PSYCHOPATHOLOGY PSY 103
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Date Created: 10/22/15
Introduction to Psychopathology Alan J Fridlund PhD What Is A Mental Illness Why Is This Issue Important quotOur culture is permeated with psychiatric thought Psychiatry which had its beginnings in the care of the sick has expanded its net to include everyone and it exercises its authority over this total population by methods that range from enforced therapy and coerced control to the advancement of ideas and the promulgation of values Jonas Robitscher The Concept of Mental Illness Depends on Basic Philosophical Assumptions 0 Monism Mind Is equalreducible to Brain 0 Dualism Mind is different from Brain 0 Emergentism Mind is an emergent property of Brain as liquidity is to water but Mind can never equalreduce to Brain just as liquidity is lost if water is reduced to constituents Philosophical Implications for Mental Illness o Monism Mental illness is brain illness a type of medical illness 0 Dualism Emergentism Mental Illness is L quotThe mind cannot really become diseased any more than the intellect can become abscessed Furthermore the idea that mental 39diseases39 are actually brain diseases creates a strange category of 39diseases39 which are by definition without known cause Body and behavior become intertwined in this confusion until they are no longer distinguishable It is necessary to return to first principles a disease is something you have behavior is something you do E Fuller Torrey MD Scope of Mental Illness 0 Originally mental illness was synonymous with insanity reserved for psychoses and sudden disabling or bizarre changes in behavior thinking 0 Mental illness has been broadened Now mental disorder rather than mental illness Mental disorders now span a wide range of severity o Schizophrenia Alzheimer s type dementia o Controversially Homosexuality now declassified alcoholism pedophilia psychopathy intermittent explosive disorder 0 Premature ejaculation PMS flying phobias gambling addiction voyeurism exhibitionism insomnia sleepwalking nightmares Why Worry About How To Define Mental Disorder 0 Mental disorder diagnoses are stigmatizing 0 Mental disorder diagnoses are sometimes used as tools of political persecution 0 Mental disorder diagnoses are used to marginalize dissent S Halleck The politics of therapy 1971 0 Mental disorder diagnoses are used to excuse defendants and others from responsibility for their actions excuse abuse 0 Hope A valid and consistent definition of mental disorder will produce no false positives and no false negatives Underlying Dichotomies That Drive Attempts to Define Mental Disorder C Is a condition normal or abnormal C Is a person ill or evil C Is the professional response to the condition treatment or oppression Mental Disorders Some Classic Views 0 Skeptical antipsychiatric view 0 Pure values approach 0 Whatever professionals treat 0 Statistical deviance 0 Biological disadvantage 0 Prototype approach 0 DS MIV view unexplained distress or disability 1 Skeptical AntiPsychiatric View Breggin Szasz Laing 0 Claim 1 Because psychodiagnosis is often used for social control then the diagnoses themselves are suspect Rosenhan Experiment On being sane in insane placesquot Counterclaim The use of diagnosis does not speak to the validity of diagnosis eg Leper colonies SARS quarantines 0 Claim 2 Because there is often no identifiable lesion in mental disorders only altered behavior then there is no basis for diagnosing a disorder Counterclaim 1 Many recognized physical disorders have no identifiable lesion eg many backaches stomach aches headaches some cases of epilepsy Counterclaim 2 Presence of a lesion does not automatically mandate a physical disorder diagnosis birthmarks innocent heart murmurs supernumerary breasts Rosenhan Experiment Science 1973 0 Eight supposedly normal persons including some psychology faculty faked symptoms of schizophrenia and were admitted for a total of 12 inpatient hospitalizations 0 Immediately upon admission all reverted to normal behavior except for taking notes on ward behavior 0 None was undiagnosed even after weeks in the hospital 0 Hospital stays ranged from 7 to 52 days most of the patients were discharged paranoid schizophrenia in remission O Rosenhan s conclusion mental disorder is a matter of social labeling 2 Pure Values Approach MeadSullivanLemertBeckerScheff 0 Claim Diagnoses are merely social judgments based on societal norms of behavior cf labeling