Psychopathology

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Psychopathology
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Mental Disorder

• What is a disorder?
• A behavioral or psychological syndrome associated
  with
• Present distress (e.g., painful symptom) OR
• Disability (i.e, impairment in one or more
  important areas of functioning) OR
• Significant increased risk of suffering death,
  pain, disability, or important loss of freedom

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DSM

• Diagnostic Statistical Manual Fourth Ed.
  (DSM-IV)
• Standard instructions (criteria) for diagnosing
  mental disorders
• Categorical (disorder present or absent) not
  dimensional model
• Each disorder a distinct entity

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DSM Diagnoses

• Polythetic or prototypical approach
• List of symptoms
• If person exhibits enough get the diagnosis
• Results in a heterogeneous population

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Major Depression

• 5 (or more) of the following present in during
  the same 2-week period and represent a change in
  previous functioning at least one symptom is
  depressed mood or loss of interest or pleasures
• Depressed mood most of the day nearly every day
• Markedly diminished interest or pleasure in all,
  or almost all, activities MODNED
• Significant weight loss when not dieting or
  weight gain, or decrease or increase in appetite
  NED
• Insomnia or hypersomnia NED
• Psychomotor agitation or retardation NED
• Fatigue or loss of energy NED
• Feelings of worthlessness or excessive guilt NED
• Diminished ability to think or concentrate, or
  indecisiveness NED
• Recurrent thoughts of death, suicidal ideation,
  or suicide attempt
• Symptoms not due to Mixed episode or Bereavement

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Mental Disorders

• There are 100s of disorders in the DSM
• Only about 20 are rigorously studied and treated
• Review major mental disorders
• Life time prevalence rate for some disorders
  (collapsed across gender) are in parentheses

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Mood Disorders

• Major Depression (17.1)
• Sad, depressed mood, anhedonia,
• Dysthymia (6.4)
• Subthreshold depression that lasts at least 2
  years
• Bipolar or Manic Depression
• Characterizes episodes of mania (1.6)
• Cycle of manic and depressive episodes

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Anxiety Disorders

• Characterized by persistent, uncontrollable
  feelings of worry, apprehension and dread
• Generalized Anxiety Disorder (GAD 5.1)
• Chronic, uncontrollable, diffuse feelings of
  worry, apprehension
• Obsessive Compulsive Disorder (OCD)
• Obsessive thoughts to perform some action and
  anxiety if dont perform action

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Anxiety Disorders

• Simple phobia (11.3)
• Fear of specific stimulus, e.g., spiders, snakes,
  heights, flying
• Social phobia (13.3)
• Fear of evaluation of others and social
  humiliation
• Panic Disorder (3.5)
• Recurrent panic attacks
• Agraphobia w/o panic disorder (5.3)
• Fear of open or public spaces
• Post Traumatic Stress Disorder (PTSD)
• Anxiety syndrome in response to a traumatic event

10
Substance Use Disorders

• Excessive use, hazardous use, tolerance, and
  characteristic withdrawal symptoms for a
  psychoactive substance
• Nicotine
• Alcohol (14.1)
• Marijuana
• Other drug (7.5)

11
Antisocial Behavior Disorders

• Persistent pattern of behavior that violates the
  rights of others
• Conduct Disorder (CD)
• Antisocial behavior before age 15
• Antisocial Personality Disorder (ASPD 3.5)
• Antisocial behavior that persists into adulthood
  (after age 18)

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Eating Disorders

• Anorexia
• Failure to maintain a body weight that is 85 of
  ideal body weight
• Bulimia
• Episodes of binging and purging

13
Psychotic disorders

• Schizophrenia spectrum disorders Characterized by
  thought disorder and bizarre behavior
• Hallucinations
• Delusions
• Disorganized speech
• Disorganized behavior
• Negative symptoms

14
Other Disorders

• Organic Disorders
• Dementia, delirium
• Somatoform Disorders
• Hypochondriasis, somatization, body dysmorphic,
  conversion
• Childhood Disorders
• ADHD, autism, equivalents to adult dx

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Organization of Mental Disorders

• DSM-IV utilizes a medical model and
  conceptualizes mental disorders as individual
  disease states
• Alternative organization
• Common mental disorders
• Common uncommon mental disorders
• Organic or Neurological disorders

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Common Mental Disorders

• high lifetime prevalence gt1 to 30 for meeting
  criteria of a diagnosis
• depression, anxiety, substance, and antisocial
  behavior disorders
• Think of these disorders and their symptoms as
  extremes of normal human emotions, thoughts, and
  behaviors
• e.g., low mood, feelings of worry or dread,
  consume psychoactive substances, and breaking
  rules and societal norms are typical of normal
  human experience

