EXAM REVIEW

INTRODUCTION + STIGMA
● Clinical Psychology: a field of study that focuses on understanding, assessing, and treating
psychological disorders.
○ Research and practice are tightly inter women
● Different approaches to understanding the psychiatric illness:
○ Behavioral approaches: studying the behavior in either animal models or human models
○ Cognitive approaches: studying the cognitive processes
○ Cognitive neuroscience: using neuroimaging like fMRI to study how recruitments of
different neurocognitive mechanisms is altered in individuals with different traits or
psychiatric conditions
■ Like for people with high trait anxiety, if certain parts of their brain would light
up when they have to deal with threat stimuli
● The importance of clinical psychology:
○ ⅕ Americans are diagnosed with psychiatric disorder
○ 4 out of 10 most significant causes of disability in the U.S. are psychiatric disorders
○ Accounts for more than 15% of the disease burden in the U.S.
● Defining abnormality:
○ Statistical infrequency (if everyone has it, it will not be count as abnormal)
■ But not everything that is not common is abnormal like high IQ or athletes
○ Violation of social norms
■ But differ from one social contexts to another like being hysterical when losing a
loved one would be considered normal, but being hysterical for no reason would
get the person weird looks
■ Varies across culture and times as well
● Homosexuality was regarded as a mental disorder until 1968
■ Also some psychiatric illnesses (like anxiety) entail no violation, and criminal
behavior entail violation but no illness
○ Personal distress
■ Behavior is abnormal if it causes distress to the individual and/or others
● Like symptoms of bipolar disorder or depression can cause huge distress
to both the individual and their family
■ But does not apply to every disorder
● Like individual with antisocial personality disorder, they do not
experience distress but their disorder does cause harms to others
○ Disability
■ The disorder will cause impairment to the individual in their social,
occupational;, or other important areas
■ But does not applies to every disorder
● Like bulimia nervosa (binge eating and vomiting later in an attempt to
control their weight) does not necessarily involved disability
○ Dysfunction
■ An internal mechanism is unable to perform its function
 ■ Assessments are needed in order to determine what internal mechanism is not
working properly
● DSM-V definition of abnormal:
○ Occurs within the individual (internally)
○ Causing significant impairment to their thought process, feelings, or behaviors
○ Usually involves personal distress
○ Involves dysfunction of psychological, developmental, and/or neurobiological processes
that are needed to support one’s mental functioning
○ Not culturally or event-specifically reactions (consistent across situations and times)
○ Not primarily a result of social deviance or conflict with society
● Stigma: discrimination against a certain group, a place, or a nation.
○ Is stigma the same as stereotypes?
● Four characteristics of stigma:
○ Distinguished label is applied
○ Label refers to undesirable attributes
○ People with these labels are seen as different
○ People with the label are being discriminated against
● Rosenhan 1973 – “Being Sane in Insane Places”
○ 8 pseudo patients entered mental hospitals to assess the mental hospitals
○ The staffs did not notice but the patients there did (0/8 pseudo patients detected)
○ Poor reliability of the treatments – people with no actual disorder were treated as one
○ The stigma of their illness continued with them even after they left the hospital
■ “Once ill, will always be ill”
○ Follow-up study: 41/193 patients were miscategorized as pseudo patients
● BBC documentary “How Mad are You?”
○ 2008 follow-up to Rosenhan’s 1973 experiment
○ Some of the participants are officially diagnosed with disorders and others are pseudo
○ Risked being stigmatized to study the fine line between the sane and the insane

DIAGNOSIS
● Binary diagnoses: a test used by physicians to diagnose disorder – either a negative or positive
diagnosis is made for the patients
○ Used for simplicity – either you have it or not
○ Could miss the criteria where one could be diagnosed with the disorder – might prevent
the person from getting help they need
○ Insurance can also interfere with the diagnosis and treatments for the patients
● Continuum: an approach where the behavior is ranges over a continuum from effective
functioning to severe abnormality
○ Polygenic – lots of different genes contributes to the risk of having the disorders
○ Mental illness represents one end of a continuum but not a completely separate state that
strikes individuals and not others
● Diagnosis: classification of disorders by symptoms and signs
○ Advantages of diagnosis:
■ Facilitates communication among professionals
 ■ Advances the search for causes and treatments
■ Cornerstone of clinical care
● Staying too attached to the binary diagnoses might causes mistakes and
harm as the causes and treatments might not match the criteria
● Differences between DSM-IV-TR and DSM-5:
○ The previous one would divided disorders into different categories, general medical
conditions, psychological and environmental problems, and global assessment of
functioning scale (GAF scale)
○ The latter one grouped all the disorders into psychiatric and medical diagnoses,
psychosocial and contextual factors, and disability
○ Changes in organization of diagnoses:
■ DSM-IV-TR clusters diagnoses based on similarities of symtoms
■ DSM-5 are organized based on new knowledge of comorbidity and shared
etiology
○ New information in DSM-5
■ New diagnoses like disruptive mood dysregulation, premenstrual dysphoric
disorder, etc
■ Renaming of diagnoses
● Mental retardation to intellectual disability
● Dysthymia to persistent depressive disorder
■ Combining diagnoses
● Substance use disorder replaces substance abuse and substance
dependence
■ Clearer criteria
● Prevalence: 12 month is the most common prevalence rate
● Ethnic and cultural considerations:
○ The influences of cultures:
■ Risk factors
● like losing a job or being outcasted by the community because they
assumed all people with mental disorders are crazy and dangerous people
■ Types of symptoms experiences
● Go from one mood to another mood suddenly would be seen as someone
being possessed and need religious help and not that they might be a
person with bipolar disorder and likely to be harmless to others
■ Willingness to seek help
● Stigmatization of the disorders and afraid of being seen differently from
the community – some community are less open-minded and flexible
■ Availability of treatments
● Not much resources and education on the topic of mental illness
● Like in Cambodia, people just clustered all mental disorders into either
one of these categories “Drug User” or “Crazy People” and are all seen
as harmful and a menace to society
● Some have better social supports and lead to better treatment and less or
more statistical data
 ● Criticisms of DSM:
○ Are there too many diagnoses?
■ Should relatively common reactions be pathologized?
● Just because a lot of people have it does not mean that they do not
deserve any treatment
■ Comorbidity
● Presence of a second diagnosis
● 45% of people diagnosed with one disorder will meet criteria for a
second disorder
■ Reliability in everyday practice

VALIDITY AND RELIABILITY

● Validity: the extent to which it measures what it is supposed to measure (accuracy)
● Type of validity:
○ Content validity: the extent to which it cover the domain of interest
■ Does it cover all the symptoms involved in a given diagnosis?
○ Criterion validity: the extent to which a result of one test corresponds to the result of
another test on the same matter?
■ Concurrent: measure at the same time
■ Predictive: the first test helps predict the second test
○ Construct validity: does the test measure what we want to measure vs. what we do not
want to measure?
● Reliability: the extent to which an observation or measurement is dependable, stable, and can be
replicated and generalized.
● Types of reliability:
○ Interrater reliability: the degree to which two independent observers/raters agree (same
test; same time; different observers)
■ Across observers reliability
● If two or more clinicians agree on the same diagnosis, then it is a reliable
diagnosis
● How easy is it for two different doctors to diagnose the same patient with
the same diagnosis?
■ Categorical: “Yes or No” – the presence or the absence of the disorder (binary
diagnosis)
● Either you are depressed or you are not
○ Test-retest reliability: the same test is given to the same group at two different time
points (same test; different times)
■ Across time; temporal reliability
■ Study the correlation and the parametric/non-parametric version between the first
and the second time
■ Only makes sense for “trait” and not “scale” variable
■ Dimensional: rank on a continuous quantitative dimension (continuum)
● The degree to which a symptom is present?
● How anxious are you on a scale of 1 to 10?
 ○ Alternate-form reliability: two different tests are given to the same group and the
consistency of the score are being studied (different test; same/different times)
■ Parallel test reliability; across tests
■ Study the correlation between one measure of construct and the other
○ Internal consistency reliability: the extent to which the test items are related to one
another
■ Split-half reliability; across item integrity
■ The first half of the test should strongly correlate with the second half of the test

