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by: Nellie Runte


Nellie Runte
GPA 3.8

A. Fridlund

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A. Fridlund
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This 65 page Class Notes was uploaded by Nellie Runte on Thursday October 22, 2015. The Class Notes belongs to PSY 103 at University of California Santa Barbara taught by A. Fridlund in Fall. Since its upload, it has received 31 views. For similar materials see /class/227098/psy-103-university-of-california-santa-barbara in Psychlogy at University of California Santa Barbara.




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Date Created: 10/22/15
History and Concepts 4192009 94700 PM Asylums o Institutions whose primary purpose was to care for people with mental illness o Once they started to overflow they became virtual prisons where patients were held in filthy conditions and treated cruelly Comorbidity o The presence of two or more disorders in a single person Course of Illness o How a disorder or illness progresses from the time of diagnosis to the time of death Deinstitutionalization o Process of replacing longstay asylums with community mental health services c Based on the views of moral treatment o Institutions had become isolated untherapeutic and overcrowded Demonological View o Regarded abnormal behavior as the work of evil spirits o Battle of good and evil where abnormal behavior was the resultant of evil winning o Treatments included trephination and exorcism Diagnosis o After hearing their symptoms figure out what kind of suffering is going on attempt to label a nosology category to the patient o A determination that a person s problems reflect a particular disorder Etiology o Study of causation of pathologies General Paresis and Malarial Cure o General paresis is caused by syphilis a disorder affecting the brain and central nervous system c Malarial cure discovery that use of penicillin to treat syphilis lead to full recovery Humoral Theory Hippocrates o abnormal behavior as a disease from internal physical problems 0 Each of the four humors bodily chemicals were thought to have a different effect on the body and personality o The humors were yellow bile choleric black bile melancholic blood sanguine and phlegm phlegmatic 0 Le yellow bile drives a husband to beat his wife Hysteria o Used to describe conversion disorder somatization disorder and pain disorder associated with psychological factors Incidence o The number of new cases of a disorder occurring over a specific period of time IQ tests o Results represent the person s mental age to his or her chronological age o Measure a person s intellectual ability Mesmerism o Friedrich Mesmer o Had his patients who suffered from hysterical disorders sit in a darkened room filled with music then he appeared dressed in a costume and touched the troubled area of each person s body with a special rod Moral Treatment o Emphasized moral guidance and humane and respectful treatment when treating those with a mental illness o Philippe Pinel and William Tuke o 19th century Neuropsychological tests o A test that detects brain impairment by measuring a person s cognitive perceptual and motor performances o Bender VisualMotor Gestalt Test patients look at simple designs and copy them onto a piece of paper Nosology o The science of classification how human suffering is categorized into different types how they are distinguished from one another scheme of classification Pharmacogenomics o Concerned with developing drug therapies for patients with disordersillnesses Phrenology Bumps on the skull were considered areas of personality traits Premenstrual dysphonic disorder PMDD basically sever PMS 5 to 11 symptoms during the week before the menses sad or hopeless feelings tense or anxious feelings marked mood changes frequent irritability or anger and increased interpersonal conflicts decreased interest in usual activities lack of concentration lack of energy changes in appetite insomnia or sleepiness feeling overwhelmed out of control physical symptoms such as swollen breasts headaches muscle pain bloated weight gain Prevalence The total number of cases of a disorder occurring in a population over a specific period of time Prognosis The prediction of the probable course of an illness Projective assessment Require that subjects interpret vague stimuli such as inkblots or ambiguous pictures or follow openended instructions such as draw a person Psycho physiological tests amp polygraph Measure physiological responses as possible indicators of psychological problems States of anxiety are accompanied by the physiological changes increases in heart rate body temperature blood pressure sweat muscle contraction Psychogenic view of mental illness The chief causes of abnormal functioning are psychological Selfreport inventories Aka personality inventory a test designed to measure broad personality characteristics consisting of statements about behaviors beliefs and feelings that people evaluation as either characteristic or uncharacteristic or them MMPI SOO true false cannot say The statements describe physical concerns mood morale attitudes toward religion sex and social activities psychological symptoms ie hallucinations Signs and Symptoms o Signs objective evidence or a manifestation of the illness 0 Can be seen or measured ie rash 0 Observable markers o Symptoms things that only the patient can seefeel o Hallucinations are a symptom 0 Patient reports Somatogenic view of Mental Illness o Abnormal psychological functioning has physical causes Structured types of assessment o Clinical interview facetoface interview where clinician asks questions of client weigh responses and reactions and learn about them and their psychological problems Syndrome o A cluster of symptoms that usually occur together Trephination o A trephine a stone instrument was used to cut a circular section of the skull as treatment for severe abnormal behavior involving hallucinations or melancholia depression o Purpose to release the evil spirits that were causing the problem Types of brain imaging o some problems in personality or behavior are caused primarily by damage to the brain or changes in brain activity 0 EEG electroencephalogram records brain waves which is the electrical activity taking place as a result of neurons firing o CATCT scan computerized axial tomography X rays of the brain are taken at different angles 0 PET scan positron emission tomography a computer produced motion picture of chemical activity throughout the brain 0 MRI magnetic resonance imaging uses magnetic property of certain atoms in the brain to create a detailed picture of the brains structure and activity Assessment and Diagnosis 4192009 947 00 PM Alternative ways of defining psychopathology o Deviance from culture norms they violate a society s ideas about proper functioning o Distress behaviors ideas or emotions cause distress and proceed abnormal behavior o Dysfunction behavior that interferes with daily functions o Danger behavior that is dangerous to one s self and others Clinical interview o Signs Noted in Clinical Interview 0 O O O O O O O O O Attire amp grooming Posture Physical characteristics Skin tone complexion Weight stature Symmetry atrophy bodily anomalies Mannerisms spasms or tics Speech Articulation Prosody tone of voice is it normal abnormally flat or abnormally pitchy Consciousness Level of alertness fogginess hyperalert Emotional state General attitude Defiant compliant guarded defensive sincere plaintive resistant apathetic etc Thought content Solicited by free inquiry delusions false beliefs Thought processes Thought broadcasting your thoughts have become available to everyone removal insertion hallucinations false experiences auditory hallucinations hearing voices General knowledge General facts pop culture Abstract thinking O O 0 Social judgment Insight Cognitive functioning Usually current mental status via MMSE Mini Mental Status Exam Neuropsychological screens like clock drawing MiniMental Status Exam MMSE O O O O O Orientation up to x3 Time year season date day month Place state county city facility Person name age Registration Slowly say the names of 3 common objects apple table penny and ask patient to repeat them Attention amp calculation Serial 7 s or WORLD 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 Clock Drawing as a Neurological Screen have them draw a clock where and how they lay it out can suggest a diagnosis Epidemiological studies Reveals the incidence and prevalence of a disorder in a particular population without trying to predict or explain when or why it occurs They interview people on large scales Prevalence the total number of cases during a given period of time Incidence the number of new cases that emerge during a given period of time AdvantagesDisadvantages of o external validity the degree to which the results of the study may be generalized beyond the study o internal validity the accuracy with which a study can pinpoint one of various possible factors as the cause of a phenomenon o Clinical case study case history 0 source of new ideas about behavior may offer tentative support for a theory may challenge a theory s assumptions may inspire new therapeutic techniques present opportunities to study unusual problems that do not occur often enough to permit a large number of observations 0 therapists who have a personal stake in seeing their treatments succeed become biased observers these studies rely on subjective evidence internal validity generalization bias does this cause apply to everyone external validity o Experimental methods 0 blind design random assignment experimental group control group 0 mostly still in a lab not real life situations o Correlation methods 0 possesses high external validity o does the sample accurately reflect a real correlation in the general pop lack internal validity they show a relationship but don t explain it do not mean causation Experimental Studies Experiment groups the subjects exposed to the independent variable o Control groups subjects who are not exposed to the IV o Blind designs an experiment in which the subjects do not know whether they are in the experimental or the control condition 0 So that participants do not bias an experimenter s results o Experimenter bias bias towards a result by the experimenter the inability for a human to remain completely objective o Natural experiment nature itself manipulates the IV while the experimenter observes the effects 0 Used to study the psychological effects of unusual and unpredictable effects such as floods earthquakes plane crashes and fires o Analogue experiment induce lab subjects to behave in ways that seem to resemble reallife abnormal behavior and then conduct experiments on the subjects in the hope of shredding light on the reallife abnormality 0 Sometimes use animals but mostly humans o Singlesubject experiment a single subject is observed and measured both before and after the manipulation of an independent variable 0 Rely on baseline data info gather prior to manipulation Rosenhan experiment o 8 normal people faked symptoms of schizophrenia and were hospitalized o reverted to normal behavior following admission 0 none were undiagnosed after weeks of in hospital 0 after their stays discharged as schizophrenia in remission o Rosenhan s Conclusions mental disorder