V. V. Mood DisordersMood Disorders

It was called as a "depressive disorders" It was called as a "depressive disorders"

or as an "affective disorders“ or as or as an "affective disorders“ or as "depressive neuroses”."depressive neuroses”.

In DSM-III-R, changed asIn DSM-III-R, changed as "Mood Disorders""Mood Disorders" most common diagnosismost common diagnosis

-> -> major depressive episode Diagnosis criteriaDiagnosis criteria extreme depressive symptoms at least two extreme depressive symptoms at least two

weeksweeks Cognitive symptoms (feeling of Cognitive symptoms (feeling of

worthlessness, difficulty in decision worthlessness, difficulty in decision making)making)

Bodily symptoms Bodily symptoms (change of sleep pattern, (change of sleep pattern, appetite, weight, reduced energy)appetite, weight, reduced energy)

Body symptom is most important Body symptom is most important

componentcomponent General loss of interest in thingsGeneral loss of interest in things Inability to experience any pleasure from Inability to experience any pleasure from

life, including interaction with family or life, including interaction with family or friends or accomplishments at work or at a friends or accomplishments at work or at a schoolschool

Lasts in average 9 months, if not treatedLasts in average 9 months, if not treated Second most common disorderSecond most common disorder

-> -> manic episode

Diagnosis criteria ->Diagnosis criteria -> Symptom lasts at least 1 weekSymptom lasts at least 1 week Require less, if symptoms are severe Require less, if symptoms are severe

enough to require hospitalizationenough to require hospitalization

Elated mood, extreme excitement, euphoria Excessive activities, reduced need of sleep develop grandiose plan believing they can accomplis

h anything they desire flight of ideas : speech is typically rapid and may bec

ome incoherent, because the individual is attempting to express so many exciting ideas at once

Often accompanies anxiety, especially in the ending phase

Lasts 6 months, if not treated

hypomanic episode => not severe manic no difficulties in adjusting to daily life or work

Characteristics of mood disorderCharacteristics of mood disorder

Unipolar mood disorderUnipolar mood disorder experience either depressive or manic symptom, althoexperience either depressive or manic symptom, altho

ugh it is rare that only manic symptoms are presentugh it is rare that only manic symptoms are present

bipolarbipolar mood disorder mood disorder -> experience both depressive and manic symptoms a-> experience both depressive and manic symptoms a

lternatelylternately

depression and elation are relative independent -> an depression and elation are relative independent -> an individual can experience manic symptoms but feel soindividual can experience manic symptoms but feel somewhat depressed or anxious at the same time -> mimewhat depressed or anxious at the same time -> mixed manic episodexed manic episode

feeling of out of control or dangerousfeeling of out of control or dangerous Manic patients experience often depression and anxietyManic patients experience often depression and anxiety

Course of disease Course of disease Individual difference in terms of frequency, severity, and oIndividual difference in terms of frequency, severity, and o

f symptomsf symptoms Unipolarity, bipolarityUnipolarity, bipolarity Different intervention according to courseDifferent intervention according to course Most depression eventually remit on their own within 6 mMost depression eventually remit on their own within 6 m

onthsonths 10% last longer than 2 years10% last longer than 2 years

1. Depressive Disorders1. Depressive Disorders < < clinical description clinical description >>

major depressive disorder, single episode - Pure depression without manic or hypomanic episodes before or during the disorder - An occurrence of just one isolated depressive episode in a lifetime is rare

major depressive disorder, recurrent - If two or more major depressive episodes were occurred and were separated by at least two months during which the least two months during which the individual was not depressedindividual was not depressed - repeats recovering and relapse lifelong- repeats recovering and relapse lifelong

Relapse in average 4 times in a lifeRelapse in average 4 times in a life and lasts 5 monthsand lasts 5 months High heredityHigh heredity 85% of major depression, single episode 85% of major depression, single episode -> later becomes major depression, recurrent type -> later becomes major depression, recurrent type

(Solomon et al, 2000)(Solomon et al, 2000)

Feeling of worthlessness, difficulty in concentrationFeeling of worthlessness, difficulty in concentration Repeated suicidal ideationRepeated suicidal ideation, sleep difficulties, and loss of , sleep difficulties, and loss of

energyenergy Abraham Lincoln Abraham Lincoln severe depressionsevere depression => postponed his marriage for 3 days=> postponed his marriage for 3 days

< dysthymic< dysthymic disorder > disorder >

Similar to major depressionSimilar to major depression Symptom is weakerSymptom is weaker Duration is far longer (20, 30 years)Duration is far longer (20, 30 years) Lasts at least 2 yearsLasts at least 2 years + should not be without symptoms longer + should not be without symptoms longer than 2 monthsthan 2 months If major depression and If major depression and dysthymicdysthymic disorder are present disorder are present

at the same timeat the same time -> -> double depression

In most cases, it begins as In most cases, it begins as dysthymicdysthymic disorderdisorder -> later develops a -> later develops a major depression major depression in which case the prognosis is not goodin which case the prognosis is not good

After recovery of major depressionAfter recovery of major depression ->-> dysthymic dysthymic disorder disorder -> major depression -> major depression (Akiskal(Akiskal & & Kassano, 1997)Kassano, 1997)

< < onset and duration > >

Average onset of the major depressionAverage onset of the major depression -> general group : -> general group : 2525 age age -> clinical group : -> clinical group : 2929 age age

Recently earlier onsetRecently earlier onset Higher prevalenceHigher prevalence

Born before 1905Born before 1905 -> less than 1 % at the age of 75-> less than 1 % at the age of 75 Born after 1955Born after 1955 -> 6% at the age of 24-> 6% at the age of 24

Confirmed in Puerto Rico, Canada, Italy, Germany, FraConfirmed in Puerto Rico, Canada, Italy, Germany, France, Taiwan, Lebanon, New Zealand that this trend tonce, Taiwan, Lebanon, New Zealand that this trend toward developing depression at increasingly earlier ageward developing depression at increasingly earlier ages is occurring worldwide s is occurring worldwide (Cross National Collaborative (Cross National Collaborative group, 1992)group, 1992)

DysthymicDysthymic disorder with onset before age 21 disorder with onset before age 21 -> more chronic, poor prognosis-> more chronic, poor prognosis -> higher heredity-> higher heredity -> more often comorbid with a personality disorder-> more often comorbid with a personality disorder

According to recent researchAccording to recent research High prevalence of children High prevalence of children dysthymicdysthymic disorder disorder -> 76% of these children develop later a major dep-> 76% of these children develop later a major dep

ressionression Patients with dysthymia are more likely to attempPatients with dysthymia are more likely to attemp

t suicide than major depression patientst suicide than major depression patients It is relatively common for major depressive episoIt is relatively common for major depressive episo

des and dysthymic disorder to co-occur (double ddes and dysthymic disorder to co-occur (double depression) (McCullough et al., 2000)epression) (McCullough et al., 2000)

2. Bipolar2. Bipolar Disorders Disorders

Alternation of manic episodes with major depressive Alternation of manic episodes with major depressive episodesepisodes

-> -> bipolarbipolar I disorder I disorder Alternation of hypomanic episodes with major depresAlternation of hypomanic episodes with major depres

sive episodessive episodes -> -> bipolarbipolar IIII disorder disorder

Similar to major depressionSimilar to major depression only manic or hypomanic symptoms are addedonly manic or hypomanic symptoms are added

cyclothymiccyclothymic disorder disorder -> milder form of bipolar disorder-> milder form of bipolar disorder similar to dysthymicsimilar to dysthymic disorder disorder 1/3 of them develop later a bipolar disorder1/3 of them develop later a bipolar disorder onset onset 12-1412-14 세 세

< onset and duration >< onset and duration >

bipolarbipolar I disorder -> average I disorder -> average 18 age18 age bipolarbipolar IIII disorder -> average disorder -> average 2222 age age Both can begin in childhoodBoth can begin in childhood

Rarely begins later than Rarely begins later than 40 age40 age Earlier onset than major depressionEarlier onset than major depression More abrupt onsetMore abrupt onset

1/3 of them begin in adolescence1/3 of them begin in adolescence Mostly begins as a mild cyclothymicMostly begins as a mild cyclothymic mood swing mood swing 10-13% of bipolar10-13% of bipolar II disorder II disorder -> leads to bipolar-> leads to bipolar II disorder disorder

Unipolar disorder and bipolar disorder are two indepeUnipolar disorder and bipolar disorder are two independent disorderndent disorder

381 patients were observed for381 patients were observed for 10years10years -> only 5.2% of unipolar depression patients experien-> only 5.2% of unipolar depression patients experien

ce ce manic episode (Coryell, Endicott, etmanic episode (Coryell, Endicott, et al., 1995)al., 1995)

Frequent suicidal attempt (19%; Jamison, 1986)Frequent suicidal attempt (19%; Jamison, 1986) Mostly takes place during major depressive episodesMostly takes place during major depressive episodes

symptom specifierssymptom specifiers

1. atypical features specifier (type)1. atypical features specifier (type)

specific features of depressionspecific features of depression excessive sleep, intake of foodsexcessive sleep, intake of foods gain weight during depressive episodegain weight during depressive episode Partial interest in specific objectPartial interest in specific object

2. melancholic features specifiers (type)2. melancholic features specifiers (type)

In case of major depressionIn case of major depression Severe body symptomsSevere body symptoms Wake up early, loss of weight, loss of libidoWake up early, loss of weight, loss of libido Excessive and inappropriate guilty feelingExcessive and inappropriate guilty feeling AnhedoniaAnhedonia

Respond well to physical treatment (ECT)Respond well to physical treatment (ECT) Respond well to drug Respond well to drug (tricyclic antidepressant)(tricyclic antidepressant)

Occur independent of stressOccur independent of stress Can find more among the elderlyCan find more among the elderly

3. Chronic features specifiers3. Chronic features specifiers Continuous symptoms of major depression in lContinuous symptoms of major depression in l

ast 2 yearsast 2 years

4. Catatonic4. Catatonic featuresfeatures specifiersspecifiers

Rare, but in major depression or manic disordeRare, but in major depression or manic disorderr

