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GWU / Psychology / PSYC 2011 / What is the most common treatment for adhd?

What is the most common treatment for adhd?

What is the most common treatment for adhd?

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School: George Washington University
Department: Psychology
Course: Abnormal Psychology
Professor: P woodruff
Term: Fall 2015
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Cost: 50
Name: PSYC 2011.11 - STUDY GUIDE FOR EXAM 3
Description: STUDY GUIDE FOR THE THIRD (AND FINAL) EXAM. This is a bundle of the notes PLUS an added guide breaking down each personality disorder (common traits, DSM details, etc.). Good luck and happy studying!
Uploaded: 12/02/2015
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What is the most common treatment for adhd?



STUDY GUIDE FOR EXAM THREE – 12/3/15 

ABNORMAL PSYCHOLOGY (PSYC 2011.11)

**NOTE: THIS IS NOT AN EXHAUSTIC STUDY GUIDE. EVERY TERM AND TOPIC  COMES FROM MATERIAL WE COVERED IN CLASS NOTES OR READINGS FROM  THE TEXBOOK. MOST NOTES ARE TAKEN FROM CLASS AND SUPPLEMENTED  

WITH TEXTBOOK MATERIAL. There might be other things that will appear on the  exam – your best preparation is paying attention in class!**

Chapter 14, 15 – Schizophrenia and Other Psychotic Disorders 

Psychosis: loss of contact with reality

• Conditions: high temperature, vitamin deficiency, using hallucinogens, severe  depression/bipolar

• Puts drain on healthcare system (schizophrenia)

• Positive symptoms: most readily respond to meds


Who is henry stack sullivan?



o Delusions: disturbances in thought/reality

???? Control: others are removing or inserting thoughts into minds,  

thoughts/feelings controlled by force

???? Reference: attach personal significance to themselves

???? Persecution: fear that person/group/government is out to get individual ???? Grandeur: thoughts that you’re a specific/very important person (fictional  or real) Don't forget about the age old question of Define art.

o Disorganized thinking and speech form of thought

???? Loose association: speaker’s thoughts/ideas shift from one topic to another ???? Clang association: using voices only because they rhyme We also discuss several other topics like What are the factors that affect the policy­making influence of legislatures?

???? Incoherence: word salad

???? Preservation: repeating same word/phrase


Who labeled the disorder moral insanity?



???? Neologism (“pretigitis”): make up word with individual meaning  

(nonsense words)

o Heightened perceptions/hallucinations

???? No perceptual extreme stimulus

???? Most common sense causing hallucination – auditory (hearing voices,  good and bad)

o Inappropriate affect: sudden unpredictable outbursts at wrong time (laughing at a  funeral)

• Negative symptoms: much harder to treat

o Poverty of speech (“alogia”): brief responses, stopping midsentence, vague and  repetitive

???? Restricted affect: showing lack of emotions If you want to learn more check out It is an ongoing marketing research system that collects customer inputs and integrates them into managerial decisions?

???? Disturbances in violation: disturbance in goal-related activity

o Disturbed relationships, social, withdrawal, asocial, poor hygiene

• Makes up 50% of individuals in mental hospitals

• 3 million in US

• Psychomotor symptoms

o Odd gestures/mannerisms

11/12If you want to learn more check out How was the english empire formed?

o Catalonia: excessive/lack of movement

???? Rigidity: stands up and resists being moved

???? Flexibility: lets you move them but stays standing

???? Posturing: awkward and bizarre positions held for long time; can be  dangerous

???? Excitement: move quickly, mayhem, self-loathing

• Onset is late teens/early 20s

o Insidious – slow and subtle onset

o Illness phases

???? Prodromal – starts to deteriorate from normal level of functioning – weird  habits/actions

???? Active-florid symptoms – caused by stress

???? Residual – after treatment, person returned to prodromal level

• About 25% have a very good recovery prognosis

• About 50% return to active stage

• Historical overview:

o Hippocrates: “phrentis” until 19th century (inflammation of mind and body) o Moral “demonic praecox” – had son, became withdrawn, all functioning  deteriorates If you want to learn more check out It is a collection of data whose properties are analyzed, what is it?

o Kraepelin – “dementia praecox” – deterioration to a younger state (dementia of  early life)

o Bleuler – schizophrenia - to be split off from reality

• Schizophrenia I: mostly positive symptoms (later onset)

• Schizophrenia II: mostly negative symptoms (linked to structural abnormalities) • Causes Don't forget about the age old question of Why do governments fail?

o Socio-cultural: social labeling, self-fulfilling prophecies

???? David Rosenhan: went to hospitals pretending to be schizophrenic (“Being  Sane in Insane Places”)

o Genetic:

???? Family stories: biological explanation (closest relative = greater  

concordance)

???? Twin studies: dizygotic concordance rate = 17%, monozygotic = 40% ???? Adoptions studies: development under adoption situations

???? Chromosomal mapping: related to autism?

• Polygenic model: several

o Brain:

???? Structural abnormalities:

• Larger ventricles: fluid waiting away

???? Biochemical

• Dopamine hypothesis – over activity of dopamine, antipsychotic  

• meds reduce hallucinations by blocking dopamine receptors (at the  dendrite)

• Certain drugs increase frequency of symptoms

???? Serotonin

• Viral theory - during utero mother has virus that manifests

• Most born during winter months

11/12 11/17

???? Psychological

• Freud (primary narcissism) person isn’t getting enough attention so  they regress back  

• Family relationships

o Schizophrenic mother: preoccupied by mother-child  

relationship – too protective, accepted in 50-70s

o Double-blind communications – damned if you do, damned  

if you don’t: demands too high

• Behavioral: child pulls into fantasy universe

o Faculty learning and coping

• Treatment

o Institutionalization: “snake pits” not effective

o Milieu therapy: psych ward = community like based on humanistic psych, loss of  conversation

o Token economy: tokens received for doing things

???? Traded in for prizes

o Neuroleptics (antipsychotic drugs)

???? Seize/grab the nerve

o Thorazine – used to sedate patients before surgery

???? Low potency medication – larger doses

???? Long-term used side effects

• Tardive dyskinesia: involuntary movements that make living hard

• Atypical antipsychotics (expensive) (clozapine?)

