts about the seriousness of noe’s symptoms
-Persistently high level of anxiety about health or symptoms
-Excessive time and energy devoted to these symptoms or health concerns
C) Although any one somatic symptom may not be continuously present, the state of being
symptomatic is persistent (typically more than 6 months)

Specify if:
-With predominant pain (previously pain disorder): This specifier is for individuals whose
somatic symptoms predominantly involve pain
-Persistent: A persistent course is characterized by severe symptoms, marked
impairment, and long duration (more than 6 months)

Specify current severity:

-Mild: Only one of the symptoms specified in Criterion B is fulfilled
-Moderate: Two or more of the symptoms specified in Criterion B are fulfilled
-Severe: Two or more of the symptoms specifies in Criterion B are fulfilled, plus there are
multiple somatic complaints (or on very severe somatic symptom)
-Illness Anxiety Disorder
A) Preoccupation with having or acquiring a serious illness
B) Somatic symptoms are not present or, if present, are only mild in intensity. I f another
medical condition is resent or there is a high risk for developing a medical condition (e.g.
strong family history is present), the preoccupation is clearly excessive or
disproportionate
C) There is a high level of anxiety about health, and the individual is easily alarmed about
personal health states
D) The individual performs excessive health-related behaviors (e.g. repeatedly checks his
or her body for signs of illness) or exhibits maladaptive avoidance (e.g. avoids doctor
appointments and hospitals)
E) Illness preoccupation has been present for at least 6 months, but the specific illness that
is feared may change over that period of time
F) The illness-related preoccupation is not better explained by another mental disorder,
such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body
dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic
type.

Specify Whether:
-Care-seeking type: Medical care, including physician visits undergoing tests and
procedures, is frequently used
-Care-avoidant type: Medical care is rarely used.

-Conversion Disorder
A) One or more symptoms of altered voluntary motor or sensory function
B) Clinical findings provide evidence of incompatibility between the symptom and
recognized neurological or medical conditions
C) The symptom or deficit is not better explained by another medical or mental disorder
D) The symptom or deficit causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning or warrants medical evaluation

Specify symptom type:

-With weakness or paralysis
-With abnormal movement (e.g. tremor, dystonia, myoclonus, gait disorder)
-With swallowing symptoms
-With speech symptom (e.g. dysphonia, slurred speech)
-With attacks or seizures
-With anesthesia or sensory loss
-With special sensory symptom (e.g. visual, olfactory, or hearing disturbance)
-With mixed symptoms
Specify if:
-Acute episode: Symptoms present for less than 6 months
-Persistent: Symptoms occurring for 6 months or more
 Specify if:
-With psychological stressor (specify stressor)
-Without psychological stressor

-Malingering vs. Factitious

Malingering: deliberate efforts to fake or exaggerate sx for personal gain
-Not considered a mental disorder
Factitious: Also fabricated, absence of visible gain.
-Because of psychological needs, considered a mental disorder
-Munchausen - deliberate fabrication to assume patient role
-By proxy–to assume caretaker role

Somatic Symptom and Related Disorders: Theoriesty

-Motivates:
-Unconscious Conflicts or exposure to anxiety-evoking situations
-Development of Conversion (Hysterical) Symptoms
-Which is Reinforced by
-Relief from Anxiety
-Psychodynamic Theory: Symptoms prevent anxiety by blocking awareness of
unconscious conflicts (primary gains); they also relieve burdensome
responsibilities (secondary gains)
-Learning Theory: Adoption of sick role reduces anxiety by relieving stressful
responsibilities; secondarily, it is reinforced by support, attention,and sympathy
from others

Treatment
-Psychodynamic:Bring conflicts to the level of awareness, rooted in childhood.
When worked through

-Behavioral: Removing sources of reinforcement

-Cognitive: Response prevention and cognitive restructuring

Chapter 7

Mood
-a group of persisting feelings associated with evaluative and cognitive states which influence all
the future evaluations, feelings and actions.
-Psychological state comprised of thoughts, feelings, physiological changes, expressive
behaviors, and inclination

Range of mood discussed in Mood Disorders

Mania: unusual elation, energy and activity

Hypomania: a mild state of mania

Normal Mood:
Mild: is 5 symptoms (minimum for a dx)
Moderate: is 6 to 7 symptoms
Severe: is 8 to 9 symptoms

Causal Factors in Mood Disorders

Stress and Depression

Stress events:
-the loss of a love one
-interpersonal struggles
-physical illness
-Economic hardship
-Lack of secure attachment
Increase vulnerability for both major depression and bipolar disorder

Social support from family and friends may buffer the effects of stress and reduce the risk of
depression

Theories

-Psychodynamic
-Depression: anger turned inward
-Bipolar: balance between ego and superego

-Humanistic
-Depression and lack of meaning and authenticity in life

-Learning
-Depression results from situational factors, such as reduction in reinforcement
-Environment

