Mental Health Issues on Campus
Today
David Mays, MD PhD
dvmays@wisc.edu
“If the human brain were so
simple that we could
understand it, we would be so
simple that we couldn’t.”
Emerson Pugh
The Current Model
• Mental Disorders are disorders of brain circuits
caused by developmental processes shaped
through a complex interplay of genetics and
experience.
• The onset of mental disorders is almost entirely
before the age of 25.
• Medications, cognitive behavioral therapy, and
other interventions appear to affect different
parts of the brain circuitry involved in mental
disorders.
Complex Genetic Risk Plus Experiential
Factors
• The genetics of mental illness are
characterized by very rare, but potent
variations.
• These rare variations result in changes in brain
circuitry that, in complex interactions with
environmental influences, result in many
pathways to phenotypes of mental illness.
Plan for this morning…
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Substance Use
Anxiety disorders
Depression
Attention Deficit
Bipolar Disorder
Schizophrenia
Borderline Personality Disorder
The Range of Substance Use
• Use (a cocktail every evening)
• Misuse (getting high)
• Risky use (adolescent use, bingeing, use while
pregnant)
• Problem use (driving while intoxicated)
• Abuse (heavy use interferes with quality of life)
• Addiction (loss of control, brain changes)
• Disability
• Death
Addiction
• From a biological perspective, addiction is
characterized by
– 1) uncontrollable, usually compulsive drug seeking
and drug use, in spite of severe aversive
consequences
– 2) preoccupation with the drug, enhanced cue
responsiveness
– 3) the experience of craving, often for years or
decades after abstinence has been obtained.
Variance of Risk
Environmental Factors
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Availability
Social norms (smoking bans)
Legal consequences
Peer pressure
Parents – use, attitudes, rules
SIBLINGS!
Gender Issues
• Men are twice as likely to meet criteria for any
drug use disorder over a lifetime (13.8% vs.
7.1%.) the 12-month prevalence rates of alcohol
abuse are 3 times higher in men (6.9% vs. 2.6%.)
By contrast, prescription drug abuse occurs at the
same rate among men and women. Women are
more likely to have comorbid anxiety, depression,
eating disorders, and borderline personality
disorder. Men are more likely to have antisocial
personality disorder.
Kinds of Alcohol Dependence
• Age-limited heavy drinking: 30% of people with
alcohol dependence are symptomatic between
the ages of 18-25. The problems are usually gone
by 25 to 30 years old. They seldom seek help.
• Variable onset: 40% have an average age of onset
of about 35, but this is highly variable. The
symptoms are relatively moderate and it usually
resolves without intervention.
• Familial/ Early onset: 30% with onset in the mid
teens have a strong family history, chronicity and
recurrence. 10-12% of these end up in rehab.
Can We Recover?
• Several long-term studies have shown that
years of abstaining can allow brain regions to
return to their normal size, and some neural
connections can be repaired.
• Some reports have found sustained injury to
certain areas, especially to the hippocampus
(memory) and white matter lesions.
Brain Susceptibility
• The teen brain is more susceptible to damage
than the adult brain for developmental reasons.
There is more impairment of memory than in
adults, more cognitive impairment, longer term
brain damage.
• Kids don’t drink like adults.
– They drink exclusively to get drunk.
– Binge drinking is the norm, not the exception.
– They experience more bad outcomes – accidents,
drownings, pregnancies, STD’s, depression, anxiety
Opioid Analgesics
• As of 2007, 35 million Americans (14% of the
population) reported having abused opioid
analgesics.
• In this same year, prescription opioids surpassed
marijuana as the most common gateway to illicit
drug abuse among adolescents, with 9,000
Americans becoming new opioid users each day.
• Wisconsin leads most other states in rates of nonmedical use of pain relievers in persons aged 1217. (>9% of kids 14-15, >16% kids 16-17)
How Did This Happen?
• In the 1990’s, physicians began to be criticized for
undertreating pain syndromes. As a result, opioid
prescriptions increased. Addiction risk was
underestimated.
