Psychiatry

biologically based drives and motives

executive apparatus, mediates reality, drives, conscience, and makes adaptations

Conscience, socially determined values and behaviors

REGULATION OF DRIVES, AFFECT, AND IMPULSE
CAPACITY FOR INTERPERSONAL RELATIONSHIPS
SENSE OF SELF
CAPACITY FOR PLEASURE
REALITY TESTING
SYNTHETIC INTEGRATION
DEFENSIVE ADAPTATION

UBIQUITOUS
TRIGGERED BY ANXIETY OR CONFLICT
UNCONSCIOUS
MATURATIONAL HIERARCHY
IMMATURE DEFENSES MAY APPEAR IN THE FACE OF SEVERE STRESS BUT PERSISTENCE INDICATES PATHOLOGY:
Examples such as:
DENIAL
PROJECTION
FANTASY
ACTING OUT
SPLITTING
HYPOCHONDRIASIS (SOMATIZATION)
DISSOCIATION
PASSIVE AGGRESSION
TURNING AGAINST THE SELF
REACTION FORMATION
ISOLATION OF AFFECT
INTELLECTUALIZATION
DISPLACEMENT
REPRESSION
HUMOR
ALTRUISM
SUPPRESSION
SUBLIMATION

MATURE - sublimation, suppression, altruism, humor
NEUROTIC - repression, displacement, isolation, reaction formation
IMMATURE - dissociation, acting out, fantasy, projection, hypochondriasis, splitting
PSYCHOTIC - denial

changes an unacceptable wish (instinct, impulse) into one that is socially acceptable.

–involves some degree of conscious decision to postpone or avoid an emotionally troubling issue

addresses an emotional conflict through constructive attention to the needs of others, as opposed to the needs of self

direct expression of feelings without discomfort or harm to others

emotional energy targets the unacceptable thought or feeling and keeps it out of consciousness while allowing the possibility of some symbolic representation to be expressed

transfers the problematic feeling or impulse from its original context to a substitute that carries less intensity

strips all the feeling away from the thought

similar to isolation, above. Involves excessive rational thought, divorced from any affect, as a means of addressing an emotionally uncomfortable issue. Also similar to rationalization which tries to make the intolerable tolerable via a plausible explanation

deals with an unacceptable thought or feeling by substituting its opposite.

anger expressed indirectly through passivity or inaction

a form of passive aggression that involves hostile feelings towards another redirected toward the self

splitting off a portion of experience (may involve consciousness, memory, identity, perception, or some combination of these) that would ordinarily be integrated with other parts of the conscious self

direct expression of a feeling or wish via impulsive behavior that usually results in some harm to self or others

transfer of emotional conflict or painful feelings to somatic symptoms or complaints. Note that this is not malingering

creation of self-contained fantasies as a means of restoring emotional equilibrium

attributing one’s own unacceptable thought, feeling, or impulse toward another

disavowing thoughts, feelings, or impulses which are intolerable – refusing to recognize reality

inability to tolerate ambivalence (mixed feelings). Involves concrete, usually intense “black and white” thinking and emotions (idealization and devaluation) that can shift back and forth with time, depending on the person’s emotional state

dependent, demanding - dependent
orderly, controlling - obsessive compulsive
dramatizing, emotional - histrionic
long-suffering, self sacrificing - masochistic
guarded, suspicious - paranoid
superior, special - narcissistic
seclusive, aloof - schizoid

Alternate names: Hysteria, Briquet’s Syndrome
Multiple physical symptoms (“complaints”) from four different systems (pain, GI, sexual, quasi-neurological)
Starting before age 30
Lasting “several years”

Physical symptoms or concern about physical symptoms
Not explained by an actual physical condition or somatic symptoms of another psychiatric disorder
Symptoms not intentionally produced or feigned (i.e., Factitious Disorder or Malingering)
Symptoms cause distress or impairment

Alternate names: Abridged Somatization, Subsyndromal Somatization Disorder
> 1 physical symptom
Lasting > 6 months

Alternate names: Hysteria; Hysterical Neurosis, Conversion Type
> 1 deficit(s) of voluntary motor or sensory function (subtypes -- Motor, Sensory, Seizures/Convulsions, Mixed)
Excludes pain and sexual dysfunction
Evidence of psychological factors: preceded by stressor

Alternate name: Somatoform Pain Disorder
Pain
Evidence of psychological factors
Can be associated with a General Medical Condition or not

Alternate name: Hypochondriacal Neurosis
Preoccupation with having a serious disease despite reassurance
Preoccupation not delusional, not about appearance
> 6 months’ duration

Alternate name: Dysmorphophobia
Excessive preoccupation with perceived defect in physical appearance

Includes Pseudocyesis; symptoms not qualifying for other diagnoses, e.g, duration too short

Prevalence: F - .2-2%, M - .2% (DSM-IV); 3-9% in general medical populations; 1.1% in children (Garber 1991); may vary with culture (e.g., higher in Puerto Rico)
Usually starts by early adulthood
Generally chronic

Frequently associated with MDD, Panic Disorder, Substance-Related Disorders, Axis II (Histrionic, Borderline, Antisocial)
Evidence of association with childhood sexual abuse (Morrison, 1989)
Familial association with itself, Antisocial Personality Disorder, Substance-Related Disorders - both genetic, environmental factors

?Somatization as an unconscious process; alexithymia
?Social learning theory - expression of social needs
?Frontal lobe dysfunction
?Relationship to hypnotizability - 81% highly hypnotizable, 42% had DID (Bliss, 1983)

Appropriate medical work-up (60% of “hysterics” had organic disease in 9-year follow-up (Slater, 1965))
Management, not cure

?Trial of SSRI, MAOI, TCA
Nefazodone (Menza, et al., 2001)
St. John’s Wort (Volz, et al., 2002)
Gabapentin (García-Campayo & Sanz-Carrillo, 2001)

Consistent care with single physician - regular, brief, supportive visits; perhaps education; minimize unnecessary testing (limited research support)
Consultation letter from psychiatrist to physician reduced health care costs (in Looper & Kirmayer, 2002)

Psychoeducational group (Kashner, 1995)
?Move patient towards talking about personal/emotional concerns from physical concerns
5-10% recovery rate for psychodynamic psychoRx (Coen, 1992)
Cognitive-behavioral therapy - physical symptoms responded better than psychological distress (review, Kroenke & Sindle, 2000)

Prevalence: 4.4% (Smith, 1987), 12% (Escobar, 1991); 17% in general medical populations (Kirmayer & Robbins, 1991)

Little explored
Probably as for Somatization Disorder

Prevalence: .01-.3%, 1-3% of mental health outpatients (DSM-IV)
20-25% of medical inpatients (Engel, 1970), 24% of psychiatric outpatients (Guze, et al., 1971)
5-40% of epilepsy patients, F:M = 3:1 (Chabolla, et al., 1996)
F>M (2:1 TO 10:1)
Greater in lower SES, less educated, more rural populations (supposedly)

?Association with childhood abuse
L>R
Wide range of time courses
Associated with Dissociative Disorders, MDD, Axis II (Histrionic, Antisocial, Dependent)
Some evidence for genetic factors; familial association with ?itself, Antisocial Personality Disorder

Psychodynamic theory - resolution of unconscious conflict
-Primary and secondary gain
-La belle indifference

Dissociation theory - self-hypnosis

?Underlying organic disease predisposing (67% of patients with Conversion Disorder had another medical diagnosis (Merskey & Buhrich, 1975); 10-60% of patients with pseudoseizures also have epilepsy (Lesser, 1996))

Decreased blood flow in thalamus, basal ganglia contralateral to symptoms (?”disorder in striatothalamocortical circuits controlling sensorimotor function”), resolved after recovery (Vuilleumier, et al., 2001)

“the same subcortical premotor circuits are also involved in unilateral motor neglect after organic neurological damage, where voluntary limb use may fail despite a lack of true paralysis”

Prevalence unclear - up to 50% of pain with no clear medical cause; 1-82% (Verhaak, et al., 1998)
Prognosis of acute pain good, of chronic pain poor
?L>R (Miller, 1984)


Associated with Mood Disorders, Anxiety Disorders
Possible familial associations with itself, Mood Disorders, EtOH Dependence

Appropriate medical work-up (60% of “hysterics” had organic disease in 9-year follow-up (Slater, 1965))
More recent studies suggest only 0-3% of conversion disorders had organic cause (Binzer & Kullgren, 1998; Crimlisk, et al., 1998)
Confrontation
Suggestion
Hypnosis
Amytal interview
Recovery rates - usually found to be ~90 % (63% (Heruti, et al., 2002))

?Conditioned behavior
?Decreased pain threshold
?Social/cultural factors
Neural correlates of social exclusion similar to those of physical pain (anterior cingulate cortex activation) (Eisenberger, et al., 2003)

Maintain activity (can include PT/OT)
Cognitive-behavioral therapy
Hypnosis
Complementary therapies, e.g., massage (Cherkin, et al., 2001), acupuncture, Therapeutic Touch, Reiki


NSAIDs
Minimize opioids
SSRI, TCA, MAOI, anticonvulsants
TENS

Prevalence - 4-9% in medical outpatients (DSM-IV); up to 50% of medical outpatients have at least some hypochondriacal aspect (Kellner, 1985)
Intermittent worry about illness in 10-20% of people, 45% of “neurotics” (Kellner, 1987)


M = F (F seek help for it more)
Usual onset in early adulthood
Generally chronic
High Axis I comorbidity (62-88% (Noyes, 1999) - especially Anxiety Disorders, but also Depression Disorders


Conflicting data on familial tendency; increased Somatization Disorder, Anxiety Disorders in relatives (Noyes, 1999)
Are there subtypes, e.g., obsessive-compulsive/phobic, disease conviction/disease phobia, personality disorder/depression/anxiety?

Somatization/alexithymia (means the inability to express feelings)
Misinterpretation of bodily sensations
Psychodynamic theories - defenses/manifestations related to anger/internal threat; dependency; self-deficit
Learned social behavior communicating interpersonal meaning
Serotoninergic deficit

?Regular visits, ?reassurance
Cognitive-behavioral therapy (limited effectiveness)
SSRI, clomipramine, imipramine
[Pimozide, neuroleptics (monosymptomatic hypochondriasis)]

Prevalence unclear - perhaps 2% of general population, 12% of psychiatric outpatients (Allen & Hollander, 2000)
Alternatively, 7-15% of patients seeking cosmetic surgery, dermatologic procedures (in Crerand, et al., 2004)
But similar rates (8%) of BDD (by self-report) among patients seeking non-cosmetic surgery and cosmetic surgery (Crerand, et al., 2004)


Usually begins in adolescence, usually chronic
37% of BDD patients have OCD (Simeon, et al., 1995), 80% have Major Depression (Phillips, 1998), high comorbidity of Anxiety Disorders, Axis II also reported
Level of insight ranges to delusionality (in which case Delusional Disorder, Somatic Type is additional diagnosis)

Serotoninergic deficit
Influence of social ideals
?Variant of OCD
?Variant of “Body Image Disorder” (along with Eating Disorders)

Cognitive-behavioral therapy, group CBT (Molenaar, 2010)
SSRI, clomipramine, [MAOI] (even for delusional BDD)
Levetiracetam (Phillips & Menard, 2009)
Severe cases - augment with neuroleptic, buspirone, gabapentin, stimulants
ECT, psychosurgery (limited data)
Mixed data on cosmetic surgery

In fact, many of the studies of CBT for BDD apparently are of patients with weight/body shape dissatisfactions.

