Jill Norvilitis

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Is he mentally ill?
How do you know?
What type of mental illness do you think he has?

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Incorporates
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Psychological distress—neither necessary nor sufficient
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Maladaptive—interferes with our well-being, etc.
Statistical abnormality or deviancy
Violation of the standards of society
Social discomfort
Irrationality and unpredictability—dangerous at times

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Nomenclature—a naming system to structure information allows us to study, assess, and treat
Shorthand—like a diagnostic system—leads to a loss of information
Stigma—people fear what will happen if they reveal a disorder
Stereotyping—automatic beliefs based on knowing one thing about someone
Labeling

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Definition of mental disorders
A clinically significant behavioral or psychological syndrome or pattern
Associated with distress or disability
Not a predictable response to a particular event
Considered to reflect behavioral, psychological, or biological dysfunction

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Epidemiology—study of the distribution of diseases, disorders, etc.
Prevalence—point, one-year, lifetime
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Any disorder in lifetime—46.6 %
Incidence
Comorbidity

1-year
MDD 6.7%
Alcohol abuse 3.1
Specific phobia 8.7
Lifetime
16.6%
13.2
12.5

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Not dysfunctional
Thought processes are not seriously disrupted
Fewer emotional problems than general population
Characteristics: Nonconformity, creativity, strong curiosity, idealism, happy obsession with hobbies, lifelong awareness of being different, high intelligence, outspokenness, noncompetitiveness, unusual eating and living habits, disinterest in others’ opinions or company, nonmarriage, eldest or only child, poor spelling skills

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500,000 yrs ago— trephination
Later ancient societies indicate possession
Babylonians—Idta—spirit who caused insanity
Greek and Roman views and treatments
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Hippocrates—460-377 BC—denied influence of demons
Somatogenesis
Plato—Criminally insane shouldn’t be held responsible like others
Galen—130-200 AD believed disorders could have either physical causes (injury to the head) or mental causes (stressors)
After Hippocrates, treatments included pleasant surroundings, giving patients constant activities

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Increase in power of the clergy, church rejected scientific forms of investigation.
Mass madness: group behavior disorders, apparently hysterical. Peak in 14 th -15 th centuries.
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Tarantism
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Lycanthropy
Treatment of mental illness was left to clergy.
Return of exorcism. Not generally treated as witches, though this did happen.

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Agrippa -1486-1588-began to speak out against possession
Johan Weyer first physician to specialize in mental illness. 16 th cent. On—asylums grew in number
Gheel, Belgium—first colony of mental patients
1547—St. Mary’s of Bethlehem Hospital— bound in chains, popular tourist attractions, mildly mentally ill were forced to beg on the streets

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La Bicetre—Philippe Pinel
William Tuke—1732-1822—English Quaker— established York Retreat.
Moral management—focused on patient’s social, individual, occupational needs—rehabilitation of character. High degree of effectiveness—
Buffalo Psychiatric Center—originally Buffalo State
Hospital for the Insane. Proposed by physician White in 1864, first received patients in 1880. Followed
Kirkbride Model of connected buildings.
Mental hygiene movement—focused on physical well being, not treatment
Dorothea Dix—1802-1887—champion of the poor and forgotten in mental institutions and prisons.

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Two opposing views: somatogenic and psychogenic
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Syphilis
Mental hospitals in the 20 th century
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Over 500,000 by 1950s
Deinstitutionalization
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Thorazine
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Today about 55,000 in state hospitals
Criminalization of the mentally ill. By some estimates, 300,000 inmates, 500,000 on probation

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28 % psychologists who were female in 1978
52 % female today
75 % female undergrad psych majors
66 % female psych grad students

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Retrospective vs. prospective
Case studies—begin with Hans
Correlational method—can correlations be trusted?
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Epidemiological studies
Longitudinal studies
Experimental method
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Control groups
Random assignments
Blind designs, placebo treatments
Quasi-experimental designs

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Concerns remain
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New drug studies without adequate informed consent
Placebo studies
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Symptom-exacerbation studies
Medication-withdrawal studies

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Etiology
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Necessary—must exist for a disorder to occur
Sufficient—condition that guarantees the occurrence of a disorder
Contributory—increases the probability of a disorder
Time frame
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Distal—in the past
Proximal—immediate

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Diathesis—vulnerability for the disorder
Stress—proximal stressor
Protective factors
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Individual
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Family
Community
Resilience
Biopsychosocial viewpoint

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Disease or medical model
Brain anatomy and abnormal behavior—
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100 billion nerve cells called neurons and thousands of billions of support cells called glia.
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Bottom of the brain—hindbrain—
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Cerebellum—regulates smooth coordinated movement
Pons
 Medulla—controls heart rate, breathing, digestion
Midbrain
Forebrain—
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Hypothalamus—temperature, hunger, thirst, sex
Thalamus—
 Corpus callosum—connects hemispheres

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Over 100 neurotransmitters discovered to date
Those most studied with psychopathology
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Norepinephrine—emergency reactions in stressful situations
Dopamine—schizophrenia and Parkinson’s
Serotonin—thinking and information processing, anxiety and depression
Gamma aminobutyric acid (GABA)—anxiety and arousal
Neurotransmitter imbalances
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Excessive production and release of neurotransmitter
Dysfunction in deactivation process
Problem with receptors—abnormally sensitive or insensitive

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Genetics
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Genotype
Phenotype
Behavior genetics—study of individual differences in beh. that are in part attributable to genetic makeup
Family history (pedigree) method—we know what
% of genes are shared
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Twin method
Adoption
Evolution and abnormal behavior
Viral infections

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Temperament—reactivity and self-regulation
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Behavioral inhibition seems to be innate
Biological treatments
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Psychotropic medications
Electroconvulsive therapy
Neurosurgery
Assessing the Biological Model
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Lots of valuable new information
Treatments bring great relief
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Shortcomings—
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 1) some proponents seem to think that everything can be explained by biological terms
2) lots of evidence is incomplete and inconclusive
3) biological treatments can produce undesirable side effects

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Freud—very deterministic
Structure of the personality:
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Id—comprised of instinctual drives of two types
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Ego—secondary process thinking—reality principle
Superego—conscience
Defense mechanisms—control unacceptable id impulses or reduce the anxiety they create
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Repression
Projection
Rationalization
Reaction formation
Sublimation

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Psychosexual stages of development
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Oral—birth to 2
Anal—2-3
Phallic—3 to 5 or 6
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Oedipus
Electra
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Latency
Genital—After puberty
How to tap the unconscious?
Advantages of Freud’s theory…
1) Helped establish the field
2) Emphasized the importance of childhood for a healthy adulthood
Disadvantages…
1) Hard to Research
2) Largely based on case studies
19 % of clinical psychologists describe themselves as psychodynamic
(Prochaska & Norcross, 2003)

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Of course, Freud created his theory over 100 years ago. There have been major updates:
Object relations theory: importance of the caregiver is key
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Melanie Klein
Healthy relationships as infants result in healthy relationships as adults
Attachment theory: Bowlby, 1969; Ainsworth,
1978
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Secure, ambivalent, avoidant, disorganized (in 4/5 abused kids)

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Classical conditioning
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Pavlov
Important for fears and anxiety
Instrumental conditioning AKA operant conditioning
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Thorndike
Law of effect—behavior that is followed by consequences affects repetition
Generalization
Discrimination
Shaping—successive approximations
Observational learning
Behavior therapies—systematic desensitization, assertion training, token economy, role playing

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Can be tested in the laboratory
We can show that symptoms can be acquired these ways, but is this the way they are ordinarily acquired?
Improvements in therapists’ offices do not always extend to real life, nor do they always last without continued therapy
Critics argue that it is too simplistic—no cognitions involved; pts. must develop selfefficacy

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Schemas
Observable behavior can be influenced by mental processes
Automatic thoughts
Cognitive distortions
Attributions
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Assessing the Cognitive Model
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24 % of psychologists identify approach as cognitive
Appealing because it focuses on a process unique to humans
Lends itself to research
Precise role of cognitions (cause or effect) has yet to be determined
Narrow—deals only with cognitions, not values, meaning, etc.

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Family Systems Theory
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Identified patient
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Homeostasis
Family structures (parents in charge) and alliances
(parents united) are often disrupted
Communication is also often disrupted
Can be enmeshed or disengaged

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Macrosystem—beliefs and values of the culture
Exosystem—social structures like family, neighborhood, SES
Mesosystem—interconnections between various community systems like peer groups, religious organization, etc.
Microsystem—child’s immediate environment, family, school, work
Ontogenic Development—the child’s own development and adaptation

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Neglect and abuse in the home:
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Disorganized and disoriented attachment
Problems in all domains
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1/3 will go on to repeat the trauma
Parental Psychopathology
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Tiffany Field—transmission of depression, even with those as young as 6 mos.
Parenting styles:
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Authoritative—energetic/friendly
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Authoritarian—conflicted/irritable—also moody, eating disorders
Permissive/Indulgent—impulsive/aggressive—demanding, immature
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Neglectful/Uninvolved—low s-e, conduct problems, moody, peer and academic problems
Divorce
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Ongoing stressor—not just one
Most (3/4) will be fine
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But…2x as likely to repeat a grade, report more delinquency, more negative health stuff like smoking, more depression
Poverty!
Peer Relationships
Deviancy training
Rejected, neglected, controversial, accepted—neglect is particularly negative

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Universal vs. culture-specific
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Schizophrenia—different presentation, more paranoia in Western cultures, also more negative outcome
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Depression—universal, but different presentation— more somatic in China, for instance
Overcontrolled vs. undercontrolled behavior—more under in US, over in Thailand (Weisz et al, 1993)
Culture bound syndromes

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Intake interview—
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History of present problem
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Thorough personal and family history
Social context
Structured vs. unstructured
Physical assessment
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General exam
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Neurological exam for neurological disorders. For example, may want an EEG if there are memory deficits, etc.

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Variety of sources in assessment
Reliability—consistency or agreement among assessment data
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Test-retest
Internal consistency
Interrater
Validity—does it measure what it is supposed to measure
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Content validity—all domains that is supposed to measure
Predictive validity
Concurrent validity
Diagnostic errors—true positives, true negatives, false positives (Type 1), false negatives (Type 2)
Sensitivity—correctly diagnose someone with any disorder
Specificity—likelihood that people without disorder will be diagnosed that way

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Life records—school, police, hospital
Interviews
Observation
Psychological tests
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Standardized
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Normed
Several subtypes:
 Rating Scales (specific vs. broad)

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Intelligence Tests
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WISC-IV, WAIS-III, Stanford-Binet
Neuropsychological testing—measure deficits in behavior, cognition, or emotion that correlate with brain damage
Personality Tests
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Projective—Ambiguous stimuli that allow for individual responses
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Rorschach
TAT/RAT
Draw A Person
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Objective
 MMPI-2 Revised in 1989, first ed. in 1943 (10 clinical scales, + validity scales and special scales

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1) Potential for cultural bias of the instrument or clinician
2) Theoretical orientation of clinician
3) Underemphasis on the external situation
4) Insufficient validation
5) Inaccurate data or premature evaluation

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Efforts go back thousands of years
Scientific efforts in 19 th century
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Emil Kraepelin—3 categories—dementia praecox (schizophrenia), manic-depressive psychosis, & organic brain disorders (delirium, dementia, amnestic)
1917—1 st American system, didn’t work
30s and 40s—military developed system
1948—Manual of the International Statistical Classification of
Diseases, Injuries, and Causes of Death—now on ICD 10
1952--Diagnostic and Statistical Manual of Mental Disorders
Then DSM-II-in 1968
DSM-III in 1980, III-R in 1987, IV in 1994, TR in 2000
DSM I and II lacked consistency, some criteria were based on theories of causation, others on clusters of sx, little effect on tx

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Multiaxial
Clearly defined diagnostic criteria,
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Operationally (not theoretically) defined diagnosis
5 Axes
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I—Major mental disorders
II-Developmental and personality disorders
III-General medical conditions that affect disorders
IV-Psychosocial stressors—topical, labeled acute or chronic
V-Global assessment of functioning
Polythetic approach—must have some # of criteria out of a larger group
Comorbidity

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Labeling produces stereotypes, prejudices, and harm
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Rosenhan (1973)—voices saying thud, empty, or hollow; kept 7-52 days
Self-fulfilling prophecies
Gender/ethnic bias—
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Antisocial PD more often diagnosed in men, histrionic in women
In a study with randomly assigned gender to APD or HPD criteria, psychologists underdiagnosed women with APD and men with HPD
People are more likely to diagnose others like themselves with less severe diagnoses, those not like them get more severe diagnoses
Disorders are on a continuum, not discrete categories
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Why do we use categorical?
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Medical model
Easy
No one agrees on personality dimensions
Not enough attention to validity

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From Opinion Research Corporation, 2004
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67% Am. would not tell their employer that they were seeking mental health treatment
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51% would hesitate to see a psychotherapist if a diagnosis were required
41% believe they should be able to handle psychological problems on their own
37% would be reluctant to seek tx because of confidentiality concerns
33% would not seek counseling for fear of being labeled mentally ill

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1935 Egaz Moniz—prefrontal leucotomy/lobotomy
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Won the 1949 Nobel Prize in medicine
Originally 18 patients, 6 cured, 6 improved, 6 same. Idea took off.
Freeman and Watts—frontal lobotomy—cutting into side of skull and then pivoted
Transorbital lobotomy—
In 20 yrs, 40,000 pts had lobotomies
Side effects—seizures, incontinence, poor judgment, lack of motivation, lethargy, impaired thinking, 5 % died
All surgeries were blind
2 procedures are done today.
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Cingulotomy and stereotaxic subcaudate tractotomy

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Convulsions to treat mental illness date back to
Paracelsus (1493-1591)
Today, use of electro shock dates to 1938
Bilateral vs. unilateral
About 100,000 per year
Injuries in 1/1400 tx
Post tx side effects—temporary memory loss, h/a, confusion
Used for severe mood disorders—about 80% are severely depressed

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Antipsychotics—aka major tranquilizers, neuroleptics
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60-80% show some improvement
Thorazine-1955, Haldol-1960s—less sedation
 Side effects—extrapyramidal symptoms—Parkinsonism— shuffling gate, tremor, muscular weakness, rigidity
 Tardive dyskinesia—jerks, tics, twitches of the face and tongue—doesn’t appear for several years and is permanent
Atypical antipsychotic—developed in 1980s and beyond—first Clozaril, now Risperdal, Abilify, Geodon,
Zyprexa, Seraquel
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Newer meds are better at treating negative symptoms
Side effects—weight gain, drooling, agranulocytosis (drop in white blood cells)

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Monamine oxidase inhibitors—Parnate, Marplan—dev. as tx for TB, but people became less depressed
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-slow activity of serotonin and norepinphine
-work well, but decreases REM sleep, can’t eat foods with tyramine
Tricyclics—Tofranil, Elavil, Anafranil, Pamelor
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Fewer serious side effects but—fatal in overdose
SSRIs—1988-Prozac—most widely prescribed antidepressant in the world, others include Zoloft, Paxil,
Celexa, fluvoxamine, Lexapro
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Less deadly in overdose
Better tolerated but nervousness, insomnia, sexual dysfunction, long time to effectiveness
60-70% on antidepressants improve
More effective for major depression, less effective for dysthymia
Elderly are less able to metabolize

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Mood stabilizers—lithium--some pts miss the highs
Anxiolytics—most prescribed class of psychoactive drugs
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At times, on top of all drugs prescribed
Benzodiazepines—minor tranquilizers—prescribed by length of action or time to onset
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Long acting—valium, Librium
Intermediate—ativan, klonopin
Short acting—xanax, halcyon
Side effects—rebound, addiction, drowsiness, fatigue, clouded thinking
But they work—after 8 wks, 50-60% are free of panic
Psychostimulants—ritalin, dexadrine, etc.
Why might you not want to prescribe meds?
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Reliance on drugs
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Decreased self-efficacy

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Why does it work?
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Common factors are not inert or trivial
Hawthorne effect
Placebo effect—phone call improvement
Insight-oriented therapy—assumes beh, emo, and thoughts become disordered because people don’t understand what motivates them, esp. when needs and drives conflict
Psychoanalytic therapy—remove repressions that have prevented the ego from helping the individual grow into a healthy adult.— unresolved, buried conflicts
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Focus of therapy is not on presenting problems such as anxiety, but conflicts in the psyche from childhood
Techniques—free association
Resistance—blocks to free association—come late, change subject, miss appointments.
Is it effective? Time consuming, expensive, no rigorous, controlled outcome studies of traditional analysis. Appears to have some utility.
Newer forms of short-term psychoanalytic have had some outcome studies, look good.