• Multiple providers prescribed opioids without
coordinating services.
• Patients were routinely given a 2-week supply.
Sometimes with multiple refills. Patients used
them for a few days, then kept the rest in their
medicine cabinet, where family members had
access to them.
Reasons Young People Choose
Prescription Medications
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Easy to get from parents’ medicine cabinet 62%
Are available everywhere
52%
They are not illegal drugs
51%
They are cheap
43%
They are safer than illegal drugs
35%
Less shame attached to using
33%
Fewer side effects than other illegal drugs 32%
Parents don’t care as much if you get caught 21%
Sources of Painkillers (SAMHSA 2009)
LOCK UP YOUR MEDS!
Universal Prevention
• Increased consumption in a locality is associated
with increased rates of alcohol related problems
in that area.
• Price increases via taxation can reduce cirrhosis,
mortality, and automobile fatalities.
• Availability can be controlled by restricting time
of sales, restricting what kind of stores can sell
alcohol, and locations of stores.
• The lower the age for legal drinking, the higher
rate of consumption and related problems.
Alcohol Screens
• “How much?” and “How often?” are usually not
very helpful questions. A better focus is on the
impact that drinking has on the client.
• CAGE (Cut down, Annoyed, Guilt, Eye-opener)
• AUDIT (Alcohol Use Disorders Identification Test)
• AUDIT-C
• Questionnaires are better than laboratory tests,
but both together are very effective.
– GGT, AST, ALT, MCV, CDT
Alcohol Use Disorders Identification
Test (AUDIT)
• How often do you have a drink containing
alcohol?
• How many drinks do you have on a typical day
you are drinking?
• How often do you have 6 or more drinks on one
occasion?
• How often during the last year have you been
unable to stop once you have started drinking?
• How often during the last year have you needed a
drink in the morning to get yourself started after
a night of heavy drinking?
Alcohol Use Disorders Identification
Test (AUDIT)
• How often in the last year have you
experienced guilt or remorse after drinking?
• How often during the last year have you been
unable to remember what happened the night
before because of your drinking?
• Have you or someone else been injured
because of your drinking?
• Has anyone been concerned about your
drinking and urged you to cut down?
Treatment
• Most of those who change their problem drinking
do so without treatment of any kind, including
self-help groups.
• A significant percentage maintain their recovery
with follow-up periods of more than 8 years.
• Many problem drinkers can maintain a pattern of
non-problematic moderate use of alcohol
without becoming re-addicted.
• Those who seek treatment have more severe
alcohol and related problems than those who do
not.
Alcohol Interventions
• The Physicians’ Guide to Helping Patients With Alcohol
Problems: www.niaaa.nih.gov
• Brief, supportive intervention - 1 or more sessions in
the clinician’s office consisting of education, negotiated
plan, follow-up. This is more efficacious than longer
term , more formal therapy.
• Motivational interviewing
• Pharmacotherapy: disulfiram, naltrexone,
acamprosate, topiramate, baclofen. SSRI’s can trigger
an increase in alcohol use in late onset alcoholism.
• Self-help groups
Behavioral Therapies
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Contingency management
Cognitive behavioral therapies
Relapse prevention
Motivational interviewing
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Empathy
Develop discrepancy
Avoid arguments
Roll with resistance
Support self-efficacy
• Couples/ Family Treatment
• 12-Step groups
Behavioral Therapies
• Brief Interventions
– 10-15 minutes counseling for feedback, education
and goal setting, follow-up visits
• Alternative Therapies
– Exercise
– Mindfulness training
– Biofeedback
– Acupuncture
Cannabis Use
• Cannabis is the most commonly used illicit
drug in the US - about 15 million people, 33%
of high school seniors.
• Most users do not develop any problems, but
a subset do - 9% develop dependence. It is
now known that cannabis abuse can lead to
tolerance and withdrawal.
Medical Use of Marijuana
• Unfortunately, most of the research on marijuana is
based on people who smoke the drug for recreational,
rather than medical purposes.