• Serotonin blocker, works on D1/D4 receptors

• Sialorrhea: excessive drooling

• Causes: heightened blood sugar level, weight gain, seizures,  

fatigue

???? Can cause lack of white blood cell production

???? Risperidone = Risperdal

• Psychotherapy

o Freud did very little to adapt psychoanalysis to the treatment of schizophrenia • He felt that if only a close relationship could be formed then good  

psychoanalysis would be carried out

• They can’t do this

• Henry Stack Sullivan – American psychoanalyst

o Did his work in Baltimore

o He thought that schizophrenia had returned to an early childhood  

form of communication

o That their egos were very fragile

o You had to gradually gain their trust in nonthreatening ways

???? Like you could never have direct eye contact

???? He began to encourage patients to look at the fact that they  

didn’t have interpersonal relationships

???? Another symptom of schizophrenia is to withdraw into  

oneself

11/17

???? Dyad: an interaction between two people (this is important  

– to be emotionally healthy you needed to interact  

meaningfully with other people)

o Later worked with Frieda Fromm-Reichmann

???? Came to US after fleeing Germany

???? Worked at the Chestnut Lodge in Maryland (psychiatric  

hospital)

???? Reichmann thought schizophrenia was the reboot

• Said you can give up the other world you created  

whenever it feels safe enough

• “I Never Promised You a Rose Garden” (book)

o Depicts auditory and visual hallucinations

o These people were all working before they  

had the antipsychotic drugs

o The question then is: were they really  

schizophrenic?

o The disorder is probably not a single entity

• Evaluation using psychoanalysis as treatment is not very good

o Definitely always has to be combined with medication

o Family therapy has been used with much better results

???? Family therapy first came about because schizophrenics  

would return to the family after being in a mental hospital  

but the family would make them crazy again and they  

would relapse

???? You can help a family learn to be supportive

o Therapist helps the patient deal with any stresses within the family • NAMI – it provides a lot of support for families as well as for schizophrenics o They loan out headphones so that a healthy person can see what it’s like to  function while you’re listening to voices

o There are some community approaches that were first instituted five decades  ago

• 1963 – the Community Mental Health Act

o Strongly pushed

o Supported by John F. Kennedy

o It was one of the last things he got pushed through congress before his  assassination

o Pushed mental hospitals in communities and would do treatment to keep their  from being a readmission

o Went from 600,000 patients down to about 40,000

o It’s the community resources that weren’t there

o You didn’t end up with a community mental health center in every community o They weren’t always well-funded

o Deinstitutionalization has decreased the rate of chronic mental illness • There are also halfway houses – staffed by paraprofessionals

o Live as close as they can to being in the real world

o Sessions where the patients would talk to each other

11/17

• Day treatment – community mental health centers

o There might be a van that picks them up

o When they arrive they carry out activities that would also mirror the real  world

• Individual ends up in a boarding house, rooming house, etc.

o “Flop-houses”

o They’re entitled to disability money

o All it means is they have a room that might be absolutely filthy

o No one sees to it that they might get meals

o Sometimes they’re taken advantage of when they do get money

• About 1/3 of the homeless population here has one or more mental health illnesses o Schizophrenia, but also alcoholism, addition

• Then they’re in prisons

o About 50% are thought to have a serious mental illness

o Often in prison because due to the illness they have committed  

some minor offense

o We have the District of Columbia Jail

???? The estimate there is about 40% of those people in that  

particular jail have a mental illness

???? This is from the Washington Post – city mental hospital St.  

Elizabeth’s

• Since 1973 patients there

• Just gauged out his eyes even though they were told  

to restrain them

• Due to cutbacks and layoffs there are about 10,000  

people in need of good mental health treatment

• Schizophrenia has sparked more research but we’re so far from fully  

understanding it

Chapter 16 – Personality Disorders 

Personality disorders

What is your personality?

• Thoughts, feelings, behaviors that distinguish you from other people

• We speak of personalities as if they were real or concrete

o It really has no existence apart from behavior

o It’s a concept, construct

• But when they’re maladaptive then you have a personality disorder

Individuals:

• Different perceptions about themselves of others

• Sometimes troubled by their personality but unable to change these characteristics • When they can’t change they say it’s other people who can’t understand them • Tend to excuse themselves

• Often it’s behavior that really alienates other people

• So these are longstanding patterns of behavior

• Certainly may coexist with other disorders

11/17

• These are patterns that usually apply late in childhood or at least by adolescents • Mostly they are dysfunctional in relating to other people

• They’re likely to be a source of irritation and worry

• Maybe even fear and fury

• But they have absolutely no understanding of how they’re contributing to the problem • They don’t feel they need treatment

• Sometimes treatment is mandated by a court

• So many people with a personality disorder don’t actively seek treatment the places that  keep track with the numbers and percentages we don’t have a good estimate of the  number of people in our population that have these disorders

• Diagnosing them can be difficult

• Many of the symptoms overlap

• **Professor recommends that you make a chart for yourself of the most salient  characteristics of each of the personality disorders**

• There were supposed to only be six disorders in the new DSM but that didn’t happen – we still have 10

• However, they’re grouped in three clusters and the clusters are simply labeled A, B, and  C

• Cluster A consists of odd, eccentric, detached behaviors

o Paranoid personality disorder (paranoid PD)

???? They’re suspicious, argumentative, mistrusting of others

???? Bear grudges, see themselves as absolutely blameless

???? Others are responsible for any mistakes

???? See evil in the motives of others

???? Paranoid may have very brief psychotic episodes where they’re delusional ???? Leaves them with a lot of difficulties in their interpersonal relationships ???? A man may believe his wife is having an affair