ImmobilityImmobility, waxy posture, waxy posture Excessive aimless movementsExcessive aimless movements

5. 5. PPsychotic features specifierssychotic features specifiers

major depression or manic disordermajor depression or manic disorder can have hallucination or delusion can have hallucination or delusion bodily delusion bodily delusion (example: part of body (example: part of body decay)decay) mood congruent hallucinationmood congruent hallucination mood incongruentmood incongruent hallucination hallucination (depression (depression -> delusion of grandeur)-> delusion of grandeur) more severemore severe -> likely to develop a schizophrenia-> likely to develop a schizophrenia

5-15% of depressive disorder patients experience hallu5-15% of depressive disorder patients experience hallucination cination

poor premorbidpoor premorbid adjustment -> more likely to experience adjustment -> more likely to experience psychotic symptomspsychotic symptoms

need to be treated with neurolepticsneed to be treated with neuroleptics

6. postpartum onset specifier6. postpartum onset specifier

severe major depression or manic episodesevere major depression or manic episode Within 4 weeks after delivery (typically within Within 4 weeks after delivery (typically within 2-3 days)2-3 days) Experiences psychotic symptomsExperiences psychotic symptoms Could be a beginning sign of a bipolar disorderCould be a beginning sign of a bipolar disorder 1 out of every1 out of every 1,0001,000 women after a delivery women after a delivery 50% of those who had already experienced one episod50% of those who had already experienced one episod

e experience againe experience again In some case, kills their babyIn some case, kills their baby

Mild depression after delivery excludedMild depression after delivery excluded Physical exhaustion through laborPhysical exhaustion through labor A new task to fulfillA new task to fulfill Change of the identityChange of the identity Change of the environmentChange of the environment Burden of child rearingBurden of child rearing

Relationship between childbirth and depressionRelationship between childbirth and depression ->-> comparative study comparative study no difference found between the group with childbirth ano difference found between the group with childbirth a

nd the group with no childbirth (Whiffennd the group with no childbirth (Whiffen & & Gotlib, 1993)Gotlib, 1993) postpartum bluespostpartum blues tearful, temporary mood swingtearful, temporary mood swing 50-80% of mother show this symptom 1-5 days after c50-80% of mother show this symptom 1-5 days after c

hildbirth hildbirth -> -> disappears within a few daysdisappears within a few days

Specifiers describing course of Mood disorders Specifiers describing course of Mood disorders

3 characteristics that distinguish between 3 characteristics that distinguish between recurrent depression and manic disorder recurrent depression and manic disorder

- - longitudinal courselongitudinal course - rapid cycling, - rapid cycling, - seasonal pattern- seasonal pattern

They differ in the course and time pattern They differ in the course and time pattern -- needs different intervention strategies-- needs different intervention strategies

1. Longitudinal course specifiers1. Longitudinal course specifiers

It is important to know whether the individual had a mIt is important to know whether the individual had a major depressive episode or manic episodeajor depressive episode or manic episode

Whether he/she recovered fully from itWhether he/she recovered fully from it Whether a major depressive patient had in the past a Whether a major depressive patient had in the past a

dysthymiadysthymia -> if yes, -> if yes, double depressiondouble depression

Whether a bipolar disorder patient had in the past a Whether a bipolar disorder patient had in the past a dysthymia ordysthymia or cyclothymiacyclothymia

-> if yes, low chance of full -> if yes, low chance of full inter-episodeinter-episode recovery recovery In case of major depression,In case of major depression, bipolar bipolar I, bipolar I, bipolar IIII disord disord

er, it is important to know the courseer, it is important to know the course

2. Rapid-cycling specifier2. Rapid-cycling specifier

It pertains to bipolarIt pertains to bipolar I, I, bipolarbipolar IIII disorder disorder Whether it has a slow or rapid cyclingWhether it has a slow or rapid cycling In case of rapid cyclingIn case of rapid cycling -> more than 4 times per year-> more than 4 times per year -> traditional therapy not effective-> traditional therapy not effective Tricyclic antidepressant -> there is a risk to evoke a rapiTricyclic antidepressant -> there is a risk to evoke a rapi

d cyclingd cycling

3. Seasonal pattern specifier3. Seasonal pattern specifier

It pertains to bipolar disorder and recurrent major depreIt pertains to bipolar disorder and recurrent major depressive disorderssive disorder

Changes according to season Changes according to season Mostly begins at late fall and ends early springMostly begins at late fall and ends early spring

During the winter depression, summer manic episodeDuring the winter depression, summer manic episode -> seasonal affective disorder (SAD)-> seasonal affective disorder (SAD) In most cases depression during winterIn most cases depression during winter -> -> 5%5% of American are afflicted -> excessive sleep and of American are afflicted -> excessive sleep and

eating -> gaining weighteating -> gaining weight diminishing sun light in winter -> increase of thediminishing sun light in winter -> increase of the pineal g pineal g

land hormone melatoninland hormone melatonin

PPhototherapyhototherapy -> exposing to bright light in early morning 2 am-> exposing to bright light in early morning 2 am effects show up within effects show up within 3-43-4 days days within within 1-2 weeks 1-2 weeks SAD remitSAD remit side effect : side effect : 19% experience headache19% experience headache 17% eyestrain (Levitt et17% eyestrain (Levitt et al., 1993)al., 1993)

< Prevalence of mood disorders < Prevalence of mood disorders >>

Life time prevalence in US 19% (Life time prevalence in US 19% (Kessler, 1994)Kessler, 1994) Female have higher prevalence than men 2 : 1Female have higher prevalence than men 2 : 1 In case of bipolar disorder, no differenceIn case of bipolar disorder, no difference Black people show lower rate compared to whites or hiBlack people show lower rate compared to whites or hi

spanicsspanics

disease last year lifelongdisease last year lifelong ---------------------------------------------------------------------------------------------------- major deprmajor depr 6.5% 16.1%6.5% 16.1% dysthymiadysthymia 3.3% 3.6% 3.3% 3.6% bipolarbipolar 1.1% 1.3% 1.1% 1.3%

< Depression o< Depression of children and adolescence f children and adolescence >>

3 month old infants can have also depression3 month old infants can have also depression Related to mother’s depressionRelated to mother’s depression (by way of genetics and interaction)(by way of genetics and interaction) Child depression and adults depression are similar in their Child depression and adults depression are similar in their

charactercharacter

There are no difference in regard to developmental stagesThere are no difference in regard to developmental stages But ‘look’ of depression changes with ageBut ‘look’ of depression changes with age child-> facial expression, eating, sleep disorder -> facial expression, eating, sleep disorder adolescence -> low self-esteem -> low self-esteem frequent suicidal attempt frequent suicidal attempt Prevalence rate of childhood lower than adultPrevalence rate of childhood lower than adult During adolescence, it increases dramaticallyDuring adolescence, it increases dramatically

In childhood-> In childhood-> dysthymiadysthymia is more frequent is more frequent In adolescence In adolescence -> major depression is more frequent -> major depression is more frequent Bipolar disorder very rare in childhood Bipolar disorder very rare in childhood During adolescence -> dramatic increase of bipolar diDuring adolescence -> dramatic increase of bipolar di

sordersorder Adolescence major depression occurs in most cases tAdolescence major depression occurs in most cases t

o girlso girls

Childhood major depression Childhood major depression -> irritability, mood swing-> irritability, mood swing -> easily misdiagnosed as a hyperactivity-> easily misdiagnosed as a hyperactivity Childhood depression accompanies aggressive behaviChildhood depression accompanies aggressive behavi

or, especially for boysor, especially for boys -> easily misdiagnosed as a hyperactivity or-> easily misdiagnosed as a hyperactivity or conduct diconduct di

sordersorder

Quite often conduct disorder and childhood depressioQuite often conduct disorder and childhood depressio

n occurs together (comorbid) n occurs together (comorbid)

32% of ADHD children 32% of ADHD children -> major depression comorbid-> major depression comorbid (Biederman(Biederman etet al., 1987)al., 1987)

Adolescence bipolar disorderAdolescence bipolar disorder -> aggressive, impulsive, excessive sexual behavior, tr-> aggressive, impulsive, excessive sexual behavior, tr

affic accidentsaffic accidents

< Depression among the elderly >

18-20% of 18-20% of nursing home residents experience major dnursing home residents experience major depressive episodesepressive episodes

after age after age 60 mostly become chronic60 mostly become chronic

In case of late In case of late onset, sleep disorderonset, sleep disorder hypochondriasishypochondriasis Physical illness, dementia, decrease of social support -> dePhysical illness, dementia, decrease of social support -> de

pressionpression prevalence rate in the elderly -> similar to that of general poprevalence rate in the elderly -> similar to that of general po

pulationpulation

Physical illness with depressionPhysical illness with depression -> needs longer treatment than pure physical illness-> needs longer treatment than pure physical illness No sexual difference in terms of prevalence after age 65 No sexual difference in terms of prevalence after age 65

< cultural differences >< cultural differences >

Differences among different culturesDifferences among different cultures Individualistic culturesIndividualistic cultures -> "I feel blue" or "I am depressed"-> "I feel blue" or "I am depressed"

Collectivistic culturesCollectivistic cultures -> "my heart is broken"-> "my heart is broken" "our life has lost its meaning""our life has lost its meaning"

American Indian American Indian Prevalence rate Prevalence rate men men 19.4% ; women19.4% ; women 36.7% (Kinzie36.7% (Kinzie etet al., 1992)al., 1992)