theory thus societies make mental disorders Counterclaim 1 Because this view deprives disorder of any intrinsic validity nothing can be disqualified as a disorder eg drapetomania rape pedophilia and homosexuality as arousal disorders Counterclaim 2 Many conditions that are highly undesirable and are a target for social control are not labeled disorders temper tantrums tagging buildings ignorance illiteracy begging the question of what makes society use the disorder label when it does 3 Whatever Professionals Treat 0 Claim There is no logical basis for distinguishing disorder from normalcy simply put societyjust places certain people under the purview of mental health professionals Disorder then is defined by what gets treated Counterclaim 1 Mental health specialists treat many states of affairs that neither they nor anyone else consider disorders marital counseling family therapy assertiveness training sexual enhancement Counterclaim 2 Like the Pure Values approach this approach leaves no way to disqualify a condition as a disorder eg a criminal in therapy homosexuality rapism domestic assault child abuse Variant of Whatever Professionals Treat Whatever Responds to Treatment 0 Claim An individual has a mental disorder if heshe is improved when treated for that disorder eg diagnosis by medication symptomatic treatment Counterclaim 1 Treatments are typically not specific to single disorders Counterclaim 2 The boundary between normalcy and disorder is diffuse and so treatments can improve even normal functioning 4 Statistical Deviance 0 Claim Mentally disordered behavior doesn t differ in kind from normal behavior it just differs in frequency intensity etc Thus statistical deviance defines mental disorder Normal blues vs depression normal exhilaration or irritability vs mania Losing one s temper vs Impulse Control Disorder Normal worrying and superstitions vs ObsessiveCompulsive Disorder Counterclaim 1 Many conditions are statistically deviant but are not considered disorders genius articulateness diplomacy artistry Counterclaim 2 Many statistically normal conditions are regarded as disorders obesity in America tooth decay alcoholism among certain tribes of American Indians prostate cancer in aged males 5 Biological Disadvantage 0 Claim A mental disorder is a condition in which the mind does not function as it should It places the individual at a biological evolutionary disadvantage ie it lowers longevity or fertility Reigning model in physical medicine eg heart disease compromises circulation pulmonary disease compromises breathing etc Assumes that disorder definitions whether mental or physical can be value free Counterclaim 1 Cannot exclude supranormal skills talents eg math or computer prodigies that can result in social marginalization Counterclaim 2 Requires arbitrary definition of normal longevity or fertility and normal may not mean optimal eg more educated people reproduce less Counterclaim 3 Lowered longevity or fertility often stems from the social consequences of a person s condition not from the individual himherself eg illiterate people get worse health care Counterclaim 4 Conditions with a late onset would be excluded as disorders eg Alzheimer stype dementia Counterclaim 5 Socialization often entails training dysfunction and proper functioning is diagnosable aggression spousal jealousy maybe rape and depression 6 Mental Disorder As a Set of Prototypes Theories of meaning 0 Definitional theory of meaning 0 Prototype theory of meaning Where Do People Acquire These Mental Disorder Prototypes 0 Repeated exposure to conditions perceived as necessitating medical intervention 0 Personal and indirect books films TV experiences in which people are seen to have unwanted conditions requiring medical or therapeutic intervention 7 DSMIV View American Psychiatric Association 1994 CLAIM A mental disorder is a clinically significant behavioral or psychological syndrome 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 significantly increased risk of suffering death pain disability or an important loss of freedom and must not be merely an expectable and culturally sanctioned response to a particular event for example the death of a loved one C Counterclaim 1 The not expectable criterion might inaccurately include expectable reactions to abuse or neglect O Counterclaim 2 The syndrome criterion would include many conditions not usually considered mental disorders illiteracy Nosology Science or scheme of disease categorization