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PSY 103 Introduction to Psychopathology Spring Quarter 2012 Instructor Alan J Fridlund PhD TA Alexandra Chambers Tentative Fair Game Sheet Midterm Exam Updated 422012 History and Basic Concepts Wa s of definin s cho athologv eg four D s39statistica moral 1 self andor others inability efficiency maladaptation self andor others Mesmerism Supported psychogenic view of mental disorders Believed that problems were caused by a block up of energy Sitting next to iron fillings would free up this energy and make you feel better Trephination Ancient method to let out demons that were causing the mental disorder Drilled holes in the skull Humoral theorv Mental disorder caused by the imbalance in the four main humors back bile melancholic yellow bile choleric blood sanguine and phlegm phlegmatic Thought of by Hippocrates Asylums in early nineteenth century asylums were like zoos for the mentally ill They were chained and kept in dark dungeons They were treated like animals disease and malnutrition we rampant Restraint was a common punishment and treatment for the mentally ill Many people paid to visit the savage Mture of lunacv primitive societies believed that the moon had magical mystical powers and that39s its changes portended events of many kinds The moon supposedly had the power to impregnate women to make plants grow and to drive eo le craz Later societies also credited the ower of the moon to affect behavior the so called Hysteria a term once used to describe what are now known as conversion disorder somatization disorder and pain disorder associated with psychological factors Phrenology Determining illness or ersonalit b stud in the bum s on the skull scalp Qemonoloqical view saw y was ruled m catholic norms Especially women that were You could also h out of the bod or burn the bod to et the devil out Usuall killed the person Animal view monqolism T Half assed attempts to arrive to the top of the chain as a human regressed to the animal phase Not all humans were equally evolved less evolved were the mentally ill John down studied kids with down syndrome and said that they looked very Asian and that they didn t evolve to be British and termed them Mongols Asians far down on evolutionary ladder Moral treatment suggested that the mentally ill should be unchained from the wall and should try to live a normal life as possible They should be treated with kindness and care It was a series of principles Re civilized in a humane environment Done outside society in hospitals era 19001960 They were selfcontained cities because population centers didn t want to have anything to do with mentally ill patient Died around 1960 because they were so expensive to run also because that civil rights groups said that the hospitals were conditionaforcing patients to take medications and that they didn t give enough rights to patients Primaril due to One Flew over the Cuckoo s Nest Somatogenic view of mental illness Two factors were responsible for this rebirth One was the work of who published a textbook arguing that physical factors such as fatigue are responsible for mental dysfunction New biological studies also triggered the rise of the somato enic ers ective One of the most im ortant discoveries was that an or anic disease General paresis and malarial cure also see Text Addenda below Read above Psychogenic view of mental illness In the 19quot century there were views Mesmer had iron filings that were magnetically charged and wealthy people would come and sit next to them to feel better and 6 Charcot did demonstrations on that could free up bodily energies that were trapped up by these inter psychological problems Also Freud said that childhood problems caused inter psychological problems These problems are rooted in childhood but show themselves as mental problems in adult hood However these childhood problems are usually forgotten psychodynamic view Behavioral View People acquired mental disorders by distress disorder Also how you reacted to certain set such as post traumatic Deinstitutionalization Mentally ill patients should be free out of state hospitals and be let in community heath clinics These health clinics were so expensive that many patients did not get in and had no where to go and therefore became homeless Biological View Breakthrough with the invention with Prozac It helped countless patients with little side effects Multicultural s cholo Tvpes of professions in mental health physicians who complete three to four additional years of training after medical school a residenc professionals who earn a doctorate in clinical psychology by completing four years of graduate training in abnormal functioning and its treatment and also complete a oneyear internship at a mental hospital or mental health a enc Psychotherapy and related services are also provided by counseling psychologists Managed care So many people now seek therapy that private insurance companies have handed their coverage for mental health patients a program in which the insurance company determines such key issues as which therapists its clients may choose the cost of sessions and the number of sessions for which a client may be reimbursed Research Methods in Psychopathology Advanta esdisadvanta es of a clinical case stud case histor b ex erimental methods and c correlational methods also speculate about why the problems developed and it may describe the a lication and results of a articular treatment Some cons for a clinical case study is that the have a and that they have little basis for generalization A correlational study has In experimental methods researches try to explain the relationship between two variables by manipulating an independent variable and measuring the dependent variable Mture of correlation in clinical studies A correlational study is a research procedure that is used to determine a co reationship between variables E idemiolo ical studies how information is obtained39 revalence incidence Incidence is the number of new cases that emerge during a given period of time and prevalence is the total number of cases in the population during a given time period prevalence includes both existing and new cases To obtain information researchers interview many people to find the prevalence of many psychological disorders Experimental studies