-Cognitive
-Beck’s cognitive triad and learned helplessness

Learned Helplessness
-Uncontrollable bad events→perceived lack of control→generalized helpless behavior
-Factors can be internal, global, or stable
Genetics
-Imbalances in neurotransmitter activity in the brain appear to be involved in depression and
mania
-Brain abnormalities may contribute to mood disorders, as reduced volume and lower metabolic
activity in the areas of the brain involved in regulating thinking processes, mood, and memory
have been observed
-The diathesis-stress model is used as an explanatory framework to illustrate how biological or
psychological diathesis may interact with stress in the development of depression

Types of Mood Disorders

Major Depression Disorder

A) Five or more of the following symptoms have been during the same 2 week period and
represent a change from previous functioning:
1. Depression mood most of the day, nearly every day, as indicated
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the
day, nearly everyday (as indicated by either subjective account or observation)
3. Significant weight loss when not dieting or weight gain (e.g. a change of more
than 5% of body weight in a month), or decrease or increase in appetite nearly
every day. (Note: In children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not
merely subjective feelings of restlessness or being slowed down)
6. Fatigue or loss of energy nearly every day
 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be
delusional) nearly every day (not merely self-reproach or guilt about being sick)
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day
(either by subjective account or as observed by others)
9. Recurrent thoughts of death (not just fear of dying); recurrent suicide ideation
without a specific plan; a specific suicide plan; or a suicide attempt.
A) The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning
B) The episode is not attributable to the physiological effects of a substance or another
medical condition
C) At least one major depressive episode is not better explained by schizoaffective,
schizophreniform disorder, delusional disorder, or other specified and unspecified
schizophrenia spectrum and other psychotic disorders
D) There has never been a manic episode or a hypomanic episode

Persistent Depressive Disorder

Chronic form of MDD
A) Depressed mood for most of the day, for more days than not, as indicated by either
subjective account or observation by others, for at least 2 years
Note: In children and adolescents, mood can be irritable and duration must be at least 1
year
B) Presence, while depressed, of two (or more) of the following:
Poor appetite or overeating
Insomnia or hypersomnia
Low energy or fatigue
Low self-esteem
Poor concentration or difficulty making decisions
Feelings of hopelessness
C) During the 2-years period (1 year for children or adolescents) of the disturbance, the
individual has never been without the symptoms in Criteria A and B for more than 2
months at a time
D) Criteria for a major depressive disorder may be continuously present for 2 years
E) There has never been a manic episode or a hypomanic episode
F) The disturbance is not better explained by a persistent schizoaffective disorder,
schizophrenia, delusional disorder, or other specified or unspecified schizophrenia
spectrum and other psychotic disorder
G) The symptoms are not attributable to the physiological effects of a substance (e.g. a
drug of abuse, a medication) or another medical condition (e.g. hypothyroidism)
H) The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning
Premenstrual Dysphoric Disorder
-Clinically significant changes in mood during premenstrual period
A) In the majority of menstrual cycles, at least five symptoms must be present in the final
week before the onset of menses, start to improve within a few days after the onset of
menses, and become minimal or absent in the week postmenses.
B) One (or more) of the following symptoms must be present:
a. Marked affective lability (e.g. mood swings; feeling suddenly sad or tearful, or
increased sensitivity to rejection)
b. Marked irritability or anger or increased interpersonal conflicts
c. Marked depressed mood, feelings of hopeless, or self-deprecating thoughts
d. Marked anxiety, tension, and/or feelings of being keyed up or on edge
C) One (or more) of the following symptoms must additionally be present, to reach a total of
five symptoms when combined with symptoms from Criterion B above.
a. Decreased interest in usual activities (e.g. work, school, friends, hobbies)
b. Subjective difficulty in concentration
c. Lethargy, easy fatigability, or marked lack of energy
d. Marked change in appetite; overeating; or specific food carvings
e. Hypersomnia or insomnia
f. A sense of being overwhelmed or out of control
g. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a
sensation of “bloating,” or weight gain
D) The symptoms cause clinically significant distress or interference with work, school,
usual social activities, or relationships with others (e.g. avoidance of social activities;
decreased productivity and efficiency at work, school, or more)
E) The disturbance is nor merely an exacerbation of the symptoms of another disorder,
such as major depressive disorder, panic disorder, persistent depressive disorder, or a
personality disorder (although it may co-occur with any of these disorders)
F) Criterion A should be confirmed byh prospective daily ratings during at least two
symptomatic cycles. (Note: the diagnosis may be made provisionally prior to this
confirmation)
G) The symptoms are not attributable to the physiological effects of a substance (e.g. a
drug of abuse, a medication, other treatment) or another medical condition (e.g.
hyperthyroidism)

Depressive Disorder Specifiers

-With anxious distress
-With mixed features
-With melancholic features
-With atypical features
-With mood-congruent or mood-incongruent psychotic features
-With catatonia
-With peripartum onset
-With seasonal pattern

-Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, the
intensity of the symptoms is distressing but manageable, and the symptoms result in minor
impairment in social or occupational functioning.