???? NOTHING she can do can convince him otherwise

???? You can’t do anything about it, you can’t reason with them

???? More males than females have this

o Schizoid PD

???? Far reserved, socially withdrawn

???? Seem to lack the capacity for a close-loving, warm relationship

???? Are disinterested in others

???? They don’t know how to respond appropriately to you

???? They have very poor social skills

???? They will cross the street to avoid an acquaintance

???? Unable to initiate conversation

???? Avoid eye contact

???? Most prefer a solitary work environment

???? Working from home would be ideal

???? Central problem of this is the inability to form attachments

???? Their need for love/belonging never developed

???? Used to think this was a precursor for schizophrenia

11/17

???? (People think Batman in the Dark Knight has schizoid PD)

???? Book – “Bitter Harvest”

• Keeps trying to poison her husband and burns the house down  

twice

• Second time killing one of her three children

• She’s given this diagnosis

o Schizotypal PD

???? Oddities in communication, thinking, and behaving

???? Deviations aren’t as extreme as in schizophrenia

???? Emotionally very shallow

???? Socially unskilled

???? Not understood often because of using common words in unusual ways  (schizoid PD has no oddities in communication)

???? Also suspicious, aloof, etc.

???? Peculiar thought patterns associated with loosening ties to reality ???? Lacks key integrative confidence

???? Can’t hold things together

???? Some of these people do go on to develop full-blown schizophrenia ???? Some researchers say this is a mild form of schizophrenia

???? Delusions of reference

• They hear a dialogue in a film and they think it’s about them

???? Men are more likely to show the negative symptoms

???? Females tend to have more of the positive symptoms

???? More males than females in general with this

• Cluster B – dramatic, emotional, erratic behavior

o Antisocial personality disorder

???? People use “antisocial” in an inaccurate way

???? Like if you’re quiet at a party that’s kind of antisocial

???? But that’s not what this means

???? You’re aloof, shunning the competition of others – this is asocial (NOT  antisocial)

???? Antisocial – going against the norms of society

???? Refers to a person that’s disloyal, callus

???? Irresponsible, without guilt for behavior

???? Disregard the rights of others

???? It receives special attention because this is so commonly dangerous to  others

???? Philippe Pinel (French)

• He noted that with the patients he had sometimes some of them  

were unaware of how hurtful they were being to others

• He noted they had excellent intellectual function

• They don’t show the cognitive symptoms that other people show ???? 1830 James Prichard

• Labeled the disorder moral insanity

• They can’t guide their lives according to moral principles

???? 1891 – Charles Mercier – moral perversion

11/17

• Considered insane

???? Freud jumps in

• Calls it psychopathic personality

• This gets shortened to “psychopath”

???? Then w/ first edition of DSM got changed to sociopathic personality  (individual would be a sociopath)

???? They’re both synonyms for antisocial personality disorder

???? Third edition of DSM – we get the name we have today

???? Central feature is violating the rights of others

???? Happens early on in life

???? If it occurs before the age of 18 it’s conduct disorder

???? After that then it’s antisocial PD

???? Conduct disorder would be lying, truancy, physical aggression ???? Doesn’t necessarily go on to become antisocial PD

???? So far we don’t have a good measure to predict if the child has this if it  will stop or continue in adulthood

???? Characteristics in adult – they don’t conform to social norms

???? They have a great deal of social charm they just don’t mean it ???? They lie with ease

???? They’ll say oh yes I’m at fault but they don’t mean it

???? There’s no shame, remorse, etc.

???? They’re self-centered, very poor judgment

???? May commit unlawful acts for very small gain

???? They just repeat the offenses once they’re out

???? They try to replicate good ways of living but there’s very little response ???? Many would rather be in prison

???? We don’t know the cause of this

???? Something about the alpha waves

???? Something having to do with the families

???? So they’re very depressed – have low levels of chemicals

o Borderline personality disorder

???? First introduced in 1938

???? Thought that it was a disorder somewhere between neurosis and psychosis ???? They’re emotionally unstable

???? Have some delusions, some paranoid beliefs, some magical thinking ???? Some say they’re out-of-touch with reality

???? They’re bored, have low tolerance for frustration

???? They’re chaotic sexually, sometimes change sexual orientation ???? They’re manipulative, narcissistic, and they self-mutilate (cutting or  burning)

???? However if that’s the only symptoms then that’s a different disorder ???? This is just one of several symptoms

???? They’re extremely unstable, they just have drastic mood shifts ???? A lot of self-destructive behavior like gambling irresponsibly, shoplifting,  instance relationships where they’re idealize a friend or lover but then say  they’re disappointed in them

11/17

???? They can have angry outbursts

???? They can be verbally abusive to someone very close to them

???? Might threaten suicide

???? Manipulate others through threats and self-mutilation

???? Not until 1980 (first recognized in 1938) that it was given official  

recognition in the DSM

???? 75% are female

???? We think something goes wrong in them trying to achieve a self-identity ???? There are a few biological findings

???? The serotonin levels are low

???? They have the sleep patterns of a depressed person

???? With a normal sleep you go through stages of REM

???? What reverses as you go through the night? Non rem gets shorter, rem gets  longer

???? They go into REM quickly and the non-REM is different for this disorder ???? They do the opposite

o Histrionic PD

???? Used to be called hysterical

???? Word means theatrical, having deliberate affectations

???? They display exaggeration expressions of emotion

???? Overly concerned with physical attractiveness, no tolerance in delaying  gratification

???? The Id – “I want this and I want it now”

???? They have a way of constantly seeking approval

???? They want to be the center of attention

???? They show inappropriate sexual ___ but they don’t actually want to have  sex

???? They’re behaving in ways that are the opposite to what they feel

???? The ratio with male to female is equal

o Narcissistic OD

???? The last one – in cluster B is the narcissistic personality disorder

???? If you know the story from Greek mythology – aw his reflection in the  water

???? They’re self-absorbed and they need a lot of praise

???? They exaggerate their self-importance

???? They cannot accept criticism

???? They lack empathy towards others

???? They always try to place themselves in the best light

???? They use the defense mechanism of rationalization

more males than females have this

• Cluster C – anxious and fearful behaviors

o Avoidant personality disorder

???? Extremely shy

???? Socially withdrawn

???? A fear of criticism

???? Hypersensitivity to being rejected

11/17

???? They exaggerate their shortcomings

???? They’re self-esteem is very low

???? They usually have no close friends

???? Over time are socially isolated and depressed

???? **Page 32 – change “tied to social anxiety and depression” to “tied to  social anxiety disorder and depression”**