• Consensus exists that marijuana may be helpful in
treating certain carefully defined medical conditions:
– Modest efficacy for nerve pain
– Appetite stimulation for AIDS wasting syndrome
– Control of chemotherapy related nausea and vomiting
• There are FDA approved medications for each of these
conditions.
Medical Use
• Drug delivery is a major challenge. The FDA
has approved two pills containing THC. Most
of the active ingredient is metabolized during
digestion, and the drugs work slowly.
• Inhalation is the fastest way to deliver THC to
the bloodstream. But smoking cannabis seems
to have more rapid toxic effects on the
respiratory system than cigarette smoking.
Psychiatric Risks
• There are more psychiatric risks than benefits for
marijuana:
– Addiction: >10% of regular users show evidence of
physical dependence. The average THC concentration
has risen from 1-4% to 7% over the last few decades.
– Anxiety: The most commonly reported side effects are
intense anxiety and panic attacks – 20-30%.
– Induction of manic episodes, rapid cycling in bipolar
clients
– Psychosis
Categories of Anxiety Disorders
• Generalized Anxiety Disorder (GAD)
– 5.1% (women 6.6%, men 3.6%)
• Panic Disorder
– 3.5% (women 5%, men 2%)
• Obsessive Compulsive Disorder (OCD)
– 2% (women 2.5%, men 1.5%)
• Phobias
– Simple phobia 11% (women 15.7%, men 6.7%)
– Agoraphobia 5.3% (women 7%, men 3.5%)
– Social phobia 13.3% (women 15.5%, men 11.1%)
• Post Traumatic Stress Disorder 7.8%
Demographics
• Anxiety disorders are the most common
emotional disorders. Lifetime prevalence is
24.9% (women 30.5%, men 19.2%), 25 million
people.
• 33% of total mental health bill, average of 37
medical visits/year (vs. average of 5)
• Comorbidity with depression 60-80%.
Anxiety and Substance Abuse
• 18% of substance abusers suffer from an
independent anxiety disorder. 70% of alcoholics
have anxiety problems, mostly caused by the
alcoholism. 15% of anxiety disorder clients have
substance abuse problems. The relationship is
bidirectional and complex.
• Alcohol relieves anxiety in the short term, but
chronic drinking makes agoraphobia and social
phobia worse.
Generalized Anxiety Disorder
• GAD is a clinical syndrome characterized by excessive
worrying, hypervigilance, and anxiety
• Lifetime prevalence of 5.7% (women 6.6%, men 3.6%)
• Median age of onset is 31 – oldest of any anxiety
disorder. It looks like major depression.
• It is unique in that sufferers will present to their primary
care physician, where it is the second most frequent
mental disorder. The main complaints will be insomnia
and somatic problems. Clients will regard themselves as
in poor health and will be high utilizers of healthcare
resources. No other anxiety disorder has such a high
rate of disability.
Natural History
• Course of illness is chronic, with waxing and waning
symptoms.
• Unlike other anxiety disorders, GAD does not decrease
with age. Older people tend to worry more and for
longer periods of time. Fewer than 33% completely
remit. They experience the same degree of disability as
major depressive disorder and coronary artery disease.
• People with GAD often report problems with memory
and attention.
• There is a strong association with suicidal behavior.
Treatment of GAD
• Short term stabilization with benzodiazepines is
appropriate. Long term treatment should focus
on lifestyle changes, stress reduction techniques,
cognitive therapy, appropriate work situation,
management of personal affairs.
• Little is known about long term treatment and
the natural course of the disorder.
• A poor prognosis is associated with poor family
relationships, comorbid avoidant, dependent, or
obsessive compulsive personality, other mental
illnesses, or female gender.
Panic Attack
• A panic attack is a discrete episode of
unexpected terror accompanied by a variety
of physical symptoms including fear, anxiety,
catastrophic thinking with a sense of
impending doom, or the belief that loss of
control, death, or insanity is imminent.