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Common Uncommon Mental Disorders

• Schizophrenia and Bipolar Disorder
  (manic-depression)
• relatively low prevalence rate 1, but very
  severe disorders
• both typically require hospitalization at some
  point and continual monitoring
• account for a disproportionate amount of mental
  health services

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Common Uncommon Mental Disorders

• Though debatable, the florid psychotic episodes
  and manic episodes that characterize these
  disorders are typically not part of normal human
  experience
• Therefore, may be best to consider these
  disorders more as categories rather than extremes
  of normal behavior

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Organic or Neurological Disorders

• Includes
• Demenita or senility (e.g., Alzheimers disease)
• Autism
• Mental Retardation
• The cause of these disorders is most likely the
  direct consequence of brain dysfunction or a
  problem in brain development
• the brain either is no longer able to perform the
  normal functions of a human brain (dementia), or
  the brain was never able to perform these
  functions adequately due to problems in its
  development (autism, most forms of mental
  retardation).

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National Comorbidity Survey (NCS)

• Congressionally mandated survey to determine the
  lifetime and 12-month prevalence rates for 14 DSM
  disorders
• Survey data was collected from 1990 to 1992

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NCS

• Administered structured clinical interview to a
  nationally representative sample
• N 8098
• Age 15-54
• 48 coterminous states
• Sample matched U.S. census data
• Sex
• Race (white, black, hispanic, other)
• Education
• Marital status

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Summary of Prevalence

• Nearly half the population with meet criteria for
  major mental disorder at some point in the life
• Women gt Affective Anxiety dx
• Men gt Substance use ASPD
• A minority of persons (14) account for a
  majority of diagnoses (54) and mental health
  care

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Demographic Correlates

• Age
• younger gt ASPD Substance use
• Race
• Blacks lt Affective, Substance use, any dx
• Income
• Lowest income gt all dx lower incomes gt Anxiety
  ASPD
• Education
• Lower education gt ASPD, Anxiety, Substance
• Urban vs. Rural
• No increased risks
• Region
• Lowest in South, greater in West Northeast

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Personality Mental Disorders

• Personality traits may be risk factors for
  certain mental disorders
• e.g., high Stress Reaction risk for anxiety and
  depression
• Look at Personality Profiles of four types of
  mental disorders
• Affective Major Depression, Dysthymia
• Anxiety Panic, GAD, OCD, Social Simple Phobia
• Substance Alcohol Drug
• Antisocial Behavior

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Personality Mental Disorders

• Also look at pure and comorbid cases
• pure only have the one disorder of interest
• comorbid have the disorder of interest but also
  meet criteria for other disorders

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Personality Mental Disorders

• Why important?
• Is the personality profile due to disorder of
  interest or the comorbid disorder?
• However, most people who meet criteria for one
  disorder also meet criteria for another, so
  pure cases may not be representative

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Personality Predicts Mental Disorders

• Personality at age 18 predicts mental disorders
  at age 21
• After controlling for disorders at age 18
• Anxiety Affective disorders
• NEM
• Substance use Antisocial Behavior
• NEM low CON

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Personality Mental Disorders

• pure cases less extreme personality differences
• Personality more important for severe cases
• Affective Anxiety Disorders
• High NEM (stress reaction)
• Substance Antisocial Behavior Disorders
• High NEM (aggression)
• Low CON
• Suggests a two-factor model of common mental
  disorders

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Comorbidity

• Vast majority of people that meet criteria for
  one disorder also meet criteria for another
  disorders e.g.,
• Anxiety depression
• Substance abuse antisocial behavior
• Rates of comorbidity are higher than would be
  expected by chance

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Comorbidity Psychometric Model of
Psychopathology

• Disorders co-occurrence in systematic ways
• Comorbidity as covariance (correlation)
• Suggests a meaningful structure to the relations
  among disorders
• Can the comorbidity be explained by a few general
  factors?
• Disorders co-occur due to a common process or
  risk factors

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Structure of Common Mental Disorders

• Examine the patterns of comorbidity for 10 common
  mental disorders
• Affective
• Anxiety
• Substance Use
• Antisocial Behavior
• Test a 1, 2, and 4-factor model in the Dunedin
  sample

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Age 18
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Structure of Mental Disorders