experimental control qroups39 blind desi ns and ex erimenter bias natural analo ue and sin lesub39ect ex eriments The experimental group is the group that is tested on while the control group has no tests but is very similar to the experimental rou in artici ant and experimental parameters To get rid of confounds the experimenter needs to and make sure he has a control group to compare whether it was really the changed variable that caused the effect or it if was confound that caused the effect To and participant bias blind experiments are used which makes individuals blind to their assigned group A double blind is when the experimenter and participants are blind to which is the experimental group and control group In a singlesubject experiment a single participant is observed both before and after the manipulation of an independent variable In a natural experiment nature itself manipulates the independent variable and the experimenter observes the effects In analogue experiments researchers induce laboratory participants to behave in ways that seem to resemble reallife abnormal behavior and then conduct experiments on the participants in the hope of shedding light on this real life abnormality Assessment and Diagnosis Qefinition of a MentaIisorder A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress disability or with a significantly increased risk of suffering death pain disability ect Semantic vs Drototvpe conceptions of diagnosis Semantic is due do the definitional theory of meaning Prototype is due to we all have an idea of what typicality is dogiest dog and fruitiest fruit We acquire these prototypes of mental disorders due to repeated exposures of true blue mental disorders DSMIVTR conception of mental disorder Conception of mental disorder clinically significant behavior or psychological syndrome or pattern that occurs in an individual and is associated with present distress disability increased risk of suffering and must be out of excusable cultural response Phenotvpic vs qenotvpic diaqnosis Phenotypic are the signs symptoms course outcome and response to treatment In the past diseases used to be purely phenotypic until the discovery of germs and viruses In mental health nearly all diagnosis is phenotypic with some endophenotypic evidence emerging Genotypic are the causes genes germs In physical medicine progress consists of moving from phenotypic to genotypic diagnosis Advantages and disadvantages of psychodiagnosis look at basic diagnostic concepts Kinds of information that qo into a psychodiagnosis information from assessment Ingredients of a diagnosis incudes symptoms signs course of illness age of onset family history recent events recent behavior psychological tests laboratory tests and response to treatment Clinical interview kinds of information solicited or observed Signs observed and symptoms solicited How the patient experiences their world assess how they look how they talk their education level level of alertness ect Lasts about 1 hr most valuable single source of information leading to a diagnosis Personal and family history re medical metal health social occupational financial problems Treatments that have workednot worked in past Symptomatology Signs from patient s presentation Goals Suitability and readiness for psychotherapy and determine need for referral to psychiatrist or PCP for medication neurologist for neurological testing andor neuroimaging or social worker vocational counselor physical therapist etc Basic diagnostic concepts diagnosis is based on the patient s assessment how they act talk their education level level of alertness ect Patients usually have more than one diagnosis Diagnoses is important for prognosis treatment implications communication among professions establish prospects for contagion or other transmission and possible prevention legal reason competence insanity determinations financial reasons and research Some problems are it sacrifices the uniqueness of individual patient can falsely imply etiology rigidifies treatment aternativesgeneraizes everybody and therefore generalizes treatments and does not consider the uniqueness of people Iatrogenic inessthe healer causes another illness stigmatization and secondary gain use mental treatment for unfair advantage ie workers compensation and still getting a jobngredients of a diagnosis incudes symptoms signs course of illness age of onset family history recent events recent behavior psychological tests laboratory tests and response to treatment There is no single sign or symptom defines a mental disorder Nosoloqv Diaqnosis Science of disease classification Every branch of medicine has their own classification of diseases Bases off an assessment doctors diagnose a patient by putting a nosological category to a patient A patient usually has more than one diagnosis Assessment Gathering information about a patient to decide whether they have a mental disorder Finding out how they experience their world assess how they look how they talk their education level level of alertness ect Put this info together to decide if they have a disorder These assessments will also be used to diagnose a patient A diagnosis is putting a nosological category to a patient Patients usually have more than one diagnosis Siqns 8 Svmptoms Svndromes Signs are what you can observe from the patient A symptom is something that the patient has told you Signs plus symptoms cause a syndrome they are congruent However sometimes they are not congruent Proqnosis Course of illness based off of a diagnoses It describes the course of the illness future symptoms treatments and ultimately the result of the illness Etioloqv Comorbiditv Theory if you have one disorder you re more likely to have another Cognitive tasks commonly used in the clinical interview and MiniMental Status Exam MMSE Orientations time place person Registration slowly sat the name of 3 common objects and ask patient to repeat them Attention and calculation clock drawing and addition Recall Language name a pencil and a watch when pointed to Repeat Noifs ands or buts Follow a 3 stage command take a paper in your right hand fold it in half and put it on the floor Write a sentence Overview of TAT and Rorschach administration interpretation and value The TAT and Rorschach are projective tests These require that clients interpret vague