-Moderate: The number of symptoms, intensity of symptoms, and/or functional impairment are
between those specified for “mild” and “severe”

-Severe: The number of symptoms is substantially in excess of that required to make the
diagnosis, the intensity of the symptoms is seriously distressing and unmanageable, and the
symptoms markedly

Bipolar Disorder
-Fluctuating mood states that interfere with functioning

Two types:

-Bipolar I:
-Manic episode required for dx
-Major depression episodes, or hypomania, can occur before or after, but not
necessarily.

-Bipolar II:
-Major depression episode required for dx
-Hypomanic episodes required for dx
-No episodes meet criteria for manic episodes

Bipolar I Disorder:
A) Manic Episode: A distinct period of abnormally and persistently elevated, expansive, or
irrational mood and abnormally and persistently increased activity or energy, lasting at
least 1 week and present most of the day, nearly everyday (or any duration if
hospitalization is necessary)
 B) During the period of mood disturbance and increase energy or activity, three (or more) of
the following symptoms (four is the mood is only irritable) are present to a significant
degree and represent a noticeable change from usual behavior:

Bipolar Criteria: Manic and hypomanic symptoms

a: Inflated self-esteem or grandiosity
b: Decreased need for sleep (eg. feel rested after only 3 hours sleep)
c: More talkative than usual or pressure to keep talking
d: Flight of ideas or subjective experience that thoughts are racing
e: Distractibility (eg. attention too easily drawn to unimportant or irrelevant external
stimuli), as reported or observed
f: Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation (purposeless non-goal-directed activity)
g: Excessive involvement in activities that have a high potential for painful
consequences (eg. engaging in unrestrained buying sprees, sexual indiscretions, or
foolish business investment)

C) The mood disturbance is sufficiently severe to cause marked impairment in social or

occupational functioning or to necessitate hospitalization to prevent harm to self or
others, or there are psychotic features
D) The episode is not attributable to the physiological effects of a substance (eg. a drug of
abuse, a medication, other treatment) or another medical condition.

Difference between Mania vs. Hypomania

Bipolar II Disorder
A) Hypomanic Episode: a distinct period of abnormally and persistently elevated, expansive
or irritable mood and abnormally and persistently increased activity or energy, lasting at
least 4 days and present most of the day, nearly everyday, and at least one major
depressive episode.
B) There has never been a manic episode
C) At least one hypomanic episode and at least one major depressive episode are not
better explained by schizoaffective disorder and are not superimposed on schizophrenia,
schizophreniform disorder, delusional disorder, or other specified or unspecified
schizophrenia spectrum and other psychotic disorder
D) The symptoms of depression or the unpredictability caused by frequent alternation
between periods of depression and hypomania causes clinically significant distress or
impairment in social, occupational, or other important areas of functioning

Cyclothymic Disorder
A) For at least 2 years (at least 1 year in children and adolescents) there have been
numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic
episode and numerous period with depression symptoms that do not meet criteria for a
major depressive episode
B) During the above 2-year period (1 year in children and adolescents), Criterion A
symptoms have been present for at least half the time and the individual has not been
without the symptoms for more than 2 months at a time
C) Criteria for a major depression, manic, or hypomanic episode have never been met
D) The symptoms in Criterion A are not better explained by schizoaffective disorder,
schizophrenia, schizophreniform disorder, delusional disorder, or other specified or
unspecified schizophrenia spectrum and other psychotic disorder
E) The symptoms are not attributable to the physiological effects of a substance (e.g. a
drug of abuse, a medication) or another medical condition (eg. hyperthyroidism)
F) The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning

Difference between Depressive and Manic/ Hypomanic Symptoms

Treatment
-Psychodynamic: Focus on relational work, support client self-awareness and understanding
of the influence of the past on present behavior. Goal of achieving self-worth and resolving
interpersonal conflicts
-Free association: Expression of whatever comes to mind without judgment to unblock
defenses
-Dream analysis: Analysis of mind content with less barriers
-Transference: displacement of feelings towards another onto the therapist
-Countertransference: Feelings projected onto of feelings towards the client by the
therapist
-Interpretations: Pairing of connections observed by therapist to support client insight
-Introjection: Feelings or thoughts of others taken on by the client
-Cognitive: Focus on correcting faulty thinking, distorted beliefs and self defeating attitudes
Usually short term, 8-10 sessions
-Rational Emotive Behavior Therapy (REBT): Therapists collaboratively dispute irrational
beliefs and substitute with better behaviors
-Beck’s Cognitive Therapy: Help clients to recognize and change cognitive distortions
and test reality
 -Cognitive Behavioral Therapy (CBT): Identify and correct maladaptive beliefs and
negative thoughts with cognitive restructuring and behavior changes
-Biomedical Treatment:
-Antidepressants
-Tricyclic antidepressants (TCAs), Monoamine Oxidase Inhibitors (MAOiS)
Increase availability of Serotonin and Norepinephrine neurotransmitters
-Selective Serotonin Reuptake Inhibitors (SSRIs)
Specifically targets serotonin, blocks reuptake (reabsorption)
-Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Targets both Serotonin and Norepinephrine, also by blocking reuptake
(reabsorption)
-Lithium and Anticonvulsive Drugs
Used to treat mania and mood swings in people with bipolar disorder
-Electroconvulsive Therapy
Electric shocks cause chemical and cellular changes in the brain that causes
changes to the molecules and cells of the brains of people with depression,
helping relieve severe depression
-Transcranial magnetic stimulation (TMC)
Applies a series of short magnetic pulses to stimulate nerve cells and influence
activity in areas of the brain associated with depressive symptoms

