Clinical & Cognitive Psychology

Psychology integrates ClinPsych, CogPsych, neuropsych, and developmental perspectives. Evidence-based practice requires understanding DX criteria, therapeutic modalities, and cognitive architecture.

## Diagnostic Frameworks

DSM-5-TR provides standardized DX criteria for mental disorders. Key changes from DSM-IV: eliminated multiaxial system, dimensional assessments added, reorganized chapter structure based on developmental/neurobiological relationships. ICD-11 used internationally, increasingly aligned w/ DSM.

Assessment process: clinical interview (structured SCID vs semi-structured vs unstructured), behavioral observation, psychological testing (validity scales critical — MMPI-3 has F, L, K scales to detect over/underreporting), collateral information. Differential DX: rule out medical causes first (thyroid for depression/anxiety, substance-induced, medication effects). Biopsychosocial model: biological (genetics, neurochemistry), psychological (cognition, personality, coping), social (relationships, SES, culture).

## Major Diagnostic Categories

Depressive disorders: MDD requires 5+ Sx for ≥2 weeks including depressed mood OR anhedonia. SIGECAPS mnemonic: Sleep, Interest (decreased), Guilt, Energy (decreased), Concentration, Appetite, Psychomotor changes, Suicidality. Persistent depressive disorder (dysthymia): depressed mood most days for ≥2 years. Specify: w/ anxious distress, mixed features, melancholic, atypical, psychotic features, peripartum onset, seasonal pattern.

Anxiety disorders: GAD — excessive worry about multiple domains ≥6 months + 3+ somatic Sx (restlessness, fatigue, concentration difficulty, irritability, muscle tension, sleep disturbance). Panic disorder: recurrent unexpected panic attacks + ≥1 month concern about future attacks or maladaptive behavioral change. Social anxiety: marked fear of social situations where scrutiny possible. Specific phobias: marked fear disproportionate to actual danger.

PTSD: exposure to actual/threatened death, serious injury, or sexual violence. 4 symptom clusters: intrusion (flashbacks, nightmares), avoidance (stimuli associated w/ trauma), negative alterations in cognition/mood (persistent negative beliefs, emotional numbing, detachment), arousal/reactivity (hypervigilance, exaggerated startle, irritability). Duration >1 month. Distinguish from ASD (<1 month). Complex PTSD (ICD-11): adds affect dysregulation, negative self-concept, relational disturbance.

Bipolar spectrum: Bipolar I — at least one manic episode (≥7 days or hospitalization, elevated/irritable mood + ≥3 of DIGFAST: Distractibility, Insomnia decreased, Grandiosity, Flight of ideas, Activities increased, Speech pressured, Thoughtlessness/risk-taking). Bipolar II — hypomania (≥4 days, less severe, no psychosis/hospitalization) + MDE. Cyclothymia: chronic fluctuating mood ≥2 years, never meeting full criteria.

Personality disorders: Cluster A (odd/eccentric — paranoid, schizoid, schizotypal), Cluster B (dramatic/erratic — antisocial, borderline, histrionic, narcissistic), Cluster C (anxious/fearful — avoidant, dependent, OCPD). BPD characterized by identity disturbance, unstable relationships, affective instability, impulsivity, chronic emptiness, frantic efforts to avoid abandonment, transient paranoia/dissociation. Prevalence ~1.6% general population, ~20% psychiatric inpatients.

## Evidence-Based Treatments

CBT: gold standard for depression, anxiety, PTSD. Core model: situation → automatic thoughts → emotions/behaviors. Cognitive distortions: all-or-nothing thinking, catastrophizing, mind reading, emotional reasoning, should statements, personalization, overgeneralization. Behavioral activation for depression: schedule pleasurable/mastery activities to break avoidance cycle. Exposure therapy for anxiety: systematic desensitization (hierarchy + relaxation) or flooding. ERP for OCD: expose to obsession trigger, prevent compulsive response — habituation occurs.

DBT: developed by Linehan for BPD. Four modules: mindfulness (observe, describe, participate w/o judgment), distress tolerance (TIPP: Temperature, Intense exercise, Paced breathing, Paired muscle relaxation), emotion regulation (opposite action, ABC PLEASE skills), interpersonal effectiveness (DEAR MAN, GIVE, FAST). Biosocial theory: emotional vulnerability + invalidating environment → emotion dysregulation.