is a matter of social labeling and the mental health profession is a matter of social control o Criticisms 0 Most psychiatric patients get better quickly under confines of the hospital so they couldn t tell they were faking it 0 Hospital admissions don t expect people to lie about being mentally ill MMPIZ personality inventory o 567 items objectively scored o includes selfstatements that are true false or cannot say o The statements describe physical concerns mood morale Attitudes toward religion sex and social activities o Includes psychological symptoms like fears and hallucinations Interpretation value overview of o TAT thematic apperception test pictorial projective test viewers shown 30 black and white picture of people in vague situations and asked to make up a dramatic story about each card o Rorschach administration patients interpreted inkblots images the viewer saw seemed to correlate with their psychological condition Psychodiagnosis o Advantages and disadvantages o Avalid and consistent definition of mental disorder will produce no false positives and no false negatives 0 People with mental dosprdersgt social stigma o Excuse abuse by criminals o Type of information that go into it o Phenotypic Signs symptoms course outcome response to treatment 0 Genotypic cause laboratory tests Diagnosis or assessment o Semantic vs prototype conceptions of diagnosis 0 Definition vs prototype o Phenotypic vs genotypic diagnosis 0 Phenotypic Signs symptoms course outcome response to treatment In mental health most diagnosis are phenotypic o Genotypic Cause and laboratory tests Physical medicine consists of moving from a phenotypic to genotypic diagnosis DSMIV TR o conception of mental disorder 0 a clinically significant behavior or psychological syndrome or pattern that occurs in an individual associated with present distress disability significant risk of suffering death pain disability or loss of freedom o Axes 0 Axis I an extensive list of clinical syndromes that typically cause significant impairment 0 Axis II includes long standing problems that are frequently over looked in the presence of disorders on Axis I o AXIS III general medical conditions that the person may be suffereing 0 Axis IV special psychological or environmental problems 0 Axis V GAF o GAF Scale global assessment of functioning rate a person s psychological social and occupational functioning overall Depression 4192009 94700 PM CognitiveMotivational vs Neurovegetative SignsSymptoms of Major o Cognitive o Pervasive sadness guilt or feelings of worthlessness o Recurrent thoughts of death or suicide o Motivational o Pervasive anhedonia losing all sense of pleasure in life o Neurovegetative 0 Significant change in weight Sleep disturbance Psychomotor agitation or retardation Pervasive fatigue or loss of energy Difficulty concentrating Depression and cultural specificity o Nonwestern depressed people tend to have fewer cognitive symptoms negative views of themselves and more physical symptoms such as fatigue weakness and sleep disturbances Anaclitic and Postpartum depression possible etiologies of postpartum depression o Postpartum may last up to a year extreme sadness intrusive thoughts compulsions feeling of inability to cope suicidal thoughts 0 Hormonal changes accompanying childbirth may trigger postpartum depression all women experience a hormonal withdraw after delivery 0 May be a genetic predisposition to postpartum depression o Babies may suffer from their mother s depression anaclitic depression a pattern of depressed behavior found among small children that is caused by separation from one s mother Atypical depression o Atypical Depression hysteroid dysphoria reversed neurovegetative signssymptoms Weight gain carbohydrate binging Hypersomnia Leaden paralysis o Interpersonal rejection sensitivity o Often o Histrionic traits very dramatic O O O O O O O o Selfmedication with caffeine or chocolate o Sometimes uniquely responsive to MAOInhibitors Sex ratios in prevalence of Major Depression possible explanations and implication of Amish findings o Why Are Women Diagnosed with Depression Twice as Much as Men Some Possibilities o Xlinked depression genes Premenstrual symptoms Quality of female vs male life Female masochism Freud Cognitive style Females dwell on problems Males ignore or escape them Male depression masked by alcohol drug abuse Amish study Genetic evidence on incidence of depression o Family pedigree twin adoption and molecular biology gene studies all reveal that a person is at elevated risk of depression if they have a family history of depression as compared to the general population Kindling and depression risk o Each Depression Increases the Risk of Later Depression Regardless of Life Stress Psychotic features in severe Major Depression Learned helplessness model of depression and limitations o Based on past experiences one learned to have no control over one s rewards and punishments one is responsible for this helpless state 0 O O O O O O o Limited to laboratory and mostly animal subjects anxiety not always a factor in depression Types of psychotherapy for Major Depression rationales evidence for effectiveness Brain changes including BDNF neocortical and neurotransmitter disturbances in depression and possible mechanisms of action of major classes of antidepressant drugs Brain derived neurotrophic factor BDNF the activity of key neurotransmitters or hormones ultimately leads to deficiencies of important proteins and other chemicals particularly in the chemical BDNF The endocrine system may play a role in depression release hormones people with depression seem to have abnormal levels of cortisol which is released in times of stress Depression may be caused by abnormal levels of the neurotransmitters serotonin dopamine norepinephrine and acetylcholine Medical disorders that can mask as major depression Hyperthyroidism Low Testosterone or Estrogen levels Undiagnosed illness eg infectious mononucleosis Anemia Chronic Fatigue Syndrome Types of antidepressant medications uses in depression and other disorders side effects precautions and general drug classes you will not need to recall any specific drug names o The drugs do not cure depression they treat the symptoms and only work as long as they are taken 0 Monoamine Oxidase Inhibitors MAO Inhibitors Introduced in the late 1950 s Had severe dietary restrictions and very unpleasant side effects and are no longer in common use Get suicidal eat peanut butter or something else on restricted diet list 0 Tricyclics Introduced in the early 1960 s very unpleasant side effects eg weight gain dry mouth constipation dizziness blurred vision and are no longer in common use Hypotension get out of bed too fast faint Cardiotoxic poison for the heart Suicidal could down their pills o Selective Serotonin Reuptake Inhibitors SSRI s Introduced in the late 1980 s and revolutionized medication treatment for depression ie Prozac very hard to OD just bodily sideeffects o Atypical Antidepressants Introduced beginning in the 1960 s and through the 2000 s Various kinds with various modes of action Together the mostprescribed class of current antidepressants Relationship between antidepressant medication and suicidality ECT nature of treatment effectiveness and side effects o Works fastest of any therapy for depression o Mechanism of action unknown o Has fewest side effects of any therapy for depression very high satisfaction ratings o Sometimes causes spotty memory losses episodic gtgt semantic o Usually applied only to right hemisphere to minimize speech disturbance o Abused in past and now used only as a last resort and for most severe cases Comparative effectiveness of medications vs psychotherapy for Major Depression o ECT works fastest for most people and with fewest side effects o Medication and psychotherapy esp cognitive or interpersonal therapy work equally well for most people but medication works faster o For adults a combination of therapy and medication seems no more beneficial than either one alone for adolescents a combination is preferred o For adolescent depression current recommendation is an SSRI by 2009 two were FDAapproved for adolescents Prozac and Lexapro plus cognitivebehavior therapy Overview of SADs seasonal affective disorder and phototherapy o Melatonin is released in the pineal gland melatonin secretions increases during winter season calls for less energy and more rest o Phototherapy increased exposure to artificial light or talking long walks outside seem to be effective Suicide Highrisk groups major triggers warning signs biological contributors sociocultural aspects o Those with a serious illness abusive environment and occupational stress o Sudden change in mood 0 Sense of hopelessness and dichotomous thinking everything is eitheror o Modelinggenetics suicide in the family o Older white males Findings of TADS study and implications for childhood and teenage depression treatments o Compared the effectiveness of cognitive therapy alone antidepressant therapy alone cognitive and antidepressant therapy together and placebo therapy for teenage depression o Findings Cognitive therapy antidepressant therapy is best cognitive therapy is useless alone and antidepressant therapy alone is better than no therapy at all Case Descriptions and Anxiety Depression Postpartum vs Baby blues 0 Baby blues disappear within days or weeks has to do with coping with wakeful nights rattled emotions of having a new baby and can cause crying spells fatigue anxiety insomnia and sadness o Postpartum may last up to a year extreme sadness intrusive thoughts compulsions feeling of inability to cope suicidal thoughts Anxiety Disorders Brain areas neurotransmitters and ANS involvement in anxiety Physical conditions that can masquerade as anxiety disorders Hyperthyroidism Pheochromocytomas adrenal tumors that oversecrete adrenalin Inner ear disease Angina pectoris Hypoglycemia Mitral valve prolapse Cardiac arrhythmias Drug effects caffeinism nicotine addiction nasal decongestants asthma inhalers or other stimulants Types of symptomatic treatments for anxiety including types of anxiolytic medications differences precautions side effects and general classes of drugs Psychotherapy relaxation and meditation techniques Stress management training Biofeedback Exercise Support groups Anxiolytic antianxiety medications o For acute use Benzodiazepines eg Xanax Ativan Konopin Valium Rarely Betablockers eg Tenormin Indera 4192009 947 00 PM O For chronic use Most often SSRI s Prozac Lexapro etc or atypical antidepressants eg Cymbata Effexor Occasionally Atypical anxiolytics eg Buspar buspirone Know major features of and treatments for Generalized anxiety disorder 0 O O O 0 Panic O O O O O O Debilitating worry fretfulness 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 Treatments ssri disorder with and without agoraphobia Occurrence of panic attacks without warning Pattern of avoidance and disability as a result Ritualized avoidance becomes panic disorder with agoraphobia home or room within the home becomes safety zone reluctance to venture outside safety zone without escape route treatments Dietary medication control eg caffeine nicotine marijuana Anxiolytic medications benzodiazepines mainly Xanax for acute use only Antidepressant medication mainly SSRI s chronically as preventative Psychotherapy a cognitive therapy normalization de