Suicide
-Mood disorders are often linked to suicide
-Women are more likely t attempt suicide, more men actually succeed, probably because they
select more lethal means
-The elderly, not the young, are more likely to commit suicide
-Rate of suicide among the elderly appears to be increasing
-People who attempt suicide are often depressed, but they are generally intouch with reality
Chapter 8
Classification of Substance-Related and Addictive Disorder
-Substance Use and Abuse
The line between substance use and substance abuse is the point at which a pattern of
substance use significantly impairs the person’s occupational, social, or daily
functioning or causes significant personal distress

Substance induced disorders: repeated episodes of drug

intoxication or development of a withdrawal syndrome
-Tolerance: State of physical habituation to a drug, resulting from frequent use, so that
higher doses are needed to achieve the same effect
-Withdrawal: Cessation of (or reduction in) use of a substance that has been heavy and
prolonged
The development of a substance-specific syndrome shortly after the cessation of (or
reduction in) substance use

Example: Alcohol Withdrawal

A) Cessation of (or reduction in) alcohol use that has been heavy and prolonged
B) Two (or more) of the following, developing within several hours to a few days after the
cessation of (or reduction in) alcohol use described in Criterion A:
a. Autonomic hyperactivity (e.g. sweating or pulse rate greater than 100 bpm)
b. Increased hand tremor
c. Insomnia
d. Nausea or vomiting
e. Transient visual, tactile, or auditory hallucination or illusions
f. Psychomotor agitation
g. Anxiety
h. Generalized tonic-clonic seizures
C) The signs or symptoms in Criterion B cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning
 D) The signs or symptoms are not attributable to another medical condition and are not
better explained by another mental disorder, including intoxication or withdrawal from
another substance

Substance use disorders: maladaptive use of a substance leading

to psychological distress or impaired functioning
-Separate diagnostics, the overall criteria are almost identical for the following disorders:
-Alcohol Use Disorder
-Cannabis Use Disorder
-Inhalant Use Disorder
-Opioid Use Disorder
-Sedative, Hypnotics, Anxiolytic Use Disorder
-Phencyclidine Use Disorder
-Tobacco Use Disorder
-Hallucinogen Use Disorder
-Stimulant Use Disorder
A) A problematic pattern of X use leading to clinically significant impairment or distress, as
manifested by at least two of the following, occurring within a 12-month period:
1. X is often taken in larger amounts or over a longer period than was intended
2. There is a persistent desire or unsuccessful efforts to cut down or control X use
3. A great deal of time is spent in activities necessary to obtain X, use X, or recover
from its effects
4. Craving, or a strong desire or urge to use X
5. Recurrent X use resulting in a failure to fulfill major role obligation at work,m
school, or home
6. Continued X use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of X
7. Important social, occupational, or recreational activities are given up or reduced
because of X use
8. Recurrent X use in situations in which it is physically hazardous
9. X use is continued despite knowledge of having persistent or recurrent physical
or psychological problem that is likely to have been caused or exacerbated by X
10. Tolerance, as defined by either of the following:
-A need for markedly increased amounts of X to achieve intoxication or desired
effect
-A markedly diminished effect with continued use of the same amount of X
11. Withdrawal, as manifested by either of the following:
-The characteristic withdrawal syndrome for X (refer to substance specific
withdrawal diagnosis)
-X (or a closely related substance) is taken to relieve or avoid withdrawal
symptoms
Specifiers for Use Disorders
-In early remission:
After full criteria for X use disorder were previously met, none of the criteria for X use
disorder have been met for at least 3 months but for less than 12 months (with the exception
that Criterion A4, “Craving, or a strong desire or urge to use X,” maybe met)
-In sustained remission:
After full criteria for X use disorder were previously met, none of the criteria for X use
disorder have been met at any time during a period of 12 months or longer (with the exception
that Criterion A4, “Craving, or a strong desire or urge to use X,” may be met).
In a controlled environment: This additional specifier is used if the individual is in an
environment where access to x is restricted

Example: Gambling Use Disorder

A) Persistent and recurrent problematic gambling behavior leading to clinically significant
impairment or distress, as indicated by the individual exhibiting four (or more) of the
following in a 12-month period:
1. Needs to gamble with increasing amounts of money in order to achieve the
desired excitement
2. Is restless or irritable when attempting to cut down or stop gambling
3. Has made repeated unsuccessful efforts to control, cut back, or stop gambling
4. Is often preoccupied with gambling (e.g. having persistent thoughts or reliving
past gambling experiences, handicapping or planning the next venture, thinking
of ways to get money with which to gamble)
5. Often gambles when feeling distressed (e.g. helpless, guilty, anxious, depressed
6. After losing money gambling, often returns another day to get even (“chasing”
one;s losses)
7. Lies to conceal the extent of involvement with gambling’Has jeopardized or lost a
significant relationship, job, or educational or career opportunity because of
gambling
8. Relies on others to provide money to relieve desperate financial situations
caused by gambling