• Physical symptoms can be neurological,
gastrointestinal, cardiac, or pulmonary.
Panic Attack
• A panic attack lasts from 5 to 30 minutes, with
symptoms usually peaking at 10 minutes. They
may occur during sleep.
• Many psychiatric disorders have panic attacks
associated with them.
• Panic attacks can be triggered by certain
situations - driving in the rain, crossing a
bridge, being crowded, waiting in line.
Panic Disorder
• Panic disorder is the presence of recurrent,
unexpected panic attacks followed by at least
a month of persistent anxiety or concern.
• 10% of the population report having a panic
attack.
• 4.7% of the population develop panic disorder.
Five Aspects of Panic Disorder
• Panic attacks
• Anticipatory anxiety
• Panic related phobias (80% will be
agoraphobia)
• Impaired sense of well-being
• Functional disability
Treatment of Panic Disorder
• All the newer antidepressant medications
have efficacy in treating panic disorder. (Two
medications used for other anxiety disorders
do not - buspirone and gabapentin.)
• Clients with panic disorder are extremely
sensitive to side effects and may need to start
at lower medication doses than normal.
Social Anxiety Disorder
• Sufferers experience the triad of worry,
avoidance, and physical complaints.
• Few seek help.
• 70-80% will have a comorbid condition - alcohol
dependence, depression, another anxiety
disorder.
• 20% are unable to work. 70% will make a below
average income.
• 66% are single, divorced or widowed.
• Risk of suicide is increased.
Post Traumatic Stress Disorder
• PTSD is an illness that
occurs in vulnerable
people exposed to
severe trauma.
• Some people with
PTSD do not
experience a single
episode of trauma,
but rather repeated
physical assaults.
Acute Stress vs. PTSD
• After a traumatic event, most people will experience
elements of both stress and traumatic stress. Perceived
threat triggers intense bodily reactions that influence
memory storage and retrieval, as well as cognitive
factors and symptoms of autonomic arousal.
• Acute Stress symptoms appear shortly after the event,
subside in many survivors, but persist in others in the
form of chronic PTSD. Since at least 60% of people with
early PTSD symptoms recover over the next 6 years,
almost all within the first year, chronic PTSD might be
seen as a “disorder of recovery.”
Psychological First Aid
• PFA is a form of single-session psychological debriefing
developed by the National Center for PTSD. There is no
empirical support as yet. PFA consists of 8 core
components:
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Contact and engagement
Safety and comfort
Stabilization
Information gathering
Practical assistance
Connection with social supports
Information on coping support
Linkage with collaborative service
Symptoms of PTSD
• The symptoms of re-experiencing and
hyperarousal are common and reflect normal
responses to trauma.
• Avoidance and Numbing are more markers of
psychopathology and more predictive of
developing chronic PTSD.
Demographics
• 61% of men and 51% of women will
experience trauma in their lives. Of these, 8%
of men and 20% of women will go on to
develop PTSD.
• Some clinicians believe that PTSD is widely
under-diagnosed, and healthcare providers
need to ask clients about a history of trauma
and any resulting symptoms, especially
women with substance abuse problems.
Natural History
• Once PTSD develops, it is often chronic. The
typical person with PTSD has over 20 years of
active symptoms. There is a high degree of
academic failure (40%), teenage pregnancy
(30%), marital instability (60%), and
unemployment.
• There is significant risk of comorbidity including
depression, GAD, panic, and suicide (19%).
• Currently there is strong interest in using brain
scans to better understand and predict pathology.
Treatment of
Established PTSD
• Treatment should start within 5 months of
exposure, include only those with full-blown
PTSD, and use trauma-focused CBT.
• CBT
– Psychoeducation (teach about the illness, address
distortions – I can never trust anyone again, etc.)
– Exposure (disconnect the memory from its ability to
trigger the aroused emotional state)
– Breathing and relaxation training
– Eye movement desensitization and reprocessing
(EMDR)
Treatment of
Established PTSD: Medication
• The British National Institute for Clinical Excellence no
longer recommends antidepressants as first line
treatment, instead recommending CBT.