< creativity >< creativity >

Relationship between Mood disorder and creativityRelationship between Mood disorder and creativity In the New Oxford Book of American Verse In the New Oxford Book of American Verse of the of the 36 poet enlisted, 8 were bipolar disorder ( 5 co36 poet enlisted, 8 were bipolar disorder ( 5 co

mmitted suicide )mmitted suicide ) Virginia Wolf was also bipolar disorder and committed Virginia Wolf was also bipolar disorder and committed

suicidesuicide

< Anxiety and depression >< Anxiety and depression >

Anxiety and depression are closely related to each otherAnxiety and depression are closely related to each other Most of the depressive patients experience anxietyMost of the depressive patients experience anxiety But not all the anxiety disorder patients experience depreBut not all the anxiety disorder patients experience depre

ssion ssion

Pure depression component Pure depression component ->-> anhedonia anhedonia Lowered cognitive and motor functioningLowered cognitive and motor functioning most depression begins with anxietymost depression begins with anxiety

cause cause

It is very complexIt is very complex biological, psychological and social factors biological, psychological and social factors

interacting with each otherinteracting with each other

1. B1. Biological dimensionsiological dimensions

FFamily researchamily research Family members of mood disorder patients Family members of mood disorder patients

have higher prevalence ratehave higher prevalence rate -> 2-3 times higher than general population-> 2-3 times higher than general population Family members of bipolar disorderFamily members of bipolar disorder -> higher only in major depressive symptoms-> higher only in major depressive symptoms Family members of the major disorder patientsFamily members of the major disorder patients -> higher prevalence only in major depressive -> higher prevalence only in major depressive

symptomssymptoms

Is bipolar disorder -> an extension of unipolar disordeIs bipolar disorder -> an extension of unipolar disorder r ? (Blehar? (Blehar etet al., 1988)al., 1988)

Adoption studyAdoption study Parents prevalence of the adopted mood disorder chilParents prevalence of the adopted mood disorder chil

drendren - compared with the parents of the adopted - compared with the parents of the adopted children without mood disorder symptom :children without mood disorder symptom : MendlewiczMendlewicz & Rainer(1977) & Rainer(1977) -> higher prevalence-> higher prevalence Von KnorringVon Knorring etet al(1983)al(1983) -> no difference-> no difference

Twin researchTwin research Identical twin are likely to present 3 or more times wiIdentical twin are likely to present 3 or more times wi

th mood disorder than fraternal twins, if the first twin th mood disorder than fraternal twins, if the first twin shows a mood disorder.shows a mood disorder.

If the first twin has a bipolar disorder, then If the first twin has a bipolar disorder, then

even higher concordance rateeven higher concordance rate ->-> if he /she is a bipolar if he /she is a bipolar I disorder I disorder -> then the rate that the other twin shows a -> then the rate that the other twin shows a

mood disorder (notmood disorder (not bipolar bipolar) is over 80%) is over 80%

in case of severe mood disorderin case of severe mood disorder if the first twin is severe major depressionif the first twin is severe major depression -> identical twin : -> identical twin : 59% 59% ->-> fraternal twin : fraternal twin : 30% concordant30% concordant In case of not severe major depression In case of not severe major depression -> identical twin : -> identical twin : 33%33% ->-> fraternal twin : fraternal twin : 14% concordant14% concordant

Neurotransmitter systemsNeurotransmitter systems Close relationship between mood disorder and neurotrClose relationship between mood disorder and neurotr

ansmitteransmitter serotonin’s function of emotion regulationserotonin’s function of emotion regulation - by way of norepinephrine and dopamin - by way of norepinephrine and dopamin if serotonin level diminishes => get impulsive and fluctif serotonin level diminishes => get impulsive and fluct

uation of emotionsuation of emotions

Absolute quantity of a single neurotransmitter is not sAbsolute quantity of a single neurotransmitter is not so much important as the balance with other neurotrano much important as the balance with other neurotransmitterssmitters

The importance of The importance of dopaminedopamine in the etiology of the moo in the etiology of the mood disorder gets attentiond disorder gets attention

The relationship between The relationship between L-dopaL-dopa and hypomania and hypomania (Van Praag(Van Praag & & Korf, 1975)Korf, 1975)

The endocrine systemThe endocrine system

Mood disorder-> related to endocrine systemMood disorder-> related to endocrine system hypothyroidism (Cushing’s disease)hypothyroidism (Cushing’s disease) -> excessive secretion of cortisol-> excessive secretion of cortisol -> -> depressiondepression HPA axisHPA axis (brain circuit)(brain circuit) hypothalamic-pituitary-adrenalcortical axishypothalamic-pituitary-adrenalcortical axis

DST (dexamethasone suppression test)DST (dexamethasone suppression test) dexamethasone is a glucocorticoiddexamethasone is a glucocorticoid that suppresses cortisol secretion in that suppresses cortisol secretion in

normal subjects.normal subjects. -> however, when this substance was given to depressive patients, muc-> however, when this substance was given to depressive patients, muc

h less suppression was noticedh less suppression was noticed =>=> 50% of depressive patients showed reduced suppression50% of depressive patients showed reduced suppression

In depressive patients the adrenal cortex secretIn depressive patients the adrenal cortex secret

ed enough cortisol to overwhelm the suppressive ed enough cortisol to overwhelm the suppressive effects of dexamethasoneeffects of dexamethasone

In recent study anxiety disorder patients demonstIn recent study anxiety disorder patients demonstrated also non-suppression on DSTrated also non-suppression on DST

Sleep and circadian rhythmsSleep and circadian rhythms

Sleep patterns of depressive patientsSleep patterns of depressive patients sleep time before REM phase is shorter than the sleep time before REM phase is shorter than the

normal (90min)normal (90min) Lack of deep sleep (slower wave sleep)Lack of deep sleep (slower wave sleep) More intensive REM sleep than the normalMore intensive REM sleep than the normal

More often awake in the middle of nightMore often awake in the middle of night If being waked up in the later phase of the sleIf being waked up in the later phase of the sle

epep -> improves depressive symptoms-> improves depressive symptoms -> relationship between depression and biorh-> relationship between depression and biorh

ythm (Wehr & Sack, 1988)ythm (Wehr & Sack, 1988)

Depression which came after stressful event Depression which came after stressful event -> didn’t show REM sleep disorder -> didn’t show REM sleep disorder -> better responded to psycho-social -> better responded to psycho-social treatmenttreatment

2. 2. Psychological dimensionsPsychological dimensions

SStressful life eventstressful life events Stress events prior to onset of mood disorderStress events prior to onset of mood disorder context and meaning of the stress is more context and meaning of the stress is more

important than stress event itselfimportant than stress event itself In most research was proven :In most research was proven : The relationship between mood disorder and The relationship between mood disorder and

stressful eventstressful event Mood disorder following a severe stress event => Mood disorder following a severe stress event =>

takes longer time for treatmenttakes longer time for treatment

Etiology of mood disorderEtiology of mood disorder -> -> related to stressful eventsrelated to stressful events -> -> its own dynamic after outbreakits own dynamic after outbreak

Only Only 20 - 50%20 - 50% of the normal population of the normal population who experienced a severe stress event who experienced a severe stress event develop a mood disorderdevelop a mood disorder

-> interaction between stressful event, -> interaction between stressful event, biological and psychological vulnerabilitybiological and psychological vulnerability

Learned helplessness and Learned helplessness and dysfunctionaldysfunctional attitude attitude

Seligman’s(1975) Seligman’s(1975) rat experimentrat experiment

If electric shocks are not avoidableIf electric shocks are not avoidable -> develops a depression-> develops a depression First reacts with anxietyFirst reacts with anxiety -> learns that it is uncontrolable-> learns that it is uncontrolable -> depression-> depression

The depressive attributional stylesThe depressive attributional styles a) internal (“it is all my fault”)a) internal (“it is all my fault”) b) stable (“additional bad things will always b) stable (“additional bad things will always be my fault”)be my fault”) c) global (c) global (“the bad situations is “the bad situations is all my fault”)all my fault”)

The causality of depressive attributional styleThe causality of depressive attributional style Is that the cause or the result ?Is that the cause or the result ? Child study ofChild study of Nolen-Hoeksema, Girgus Nolen-Hoeksema, Girgus & & SeliSeli

gman (1992) gman (1992)

Life stress events explained more variance thLife stress events explained more variance than attributional style an attributional style

- but childhood attributional style- but childhood attributional style explained much of the varianceexplained much of the variance in adult depressionin adult depression -- childhood stress event influences childhood stress event influences children’s attributional stylechildren’s attributional style

Negative attributional style is to be found not only in dNegative attributional style is to be found not only in d

epression but also in anxiety disorderepression but also in anxiety disorder

Abramson, MetalskyAbramson, Metalsky and Alloy and Alloy -> revised the importance of the attributional style-> revised the importance of the attributional style in the etiology of depressionin the etiology of depression -> -> the sense of hopelessness is more important the sense of hopelessness is more important Both anxiety disorder patients Both anxiety disorder patients and depressive disorder patientsand depressive disorder patients experience experience helplessness, helplessness, but, only depressive patients but, only depressive patients give up give up -> hopelessness about regaining the control-> hopelessness about regaining the control

Beck’s cognitive theory of depression (1967)Beck’s cognitive theory of depression (1967) cognitivecognitive errors of the depressive patients

1) Arbitrary inference1) Arbitrary inference -> fails to see various aspects of things -> fails to see various aspects of things (A (A

high school teacher infers that he is a terrible high school teacher infers that he is a terrible teacher, because one student out of 20 teacher, because one student out of 20 students fell asleep) students fell asleep)

2) Over-generalization2) Over-generalization -> when a professor makes a critical remark -> when a professor makes a critical remark

on your paper, you then assume you will fail on your paper, you then assume you will fail the class despite a long string of positive the class despite a long string of positive comments and good grades on other paperscomments and good grades on other papers

The depressed always makes thinking errorsThe depressed always makes thinking errors -> they think negatively about themselves, -> they think negatively about themselves,

their immediate world, and their futuretheir immediate world, and their future => => depressive depressive cognitive triadcognitive triad

Negative cognitive schema of the depressive patients

1) self-blame schema1) self-blame schema individuals feel personally responsible forindividuals feel personally responsible for every bad thing that happens.every bad thing that happens. 2) 2) negative self-evaluation schemanegative self-evaluation schema individuals believe they can never doindividuals believe they can never do anything correctly.anything correctly.