???? The ratio of genders is equal

o Dependent PD

???? Passive

???? Let others control their lives

???? They lack self-confidence

???? Can’t function independently

???? Subordinate own needs to the needs of others

???? This insures that they don’t lose their dependent position so they make  themselves very likeable

???? They’re meek, submissive, clingy

???? Things can go wrong this way though, especially if they’re a dominant  personality because then they can be physically abused

???? There are some battered women and occasionally some battered men who  have this PD and they accept repeated abuse

???? Hedda Nussbaum from Manhattan

• Editor for a publishing house

• Husband was a lawyer

• They had an apartment

• Decided they wanted children

• The husband said they should adopt

• First there was a little girl – when she was 6 they adopted a little  boy

• The husband started beating the wife and then turned on the little  girl

• One day threw her so hard against the wall that he killed her

• Husband served a long prison term but she was acquitted because  her dependent personality disorder was so severe that she couldn’t  act to protect the child

• Since that time she’s become an activist

o Obsessive compulsive PD – “living machines”

???? Unusually serious, overly conscientious

???? Perfectionistic

???? Focus on lists, rulemaking, very small details

???? Neatness – nothing can be out of place, has to be the same way at the desk,  the kitchen

???? They’re not able to express warm, tender feelings

???? Insist that their way of doing things be followed

???? They aren’t aware that they’re distressing other people

???? Tom Henderson

• Went to GW for medical school

11/17 11/19

• Armchair diagnosis of this personality disorder

• He’s a cardiologist

• During medical school he loved Pringles

• They’re all the same shape, size, they’re neatly stacked

• Back when you paid bills by putting a postage stamp on an envelop  

he loved commemorative stamp there because he had to put the  

stamps that were little stamps

• When you put checks in the boxes – he had to put x

• When he offers you something healthful to drink

• He puts down the napkin and then the glass of juice right in front  

of you

• To torment him – take a little sip and then you move the napkin

• His husband and two young adult children have lived like that

• He has required that they do things like that to

• That’s where some of the friction has come from

• There has never been found a link yet between the PD and the Cd  

disorder

• Those with the PD are rigid, restricted in their behaviors

• But they don’t have the obsessional thinking and they don’t engage  

in irrational rituals like constant hand washing

• People with OCD know it’s bad but can’t stop, but with PD they  

feel like it’s under control

• More males than females have this

Chapter 17 – Disorders of Childhood and Adolescence 

Childhood anxiety disorders

• Separation anxiety

o Child shows anxiety or panic when he or she is not with a major figure or in  unfamiliar surroundings

o Might not be able to stay in a room by themselves

o Might refuse to go to school

o Uncomfortable visiting the home of a friend

o When you ask the child why he or she is afraid they might say “I might get lost,  etc.”

o Have exaggerated fears of accidents, kidnappers, etc.

o In early childhood almost every child experiences separation anxiety

o But for this to be diagnosed there must be a reaction for at least four weeks o Treatment is very effective

???? Best is play therapy

???? Toys are specifically selected by the therapist to help the child through the  play activity

???? Also family therapy so the child isn’t singled out

???? Systematic desensitization – Wolpe – hierarchy of fears and teach yourself  to relax

???? Hypnosis – sometimes been effective

11/19

???? 14 years ago the FDA approved Luvox antidepressant in children 6-17 so  sometimes they’re given that as well as an antianxiety

• Phobias

o In children almost always specific

o In most they outgrow it but some children have phobias that are so severe and  intense that they need to be treated

???? “School phobia”

???? Modeling is the most effective – the model is not the therapist but another  child

???? Usually matching the child with the phobia

???? Also systematic desensitization works here

???? Children can be a little more relaxed so they counter the anxiety

???? Then cognitive therapy where the child learns a few positive statements: ???? “I am great,” “I can take care of myself”

• Childhood depression

o For a long time thought it was only in adults

o About 2% of children and 9% of adolescents have depression (teens more  common than children)

o Symptoms:

???? Withdrawal

???? Crying very easily or frequently

???? Poor appetite

???? No/poor eye contact

???? Sense of helplessness

???? Suicidal thoughts

o It has been found that children who didn’t have suicidal thoughts previously who have them on medication

o You must monitor the child and they must regularly see a therapist o Very few cases where a child or adolescent has actually died but many attempts  have been made

o People thought that children would respond similarly to adults on meds – this is  not the case

o There’s a black box warning with this – if the child is between 6-17 o The best approach is probably medication along with behavioral cognitive therapy ???? Change the thoughts

???? Improve the self-esteem

o There are far too few child psychologists and psychiatrists

o What we do know is that by ratio up until the age of 13 boys and girls are equal  when it comes to getting this

o After 13 it’s 2:1 female to male

o It’s not just hormones – could be flora in the stomach

o Prozac, Paxil, Zoloft, and Effexor are used

• Bipolar disorder

o Often people don’t think young people can get bipolar disorder but when you  survey adults you can find many of them saw symptoms themselves in their teens  or adolescence

11/19

o Most children are very rapid cyclers

o They can cycle a number of times in a single day

o If one parent has it there’s a 30% of the child develop it

o If both parents – 75% risk

o That is offspring of dual mating

o Too much activity in the amygdala (emotions) and too little activity in the  prefrontal cortex (rational thought)

???? Usually start child on a mood stabilizer

???? Never really start the child on lithium because it’s so toxic

• Kidneys, intestine

???? Then they might be put on an atypical antipsychotic (Seroquel)

• That leave the child very hungry and with weight gain

• It can also leave the child with ticks

???? Finally an antidepressant may be added

???? Individual and family therapy are very much recommended as well as  limiting caffeine

???? Then a change to that the child (and preferably the rest of the family) live  with a routine