• In the US, two SSRI’s are approved for PTSD, but their
efficacy is modest, and they do not appear to work for
combat-related PTSD.
• Benzodiazepines may be useful, but should be avoided
if substance abuse or dependence is also a problem.
• Off-label uses of medication with some clinical support
include clonidine for hyperarousal, prazosin for
insomnia, topiramate for flashbacks and nightmares,
trazodone for insomnia and nightmares
Depression
• Depression is a commonly experienced mood and a
syndrome. A clinical depression is distinguished from a
depressed mood by the intensity and pervasiveness of its
symptoms. Depressed people are usually not able to relate to
others and may be able to express only a limited range of
emotions. They are frequently obsessively focused on
themselves and how they are feeling moment to moment. In
a primary care setting the following complaints may identify
depression: sleep disturbance, fatigue, somatic complaints.
Demographics
• Depression is the fourth leading cause of disease
burden worldwide, 1st in the United States. Lifetime
prevalence may be 7-12% of men, 20-25% of women.
High risk groups include Native Americans (19.17%)
and Caucasians (14.58%). Asians are at lowest risk
(8.77%).
• There is high comorbidity with anxiety disorders (36%)
and personality disorder (37%).
• Mortality is high. 46% wish to die. 9% report a suicide
attempt. Risk of suicide death is 20x higher – 15%
lifetime risk. 30-70% of suicides have a depressive
disorder.
Symptoms
• Affective
– Depressed mood
• Vegetative
– Weight loss or gain
– Insomnia or hypersomnia
– Decreased sex drive
• Behavioral
– Psychomotor retardation or agitation
– Fatigue
– Diminished interest or pleasure in most activities
Symptoms
• Cognitive
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Feelings of worthlessness or guilt
Diminished ability to think and concentrate
Poor frustration tolerance
Negative distortions
Affective agnosia and apraxia
• Impulse Control
– Recurrent thoughts of suicide, homicide, or death
• Somatic
– Headaches, stomach aches, muscle tension
• Chronic Painful Physical Conditions
Natural History
• Depression is a lifelong illness, likely to relapse
within a few months after the first episode.
• Average age of onset is late 20-40 years old.
Symptoms develop over days or weeks.
• Prodromal symptoms include anxiety, panic,
phobias, low grade depression.
• Episodes last from 6 to 24 months.
• There is strong evidence that sub-syndromal
continuation of symptoms represent a
continuation of the illness, and will lead to
relapse.
Risk of Recurrence of Depression (DSMIV-TR)
Behavioral Activation for Depression
• Encourage people not to wait until they feel like doing
something, but just go ahead and do it. It is usually the
case that people who are depressed are unable to do
things, it’s just that they can’t start things.
• People often underestimate what they are capable of
doing. Helping them break tasks down to size and act
on them is a good therapeutic activity.
• In a recent study, depressed individuals who were able
to question their negative beliefs and practice
behavioral activation were least likely to relapse
Treatment Response
• 33% of patients with depression will achieve
remission on their first antidepressant. Up to
65% will achieve remission on the second
medication. Expect a relapse to depression in
50% of those who achieve remission within 12
months.
• Women and men are equally likely to respond
to antidepressants.
Choosing an Antidepressant
• There is no evidence that any antidepressant
is any more efficacious than any other.
Therefore, the choice of the first
antidepressant should be based on patient
preference of what side effects are tolerable.