catastrophization paced metronomic breathing a supportive therapy a In vivo desensitization if agoraphobia is present Social anxiety disorder Most common anxiety disorder More common in females ratio of 15 to 1 Develops in late adolescence or young adulthood Grossly underdiagnosed in managed care population 0 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 non generalized Onethird are sufferers are very disabled and are more likely to be depressed divorced unemployed or under employed 0 Awareness that fears are excessive 0 Common performance situations Public speaking Toastmasters Public restroom use Going to parties Eating in front of others Bedroom some erectile dysfunction some orgasmic dysfunctions 0 Most commonly treated with medications benzodiazepines and or SSRI s plus supportive and proactive psychotherapy o Specific phobias types 0 Types of Specific Phobias Animal type Natural environment type ie storms heights water Situation type ie claustrophobia tunnels bridges flying driving Bodily reactions vomiting headache fever Bloodinjuryinjection type vasovaga reaction Nature of phobic stimuli undercuts a straightforward conditioning view of specific phobia o Treatments for Specific Phobias All treatments are complicated by avoidance behavior Anxiolytic or antidepressant medication preferably an SSRI Systematic desensitization In vivo desensitization effective but low treatment acceptance and high therapy dropout rates Applied tension for bloodinjection phobias Experimental VR therapy for flying and height phobias Selfhelp groups 0 Behavioral account of etiology of phobias and its validity idea of phobia preparedness Classicalconditioning Model learning see someone else afraid from it o 0CD Obsessivecompulsive Disorder diagnosed when obsessions or compulsions feel excessive or unreasonable cause great distress consume considerable time least 1 hour per day or interfere with daily functions o A person has recurrent and unwanted thoughts a need to perform repetitive and rigid actions or both 0 Risk factors signssymptoms course prognosis treatments Drugs and antidepressant treatments that increase serotonin activity seem to help some 0CD cases Antidepressant therapy with serotoninboosting medications n SSRIs eg Prozac Luvox Celexa Lexapro n Tricyclics esp clomipramine Anafranil Behavior Therapy a Thought stopping a Response prevention Psychosurgery cingulotomy for otherwise intractable cases 0 Brain areas involved in 0CD The frontal cortex and the caudate nuclei in basal ganglia gt these convert sensory info into thoughts and actions These regions may be over active in 0CD patients 0 0CD spectrum disorders Body Integrity Identity Disorder BIID n 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 quotwholenessquot Gilles de la Tourette Syndrome n n 1 Anxiety Tics people can control them but it puts them in a heightened state of tension Coprolalia making noises loudly suddenly I PAN DAS n Streptococcus and 0CD 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 Sudden onset of tic disorder or 0CD 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 0CD but may point to possible mechanisms involved in 0CD autoimmunity neurotoxicity Reactions to Extreme Trauma o Intrusive recollections daytime flashbacks nightmares illusions and acute distress upon cues suggestive of the trauma o Dissociative symptoms psychic numbing emotional detachment being in a daze dropping out of usual activities avoidance of topics related to trauma forgetting or fogginess re key aspects of trauma feeling that the current setting is not real dereaization feeling detached from one s body depersonaization O O O O O O O Chronic hyperarousal exaggerated startle hypervigilance motor restlessness Irritability and aggressiveness esp males Survival guilt insomnia Acute Stress Disorder and PTSD risk factors treatment Acute stress disorder Disability gt 2 days and lt 1 month Posttraumatic stress disorder PTSD Disability gt 1 month Men and women show similar signsymptom patterns in PTSD except that 0 women are likelier to show numbing and anxious avoidance 0 men are likelier to show irritability and ETOH abuse Risk factors 0 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 Meaney Effect Severity and chronicity of trauma Poor social support Treatment 0 Anxiolytics for anxiety panic attacks 0 Antidepressants mainly SSRI s for depression irritability o Antipsychotics eg Abilify Risperdal for any paranoia social estrangement etc 0 Sleep medications eg Lunesta Ambien Trazodone for insomnia 0 Experimental and unproven propanolol Inderal an anti hypertensive drug that blocks adrenalin may block memory consolidation after stress and reduce chances of developing PTSD o Psychotherapy 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 0 O O O Teaching phase Educate victim regarding traumas and typical reactions to trauma Reentry phase Wrapup answer Q s provide referrals develop plan of action 0 Psychotherapy PTSD Guided reexposure and abreaction controversial due to risk of retraumatization EMDR Eye movement desensitization reprocessing no evidence for special effectiveness Cognitive skills training thought neutralization Group therapy selfhelp rap groups for estrangement abreaction and support Stress management training Finding meaning in tragedy sublimation BipolarI and II Disorders Hypotheses about etiology including neurochemistry o Brain mechanism is unknown but most antimanic appear to operate on ProteinKinase C PKC an enzyme involved in the calcium metabolism of neurons o Mania may be related to high norepinephrine activity along with a low level of serotonin activity Genetic evidence o Family history of Bipolar Disorder in 30 of BD patients o 65 concordance rate in identical twins 14 in fraternal twins Signssymptoms o Crying o Irritability anger o Suicidal ideation o Euphoria o Hypersexuality o Racing thoughts o Severe insomnia o Auditory hallucinations Differences between major depression and bipolar depression 11 sex ratio of diagnosis instead of 21 Types of antimanic medications side effects precautions and general classes of medications you will not need to recall any specific drug names Lithium carbonate strong antimanic and antisuicide but weak antidepressant actions Anticonvulsants moderate antimanic and antidepressant actions Antipsychotic agents moderate antimanic and antidepressant actions Antidepressants strong antidepressant actions but increase risk of switching into mania or mixed states Nonmedication treatments Psychotherapy O O O 0 usually requires prior medication response to be valuable builds compliance to medication helps patient and family understanding impact of disorder no effect on disorder itself ECT rarely used but effective Induced Sleep very rarely used General features of 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 12 of severe childhood depressions become adult bipolar disorder About 12 of children treated for depression with SSRI 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 Relationship of bipolar disorder andor depression to creativity Depression only Major Unipolar Depression Depression Mania Bipolar Disorder Hypomania often produce sharpened and creative thinking and greater creativity o Mild psych disturbances more creative enabling Other disorders associated with bipolar disorder Bipolar I full manic and major depressive episodes Bipolar II hypomania episodes alternate major depressive episodes Cyclothymic disorder hypomanic and mild depression lease severe than bipolar disorders I and II Introduction to Psychopathology Alan Fridlund PhD Affective Disorders Clinical Features of Major Depression Pervasive sadness guilt or feelings of worthlessness Recurrent thoughts of death or suicide Pervasive anhedonia Signi cant change in weight Sleep disturbance Psychomotor agitation or retardation Pervasive fatigue or loss of energy Difficulty concentrating iosably depressed One Yeatprevzlcnce about 10 Lt ameptevalence 1520 26 of women 12 of men 1520 of U S population at any time may suffer from subsyndromal depression with nearly equal disability whom to diagnose Depressions in nonWestern countries differ from those in Western countries Risk Factors for Depression Genetic predisposition evidence from adoption and twin studies animal models Personal loss or gain no silver lining wo a cloud Prolonged psychological stress Depression I collapse History of early abuse or neglect Being in an industrialized nation Overall notrace or social class Age of first onset in latter 20 s Physical illnesschronic pain need to exclude undiagnosed other illnesses 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 depression Harry Harlow s Monkey Depression Research Kindling Each Depression Increases the Risk of Later Depression Regardless of Life Stress Why Are Women Diagnosed with Depression Twice as Much as Men Some Possibilities Xlinked depression genes Premenstrual symptoms Quality of female vs male life Female masochism Freud Cognitive style Females dwell on problems Males ignore or escape them Male depression masked by alcohol drug abuse Amish study 1stLine Depression Treatments O P J 39 39 esp 39 r 39or quot39 therapy 0 Antidepressant medication 0 Phototherapy for seasonal depression 0 ECT for treatmentrefractory depression Cognitive Therapy Uncovering automatic selfdefeating thinking patterns I Developing new ways to interpret setbacks um logically J 39 39 39 Replacing old automatic thoughts with new ones Prime areas of concern the self life events the future Primitive vs Mature Thinking in Cognitive Therapy Nondimensional and global Absolute and moralistic Invariant Selfdenigrating Irreversible Versus Multidimensional Relativistic and noniudgmental Variable Selfdescribing Reversible I am fearful I am a despicable coward I have always been and will always be a coward Something about me is seriously defective Nothing can be done about it I am moderately fearful quite generous and fairly intelligent I am more fearful than most people I know My fears vary from time to time and situation to situation I avoid situations too much and I have many fears I can learn to master many situations and overcome my fears Central Themes in Interpersonal Therapy 0 Grief Delayed 39 39 I I 1 l I O Fights Building skills in communication negotiation and assertiveness 0 Role Transitions eg leaving home divorce retirement Reevaluating the lost role building a new role developing new social supports 0 Social Deficits eg failure patterns in past relationships using role playing to learn new behavior in relationships Biochemical Theories of Depression 0 Neurotransmittter theories 0 Major transmitters implicated orepinephrine Epinephrine op amlne Serotonin SHT 0 Also Substance P NMDA NmethylDaspartate Neurosteroids O Endocrine HypothalamusPituitary Th oid Adrenal cortisol Sex hormone Testosterone Estrogen O Neurotrophic neuronal growth factors such as BDNF BrainDerived Neurotrophic Factor that promote neuronal growth and axonal and dendritic sprouting Classic View of Neurotransmitter Actions in Depression Neurotransmitter Disturbances in Depression 0 Neurotransmitter abnormalities in depression represent just one part of the neurobiological changes in depression 0 Depression is also associated with 7 reductions of BrainDerived Neurotrophic Factor BDNF and other growth factors 7 altered levels of activity in the limbic system prefrontal area and other