???? Some feel that the diagnosis is over-applied

???? 66% are boys

• Disruptive mood regulation disorder

o Sudden outbursts of rage – you look at the situation and can’t understand what has  caused it

• Oppositional defiant disorder

o This is where a child shows negative hostile and defiant behavior for at least six  months

o Defying adult rules

o Annoying others but also annoying themselves

o Easily losing temper

o Being very angry, resentful towards others repeatedly

o Blaming others for their problems

o Being spiteful and vindictive

o More common in boys until puberty and then after that the gender ratio is equal o Some develop something even more serious – conduct disorder

o Might have onset in childhood or adolescents

• Conduct disorder

o Lying, cheating, stealing, setting fires, vandalism

o Cruelty to animals

o When kids break the law they’re juvenile delinquents/offenders

o Sometimes they have surrogate parents who constantly try to reinforce socially  approved behaviors

o It’s still very hard to treat

???? They might come out of a facility and go right back in

???? This happens a lot

o Some of these kids simply remit and you never see the behavior again

11/19

• ADHD

o Has gone by many names

o Years ago we called it minimal brain dysfunction

o 1950s – started calling it hyperkinetic syndrome of childhood

o 1980 – attention deficit was used for the first time

o 1987 – hyperactivity was added to the majority of the cases

o About 70% are male

o Disorder lessens as the child goes through adolescence

o About 1/3 keep it into adulthood

o There is ADHD predominantly attentive type 20%

o Then ADHD predominantly hyperactive type 80%

o There is a form where there’s a combination

o They show some cognitive impairment in impulsiveness, etc.

o Interrupting while others are talking

o Doing dangerous things without considering the consequences

o They’re also accident prone

o Then the hyperactivity

o The inability to remain in one’s seat

o If you can get the child to stay in the seat they wriggle

o Then there’s fidgeting

o Inattention

o Not following directions

o There’s often also learning disabilities, depression

o Some develop conduct disorder

o Seem to be a number of causes

???? Running families

???? Dopamine, norepinephrine, serotonin, and glutamate are also involved o Probably a combination of genes too

o We know the cerebellum is a little smaller is the third that extends through the o Ritalin is the most common treatment

o It’s related to amphetamines

o It was the earliest and has been in generic form now for years

o Wellbutrin and Zyban

???? Both psychostimulants

???? Increasing the dopamine increases impulse control

???? Ritalin can have positive short-term effects

???? Weight loss

???? Outbursts of rage

???? Some have ticks

???? People who carry this into adulthood there might be cardiac problems ???? Sometimes they get headaches, etc.

Teachers have to be specially allowed to administer this medication

January 2003 – Stratera (new drug)

• First to not be a psychostimulants

11/19

• Had the potential for abuse

• It increases the norepinephrine

• It only needs to be taken once a day, at home

• It doesn’t cause insomnia

• They’re still doing studies to compare it to Ritalin

2006 – Nitrana became available for ages 6-12

• Administers Ritalin via in injection?

People who work with children who have ADHD say to never rely on medication alone There really needs to be behavioral therapy

Modification of behavior, lots of positive reinforcement

(Hitting, spanking, yelling at child is totally ineffective)

Family therapy – you can teach the parents to be calm around the child

Feingold Diet

• Dr. Feingold believed that sugars and certain food dyes attributed to ADHD • The recommendation is to avoid these kinds of food (low in carbohydrates, certain food  dyes)

• In a tiny subset of children this works

• Many parents feel it’s worth trying anyway

Other treatments include:

• Magnets in the bed, or in a bracelet

• These are not effective

• Personal life coaches (to do the behavior modification)

• Swimming with dolphins (some say this helps)

There is a common recommendation that when a child is diagnosed you work with the parents as  well – often you will find it unrecognized in the parents

• If you can stabilize the parents you may be able to stabilize the child

• The outcome is not always good

o Children with ADHD have a higher rate of dropping out of school, being  unemployed, teen pregnancy, having car accidents, spending time in jail

• There is a book called “Buzz: A Year of Paying Attention”

o She was diagnosed with ADHD at the same time as her 10-year-old son o She and her husband had excellent income

o She was a journalist, he was an editor

o They had two sons

o The mother and the child tried every type of treatment except for medication  together for a whole year (the son got some of the royalties)

o Did any of it work? No

o They both ultimately went on medication

o But she had the money and the time to try all the alternatives

• Ritalin on campuses

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o The usage is abused

o It keeps you up to study, write papers

o Memory retention while on Ritalin is unknown

Two elimination disorders

• Bed wetting (enuresis)

o Child involuntarily wets the bed during the night or the pants during the daytime o Persistent difficulty controlling urination by a chronological age of five and a  mental age of four

o You must be sure it is not caused by a physical problem (allergies, UTI) o Must be two events per month between ages five and six and one event per month  by age seven or older, for three consecutive months

o Most children do outgrow it because it causes distress

o Two ways to treat it

???? Set an alarm (this is hard on the parents) – every two hours wake up and  take child to bathroom

???? Bell and pad – pad on the child that has a sensor and a bell – as soon as the  first drop of urine hits the pad the bell rings, the child wakes up, and then  can go to the bathroom on his or her own

o If the child helps strip the bed, etc. this will help

o Limit liquids as the evening goes on, quiet activities

o These kinds of therapies can be effective

o There are also underpants that fit any size – for incontinence

o At one point the military would not take anyone who had enuresis as an adult • Encopresis

o Passage of feces of normal consistency into the clothing or onto the floor o Must be a chronological and mental age of at least four and an episode of once a  month for three consecutive months

o Need to first be checked for any physical problem

o Sometimes this is tied into constipation

o Very little research has been done

o Family therapy has been found to be helpful with lots of positive reinforcement o Sometimes has to do with environment

The Autism Spectrum (Autism Spectrum Disorders)

• Higher functioning is more commonly Asperger’s

• It was here in the US (Johns Hopkins) that Leo Kannner – prominent child psychologist – in 1943 first used the term “infantile autism”