B) The gambling behavior is not better explained by a manic episode

Dependence
-Physiological: repeated use of a substance alters the body’s physiological reactions, leading to
tolerance and/or withdrawal syndrome
-Psychological: dependence occurs when compulsive use of a substance meets a psychological
need
Addiction=compulsive use of a drug + by signs of physiological dependence

Pathways to Addiction
-Experimentation
-Routine Use
-Addiction/Dependence

Drug of Abuse

Depressants
-Slow down or curbs the CNS activity.
-Reduction of feelings of anxiety, slowing movement, and impairs cognitive processes
-Major types of depressants:
-Alcohol
-Barbiturates
-Opioids

Gabor Mate on Opiates

-Function of Opiates
-Opiates are the “chemical linchpins of the emotional apparatus” that allow for the basic,
primal, and key regulator that is the attachment instinct (i.e. love, relationships)
-By allowing for the attachment of the child and caregiver to exist, opioids ideally ensure
the physical and emotional regulation that comes from secure attachment and care
-Opiates don’t reduce attention to it. In this sense, opiates make the pain bearable, and
allow the user to continue their existence without the incapacitation of their physical or
emotional pain
-Physical pain is registered in the thalamus, but the emotional experience of it is
experienced in the anterior cingulate cortex (ACC)— “the brain gets the pain message in
the thalamus but feels it in the ACC.”
-ACC is the part of the brain where hurtful and negative feelings and emotions register.
The opiate then provides relief not to the thalamus, but to the ACC in decreasing the
emotional impact.
-The physical pain an infant feels activates their ACC which in turn has them signal their
caregiver (crying to the parent, screaming, etc.) to ensure care, emotional soothing
through endorphins, and subsequent survival).
 -Systems can be complicated by the introduction of substances —activation of these
receptors allow for the pleasure of things like alcohol, cocaine, and marijuana. While
increased use can lower the effectiveness of the system, the already less effective
system pushes for joy or relief seeking through ‘rewarding’ things such as substances

Stimulants
-Increases the CNS activity
-Enhance states of alertness, and can produce pleasure or highs
-Major types of depressants
-Amphetamines
-Ecstasy
-Cocaine
-Nicotine

Gabor Mate on Dopamine + Stimulants

Hallucinogens
-Produce sensory distortions or hallucinations, including color perception and hearing alterations
-Major types of depressants:
-LSD
-Phencyclidine
-Marajuana
Theoretical Perspective
-Biological Perspective:
-Neurotransmitters: Focus on the role of neurotransmitter imbalance and the biological
pathways:physiological dependence
-Genetics: Focus on the role of genetic vulnerability. MZ twins have higher rates of
alcoholism (cultural related)
-Psychological Perspective:
-Learning Theories: substance use disorders as learned patterns of behavior that, in
principle, can be unlearned (classical, operant conditioning and observational learning)
-Reinforcement of tension reduction/negative
-Conditioning to stimuli of cravings
-Parental and social modeling of use
-Cognitive: roles of attitudes, beliefs, and expectancies in accounting for substance use
and abuse
-Increase of self efficacy “getting out of the shell”
-Positive expectancies increase likelihood of use
-Psychoanalysis Theories: sign of oral fixation in alcohol or smoking use.
Psychodynamic views of function of the substance and role as a defense against difficult
unconscious content.
-Sociocultural perspectives have focused on the adoption of culturally sanctioned
prohibitions against excessive drinking in explaining differences among various ethnic
and religious groups in rates of alcoholism

Treatment

-Stage of Change Model

**Relapse is normal!
Precontemplation: someone maybe need
Contemplation: What would be?
Preparation: Thinking back to symptoms
Action:

-Biological Treatment:
-Detoxification: helping through withdrawal from substances
 -Drug intervention:
-Disulfiram: produces negative responses to alcohol
-Smoking cessation (bupropion, varenicline), nicotine replacement
-Methadone: blunts heroin cravings
-Naltrexone: blocks high/ pleasurable feelings from alcohol, opioids and
amphetamines

-Psychological/Therapeutic Approaches
Depending on level of severity:
-Individual therapy, often in conjunction with drug counseling
-Group therapy, professional (Substance recovery groups) or non-professional led (AA,
NA, etc.)
-Hospital settings, such as inpatient for withdrawal
-Different settings require different relationships to drugs (harm reduction vs. abstinence
vs. active use

-Psychodynamic:
Uncovering and working through inner conflicts originating in childhood. Increased awareness of
+ resolution of conflict = lessened need for use or “escape.”