• Two factor model
• Fit better than a 1- or 4-factor model
• Correlated factors indicates both are associated
  with psychological distress
• Both high NEM
• EXT also low CON

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Structure of Mental Disorders

• Internalizing
• Unipolar mood anxiety disorders
• Psychological distress focused inward
• Hi NEM (stress reaction)
• Externalizing
• Substance and antisocial behavior disorders
• Psychological distress focused outward
• Hi NEM (aggression), lo CON

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Structure of Common Mental Disorders

• Similar to the General factor for intellectual
  ability, there are two general factors for common
  mental disorders
• Just as subtests from the WAIS all measure
  General intelligence, specific disorders and
  symptoms are different expressions of the
  Internalizing and Externalizing vulnerability
  factors

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INT-EXT model

• The factors represent what the different
  disorders have in common
• Factors are the latent vulnerability to all the
  disorders
• Represent a core psychopathological process
• Different disorders are different expressions of
  the same core process

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Age 21
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INT-EXT model

• High rank-order stability for both INT (r .69)
  and EXT (r .86) from age 18 to 21
• Findings have been replicated in the NCS,
  nationally representative sample of the
  Netherlands, and in a multi-national study

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Cross-Cultural INT-EXT

• Investigation examined 7 disorders in 14
  countries
• U.S., France, Germany, Greece, Italy,
  Netherlands, Turkey, U. K.
• Nigeria, India, China, Japan
• Brazil, Chile

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Cross-Cultural INT-EXT

• For all countries, an INT factor could be
  differentiated from hazardous use of alcohol
• Mean observed symptom levels for differed by
  region
• Asian lt Western Europe US lt Latin America

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Cross-Cultural INT-EXT

• Suggests a common structure to abnormal behavior
• Cultural or context can effect the expression and
  mean level of expression
• Increase or decrease mean
• Cultural expression of underlying vulnerability

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Heritability of Schizophrenia Bipolar

• Severe and persistent mental illness tends to be
  more heritable than common mental disorders

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Schizophrenia risks (Gottesman, 1994)
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Biometric model fitting for Operational Diagnoses
(lifetime ever) Liability models(England strong
diagnosis)
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Heritability of Common Mental Disorders

• Affective Anxiety dx
• h2 .25 to .40, no c2
• Substance use ASB dx
• h2 .35 to .60
• c2 .20 to .35 for childhood ASB

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Sources of Comorbidity

• Why are certain disorders comorbid?
• Common genetic or environmental factors?

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Sources of Comorbidity

• Mostly due to common genetic risk factors
• Genetic correlation between MD and GAD 1.0
• Big genetic correlations among EXT disorders

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Sources of Comorbidity

• Heritability of INT and EXT
• What is the heritability of the general
  vulnerability to common mental disorders?
• EXT Minnesota Twin Family Study
• INT-EXT Virginia Twin Registry

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Non-heritable (19)
Heritable (81)
Externalizing Psychopathology
.47
.78
.58
.71
.63
Adult Antisocial
Conduct Disorder
Alcohol Dependence
Drug Dependence
(Low) Constraint
E
A
E
E
E
C
E
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Sources of Comorbidity EXT

• EXT factor is the genetic vulnerability to the
  different specific disorders
• Disorders co-occur due to common genetic risks
• Non-shared environmental factors shape the
  particular expression of the common vulnerability

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Ac1
Ac2
.54
.53
.33
.56
.37
.58
.65
Major Depression
GAD
Phobia
Adult Antisocial
Child Antisocial
Alcohol Dep
Drug Dep
A
E
E
E
E
E
E
E
C
A
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Source of Comorbidity

• For both INT and EXT, the primary source of
  comorbidity are common genetic risk factors
• EXT tends to be slightly more heritable and
  stable across time than INT
• Specific genetic and environmental risk factors
  for different disorders
• Specific factors shape the expression of the
  common risk factor

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Family Transmission of EXT

• Why do family members resemble each other for EXT
  disorders?
• What do parents pass on to the next generation?
• General risk or specific risk factors?
• Genetic or Environmental risk factors?
• Why are siblings similar for EXT disorders?
• Same or different transmission as parents to
  children?