brain regions observable by neuroimaging 7 increased levels of neurosteroid hormones which promote neuronal death and glial cell damage 0 Regardless ofthe mode of action 39 39 of 39 I 39 with 39 39 I 139 results in restoration of normal levels of BDNF and neurosteroids and return of normal neural activity 0 Reduced gray matter volume is seen in chronic depression and appear to be restored with successful antidepressant therapy People with lower amounts of gray matter in the right hemisphere 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 eg infectious mononucleosis Anemia Chronic Fatigue Syndrome Antidepressant Medications General Use Do not cure depression only hold it in check for so long as they are taken Take 2 weeks after rst dose to produce an antidepressant response Not addictive or habitforming Are not euphoriants All have some unpleasant side effects No known 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 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 antidepressants each year The highestusage state is Utah at 184 and the lowestusage state is New York at 91 Califomia 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 0 As of 2004 all antidepressants in US must now carry warnings about suicidality 0 Although some studies show that suicidal ideation is increased with antidepressant medication various studies have shown no link between antidepressant medication and actual suicides O quot1quot is 39 Jwith39 antidepressant medication r from quot of the presence of Suicide and Antidepressant Use in Sweden Suicide Attempts and Treatment for Depression Suicide Rates in the United States Teen Suicide in the United States 20002005 In 2004 the FDA demanded that blackbox warnings be included with all antidepressants resulting in a downturn in medication prescriptions to adolescents this may account in part for the rise in teenage suicides Classes of Antidepressant Medication O Monoamine Oxidase Inhibitors MAO Inhibitors Introduced in the late 1950 s Had severe dietary restrictions and very unpleasant side effects and are no longer in common use 0 Tricycljcs Introduced in the early 1960 s Eliminated the dietary restrictions of the MAO Inhibitors but still had very unpleasant side effects eg weight gain dry mouth constipation dizziness blurred vision and are no longer in common use 0 Selective Serotonin Reuptake Inhibitors SSRI s Introduced in the late 1980 s and 39 39 39 39 quot 39 for 39 Atypical Antidepressants O Atypical Antidepressants Introduced beginning in the 1960 s and through the 2000 s Various kinds with various modes of action Together the mostprescribed class of current antidepressants Atypical Depression 0 Weight gain carbohydrate binging O Hypersomnia O Leaden paralysis O Interpersonal rejection sensitivity Often O Histrionic traits O Selfmedication with caffeine or chocolate uniquely r 39 to MAh 39 quot 39 Selective Serotonin Reuptake Inhibitors SSRI s O Prozac Sarafem Zoloft Paxil Luvox Celexa Lexapro 0 Work largely on serotonin brain systems 0 Better side effect pro le than either MAOinhibitors or tricyclics 0 Can be effective for both depression and anxiety 0 Extremely safe and have transformed psychiatric prescription practices 0 Common side effects include insomnia lowered sexual interest and delayed or inhibited orgasm O Afew individuals may develop 39 39 if the quot 39 is 39 39 J and 39 39 39 O Rapidly metabolized SSRI s mainly Paxil can I 39 39 I 39 39 J 39 39 if drug is dc ed abruptly Some children on Paxil may become irritable aggressive or have suicidal ideation People who do not respond to one SSRI have a 4070 chance of responding to a second one Why Answer may lie in pharmacogenomics Atypical Antidepressants Cymbalta Effexor Pristiq Remeron Trazodone Wellbutrin Have different modes of action variously affect J l 39 systems Have fewer sexual side effects but have others eg sleepiness or agitation headache Wellbutrin NEDA activity only is stimulating and is used to treat adult ADHD and nicotine cravings sold as Zyban Cymbalta is activating but has good antianxiety effects and helps in patients with chronic pain the current bestselling antidepressant Trazodone and Remeron are both sedating and are used widely in elderly patients with insomnia I I 1 ine and 39 brain How Long Should People Take Antidepressant Medication Most depressions remit with no treatment in 34 months However odds are gt50 of 1st recurrence gt75 of 2nd recurrence etc Each recurrence tends to be longer and leaves the person with greater disability ie depression is often progressive I I 39 that is 39 J medications predicts less recurrence Medication can be tapered and then resumed if depression reemerges Slight risk of acquired medication immunity if medication is tapered then resumed 1 139 for life 1 139 39 is m 39 but so is depression In 39 early by high doses and multiple or multipleaction Increased Risks Associated with Antidepressant Medications As a whole modern antidepressants are quite safe but 0 SSRI s maybe associated with heart and lung defects in the infants of mothers taking some SSSRI s while pregnant ndtngs are precautionary and uncertain O 39 J eg quot 39 39 39 39 fever seizures in people who are taking SSRI s along with MAOI s or other serotoninraising drugs Abruptly stopping any antidepressant can result in a Tquot quot tremor zaps anxiety and panic nausea and vomiting and confusion Any antidepressant discontinuation should be tapered Alternative Depression Treatments Medications Augmentation of antidepressant therapy by lithium or antipsychotic medication like 111717167 St John s Wort Same th oxin Testosterone M F Estrogen F in menopausal and postpartum depression Phototherapy for seasonality Exercise Sleep deprivation temporary Conditions Associated with Major Depression and Often Treated with Antidepressant Medication Chronic pain BingeEating Disorder Bulimia nervosa Migraine headache Misc anxiety disorders eg Panic Disorder OCD Trichitillomania Compulsive zitpopping Compulsive shopping Compulsive gambling Hypochondria Sexual addiction Premature ejaculation Premenstrual dysphoric disorder ECT Old and New ECT Before and After 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 39 39 39 therapy work equally well for most and r 7 7 CSP39 u or i r people but medication works faster For adults a combination of therapy and medication seems no more beneficial than either one alone for adolescents a combination is preferred For 39 I current is an SSRI by 2009 two were FDAapproved for adolescents Prozac and Lexzpro plus cognitivebehavior therapy Medication is the least expensive single mode of treatment TreatmentResistant Depression 0 Up to 30 of patients do not respond to standard treatments 0 Strategies Medication augmentation 39 Lithium 39 A second antidepressant 39 Thyroid medication 39 Stimulants Ritalin Straterra 39 Sideeffect management sleep sexual response 39 Estrogen testosterone Risks of medication augmentation 39 Serotonin syndrome agitation euphoria delirium fevers muscle contractions seizures 39 Precipitation of manic states Medication ECT Vagal Nerve Stimulation Experimental Therapies for TreatmentResistant Depression Magnetic Stimulation O Transcranial magnetic stimulation TMS Uses magnetic field sufficient to produce twitches in fingers Treatment is 12 weeks of short daily sessions Initial optimism has dimmed 0 Magnetic seizure therapy MST Replaces 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 O Delivers 20 pulses per sec to electrodes wrapped around Vagus nerve in back of throat stimulator implanted in chest 0 Arose from ndings that depressed epileptic patients treated with VNS showed improvement in depression 0 FDAapproved for recurrent treatmentresistant depressant in July 2005 0 Effects accumulate over months and 13 to 12 show substantial improvement over a year 0 Exact mechanism is unknown Standard of Care for Major Depression Osheroff vs Chestnut Lodge 0 Depressed patient can start with either medication or psychotherapy 0 Medication should be started ifpatient doesn t respond quickly to psychotherapy O ECT is 39 139 1 when quot 39 proves 39 ff 39 Clinical Features of Mania 0 Euphoria or irritability O Purposeless or reckless behavior 0 Persistent insomnia O Pressured speech ight of ideas 0 Poor insight or frank psychosis o I or J Major Depression and Bipolar Disorder 0 Depression only 2 Major Unipolar Depression 0 Depression Mania 2 Bipolar Disorder Unipolar and Bipolar Disorders Unipolar Mood History 0 Unipolar Major Depression 0 Hypomania Mild mania O Unipolar Mania rare Bipolar Mood History 39 MildT l 39 wI39Jr O Bipolar I Disorder Bipolar depression w Mania O Bipolar II Disorder Bipolar depression w Hypomania 0 Mixed Episodes Bipolar depression Mania Bipolar Dis order Point prevalence 115 but more recent studies suggest 35 Probably no sex difference in prevalence Associated with high rates of alcohol drug abuse 4050 higher than any other Axis I disorder criminal behavior and anxiety disorders 40 e of rst dis 105139s ran es from15 to 45 with most e0 le dia nosed in their 20 s Ag 1 g a P P g BUT sometimes seen in children pediatric bipolar disorder Runs in families 7 Family history ofBipolar Disorder in 30 ofBD patients 65 concordance rate in M2 twins 14 in DZ twins In 20 of M2 twins in which one has BPD the other will have major depression suggesting some common inheritance 10 concordance rate in 1stdegree relatives Probably multiple routes of genetic involvement Bipolar Depression Compared to Major Unipolar Depression Depression is the more problematic state in Bipolar Disorder Most cases of Bipolar Disorder rst 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 39 signs I and r 39 39 11 sex ratio of diagnosis as opposed to 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 Dis order Brain mechanism is unknown but may re ect defects in the metabolism of ProteinKinase C PKC an enzyme involved in the calcium metabolism of neurons in specific brain areas The result is unstable levels of neurotransmitter release by these neurons PKC activity is increased in manic patients and is normalized by antimanic medications Speci c PKC inhibitors eg tamoxifen used to treat breast cancer quickly bring acute mania under control Pediatric Bipolar Dis order 0 Occurs in about 1 of children sometimes as early as infancy O Manifested by mood instability eg rages J I J hyper quot I 39 speech racing thoughts impaired J 39 39 39 and 39 39 0 Up to 12 of severe childhood depressions become adult bipolar disorder 0 About 12 of children treated for depression with SSRI s develop manic or hypomanic episodes 0 Typically a 10year lag between occurrence of first signssx and onset of treatment 0 Often confused with Attention De cit Hyperactivity Disorder ADHD due to shared sx of distractibility and hyperactivity Mixed Episodes Mania and Depression Are Not Opposites O Crying O Irritability anger O Suicidal ideation and O Euphoria O Hypersexuality 0 Racing thoughts 0 Severe insomnia O Auditory hallucinations Many mixed episodes are actually switches or manias emerging out of depressions Rapid Cycling Bipolar Disorder 0 DSMIV Four or more episodes depressions or maniashypomanias per year 0 Cycling can occur within days or hours 0 About 15 of bipolar patients are rapid cyclers more frequent in women 0 May be associated with coexisting endocrine disorder Treatments for Bipolar Disorder 0 Medication is 