• It is a PDD – persistent developmental disorder

• About 80% are male

• The spectrum consists of certain characteristics

o Unresponsive to others

o Poor communication skills

o Difficulty playing with others

o Odd reactions to the environment

• 1998 – 1 in 2,000

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• 2008 – 1 in 150

• 2012 – 1 in 88

• 2041 – 1 in 48 male, 1 in 68 female

• Why is this?

o Are we better at diagnosing it? Do we have a better understanding of the  disorder?

o Could be something in the environment

o ***VACCINES DO NOT CAUSE AUTISM***

• Kanner suggested that relationships between the parents and child could be disruptive o Mother was a “refrigerator parent” – cold and unemotional with the child, hadn’t  bonded

o Mothers in particular were blamed for this

• Today we know that it is a lifelong neurological problem

o Appears with the normal development of reasoning

o Makes learning difficult

o Can lead to serious behavior problems

o Can be evident in the first few weeks of life, or sometimes the child is as old as  three

o The concordance rate with identical twins is 90%

???? This means that there has to be a genetic component with it

• Seems to be abnormal development in the cerebellum

o Excessive amount of white matter in the brain

o Glial cells (that support the neurons), greatly enlarged frontal lobes o Brain is normal size at birth but by age of two the head may be as big as an  adolescent

o Pediatricians are thus urged to regularly (among other things) measure the head  size at various times

• We think that there are as many as 15 genes that play a role in this, and that mutated  genes are involved

• This spontaneous mutilation is thought to come from the father

• There is a high rate of older fathers where you have an autistic child • There are three broad areas of symptoms

o Failure to develop social relationships

???? Baby does not care if it is held

???? They seem to not need affection

???? Do not make eye contact with the caretaker

???? Don’t seek comfort when distressed

???? They don’t smile sometimes

???? No imitative behavior

???? No social play

???? They become preoccupied and form strong attachments to objects

o Language and communication deficits

???? 50% never learn to speak

???? Some are mentally retarded (so some comorbidity)

???? About 5% have isolated skills or great talent in art, music, or mathematics • This is called being a savant

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• They used to be called “idiot savants”

• They may be able to do great things in a field but cannot do very  

basic other things

???? Echolalia – may repeat phrases spoken by others (even same accent or  inflection sometimes)

???? Delayed echolalia – hours or days later will repeat many times the phrase  they heard

???? Pronominal reversal – reverse or confused pronouns

• “They are having a good time” when the child means “I am having  a good time”

???? Make up nonsense words

o Limited imaginative play and responses to environment

???? Self-injurious behavior

???? Head banging against things

???? Sometimes bite parts of their bodies

???? Can pull out their hair

???? Self-stimulating behavior

• Spinning

• Hand-flapping

• Walking on tip-toes

• Body rocking

???? Grimacing

???? Fascinated with movement

???? Preservation of sameness

• Must have the same kind of things all the time, furniture has to be  

in the same place, must speak to the child in the same way

• Treatments we have so far:

o Haldol (antipsychotic)

???? Given with vitamin B6 and magnesium

???? Helps some children with language development

???? Can reduce tantrums and self-stimulating behavior

o Behavior therapy

???? First introduced by late Ivar Lovaas

???? Program that parents paid their child to go through 40 hours a week for  two years

• Parents would then work with child on weekends and evenings

???? It worked with certain behaviors

???? If a child came close to a behavior that the adult desired the child would  be given a reward

???? He also used punishment, electric shock sometimes

o Facilitated communication

???? Therapist puts hand out

???? Child’s hand is over the therapist and there is keyboard in front

???? Child communicates that way

• Books

o The Curious Incident of the Dog in the Nighttime (Haddon)

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Intellectual development disorder (intellectual disability) – mental retardation • Mental retardation = term applied to a lot of different situations

• Recently “intellectual disability” has been used (clinical settings)

o Almost 3 of ever 100 people meet the criteria for the diagnosis

• Intellectual functioning is below average

• Poor adaptive behavior

• Symptoms appear before age 18

IQ test can measure this

• Test not necessarily 100% accurate – depends on socioeconomic status sometimes • Some children are not as used to seeing exam language, etc.

• Would be more accurate to observe child in their home/everyday environment rather than  test (in order to diagnose mental retardation)

o 80-85% of people who are mentally retarded are mildly so

o Children with mild mental retardation might need help when they’re stressed but  seem to play with others well

o Jobs tend to be unskilled or semiskilled

• Mental retardation itself linked to sociocultural and psychological causes o Poor, unstimulating environments

• Moderate retardation

o Diagnosed earlier in life

o Most can function well later if they are supervised

• Severe retardation

o During infancy

o Increased risk for brain seizure disorder

o Rarely able to live independently

• Profound retardation

o During birth or early infancy

o Often symptoms can be related to a physical disorder as well

o Extremely low intellectual functioning (basic things – walking, talking, feeding) o Can be fatal  

IQ

Mild 50-70 85% Moron

Moderate 35-49 10% Cretin

Severe 20-34 3-4% Imbecile

Profound Below 20 1-2% Idiot

Causes

• Chromosomal

o Down syndrome

???? Most common chromosomal disorder

???? Less than 1 of every 1,000 births

???? Mother over 35 = increased risk

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???? Small head, flat face, slanted eyes, high cheekbones

???? Close with family but similar in personality to most in the general  

population

• Caused by chromosome 21

• Can cause early dementia

• Metabolic

o PKU – phenylketonuria

???? 1 of every 14,000 children

???? Cannot break down phenylalanine

???? Chemical builds up, causes retardation

o Tay-Sachs disease

???? Progressively lose mental functioning, vision, and motor ability, and  

eventually die

???? Lipid storage disorder, very fatal

???? Very common in Eastern European Jewish ancestry

• Prenatal

o Mother has too little iodine in diet = cretinism (problem with thyroid) o Fetal alcohol syndrome – previously covered in class

???? Level of alcohol consumption during pregnancy

o Some infections – syphilis, rubella, etc. – can also cause mental retardation in the  child

• Birth-related

o Lack of oxygen for a certain amount of time (anoxia) = very dangerous and can  cause brain damage

• Following the birth (childhood)

o Some injuries/accidents can cause mental retardation/intellectual dysfunction ???? Head injuries, exposure to X-rays, drugs

???? Lead poisoning

???? Mercury, radiation also

???? Some can be diagnosed and treated but if it is too late it can lead to mental  retardation

Chapter 18 – Disorders of Aging and Cognition 

• Disorders of later life

o Depression

???? Very common among elderly people

???? Low self-esteem, guilt, pessimism, loss of appetite, sleep

???? If the individual has recently experienced a trauma this can also affect ???? More likely to commit suicide than younger people

???? More than half improve with various treatments (cognitive-behavioral  therapy, antidepressants, combinations, etc.)