stimuli such as inkblots of ambiguous pictures Theoretically people will project aspects of their personality into the task Projective tests are used primarily by psychodynamic clinicians to help assess the unconscious drives and conflicts they believe to be at the root of abnormal functioning The Rorschach test uses inkblots and patients have to describe images which seemed to correspond in important ways with his or her psychological condition In the Thematic Apperception Test TAT people are shown 30 black and white pictures of individuals in vague situations and are asked to make up a dramatic story about each card They must tell what is happening in the picture what led up to it what the characters are feeling and thinking and what the outcome of the situation will be Clinicians who use the TAT believe that people always identify with one of the characters on each card called the hero General makeup of MMPIg not specific scalg The MMPI2 is a personality inventory The personality inventory asks respondents a wide range of questions about their beliefs and feelings In the typical personality inventory individuals indicate whether each of a long list of statements applies to them Clinicians then use the responses to draw conclusions about the person s personality and psychological problems It is standardized so one person s scores can be compared to those of many others Moreover they often display general testretest reliability that projective tests For example people who take the MMPI a second time after a period of less than 2 weeks receive approximately the same scores Psvchophvsioloqical tests amp polvqraphv Clinicians may also use psychophysiological tests which measure physiological responses as possible indicators of psychological problems This practice began 3 decades ago after several studies suggested that states of anxiety are regularly accompanied by physiological changes particularly increases in heart rate body temperature blood pressure skin reactions and muscle contraction One psychophysiological testis the polygraph known as the lie detector Electrodes attached t various parts of a person s body detect changes in breathing perspiration and heart rate while the individual answers questions If breathing perspiration and heart rate suddenly increase the person is suspected of lying Maior woes of brain imaqinq A CT scan is a procedure in which xrays of the brain s structure are taken at different angles and then the images are combined by a computer A PET scan reveals the functioning of different areas in the brain A person who undergoes this procedure is administered a harmless radioactive compound which travels to the brain Then as the individual experiences particular emotions or preforms specific cognitive tasks his or her brain area is scanned for radiation Higher radioactivity in various brain areas reflect higher blood flow and neuron activity in those areas An MRI is a procedure in which a computer gathers information about the magnetic properties of hydrogen atoms in the brain and then produces a very detailed picture of the brains structure An fMR goes still further producing a detailed picture of the functioning brain In this procedure an MRI scanner detects rapid changes in the flow or volume of blood in areas across the brain while an individual is experiencing emotions or preforming specific cognitive tasks Lt testinq and use of IQ French psychologist Alfred Binet and his associate Theodore Simon produced a intelligence test consisting of a series of tasks requiring people to use various verbal and nonverbal skills The general score derived from this and subsequent intelligence tests is termed an intelligence quotient or IQ Intelligence tests play a key role in the diagnoses of mental retardation but they can also help clinicians identify other problems Neuropsvcholoqical tests Neuropsychological tests measure cognitive perceptual and motor performances on certain tasks and interpret abnormal performances as an indicator of underlying brain problems In the Bender VisualMotor Gestalt Test patients look at the designs one at a time and copy each one on a piece of paper Later they try to redraw the designs from memory Notable errors in accuracy are thought to reflect organic brain impairment Clinicians often us a battery or series of neuropsychological tests each targeting a specific skill area Historv development and construction of DSMVTR principles axes orqanization They are the diagnostic and statistical manuals for mental disorders Started as a tiny book with 100 disorders in 8 categories then divided into 10 categories The diagnoses are very vague and completely idiotic In the DSM Ill science was introduced and based on only observable signs and symptoms Added the Chinese menu decision tree approach with inclusion criteria and exclusion criteria Mutiaxia diagnoses axis one are the major disorders and vcodes Axis two are personality disorders Axis three are general medical conditions Axis four is psychosocial environmental problems Axis five are global assessment functioning GAF Scale DSMIVTRGlobal assessment of functioning scale Scales people based on how well they are doing in their life 100 is the best 00 is the worst and inadequate Overall Chanqes in DSMV due midg013 redoing categories because some don t match the current research They might get rid of the subtypes Many disorders now considered separate categories are now defined as part of a disorder spectrum Behavioral addictions are included More stringent definitions based on absolute severity of signs and symptoms are used to diagnose disorders There is greater recognition of crosscutting symptoms that span multiple disorders anxiety depression Certain risk syndromes are defined as predictive of later disorders such as dementia and psychosis Pharmacogenomics The branch of pharmacology which deals with the influence of genetic variation on drug response in patients by correlating gene expression of singlenucleotide polymorphisms with a drug s efficacy or toxicity Comorbiditv people who have multiple disorders at the same time They have signs and symptoms of both and sometimes it39s difficult to tell what they have Depression Coqnitivemotivational vs neuroveqetative siqnssymptoms of Major Depression and cultural specificity Cognitive pervasive sadness guilt or feelings of