These cognitive errors and schemas are These cognitive errors and schemas are automatic, that is, not necessarily conscious.automatic, that is, not necessarily conscious. Beck’s cognitive theory of depression Beck’s cognitive theory of depression (1967)(1967)

=> => automatic thoughts automatic thoughts

DDysfunctionalysfunctional attitude and hopelessness attitude and hopelessness attribution (negative outlook)attribution (negative outlook) -> high risk for depression -> high risk for depression (M. Seligman)(M. Seligman) Temple-Wisconsin study of cognitiveTemple-Wisconsin study of cognitive vulnerability of depression vulnerability of depression Student group longitudinal study Student group longitudinal study (2.5year) (2.5year)

->-> high risk group -> 17%high risk group -> 17% low risk group -> 1% low risk group -> 1% developed a major depression

High risk group -> 39%High risk group -> 39% Low risk group -> 6% Low risk group -> 6% developed a minor depression (Gotlib(Gotlib & & Abramson, 1999)Abramson, 1999)

Psychological vulnerabilityPsychological vulnerability + biological + biological vulnerability vulnerability -> -> slippery path to depression slippery path to depression

social and cultural dimensionsocial and cultural dimension

Influence of divorce on depressionInfluence of divorce on depression study of study of Bruce and Kim(1992)Bruce and Kim(1992) 695 women and695 women and 530530 men were re-interviewed men were re-interviewed 1 year after divorce1 year after divorce

21% of divorced women showed severe depression21% of divorced women showed severe depression -> 3 times as much as women who were not -> 3 times as much as women who were not

divorceddivorced 17% of divorced men showed severe depression17% of divorced men showed severe depression -> 9 times as much as men who were not divorced-> 9 times as much as men who were not divorced

Marital support have a significant impact on deMarital support have a significant impact on developing a depressionveloping a depression

- high marital conflict + low marital support- high marital conflict + low marital support -> susceptibility of depression -> susceptibility of depression (Gotlib(Gotlib & Beach, 1995) & Beach, 1995)

Depression -> endangers maritalDepression -> endangers marital relationship relationship ( in men )( in men ) Marital problem Marital problem ->-> depression (in women) depression (in women) => treatment of marital problem is important f=> treatment of marital problem is important f

or treating depressionor treating depression (Fincham(Fincham etet al., 1997)al., 1997)

Mood disorders in womenMood disorders in women Bipolar disorder -> no gender difference in terms Bipolar disorder -> no gender difference in terms

of prevalenceof prevalence Major depression-> Major depression-> 70% are women70% are women similar distribution worldwidesimilar distribution worldwide the same with anxiety disordersthe same with anxiety disorders

Low controllability of womenLow controllability of women MenMen are are expected to be independent, self asserti expected to be independent, self asserti

ve, whereas women to more passive, to be sensitve, whereas women to more passive, to be sensitive to other people, and perhaps to rely on others ive to other people, and perhaps to rely on others more than males domore than males do (Hammen(Hammen etet al., 1985) al., 1985)

Men are at greater risk in the process of divorMen are at greater risk in the process of divor

cece Women are more disadvantaged in the societyWomen are more disadvantaged in the society

More discrimination, poverty, sexual harassmMore discrimination, poverty, sexual harassment, and abuseent, and abuse

Full time working womenFull time working women ->-> no difference compared to control no difference compared to control men groupmen group

Men group Men group ->-> higher rate on the problem related with agg higher rate on the problem related with agg

ressivity, hyperactivity, drug abuseressivity, hyperactivity, drug abuse

Social supportSocial support

Existence of social support has great influence Existence of social support has great influence on the development of depressionon the development of depression

Severe life stressSevere life stress When there is social supportWhen there is social support -> 10% developed a depression-> 10% developed a depression when there is no social supportwhen there is no social support -> 37% developed a depression-> 37% developed a depression (Brown et(Brown et al., 1978)al., 1978)

Social support have also influence onSocial support have also influence on the recovery of a depression (Keitnerthe recovery of a depression (Keitner etet al., 1al., 1

995)995)

Integrative theoryIntegrative theory

Anxiety and depression may share a commonAnxiety and depression may share a common genetically determined biological vulnerabilitygenetically determined biological vulnerability -> excessive neurophysiological response to -> excessive neurophysiological response to stressstress Stress event-> stress hormon-> influence on neurotraStress event-> stress hormon-> influence on neurotra

nsmitter, especially on snsmitter, especially on serotonin and erotonin and norepinephrinenorepinephrine

New theoryNew theory stress hormone "turn on" certain genesstress hormone "turn on" certain genes -> atrophy of neurons in the hippocampus-> atrophy of neurons in the hippocampus that help regulate emotions.that help regulate emotions.

Childhood stress experienceChildhood stress experience -> cognitive vulnerability -> cognitive vulnerability -> influences on adult stress response-> influences on adult stress response

Problem Problem : cannot explain specific psychologica: cannot explain specific psychological disordersl disorders

- need a theory that differentially explains bet- need a theory that differentially explains between anxiety, depression, bipolar and unipolar ween anxiety, depression, bipolar and unipolar disorderdisorder

TTreatment of mood disordersreatment of mood disorders

Drug therapyDrug therapy Change in the level of neurotransmittersChange in the level of neurotransmitters or in neuro-chemical structuresor in neuro-chemical structures - inhibition of reuptake of specific- inhibition of reuptake of specific neurotransmitters in the synapsesneurotransmitters in the synapses - down regulation of specific- down regulation of specific neurotransmittersneurotransmitters

TTricyclicricyclic antidepressants antidepressants

Imipramine (Tofranil)Imipramine (Tofranil) Amitriptyline (Elavil)Amitriptyline (Elavil) -> down-regulate norepinephrine-> down-regulate norepinephrine -> down-regulating process take 2-8 -> down-regulating process take 2-8 weeksweeks Side effectsSide effects - - blurred vision, dry mouth, constipationblurred vision, dry mouth, constipation difficulty urinating, drowsiness, weight gaindifficulty urinating, drowsiness, weight gain (at least 13 pounds on average)(at least 13 pounds on average) sexual dysfunctionsexual dysfunction -> 40% of patients-> 40% of patients drop outdrop out

50% of the patients benefit50% of the patients benefit Placebo effect -> Placebo effect -> 25-30% 25-30% For patients who stayed to the end of the tre

atment

->-> 65-70% 65-70% benefitbenefit

Excessive use of tricyclic antidepressants -> danger of death

-> needs attention when prescribed to a -> needs attention when prescribed to a suicidal patientssuicidal patients

MAO inhibitorsMAO inhibitors Block the MAO enzyme that break down such nBlock the MAO enzyme that break down such n

eurotransmitters as norepinephrine and serotoeurotransmitters as norepinephrine and serotoninnin

-> down-regulate the two neurotransmitters-> down-regulate the two neurotransmitters -> have less side effects than -> have less side effects than tricyclicstricyclics

More effective to the More effective to the atypical feature depressioatypical feature depressionn

Interacts with foods that contain tyramine (cheInteracts with foods that contain tyramine (cheese, red wine, beer )ese, red wine, beer )

-> might induce high blood pressure-> might induce high blood pressure -> interact with other drugs and risk of fatal sid-> interact with other drugs and risk of fatal sid

e effectse effects

SSRIs (selective serotonergicSSRIs (selective serotonergic reuptakereuptake inhibitors) inhibitors) Inhibit reuptake of serotoninInhibit reuptake of serotonin

Enhance serotonin level in the receptor siteEnhance serotonin level in the receptor site - exact mechanism is still not clear- exact mechanism is still not clear - most well known - most well known SSRISSRI -> -> fluoxetine (Prozac).fluoxetine (Prozac). was regarded as a break throughwas regarded as a break through (newsweek 3/26/90 cover story)(newsweek 3/26/90 cover story) side effect become known to publicside effect become known to public physical agitation, sexual dysfunction or low desire (7physical agitation, sexual dysfunction or low desire (7

5%), insomnia, and gastrointestinal upset5%), insomnia, and gastrointestinal upset

But less side effects compared to those of tricyclic antiBut less side effects compared to those of tricyclic antidepressantsdepressants

< Two new antidepressants >< Two new antidepressants >

VenlafaxineVenlafaxine -> related to tricyclic -> related to tricyclic antidepressants, but less side effectsantidepressants, but less side effects and less damage to the cardiovascularand less damage to the cardiovascular systemsystem NefazodoneNefazodone -> similar to -> similar to SSRIsSSRIs improve sleep efficiencyimprove sleep efficiency

Great deal of interest in the antidepressant properties Great deal of interest in the antidepressant properties of the natural herb of the natural herb

-> St. John's Wort (hypericum)-> St. John's Wort (hypericum) alters serotoninalters serotonin function function

Drug therapy of childhood depressionDrug therapy of childhood depression -> difference between children and adults-> difference between children and adults -> side effects of tricyclic antidepressants-> side effects of tricyclic antidepressants

Risk of death due to cardiac side effectsRisk of death due to cardiac side effects (Tingelstad, 1991)(Tingelstad, 1991)

Drug therapy of depression of the elderlyDrug therapy of depression of the elderly - - - side effects such as memory impairment, - side effects such as memory impairment, physical agitationphysical agitation

Prevention and delay of the next Prevention and delay of the next

depressive episode are more important depressive episode are more important than treatment of depression itselfthan treatment of depression itself

Because most of the depression remit Because most of the depression remit after some timeafter some time

Need medication further Need medication further 6-12 month 6-12 month after the recoveryafter the recovery

Women who are going to plan to have a Women who are going to plan to have a baby needs caution when considering baby needs caution when considering drug therapy, because the fetus can be drug therapy, because the fetus can be affectedaffected

40-50% of the patients didn’t benefit 40-50% of the patients didn’t benefit from drug therapyfrom drug therapy

LithiumLithium

In treatment of depression and bipolarIn treatment of depression and bipolar symptomssymptoms More side effect than other antidepressantsMore side effect than other antidepressants - toxicity, lowered thyroid functioning- toxicity, lowered thyroid functioning - intensify lethargy associated with depression- intensify lethargy associated with depression - substantial weight gain- substantial weight gain