and classification Basic Terminology O Etiology Cause 0 Course Trajectory O Prognosis Outcome 0 Signs Observable markers 0 Symptoms Patient reports 0 Signs Symptoms Syndrome O Syndrome Course Disease Why Diagnose At All C Prognosis 0 Treatment implications 0 Communication among professions 0 Establish prospects for contagion or other transmission and possible prevention 0 Legal reasons eg competence insanity determinations 0 Financial reasons compensation to patient andor treatment provider 0 Research Problems Inherent in the Act of Diagnosis 0 Sacrifices the uniqueness of individual patient 0 Can falsely imply etiology cause 0 Rigidifies treatment alternatives 0 Iatrogenic illness 0 Stigmatization 0 Secondary gain Two Kinds of Diagnosis 0 Phenotypic Signs Symptoms Course Outcome Response to treatment 0 Genotypic Cause Laboratory tests Ingredients of a Diagnosis 0 Symptoms 0 Signs 0 Course of illness 0 Age of onset C Family history 0 Recent events 0 Recent behavior 0 Psychological tests 0 Laboratory tests for example endocrine genetic 0 Response to treatment prior or current Nature of Diagnosis 0 No single sign or symptom defines a mental disorder ie is pathognomonic of a mental disorder 0 Diagnosis is based on a pattern of signs and symptoms ie a syndrome 0 The patterns of syndromes and courses of illness that define mental disorders are spelled out in the nosology of mental disorders Diagnostic and Statistical Manuals for Mental Disorder DSM series American Psychiatric Association 0 1952 DSM I O 1968 DSM II C 1980 DSM III 0 1989 DSM quotIR Revised 0 1994 DSM IV O 2010 DSMV Features of DSMIll IIIR IV 0 Multiaxial diagnosis 0 Fieldtested for reliability 0 Phenotypic diagnosis 0 Based only on observable signssymptoms 0 Abandoned terms like neurosis and reaction 0 Chinesemenu decisiontree approach 0 Inclusion criteria 0 Exclusion criteria DSMIV Multiaxial Diagnosis 0 Axis I Major Mental Disorders amp VCodes 0 Axis II Personality Disorders amp M R 0 Axis III General Medical Conditions 0 Axis IV Psychosocial Environmental Problems 0 Axis V Global Assessment of Functioning Axis I VCodes O V1581 Noncompliance With Treatment 0 V611 Partner Relational Problem Physical Sexual Abuse of an Adult V6120 ParentChild Relational Problem V6121 Child Neglect Physical Sexual Abuse of a Child V618 Sibling Relational Problem V619 Relational Problem Related to a Mental Disorder or General Medical Condition C V622 Occupational Problem 0 V623 Academic Problem 0 V624 Acculturation Problem 0 V6281 Relational Problems 0 V6282 Bereavement V6289 Borderline Intellectual Functioning Phase of Life Problem Religious or Spiritual Problem 0 V652 Malingering O V7101 Adult Antisocial Behavior 0 V7102 Child or Adolescent Antisocial Behavior V7109 No Diagnosis on Axis II No Diagnosis or Condition on Axis Global Assessment of Functioning GAF Scale 0 100 91 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 symptoms90 81Absent 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 satisfied with life no more than everyday problems or concerns eg an occasional argument with family members 0 8071 If symptoms are present they are transient and expectable reactions to psychosocial stressors eg difficulty concentrating after family arguments no more than slight impairment in social occupational or school functioning eg temporarily falling behind in schoolwork C 7061 Some mild symptoms eg depressed mood and mild insomnia OR some difficulty in social occupational or school functioning eg occasional truancy or theft within the household but generally functioning pretty well has some meaningful interpersonal relationships 0 6051 Moderate symptoms eg flat affect and circumstantial speech occasional panic attacks OR moderate difficulty in social occupational or school function eg few friends conflicts with peers or coworkers 0 5041 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 ajob 04031 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 C 3021 Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication orjudgment eg sometimes incoherent acts grossly inappropriately suicidal preoccupation OR inability to function in almost all areas eg stays in bed all day no job home friends 0 2011 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 0104 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 0 00 Inadequate information Clinical Interview Types of Information Signs Noted in Clinical Interview 0 Posture O Attire amp grooming O Mannerisms spasms or tics 0 