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Greater emphasis on freedom of choice
Free will-most important characteristic—offers pleasure but also pain
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Carl Rogers’ client centered therapy
Techniques—
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Genuineness-spontaneity, openness, authenticity
Unconditional Positive Regard—get rid of conditions of worth
Accurate empathic understanding—accept, recognize, and clarify feelings
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 Reflect back statements
Inconsistent results
Gestalt Therapy—Fritz Perls—originally an analyst; we react to people in the context of our needs. Clients are made aware of what is going on now in session.
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Techniques—I language; Empty chair; Reversal (beh. opposite)
Evaluating Humanistic-Experiential therapies—
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Many of the ideas have had an impact on psychotherapy
However, lack of agreed upon procedures, a bit vague
More research these days—looks ok

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Exposure therapy
Systematic desensitization
Aversion therapy—pair negative stimuli with stimuli that are inappropriately appealing
Token economy
Premack principle
Modeling
Evaluating Behavior Therapy
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Achieves results in a short period of time—less distress, lower cost
Methods are clearly delineated; results easily measured
Works better with some problems than others—rarely used for complex personality disorders (except dialectical behavior tx for borderline)

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Ellis—Rational Emotive Therapy
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Sustained emotional reactions are caused by internal sentences that people repeat to themselves—irrational beliefs
Eliminate self-defeatingness by rational examination
Beck—Cognitive therapy
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Negative beliefs that people have about self, world and future cause disorders.
Both behavioral and cognitive.
Ellis is more harsh and direct
Beck—inductive—seek negative beliefs
Social problem solving; skills training, assertion training
Efficacy
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Less research on Ellis’ model—what is there says that it does not work as well as Beck’s approach.
Combined use of cog and beh is routine these days.

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Generally depends
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1) therapist’s impression of change
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2) client’s report of change
3) reports from clients family or friends
4) pre and post scores on tests
5) changes in overt behaviors
Would change occur anyway? After 40 sessions,
75 % have improved; 50 % show significant change after 21 sessions
Can therapy be harmful? 5-10% deteriorate in tx.
BPD and OCD show the most negative outcomes.

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What is stress?
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When environmental or social threats place demands on people
How we react depends on:
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Nature and timing of stressor
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Psy characteristics and social situation
Biochemical variables
Types of stress: eustress and distress
Frustrations—when strivings are thwarted
Conflicts—two incompatible needs or choices
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1) Approach-avoidance—a mixed blessing
2) Approach-approach
3) Avoidance-avoidance

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The nature of the stressor
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Chronic or short term
# of stressors at once
Length of the ordeal
Personal involvement
Persons’ perception and tolerance of stress
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Perception of threat
Stress tolerance—ability to withstand stress without becoming seriously impaired—risk factors
External resources and social supports
Life changes—Holmes and Rahe (1967)—Social Readjustment
Rating Scale
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Horowitz et al 1979—those with scores of over 300 were at increased risk for major illness in next two years
All of these factors can build upon one another and make stress worse

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Begins in hypothalamus
Stimulates sympathetic nervous system
Causes adrenal glands to secrete adrenaline and noradrenaline.
This causes an increase in heart rate and increased rate of glucose metabolization
Hypothalamus also causes the release of corticotrophinreleasing hormone (CRH), which stimulates pituitary gland.
Pituitary then secretes adrenocorticotrophic hormone (ACTH) which causes adrenal cortex to produce stress hormone cortisol.
Cortisol prepares body for fight or flight.

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Allostatic load—biological cost of adapting to stress
Hans Selye (1936) General Adaptation Syndrome
(GAS)
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1) First stage—alarm reaction—fight or flight—autonomic nervous system activates
2) If stressor ends, ANS calms down. If it persists or new ones are added, alarm is followed by a stage of resistance.
3) If stressors continue, state of exhaustion begins as a result of long-term resistance. Physical signs: indigestion, loss of wt., insomnia, fatigue. Psychological signs: violence, delusions, stupor. May result in death.

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Experiencing alarm—heightened vigilance and concentration; dizziness, light-headedness, shakiness
Prolonged stress—release of stress hormones can cause chronically high b.p., damage muscle tissues and inhibit healing after injury
Innate immunity—1st line of defense; skin, mucus membranes
Specific immunity—acquired rather than innate
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Detection
Destruction
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Once battle is over, suppressor T cells call a halt, if not, body turns on itself.
Short term—stress can boost immune system
Long term—decrease in immunological strength; can effect some parts and not others

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Types of coping:
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Problem-focused: Change the stressor itself
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Cognitive reappraisal: Change how you think about the stressor
Emotion-focused: Change emotional responses
Social support: Direct and buffering effects
Effects: No best way—best to be flexible in type and timing of strategy.
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Men: more often active, problem-focused
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Women: Distraction, venting, social support
Pennebaker’s work

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Sleep disorders
Adjustment disorders
PTSD and Acute Stress Dis.
Dissociative and somatoform disorders
Psy factors affecting a medical condition

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Coronary Heart Disease—more than 500,000 deaths per year
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Main cause is atherosclerosis
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Results of CHD include: Angina pectoris and Myocardial infarction
Risk factors: men, older people, high bp, parental history of heart problems, cigarettes, high levels of bad cholesterol
Hypertension—another correlate of atherosclerosis
Stress and cardiovascular disease
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Manuck et al 1983—monkeys who were exposed to a threatening stimulus
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Learned helplessness
Psych factors: internal, global, stable
Perceived control over the situation
Belief in coping abilities
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Social isolation and a lack of social support
Hostility component of Type A personality
Depression increases risk

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When a response to common stressor is maladaptive and occurs within 3 months of the stressor.
Unable to function as usual
Reaction to particular stressor is excessive
Dx is discontinued if stressor subsides or if individual learns to cope
If it persists beyond 6 mos, change diagnosis
Multiple types—depression, anxiety, disturbance of conduct, mixed

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Difference between the two is timing—Acute Stress occurs right after the event, lasts from 2 days to 4 weeks. After 4 wks after the event, it is PTSD. Onset can also be delayed for PTSD beyond 6 months.
Symptoms:
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Frequent reexperiencing of the event through intrusive thoughts, flashbacks, nightmares, and dreams
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Persistent avoidance of stimuli associated with trauma and a general numbing or deadening of emotions
Increased physiological arousal with an exaggerated startle response

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Lower rates in areas with less crime and few natural disasters
Perception of trauma
Social support
Those who develop it tend to have preexisting more somatic concerns
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More social maladjustments and irresponsibility
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Be more passive and inner directed
Be more sensitive to criticism and suspicious of others

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Short-term crisis therapy—face to face discussion
Direct exposure therapy—in vivo or imagined
Telephone hotlines
Psychotropic medications

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Anxiety—common features
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Relative intactness of reality testing
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Experience of anxiety
Recognition that this is not a typical response
Affects 25-29% of US population (over 23 million) at some point in life
Most common category of disorders for women, second for men
Lots of comorbidity in anxiety—suggests common mechanisms

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Fear or panic activates the fight-or-flight response
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Has cognitive/subjective components “I feel terrified”
Physiological components—hr and bp
Behavioral components-urge to run
Anxiety is a complex blend of unpleasant emotions and cognitions that is more oriented to the future and much more diffuse than fear
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Adaptive in that it helps us prepare for a threat. At mild or moderate levels, enhances learning and performance
Also has cognitive, physiological, and behavioral components
Anxiety and fear can be unconditioned or learned

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Unrealistic and irrational fears of disabling intensity
7 different disorders in DSM-IV
Relatively common (phobias most common)
Commonalities in causes
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Genetic vulnerability—personality trait of neuroticism
Limbic system commonly involved
Neurotransmitters include GABA, norepinephrine, and serotonin
Classical conditioning
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Those who perceive a lack of control are more vulnerable
Commonalities in treatment
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Graduated exposure—single most effective treatment
Cognitive restructuring
Benzodiazepines and antidepressants

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Taijin-kyofushu—Japan—similar to social phobia, fear that they will offend or embarrass, concerned with body odor
Nervios—Latino cultures—chronic worrying and negative thinking, expressions of anger, headaches, other somatic ailments.
Tied to poverty and poor education.
Ataque de nervios—Latino cultures—panic-like attacks dominated by trembling, heart palpitations, numbness. Tied to stress and spiritual causes.
Shen-k-vei—China—pattern of severe anxiety or panic, accompanied by bodily complaints. Supposedly tied to excessive semen loss after frequent masturbation or intercourse, a loss believed to endanger the individual’s vital essence Similar to dhat a disorder found in India.

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Disrupting fear, avoidance out of proportion to the danger posed by a particular object or situation; generally recognized as groundless by sufferer
Five subtypes: Animal, Natural Environment, Blood-Injection-Injury,
Situational, Other
Common ones: claustrophobia, acrophobia (ht), agoraphobia (open, public spaces)
Common in women
Lifetime prevalence—12%
Animal, dental, and blood-injection-injury typically begin in childhood
Agoraphobia and claustrophobia—adolescence and early adulthood
Animal phobias are most common, but tend to diminish with time, even without treatment
Blood-injection-injury—3-4 % of population, but about 15 % of adults have had a blood or injury related fainting spell
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Disgust is as common as fear
Initial heart acceleration, followed by a drop in rate and pressure
Leads to nausea, dizziness, and or fainting (don’t find this with other phobias)

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Psychodynamic viewpoint—look at content of phobia. Today view phobia as defensive in some way, such as fear in place of something else.
Behaviorist viewpoint
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Classical conditioning and generalization
Direct traumatic conditioning (think of the dentist)
Vicarious conditioning—Mineka and Cook
Cognitive factors maintain fear
Evolutionary preparedness
Cognitive viewpoint
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Phobics are attuned to stimuli that elicit fear—shadowing studies—phobics attend to ear that they are supposed to ignore and start saying phobia-related words
Also—socially anxious—concerned about evaluation
Genetic and temperamental—
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ANS—more easily aroused
1st degree relatives have increased likelihood of all anxiety
Behaviorally inhibited toddlers (21 mos)

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Systematic desensitization—fear hierarchy; in vivo or in session
Exposure
Modeling
Anxiolytics—not effective
Cognitive—dispute irrational beliefs—not effective alone, not much incremental benefit

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Fear of one or more specific social situations—fear is really of scrutiny by others and potential embarrassment
About 60% of sufferers are women. Lifetime prevalence rates vary—your book says 12%, I’ve seen as low as 2%
Onset is typically in adolescence
Culture—in collectivist cultures—fear of offending others or bringing shame to the family; individualist cultures—guilt or embarrassment
High comorbidity with GAD, panic, specific, compulsive PD, depression

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Learning—
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Direct or vicarious conditioning such as experiencing or witnessing a social defeat
More likely to have grown up with parents who were socially isolated or avoidant
Evolutionary—a by-product of dominance hierarchies—had to be prepared to flee; had to be attuned to others’ expressions
Genetic and Temperamental factors
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Modest genetic contribution
Behavioral inhibition
Cognitive variables—expect that others will reject them; preoccupied with their own bodily responses and negative selfimages.
Perceptions of uncontrollability and unpredictability
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Lead to submissive and unassertive behavior

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Behavioral treatments—exposure
Cognitive treatments-challenge negativeautomatic thoughts
Antidepressants—may be helpful, but takes a while to build up, can’t just stop taking them
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Recent research suggests cognitive-behavioral tx has longer lasting effects

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Short, periodic bouts of panic that occur suddenly, reach a peak in
10 minutes, and then gradually pass. Must include at least 4 symptoms:
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Palpitations, pounding heart, accelerated heart rate
Sweating
Trembling or shaking
Sensations of shortness or breath or smothering
Feeling of choking
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, lighthearted or faint
Derealization or depersonalization
Fear of losing control or going crazy
Fear of dying
Numbness or tingling sensations
Chills or hot flashes
Attacks can be cued or uncued

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Recurrent unexpected panic attacks
Month or more of one of the following after at least one of the attacks
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Persistent concern about having additional attacks
Worry about the implications or consequences of the attack
Significant change in behavior related to the attacks
Often accompanied by agoraphobia
Panic is now dx’d with agoraphobia or without
About 2.7 % suffer from one or the other pattern in a year, about 5
% lifetime prevalence
Likely to develop in late adolescence or early adulthood
Twice as common in women as men
About 35 % of those with panic disorder are currently in treatment

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Genetic factors—moderate heritability, overlap in heritability of panic and phobias
Biochemical abnormalities
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No single neurobiological mechanism
GABA related to anticipatory anxiety
Noradrenergic and serotonergic pathways are implicated
Related to mitral valve prolapse
Behavioral and cognitive causal factors
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Fear of fear hypothesis
Interoceptive awareness
Sense of perceived control or having a safe person may block response
Safety behaviors and persistence of panic
Safety behaviors need to stop for effective treatment
Attentional biases toward threat cues

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Benzodiazepines—rapid effects, addictive, need gradual withdrawal, rebound panic
Antidepressants—high relapse rates
Behavioral and cognitive-behavioral tx
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Prolonged exposure effective in 60-75 % of pts
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Combined with meds—greater relapse—better to use alone