Advantageous to treat manic symptomsAdvantageous to treat manic symptoms Tricyclic antidepressantsTricyclic antidepressants -> can induce manic symptoms-> can induce manic symptoms

Can be prescribed to patients without bipolar diCan be prescribed to patients without bipolar di

sordersorder Mechanism are not knownMechanism are not known probably influences the level of probably influences the level of dopaminedopamine and and nn

orepinephrineorepinephrine Influences the production and availability of Influences the production and availability of sodisodi

umum and and potassium, which is electrolytes found ipotassium, which is electrolytes found in body fluidsn body fluids

30-60% of bipolar patients respond (Prien30-60% of bipolar patients respond (Prien & Pot & Potter, 1993)ter, 1993)

Prevents relapse for 66% of the patients Prevents relapse for 66% of the patients Manic symptomsManic symptoms -> euphoric -> euphoric -> compliance problem-> compliance problem

ElectroconvulsiveElectroconvulsive Therapy( Therapy(ECT)ECT)

In the past, immature ECTIn the past, immature ECT technique technique -> recently improved-> recently improved For the patients who don’t respond to For the patients who don’t respond to

drugs well and those who have psychotic drugs well and those who have psychotic depression or are at risk of suicidal depression or are at risk of suicidal attemptattempt

-> 50-70% benefit from ECT-> 50-70% benefit from ECT

After anesthesia After anesthesia -> electric shock to -> electric shock to brainbrain

- shocks last shorter than 1 second each - shocks last shorter than 1 second each timetime - once every two days - once every two days 6-10 times per day6-10 times per day

Side effectsSide effects relatively smallrelatively small temporary memory disturbancetemporary memory disturbance -> recover within 1-2 weeks-> recover within 1-2 weeks

Mechanisms Mechanisms -> not known-> not known functional and structural changefunctional and structural change in brainin brain

< psychotherapy of major depression >< psychotherapy of major depression >

A.T. Beck’s cognitive behavior therapyA.T. Beck’s cognitive behavior therapy Once a week and 10-20 sessionsOnce a week and 10-20 sessions monitoring thought process whilemonitoring thought process while depressive symptoms come updepressive symptoms come up

-> find out "depresssive errors in thinking"-> find out "depresssive errors in thinking" -> replace with a more realistic thinking-> replace with a more realistic thinking

Negative cognitive schemas Negative cognitive schemas -> find out them with the therapist as a team-> find out them with the therapist as a team -> test them as a home work-> test them as a home work

HHypothesis testing (as to responses of other people)ypothesis testing (as to responses of other people)

Reactivating the patientsReactivating the patients -> compensate the patients through activity-> compensate the patients through activity -> improve self concept-> improve self concept

Peter Lewinsohn, GotlibPeter Lewinsohn, Gotlib & Clarke & Clarke Focused on Focused on reactivating patients in the beginningreactivating patients in the beginning Recently they deal with cognitions tooRecently they deal with cognitions too

Interpersonal Psychotherapy; IPTInterpersonal Psychotherapy; IPT

Klerman, Weissman, Rounsaville, Chevron, MaKlerman, Weissman, Rounsaville, Chevron, Markovitz et alrkovitz et al

A structured therapy like that of CBTA structured therapy like that of CBT brief therapy with 15-20 sessionsbrief therapy with 15-20 sessions

Mainly focuses on the interpersonal relationshiMainly focuses on the interpersonal relationship and coping stylep and coping style

Focuses on one of the following 4 problemsFocuses on one of the following 4 problems

Interpersonal disputesInterpersonal disputes The loss of a relationshipThe loss of a relationship Acquiring new relationshipsAcquiring new relationships Identifying and correcting deficits in Identifying and correcting deficits in

social skillssocial skills

Similar effects as medication, CBT Similar effects as medication, CBT (Elkin(Elkin etet al., 1989)al., 1989)

Preventing relapsePreventing relapse

Medication -> Medication -> rapid responserapid response Psychotherapy Psychotherapy -> improve social -> improve social

functioning and relapse preventionfunctioning and relapse prevention

medicationmedication + psychotherapy + psychotherapy -> -> combined effectscombined effects After medication offer a psychotherapyAfter medication offer a psychotherapy

For the bipolar disorder, combined therapy of For the bipolar disorder, combined therapy of psychotherapy and family therapy are effective psychotherapy and family therapy are effective

Family conflict Family conflict -> related to relapse-> related to relapse When treated with psycho-social therapyWhen treated with psycho-social therapy relapse rate decreased up to 50% comparedrelapse rate decreased up to 50% compared to drug therapy alone to drug therapy alone (Miller (Miller etet al., 1991)al., 1991)

5-6 graders of elementary school social skill training teaching cognitive strategies - was effective in the prevention of depression (Gilham et al., 1995)

50% of depression patients relapsed within 4 months, if medication was stopped

(Hollon et al., 1990) after 24month

s -------------------------------------

medication stop group 50% relapsed

medication cont. group 32% CBT group 21% CBT + drug therapy 15%

psychotherapy -> biophysiological changepsychotherapy -> biophysiological change Medication Medication -> pcychological change-> pcychological change Both of them lead to theBoth of them lead to the DST change after trDST change after tr

eatmenteatment The level ofThe level of tyroidtyroid hormone hormone thus, psychotherapy and medication combinethus, psychotherapy and medication combine

d brings an integrative change d brings an integrative change (Joffe, segal(Joffe, segal & & Singer, 1996)Singer, 1996)

VI. Schizophrenia and Related VI. Schizophrenia and Related Psychotic DisordersPsychotic Disorders

Complex disorder Disorders in perception, thought, emotion, langu

age, movement, behavior 16-19 billion dollars annually spent for the treat

ment in US 2.5% of total medical costs (Rupp & Keith, 199

3) 1801, Pinel, 1809, John Haslam 1899, German psychiatrist Emil Kraepelin combined three symptoms

“catatonia”, “hebephrenia” and “paranoia” that were

regarded at that time as independent conditions into one category

=> dementia praecox

Catatonia (alternating immobility and excitedCatatonia (alternating immobility and excited agitation)agitation) HebephreniaHebephrenia (silly and immature (silly and immature emotionality)emotionality) Paranoia (delusions of grandeurParanoia (delusions of grandeur or persecution)or persecution)

These three symptoms shared similar These three symptoms shared similar

underlying featuresunderlying features Early onset is at the heart of the three Early onset is at the heart of the three

symptomssymptoms that will eventually lead to “mental that will eventually lead to “mental

weakness” weakness” ->-> a diagnostic system that was focusing a diagnostic system that was focusing

onon the onset and course of a disease the onset and course of a disease

He pointed out that dementia praecox is He pointed out that dementia praecox is different form manic depressive illness in different form manic depressive illness in their onset and coursetheir onset and course

In 1908, swiss psychiatristIn 1908, swiss psychiatrist EugenEugen BleulerBleuler introduced the term schizophrenia introduced the term schizophrenia The core problem of schizophrenia is according to himThe core problem of schizophrenia is according to him -> -> associative splitting of the basic functionsassociative splitting of the basic functions of the personality of the personality ->-> breaking of associative threads breaking of associative threads

< < Clinical description Clinical description >>

positive symptomspositive symptoms

-> more active manifestations of abnormal behavior -> more active manifestations of abnormal behavior or an excess or distortion of normal behavioror an excess or distortion of normal behavior -> delusions or hallucinations-> delusions or hallucinations

Negative symptomsNegative symptoms

Deficits in normal behavior like in speech and motivationDeficits in normal behavior like in speech and motivation

Disorganized symptomsDisorganized symptoms

Rambling speech, erratic behavior, inappropriate affectRambling speech, erratic behavior, inappropriate affect

At least two of three symptoms must be present At least two of three symptoms must be present at least longer than a month to be diagnosed as at least longer than a month to be diagnosed as a schizophreniaa schizophrenia

Positive symptoms

DelusionsDelusions

Unrealistic thoughtsUnrealistic thoughts ““squirrels are aliens sent to Earth on a squirrels are aliens sent to Earth on a

reconnaissance mission"reconnaissance mission" ““I can end starvation for all of the world’s I can end starvation for all of the world’s

children.”children.” ““I will set up a base in the moon and evacuate I will set up a base in the moon and evacuate

children there."children there." “ “My opponent will spray my bicycle with My opponent will spray my bicycle with

chemicals that would take my strength away.”chemicals that would take my strength away.”

Individuals with delusionIndividuals with delusion -- different emotion from depression different emotion from depression -- less depressive but less wise less depressive but less wise

HallucinationsHallucinations

The experience of sensory events without input from the The experience of sensory events without input from the surrounding environmentsurrounding environment

Can involve any of the sensesCan involve any of the senses But auditory hallucination is most commonBut auditory hallucination is most common

“ “It’s too damn loud. Turn it down."It’s too damn loud. Turn it down." “ “Good day for fishing. Got to go fishing.”Good day for fishing. Got to go fishing.” ““You are strange. You are out.” You are strange. You are out.” People tend to experience hallucinations more People tend to experience hallucinations more

frequently, when they are unoccupied or frequently, when they are unoccupied or restricted from sensory inputrestricted from sensory input

SPECT (single photon emission computed tomSPECT (single photon emission computed tomography)ography)

Cerebral blood flow of men with schizophrenia Cerebral blood flow of men with schizophrenia Were tested when they are hearing auditory halWere tested when they are hearing auditory hal

lucinationlucination -> Broca's-> Broca's area was being activated area was being activated

Broca’s area is in charge of Broca’s area is in charge of speechspeech productionproduction The area that involves languageThe area that involves language comprehension iscomprehension is Wernicke'sWernicke's area area

This is a surprising discovery, because it meaThis is a surprising discovery, because it mea

ns that auditory hallucination is not hearing thns that auditory hallucination is not hearing the voices of others but are listening to their owe voices of others but are listening to their own thoughts or their own voices (Hoffman, Rapon thoughts or their own voices (Hoffman, Rapoport, Maure, & Quinlan, 1999)port, Maure, & Quinlan, 1999)

Negative symptomsNegative symptoms

Absence or insufficiency of normal behaviorAbsence or insufficiency of normal behavior Emotional and social withdrawalEmotional and social withdrawal ApathyApathy Poverty of thought or speechPoverty of thought or speech

AvolitionAvolition

Volition means aVolition means act of willing, choosing or decisionct of willing, choosing or decision Avolition means inability to initiate and persist in activAvolition means inability to initiate and persist in activ

ities.ities.