???? BUT antidepressants can cause cognitive impairment in this population o Anxiety

???? 6% of elderly men, 11% of elderly women

???? Increases throughout old age

???? Many things can increase anxiety

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• Medical illnesses

• Overall health

???? Usually treated with drugs but have to be careful with the elderly  

population

o Substance abuse

???? Majority of older adults do not have an alcohol or substance problem ???? 4 to 7% of older people have alcohol-related disorders

???? Difference between having had alcoholism before their old age and having  “late-onset alcoholism”

???? With substances – most often unintentional, most often prescription drugs o Psychotic disorders

???? Higher rate of psychotic disorders than young people

???? Usually related to delirium or dementia

???? Some suffer from schizophrenia, but less common in older people than in  younger people

???? Very rare that schizophrenia comes up in old age, but women outnumber  men in this at least 2 to 1

o Disorders of cognition

???? Common by age 60 or 70

???? Delirium

• Awareness of environment is less clear

• Difficulty focusing, thinking, interpreting

• Sometimes hallucinations occur

• 60% of patients older than 75 in a nursing home have this

• Can be caused by infection/disease, injury, stroke, stress, and poor  nutrition

• Memory

o Sensory memory

???? Shortest of memory (extremely short-term)

???? Retains sensory images and information

???? Lasts a very short time

o Short-term memory (working memory)

???? Gathers the new information

???? Must be transformed into long-term memory to store it

???? Prefrontal lobe

o Long-term memory

???? Information we’ve stored over the years

???? Retrieval – remembering information in this memory system

???? Temporal lobe (hippocampus, amygdala), diencephalon (mammillary  bodies, thalamus, hypothalamus)

???? Declarative memory – type of long-term memory – can be consciously  recalled

• Episodic – experiences and specific events

• Semantic – facts, knowledge, and meaning

???? Procedural memory – knowing how to do things (tasks and skills)

• Part of long-term memory

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• Motor skills etc.

• Organic disorders that effect memory and identity

• Alzheimer’s disease and other neurocognitive disorders

o Alzheimer’s disease

???? Most common form of dementia

???? Gradually progressive

???? Vast majority occurs in age 65

???? Time between onset and death is 8 to 10 years

???? Memory loss, poor judgment

???? Late stages = require constant care

???? Has to do with brain structure – problems with short-term and long-term  memory

o Pick’s disease

???? Very rare

???? Affects the frontal and temporal lobes

???? Clinical picture very similar to Alzheimer’s – distinguishing  

characteristics can be seen after death

o Creutzfeldt-Jakob disease

???? Another source of dementia

???? Also often includes spasms, etc.

???? Disease has a very rapid course

o Huntington’s disease

???? Genetic – inherited progressive disease

???? Memory problems worsen over time

???? Severe spasms, personality and mood changes

???? Children of Huntington’s parents have 50% chance

???? Ultimately can be fatal

o Parkinson’s disease

???? Tremors, spasms, unsteadiness, and dementia

???? Michael J Fox and Muhammad Ali

• “As all rivers flow to the same home, the sea; all lives reach the same end, death”

Chapter 19 – Mental Health and the Law 

Insanity

• Obviously affects a person’s state of mind

• Comes into question when we talk about law and mental health

• Insane people can cause crimes, but then where is the fault?

Mens rea (guilty mind)

• Mental state an individual must be in in order to be guilty of a crime

• Basically the person must be in this state of mind (sanity) in order for the crime to have  been intentional

Criminal commitment

• People accused of a crime are deemed mentally unstable and unfit for trial and are sent to  a mental hospital, etc. for treatment

• Two forms: NGRI and mentally unfit for trial

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o Mentally unfit for trial means they cannot understand the trial at the time it  happens – don’t know court proceedings, etc. and cannot then defend themselves  Not guilty by reason of insanity (NGRI)

• Innocent of crime because of state of mental health

• Must then get treatment or therapy

o M’Naghten rule (1843)

???? Experiencing a mental disorder at time of crime does not mean the person  was insane – person might not have a conscience

???? Might not know right from wrong

???? Led to the adoption of a different test

o Irresistible impulse test (1834)

???? Emphasizes inability to control actions

???? “Fit of passion”

???? Not guilty under this test

o Durham test (1954)

???? Later became popular among these other two

???? Meant to offer more flexibility for court decisions but too flexible

???? Under this test alcoholism could deem someone not guilty, etc.

o ALI test (1955) (American Law Institute Test)

???? People can’t be held accountable if they had a mental disorder that kept  them from knowing right from wrong

???? Also cannot be held accountable if they weren’t able to control themselves ???? So it accounts for both

???? APA later recommended that only the first – right from wrong – was an  accurate measure and that people unable to control themselves wasn’t a  

valid reason for insanity

???? Called for return of M’Naghten test

???? Often schizophrenia is part of the diagnosis for these criminals

• Guilty but mentally ill (GBMI)

o Verdict – defendants are guilty of committing a crime but are also mentally ill  (but it doesn’t have any bearing on their innocence) (they are treated in prison) • Diminished responsibility defense (guilty with diminished capacity)

o Some states allow this

o Mental dysfunction is an extenuating circumstance

o The person may not have intended to kill someone but they did

o This would be manslaughter (without intent)

• Competence to stand trial

o Individual can’t understand the charges they face

o Thus they can’t adequately defend themselves or testify

• Civil commitment

o Individual can be forced to undergo mental health treatment

o They might not be aware of the problems they have

o Then the legal system has to take responsibility

• Voluntary hospitalization

o Person decides for themself

• Patient’s rights

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o Right to treatment

???? States are obliged to provide treatment to those who need it (who have  been committed involuntarily)

???? They can’t force people in and then mistreat them

o Right to refuse treatment

???? Too many different kinds of treatment that could have negative effects ???? These are mostly on biological treatments, not therapies etc.

o Legal limits to confidentiality – therapist confidentiality

???? Tarasoff case: Prosenjit Podder (Tarasoff v. Regents of the University of  California)

• Outpatient at UC hospital

• Told a therapist he wanted to harm his girlfriend, and then when he  was released he killed her

• Confidentiality should have been broken in this case?

