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Psych 103 Notes Lecture 1 412014 Topic 1 Introduction to Psychopathology Prevalence Females are twice as likely to be diagnosed in any particular year with a serious mental disorder 1825 year olds are more likely to be diagnosed then 2649 then 50 The lowest rate is Asian and the highest is white in ethnicity Premature death is highest in neuropsychiatric disorders Avg of 285 years lost The mental disorders are taking a big toll in loss of life and it seems to be even higher than cardiovascular disease the biggest killer Professions involved in Mental Health Practice Psychiatrists MD s Clinical Psychologists PhD Social Worker MSW s DSW s Psychiatric nurse RN Marriage and Family Therapist MFT s Psych technicians MH Intake Workers Staff Primary Care Practitioner MD sPCP s Physician assistants PA s and Nurse Practitioners NP s Mental Health Researchers Neuroanatomists Neurochemists Geneticists Epidemiologists Psychopharmachologists Psychiatrists Clinical Psychologists Lecture 2 4314 Early Views of Psychopathology Trephining Cutting holes in the sides of the skulls to let the spirits escape Evidence of bone growth displays that the people most likely lived for a while after the procedures Humoral Theory Hippocrates 400 BC The idea that there was a basic bodily chemistry that went out of whack explaining why people behaved in a weird way Argued there were four basic bodily functions and if one went out of whack or there was a surplus it would result in changes in your temperament Melancholic an excess of black bile results in a depressed guilty and sad person Choleric an excess of yellow bile results n a hair triggered temper who s anger and irritable discontrol disorder Phlegmatic an excess of phlegm results in a person who is unrufferable like Eeyore and almost too stable Sanguine an excess of blood results in a person who is very cheerful and manic Early Views in the Middle Ages Demonic Possession people began to resort to supernatural explanations for sicknesses like syphilis People began seeing mental illnesses in terms of demons Methods of treating demonic possession putting one s head in an oven to bake out the demons and this was considered a success Another alternative was to get someone drunk and keep them drunk The Catholic church began to be obsessed with mental disorders and the hierarchy began to see mental disorders as a sign of possession by the devil Women were suspects and witches were almost always women The causes of men behaving badly were almost always women and those that were possessed were almost always women Pope innocent the 8 had a commission that was called the Malleus Maleficarum Witches Hammer 1946 and it was about diagnosing witcherydevil possession However behind the scenes there was a great deal of pastoral care of the mentally ill by members of the Catholic Church Diagnosing Witches dumping them in water water was a pure substance so if you were a witch you would float because the water would repel you Treating Witches Exorcism if you were in the right parish with a fairly moderate priest you were allowed to have an exorcism done to get the devil out of you and then you would be free of the devil Exorcisms would be driven so violent that you may be on the brink of death before the exorcism was complete Treating Witches Burning Early Views of Psychopathology from 17001850 Eventually the pastoral view took over in the Catholic church The psychologists were the descendents of the philosophers in the earlier ages 0 Mental Illness as Evolutionary Regression Predarwininan evolution there was a ladder conception of evolution The lower animals on the Earth were sinfully waste stations on the way to the White British Male at the top Caucasians were considered the most divine of all races Slightly below the British were the French then the eastern Europeans then the Asians then the Aboriginals then the Negroids Mongolism Down Syndrome Leads to an eye fold that looks Asian and leads to retardation Most people with Down Syndrome have a large tongue and develop Alzheimer s by the time they are 3035 0 Doctor John Langdon Down was so interested in this disease and saw that it looks Asian and called in Mongolism as a sign of regression to the Asians Mental Illness as Evolutionary Regression People see those that are mentally ill as brutes or dumb animals The idea was Here s a noble savage that lost his nobility and is simply a savage Mentally Ill Housed as Animals The wealthy used to visit on weekends as a tourist attraction The inmates in the Asylum were on display They were treated like animals and often whipped or malnourished Goya s Madhouse 1810 Literally was a madhouse Treatment By Restraint Moral Treatment or Unchaining the lnsane seen as a grave moral wrongdoing The argument was children were basically ill formed like putty and it was every generation of adults through strict moral training They were animals and they had to be taught and molded to fit society The idea was that people that were insane had gotten off track and needed to be free to be retrained This didn t necessarily mean punishment but rather close supervision to remold reparent them This was to be done in state hospitals away from major cities which replaced the insane asylums and treated them much better 19001960 Some of the wards were opened although there were some that were locked when the patients could not be contained The State Hospital Era 19001960 0 Camarillo state hospital Hotel California and Napa State Hospital there were fields where patients could grow crops and they could make their own clothes For the most part these state hospitals closed down Deinstitutionalization 1960 Present Day Deinstitutionalization Camarillo State Hospital to Cal State University Channel Islands Series of lawsuits regarding inadequate staffing and infringements or patients civil rights Inadequate safeguards in terms of patient health They were also extremely expensive to maintain The plan to do away with the State Hospitals The hospitals would be closed and the mentally ill would go back into communities get jobs and they would check in at local mental health centers However after closing the State Hospitals community mental health centers were really expensive to set up and the mentally ill people weren t excited to get job training and go to mental health centers 23 of the nation s homeless people are the causalities of deinstitutionalization Contemporary Views of Psychopathology Psychodynamic Views Classically there have been 3 ways of understanding psychopathology Mesmer Freud and Charcot Metaphysical View Mental disorders are a spiritual possession Psychodynamic view Your early experiences are important in how you act and view the world Mesmer argued that magnetic forces were powerful forces for the mind He thought he could help treat mental disorders Mesmerism which later became known as Hypnosis Charcot popularized hypnosis by bringing in patients who apparently couldn t walk see or feel things Once he did his demonstrations the blind could apparently see and the lame could walk it took a century before a historian showed that Charcot was a fraud Sigmund Freud came in from Vienna and told people of how he saw Charcot and he tried it himself He turned out to be a terrible therapist and he had them imagine what came to their mind psychoanalysis All of these men had the belief that trapped energy results from earlier experiences and traumatic experiences In unclogging this energy you can simplify your life and see the world anew Behavioral Views Pavlov and the dogs John Watson and his graduate student with whom he left his wife Little Albert Watson s view Pavlovian conditioning was responsible for the full range of human emotions Wrong Eugenics The best people reproduced to create the best people The best emotions most intelligent etc Operant conditioning Mental disorder reflects an excess of wanted behavior or not enough of it and different conditioning allows changing that Biological Views View that mental disorders are seen as deviations from normal functioning of the brain Ex Depression running low on some neurotransmitter Stabilizing mechanisms 0 Medications have come about recently that have greatly healed people that deal with depression anxiety etc Prozac 0 These mediations have caused us to consider biological reasons to the be all end all Topic 2 Psychodiagnosis What is a Mental Disorder Why is this issue important 0 Everyone is on the bandwagon with the mental disorders and we need to understand things in a different way than just believing what we hear 0 I once was bad but now I m good Philosophical Implications for Mental lllness Monism Mind is equall reducible to the brain Mental illness is a brain illness a type of medical illness Duaism The mind is different from the brain Mental illness is The brain is the hardware but what you do with your brain is the software Aspects of Psychopathology Nosology The science of disease classification every branch of health care has this The categorization of diseases and also the science by which you categorize diseases Ex The Nosology of Medical Disorders Assessment Obtaining information about a patient Diagnosis The act of assigning a nosological category to a patient Ex major depressive episode 0 Treatment Prevention 0 Patients can have more than one diagnosis so you cannot put a patient in a category but rather put labels on the patient Lecture 3 482014 Scope of Mental Illness Originally mental illness was synonymous with insanity reserved for psychoses and sudden disabling or bizarre changes in behavior thinking Mental illness has been broadened Now mental disorder rather than mental illness 0 Menta disorders now span a wide range of severity Why 9 Schizophrenia Alzheimer s type dementia Controversially homosexuality now declassified alcoholism pedophilia psychopathy intermittent explosive disorder 9Premature ejaculation premenstrual syndrome painful intercourse flying phobias gambling addiction voyeurism exhibitionism insomnia sleepwalking nightmares Many ways of defining mental disorders have been proposed all have problems and there is no consistent logical way of defining psychopathology All have flaws with consistency You end up in a pickle one way or another Statistical deviance is seen as an indication of abnormality Worry About How to Define Mental Disorder Mental disorder diagnoses are stigmatizing Mental disorder diagnoses are sometimes used as tools of political persecution Mental disorder diagnoses are used to marginalize dissent Mental disorder diagnoses are used to excuse defendants and others from responsibility for their actions Hope A valid and consistent definition of mental disorder will produce no false positives and no false negatives This is fiction because disorders don t pop out and as you see real patients people don t look like the textbook categories A diagnosis is not good forever After one session a psychologist can even change hisher working opinion Underlying Dichotomies That Drive Attempts to Define Mental Disorder Is a condition normal or abnormal Many different criteria Deviance statistical moral Distress self andor others Dysfunction inability efficiency maladaptation Danger self andor others is a person ill or evil Disorder or sin is the professional response to the condition treatment or oppression How a society responds to mental disorders is a way of determining how it regards mental disorders Current Official View American Psychiatric Association 1994 A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with Present distress a painful symptom Etc Disability impairment in one or more important areas of function etc or with a significantly increased risk of suffering death pain disability or an important loss of freedom And must not be merely an expectable and culturally sanctioned response to a particular event for example the death of a loved one This view is the basis of the diagnostic and statistical Manual of Mental Disorders current in its 4 edition How do we learn what Mental Disorders Look Like Prototype Theory Theories of meaning Definitions of disorder Definitional theory of meaning 9 Semantic definitions of mental disorders Prototype theory of meaning 9 Prototype definitions of mental disorders Ex Dog A semantic definition is a dog has a tail barks has fur fetches etc These list definitions don t work very well however because some dogs don t have tails The Prototype definitions are what we see as a picture in our head Based on our experience with dogs certain dogs seem doggier Where Do People Acquire These Mental Disorder Prototypes Repeated exposure to conditions perceived as necessitating mental health intervention Personal and indirect books films TV experiences in which people are seen to have unwanted conditions requiring mental health intervention In training as a mental health professional through classic case studies or supervised clinical experiences PSYCH TERMS NosoIogV Science or scheme of disease categorization and classification Diagnosis Act of assigning a nosological category to a patient BASIC TERMINOLOGY Emil Kraepelin Etiology cause a bunch of risk factors put together there is no smoking gun for a disease Course Trajectory some mental disorders have a deteriorating course such as Alzheimer s type dementia Some have a fluctuating course like depression Prognosis Outcome the ultimate outlook Signs Observable markers it s what you notice about a patient s behavior like yelling at a garbage can Symptoms Patient reports it s what the patient is dealing with such as hearing voices Syndrome Signs Symptoms Disease Syndrome Course Why Diagnose At All Prognosis Treatment Implications Communication among professions Establish prospects for contagion or other transmission and possible prevention Legal reasons ex Competence insanity determinations Financial reasons compensation to patient andor treatment provider Research Lecture 4 4102014 Problems Inherent in the Act of Diagnosis Sacrifices the uniqueness of individual patient calling an individual one things schizophrenic for instance ignores their whole life story Can falsely imply etiology cause Rigidifies treatment alternatives Iatrogenic illness an illness caused by the healer Ex Chemotherapy killing a patient faster than the actual cancer Stigmatization the act of putting a label on a person can jeopardize their employment status even themselves etc Secondary gain the payoff you get from having a mental