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Experience excessive anxiety under most circumstances and worry about anything
Sometimes called free-floating anxiety
Somatic complaints—sweating, flushing, pounding heart, upset stomach, diarrhea, cold clammy hands, dry mouth, high pulse and respiration
Disturbances of skeletal musculature—muscle tension, eyelid twitches, trembling, tire easily, inability to relax
Easily startled, fidgety, restless, sighs a lot
Generally apprehensive—often imagining and worrying about disasters, losing control, having a heart attack, dying
Impatience, irritability, insomnia, distractibility
4-6 % prevalence
Twice as common in women
Most continue to function despite symptoms
Begins in mid-teens, many report problems through life
Comorbid with social anxiety and OCD

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Psychoanalytic view
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Sx or aggression impulses are in conflict with the ego; ego can’t allow expression because of fear of punishment. Because anxiety source is unconscious, person is in distress and doesn’t know why
Learning—
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Attempts to control thoughts and images actually increases them
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Classically conditioned to external stimuli—like phobia, only broader
Cognitive—control vs. helplessness-in yoking studies, rats with control have less anxiety
Biological—small to modest heritability
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Predisposition to neuroticism
Treatment
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Benzodiazepines—not all that effective, gains often lost
Antidepressants, Busipirone may help
Muscle relaxation and cognitive restructuring quite effective

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1-3 % have OCD-lifetime
>90% have both o and c, if include mental rituals, this is 98%
Usually begins in early adulthood, often following some stressful event
Gradual onset and chronic—poor prognosis
80% may experience depression
Early onset—more common in men—checking compulsions
Later onset—more common in women—cleaning compulsions

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Obsessions—intrusive and recurring thoughts, impulses, and images, appear irrational and uncontrollable to pat
Doubts—75 % of pts.—persistent thought that a completed task hadn’t been adequately completed
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Thinking—34 %--endless chain of thoughts focusing on future events
Impulses-17 %-urges to perform certain acts (whims to assaults)
Fears-26 %-afraid of losing control or doing something embarrassing
Images-7 %--seen or imagined
Compulsions—Five primary types—cleaning, checking, repeating, ordering/arranging, counting. Performance of act reduces tension, increases satisfaction, gives sense of self control
Fear that something will happen to them or others because of them
Have tendency to judge risks unrealistically

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Behavioral viewpoint—
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Mowrer—two process—in place classically, maintained operantly
OCD and preparedness—evolutionarily adaptive in some ways
Biological –
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Genetic—moderately high heritability
Some abnormalities in brain function that normalize on meds
Treatment—
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Difficult to treat
Behavioral treatment that combines exposure and response prevention—effective in 50-75 %
Relapse of up to 90% following med discontinuation
SSRIs—
Combination of meds and therapy not more effective than therapy alone in adults, may be in children

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Somatoform—pt. complains of bodily symptoms that suggest a physical defect or dysfunction, but no phys. basis
Dissociative—disruptions of consciousness, memory, and identity. Individuals with these disorders may be unable to recall events, may forget identity, may assume a new identity.

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Preoccupied with fears of a serious disease—not reassured by physician
Overreact to ordinary physical sensations or minor abnormalities—irregular heartbeat, sweating, coughing, sort spot, stomachache
Not faking—sincere
Vague and ambiguous symptoms are common
Causes—
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Not well understood
Clearly anxiety related—some researchers like term health anxiety
Attentional bias for illness-related information
Misinterpretations of bodily sensations are seen as causal by cog-beh types
Role of secondary reinforcement
Treatment
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Cog-beh
SSRIs may be helpful

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Formerly called Briquet’s Syndrome
Multiple somatic complaints for which medical attention is sought, but have no apparent physical cause
Most often seen in primary medical care—common complaints include headache, fatigue, abdominal, back and chest pain, genitourinary and sexual symptoms, heart palpitations, gastrointestinal sx, neurological sx
3-10 x more common in women
Usually begins in adolescence
More often in low SES
Lifetime prevalence .2-2% in women, .2% in men
Comorbid with anx disorders
Causes—Similar to hypochondriasis—hyperattentive to bodily sensations
Interaction of personality, cognitive, and learning variables
TX-medical management and cog-beh

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Subjectivity of pain
Diagnosed more commonly in women
Comorbid with anxiety and mood disorders
May allow individuals to avoid some unpleasant activity
Diagnosed when onset, severity, and maintenance of pain causes distress with no pathology
Can be either psych alone or psych and physical
TX—cog-beh; relaxation training, support and validation that pain is real; reinforcement of “no pain” behaviors

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Symptoms suggest neurological damage, but everything is found to be fine
Usually appear in stressful times. Primary and secondary gain.
So named because energy of a repressed instinct was diverted into sensory-motor channels and blocked functioning. Thus anx and conflict are converted into physical sx
AKA conversion hysteria
La belle indifference in about 20-50% of cases
1-3% of those referred for tx. Prevalence in general pop is very low—may be only about .0005 percent
2-10X more common in women.
Issues in diagnosis—sx do not conform clearly to the particular diseases simulated; selective nature of the dysfunction; sx may go away under hypnosis or narcosis
Distinguishing from malingering and factitious disorder
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Malingering—fake an incapacity to avoid responsibility—under voluntary control
Factitious disorder—fake illness to assume role of pt
Tx of conversion—behavioral, hypnosis

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Preoccupied with an imagined or exaggerated defect in appearance. Often leads to may visits to plastic surgeons. 70% or more of students indicate some dissatisfaction.
Would you change something about your appearance if you could? 99% of women, 93 % of men say yes
Social and cultural factors play a role.
Most common—skin (73%), hair (56%), nose (37%), stomach (22%), breasts, chest, nipples (21%), eyes (20%)
No official estimates of prevalence. No gender difference. Onset typically in adolescence.
50% comorbid with depression
Over 75% seek non-psych help
Related to OCD—similar brain structures implicated; same tx are effective (SSRIs, cog-beh helps in 50-80%)

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Suddenly unable to recall important personal information, usually after a stressful situation.
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Most often—for all events in a given period of time.
More rarely—selected events in a period; continuous from traumatic event to present; total
Behavior looks normal, but may be disoriented
Usually person retains ability to read, write, play piano, have knowledge
Comes and goes suddenly
Not the same as with organic brain disorders or substance use— either a definite cause or fails slowly over time
Fugue—new identities may be assumed; may last for days, weeks, or years
Similar to conversion in that threatening information becomes inaccessible; suppression is involved in memory loss

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Two or more personality systems are created from stressful precipitating events
Personalities are dramatically different
Needs inhibited in one personality are displayed in another
Alter identities represent fragments of a single person
Some alters may have more knowledge than others
Switches can be sudden or gradual
Often see depression, self-mutilation, suicide attempts and ideation, BPD, substance abuse, phobias
Gaps in memory are common
Usually starts in childhood, but not dx’d until 20s or 30s
3-9x more common in women—due to sexual abuse
Number of alters has increased over time—50% now show more than ten identities; bizarre and unusual identities have also increased
Before 1979, only 200 cases had ever been reported. Post-Sybil and Three
Faces of Eve, that has risen to 30-40,000 in North America
May have previously been dx’d as schizophrenia

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Use of DID as a criminal defense is rare—Kenneth Bianchi—The Hillside
Strangler
Factitious and malingering cases are rare
Post-traumatic theory—over 95 % have memories of severe abuse. DID as a way to cope with overwhelming sense of hopelessness and powerlessness.
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Escape—dissociation—occurs through a process like self-hypnosis/
Only some abused kids develop DID—diathesis stress model
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Tend to be prone to fantasy, easily hypnotizable, intelligent
Sociocognitive theory—DID develops when a highly suggestible person learns to adopt and enact the roles of MPD due to therapist suggestions and reinforcement and because identities allow person to achieve personal goals—unintentional process.
Spanos and colleagues—normal college students could be induced by suggestion under hypnosis to show DID sx
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This is consistent with those who have no sx of DID before therapy, but emerges in tx; also consistent with increase in dx as therapists became aware of dx

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Tends to focus on integration
Psychodynamic and insight based
Few outcome studies. Many of those seem to be biased for positive results
Recovered memories—real or fake
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Practitioners more likely to believe in recovered memories but
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Memory is malleable and memories are subject to modification

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Intense fear of gaining weight or becoming fat is coupled with a refusal to maintain minimal wt.
At least 15 % wt loss without organic cause (usually 25-30%)
Active pursuit of thinness
Distorted body image
Amenorrhea
Two types: Restricting and Binge-eating/purging type—about 30-
50% go from restricting to binge/purge
Restrictors are admired
Mortality: 3-21%--about 12x higher than other females age 15-24
Normal awareness of hunger, but terrified of giving in to impulse to eat.
Distorted perception of satiety.
Excessive activity.

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90-95 % of cases are in females
Peak onset between 14-18
.5-2% prevalence in clinical populations. Higher rates of behaviors when we use an epidemiological approach.
Males tend to fall in a few specific groups—jockeys, wrestlers, models
So called Golden Girls disease.
Most common in industrialized nations (highest rates are here) but increasingly found everywhere.
Medical complications: Hair and nails thin and become brittle, dry skin, lanugo, yellowish tinge to skin, cold all the time, low bp, kidney damage, heart arrhythmias, electrolyte imbalances, osteoporosis

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40% totally recover
30% considerably improve
20% unimproved, seriously impaired
Remainder die
Early onset—more favorable prognosis
Poor prognosis—chronicity, pronounced family difficulties, poor vocational adjustment

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Depression in 50-70%, appear to be separate disorders
OCD also fairly common
Some studies have found increased rates of sexual abuse, but these have generally all been methodologically flawed

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1st classified as a disorder in 1980, therefore less research
Two types—purging and non-purging
Some argue that anorexia with binge/purge is just an underweight form of bulimia
Recurrent episodes of binge eating and repeated attempts to lose weight by severe dieting or purging (laxatives, vomiting, exercise)
Typical picture: white female begins overeating around 18 and purging a year later, generally vomiting
May be over or underweight, typically about average
Family hx often includes obesity or alcoholism
Prevalence about 1-3 %, higher rates when we look at # with behaviors
>90% are female
Preoccupied with food, eating, and vomiting so that concentration on other subjects is impaired. May steal food (increased food costs assoc. with binging)

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Less time socializing, more time alone than non-bulimics
Terrified of losing control over eating—all or none thinking
Lots of shame, guilt, self-deprecation, and efforts at concealment
More extroverted
More likely to abuse ETOH, steal, attempt suicide
More affectively unstable than depressed
Difficulty with self-regulation
Some evidence of hx of pica
More sexually active than controls, but less interested in sex and enjoy it less
Hx of childhood maladjustment; alienated from family
Higher rates of borderline

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50-75% show full recovery
Health risks: Electrolyte imbalances, hypokalemia (low potassium) leading to heart problems, damage to heart muscle, calluses on hands, tears to the throat, mouth ulcers and cavities, small red dots around eyes, swollen salivary glands

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Risk of anorexia for relatives is 11.4X greater than controls—concordance for MZ twins is about 50%, DZ twins about 5%
Risk of bulimia is 3.7x greater
Some linkage to chromosome 1 for anorexia, chromosome 10 for bulimia
Serotonin—neurotransmitter linked to obsessionality, mood disorders, impulsivity—also modulates appetite and feeding behavior
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Link is still not entirely clear
Set point—90-95% of those who lose weight regain it

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Peer and media influences
Fiji—Becker
Objectification theory (Frederickson and Roberts, 1997)
--women’s bodies are sexually objectified
--use observer perspective when viewing selves
--leads to habitual body monitoring-increased shame and anx, fewer peak states, increased depression and eating disorder
Hebl et al 2004—swimsuit vs. sweater paradigm

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1/3 of pts report that family dysfunction contributed to dev of anorexia
No typical family profile with anorexia
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 associated family behaviors—rigidity, parental overprotectiveness, excessive control, marital discord triangulation double message of nurturant affection and neglect of dtr’s need to express her own feelings
Many parents have same issues—preoccupied with desirability of thinness, dieting, good physical appearance
Bulimia—high parental expectations, other family members’ dieting, critical comments about shape, weight, or eating

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Fat spurt—more associated with increased body dissatisfaction than age
Girls who are underweight are most satisfied with weight
Internalizing the thin ideal is associated with
Body dissatisfaction, dieting, negative affect
Perfectionism—more common in women
Sexual abuse in bulimia and binge-eating

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Anorexia Nervosa
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Treatable but motivation is a big issue
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Many have been tried (nutritional counseling, individual and group tx, 12 step, meds, beh. contracts)—most have weak evidence
Best results—cog-beh approaches and response prevention; family tx for adolescents
Most are outpt-inpt for brief periods
Meds—not initial tx of choice, SSRIs used 1st—none has consistently improved wt. maintenance or prevented relapse of anorexia

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SSRIs are more helpful for bulimia—seem to decrease frequency of binges as well as improving mood and preoccupation with shape and weight
Cog-beh is tx of choice—multiple controlled studies show CBT superior to meds and interpersonal tx.
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Behavioral components focus on meal planning, nutritional education, ending binging and purging cycles by teaching person to eat small amts more frequently

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Obesity is a widespread epidemic
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2/3 of adult population in US, 31% of those are obese
WHO –obesity is one of top 10 global health problems
BMI: below 18.5 underweight
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18.5-24.9—normal
25-29.9—overweight
30 or above—obese
To calculate: (weight in pounds*703)/ht in in sq
In US—6x more common in lower SES adults, 9x more common in lower SES children
Risk factors: low parental education, children who are seriously neglected
Associated with diabetes, joint disease, high bp, coronary artery disease, sleep apnea, CA

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Role of genes
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Genes assoc with leanness have been id’d in animals
Genetic mutation assoc with binge eating
Hormones involved in appetite and weight regulation
Leptin acts to reduce our intake; inability to produce leptin is assoc with morbid obesity
People who are obese tend to have high levels of leptin, but are resistant to its effects
Sociocultural influences
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Culture encourages consumption and discourages exercise
Time pressure: on any given day, 30% of Am kids eat fast food
In children: peers view obesity more negatively than physical handicaps
Peer eating behavior
Availability of exercise facilities

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
Family influences


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

Family behavior patterns
Food availability (home, neighborhood, school)
Parental knowledge and attitudes about food
Eating may become an habitual way of alleviating emotional distress
Overfeeding young children causes them to develop more adipose cells and may predispose them to weight problems in adulthood
Stress and Comfort Food




When under stress, people and animals eat foods high in fat or carbohydrates
Weight gain as a function of basic learning principles
Obese people are conditioned to eat more in response to both external and internal cues than normal-weight individuals
Eating is reinforced—food is pleasurable and emotional tension is reduced
Binge eating may be a predictor of later obesity






Success rates are quite low
Weight loss groups—


Many exist, but only Weight Watchers has been shown to be effective
Groups provide support education, encourage record-keeping
Medications

Two types—appetite suppressants and those that prevent some nutrients from being absorbed


Meridia—inhibits reuptake of serotonin and norepinephrine—typical weight loss 5-8%
Xenical—reduces amt of fat that can be absorbed—not all that effective. Ditto for Alli
Gastric Surgery



Reduces amt that can be consumed
Recovery is tough
Weight loss can be dramatic—average loss of about 60% of excess weight and loss is maintained over 8 or 9 years
Psychological tx

Most effective—behavioral management


CBT for binge eating
Gradual weight loss more effective than low-calorie diets



Losing weight is contrary to biology
Brownell: Public policy recommendations

Improve opportunities for physical activities



Regulate food advertising directed at children
Prohibit the sale of fast food and soft drinks in school
Subsidize the sale of healthful foods



Two key moods:




Depression (melancholia)—great sadness, apprehension, feelings of worthlessness, guild, withdrawal, loss of sleep, appetite and sexual desire, loss of interest and pleasure in usual activities
Often associated with other psych conditions and medical conditions
May go 6-8 mos if untreated—tends to dissipate with time
In kids—aggression and overactivity, irritability, somatic complaints
Mania—emotional state of intense but unfounded elation, hyperactivity, talkativeness, flight of ideas, distractibility, impractical, grandiose plans, spurts of purposeless activity



Rare individuals experience only mania
Manic stream of thought—loud incessant, full of puns and jokes
Comes on relatively suddenly, lasts a few days or months, may be irritable




Loss and the grieving process


Normal response—Bowlby—1) numbing and disbelief, 2) yearning and searching for the dead person 3) disorganization and despair, 4) reorganization
If symptoms haven’t resolved in 2 mos, dx
Baby Blues

Normal response, experienced by 50-80% of women, lasts just a few days. Caused by stress, sleeplessness, radical change in hormones. Marked by tearfulness, being overwhelmed.
Not to be confused with Postpartum depression—

Difficulty functioning. More common in those with predisposing factors—social isolation, less family support, history of depression.