ASSESSMENTS
● Different types of assessments:
○ Interview:
■ Structured: the clinicians would follow a skit to assess the patient’s symptoms
● Pros:
○ Directly assess all relevant symptoms based on DSM IV/V
○ There is a list of questions for the clinicians to follow
○ Using the branching method like if “YES” for this, you go to this
question
○ Clear guidelines to score the severity of the symptoms
○ Generally good interrater reliability (different observers give the
same result)
● Cons:
○ The questions can be seem to leading
○ Arbitrary threshold for severity of symptoms
○ Some symptoms are too similar and might lead to the wrong
questions or answers
■ Unstructured: free-form of questions and answers; less uses of the scripts
● Pros:
○ Helps the patients feel more at ease
○ Helps get more information from the patient – things that a
structured questions might have missed
○ More individualized
● Cons:
○ Key questions might be missed or incorrectly assessed
■ Might diverge from the DSM criteria and lead to the
wrong diagnosis
■ Example of DSM-V diagnosis of Social Anxiety Disorder:
● Fear or anxiety of social or performance situations
● Fear of showing anxiety symptoms
● Fear of being scrutinized by others
● Exposure to the feared situation(s) almost always provoke fear or anxiety
(consistency)
● Avoid the situation or endured it under intense pressure/anxiety
 ● Fear or anxiety is out of proportion to the actual threat posed
(overexaggerated/dramatic)
● Last at least 6 months; interfere with daily life
● Not secondary to other mental disorder or substance uses or medical
condition
○ Behavioral observation:
■ Formal/structured: behavior are being observed and scored in a test situation
● Often used in neuropsychological treatment (rehabilitation after brain
injury)
● Observed by more than one person
■ Unstructured:
● No structured task was given (aside from the scoring guidelines)
● May result in poor interrater reliability and content validity
■ Pros:
● May be more sensitive to problems in everyday life compared to
interviews and cognitive tests
● Can be used to assess severity of behavioral problems
● Can be used to track progress in therapy and rehabilitation (under
surveillance of multiple observers)
■ Cons:
● People might act differently if they are aware that they are being
observed
● Subjectivity in interpretations
○ Self-report questionnaires:
■ Screen for psychological problems
● Using personality profile with items that can be used to distinguish
between experimental and control group
■ Assess specific traits or characteristics
● Like traits of depression
■ Assess current levels of symptomatology
● How severe is it based on the person’s answers?
■ These measures all depend upon standardization
● Measures given to many people (both with and without relevant
disorders) to ensure test validity and reliability
■ Pros:
● Quick and informative
● Person has the most insight to their own thoughts and feelings
■ Cons:
● Subject to bias in self-presentation and self-assessment
● Often retrospective – rely on memory
● May not be useful for people with limited cognitive abilities
● Reliability and validity can be varied
○ Cognitive style questionnaires:
■ Used to assess attitudes, interpretations, schema about the world and so on
 ■ Can provide insight into cognitive mechanisms disrupted in different disorders
■ Examples:
● Dysfunctional Attitude Scale – people with depression score higher
● World Assumptions Scale – distinguish people with/without PTSD
○ Self-observation:
■ Self-monitoring: people can monitor their own behavior, thought, and feeling
● Not completed on-line (do it at the end of the day)
■ Ecological momentary assessment: completed online (do it when receive a PDA
prompt)
■ Limitation:
● Behavior can be altered by self-monitoring
● But, it can also be useful depends on the tasks like monitoring one’s
executive functioning or in addiction (like smoking)
○ Psychological tests:
■ Used to assess different aspects of psychological or cognitive functioning
■ Examples: IQ tests, test on a person’s body dysmorphia
○ Neuropsychological tests:
■ Focus on cognitive functioning after the damage to the brain
■ Based on the idea that different cognitive functions are localized in different
regions
■ Commonly used to create a profile of intact vs. disrupted function
■ Two main purposes:
● Diagnosis or characterization of profile of deficits
● Rehabilitation planning and evaluation
■ Two main approaches:
● Fixed-battery: predetermined set of tests are used to assess various
abilities that have been shown to be sensitive to brain damage
○ Useful for profiling strengths and weaknesses
○ Lots of normative data
● Flexible, process-oriented approach: specific tests are used to get an
in-depth evaluation of relevant cognitive abilities.
○ More detailed analysis of language, attention skills, etc
○ Easier to incorporate new and improved measures derived from
research advances
■ Limitations:
● Some cognitive functions can be hard to assess
● Findings in the clinic might not predict real-world behaviors
● Summary from the video clip:
○ People tend to perceive their body size bigger than it usually is
○ Society pressure on how people should conform to a certain body shape
○ People, does not matter if they are diagnosed with eating disorders, can still displayed
with certain body-cognitive distortions
○ People's explicit biases are not always the same as their implicit ones
■ So an attempt to change the explicit biases does not always get internalized
 ■ Obesity leads to health problem → stigma around it → body-image distortions
● Neuropsychological tests: historical perspectives
○ In 1800s, Broca described patients who could no longer speak but could understand the
language
■ Non-fluent aphasia: could not speak but can understand
■ Lesions in the brain known as Broca's area
○ Wernicke described patients who could no longer understand the language but could
produce jumbled speech
■ Fluent aphasia: could speak but could not understand (nonsense talking)
■ Lesions in the brain known as Wernicke's area
○ These two studies are classical example of case studies and double dissociation
● Neuroimaging: a way to look into a person's brain structure and function
○ Limitations:
■ More useful at a group level than individual level
● Does not do a good job of categorizing and diagnosing individuals
■ Can produce false results
● Paradigms: an approach to research where the causes and treatment of psychiatric illnesses are
studied scientifically (Thomas Kuhn)
● Behavioral paradigm: a study where observable behaviors are emphasized
○ Classical conditioning: pairing an involuntary response with a stimulus
■ Example: Pavlov's dog – sounds of the bell make the dog salivated (after pairing
dog's salivation to the sound of the bell, through the use of the meat powder)
● Unconditioned stimulus (UCS): meat powder
● Unconditioned response (UCR): salivation (pre-pairing)
● Conditioned stimulus (CS): sound of the bell
● Conditioned response (CR): salivation (post-pairing)
■ Can be used when dealing PTSD, phobias, panic disorders
○ Operant conditioning: pairing a voluntary response with a positive/negative
consequences (Skinner)
■ Positive reinforcement: desired behavior is reinforced if followed by a positive
outcome (like food); a reward is given for doing something well
● Rats push the lever → get food; dressed properly → praise from family
■ Negative reinforcement: desired behavior is reinforced if followed by a negative
outcome (like electric shock); a negative outcome is removed once doing
something well
● Get better grade → reduce in belt-whoopings
■ Shaping: reward is given when a desired behavior is shown
● Pet training: sit at command → gets a treat
■ Modeling: observational learning – watch other get rewards for doing something
● Can lead to an increase in either a positive or a negative behaviors
○ Watch your brother get scolded → avoiding doing what he did //
see others doing drugs → thinks it is the norm and follow suit
○ Behavioral therapy: emerged in 1950s; procedures are based on classical and operant
conditioning to treat clinical problems
 ○ Systematic desensitization: based on classical conditioning
○ Graded exposure: based on classical conditioning (used to treat phobias; also used as a
component of CBT)
○ Behavioral modification: based on operant conditioning
● Cognitive paradigm: a study that focuses on cognitive processes (like attention, memory,
reasoning,...)
○ CBT (Cognitive and Behavioral Therapy): help client deals with maladaptive thoughts
■ Client has negative thoughts → therapist helps challenge it → client learns to
navigate around it
○ The standard stroop test: name the ink color of the words (various name of colors)
○ The emotional stroop test: name the ink color of the words (various name of things)
■ Words with negative meaning might cause the person to read the ink color slower
as the brain has to process the danger behind those words
○ Cognitive neuroscience: uses a variety of modern techniques like fMRI to look at the
active brain region during a certain task condition relative to others
■ fMRI:
● Pros:
○ Enables integration of results from multiple studies
○ Helps to see if the effect is reliable and generalizable
● Cons:
○ Small sample size
○ Only as valid and reliable as studies included in the
meta-analysis
○ Often studies do not report null or negative results → bias
meta-analysis
■ PET (Positron Emission Tomography and Ligand Binding): look at
neurotransmitters binding to receptors in different parts of the brain
■ MRI: look at brain structure and functional connectivity
○ Assumption of modularity: an assumption that different parts of the brain support
different activity
● Basic Neuroscience: used animal models in order to model psychopathology in humans
○ Neurotransmitters: brain chemicals messengers
■ When a neuron is stimulated thoughts its dendrites or cell body → nerve impulse
travel down the axon to the terminal endings
■ Synapse: a gap between terminal ending of one neuron and the cell membrane of
the receiving neuron
■ Neurotransmitters allow the nerve impulse to cross the synapse
■ Presynaptic neurons release neurotransmitters
● Flow into synapse
● Some will bind to the postsynaptic receptors (only responsive to a given
neurotransmitter)
● Excitatory will increase the likelihood of firing of the postsynaptic
neuron → nerve impulse
● Inhibitory will decrease the likelihood of firing
 ● Reuptake: postsynaptic receptors that did not bind will be taken back
into the presynaptic neuron
● Some of the released neurotransmitters in the synapse will be broken
down by enzymes
● Vary across brain regions
■ Altered neurotransmitters reuptake and/or breakdown may causally implicated in
psychiatric illnesses
○ Key neurotransmitters in psychopathology are:
■ Dopamine: influences prefrontal function and attention, striatal function and
rewarding processing
● Implicated in depression, mania, schizophrenia
■ Serotonin: influences amygdala function and emotional responsivity
● Implicated in depression, mania, schizophrenia
■ Norepinephrine: involved in arousal and stress response
● Implicated in anxiety disorder
■ Gamma-Aminobutyric acid (GABA): key inhibitory neurotransmitter
● Inhibit postsynaptic activity
● implicated in anxiety disorder
● Genetics:
○ Almost all behavior is heritable to some degree
○ Genes influence our environment = environment influence our genes
● Genetic terminology:
○ Gene expression: where certain gene's protein turn on/off other genes
○ Polygenic contributions to vulnerability: multiple genes are thought to contribute to
vulnerability to most psychiatric illnesses
○ Heritability: an extent to which variability in a given behavior in a population is due to
genetic factors
○ Shared environmental factor: events and experiences that the family members have in
common
○ Nonshared environmental factor: events and experiences that are unique to each
member of the family
■ Research suggests that genetic and nonshared environmental factors are highly
important to the risk of psychiatric illnesses
○ Genotype: individual's genetic makeup (inherited genetic material)
■ Assessed it through "whole genome scan/sequencing"
○ Phenotype: observable behavior and characteristics that changes over time and is
influenced by the interaction with genotype and environment (like high anxiety)
○ Two main approaches are:
■ Behavioral genetics
■ Molecular genetics
● Behavioral genetics: the study of to which extent genetic and environmental factors influence
behavior (focus on genetic and environmental factors)
○ Two methods/approaches in behavioral genetics:
 ■ Family method: if the disorder is highly heritable → the relatives of that
individual is expected to have higher rates of the disorder as well
■ Twin method: the extent to which concordance rates are higher in
monozygotic/identical (MZ) than in dizygotic (DZ) pairs → gives an estimate of
the heritability of the disorder
● Twin reared apart: looks at the genetic influences despite being different
environment; more similar for MZ than for DZ twins
● Molecular genetics: a study that focuses on the effect of specific polymorphism or variants in
particular genes (focus on the DNA components)
○ Genetic polymorphism: a difference or variation in DNA sequence observed within the
population
■ Alleles: different form of a gene resulting from a given genetic polymorphism
■ If impact DNA sequence → can change proteins → altering gene function and/or
gene expression through impacting promoter function
● Promoter function: a region of DNA that facilitates genes transcription
○ The Serotonin Transporter Polymorphism (5HTT-LPR) study:
■ Individual possess 1-2 copies of the short allele (44-bp deletion) or long allele
(44-bp insertion)
■ Possession of ≥1 = reduced 5HTT expression (serotonin transporter) and
increased anxiety symptoms
■ Methods:
● Knockout studies (animal): specific genes are taken out from the mouse
then studied the behavior of the mouse
○ E.g. 5HT1A knockout (anxious phenotype)
● Association studies (humans): examine the correlation between a specific
allele of a given genetic polymorphism and a behavior in a population
○ Linking genotype to diagnosis
○ E.g. 5HTT-LPR and anxiety & depression; APOE-4 and
alzheimer's
○ Gene and environment interplay:
■ Gene-environment interaction: participant's responses to a specific
environment event are influenced by genetic factors
■ Epigenetics: study of the influence or how environment can alter expression or
function of genes
● E.g., transmission of good mothering (licking, grooming) triggers an
increase in expression of a certain gene in adopted offspring
○ Caspi et al. 2003: Gene-Environment Interaction
■ 5HTT genotype interacted with childhood maltreatment to predict probability of
occurrence of major depressive disorder
■ If there is no childhood maltreatment → no difference between the group in the
possibility of development MDD
■ However, as the likelihood of childhood maltreatment increases, so does the
possibility of each group developing MDD
 ■ Noted: did not see this gene by environment interaction, but a main effects of
genotype
● Not 5HTT number of short allele and MDD – but it does not matter as it
did not depend on an exposure to stress