disorder ExThey don t like their job and are happy they don t have to go back to work or they are happy to take the drugs they re forced to take Two Kinds of Diagnosis Phenotypic 9 Genotypic Signs Causes Genes Germs Symptoms Course Endophenotypic Lab Tests Outcome RGSDOHSG tO treatment In Physical medicine progress consists of moving from phenotypic to genotypic diagnosis In mental health nearly all diagnosis is phenotypic with some endophenotypic evidence emerging Ingredients of a Diagnosis Symptoms Signs Course of illness Age of onset Family history 0 Recent events 0 Recent behaviors Psychological tests Laboratory tests Ex Neuroimaging hormonal assays genetic testing Response to treatment prior or current can run in families Multifactorial Nature of Diagnosis No single sign or symptom defines a mental disorder ie is pathognomonic of a mental disorder hearing voices doesn t name the disorder of schizophrenia 0 Diagnosis is based on a pattern of signs and symptoms ie a syndrome 0 The patterns of syndromes and courses of illness that define mental disorders are spelled out in the Nosology of mental disorders Nosologies for Mental Disorder Diagnostic and statistical manuals for Mental Disorder DSM Series American Psychiatric Association 1952 DSM I 100 disorders in 8 categories 0 1968 DSM II 100 disorders in 10 categories 1980 DSMIll 230 disorders in 19 categories 1989 DSM IIR Revised amp750 disorders in 40 categories 1994 DSM IV 2000 DSMIVTR Text revisionUpdate 2013 DSM 5 see wwwdsm5org DSM I and DSM ll Diagnosis Consisted of brief paragraphs containing horoscopic descriptions of each disorder eg 30004 Depressive neurosis This disorder is manisfested by an excessive reaction to an internal conflict or to an identifiable event such as the loss of a love object or cherished possession Deciding which disorder fit a particular patient was highly subjective and proved statistically unreliable Features of DSMIII IIIR IV IVTR DSM5 Phenotypic diagnosis Based only on observable signssymptoms Abandonment of intrapsychic conjectures and terms like neurosis and Teac on Field tested for reliability Dimensional diagnosis acknowledgement of medical and psychosocial factors Decision tree approach Inclusion criteria Exclusion criteria DSM5 Dimensinal Diagnosis Disorder Major Depressive Episode Code 2963x Severity Moderate Code 29632 Ancillary Information Medical Lung Aden carcinoma diagnosed 114 hypertension Psychosocialcontextual child with autistic spectrum disorder marital conflicts job stress DSM5 Phenotypic Diagnosis Major depression single episode inclusion criteria Insomnia depressed mood most of the day agitation retardation loss of energy almost every day inappropriate guilt recurrent thoughts of death not just fear of dying etc You have to have a majority of the list to be considered diagnosed with major depression The symptoms cause clinically significant distress o impairment in social occupational or other important areas of functioning DSM5 Phenotypic Diagnosis Exclusion Criteria The episode is not attributable to the physiological effects of a substance or to another medical condition The occurrence of the major depressive episode is not better explained by schizoaffective disorder delusional disorder or other specified and unspecified schizophrenia and other psychotic disorders There have been a manic episode or a hypomanic episode Major Changes in DSM5 Many separate disorders Asperger s syndrome and autism now part of autism spectrum disorders New category of behavioral addictions eg shopping porn and internet 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 Suicide scales for adults and adolescents Clinical Interview Types of Information and Goals 9Assessment leads to diagnosis Lasts about 1 hour most valuable single source of information to a diagnosis Personal and family history re medical mental health social occupational financial problems Treatments that have workednot worked in past Symptomatology Signs from patient s presentation Goals Suitability and readiness for psychotherapy self or another therapist Determine need for referral to Psychiatrist or PCP for medication Neurologist for neurological testing andor neuroimaging Social worker vocational counselor physical therapist etc Social worker vocational counselor physical therapist etc Signs Noted in Clinical Interview Attire and grooming Posture Physical characteristics Skin tonecomplexion Weightstature Symmetryatrophybodily anomalies Mannerisms spasms or tics Speech Articulation Prosody Consciousness Level of alertness fogginess hypervigilance Emotional state General attitude Defiant compliant guarded defensive sincere plaintive resistant apathetic etc Thought content Soicited by free inquiry Thought processes Thought broadcasting removal insertion General knowledge General facts pop culture Abstract thinking Social thinking Insight Cognitive functioning Usually current mental status via MMSE Neuropsychological screen likes clock drawing Mini Mental Status Exam MMSE Folstein et al 1975 Orientation up to x3 Time year season date day month Place state country city facility Person name age Registration Slowly say the names of 3 common objects appe tabe penny and ask patient to repeat them Attention and calculation Serial 7 s or WO R LD backwards Recall Ask for names of 3 objects above Language Name a pencil and a watch when pointed to Repeat No ifs ands or buts Follow a 3stage command Take a paper in your right hand fold it in half and put it on the floor Read and obey the following CLOSE YOUR EYES Write a sentence Copy the following design Helpful Ancillary Diagnostic Information Info from family members Info from physicians employers Medical chart Obtaining this kind of information usually require signed releases and informed consents obtained at the beginning of the first session Topic 3 Depression and Mania Lecture 5 4152014 Affective Disorders 0 Refers to emotion and mood and motivation Clinical Features of Major Depression Cognitive Pervasive sadness guilt or feelings of worthlessness Recurrent thoughts of death or suicide Motivational Pervasive anhedonia inability to experience pleasure Neurovegetative goes back to Aristotle disturbances of basic functions Significant change in weight Sleep disturbance early morning awakenings are most common Psychomotor agitation or retardation feeling like everything is slower and everything takes too much effort Pervasive fatigue or loss of energy Difficulty concentrating studying working etc Prevalence of Depression Prevalence how much of a disorder is there in a population t s a snapshot of a population in a particular interval of time 0 Point prevalence At any particular point in time the percentage a population that has it About 5 of US population are diagnosably depressed OneYear prevalence How many people will have had that in a year about 10 Lifetime prevalence 1520 26 of women 12 of men 1520 of US population at any time may suffer from subsyndromal depression with nearly equal disability Women are twice as likely to be diagnosed with depression than men in their lives 0 Depressions in nonWestern countries differ from those in Western countries Risk Factors for Depression All of these are known to be contributors Genetic predisposition evidence from adoption and twin studies animal models Personal loss or gain no silver lining wo a cloud Prolonged psychological stress Depression possible physiological coHapse History of early abuse or neglect 0 Being in an industrialized nation Overall not race or social class they do not relate to the prevalence of depression Age of first onset in latter 20 s Physical illnesschronic pain need to exclude undiagnosed other iHnesses 0 Giving birth freq baby blues can lead to postpartum depression Female male ratio is 21 after puberty in childhood ratio is 11 Previous depression kindles later depressions chances of another episode is 4050 Harry Harlow s Monkey Depression Research Was abused as a child Interested in studying child abuse 0 He built a chamber to keep monkeys babies in away from their moms An analog to infant neglect to compare to child neglect which often was believed to lead to depression anaclytic The baby monkeys after depressed would cling on to each other 0 Eventually the depressed monkeys would eventually interact with the normal monkeys but they showed depression signs when frightened crawling into a ball becoming very shy etc Kindling Each Depression Increases the Risk of Later Depression Regardless of Life Stress The risk of you having another depression is proportional to the number of depressions you have had in the past already 0 The later depressions are more likely to be self kindled In the majority of cases most people will tell you everything was going fine and they just started to feel worse and worse There is often no big trauma that accounts for people s depression it s a combination of things Why are women diagnosed with depression twice as much as men Some possibilities include Xlinked depression genes Premenstrual symptoms Quality of female vs male life 0 Female masochism Freud Cognitive style 0 Females dwell on problems Males ignore or escape them 0 Male depression masked by alcoholdrug abuse Amish study 1st Cogni Line Depression Treatments Psychotherapy esp interpersonal or cognitive therapy been proven over the years that in most cases they don t do much damage are effects to most patients Roughly equal in effectiveness Antidepressant medication Phototherapy for seasonal depression For people that have depressions that come on when winter comes on ECT for treatmentrefractory depression tive Therapy Positive thinking underlies a lot of this therapy Uncovering automatic selfdefeating thinking patterns Developing new ways to interpret setbacks normalization analyzing logically decatastrophizing Replacing old automatic thoughts with new ones Prime areas of concern The self Life events The future Lecture 6 4172014 Primitive vs Mature Thinking in Cognitive Therapy Nondimensinal and global Absolute moralistic I am fearful I am a despicable coward I have always been and will always Invariant be a coward Selfdenigrating Something about me is seriously Irreversible defective Nothing can be done about it Central Themes in Interpersonal Therapy Grief Delayed mourning developing replacement relationships Not just people but other aspects of our lives Fights Building skills in communication negotiation and assertiveness Role Transitions ex Leaving home divorce retirement reevaluating the lost role building a new role developing new social supports Social deficits ex Leaving failure patterns in past relationships using role playing to learn new behavior in relationships Something to think about The majority of depressive episodes go away by themselves within 2 or 3 months However if the depression is due to maladaptive thinking patterns this should not happen The rationales given for the onset of depression for cognitive and interpersonal aren t the best because they cant explain why the therapies work We also don t know why biochemical theories work but they just work Neurochemical Theories of Depression Neurotransmitter theories Major transmitters implicated Norepinephrine epinephrine Dopamine Serotonin 5HT Also Substance P NMDA NmethylDaspartate Neurosteroids Endocnne Hypothalamuspituitary Thyroid Adrenal cortisol Sex hormones testosterone estrogen Neurotrophic neuronal growth factors such as BDNF Brain Derived Neurotrophic Factor that promote neuronal growth and axonal and dendritic sprouting When a person is depressed the brain literally kills off synapses among neurons A depressed brain is a stressed brain Neurochemical Disturbances in Depression Neurotransmitter abnormalities in depression represent just one part of the neurobiological changes in depression They probably account for the side effects of antidepressant medications more than the main effects Depression is also associated with reductions of BrainDerived Neurotrophic Factor BDNF and other growth factors Altered levels of activity in the limbic system prefrontal area and other brain regions observable by neuroimaging Increased levels of neurosteroid hormones which promote neuronal death and glial cell damage Regardless of the mode of action remission of depression with antidepressant medication follows restoration of normal levels of BDNF and neurosteroids and return of normal neural activity Reduced gray matter volume is seen in chronic depression and appears to be restored with successful antidepressant therapy People with lower amounts of gray matter in the righthemisphere neocortex carry a greater risk of later depression Some Physical Conditions that can Masquerade as Major Depression Hypothyroidism Low Testosterone or Estrogen levels Undiagnosed illness ex infectious mononucleosis Anemia Chronic Fatigue Syndrome Antidepressant Medications General Use Are effective for both anxiety and depression Do not cure depression only hold it in check for so long as they are taken it s like a patch fills in the rough spots Take 23 weeks after first dose to produce an antidepressant response Not addictive or habit forming but must be tapered slowly to avoid rebound symptoms Are not euphoriants All have some unpleasant side effects No certified time bomb effects or damage to fetus can be taken for life Recovering patient must be watched for suicidal or other violent behavior Work only so long as taken depression may relapse afterward Can precipitate manic episodes in bipolar patients switching Antidepressant medications are in wide use throughout the United States Antidepressants are the most frequently prescribed medications in the US Antidepressant use has tripled from 1988 to 2000 Over 12 of people in the United States obtain prescriptions for the antidepressants each year The highestusage state in Utah at 184 and the lowestusage is New York at 91 California s usage rate is 99 Suicidality and Antidepressants 40 of people with major depression make at least one suicide attempt and 5060 have suicidal ideation As of 2004 all antidepressants in US must now carry warnings about suicidality Although some studies show that suicidal ideation is increased with antidepressant medication various studies have shown no link between antidepressant medication and actual suicides Suicidality is associated with improvement from depression regardless of the presence of antidepressant medication Classes of Antidepressant Medication Monoamine Oxidase Inhibitors MAO inhibitors intro late 1950 s