• The girlfriend wasn’t warned

???? Duty to warn and to protect principle

• Responsibility to break confidentiality

• This is only if it is necessary in order to protect the client or other  people

• Must be in danger or potential danger

PERSONALITY DISORDER BREAKDOWN

Paranoid:

• *DSM-IV Cluster: Odd

• *Similar disorders on Axis I: Schizophrenia; delusional disorder

• *Responsiveness to treatment: Modest

• Central features:

o Suspicious/distrustful

• Prominent features:

o Relationship problems

o Hostile

o Blames others

o Controlling/manipulative

o Jealous

o Sensitive

o Aloof/isolated

o Self-absorbed

o Grandiose/egocentric

o Emotionally unstable

o Depressed/helpless

o Anxious/tense

o Cognitive/perceptual eccentricities

o Psychotic-like episodes

Schizoid:

• *DSM-IV Cluster: Odd

• *Similar disorders on Axis I: Schizophrenia; delusional disorder • *Responsiveness to treatment: Modest

• Central features:

o Relationship problems

o Aloof/isolated

• Prominent features:

o Self-absorbed

o Psychotic-like episodes

Schizotypal:

• *DSM-IV Cluster: Odd

• *Similar disorders on Axis I: Schizophrenia; delusional disorder • *Responsiveness to treatment: Modest

• Central features:

o Relationship problems

o Cognitive/perceptual eccentricities

• Prominent features:

o Suspicious/distrustful

o Sensitive

o Aloof/isolated

o Self-absorbed

o Grandiose/egocentric

o Depressed/helpless

o Anxious/tense

o Attention deficiencies

o Psychotic-like episodes

Antisocial:

• *DSM-IV Cluster: Dramatic

• *Similar disorders on Axis I: Conduct disorder

• *Responsiveness to treatment: Poor

• Central features:

o Deceitful

o Controlling/manipulative

• Prominent features:

o Relationship problems

o Suspicious/distrustful

o Hostile

o Blames others

o Aloof/isolated

o Self-absorbed

o Compulsive/reckless

o Grandiose/egocentric

o Emotionally unstable

o Depressed/helpless

o Attention deficiencies

Borderline:

• *DSM-IV Cluster: Dramatic

• *Similar disorders on Axis I: Mood disorders

• *Responsiveness to treatment: Moderate

• Central features:

o Relationship problems

o Emotionally unstable

• Prominent features:

o Suspicious/distrustful

o Hostile

o Blames others

o Deceitful

o Controlling/manipulative

o Jealous

o Sensitive

o Self-absorbed

o Self-critical

o Compulsive/reckless

o Grandiose/egocentric

o Overly emotional

o Depressed/helpless

o Anxious/tense

o Attention deficiencies

o Psychotic-like episodes

Histrionic:

• *DSM-IV Cluster: Dramatic

• *Similar disorders on Axis I: Somatoform disorders; mood disorders • *Responsiveness to treatment: Modest

• Central features:

o Grandiose/egocentric

o Overly emotional

• Prominent features:

o Relationship problems

o Hostile

o Deceitful

o Controlling/manipulative

o Jealous

o Sensitive

o Self-absorbed

o Self-critical

o Compulsive/reckless

o Emotionally unstable

o Depressed/helpless

o Anxious/tense

o Cognitive/perceptual eccentricities

Narcissistic:

• *DSM-IV Cluster: Dramatic

• *Similar disorders on Axis Cyclothymic disorder (mild bipolar disorder) • *Responsiveness to treatment: Poor

• Central features:

o Self-absorbed

o Grandiose/egocentric

• Prominent features:

o Relationship problems

o Suspicious/distrustful

o Hostile

o Blames others

o Deceitful

o Controlling/manipulative

o Jealous

o Sensitive

o Aloof/isolated

o Emotionally unstable

o Overly emotional

o Depressed/helpless

o Cognitive/perceptual eccentricities

o Attention deficiencies

Avoidant:

• *DSM-IV Cluster: Anxious

• *Similar disorders on Axis I: Social phobia

• *Responsiveness to treatment: Moderate

• Central features:

o Relationship problems

o Sensitive

• Prominent features:

o Suspicious/distrustful

o Aloof/isolated

o Self-absorbed

o Self-critical

o Depressed/helpless

o Anxious/tense

o Cognitive/perceptual eccentricities

Dependent:

• *DSM-IV Cluster: Anxious

• *Similar disorders on Axis I: Separation anxiety disorder; dysthymic disorder (mild  depressive disorder)

• *Responsiveness to treatment: Moderate

• Central features:

o Relationship problems

o Self-critical

o Anxious/tense

• Prominent features:

o Suspicious/distrustful

o Controlling/manipulative

o Sensitive

o Depressed/helpless

Obsessive-compulsive:

• *DSM-IV Cluster: Anxious

• *Similar disorders on Axis I: Obsessive-compulsive anxiety disorder • *Responsiveness to treatment: Moderate

• Central features:

o Controlling/manipulative

• Prominent features:

o Relationship problems

o Suspicious/distrustful

o Hostile

o Blames others

o Self-absorbed

o Self-critical

o Depressed/helpless

o Anxious/tense

o Cognitive/perceptual eccentricities

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