worthlessness Recurrent thoughts of death or suicide Motivational pervasive anhedonia nothing gives you pleasure Neurovegetative significant change in weight sleep disturbance psychomotor agitation or retardation pervasive fatigue or loss of energy and difficulty concentrating In non western societies depression takes form in physical symptoms while in western societies depression is more cognitive clitic and postpartum depression possible etioloqies of postpartum depression Atvpical depression Known as Hysteroid Dysphoria Reversed Neurovegetative signssymptoms Causes weight gain carbohydrate binging selfmedicate with caffeine and chocolate Hypersomnia leaden paralysis and interpersonal rejection sensitivity hypersensitivity of all interactions They often have Histrionic traits pretending to be on a stage and aware of others reactions and sef medicate with caffeine or chocolate Anaclitic depression is when children experience depression due to the separation of their mothers Manifests in crying bouts and sadness Qvsthvmic disorder and double depression Dysthymic disorder is when people display a longer lasting at least 2 years but less disabling pattern of unipolar depression When dysthymic disorder leads to major depressive disorder the sequence is called double depression Sex ratios in prevalence of Ma39or Depression possible explanations and implication of Amish findings Women are at least twice as likely to receive a diagnosis of unipolar depression Women also appear to be younger when depression strikes to have more frequent and longer lasting bouts and to respond less successfully to treatments The artifact theory says that women and men are equally likely to have depression but clinicians often fail to detect depression in men The hormone explanation holds that hormone changes trigger depression in many women The life stress theory suggests that women in our society experience more stress than men The body dissatisfaction explanations states that females in western society are taught almost from birth to seek a low body weight and slender body shape Amish studies suggest that depression may be inherited on the X chromosome Genetic evidence on incidenceprevalence of depression Four kinds of research family pedigree twin adoption and molecular biology gene studies suggest that some people inherit a predisposition to unipolar depression Family pedigree studies have revealed that if someone in a family has unipolar depression that as many as 20 of those relatives are depressed as well In twin studies if a twin had unipolar depression then there was a nearly 46 chance that the other twin would have the same disorder Researchers have found evidence that unipolar depression may be tied to genes on chromosomes 14910111213141718202122 and X Individuals who are often depressed have an abnormality of their 5HHT gene a gene located on chromosome 17 This gene is responsible for the brain s production of serotonin transporters or 5HHT s proteins that help the neurotransmitter serotonin carry messages from one neuron to another Kindlinq and depression risk If one has a major depressive episode due to stress or trauma the chances of a second episode increase If a person has a second episode then the chances of a third episode increases even more Psvchotic features in severe Ma39or Depression Have cases of hallucinations or delusions L arned helplessness model of depression and limitations It holds that people become depressed when they thing 1 that they no longer have control over the reinforcements the rewards and punishments in their lives and 2 that they themselves are responsible for this helpless state However it does have its limitations first laboratory helplessness does not parallel depression in every aspect Uncontrollable shocks in the laboratory for example almost always produce anxiety along with the helplessness effects but human depression is not always accompanied by anxiety Second much of the learned helplessness research relies on animal subjects It is impossible to know whether the animals symptoms do in fact reflect the clinical depression found in humans Third the attributational feature of the theory raises difficult questions What about the dogs and rats who learn helplessness Can animals make attributions even implicitly Types of psvchotherapv for Maior Depression rationales evidence for effectiveness Cognitive therapy Uncovering automatic selfdefeating thinking patterns Developing new ways to interpret setbacks normalization analyzing logically decatastophinzing Replacing old automatic thoughts with new ones Prime areas of concern the self life events and the future Psychodynamic therapy seek to bring underlying issues to consciousness and work through them Help client review the past feelings and experiences Interpret their dreams signs of resistance associations etc Hopefully client will eventually gain awareness of the losses and become less dependent on others Longterm psychodynamic therapy is only helpful in some cases depressed clients may be too passive or weary of therapy therapy does not provide immediate results so the patient may become discouraged Psychotherapy is most helpful form of therapy for depression that involves loss self criticism emptiness perfectionism Brain changes including BDNF neocortical and neurotransmitter disturbances in depression and Dossible mechanisms of action of maior classes of antidepressant drugs Low activity of two neurotransmitter chemicals norepinephrine and serotonin has been strongly linked to unipolar depression Research suggests that interactions between serotonin and norepinephrine activity or between these neurotransmitters and other kinds of neurotransmitters in the brain rather than the operation of any one neurotransmitter alone may account for unipolar depression Biological researcher have also learned that the bodies endocrine system may play a role in unipolar depression People with unipolar depression have abnormally high levels of cortisol Other researchers believe that unipolar depression is tied more closely to what happens within neurons than to the chemicals that carry messages between neurons They believe the activity by key neurotransmitters or hormones ultimately leads to deficiencies of certain proteins and other chemicals within neurons particularly to deficiencies of brainderived