Depressed mood of mild to moderate intensity
Primary hallmark is chronicity

Average duration is 5 years (4 years in kids)
Chronic stress increases the severity of symptoms
Half relapse
Lifetime prevalence of 2.5-6 %
Two of the following—poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self esteem, poor concentration or difficulty making decisions, feelings of hopelessness
Can be diagnosed with major depression—called double depression

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


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


5 symptoms nearly everyday for 2 weeks
Must have either sad, depressed mood or anhedonia
Difficulties sleeping
Shift in activity level
Poor appetite with weight loss or increased appetite with weight gain
Loss of energy or fatigue
Negative self-concept
Difficulty concentrating
Recurrent thoughts of death or suicide
Lifetime prevalence—about 17 %, though some estimates are as low as 4-
5%
90% recover in a year, but ¾ of cases will recur (average duration of an untreated episode is 8-10 months)
Typical onset is age 24-29
Symptoms of anxiety are common (not factor analytically distinct in children)





Melancholic features—more severe type, loss of pleasure, more of a genetic loading
Psychotic features—hallucinations and delusions tend to be content appropriate
Atypical features—mood reactivity (brightens at times in response to events).

May respond better to MAOIs than other subtypes
Seasonal pattern (AKA Seasonal affective disorder)





Genetic influences


3x more common among blood relatives
MZ concordance—46 %, DZ 20%
Biochemical factors


Low levels of norephinephrine and serotonin have been linked to depression
Some theorists look to a balance of these two, dopamine and acetylcholine
Hormonal regulatory systems




Hypothalamic-pituitary-adrenal axis
--elevated levels of cortisol in 60-80% of severely depressed hospitalized pts
Hypothalamic-pituitary-thyroid axis
--20-30% of depressed with normal thyroid show dysregulation here.
Increasing thyroid hormone levels may help
Sleep and other rhythms


Greater amounts of REM sleep, enter it earlier in night
Circadian rhythms may be out of sync, particularly in SAD



Psychoanalytic


Freud
More recent analytic work—Bowlby’s attachment theory
Beck’s cognitive theory








Depressogenic schemas/Dysfunctional beliefs
Beliefs predispose a person to depression
Develop in childhood and adolescences as a function of negative experiences with parents and sig others
Activated by current stressors or depressed mood—create a pattern of automatic negative thoughts
Negative cognitive triad—self, world and future
Negative cognitive biases—




Arbitrary inferences
Selective abstraction
Overgeneralization—overall, sweeping conclusions
Magnification and minimization
Dichotomous or all-or-none thinking
Support for Beck’s theory—strong support as a descriptive theory, mixed but positive support as a causal theory






Helplessness and Hopelessness theories of depression


Learned helplessness—individual’s passivity and sense of being unable to act and control life is acquired through unpleasant experiences
Revisions—attribution theory—Global, stable, internal
Hopelessness-expectation that desirable outcomes will not occur. Has generated a lot of research.
Interpersonal theory



Social support
Depressed people elicit negative reactions
Depressed people seek other depressed people and bring others down, too
Stressful life events


Severely stressful life events play a causal role in 20-50% of cases
Risk and resilience
Personality risk factors



Neuroticism
Introversion
Negative patterns of thinking



Cyclothymia—cycles between hypomania and depression

Mild form of major bipolar disorder
Bipolar Disorders (I and II)



Kraepelin 1899—manic-depressive insanity
Bipolar I
 One episode of mania or mixed episode
Bipolar II


Hypomania
More common than bipolar I







Symptoms of depression are almost identical to that of major depression
Suicide attempts may be more common in bipolar
May be misdiagnosed (until first mania appears)
Rapid cycling in 5-10%
24 % relapse in 6 mos, 77 % have a new episode in 4 yrs, 82 % by 7 yrs
Onset typically in early 20s





Genetic influences



Account for 80-90% of the variance
About 70% of heritability is distinct from unipolar
Polygenic
Neurotransmitters

Increased levels of dopamine may be related to mania

Abnormalities in how ions are transported across neural membranes (this is where lithium helps)
Some differences in brain structures—enlarged basal ganglia and amygdale
Psychosocial causal factors


Diathesis stress
Low social support



Where do depressed people go first? Katon and
Walker 1998


41 % initially go to physician with complaints of feeling ill
37 % report pain, 12 % report general fatigue and tiredness
Treatments for Unipolar Depression


Only about 40 % of people with mood disorders receive minimally adequate care
In one study of the depressed poor, only 2/3 said that they had ever received the diagnosis (Bazargan et al 2005)




Second most prescribed class of meds (behind blood pressure)

3 of the 12 most prescribed meds are antidepressants
(Gitlin, 2002)

74 % of those who are depressed take meds alone or with therapy. In 1990, that was 37 % . Today 60 % receive therapy. In 1990, that was 71 % (Boyles, 2002).
Will meds help us all?


Knutson et al 1998—Gave nondepressed volunteers antidepressants—noted improvements in negative symptoms like hostility and fear, but did not increase positive feelings like happiness and excitement
First class—MAOIs—developed in 1950s

Monamine oxidase inhibitors—Parnate, Marplan—dev. as tx for TB, but people became less depressed
Slows activity of serotonin and norepinephrin



Tricyclics—Tofranil, Elavil, Anafranil, Pamelor

Named for molecular structure


Created for schizophrenia, but work better for depression
Fewer serious side effects but—drowsiness, dry mouth, constipation, decreased sex drive, nausea, tremors, blurred vision, can occas. stimulate mania, increase effects of both when taken with alcohol, fatal in overdose
SSRIs—1988-Prozac—most widely prescribed antidepressant in the world

Less deadly in overdose



Better tolerated but nervousness, insomnia, sexual dysfunction, long time to effectiveness
60-70% on antidepressants improve
Course of treatment—



Take 3-5 weeks to become effective
50% do not respond to the first drug tried
25 % relapse while on drugs





ECT—severely depressed at imminent risk; 6-12 sessions every other day, varying levels of amnesia persist; can be useful in the elderly. Effective for 50-80
% who do not respond to meds
Bright light therapy—originally just for SAD, but may help with other types of depression
Transcranial magnetic stimulation—brief, intensive pulsating magnetic transmissions


Noninvasive, done in awake patients
May be more effective than antidepressants without side effects of ECT
Psychopharm for biopolar

Mood stabilizers—lithium

Tegretol, depakote




Cognitive-behavioral and behavioral activation therapy





Focuses on here and now problems
Teaches people how to evaluate their beliefs and automatic thoughts
Equally or more effective than antidepressants
More effective at preventing relapse
Modified CBT may work for bipolar
Interpersonal therapy




Not as extensively studied or used
Also effective
Focuses on current relationship issues, trying to help person understand and change maladaptive interaction patterns
Modified for bipolar to stabilize daily life
Family and marital therapy


Unipolar—focus on reducing marital discord is effective
Bipolar—focus on reducing ee and increasing coping effective in preventing relapse








Cognitive, interpersonal and biological are all effective.
Elkin et al 1994, 1989—compared the three with a placebo.
Among those who completed tx, sx were almost completely eliminated, compared with 29 % of those on placebo. Drug therapy was faster, but may not prevent relapse as well.
Cognitive and interpersonal are not relapse-proof. As many as 30
% of those who respond to these methods may relapse.
Continuation or maintenance approaches may help.
Behavior therapy alone is not as effective as the other types of tx.
Psychodynamic tx is also less effective.
Combo of meds and therapy is modestly more effective.
ECT acts more quickly than meds, but is equally effective.

Myths about suicide


People who discuss suicide won’t do it
Suicide is committed without warning







Only people of a certain class commit suicide
Religion prevents suicide (devoutness may, though)
People who commit suicide are psychotic
People who use low-lethal means aren’t serious
Thinking about suicide is rare
Improvement in emotional state means decreased risk
All suicidal people want to die







Estimated that 700,000 people each year, 31,000 in the
United States
600,000 unsuccessful attempts in the US each year
11th most common cause of death in the US according to the US National Center for Health Statistics—about
1.3 %of all deaths
Depressed individuals are 50X more likely to commit suicide than nondepressed; 40-60% of those who complete suicide are in a depressive episode or recovery phase
Only half of those who commit suicide are found to have close friends
China—300,000 suicides a year—gender gap—accounts for about 50 % of female suicides around the world







Peak age used to be 25-44. Now it is 18-24.
Four times as many men as women die from it. But women are 3x as likely to attempt and fail.
Highest rate of completed suicides is among the elderly.
Method of suicide varies among genders—males—firearms and hanging. Women—pills
Other high risk groups—schizophrenia, alcoholics, divorced people, people living alone, people from socially disorganized areas, certain professions (highly creative or successful scientists, physicians, psychologists, businessmen, composers, writers, and artists)
Rates in US are about twice as high for whites as for African
Americans and Hispanics, but Native American rate are 1.5 times higher than national average




Children




Rates increasing--up 70% for kids 5-14 since 1981
Increased risk if child has lost parent or been abused.
Absolute numbers are still low (.7 per 100,000 or about 500)
Interviews with school kids find that between 6 and 33 % have thought about suicide.
Adolescents




Suicide is the third leading cause of death
About ½ of all teens have thought of killing themselves
Period of adolescence creates a stressful climate of growth, conflicts, etc. Teens tend to react more sensitively, angrily, dramatically, and impulsively than other age groups.
Rate of attempts to completions may be as high as 200:1
Elderly—rate in US is 19/100,000.




Accounts for 19% of suicides, but 12% of population
Often medically ill
Rate also high among those who have lost a spouse
One in 4 who attempts succeeds.









Depressive disorder and certain other mental disorders
Alcoholism and other forms of substance abuse—as many as 70% drink before the act
Suicide ideation, talk, preparation
Prior suicide attempts
Lethal methods
Isolation, living alone, loss of support
Hopelessness, cognitive rigidity—dichotomous thinking (Suicide was the only thing I could do)
Impulsivity and risk taking









Being an older white male
Modeling, suicide in the family, genetics
Economic or work problems
Marital problems or family pathology
Stress and stressful events— both immediate and longterm
Anger, aggression, irritability
Psychosis
Physical illness—37% in poor health
Repetition or combination of the previous factors




Biological causal factors—


Concordance rates in MZ twins is 19X higher than fraternal twins
Reduced serotonergic activity
Sociocultural factors


Rates vary from one society to another-Lithuania 42, Russia 37,
32/100,000
Japan—suicide long been an acceptable solution to serious problems— death is an appropriate response to shame; death is also freeing oneself from illusion and suffering
Communication of intent




40% communicate intent in clear and specific terms
Additional 30 % had talked about death and dying
50 % had never seen a mental health professional
15-33% leave notes—typically coherent and legible younger people’s notes express more hostility




Emphasis on



Maintenance of supportive contact with person
Helping person realize that distress is impairing judgment
Helping person see that distress is not endless
Goals of person on line (Schneidman & Farberow, 1968)





Establishing a positive relationship
Understanding and clarifying the problem
Assessing suicide potential
Assessing and mobilizing caller’s resources
Formulating a plan
Do prevention programs work?



Only a small percentage of suicidal people call lines
Evidence is mixed for success
But, programs do seem to reduce risk among those who call








Heterogeneous group


Enduring, inflexible patterns of inner experience and behavior
Deviate from cultural expectations and cause distress and impairment.
Must be of long duration, stable
Must lead to clinical distress or impairment in functioning
Must be manifested in at least two areas.
Little evidence about prevalence—perhaps 13% of the pop at some point in life
Axis II—must be considered in all diagnoses
Hard to treat because people don’t see selves as disordered







Criteria are not sharply defined
Dx relies on inferred traits or consistent patterns of beh rather than more objective means
There are self-report inventories and semi-structured interviews, but no good assessment device
Diagnostic reliability and validity is still low
Categories are not mutually exclusive
Difficulties in studying causes





Comorbidity
Little prospective research --almost all is retrospective among people already dx’d
Temperamental characteristics are possible biological factors
Possible psych factors include maladaptive habits and cognitive styles that may originate in disturbed attachment, ineffective parenting, early emo, phys or sexual abuse
Sociocultural factors—social stressors, societal changes, cultural values




Cluster A—odd—paranoid, schizoid, schizotypal—odd or eccentric behaviors that are similar to, but not as extensive as those seen in schizophrenia. Often leave person isolated.
Cluster B—dramatic—antisocial, borderline, histrionic, narcissistic—dramatic, emotional, erratic. Almost impossible to have a satisfying, giving relationship.
More commonly dx’d than others.
Cluster C—anxious—avoidant, dependent, obsessive compulsive pd—anxious and fearful behavior, similar sx to anxiety disorders, but no direct link between these and Axis I





Suspicious of people, frequently angry, hostile, expects to be mistreated and abused.

Thus—secretive, looking for signs of trickery, reluctant to confide; blaming, bear grudges, way jealous, doubts about loyalty and trustworthiness, may read hidden messages \
Prevalence maybe .5-2.5%, males>females
Causal factors—little is known, inconsistent findings on genetic transmission


High concordance between MZ twins
Psychosocial factors are suspected
Treatment of Paranoid PD:



Do not typically see selves as needing help; few come willingly
View role of pt as inferior and distrust/rebel against therapists
Therapy has limited effect and moves slowly



Central symptoms

Inability to form social relationships and an indifference toward developing them.




