Psych 309 Abnormal Psych Final Exam Notes

Chapter 6: Anxiety Disorders Monday, February 28, 2011

Pre-lecture: 1. 6 lectures (6 weeks)

a. Anxiety disorders b. Somatoform c. Dissociative d. Mood disordere. Psychotic f. Personality

Lecture: 1. Anxiety (good place to start, because we all have experienced it)

a. Physiological / Physical i. Job interviews

ii. Heart palpitation, sweaty, increased heart rate, shaking (hands trembling), nausea (sick to stomach), speaking faster, dry mouth, rapid and shallow breathing

iii. Unique/individual pattern for each person iv. Increased in sympathetic nervous system/activity

1. “Flight of Fight” response 2. Prepares body for threat (threats to live, we want body to run

really fast/ try to fight/ tolerate high degree of pain) 3. Response to pain is minimized (good things to have happened)

v. However, in anxiety, this response is counter-productive. b. Cognitive / Thoughts

i. Negative Outcome (worries) c. Behavioral

i. Depends on situation and degree to which they are experiencing anxiety ii. Public speaking

1. 50% of grade is based on talk, so in this situation, some people will just do it.

2. However take same person, and say the grade is worth 5% instead, they will avoid it.

iii. Pattern of avoidance* 1. Across other anxiety disorder

iv. Fear is much more “present” orientated/ Anxiety much more “future”orientated

v. Acute anxiety can be quite similar to fear d. What positive benefits can anxiety have?

i. Anxiety could be a motivating factor

ii. Can help you become better prepared iii. There are some good things that come out of the state of anxiety

2. The Anxiety Disorders (when it becomes so distressing/ starting to impair ability to function; a move from normal anxiety to pathological- mental health problem; quite commonly diagnosed)

a. Panic Disorderb. Generalized Anxiety Disorderc. OCDd. PTSD (is in the DSM as anxiety disorder)

3. Most common of the anxiety disorder are the phobia, there is a gender pattern (more females are diagnosed with anxiety disorders with exception to OCD)

4. High rates of comorbidity *a. Anxiety do not often occur in isolation; if it does, it has higher chance of

treatment success b. i.e anxiety + mood disorder

5. Low rates of evidence based treatments 6. High degree of avoidance*

a. Always some degree of avoidance 7. A story:

a. A guy early in his 20’s going university, some binge drinking, shared housing, good social group, doing well in school, working part time, and was his time to go do grocery shopping. On budget. Looks for toilet paper, then all of sudden he feels pain across chest, heart race, skips beats, difficulty breathing, feels dizzy, doesn’t lose consciousness, back against wall. People start coming up to him to check what’s going on, and calls ambulance for him. ER-and turns out there is nothing wrong with his heart. Had a panic attack.

8. Definition of a Panic Attack *** on exam for sure; case scenario; if this is a panic attack or not?

a. Panic Attack Criteria (feels like having a heart attack to the guy)i. THIS ISNT FUN

ii. Trembling + dizziness iii. Hot Flushes + Cold Spells iv. Increased heart rate; palpitations v. Sweating

vi. Inspiration -> choking sensations vii. Shortness of breath

viii. Numbness or tingling ix. Tightness in chest x. Fear of: Dying, going crazy, losing control

xi. Unreality (sense of) xii. Nausea

b. DSM requires 4 or more c. Peaks Quickly ( not gradual*) d. Brief and intense

e. Also common (though not part of the criteria) is “feeling like one needs to flee” f. Single attack does not equal a disorder (just because a person has a panic attack

does not mean they have a mental illness or disorder; in fact stats indicate that most people will have a panic attack in their lifetime )*

g. Need to distinguish the type of panic attack i. Cued (situationally –bound)

1. More common 2. Friend who gets a door knob told that husband is in car crash

ii. Uncued (“out of the blue”) 1. If you ask the guy in the description, nothing comes to mind about what

caused the panich. Panic attack can occur across all anxiety disorder

i. When occur is usually acute; example somebody who has public speaking phobia gets panic attack

ii. Phobia of black cat, sees it get cued panic attack i. When we get to the uncued panic disorder, that’s when we consider the DSM criteria*

9. Panic disorder a. DSM Criteria

i. Recurrent, unexpected (uncued*) panic attacks b. 2 + 1 or more for at least one month of :

i. Persistent concern about having another attack ii. Worry about implications (heart problems “going crazy)

iii. Significant change in behavior *** (we are most concern with this criteria) / AVOIDANCE

1. Not willing to go shopping on own; requires roommate to come with him

2. Requiring roommate to go class with him iv. (people with panic disorder usually have all 3 as in the case of the guy)

1. Significance avoidance = agoraphobia a. Much common to see agoraphobia with panic disorder

2. Panic disorder without agoraphobia (hopes for this one; easier to treat) 3. Or panic disorder with agoraphobia)4. DSM Definition: Agoraphobia is anxiety about being in places or

situations where escape is difficult or embarrassing in the event of a panic attack -> lead to avoid situation (pattern of avoidance sets in/ world gets smaller for them; hence we want to treat it as quickly as possible and prevent this from happening)

c. Causes i. No single cause for any disorder

ii. Do have evidence that it runs in family (genetic component; not a very strong one)

iii. Higher level of norepinephrine iv. Lower level of Gaba

v. Brain area (eg. amygdala (crucial to experience of fear; overactive triggers panic attack)

vi. Two competing theories: 1. CO2 hypersensitivity theory

a. That people who were having spontaneous panic attack that brain were too sensitive to carbon dioxide

b. Based on research and got people who had panic disorder and people who didn’t and had them breath this air.

c. People with panic disorder had panic attack/ people without panic disorder did not have panic attack

d. 4/5 vs 1/5 e. Critisized

2. Cognitive Theory a. Used same design b. What they did differently was this time gave them some

information; this mask contain a slightly higher level of CO2, that you may notice your heart rate increasing, this is fine this is normal; we keep mask on face, if at anytime you feel intolerable of this; let us know and we ll stop.

c. Gave them information. d. Found no difference in this one. e. 1/5 vs 1/5 f. Argues Catastrophic misinterpretation of benign

physiological changes * g. Hence, CO2 hypersensitivity theory didn’t have much

support d. Treatments

i. CBT 1. interoceptive exposure

a. Exposure to internal cues i. Eg. tell them to go run around in circles to have

them feel a little dizzy, spin them in office chairs, having them exposed to physiological cues

2. Thought restructuring 3. Relaxation + breathing training 4. If agoraphobia -> exposure to situations that are avoided

a. Having them walk into the den and standing there for 5 minutes.

b. Then have them to other roomsc. Then stand outside (gradual) d. Person experiences a lot of anxiety doing this.