ANXIETY DISORDERS
● DSM-5 Anxiety disorder includes:
○ Specific phobias
○ Social anxiety disorder
○ Panic disorder
○ Agoraphobia
○ Generalized anxiety disorder
● DSM-5 criteria for anxiety disorders (varied on different disorder):
○ Symptoms interfere with important areas of functioning and cause distress
○ Symptoms are not caused by drugs or medical conditions
○ Symptoms persist for at least 6 months or at least 1 month for panic disorder
○ The symptoms are distinct from other anxiety disoder's symptoms
● General issues: onset of ADs
○ Many onset in late childhood/adolescence
○ Most age at first diagnosis are 11-18
○ Higher prevalence in women than in men
■ Society and cultural pressures
■ Women might be more likely to report it than men (toxic masculinity)
■ Genes and hormones
○ Comorbidity with other ADs
■ Over 50% of patients with an anxiety disorder will meet criteria of another AD
■ Comorbidity is even higher if taken into account of the subthreshold symptoms
of other AD
● Overlapping of symptoms
● Common genetic and environmental risk factors
● Common neural and neurochemical substrate
■ 75% of those with AD also meet criteria for other psychological disorders
● Disorder commonly comorbid with ADs are:
○ Depression
○ Substance abuse
○ Personality disorders
○ Medical disorders (e.g. coronary heart disease)
○ Odd ratios: the likelihood of having one disorder given that you have another disorder
relative to it, given that you do not have other anxiety or mood disorder
● Common risk factors to AD:
○ Genetic factors:
■ Heritability
■ Environmental influences
● Hettema et al. 2005: Twin study design
 ○ Genetic risk factor common to GAD, panic, agoraphobia, social phobia
■ Does not tell which genes
○ Separate genetic risk factor for specific phobias
○ Nonshared environmental risk factor increase risk for all ADs investigated
■ Negative life events
● Disruption to neurotransmission:
○ Altered serotonin (5HT), Norepinephrine (NE; USA) or Noradrenaline (NA; UK), and
Gamma-Aminobutyric acid (GABA) function associated with many ADs
○ These alterations may reflect genetic influences and exposure to stressors → alter gene
expressions
■ 5HT influences amygdala function and emotion responsivity
■ NE or NA involved in arousal and stress responses; regulation of frontal activity
(along with dopamine)
■ GABA is the key inhibitory neurotransmitter – inhibit postsynaptic activity
● Common neural substrates:
○ ADs show presence of both amygdala hyper-responsivity and frontal hypo-responsivity
■ Amygdala hyper-responsivity: increase in amygdala responsivity to threat
stimuli
■ Frontal hypo-responsivity: under-recruitment of frontal regions
● Common treatment for ADs:
○ Behavioral: exposing the clients to feared objects/stimuli under arousal levels go down
■ Methods include:
● Systematic desensitization: based on classical conditioning
● Relaxation plus imaginal exposure
■ Should include as many triggers as possible
■ Should be conducted in as many settings as possible
○ Cognitive: therapists challenge the client's dysfunctional beliefs about the likelihood of
occurrence of feared stimuli
○ Pharmacological: SSRIs is most common right now – help reduces anxiety
symptomatology without severe side effect
● Cognitive biases in anxiety: bias in attentional processing to focus more threat and the
environment
○ Evolutionary bias:
■ Threat-related attentional bias: evolutionary – adaptive to detect threat
■ Threat-related interpretative bias: treating ambiguousness as threat
● Anxious individuals are more likely than control to adopt the threatening
meaning like stroke (disease vs. caressing)
○ The emotional stroop task: name the ink words that are either threat-related or
emotionally neutral in meaning
■ Individuals take longer to name the ink words with threat-related meaning
■ Seen in patients with ADs or high-trait anxious individuals > low-trait anxious
individuals
○ Williams et al. 1996: the emotional stroop test
 ■ Slow color naming for threat-related words found in ADs and high-trait anxious
individuals
■ Naming speed decrease even further when the meaning of the word is related to
the patient's concern (e.g. spider phobia and a word related to spiders)
○ The dot probe task:
■ Patients are asked to fixate on the center screen
■ Two pictures/faces/words are shown in the middle – one is threat and another is
neutral word
■ After a short presentation, the pictures are replaced and a probe is presented in
the position of the photos
■ Slower probe identification when the probe occurs in the neutral picture position
→ an identification of attentional capture by threat
■ The argument here is that negative picture grabs your attention more → faster to
respond to the probe at the threat-picture
■ Anxious patients respond faster to probes replacing threat-picture