Demonstrate little emotion
Focus mainly on themselves
Little affected by praise or criticism
Not interested in sex
<1%, males > females



Causal factors



Used to think that this was a precursor to schizophrenia
No evidence of hereditary link
Parents may have been abusive or unaccepting of children

Cognitively—thoughts seem to be vague and empty, unable to pick up emotional cues
Treatment—social withdrawal keeps them from entering therapy



Generally remain emotionally distant from therapist, seem not to care about treatment, and make limited progress at best.
Cognitive therapists—help them focus on pleasurable experiences or think about emotions
Behavioral therapists—teach social skills—role playing, exposure therapy, homework assignments







Extreme introversion
Sensitivity
Eccentricity
Oddities of thought, perception and speech that are similar to schizophrenia (ideas of reference, bodily illusions –such as having extrasensory abilities or being able to sense external forces
3% prevalence
Males>females



Perhaps similar causes to schizophrenia.


High activity of dopamine
Higher rates of this among relatives of those with schizophrenia and those with depression
Therapy is difficult—need to reconnect with the world and recognize limits of thinking and powers. Try to set clear limits. Increase positive social contacts. Ease loneliness.



Cognitive—try to help them see inaccuracy of thoughts
Behavioral methods—speech lessons, social skills training, tips on appropriate dress and manners
Low doses of antipsychotics may have some success












Overly dramatic and attention seeking
Explain emotion extravagantly
Very shallow, self-centered
Overly concerned with physical attractiveness
Uncomfortable when not the center of attention
Believe relationships are more intimate than they are
Inappropriately provocative
Easily influenced by others
Speech vague, lacks details
2-3% prevalence
Males=females or females slightly greater





Psychodynamic

Cold and controlling parents left them feeling unloved and afraid of abandonment; to defend against fear of loss, act provocatively so that they have to be rescued
Cognitive

Less and less interested in knowing about the world because they are so self-focused; must rely on other people or hunches to get direction in life
Sociocultural

Society encourages girls to be vain, dramatic and selfish— histrionic is just this to an extreme degree
Biological

Possible genetic link with APD










Grandiose view of their own uniqueness and abilities
Self-centered is an understatement
Require constant attention and admiration
Believe only high status people will understand them
Lack of empathy
Envious
Arrogant; take advantage of others
<1% prevalence
Males>females (up to 75 % male)




Psychodynamic—cold rejecting parents lead to children spending lives defending against feeling unsatisfied, rejected, unworthy

Support for this—research says that kids who are abused or who lost parents through adoption, divorce, or death are at increased risk
Behavioral and cognitive types say just the opposite— people develop this when they are treated too positively early in life. Admiring doting parents teach them to overvalue self worth.

Support for this—onlies and firstborns are at increased risk.
Sociocultural theorists—link between disorder and eras of narcissism in society.





One of the most difficult patterns to treat

If they seek, it is because of other disorders, generally depression

May try to manipulate therapist into supporting their sense of superiority
Psychodynamic—recognize and work through basic insecurities and defenses
Cognitive—focus on self-centered thinking, try to redirect onto the opinions of others, to interpret criticism more rationally
No approach has had a lot of success



2% females>males (about 3:1)
Males with the disorder tend to be more aggressive, disruptive









Instability in relationships, mood and self-image
Erratic emotions
Argumentative, irritable, sarcastic
Unpredictable, and impulsive behavior—spending sex
No clear sense of self—values, career, loyalty
Intense relationships—stormy and transient
Emptiness
Manipulative attempts at suicide
Paranoid ideation and dissociative symptoms (75% show short or transient psychotic-like symptoms)

This PD affects job performance more than other PDs







High frequency of physical and sexual abuse
Comorbidity with other Axis I disorders

Disorders ranging from mood and anxiety disorders to substance abuse and eating disorders
Comorbidity with other personality disorders, esp. histrionic, dependent, antisocial and schizotypal
Self-destructive—self-injurious or self-mutilation behaviors
Suicidal behaviors—at last 70% of BPD attempt suicide at least once and 6-10% actually commit suicide
Pain to feel alive






Genetic factors play a significant role
Biological


Lowered functioning of serotonin may explain impulsivity and aggression
Disturbances in regulation of noradrenergic transmitters may explain their hypersensitivity to environmental changes
Psychosocial—negative, traumatic childhood events
Diathesis stress model—who are abused are 4x more likely to develop BPD than general pop
Biosocial theory—Marcia Linehan—combination of internal forces and external forces

If children have intrinsic difficulties identifying and controlling emotions and if parents teach them to ignore emotions, children never learn how to recognize and control emotional arousal, how to tolerate distress, when to trust emotional responses.






Psychotherapy can eventually lead to some improvement
Tough balance to strike
Relational psychoanalytic therapy—fairly effective
Dialectical behavior therapy—Marcia
Linehan—an integrative treatment approach— considered by many to be treatment of choice.
Antidepressants, mood stabilizers, antianxiety, and antipsychotics are controversial, but can help reduce aggression and emotionality.





AKA psychopaths or sociopaths
2 components to antisocial pd


Conduct disorder before age 15 and
Antisocial behavior in adulthood—not working consistently, breaking laws, lying, being irritable, physically aggressive, defaulting on debts, being reckless, impulsive, not planning ahead, no regard for truth, no remorse
Psychopathy


Cleckley; Hare--two basic dimensions: affective and interpersonal core and behavioral aspects
DSM diagnosis may omit those who don’t show violence
3-4 % of men, 1% of women





Studied a lot in jails—among urban jails, apd is linked to violent crimes; about 70-80% of prison inmates have apd
For many, criminal behavior declines after 40; behaviors change more than psychopathy
Higher rates of alcoholism and substancerelated disorders
About 50% of kids with ADHD also have CD





Psychodynamic


Absence of parental love during infancy leading to a basic lack of trust—respond to early inadequacies by becoming emotional distant, build relationships through power and destructiveness.
Support—more likely than others to have had significant stress in childhood, particularly poverty, parental conflict, divorce, family violence
Behaviorists


Modeling or imitation—lots of parents with the disorder
Patterson—coercion theory/reinforcement trap
Cognitive view


Trivialize importance of other people’s needs
Genuine difficulty recognizing viewpoint other than their own
Biological factors

Experience less anxiety than others, lower arousal levels—slow EEG waves, slow autonomic arousal






Approximately ¼ of those with APD get tx for it, yet tx is typically ineffective
Major obstacle—lack of conscience and lack of motivation
Most are forced to attend—work, court, family
About 70% leave tx prematurely (Gabbard & Coyne,
1987)
Cognitive-behavioral—increasing self-control, selfcritical thinking, social-perspective taking; victim awareness, anger management, curing drug addiction

Requires a controlled situation; even the best programs have only a modest improvement

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Keenly sensitive to criticism, rejection, disapproval
Reluctant to enter relationships unless they know they’ll be liked
Afraid of being perceived as foolish or being embarrassed by blushing or looking anxious
Believe they are incompetent or inferior
Avoid school and work
Overlap with Dependent PD and BPD
.5-2% prevalence
Males=females
Similar to social phobia; often have both dx

Key difference—social phobics fear social circumstances, avoidant pd fear social relationships





Assumed to be related to the same causes as anxiety disorder, but this has not yet been shown by research
Psychodynamic

Focus mainly on sense of shame; think punishment for early bowel accidents—may develop negative self-image—leads individual to feel unlovable
Cognitive



Harsh criticism and rejection in early childhood lead people to believe that environment will always treat them negatively
Expect rejection; misinterpret the reactions of others to fit that expectation; discount positive feedback; generally fear social involvements
Support—pts recall feelings rejected and isolated; receiving little encouragement from parents; experiencing few displays of parental love or pride
Bio—inhibited temperament

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Come to tx to experience affection and acceptance
Keeping them in tx is a challenge—soon begin to avoid sessions
Key—gaining trust
Treating much as one would treat social phobia has shown modest success
Cognitive—carry on the face of painful emotions; improve self-image; challenge distressing thoughts
Behavioral tx—social skills training; exposure tx
Group tx—practice in social situations
Antianxiety and antidepressants show some success

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Lacks self-confidence and self-reliance
Passively allow spouses/partners to assume responsibility for choice of jobs, housing, even friends
Can’t initiate activities
Agree even when they know it is wrong
Uncomfortable when left alone—even panicky
Unable to make demands on others
Seek new relationships quickly when old ones end
May accept abuse to stay in relationships
Both dependent behavior and attachment problems
2%; either males=females or females>males



Causes




Small genetic influence
Psychodynamic—unresolved oral issues; attachment issues; fear of abandonment
Behaviorists—parents unintentionally reward clinging and loyal behavior, while punishing acts of independence, perhaps through withdrawal of love
Cognitive—two key views: I am inadequate and helpless to deal with the world and I must find a person to provide protection so I can cope.
Treatment—



Modestly helpful
Group therapy can be helpful
Also the usual suspects

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Perfectionist
Preoccupied with details, rules, etc
Never finish projects
Work—not pleasure—oriented
Inflexible regarding moral issues
Hoard money, may be unable to discard worn out and useless stuff
Stubborn, everything must be done today
Difference with OCD—those with OCD typically do not want or like their sx, those with OCPD embrace their symptoms
2-5% (your book says 1%) prevalence
Males>females by about 2:1
Some overlap with narcissistic, antisocial, and schizoid pd



Causes

Dimensional approach—high levels conscientiousness and assertiveness, but low level of compliance


Psychodynamic—anal regressive or retentive
Cognitive—little to say about origin, but illogical thinking keeps it going
Treatment

Not likely to seek tx unless also have anx or depression


Often respond well to cog or dynamic tx
Do not respond well to behavioral or meds








Axis II dx are often unreliable
Personality processes are dimensional
Arbitrary decisions are used to define degree of trait
Dx are not based on mutually exclusive criteria
Need clearer sets of classification rules

Nonoverlapping
Dimensional approach has been proposed, but which is best?
Where is edge between personality and personality disorder?



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



Homosexuality and American Psychiatry
Removed from DSM in 1974

Prior to that was considered a disorder
However, early sexologists such as Magnus Hirschfeld and Havelock Ellis both believed that it was natural
Freud believed that its origins were early and it was unchangeable—nothing to be ashamed of
Kinsey said 10 % (but this is wrong)—more like 2.5%
Homosexuality around the world



Never predominant
Always men>women
Never above 5% or so
Some increased likelihood of stress, anxiety, and depression. More suicidal ideation.




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

Paraphilias
Recurrent, intense sexually arousing fantasies that generally involve nonhuman objects, suffering or humiliating oneself or one’s partner, or nonconsenting people
Compulsive quality
Nearly all male
Usually occur in clusters—over half show more than one
To dx, must be present for 6 months. There are 8 paraphilias, 5 of which we can dx if people act on them, regardless of whether or not the person experiences distress.



Sexual fixation on some object other than another human and attachment of erotic importance to that object



Media—type of material
Form—particular shape
Related—partialism—excessively aroused by a particular body part
Transvestic fetishism







Cross dressing does not equal transvestism—some men dress in drag for other reasons
For the transvestite—sexually arousing
Not typically harmful—typically in private or with consent of partner
Typically operantly conditioned as children—many were dressed as girls; petticoat punishment
Reasons as adults—sexually arousing, relaxing, role playing, adornment
68% are hetero
Most keep it secret, even from partners or wives. When wives find out, most are confused or shocked. Most try to be understanding at first, but later become more negative


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




Become sexually aroused from secretly viewing nudes
Usually begins by age 15. Almost exclusively found in males
Unsuspecting is key—not pornos or strippers
Most are nonviolent, but may be violent if provoked
More dangerous

 those who break in those who draw attention to themselves
Risk is an element of the arousal
Tend to be less sexually experienced, not likely to be married, harbor feelings of inadequacy, lack social skills, less likely to have sisters or female friends


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Sexual arousal from exposing genitals to others in culturally inappropriate situations
Cross-culturally, fewer than 20% are reported to police
1/3 of college women have been victims of this
30% of all arrests for sexual offenses are for flashing
About 10% of rapists and child molesters (in one sample) began as flashers
Urge to exhibit begins in early adolescence., exhibitionism itself usually begins before age 18. Frequency declines after 40
What they are like:

Typically young, unhappily married, timid, unassertive, lacking in social skills, lacking in sexual skills, doubts about own masculinity, suffer from feelings of inadequacy, many report overprotective mothers and poor rel. with fathers
Preferred victims are girls or young women
Indirect means of expressing hostility toward women, but they aren’t in touch with this
About 50% report erections during, usually masturbate later






Few are women—women who do this are typically motivated by rage/revenge
Males—motivated by desire for sexual excitement
Most aren’t dangerous, don’t make repeated calls to the same person
Many patterns—obscenities, breathe heavily, sexual overtures, sex surveys, etc.
Life exhibitionist-socially inadequate heterosexual male who can’t form intimate rel.

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Sexual sadism—sexual arousal from inflicting pain on another person
Sexual masochism—experiencing pain
Masochism is the only paraphilia found with any frequency in women—about 5% of masochists are women
Sadomasochism is highly ritualized—not all pain is gratifying
In a mild form—not uncommon
Pain may be symbolic—like rubber paddle
Serious injury is usually avoided
Survey from S&M magazine—3/4 male, most married, men interested since childhood, women introduced to it
Causes



May have bio links to pleasure—pain causes release of endorphins, but this doesn’t explain symbolic pain or sadism
Learning theorists—being spanked for masturbation
Sociologists—losing control, letting go




Problems—




1) Don’t want/seek tx
2) No motivation to change even if in tx (thus cog tx doesn’t work)
3) Should therapist impose own goals?
4) Perceived responsibility—client must know he can change
Behavior tx




Systematic desensitization—pair relaxation with arousing images
Aversion tx—shock, nausea inducing drugs
Social skills training
Orgasmic reconditioning—begin with old images, then switch to appropriate ones
Drugs


Prozac—some effectiveness for exhibitionism, voyeurism, fetishism (OCD-type beh)
Anti-androgen drugs—depo provera—decreases sexual desire in those at risk for sexual offenses. Decreases desire—not urges or behavior in a particular direction. High refusal and drop out rates for this treatment.


Money (1978)—8 variables of gender

Chromosomal (xx vs. xy)


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
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

Gonadal (testes vs. ovaries)
Prenatal hormonal gender
Prenatal and neonatal brain hormonalization
Internal accessory organs
External genital appearance
Pubertal hormonal gender
Assigned gender identity








1) Persistent cross-gender identification
2) Profound discomfort or disgust with biological sex
In kids



Girls—tomboys
Boys—less interest in rough and tumble play, lower activity levels, more creative, theatrical. More often described as beautiful or feminine babies.
Typically show cross-gender preferences as early as 2 or 3—around that age— boys will seek dolls, may tuck away penis when playing.
Typically ostracized in school.
Transsexualism, also known as transgender—people with GID who do something about it


Male to female 3x as common ; 1/30000 males, 1/100,000 females seek surgery.
Also more effective
Don’t consider selves to be homosexual
Found throughout history
Typically show cross gender preferences in play and dress early in childhood. Many say they have felt this way forever.