Marplan Parnate Nardil Had severe dietary restrictions and very unpleasant side effects dizziness drowsiness blurred vision weight gain Tricycics Elavil Norpramin Tofrainl Anafranil intro Early 1960 s Eliminated dietary restrictions of the MAO inhibitors but still had very unpleasant side effects ex All above plus dry mouth constipation and are cardiotoxic Selective serotonin Reuptake Inhibitors SSRl S intro late 1980 s ProzacSerafem Zoloft Celexa Lexapro Paxil Luvox 3040 of patients on SSRl s suffer from sleep and sexual symptoms Children on Paxil may develop suicidal ideation but not suicide One of the side effects of an SSRI can be insomnia which is also a symptom of depression In many cases doctors will also prescribe a sleeping pill along with it at least at the beginning People who do not respond to one SSRI have a 4070 chance of responding to a second one Answer may lie in pharmacogenomics Loss of sexual interest for both sexes when taking SSRI but it doesn t feel depressing it feels like it s no big deal Atypical Antidepressants Effexor Cymbalta Wellbutrin Pristiq Remeron Tazodone intro late 1960 s and through the OOO s Together the most prescribed cass f current antidepressants Fewer sexual side effects varied in actions and side effects Lecture 7 4222014 Atypical DepressionHysteroid Dysphoria Reversed Neurovegetative SignsSymptoms Weight gain carbohydrate binging Hypersomnia Leaden paralysis Interpersonal rejection sensitivity Histrionic traits if everyone is their audience they re either applauding or giving them a bad review They become attention seekers in a way Selfmedication with caffeine or chocolate Sometimes uniquely responsive to MAOinhibitors SpecialUse Antidepressants Wellbutrin is very stimulating and is used to treat adult ADHD and nicotine cravings sold as Zyban Cymbalta is activating but has good anti anxiety effects and helps in patients with chronic pain the current bestselling antidepressant A very important antidepressant for patients with chronic back pain nerve pain diabetes Tazodone and Remeron are both sedating and are used widely in elderly patients with insomnia Remeron promotes appetite and is especially indicated in patients with excessive weight loss Tazadone is just a sleeping pill How Long Should People Take Antidepressant Medication Most depressions remit with no treatment in 34 months However odds are gt50 of 15 recurrence gt75 of 2 recurrence etc Each recurrence tends to be longer and leaves the person with greater disability ie depression is often progressive Depression that is aggressively controlled early by high doses and multiple or multipleaction medications predicts less recurrence Medication can be tapered and then resumed if depression re emerges but there is a slight risk of acquired medication immunity if the medication is tapered then resumed Medication for life Medication is unnatural but so it depression If you find a medication to work for you and if you ve had recurrences of depression then you should take the medication like a vitamin pill as mediation for life Increased Risks Associated with Antidepressant Medications As a whole modern antidepressants are quite safe but SSR s may be associated with heart and lung defects in the infants of mothers taking some SSRl s while pregnant findings are precautionary and uncertain Serotonin syndrome eg confusion hallucinations fever seizures can occur in people who are taking SSRl s along with MAOl s or other serotonin raising drugs Abruptly stopping any antidepressant can result in a Discontinuation Syndrome dizziness tremor zaps anxiety and panic nausea and vomiting and confusion Any antidepressant discontinuation should be tapered Alternative Depression Treatments Medications Lithium augmentation of antidepressant therapy often lithium boosts the action of antidepressant ST John s Wort a weak MAO inhibitor not very effective causes some sensitivity and a skin rash and also more expensive than going to the doctor Same most people don t find it very effective Thyroxin a lot of people have low thyroid so mood boosting Testosterone MF Estrogen F in menopausal and post partum depression Phototherapy seasonal depression Exercise mild depression Sleep deprivation temporary Conditions Associated with Major Depression and Often Treated with Antidepressant Medication Chronic pain Binge eating disorder Bulimia nervosa Migraine headache Misc anxiety disorders eg panic disorder OCD Trichotillomania pulling at hair or picking at scalp Compulsive zit popping Compulsive shopping Compulsive gambling Hypochondria illness anxiety disorder a cycle of anxiety about illness where you are sure you have a certain disease and you ve talked yourself into thinking you have this disease because of certain symptoms Sexual addiction you pursue sex to your own detriment and you do things that are damaging to yourself and damaging to the other people Premature ejaculation Premenstrual dysphoric disorder ECTOld and New electric convulsive therapy OLD 190s 1960s Muscles freeze up Then body shakes Often the person is exhausted they re bewildered and cannot eat for the rest of the day ECT wipes out all memory of itself ECT Today use muscle relaxers and anesthesia t s used as a last resort today Electroconvulsive Therapy ECT Works fastest of any therapy for depression Mechanism of action unknown Has fewest side effects of any therapy for depression very high satisfaction ratings Sometimes causes spotty memory losses episodic gtgt semantic Usually 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 Efficacy of Depression Treatments ECT works fastest for most people and with fewest side effects Medication and psychotherapy esp cognitive or interpersonal therapy 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 and SSRI by 2009 two were FDAapproved for adolescents Prozac and Lexapro plus cognitive behavior therapy Medication is the least expensive single mode of treatment TreatmentResistant Depression Up to 30 of patients do not respond to standard treatments Strategies Medication augmentation 9Lithium 9A second antidepressant 9Thyroid medication 9Stimulants Ritalin Straterra 9Sideeffect management sleep sexual response 9 Estrogen testosterone supplementation Risks of medication augmentation 9Serotonin syndrome agitation euphoriadelirium fevers muscle contractions seizures 9 Precipitation of manic states a hidden bipolar state may be going on so must be careful Medication ECT Ketamine Infusion lntranasal Ketamine NMDAReceptor Antagonism When people take this they go into their weird twilight sleeping state and they have these incredibly potent hallucinations When they come out of this Euthanasia they bound out of their depression for a few days Vagal Nerve Stimulation amp TMS putting a strong magnet over a person s head and it induces a seizure with magnetism as opposed to electricity Doesn t seem to work as well as ECT but Vagal Nerve Stimulation is helping dozens a pacemaker with a wire into the back of the throat where the vagas nerve exits the brain and goes all the way down into their gut In epileptic patients when its stimulated people have felt calm Direct Brain Stimulation people report elevations in their mood and people are thinking maybe that can possibly be a treatment in the future Magnetic Stimulation Transcranial magnetic stimulation TMS Uses magnetic field sufficient to produce twitches in fingers Treatment is 12 weeks of short daily sessions lnitial optimism has dimmed Magnetic seizure therapy MST 9Replaces shock electrodes of ECT with a magnetic field sufficient to produce seizures initial results suggest equivalent efficacy to ECT but fewer problems with memory and disorientation Vagal Nerve Stimulation Delivers approx 20 pulses per sec to electrodes wrapped around vagus nerve in back of throat stimulator implanted in chest Arose from findings that depressed epileptic patients treated with VNS showed improvement in depression FDAapproved for recurrent treatment resistant depressant in July 205 Effects accumulate over months and 13 to 2 show substantial improvement over a year Exact mechanism is unknown MANIA Clinical Features of Mania Euphoria or irritability Purposeless or reckless behavior Persistent insomnia Pressured speech flight of ideas Poor insight or frank psychosis Sometimes assaultiveness or suicidality They are intense and quite impulsive in their actions Mania and depression are not opposites in terms of mood but rather energy level Major Depression and Bipolar Disorder 0 Depression only Major Depression Unipolar Depression Depression and History of Mania Bipolar I Disorder Depression and any History of Hypomania Bipolar ll Disorder Unipolar and Bipolar Disorders Unipolar Mood History Unipolar Major Depression Hypomania Mild Mania 0 Unipolar Mania rare Bi poIar Mood history Cyclothymia History of mild depression and hypomania 0 Bipolar I Disorder History of depression and mania Biopolar ll Disorder 7 History if Depression and hypomania Mixed Episodes Concurrent Depression Mania Lecture 8 4242014 Bipolar Disorder Point prevalence historically approx 115 but more recent studies suggest 35 0 Probably no sex difference in the prevalence Associated with high rates of alcoholdrug 4050 higher than any other Axis I disorder criminal behavior and anxiety disorders approx 40 Age of first diagnosis ranges from 15 to 45 with most people diagnosed in their 20 s BUT sometimes seen in children Pediatric bipolar disorder Runs in families 9 Family history of bipolar disorder in 30 of BD patients 9 65 concordance rate in MZ twins 14 in DZ twins 9n 20 of MZ twins in which one has BPD the other will have major depression suggesting some common inheritance 910 concordance rate in 15 degree relatives 9Probably multiple routes of genetic involvement People with bipolar disorder are more likely to hear voices While is a break down in logical thinking and social withdrawal bipolar is different Bipolar Depression Compared to Major Unipolar Depression Depression in the more problematic state in bipolar disorder Most cases of Bipolar Disorder first appear as depressed phase 40 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 likely to 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 signssymptoms and psychomotor retardation Approx 11 sex ratio of diagnosis as opposed to approx 21 female male ratio in Major Depression More than 10 of people with Bipolar Disorder eventually suicide mostly in depressed phase Many Gene Loci Have Been Associated with Bipolar Disorder Brain Mechanisms in Bipolar Disorder Brain mechanism is unknown but may reflect defects in the metabolism of ProteinKinase C PKC an enzyme involved in the calcium metabolism of neurons in specific brain areas The result in unstable levels of neurotransmitter release by these neurons PKC activity is increased in manic patients and is thought to be normalized by antimanic medications Specific PKC inhibitors eg tamoxifen used to treat breast cancer quickly bring acute mania under control Many other hypotheses are under investigation Pediatric Bipolar Disorder Occurs in about 1 of children sometimes as early as infancy Manifested by mood instability eg rages despondency hyper sexuality pressured speech racing thoughts impaired judgment delusions and hallucinations Up to 2 of severe childhood depressions become adult bipolar disorder About 2 of children treated for depression with SSR s develop manic or hypomanic episodes Typically a 10year lag between occurrence of first signssx and onset of treatment Often confused with Attention Deficit Hyperactivity Disorder ADHD due to shared sx of distractibility and hyperactivity Mixed Episodes Mania and Depression Are NOT opposites Rapid Crying rritabiity Anger Suicidal ldeation And Euphona Hypersexuality Racing thoughts Severe Insomnia Auditory hallucinations Many mixed episodes are actually switches or manias emerging out of depressions Cycling Bipolar Disorder DSMIV Four or more episodes depressions or maniashypomanias per year Cycling can occur within days or hours About 15 of bipolar patients are rapid cyclers more frequent in women May be associated with coexisting endocrine disorder Treatments for Bipolar Disorder Medication is 15 line treatment but med compliance only approx 30 Acute management with antipsychotic medications followed by introduction of a mood stabilizer for chronic management Psychotherapy usually requires prior medication response to be valuable builds compliance to medication helps patient and family understand impact of disorder 9 no effect on disorder itself ECT rarely used but somewhat effective when medication is insufficient often helps and is necessary for many bipolar patients Induced Sleep very rarely Medications for Chronic Management of Bipolar Lithium carbonate strong antimanic and anti suicide but weak antidepressant actions This is by far the best medication to treat bipolar disorder Anticonvulsants moderate antimanic and antidepressant actions These are the medications that are most often liked by those prescribed it Most people that take this do beautifully and their mania is contained There are very few side effects 9 Lamictal has uniquely strong antidepressant properties and appears weight neutral 9 Also Tegretol Neurontin For rapidcycling Bipolar Disorder Depakote and Topamax Antipsychotic agents moderate antimanic and antidepressant actions 9Abilify weight neutra Zyprexa Risperdal Antidepressants strong antidepressant actions but increase risk of switching into mania or mixed states Standard of care Polypharmacy You have a mood stabilizer and an antidepressant to prevent relapse into depression and at the same time treat bipolar disorder Other medications added on may include side effect medication or sleep medication Affective Disorders May Be associated with Creativity No one has ever written painted sculpted modeled built or invented except literally to get out of hell People have wondered if there is anything that could possibly be an upside to bipolar disorder Likely Sufferers of Bipolar Disorder Abraham Lincoln Winston Churchill Theodore Roosevelt Goethe Balzac Handel Schumann Berlioz Tolstoy Virginia Woolf Hemingway Robert Lowell Anne Sexton The Upside of Bipolar Disorder The well relatives of people with Bipolar Disorder appear to have higher rates of achievement success and creativity Thus the dilute genotypes of the illness may have evolved to subserve adaptive functions such as exploration and risk taking Such an evolutionary perspective represents the ultimate theoretical