5. Clip: Person has to be willing to expose self, needs to expose to each situation in turn, takes time, have to have the person

motivated; ideally, we want to treat the person early to prevent this level of avoidance to set in.

ii. Antidepressants (eg. SSRis) 1. Concern high relapse rates when discontinues

Phobia

1. Persistent+irrational fear of a specific object or situation that results in desire to avoid 2. Fear is excessive or unreasonable 3. Reinforced by decreased anxiety when the situation is avoided*4. Social Phobia

a. Situational b. Generalized c. Fear of social or performance situations in which the person is exposed to

unfamiliar people or scrutiny by others d. Fear is one of humiliation of embarrassment e. Situational

i. More common than generalized; most common ii. Public speaking

1. Other high ups includes using public bathroom, eating in front of people

iii. Tends to develop in teens/ adolescents iv. Exposure Therapy

1. Person has to be motivated to make the change 2. Need own internal motivation 3. Do it in a gradual way; sign up for community where other people

have same problem and you start practice; strategies; gradual. f. Generalized Social Phobia

i. All social situations cause the person to have anxiety 1. Difficult to walk into this classroom to take a seat 2. Difficult to go to party

ii. Lots of avoidance1. Going shopping 2. Going to the mall 3. Of many places and situations

iii. Severe case : House bound 1. When you look at severe agoraphobia and severe generalized

social phobia can be difficult to tease a part a. Ask if it is people around

iv. CBT +/or antidepressants 1. Lot of gradual exposure

a. Go mall, then pick something out, v. More difficult to treat than situational social phobia

vi. Take time, may not get complete recovery, but can get person back to functional level

vii. Central theme: Fear of Humiliation or Embarassment

Specific Phobia

1. Types a. Animal; 4 most common

i. Snakes, Spiders, cats, dogs b. Always see a childhood onset (most often start in young kids) c. Interesting Gender pattern : little boys are as fearful as little kids, but near

teenager/adult, there is a significant change. Men drop a lot, but the women hasn’t really lost it. Why? Process of socialization . Boys throw at girls reinforcing the phobia in them.

d. Boys Forced Exposure through socialization* e. Natural Environment

i. storms, water, heights f. Blood Injection Injury

i. Unique physiological response *ii. Increase in physical tension (in all phobias) + Blood Pressure drops (<- this

is the unique) -> fainting iii. Exposure therapy and teaching person strategies to prevent them from

fainting. g. Situational Phobia

i. Elevators, bridges, driving h. Others

2. Causes a. Traumatic Conditioning

i. 50% of all phobias ii. Eg. recalling that you got bid by a dog

iii. So how do people who never had any traumatic conditioning develop it? b. Preparedness Theory *

i. Research in monkeys ii. Born and raised in the lab; never been the jungle

iii. So experimenters wanted to try and get these monkeys to develop the phobia

iv. So they get monkey afraid to these objects (i.e stuff crocodiles, a rubber snake, a stuff bunny, some plastic flowers.)

v. Put monkey in room with electrical floor, so they take the snake and throw it at monkey. At same time have them sapped. This is traumatic conditioning. So what happens after? Monkey feared the snake.

vi. Crocodile, snake very quickly to develop fear, bunny and flowers took longer * so experimenters wonder why. Video taped it.

vii. So monkey infront of tv watching the other monkeys do it.

viii. Have this monkey with no electric floor, but there was fear. *ix. Conclusion: easier to develop phobias to certain objects *

1. Found that human to snake was quicker, but not to knifes, flowers,

x. This is referred to preparedness (evolutionary even if we have never seen them before) innate instinct

xi. Fear of phobias can develop through observation (i.e do not need traumatic conditioning)* ; observation through modeling; through watching someone else afraid, phobia can develop this way. Perhaps seeing parent or another child being afraid of something.

c. Treatments i. CBT

1. Emphasis on exposure 2. Modeling

a. Getting peers to touch it, and you see it. 3. Good outcomes

ii. Antidepressants 1. For certain types of phobic disorders

Generalized Anxiety Disorder (GAD)

1. “worry disorder” 2. Excessive, pervasive, and difficult to control worry 3. About a whole number of things, doesn’t have a specific focus

a. Eg. I’m worry about family, job, friendship, health, whole range b. Views self as a worrier

4. Not limited to realistic worries a. i.e something that is not worth worrying b. excessive

5. for at least 6 months (DSM)6. tends to develop early + chronic cause

a. have this feature of worrying in early parts of life and has been there for a long time

7. in addition to worry, must have 3 of the 6 : a. restlessness b. fatigue c. decreased concentration d. irritability e. muscle tension f. sleep disturbance (insomnia)

8. treatment success is more limited 9. CBT and Antidepressants

a. Easier to get rid of the 6 characteristics (getting more sleep) b. Getting them to stop worrying is harder.

OCD

1. Obsessions a. Unwanted (egodystonic) mental thoughts that are intrusive b. Recurrent and persistent c. Recognized as a product of one’s own mind d. Causes a lot of anxiety or discomfort

2. Compulsiona. Behavioral strategy to reduce anxiety b. Repetitive behaviors in response to obsession c. Ritualistic + applied rigidly d. Washing, counting (ceiling tiles), checking (going back and checking if door is

locked), ordering e. Relief from anxiety f. OCD don’t report anxiety g. But when we separate Obsession from Compulsive behavior, anxiety hits in. h. If prevented from engaging in compulsive behavior, this is when anxiety comes

out i. Otherwise, OCD individuals don’t report it unless above occurs, because they

don’t have time to experience it 3. Treatments

a. SSRI’s i. high dose therapy

ii. Drop out rate is fairly high iii. High relapse rate iv. Should not be used in isolation

b. Exposure + response Prevention i. This is what causes the anxiety to come in

ii. Stops them from hand washing iii. Then you start increasing the interval; wait 3 minutes, then 5 minutes,

then 30 minutes. iv. You want the person to start telling you they no longer need to engage in

compulsion and they are not experiencing anxietyv. Fairly high drop out rates

1. Person needs to be highly motivated vi. Relapse rate does decrease ?

1. Person less likely to have these symptoms come back?vii. Clip:

1. A lady with a son who has OCD a. At stop lights always have to look at his son for fears that

someone who steal himb. Fear contamination c. Washes hand d. Symmetry issues

e. Number issues viii. Combine with conveying facts or therapist modeling

c. Neurosurgery i. Only used for very severe presentations

ii. When life is at risk and nothing else really helps iii. Cuts the connection between the orbital gyrus and caudate nucleus

1. 50% effective ; not 100% d. High rates of people with tick disorders in people with OCD *

Clinically significant criteria

4. Must be associated with clinically significant distress, and/ or impairment of functioning, and/or (addition for OCD) very time consuming (>1 hour per day)

PTSD

1. “shell shock”a. PTSD + conversion disorder (one of the somatoform disorder) b. Older notion of what can happen to people who experience extreme trauma c. Clip: mix of conversion disorder (changes in movement) no longer associated

with current notion of PSTD 2. Trauma

a. Have to have experienced some traumatic event to even consider that PTSD is possible

b. Experienced, witnessed or confronted with an event involving actual or theoretical death or serious injury to self or others + react with intense fear, helplessness or horror

c. What kind of events might fit this? i. Wars (More men are diagnosed)

ii. Abuse iii. Natural disasters, terrorist acts iv. Rapes (More females) v. Accidents

d. Just because someone experiences a traumatic event does not mean they will develop PTSD *

e. In general, 1/10 will develop PTSD (still a significant portion) i. Individuals who didn’t develop PTSD may still have sleep problems but

not the diagnoses for full blown PTSD 3. Triad of Symptoms

a. Have to have some symptoms under each category b. Re-experiencing

i. Reactivity to exposures to cues 1. Cues that remind them of the trauma, the person may panic,

show anger

ii. Dreams (nightmares) iii. Intrusive recollections

1. Intrusive thoughts about what happens that come back to them 2. Flashbacks (feel as though they are back)

iv. Re-enactment (may feel like they are back in the battle field); vivid c. And avoidance + numbing

i. Avoiding anything that is a reminder to them about the trauma ii. Memory loss

1. Forgetting certain things about what happened 2. Can be accessed though. Can reinsert.

iii. Adhedonia 1. Inability to enjoy things

iv. Flat affect 1. Not displaying sadness or happiness (neutral)

d. And Increased Arousal i. Exaggerated startled response

ii. Decreased concentration/focusing on things iii. Insomnia iv. Irritability/outburst

e. Greater than 1 month * i. If less than 1 month, then acute stress disorder is appropriate

f. PTSD- typically a more chronic course with symptoms fluctuating over time * 4. Treatment

a. Preventions i. Intervene as early as possible after the trauma

ii. Designed for individuals that we know are going to be exposed to traumatic events

iii. Emergency responders, firemens, iv. Stress-innoculation training

b. Early Interventions i. Short term CBT

ii. Responding to the individual after the trauma has occurred iii. Example someone who gets in a car crash and immediately doing some

short term cognitive therapy to help them process c. Treatment

i. CBT involving exposure ii. Exposing the person to things they are avoiding

1. Imaginal/direct exposures iii. Antidepressantsiv. Relaxation therapy v. Treatment not very effective.

5. Aside: Some people says that OCD should be not part of Anxiety Disorder. Controversy. 6. In common:

a. Anxiety

b. Avoidance c. Exposure +/or antidepressants (first line treatments)