Articulation 0 Speech prosody 0 Consciousness 0 Emotional state 0 General attitude 0 Thought content 0 Thought processes 0 Memory 0 Gen l knowledge 0 Attention 0 Abstract thinking 0 Social judgment 0 Insight Mental Status Exam MSE 0 Orientation up to x3 Time year season date day month Place state county city facility Person name age Introduction to Psychopathology Alan J Fridlund PhD Schizophrenia ERRUR S DIRTY LAUNDRY 39 THE TROUBLE WITH POP MIISIG naxacnmtn LaxEr Luv 1 C OLS IllmlIlRRmllllnnulllmlll Huhl manmsnsxmlslm 1 3 man What is Schizophrenia o Psychotic disorder 0 Affects 12 of population across cultures 12 of all psychiatric inpatients 1A of all 1st admissions to mental hospitals 23 of all homeless 0 Known for over 100 years Auguste Morel 1860 mental deterioration at an early age Emil Kraepelin 1898 dementia praecox Eugen Bleuler 1911 schizophrenia 0 Primary symptoms thought disorder breakdown of associations 0 Restitutional symptoms hallucinations delusions 0 Not multiple or split personality 0 One schizophrenia or many schizophrenias Em Typical Features of Schizophrenia 0 Loss of previous level of functioning O Disturbances of language and communication 0 Formal thought disorder Altered thought boundaries thought broadcasting insertion removal Hallucinations usually auditory Delusional experiences Delusional beliefs I Disordered emotionality flat paranoid or silly affect o Disturbances of the will 0 Social withdrawal and autistic thinking 0 Motor abnormalities Reduced spontaneity or Bizarre or stereotyped gestures and postures Classical DSM Subtypes of Schizophrenia O Disorganized Hebephrenic o Catatonic o Undifferentiated O Paranoid Problems with classical subtypes 0 Individuals can change subtypes over time 0 Subtypes may instead reflect course and intensity of illness 0 Treatment not specific to subtype Risk Factors Who Becomes Schizophrenic 0 Not childrearing 0 Genetic relatedness consanguinity Odds of a child becoming schizophrenic are c 15 if one parent is schizophrenic vs 1 base rate 0 46 if both parents are schizophrenic vs 1 base rate Above risk applies even if children are adopted early into new homes Twin concordances M2 55 DZ 15 57 Tim11mg 1I7 Mg wammmssa y a Cquot 4 Nongenetic Risk Factors in Schizophrenia 0 Birth complications eg protracted labors forceps deliveries O Maternal malnutrition O Seasonality of birth 0 Geographic clusters of 46 incidence O Maternal exposure to influenza virus Risk greatest at 6th month of gestation Viral exposure may explain MZ I DZ difference 0 Other infectious agents may be involved Rubella German measles Toxoplasmosis spores greater prevalence of cat ownership among parents of schizophrenlcs Endogenous retroviruses eg herpes simplex ll 0 Old sperm odds of schizophrenic child are About 1 in 200 if father is 25 About1 in 120 if father is 40 About 1 in 70 if father is 50 Two Cases of Paranoid Schizophrenia Maximal Schizophrenia Risk from Maternal Viral Infection 6th Month Gestational Age quot 39 v g 39 Jason Waldmann Born 212000 at 25 weeks gestation Life May 2000 Prenatal Environment and Two Types of M2 Twins One Placenta Two Placentas Monochorionic Twins Dichorionic Twins What Is the Damage in Schizophrenia 0 Early views discredited Metabolic disorder Kraepelin Doublebinding mother Freudians 0 Structural brain damage autopsy CT scans Cellular derangement Enlarged ventricles O Disordered brain activity PET amp fMRl scans Frontal lobe Basal ganglia Cerebellum O Neurotransmitter disorder Transmethylation theory Dopamine hypothesis Dopamineserotonin interaction 0 Modern view schizophrenia is a neurodevelopmental disorder Research Classifications of Schizophrenia eg Timothy Crow Nancy Andreasen O Positivesymptom schizophrenia Type I Hallucinations Delusions Psychotic Paranoid or silly affect Bizarre or disorganized behavior D39 39 d Disordered thought processes 39sorgamze O Negativesymptom schizophrenia Type II Deficit Syndrome Flat affect Psychomotor retardation Mutism and blocking Poor grooming Social withdrawal Positive vs 0 o o Symptom Schizophrenia o 0 versus 0 o o Symptom o Schizophrenia o 0 Negative Symptom Schizophrenia Childhood oddity irritability aggressiveness Later age of diagnosis 2025 Females gt Males Better prognosis DA abnormalities Responds to classical antipsychotic meds Less chance of observable brain damage Childhood withdrawal passivity Earlier age of diagnosis 1618 Males gt Females Worse prognosis No DA abnormalities Poor response to classical antipsychotic