underpinnings of the concept of bipolar spectrum The temperaments themselves particularly the cyclothymic and hyperthymic may further subserve such functions as interpersonal charm and sexual selection and territoriality Topic 4 Anxiety Disorders Commons SignsSymptoms of Anxiety Cognitive Objectess fear or feeling of apprehensiveness Heightened sense of and vulnerability Worrying and rumination going over the same thing again and again Going blank or spacing out lrritability impatience distractibility Hypervigilance Physiological 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 SignsSymptoms of Panic Attack Acute Anxiety Episode 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 unreality Depersonalization being detached from oneself Fear of dying losing control or going crazy Paresthesias numbness or tingling sensations Chills or hot flushes Autonomic Arousal and the Brain 0 Amygdaa registers situations as threatening it connects what we experience with the emotion you see a bear and you get terrifed Locus Coerueus governs activation of neocortex hypothalamicpituitary axis and ANS AnxietyRelated Actins of the Sympathetic NS Pituitary release of ACTH Adrenal section of epinephrine and norepinephrine Pupillary dilation GABA and Anxiety Sites related to anxiety in animals involve the neurotransmitter GABA GammaAminobutyric Acid Anxietyprone people have deficits in GABA Chemically blocking GABA increases anxiety GABA is only one of the many neurotransmitters involved in anxiety 9GABA and 5HT serotonin inhibit anxiety 0 9Epinephrine no Major Anxiety Disorders Most frequently occurring psychiatric problems in the general population 0 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 0 Carry increased risk of acohoism drug abuse and sef medication DSM5 TR Classification of Anxiety Disorders Generalized Anxiety Disorder Panic Disorder Agoraphobia Social Anxiety Disorder Social Phobia Specific Phobias Obsessive Compusive disorder Lecture 9 4292014 Some Common Physical Disorders that can mask as Anxiety Disorders Hypothyroidism Pheochromocytomas adrenal tumors that over secrete adrenalin Inner ear disease Angina pectoris chest pain Hypoglycemia Mitral valve prolapse blood back flows into the ventricle 0 Cardiac arrhythmias rhythm disturbances in the heart Drug effects caffeinism nicotine addiction nasal decongestants asthma inhalers or other stimulants General Diagnostic Criteria for Generalized Anxiety Disorder GAD Debilitating worry fretfulness often defends the worries Worry is hard to control Varied anxiety symptoms incl restlessness fatigue difficulty concentrating or mind going blank irritability muscle tension insomnia Often arises with or just before or after major depression Facts About Generalized Anxiety Disorder 1year prevalence 34 Usually emerges during adolescence Females gt Males 21 ratio 75 of GAD sufferers have another mental disorder usually major depression Affects 1020 of the elderly who are beset with frailty medical illness and losses which lead to vulnerability and fear 36 of GAD sufferers selfmedicate wETOH and other drugs ex Marijuana Symptomatic Treatments for Anxiety Habit control ex Coffee cigarettes stimulant medications Anxiolytic antianxiety medications For acute use Benzodiazepines ex Xanax artisan Looping Valium acts like alcohol but without the bad side effects but it can cause black outs and long term memory problems just like long term alcohol use Rarely Betablockers ex Tenorin inderal For chronic use Most often SSRl s Prozac LexiROM etc or atypical antidepressants ex Cymbals Flexor Occasionally Atypical anxiolytics ex Buspar buspirone Antipsychotics like Abilify Latuda Seroquel Risperdal and Zyprexa Psychotherapy Supportive cathartic 0 Relaxation and meditation techniques Stress management training Biofeedback Exercise Support groups Panic Disorder Occurrence of panic attacks without warning More than 1 month of Apprehensiveness about further attacks Pattern of avoidance and disability as a result Facts About Panic Disorder 1St One year prevalence approx 23 Lifetime prevalence approx 35 Develops mostly during late teens 1519 Female male ratio approx 21 Increased risk with background of child abuseneglect and with mitral valve prolapse Panic attacks can be triggered in susceptible people by yohimbine sympathetic NS stimulant Sodium lactate exercise wasteproduct Caffeine nicotine sympathetic NS stimulants Marijuana Line Panic Disorder Treatments Dietarymedication control ex Caffeine nicotine marijuana Anxiolytic medications benzodiazepines mainly Xanax for acute use only note Xanax often causes rebound anxiety longerlasting benzos ex Ativan klonopin indicated Benzos are much preferred in treating panic disorder Antidepressant medication mainly SSRl s chronically as preventative Psychotherapy Cognitive therapy normalization decatastrophizing paced metronomic breathing supportive therapy very many people have gotten through this you re going to get through this don t worry Agoraphobia Prevalences age of onset about the same as Panic Disorder Often develops as ritualized avoidance of panic attacks and then can be diagnosed with Panic Disorder Home or room within the home becomes safety zone Reluctance to venture outside safety zone without escape route Treatment Antidepressant medication panic attacks will be blocked In vivo desensitization Social Anxiety Disorders Social Phobia Most common anxiety disorder 1yr prevalence of approx 8 lifetime prevalence up to 15 0 More common in females ratio is 15 to 1 Develops in late adolescence or young adulthood Grossly under diagnosed in managed care population Occurs when people become disabled by Intense persistent and chronic fears of being watched and judged by others and of doing things that will be humiliating or embarrassing Can be generalized or occur in specific situations nongeneralized Onethird are sufferers are very disabled and are more likely to be depressed divorced unemployed or underemployed 9Awareness that fears are excessive Common performance situations 0 Public speaking Toastmasters Public restroom use Going to parties Eating in front of others 0 Bedroom some erectile dysfunction some orgasmic dysfunctions Most commonly treated with medications benzodiazepines andor SSRI s plus supportive and proactive psychotherapy Specific Phobias 0 Persistent tears or panic attacks out of proportion to situation the person who has them knows that they re irrational Compelling desire to avoid phobic stimulus Insight that fear is excessive 0 Symptoms are unrelated to another disorder Facts About Specific Phobias 0 Have a oneyear prevalence of approx 7 and a lifetime prevalence of approx 9 in the US 0 Mean duration of a specific phobia is about 20 yrs 0 Females gt Males 21 to 31 ratio Most specific phobia sufferers have multiple fears Types of Specific Phobias Animal Type 0 Natural environmental type ex Storms heights water Situation type ex Claustrophobia tunnels bridges flying driving Bodily reactions vomiting headache fever Bloodinjuryinjection type vasovagal reaction 0 Nature of phobic stimuli undercuts a straightforward conditioning views of specific phobia Treatments for Specific Phobias All treatments are complicated by avoidance behavior nobody wants to face the thing they are scared of Anxiolytic or antidepressant medication preferably an SSRI Systematic desensitization Flooding have snakes crawl all over a person In vivo desensitization facing fears slowly effective but low treatment acceptance and high therapy dropout rates Applied tension for blood injection phobias Experimental VR therapy putting you on tall buildings and wear glasses that make you feel like you re walking on a bridge or the edge for flying and height phobias Selfhelp groups Lecture 10 562014 ObsessiveCompulsive Disorder OCD One of the most anguish filed of all mental disorders It is definitely the most anguish filled of all anxiety disorders OCD is caught in hisher private health Debilitating unwanted Egodystonic Obsessions intrusive thoughts impulses images Compulsions repetitive behavior to ward off anxiety or an unwanted impulse Recognition that one s obsessions and compulsions are excessive or unreasonable Significant distress or impairment for over one hour per day Facts About OCD One year prevalence approx 2 About 80 of OCD sufferers have coexisting Major Depression 2 of OCD cases begin in childhood and these childhood cases are mostly males and are more severe Ex a boy in school circling around the water fountain 3 times clockwise before he drinks the water OCD cases beginning in adolescence or adulthood are less severe and females males in prevalence 20 of OCD cases have 15 degree relatives with OCD Anxiety disorders generally run in families Basal Ganglia and Frontal Cortex Brains go into a loop and they can t get out Ex someone starts counting everything This kind of brain problem desire for balance etc involves the basal ganglia The basal ganglia is part of the extraperamital nervous system We thought it had only to do with smooth movements but we now know that they play a role in smooth transitions in thinking If there is overactivity in the basal ganglia and frontal cortex that s what you see in OCD Common Obsessions and Compulsions in OCD Obsessions 60 Multiple obsessions 45 Contamination 42 Excessive Doubt 36 Somatic metaphobia every sensation makes people think something is wrong with them 31 Need for symmetry or exactness 28 Fear of causing harm to self or others 26 Fear of being sexually inappropriate 13 Other praying repeating words Compulsions 63 Checking 50 0 o washing 36 Counting 31 Need to ask or confess 28 Arrangingorganizing 18 CollectingHoarding 48 Multiple compulsions ObsessiveCompulsive Related Disorders OCDSpectrum Disorders Hoarding Trichotillomania hairpulling Excoriation skinpicking nailbiting Body Dysmorphic Disorder emphasis on perfection and body image People develop an obsessive concern about their appearance typically the skin hair and the nose These people are often those that get their nose done 5 times and are constantly at the plastic surgeon s office Obsessive concern about appearance and body parts usually skin hair nose and compulsive acts mirror checking camouflaging excessive grooming and skin picking Half of BDD individuals are delusional wdelusions of reference the idea people out there are thinking about you everyone notices things about you that you don t want them to notice Pattern of anxious avoidance of others Unofficial members of OCD Spectrum Gilles de la Tourette Syndrome 9 Anxiety 9 Tics jerky movements 9 Coprolalia involuntary swearing or yelling out words Many people with Tourettes can self manage the disorder by monitoring their anxiety levels When you feel the anxiety coming you go somewhere where you know you won t publicly tic Hypochondriasis DSM 5 Illness Anxiety Disorder Bulimia nervosa Anorexia Nervosa Body Integrity Identity Disorder BIID An OCD Spectrum Disorder Is this really a disorder or a variation It puts the physician in a box When a patient is telling you they want to be amputated in order to gain relief you do not know what to do A belief usually from early childhood that one or more limbs usually the legs do not belong to one s body and that amputation of the limbs will achieve wholeness Certainly regarding the limbs involved and the level of amputation deshed Rehearsal activity pretending during which they imitate the amputated state in private and in public Pursuit of elective amputation or attempts at sef amputation BIID can include nonamputation bodily changes such as beliefs that one should be deaf blind paralyzed or disfigured Amputation or other surgery is the only known treatment They often try and amputate their own legs There has not been a case of having regret about the amputation Streptococcus and OCD PANDAS Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections Seen in schoolage children who develop strep throat or strep rash usually with fever and urinary incontinence OCD following strep infection Sudden onset of tic disorder or OCD signssymptoms most commonly handwashing and preoccupation with germs Rapid remission of symptoms usually occurs with antibiotic therapy PANDAS accounts for only a small of childhood OCD but may point to a possible mechanisms involved in OCD autoimmunity neurotoxicity Maybe immune systems are targeting the basal ganglia Possibility of neurotoxicity People are still following this but it has not led very far Infections may be a possible risk factor in OCD 15 Line OCD Treatments For mild OCD medication is usally effective and mainly uses SSRls Makes obsessions and compulsions manageable Antidepressant therapy with serotonin boosting medications 9SRls eg Prozac Luvox Celexa Lexapro 9Tricycics esp clomipramine Anafranil Behavior therapy to help the person face the world and deal with the obsessions and compulsions 9Thought stopping a technique in which you go over your obsessions with the therapist and the therapist yells STOP It helps the patient build the strength to say stop to hisher own obsessions 9Response prevention A risk in OCD treatment is you never want to give the person more than heshe is comfortable with because it s so easy to retraumatize them Always take things very slowly and present the person with something that makes them anxious and desire to have a compulsion Psychosurgery cingulotomy for otherwise intractable cases Lecture 1 1 582014 Topic 5 Stress Disorders Reactions to Extreme Trauma Intrusive recollections daytime flashbacks nightmares illusions and acute distress upon cues suggestive of the trauma Dissociative symptoms psychic numbing 9 emotional detachment a muted reaction to things 9 being in a daze 9dropping out of usual activities 9avoidance of topics related to trauma 9 forgetting or fogginess re key aspects of trauma 9feeling that the current setting is not real derealization 9 feeling detached from one s body depersonalization Chronic hyperarousal you can t relax exaggerated startle insomnia hypervigilance motor restlessness Irritability and aggressiveness esp males Survival guilt Traumas That Can Precipitate Stress Disorders Most common traumas rape attempted rape and assault gt300000 rapes and attempted rapes per year in US 151 women men Military combat men usually Other precipitants Other precipitants 0 Accidental human calamities motor vehicle accidents place crashes Floods earthquakes fires Deliberate human calamities bombings torture death camps being held hostage PhysicaI emotional abuse