SCIENTIFIC METHOD
● Role of research:
○ Test reliability and validity
○ Test efficacy of treatments
○ Better understanding of the illnesses: determine the cause, how does it start, and how it
affects the person – socially, cognitively, and emotionally
● Research process:
○ Observe a phenomenon
○ Formulate a theory
○ Generate hypotheses based on the theory
■ Hypothesis: an educated guess about the specific outcome that should happen if
the theory is true
○ Test the hypothesis
○ Revise the theory based on the results
● Single case report/study:
○ Detailed report of one person
○ Great for generating theory
○ Hard to test hypothesis – hard to generalize as this is individualized
○ Most effective for rare cases
○ Example: 19th century, Phineas Gage
■ Iron road shot through his eye socket → destroy part of his frontal lobe
■ Change personality and social functioning → no longer Gage
■ Damage of a certain region of the brain → affect personality and behavior
● Correlation study:
○ Test whether two or more variables are related
○ Not causation
○ When A is correlated with B: A causes B, or B causes A, or A causes B via C
(moderation), or both A and B are caused by C (mediation)
 ● Experimental study:
○ Examine the impact of an independent variable upon a dependent variable
■ Independent variable: a variable we manipulated
■ dependent variable: outcome measure
○ Between-group design: to look at control group vs. experimental group
■ Two or more groups, one is usually control
■ Usually randomly assigned
■ Treatment trials, groups are usually matched when they shared the same variables
like age, gender, or medical/psychological conditions
● Experimental drug or therapy
● Established drug or theory – to test efficacy against a known treatment
● Placebo drug or theory – should be double-blind to avoid spoiling the
effect
○ Within-subject designs: each person do two or more task conditions
■ Experimental and control conditions are administered to the same person
■ Order of conditions usually are randomized
■ Sometimes A-B-A-B design is employed to see whether control/experimental
effects are reliable
○ Meta-analysis:
■ Used to integrate results of multiple studies
■ Helps to see if the effect is reliable and generalizable
■ Only as valid and reliable as studies included in the meta-analysis
■ Often studies do not report null results → bias overall picture
● Ethical considerations:
○ Incorrect diagnosis → stigmatized or wrong treatment
○ Best available treatment should be considered first
○ Treatment should be voluntary unless the person is suicidal or homicidal → 72 hour hold
by the professionals
○ Person with psychiatric disorders = vulnerable population → special ethical guidelines
■ Special care should be taken → patient can provide informed consent
● If not, then a guardian is required
■ Patient's safety above all
■ Patients that are too ill should not be enrolled in studies that have placebo or
waiting conditions

BRAIN MECHANISMS
● Across anxiety disorders both amygdala hyper-responsivity (stronger response to threat) and
frontal hypo-responsivity (attention control) have been reported
● Vuilleumier et al. (2001) study:
○ Task: match faces or match houses (same or different)
○ Factors:
■ Attention: faces attended vs. face unattended – are they the one being matched or
not?
■ Expression: neutral vs. fearful
 ○ Results for amygdala:
■ Study the activity in the amygdala as different factors are in play
■ Amygdala response is stronger when faces are fearful
● Regardless of whether the faces or houses are attended
■ There is no main effect of attention and no interaction of attention x expression
● The differences between the amygdala responses between the two graph
was not significant = no interaction

● According to this model, the amygdala response to fearful faces is not

influenced by the allocation of attention
○ LPFC attentional control: top-down prefrontal attentional control
mechanism
■ Mechanism to help you match either the house
○ Amygdala threat detection → assessed for threat value →
compete for attention → lead to the output where fearful faces
received stronger response
● Pessoa et al. (2002) study:
○ Thought Vuilleumier got it wrong → do a follow-up
○ Task: determine whether the face is male or female, or whether the bar has similar
orientation or not
○ Factors:
■ Attention: faces or bars
■ Expression: fear, happy, or neutral
○ Results for amygdala:
■ Interaction of expression by attention
■ Amygdala only response more strongly to fearful than neutral faces when faces
were attended
● Similar to happy faces
● Only when the faces are attended
■ Amygdala response to fearful faces is influenced by attentional competition
 ● Discrepant findings between Vuilleumier (2001) and Pessoa (2002):
○ The level of the task difficulty:
■ The Vuilleumier's task was easier → spare attention to faces
○ Effects of anxiety:
■ Maybe the amygdala response to threat distractors (the unattended fearful faces)
is only high in high-trait anxious individual and not in low-trait anxious
individuals
■ Different ratio of high and low trait individual in both studies might account for
the discrepant findings

SPECIFIC PHOBIA AND SOCIAL ANXIETY DISORDER

● Specific phobia:
○ Marked and persistent fear of specific situation/object
○ At least 6 months
○ Exposure to feared stimulus → provokes immediate anxiety or fear
○ Avoidance of situation or endurance with intense anxiety
○ Fear or anxiety is disproportionate to actual danger posed
○ Distress interfered with social and daily life
● Etiology of specific phobia:
○ Mowrer's two-factor model:
■ Step 1: classical conditioning
● Developing a fear of something
■ Step 2: operant conditioning
● Avoidance of CS maintained through negative reinforcement
● Problems with Mowrer's two-factor model:
○ Many people never experience aversive interaction with phobic object
■ Possible solution – different pathways to conditioning (Rachman 1977)
● Direct experience
● Modeling (observation of CS-UCS pairing or of CS generating CR in the
case of another actor)
● Verbal instruction
○ Parents warning child of strangers, rape stories, kidnappings
■ Modeling: watching other behavior → learnt from it
● Example #1: involves vicarious conditioning
○ Volunteers watched a model receive shocks every time a buzzer
sounded
○ The model was in fact feigned pain
○ Volunteers observing this displayed greater physiological arousal
when the buzzer sounded (classical conditioning)
● Example #2: young rhesus monkeys raised by parents who have a fear of
snakes
○ Parents react fearfully to real or toy snakes
○ After 6 observations → young monkey demonstrated fear as
intense as their parents
 ● Example #3: use as treatment
○ Dog phobias: observe a fearless model → own fear reduces
● Not all phobias are developed through modeling
○ Assume that with classical conditioning any stimulus could become object of the phobia
■ Seligman (1971) – Preparedness: conditioned response will develop more quickly
to threatening stimuli if relevant to mankind's past
● Example: spiders/snakes (phylogenetic fear-relevant) vs. gun/electricity
plug (ontogenetic fear-relevant) vs. mushroom (neutral)
■ Evidence for Preparedness:
● Mineka et al. (1984): young rhesus monkeys can acquired fear response
to toy snakes but not toy flowers
● Fear reactions to stimuli measured before and after showing video clips
of parents behaving fearfully
● No difference pre or post for the flowers but a significant difference for
the snake
● Neurobiology of phobic anxiety:
○ Amygdala is important to the acquisition of conditioned fear – how easily you learn a fear
response
■ People with a hyper-responsive amygdala might acquired conditioned fear
response more easily
○ Medial prefrontal cortex is important to the extinction/recall (maintenance) of extinction
of conditioned fear
■ People with impoverished recruitment of prefrontal regions might be slower to
extinguish conditioned fear responses (as a result of exposure)
○ Schienle et al. (2005): scan people using fMRI; those with spider phobia and those
without
■ Spider phobic showed greater amygdala responses compared to control to phobic
pictures
■ But cannot tell whether the amygdala response is the cause or effect of stronger
conditioned fear response
● AD vulnerable individuals and novel fear conditioning:
○ Task:
■ Predictable context – cued fear conditioning: model put hand to their ear → loud
noise
■ Unpredictable context – background contextual fear conditioning: loud noise and
model's hand movement are not related
■ Safe context – no UCS presentation
○ Results:
■ Elevated trait anxiety was associated with increased amygdala responsivity to
phasic fear cues (cue CS in predictable room vs. cue CS in safe room)
■ Amygdala responsiveness to phasic fear cues (CS pred vs. CS safe) linked to
stronger initial acquisition of cued fear (SCR to CS pred vs CS safe)
■ More anxious developed stronger initial acquisition to cued fear
 ■ Amygdala responsivity to phasic fear cues (CS pred vs CS safe) mediates
relationship between trait anxiety and initial acquisition of cued fear
■ Trait anxiety also linked to reduce recruitment of ventromedial prefrontal cortex
● Linked to maintain expression of conditioned fear response
● Dysregulation of both amygdala and VMPFC function may be implicated
● Social anxiety disorder:
○ Persistent and disproportionate fear of social or performance situation
○ Fear of being exposed to unfamiliar people and possible scrutiny by others
○ Prolonged of at least 6 months
○ Fear of acting in a way that will be negatively evaluated
○ The social situations almost always provoke fear/anxiety → avoidance of the situation or
endured with intense fear
○ Distress → impairment in social and occupational functioning
● Mowrer's two-factor model also applied here, except the phobic stimulus (CS) is social situation
● Cognitive biases seem to play a bigger role in social anxiety disorder
○ People with social anxiety disorder judge their performance more harshly
○ Behavioral exposure therapy is most effective here
● Treatment of phobias:
○ Exposure to situations of objects that provoke that anxiety
■ Systematic desensitization vs. flooding
● Both rely on exposure during relaxation
● CS – UCS association being overwritten with anew less negative
association CS – safety/relaxation
● Involved nothing bad happening
● It is critical to have exposure to last long enough for anxiety to decrease
or to replace CS – fear association with CS – safety/relaxation
○ Otherwise avoidance may be reinforced
● Both flooding and systematic very effective
● More people find systematic desensitization acceptable (more
comfortable)
■ Desensitization can be imaginal or in vivo
● In vivo works much better than imaginal
● Gradual exposure
○ Social skill training
○ Challenging irrational thoughts
○ Pharmacotherapy: benzodiazepines, SSRIs
● Ost et al. (1997) study:
○ One session treatment
○ Detailed rationale for exposure
■ Exposure to 4-5 spiders of increasing sizes
■ Modelled by therapist first and then the client attempts the same task
■ Catching spider with glass and a piece of paper
■ Spider walking on the client's hand
■ Spider walking on the client's back or hair
 ○ Three conditions:
■ Direct treatment (DT)
■ Direct observation – watching the treatment live (DO)
■ Indirect observation – watching the treatment via video (IO)
■ In vivo better than direct observation and indirect observation
● CBT: many ADs including phobias are maintained by irrational beliefs
○ Patients are taught to dispute those irrational thoughts