Show no interest in carrying out basic life functioningShow no interest in carrying out basic life functioning Neglects personal hygieneNeglects personal hygiene

AlogiaAlogia

Relative absence of speechRelative absence of speech Respond to questions with brief replies that have little Respond to questions with brief replies that have little

content and appear uninterested in the conversationcontent and appear uninterested in the conversation

Reflect a negative thought disorder rather than inadequate coReflect a negative thought disorder rather than inadequate communication skillsmmunication skills

Have trouble finding the right word to formulate their thoughtsHave trouble finding the right word to formulate their thoughts

Delayed comments or slow response to questionsDelayed comments or slow response to questions

AnhedoniaAnhedonia Lack of pleasureLack of pleasure Not interested in the activities that bring pleasure -> sex, fooNot interested in the activities that bring pleasure -> sex, foo

d, social activityd, social activity

Affective flatteningAffective flattening

Flat affectFlat affect 2/3 of the patients show this symptom2/3 of the patients show this symptom As if one has a mask onAs if one has a mask on Looks pointlesslyLooks pointlessly Speaks monotonouslySpeaks monotonously

Uninterested in what happens in the Uninterested in what happens in the surroundingsurrounding

Have feelings insideHave feelings inside ->-> difficulty expressing emotions, not a lack of difficulty expressing emotions, not a lack of

feeling (Berenbaumfeeling (Berenbaum & & Oltmanns, 1992) Oltmanns, 1992) ->-> emotional responses through physiological emotional responses through physiological recordingsrecordings

Facial expressions of schizophrenic patients in Facial expressions of schizophrenic patients in childhood childhood displayeddisplayed

->-> less positive and more negative affects less positive and more negative affects

Disorganized symptomsDisorganized symptoms DDisorganized speech

- difficult to get informations when talking- difficult to get informations when talking - lack of insight about one’s illness- lack of insight about one’s illness - - associative splitting associative splitting -- cognitive slippage cognitive slippage - inconsistent in speaking - inconsistent in speaking - illogical language- illogical language

Tangentiality -> cogintive slippage-> cogintive slippage

Dr: why are you here in the hospital ?Dr: why are you here in the hospital ? Pt: I don’t want to stay here. I’ve got other thingsPt: I don’t want to stay here. I’ve got other things to do. The time is right, and you know, to do. The time is right, and you know, when opportunity knocks.when opportunity knocks.

Loose association, Derailment

Dr: I was sorry to hear that your uncle Bill died a fewDr: I was sorry to hear that your uncle Bill died a few years ago. How are you feeling about him theseyears ago. How are you feeling about him these days ?days ?

Pt: Yes, he died. He was sick, and now he’s gonPt: Yes, he died. He was sick, and now he’s gon

e. He likes to fish with me, down at the river. He’e. He likes to fish with me, down at the river. He’s going to take me hunting. I have guns. I can shs going to take me hunting. I have guns. I can shoot you and you’d be dead in a minute.oot you and you’d be dead in a minute.

< Inappropriate affect and disorganized > Emotional expression not fitting in the situationEmotional expression not fitting in the situation BizzareBizzare actions like hoarding objects actions like hoarding objects or acting strangely in public or acting strangely in public catatoniacatatonia -> wild agitation or immobility-> wild agitation or immobility pace excitedly or move finger or arms pace excitedly or move finger or arms in stereotyped waysin stereotyped ways

Hold unusual posturesHold unusual postures waxy flexibilitywaxy flexibility ->-> tendency to keep the body and limbs in tendency to keep the body and limbs in

the position they are put in by someone the position they are put in by someone elseelse

Schizophrenia subtypesSchizophrenia subtypes

Three divisions have persisted as Three divisions have persisted as subtypes of schizophreniasubtypes of schizophrenia

catatonic, hebephrenic, paranoid typecatatonic, hebephrenic, paranoid type

DSM-IV-TRDSM-IV-TR

1. Paranoid type1. Paranoid type

- - Delusion, hallucination being main Delusion, hallucination being main

symptom symptom

- Cognitive skills and affects are- Cognitive skills and affects are

relatively intact relatively intact

- Better prognosis- Better prognosis

- Delusions and hallucinations usually- Delusions and hallucinations usually

have a theme such as grandeur orhave a theme such as grandeur or

persecutionpersecution

2. Disorganized type2. Disorganized type

Flat or inappropriate affectFlat or inappropriate affect such as laughing in a silly way at the such as laughing in a silly way at the

wrong timewrong time

Delusion or hallucinationDelusion or hallucination not organized around a central themenot organized around a central theme as in the paranoid type, but are moreas in the paranoid type, but are more fragmentedfragmented

Early onset, chronicEarly onset, chronic lacking the remissionslacking the remissions

3. Catatonic3. Catatonic type type

Waxy flexibilityWaxy flexibility Excessive movementExcessive movement Defiant attitude Defiant attitude Odd mannerismOdd mannerism stereotypical body movement, grimacingstereotypical body movement, grimacing EcholaliaEcholalia EchopraxiaEchopraxia Relatively rare, because of recent Relatively rare, because of recent success of neuroleptic medicationssuccess of neuroleptic medications

4. Undifferentiated type4. Undifferentiated type

People who have the major symptoms of People who have the major symptoms of schizophrenia but who do not meet the criteria schizophrenia but who do not meet the criteria for paranoid, disorganized, or catatonic typesfor paranoid, disorganized, or catatonic types

5. Residual type5. Residual type

People who have had at least one episode of People who have had at least one episode of schizophrenia but who no longer manifest major schizophrenia but who no longer manifest major symptoms are diagnosed as symptoms are diagnosed as residual type of residual type of schizophreniaschizophrenia

They may display residual or “left over” symptomsThey may display residual or “left over” symptoms Such as negative beliefs, or they may still have Such as negative beliefs, or they may still have

unusual ideas that are not fully delusionalunusual ideas that are not fully delusional

Residual symptoms can include social withdrawal, Residual symptoms can include social withdrawal, bizarre thoughts, inactivity, and flat affectbizarre thoughts, inactivity, and flat affect

< Other psychotic disorders >< Other psychotic disorders >

There are other psychotic disorders that don’t fit under the haThere are other psychotic disorders that don’t fit under the hading of schizophreniading of schizophrenia

SchizophreniformSchizophreniform Disorder Disorder Symptoms of schizophrenia for a few months onlySymptoms of schizophrenia for a few months only Good premorbid social and occupationalGood premorbid social and occupational functioningfunctioning absence of bluntedabsence of blunted or flat affect or flat affect

SchizoaffectiveSchizoaffective Disorder Disorder People who have both schizophrenia and mood disordePeople who have both schizophrenia and mood disorde

r at the same time. r at the same time. MMood disorder + delusion or hallucination longer than ood disorder + delusion or hallucination longer than

2 weeks2 weeks

Delusional DisorderDelusional Disorder

A persistent belief that is contrary to reality in A persistent belief that is contrary to reality in the absence of other characteristics of schizothe absence of other characteristics of schizophreniaphrenia

-Different from schizophrenia, the delusions of -Different from schizophrenia, the delusions of delusional disorder are theoretically possibledelusional disorder are theoretically possible

Not organically caused delusion Not organically caused delusion Not caused by drugs or alcohol eitherNot caused by drugs or alcohol either There are no negative symptoms such as flat There are no negative symptoms such as flat

affect, anhedoniaaffect, anhedonia

Late onset Late onset (age 40-49)(age 40-49) subtypes subtypes =>=> erotomanic, grandiose, jealous, persecutory, erotomanic, grandiose, jealous, persecutory, somatic somatic

Brief Psychotic DisorderBrief Psychotic Disorder Characterized by the presence of one or more positive symptoms Characterized by the presence of one or more positive symptoms

such as delusions, hallucinations, or disorganized speech or behsuch as delusions, hallucinations, or disorganized speech or behavior lasting 1 month or lessavior lasting 1 month or less

Often precipitated by extremely stressful situationsOften precipitated by extremely stressful situations

Shared Psychotic DisorderShared Psychotic Disorder

- - An individual develops delusions simply as a result of a An individual develops delusions simply as a result of a close relationship with a delusional individualclose relationship with a delusional individual

1. 1. StatisticsStatistics

Lifelong prevalence 0.2% - 1.5%Lifelong prevalence 0.2% - 1.5% Similar prevalence world wide, and Similar prevalence world wide, and

no gender differenceno gender difference Onset of male begins earlier than Onset of male begins earlier than

that of femalethat of female More men before age More men before age 36, more 36, more

women after age 36women after age 36

< Development< Development >>

Children show some abnormal signs before they displaChildren show some abnormal signs before they display the characteristic sympotomsy the characteristic sympotoms

(cf: (cf: 조승희조승희 , Virginia College of Technology. Massacre in April 17. 2007 killin, Virginia College of Technology. Massacre in April 17. 2007 killing 32 students and injuring 15 students)g 32 students and injuring 15 students)

Negative affects domineeringNegative affects domineering Bad adjustmentBad adjustment 40 years follow up study of 40 years follow up study of 52 schizophrenic patients52 schizophrenic patients Symptoms decreased as getting oldSymptoms decreased as getting old (Winokur(Winokur etet al., 1987)al., 1987)

Most of the patients kept their symptoms lifelong,Most of the patients kept their symptoms lifelong, ((moderate to sever symptoms)moderate to sever symptoms)