neurotropic factor BDNF a chemical that supports the growth and survival of neurons Several imagining studies have found lower activity and blood flow in the prefrontal cortex of depressed people Several studies indicate that hippocampus neurogenesis decreases dramatically when individuals become depressed and also a reduction in the size of the hippocampus PET and fMRI scans indicate that activity and blood flow in the amygdala is 50 greater among depressed persons Brodmann area 25 helps serotonin transporters tends to also be smaller in depressed people and like the amygdala is significantly more active Medical disorders that can mask as ma39or depression Hypothyroidism Low testosterone or estrogen levels undiagnosed illness anemia chronic fatigue syndrome Types of antidepressant medications uses in depression and other disorders side effects precautions and qeneral druq classes vou will not need to recaytnv specific druq names The drugs are effective for both anxiety and depression However the drug does not cure depression it only holds it in check for long as they are taken It usually takes 23 weeks after first dose to produce an antidepressant response The drugs are not addictive or habit forming but must be tapered slowly to avoid rebound symptoms The drugs are not euphoriants All have some unpleasant side effects There are no certified time bomb effects or damage to fetus can be taken for ifeRecovering patient must be watched for suicidal or other violent behavior They work only so long as they are taken depression may relapse aftenivard Can precipitate manic episodes in bipolar patients switching Some types are Monoamine Oxidase Inhibitors MAO Inhibitors intro Late 1950s Names are Marplan Parnate and Nardil Had severe dietary restrictions and very unpleasant side effects dizziness drowsiness blurred vision and weight gain Another is Tricyclics such as Elavil Norpramin Tofranil and Anafranil intro Early 1960s It eliminated the dietary restrictions of the MAO inhibitors but still had very unpleasant side effects eg all the above plus dry mouth constipation and are cardiotoxic Another is Selective Serotonin Reuptake Inhibitors SSR sintro late 1980s such as ProzacSerafem Zolof Celexa Lexapro Paxil and Luvox 3040 of patients on SSRl s suffer from sleep and sexual symptoms Children on Paxil may develop suicidal ideation but not suicide People who do not respond to one SSRI have a 4070 chance of responding to a second one Answer may lie in pharmacogenomics Another is Atypical Antidepressants Effexor Cymbalta Wellbutrin Pristiq Remeron Trazodone intro late 1960s and through the 2000s together the mostprescribed class of current antidepressants Fewer sexual side effects varied in action and side effects As a whole modern antidepressants are quite safe but SSRs may be associated with heart and lung defects in the infants of mothers taking some SSRl s while pregnant findings are precautionary and uncertain and Serotonin Syndrone eg confusion hallucinations fever seizures can occur in people who are taking SSRl s along with MAO s or other serotoninraising drugs Abruptly stopping any antidepressant can result in a discontinuation syndrome dizziness tremor zaps anxiety and panic nausea and vomiting and confusion Any antidepressant discontinuations should be tapered Most depressions remit with no treatment in 34 months However odds are gt50 of 13 recurrence gt75 of 2quot recurrence ect Each recurrence tends to be longer and leaves the person with greater disability ie depression is often progressive Depression that is aggressively controlled early predicts less recurrence Medication can be tapered and then resumed if depression reemerges but there is a slight risk of acquired medication immunity if ternative Depression Treatments Medications lithium augmentation of antidepressant therapy St John s Wort Same Thyroxin Testosterone MF Estrogen Fin menopausal and postpartum depression Phototherapy seasonal depression Excerise mild depression sleep deprivation temporary Treatment Resistant Depression Up to 30 of patients do not respond to standard treatments There are some other strategies to cope with this such as Medication Augmentation with lithiuma second antidepressant thyroid medication stimulants side effect management Estrogen and testosterone However there are some risks such as serotonin syndrome and precipitation of manic states Another treatmentresistant depression treatment is magnetic stimulation There are two types such as transcrania magnetic stimulation TMS and magnetic seizure therapy MST TMS uses magnetic field sufficient to produce twitches in fingers The treatment is 12 weeks of short daily sessions However the initial optimism as dimmed MST replaces shock electrodes of ECT with a magnetic field sufficient to produce seizures Initial results suffest equivalent efficacy to ECT but fewer problems with memory and disorientation Another treatment is Vagal Nerve Stimulation which delivers 20 pulses per sec to electrodes wrapped around vagus verve in back of throat where the stimulator is implanted in the chest This treatment arose from findings that depressed epilecptic patients treated with VNS showed improvement in depression IT is FDA approved for recurrent treatmentresistant depressant in July 2005 Effects accumulate over months and 13 to 12 show substantial improvement over a year The exact mechanism is unknown ECT nature of treatment effectiveness and side effects Works fastest of any therapy for depression but the mechanism of action unknown It has the fewest side effects of any therapy for depression very high satisfaction ratings It sometimes causes spotty memory losses episodicgtgtsemanticUsuaIy applied only to right hemisphere to minimize speech disturbance Abused in past and now used only as a last resort and for most severe cases Comparative effectiveness of medications vs psychotherapy for Major Depression ECT works the fastest for most people and with the fewest side effects Medication and psychotherapy work equally well for most adults but medication works faster For adults a combination of therapy and medication seems no more beneficial than either one alone For adolescent depression current recommendation is an SSRI Medication is the least expensive single mode of treatment Overview of SADS and phototherapy The heightened melatonin secretions