childhood sexualphysical abuse partner abuse workplace abuse Physical trauma surgery disease disfigurement head trauma Infertility Stress Disorders DSMIV Acute stress disorder Disability gt2 days and lt1 month Post traumatic stress disorder PTSD Disability gt 1 month Acute Stress Disorder US Airways Flight 1549 11509 I was terrified for my soul you knew that you were going to crash I was two seconds from drowning The first few nights in the hospital I had water dreams about drowning in the galley of the plane My insides have no stopped shaking PostTraumatic Stress Disorder US Airways Flight 1549 11509 Each flight is getting more stressful said passenger Joe Hart who flew over 11 times in the months following the crash It starts with an adrenaline rush your heart skips a beat Then you start thinking Was that a normal sound or was it another bird going through the engine I hope it will pass PostTraumatic Stress Disorder Point prevalence of 23 in the general population women gt men About 90 of PTSD sufferers had Acute Stress Disorder only about 10 show just delayed stress not telling for a few weeks what has happened to them PTSD tends to be less preoccupying over the years Developed by 18 of combat veterans and 70 of POW s Typically lasts 12 years but PTSD is lifelong in 29 of combat veterans and 78 of POW s Men and women show similar signsymptom patterns in PTSD except that women are likelier to show numbing and anxious avoidance men are likelier to show irritability and ETOH abuse they try and black out what happened Risk Factors for Stress Disorders Family history of depression anxiety disorders or PTSD perhaps these reflect common inheritance Depression or anxiety disorder at the time of the trauma Early prenatal traumatic conditioning Meany Effect Severity and chronicity of trauma Poor social support Medication Treatment of Acute and PostTraumatic Stress Disorders Anxiolytics for anxiety panic attacks Antidepressants mainly SSR s for depression irritability Antipsychotics eg Abilify Risperdal for any paranoia social estrangement feeling like nobody understands what they ve been through etc Sleep medications eg Lunesta Ambien Trazodone for insomnia Experimental propanolol lnderal an antihypertensive drug that blocks adrenalin may affect memory consolidation after stress and reduce the intensity of subsequent PTSD symptoms Shown to reduce bodily post stress symptoms shortterm but unproven in longterm clinical studies Psychotherapy for Acute Stress Critical Incident Stress Debriefing Fact phase Ask victims to tell their story Reaction phase Ask victims to report their thoughts and feelings about the incident Symptom phase Solicit symptomatology and suggest coping strategies Teaching phase Educate victim regarding traumas and typical reactions to trauma Reentry phase Wrapup answer Q s provide referrals develop plan of ac on Psychotherapy for PostTraumatic Stress Disorder Guided re exposure and abreactionreliving trauma controversial due to risk of retraumatization EMDR Eye movement desensitizationreprocessing no evidence for special effectiveness Cognitive skills training thought neutralization Group therapy selfhelp rap groups for estrangement abreaction and suppon Stress management training Finding meaning in tragedy subimination Lecture 12 5132014 Topic 6 Dissociative Disorders Reactions to Extreme Trauma Intrusive recollections daytime flashbacks nightmares illusions and acute distress upon cues suggestive of the trauma Dissociative symptoms psychic numbing emotional detachment being in a daze dropping out of usual activities forgetting key aspects of trauma feeling that the current setting is not real derealization feeling detached from one s body depersonalization Chronic hyperarousal exaggerated startle insomnia hypervigiliance motor restlessness Agressiveness males Survival guilt Possible Relationship Between Anxiety and Dissociation Normal 9 Anxiety 9 Dissociation May dissociate during a fight I don t know I don t want to talk about it I can t handle it It is in some ways very normal but it can be very dysfunctional People can differ in their ease of dissociation Dissociation Can Be Normal Daydreaming Highway hypnosis driving down the road on a long ways to go and you go into a trance Losing oneself in a book or movie Spacing out in conversation Dissociative Disorders Dissociative Amnesia Dissociative Amnesia and fugue fleeing running away Depersonalizationl derealization disorder Dissociative identity disorder Multiple personality disorder one personality is shattered into different parts not really multiple personalities To be diagnosable there must be significant stress or impairment Dissociative Amnesia DSM5 Inability to recall important personal information at a level exceeding normal forgetfulness Brief episodes may be due to drug or medication side effects True amnesia nonacknowledgement or selective operation of memory Dissociative Amnesia Basic Facts Occurs more in women than in men Often associated with PTSD and incidence increases after war catastrophe etc Most often the amnesia is confined to a period of time following some stressful event only retrograde losses almost never anterograde amnesia Failures may be in memory encoding or retrieval stressrelated hormones in brain may block proper memory consolidation and retrieval In most cases the amnesia is restricted mostly to personal episodes autobiographical memory generic memory usually remains intact Episodes tend to recur in about 40 of patients and may be more likely to traumatic history eg early abuse Each stress kindles their ease of dissociating for the next time Often ends within hours or days and patient may even recall the triggering episode Sometimes memory recovery is only fragmentary Treatment usually involves anxiolytic medications and supportive psychotherapy occasionally with sedativehypnotic medications Dissociative Amnesia With Fugue Sudden unexpected travel away from home or usual workplace with amnesia for one s past Confusion about one s identity or adoption of a new identity Often diagnosed retroactively after episode is over and memories return Tends to occur after personal trauma and is more common in war and after accidents and natural disasters 0 Episodes may last from hours to months they are usually shortlived and completely reversible 0 Brief fugue states can result from medication sideeffects most commonly Ambien 0 With repeated fugues physician must rule out complex partial seizure disorder 0 Treatment usually involves anxioltyic medications and supportive psychotherapy occasionally along with sedativehypnotic medications Occasionally there are lasting repercussions a soldier is charged as a deserter a man is charged with bigamy Depersonalizationl Derealization Disorder DSM5 Experience of being outside one s own body or having distorted perceptions of oneself Intact reality testing during episode patient is not psychotic Significant distress or impairment Not due to schizophrenia drugs or medications Panic Disorder or Acute Stress Disorder or a general medical condition seizures Common Depersonalizationl Derealization Experiences 0 One s own voice sounds remote and unreal Can t touch things properly with hands 0 Surroundings feel distant and unreal Things look flat like in a picture Personal memories feel like someone else had them Body feels like it doesn t belong to the person One s actions feel robotic and mechanical Emotional behavior unaccompanied by matching experiences Jamais vu what was familiar feels unfamiliar opposite of deja vu Objects look smaller or further away than they are Feeling like one s self and the world are all illusions 0 Watching the world from behind one s eyes Feeling like one is shrinking or disappearing Feeling like it can t really be happening this must be a movie Depersonalizationl Derealization Disorder Basic Facts 0 Commonly found DD Triad emotional numbing altered visual perception altered experience of one s body Depersonalizationl derealization episodes are common up to 50 of population reports at least one Early emotional abuse and recent intense stressors and risk factors Diagnosed twice as often in women as men Often peaceful dreamy affect May explain many neardeath experiences seeing the light and watching over one s body Episodes rarely last long enough to be diagnosable Dissociative Identity Disorder DSM5 Multiple Personality Disorder Typic The presence of two or more distinct identities or personality states each with its own relatively enduring pattern of perceiving relating to and thinking about environment and self At least two of these identities or personality states recurrently take control of the person s behavior Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness The disturbance is not due to the direct physiological effects of a substance eg blackouts or chaotic behavior during Alcohol intoxication or a general medical condition eg complex partial seizures Note In children the symptoms are not attributable to imaginary playmates or other fantasy play al Presenting Complaints of DID Patients Inability to remember events in all or part of a proceeding time period Repeated encounters with unfamiliar people who claim to know them Finding themselves somewhere without knowing how they got there Finding items among their possessions that they don t remember purchasing Dissociative Identity Disorder Basic Facts NOT schizophrenia Diagnosed in up to 5 of inpatient psychiatric admissions but prevalence figures vary widely across countries fromlt001 to gt10 o Mostly diagnosed in females diagnosis in males often masked by substance abuse or other disorders Associated with severe child abuse before age 9 usually 46 but the link remains unproven Can also occur with other trauma natural disasters war 80 of DID patients carry a secondary diagnosis of PTSD DID patients are extraordinarily good at selfhypnosis The Nature of SubPersonalities of Alters 0 Not multiple personalities but fragments of one personality separated by dissociative barriers Average DID case has about 10 alters number can range from 2100 0 Alters can know each other or be mutually amnestic Alters can differ in Name Speech Mannerisms Attitudes Thoughts Sexual Orientation Physical characteristics like allergies handedness eyesight and EEG Doubts about DID MPD is an iatrogenic cause by healer behavioral syndrome promoted by suggestion social consequences and group loyalties Lecture 13 5152014 Iatrogenic Creation of DID It may happen that an alter personality will reveal itself to you during this assessment process but more likely it will not So you may have to elicit an alter You can begin to indirect sic questioning such as Have you ever felt like another part of you does things that you can t control If she gives positive or ambiguous responses ask for specific examples You are trying to develop a picture of what the alter personality is like At this point you may ask the host personality Does this set of feelings have a name Often the host personality will not know You can then focus upon a particular event or set of behaviors Can I talk to the part of you that is taking these long drives in the country Treatment of DID by Recovered Memories Popularization of DID spawned an iatrogenic Memory Recovery Movement based on recovered memories of abuse associated with tales of ritual Satanic abuse bestiality encounters with animals demons angels etc likely confabulation False Memory Syndrome many treatment failures false accusations and family upheavals This Memory Recovery Movement is now in professional disfavor Dissociative Identity Disorder Current Treatment Psychotherapy hypnosis frequently used sometimes sodium amytal lasts an average of 4 years 23 times per week reintegration of personalities removal of the dissociative barriers between them psychodynamic group therapy for the personalities Cognitivebehavioral isolation and strengthening of the dominant personality minimizing naming of personalities calling for specific ones no interpersonality conversations Sometimes antianxiety and antidepressant medications Most DID patients are moderately improved by end of therapy typica outcome is reintegration but fractionation under stress Topic 7 Personality Disorders Personality Disorders Possession of chronic even lifelong maladaptive traits Often are exaggerations of normal character traits Traits either preclude a satisfying life Alienate others and create estrangement and loneliness Result in moral and criminal violations Coded on Axis II Obsolete in DSM 5 Aka Character disorders once thought to respond only to longterm therapy Personality Disorder Clusters Cluster A Odd eccentric where people have always been socially somewhat withdrawn Some research suggests that these are weak forms of schizophrenia Paranoid PD hypervigilant distrustful Schizoid PD socially detached and alienated Seems cold and aloof Schizotypal PD Cluster B Dramatic emotional unstable Histrionic PD drama queenking Narcissistic PD Borderline PD Antisocial PD Cluster C Anxious apprehensive Avoidant PD person who shies away from social interaction out of fear Dependent PDalways cleaning onto someone but the person may not reciprocate this Must consult other people for all decisions ObsessiveCompulsive PD everything must be done to perfection these people are huge procrastinators Paranoid Personality Disorder 0525 of population Pervasive unwarranted suspiciousness and mistrust Hypersensitivity Restricted emotion Often moralistic and grandiose Sometimes charismatic Rarely seen in psychotherapy or medical settings Borderline Personality Disorder 2 of population are F Unstable chaotic and intense relationships Selfdamaging behavior sex ETOHdrugs gambling overeating Inappropriate intense anger and marked mood shifts transient psychotic episodes Splitting idealization devaluation seeing someone as wonderful or horrible Intolerance of being alone with deep abandonment depressions Feelings of internal emptiness and void Repeated suicidal gestures self mutilation Borderline Personality Disorder Cluster B Some cases related to early physical or sexual abuse Psychoanalytic theory failure to master separationindividuation PTSD irritability transient psychotic episodes dissociation Common differential dx Bipolar ll disorder Treatment Medication for symptoms 9Antimanics for mood instability antidepressants andor anxiolytics 9Sometimes antipsychotics Longterm therapy 9Highly structured psychodynamic therapy or Dialectical Behavior Therapy DBT 