Somatofoam Disorders

o Soma (means body) o Somatization Disorder o Conversion Disorder o Hypochondriasis o Pain Disorder o Body Dismorphic Disorder

1. Commonalities ( MC) a. Physical symptoms or preoccupation with body/physical health b. No identifiable medical cause c. Because there is no identifiable medical cause it is assumed there are

psychological basis. Something about their psychology is causing this. i. Stress being converted to physical symptom

d. Defend against any psychological explanations e. Symptoms are not intentionally fake*

2. Somatization Disordera. Women since she was 22 years old, now 30, has been experiencing all kinds of

physical problems, severe head aches, back pains, hip hurt, sometimes feel like her fingers have gone numb, periods of diarehia, sexual symptom of some type, goes on for a long time. Whole range. Comes and goes. Been concern. Undergo numerous test. We have no idea what is going on.

b. Used to be called Briquet’s Syndrome i. Numerous physical symptoms

c. DSM Criteria i. 4 pain symptoms

ii. And 2 Gastro Intestinal iii. And 1 Sexual Symptom (problems in functioning, menstrual problems) iv. And 1 seemingly neurological symptom (loss of movement or sensation;

numbness, ringing in ear; something that sounds like there is a neurological cause to it)

v. Must have started before age 30 * 1. Rational is that after age 30, one is getting older and more likely

to report these symptoms 2. Aside: A problem could with this diagnosis is that there could still

be medical conditions. Even the test is not identifying the medical condition, it does not mean there is a psychological cause.

3. Longitudinal research, you also see people actually developing medical conditions. Before 30, you are still young and trying to fight it off, so you don’t see it. You do really see the medical conditions later on.

d. Treatmenti. Need to do a very thorough + ongoing medical assessments

ii. Need to provide medical support iii. Stress management

1. Lets explore what your thoughts are thinking iv. CBT

1. What are you really concern about? v. Antidepressants

vi. Social support 1. Get them to get back out there and engaging in their social

interaction 3. Conversion Disorder

a. Something very stressful happens, person does not seem to care when he/she lost sight.

b. 1 or more physical symptoms that affect motor or sensory functioning :c. Blindness, Deafness, paralysis, seizures, anesthesia(entire hand going numb)d. Sudden onset e. Some inconsistencies that can be picked up on

i. Example blind can still navigate. f. Has been going on for a long time

i. Hippocratees -> 400 BC ii. Called it hystera (thought that it was something going on with the uterus)

and thought that these old 20 years old women were frustrated because of “wandering uterus”

iii. Thought to be a women condition that had a sexual cause g. Late 1800’s -> pelvic message h. Early 1900’s -> hypnosis (Freud was very interested; Freud also thought it was a

condition due to a sexual cause; that these women were experiencing sexual anxiety, guilt that these were being converted to other symptoms-> called it conversion hysteria) -> numbness of hands

i. WWI -> male soldiers started to experience these things, the thinking about hysteria changed, thought to be a reaction to a very stressful event

j. Incidence has decreased to the fact that it now becomes rarei. Why?

4. Hyochondriasisa. This guy in shower, early 20’s, never really had any kind of significant health

problem, no mental health history, looks over his shoulder and sees a black mold there. So he gets it checked out. The physician looks at it and there’s nothing to worry about. So he goes back home, working on assignment, and he is thinking that he was sure it wasn’t there before, so he started looking up skin cancer.

Takes a photo of his mold. Puts it on screen. So he’s not satisfied. So starts reading all kinds of medical literature. Demands biopsy. Comes back negative. Still not satisfied. Goes to another doctor.

b. Extreme “health” anxiety (very similar to OCD) c. Preoccupation (or obsessions) that one has a serious medical condition. d. Beliefs persist despite medical reassurance. e. Often read a lot of medical information.

i. Becomes expert on the information f. Doctor shopping

i. Finding different physicians g. Over the counter medication h. Real illness

i. Hypochondria cal symptoms decreased * 1. Why might this be? It is so counterintuitive. 2. Eg. told that you do have diabetes. 3. Sense of relief. Now I know what has been going on.

i. Similar to OCD in terms of presentation (compulsions; getting on internet; collecting different pills, bring relief from intrusive thoughts)

j. Treatmentsi. Similar to OCD in symptoms and treatment

ii. Exposure + response prevent (don’t get on internet, don’t stare at the part), + antidepressants.

5. Pain Disorder a. Guy who works at wearhouse, job is moving crates around, one day takes a box,

falls down, bruises himself, feeling a lot of pain in back immediately, goes home makes appointment with doctor. Doctor tells him to take it easy. Don’t do anything too active. 1 week goes around, he feels as though he has more pain; has more difficulty, goes back to doctor. Try another week and then come back. A month.. 2 months..

b. Pain is of greater severity + duration that can be accounted for by a medical explanation

i. Problem with this is pain is subjective. c. Treatment

i. Medical support 1. Pain medications

a. Risk: develops tolerance and relapse is more pain ii. Relaxation training/biofeedback

iii. Allied health professionals (physios) iv. Antidepressants

1. Helps with mood. v. CBT -> scheduling daily activities

1. Because people with pain often stops doing things so you want them to gradually start doing things again

2. Reinforced no pain behaviors *

a. See how family is supporting them; that they are; have family praised for going out instead of making soup for them etc.

vi. Avoid vicious circle of 1. Increasing pain meds 2. Invasive surgical procedures

6. Body Dysmorphic Disorder (BDD) a. “imagined ugliness” b. Imagined defect in appearance c. Spend a lot of time checking + hiding what it is that they are concerned about d. Constantly seeks reassurance from others e. Aside: does not get happy after surgeryf. Clip: constantly checks appearance. Suicidal. g. RELATED: To eating disorder and OCD

i. 1 to 1 ratio for men and women h. Treatment:

i. Expose and response therapy ii. Antidepressants

Lecture 3 Monday, March 14, 2010

1. Contrast somatoform disorders to: a. Malingering

i. not a DSM diagnosis ii. faking illness for gain (i.e trying to get a lawsuit, get an insurance, aware

they are faking, get out of having to do work, get out of exam ) b. Factitious Disorder

i. Enter different category of mental disorder (is 1 of the 16 disorder) of the DSM

ii. Also known as: Used to be referred to as Munch ausen’s Syndrome iii. Person is also faking illness iv. Difference from malingering: no obvious gain other than to be in the “sick

role” v. The extremes person going to be labeled sick looks extreme; just wants

to be viewed as sick to get sympathy. Goes to extremes to make themselves look ill. So they might be injesting toxic, creating wounds, breaking own bones, grind up glass and swallow, taking substances that would make people cough up blood, or have diarrhea)

c. Factitious Disorder by proxy i. Munchausen’s Syndrome by proxy

ii. Ie. A parent making their child look sick iii. There has been cases where the adult child tries to make their parents

look ill

iv. Getting child to drink toxin, getting child injured, internal problems, giving child medications that give seizures.

v. Person then brings child to physician, and tells them their child is sick. Is aware what is doing.

vi. Clip: the parent gets the diagnosis not the child. If the parent is diagnosed with this mental disorder, shouldn’t she be innocent and sent to a mental hospital? No, she had the power to control her intent. What’s the motivation? Not very clear. To get sympathy from having a sick child. Person will deny what they are doing.

d. MC: be able to contrast malingering and factitious disorder from somatoform that this involves faking and somatoform does not.