Group1 (22%) -> one episode only, no Group1 (22%) -> one episode only, no

impairment impairment Group2 (35%) -> several episodes with Group2 (35%) -> several episodes with

no or minimal impairment no or minimal impairment Group3 (8%) -> impairment after the Group3 (8%) -> impairment after the

first episode with subsequent first episode with subsequent exacerbation and no return to normalityexacerbation and no return to normality

Group4 (35%) -> impairment increasing Group4 (35%) -> impairment increasing with each of several episodes and no with each of several episodes and no return to normalityreturn to normality

Schizophrenia found in all culturesSchizophrenia found in all cultures Differed in terms of prevalence rate or recovery rDiffered in terms of prevalence rate or recovery r

ateate In US more African Americans receive the diagnoIn US more African Americans receive the diagno

sis of schizophrenia than whites.sis of schizophrenia than whites. People from devalued minority groups maybe victiPeople from devalued minority groups maybe victi

ms of bias and stereotyping.ms of bias and stereotyping. Blacks were more likely to be detained against thBlacks were more likely to be detained against th

eir will, brought to the hospital by police, and giveir will, brought to the hospital by police, and given emergency injections (Goater et al., 1999)en emergency injections (Goater et al., 1999)

2. Cause2. Cause

< Genetic influences >< Genetic influences >

19381938 Franz KallmannFranz Kallmann Examined family members of more than 1,000 people Examined family members of more than 1,000 people

diagnosed with schizophrenia in a Berlin Psychiatric Hdiagnosed with schizophrenia in a Berlin Psychiatric Hospitalospital

The severe the symptoms, the higher concordance ratThe severe the symptoms, the higher concordance rate of family memberse of family members

Various subtypes found in the same familyVarious subtypes found in the same family -> general predisposition for schizophrenia,-> general predisposition for schizophrenia, not specific predispositionnot specific predisposition

The closer genetically the higher concordance rateThe closer genetically the higher concordance rate Identical twin Identical twin 49%49% Fraternal twin Fraternal twin 17%17% Sibling Sibling 6%6% Cousin Cousin 2%2% (Gottesman, 1991)(Gottesman, 1991)

Quadruplets schizophrenia observed over the years and all Quadruplets schizophrenia observed over the years and all 4 sisters developed schizophrenia4 sisters developed schizophrenia

But they showed all very different courses the same parentBut they showed all very different courses the same parents and family-> individually different experiencess and family-> individually different experiences (Rosenthal, (Rosenthal, 1963)1963)

Adoption studies Adoption studies

1. adopted child research1. adopted child research

firstfirst, identify schizophrenic patients, identify schizophrenic patients nextnext, find their children given , find their children given to other familiesto other families

2. 2. Relatives studiesRelatives studies

firstfirst, , schizophrenic patients who were adopted schizophrenic patients who were adopted areare

identifiedidentified nextnext, find their parents and siblings, find their parents and siblings

Research in Finland Research in Finland (Tienari, 1992)(Tienari, 1992) Adoption studiesAdoption studies

Of the Of the 20,000 female schizophrenic patients20,000 female schizophrenic patients 164 were identified who gave their children aw164 were identified who gave their children aw

ay for adoptionay for adoption => 155 children of these patients were identifi=> 155 children of these patients were identifi

ed who were brought up in foster homeed who were brought up in foster home 185 children of the normal parents were comp185 children of the normal parents were comp

ared as a control group who were also brought ared as a control group who were also brought up in foster homeup in foster home

Of the patients’ children, Of the patients’ children, 16 were diagnosed either schizophrenia 16 were diagnosed either schizophrenia or other psychosis or other psychosis -> -> 10.3% 10.3% Of the normal parents’ children,Of the normal parents’ children, 2 were diagnosed as psychosis 2 were diagnosed as psychosis -> -> 1.1% 1.1%

GottesmannGottesmann’s research ’s research (1989)(1989) Children of identical twin patients Children of identical twin patients ->-> 16% 16% Children of identical twin patient’s sibling Children of identical twin patient’s sibling

who are not patients -> who are not patients -> 17%17%

Children of fraternal twin patients -> Children of fraternal twin patients -> 16%16% Children of fraternal twin patient’s sibling Children of fraternal twin patient’s sibling

who are not patients -> who are not patients -> 1.7%1.7%

The fact that the probability of outbreak The fact that the probability of outbreak of schizophrenia in children of patient of schizophrenia in children of patient twin and in normal twin are the same twin and in normal twin are the same proves high heredityproves high heredity

But it is only But it is only 17% 17% -> the rest can be -> the rest can be attributed to other causes attributed to other causes

Defects of not a single but several genes Defects of not a single but several genes combined together -> severe pathologycombined together -> severe pathology

Search for markersSearch for markers Characteristics common to schizophrenic patientsCharacteristics common to schizophrenic patients => =>

will lead to a discovery of related geneswill lead to a discovery of related genes

One of them is :One of them is : Smooth-pursuit eye movement or eye trackingSmooth-pursuit eye movement or eye tracking

The ability to track objects with eye movement The ability to track objects with eye movement keeping head still.keeping head still. schizophrenic patients lack in this abilityschizophrenic patients lack in this ability And this independent of drug And this independent of drug or hospitalization or hospitalization (Liebermann(Liebermann etet al., 1993)al., 1993)

< Neurobiological factors< Neurobiological factors >>

Dopamine over-activity hypothesisDopamine over-activity hypothesis It is still controversial, but long lived It is still controversial, but long lived

hypothesishypothesis

Evidences that support dopamine Evidences that support dopamine hypothesishypothesis

1. Antipsychotic drugs that are often1. Antipsychotic drugs that are often

effective in treating people witheffective in treating people with

schizophrenia are dopamine antagonistsschizophrenia are dopamine antagonists

2. These drugs can produce negative side 2. These drugs can produce negative side

effects similar to those in Parkinson’s effects similar to those in Parkinson’s disease, a disorder known to be caused disease, a disorder known to be caused by insufficient dopamine. by insufficient dopamine.

3. The drug L-dopa, a dopamine agonist 3. The drug L-dopa, a dopamine agonist used to treat people with Parkinson’s used to treat people with Parkinson’s disease, produces schizophrenia-like disease, produces schizophrenia-like symptoms in some peoplesymptoms in some people

4. Amphetamines, which also activate4. Amphetamines, which also activate dopamine, can make psychotic dopamine, can make psychotic

symptoms worse in some people with symptoms worse in some people with schizophreniaschizophrenia

In other words, when drugs are In other words, when drugs are

administered that are known to administered that are known to increase dopamine (agonist), there is increase dopamine (agonist), there is an increase in schizophrenic behavior;an increase in schizophrenic behavior;

when drugs that are known to when drugs that are known to decrease dopamine activity decrease dopamine activity (antagonists) are used, schizophrenic (antagonists) are used, schizophrenic symptoms tend to diminish.symptoms tend to diminish.

(mostly drugs that block the activity of(mostly drugs that block the activity of D2D2 receptor receptor))

< Evidences that contradict the dopamine theory < Evidences that contradict the dopamine theory >>

1. A significant number of people with schizophre1. A significant number of people with schizophrenia are not helped by the use of dopamine annia are not helped by the use of dopamine antagoniststagonists

2. Although the neuroleptics2. Although the neuroleptics block the reception block the reception of dopamine quickly, the relevant symptoms of dopamine quickly, the relevant symptoms subside only after several days or weeks, musubside only after several days or weeks, much more slowly than researchers would expecch more slowly than researchers would expectt

3. These drugs are only partly helpful in reducing 3. These drugs are only partly helpful in reducing the negative symptoms (e.g., flat affect, anhethe negative symptoms (e.g., flat affect, anhedonia) of schizophreniadonia) of schizophrenia

4. There is no evidence that schizophrenic patients 4. There is no evidence that schizophrenic patients

have more D2 receptors than normals.have more D2 receptors than normals.5. The research haven’t proved yet that there is ab5. The research haven’t proved yet that there is ab

normality in D2 receptors of schizophrenic patiennormality in D2 receptors of schizophrenic patients.ts.

6. Clozapine6. Clozapine is effective to those patients who don’ is effective to those patients who don’t respond well to the traditional drugs. But this drt respond well to the traditional drugs. But this drug is very weak in blocking D2 receptors.ug is very weak in blocking D2 receptors.

Dopamine is related to schizophrenia, but its role Dopamine is related to schizophrenia, but its role is very complexis very complex

Dopamine has a different effect in combination wDopamine has a different effect in combination with serotoninith serotonin

Appropriate proportion of dopamine and serotonin Appropriate proportion of dopamine and serotonin is important in regulating positive symptoms such is important in regulating positive symptoms such as hallucination or delusionas hallucination or delusion

CClozapine plays a role in mediating these two neurlozapine plays a role in mediating these two neurotransmitters.otransmitters.