PANIC DISORDER
● Panic disorder:
○ Sudden experience of intense fear or discomfort that peak within minutes
○ At least four other symptoms like the sensation of shortness of breath, palpitations,
shaking, sweating,...
○ Occasional symptoms like derealization, depersonalization, fear of losing control or
going crazy, fear of dying
○ Intense desire to flee whenever they are going through PD
○ Recurrent of unexpected panic attack
■ 1 month+ concern/worry about having more attack, worry about consequences of
an attack, maladaptive behavioral changes
■ Not due to substance abuse, medical condition or other mental disorder
○ More prevalence in female
○ Panic attack does not always developed PD
● Neurobiological factors:
○ Panic attack reflects a misfire of the fear circuit, with a surge in activity in the
sympathetic nervous system (SNS)
○ LC = source of neurotransmitter norepinephrine (which triggers SNS activity)
■ Overstimulated of LC → panic attack
○ In monkeys: when shown snakes → monkey exhibit high level of activity in LC
■ When LC is stimulated → monkey behaved as if they are having a panic attack
○ In humans:
■ drug that increase activity in the LC can trigger panic attacks
■ Drugs that decrease activity in the LC can decrease the risk of panic attacks
● From panic attack to PD:
○ Role of classical conditioning
○ First attack may occur for random reasons
○ Bodily sensation become associated with aversive event
○ Subsequent experience of somatic sensations lead to fear response which increase them
■ Spiral into a new panic attack – known as interoceptive conditioning
○ May depend on misinterpretation of bodily sensation and also on perception of control
● Cognitive model of panic attack by Clark (1986):
○ Trigger stimulus (internal or external) → perceived threat → apprehension → body
sensation → interpretation of sensation as catastrophic → perceived threat
○ Evidence for importance of misinterpretation of bodily sensations:
 ■ Individuals with history of panic attacks & those scoring highly on measure of
fear of bodily sensations are more likely to experience panic attacks after
breathing CO2 (but only if not told it would produce symptoms of increased
arousal)
■ Participants told when light came on if turned dial could control level of CO2
● 80% – no perceived control (light off all the time) had panic attack vs. 20
– perceived control (light on half of the time)
○ Catastrophic misinterpretation leads to:
■ Hypervigilant scanning of body
● Internal focus of attention – causes patients to notice sensations others
would not be aware of
● Safety behaviors – global or subtle avoidance
○ Used because patients think they will prevent danger from
materialising but prevent disconfirmation
● CBT of PD:
○ Reversing the maintaining factors identified in the model
■ Derive idiosyncratic version of the panic cycle
■ Diaries and in-session discussions to identify triggers
■ Help creates more realistic interpretations
■ Behavioral (exposure based) procedures
● Agoraphobia:
○ Marked fear or anxiety about 2+ of the following situations: using public transport, open
space, enclosed space, being in a crowd, outside of home
○ Fear that escape might be difficult or help is unavailable
○ Avoidance behavior
○ Persistent for at least 6 months
○ Distress impairs functioning
○ Symptoms are not better explained by another disorder
● Fear of fear model (Goldstein & Chambless, 1978)
● Treatment (CBT) involves systematic exposure, self-guided treatment can also be useful

OBSESSIVE COMPULSIVE DISORDER

● Obsessive compulsive disorder:
○ Obsession:
■ Persistent recurring, intrusive unwanted thoughts, images or urges
■ Person tries to ignore, suppress or neutralize → causes marked distress or anxiety
○ Compulsion:
■ Repetitive behaviors or mental acts that a person feels compelled to perform
● To prevent or reduce anxiety
■ Can be in response to an obsession
○ Time consuming (require at least 1hr per day)
○ Cause clinically significant distress or impairment
○ ~ 1-2% population
● Mowrer's two-factor theory also applied to OCD:
 ○ Fear of thought is acquired through classical conditioning → obsession leading to anxiety
○ Compulsions maintained by operant conditioning → reduce anxiety through engaging in
compulsive behaviors
● Etiology of OCD:
○ Rachman & de SIlva (1978)
■ Intrusions reported by almost 90% of a non-clinical sample
■ Critical differences as to why some do not develop OCD despite most people
have intrusions may be whether intrusions are experienced as distressing –
leading to compulsions in an attempt to reduce this distress
○ Salkovskis et al., (1997)
■ Normal subjects could dismiss intrusive thoughts/images easily compared to
people with OCD
○ de Silva (1990)
■ People with OCD have overdeveloped sense of their own responsibility
● Lopatka & Rachman (1995) study:
○ Methods: 30 patients who met criteria for OCD (focus on checking)
■ Factor: responsibility manipulation (3 levels)
● Low, high, control
○ Results:
■ Low responsibility was followed by reductions in discomfort or urge to carry out
compulsions
● Thought suppression: deliberate attempt to suppress a target thought will increase the likelihood
of its occurrence
○ White bear experiment
○ May be a lab model for intrusions
○ Believe that thinking about something can alter its likelihood and sense of responsibility
may increase attempts at thought suppression
● Disruption to neural function in OCD:
○ Three regions activate when participants with OCD shown objects that provoke their
symptoms:
■ Orbitofrontal cortex
■ Anterior cingulate
■ Caudate nucleus (part of the basal ganglia)
○ Unclear whether these reflect cause or effect of OCD
○ Or indeed if this is simply activation of brain regions involved in evaluating and
responding (or withholding responses to) emotionally salient stimuli
● Behavioral treatment of OCD:
○ ERP (exposure and response prevention)
■ Asked to refrain from engaging in compulsion for at least 90 mins
■ Exposure with compulsion prevented is hope to lead to extinction of anxiety
response
■ Challenge any dysfunctional beliefs about consequences of not engaging in
compulsions
● Cognitive treatment of OCD:
 ○ Identification and modification of beliefs relating to responsibility and what will happen
if not complete compulsive ritual
○ Help the client conclude that obsessional thoughts are irrelevant to further action
■ Trying to control thoughts is unnecessary
○ CBT is as good as ERP
■ ERP – may be a cognitive rationale for it working (help challenge the beliefs)
○ Pharmacotherapy: SSRIs
■ Stop might cause a problem of relapse
● Post Traumatic Stress Disorder (PTSD):
○ Patients must have been exposed to an event that involved actual or threatned death,
serious injury or sexual violence by:
■ Directly experienced
■ Witnessed in person
■ Learning that the event occured to a close other
■ Experienced repeated or extreme exposure to aversive details of the events
○ Intrusion symptoms beginning after event (at least 1):
■ Recurrent, involuntary and intrusive distressing memories of the trauma
■ Recurrent distressing dreams with content or effects related to the trauma
■ Dissociative reactions (flashbacks) in which individuals feels or acts as if trauma
recurring
■ Intense or prolonged psychological distress or physiological reactivity in
response to the trauma
○ Persistent avoidance symptoms (at least 1):
■ Avoidance or efforts to avoid memories, thoughts,or feelings linked to the trauma
■ Avoidance or efforts to avoid external reminders that arouse distress those
memories or thoughts of that trauma
○ Negative alterations in cognition and mood (at least 2):
■ inability to remember an important aspects of the trauma
■ Persistent and exaggerated negative expectations about self, others, or the world
■ Persistently excessive blame of self or others about the trauma
■ Pervasive negative emotional state
■ Markedly diminished interest or participation in significant activities
■ Feeling of detachment or estrangement from others
■ Persistent inability to experience positive emotions
○ Alterations in arousal & reactivity (at least 2):
■ Irritable or aggressive behavior / angry outbursts
■ Reckless or self-destructive behavior
■ Hypervigilance
■ Exaggerated startle response
■ Problems with concentration
■ Sleep disturbance
○ At least one month
○ Clinically significant distress impairment to function
○ Cannot be a symptoms to other mental disorders
 ● Predictors of increased rates of PTSD:
○ Type of trauma (like rape, wars,...)
○ Witnessing death
○ Proximity to epicentre of trauma
○ Vulnerability factors:
■ Early environment
■ Genetics
■ Pre-trauma volume or function of different brain regions
● Neurobiology of PTSD:
○ Amygdala hyper-reactivity (over activity)
○ Fronto hypo-activity (under activity)
○ Small volume of hippocampus
● Fear conditioning model of PTSD:
○ Mowrer's two-factor model
○ Exposure therapy is often used
● Neurobiology of fear conditioning:
○ Amygdala – conditioned fear acquisition
○ Frontal cortex – conditioned fear extinction
○ Hippocampus – conditioned fear generalization / contextual modulation
○ One or more of these mechanisms may be disrupted in PTSD
○ Gene-environment interactions
● Cognitive aspects of PTSD:
○ Strive for perceived control
○ Social support
○ Models of the world (people with PTSD might have extreme model of the world "safe
place or bad thing never happen to good people")
● Treatment of PTSD:
○ Exposure based therapies seem particularly effective
○ Imaginal exposure often used
○ Virtual reality also increasingly useful
○ Exploration of using drugs that alter learning to either:
■ Interfere with consolidation (or reconsolidation) of the trauma memory –
Propranolol
■ Enhance extinction learning in exposure – DCS
● Acute stress:
○ Criteria is exactly the same to PTSD
○ Lasted 3-31 days
○ At least 9 symptoms from any of the 5 categories of intrusion, negative mood,
dissociation, avoidance, and arousal
○ Causes clinically significant distress or impairment to function
○ No secondary to other medical condition