9Short hospital stays for abandonment depression Dialectical Behavior Therapy Marsha Linehand1991 Developed parasuicida patients especially those with BPD Dialectic refers to tension between environment of acceptance and therapeutic goal of change DBT is a manualized therapy that combines weekly individual and group sessions and diary cards to track therapy interfering behaviors eg suicidal thoughts cutting purging Four modules comprise DBT Mindfulness accepting thoughts and feelings Distress tolerance calmly recognizing current situations Emotion regulation analyzing emotional reactions instead of becoming overwhelmed by them lnterpersona effectiveness assertiveness and problemsolving Gives therapists a structure by which to handle difficult patients Preliminary evidence is promising but preliminary evidence is promising for most new therapies Antisocial Personality Disorder 3 of men approx 1 of women A subset of those psychopaths who get in trouble with the law they cause other people to bring them into therapy because of their behavior Continual violation of the rights of others Deficient in guilt and remorse Concrete morality Strong genetic contribution heritability approx 06 Linked to deprivation incompetent parenting Vs Psychopaths and Sociopaths psychopaths smooth manipulative consciencefree sociopaths normal people enculturated into criminality Lecture 14 5202014 Antisocial Personality Disorder 0 Accounts for 20 of all prisoners 50 of all crimes Diagnosed only after age 18 0 Common preceding diagnoses ADHD conduct disorder diagnosed before age 18 ADHD 25 of boys with ADHD will be APD antisocial personality disorder 0 Cortical immaturity prefrontal area dysfunction like being in the terrible 2s for the first 20 years of life Low slow or hypervariable arousal hypothesisgt insensitivity to reward and punishment 0 Frequent ETOH drug abuse Treatment Incarceration LifeSpan Manifestations of Antisocial Personality Disorder Childhood lying stealing truancy resisting authority 9Early psychopathic triad fire setting enuresis cruelty to animals Adolescence 9Unusually early aggressive or sexual behavior 9Excessive drinking or illicit drug use Adulthood persistence of adolescent behavior 9Failure to hold down a job 0 lrresponsible parents 9Frank lawbreaking illegal activities for work 0 9N0 close relationships or loyalties lnterpersonal manipulativeness 90ften charming and intelligent gt Successful psychopaths ln women may be seen as Somatization Disorder or Muchausen s by proxy can be argued to be a subtype of this disorder usually seen by people who have been in the medical system They ve been close to doctors and they feel they have been screwed over by doctors The child s illness these women get perverse freaky jollies from stumping the doctors Topic 8 Schizophrenia What is Schizophrenia A psychotic disorder Affects approx 12 of population across cultures 12 of all psychiatric inpatients A of all 15 admissions to mental hospitals 23 of all homeless Known for over 100 years August Morel 1860 mental deterioration at an early age Emil Kraepelin 1898 dementia praecox now we know aging doesn t mean dementia Eugen Bleuler 1911 schizophrenia shattered head primary symptoms thought disorder breakdown of associations 9Restitutiona symptoms hallucinations delusions when nothing makes sense you start creating your own world to make things make sense It is not a split personality or multiple personalities but it is a personality who s thinking processes are breaking down and becoming incoherent Not multiple or split personality One Schizophrenia or many schizophrenias Typical Features of Schizophrenia Loss of previous level of functioning Disturbances of language and communication Formal thought disorder Altered thought boundaries thought broadcasting when a person tells you they think their thoughts are leaking out of their heads insertion removal Hallucinations usually auditory Delusional experiences like feeling the presence of alien beings in your room Delusional beliefs all the network anchors are conspiring to share information to the police in their news casts Disordered emotionality flat paranoid or silly affect like in les mis 24601 suspicious goofy Disturbances of the will Social withdrawal and autistic thinking thinking that doesn t seem decipherable to people outside Motor abnormalities motor effects of the disease due to basal ganglia etc Reduced spontaneity or Bizarre or stereotyped gestures and postures ls Schizophrenia a Violent Disorder Schizophrenia is often portrayed in the media as the takeover of one s personality by violent forces This is a false depiction The best predictors of violence among people in anyone are Prior history of violence Drug and alcohol abuse Additionally for people with schizophrenia violence is likelier with Failure to take medication Presence of command hallucinations Schizophrenics commit violence at increased odds of 12 1 without substance abuse 44 1 with substance abuse Most schizophrenic violence is suicide or violence towards family members when a person is off medication People are much more likely to commit crimes if they re on drugs or alcohol Lecture 15 5222014 Classical DSM Subtypes of Schizophrenia Disorganized Bebephrenic Catatonic Undifferentiated Paranoid Residual Problems with classical subtypes Individuals can change subtypes over time Subtypes may instead reflect course and intensity of illness Treatment not specific to subtype So the previous subtypes are taken out on DSM 5 Risk Factors Who Becomes Schizophrenic Not childrearing Genetic relatedness consanguinity Odds of a child becoming schizophrenic are 9 15 if one parent is schizophrenic vs 1 base rate 946 if both parents are schizophrenic vs 1 base rate Above risk applies even if children are adopted early into new homes Twin concordances MZ approx 55 DZ approx 15 Heritability plays a big role Nongenetic Risk Factors in Schizophrenia Birth complications eg protracted labors forceps deliveries Maternal malnutrition Seasonality of birth more likely to have in the winter months Geographic clusters of 4 6 incidence Maternal exposure to influenza virus during 6 month of gestation odds increase later Risk greatest at 6 month of gestation Viral exposure may explain MZDZ difference 0 Other infectious agents may be involved Rubella German measles Toxoplasmosis spores greater prevalence of cat ownership among parents of schizophrenics Endogenous retroviruses eg herpes simplex ll Old Sperm odds of schizophrenic child are About 1 in 200 if father is 25 About 1 in 120 if the father is 40 About 1 in 70 if the father is 50 Cannabis Use and Later Schizophrenia Likeliness of developing schizophrenia increases when you have smoked weed more often under the age of 18 Prenatal Environment and Two Types of M2 Twins One pacenta monochorionic twns Two pacentas dichorionic twins Because of the two types of identical twins chances are only half that both will have schizophrenia What is the Damage of Schizophrenia Early views discredited 0 Metabolic disorder Kraepelin Doublebinding mother Freudians Structural brain damage autopsy CT Scans 0 Cellular derangement 0 Loss of gray matter with enlarged ventricles loss is twice as fast with cannabis use Disordered brain activity PET amp fMRl scans 0 Frontal lobe Basal ganglia Cerebellum Neurotransmitter disorder Transmethylation theory not a lot of evidence for it Dopamine hypothesis Dopamine serotonin interaction Modern view schizophrenia is a neurodevelopmental disorder Research Classifications of Schizophrenia eg timothy crow Nancy andreasen 0 Positive symptom schizophrenia Type I 0 Two basic subtypes psychotic and disorganized Hallucinations psychotic Delusions psychotic Paranoid or silly affect disorganized Bizarre or disorganized behavior disorganized Disordered though processes disorganized Negativesymptom schizophrenia Type II Deficit syndrome Flat affect psychomotor retardation very slowed down in their behavior Mutism and blocking it s hard for them to initiate speech or talk Poor grooming Social withdrawal Positive vs Negative Symtpom Schizophrenia Positive 0 Childhood oddity irritability aggressiveness Later age of diagnosis 2025 Females gt Males Better prognosis DA abnormalities Responds to classical antipsychotic meds Less chance of observable brain damage Versus Negative Childhood withdrawal passivity Earlier age of diagnosis 1618 0 Males gt Females Worse prognosis No DA abnormalities 0 Poor response to classical antipsychotic meds Greater chance of observable brain damage Schizophrenia The Dopamine DA Connection Autopsied brains of schizophrenics show high levels of DA Drugs that increase brain DA can cause disorder that resembles symptom schizophrenia Classical medications used to treat symptom schizophrenia lower brain DA Individuals treated with those classical medications develop motor signs symptoms that resemble Parkinson s disease which involve the loss of DA neurons Individuals 10 suffering from Parkinson s disease when taking medications to restore DA levels may suffer from a disorder that resembles symptom schizophrenia Schizophrenia Dopamine Serotonin Classical medications that affect DA control only symptoms Newer medications that reduce both DA and serotonin can treat both and symptoms On PET and fMRI scans reduction of symptoms associated with return of normal brain activity Schizophrenia Other Neurochemical Involvement Neurokinin 3 NK3 movement disorder component Glutamate NMDA receptor negative signs symptoms and cognitive signs Medications affecting each of these neurochemical systems are in varying stages of development Treatments for Schizophrenia Medication Primary Acute sedation and Chemical restraint Chronic normalization of cognition and behavior BUT overall compliance lt30 Individual Psychotheraphy Adjunctive Adjustment to illness 9Famiy 9Friends 9Work 9Love Deal with secondary depression anxiety Symptom selfmonitoring Building compliance with medication Medication for Schizophrenia AntipsychoticsMajor TraniquilizersNeuroleptics Some classical antipsychotics Treat mainly the symptoms thorazine haldol stelazine prolixin Dirt cheap and still used on occasion Some Atypical 2 39 generation Antipsychotics treat both and symptoms Abilify zyprexa clorazil invega risperdal seroquel Geodon Vastly preferable Note ability and Geodon are weightneutral Side Effects of Antipsychotic Medications Drowsinesssedation can be beneficial in agitated patients Metabolic syndrome 0 Weight gain especially in abdomen Elevated blood lipids cholesterol and triglycerides Diabetes blood glucose dysregulation Motor side effects much great with classical antipsychotics like thorazine and haldol Akathisia cruel restlessness eg rocking Thorazine shuffle Acute dystonias Lock jaw oculogryic crisis Pseudoparkinsonism resting tremor slowness of movements 0 muscular rigidity Tardive dyskinesia rare with 2 generation medications early rabbit sign 0 eventually tongue and limb writhing Lecture 16 5292014 Side Effects of Antipsychotic Medications Drowsinesssedation can be beneficial in agitated patients Neuroleptic malignant syndrome rare delirium fever tremor Metabolic syndrome Weight gain especially in abdomen Elevated blood lipids cholesterol and triglycerides Type 2 Diabetes blood glucose dysregulation Motor side effects much great with classical antipsychotics like thorazine and haldol Akathisia cruel restlessness eg rocking Thorazine shuffle Acute dystonias Lock jaw oculogryic crisis Pseudoparkinsonism resting tremor slowness of movements muscular rigidity Tardive dyskinesia rare with 2 generation medications early rabbit sign eventually tongue and limb writhing Other Disorders didn t really go over this slide Prognosis in Schizophrenia Formerly Rule of thirds 13 improve 13 stay same 13 deteriorate rule probably reflects misdiagnosed bipolar disorder Now outlook is considered more dismal On 30year followup 20 show good adjustment 35 show fair adjustment 45 incapacitated Prognosis worse for symptom schizophrenia Newer medications may improve prognosis Incidence of schizophrenia appears to be declining worldwide perhaps due to better infant nutrition and childbirth methods Topic 9 Eating Disorders Eating Disorders Are Overwhelming female disorders Overwhelmingly found in Western Countries Apparently related with Western cultural conceptions about food and femininity Increasing in nonWestern countries as they Westernize As cultures westernize more females join the workforce Thinness replaces obesity as a sign of wealth and status In several studies of non Western cultures disordered eating attitudes have been associated with exposure to television Why are eating disorders overwhelmingly female Across western cultures males are more likely to be obese but are less likely to care Mass media emphasize dieting and body shape in women s magazines but fitness and bodybuilding in men s magazines Weight loss ads are 10x as frequent in women s magazines 0 Men in sports that emphasize thinness or weight control wrestling boxing crew jockeying or in competitive bodybuilding rather than agility or strength show rates of disordered eating comparable to females 0 Gay men in the gay social scene who are subject to the same physical attractiveness pressures as heterosexual females appear to have elevated rates of eating disorders Rates of eating disorders in males may be increasing Changed standards of female attractiveness Women who were larger used to be more desirable Slightly Changed standards of male attractiveness 0 It has only changed slightly yet still in the past desirable men were slightly larger General Fallacy Underlying Most Eating Disorders That Dieting Works Actually about 95 of diets fail as a means of weight loss They can produce transient weight losses but the weight is almost always quickly regained and more The only long term successful weightloss method is a lifelong pattern of healthy food selection meal planning good sleep and consistent exercise Types of Eating Disorders DSMIV Anorexia nervosa selfstarvation to precariously low body weight Bulimia nervosa recurrent binge eating accompanied by compensatory behavior purging via vomiting laxatives emetics or nonpurging behavior such as fasting andor exercising Binge eating disorder recurrent binge eating without compensatory behavior 0 Eating disorder NOS not otherwise sepcificed disorders that do not fit either category Anorexia Nervosa Literally nervous loss of appetite Refusal to maintain adequate weight defined as less than 85 