Intentional production of signs or symptoms for external reward
Antisocial Personality Disorder a risk factor
Pseudo-malingering – pretending to have a disease that one eventually discovers one has (Schneck, 1962; Schneck, 1970; Hay, 1983)

Three types: With Predominantly Psychological Signs and Symptoms; With Predominantly Physical Signs and Symptoms; With Combined…
Psychological type rarely diagnosed (at DHMC)

Intentional production of signs or symptoms to assume the sick role (deception not actually necessary: “factitious” = “artificial” (OED))


Two predominant patterns -
-F, 20-40, often a health care worker
-M, middle-aged, socially isolated (“Mu(e)nchausen syndrome” - severe form with physical symptoms, pseudologia fantastica)

No good treatment - can provide face-saving alternative (one interesting approach is to double-bind the patient: “You may have physical illness or factitious illness; if the former it will improve with this treatment.” Teasell & Shapiro, 1994; Eisendrath, 1994)
Anecdotal reports of resolution after chance to express distress (Zegans, pers. comm.)

Research criteria in DSM-IV
Literature review (Sheridan, 2003)
Victims --
usually <4 y.o.
22 mo. from symptoms to diagnosis
6% dead, 7% long-term injury
25% of siblings dead, 61% of siblings had suspicious symptoms
Mothers the perpetrators in 76%

Emotional and behavioral traits that characterize the person in day-to-day living under ordinary conditions
Cognition, affect, behavior and interpersonal style
Relatively stable and predictable
Types and traits vs Pathology
Personality Tests – Briggs Myers, etc

Longstanding pervasive and inflexible patterns of behavior
Depart from cultural expectation
Impair social and occupational functioning
Cause emotional distress
Coded as Axis II and can be co-morbid with Axis I

Dimensional vs Categorical

Knowledge of personality disorders can improve relationships, enhance compliance and reduce stress

Axis I

Cluster A – Odd and Eccentric
Paranoid, Schizotypal & Schizoid

Cluster B – Dramatic, Emotional and Erratic
Borderline, Histrionic, Narcissistic & Antisocial

Cluster C – Anxious & Fearful
Avoidant, Dependent and Obsessive-Compulsive

0.5-2.5% of the population.
Men > Women.
Likely on continuum of schizophrenia
Lacks hallucinations


Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.
Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.
Reads hidden meaning or threatening meanings into benign remarks or events.


Persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights.
Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.
Does not occur exclusively during the course of a Psychotic Disorder and is not due to a general medical condition.

3%
New Orleans
M>F
Cultural norms?
Associated with schizophrenia


Ideas of reference (excluding delusions of reference).
Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”).
Unusual perceptual experiences, including bodily illusions.
Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped).
Suspiciousness or paranoid ideation.


Inappropriate or constricted affect.
Behavior or appearance that is odd, eccentric. Or peculiar.
Lack of close friends or confidants other than first-degree relatives.
Excessive social anxiety that does not diminish with familiarity and tends to be associated withparanoid fears rather than negative judgments about self.
Does not occur exclusively during the course of a Psychotic Disorder or a Pervasive Developmental Disorder.

Lighthouse Keeper
Prevalence < 1%, M>F
? Relationship with schizophrenia


Neither desires nor enjoys close relationships, including being part of a family.
Almost always chooses solitary activities.
Has little, if any, interest in having sexual experiences with another person.
Takes pleasure in few, if any, activities.
Lacks close friends or confidants other than first-degree relatives.


Appears indifferent to the praise and criticism of others.
Shows emotional coldness, detachment, or flattened affectivity.
Does not occur exclusively during the course of a Psychotic Disorder, or a Pervasive Developmental Disorder and is not due to a general medical condition.

1-2% of the population.
Twice as common in women as in men.
Increased prevalence of Major Depressive Disorder, Alcohol Abuse/Dependence, and Substance Abuse found in first-degree relatives.
Border of psychosis
DBT – Linehan
Abuse or “invalidating” family environment
F > M

Frantic efforts to avoid real or imagined abandonment.
A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
Identity disturbance: markedly and persistently unstable self-image or sense of self.
Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
Chronic feelings of emptiness.


Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
Transient, stress-related paranoid ideation or severe dissociative symptoms.

2-3%.
Diagnosed more frequently in women than in men
Medical student example
F > M slightly
Hollywood – Marilyn Monroe

Is uncomfortable in situations in which he or she is not the center of attention.
Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.
Displays rapidly shifting and shallow expression of emotions.
Consistently uses physical appearance to draw attention to self.

Has a style of speech that is excessively impressionistic and lacking in detail.
Shows self-dramatization, theatricality, and exaggerated expression.
Is suggestible, i.e., easily influenced by others or circumstances.
Considers relationships to be more intimate that they actually are

Ivy League
Hanover Inn
High suicide rates – narcissistic injury
1%
Adaptive – athletes, business, etc.

Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
Requires excessive admiration.

Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations.
Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends.
Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
Is often envious of others or believes that others are envious of him or her.
Shows arrogant, haughty behavior or attitudes.

3% in men and 1% in women
High in prison populations.
Familial pattern present
High co-morbidity with etoh dependence
Pulp Fiction
RI Case
Name issue
Genetic link
Developmental issues
Twin studies – greater concordance with MZ than DZ twins

Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest.
Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
Impulsivity or failure to plan ahead.
Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
Reckless disregard for safety of self or others.

Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.
The individual is at least age 18 years, and there is evidence of Conduct Disorder with onset before age 15 years.
The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.

Overlap with social phobia
1%
Treatment – exposure therapy

Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection.
Is unwilling to get involved with people unless certain of being liked.
Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
Is preoccupied with being criticized or rejected in social situations.
Is inhibited in new interpersonal situations because of feelings of inadequacy.
Views self as socially inept, personally unappealing, or inferior to others.
Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.

High medical/obesity
1.5%
F>M

Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.
Needs others to assume responsibility for most major areas of his or her life.
Has difficulty expressing disagreement with others because of fear of loss of support or approval.
Has difficulty initiating projects or doing things on his or her own (because of a lack of selfconfidence in judgment or abilities rather than a lack of motivation or energy).
Dependent
Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.
Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself.
Urgently seeks another relationship as a source of care and support when a close relationship ends.
Is unrealistically preoccupied with fears of being left to take care of himself or herself.

Unfortunate name
OCD vs OCPD
1%

Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.
Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overtly strict standards are not met).
Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships.
Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values.

Is unable to discard worn-out or worthless objects even when they have no sentimental value.
Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.
Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.
Shows rigidity and stubborness

Passive-Aggressive Personality Disorder.
Depressive Personality Disorder.
Patient with features of more than one Personality Disorder.

Symptomatic
Psychotherapy – change disorder into traits
Psychodynamic, CBT, DBT
Social skills training
Medications

Linking thoughts, emotions behaviors, physical symptoms
Change one --> change in another
Linking past to present
Understanding past increases understanding of present
Linking patient to others
Linking patient to higher meaning

Physician is
-safe figure, non-judgmental, empathic, consistently supportive
-provides explanation, understanding
-encourages old and new coping strategies
-confidential
-social sanction for healing

Provides and adheres to boundaries

Be sure to keep the focus on:
-Patient goals
-Patients thoughts, feelings and behaviors

Collaboration - do “with” not “to”

Explore resistance rather than confront resistance

Modalities
Individual, group, martial, family
Supportive
Expressive
Behavior
Cognitive

Focus on education, strengthening existing adaptive behaviors, advice

Supportive therapy
Help pts cope with difficult situations through support, enhancing coping mechanisms

Crisis intervention
Brief problem solving approach to stressful situations

Mutual self help
Alcoholics Anonymous, church groups. Involves education and peer support. May involve strategies taught in cognitive, behavioral, and insight-oriented therapies

Involves developing insight or better understanding of meaning of current behavior, symptoms, situation

Exploration of unconscious thoughts & feelings

Psychoanalysis

Psychodynamic psychotherapy

Insight-oriented psychotherapy

Involves concepts of the unconscious, conflicts and transference


Developed by Freud and expanded by others
Less well developed research base, although 2 new studies support this approach for the treatment of depression

A. Psychoanalysis
Frequent visits, very long term, change through insight, too costly and time consuming for most people

B. Psychodynamic psychotherapy
Based on analytic principles but more problem focused and short term.

C. Insight-oriented therapy
Focuses more on here and now as opposed to the past. Focus on relationships

Focus on changing behavior rather than understanding the problem - can be used in the treatment of most mood, anxiety, psychotic and substance use disorders
-Relaxation training
-social skills training
-exposure with or without response prevention
-contingency management


Helpful for illnesses with abnormal behaviors: eating disorders, substance use disorders, obsessive compulsive disorder
Therapist acts as teacher, role model, guide
Multiple types

Focus on changing cognitions (patterns of thinking) that contribute to the problem
-Well known model developed by Aaron Beck
-Utilized in treatment of most mental illnesses
-Often combined with behavioral therapies (cognitive-behavioral therapy)
-Manualized CBT proven effective for most psychiatric illnesses - mood, panic, GAD, PTSD, bulimia, anger problems, other

Classical conditioning

Operant conditioning

Link between behavior and reinforcing cognitions, emotions, social interactions

Self monitoring is cornerstone to identify antecedents and consequences

Principles of learning: modeling, positive reinforcement, shaping, generalization

Used for mood, anxiety, substance use, somatoform, pain, anger problems

Purposeful muscle relaxation with concurrent slowed breathing. May include visualization of relaxing situations
Yoga and meditation use similar strategies with same results

Social skills necessary for naturally reinforcing activities that help in recovery from mood, anxiety, substance abuse, schizophrenia, other disorders
Interpersonal skills often taught: starting conversations, listening skills, assertiveness, giving and receiving criticism, refusing requests
Example: treatment of substance use disorder

Positive rewards are offered immediately contingent on pre-agreed upon appropriate behavior that is incompatible with problem behavior (e.g. gift cert for drug free urine)

Rapidly produces behavior change when properly implemented

Includes “flooding,” “contact desentization” for mood and anxiety disorders

Avoidance is a reinforcer of problematic mood or cognitions in many mental illnesses
Perpetuates the problem - avoidance does not allow for maladaptive thoughts and emotions to be challenged - e.g. spider phobia

Exposure can be sole or prominent intervention (phobias, panic disorder, OCD)

Most therapies use some imaginal exposure via patient talking about the problem

Basic premise: Automatic thoughts, which are distorted or dysfunctional, are related to dysfunctional behaviors and uncomfortable emotions. Modification of thoughts will lead to changes in behavior and emotion

**This is an active treatment, which requries patient motivation

Automatic thoughts are maintained by fixed perceptions or schemata (basic beliefs about oneself) These are developed early and shaped by experience
automatic tho’t - “I should lose weight.”
dysfunctional behavior - vomiting
schema “I’m OK or loveable only if I’m perfect”


Patients learn to identify automatic thoughts in relation to preceding distressing behaviors/events and following consequences
Often termed “Functional Analysis”

A: actual event or antecedent

B: automatic thought (or problem behavior)

C: consequences

All or none thinking

Overgeneralization

Evaluative statement “Must, never, should”

Catastrophizing

Emotional reasoning

Labeling

Fortune telling

8-20 1 hour sessions


Explain rationale for treatment

Identify problem behaviors/emotions/cognitions

patient monitor cognitions

Teach patient skills to strategies to challenge dysfunctional cognitions and schemata

Give patient homework to practice these techniques

Follow- up on homework

Identify the distortion

Examine the evidence

Thinking in shades of grey

The double standard method

The experimental technique

The semantic method

Define your terms

The survey method

The cost benefit analysis

Have patient describe situation

Identify the strongest emotion

Identify the strongest thought or belief

Challenge the thought with techniques from previous slide

Take action (change the thought, develop an action plan, or both)

Physician provides info about: benefits of med (expected outcome), risks of med (potential side effects), alternatives (including their risks and benefits)

Patient provides info about symptoms, preferences, and past experience

**Patients with psych disorders have high level of interest in collaboration with physicians

A natural emotion experienced by everybody.
A certain amount is beneficial as a driving force to promote optimal performance.
Prepare for threat or danger by motivating us to avoid potentially dangerous situations and by making it easier to shift in the fight or flight state (the natural reaction to imminent danger) when avoidance is not possible.