Psychopharmacology: SSRIs first-line for MDD and anxiety (fluoxetine, sertraline, escitalopram). Mechanism: block SERT → increased 5-HT in synaptic cleft. Onset 2-4 weeks (receptor desensitization hypothesis). Side effects: GI, sexual dysfunction, activation in first week (monitor suicidality in youth). SNRIs (venlafaxine, duloxetine): add NE reuptake inhibition, useful for comorbid pain. Mood stabilizers: lithium (gold standard for bipolar, narrow TI, monitor levels/renal/thyroid), valproate, lamotrigine (bipolar depression). Antipsychotics: typical (D2 blockade, EPS risk) vs atypical (broader receptor profile, metabolic syndrome risk).

ACT: acceptance and commitment therapy. Six core processes: cognitive defusion (thoughts as mental events not facts), acceptance (willingness to experience), present moment awareness, self-as-context (observing self), values clarification, committed action. Psychological flexibility as treatment goal. Growing evidence base for chronic pain, anxiety, depression.

## Cognitive Psychology

Attention: selective (cocktail party effect, Broadbent's filter theory → Treisman's attenuation), divided (dual-task paradigm, bottleneck theories), sustained (vigilance decrement over time). Inattentional blindness (Simons & Chabris gorilla study) demonstrates attention as limited resource. Executive attention: anterior cingulate cortex, conflict monitoring.

Memory systems: sensory (iconic ~250ms, echoic ~3-4s), STM/WM (Baddeley's model: central executive + phonological loop + visuospatial sketchpad + episodic buffer, capacity ~4 chunks per Miller's updated estimate), LTM: declarative (explicit — episodic vs semantic) vs nondeclarative (implicit — procedural, priming, classical conditioning). Encoding: levels of processing (Craik & Lockhart — deeper semantic processing → better retention). Retrieval: encoding specificity principle, context-dependent and state-dependent memory.

Forgetting: decay (time-based, controversial), interference (proactive: old interferes w/ new, retroactive: new interferes w/ old), retrieval failure (tip-of-tongue). Ebbinghaus forgetting curve: exponential decay, but spaced practice (distributed practice effect) dramatically improves retention. Testing effect: retrieval practice > re-reading for long-term retention.

Decision making: dual process theory (Kahneman): System 1 (fast, automatic, heuristic) vs System 2 (slow, deliberate, analytical). Heuristics and biases: availability (frequency estimation from ease of recall), representativeness (base rate neglect, conjunction fallacy), anchoring (insufficient adjustment from initial value). Prospect theory: loss aversion (~2x), reference dependence, diminishing sensitivity. Framing effects: identical information presented differently → different choices.

## Developmental Psychology

Piaget's stages: sensorimotor (0-2, object permanence), preoperational (2-7, egocentrism, centration, conservation failure), concrete operational (7-11, conservation, classification, seriation), formal operational (11+, abstract reasoning, hypothetical-deductive). Criticisms: underestimates children's abilities, stages not universal, domain-specific development.

Attachment (Bowlby/Ainsworth): secure (distressed at separation, comforted at reunion, 60-65%), insecure-avoidant (little distress, ignores caregiver, 20%), insecure-ambivalent (extreme distress, resists comfort, 10-15%), disorganized (contradictory behaviors, associated w/ maltreatment, 5-10%). Strange Situation procedure. Internal working models influence adult relationships (Hazan & Shaver). Secure attachment predicts better emotion regulation, social competence, and mental health outcomes.

Erikson's psychosocial stages: trust vs mistrust (infancy), autonomy vs shame (toddler), initiative vs guilt (preschool), industry vs inferiority (school age), identity vs role confusion (adolescence), intimacy vs isolation (young adult), generativity vs stagnation (middle adult), integrity vs despair (late adult). Identity development particularly relevant in clinical work w/ adolescents and emerging adults.

## Research Methods & Ethics

Experimental design: IV manipulation, DV measurement, random assignment (controls confounds). Between-subjects vs within-subjects (repeated measures — controls individual differences but order effects → counterbalancing). Quasi-experimental: no random assignment (natural groups), threatens internal validity.

Effect size: Cohen's d (small 0.2, medium 0.5, large 0.8). Statistical significance ≠ clinical significance. NNT (number needed to treat) more clinically meaningful. Replication crisis: many classic findings failed to replicate (Open Science Collaboration 2015 — ~36% of 100 studies replicated). Pre-registration, open data, and larger samples as correctives.

Ethics: APA Ethics Code — beneficence/nonmaleficence, fidelity/responsibility, integrity, justice, respect for autonomy. Informed consent: competence, voluntariness, understanding. Confidentiality limits: danger to self/others (Tarasoff duty to warn/protect), child/elder abuse, court order. Dual relationships: avoid when possible, manage when unavoidable.