of ideal body weight Women 5 100b to 5b for each extra inch Men 106b 6lb for each extra inch over 5 Intense fear of weight gain Bodyimage distortion person feels fat even when obviously underweight confirmed with tricklens studies In females amenorrhea due to loss of body fat which secretes estrogen for at least 3 menstrual cycles in males loss of sexual desire Who gets anorexia Nervosa Relatively rare Lifetime prevalence of 25 to 6 in the general female population in males about 110 as prevalent May be frequent rates from 15 to 60 in woman athletes and dancers eg ballet Most cases begin in adolescence peak ages 13 to 20 Runs in families MZDZ concordance rates 44 vs 12 Relatives of family members with anorexia nervosa have 1012x chance of developing the disorder themselves Elevated rates of both anorexia nervosa and bulimia nervosa are found in affected families How Does Anorexia Begin Often develops in adolescents who as children were picky eaters are generally perfectionist and socially avoidant Typically begins with a period of dietary restriction after a period of weight gain and negative comments about the person s weight Sometimes begins after a stressful life event Altered Eating Habits in Anorexia Nervosa Development of obsessive thinking about food how much did I eat how much can I let myself eat Establishing irrational rules about food eat only green foods eat only X of what s on my plate eat only the insides of fruits or vegetables and leave the outsides Food rituals sipping water between bites chewing X times before swallowing 2 of all anorexics binge and purge although the binges are usually small and the purging is most often via excessive exercise Up to 70 of patients with anorexia nervosa also have OCD and some researchers consider it an OCD spectrum disorder What Goes Wrong in Anorexia Nervosa Old psychoanalytic view food in symbolic impregnation rejecting food in rejecting one s sexuality No longer believed As with all illnesses etiology is complex Suspected risk factors genetic involvement is likely hypothalamic and pituitary abnormalities Abnormalities in brain serotonin that may inhibit eating Emotional reactivity and obsessive personality traits that give rise to Two P s of Anorexia Nervosa 0 9PowerIesslness 9Perfectionism 9 If I can control my body then I can have a perfect body and a perfect life Early Warning Signs of Anorexia Nervosa Falling off the growth curve losing weight needlessly No longer eating with the family Saying things like I hate my body or feel fat Being very anxious or depressed but guarded about why 0 Going on a diet needlessly Conditions to Rule out in Anorexia Nervosa Stimulant abuse Obvious hormone abnormalities eg pituitary problems diabetes Major depression or an anxiety disorder Malignancies Psychotic conditions involving food delusions Infections that can cause anosmia loss of smell agustia loss of taste or other loss of appetite eg AIDS What s the Damage in Anorexia Nervosa Osteoporosis thinning of the bones 0 Heart damage that can cause sudden death Kidney and liver disease How is Anorexia Nervosa Treated Patient s denial of illness is a major impediment 0 Medical management of any physical illnesses that may have resulted from starvation Hospital refeeding if necessary intravenous at first the progressing to feeding my mouth with social reinforcement Hospitalization indicated if individual falls below 75 of body weight Inpatient 9 Outpatient family therapy Reassert parents control of eating Begin a program of refeeding Medication lneffecive so far but some medications show promise Zyprexa Used to treat any accompanying depression anxiety etc Treatment Effectiveness in Anorexia Nervosa Mortality Rate in 1025 from illness or suicide Most severe anorexics die of cardiovascular complications Fewer than 50 of people with anorexia nervosa ever achieve a normal weight and among those who have recovered their social and occupational functioning is often poor Bulimia Nervosa Bulimia translates to ox appetite to describe food intake Binge eating at least twice weekly for at least three months Compensatory behavior to maintain or lose weight Purging self induced vomiting manual or emetic medications laxatives or diuretics Non purging exercise andor temporary fasting Preoccupation with body size weight as critical to selfesteem Who Gets Bulimia Nervosa Adolescents and young adults 90 female Peak ages 15 to 18 in females and 18 to 26 years for males Point prevalence of approx 1 for full bulimia to 5 for partial bullimi syndrome Among college students point prevalence of bulimia nervosa may be 10 or even higher High prevalence may relate to the Freshman 15 The weight gain seen when starting college Actually on average Students gain about 4lb during their first 3 months of freshman year a rate 11x higher than typical for their age BUT most don t gain 15lb during the first year men gain 6lb and women gain 45 lb Emotionality and Bulimia Nervosa Some studies find associations between bulimia nervosa and early sexual abuse although this fits a minority of bulimia sufferers People with bulimia nervosa are more likely to be emotionally impulsive and unstable and diagnosable with borderline histrionic or narcissist personality disorders Up to 33 of people with bulimia nervosa also have OCD and like anorexia it is sometimes considered to be an OCD spectrum disorder Like anorexia abnormalities in brain serotonin are suspected Binging Binge eating involves consuming amounts of food that are larger than average portions within a twohour period The binge is associated with a feeling of loss of control and ends When the person develops stomach pain becomes tired gets interrupted or when the food runs out Foods tend to be highcalorie highfat or highcarb foods eg fast foods and junk foods Typically a single binge can contain 20003000 calories as much as the average adult needs in one day How Does Bulimia Nervosa Start Part 1 Bulimia is often triggered when a person attempts restrictive diets fails and reacts by binge eating In response to binges patients compensate usually by purging by vomiting by using enemas or by taking laxatives diet pills or drugs to reduce fluids In a 2006 5year study of female adolescents by age 20 nearly 20 had used diet pills appetite suppressants laxatives or stimulants to help curb their appetites Going off the diet pills nearly always results in binging Patients then revert to sever dieting excessive exercise or both Some patients with bulimia follow binging only with fasting and exercise They are then considered to have nonpurging bulimia The cycle then swings back to binging and then to purging again How Does Bulimia Nervosa Start Part 2 Patients with bulimia appear to average about 14 episodes of binge purging per week DSMIV requires only at least twice a week for three months and some researchers believe that only once a week should be diagnosable In contrast to anorexia nervosa most people with bulimia have a normal to highnormal body weight although it may fluctuate by more than 10 pounds because of binge purge cycling The binging and purging are often done privately and are shrouded in shame and guilt Sometimes the binging is public while the purging is private Selfinjurious Behavior In severe bulimia nervosa the low selfesteem and impulsivity may result in self injurious behavior such as Cutting Burning Punching or slapping Hitting oneself with an object Eye pushing Biting and head banging Less commonly bone breaking or amputation These are often perceived as attempts to ward off feelings technically to induce dissociation What is the Damage in Bulimia Nervosa Most of the damage is from repeated vomiting Rupture of stomach or esophagus Heart damage from loss of electrolytes mainly potassium Erosion of teeth gums and fingernails Broken blood vessels in the eyes Swollen salivary glands chipmunk faces Menstrual irregularities and higher risk of pregnancy complications Also associated with high 3070 rates of ETOH andor drug abuse smoking in order to maintain weight other impulsive behavior sexual promiscuity cutting kleptomania How is bulimia treated Unlike anorexia nervosa bulimia nervosa usually responds well to treatment 15 line treatment high doses of SSR s such as Prozac which have been shown to reduce binging by up to 70 and vomiting by up to 60 Therapy is also indicated support groups Cognitivebehavior therapy Focus is on resisting impulses to binge or purge healthy eating and developing positive alternatives to foodcentered behavior Treatment over several years is usually successful 70 90 but relapse is common and patients should not expect cures Lecture 17 632014 Topic 10 Addiction What is Addiction The uncontrolled compulsive use of a substance despite ongoing negative consequences to one s health mental state or social life All addictions share the experience of loss of control over the substance or behavior and how to explain this loss of control led to two classic views about addictions the Moral View and the Medical Disease View Loss of Control in Addiction Two Classic Views Moral Views Addicts are morally weak choose to yield to temptation and are consciously selfdestructive and uncaring about the damage they cause others They need to start making good choices and get their act together Medical Disease View Possibly aided by a genetic predisposition andor social learning addicts begin using voluntarily but then have their brains biologically hijacked by the addictive substances They need treatments that block hijacking restore normal brain function and thereby give them back their will Social Costs of Alcohol and Drug Addiction Annual US costs of substance abuse in health crime and productivity 185 billion for alcohol ETOH 181 billion for illicit drugs 168 billion for tobacco Uncounted other costs in accidental deaths family disintegration job malperformance loss of employment school failure domestic violence child abuse Drug Use Norms Every culture has norms about the ingestion of substances that dictate what should be consumed when it can be consumed who can consume them how much should be consumed what range of reactions is permissible USE ingesting a drug in accordance within those sociocultural norms eg peyote in vision quests ceremonial wine in communion champagne at weddings beer at frat parties ABUSE taking a drug outside of sociocultural norms causing personal and social problems as a result Abuse may lead to dependence Commonly Abused Drugs Ethyl alcohol ETOH Sedativehyptnoic anxiolytics barbiturates benzodiazepines Opiates heroin morphine Codeine oxycodone Stimulants Amphetamines Ritalin Cocaine MDMA X or Ecstasy Hallucinogens LSD mushrooms DMT Dissociative anesthetics Phencyclidine PCP dextromethorphan ketamine Special K Cannabis Hashish pot lnhalants Glue solvents aersols cleaning fluids Other substances Nicotine Caffeine Anabolic Steroids Nitrate inhalants AbuseProne Substances Work on neurotransmitter systems that affect mood and motivation Most abused substances have beneficial effects and many have been used as medicines heroin and other narcotics are used as analgesics pain relievers antidiarrheal agents and in cough medicines Cocaine is a mental stimulant local anesthetic eg dentistry appetite suppressant and was once in CocaCola Alcohol ETOH is a potent anti anxiety agent and moderate use under a physician s guidance appears to be cardio protective Nicotine is a mental stimulant produces weight loss and may be beneficial in schizophrenia and Parkinson s disease As a side effect these substances may generate temporary buzz euphoria calm andor disinhibition and these reactions help lend them strong potential for abuse Nonsubstance Behavioral Addictions Historically addiction referred just to substances like alcohol stimulants and narcotics More recently some observers have argued for widening addictions to include behavior like sex exercise eating gambling shopping pornography and the Internet This is controversial In DSM5 some behavioral addictions eg Gambling Disorder are listed alongside Substance Use Disorders because of their addictive patterns Substance Related Diagnoses in DSM5 Spectrum of Severity Intoxication ingestion leading to reversible impairment Substance Use Disorder most severe Abuse harmful pattern of use Dependence habitual abuse and development of withdrawal and tolerance NOTE addiction does not appear in DSM5 DSM5 Substance Use Disorder do not have to memorize Maladaptive pattern of substance use leading to significant ipairment or distress Presence of 2 or more of the following within a 12month period 9Taking the substance in larger amounts or for longer than you meant to wanting to cut down or stop using the substance but not managing to spending a lot of time getting using or recovering from the use of substance not managing to do what you should at work home or school because of substance use continuing to use even when it causes problems in relationships giving up important social occupational or recreational activities because of substance use using substances again and again even when it puts the you in danger continuing to use even despite physical or psychological problems that could have been caused or made worse by the substance needing more of the substance to get the effect you want tolerance 9Development of withdrawal symptoms which can be relieved by taking more of the substance 9Cravings and urges to use the substance Alcohol Use Disorder What is Alcohol Ethanol ethyl alcohol ETOH C2H5OH Volatile clear flammable liquid produced by fermentation of sugar Acts as a central nervous system depressant by stimulating brain receptors for GABA the major known inhibitory neurotransmitter in the brain and one related to anxiety By blocking receptors of glutamate probably the main excitatory neurotransmitter in the brain and one especially involved in memory and cognition is a potent neurotoxin that can cause loss of gray matter mostly dendritic loss especially in the hippocampus memory and cerebellum coordination These changes are mostly reversible if the drinking is only moderate and the drinker is young Alcohol Addiction in US ETOH in the form of beer wine spirits etc is consumed by 80 of the population ETOH is most common substance of abusedependence In US and Western Europe lifetime prevalence is approx 15 Point prevalence is 2550 among medicalsurgical inpatients and in approx 50 of psychiatric inpatients LicitIllicit Drug Use of UCSB 1quarter prevalence 85 Alcohol 39 Marijuana pot hash