Chronic anxiety involves a constant state of preparation for threat.
The threat does not have to be real or actually dangerous, but only perceived as such (e.g., threat of ridicule,embarrassment or failure).
Too much anxiety feels aversive and either prevents or interferes with behaviors required for optimal daily functioning, concentration and systematic thinking.

Panic Disorder with/without Agoraphobia

Specific Phobia

Social Phobia

Generalized Anxiety Disorder

Obsessive-Compulsive Disorder (OCD)

Post-traumatic Stress Disorder (PTSD)

Panic Disorder: 3.5 2.3
Agoraphobia without PD 5.3 2.8
Social phobia 13.3 7.9
Specific phobia 11.3 8.8
Generalized anxiety disorder 5.1 3.1
Any anxiety disorder 24.9 17.2



NCS: Anxiety Disorders (no PTSD OCD)
24.9% lifetime
17.2% 12 month
Lifetime PTSD 7.8%
ECA: Panic disorder & phobias 2x more prevalent in women than men

bodily sensations (of panic attacks)

Whatever the specific situation/thing the phobia is of

embarrassment

bad things happening

Whatever the specific thought is specifically acting on it or that it will come true.

Left stove on... house will burn down.

external danger

Palpitations, pounding heart
Sweating
Trembling or shaking
Sensation of shortness of breath or smothering
Feeling of choking
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, lightheaded or faint
Derealization (feeling of unreality) or depersonalization (being detached from oneself)
Fear of losing control or going crazy
Fear of dying
Parasthesias (numbness or tingling sensations)
Chills or hot flashes

A.Both (1) and (2):
1.) Recurrent unexpected panic attacks
2.) At least one of the attacks has been followed by a month (or more) of one (or more) of the following:
a) persistent concern about having additional attacks
b) worry about the implications of the attack or its consequences (e.g. losing control, having a heart attack, “going crazy”)
c) a significant change in behavior related to the attacks


B. The panic attacks are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism)

C. The panic attacks are not better accounted for by another mental disorder, such as social phobia, specific phobia, obsessive-compulsive disorder, posttraumatic stress disorder, or separation anxiety disorder.

A. Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms. Such as being outside the home alone, being in a crowd, or standing in line, being on a bridge, and traveling in a bus, train, or automobile.

B. The situations are avoided (e.g. travel is restricted) or else are endured with marked distress or with anxiety about having a panic attack or panic-like symptoms, or require the presence of a companion.

C. The anxiety and phobic avoidance are not better accounted for by another mental disorder, such as social phobia, specific phobia, obsessive-compulsive disorder, posttraumatic stress disorder, or separation anxiety.

physical systems, behavioral action tendencies, and cognitive processes.

Noradrenergic Discharge/Heightened Sympathetic Tone
muscle tension, fatigability, restlessness, etc.

Autonomic Hyperactivity
Rapid pulse, sweating, rapid breathing, etc.
Free circulating noradrenalin maintains high arousal levels.

Attention shift toward self-evaluative

Uncontrollability of threat source.

Anxiety sensitivity
e.g., “My reaction scares me, and I can’t cope with it

Catastrophizing
seizing upon the worst possible outcome

Probability overestimation
overestimating the likelihood of negative events.

Escape and avoidance
leave or avoid situations/activities in which anxiety occurs

Procrastination
to avoid occurrence of negative events.

Jittery behaviors
tapping feet, pacing, biting fingernails as inhibited escape behaviors.

Safety checks
to ensure that everything is okay, e.g., over-checking potentially dangerous situations, reassurance seeking, keeping safe people nearby, Xanax in the pocket.

Psychoeducation

Physiological self-regulation skills training (less emphasis for many ADs)

Modification of unhelpful cognition

Exposure to phobic stimuli

Consider initiating pharmacotherapy

Psychoeducation

Breathing retraining

Cognitive therapy

Interoceptive exposure

Naturalistic interoceptive exposure

In vivo exposure

Define and explain diagnosis

Reassurance (normalizing)
You are not going crazy or extremely unusual
Give data:
80% of population lifetime panic attack
35% pop has panic attack each year
2-4% lifetime prevalence of panic disorder

Anxiety as normal, natural, and safe emotion
Role of “Fight or Flight response (Natural response occurring under unnatural circumstances “false alarm”)
Cognitive Behavioral Model of Panic Disorder (3 component model)
Bibliotherapy

Fear is initially learned through “classical” conditioning

Fear is maintained by
Avoidance behaviors
Faulty cognitions

Teaches that feared consequences do not occur

Lowers autonomic arousal

Enhances self-efficacy (mastery)

Modifies cognitive “fear structure”

Down-regulates CNS noradrenergic activity

Heart pounding/racing
Dizziness
Nausea
Shaking
Sweating
Parathesias

Repeated exposure to feared bodily sensations evoked through various exercises
Running in place
Shaking head
Breath holding
Spinning
Complete body tension
Hyperventilation
Straw breathing
Staring at light

Challenging misinterpretations: ex- My doctor says I'm healthy. It is normal for myheat to race when I am anxious. If I slow my breathing, I can cope with this situation.

De-catastrophizing: ex- it is unlikely that I will vomit, but if I feel that I will, I can go to the bathroom. Although it would be unpleasant, I will not die from vomiting.

Prediction Testing

Marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.


Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed panic attack.


The person recognizes that the fear is excessive or unreasonable.

The feared social or performance situations are avoided or else endured with intense anxiety or distress.

The avoidance, anxious anticipation, or distress in the feared social or performance situations interferes significantly with the person’s functioning or social activities or relationships, or there is marked distress about having the phobia

The fear or avoidance is not due to the direct physiological effects of a substance or general medical condition.

Marked and persistent fear that is excessive or unreasonable cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood)

Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed panic attack.

The person recognizes that the fear is excessive or unreasonable.


The phobic situation is avoided or else endured with intense anxiety or distress.

The avoidance, anxious anticipation, or distress in the feared situation interferes significantly with the person’s normal routine, occupational (or academic) functioning, or social activities or relationship, or there is marked distress about having the phobia.

Excessive worrying

More days than not for 6 month or longer

Worry about several domains

Difficult to control worrying

Worry accompanied by 3 of 6:
RestlessnessFatigue
Impaired concentration
Muscle tension
Sleep disturbance
Irritability

Significant impairment/distress

Not solely due to depression, psychotic disorder, developmental disorder

Not due to medical condition or effects of substance

No difference in content of worry between GAD and normal (finances, health, job, family)

Differences: duration, frequency, sense of controllability and validity, number of worry spheres and worry over minor matters

Verbal-linguistic vs. imaginal (predominance of thought over imagery)

Produces suppression of sympathetic arousal as evidenced by decreased variability in HR and SC (Borkovec et al, 1993)

Uncontrollable negative life events as a child
Parental modeling
Heritability -anxiety diathesis

Procrastination and indecision

Compulsive checking rituals occur in 20% of GAD pts

Worry represents a covert avoidance response to perceived threat, analogous to overt avoidance in agoraphobia

Worry is negative reinforced by dampening sympathetic activity

Worry inhibits emotional processing by focusing on verbal-linguistic rather than imaginal -affective exposure to the fear construct

Cognitive Treatment
Psychoeducation about nature and role of anxiety and GAD
Cognitive restructuring to learn to see the world as a safer place

Somatic Treatment
PMR

Worry Exposure Treatment
Repeated exposure to the worry process facilitates emotional processing

Behavioral Treatment
Reduce avoidance of situations avoided or put-off
Response prevention of safety or checking behaviors
Time management, problem-solving strategies

A. Either obsessions or compulsions

B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable

C. Cause marked distress, are time consuming (> 1 hr./day) or significantly interfere with normal routine.

D. Content not related to another Axis I disorder (e.g.g eating disorder, trichotillomania, BDD, hypochondriasis, substance abuse, paraphilias)

E. Not due to substance use or medical condition

Recurrent and persistent thought, impulses, or images that are experienced, at some time during the course of the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress

The thoughts, impulses, or images are not simply excessive worries about real-life problems.

The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action

The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)

Repetitive behaviors (e.g. hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly.

The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation: however these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.

Exposure and response prevention

Cognitive therapy showing some promise

Positive symptoms are exaggerations of normal cognitive processes that represent serious distortions of reality, for example, hallucinations and delusions

Positive symptoms tend to respond to medications.

Negative symptoms are deficits in normal functioning for example lack of motivation, paucity of thoughts and speech.

Negative symptoms respond less well to any treatment.

Phlegmatic-rational, calm, unemotional (phlegm)

Choleric-easily angered, bad tempered (yellow bile)

Sanguine-courageous, hopeful, amorous (blood)

Melancholic-despondent, sleepless irritable (black bile)

Depression is twice as common in women as men. Life time prevalence of 20% in females, 10% in males.

BPD: About the same in men and women slightly higher in women. Overall lifetime risk of ~1%

Mood symptoms (depression, elation, irritability, decreased pleasure)

Cognitive symptoms ( decreased concentration, suicidal ideation, tangentiality, loosening of associations, grandiosity)

Physical symptoms (decreased appetite, insomnia, decreased energy)

Movement symptoms (psychomotor agitation, psychomotor retardation)

FC: Frontal cortex (esp. prefrontal and cingulate) - cognitive function, attention

HP: Ventral Hippocampus - cognitive function, memory

NAc: Nucleus Accumbens (ventral striatum) - reward and aversion

Amy: Amygdala - mediates responses to emotional stimuli

HYP: Hypothalamus regulates sleep, appetite, energy, sex

VTA: Ventral Tegmental Area - Sends dopaminergic projections to other areas

DR: Dorsal Raphe nuclei - send serotonergic input to other areas

LC: Locus Coeruleus - sends noradrenergic input to other areas.

If you have a first degree relative with a mood disorder, you are at a high risk of having one yourself.

fam. hist. of alcohol
fam. hist. depression
parental loss < age 13
Increased risk of depression in lower socioeconomic groups

family history of mania/bipolar illness
20-25% of first degree relatives
increased risk of bipolar disorder in higher socioeconomic groups

At least 5 of the following symptoms (must include either depressed mood or loss of interest) every day for at least two weeks.