Dissociative Disorder

1. Dissociation (splitting off of conscious awareness from self or environment) a. Depersonalization : self

i. Being unable to remember who you are ii. Loss of identity

iii. Look at mirror and feel like it is somebody else iv. Feel changed

b. Derealization : environment i. Feel like everything around them is a dream, not real, or distorted

ii. Feels like everything around them is in slow motion c. Dimension of dissociation like experiences

i. Zoning out (out during lecture, movie) 85-90% of people ii. Not best example of dissociation, because you are not doing anything

iii. Driving on autopilot (getting in car, driving to UBC, at some point, you get to Broadway and Oak and not sure how you got here) 50% Not aware of what you doing; your conscious awareness was not there

iv. This gives sense of what dissociation is like v. Feeling as one’s body is not one’s own: 30%

vi. Finding oneself dressed in cloths one does not remember putting on 15 to 20%

vii. Caused by sleep deprived viii. Not recognizing oneself in the mirror (kind of looks like me but is not me)

10 to 15% ix. not related to any neurological defect* usually can not define cause.

d. Individual more likely to experience dissociation are i. More prone to fantasy and day dreaming

ii. Vivid imagination iii. Easier to “hypnotize”

2. Hypnosis a. Dissociation is only a problem when it becomes distressing b. State of dissociation (induce a dissociative states)

c. Involves mental absorption (when you lose yourself in your book and everything around you is just gone)

i. Complete immersion n one thing d. Suggestibility

i. When they are mentally absorbed in something, it is easier to suggest or implant something

e. Two ways to induce hypnosis i. Pharmacological induction (highly sedating; deep state of relaxation)

1. Barbiturates (used in the past) 2. “Truth serums” interests by government/military 3. Like Getting somebody really drunk and getting them to tell you

something 4. Not used often anymore 5. Give them too much of these drugs, they die. Potential for

overdose ii. Psychological induction

1. Relaxation methods 2. Person lying down, make room really dark, get them to go

through exercise (different exercise for everyone) ; find out what works for the person.

3. Takes time. (15 to 20 mins) 4. Getting person to fixate on something and getting them to look at

it intensely. 5. Less effective. People are generally too stress to get them into this

state. iii. Increase ability to imagineiv. Increase ability to remember (can cause people to create memories that

are not there) v. Increased creativity. (solutions to problems they otherwise were not able

to think of) vi. Increased Response to suggestion*<- want this usually.

vii. Not related to IQ viii. Not related to gullibility

ix. More related to fantasy proness/daydreaming f. Hypnotherapy

i. Weight loss* short term benefits ii. Smoking cessation * short term benefits

iii. Behavioral changes iv. Pain management * Medical procedure long term benefits v. Somatoform and dissociative disorder

g. Effectiveness i. Can help kickstart & short term

ii. Not a long term solution1. Long term for pain management

2. Training people to help cope with pain 3. Dissociative Disorders (do the readings to find out what is going on with them)

a. Dissociation itself is not a problem unless there is stress and affects functioning b. Depersonalization Disorder c. Dissociative Amnesia d. Dissociative Fugue e. Dissociative Identity Disorder

4. Depersonalization Disorder a. Lots of depersonalization b. Causing distress + impairment in functioning c. Late teens -> early 20’s (floating outside of yourself) d. Out of body e. Not recognizing self/body f. Suddenly different/grosteque (feeling of being in a dream or in a movie) g. Fear of going crazy; concerned. h. Usually goes away on its own with age *

i. Reassurance1. Telling them that these are not that unusual 2. Getting them to go into groups and talk about it

ii. Stress managementiii. Identifying trigger iv. Coping

i. In a very small percent, may signal decompensation into psychosis *i. You actually watch them; monitor just to be incase

ii. Can become delusion/hallucination 1. Seeing oneself in mirror and not just not recognizing yourself, but

believing you are somebody else. j. Common in teens and 20’s and goes away with age

5. Dissociative Amnesia (loss of memory) a. Psychogenic amnesia (not due to organic causes)

i. Psychological causes b. Certain type of memory loss

i. Which is often autobiographical ii. Not being able to remember certain information about one’s life

1. Marital status c. This contrasts from organic amnesia

i. i.e blow to the head, car accident ii. organic amnesia is both personal and “general” memory loss

1. i.e current events, world eventsiii. anterograde amnesia is more common iv. retrograde : little bit

1. can study for exam *2. quick to return?

v. Anterograde: inability to form new memory

1. Can not study for exam 2. Longer lasting and slower to return

d. Memories may be recalled under hypnosis i. Only works with psychogenic amesia

ii. Does not work with organic amneia iii. Usually follows a significant stressful event *

6. Dissociative Fugue a. Dissociative Amnesia + Flight + Adaption of a new Identity

i. Forgetting you were a psychologist and going somewhere else and saying you are a dentist

ii. Lots of controversy 7. Dissociative Identity Disorder*

a. Also known as multiple personality disorder b. Changed for couple of reasons is that there is a lot of dissociation that is

occurring so they added in the word dissociative c. Personality was changed to identity, because it is usually just more than

personality changing but identity (gender, age)d. Host Identity

i. Alter A ii. Alter B

iii. Alter C e. Person shifts (i.e I’m Laura, now I’m an elderly woman, now I’m a young child) f. Patterns of amnesia*

i. Host does not know anything about the alters ii. Where alter A might know about B, but B not know A.

iii. Different patterns g. More females than males diagnosed

i. 3:1ii. 9:1

h. Lots of controversy i. Theory –

1. Post traumatic theory a. Argues that this is a legitimate, valid mental disorder b. DID is “real” caused by trauma c. Severe trauma (eg. abused) in childhood d. Child have limited coping strategye. So they start separating themselves, split their

consciousness off so they can survive f. During this dissociation, they will create identity g. “creative survival strategy” in young children h. >90% report childhood abuse (more covered in textbook;

concerns on validity; memory are only recovered when they start therapy and whether those memories were valid)

i. Some of the evidence regarding changes in alters/hosts is dramatic ; some cases

i. Different brain patterns was even shown! In different alters / states

ii. Countered! Got actors to do it and measured brain patterns

2. Social Cognitive Theory a. It may be faked or it is iatrogenic(caused by dental health

professionals; i.e medications that makes the patient have amnesia; unintentional)

b. Evidence: Trends over time * i. 1900 to 1950 -> fewer than 100 cases

ii. 1950’s -> Three Faces of Eve iii. 1960’s to now -> over 40,000 cases (cases

skyrocketed) c. Argues that there was motivation to do this.

i. Media, attention d. People with the Postraumatic Disorder Theory would

counter argue this as higher recognition. i. Just having the tools to detect it

e. Diagnoses are made by a small number of professionals + the majority of cases are only detected after therapy has started

f. Increased in terms of number of alters i. Therapist increasing them

i. Clips:

Monday, March 21, 2011

Prelecture:

3 classes left. 3 topic left. Mood disorder, psychotic disorder, personality disorder Exam is on the 14th