1stline treatment but med compliance only 30 Acute management with antipsychotic medications followed by introduction of a mood stabilizer for chronic management 0 Psychotherapy usually requires prior medication response to be Valuable builds compliance to medication helps patient and family understanding impact of disorder no effect on disorder itself 0 ECT rarely used but effective 0 Induced Sleep very rarely used Medications for Bipolar Dis order Antimsnic Action 0 Lithium carbonate strong antimanic and antisuicide but weak antidepressant actions J 1 O Anticonvulsants and actions 7 Lzmt39ctal has uniquely strong antidepressant properties and appears weightneutral 7 Also Tegteto Neuroan 7 For rapidcycling Bipolar Disorder Depakote and Topztnzx I I O 39r 39 39 agents and J 7 Ab17139139j7weightneutral Zypt39cxz Risperdzl actions 1 l O quot strong I actions but increase risk of switching into mania or mixed states AnanpressantActhn Standard of Care Polypharmacy Affective Disorders May Be Associated with Creativity No one has ever Wtitten painted sculpted modeed buth or Invented exceptlitetally to get out of 11811 Artaud Schizophrenia 682009 25400 AM Dementia praecox early dementia Latin Schizophrenia split mind Greek o Fragmented thoughts splits between thoughts and emotions withdrawal from reality General manifestations o Positive symptoms pathological excesses delusions disorganized thinking and speech heightened perceptions and hallucinations inappropriate affect o Delusions false belief delusions of reference grandeur and control 0 Formal thought disordersdisorganized thinkingspeech9 loose associations rapid shift from one subject to another 0 Neologisms made up words 9 perseveration repeating words amp statements 0 Clang rhyme to thinkexpress oneself o Hallucination mostly auditory experiencing of sights sounds or other perceptions in the absence of external stimuli o Inappropriate affect display of emotions unsuited to the situation o Negative symptoms pathological deficits 9 poverty of speech blunted and flat affect loss of volition social withdrawal 0 Poverty of speech alogia reduction in speech or speech content 0 Blunted affect show less anger sadness joy etc than most people 0 Flat affect show almost no emotion at all 0 Loss of volition avolition apathy feeling drained of energy and interest in normal goals and unable to startfollow through on a course of action 0 Social withdrawal withdrawal into their own ideas and fantasies and further from reality o Psychomotor symptoms awkward movements repeated grimaces and odd gestures o Catatonia 9 Catatonic stupor stop responding to their environment motionless and silent Catatonic rigidity maintain rigid upright posture for hours resist help to move Catatonic posturing assuming awkward bizarre posturing for long periods of time Catatonic excitement move excitedly with wild waving limbs Risk Factors Genetic predisposition o 1 general population 3 among second degree relatives 10 first degree relatives MZ twins 48 DZ twins 17 twin concordances MZ 55 DZ15 Nongenetic risks 0 Birth complications maternal malnutrition maternal exposure to flu virus or rubella German measles herpes toxoplasmosis spore old sperm DSMIVTR classification subtypes Disorganized type of schizophrenia 9 confusion incoherence and flat or inappropriate affect Catatonic type of schizophrenia 9 psychomotor disturbance of some sort ie catatonic stuporexcitement Paranoid type of schizophrenia 9 organized system of delusions and auditory hallucinations that may guide their lives Undifferentiated type of schizophrenia 9 vague overused Residual type of schizophrenia 9 continue to display blunted affect or inappropriate emotions social withdrawal eccentric behavior and illogical thinking but in less strength and number Positive versus negative symptom schizophrenia POSTIVE Childhood oddity irritability aggressiveness 9 dopamine abnormalities 9 later age of diagnosis 2025 9 female gt males 9 better prognosis 9 respond to classical antipsychotics 9 less chance of observable brain damage 0 Versus NEGATIVE Childhood with withdrawal passivity 9 earlier age of diagnosis 1618 9 male gt females 9 worse prognosis 9 poor response to classical antipsychotics 9 probably observable brain damage 9 no dopamine abnormalities Medications for schizophrenia o Classical antipsychotics ie thorazine teat mainly positive symptoms o Some atypical 2nd generation antipsychotics treat both positive and negative symptoms ie abilify o Sideeffects drowsinesssedation metabolic syndrome weight gain diabetes elevated blood lipids Motor side effects greater with classical o Akathsia 9 cruel restlessness rocking Dystonias 9 lockjaw oculogyric crisis Pseudo parkindson Tardive dyskinesia rare with 2nd generation early rabbit sign eventually tongue and limb withering Antipsychotics also treat major depression bipolar disorder PTSD borderline personality disorder and paranoid schizoid and schizotypal personality disorders Psychotherapy in schizophrenia o Adjustment to the illness family friends work love deal with secondary depressionanxiety symptom selfmoitoring Rule of thirds old prognosis probably reflects misdiagnosed bipolar disorder c 13 improve 13 stay the same 13 deteriorate NEW PROGNOSIS o 20 good adjustment 35 fair adjustment 45 incapacitated o prognosis is worse for negative schizophrenia incidence of schizophrenia appears to be declining worldwide perhaps due to better infant nutrition and childhood methods 0 O O O Eating Disorder 682009 25400 AM Types of males susceptible o Ajob or sport with requirements and pressures Jockeys wrestlers distance runners body builders and swimmers o Gay guys same body image pressures as women Westernization c We equate thinness with health and beauty o 05 to 2 of all females develop a disorder mostly western o 9095 occur in females Dieting o 95 diets fail for weight loss weight almost always quickly regained plus more Anorexia nervosa 9 o Refusal to maintain more than 85 of her normal body weight intense fear of gaining weight even though underweight has a distorted view of her weight and shape has stopped menstruating o Overestimate their body proportions more than normal women 0 Psychological problems depression anxiety low self esteem obsessive compulsive patterns 0 Perfectionist personality o Risk factors genetic involvement likely o Hypothalamic and pituitary abnormalities 0 Abnormalities in serotonin may inhibit eating 0 Obsessive personality traits two Ps Powerlessness 9 seeking control Perfectionist 9 life and body o Altered eating habits 0 Establishing irrational rules about food development of obsessive thinking food rituals sipping water between bites 0CD small binge with exercise purge o Treatment 0 Medical for physical illness hospital refeeding when 75 of body weight Inpatientoutpatient family therapy Parents control of eating and a Program of refeeding 0 Medication symptomatic depression Anxiety etc but for anorexia only Zyprexia shows promise O o Prognosis 0 1015 mortality rate from suicide illness or cardiovascular complications 0 less than 50 ever achiever normal body weight 0 poor social and occupational functioning Bulimia Nervosa bingepurge syndrome o Recurrent episodes of binge eating recurrent inappropriate compensatory behavior in order to prevent weight gain symptoms continue at least twice a week for three months undue influence of weight or shape on selfevaluation o Nonpurging type bulimia nervosa compensate by fasting or exercising Purgingtyping bulimia nervosa compensate by forced vomiting or misuse of laxatives diuretics or enemas o Damage from repeating vomiting rupture of stomach or esophagus heart damage erosion of teeth gums and fingernails broken blood vessels in the eyes swollen salivary glands menstrual irregularities and higher risk of pregnancy complications 0 Drug abuse nicotine use impulsive behavior such as sexual promiscuity and cutting and kleptomania o Susceptible populations 0 College students 1518 females and 1826 males 90 female o Treatment 0 SSRI s reduce bingeing by 70 and vomiting by 60 o Therapy support groups cognitivebehavior therapy 0 Treatment over several years is usually successful 7090 but relapse is common and patients should not expect cures BingeEating Disorder o Frequent episodes of eating what others would consider an abnormally large amount of food with bingeing at least two days a week for six months Eating Disorder NOS o Infrequent bingepurging episodes repeated chewing and spitting of food without swallowing anorexialike behavior at normal weight Dissociative Disorders 682009 25400 AM Nature and manifestations o Emotions detachment being in a daze dropping of usual activities avoidance of topics related to trauma forgetting key aspects of trauma derealization feeling the current setting is not real depersonalization feeling detached from one s body Anxiety spectrum 9 9 9 increasing anxiety o Anxiety disorders anxiety is felt 9 0CD anxiety is ritualized and warded off by obsessions and compulsions 9 9 dissociative disorders anxiety is isolated and denied Dissociative amnesia inability to recall important information about their lives and is more extensive than normal forgetfulness o Brief episode may be due to drug or medication sideeffects o Often confined to a period of time following a stressful event PTSD only retrograde loss rarely anterograde amnesia o Stressrelated hormones in brain may block memory consolidation and retrieval o More likely with a traumatic history o Often ends with in hours or days o Treatment involves anxiolytic meds and supportive psychotherapy sometimes with sedativehypnotic meds Dissociative Fugue DSMIV o Confusion about persona identity or assumption or a new identity o Person usually travels to a new location and forgets their past o Same treatments as above Depersonalization Disorder o Experience of being outside one s own body or having distorted perceptions of oneself o Patient is not psychotic o Patient has significant stress or impairment o Not due to general medical conditions schizophrenia medsdrugs panic disorder or acute stress disorder Dissociative Identity Disorder a dissociative disorder in which the person develops two or more distinct personalities o Iatrogenic illness Some researchers believe therapists cerate the disorder by asking the patient to cerate different personalities while under hypnosis o The patient may experience gaps in time and an inability to recall important person information o Treatment 0 O O O Psychotherapy group therapy for the personalities hypnosis reintegration of the personalities Sometimes antianxiety and antiOdepressant medications Most DID s improve with therapy but fragment under stress Recovered memory therapy false memory syndrome 9 professionally disfavored ADHD 682009 25400 AM Two main kinds inattentive type hyperactiveimpulsive type combination type c Inattentive easily distracted forgetful poor attention to detail difficulty organizing task s and activities doesn t listen when spoken to o Hyperactiveimpulsive fidgetssquirms leaves seat often restless runs aroundclimbs excessively excessive talking difficulty waiting turn Risk factors genetic link 4050 of people with ADHD have first degree relative with it o Infants with prenatal complications premature birth low birth weight o Anxious mothers 1222 weeks of pregnancy o Children with high blood lead levels Prevalence o 35 