Depressed mood

Loss of interest or pleasure (anhedonia) in every day activities

Feelings of worthlessness, self-reproach or inappropriate guilt

Loss of energy; fatigue

Diminished ability to think or concentrate

Poor appetite or weight loss, or increased appetite or significant weight gain

Psychomotor agitation or retardation (objective)

Insomnia or hypersomnia

Suicidal ideation, recurrent thoughts of death, wishes to be dead or suicide attempts

S(ad)
I(nterest, lack of)
G(uilt)
E(nergy, lack of)
C(oncentration, poor)
A(ppetite, abnormal)
P(sychomotor abnormality)
S(leep abnormality)
S(uicide)

General appearance and behavior: Psychomotor retardation or agitation, unkempt, poor eye contact

Affect: constricted, intense, sad, tearful

Mood: depressed, irritable

Speech: Low volume, slow, paucity of speech, long pauses

Thought content: hopeless, guilty, suicidal, somatic preoccupations, delusions

Cognitive: distractible, difficulty concentrating, disoriented, suicidal ideation, delusions

Insight and Judgment: impaired because of feelings of worthlessness

The development of emotional or behavioral symptoms in response to an identifiable stressor occurring within three months of the onset of the stressor.

These symptoms are clinically significant as evidenced by either of the following
-Marked, excessive distress
-Significant impairment in social (academic) functioning

The symptoms do not represent bereavement.

Depressed mood must be present for most of the day most days for at least two years

At least two of these symptoms: deranged appetite, disturbed sleep, low energy, low self-esteem, difficulty making decisions, feelings of hopelessness.

During the 2-year period the person has never been symptom free for more than two months.

No MDE during the first 2 years of disturbance.

No history of mania, hypomania or cyclothymia.

SSRIs, SNRIs, tricyclics, MAOIs

tricyclics and MAOIs are 1st generation

Imipramine, Desipramine, Amitryptyline, Nortryptiline, Doxepin
Have many side effects
Can cause lethal cardiac arrythmias at low blood levels
Very effective
Lethal in overdose

Phenelzine, Tranylcypromine
Necessitate avoidance of certain foods
Have many side effects
Very effective

Amoxapine, Maprotiline, Trazodone
Amoxapine and Maprotiline are used infrequently
Have many side effects
Trazodone common for sleep

SSRI’s


All inhibit the specific serotonin transporters that take up serotonin after it is released, increasing serotonin levels in the brain

Prozac (fluoxetine)
Zoloft (sertraline)
Celexa (citalopram)
Paxil (paroxetine
Lexapro (escitalopram)

They all affect multiple neurotransmitter systems.


Effexor (venlafaxine)

Remeron (mirtazapine)

Cymbalta (duloxetine)

increased safety profiles

decreased side effect burden

increased patient satisfaction

increased adherence to therapy which is REALLY important for long term maintenance therapy.

Gold standard for severe depression
Mechanism of action remains unclear
Improvements in anaesthesia have made the procedure more tolerable
ECT remains underused as a first line treatment for depression

Major depression
Bipolar depression
Psychotic depression
Mania or depression during pregnancy
Depression in the elderly
Mania
Refractory schizophrenia
Catatonia/neuroleptic malignant syndrome
Status epilepticus

Retrograde amnesia < six months prior to treatment
Anterograde amnesia for new material learned during treatment
3/1000 patients permanent memory loss
Common side effects = headache, nausea

Weak electrical currents are induced in brain tissue by rapidly changing magnetic fields
FDA approved rTMS for medication refractory depression on 10/8/2008
Small risk of seizure in pts. with epilepsy
Discomfort from scalp stimulation
Loud machine

Dramatically elevated, expansive or irritable mood lasting at least one week (or less if hospitalized).


Three or more of these symptoms:
Grandiosity
Decreased need for sleep
More talkative than usual; pressured speech
Flight of ideas
Distractibility
Increase in goal-directed activity or agitation
Excessive involvement in pleasurable activities that have a high potential for painful consequences

D(istractibility)
I(ndiscretion-enagaging in pleasurable activities with negative consequences)
G(randiosity)
F(light of ideas)
A(ctivity increase)
S(leep, decreased need for)
T(alkativeness, pressured speech)

General appearance: psychomotor agitation, seductive colorful clothes/makeup, grooming, intrusive, entertaining, threatening, bizarre
Affect: labile, intense
Mood: euphoric, irritable, demanding, flirtatious
Speech: pressured, loud, dramatic, incoherent
Thought content: Grandiosity, egocentric, delusions, occasionally hallucinations
Thought process: racing thought, flight of idease
Sensorium: distractible
Insight and judgment: impaired, denial of illness, disorganized

At least four days of elevated or irritable mood that is clearly different from the usual non-depressed mood.


Three or more of these symptoms:
Grandiosity
Decreased need for sleep
More talkative than usual; pressured speech
Flight of ideas
Distractibility
Increase in goal-directed activity or agitation
Excessive involvement in pleasurable activities that have a high potential for painful consequences


The episode is not severe enough to require hospitalization or to cause marked impairment in function. There are no psychotic features.

Classification of bipolar illnesses are based on mania or hypomania criteria only
Patient has met the criteria for a full manic episode, usually sufficiently severe as to require hospitalization
May occur with major depressive or hypomanic episodes

Classification of bipolar illnesses are based on mania or hypomania criteria

Patient has had at least one major depressive episode and one hypomanic episode but no manic episode.

Rapid Cycling
Mania/dep. cycle within 48-72 hours
May be more chronic, diff. to treat

Cyclothymic Disorder
Hypomania/depression alternating 2 years
Substance use common

Lithium = treatment of choice for Bipolar Type I and cyclothymic disorder
Effective 80% of bipolar type I
Lithium =treatment of choice for treatment/prevention of the depressed phase of the bipolar disorder
Acute manic symptoms managed by addition of an anti-psychotic; if severe, consider ECT

they can be mood stabilizers if lithium isn't working!!

Ones that can be tried...

Topamax (topiramate)
Depakote (valproic acid)
Tegretol (carbamaepine)
Lamictal (Lamotrigine)

They can precipitate mania

Bupropion and paroxetine are less likely than others

Anti-depressants in bipolar depression can lower the risk of suicide (19% lifetime risk in BPAD) but are risky.

Consider using ECT instead if patient is willing.

Intimacy vs isolation

career consolidation vs self-absorption

generativity vs stagnation

Love

Work

Care

Self, Emotional, relational, moral, gender, kinesthetic, spiritual, humor, creativity, aesthetics, other

The stages are evolutionary.

There are multiple lines of development

Individuation/ differentiation

Integration

It is all about finding your permanent love object.

Tasks: Emotional intimacy and sustained relationship

Methods: Trial and error, Parents are the role model and safety net, figuring out commitment vs autonomy

Outcomes:
Success- Committed love
Failure: self-absorption

Tasks:
commitment to a specific field
Job transition to career
Commitment, compensation, contentment, competence.

Methods: formation of a dream
finding a mentor
commitment vs autonomy
gender differences

Outcomes:
successful-career
failure- insecurity inside and out
Childrearing

Tasks: accept death, wisdom over power, socialized over sexualized, guide/mentor, mental flexibility

Methods: identify values, rebuild and rework, find roles to mentor

Outcome:
Successful: reconciliation of polarities, sense of mastery, shift focus to community

Failure: chronic depression, mid-life crisis

Illness can slow down or speed up the stages

Culture factors can be the same way and involve different rites of passage and or myths.

Timing/sequence: the social age clock.

primary love relation

profession

contribute to community

contribute to world

Increasing spheres

phases of stability/ change

increasing commitment/ responsibilities

self moving towards outward looking

Being mentally active

Positive outlook

Exercise

Higher intake of folic acid is associated with lower cognitive decline

Lack of hx of head injury, stroke, or brief loss of consciousness associated with less cognitive decline

MYELIN sheathes of axons in white matter, added continuously, peaking at age 50 but continuing until end of life


HEMISPHERIC ASYMMETRY REDUCTION in older adults on fMRI and PET for problem solving, verbal memory, facial recognition


DECREASED ACTIVATION OF AMYGDALA with aging in response to negative emotions such as fear, anger, hatred

Absence of disease

engagement with life

preserved cognitive and physical function

Adolescence defined by appearance of secondary sex characteristics

Tanner’s 5 stages of sexual maturation describe changes in pubic hair, genital and breast development

Timing of onset varies greatly, but sequence is quite uniform; girls 2 years in advance of boys

Growth spurt precedes sexual maturation by a year
Average age 9 1/2 in girls, 11 1/2 in boys

Early adolescent brain and adult brain weigh the same

Connections to prefrontal cortex, locus of executive functioning & judgment are developing

“Second wave” of dendritic proliferation prior to puberty

Neural pruning and maturation continue until mid-20’s

MRI corroborates ongoing neural development until age 25

Emotional information is processed primarily through the amygdala, not the prefrontal cortex

Testosterone in boys surges 5-7 times daily and stimulates the amygdala

Estrogen & progesterone levels in girls affect neurotransmitter secretion and possibly hippocampal function

To define oneself

To define one's sexuality

to differentiate oneself from parents

New “transition objects”
Early-same sex peers
Middle- mixed sex groups
Late- pairing

Appearance as self-identity
Early- neglect
Middle- stereotyped
Late- individualized

Self-exploration: “Who am I?”

Affiliations
Shifting from family to groups, clubs, teams to close peers, self-defined friendships

Sexuality
Shifting from abhorrent, but interesting to experimentation to sexual identity and continued relationship exploration

Boys versus girls
Autonomy versus “self in relationship”

Age 11-13

Physical changes begin

Thinking is concrete

Peer groups are same-sex

Early “crushes”

Conflicting loyalties between family and friends; superego “lightens”

Speech and self-care initially deteriorate

Ages 14-16


Abstract thinking begins

Mixed sex peer groups

Peer opinion trumps parents

Relational experimentation

Sexual identity exploration
http://www.youtube.com/watch?v=Gm4lBfYaeqc

Initial self-identity can be extreme
Idealism, asceticism, intolerance for differences

Age 16+


Good abstract thinking

Practicing by arguing

Idealism blends with pragmatism

Parental values still challenged

More serious relationships

Less worry about appearance

CULTURE!!!

Duration, ceremonies and markers, expectations and roles are determined by culture.

It is the period between when an individual is no longer a child but is not yet a full status adult.

Identity confusion

Psychological dependence

social isolation

impulsivity and aggression

Cohesive sense of self

goals for the future

self-identity separate from family

self-confidence within peer group

Normalize physical & emotional changes

Mirror and validate trial & error process

Model risk assessment strategies

Describe personal experiences, as appropriate

Young adults
Older Adults
Chronic Behavioral Problems in someone with an Acute Exacerbation
Substance Abuse Pts (especially Alcohol)

Depression
Anxiety
Situational Crises (Adjustment Disorders)
Personality Disorders
Alcohol and Drug Related Behavior
Psychoses
Cognitive Disorders --Delirium /Dementia

Suicidal actions or thoughts
Violence_ more common toward self than others
Agitation/Extremes of Affect
Social Withdrawal
Recent Change in behavior

depression

schizophrenia (50% attempt, 10% complete)

substance abuse

To escape from unbearable anguish from which the patient sees no other way out.