Mood Disorders

1. Mood Episodes a. Diagnosis of a mood disorder is dependent on which mood episodes are present

or there is a history of b. We are not looking at what is currently is happening, but also from their past. c. 4 different types:

i. Major Depressive Episode (MDE) *ii. Manic Episode *

iii. Mixed Episode iv. Hypomanic Episode

d. Can have psychosis occurring with all mood episode except hypomonic i. Can not have psychosis in hypomonic episode. *

e. Good inter-rator reliability across episodes with the exception of hypomanic 2. Major Depressive Episode (MDE)

a. Mnemonics: SAD IMAGES DSM Criteria b. Sleep (either /or sleeping a lot or sleeping little (insomnia) c. Appetite (weight disturbance (up or down)) eating more/gaining weight d. Depressed mood * must have e. Indecisiveness (or decreased in concentration )

i. Going to grocery store and standing there frozen not able to make decision

ii. Can’t concentrate, can’t retain information ; cognitive effects – problem solving

f. Movements (up or down ) – agitations(increased) or psychomotor retardation (decreased)

g. Anhedonia* Must have h. Guilt or worthlessness

i. A client now in her late 50’s expresses guilt about how she raises her kids ii. Sending her kids to the wrong school, feeling overwhelmed.

iii. When not depressed, she realizes it is silly iv. “I don’t feel like I am good for anything, husband, employee”

i. Energy Changes (down) -> Fatigue j. Suicide (thoughts of death)

i. Thoughts of death such as my wife dying, her being dead, thoughts of my dog dying. It is not that you want to suicide, but just themes about death occurring)-intrusive thoughts about death themes.

k. Either depressed mood or anhedonia must be present. <- l. Exam question: This person is experiencing the following symptom, which of

these are part of the criteria. m. 5/9 criterias. On exam must check if depressed mood or anhedonia is on it. n. Duration -> minimum of 2 weekso. MDE Severity should be measured as well.

i. Standardized rating scale (eg. Beck depression inventory) 1. Mild2. Moderate 3. Severe

ii. Severity influences treatment iii. Criticized for using it with elderly.

1. Potentially diagnosing people with depression when they don’t iv. Therefore you use the Geriatric Depression Inventory

1. Cognitive + Mood elements (less focus on somatic changes or age related changes )

a. Has the person appetite been changingb. Do you feel good about yourself?

c. Do you get enjoyment? d. More emphasis on these vs somatic changes or age related

change 3. Manic Episode

a. Elevated, expansive/euphoric OR irritable mood must be present i. Have to see a cycle between the above two mood

b. Mnemonic: SIDE TAG c. If mood is Euphoric, we need 3/7 criteria d. If mood is irritable, we need 4/7 criteria

i. To avoid false positive that is why we have 1 more , because irritable is less certain

e. Sleep (less) f. Ideas Flying (flight of ideas)

i. One idea leads to another g. Distractibility (hard for the person to maintain focus; hard to engage in an

interview process with them) h. Excessive Behavior with Potential For Negative Consequences

i. Gambling (risky investment) ii. Risky sexual behaviors

iii. Drug uses iv. Spending

i. Talkative (pressure of speech) j. Activity increased or agitation k. Grandiosity (increased in self-esteem)

i. May think they have special power, big ideas l. Example of her client: married to her husband since highschool; middle aged

now, never had any affair, got into manic episode. Her husbands and kids knew something with up. Missed out early warning sign. Found her later on Granville street. She hooked up with a couple guys, she was having sex with everyone. Started doing cocaine. In her opinion, she feels like nothing was wrong. It was a very rocky road. He felt very betrayed.

m. Duration is 1 week. (or any duration if hospitalization is required) i. Some people become manic very quickly

n. Another question on the exam about the criteria 4. Mixed Episode (Dysphoric Mania)

a. at the same time both criteria for MDE + manic are met (same moment in time) b. poorer prognosis *

5. Hypomanic Episode a. Similar to manic episode but not severe enough to cause problems in

functioning, require hospitalization+ no psychotic symptoms. i. May in fact be higher functioning

ii. Producing good work, this contrasts from the other 3. b. Should be 4 days or higher c. No psychotic symptoms

d. Poor inter-rated reliability e. If people have this only a few times, it wouldn’t be considered a mood disorder,

it is only when it occurs with the other. 6. Mood Disorders

a. Depressive Disorders i. Dysthymic Disorder (Dysthymia)

ii. Major Depressive Disorder (MDD) b. Bipolar Disorders

i. Bipolar 1 Disorder ii. Bipolar 2 Disorder

iii. Cyclothymic Disorder (cyclothymia) 7. Dysthymic Disorder

a. Chronically depressed mood for most days for at least 2 years. b. Must also have 2 of the following:

i. Appetite change sii. Sleep changes

iii. Decreased energy iv. Decreased self-esteem v. Decreased concentration

vi. Hopelessness c. Dysthymia+ MDE

i. Double Depression ii. Often a much longer duration

1. Some people says they have it since they were a kid. iii. It tends to be chronic + treatment resistant iv. Like a personality disorder?

1. Depressive personality disorder. 2. Clip: Steve and depression

8. MDDa. Diagnosed if one (or more) MDE in the absence of a history of mania, mixed or

hypomonic episodes b. High rate of reoccurrence -> 25% in one area -> 80% in 10 years c. Spontaneously remits (improvements without treatment) average untreated

duration is 6-9 months i. Treatment wants to shorten the among of time a person is in an episode

ii. Decreased the number of reoccurrence d. Twice as common in women

i. 20-30% of women some point at their life will meet diagnostic criteria for MDD

ii. 10-15% for meniii. Read textbook for reasons why this is case

1. Women more likely to seek treatment 2. Men more likely to use substance 3. Hormonal theories

4. Different styles of coping: women tend to ruminate 5. Social roles- interpersonal styles

e. Mean age of onset i. Mid’ 20’s (used to be 40’s)

f. MDD-subtypes i. Melancholic

1. Oldest notion; used to be only type of depression that was recognized

2. Considerable anhedonia 3. Depressed mood -> worse in the morning 4. There is a rhythm 5. Decreased sleep -> insomnia – unique. No problem going to sleep,

but wakes up early. And can’t go back to sleep. Waking up in middle of night and can not get back to sleep.

6. Appetite changes (reduction) –anhedonia not bringing them pleasure in food

a. Significant weight loss 7. Movement changes (agitations or psychomotor retardation) 8. Lack of mood reactivity

a. Where mood would not improve even when something good happens to them

b. U can tell them they won 1 million dollar and they will still be depressed

9. Males= females , middle age 40-50 getting it ii. Atypical

1. Depressed mood > anhedonia a. Person is saying they feel sad, appears depressed, crying a

lot (not seen with melanchonic) 2. Increased in sleep 3. Appetite increased (crave certain food/chocolate/potato chips)

a. Gain weight 4. Interpersonal rejection sensitivity

a. Person is very sensitive to what others say 5. Mood reactivity is present

a. Won a lottery- no longer feel depressed. b. Will see mood improved.