of preadolescents have ADHD o hyperactive type males gt females 3191 o inattentive type femalesgtmales Defects people with ADHD show 35 year delays in growth of neurons especially in frontal lobes Comorbidity of possibly o Bipolar disorder conduct disorder depression 0CD oppositional defiant disorder specific learning disorder Tourette s syndrome Consequences of ADHD o Bad grades 50 of felonsjuvies have untreated ADHD teens with hyperactive ADHD more likely to have car accidents get pregnant get an STD commit arson or run away o 80 ADHD children retain symptoms past adolescence o 5 college students with ADHD graduate Treatments for ADHD o Stimulant drugs ie Ritalin lowers rate of substance abuse side effects 9 insomnia headache nausea o Nonstimulants not controlled drugs Welbutrin esp adults Straterra SNRIoften as good as stimulants but with less insomnia ProvigilNuvigil esp inattentive patients o Structuring school and home environments with scheduling minimal distraction clear immediate rewardspunishment for target behavior punishment timeout or withdrawal of privileges Adult ADHD signs o Seeks noisybusy place to get work done Frequent changing of the tvradio stations Difficulty waiting in line Tuning out in conversation and intimate moments Blurting Intuitiveness out of the box approaches to problems DAT Alzheimer s Disease 682009 25400 AM Risk Factors o increasing age being female history of heart injury having heart disease stroke or hypertension periodontal gum disease possibly small head circumference and simplistic early writing o genetics and family history 0 M2 twins 4060 concordance 0 Some early onset DAT mutated genes on chromosomes one or 14 Almost all Down s syndrome who live 4050 will have DAT maybe some DAT are Trisomy 21 mosaicism Brain and neurotransmitter changes o Cell death and loss of acetylcholine o Senile amyloid plaques cell debris and betaamyloid peptide o Neurofibrillary tangles tau protein Early SignsSymptoms o Recent memory loss affection job skills difficulty performing familiar tasks language and naming problems time and place disorientation problems with abstract thinking personalitymood changes loss ofjudgmentinitiative misplacing things Late signssymptoms FAST slide o Assistance in dressing bathing and toileting o Urinary and fecal incontinence o Speech ability declines o Progressive loss of abilities to walk sit up smile and hold head up Course of illness o Early onset DAT due in 1 to 2 years c DAT functional assessment staging normal adult to severe DAT 0 Usually live normal life expectancy Treatments o Assisted living in dementia facility with a structured labeled environment o Estrogen for women o Acetylcholine boosters will delay the progression of the illness Prevention o Estrogen for women NSAIDs Advil Ibprophin O Fair Game Sheet Final Exam I BE ABLE TO DESCRIBE DEFINE 0R ANSWER QUESTIONS RELATED TO Dissociative Disorders Nature of dissociation typical manifestations of dissociation daydreaming spacing out Possible relationship of anxiety to dissociative disorders dissociative disorders may be from high anxiety anxiety isolated and denied spectrum anxiety to OCD to dissociation Experiences of depersonalization and de realization own voice or surroundings sound unreal things look at personal memories like others had them actions feel robotic jamais vu what was familiar feels unfamiliar Typical signssymptoms and the course of each Dissociative amnesia inability to recall imp01tant personal info signi cant distressimpairment often following stressful event like PTSD tend to recur episode often ends within hours or days or ch drugs more in W can still form new memories stress related hormones maybe blocked consolidation generic memory usually intact Treatment anxiolytic meds and psychotherapy Dissociative fugue sudden unexpected travel away from home with amnesia for hisher past confusion about identity or adoption of a new one signi cant distress or impairment Often triggered by traumatic event episodes shortlived and completely reversible hours to months often diagnosed after Treatment anxiolytic meds and psychotherapy Depersonalization disorder experience of being outside of own body are aware of odd perception signi cant distress or impairment rarely last long enough to be diagnosable 2x more in W abuse stressors and having it before may be risk factors Dissociative identity disorder the presence of two or more distinct identities 2100 average 10 can know each other or not inability to recall important personal info not due to substance general medical condition or child fantasy play Can occur with abusetrauma good at selfhypnosis Predominant explanation of DID try to dissociate from feeling anxiety View of DID as an iatrogenic illness maybe promoted by suggestion eliciting Preferred treatments for DID Treatment Psychotherapy average of 4 years usually hypnosis reintegrating personalities sometimes truth telling sleepy medicine sodium amytal psychodynamic group therapy for the personalities cognitive behavioral for isolating dominant personality minimizing naming of others no interpersonality conversations Other treatment antianxiety or antidepressant medications Most are moderately improved by end of therapy 7 typical outcome is reintegration but fractionation under stress Effectiveness of recovered memory therapy likely confabulation false memory syndrome many treatment failures false accusations and family upheavals depopular now Personality disorders Who has them sex age Typical signs and symptoms for each type of personality disorder Cluster A odd eccentric Paranoid Personality Disorder unwarranted suspiciousness or mistrust hypersensitivity restricted emotion sometimes charismatic moralistic and grandiose hypersensitivity rarely seen in therapy or medical settings because doesn t trust Schizoid Personality Disorder defective ability to form close relationships only 12 people cold aloof absence of interpersonal warmth indifference to praise or criticism loners usually referred by others Treatment antipsychotics antidepressants therapy Schizotypal Personality Disorder mostly M odd thinking magical thinking ideas of reference to self eccentric speech might invent words paranoia cold aloof socially isolated hypersensitivity might have hallucinations or delusions under stress high suicide risk Treatment antipsychotics therapy Cluster B dramatic emotional unstable Histrionic Personality Disorder mostly F genetic component attention seeking overly dramatic interpersonal difficulties because shallow transient relationships vain demanding self indulgent egocentric dependant and helpless prone to make suicidal threats frequent health complaints sexually promiscuous or withholding manipulative Treatment antidepressants therapy Narcissistic Personality Disorder mostly M grandiose sense of self importance or uniqueness fantasies of unlimited power success brilliance ideal love demands for approval and agreement reacts to criticism with rage or indifference disturbed interpersonal relationships sense of entitlement exploits for self advancement others are either allies or obstacles Splitting idealizationdevaluation of people either liked or hated and can turn on a dime doesn t tolerate aws lack of empathy Treatment rarely seeks it usually drops out Borderline Personality Disorder mostly F unstable chaotic and intense relationships self damaging behavior like sex drugs gambling overeating Inappropriate intense anger and marked mood shifts Splitting idealization devaluation of people either liked or hated and can turn on a dime can t stand being alone with deep abandonment depressions feelings of internal emptiness and void repeated suicidal gestures self mutilation some cases related to early abuse gtSelfmutilation and dissociation transient psychotic episodes Etiological hypotheses maybe borderline mother created borderline child child feels black and white with relationships Treatments Psychodynamic and medicinal Psychodynamic theory says failure to master separation and individuation Medicines antimanics antidepressants and or anxiolytics sometimes antipsychotics Long term therapy is high structured psychodynamic therapy short hospital stays for abandonment depressions Antisocial Personality Disorder mostly M violates rights of others doesn t feel guilt and remorse concrete morality insensitive to punishment and rewarding strong genetic contribution and incompetent parenting sometimes diagnosed with ADHD or conduct disorder early frequent drug abuse incarceration Relationship between psychopathy and DSM IV Antisocial Personality Disorder APD are only the ones that get caught again and again the dumb ones Etiological hypotheses cortical immaturity prefrontal area dysfunction genetic incompetent parenting de cient in arousa Anxiety and physiological arousal they have low slow or hypervariable arousal de cient 100k sleepy if juice them with amphetamine make normal decisions Successful psychopaths charming can get away with it Course of disorder through childhood adolescence and adulthood Childhood lying stealing truancy hurt other kids and animals resist authority early psychopathic triad re setting bedwetting enuresis animal cruelty Adolescents early aggressive and sexual behavior excessive drinking or dru s Adulthood persistence of adolescent behavior cant hold a job are irresponsible parents law breaking illegal activities no close relationships or loyalties manipulative sometimes charming often burn out around 40 s Treatments incarceration Cluster C anxious apprehensive Avoidant Personality Disorder MF hypersensitive to rejection or ridicule strong desire for relationships for extreme skittishness about them social withdrawal retreat to secondary roles to not be in center of crowd desire for acceptance and affection low self esteem devalues personal strengths and overvalues shortcomings Treatment medication for anxiety and depression therapy for social skills and assertiveness supportive individual therapy group therapy Dependant Personality Disorder MF allows life to be run by others puts major decisions on others subordinates own needs to others sees self as helpless and stupid does not make demands for fear of jeopardizing relationships thankful for relationships typically appears sel ess and bland sometimes precipitated by chronic physical illness Treatment medication for symptoms group family or couples therapy ObsessiveCompulsive Personality Disorder mostly M belief in how they think cold sh restricted warmth or tenderness perfectionist extremely moralistic judgmental about self and others preoccupied with small details lists rules and schedules insists that others conform to person s way workaholic l l 39 with A 39 quot 39L 39 39 to criticism by authority indecisive fear of making mistakes 7 procrastination thinks a lot about priorities not necessarily more productive Treatment psychotherapy and antidepressants Relationship between OCD and Obsessivecompulsive personality disorder OCD people are overcome bothered and disturbed by their compulsions don t want it there while OCPD believe in how they think PassiveAggressive Personality Disorder continuous pattern of negative attitudes hostile compliance begrudging agreement that beings in early adulthood passive resistance to demands for adequate performance in social and occupational structures expressed ass procrastination intentional inefficiency