SECTION #1 – INTRODUCTION + STIGMA

● Who can experience stigma?
 ○ Anybody can experience stigma, but it mostly applies to those who we considered
different like people with disorders or disabilities
● Examples of stigma: in Cambodia, lesbians were viewed as an obsessive and dangerous person to
be around; hence, a lot of parents would tell their kids to not befriend such person as they are
afraid that they would fall in love with their children and obsessed over them
● Are there different forms and types of stigma?
○ Yes, there are many different forms and types of stigma as it varies from one culture to
another, and differs from time to time.
● Is stigma different from one society and culture to another? How so?
○ Yes, it varied from one society and culture to another, like people in Cambodia would
have just called people with depression or anxiety as attention seekers or just plain crazy
people that overdosed on drugs. But in the western countries, it is seen as an illness or a
disability if it is extreme.
● What characteristics of stigma might differ?
○ Attributes that are considered desirable or undesirable can be different from culture to
another
● How does internalization of stigma impact people? What are the potential consequences?
○ Harder for them to get help or acknowledge for their works and efforts
○ Can be seen as a menace to the society
○ Might be looked down upon
○ The stigma might exaggerated their disorders
● Do you think some forms of mental illness are more stigmatized than others? What might
contribute to this?
○ Yes, I believe that some forms of mental illness are more stigmatized than others. It is
likely due to how extreme some symptoms of that mental illness are and how common it
is. Movies and media can also be another factor that contributed to the stigmatization of
those illnesses.
● What are some things that we can do to help combat stigma?
○ Educate ourselves and others around us
○ Communicate more
○ Get to know the people with those disorders better (at the same time also being careful
for any extreme or violence symptoms)
● What are some barriers to combating stigma in society?
○ Lack of resources
○ Ignorance people
○ Discrimination – some people do not want be lumped with the ones that they considered
abnormal

SECTION #2: TREATMENT

● Assessment: scoring guidelines that are used to understand the problems/symptoms, determine
the cause, make appropriate diagnosis, determine the treatment, and keeping track of the progress
● Pros and cons of receiving a diagnosis:
○ Pros:
■ Help determine the causes of the disorder
 ■ Get appropriate treatments
■ Act as a form of communication between the professionals
■ Provide an overview or expectation about the course of the illness
■ Help the individual understand themselves better
■ Insurance coverage and access to suitable services and resources
○ Cons:
■ The stigma sticks to the individual once they are diagnosed like the article “Being
Sane in Insane Places”
■ The risk of being misdiagnosed as different people display different symptoms
that the dx label might not have captured
● Comorbidity: there is a secondary cause like substance abuses
● Symptoms may not relate to the cause
● Psychological disorder cannot be diagnosed through blood test or a brain scan – more detailed
study and observations have to be done in order to diagnose someone properly
○ More harm than good if they were misdiagnosed
○ A diagnosis is not necessary for treatment to be beneficial
● Types of therapy:
○ Psychodynamic: emphasize on the influence of childhood experiences; help individuals
understand themselves and their current relationships better
■ Basic theory:
● The influence of unconsciousness on an individual
● Unconscious conflict can cause symptoms
● Focus on early parent/caregiver relationships
● Unconscious motivation/desires
● Identify interpersonal patterns
■ Goal: study the patient’s early childhood experiences and patterns in order to give
them a better insight and understanding of themselves and their current
relationships
■ Limitations:
● Less empirical support than other forms of therapy – may be unlimited
sessions
● Long course of treatment
■ Target: individual with complex past, facing interpersonal difficulties, and/or
those that prefer unstructured sessions
○ Behavioral Therapy: help modified undesirable behaviors
■ Basic theory:
● Based on operant conditioning (behavior can be modified by outside
stimuli)
○ Reward the desired behavior and punished the undesirable one
■ Goal: help modified the undesirable behavior of the patients and assist in
reducing the avoidant behaviors
■ Limitations: limited access to the past experiences of the client and the
understanding of the cause of those undesirable behaviors
■ Target: people with phobias, behavioral problems, and addictions
○ Cognitive Behavioral Therapy (CBT): help the clients deal with maladaptive thoughts
■ Basic theory:
● Focus on the link between thoughts and consequences/outcome
● Less focus on the past and more focus on the present
● Emphasized on problem-solving
● Clients are assigned homework after each session
● Look into the effect of one’s environment on their thoughts, feeling,
behaviors, and their genetics
■ Goal: there are three waves to help treat their client:
● 1st wave: aim to help client understand and being aware of their
maladaptive thoughts (self-critical thoughts), and the underlying schemas
● 2nd wave: aim to help client become more aware of the interconnection
between their thoughts, feelings, and emotions – and how changing one
can affect the others
● 3rd wave: teach the client about non-judgmentally observing thoughts,
feelings, and emotions – less judgemental and harsh on oneself. Also
help client to be more aware and accepting of their own experience
without trying to change it.
○ Example: Mindfulness-based Cognitive Therapy (MBCT),
Dialectical Behavioral Therapy (DBT), Acceptance and
Commitment Therapy (ACT)
■ Limitations:
● Less helpful for the client with cognitive limitations – those who has
poor insight into their challenges
● Does not work with young children
■ Target: most effective for people with anxiety, depression, schizophrenia,
bulimia, and pain
● Many believed it is helpful because clients are taught skills that can be
used outside of therapy
○ Emotional Focused Therapy (EFT): help clients be more aware of their maladaptive
thoughts and how to understand and express their emotions better
■ Basic theory:
● Incorporates elements of client-centered therapy and Gestalt techniques
(our brain filled in the gap and make us see things as a whole)
● Therapies focus on the idea that some behaviors/emotions are adaptive
(suitable to the situation) and some are maladaptive (responses based on
prior experiences)
○ Maladaptive emotions are based on negative underlying factors
like loneliness, abandonment, worthlessness, anger, or
inadequacy
○ If maladaptive emotions happened frequently and consistently, it
will damage the relationship and one’s lifestyles
■ Goal: help clients be more aware of their maladaptive emotions, understand the
source of their emotions, and learn skills to help regulate those emotions
 ■ Limitations:
● Aim to improve overall functioning but not a specific symptom
○ Might not be a suitable therapy for those who seek to treat a
specific psychological symptom
● If the client is dishonest then it will cause a challenge for the therapist
and that incorrect treatment might be given
■ Target: was first used to help treat those with depression but is now modified to
help those who is struggling with relationship distress
○ Family Therapy: help family members communicate with one another better
■ Basic theory:
● The influence of the one’s family dynamic on that individual and how
each member of the family influence one another
● Used to address a specific symptoms in a given family member
○ Particularly when treating childhood problems
■ Goal:
● Teach strategies that will help the family communicate better
● Goals adjusted to meet needs of different clients
● Psychoeducation is often a component
■ Limitations: resistant families, dishonest client or fearful to speak up
■ Target: usually used for family who has gone through a traumatic event