of winter do apparently cause us to slow down have less energy and need more rest While some people adjust to these changes some individuals seem so sensitive to winter39s heightened secretions that they find it impossible to carr on with business as usual Their slowdown takes the form of de ression each winter a attern called throughout the winter When seasonally depressed patients sit under special lights for several hours every winter their depression is often reduced or eliminated Suicide Hiqhrisk qroups ma39or triggers warning signs biological contributors sociocutura aspects In 2004 a back box warning sign was required by the FDA to warn of that the antidepressants may cause suicide They also did not permit the sale of antidepressant drugs to teenagers In that year teenage suicides went up Other disorders associated with de ression and fre uentl treated with antide ressant medications Findings of TAQS study and implications for childhood and teenage depression treatments Mania and Bipolar Disorder H otheses about etiolo includin neurochemistr Brain mechanism is unknown but may reflect defects in the and is thought to be normalized by antomanic medications Specific PKC inhibitors quickly bring acute mania under control Many other hypotheses are under investigation Genetic evidence on incidenceprevalence Family pedigree studies support this idea Identical twin studies of persons with a bipolar disorder have 30 likelihood of developing the same disorder and fraternal twins siblings and other close relatives of such persons have 5 to 10 percent likelihood In genetic linkage studies researchers have tried t identify possible patterns in the inheritance of bipolar disorder After studies families with high rates of bipolar disorder the research had shown high rates of bipolar disorder across several generations and possibly linked bipolard disorder to genes on the X chromosome Signssymptoms Some clinical features on Mania are y It is a state of intensity and usually have no train of thought They have no perspective on what they are thinking They are so hyper and so impulsive because they are moving so fast they don t think in time of certain consequences Differences between ma39or depression and bipolar depression Depression is only depression uniolar deression not a fullfleded mania and full blown depression and mania at the same time Depression is the more problematic state in bipolar disorder Most cases of bipolar disorder first appear as depressed phase 4000 of persons with bipolar disorder are initially diagnosed with major depression Average age on onset is below age 25 compared to late 20 s for major depression Bipolar depression lasts longer recurs more frequently is more likelyt reach psychotic levels and can take twice as long to obtain remission with treatment People with bipolar disorder spend up to 13 of their adult lives in depression More likely to include reversed neurovegetative signs symptoms and psychomotor retardation as opposed to 21 ratio major depression More than 10 of people with bipolar disorder eventually suicide mostly in depressed phase Tvpes of antimanic medications mood stabilizers side effects precautions and qeneral classes of medications Vou will not need to recaianv specific druq names Medication is the 15 line treatment but med compliance only 30acute management with antipsychotic medications followed by introduction of a mod stabilizer for chronic management Some medications are IamictaIhas uniquely strong antidepressant properties and appears weightneutral Also tegretol and Neurontin for rapid cycling BPD depakote and Topamax moderate anti manic and antidepressant actions AbiIify weight neutraI Zyprexa Risperdal strong antidepressant actions but increase risk of switching into mania or mixed states Nonmedication treatments usually requires prior medication response to be valuable builds compliance to medication helps patientand family understand impact of disorder no effect on the disorder itself ECT rarely used but somewhat effective Induced sleep Very rarely General features of bipolar disorder and ediatric bi olar disorder The point prevalence is about 1 15 but more recent studies su est 35 4050 hi her than any other Axis I because they are impulsive The a e of first with most people diagnosed in their 2039s There is famil histor of bi olar disorder in 30 of BD patients In 20 of MZ twins in which one has BPD the other will have major depression suggestion some common inheritance 10 concordance rate in 15 de ree relatives There are robably multiple routes of genetic involvement UP to 12 of severe childhood depressions become adult bipolar disorder About 12 of children treated for depression with SSRIS develop manic or hypomanic episodes There ist icall a 10 ear Ia between occurrence of first si nssx and onset of treatment There Relationship of bipolar disorder andor depression to creativity There is a correlation between having bipolar disorder and being creative Other disorders associated with bipolar disorder ADHD Anxiety Disorders Brain areas neurotransmitters and ANS involvement in anxiet 39 BDNF involvement in anxiet autonomic nervous system look at slide Sites related to anxiety in animals involve the neurotransmitter GABA GABA calms people down and keeps people in calm by inhibiting neuron activity Anxietyprone people Chemically blocking GABA increases anxiety GABA is only one of many neurotransmitters involved in anxiety GABA and 5HTserotonin inhibit anxiety Alcohol commonly mimics GABA BDNF interferes with antidepressants Physical conditions that can masguerade as anxietv disorders adrenal tumors that oversecrete adrenalin caffeinism nicotine addiction nasal decongestants asthma inhalers or other stimulants Types of symptomatic treatments for anxietv includinq types of anxiolvtic medications differences precautions side effects and General classes of drugs Habit control eg coffee medication for acute use cigarettes stimulant medications Anxiol tic antianxiet signs of anxiety eg eg Xanax Ativan konopinvaIium and Tenormin Indera for chronic use Prozac Lexaproetc or atypical antidepressants eg Cymbalta Effexor occasionally eg buspar and antipsychotics like abilify Seroquel Risperdal and zyprexa Psychotherapy supportive cathartic relaxation and meditation techniques stress management training biofeedback Exercise