and obstructionism forgetting obligations always arriving late repeated evasion sulking or arguing when asked to do something unpleasant stubbornnessresentment of useful suggestions complaining about unreasonable demands making unreasonable criticism of authority gures manipulations others into assuming their obligations caustic ass joking unacknowledged hostility Treatment psychotherapy build self con dence teach assertiveness to say from beginning rather than sulking medications for any depression or anxiety General personality disorder treatment quot anxiolytics treatment quot39 J for 39 l 39 quot 39 quot Schizophrenia shattered head Dementia praecox in Latin by Kraeplin General manifestations loss of previous level of functioning disturbance of language and communication altered thought boundaries broadcasting insertion and removal hallucinations usually auditory delusional experiences and beliefs emotionally disordered at paranoid or silly affect disturbance of the will harder to get them started social withdrawal and autistic thinking motor abnormalities reduced spontaneity or bizarre gestures or postures Risk factors Genetic predisposition closer the relative high the chance and concordances 15 if one parent is 46 if both parents are 50 if your identical twin is 15 if your fraternal twin is Infectious agents rubella german measles spores like owning cats retroviruses like herpes 2 Bi1th trauma forcep deliveries protracted labors maternal malnutrition old sperm older the father is higher the chance Seasonality effects in schizophrenic biiths more in the FALL MZ twin types and implications Monochorionic twins share a placenta blood supply and have higher concordance rates 70 than dichorionic twins who have their own separate placentas 18 concordance which suggests shared environment Classical schizophrenia subtypes and problems with subtypes Disorganized hebephrenic Catatonic mold them exible waxy then frenzy Paranoid most common suspicious conspiracies lots of auditory hallucinations Undifferentiated if don t t other 3 gtgtgtProblem people can change subtypes over time or it may instead re ect intensity or course of illness and treatment is not speci c to subtype it s all the same Positive vs negative signssymptoms of schizophrenia range of symptoms Positive symptom type 1 more in E things that are added like hallucinations delusions paranoid or silly affect bizarre or disorganized behavior disordered thought processes Childhood odd irritability aggressiveness later age of diagnosis 2025 better prognosis has too much dopamine responds to classical antipsychotic meds less chance of observable brain damage Negative symptom type 2 or de cit syndrome more in M things that are lacking like at affect psychomotor retardation mutism blocking freeze in middle of sentence and don t nish social withdrawal poor grooming Childhood withdrawal and passivity earlier age of diagnosis 1618 worse prognosis no dopamine abnormalities poor response to meds greater chance of observable brain damage Classical atypical antipsychotic medications effects side effects and major classes of medications Classical Antipsychotics treat mostly positivesymptom schizophrenia Atypical Antipsychotics treat both positive and negativesymptoms Motor and metabolic side effects of antipsychotic medications drowsiness weight gain esp abdomen motor side effects like akathisia restlessness like rocking acute dystonias muscles lock lock jaw stuck eyes pseudoparkinsonism resting tremor slowness of movements muscular rigidity new meds lessen this tardive dyskinesia early rabbit sign eventually tongue and limb writhing Role of psychotherapy in schizophrenia they work on adjustment to illness family friends work love to live with what they have better deal with secondary depression and anxiety help them selfmonitor symptoms Other disorders often treated with J 39 quot quot quot major 39 A 39 bipolar disorder paranoid schizoid and schizotypal personality disorders borderline personality disorder posttraumatic stress disorder Worldwide trends in schizophrenia incidence and possible causes new cases are slowing down in rate u vaccine Better nutrition Diagnosing bipolar disorder separately now Rule of thirds and newer outcome estimates in schizophrenia Former Rule of thirds said that l 3 improve l3 stay the same and l 3 deteriorate But the true proportions are actually slightly worse with 45 deteriorate 35 fair adjustment 20 good adjustment Might re ect former misdiagnosed bipolar disorder Prognosis worse for negative symptom schizophrenia Eating Disorders serotonin DSM IV eating disorders be able to de ne or identify from brief case descriptions Prevalence as a function of sex and Westernization and explanations overwhelmingly F overwhelmingly found in Western countries and increasing in countries as they Westernize because as cultures Westernize more F join the work force thinness replaces obesity as a sign of wealth and status exposure to television Types of males who are especially susceptible to eating disorders men in sports that emphasize thinness or weight control wrestling boxing crew jockeying competitive body building gay men Effectiveness of dieting as a weightloss method ineffective weight is almost always quickly regained and more Anorexia nervosa n Bulimia ervous loss of appetite Nature of body distortion person feels fat even when obviously underweight tricklens studies Susceptible populations females women athletes and dancers most cases begin in adolescence ages 1320 runs in families Altered eating habits refusal to maintain adequate weight intense fear of weight gain loss of period amenorrhea often in children who were picky eaters perfectionistic and socially avoidant Begins with period of dietary restriction after a period of weight gain and negative cements about the person s weight or after stressful life event Develops obsessive thinking about food how much did I eat how much can I let myself eat establish irrational rules about food food rituals excessive exercise quotTwo P39squot of anorexia Powerlessness and Perfectionism How anorexia nervosa is treated and typical treatment outcome denial is rst problem medical management of any physical illnesses that may have resulted from starvation hostpital re feeding if necessary Inpatient to outpatient family therapy reassert parents control of eating begin a program of re feeding Medication so far ineffective but some show promise Treat any accompanying depression or anxiety Effectiveness mortality rate 1025 from illness or suicide sometimes cardiovascular complications Fewer than half of all anorexics ever achieve a normal weight and among the recovered their social and occupational functioning is poor nervosa 0x appetite Susceptible populations F adolescents and young adults ages 1518 for M 1826yrs college students early sexual abuse emotionally impulsive unstable maybe Personality disorder OCD Types of compensatory behavior among bulimics Purging selfinduced vomiting manual with meds laxatives or diuretics Nonpurging exercise and or temporary fasting Bodily damage suffered in bulimia nervosa mostly from vomiting rupture of stomach or esophagus heart damage erosion of teeth gums and fingernails broken blood vessels in the eyes swollen salivary glands chipmunk face menstrual irregularities more drug abuse smoking or other impulsive behavior sexual promiscuity cutting kleptomania low self esteem and impulsivity might have them hurt injure themselves How bulimia nervosa is treated and typical treatment outcome usually responds well to treatment First high doses of SSRI s which reduce bingeing and purging signi cantly Then therapy like support groups cognitive behavioral therapy focus is on resisting impulses to binge and purge healthy eating developing positive alternatives to foodcentered behavior Treatment over several years is usually successful but relapse is common so don t expect cure ADHD ADHD types with general features of each Inattentive Type need 6 or more mostly F Poor attention to detail careless mistakes in school work 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 dif culty organizing tasks and activities Avoids dislikes tasks requiring sustained mental effort Often loses things Easily distracted Frequently forgetful HyperactiveImpulsive Type need 6 or more mostly M Hyperactive usually declines with age Frequent dgeting and squirming Leaves seat frequently Runs around or climbs excessively in adolescence feelings of restlessness Difficulty at quiet play Excessive talking Impulsive oftenpersists Blurts out answers before Q is nished Has dif culty waiting his her turn Frequently interrupts and butts in activities Who is affected by ADHD risk factors family and genetic contributions Mostly in M Found in every culture and socioeconomic level but US has one of the highest with Japan 4050 of adhd people have at least one lst degree relative with it concordance MZ twins 50 DZ 40 Infants with prenatal complications premature births low birth weight Infants whose mothers had high anxiety in weeks 1222 Children with high blood levels of lead Children who have had frequent changes of residence whose parents have divorced whose fathers are irresponsiblyantisocial cause or effect Hypotheses about defects that may occur in ADHD show 35 year delay in growth of neurons especially in frontal lobes attention impulse control and initiation perception of movementtime seems slow low dopamine sensory screen Comorbidity of ADHD occurrence with other disorders 5090 also have bipolar disorder conduct disorder depression OCD learning disorders tourette s syndrome Consequences of ADHD poor school performance 20 have also learning disability 50 develop conduct disorder delinquency andor drug abuse only 5 of college students graduate up to 80 of children retain symptoms through adulthood Accepted treatments for ADHD 7 quot quot 7 ff quot 39 J quot 39 and side effects Long term positive effects Stimulant drugs controlled drugs 80 of ADHD children may unmask tic disorder frequent side effects insomnia headache nausea usually subside Leave children shorter at high doses but with a break catch up sometimes liver problems no longer given Increases experience but on the outside look calm and quiet can be dangerous if heart defect N0nStimulant drugs non controlled drugs April 04 2011 Psychopathology Intro to psychopathology 1 Mental illness basis in philosophy a Monism i Mind is equalreducible to brain ii Change the brain then change the person iii Mental illness is brain illness atype of medical illness b Dualism i Mind is different from Brain ii Mental illness is a behavior II Scope ofmental illness a Originally menml illness was synonymous with insanity reserved for psychoses and sudden disabling or bizarre changes in behavior thinking b Menml illness has been broadened i Now mental disorder rather than menml illness ii Menml disorders now span a wide range of severity l Schizophrenia Alzheimer s type dementia 111 Why worry about how to de ne mental disorder a Menml disorder diagnoses are stigmatizing b Menml disorder diagnoses are sometimes used as tools ofpolitical persecution c Menml disorder diagnoses are used to marginalize dissent S Halleck Tbepolz39tz39m of therapy 1971 d Menml disorder diagnoses are used to excuse defendants and others from responsibility for their actions ie Allan Dershowitz s excuse abuse e