SECTION #3: CASE FORMULATION & ANXIETY CASE STUDY

● Case formulation: a hypothesis on the psychological mechanisms that are causing and
maintaining an individual’s symptoms and problems.
○ A cohesive story connecting the client’s previous experiences, current stressors, and their
psychiatric history
○ A set of working hypotheses on the variables that serve as a cause, a trigger, or a
maintaining factor for the client’s problem
○ Client will need to be involved in the process (collaborative empiricism)
○ Over the course of the treatment, this form may be revised, revisited, updated multiple
times
○ Most useful when:
■ A client has several disorders or problems
■ No treatment manual exists for a particular disorder or problem
■ A client that has numerous treatment providers
■ Problems that arises that are not addressed in the manual
● The function of a case formulation:
○ For the clinician:
■ Act as an informed treatment plan and guide decision-making
■ A form of communication between professionals
■ An organized clinical case that the therapist can used to help organized and
understand the patient’s symptoms
○ For the client:
■ Help engage the patient in their treatment
 ■ Ensured that the patient can provide a fully informed consent
● Components of a case formulation:
○ Client’s symptoms, specific diagnoses, and problems
○ Proposes hypotheses on the mechanism that is causing the problems (the initial cause)
○ Propose the recent precipants (triggers) of the most current episode
○ Maintaining factor (factor that cause the prolonging and continuing of the problems
● Steps to create a case formulation:
○ Comprehensive problem list
■ Problems – symptoms, specific diagnoses, and difficulties that the client are
facing
● Psychological/psychiatric symptoms (like anxiety and depression)
● Interpersonal difficulties (like divorce, isolation)
● Occupational difficulties (like unemployment)
● Medical problems (like low BMI, obesity)
● Financial stressor (like facing bankruptcy)
● Legal issues (like arrest for DUI)
○ DSM (or ICD-10) Diagnoses
■ Help provide ideas for treatment that will be most effective of the individual
■ A form of communication between the clinician and the client
■ A set of expectations for the course of the treatment
■ Individualized to the client
○ Mechanisms (the initial cause of the problem – what start that problem in the first place)
■ A set of hypothesis of what is causing the problem
■ Trying to answer the question “why is this happening?”
■ Vulnerability mechanisms:
● Pervasive beliefs like negative schemas, meta cognitive beliefs
● Specific cognitive constructs like intolerance of uncertainty, fear of
evaluation, perfectionism
● Multidimensional constructs like distress tolerance
● Neurophysiological predispositions like deficits in sleep regulation,
information processing, executive functioning
● Learned responses like classical conditioning, operant conditioning,
modeling
■ Response mechanisms:
● Experiential avoidance like:
○ Avoidance and escape strategies: safety seeking, reassurance
seeking, compulsions
○ Behavioral avoidance: situational
○ Cognitive avoidance: thought control, thought suppression,
worrying (as a function to reduce uncertainty)
○ Interoceptive (somatic) avoidance
○ Emotional avoidance
○ Emotion-driven behaviors
● Cognitive misappraisal
 ● Attentional focus
● Attribution also bias like internalizing (self-attacking), and externalities
(attacking others)
● Repetitive negative thinking (prolonging harsh self-criticism)
○ Origins: hypothesized of the initial case of the problem based on the client’s family and
social history
■ Look into the client’s previous experiences that are relevant to the problem like
the client’s childhood experience, trauma, changes in brain chemistry, genetics)
■ Origins are more distal
○ Precipitants: trigger(s) of the most current episode
■ Situations or events that occurred before the presence of the symptoms or distress
like a break-up, losing a loved one
■ Can be internal, external, biological, and/or psychological
■ Precipitants are more proximal
○ Treatment plan: this section should include:
■ Goals of the therapy
■ Types of therapy chosen for the client
■ Frequency and duration of the treatment
■ Potential obstacles to the treatment
■ Other therapeutic support like family therapy, occupational therapy, social
support group,…
■ Strengths and assets that may make the treatment more effective like social
support, detailed insight,…
● Social Anxiety Disorder (SAD):
○ Fear of being scrutinized by others when put in social situations
○ Fear that others will negatively evaluated them if they act in a certain way or display
symptoms of anxiety
● Panic Disorder (PD):
○ Recurrent unexpected panic attacks
○ A sudden surge of intense fear or discomfort that reaches a peak within minutes,
accompanied by several physical symptoms (like heart pounding, sweating, shaking,…)
○ Continued for one month or more – significant maladaptive change in behavior related to
the attacks
● Agoraphobia:
○ Marked fear or anxiety about two (or more) of the following five situations:
■ Using public transportation
■ Being in open spaces
■ Being in enclosed spaces
■ Standing in line or being in a crowd
■ Being outside of their home alone
○ Individuals avoid these situation as they are afraid of the thoughts that escape might be
difficult, help might not be available, or facing other embarrassment
● Generalized Anxiety Disorder (GAD):
 ○ Excessive anxiety and worry about a number of events/activities that occurs more days
than not; continued for at least 6 months
○ Individual finds it difficult to control their worries
○ Anxiety and worry are associated with 3+ of the following symptoms:
■ Restlessness or feeling on edge, easily fatigued, difficulty concentrating or mind
goes blank, irritability, muscle tension, and sleep disturbance
○ GAD differs from other form of anxiety disorders through:
■ Dominant symptoms of tension as opposed to autonomic arousal
■ Hypervigilance is more generalized than specific to a particular stimulus

SECTION #4: ANXIETY PAPERS

● Reading journal articles:
○ Abstract: brief summary of the problem studied, hypothesis, participants, method, and
result
○ Introduction: address the problem being studied, the reason why, how does this study
relate to or go beyond the past investigation of the problem, and the type of questions that
the researcher was hoping to answer
○ Method: translation of their hypothesis into testable questions, the variables of interest
(manipulated or measured), how are they going to measure their variables
○ Results: major findings of the study, are the manipulation effective, does the result
support their hypotheses
○ Discussion: the conclusion that can be drawn for the study, limitations of the study,
contribution of the study to their field, practical and theoretical implications of the study’s
findings
● Attentional bias: the tendency to focus on items that are negative and signal danger (cause by
our survival instinct)
○ McNally et al., 1990
● Interpretative bias: the tendency to interpret ambiguous information as threatening (better safe
than not)
○ Macleod & Cohen, 1993

SECTION #5: NEUROIMAGING STUDIES OF ANXIETY

● fMRI (Functional Magnetic Resonance Imaging)): a type of machine used to measure brain
function by studying the metabolic changes in the brain
○ BOLD signal = Blood Oxygenation Level Dependent
■ Brain becomes active → neuron fires → oxygen needed → oxygen will
concentrate at the active region
■ BOLD is represent the neural activity in that active region
■ fMRI is useful when it comes to localization of a brain region that corresponds to
a specific activity/behavior
● Summary from the 2-Minute Neuroscience video:
○ fMRI exposed the brain to multiple magnetic fields
○ Hydrogen protons respond by emitting an electromagnetic signal
○ Scanner receives signal → reconstruct a high-res image of the brain
 ○ BOLD is the measurement used to localize the active region
○ Developed in the early 1990s
● BOLD signal measures the blood flow (the activity) in the brain
● Brain bases of attentional bias:
○ Amygdala hyper-responsivity: amygdala is over responsive which takes over attentional
capture
○ Frontal hypo-responsivity: there might be a healthy amount of amygdala response, but
the frontal cortex is not strong enough to override the amygdala (under-recruitment of
frontal cortex)
■ Amygdala > Frontal Cortex