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Family Transmission of EXT

• Parents pass on a general vulnerability to a
  spectrum of disorders
• No specific risk factors
• Primarily genetic risk is whats passed on
• Specific environmental factors increase sibling
  resemblance

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Developmental Course

• What is the course of mental disorders?
• How persistent are the disorders?
• What is the risk for adult disorders given a
  history of disorders?
• Dunedin sample at age 26
• Look at the participants current and history of
  mental disorders
• Longitudinal, no retrospective bias

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Developmental Course

• At age 26, almost everyone (82-100) meeting
  criteria for a diagnosis had done so at an
  earlier age
• Developmental histories do not differ much by
  treatment users, intensive mental health
  services, and non-treatment seekers
• About 50 of persons with dx at age 26 had a
  diagnosis by age 15

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Link between Adolescent (age 11 to 15) Disorders
and Diagnosis at age 26

• Anxiety
• Anxiety, Depression, ADHD, CD/ODD
• Depression
• Depression, Anxiety, CD/ODD
• Substance Use
• CD/ODD

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Link between Adolescent (age 11 to 15) Disorders
and Diagnosis at age 26

• ASPD
• CD/ODD
• Mania
• CD/ODD, Depression
• Schizophrenia spectrum
• Anxiety, Depression, ADHD,CD/ODD
• Eating Disorders
• CD/ODD

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Developmental Course

• Homotypic continuity
• Adults with a diagnosis usually had the same
  diagnosis in childhood-adolescence
• Most adult disorders preceded by a variety of
  disorders
• CD/ODD a precursor for every adult disorder

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Adolescent Problem Behaviors and Adult Mental
Disorders

• Are problem behaviors in adolescence harbingers
  of adult mental disorders?
• Yes, in particular problem behaviors with an
  EARLY ONSET
• Examine the relation between adolescent problem
  behavior and EXT in the MTFS sample

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Problem Behaviors in 17-Year-Old Adolescents
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Correlations Among Adolescent Problem Behaviors
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Adolescent Problem Behavior Index
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Age 20 Diagnoses of EXT Disorders

• Nic Lifetime Nicotine Dependence at 20
• Alc Lifetime Alcohol Abuse or Dependence at 20
• Drug Lifetime Illicit Drug Abuse or Dependence
  at 20
• AAB Lifetime Adult Antisocial Behavior at 20

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Mean of Age 20 Diagnoses as a Function
Adolescent Problem Behaviors
Number of Problem Behaviors
86
Even more important than whether is how early an
adolescent engages in problem behavior
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Alcoholism and Age at First Drink(N27,616
Grant Dawson, 1997)
Rate of Alcoholism
Age at First Drink
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Age at First Drink (AFD)

• Specific vs. General effect
• Also associated with ASPD, Drug Dependence,
  Nicotine Dependence, Educational
  Underachievement, reduced P3 amplitude (McGue et
  al. 2001)
• Heritable vs. Environmental basis
• Relationship between AFD and alcoholism risk
  appears to be predominantly genetically mediated
  (Prescott Kendler, 1999)

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• Generality of the AFD effect suggests that other
  adolescent problem behaviors may represent risk
  factor for adult pathology when expressed early
• Is risk impact genetically or environmentally
  mediated?

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Early vs. Late Adolescent Problem Index
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Mean of Age 20 Diagnoses in Males as a Function
of Ever vs Early Problem Behavior
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Mean of Age 20 Diagnoses in Females as a
Function of Ever vs Early Problem Behavior
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Correlation of Problem Index with Indicators of
EXT
(CONST) Constraint has been reverse scored
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Generality of Adolescent Problem Behavior effects
on Adult EXT Disorders

• Each adolescent problem behavior is predicts
  homotypic outcome
• Early drinking predicts adult Alc Dep
• Smoking predicts adult Nic Dep
• Each adolescent problem behavior also predicts
  each EXT disorder
• Smoking predicts Alc Dep
• Sexual intercourse predicts Drug Dep

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Biometric Analysis of the Early and Ever Indexes
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Does this mean that Early problem behavior
indexes environmental risk for adult
psychopathology?
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1.00
1.00
C
C
.20
E
A
E
A
.41
.07
.18
.41
.17
.76
Early
EXT
.69
1.0
.72
.70
.78
Early
ALC
DRUG
AAB
NIC
.23
.29
.12
.36
.15
.36
.07
.32
A
A
A
A
E
E
E
E
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Decomposition of Early-EXT Correlation

• Estimated correlation of .59 is apportioned as
• Genetic 61.8
• Shared Environment 29.4
• Nonshared Environment 8.7

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Conclusions

• Adolescent problem behavior, especially when
  expressed early, is a potent predictor of
  early-onset adult psychopathology
• Adolescent problem behavior, especially when
  expressed early, is strongly environmentally
  influenced
• Nonetheless, the association between early
  problem behavior and adult psychopathology is
  primarily genetically mediated