Acute or chronic.

Sex: females more likely to attempt; males to complete

Age: increases with age except for peak during adolescence for males

Past attempts: half of those who complete have made previous attempts.

Past Attempts: half of those who complete have made previous attempts.

Marital Status: marriage is protective, esp. for men

Employment: jobless or those with recent job loss at higher risk. Professionals > blue collar

Psychiatric disorders: majority of suicides committed by those with a major psychiatric disorder

Serious Medical Problems: Increase risk.

Intentionality: level of intent

Lethality: plan? lethal plan?

Means: availability (danger decreases when means not immediately available)

Ability of patient to accept help and have hope resulting from it.

Older male (50 and up)

Financial or medical problems

Living Alone

Alcohol Use

Recent Loss

when
lethality is high

intent is high

means are available

viability is low

support is absent or inadequate

do not send home with lethal amounts of meds

involve others to monitor patient

establish a contract concerning the patients safety

Often have a history of past violence.

Most violence aimed at family members

80% < 50 years old

Majority are males ages 15-30.

Angry with low self-esteem.


Violence very often occurs in situations where the perpetrator has been shamed, lost face, “put down.”

Alcohol greatly increases likelihood of violence.


Elderly patients frequently become violent in context of Delirium or Dementia

physical agitation

unresponsive to efforts to calm

Alcohol, Stimulants, PCP

Cognitive Impairment

Traumatic Brain Injury

Mania (Impulsiveness/Irritability)

Schizophrenia (Paranoia/Commands)

Paranoid states (Delusional Disorder)

Never place yourself in harm’s way.
Seek help
Avoid weapons


Those who seek help are seeking control.
BE CALM
Inform them they will not be allowed to do harm.
Set clear limits.
Inform of consequences if behavior occurs.


Clarify precipitants of the violent behavior.

Give the patient a chance to express his grievance.

Calm, empathic, respectful response helps patient feel he is being heard and taken seriously.


Restrain if necessary.- Observe carefully if restrained.

Use medication if necessary.
Haloperidol/Lorazepam (5/2. 10/4)

It is an objective description of the patients current state. Not a hx, NOT interpretation/ dx, NOT just a cognitive exam... part but not sufficient!

analogous to the PE

data collected in the context of convo / interview with the patient organized into MSE write up format

Appearance

Behavior

Mood and Affect

Thought

Perceptions

Cognition

Clothing
Hygiene
Apparent physical health
Notable physical characteristics
Overall appropriateness of appearance

Facial expressions (or lack)

Psychomotor activity
spectrum: Agitation --- Retardation

Abnormal or bizarre movements

Speech
Rate, volume, idiosyncrasies - NOT content

Attitude toward exam, examiner

Mood: overall feeling, subjective state (so what the patient tells you about their emotional state)
examples: depressed, anxious, angry, neutral (euthymic), elated

Affect: objective feeling tone (i.e. what you observe about patient's emotions)
Examples: blunted, flat, labile, full

Process: structure of thought
Examples: goal-directed (normal), loosening of associations, flight of ideas, tangential, circumstantial

Content:
Preoccupations: obsessions, phobias, suicidal or homicidal ideation

Delusions=fixed, false belief
Examples: paranoid, persecutory, grandiose, etc.

Hallucinations
Sensory perceptions in the absence of any external sensory stimulus
Auditory, visual, tactile, olfactory, gustatory

Illusions
Sensory perceptions based on misinterpretation of a benign sensory impulse

Orientation
Attention and concentration
Memory
Visuospatial ability
Abstraction
Insight and judgment

You evaluate it to time, place, person, and often the situation.

A & O x 3 = to time, place, and person

Ability to focus and direct cognitive process

Best test of attention: DIGIT SPAN

Ability to sustain attention over time

Standard tests:
Serial 7’s
WORLD backwards

Registration

Short Term (Working) Memory

Long Term Memory
Recent
Remote
Semantic
Episodic

Capacity for immediate repetition/recall of new learning

Prerequisite for storage and later recall

Impaired in delirium; moderate dementia

Test:
Repeat these words: “table, ball, pony”

Temporary; either lost, or stored into long term memory within seconds to minutes

Requires intact attention, registration

Analogous to computer RAM

TEST OF SHORT TERM MEMORY: recall 3 items after 2 – 5 minutes

Recent
(hours to days)
Remote
(months to years)
Analogous to computer hard drive


Semantic:
General fund of knowledge
“Name the last 4 presidents of the United States”
State capitals
Grocery items – how many can you name in one minute?


Episodic:
Memorable events (“episodes”) in one’s life
College graduation
Medical history
Wedding

“Internal compass”

Impaired visuospatial ability leads to poor driving, getting lost - even in one’s own house

Involves multiple brain areas

Standard tests of visuospatial (visuoconstructive) ability:
Connecting numbers to letters in order.
Draw-a-clock

Similarities:
"How are a car and an airplane alike?"
"How are a dog and a tree alike?"

Proverbs: "What do people mean when they say: don't cry over spilled milk; or Rome wasn't built in a day"

Frontal lobe!

It doesn't tell you what is wrong only that there is a cognitive problem.

Dependent on education, intelligence, and verbal skills:
-highly intellectual person with mild dementia can still obtain perfect or normal score
-less educated person with no cognitive impairment may score in abnormal range.

Environment: location and expectations

Genetics: careers in the family, family hx of significant devo delays or advancements?

Culture: girls vs boys, education vs farming.

Gross motor development

Fine motor development

Language development

Social development

Born -Regards face
1 month Smile spontaneously
2 months Smile responsively
5 months Work for a toy
8 months Wave bye-bye
10 months Indicate wants –crying/pointing
12 months Play pat-a-cake, joint attention

1 month –vocalize/ respond to a bell (r/e)
2 month –ooh/aah(e)
4 months –laugh(e)
6 months –turn to a voice (r)
9 months –mama/dada non specific, babble (e)
12 months –mom/dad specific (e)

*These are the Denver criteria and not the best. the CLAMs test may be a better option.

Ear/nerve
microtia
Hearing loss

Brain
Auditory processing
Oromotorfunction of muscles and nerves
Cerebral palsy or stroke
Oromotordyspraxia
Normal variant
Selective mutism
Autism spectrum disorders

Genetics
Trisomy21, fragile X, Klinefelter’ssyndrome

Autism is an impairment in communication, social interactions, and with repetitive actions.

Boys/girls 4:1
no clear racial connection
40-60% have cognitive impairment
1 in 150 kids affected.

Genes
located on 2q, 7q, 15q, 16p+

Associated with
fragile X,
tuberous sclerosis,
PKU,
congenital rubella,
use of thalidomide

Fathers >40 years are 6 x more likely to have a child with autism than fathers<30 years

Risk to others
60-90% for identical twins, (triplets , autism and ABC 12/27/07)
10% for fraternal twins and sibs

Pervasive Developmental Disorder. (PDD)

Examples: Autistic disorder, Asperger disorder, PDD/ NOS, child disintegrative disorder, Rett syndrome

1. Total of six (or more) items from (A), (B), and (C), with at least two from (A),and one each from (B) and (C)

A. qualitative impairment in socialinteraction, as manifested by at least two of the following:
1.marked impairments in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body posture, and gestures to regulate social interaction ,
2.failure to develop peer relationships appropriate to developmental level
3.a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people, (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)
4.lack of social or emotional reciprocity (not actively participating in simple social play or games, preferring solitary activities, or involving others in activities only as tools or "mechanical" aids )
first words-social interaction 1

(B) qualitative impairments in communicationas manifested by at least one of the following:
1.delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
2.in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
3.stereotyped and repetitive use of language or idiosyncratic language
4.lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
first words-communication, expressive 3

(C) restricted repetitive and stereotyped patterns of behavior, interests and activities, as manifested by at least one of the following:
1.encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
2.apparently inflexible adherence to specific, nonfunctional routines or rituals
3.stereotyped and repetitive motor mannerisms (e.ghand or finger flapping or twisting, or complex whole-body movements)
4.persistent preoccupation with parts of objects

1. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years:
(A) social interaction
(B) language as used in social communication
(C) symbolic or imaginative play
2. The disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative Disorder

Macrocephaly; microcephaly; large, prominent ears; posteriorly rotated ears; neurocutaneous syndromes: hypo/hyperpigmented lesions; difficulty with attention; hyperactivity; hypoactivity; CN asymmetry; CN palsies; hypotonia; hypertonia; asymmetrical reflexes; increased or decreased reflexes; toe-walking; loose gait; poor coordination

Applied Behavioral Anaysis, ie
Effort to modify the behavior of children
Based on the A,B,C theory to alter behavior
Antecedant
Behavior
Consequence
Teaching appropriate behaviors
Studies show 30 hours a week of ABA may help alter nonfunctional behavior

Occupational Therapy
Sensory integration disorder ( Sensational Kids)

Physical Therapy

Speech Therapy
Augmentative communication

Brain-imaging
Encephalitis
Motor Skills Disorder
Severe visual impairment
Cerebral palsy

Spinal cord –neuroexam
Transverse myelitis
Spinal dysraphism
Poliomyelitis
Spinal muscle atrophy

Peripheral Nerve –neuroexam
Charcot-Marie-Tooth

Muscle -exam
Congenital myopathies
arthrogryposis

Bone -imaging
Dislocated hips
Arthritis

It would suggest a congenital myopathy and/or motor skills disorder. (Example is muscular dystropy)

It is a progressive myopathy.

X linked recessive gene

Alters the dystrophin in the muscle.

Mostly male and wheelchair bound by 10.

Live until 20s when respiratory distress may develop.

3 month-grasp a finger, hand stops being fisted
4 months-Extend and rake, bring to mouth
6 months–rake pellet into hand, transfer, hold a cube
7 months–lateral pincer grasp, clap
9 months–pincer grasp b/w lateral thumb and proximal index finger
10 months–grasp b/w pad of index and thumb, points
12 months–pincer grasp b/w finger tips

0-6 months -Flexion to extension
7-12 –hands together, use of thumb/finger

Incidence of 1-5/1000
Not caused by a difficult delivery or lack of oxygen to the brain during the delivery
In the vast majority of cases –No cause and normal delivery
Best Predictor is echodensities in the periventricular white matter
50% of patients may have Global Developmental Delay
Hard to pick up before 6 months, b/c movements may be reflex related and use of different neurologic pathways
Developmental test may need to be modified since she can’t do 2 handed skills.