ARTICLE #1: KINGDON & DIMECH (2008) “COGNITIVE-BEHAVIORAL THERAPIES”

● ABSTRACT:
○ CBT used for both clinical and non-clinical problems
■ Emotional problems to psychoses
■ Substance misuse, personality disorders, marital problems
■ CBT has many benefits and effective for many different age groups
■ Used for depression, various anxiety disorders, substance use disorders,
personality disorders, schizophrenia
■ “Third wave interventions” such as mindfulness, dialectical behavior
therapy, and acceptance and commitment therapy
● CBT (cognitive behavioral therapy) comprise a collection of psychotherapeutic
interventions that target an increasing range of psychological problems
○ Internationally more than any other class of psychological intervention
○ Relatively short-term intervention, delivered over a finite number of sessions
● CT (cognitive therapy) focuses on links between thoughts, emotions, physical symptoms,
behavior, and the environment
○ Emphasize the central role of thoughts
● Developments: the ‘third wave’
○ Behavior therapy is the first wave of cognitive behavioral revolution
○ Second wave is emphasizing the links between thoughts, feelings, and actions
○ Ct targeted the maladaptive beliefs and biased
information processing that create distressing
emotions and damaging behaviors
● Evidence
○
● Advances in CBT-based therapies
○ Used for depression, anxiety, personality disorders,
substance use disorders, and schizophrenia and
bipolar disorder
● Summary:
○ The use and acceptance of CBT continues to grow
○ There is now widespread availability, support from
national guidelines and resources
MCNALLY (1990): SELECTIVE PROCESSING OF THREAT CUES IN PANIC DISORDER
● Research questions:
○ The differences in cognition between people with panic disorders and those without
○ Understanding cognition can help us identify an underlying mechanism to this disorder
○ Do people with panic disorder have an attentional bias toward threats? Do some threat
cues cause more interference than others?
● Method: Examined color naming for three types of threat/PD-related words and neutral words
○ Examples of threat/anxiety concern words are:
■ Fear words like "panic"
■ Bodily sensation words like "heartbeat"
■ Catastrophe words like "heart attack"
○ Participants: patients with PD (panic disorder) and a control group of clinicians who is
treating PD
○ Dependent variable: stroop interference (the difference in reaction time between
threat-related words and neutral words)
○ Independent variables: [between-subjects variables] groups: PD group and Controlled
group, and word types: Fear, Bodily Sensation, and Catastrophe
● Results:
○ Stroop interference: average time taken to name the threat words minus average time
taken to name the neutral words
○ Both groups display cognitive bias → slowing down for threat-words
○ PD showed greater slowing of color naming for all three categories compared to the
controlled group
○ The slowing becomes greater as the words displayed become more extreme
○ The graph provides evidence for attentional captures for threat cues in the PD group
○ The graph also shows that the control group is slowed down as they progress through the
threat-word categories, from "fear" to "catastrophe"
○ The group and word type effects were significant → PD group has more stroop
interference compared to control group, and stroop interference increase as they go from
"Fear" to "Catastrophe" word type
○ The group and word type interaction was not significant → the PD groups are not
disproportionately slower but are equally slower for all three types of words. Unless one
of the bars is on the lower ratio, then there would be a significant interaction. Or, if two
bars are the same and only one bar was higher, then there would be a significant
interaction.
● Discussion:
○ Using clinicians as a controlled group:
■ Wanted to control for familiarity with the concept // but they are not testing for
familiarity
■ They are aware of the purpose tasks – knowing what they are looking for
■ Might have a higher educational level
○ The result does not fully prove that attentional capture by threat is specific to patients
concerns in PD patients
 ■ Both the PD group and control group showed a decrease in the naming of the
words as they progressed go from the "fear" to "catastrophe" category; even
though the controlled group do not have PD and has no specific concern
● Limitations:
○ The controlled group – they are not measuring for familiarity so try a new sample next
time
○ Small sample size – hard to generalize
○ The words used; maybe tried using different category of words like the words that related
to the fear of height, and see if there will be any difference – whether it has something to
do PD, specific concern, or just the effect of threat-words in general

MACLEOD & COHEN (1993)

● Research questions:
○ Compared to those who are low in anxiety, are people who are high in anxiety more
likely to interpret ambiguous sentences as threatening?
○ Does arousal play a role?
● Method:
○ First task: participants are asked to read ambiguous sentences, which are then followed
by a threat-related, a neutral-related, or no cue continuation sentence
■ Look at whether the "no cue" condition resemble the threat cue condition or the
neutral cue condition
○ Second task: participants are shown ambiguous words, then shown two words (threat vs.
neutral) – lexical decision
○ dependent variable: speeding on threat continuations
○ Independent variable:
■ Conditions: threat continuation, non-threat continuation, and no cue
■ Group: high-trait vs. low-trait anxious subjects
● Results:
○ The speed taken to read the continuation sentence (button pressed when completed) is
influenced by its compatibility with the meaning attributed to the first sentence
■ Faster when the meanings are compatible
■ Give index of the interpretation drawn
○ For the high-trait anxious group, the no cue condition resemble to the threat cue
conditions
■ Automatically assessing threat interpretations upfront
○ For the low-trait anxious group, the no cue condition resemble to the neutral cue
conditions
■ Automatically assessing the neutral interpretation upfront
○ For the second task, the speed taken to endorse the second word as being a word versus a
non-word
● Discussion:
○ Time needed to read the sentence: slower vs. faster reader
○ Reading ability or education level
● Limitations:
 ○ Pick participants with the same level of education
○

BISHOP ET AL. (2004) SECTION #5

● Research question:
○ Is the amygdala's response to threat modulated by attention? Does this differ as a function
of state anxiety?
● Method: face/house matching trials task from Vuilleumier et. al (2001)
○ Looked at the effects of the participants' scores on the Spielberger State Trait Anxiety
Inventory
○ Participants: 27 participants (74% female)
○ Factors:
■ Attention: faces attended vs. faces unattended
■ Expression: fearful vs. neutral
■ Anxiety level: continuous or high vs. low
○ dependent variable: left amygdala activity (BOLD signal)
○ Independent variable: attention, expression, and anxiety level
● Results:
○ There was an interaction of attention x expression x anxiety level
○ Low anxious subject behaved like the participants in Pessoa's study
■ Amygdala activity is higher for fearful than neutral faces only when it is attended
○ High anxious subject behaved like the participants in Vuilleurmier's study
■ Amygdala activity is higher to fearful faces than neutral faces for both when the
faces are attended and unattended (house matching)
● Discussion:
○ Amygdala activity to unattended fearful faces only notable in high anxious individual
○ Could this be the brain basis for anxiety-related attentional bias toward threat?
● Limitations:
○ Cannot be sure that this not the consequence of attentional capture by threat rather than
the cause of attentional capture by threat

CLINICAL CASE: “BONNIE LARUE”

● Problem list that Bonnie was facing:
○ Nervous about social interactions and trying new things
○ Worried about public scrutinization
○ Anxiety when it comes to talking with strangers
○ Anxiety when it comes to performing in front of others
○ Anxious about her appearance
○ Panic attacks when faced difficult social situations
○ Low initiation with friends and peers
○ Depressive moods
○ Poor sleep, fatigued, difficulty concentrating, and prolonging feelings of worthlessness
● Mechanisms:
○ Thoughts and fear of rejection
 ■ Selectively focus on the negative thoughts and beliefs
○ Social norm in peer group (like friends and new boyfriend)
■ Surrounding herself with friends and boyfriends who are equally shy May
reinforce her shy behavior
○ High standards of how one should behave or appear in front of others
○ Avoidance of social situation
■ Avoid others after her negative cognitive constructs like the thoughts that other
might be viewing her negatively
○ All these prevent Bonnie from learning to be non-fearful when faced with these situations
● Origins:
○ Pressures from her parents and their expectations of her
○ Temperament (shy since birth)
● Precipitants:
○ Break up with her boyfriend – might lead her to having the fear of rejection and low
self-esteem (like her appearance)
○ Recent transition into high school – acute stressor; increase in student body size and
unfamiliar people
● Treatment: attending sessions where she was taught how to deal with her shyness, and negative
thoughts
○ Learn to talk in front of others, eat with others, and perform in front of others (one step at
a time)