6. New notion of depression 7. F>M, late teens 20’s

iii. Severityiv. Chronicv. Postpartum onset

1. Postpartum blues a. Not unusual for women who just given birth to experience

mood disturbance

b. Not a diagnosis c. Does not meet MDE criteria

2. MDE criteria a.

vi. Psychotic1. Antipsychotics want to treat this first use 2. Treating as a psychotic disorder as opposed to depression 3. After treating the psychosis, then we treat the mood

vii. Seasonal pattern 1. Also known as seasonal affective disorders (SAD) 2. Where the person has a seasonal pattern to their depression 3. In what seasons do people tend to get depressed:? Winter-> Fall

when there is less light 4. Winter season when we have decreased light 5. Sort of resembles atypical depression than me6. What is the treatment?

a. Light therapy 9. Causal Theories of Depression (there is no one single cause/but combination)

a. Biological Theories i. Genetic

1. Moderate contribution 2. If parents have it, then you may have it

ii. Neurochemical 1. Monoamine hypothesis

a. That is depression is caused by low serotonin and low norepinephrine

b. Dysfunction at the receptor level i. Increased or decreased receptors

ii. Rather than overall level of the neurotransmitter iii. Hormonal

1. Stress hormones 2. Too much stress leads too much cortisol

iv. Neurological 1. Certain area where we have lower brain activity 2. Especially in the prefrontal cortex 3. Decreased volume of certain brain area (e.g. Hippocampus)

v. Other 1. Light2. Sleep patterns

b. Psychosocial Theories i. Stress

1.ii. Psychodynamic

1. Anger turned inwards (psychodynamic)

iii. Behavioral 1. Lack of positive reinforcement

iv. Cognitive1. Evidence CBT works 2. Dysfunction beliefs 3. Negative thoughts

v. Learned helplessness 1. Attributes that lead to depression

a. Internal b. Stablec. Global d.

vi. Other 1. Social rejection

vii. Main point is we have a whole range of theories. In the past we used to look everything in separate. Now we look at the complex models.

viii. Biopsychosocial Model of Depression

Lecture (Mood Disorder) Monday, March 28, 2011

Prelecture:

Finish up mood disorder today. Start on psychotic today. With respect to depression, dysthymia, the potential causes, the biopsychosocial model (which puts the pieces of puzzles together). Now we talk about the treatments for depression.

1. Treatments for Depression a. Antidepressants

i. SSRI’s -> first line (typically recommended for the starting point) ii. MAOI’s

iii. Tricyclics iv. Others

b. Psychotherapy i. CBT

ii. Interpersonal Therapy iii. Brief Psychodynamic Therapies iv. The advantage of the psychotherapy over antidepressants is to prevent

relapse; that is why it is always better to combine medication with this v. Regardless of the treatment we first use, it will help 60-70% efficacy rate.

c. ECT i. Treatment-resistant depression (severe)

d. When mild MDD, behavioral activation (getting out and starting to do things again; i.e signing them out for sport, aerobics, getting them to see their friends) + self help

e. When we move up in level of severity , self help, behavioral activation is more difficult to do. I.e Person has difficulty cooking food, getting out of bed; here we look at using psychotherapy or medications to treat the person.

f. MDD people can get better without treatment* / preventing future episodes from occurring

g. Antidepressants+ other Biological Treatmentsi. Risk: can induce a manic episode in a very small number of people

h. Bipolar 1 Disorder i. Criteria: 1 or more manic (or mixed) episode

1. All we need is this criteria for this diagnosis to be made ii. Unipolar mania is diagnosed as bipolar one

1. if you just saw someone who was manic once, you can diagnose them as having bipolar 1

2. so you don’t have to have MDE (mixed ) to have be diagnosed with this

iii. Life Term Prevalence 1. 1% 2. Equally common in both gender (women=men) 3. Associated with the highest suicide rates (15% suicide completion)

a. Higher than MDD b. When is suicide attempt/completion rate?

i. From Manic down to MDE 4. Very high comorbidity with substance use 5. >90% will have recurring episodes

a. Will have more episodes at some point b. “Rapid cycling”

i. 4 or more episodes per year c. Majority return to functional + normal mood states in

between iv. Core Treatments

1. Lithiums + other mood stabilizers (anticonvulsants) i. Bipolar 2 Disorder

i. Criteria: Present (or history) or one of more MDE + one or more hypomanic episodes; NEVER any manic/mixed episodes

ii. Exam: if you ever see manic or mixed, you choose bipolar 1. iii. has a higher risk of getting manic from taking antidepressants

j. Cylothymia i. Criteria: For at >2 years numerous periods of hypomania+depressive

symptoms; Never any manic/mixed or MDE’s ii. (Manic/Hypomanic/Euthymic/Depressive symptom/MDE)

k. Treatmentsi. Some people suggest that we use mood stabilizers for Bipolar 2 /

Cylothymia l. Bipolar 1 Disorder

i. Greater genetic contribution1. High rates of concordance between twins 2. Specific chromosomes that has been implicated 3. As stressors increase, for people with genetic vulnerability, risk of

getting the disorder increases m. Treatment:

i. Pharmocological strategies 1. Lithium2. Other Mood Stabilizers

a. May use antidepressants b. May use antipsychoticsc. Lots of pharmological strategies

ii. Psychosocial strategies 1. Psychoeducation

a. Family/education therapy 2. CBT 3. Relapse Prevention

a. Paying attention to their sleepb. Making sure they are sleeping 8 hours a night

4. Omega-3a. Fish oilb. Increasing evidence that these can help individuals

iii. Note:* low compliance rates for these treatments because of high relapse

iv. People with Bipolar 1 can also have psychosis

Psychotic Disorders

1. Psychosis a. 3/100 individuals will have psychotic episodesb. Most occurring at late teens or 30’s c. As you can see from the diagram, it is associated with mood disorders, a large

portion (1/3) is associated with schizophrenia, 2. Psychotic Symptoms

a. Psychosis = “break from reality” b. Positive (in the sense that we have it)

i. Positive= something gain ii. Hallucinations (false perceptions)

1. Auditory is most common a. Hearing voices

iii. Delusions (false beliefs) 1. Nonbizarre to bizarre (not possible)

c. Treatmentsi. Antipsychotics work best here* effective for these positive symptoms

d. Negative Symptoms (Less subtle; more dramatic) i. “these are the things I most struggle with”

ii. Negative = something lost iii. 5 A’s

1. Avolition a. Lack of motivation

2. Alogia a. Lack of speech (does not talk a lot

3. Anhedonia a. Inability to experience enjoyment

4. Attentional Impairmenta. “when ever I say the letter g, I want you to tap” b. People who have psychosis have difficulties with tasks like

this ; lacks attention 5. Flat Affect

a. Unemotional iv. Treatments

1. Are less effective e. Disorganization

i. Thought process disorders 1. Loss association

ii. Disorganized behavior 1. Getting up, getting dressed

f. Catatonia i. Changes to movements ii. WRENCHESiii. Weird movements

1. With arms or ways they walk iv. Rigidity

1. If you have somebody who is laying down in bed, their head is straight and does not lay down

v. Echopraxia 1. Copy movements 2. Only able to copy what other says

vi. Negativism 1. Opposition to any kind of movements; if you try to move people,

they will resist vii. Catalepsy

1. Video clip2. Referred to as waxy flexibility 3. Can mold them into different positions and they sort of stay

frozen in itviii. High motor activity

1. Going physically crazy

ix. Echolalia- copy speech x. Stupor

1. Immobility 2. Sagging

xi. Treatments 1. Poorer outcomes 2. Due to major dysfunction in brain system (dopaminergic

pathways) 3. Much less common today in more developed countries

g. Schizophrenia i. also has a lot of stigma associated with it ii. The Soloist / A Beautiful Mind movies about people who develops

schizophrenia iii. History

1. People knew that people go mad; it was not until the 1980’s that there was a classification (Kreapelin)

2. He was noticing that this was occurring in young people 3. Kreapelin

a. Dementia (cognitive decline ) b. Praecox (premature youth) c. Conceptualized it as a brain disease

4. Bleuler a. Renamed it to schizophrenia b. Which means split mind.

i. He didn’t mean the mind is split in half but rather there is this break/split from reality