meds Greater chance of observable brain damage Schizophrenia The Dopamine DA Connection 0 Autopsied brains of schizophrenics show high levels of DA 0 Drugs that increase brain DA can cause disorder that resembles symptom schizophrenia 0 Classical medications used to treat symptom schizophrenia lower brain DA 0 Individuals treated with those classical medications develop motor signssymptoms that resemble Parkinson s disease which involves the loss of DA neurons 0 Individuals 10 suffering from Parkinson s disease when taking medication to restore DA levels may suffer from a disorder that resembles symptom schizophrenia Schizophrenia DopamineSerotonin Interaction Hypothesis 0 Classical medications that affect DA control only symptoms 0 Newer medications that reduce both DA and serotonin can treat both and symptoms 0 On PET and fMRI scans reduction of symptoms associated with return of normal brain activity Schizophrenia Other Neurochemical Involvement O Neurokinin 3 NK3 movement disorder component 0 Glutamate NMDA receptor negative signs I symptoms and cognitive signs 0 Secretin peptide hormone autistic social withdrawal 0 Medications affecting each of these neurochemical systems are in varying stages of development Treatments for Schizophrenia 0 Medication Primary Acute sedation and chemical restraint Chronic normalization of cognition and behavior 0 Individual Psychotherapy Adjunctive Adjustment to illness 0 Family 0 Friends OWork 0 Love Deal with secondary depression anxiety Symptom selfmonitoring Medication for Schizophrenia Antipsychotics Major Tranquilizers NeurolepticS Some Classical Antipsychotics Treat Mainly Symptoms Thorazine Haldol Stelazine Prolixin Some Atypical 2 3I Generation Antipsychotics Treat Both and Symptoms Clorazil Invega Risperdal Seroquel Zyprexa Abilify Geodon Note Abilify and Geodon are weightneutral Side Effects of Antipsychotic Medications O Drowsiness I sedation can be beneficial in agitated patients 0 Metabolic syndrome Weight gain especially in abdomen Elevated blood lipids cholesterol amp triglycerides Diabetes blood glucose dysregulation 0 Motor side effects much greater wlclassical antipsychotics like Thorazine and Haldol Akathisia cruel restlessness eg rocking Thorazine shuffle Acute dystonias lockjaw oculogyric crisis Pseudoparkinsonism o Resting Tremor o Slowness of movements 0 Muscular rigidity Tardive dyskinesia rare with 2quotdgeneration medications 0 Early rabbit sign 0 Eventually tongue and limb writhing Phases of Clinical Trials in Medication Development Phase I conducted in a small group of people 2080 to assess safety dosage range and possible side effects The primary goal of these trials is to look at the overall safety of a given medication Phase I studies may last several months Phase II further assessment of efficacy and safety in a larger group of people 100300 Although safety is still a serious consideration the primary goal of Phase II trials is to determine effectiveness Phase II studies will last from several months to up to two years Phase III testing with approximately 10003000 subjects to confirm efficacy compare with other treatments monitor safety and side effects Phase III trials can last from 14 years and are a final consideration of safety effectiveness and dosage of a given medication Phase IV Postmarketing studies to gather further information about safety efficacy or optimal use Only 2530 of candidate medications proceed to Phase III trials and only 20 are ever marketed Bringing a new drug to market typically costs 200 million to 800 million and takes 1015 years Other Disorders Usually with Psychotic Features In Which Antipsychotic Medications Are Sometimes Used 0 Major Depression 0 Bipolar Disorder several antipsychotic medications such as Abilify are FDAapproved for both schizophrenia and bipolar disorder 0 Paranoid Schizoid and Schizotypal Personality Disorders 0 Borderline Personality Disorder 0 Posttraumatic Stress Disorder Prognosis in Schizophrenia O Formerly Rule of thirds 13 improve 1l3 stay same 1l3 deteriorate rule probably reflects misdiagnosed bipolar disorder 0 Now outlook is considered more dismal On 30year followup 20 show good adjustment 35 show fair adjustment 45 incapacitated O Prognosis worse for symptom schizophrenia O Newer medications may improve prognosis 0 Incidence of schizophrenia appears to be declining worldwide perhaps due to better infant nutrition and childbirth methods
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