There is no clear cause or understanding of this disorder.



Psychotherapy typically fails.
May be influenced by prenatal hormonal imbalances
Also possibility that they are treated inappropriately or ambiguously by parents
Sexual reassignment surgery—long process







Counseling to assure adjustment (ie not someone who is lonely or schizophrenia)
Hormone tx
Real life test—live 1-2 yrs as new gender
Surgery—male—remove genitalia without severing nerves. Then artificial vagina is created with skin of penis. Use device to dilate it for next 6 mos so it doesn’t close. Female—penis and scrotum are created from tissues in genital area. Need implants to stiffen penis.
Largely cosmetic.
Hormones for life.
Outcome—Lundstrom et al (1984)—international literature—90% happy with surgery, positive results.
Less unhappy with life. Those with better looking results have more positive outcome.




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

Links between childhood sexual abuse and many negative outcomes

PTSD, low self-esteem, depression, anxiety, sexual precocity, sexual withdrawal

About 1/3 show no signs
Prevalence—depends on definition, but about 10-12% men and 15-
20% of women
Recovered memories—induction of false memories
Effects are more negative




Ongoing
Penetration
Threat or force
Step or bio father
Most cases—know victim
Boys are more likely to be abused in public and by strangers


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

Brother-sister is most common and not always harmful
Father-daughter is second most common-
Younger daughters—more socially inept, dependent fathers
Older daughters—more authoritarian, angry fathers
Fathers who are actively involved in child care are less likely to abuse
General family disruption—conflict, abuse, alcoholism


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


Recurrent intense sexually arousing fantasies, urges, and behaviors involving sexual activity with a prepubertal child
Nearly all pedophiles are male; 2/3 of victims are girls
Pedophiles are more likely to believe that children benefit from sexual contact
Begins in adolescence and persists over a person’s life
Tend to be shy, introverted, yet still desire to have mastery or control over someone

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
How common?
Definitions vary and way info is gathered varies, leaving wide estimates in how common this is.
Somewhere between 14% and 25% of women in US are raped in their lifetimes. Reported rapes are 20x greater than Japan, 13x greater than GB
Types of rape—





Stranger—4%
Spouse—9% (often a part of other violence in the home, rarely reported, marital rape exemption laws have all been repealed in this country)
Acquaintance—19%
Know well—22%
In love with—46%
Some studies have found rates of 80% by acquaintance or known person—these #s are hard to call because they may not perceive themselves as victims.

Perhaps 5-16% of acquaintance rapes are reported.



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


1) Might not fit her idea of what a real rape is, even though she still feels the trauma
2) Might blame herself or be aware that others will
3) Might not recall incident well because of alcohol or drug use
4) Mistrust of police or legal system
5) Fear reprisals from rapist, his friends or his family
6) Fear publicity



Both.
1970s—big thing about power, but sex seems to be a part of it

Victims tend to be in teens/early 20s


Rapists cite sexual motives
Rapists share similarities with some of the paraphilias

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60% are under 25
Hypersexual peer group
Sexually active, but actually know little about sex
Low SES
Prior criminal record
Accepting of rape myths
Date rapists—tend to be more middle to upper middle class
Poor cognitive appraisal of women (believe women lie)
Poor social and communication skills
Impulsive
Sexually aroused by depictions of rape
May have hx of sexual abuse
Use strength to get what they want





Difficult to treat successfully
Meta-analyses show modest effects
Cognitive-behavioral techniques are most effective
Nonpedophile child molesters and exhibitionists respond better than pedophiles and rapists


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
Repetitive, planned activity rather than a single event
Immediately after—trouble sleeping, crying, fear of being alone, fear of sex, eating problems, headaches, irritability, withdrawn
Distress peaks about 3 wks after, stays high for a month, then begins to decline
Physical trauma combines with psychological factors
(rape trauma syndrome)
PTSD
Negative impact on victim’s intimate relationships
STDs





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
Human sexual response
Masters and Johnson
Vasocongestion
Myotonia
4 stages—Excitement, Plateau, Orgasm, Resolution


Model was missing a cognitive piece—most sex researchers now consider a desire phase
Disorders can occur in desire, excitement, or orgasm or pain
Laumann, Paik, and Rosen (1999)




43% of women and 31% of men (18-59) experience sexual problems for women, problems decrease with age, except problems with lubrication for men, problems with decreased desire and erection increase with age pre and post marital (divorced, separated, widowed) increased risk for problems higher educational attainment is negatively corr. with sex problems for men and women




Lack of desire or interest/aversion to sex, increasing in frequency over past generation
Hypoactive Sexual Desire Disorder—little or no interest in sex, absence of fantasies





More common among women
Hard to define low desire, difficult to treat successfully
Often brought in by other member in couple
Causes
 Bio—testosterone deficiencies, thyroid, diabetes, medication for hypertension, CA, heart, and others
Psych—anxiety, fatigue, lifestyle
Sexual Aversion Disorder—phobia or panic level

May be related to a hx of erectile problems in men; also to rape or sexual abuse




Previously called impotence and frigidity
Male erective disorder—





Situational vs. generalized; primary vs. secondary
Performance anxiety—big cause; also depression, s-e, etc.
10% of men experienced erectile problem in last 12 mos—varies with age
50-80% are due to organic factors—vascular problems, diabetes, spinal cord injury
Exercise, wt loss, lower cholesterol all improve sexual functioning
Female sexual arousal disorder—both subjective arousal and lubrication





19% of women have problems with lubrication often goes with other sexual disorders like HSDD usually situational more commonly has psych causes—anger and resentment toward partner, sexual trauma, anxiety, guilt, ineffective stimulation but physical causes also possible—vascular damage, decreased estrogen




Male orgasmic disorder—cannot have orgasm even when highly aroused and had a great deal of stimulation




8% in last year –not necessarily dx most often is limited to intercourse bio causes-MS or neuro condition, side effect of meds, ETOH abuse also psy causes—hostility, anxiety, guilt
Female orgasmic disorder



24% of women in last 12 mos accts for 25-35% of cases of female sex tx may be related to education, also to spectatoring
Premature ejaculation—hard to define—but too rapid to permit selves or partner to enjoy sex fully.

Def varies--<30 sec, <1min, or no voluntary control



Dyspareunia—painful coitus





14% women, 3% men
In women, most common cause—lack of lubrication
Can also be caused by allergies to spermicides etc., vaginal infections, STDs, PID
Psych causes—guilt, anx, sex trauma
In men—genital infections, smegma
Vaginismus—involuntary contraction of the pelvic muscles that surround outer 1/3 of vaginal barrel.




Intercourse is painful or impossible.
12-17% of women seeking sex tx.
Not conscious.
Not bio based.





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





Always have a physical first!
Poor general health is related to most of these problems.
Alcohol—interplay of expectancy and actual effects
Cocaine—can decrease sexual desire, cause erectile or orgasmic dis.
Vascular problems
Cultural influences—cultures that have more negative attitudes toward sex have more dysfunctions
Ineffective sexual techniques
Irrational beliefs
Performance anxiety
Sexual trauma
Sexual orientation









5 goals





1) change self-defeating beliefs and attitudes
2) teach sexual skills
3) enhance sexual knowledge
4) improve sexual communication
5) reduce performance anxiety
Therapy usually involves both partners
Bio tx also available—viagra
Sensate focusing
Masters and Johnson—pioneered behavioral tx—focus on problem beh, not cause
Cognitive-behavioral tx—teach script flexibility—novelty is good


Need to make sure that relationship out of bed is a good one
Restructure negative thoughts—all or none thinking
Evaluation –success varies by dx—vaginismus 80%; premature ejaculation 90%; HSDD—most difficult to treat successfully
Tx works best when couples are motivated and get along well in other areas





Two types of substance disorders in three classes (alcohol; sedativehypnotics, opioids)
About 9.4 % of US adults meet criteria in a year
Abuse—person uses a drug to the extent that he/she is often intoxicated and fails to meet obligations; no physiological dependence

To dx—1 of




Failure to fulfill major obligations
Exposure to physical dangers such as operating machinery or driving drunk
Legal problems
Persistent social/interpersonal problems
Dependence—aka addiction—physio dependence—tolerance and withdrawal sx



Tolerance—greater and greater to achieve same effect
Withdrawal—cramps, restlessness, even death—both psych and phys
3 of the following to dx







Tolerance
Withdrawal or taking drug to avoid withdrawal
Uses more or more often than intended
Tried and unable to reduce use
Lots of time in obtaining or recovering from substance
Use continues despite phys problems causes or worsened
Activities given up or reduced b/c of use









Course of alcoholism is erratic and fluctuating
Often don’t seek help but appear in hospitals and jails. About
25,000 highway deaths per year—1/2 of total. ½ of all murders.
Losses dues to medical treatment, lost productivity, losses due to death cost society about 200 billion annually
Lower levels of ETOH abuse associated with ---marriage, being older, and higher levels of education
Comorbid with antisocial, mania, other drug use, schizophrenia, panic
Short term effects:
Doesn’t undergo digestion. Instead into small intestine and into blood. Absorption is rapid; removal is slow.

Depressant on CNS—sedation, sleep
Expectancy effects







Commonly:


Decreased sexual inhibition
Lowered sexual performance


Lapses of memory
Hangover
Low levels—stimulate brain cells activating pleasure areas of brain
Higher levels—depress brain functioning inhibiting glutamate—leads to impaired learning, judgment, and self-control
Effects of alcohol vary by drinker depending on tolerance, amt of food in stomach, physical condition, duration of drinking
Physical effects of chronic use:

Cirrhosis in 15-30% of chronic drinkers; 27,000 deaths per year




High caloric content can reduce the consumption of other foods leading to malnutrition
Can cause nutritional deficiencies—interferes with ability to utilize nutrients
Delirium tremens—disorientation, hallucinations, fear, tremors—lasts 3-6 days, death rates have declined due to drugs that help
Korsakoff’s—memory, confabulation
Fetal alcohol syndrome—



Bio—2 keys


1) Ability of addictive drugs to activate areas of the brain that produce intrinsic pleasure and immediate powerful reward
2) Person’s biological makeup including genetic inheritance
Psychosocial causes


Psychological vulnerability
 Emotionally immature; impulsive, aggressive; require an inordinate

 amt of praise; expect a great deal of the world; low frustration tolerance
Stress, tension reduction
Expectations of social success
Family relationship factors
 Presence of an alcoholic father





Acute marital conflict
Lax maternal supervision, inconsistent discipline
Many family moves during early years
Lack of attachment to father
Lack of family cohesiveness







Medications—block the desire to drink or reduce the side effects of withdrawal
Psychological treatments-




Group therapy
Environmental interventions—alleviate aversive life situation
Behavior and cognitive behavior


Aversive conditioning
Skills training for younger drinkers
Self-control training
Controlled drinking—about 15-18% succeed with controlled drinking
AA—dropout rates of about 50%; better than no tx
Outcome studies and issues in treatment




Low rates of success among hard-core substance abusers
Recovery rates of a 70-90% with modern tx and aftercare
Favorable outcomes—motivation to change and a positive relationship with therapist
Drinking Check Up sessions—early stages help
Relapse prevention


Recognize indulgent behaviors
Recognize apparently irrelevant decisions that serve as early warning signals






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

Opium in use for thousands of years
Morphine—powerful sedative and pain reliever—treated with acetic anhydride, you get heroin—more rapid and intense
Commonly smoked, snorted eaten, skin popped or mainlined
Withdrawal occurs after extended use within 8 yrs
Withdrawal—many withdraw without help; others experience runny nose, tearing eyes, perspiration, restlessness, etc
Social effects—centered on obtaining drug; leads to lying, stealing, etc.; disease like AIDS
Three most common reasons cited: pleasure, curiosity, peer pressure
Narcotics subculture
Withdrawal does not reduce craving
Methadone tx—newer bupenorphine—fewer side effects
Similar psych to alcoholism




Cocaine creates 4-6 hr euphoric state




Abuse—acute toxic psychotic sx—visual, auditory, tactile hallucinations
Sleeplessness
Some meds to reduce cravings
Must address feelings of tension and depression
Amphetamines


Used to treat ADHD and for appetite suppression
Effects—psychologically and physically addictive

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Rapid tolerance
High bp, enlarged pupils, unclear/rapid speech, loss of appetite, sweating, confusion, sleeplessness
Withdrawal is physically painless; can be some cramping, nausea, diarrhea; depression may be a sx of abrupt withdrawal

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Effects—calming, induce sleep; excessive use leads to tolerance and dependence but tolerance does not increase the amt needed to cause death
Brain damage and personality deterioration may occur
Middle aged and older persons are susceptible to dependency when used as sleeping pills— silent abusers
Alcohol is often used with the barbiturates
Withdrawal can be dangerous and severe

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LSD and related drugs—hallucinogens
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Chemically-synthesized—discovered in 1938
Ineffective as a psychological tx—thought it would be a model for psychosis
Trips can be pleasant or traumatic
Flashbacks are involuntary recurrences
Ecstasy (MDMA)

Both hallucinogen and stimulant—feel hypersexual and uninhibited
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Originally developed as a diet pill in 1913
Increasingly popular as party drug
Recreational use is associated with impulsivity and poor judgment
Negative psychological and health consequences

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Dried and crushed leaves of the cannabis sativa plant
Until the 1970s, marijuana rarely led to abuse or dependence, but it is now 4x stronger than it used to be, with 4x as much thc— more addictive
Physically dependent—withdrawal includes flu-like sx, restlessness, and irritability
Dangers—can cause panic reactions that last for 3-6 hrs
Can interfere with sensorimotor tasks and cognitive fx— dangerous while driving
Memory problems that persist beyond use, particularly for heavy users
Lung disease—reduces ability to expel air
Lower sperm count, abnormal ovulation
Today, about 6% of hs seniors smoke marijuana daily and fewer than 55% believe that is harmful (Johnston et al, 2005)

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Poisonous alkaloid
Dx—nicotine dependency syndrome or nicotine withdrawal disorder
Higher rates in less educated
Almost ½ of all smokers have quit
Health risks decline 5-10 yrs after cessation
Kills 1000 people a day, 1/6 deaths
Tx of withdrawal—

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 social support groups replace cigarette smoking with safer forms of nicotine self-directed change professional assistance all show about a 25 % success rate higher rates of success among those hospitalized for cancer, cardiovascular or pulmonary disease

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
Schizophrenia is a group of psychotic disorders characterized by major disturbances in thought, emotion and behavior
No one essential symptom
Lifetime prevalence of 1%
Higher risk in some groups—children of schizophrenia, schizophrenia in family, older father
(45+) at birth, people of Afro-Caribbean origins living in UK
Vast majority begin in late adolescence or early adulthood
Prodromal phase—sx not obvious, but deterioration has begun; social withdrawal
Males tend to have an earlier onset and more severe form; perhaps the female hormones are protective

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An excess or a distortion—hallucinations, delusions, bizarre beh.
Disorganized speech: aka formal thought disorder
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Person fails to make sense despite seeming to conform to the semantic and syntactic rules governing verbal communication; aka cognitive slippage, derailment, loosening of associations, incoherence
Clang
Word salad
Perseveration
Neologisms—words that have meanings only to them
May appear long before dx of schizophrenia
Not exclusive to schizophrenia
Delusions—
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From Latin verb ludere—“to play” tricks are played on the mind
Beliefs that the rest of soc would disagree with or view as misinterpreting reality
Not exclusive to schizophrenia
97% in one study of schizophrenia had delusions
Lack insight that beh is odd
Common types…
Delusions of bodily changes

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Hallucinations
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Sensory experience in the absence of any external perceptual stimulus
Auditory are the most common—75% of those with schizophrenia have these
Imaging studies show increased activity in Broca’s area—area of the temporal lobe involved in speech production. Perhaps pts misinterpret their own self-generated inner speech as coming from another source
Types:
 Audible thoughts

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Voices arguing
Voices commenting
Can also be visual, gustatory (food tastes strange), olfactory, tactile (tingling, burning, bugs), somatic (inside body)
Inappropriate affect

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Negative symptoms—absence or deficit
Poverty of speech—alogia
Blunted or flat affect—66% of schizophrenia, but report feeling just as much + and – emotion. Further, display greater skin arousal
Avolition—apathy—particularly common in those who have had schizophrenia for years.
Anhedonia—lack of interest in recreational activities; inability to experience pleasure
Social withdrawal

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Catatonia—may grimace, adopt strange facial expressions or bodily positions.