5. 1950’s a. Antipsychotics introduced b. Very good at treating these positive symptoms c. At improving overall course d. up until now, most research are focused on positive

symptoms. e. Only now, do we start to realize that cognitive impairment,

that Kreapelin was on the right track. iv. DSM-4-TR Criteria

1. 2 or more of the following for 1-month (ACTIVE PHASE)a. Delusions b. Hallucinations c. Disorganized speech d. Disorganized behavior or catatonia e. Negative symptoms

2. NOTE – only 1 criterion is required if: a. Delusions are bizarre

i. Eg. if I believed that I was 210, undercontrol by alien

b. Hallucinations consist of voice giving running commentary i. i.e reporting on everything you are doing, now you

are walking, now you are picking up the mouse c. 2 or more voices conversing

i. If you are hearing two voices and they are talking to each other

3. Duration a. Continuous signs of some type of disturbance for at least 6

months (which must include Active Phase) i. Most commonly, we see people going along fine in

their life, let s say they hit age 19 and they start becoming depressed. Some period before the person becomes acutely psychotic.

ii. If a person has 5 months of depression + 1 month of psychosis, they have met the criteria for psychosis

iii. You can also see 3 days of depression, but boom, you become psychotic for 2 months, you can not diagnosed them with schizophrenia.

iv. But if they have 3 days of depression, 2 months, then depression again for another few months (min. 6 months), then they are diagnosed

v. There are different patterns b. PRODROME – period before psychosis; period of

nonspecific symptoms + difficulty functioning before onset of psychosis

c. Can only be called a prodrome restrospectively. i. You can never say a person is in a prodrome unless

they have been psychotic ii. Prodrome is not predictive of psychosis

v. Schizophrenia Subtypes 1. Paranoid

a. Primary symptoms: Hallucinations + delusions b. Highest Functioning + best Outcomes

2. Disorganized a. Disorganized speech and behavior b. Poorer outcome

3. Catatonic a. Catatonic b. Poorer outcomes

4. Residual a. Negative symptoms

b. Intermediate outcomes 5. Undifferentiated

a. “wastebasket” b. Mixed of symptoms

i. People who have paranoid, disorganized, etc. ii. Different combinations or patterns

6. Aside: you can see shift between these subtypes a. So ie. Paranoid -> disorganized

vi. Other Psychotic Disorders 1. Schizophrenia = full 6 months

a. Poorer outcomes 2. Schizophreniform = 1 -> 5.9 months

a. Intermediate outcomes 3. Brief psychotic disorder = 1 day to 29 months

a. Main point is that people b. Good outcomes

4. Schioaffective disorder a. Psychosis leads to mood disorder vs

5. Mood Disorder with psychosis (is this considered a psychotic disorder?)

a. Where mood is diagnosed first and then leads to psychosis 6. Delusional Disorder

a. At least 1 month of non-bizarre delusions i. Ie. Thinking your neighbor is spying on you

b. Person functions well otherwise i. Able to hold jobs, keep jobs

c. Not genetically related to other psychotic disorders d. Not responsive to treatments with antipsychotics

h. Age of Onset i. Males more likely to develop schizophrenia in their late teens, younger

age on average relative to females ii. Highest risk is 15-30 years of age iii. For females there is another peak at 45-50 due to hormonal changes iv. Females generally have better outcomes relative to males v. Research suggests that estrogen appears to have some protective effects vi. Females tend to do better vii. That little second blint, losing some protective factors, may be

responsible for it. i. Genetic Risks

i. General population -> 1% ii. One Parent 5-10% iii. Identical Twins 50% iv. Genetic Component, but 85% of those with schizophrenia can not identify

any family history

v. Best risk factor is based on whether your family has schizophreniavi. Point is genetic is not the only thing, but environment too vii. Other risk factors:

1. Head and injury 2. Older father at birth 3. Mother got a virus while pregnant

j. Stress Vulnerability Model i. Some vulnerability (genetic, prenatal events) + “stress” ii. If you have little vulnerability, then you need more stressor to trigger it

and vice versa k. Prediction of Schizophrenia

i. We like to be able to predict people who will get it and prevent it ii. Current base criteria at predicting this is : Ultra-High Risk Criteria

1. Attenuated psychotic symptoms 2. Or Blips

a. Brief limited or intermittent psychotic symptoms b. So person may actually hear voice, but they don’t hear it

for another few days 3. Or Family History + a significant drop in functioning

a. Ie. A guy who is 20 but his mom has schizophrenia, but all of a sudden he stops going to class; but there is no psychosis

4. UHR- only 15 % develop psychosis in one year, after 25-30% two years

a. what she means is that 70% of people with UHR not going to develop them

5. Omega 3 a. Prelimary/promising results

Monday, April 4, 2011

Prelecture:

Final exam Thursday, April 14 th at 7pm LSK 200 80 mc, 2 hours, covers lecture since midterm Chapter 6 (page 162-180 (chapter 5)), 7, 8, 11, 14 Almost everything covered in lecture are in textbook, except for a few key points that

are not. Use textbook as main source. Make sure you understand it really well before coming back to the lecture. For the DSM criteria, make sure you know what I mentioned in lecture. Ie. How I distinguish between bipolar 1 and 2. For drug names, I don’t need you to know specific name, except lithium. Know antidepressants, SSRI’s etc.

Do not need to know the case studies. Just know the concept.

Course of Schizophrenia

1. Most people who develop schizophrenia develops it gradually 2. The prodrome, then psychotic symptoms coming on 3. Sometimes after that, we have intervention 4. Average duration of untreated psychosis is between 1-2 years.*

a. Long delay before we start treatmentb. This imposes a problem

i. Potentially lots of physiological damage that is being done c. Long DUF *

i. Poor outcomesii. Do not do as well in long runs and treatments

d. There are different patterns i. Some people have just 1 episode and they do not have further episodes

ii. Some people never return to baseline iii. Some just gets worst and worst over time

5. Factors associated with better prognosis a. Female gender

i. Females does better than males b. Sudden onset

i. People who’s psychotic disorder is quick, it has better prognosis c. Positive symptoms predominant d. Low expressed emotion

i. Relates to the dynamic between the person who develops the schizophrenia and the family

ii. Has three components 1. Criticism

a. Parents very critical of childb. I’m very disappointed you are not able to go back to

university 2. Hostile

a. Openly kind of yelling at the person 3. Emotional over involvement

a. Somebody who is 20 years old, become psychotic, drops out of school, and you might have mom or dad who says I will take care of you, do everything for you, we will do everything and take care of everything for you

b. Good initially, but a lot of parents continue thisi. So when you want to start doing things on your

own ii. Your parents still don’t let you

iii. It is especially troublesome during this age because it is when you are really developing independence.

iii. We want to see low level of all three of this for better outcome e. Short duration of Untreated Psychosis (DUP)

i. Better treated earlier

6. Other associated Features a. Homelessness b. Comorbid substance abuse

i. 50% have comorbid substance abuse ii. Poorer outcome

c. 15% complete suicide i. Similar rates as Bipolar 1

ii. In bipolar 1, people are very aware that they are ill, but in schizophrenia, they are not.

iii. Usually within the first few years d. Cognitive deterioration

i. Verbal fluencyii. Problem solving

iii. Working memory iv. All these things can be affected quite substantially v. If we have an IQ before hand, we see about a 15 points drop.