Braces
prevent progressive contractures that would lead the limb in a difficult position for function –achilles tendon and walking

Physical therapy /Occupational therapy

Assistive devices –
crutches, wheelchairs, adapted feeding utensils, augmentative communication

Medications
to decrease tone and help with function –moving a child, helping a child use their limbs

Surgery –
to help release a limb for function

Rates of Mental Disorder 14-20%


Common disorders:
ADHD 4-8%
Depression 7%
Anxiety Disorders 8-15%


Suicide 3rd Leading cause of death in teens

Chronic Health Problems
Brain Damage
Temperament (Aggression, Behavioral Inhibition)
Genetics
Family Factors
Psychosocial Factors/Stress

Prototype Internalizing Disorder
Persistent Depressed Mood, Interest Loss
Childhood Rates: Males=Females
Adolescent/Adult Rates: 2:1, Females:Males
Childhood Onset Predicts Poor Prognosis
Highly Comorbid Disorder
Caveats in Childhood Clinical Presentations

FDA Label 3 Medications

Best Evidence for Cognitive-Behavioral Tx

Emerging Evidence for SSRI’s
Standard of Care
Scientific Rationale

Unlike ADHD, a Remitting Illness

Continued Monitoring Necessary

Fluoxetine=Prozac

Zoloft(Sertraline) >6yrs
Luvox (Fluvoxamine) >8yrs
Prozac (Fluoxetine)>7yrs
Anafranil>12yrs

Fluoxetine and Cognitive Behavioral Therapy

TEMPERAMENT/GENETICS

ATTACHMENT

PARENT FACTORS
ANXIETY/DEPRESSION
PARENTING STYLE

TRAUMA/ENVIRONMENTAL STRESS

Behavioral Inhibition.

Laboratory Based Temperamental Construct (20% Caucasian)
Shy, Fearful, Novelty Avoidant
Consistent Over Time
Long Latency/Low Frequency of Verbal Response
Over arousal/Sympathetic Activation

Anxious resistant

10-20% of US Children <18 yrs Meet Diagnostic Criteria
Most Common Psychiatric Disorders
Least Likely to be Diagnosed
High Rates of Comorbidity
50-70% have 1 Comorbid Disorder
40-70% with Depression have Anxiety D.O.
Comorbid Depression , Greater Morbidity

Birth-6 months Loud noises, loss of physical support, rapid position changes, rapidly approaching /unfamiliar objects

7-12 months Strangers, looming objects, sudden confrontation, unexpected objects or unfamiliar people

1-5 years Strangers, storms, animals, the dark, separation from parents, objects, machines, loud noises, the toilet, monsters, ghosts, insects, bodily harm

6-12 years Supernatural beings, bodily injury, disease (AIDS, Cancer), burglars, staying alone, failure, criticism, punishment

12-18 years Tests and exams in school, bodily injury, scrutiny, appearance, body image, performance

Content Less Important Than Frequency & Themes

Need Multiple Informants
Inconsistent Reporting Parents vs Children
Social Phobia Best

Pathology Characterized by
Pervasiveness
Intensity
Time Consuming
Debility

Generalized Anxiety Disorder
Separation Anxiety Disorder*
Social Anxiety Disorder
Specific Phobia
Panic Disorder
Obsessive-Compulsive Disorder
Posttraumatic Stress Disorder
Selective Mutism*

Psychotherapy
Psycho-education
Cognitive
Behavioral
CBT
Family
Psychodynamic
Play-based

Exposure is Key


Pharmacotherapy
Classical Anxiolytics
Broad Spectrum Agents


Combined Therapy
Best in Severe Anxiety

Benzodiazepines: beware disinhibition

Tricyclic Antidepressants: safety/SE issues so limited use.

SSRIs: fluoxetine, fluvoxamine, sertraline

Miscellaneous: beta blockers, alpha2 agonists, non-benzo anxiolytic-buspirone, 3rd generation antidepressants

**SSRIs have the highest rates of improvement!!

3 Types:
Inattentive, Hyperactive/Impulsive, Combined
4-8% of Children
4:1 Male:Female
~60% Continue into Adulthood
Highly Comorbid Disorder
Dysregulation of NE & DA in Fronto-striatal Systems

Stimulants Most Common/Powerful Tx
Methylphenidate & Dextro-amphetamine

Robust Response =25-50% Sx Reduction

Safe & Effective Agents

Side Effects:
Insomnia
Tics
Appetite Suppression/Decreased Growth

Effective for the treatment of core symptoms: Hyperactivity, Impulsivity, Inattentiveness

Academic efficiency and accuracy

No school-time dosing

Improved compliance

Improved tolerability

Interrupted symptom relief
Limited activity in evening/early morning hours

Controlled substances
Diversion and abuse potential
Prescribing inconvenience

Tolerability and safety
Insomnia and decreased appetite
Potential adverse height and weight effects
Potential to exacerbate tics and anxiety
? Rebound effects

Fearful, anxious

emotional, dramatic, erratic

eccentric or odd behavior with fear of social relationships

It is compulsive drug seeking and use even in the face of negative health and social consequences.

It has identifiable symptoms.
It has a predictable course.
It has a treatment that is as successful as that of many chronic diseases (e.g diabetes, hypertension, asthma).
All addictive substances act an one area of the brain (the Ventrotegmental tract or reward system)


Prolonged drug or alcohol use causes pervasive changes in brain function that persist long after the drug taking stops.

The addicted brain is distinctly different from the non-addicted brain as manifested in brain metabolic activity, receptor availability, gene expression and responsiveness to environmental cues.

Social context of development and expression of use is extremely important (think about Vietnam vets and heroin use)

Exposure to conditioned cues can cause persistent and recurrent drug cravings even after successful treatment

It means that you use a substance without meeting criteria for either abuse or dependence

Problems with relationships/marriage

Problems wiht work or school

Problems with the law

Medical problems

A. Recurrent use resulting in failure to fulfill major role obligations.


B. Recurrent use in situations in which it is physically hazardous.


C. Recurrent substance use related legal problems.


D. Continued substance use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the use.

A maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by THREE or more of the following occurring at any time within a 12 month period


1.Tolerance: Result of physical adjustment to regular use of a substance in which the brain requires increasing amounts of the substance to achieve the desired effect.

2. Withdrawal: Physical Symptoms which occur on when a substance on which a person has become physically dependent is rapidly discontinued. Withdrawal symptoms vary with the substance being abused. Dangers of withdrawal also vary according to the substance.


3. Substance taken in larger amounts or over a longer period than was intended.


4. Persistent desire or unsuccessful efforts to cut down or control substance use.


5. A great deal of time spent in obtaining the substance, using it, or recovering from its effects.


6. Important social, occupational, or recreational activities given up or reduced because of substance abuse.


7. Continued substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused by or exacerbated by the substance.

NO! One can be addicted and meet criteria for substance dependence without tolerance or dependence (a binge type alcoholic) OR One can be physically dependent without being addicted (cancer patient being treated for intractable pain)

The agent (alcohol)

The host (genetic, ethnic, psychological factors)

The environment (a drinking culture, family factors etc)

Characterized by compulsive use in the face of associated negative health and social consequences of use including organ damage in multiple systems with prolonged regular use.

A. A need for markedly increased amounts of the substance to achieve intoxication or the desired effect.
or

B. Markedly diminished effect with continued uses of the same amount of the substance

Tolerance

Withdrawal

Loss of Control of Use

Obsession with the drug to exclusion of importance of other life activities.

A. the characteristic withdrawal syndrome for the substance.

or

B. the same (or closely related substance) is taken to relieve or avoid withdrawal symptoms.

Substance taken in larger amounts or over a longer period than was intended.

Persistent desire or unsuccessful efforts to cut down or control substance use.

A great deal of time spent in obtaining the substance, using it, or recovering from its effects.

Important social, occupational, or recreational activities given up or reduced because of substance abuse.

Continued substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused by or exacerbated by the substance.

It is an extremely prevalent psychiatric disorder.

No other substance affects as many organ systems with prolonged use. Alcohol literally BATHES the organs of the body. Women take less time with less alcohol.

25-45% of hospitalized patients have diagnosable substance abuse problems.

10-15% of outpatients have diagnosable substance abuse problems.

COCAINE!!!! It can cause cardiac arrhythmias and possible death in addition to strokes and seizures!

Liver damage! Fat, hepatitis, and cirrhosis. Decreased ability for blood to clot (lack of clotting factors).

Cancers of the upper GI tract: mouth, larynx, esophagus all are increased when combined with the use of alcohol plus cigarettes.

Other: gastric irritation/gastritis, reflux esophagitis, pancreatitis, diarrhea

Hypertension

Cardiac arrhythmias (Holiday Heart)

Cardiomyopathy (damage to the heart muscle) due to toxic effect of alcohol on cardiac muscle with prolonged heavy use.

Decreased sexual performance in men with excessive or prolonged alcohol use.

Sperm abnormalities with acute and chronic alcohol use.

Hypogonadism-- causes increased estrogen levels in males

Fetal alcohol syndrome and fetal alcohol effect

Small head (microcephaly)

epicanthal folds

flat midface

underdeveloped jaw

smooth philtrum

thin upper lip

short nose

small eye openings

low nasal bridge

facial edema and redness

worsening of conditions such as psoriasis

Toxic effects on bone marrow possibly resulting in:

-abnormally large red cells... more a marker for increased alcohol intake than an indicator of harmful pathology

-decreased response to infection because of decreased number of cells that fight infection

-decreased platelets and so impaired clotting

Aseptic necrosis of the femoral head

osteopenia

Limb Compression Syndrome

Injuries and fractures

It is an example of the physical effect of alcohol. It is an ischemic episode resulting in infarction of the head of the femur. This condition has been reported as having increased incidence in those with chronic alcoholism and often requires hip replacement.

It is decalcification of bone which proceeds at a faster rate in alcoholics, possibly secondary to nutritional factors. It makes patients more susceptible to fractures.

It is a physical effect of alcohol abuse. It results from ischemia of soft tissue following prolonged pressure in a position assumed by a severely intoxicated individual

is characterized by confusion, ataxia, and ocular symptoms including paralysis of the eye muscles and nystagmus. Level of consciousness is depressed often to the point of stupor. It is reversible with administration of thiamine.

Peripheral Neuropathy

Traumatic Brain Injury

Wernicke-Korsakoff Syndrome

Good nutrition with supplemental B Vitamins and active physical therapy to prevent muscle shortening and symptoms such as foot drop.

1/3

amnesia and confabulation

Confabulation is replying to questions with reports of events and memories for which there is no basis in past experience--i.e. they never happened. It is generally not reversible.

Accidents

suicide attempts

lost work time

family violence

risk of exposure to infectious diseases

money spent on substance

only detectable on clinical exam. Urine testing is very important for toxic screening. Breath and blood alcohol tests are also helpful.

Divorce or domestic violence

Problems at work: frequent job changes, tardiness, absenteeish (esp. missing Monday mornings), work-related accidents DWIs (esp. more than 1!!), arrests, trauma (fights, falls, auto accidents)

Financial problems including those related to spending on drugs and alcohol

Smoking (85% of alcoholics are smokers)

Patients tend to minimize substance use. May be more often denial or minimizing than lying.

Patient may feel threatened and defensive when asked about quantity and frequency of substance use.

Confidentiality may be an important issue with illicit drug use or underage use of alcohol.

Self-report of use is more accurate when a person is sober and less accurate when a person is intoxicated.

Best quantitative data is obtained when asking about the specific use on a specific day. ("Tell me what you drank yesterday.")

If possible, get information also from significant other, spouse, parent, etc.

When did it begin?
When did drinking become regular?
When did it become a problem?
Attempts to stop and outcome (what happened?)