May exhibit increase in activity or catatonic immobility


Unusual postures are adopted and maintained for long periods.
Waxy flexibility.

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Delusions of persecution and grandeur are common
Ideas of reference—unimportant or trivial events have personal significant
The “paranoid constitution” gives some sense of purpose and integrity
Tend to function at a higher level and have more intact cognitive skills
Prognosis generally better (in the west)
More common style in the west—less common in less developed countries

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Diffuse symptoms
Hallucinations and delusions—sex, hypochondriacal, religious, persecutory
Incoherent speech
Frequently deteriorates to the point of incontinence
Earlier, more gradual onset
Pattern of severe disorganization progressing into emotional indifference and infantile behavior
Prognosis is poor

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Alternate between catatonic immobility and wild excitement, though one may be predominant— pronounced symptoms are apparent
Can be violent
Echolalia or echopraxia (mimic actions)
Negativistic—resist instructions
Onset pretty sudden comparatively
May recall actions of stupor later on
Used to be a more common subtype, now less so here; still more common in less industrialized areas
Stupor has been interpreted as way of coping or maintaining control

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Undifferentiated—

Wastebasket category

May be in acute, early stages
Residual type

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Suffered at least one episode of schizophrenia, but not currently exhibiting any prominent positive or disorganized symptoms
Prominent symptoms are negative

Social withdrawal, impaired role functioning, blunted or inappropriate affect, lack of initiative, vague and circumstantial speech, impaired hygiene or grooming, odd beliefs or magical thinking

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Schizoaffective disorder

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Features of schizophrenia and a mood disorder (either bipolar or unipolar)
Prognosis better than for schizophrenia alone
Schizophreniform-
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Schizophrenia-like psychoses that last at least one month, but not as long as 6 months
Most often seen in an undifferentiated form
May or may not be related to subsequent psychiatric disorder
Prognosis better than for schizophrenia
Delusional disorder

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Other than delusions, behave normally
Generally nonbizarre (could happen but aren’t)

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Brief psychotic disorder

Sudden onset of psychotic, grossly disorganized, or catatonic sx


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Often lasts only days; less than a month
Often triggered by stress
Returns to normal functioning
Shared psychotic disorder (folie a deux)

Dx when individual in a close relationship with a psychotic individual begins to believe same delusions

May spread to an entire family

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Concordance rates: General pop 1%

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Spouse
First cousin
Grandchild
Kids
Siblings
DZ
MZ
2%
2%
5%
6-9%
9%
12-17%
44-48%
Studies of discordant MZ twins show that children of the well twin are at a significantly higher risk of developing schizophrenia
(17% or so)
Twin studies overestimate importance of genes because of shared environment. Adopted kids or schizophrenia parents—still at higher risk
Multiple gene disorder—regions on chromosomes 22, 7, 8, and 1
Currently looking for candidate genes—genes known to be involved in some of the processes that are known to be problematic in schizophrenia

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Prenatal viral exposures—in Northern hemisphere, more are born in spring

1957 flu epidemic in Finland—elevated rates of schizophrenia in children whose mothers had been in their second trimester
Rhesus incompatibility


Increased risk—for males, about 2.1%
Mechanism may involve oxygen deprivation
Prenatal birth complications
Early nutritional deficiency

Dutch hunger winter—conceived at ht of famine—2x increase in risk

Unclear if this is general hunger or a specific nutrient

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Brain volume—larger ventricles—3% reduction in brain volume

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Males more affected than females
Not specific to schizophrenia
Cortical tissue loss increases over time
Specific brain areas

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Problems in frontal and temporal lobes as well as neighboring (medial temporal) areas such as hippocampus and thalamus
Not specific to schizophrenia, not shown in all schizophrenia
Abnormally low frontal lobe activity associated with negative sx
Neurochemistry

Dopamine hypothesis
 Pharmacological action of Thorazine

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Amphetamine induced psychosis
Drugs increasing dopamine may create psychotic sx
Dysregulated dopamine may create aberrant salience (pay more attn to stimuli that are not relevant or important)


But no strong evidence that pts with dopamine are producing more dopamine than controls
Focus is on receptor sensitivity

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Social class—more schizophrenia in lowest class

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Why? Poor tx from others, poor ed, no opportunity
Or social selection theory (most, not all variance, by this)
Urban environment—2.7x risk
Family—expressed emotion (critical, hostile, and overinvolved) increases relapse
No evidence for schizophrogenic mother
Immigration—migrants are at 2.7x risk


Black skin migrant have higher risk than migrant with white skin
Appears to be related to stress and discrimination

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Clinical outcome

15-25 yrs after developing schizophrenia, about 38% have a favorable outcome, but this does not mean a return to premorbid functioning

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16% recover to point that they no longer need tx
12% need long term institutionalization
1/3 show signs of continued negative sx
Spontaneous improvements late in life sometimes occur

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First generation—thorazine, haldol—neuroleptics



Block action of dopamine by blocking D2 receptors
Work best for + symptoms
Side effects—drowsiness, dry mouth, wt gain, tardive dyskinesia, extrapyramidal side effects( involuntary movements, such as shaking or rigidity)
Second generation

Clozaril, Risperdal, Seroquel, Geodon, Abilify

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Fewer extrapyramidal side effects
Decrease in both + and – sx
Block a wider array of receptors, including D4
Side effects include drowsiness, drooling, wt gain, diabetes, agrunulocytosis (drop in white blood cells)

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Family therapy
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Goal to reduce EE
Involves education, coping, problem solving, communication
Case management
Social skills training
Cognitive-behavioral—goal is to decrease intensity of + sx, reduce relapse, decrease social disability. Results promising. Think A Beautiful Mind
Individual treatment

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Psychodynamic can make some pts worse
Coping skills tx is effective in enhancing social adjustment

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Ageism
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80% of the elderly report having experienced ageism, such as people assuming they have memory or physical impairments due to age
31% report being ignored or not taken seriously because of their age
58% report being told jokes that make fun of older persons (Palmore,
2005, 2004, 2001)
Positive ageism—emphasize that there are no disadvantages to growing old.
Elderly are a growing population:


1900
2000
4% were over 65
13%

2040 21-25%--baby boomers
Number of people over 80 will double in the next 10 years—fastest growing segment of the population

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Three groups
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Young old 65-74
Old-old 75-84
Oldest old 85 and up
Over 95: more clear-headed, agile, and healthy than those in their
80s and early 90s.
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Many of these are sexually active, working, enjoying the outdoors and the arts.
Resistant to disabling and terminal infections.
People themselves credit good frame of mind and healthy regular behaviors (diet and exercise, not smoking)
Age effects—consequences of being a given age
Cohort effects—consequences of being born at a particular time
Time of measurement—events at a particular point in time affect research, too
People often blame age for the problems of the old, but 10-20% have psych problems

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Depression in later life
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Overall as many as 20% of people experience depression in old age—highest rates in older women
Some studies indicate that depression decreases with age
Depression increases risk of developing significant medical problems
Also risk of secondary depression—30% of those with chronic health problems are depressed
Increased risk for suicide—even more than among the young 19/100,000
(compared to 12/100,000 for other adults). Among white men over 85 it is
65/100,000
Risk factors for suicide: physical illness, hopelessness, social isolation, loss of loved one
Depression may be confused with cognitive problems—those who are depressed complain more of memory problems than the demented do. Tend to underestimate their abilities. Make more errors of omission
Treatment does work
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Antidepressants—side effects—drugs break down differently later in life
ECT—back in favor
Cognitive tx
Interpersonal tx

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Insomnia is more common among older than younger people
At least 40% of those over 65 experience some measure of insomnia
Prone to this because of medical ailments, pain
,medications, depression, anxiety
Also normal physical changes—as we age, we spend less time in deep and REM sleep; sleep is more readily interrupted, we have trouble falling back asleep
Maybe 10% of elderly have sleep apnea

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At any given time 6% of elderly men and 11% of elderly women (Fisher et al 2001)
GAD is particularly common—up to 7% of all elderly
Prevalence increases with age—higher among those over 85
May be related to declining health—see higher rates in those with medical problems
Have not been able to identify why some get anxious and others stay generally calm
Treated with cognitive tx, benzos, prozac—just like younger people, but side effects are a risk

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Prevalence of such patterns declines after 60—perhaps declining health or reduced financial status.
Accurate abuse data are hard to come by
4-7% of older people, particularly men—alcohol related disorders in a given year
Men under 30 are 4X as likely to exhibit a behavioral problem assoc with alcohol
Higher rates in those who are institutionalized in general medical and psych hospitals among the elderly—estimates range 15-49%
Among those who begin drinking in old age—reaction to negative events, pressures of growing older such as living alone, unwanted retirement, death of a spouse
Prescription drugs are another issue
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Elderly make up 13% of the population, but consume ¼ of prescription drugs
Risk of confusing medications, missing doses is high
Overprescription is also a problem

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Psychosis is often associated with delirium or dementia
Schizophrenia actually decreases a bit— symptoms tend to diminish some with age
Delusional disorder which typically has a prevalence of about 3/100,000—increases in the elderly

Unclear about why this increase is there— researchers guess that it is related to deficiencies in hearing, social isolation, greater stress, or heightened poverty

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Brain impairment in adults
For the most part, cell bodies and neural pathways do not regenerate
Impairment may involved acquired and customary skills or anosognosia—capacity or realistic self-appraisal
Impairment depends on
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Nature, location, and extent of neural damage
Premorbid competence and personality of the individual
Individual’s life situation
Amount of time since the first appearance of the condition
Diffuse vs. focal damage


Mild to moderate diffuse damage—may impair attention; would see this type of damage with oxygen deprivation or ingestion of toxic substance like mercury
Person may complain of memory problems due to difficulty focusing


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Focal damage is to a specific region—defined trauma, stroke

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Frontal lobes—one of two patterns:

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1) behavioral inertia, apathy
2) impulsivity, distractibility
Right parietal lobe—visual-motor coordination
Temporal lobe—memory, eating, sexuality, emotions (depending on part)
Left parietal lobe—language, writing, reading, arithmetic
Problems we see with brain disorders
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Impairment of memory; including confabulation
Impairment of orientation (unable to locate self in time or space)
Impairment of learning, comprehension, and judgment
Impairment of emotional control or modulation
Apathy or emotional blunting
Impairment in the initiation of behavior
Impairment of controls over matters of propriety and ethical conduct
Impairment of receptive and expressive language
Impaired visuospatial ability

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Affects 2 million in US each year
Often misdiagnosed
More common in kids and older adults
When elderly enter hospital for general medical condition, 1/10 shows symptoms of delirium. Another 10% will develop delirium in hospital.
But—studies show that admission docs detect only about 1/15 cases of delirium (Cameron et al 1987)
Acute confusional state with sudden onset, fluctuating state of awareness

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Cognitive changes like impaired informational processing
Disturbances of the sleep cycle—worse at night—vivid dreams
May slur
Make perceptual errors—unfamiliar for familiar
Paranoid delusions in 40-70%
Swings in activity and mood
May be fever, flushed face, dilated pupils, increased heart and bp
Do have lucid intervals—fluctuation is key for diagnosis
Mortality is high—up to 40% die
In elderly, people often assume that state can’t be fixed and so don’t look into it
May be superimposed on another diagnosis

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Drug intoxication (including prescriptions)
Infections
Fever
Malnutrition
Head trauma
Pneumonia
Congestive heart failure
Cancer
Uremia
Dehydration
Stroke
Treatment: medical emergency

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Usually reversible
May involve medications (neuroleptics or benzos for drug withdrawal)
May involve environmental manipulations such as orienting techniques

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Senility
Gradual deterioration of intellectual abilities to the point that social and occupational functioning are impaired.
Onset is typically gradual
Memory for recent events is affected in early stages.
With time, increasingly marked comprehension, motor control, problem solving and judgment
Often accompanied by impairment in emotional control or moral or ethical sensibilities
Dementia may be progressive or static
Occasionally reversible if underlying cause can be treated
Causes: stroke, degenerative diseases (Alzheimer’s, Huntington’s,
Parkinson’s), infectious diseases (syphilis, meningitis, AIDS), intracranial tumors and abscesses, dietary deficiencies (B vitamins), head injury, anoxia, toxic substances
30 % of those over 80
3-9% of world’s adults
5 million Americans
70 forms identified


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


Most common form of dementia. Accounts for
50-66% of all cases.
Sometimes occurs in middle age (called early onset), but most often after age 65 (late onset).
Prevalence markedly increases in late 70s and early 80s.
Problem may be underestimated.
Women have a slightly higher risk.
May survive for 20 years, but time between onset and death is usually 8-10 years.