-Behavioral
-Self control training
-A- Antecedent
-B- Behaviors
-C- Consequences
-Aversive conditioning
-Pairing painful stimuli with substance of choice
-Skills training

-Harm Reduction:
A set of practical strategies and ideas aimed at reducing negative consequences associated
with drug use. Harm reduction is also a movement for social justice built on a belief in, and
respect for, the rights of people who use drugs

-Denning
1. A Primary injunction to do no harm
2. Addiction is not a disease, but rather a maladaptive pattern that has biological,
psychological, and sociocultural origins
 3. Denial is not a primary dynamic: We all have our smoke and mirror defenses and we all
try to avoid pain and punishment, even if we have to lie
4. People generally do not respond well to punitive sanctions
5. People know what they need to take care of themselves
6. People’s behavior makes sense and is always adaptive in some way
7. People can and do make rational decisions even while using
8. Ambivalence is normal; life and its problems are seldom black and white
9. Change occurs gradually with many setbacks
10. Come as you are: Start where the person is ( not where you want them to be)

Chapter 9
Eating Disorders
-Typical onset in adolescence
-Mainly reported as impacting women, though impacts all genders
-Disorders involve interplay of body weight, food consumption and compensatory behaviors

Anorexia Nervosa
A) Restriction of energy intake relative to requirements, leading to a significantly low body
weight in the context of age, sex, developmental trajectory, and physical health.
Significantly low weight is defined as a wight that is less than minimally normal or, for
children and adolescents, less than that minimally expected
B) Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes
with weight gain, even though at a significantly low weight
C) Disturbance in the way in which one’s body weight or shape is experienced, undue
influence of body weight or shape on self evaluation, or persistent lack of recognition of
the seriousness of the current low body weight

-Subtypes
-Restricting type: During the last 3 months, the individual has not engaged in recurrent
episodes of binge-eating or purging behavior (i.e. self-induced vomiting or the misuse of
 laxatives, diuretics, or enemas). This subtype describes presentations in which weight
loss is accomplished primarily through dieting, fasting, and/or excessive exercise
-Binge-eating/purging type: During the last 3 months, the individual has engaged in
recurrent episodes of binge-eating or purging behavior (i.e. self-reduced vomiting or the
misuse of laxatives, diuretics, or enemas)
-Specifiers
-Impartial remission: After full criteria for bulimia nervosa were previously met, some, but
not all, of the criteria have been met for a sustained period of time
-In full remission: After full criteria for bulimia nervosa were previously met, none of the
criteria have been met for a sustained period of time

-Medical Complications of Anorexia Nervosa

-Dermatological: Skin cracking, drying and discoloration, thinning of hair
-Cardiovascular: Heart irregularities, low blood pressure, dizziness
-Gastrointestinal: Constipation, abdominal pain, impacted bowels
-Menstrual: Amenorrhea
-Musculoskeletal: Muscular weakness and abnormal bone growth
-Suicide risk: 8x more likely than general population

Bulimia Nervosa
A) Recurrent episodes of ginge eating. An episode of binge eating is characterized by both
of the following:
a. Eating, in a discrete period of time (e.g. within any 2-hour period), and amount of
food that is definitely larger than what most individuals would eat in a similar
period of time under similar circumstances
b. A sense of lack of control over eating during the episode (e.g. a feeling that one
cannot stop eating or control what or how much one is eating)
B) Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such
as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or
excessive exercise
C) The binge eating and inappropriate compensatory behaviors both occur, on average, at
least once a week for 3 months
D) Self-evaluation is unduly influenced by body shape and weight
E) The disturbance does not occur exclusively during episodes of anorexia nervosa
Specifiers:
-In partial remission: After full criteria for bulimia nervosa were previously met,some, but
not all, of the criteria have been met for a sustained period of time
-In full remission:After full criteria for bulimia nervosa were previously met, none of the
criteria have been met for a sustained period of time
-Medical Complications of Bulimia Nervosa
-Impact of constant vomiting and exposure to stomach acid
-Skin irritation
-Tooth decay
-Dental cavities
-Decreased taste receptor sensitivity
-Musculoskeletal: Abdominal pain, impacted relational with bowels and reflexive
elimination, muscular weakness
-Menstrual: Amenorrhea

-Cause of Anorexia and Bulimia Nervosa

-Sociocultural factors:
-Common in Western cultures
-Idealization of thinness
-Gendered expectations of body
-Comparison to others
-Cultural value on body composition
-Psychosocial + Emotional Factors
-Not all exposed develop eating disorders
-Tie to deep emotional issues
-Linked to abusive histories
-Negative emotions can trigger episodes
-”Relief” of upsetting emotions
Bingeing: intake, endorphin rush
Purging: release and relief
Restriction: control, mastery
-Learning perspectives: weight phobia theory, negative reinforcement of relief through
compensatory behaviors
-Cognitive Factors:Black and white thinking, negative belief about self
-Family Factors: “Identified patient” represents family dysfunction. Disordered eating
often as a response to chaos in home.
-Biological Factors: brain abnormalities related to hunger and appetite, genetic
predispositions