vi. Not something we can easily treat7. Schizophrenia and the Brain

a. Neurochemical abnormalities i. Dopamine hypothesis

1. Too much dopamine a. Antipsychotic helps block dopamine

2. Has contradictions b. Brain Changes

i. Hypofrontality 1. Lower level of frontal lobe activity

ii. Enlarged Ventricles 1. Bigger holes in the brain

a. Research shows that it is not genetically caused, but happens at some point

iii. Cerebral Atrophy 1. Progressive loss 2. Loss of brain matter over time (25%)

a. Almost like Alzheimer’s8. Treatments for Psychotic Disorders

a. Early intervention i. Decrease duration of untreated psychosis

ii. Better outcome iii. Engage people in services intensively for the first few years iv. Functional improvement (not just treating symptoms)

1. Like helping the person with education 2. Work

b. Antipsychotics i. Used in conjunction with early intervention

ii. Typicals/conventional (older) 1. Risk of movements disorders

iii. Atypicals (newer) 1. Lower risk of movements disorders 2. Help a bit more with negative symptoms and help a bit with

cognition 3. Side effect is ‘weight gain’

iv. For First episode1. Atypical is considered ‘first line’ 2. ‘Start low go slow’

a. Different from old approach where you just keep them gigantic doses

b. Now you start with little and then progress the dose 9. Psychosocial treatment

a. Community treatment b. Psychoeducation

i. Educating the person about the illness c. Family involvement

i. EE (expressed emotion) significantly increases relapse rate d. Psychosocial rehabilitation e. CBT for positive symptoms/comorbidity f. Cognitive remediation

i. Not same as CBT ii. Is where you are focusing on trying to reverse their cognitive deficits

iii. Like computer games that can retrain people’s cognitive abilities

Personality Disorders

1. Extreme end of a continuum / 10 personality disorders – sat down and relate it to someone you know

2. General things a. 10 personality disorders across 3 clusters (not need to materialize the DSM

criteria; instead I want you to know what the stereotype is) i. Cluster A -> odd

1. Paranoid 2. Schizoid3. Schiotypical

ii. Cluster B -> dramatic + erratic 1. Antisocila 2. Borderline 3. Histrionic 4. Narcissistic

iii. Cluster C -> fearful + anxious 1. Avoidant

2. Dependent 3. Obsessive-compulsive

iv. Stereotype 1. Significant variation in presentation (criteria is prototypical)

a. Lots of variability b. That people with different criteria can be diagnosed with

the same personality disorder 2. Coded on Axis 2

a. Long standing (develop early) b. Resistant to treatment

3. All can be diagnosed before the age of 18 (except for antisocial ) a. With caution

4. Poor inter-rater reliability (except for antisocial) 5. Axis 2: Borderline Personality Traits

a. Diagnosis differed 6. High comorbidity between personality disorder + with Axis 1

a. You will see overlaps even between clusters 3. Cluster A

a. Paranoia P.D i. “distrustful” + “suspicious”

1. Thinking that people just wants to take advantage of you2. Thinking that other people have hidden motives3. Not easily trust other individuals

ii. “Cranky”1. Not light-hearted or easy to be around

iii. Controlling iv. Males > Females to be diagnosedv. Jealousy and distrust of partner

1. If you have a paranoia guy friend, he will want you to keep calling vi. Abusive

vii. Legal disputes1. Suing people for a variety of reasons

viii. Not engage in treatment 1. Does not trust you 2. Tend to drop out and don’t change

ix. Not related to schizophrenia or psychosis b. Schizoid PD

i. Imagine mild negative symptoms 1. Anhedonia2. Flat affect3. Attentional impairments

ii. Demonstrate high degree of detachment from others 1. Socially isolated but they prefer it that way 2. Other people might describe them as ‘cold and distant’

3. No friends; no relationship a. No interest in having friends or sexual romantic

relationshipb. Not interest in sex even c. If you ask them “how they feel”

i. Will not report feeling down ii. Not dysthlymic

iii. May be very intelligent, creative, + can function well in right environemtn iv. If treated, probably gets social skills treatment

1. They come to you, tell you they don’t do very well in job2. You help them learn a script

v. Not related to schizophrenia or psychotic c. Schizotypal PD

i. Like mild positive symptoms ii. BLIPs

1. Brief limited intermittent psychotic symptoms iii. Odd in appearance

1. Dress weird2. Like a fortune or tarot teller

iv. Odd beliefs/fringe beliefs 1. Believes they can read mind, predict future 2. Fortune telling and reading minds

v. Social interactions are difficult vi. Often socially isolated

vii. Genetically related to schizophrenia * MC viii. Vulnerable to developing schizophrenia

ix. Treatment 1. Antipsychotics if psychotic symptoms warrant it2. Social skills training

4. Cluster B a. Antisocial Personality Disorder

i. Person disregards + violates the right of others ii. Only PD with age criteria

1. Must have conduct disorder before age 15 then a. Bullying, stealing, lying, torturing the cat

2. Then diagnose antisocial at 18 iii. law breaking iv. aggression v. cheating/lying

vi. the reason it has good inter-rater reliability is because it has behavior criteria

1. how many times have the person been caught for stealing, lying? 2. As opposed to if the person looks odd which is

subjective/judgment call

vii. Replaced with psychopathy? 1. In the future. 2. Similar but not identical 3. Includes behavioral criteria + emotional criteria

a. Such as lack of remorse b. Manipulative

viii. Problem is when we look at the behavior, we are not looking at the motive behind it; the personality.

1. When we look a psychopathy, it would be better at getting at the personality construct because it involves an emotional criteria

a. Lack of remorse, being manipulative etcix. Treatment is difficult

1. can be very manipulative 2. therapy modest results at best 3. with age, we see decrease in criminal behavior

a. stops engaging in bar fighting, stealing at gas stations x. Rusell ; tends to be very successful in businesses

b. Borderline PD i. Instability *

1. Self-selfa. Likes one self then dislikes oneself

2. Relationship a. At the extreme, tends to idolize people b. But then the person fails, see them as scums c. People might see them as immature d. One day, likes you then second not.

3. Mooda. One moments feel really good, then later not so good

ii. Most common PD diagnosed iii. Feelings of emptiness iv. Self-mutilation

1. Cutting v. Suicidal gestures

1. (often manipulative) 2. Women wants boyfriend to come home, but boyfriend says he

can not, she manipulates him by saying she is going to kill herself. But she does not intend to.

vi. Anger poorly controlled (vengeful) 1. Throws rock at windows

vii. Dissociations viii. BLIPS

ix. Dialetical Behavioral Therapy*c. Narcisstic and Histrionic

i. They are very similar; seems to have a gender bias

ii. “me” orientated 1. Focused on self 2. Seek admiration 3. Attention seeking 4. Focused on appearance on overly seductive ways 5. ‘Shallow’

iii. Appears arrogant to other peopleiv. Very vulnerable self-esteem v. If they are criticized, they actually get very angry

1. These people don’t often seek treatment, very hard to treat 2. Treat only depression

5. Cluster C a. Where individuals are actually seeking treatment and we may be able to help

them more b. Avoidant PD

i. Social isolation ii. Painfully shy

iii. Un-likes schizoid, they actually wants to engage socially iv. Generalized social phobia?

1. It is like social phobia; hard to tell apart2. Looks like it and we treat it the same

c. Dependent PD i. Needs to be taken care of

ii. Fears being aloneiii. Submissive

1. As long as they are in a relationship, they will do whatever it takes to maintain it

2. If you give them any task, they will do it iv. Low self-esteem (treatment target) v. Often experiences depression (treatment target)

d. OC PD i. Not related to OCD

ii. Suggested as an alternative 1. Perfectionism

a. Somebody who just has to have everything just the way they like it

b. Tend to be viewed by other people as inflexible i. Only I can wash the dishes

2. Nothing is ever quite perfect a. Not wanting to turn your assignment in because it is not

perfect b. So life ends up being in jeopardy

iii. Interpersonal therapy, CBT, etc

End ~