and support groups Mindfulness coqnitive therapy for anxiety In mindfulness cognitive therapy therapist help clients to become aware of their streams of thoughts including their worries as they are occurring and to accept such thinking as mere events of the mind Know mgior features of and treatments for Cognitive signs objectless fearhave no clue of what you are anxious about or feeling of apprehensiveness Heightened sense of and vulnerability like you don39t have it together There is often worrying and rumination Going blank or spacing out There is irritability impatience and distractibility Hyper vigilance Physiological signs trembling twitching feeling shaky Fatigue restlessness Muscle tension jitteriness Dizziness lightheadedness Fast heartbeat breathing rate Sweating cold or clammy hands Dry mouth nausea diarrhea Altered appetite and sleep Generalized anxietv disorder SignsSymptoms palpitations pounding heart or accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath choking smothering Chest pain or discomfort Nausea or abdominal distress Feeling dizzy unsteady lightheaded or faint Derealization feelings of unrealityl this is not happening Depersonalization being detached from onesef out of body experience Fear of dying losing control or going crazy Paresthesias numbness or tingling sensations Chills of hot flushes Most frequently occurring psychiatric problems in the general population Overall they run strongly in families and are comorbid with depression and stress disorders 5070 of people with lifetime depression also have lifetime anxiety disorders suggesting a common distress inheritance Carr increased risk of alcoholismdru abuse and sefmedication General dianostic criteria for eneralized anxiet disorder GAD Some facts 1year prevalence 3 4 usually emerges during adolescence 75 of GAD sufferers have another mental disorder usually major depression affects 1020 of the elderly who are beset with frailty medical illness and osses which lead to vulnerability and fear 36 of GAD sufferers self medicate w ETOH and other drugseg marijuana substance use often develops with GAD and so causality may be bidirectional Panic disorder with and without a ora hobia It is the occurrence of panic attacks without warning Pattern of avoidance and disability as a result reluctance to venture outside safety zone without escape route Facts one year prevaence23 lifetime prevaece35 develops mostly during late teens1519 increased risk with background of child abuseneglect and with mitral valve prolapse panic attacks can be triggered in susceptible people by yohimbine sodium lactate caffeine nicotine marijuana Treatments dietarymedication control anxiolytic medications or acute use only chronically as preventative Socia mxietv disorder Fear of being embarrassed Most common anxiety disorder and one of the most disabling 1yr prevalence of 8 o lifetime prevalence up to 15 more common in females ratio of 15 to 1 develops in late adolescence or young aduthoodbecause you worry more about how you look in front of others people are afraid of being judgedconstant sense of how do I ook grossly underdiagnosed in managed care population Occurs when people become disabled by intese Persistent and chronic frets of being watched and judged by others and of doing things that will be humiliating or embarrassing can be generalized of occurrence in specific situations nongeneralized onethird are sufferers are very disabled and are more likely to be depressed divorced unemployed or underemployed Awareness that fears are excessive Common performance situations others are putting constant performance demands public speaking public restroom use going to parties eating in front of others bedroom some erectile dysfunction some orgasmic dysfunctions Most commonly treated with medicationsbenzodiazepines andor SSR s plus supportive and proactive psychotherapy Specific phobias types Persistent fears of panic attacks out of proportion situation irrational Compelling desire to avoid phobic stimulus Insight that fear is excessive Symptoms are unrelated to another disorder Most specific phobia sufferers have multiple fears There are the animal types the most frequent are snake and dog phobia Natural environment types like storms heights and water Some people have situation type phobias like claustrophobia tunnels bridges flying and driving Bodily reactions such as vomiting headache and fever Bloodinjuryinjection type like vasovagal reactions Nature of phobic stimuli undercuts a straightforward conditioning view of specific phobia We don t become phobic that are the more likely to kill us Many people argue that we have ancestral fears fears that pertained to us hundreds of years ago Some treatments include medicationSSR systematic desensitization in vivo desensitization effective but low treatment acceptance and high therapy dropout rates applied tension for bloodinjection phobias experimental VR therapy for flying and height phobias and selfhelp groups Behavioral account of etioloqv of specific phobiagtnd its validity idea of phobia preparedness Phobic reactions to animals heights and darkness are more common that phobic reactions to meat grass and houses Theorists often account for these differences by proposing that human beings as a species that a predisposition to develop certain fears Obsessivecompulsive pisorder The disorder is debilitating and unwanted egodystonic The obsessions are intrusive thoughts impulses and images There is usually significant distress or impairment for over one hour per day There is a one year prevalence in about 2of peopIe Half of OCD cases begin in childhood and these childhood cases are mostly males and are more severe OCD cases beginning in adolescence of adulthood are less severe and females equal males in prevalence 20 of OCD cases have first degree relatives with OCD Risk factors siqngsymptoms course proqnosis treatments Brain areas involved in OCQ It re ulates smooth movements of the bod It also la s a role with coordinatin with They get seized by something and they have to finish it before they can move onto the next thing In PET scans people with OCD have a high metabolism of oxygen in the basal ganglia which shows that the basal ganglia are being over worked E spectrum disorders including Body lnteqritv ldentitv Qisorder HOc nd nonpsvchotic stalking Some common