Hope A valid and consistent de nition of mental disorder will produce no false positives and no false negatives Underlying Dichotomies That Drive Attempts to De ne Mental Disorder 0 Is a condition normal or abnormal Many different criteria Deviance statistical moral Distress self andor others Dysfunction inability efficiency maladaptation Danger self andor others 0 Is a person ill or evil Disorder or sin 0 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 Of cial View Am en39can Psyclzia tzic Associa lion 1994 A mental disorder is aclinically39 quot39 39 39 or r or pattern that occurs in an individual and that is associated with 0 present distress eg a painful symptom or O disability ie impairment in one or more important areas of function or O with a signi cantly increased risk of suffering death pain disability or an important loss of freedom and must not be merely an r 39 and 39 quot 1 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 4th Edition How Do We Learn What Mental Disorders Look Like Prototype Theory Theories ofm caning De nitions of Disorder 0 Definitional theory of meaning 9 Semantic definitions of mental disorders 0 Prototype theory of meaning 9 Prototype definitions of mental disorders Where Do People Acquire These Mental Disorder Prototypes 0 Repeated exposure to quot 39 r 39 J as 39 39 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 Nosology Science or scheme of disease categorization and classification Diagnosis Act of assigning a nosological category Basic Terminology from Emil Kraepelin Etiology 2 Cause Course I Trajectory Prognosis 2 Outcome Signs 2 Observable markers Symptoms 2 Patient reports Signs Symptoms I Syndrome Syndrome Course 2 Disease Why Diagnose At All Prognosis Treatment implications Communication among professions Establish prospects for contagion or other transmission and possible prevention Legal reasons eg I insanity duc Financial reasons compensation to patient andor treatment provider Research Problems Inherent in the Act of Diagnosis o T the 39 I of 39 quot 39 39 patient Can falsely imply etiology cause Rigidifies treatment alternatives Iatrogenic illness Illness caused by care giver when trying to x the prob Mix medications Stigmatization Secondary gain Two Kinds of Diagnosis 0 Phenotypic Signs Symptoms Course Outcome Response to treatment 0 Genotypic Cause Laboratorytests In physical medicine progress consists of moving from phenotypic to genotypic diagnosis In mental health nearly all diagnosis is phenotypic Ingredients of a Diagnosis Symptoms Signs Course of illness Age of onset Family history Recent events Recent behavior Psychological tests Laboratory tests eg neuroimaging hormonal assays genetic testing Response to treatment prior or current Multifactorial Nature of Diagnosis No single sign or symptom de nes a mental disorder ie is pathognom onic of a mental disorder Diagnosis is based on ape ttem of signs and symptoms ie a syndrome 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 A T L 4 A 1 l a 1952 DSM I 100 disorders in 8 categories 1968 DSM II 100 disorders in 10 categories 1980 DSM III 230 disorders in 19 categories 1989 DSM IIIR Revised 750 disorders in 40 categories 1994 DSM IV 2000 DSMIVTR Text Revision Update 2013 DSMV see WWWdsm5og DSMI and DSMII Diagnosis Consisted of brief 39 39 I 39 I of each disorder eg 300 04 Depressive neurosis This disorder is manif sted by an excessive reaction to an internal con ict or to an identi able event such as the loss ofa love object or cherished possession Deciding which disorder fit a particular patient was highly subjective and proved statistically unreliable Features ofDSMIII IIIR IV IVTR Phenotypic diagnosis ased only on observable signssymptoms quot 39 39 39 39 39 39 and terms like neurosis and reaction r v Cl 99 1 39 39 I Inclusion criteria Exclusion criteria Fieldtested for reliability Multiaxial diagnosis DSMIVTR Phenotypic Diagnosis eg Major Depression Single Episode Inclusion Cn39ten39a Aperson must have experienced at least 5 of the 9 symptoms below for the same two weeks or more for most of the time almost every day and this is a change from hisher prior level of functioning One of the symptoms must be either a depressed mood or b loss ofinterest Depressed mood most of the day nearly every day indicated by subjective report eg fells sad or empty or observation made by others eg appears tearful For children and adolescents may be irritable mood Signi cantly reduced level of interest or pleasure in all or almost all activities most of the day nearly every day A considerable loss or gain of weight eg 5 or more change of weight in a month when not dieting This may also be an increase or decrease in appetite For children they may fail to gain an expected amount of weight Difficulty falling or staying asleep insomnia or sleeping more than usual hypersomnia nearly every ay Psychomotor agitation or retardation nearly every day observable by others not merely due to subjective report Fatigue or loss of energy nearly every day Thoughts of worthlessness or excessive or inappropriate guilt which may be delusional nearly every day not merely selfreproach or guilt about being ill Diminished ability to think or concentrate or indecisiveness Recurrent thoughts of death not just fear of dying recurrent suidical ideation without a specific plan or a suicide attempt or a speci c plan for committing suicide The symptoms cause clinically significant distress or impairment in social occupational or other important areas of functioning DSMIVTR Phenotypic Diagnosis Cont d eg Major Depression Single Episode Exclu st39on Criteria The persons39 symptoms do not indicate a mixed episode The person39s symptoms are not due to the direct physiological effects of a substance eg a drug of abuse a medication or a general medical condition eg hypothyroidism The symptoms are not better accounted for by Bereavement ie after the loss of a loved one they continue for more than two months or they include great difficulty in functioning frequent thoughts ofworthlessness thoughts of suicide psychotic I I n Orr DSMIV Multiaxial Diagnosis Axis I Major Mental Disorders amp VCodes Axis II Personality Disorders amp Mental Retardation Axis III General Medical Conditions Axis IV Psychosocial Environmental Problems Axis V Global Assessment of Functioning Axis I VCodes V1581 Noncompliance With Treatment V611 Partner Relational Problem Physical Sexual Abuse of a Adult V6120 ParentChild Relational Problem V6121 Child Ne lect Physical Sexual Abuse of a Child V618 Sibling Relational Problem V619 Relational Problem Related to a Mental Disorder or General Medical Condition V622 Occupational Problem V623 Academic Problem V624 Acculturation Problem V6281 Relational Problems V6282 Bereavement V6289 Borderline Intellectual Functioning Phase of Life Problem Religious or Spiritual Problem V65 2 Malingering V7101 V7102 V7109 100 91 90 81 8071 7061 6051 5041 4031 3021 20 11 10 1 Adult Antisocial Behavior Child or Adolescent Antisocial Behavior No Diagnosis on Axis II No Diagnosis or Condition on Axis I Global Assessment of Functioning GAF Scale Superior functioning in a wide range of activities life39s problems never seem to get out of hand is sought out by others because of his or her many positive qualities No symptoms Absent or minimal symptoms eg mild anxiety before an exam good functioning in all areas interested and involved in a wide range of activities socially effective generally satis ed with life no more than everyday problems or concerns eg an occasional argument with family members If symptoms are present they are transient and expectable reactions to psychosocial stressors eg d39 iculty concentrating after family arguments no more than slight 39 A 39 in social 39 or school L 39 39 B eg A quot falling behind in schoolwork Some mild symptoms eg depressed mood and mild insomnia OR some dif culty in social occupational or school functioning eg occasional truancy or theft within the household but generally functioning pretty well has some meaningful interpersonal relationships Moderate symptoms eg at affect and circumstantial speech occasional panic attacks OR moderate dif culty in social occupational or school function eg few friends con icts with peers or coworkers Serious symptoms eg suicidal ideation severe obsessional rituals frequent shoplifting OR any serious impairment in social occupational or school functioning eg no friends unable to keep a job Some impairment in reality testing or communication eg speech is at times illogical obscure or irrelevant OR major impairment in several areas such as work or school family relations judgment thinking or mood eg depressed man avoids friends neglects family and is unable to work child frequently beats up younger children is defiant at home and is failing at school Behavior is considerably in uenced by delusions or hallucinations OR serious impairment in communication or judgment eg sometimes incoherent acts grossly 39 A A A 39 39 suicidal A A 39 OR inability to function in almost all areas eg stays in bed all day no job home friends Some danger of hurting self or others eg suicide attempts without clear expectation of death frequently violent manic excitement OR occasionally fails to maintain minimal personal hygiene eg smears feces OR gross impairment in communication eg largely incoherent or mute Persistent danger of severely hurting self or others eg recurrent violence OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of 1 death 00 Inadequate information Clinical Interview Types of Information and Goals Lasts about 1 hr most Valuable single source of information leading to a diagnosis Personal and family history re medical mentalhealth social occupational financial problems Treatments that have workednot worked in past Symptomatology Signs from patient s presentation Goals n 39 39 quot39 and quot for r 39 r 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 Signs Noted in Clinical Interview Attire amp grooming Posture Physical characteristics Skin tone complexion Weight stature Symmetry atrophy bodily anomalies Mannerisms spasms or tics Speech Articulation Prosody Consciousness Level of alertness fogginess hypervigilance Emotional state General attitude De ant compliant guarded defensive sincere plaintive resistant apathetic etc Thought content Solicited by free inquiry Thought processes Thought broadcasting removal insertion Gen l knowledge General facts pop culture Abstract thinking 0 Social judgment 0 Insight 0 Cognitive functioning Usually current mental status Via MMSE Neuropsychological screens like clock drawing Mini Mental Status Exam MMSE Folstein et al 1975 O Orientation up to KS Time year season date day month Place state county city facility Person name age 0 Registration Slowly say the names of 3 common objects apple table penny and ask patient to repeat them 0 Attention amp calculation Serial 7 s or WO R L D backwards 0 Recall Ask for names of 3 objects above 0 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 oor Read and obey the following CLOSE YOUR EYES Write a sentence Copy the following design Clock Drawing as a Neurological Screen Helpful Ancillary Diagnostic Information 0 Info from family members 0 Info from physicians employers 0 Medical chart 0 Obtaining this kind of information usually require signed releases and informed


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