Effects on life (consequences)
Family/Relationships
Job/School
Legal: DWI's/ Arrests etc.
Medical: (Trauma and overdoses come early; other medical effects of use (GI bleeding, pancreatitis, cirrhosis) come late-- after years of drinking.

patterns of use

Daily or binges
What one drinks?
How often does pt. buy (drinking at home and not in bars)?
Estimate of how much consumed (of little help unless questions are very specific; even then denial and minimizing interfere

Have you ever felt you should Cut Down on your
drinking?

Have you ever felt Annoyed (Angry) by someone
criticizing or pointing out your drinking?

Have you ever felt Guilty about your drinking?

Have you ever had a drink in the morning to steady your nerves or get rid of a hangover? (Eye opener)

Prochaska/Clemente Stages. Moving the patient along.
Power of the White Coat
Inform patient of your concern regardless of whether he/she is “ready” or not. (Brick in the Wall)
“Dance” not “Wrestle”

Genetics and ethnicity

1.Development of a vital interest to replace the role of drinking.

2.Continuing presence of external reminders that drinking was and would again be painful.

3. Presence of a new intimate relationship, often with someone not a part of earlier alcoholic drinking.

4. Presence of a source of inspiration, hope and self-esteem.

3 to 4 times higher. One study even suggests a 9 times greater risk.

It is approximately double the risk.

Higher: native american, irish, french

Lower: Jewish, some Asians

Psychoeducation

Medication: antabuse, naltrexone, acamprosate, psych meds

Group Tx

CBT

individual sessions possibly

motivational enhancement

family/partner involvement

12 Step Encouragement

alzheimer's Disease

Mixed Dementia

Dementia with Lewy Bodies

Vascular Dementia

Frontotemporal Dementias

Dementia with Lewey Bodies

A. The development of multiple cognitive deficits manifested by both:

(1) Memory impairment (Amnesia)

(2) One (or more) of the following cognitive disturbances:
(a) Aphasia (language disturbance)

(b) Apraxia (impaired ability to carry out motor activities despite intact motor function)

(c) Agnosia (failure to recognize or identify objects despite intact sensory function)

(d) Disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)

B. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.

Jacob - Kreutzfelt disease

Progressive supranuclear palsy

Huntington's disease

Neurosyphilis

Uncorrected endocrine disorders

Brain tumors


Normal Pressure Hydrocephalus (NPH)

Chronic alcoholism

Nutritional deficiencies

HIV/AIDS, other chronic infectious illnesses

Severe head trauma

Alzheimer's.

Hispanics: 1.5 times

Blacks: 2 times

AGE

A. The development of multiple cognitive deficits manifested by both:

(1) Memory impairment (Amnesia)

(2) One (or more) of the following cognitive disturbances:
(a) Aphasia (language disturbance)

(b) Apraxia (impaired ability to carry out motor activities despite intact motor function)

(c) Agnosia (failure to recognize or identify objects despite intact sensory function)

(d) Disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)

B. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.

Activities

Behavior

Cognition

Drain on the caregiver

Cholinesterase Inhibitors: Donepezil, Rivastigmine, Galantamine

NMDA Receptor Antagonist

No. Some other outcomes that may come up are new-onset depression, other anxiety disorders, alcoholism or behavioral alteration without having PTSD

psychophysiological reactivity

neurohormonal profiles

EKG abnormalities

structural and functional brain imaging alternations

(It coordinates the generalized stress response which takes place when a stressor of any kind exceeds a threshold.)

Main components: HPA system, LC/NE system, Immunological system

The hippocampus appears to shrink after chronic stress.

Twice as common in women. Not at a greater risk for exposure to trauma but more likely to develop PTSD when exposed to trauma.

Anxiety disorders
major depression
dissociation
somatization
eating disorders
drug and alcohol abuse
suicide attempts
psychiatric hospitalizations

more attempted suicide
more medical illnesses
worse physical health, less employment
impaired vitality and social function
negative impact on personal relationships, daily activities and work performance

Ectopic pregnancies

spontaneous abortions

hyperemesis: excessive vomiting during pregnancy

Preterm contractions

excessive fetal growth

Exposure to a traumatic event in which the person:
experienced, witnessed, or was confronted by death or serious injury to self or others
AND
responded with intense fear, helplessness, or horror
Symptoms
appear in 3 symptom clusters: re-experiencing, avoidance/numbing, hyperarousal
last for > 1 month
cause clinically significant distress or impairment in functioning


Persistent re-experiencing of  1 of the following:
recurrent distressing recollections of event
recurrent distressing dreams of event
acting or feeling event was recurring
psychological distress at cues resembling event
physiological reactivity to cues resembling event


Avoidance of stimuli and numbing of general responsiveness indicated by  3 of the following:
avoid thoughts, feelings, or conversations*
avoid activities, places, or people*
inability to recall part of trauma
 interest in activities
estrangement from others
restricted range of affect
sense of foreshortened future


Persistent symptoms of increased arousal  2:
difficulty sleeping
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response

Most people recover and only a minority develop chronic and persistent symptoms.

Psychotherapy: exposure, CBT, anxiety management, desensitization, EMDR

Phamacotherapy: SSRIs, other antidepressants, mood stabilizers, atypical antipsychotics, anti-adrenergic agents

BENZOS SUCK FOR PTSD

psychoeducation

written exposure: impact of trauma on thoughts about self and others, interpretatiosn about traumatic events

Challenging patient's interpretations about traumatic events.

Cognitive restructuring of more generalized beliefs disrupted by traumatic events.

the finding that the abuse victim had no one they could turn to with whom they felt protected and safe.

the separation of usually integrated functions. This is brought on usually by significant childhood trauma.


Essential feature is a disruption in the usually integrated functions of consciousness, memory, identity, or perception of environment.
May be sudden or gradual, transient or chronic.

Dissociation or repression.

Low self-esteem
Anger /acting out
Depression
Substance abuse
Eating disorders
Personality disorders
Borderline
Antisocial

Post traumatic stress disorder
Disorders of attachment
Self mutilation
Somatization disorder
Conversion disorder
Dissociative disorders
Increased rate of Suicide

The endogenous opioid system develops as the result of adequate attachment between mother and child. Eventually serves the purpose of self-soothing when the person is distressed. In those with severe neglect and lack of attachment, this system may not develop adequately and may require hyperstimulation or pain to achieve self-soothing.

Thought to inactivate large neurons or associative fibers to produce the dissociative state.

a.Presence of two or more distinct identities or personalities (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self. )


b. At least two of these identities or personality states recurrently take control of the persons behavior.


c. Inability to recall personal information that is too extensive to be explained by ordinary forgetfulness.

d. Not due to a substance or general medical condition.

In childhood: suicide attempts and total self-injurious behavior.

In adolescence: suicide attempts and anorexia

chronic health problems, brain damage, temperament (aggression, behavioral, inhibition), genetics, family factors, psychosocial factors/ stress

has questions of increasing difficulty and where child stops answering correctly is considered mental age

Prefrontal cortex

Physical growth and motor skills
Temperament
Emotional development and attachment
Cognition, memory and language
Psychosocial development

social smile

chest/head upright and steady

rolls over

sits alone

stranger anxiety; pulls to stand

walks, uses a cup

single words, two word phrases start (up to 24 months)

– throws a ball overhead

draws a closed circle

hops on one foot, dresses with help

The characteristics of infants that indicate a consistent style or pattern to an infant’s behavior.

Often cited temperamental features include:
Emotionality (state)
Activity level (tempo, vigor)
Sociability (preference for people)

Activity level; rhythmicity; approach/withdrawal; adaptability; intensity; responsiveness threshold; mood quality; distractibility; attention span and persistence

implies a selective attachment that is maintained even when there is no contact with the person with whom the bond exists

behavior that promotes proximity or contact with the specific figure or figures to whom the person is attached

0-3 months

3-7 months

7 months-3 years

3 years

4 weeks to 5 months
Infant does not see caretaker as separate from it
Infant functions as if he/she and caretaker were in state of undifferentiation or fusion
Social smile is characteristic

Differentiation, 5 to 10 months
Physical movement away from the mother begins to occur.
The infant begins to explore through play with his/her own body.
Stranger anxiety develops.

Practicing, 10 to 16 months
The infant gains physical distance through walking.
Greater exploration occurs.
Separation anxiety occurs.

Rapprochement, 16 to 24 months
Self awareness begins to develop, which can lead to anxiety and conflict.
The child wants to stay close to the mother, but also wants to explore.

Object Constancy, 24 to 36 months
The child is able to maintain an internal representation of the mother.
The child tolerates separations from the mother, knowing that they will be reunited.

Reliance on parent for help (18 mo)
Better liked by peers (3 yrs)
More independent at preschool (4 yrs)
Less likely to be lonely and greater social competence (5-7 yrs)
Less problematic behavior in school
Higher sociometric ratings in school

Children actively avoid and ignore parents on reunion, looking away and remaining occupied with toys. May move away from parents and ignore their efforts to communicate.

Although infants seem to want closeness and contact, their parents are not able to effectively alleviate their distress after brief separation. Child may show subtle or overt signs of anger, seeking proximity and then resisting it.

Children show signs of disorganization (e.g., crying for parents at door and then running quickly away when door opens; approaching parent with head down) or disorientation (e.g., seeming to “freeze” for a few seconds).

although normal among infants and toddlers, not appropriate for older children or adolescents.
-onset before age 6; symptoms of depression, difficulty concentrating, fears at bedtime.

(Infancy/early childhood)
Two subtypes:
-Inhibited: withdrawal, unresponsive
-Disinhibited: inappropriate approach to strangers, unfamiliar or more familiar people (not PCG’s).
-Treatment: Facilitate 1:1 attachment with PCG-figure

hypervigilance, development of nonverbal skills leading to misinterpretation of non-verbal cues

Lack of predictable sense of self, with poor sense of separateness and disturbed body image

Poorly modulated affect and impulse control, including aggression against self and others

Uncertainty about the reliability and predictability of others, leading to distrust, suspiciousness, problems with intimacy, and social isolation

Children become aggressive to protect themselves

process of taking new information or a new experience and fitting it into an already existing schema

process by which existing schemas are changed or new schemas are created in order to fit new information

Information is gained through the senses and motor actions
In this stage child perceives and manipulates but does not reason
Symbols become internalized through language development
Object permanence is acquired

Emergence of symbolic thought

Egocentrism

Lack the concept of conservation

Understanding of mental operations leading to increasingly logical thought

Classification and categorization

Less egocentric

Inability to reason abstractly or hypothetically

Centration-- focus on one dimension

Lack of Irreversibility of thought--
inability to imagine reversing the physical action (e.g., the pouring process that would return the water to its original container).