hash oil 79 Cocaine 79 Ecstasy X or MDMA 58 Hallucinogens LSD mushrooms Alcohol Use at UCSB 2008 854 Annual Prevalence 78 30 Day Prevalence Underage 30day prevalence 515 Binge drinking last 2 weeks 5 or more drinks for males 4 or more for females within a 2hour period 58 UCSB students reporting personal problem such as missing class having a memory loss having a hangover vomiting at least once during the past quarter as a result of drinking Alcohol s Effects Dependent on Blood Alcohol Concentration BAC 0306 9 Sense of well being or confidence or sedation and tranquility lowered anxiety contributes to its role as a social lubricant 0610 9 lncoordination and irritability impaired reaction time and judgment 1120 9 Slurred speech ataxia widespaced unsteady gait nystagmus 2129 9 Blackouts periods of antrerograde amnesia passing out gt 30 9 Coma respiratory and cardiac depression possible death Who Becomes Alcohol Dependent I Age younger drinking predicts later problems Typical age of onset is 16 to 30 People who begin drinking before age 15 are 4x as likely to become alcoholic compared to those whose first drink is at age 20 or older About 50 of alcoholics in the US are adolescents or young adults few seek help for their addictions Sex Men are 4x as likely to have alcohol problems as women Alcoholic women however suffer more than men from health problems and die approx 11 years earlier than male alcoholics Level of Response LR to Alcohol Level or Response LR to Alcohol Mark Shuckit 1975 People with a low LR React less mentally and behaviorally than highLR people to a given amount of alcohol Need more alcohol than highLR people to achieve the same mental and behavioral effects LR concordance approx 5 between MZ twins and approx 3 between parents and children LR was measured among 20yearold males then at age 30 56 of the lowLR males had become alcoholic 14 of the highLR males had become alcoholic LR is related to genetic markers on Chromosome 15 which may be involved in the production of certain kinds of GABA receptors Who Becomes Alcohol Dependent ll Family History More than 2 of current drinkers have a family history of alcoholism Children of alcoholics are 4x as likely to be alcoholic themselves even when reared by nonalcoholic adoptive parents Ethnicity Ethnic groups differ in their susceptibility most likely a mixture of genetics and culture Asians have very low rates of ETOH abusedependence probably because about 2 of Asians have a genetic variation that complicates the metabolism of ETOH and causes an unpleasant facial flushing response Native Americans Alaskan Natives and Mexican Hispanics have the highest rates of alcoholism but the rates vary tribally and by community Ethnicity and ETOH dependence in the US addiction highest in native Americans and Mexican Americans Lowest in Asians Who Becomes Alcohol Dependent Ill Personality lmpulsive sensation seeking history of conduct disorder gt antisocial personality disorder Social Peer pressure Availability of alcohol Educa on College students drink more than sameage people not in college In college being a member of a GLO may be a risk factor of later alcoholism causality uncertain Binge Drinking in Members vs NonMembers of Greek Letter Organizations GLO s Nationally More binge drinking in both female and male for the members of letters Binge Drinking and College Residency Nationally Substance free is lowest but still about 36 The GLO members in residence is 75 Consequences of College Binge Drinking Related to alcohol each year college students ages 1824 face 1700 accidental deaths injuries eg motor vehicle accidents approx 600000 accidental injuries approx 700000 assaults approx 97000 sexual assaults date rapes approx 400000 instances of unprotected sex Alcohol accounts for approx 83 of all campus arrests approx 28 of college dropouts The Possibly Good News Adolescent Binge drinking may be on the decHne Consequences of ETOH AbuseDependence 2 of all traffic fatalities and 13 of all traffic injuries are ETOHrelated Untold costs in accidents and death criminal behavior community and domestic violence marital and family strife work perforamcne and absenteeism Personal damage due to disease and premature death gastric irritation and bleeding liver testicular and pancreatic disease Oral and intestinal tract cancer Anxiety depression and suicide peripheral neuropathy nerve degeneration causing weakness and sensory loss Dementia with chronic heavy use Korsakoff s syndrome Fetal damage Fetal Alcohol Spectrum Disorders approx 1 of US Population Associated with heavy drinking in pregnancy Craniofacial deformities Physical and mental retardation Learning disabilities and behavioral disorders eg ADHD Skeletal esp hand and finger malformations ETOH Withdrawal Syndrome lasts 34 days Shakes within 1218 hours after drinking weakness sweating nausea and vomiting Alcoholic seizures rum fits Alcoholic hallucinosis vivid unpleasant auditory hallucinations Withdrawal delirium delirium tremens or DT s confusion disorientation agitation vivid visual hallucinations Withdrawal is much more severe than opiate withdrawal and can be fatal if unsupervised Addiction Treatment Acute management usually in inpatient detox facility Treatment of acute withdrawal symptoms often with physiologically similar medications In ETOH dependence use of benzodiazepines for shakes and delirium antipsychotics for hallucinosis and sometimes anticonvulsants for seizures During inpatient stay group and family therapy Rehabilitation outpatient outcomes guarded and complicated by denial Treat co morbid conditions eg depression anxiety pain seen in up to 23 of addicted patients Refer to patient to therapyeducation programs focusing on coping strategies and relapse prevention 9a 1 2 step program for ETOH alcoholics anonymous Refer family to a support group for ETOH AlAnon for educatin and issues of codependency Relapse Rates for Common Addictions Most people fail after a year You can expect people to fail but after 3 or 4 cycles they may improve 12Step Groups Based in great on Moral View of addiction First 12step group was protestant inspired alcoholics anonymous founded in 1935 by two alcoholics Bill Wilson and Dr Robert Smith Today AA encompasses approx 2 million members across approx 110000 groups word wide Groups are selfsupporting and dependent upon donations AA teachings including the 12 steps are contained in the Big Book which stresses Frank and total admission of one s alcoholism Confessing an inability to handle one s alcoholism by himself Vow to stay abstinent clean and sober one day at a time Maker personal amends for all the damage one has caused Help others to achieve sobriety Other Addiction Recovery Groups Cocaine Anonymous CA Crystal Meth Anonymous CMA Marijuana Anonymous MA Nicotine Anonymous NicA Narcotics Anonymous NA Pills Anonymous PA and others Trends in Addiction Treatment Overall in the US addiction to ETOH has leveled off tobacco and most illicit drug abuse is declining but addiction to marijuana and to prescription drugs mostly narcotics and stimulants is increasing 12 Step abstinence groups remained and mainstay of treatment Greater willingness to treat comorbid mental disorders even while the patient is using although most common practice is still detox first More emphasis on early education detection and community and school prevention programs the path to addiction is set by high school Greater emphasis on pharmacological treatments antagonists prescribed dose controlled substitutes for abused substances Pharmacological Addiction Treatment Campral and Revia for alcohol dependence Campral acamprosate seems to reduce the glutamate surge that accompanies alcohol withdrawal and produces craving and so promotes abs nence Revia naltrexone blocks endogenous opiates in the brain and reduces the pleasure associated with drinking Chanitx varenicline for nicotine addiction also nicotine gums lozenges and patches and Wellbutrin Suboxone buprenophene naloxone or methadone for narcotics addition Experimentally Provigil modafinil for cocaine and amphetamine addiction Overall evidence is that these treatments are not cures but are moderately successful in reducing relapse Lecture 18 652014 Topic 11 Attention Deficit Hyperactivity Disorder AttentionDeficit Disorder ADD Childhood Hyperactivity 9 Attention Deficit Hyperactivity Disorder ADHD Attention Deficit Hyperactivity Disorder Two Main Kinds lna en vetype Hyperactive impulsive type And Combined type signs and symptoms of both Attention Deficit Hyperactivity Disorder ADHD inattentive Type need 6 or more Poor attention to detail careless mistakes in schoolwork etc Can t sustain attention to normal range of tasks Doesn t listen when spoken to directly Doesn t follow through on instructions fails to finish assignments Has difficult organizing tasks and activities Avoids dislikes tasks requiring sustained mental effort Often loses things necessary for tasks Easily distracted Frequently forgetful Attention Deficit Hyperactivity Disorder ADHD Hyperactive impulsive Type need 6 or more Frequent fidgeting and squirming Leaves seat frequently Runs around or climbs excessively in adolescence feelings of restlessness Difficulty at quiet play Excessive talking Blurts out answers before Q is finished Has difficulty waiting hisher turn Frequently interrupts and butts in activities Who Has ADHD Found in every culture and socioeconomic level 35 percent of preadolescents have ADHD range from 120 Males gt Females 31 to 91 ratio for Hyperactive type but for inattentive type Females gt Males Probable genetic link concordances of 05 for MZ and 04 for DZ twins 4050 of people with ADHD have at least one 15 degree relative with ADHD Infants with prenatal complications premature births low birth weight Infants whose mothers had high levels of anxiety during weeks 1222 of their pregnancies Children with high blood levels of lead Children who have had frequent changes of residence whose parents have divorced or whose fathers are irresponsibleantisocial cause or effect Consequences of ADHD Poor school grades and conduct Approx 20 of students with ADHD have a concurrent learning disability Approx 4060 of ADHD children develop conduct disorder delinquency andor drug abuse Teenagers with Hyperactiveimpulsive ADHD are much more likely to have traffic accidents get pregnant develop an STD commit arson or run away from home Approx 50 of imprisoned felons and Approx 50 of adolescents in juvenile facilities have untreated ADHD Up to 80 of ADHD children retain symptoms through adolescence and beyond Only about 5 of college students with ADHD graduate Who Goes Wrong in ADHD People with ADHD show 35 year delays in the growth of neurons especially in the frontal lobes of the brain These areas are involved in attention impulse control and initiation and perception of movement What Goes Wrong in ADHD Other Possibilities Under activation of frontal lobes Abnormally low dopamine activity Possible sensory screen Abnormalities in sensing passage of times 5090 of ADHD individuals also have at least one of the following Bipolar disorder new pediatric diagnostic fad Conduct Disorder Depression Obsessive Compulsive Disorder OppositionalDefiant Disorder Specific Learning Disorders Tourette s Syndrome ADHD Treatments Medication Approx 80 of ADHD children are helped by stimulant drugs may unmask tic disorderTourette s Note stimulants quiet everyone not addictive when used for ADHD Insomnia headache nausea are a frequent side effects These are all controlled drugs 9Ritalin Concerta methylphenidate Focalin dmethylphenidate Ritalin most common ADHD med 9Adderall amphetamine 9Dexadrine dextroamphetamine 9Cylert permoline now considered risky because of liver problems Stimulant drugs leave children shorter at high doses but this is alleviated with drug holidays people on stimulants have overall lower rates of abuse because it is not as addicting Use of stimulants lowers the rate of substance abuse in ADHD Nonstimulant alternatives not controlled drugs 9Webutrin especially ADHD adults 9Straterra atomoxetineSNRIApproved January 2003 often as effective as stimulants for ADHD but much less insomnia 9ProvigilNuvigil originally intended to treat narcolepsy and other causes of daytime somnolence may improve focus in some ADHD inattentive patients Sometimes SSRl s or Antimanic drugs are helpful ADHD Treatments Behavioral Structuring school and home environments 9Consistent daily scheduling 9Breaking tasks into small chunks 9Clear immediate rewards and punishments for target behavior 9Best punishment is time with or withdrawal of privileges spanking is ineffective and disruptive 9Minimizing of distractions ls ADHD Overdiagnosed Sales of Ritalin used in 8090 of ADHD cases have increased 700 since 1991 Ritalin s manufacturers have contributed nearly 1 million to ADHD support groups since 1991 Americans consume 90 of all the Ritalin in the world more than 1 out of every 30 Americans between 5 and 19 years old has a prescription for Ritalin On average 10 of students in US are on Ritalin and in some state Virginia New Hampshire Vermont Michigan Delaware rates are 15 20 California and Hawaii are lowest at approx 3 5 Yet several studies suggest that ADHD is not overused Nonprescribed Ritalin abused by 7 of high schooers and 5 of college students who typically share their prescribe meds with others at 56 per pill Students say it helps them concentrate and stay up late studying Unproven ADHD Treatments EEG Biofeedback Elimination diets sugar food dyes and additives Nutritional supplements Adults ADHD Frequ Prevalence is about 4 of the US adult population Up to 70 of ADHD children retain some symptoms through adulthood and approx 20 retain the full disorder By adulthood the Male Female ratio in ADHD approaches 11 possible due to a combination of 9 Maturation of the Hyperactive males 9 Increasing diagnosis of lnattentive ADHD females ent Manifestations of Adult ADHD Seeks noisy busy places in order to get work done Frequent changing of Tvradio stations listening to only parts of songs Difficulty waiting in lines Tuning out in conversation and at intimate moments Blurting inability to withhold unwelcome remarks Preference for highly stimulating situations Often intuitiveness Novel out of the box approaches to problems ls ADHD a Gift Probable ADHD ers Include Ansel Adams Ludwig van Beethoven Agatha Christie Winston Churchill Albert Einstein Benjamin Franklin John F Kennedy
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