obsession and compulsion in OCD checking washing counting need to ask or confess arrangingorganizing collectinghoarding Some obsessions are contamination excessive doubt somatic need for symmetry or exactness fear of causing harm to self or others fear of ebing sexuall ina ro riate Some disorders related to OCD OCDSpectrum disorders are gilles de la can t control sounds cuss words guttural sounds ect anxiety tics corprolalia Half of BDD individuals are delusion and have pattern of anxious avoidance of others a belief usually from early childhood that one or mre limbs do not belong to one s body and that amputation of the limbs will achieve wholeness Certainly regarding the limb involved and the level of amputation desired Rehearsal activity during which they imitate the amputated state in private and public PANDAS also see Text Addenda below Rapid remission of symptoms usually occurs with antibiotic therapy PANDAS accounts for only a small of childhood OCD but may point to possible mechanisms involved in OCD From Text Addenda Mental Disorders Infectious Diseases Problems wl neurotransmitter account of antidepressant Medication action malarial cure of neurosyphilis possible infectious etiologies of OCD major depression and schizophrenia Body Integrity Identity Disorder BIID risk factors signssymptoms course prognosis treatments controversy TLE CPSD and dissociative phenomena Tourette s Syndrome signs syndromes and position in OCD spectrum Be Able to Diagnose from Case Descriptions Depression People with severe depression feel sad and dejected They tend to describe themselves as miserable empty and humiliated They tend to lose their sense of humor Tend to display anhedonia an inability to experience any pleasure at all A number also experience anxiety anger or agitation Depressed people typically lose motivation and desire to pursue their usual activities Almost all report a lack of drive initiative and spontaneity Depressed people are usually less active and less productive Depressed people hold extremely negative views of themselves They are also usually very pessimistic and convinced that nothing will ever improve They feel helpless to change any aspect of their lives People with depression frequently complain that their intellectual ability is poor They feel confused unable to remember things People who are depressed usually have such physical ailments as headaches indigestion constipation dizzy spells and general pain Ma39or depression The presence of a major depressive episode and no history of a manic or hypomanic episode People who experience a major depressive episode without having any history of mania receive a diagnosis of major depressive disorder A major depressive episode is marked by at least five symptoms of depression and lasting for two weeks or more Postpartum vs B1bv blues depression will be diagnosed potpartum if depression occurs within four weeks of giving birth It is significantly different that the baby blues which are symptoms of crying spells fatigue anxiety insomnia and sadness from mothers trying to cope with the wakeful nights rattled emotions and other stresses that accompany the arrival of a new baby These symptoms usually disappear within days or weeks In post partum depression however depressive symptoms continue and may last up to a year These symptoms include extreme sadness despair tearfulness insomnia anxiety intrusive thoughts compulsions panic attacks feelings of inability to cope and suicidal thoughts The motherinfant relationship and the health of the child may suffer as a result Seasonal depression Seasonal depression is characterized as depression that changes with the seasons It is most common for people to become depressed during the winter Psvchotic depression marked by a loss with reality such as deusions bizarre ideas without foundation or halucinations perceptions of things that are not actually present pvsthvmic disorder Depressed mood for most of the day for more days than not for at least two years Presence while depressed of at least two of the foowing poor appetite or over eating insomnia or hyper insomnia low energy or fatigue low selfesteem poor concentration or difficulty making decisions feelings of hopelessness During the two year period symptoms not absent for more than two months at a time No history of a manic or hypomanic episode Significant distress or impairment Mania and Bipolar Disorder Those in a state of mania typically experience dramatic and inappropriate rises in mood A person in throes of mania has active powerful emotions in search of an outlet The mood of euphoric joy and wellbeing is out of all proportion to the actual happenings in the person s life In the motivational realm people with mania seem to want constant excitement involvement and companionship They enthusiastically seek out new friends and old new interests and old and have little awareness of their social style is overwhelming domineering and excessive The behavior of mania is usually very active Flamboyance is not uncommon dressing in flashy clothes giving large sums of money to strangers or even getting involved in dangerous activities In the cognitive realm people with mania usually show poor judgment and planning and hold an inflated opinion of themselves In the physical realm people with mania feel remarkably energetic even though they typically get little sleep Mania vs hypomania People are considered to be in a full manic episode when for at least one week they display an abnormally high or irritable mood along with at least three other symptoms of mania When the symptoms of mania are less severe causing little impairment the person is said to be experiencing a hypomanic episode Bipolar I vs Bipolar ll disorders People with bipolar I have full manic and major depressive episodes Most of them experience an alteration of the episodes for example weeks of mania followed by a period of wellness followed by a series of depression However some people have mixed episodes where they swing from manic to depressive symptoms and back again in the same day In bipolar II disorder hypomanic that is mildly manic episodes alternate with major depressive episodes over the course of time Types of Anxietv Disorders OCD Panic disorders Generalized anxiety disorder and stress disorders
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