Binge Eating Disorder

A) Recurrent episodes of binge eating. An episode of binge eating is characterized by both
of the following:
 1. Eating, in a discrete period of time (e.g. within any 2-hour period), an amount of
food that is definitely larger than what most people would eat in a similar period
of time under similar circumstances
2. A sense of lack of control over eating during the episode (e.g. a feeling that one
cannot stop eating or control what or how much one is eating)
B) The binge-eating episodes are associated with three (or more) of the following:
1. Eating much more rapidly than normal.
2. Eating until feeling uncomfortably full.
3. Eating large amounts of food when not feeling physically hungry
4. Eating alone because of feeling embarrassed by how much one's eating
5. Feeling disgusted with oneself, depressed, or very guilty afterward
C) Marked distress regarding binge eating is present.
D) The binge eating occurs, on average, at least once a week for 3 months
E) The binge eating is not associated with the recurrent use of inappropriate compensatory
behavior as in bulimia nervosa and does not occur exclusively during the course of
bulimia nervosa or anorexia nervosa

Treatment of Eating Disorders:

-Hospitalization: Monitored feeding, behavioral therapy-cycle breaking
-CBT: Addressing maladaptive beliefs about body image, eating, and self value
-Exposure response prevention for purging
-Psychodynamic: Healing of psychological conflicts and family dynamics leading tot he urge to
control/purge/binge
-SSRIs: appetite regulation

Sleep-Wake Disorder
-Sleep as a biological mechanism
-Sleep stage
-Stage 1: Nrem
-Stage 2: Nrem Sleep
-Stage 3: Nrem Sleep
-Stage 4: Rem Sleep

-Insomnia Disorder
A) A predominant complaint of dissatisfaction with sleep quantity or quality, associated with
one (or more) of the following symptoms:
1. Difficulty initiating sleep. (In children, this may manifest as difficulty initiating
sleep without caregiver intervention)
 2. Difficulty maintaining sleep, characterized by frequent awakenings or problems
returning to sleep after awakenings. (In children, this may manifest as difficulty
returning to sleep without caregiver intervention)
3. Early-morning awakening with inability to return to sleep
B) The sleep disturbance causes clinically significant distress or impairment in social,
occupational, educational, academic behavior, or other important areas of functioning.
C) The sleep difficulty occur at least 3 nights per week
D) The sleep difficulty is present for at least 3 months
E) The sleep difficulty occurs despite adequate opportunity for sleep
F) The insomnia is not better explained by and does not occur exclusively during the course
of another sleep-wake disorder (e.g. narcolepsy, a breathing-related sleep disorder, a
circadian rhythm sleep-wake disorder, a parasomnia)
G) The insomnia is not attributable to physiological effects of a substance (e.g. a drug of
abuse, a medication)
H) Coexisting mental disorders and medical conditions do not adequately explain the
predominant complaint of insomnia
-Episodic: Symptoms last at least 1 month but less than 3 months.
-Persistent: Symptoms last 3 months or longer
-Recurrent: Two (or more) episodes within the space of 1 year
-With mental disorder, including substance use disorders
-With medical condition
-With another sleep disorder

Hypersomnolence Disorder
A) Self-reported excessive sleepiness (hypersomnolence) despite a main sleep period
lasting 7 hours, with at least one of the following symptoms:
1. Recurrent period of sleep or lapses into sleep within the same day
2. A prolonged main sleep episode of more than 9 hourd per day that is non
restorative (i.e. unrefreshing)
3. Difficulty being fully awake after abrupt awakening
B) The hypersomnolence occurs at least three times per week, for at least 3 months
C) The hypersomnolence is a accompanied by significant distress or impairment in
cognitive, social, occupational, or other important areas of functioning
D) The hypersomnolence is not better explained by and does nor occur exclusively during
the course of another sleep disorder (e.g. narcolepsy breathing-related sleep disorder,
circadian rhythm sleep-wake disorder parasomnia)
E) The hypersomnolence is not attributable to the physiological substance (e.g. a drug of
abuse, a medication)
F) Coexisting mental and medical disorders do not adequately explain the predominant
complaint of hypersomnolence
-Acute: Duration of less than 1 month
-Subacute: Duration of 1-3 months
-Persistent: Duration of more than 3 months
-Mild: Difficulty maintaining daytime alertness 1-2 days/week
-Moderate: Difficulty maintaining daytime alertness 3-4 days/week
-Sever: Difficulty maintaining daytime alertness 5-7 days/week
-With mental disorder, including substance use disorders
-With medical condition
-With another sleep disorder