Hypothetico-deductive reasoning:


Adolescent egocentrism illustrated by the phenomenon of personal fable and imaginary audience

Underestimates children’s abilities
Overestimates age differences in thinking
Vagueness about the process of change
Underestimates the role of the social environment
Lack of evidence for qualitatively different stages

Newborn programmed to discriminate different sounds
Babbling up to 6 weeks
‘Filler syllables’ up to 5 months
Consonants from 5 months to 1 year
Words from 8-18 months
200 words by age 2
Pronouns from age 2
Rules of grammar from 2-4 years

Lifelong process
Is not fixed; identity changes over lifetime
Individuals must take responsibility for their own lives
Identity develops over 8 stages of life
Outcome of each stage is dependent on outcome of previous stage &
Successful negotiation of each stages ego crisis

1) Trust vs Mistrust-Oral Stage-Infancy (0-1yo)
2) Autonomy vs Shame & Doubt-Anal Stage-Early Childhood (1-2yo)
3) Initiative vs Guilt-Phallic Stage-Mid Childhood (3-5yo)
4) Industry vs Inferiority-Latency Stage-Late Childhood (6-11yo)
5) Identity vs Role Confusion-Genital Stage-Teens (12-18yo or later)
6) Intimacy vs Isolation-Early Adulthood (20s-30s)
7) Generativity vs Stagnation-Middle Adulthood (40s-60s)
8) Ego Integrity vs Despair -Late Adulthood (60s and older)

GOAL: successful nursing, peaceful warmth, comfortable exertion – HEALTHY BONDING – feelings of trust & hope

Disruption: feeling mistrust & abandonment-insecurity, suspicion of environment-world cannot be trusted

GOAL: child have control over body – toilet training – successful difference between right & wrong, control over impulses

Disruption: if overcontrolled & punitive-negative self-image. I am bad, I can never succeed

GOAL: to plan and carry out actions & get along with peers as autonomous & independent person – Preschool

Disruption: fear of pursuing of goals in life-inability to make decisions, lack of initiative taking- poor risk taking-low self-confidence

GOAL: derive pleasure & satisfaction from completion of tasks – Grammar-Middle school – Success- Problem solver & pride in accomplishment – competent

Disruption: feelings of inferior, unable to accomplish, incompetent, not as good as peers

Overcome Identity Crisis: self-consciousness & embarrassment of identity confusion

GOAL: adolescent experiment with different roles-integration of earlier stage identities – High School – success – clear, multifaceted sense of self-personal unique identity

Disruption: Perpetual identity crisis not sure who I am & struggle to find out

GOAL: to learn interacting on deeper level, revealing Self to others, find companionship with similar others, love relationship with partner

Disruption: inability to create strong social ties, loss self in isolation & loneliness, becomes a loner or superficial

GOAL: value giving self to others-form bearing & raising children-community service-give back to world-ensure success of future generations

Disruption: feelings that life is worthless & boring-life is meaningless-not enjoying worldly success

GOAL: in old age-derive wisdom from life experiences-look back on life see meaning, order & integrity-pleasant reflections-present pursuits

Disruption: sense of despair: I have not accomplished what I would have liked to in life-it now is too late to do anything about it

Look for Balanced Outcome

True maturity includes rather than excludes the opposite identity markers or poles involved

Importance of Society in the resolution of ego crises or identity crises

Birth – parents tend to encourage gender “appropriate” toys and behaviors
1 year – infants can recognize that male and female faces are 2 different categories
2 years – correctly label own gender
3 years – understand gender categories
3-6years – often more gender stereotyped play/behavior than adults
6-7years – spend much more time with same-gender peers

Conscious—In Freudian terms, thoughts or motives that a person is currently aware of or is remembering

Preconscious—Freud’s term for thoughts or motives that one can become aware of easily

Unconscious—Freud’s term for thoughts or motives that lie beyond a person’s normal awareness but that can be made available through psychoanalysis.

Id—According to Freud, the source of instinctual energy, which works on the pleasure principle (seeking immediate pleasure) and is concerned with immediate gratification.

Ego—In Freud’s theory, the rational part of the psyche that deals with reality by controlling the id while also satisfying the superego; (from the Latin ego meaning I)

Superego—In Freud’s theory, the part of the personality that incorporates parental and societal standards of morality

Oral Stage – first 18 months of life – pleasure centers around the mouth.
Anal stage – 18 through 36 months – pleasure involves anus or eliminative functions.
Phallic stage – three to six years of age – pleasure focuses on genitals and self-manipulation.
Latency stage – six years to puberty – child represses sexual interest and develops social and intellectual skills.
Genital stage – puberty on – sexual reawakening; source of sexual pleasure becomes someone outside the family

Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).

Intense fear of gaining weight or becoming fat, even though underweight.

Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)

During the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

During the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.

The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.

Self-evaluation is unduly influenced by body shape and weight.

The disturbance does not occur exclusively during episodes of anorexia nervosa.

Purging type: During the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

Nonpurging type: During the current episode of bulimia nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

“Catch-all”
Over 50% of Eating Disorder patients
Many are patients with subsyndromal anorexia nervosa or bulimia nervosa who meet most but not all of the DSM-IV-TR criteria
“Almost Anorexic”
Weight >85% of expected weight
Not amenorrheic for 3 months
“Almost Bulimic”
Binge and purge frequency less than twice per week
Many patients move between definitions at different stages of illness and treatment

Binge Eating Disorder
Binge eating in the absence of compensatory behaviors.
Overweight or obesity is common but not required
Psychological features typically include
body dissatisfaction
low self-esteem
depression

disordered eating, amenorrhea and osteoporosis

Genetic risk
for Anorexia Nervosa (AN): family hx of ED or affective disorder
for Bulimia Nervosa (BN): family hx of ED, affective disorder, substance abuse and personality traits of perfectionism and ineffectiveness
twin study concordance: monozygotic twins higher than dizygotic

Separation and loss
Disruption in family homeostasis
New environmental demands
Personal illness
Dieting
Social/cultural/interpersonal/intrapersonal struggles

Nutritional Rehab

Psychosocial Rehab I and II

Physical changes
frequent fluctuations in weight
menstrual irregularities
swollen salivary and parotid glands
dental problems
Alternative presentations
GI complaints: pain, nausea, spontaneous vomiting
depression or anxiety
weakness, fatigue
palpitations

Neglect of hygiene
Social withdrawal, impaired cue response
Apathy
Amotivation
Impaired role functioning (work, school)
Behavioral disturbance
Catatonia

False personal beliefs
Incorrect inferences about reality
Held despite evidence to contrary
Not shared by others, reference group

Stimuli refer to me
Radio, TV, people talking

Odd, magical thinking
superstition, clairvoyance, telepathy

Erotomanic: celebrity is my lover
Grandiose: I am messiah, prince
Jealous: partner having others in all night
Persecutory: men following me, plan to kill
Somatic: feet mechanical, device implanted
Nihilistic: world coming to an end
Bizarre: electronic circuit in brain controlled by president to manipulate political events

Hallucinations
Auditory: voices, music, clicking
Visual: people, lights
Olfactory: burning, flesh
Tactile: bugs on skin, crown of thorns
Gustatory: food, cigarettes poisoned

curtains - ghost

floor wavy

Impaired memory, concentration
Motor planning
Executive function
Sorting tasks
Problem solving
Impaired insight
Disorientation

A.Characteristic Symptoms: 2 or more, each for significant portion of 1 month
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative sxs

Only 1 criterion A symptom required if:
Delusions are bizarre
Hallucinations consist of running commentary
Hallucinations consist of 2+ voices conversing with each other


B. Social/occupational dysfunction:
work, school, interpersonal, or self-care functioning are markedly below level prior to onset

C. Duration: 6 months of continuous symptoms


D. Schizoaffective and Mood Disorder Exclusion: brief or no mood episodes

E. Substance/General Medical Exclusion

F. Relationship to Pervasive Developmental Disorder: must have hallucinations or delusions

Other Psychotic Disorders
Mood Disorders
Personality Disorders
Anxiety Disorders
Substance Induced Psychosis
Psychotic Disorder due to General Medical
Delirium, Dementia

A. Major depressive, manic or mixed episodes concurrent with criterion A for SCZ

B. Delusions or hallucinations for 2+ weeks in the absence of mood symptoms

C. Mood symptoms present for substantial portion of total duration

D. Substance/general medical exclusion

Subtypes: Bipolar type
Depressive type

A. Non-bizarre delusions, at least 1 month

B. Criterion A for SCZ never met

C. Functioning, behavior not markedly impaired

D. Mood episodes brief relative to delusional periods

E. Substance/general medical exclusion

A. A delusion develops in context of close relationship with another who has an already-established delusion

B.Delusion is similar to other person’s

C. Not better accounted for by other psychotic, mood, substance or general medical disorders

A. Prominent hallucinations or delusions in excess of usual intoxication, withdrawal
B. Developed within a month of substance intoxication or withdrawal, or medication use (ie: steroid)
C. Not better accounted for by another psychotic disorder
D. Not exclusively during delirium
eg: alcoholic hallucinosis

A. Prominent hallucinations or delusions
B. Direct physiologic consequence of general medical condition
C. Not better accounted for by another psychotic disorder
D. Not exclusively during delirium
eg: Psychosis related to Temporal Lobe sz

Paranoid: preoccupation with delusions or frequent auditory hallucinations, without prominent disorganization or catatonia

Disorganized: disorganized speech, behavior and flat or inappropriate affect


Catatonic: motor immobility, stupor, or excessive motor activity, extreme negativism, posturing or sterotyped movements, echolalia
Diminishing in frequency

Undifferentiated: not meeting above

Residual: attenuated delusions, hallucinations, disorganization or catatonia

Don't forget

Prodromal phase: social, cognitive deficits may precede active phase by many years
First Episode: highly treatment responsive
Active phase: full syndrome, typically 3-4 decades (teens or 20’s to 50’s)
Residual phase: ~1/3 remission, ~1/3 attenuation of symptoms in older years
Dopamine levels drop after age 50

Homelessness: ~50% of homeless have severe mental illness
Unemployment, underemployment
Undereducation
Impaired relationships
Family discord


Suicide: 20-40% attempt, 10% complete
20-50 x general population suicide rate
Typically in first decade of illness, between psychotic episodes
Violence: Increased risk associated with command hallucinations or persecutory delusions
Violence no more likely than gen pop when stable
Clozapine reduces risk of suicide & violence

Cerebral atrophy ~5% loss
Enlarged venticles
Reduced volume of various structures (caudate, hippocampus)
Poor organization of cortical layers
Histologic evidence of disordered neuronal migration, connection and atrophy
PET, fMRI show deficits in PFC and hippocampus during specific tasks

Functional brain abnormalities
Diffuse cerebral dysfunction, particularly prefrontal + medial temporal

Neurochemical brain abnormalities
DA hyperactivity in mesolimbic tracts
DA hypoactivity in mesocortical
Glutamate
Serotonin, GABA, norepinephrine, ACh

First Generation Antipsychotics (FGAs)
D2 antagonists
eg: chlorpromazine, haloperidol
Second Generation Antipsychotics (SGAs)
D2, 5HT2 antagonists
eg: clozapine, “atypical antipsychotic”
Third generation antipsychotics
D2 partial agonists
eg: aripiprazole

impaired attention, memory, language skills, and complex cognition (judgment, insight, problem solving)

depression, anxiety, mania, irritability, affective lability, rage/aggressio
diminished motivation (apathy),
impulsivity, perseveration, psychosis

Impulsivity
Irritability
Affective Instability
Awareness deficits

Planning
Set-shifting
Problem solving
Working memory

Apathy
Loss of interest
Loss of initiative
Loss of drive

Executive Function
Attention
Memory
Speed of Information Processing
Speech and language

Most common cognitive complaint
All types vulnerable, but most common deficits:
Working memory
Short term memory
Encoding

Some studies show increased rates of Dementia after TBI
Possible interaction between TBI and genotype
Accelerated course vs. risk factor
Does it occur after a single TBI?
Relationship to injury severity and frequency