Blocking only dopamine isn’t effectiveBlocking only dopamine isn’t effective

Dopamine and serotonin must be blocked simultaDopamine and serotonin must be blocked simultaneously to be effective (more dopamine should be neously to be effective (more dopamine should be blocked)blocked)

< Psychological and social influence< Psychological and social influence >>

Even the identical twins show different prevaleEven the identical twins show different prevalence ratence rate

Environmental and experiential influencesEnvironmental and experiential influences Research with high risk childrenResearch with high risk children In 1960, longitudinal researches of Danish reIn 1960, longitudinal researches of Danish re

searchers Mednicksearchers Mednick & & SchulsingerSchulsinger 207 children of schizophrenic mothers were o207 children of schizophrenic mothers were o

bservedbserved 104 control group children 104 control group children The research is still being doneThe research is still being done

Most of the researches are retrospective Most of the researches are retrospective

studies, the effects of which are limitedstudies, the effects of which are limited Ventura et al (1989) Ventura et al (1989)

30 patients were observed for one year30 patients were observed for one year

Interviewed every two weeksInterviewed every two weeks Relapse often after stress events Relapse often after stress events But But 55% of the relapsed hadn’t had a 55% of the relapsed hadn’t had a

considerable stress, which means there considerable stress, which means there are factors other than stress that impact are factors other than stress that impact relapserelapse

< The influence of the family and culture on the r< The influence of the family and culture on the r

elapseelapse >>

SchizophrenogenicSchizophrenogenic mother mother (Fromm-(Fromm-Reichmann, 1948)Reichmann, 1948) double bind (Bateson, 1958)double bind (Bateson, 1958) induces guilty feelings of the parents induces guilty feelings of the parents -> -> which has negative impact on familywhich has negative impact on family

Recent researchRecent research The influence of the interaction among the famiThe influence of the interaction among the fami

ly members on the relapsely members on the relapse Brown Brown et al et al (1959)(1959)

Expressed emotion (EE)Expressed emotion (EE) Patients who were restricted in their contact with familPatients who were restricted in their contact with famil

y members showed lower relapse ratey members showed lower relapse rate

Criticism, hostility and emotional intrusiveness of the Criticism, hostility and emotional intrusiveness of the family members had impact on relapse family members had impact on relapse

(Brown et(Brown et al., 1962)al., 1962)

High expressed emotion in familyHigh expressed emotion in family -> a good predictor of relapse -> a good predictor of relapse (Bebbington(Bebbington etet al., 1995)al., 1995)

Patients who lived in highPatients who lived in high EEEE family showed 3.7 times family showed 3.7 times higher relapse rate than those who lived in low EE famhigher relapse rate than those who lived in low EE family ily (Hooley, 1985)(Hooley, 1985)

2. 2. Treatment Treatment

< < Biological intervention Biological intervention >>

In 1930sIn 1930s injection of massive doses of injection of massive doses of insulininsulin -> insulin coma therapy-> insulin coma therapy serious side effects, risk of deathserious side effects, risk of death psychosurgerypsychosurgery -> prefrontal-> prefrontal lobotomies lobotomies In the late 1930sIn the late 1930s Introduction of ECTIntroduction of ECT Today it is known to have no effectToday it is known to have no effect

Dramatic change after inventingDramatic change after inventing neurolepticsneuroleptics in 1950in 1950 => control delusion and hallucinations=> control delusion and hallucinations (mainly positive symptom)(mainly positive symptom)

class example degree ofclass example degree of extra- extra- pyramidal effectspyramidal effects (side effects)(side effects)

---------------------------------------------------------------------------------------------------------------------------------------------------------------------- ConventionalConventional antipsychoticsantipsychotics phenothiazinesphenothiazines Fluphenazine / ProlixinFluphenazine / Prolixin high high Trifuluoperazine / StelazineTrifuluoperazine / Stelazine

highhigh Perphenazine / TrilafonPerphenazine / Trilafon high high Mesoridazine / SerentilMesoridazine / Serentil lowlow Chlorpomazine / Thorazine Chlorpomazine / Thorazine moderatmoderat

ee Thioridazine / Mellaril Thioridazine / Mellaril lowlow

Butyrophenone Butyrophenone haloperidol / Haldolhaloperidol / Haldol high high

others others Thiothixene / NavaneThiothixene / Navane high high Molindone / MobanMolindone / Moban lowlow Loxapine / LoxitaneLoxapine / Loxitane highhigh

NewNew Antipsychotics Antipsychotics Clozapine / ClozarilClozapine / Clozaril lowlow Risperidone / RisperidalRisperidone / Risperidal lowlow

Olanzapine / ZyprexaOlanzapine / Zyprexa lowlow Serindole / SerlectSerindole / Serlect

lowlow Quetiapine / SeroquelQuetiapine / Seroquel lowlow

These drugs influence mainly dopamineThese drugs influence mainly dopamine

but also have influence on serotonin but also have influence on serotonin systemsystem

It is only recently that we come to It is only recently that we come to understand better the mechanism of understand better the mechanism of drugsdrugs

- Drugs are effective for some patients, - Drugs are effective for some patients, but not for other patients.but not for other patients.

Clinicians and patients often must go Clinicians and patients often must go through a trial and error process to find through a trial and error process to find the medication that works bestthe medication that works best

Conventional antipsychotics are effective for apprConventional antipsychotics are effective for appr

oximately oximately 60% 60% of people who try them of people who try them (APA, 200 (APA, 2000)0)

Mostly many side effectsMostly many side effects Some people respond well to newer medicationsSome people respond well to newer medications The most common are clozapine, risperidone, anThe most common are clozapine, risperidone, an

d olanzapined olanzapine These medications tend to have fewer serious siThese medications tend to have fewer serious si

de effects than the conventional antipsychotics de effects than the conventional antipsychotics (Davis, Chen, & Glick, 2003)(Davis, Chen, & Glick, 2003)

Noncompliance Noncompliance of the patients is a significant of the patients is a significant problemproblem

Approximately Approximately 7% of the patients refuse to tak7% of the patients refuse to take medicatione medication

3 out of 4 patients refused to take the antipsy3 out of 4 patients refused to take the antipsychotic medication for at least 1 week (Weidenchotic medication for at least 1 week (Weiden etet al., 1991)al., 1991)

Negative side effects are a major factor in patiNegative side effects are a major factor in patient refusalent refusal

grogginessgrogginess Deterioration in the ability to concentrate Deterioration in the ability to concentrate (1(1

8%) 8%) Dry mouth (16%)Dry mouth (16%) Blurred vision (16%)Blurred vision (16%)

AkinesiaAkinesia

-- one of the common side effect one of the common side effect it includes an expressionless face, slow motor it includes an expressionless face, slow motor activity, and monotonous speechactivity, and monotonous speech

TardiveTardive dyskinesiadyskinesia

-- involuntary movements of the tongue, involuntary movements of the tongue, face, mouth or jawface, mouth or jaw - results from long-term use of high doses of - results from long-term use of high doses of antipsychotic medicationantipsychotic medication - often irreversible and may occur in as many- often irreversible and may occur in as many as as 20% of people who take the medications 20% of people who take the medications over long periodsover long periods

The new antipsychotics such as clozapine The new antipsychotics such as clozapine

produce fewer side effects, but even clozaproduce fewer side effects, but even clozapine brings undesirable effects and must bpine brings undesirable effects and must be monitored closelye monitored closely

The compliance problem is seriousThe compliance problem is serious Psychosocial intervention can help to increPsychosocial intervention can help to incre

ase compliance by helping patients commuase compliance by helping patients communicate better with professionals about their nicate better with professionals about their concernsconcerns

< P< Psychosocial intervention sychosocial intervention >>

Psychological intervention could bePsychological intervention could be combined with medicationscombined with medications Improving patient’s socializationImproving patient’s socialization Participation in group sessionsParticipation in group sessions self care such as bed makingself care such as bed making

Token economy, in which residents could earn Token economy, in which residents could earn access to meals and small luxuries by behaving access to meals and small luxuries by behaving appropriatelyappropriately

DeinstitutionalizationDeinstitutionalization - growth of human rights, integration- growth of human rights, integration into communityinto community - ill conceived policy produced many- ill conceived policy produced many homeless peoplehomeless people

< Social skill training< Social skill training >>

Basic conversationBasic conversation AssertivenessAssertiveness Relationship buildingRelationship building Maintaining eye contact while Maintaining eye contact while

talking to another persontalking to another person Making friends Making friends Relapse preventionRelapse prevention Utilizing social support systemUtilizing social support system

< Family education< Family education >>

Educating the family about the symptoms of schizophrEducating the family about the symptoms of schizophreniaenia

Educating about the cause of the illnessEducating about the cause of the illness Teaching the family members to communicate more eTeaching the family members to communicate more e

ffectively ffectively (learn more constructive way to express negative emot(learn more constructive way to express negative emot

ions, listening more empathically)ions, listening more empathically)

Teaching practical facts about antipsychotics Teaching practical facts about antipsychotics (effects, (effects, side effects etc)side effects etc)

Teaching about support systemTeaching about support system Teaching about problem solving strategiesTeaching about problem solving strategies

< < Vocational rehabilitation Vocational rehabilitation >>

Enhancing the vocational abilityEnhancing the vocational ability Supportive rehabilitationSupportive rehabilitation Multilevel treatment Multilevel treatment -> contribute to reducing relapse rate-> contribute to reducing relapse rate

Relapse rate of schizophrenia (after 2 yearRelapse rate of schizophrenia (after 2 year))

1. drugs + support or education 1. drugs + support or education --> 62%> 62%2. drugs + social skills training 2. drugs + social skills training --> 35%> 35%3. drugs + famil3. drugs + famil stress management -> 38% stress management -> 38% ((Falloon, BrookerFalloon, Brooker & Graham-Hole, 1992) & Graham-Hole, 1992)

< Self help groups >< Self help groups >

Recently change from large mental Recently change from large mental hospitals to family homes in local hospitals to family homes in local communitiescommunities

Self help groups of former patientsSelf help groups of former patients Fountain House in New York City (Beard etFountain House in New York City (Beard et

al., 1982)al., 1982)

Most of the PsychosocialMost of the Psychosocial club have differing club have differing models, but all are models, but all are "person centered“ and "person centered“ and focus on obtaining positive experiences focus on obtaining positive experiences through employment opportunities, through employment opportunities, friendship, and empowerment.friendship, and empowerment.

25,000 New Yorkers have participated in club-houses 25,000 New Yorkers have participated in club-houses

sponsored by New York Association of Psychiatric Rehsponsored by New York Association of Psychiatric Rehabilitation Services.abilitation Services.

Participation in club houses may help reduce relapse Participation in club houses may help reduce relapse (Beard, Malamud & Rossman, 1978)(Beard, Malamud & Rossman, 1978)

But it is difficult to interpret the improvement, becauBut it is difficult to interpret the improvement, because it is possible that those who have participated may se it is possible that those who have participated may belong to a special group of individuals belong to a special group of individuals (Mueser(Mueser etet aal., 1990).l., 1990).

You’ve done a great job ! You’ve done a great job ! I appreciate very much your efforts to come along !I appreciate very much your efforts to come along ! Have a good time during vacation !!Have a good time during vacation !!