-Narcolepsy
-Cataplexy: Loss of muscle tone and voluntary muscle control
-Sleep paralysis: Temporary state of paralysis upon waking
-Hypnagogic hallucinations: Frightening hallucinations just before sleep begins or shortly
after awakening
-Hypocretin/orexin deficiency: decreased wake drive and a disinhibition of REM sleep
occurrence
A) Recurrent period of an irrepressible need to sleep, lapsing into sleep or napping
occurring within the same day. These must have been occurring at least three times per
week over the past 3 months
B) The presence of at least one of the following:
1. Episodes of cataplexy, defined as either (a) or (b), occurring at least a few times
per month:
a. In individuals with long-standing disease, brief (seconds to minutes)
episodes of sudden bilateral loss of muscle tone with maintained
consciousness that are precipitated by laughter or joking
b. In children or individuals within 6 months of onset, spontaneous grimaces
or jaw-opening episodes with tongue thrusting or global hypotonia,
without any obvious emotional triggers
C) Hypocretin deficiency, as measured using cerebrospinal fluid (CSF) hypocretin-1
immunoreactivity values (less than or equal to one third of values obtained in healthy
subjects tested using the same assay, or less than or equal to 110 pg/ml). Low CSF
levels of hypocretin-1 must not be observed in the context of acute brain injury,
inflammation, or infection
D) Nocturnal sleep polysomnography showing rapid eye movement (REM) sleep latency
less than or equal to 15 minutes, or a multiple sleep latency test showing a mean sleep
latency less than or equal to 8 minutes and two or more sleep-onset REMperiods

-Whether with/without cataplexy or hypocretin deficiency

-Mild: Need for naps only once or twice per day. Sleep disturbance, if present, is mild.
Cataplexy, when present is infrequent (occurring less than once per week).
-Moderate: Need for multiple naps daily. Sleep may be moderately disturbed. Cataplexy, when
present, occurs daily or every few days
-Severe: Nearly constant sleepiness and, often, highly disturbed nocturnal sleep (which may
include excessive body movement and vivid dreams). Cataplexy, when present, is
drug-resistant, with multiple attacks daily

Obstructive Sleep Apnea Hypopnea

A) Either (1) or (2):
1, Evidence by polysomnography of at least five obstructive apneas or hypopneas per
hour of sleep and either of the following sleep symptoms:
a. Nocturnal breathing disturbances: snoring, snorting/gasping, or breathing pauses
during sleep
b. Daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient opportunities
to sleep that is not better explained by another mental disorder (including a sleep
disorder) and is not attributable to another medical condition
2. Evidence by polysomnography of 15 or more obstructive apneas and/or hypopneas
per hour of sleep regardless of accompanying symptoms
-Specify current severity:
-Mild: Apnea hypopnea index is less than 15
-Moderate: Apnea hypopnea index is 15-30
-Severe: Apnea hypopnea index is greater than 30

Circadian Rhythm Sleep-Wake Disorders

A) A persistence or recurrent pattern of sleep disruption that is primarily due to an alteration
of the circadian system or to a misalignment between the endogenous circadian rhythm
and the sleep-wake schedule required by an individual’s physical environment or social
or professional schedule
B) The sleep disruption leads to excessive sleepiness or insomnia, or both
C) The sleep disturbance causes clinically significant distress or impairment in social,
occupational, and other important area of functioning
-Delayed sleep phase type: A pattern of delayed sleep onset and awakening times, with an
inability to fall asleep and awaken at a desired or conventional
-Advanced sleep phase type: A pattern of advanced sleep onset and awakening times, with an
inability to remain awake or asleep until the desired or conventionally acceptable later sleep or
wake times
-Irregular sleep-wake type: A temporally disorganized sleep-wake pattern, such that the timing
of sleep and wake period is variable throughout the 24-hour period
-Non-24-hour sleep-wake type: A pattern of sleep-wake cycles that is not synchronized to the
24-hour environment, with a consistent daily drift
-Shift work type: Insomnia during the major sleep period and/or excessive sleepiness (including
inadvertent sleep) during the major awake period associated with a shift work schedule
(i.e.requiring unconventional work hours)
-Episodic: Symptoms lar at least 1 month but less than 3 months
-Persistent: Symptoms last 3 months or longer
-Recurrent: Two or more episodes occur within the space of 1 year

Parasomnia
-Parasomnias: Abnormal behavior patterns associated with partial or incomplete
arousals
-Sleep terrors: Recurrent terror arousal during sleep, typically outgrown by adolescence
-Sleepwalking: Complex motor responses completed out of consciousness
-Rapid eye movement sleep behavior disorder: Paralysis is absent or incomplete leading
to movement and action during sleep
-Nightmare disorder: Related to stress and trauma, vividly remembered intense
nightmares

Treatment of Sleep-Wake Disorder

-Biological Approaches
-Antianxiety drugs (benzodiazepines)
-Sleeping medications (Ambien)
-Decrease in arousal, inducing calm feeling
-Good at getting to sleep, not getting good quality sleep
-Physiological and Psychological dependence
-Stimulants for narcoleptics/hypersomnolence

-Psychological Approaches
-CBT
-Stimulus control: changes in sleep environment
-Consistent sleep/wake cycle
-Addressing self defeating thoughts related to sleep
-Psychodynamic
-Address energizing conflicts and concerns
-Mindfulness training
Sleep Hygiene
-Exercise
-Physiologic arousal created by exercise opposes the sleep process
-Avoid exercise within 3 hours of bedtime
-Exercising regularly during the afternoon
-Napping
-Naps of <30 minutes can be useful in the mid-afternoon, to avoid long naps.
-Longer naps can make you drowsy and interfere with a good night’s sleep