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
Begins with mild memory problems, lapses of attention, difficulties in language and communication.
As symptoms worsen, difficulty completing complicated tasks.
Eventually, sufferers have difficulty with simple tasks, distant memories are forgotten, changes in personality are very noticeable.
Typically early on deny they have a problem. Then become anxious or depressed about state of mind. Many become agitated.
As sx worsen, show less and less awareness of limitations.
During late stages, may withdraw. Also late stage—wandering, confused about time and space.
Eventually fully dependent. Fail to remember close relatives.
Uncomfortable at night (sundowners). Late phase may last 2-5 yrs.
Stay physically healthy until later stages of disease. Often succumb to opportunistic infections—spend a lot of time lying— prone to pneumonia.
Can only be officially diagnosed after death



Marked by neurofibrillary tangles


Twisted protein fibers found within the cells of the hippocampus and other areas.
Occur in all people as they age, but Alzheimer's patients have lots
Senile plaques

Sphere-shaped deposits of a small molecule called betaamyloid protein that form in the spaces between cells in the hippocampus, cerebral cortex, and other areas.


Normal part of aging, Alzheimer's patients have lots. In most people, these are comprised of 40 amino acids with a few that have 42. In Alzheimer's, there are many more AB42s.
Plaques may interfere with communication between cells and so cause cell breakdown or cell death.

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Genetics
Many, but not all cases, run in families.

Distinguish between familial vs. sporadic Alzheimer's
Early onset—three rare genetic mutations that can cause this (about 5% of cases)—on chromosomes 21, 14,
1
Late onset—chromosome 19
MZ twins are not perfectly concordant.
Genetic risks interact with environment—diet, exposure to metals such as aluminum, experiencing head trauma
Exposure to ibuprofen may be protective


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No effective treatment exists
Medications such as Cognex and Aricept and Namenda help delay
Work on vaccines continues
Behavioral techniques to control wandering, incontinence, inappropriate sexual behaviors, and poor self-care
Treating caregivers—social death of the patient; anticipatory grief

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Caregivers are at risk for depression
Counseling and support are effective
About 70% live at home
¾ of caregivers are women
Caring for a loved one takes an average of 69-100 hours per week
Major worries of caregiver—54% -cost of help, 49%-Alzheimer's related stress on family, 49%-lack of time to attend to own needs;
Alzheimer's Assoc, 1997, Thomas et al 2002


Vascular dementia—multi-infarct dementia

Similar clinical picture to Alzheimer's






Series of infarcts destroy neurons over expanding brain regions
After 50; more common in men
About 19% of all dementia cases
Vulnerable to death from stroke
Mood disorders more common than in AD
Can manage cerebral arteriosclerosis to some extent



Creutzfeld-Jakob Disease—slow acting virus that may live in the body for years; then rapid course
Dementia from HIV-1 infection


HIV can result in destruction of brain cells
May lead to psychotic phenomena


Damage may occur throughout brain, but tends to be localized in subcortical regions
30-60% of untreated pts with HIV will develop
AIDS-related dementia; with current antiviral tx, rate reduces to 20%


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
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

Central feature is strikingly disturbed memory or amnesia
Immediate recall and memory for remote events is usually preserved
Short term memory is typically very impaired
Confabulation is common
Overall cognitive functioning is relatively intact
Korsakoff’s Syndrome—follows severe alcohol abuse


May also be caused by head trauma, stroke, surgery in the temporal lobe, hypoxia
Depending on cause, may abate wholly or partially

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
Affects more than 2 million per year
Most common cause—MVA, followed by falls, assaults, sports injuries
Men 15-24 are at greatest risk
Three types of head injury—closed, penetrating, skull fractures
Immediate acute reactions—unconscious, disruption of circulatory, metabolic, and neurotransmitter regulation
Retrograde and anterograde amnesia are common
Person typically passes through stupor and confusion on way to recovering clear consciousness
Coma may occur
Treatment—prompt medical attention is required



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Mild concussions improve quickly
Minority—personality change
Severe injury—poor prognosis
24% of TBI develop post-traumatic epilepsy, presumably because of the growth of scar tissue


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
Take a developmental perspective



Tasks a child should be handling and see how they’re doing
All of this is culturally related.
Often an attempt to adapt to negative circumstances.
Issues in working with children:




1) Limited capacity to understand in children
2) More difficulty coping as cannot put problems into perspective of a past and future
3) Use unrealistic concepts to explain things (don’t understand death, etc)
4) Dependent on others for help
Adultomorphism
1/5 children has a disorder that disrupts functioning. 1/10 has a disorder that severely impairs functioning.
Loosely categorized into externalizing and internalizing.


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
Inattention—doesn’t pay attention/makes careless mistakes


Doesn’t listen when spoken to
Doesn’t follow through on instructions


Difficulty getting organized
Avoids things that require concentration
Hyperactive




Fidgets
Can’t stay seated
Runs or climbs excessively/inappropriately
Can’t play quietly

On the go/driven by a motor
Girls tend to have PI, boys PH or C; 2-3X more common in boys (not 6-9x as text says)
Other issues: 7-15 points lower IQ



Social problems
Emotional competence
Those with PI are more likely to have internalizing problems, LD, slow pace of problem solving
Prevalence is 3-5% of school aged kids
50-70% continue to have problems into adolescence and adulthood; less hyperactivity with age
Poorer prognosis when comorbid with CD
As adults—more car accidents, higher risk of substance abuse

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Causes: Multiple biological and psychological causes.
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Frontal lobe deficits
Runs in families
Mothers report more stress; negative parenting
Not caused by diet, additives
Treatments: 70-80% on stimulants improve
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Side effects: decreased appetite, insomnia, abdominal pain, headaches, crying spells, stunts growth—drug holidays. Don’t improve social skills or academics.
Behavior modification
Combination most effective
Social skills training, cognitive-behavioral effective after sx under control

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Typically kids 3-7
Poor control of emotions
Noncompliant
Argumentative with parents and teachers
Conflicts with peers
Tantrums
Problem with ODD: some sx are very common
Majority of kids with ODD will go on to show conduct problems.
Risk factors: family discord, low SES, antisocial beh. in parents

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More serious behavior problems
Repetitive, persistent problems with behaviors that are potentially harmful to child, others, or property
Sx—physical fights, weapons, stealing with or without confrontation, fires, sexual aggression, truancy, lying, running away overnight, breaking into house, bldg or car, bullying, cruelty to animals or people
Demographics vary greatly. More common in boys. Boys have more aggressive subtypes. Girls tend toward less confrontational sx.
Prognosis factors
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Childhood onset vs. adolescence-limited
Degree of callous-unemotional traits
Big three sx: fires, cruelty to animals, cruelty to people
Socialized vs. unsocialized
Early onset is linked to APD (25-40%)
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Even if not APD, often associated with life problems such as divorce, joblessness, and abusive parenting

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Biological
Danish adoption study—parent history of criminality and % of kids convicted of conduct offense
Bio
Adop yes
No
Yes
25
No
14
20 13
Generally lower levels of adrenaline—low arousal
Psychosocial causes—
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Gerald Patterson—coercive cycles—kid is obnoxious until parent relents; parents engage in negative parenting
Parents of CD kids more likely to behave in ways that encourage development of coercive styles; criticize more, issue more commands
Adverse environmental factors make it harder to use positive child rearing skills—substance abuse, marital distress, violence, poverty, social isolation, death of a family member
Self-perpetuating—deviancy training
Difficult temperament leads to poor attachment
Hostile attribution bias

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Society picks punitive rather than treatment based approaches but…
Must be multimodal
Need to address family issues
Behavioral programs
All most effective at young ages

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SAD—characterized by worry that caregiver will get hurt/child hurt if not with caregiver
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Normal in young kids—not a disorder until past normal period, generally 6-9
School avoidance present in ¾
Often have specific phobias as well
May be acute onset following big life changes; may wax and wane
More common in girls
Generalized Anxiety Disorder
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Pervasive diffuse worry
95% worry all the time
½ meet MDD criteria
Seems to be chronic

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Selective mutism—
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Persistent failure to speak in specific social situations
Can speak and understand language
Rare, most common at school entry
More common in families where taciturn behavior is prominent
Stress and family environmental factors
Phobias—simple—consider in context of kids’ normal fears
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Fears can be adaptive, but can become phobias
 Unusual age of onset
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Intensity
Persistence of fear
 Type of fear—rational or not
Morris and Kratchowill (1989)
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Toddlers—separation, animals, dark
Preschool—strangers, bodily harm, toddler fears
School age-being alone, imaginary beings, violence, death, dark, injury, storms, teasing
Teens—peer rejection, achievement, family problems, war, poverty,
AIDS

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Causal factors in anxiety disorders:
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Modeling of anxious parents
Indifferent or detached parent may instill insecurity
Temperament
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Cultural factors
Genetic link—anxiety in parents predicts anxiety in kids
Treatment:
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Meds—common, not yet well established. Possibly prozac
Behavior therapy—focused on assertiveness training and desensitization
Cognitive-behavioral tx

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Adult criteria are used, but there are limitations in this
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Kids are less adept at expressing the cognitive symptoms
Childhood depression is not factor analytically distinct from anxiety
Ability to feel and express shame and guilt does not emerge until age 7 or so
Many more somatic complaints in kids
Social withdrawal is common, but this looks different in children—not able to choose to stay home
Irritability is common instead of overtly depressed mood
Hallucinations are more common in children than adults
Wt. issues may be failure to make expected gains instead of wt. loss
Younger kids—depression is more common in boys or equal in boys and girls
By adolescence—more common in girls
Prevalence==.4-2.5% in children, 4-8.3% for adolescents

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Causal factors
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Genetic component –higher risk if parent is depressed
Early exposure to traumatic events, including death of a parent
Parent-child interaction in transmission of depressed affect
Cognitive—global, internal, stable
Treatments—
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Antidepressants are not well established. Some studies show no effect, others show a moderate effect. Concern about side effects and suicidal thoughts.
Suicide appraisal is important—longitudinal study of 8-13 yo who were depressed found that 1/3 made suicide attempts in the next 7 yrs.
 Perhaps 7%-1/10 of all teens make a suicide attempt
Cognitive behavioral techniques are effective

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75 outcome studies
Average outcome for a treated child was 2/3 of an SD better than untreated kids
Beh>nonbeh
Play or non-play did not matter
Parents or no parents did not matter
Experience, education and sex of therapist did not matter
Greatest improvements for specific problems, global issues like self-esteem and social adjustment improved less

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Group of severely disabling conditions
Result of structural differences in the brain
Examples include Asperger’s and Autism
Prevalence unclear, but increasing, maybe 3.2% of clinic cases

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Three primary features: noncommunicative speech, social isolation, need for sameness
Appears as early as 1 yr to 18 months when kid are not making eye contact
Social deficit-do not want physical contact, do not show affection
Self-stimulation—stereotyped movements
Panic if routine is changed
Intellectual ability—have thought that most have IQs in MR range.
New studies questions whether this is so or whether it is an artifact of testing.
Theory of mind deficits
Less time in symbolic play
Not the same as schizophrenia
4x more common in boys
About 5% of autistics are savants—isolated skills of great talent with no known cause or training

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Not caused parents actions (refrigerator mothers—retreat in autistic fortress)
Not caused by vaccines. Multiple big studies.
Precise cause is unknown.
Based on twin studies, 80-90% is based on genetic factors.
Fragile X in 8% of autistic males.
Increased frequency of pre and perinatal complications
Many brain abnormalities

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Poor prognosis
No medications—
Behavioral tx work best
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Eliminate self-injurious behavior
Social skills training
Development of language skills
Hard to find reinforcers
Don’t like change
Self-stimulation interferes with teaching
Difficulty generalizing learning
Lovaas—highly positive results
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Intensive, in home
47% achieved normal intellectual functioning

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Disorders of receptive and expressive language and reading, writing, mathematics
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Two groups are highly comorbid
All are more common in boys
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Look for discrepancy between expected and actual achievement
Reading disorder
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Word recognition, reading comprehension
Typically spelling too
Difficulty with oral reading—either omit or add
Phonological awareness!
2-8% of kids (5% sounds about right)
Mathematics disorder
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Difficulty with variety of skills including coding written problems into math symbols; perceptual organization skills like recognizing symbols
Less common than reading, maybe 1% of kids
Written expression
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Impairment of ability to write words, spelling, grammar, punctuation, ,handwriting
Write less complex and less interesting essays
<1% of kids
Less research on this

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Receptive-expressive language disorder
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Trouble producing and understanding spoken language
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Those with receptive may appear deaf
Phonological disorder
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Able to comprehend and use substantial vocabulary, but actual sounds are disturbed.
Later acquired speech sounds are more difficult—r, sh, th, f, z, l, ch, j
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May need speech therapy
May recover

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Causes
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Genetically influenced
Neurological deficits
Treatment
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Instruction on listening, speaking, reading, and writing skills in a logical, sequential manner.
Hands on instruction.
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Time in seat on task. Not discovery-based.
Long term
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Some deficits continue to adulthood.
Lower occupational attainment than would be expected.
Cover for deficits by listening to news instead of reading, etc.

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Significantly subaverage intellectual functioning
Deficits in adaptive functioning
Occurring prior to age 18
Intelligence testing—2 sds below
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About 2.5% of population in theory, 5% in practice
Adaptive functioning
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Problem—what is adaptive in some places isn’t in others
Time of onset—can’t occur from an accident later in life
Dx often in infancy or before birth
Mild cases most often dx’d in school—no obvious phys or neuro manifestations
Only about 25% have known organic cause.
Most mild cases have no known cause

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Mild—50/55 to 70 AKA EMI
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85% of ID pop
By late teens can learn to about 6th grade level
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Unskilled jobs or sheltered workshops
May marry, have kids
Often no brain pathology, just kids with parents with low SES, low IQ
Moderate—35/40 to 50/55 AKA TMI
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10% of ID pop
May have phys defects that hinder fine motor skills (pencils) and gross motor (running, climbing) skills
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Learn to about 2nd grade level
Learn some self-care skills
Partial independent living—group homes
Severe—20/25 to 35/40
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3-4% of ID pop
Limited sensorimotor control. Some congenital physical abnormalities
May be friendly, but can communicate only at a concrete level
Profound—IQ below 20/25
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1-2% of ID pop
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Require total supervision and often nursing care
High mortality in childhood
Can improve skills with training

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All ID have deficits to some degree in
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Communication
Academics
Sensorimotor skills
Self-help
Vocational skills
Etiology
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Lack of exposure to reading materials; poor parenting
Down syndrome (1/1000 births). Most < 50.
PKU 1/14000
FAS
Infectious diseases (German measles, syphilis) prenatally
Prematurity
Malnutrition
Accidents
Radiation in pregnancy
Lead poisoning
Anoxia

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Treatment
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Families are satisfied with choice of institutionalization or not
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Community-oriented care has positives for adolescents
Mainstreaming vs. self-contained---
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Children do well in mainstreaming—modest gains in social skills
No particular academic advantage (except for mild MR who may not have rec’d enough attn in self-contained room)
Other children are not harmed by ID kids in room

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Child’s inability to seek assistance
Parental consent is needed except for mature/emancipated minors, emergencies, court order
Risk factors for kids
Need to address family issues
Placement issues
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Juvenile detention
Boot camps
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Deviancy training