Complementary and Alternative
Treatments
• Omega-3 fatty acids: epidemiologic evidence, modest
efficacy data as adjunctive treatment, low risk
• St John’s wort: greater consensus for mild to moderate
depression than severe, significant drug-drug
interactions
• SAMe: studies support that more rigorous research is
needed – so far we have small samples, different
delivery systems, few comparison studies, unstable
preparations
• Folate: which forms cross the blood-brain barrier? Low
risk as an augmenter
Client Adherence
• Clients need a lot of education during the beginning of
treatment. 10% never fill their prescription, 16% stop
the first week, 41% within two weeks, 59% in three
weeks, 68% in four weeks. The number of educational
messages given to clients by their physician was the
single greatest predictor of adherence. Best messages
were:
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Take pills daily
They won’t work for 2-4 weeks
Continue even when you feel better
Don’t stop without calling your doctor
Feel free to call
ADHD Incidence and Prevalence
• More frequently diagnosed in boys, but it is being
recognized more in girls, who may have more of the
inattention subtype.
• 50-60% will have another condition, such as learning
disorder, restless-legs syndrome, depression, anxiety,
conduct disorder, obsessive-compulsive behavior
• It is not clear how much is carried over into adulthood.
NCR estimates persistence into adolescence in 40-60%,
into adulthood in 40%.Hyperactive symptoms may
decrease with age because of increased self-control.
Attention problems may continue. Many youths seem
to get better.
Executive Functions and ADHD
• There are six dimensions of cognitive “executive
functions” that are problematic for people with ADHD
– 1) Self-awareness: probably the “chief” executive function
is the ability to see yourself and monitor your actions.
ADHD patients do not monitor their actions and are less
aware of their failures. They also tend to have a “positive
illusory bias.”
– 2) Non-verbal working memory: hindsight – the ability to
remember the past and predict the future. People with
ADHD are terrible at time management and making
predictions.
– 3) Verbal working memory: self-speech, using internal
language to reason with and guide yourself
Executive Functions and ADHD
• 4) Inhibition: People with ADHD can’t inhibit their initial
reactions and responses to situations and things.
• 5) Emotional regulation: ADHD patients cannot inhibit their
initial emotional reactions and don’t have the tools to
regulate their feelings when they occur. They come across
as very emotional, quick to anger, silliness, overly
affectionate. People forgive the silliness, but not the
hostility. 50-70% of ADHD children have no friends by the
3rd grade.
• 6) Self-motivation: the ability to activate yourself when
their are no immediate rewards. People with ADHD are
very dependent on immediate feedback, If there are no
consequences, they fall apart. They can pay attention to
video games, but can’t sit still to do homework.
Problems
• Complicated diagnosis: inattention and impulsivity
are seen with bipolar, depression, anxiety,
oppositional defiant disorder, conduct disorder,
learning disabilities
• Heavy pharmaceutical marketing
• Those with diagnosis get special considerations
• Primary care MD’s have difficult time with diagnosis requires time and testing
• Diagnosis is unusually dependent on social and
educational circumstances
Treatment
• Stimulant medication has become the mainstay of
treatment. All of the medications seem to be equally
effective. Studies of efficacy beyond 2 years are rare.
Core symptoms seem to benefit, but associated
domains (social skills, achievement, family function) do
not.
• The question of medication effect on the development
of substance use disorders remains unclear. Studies
have shown conflicting results. Controlling for conduct
disorder is difficult.
• Also required are psychoeducation, behavioral
interventions, parent training, and school support.
Side Effects of Stimulants
• Side effects of all the stimulants are the same:
decreased appetite, initial sleep difficulty, headaches,
stomachaches, tics, and irritability.
• The most common sustained side effect is appetite
loss.
• Cardiovascular effects include a slight increase in blood
pressure and heart rate. Because of reports of sudden
death, the Am Heart Assoc recommends ECG’s for all
children before starting stimulants. All psychiatry
groups disagree. (Rate of cardiac death with stimulants
2:million, rate of sudden death in non-treated children
8-62:million)
Adult ADHD
• One study suggests that ~4% of adults meet the criteria for
ADHD.
• ADHD probably does not arise spontaneously as an adult.
There should be a history of the disorder.
• Symptoms of ADHD evolve. In adults, we are most likely to
see difficulty with memory and attention.
• Two studies of adults with ADHD found extensive
comorbidity: anxiety, major depression, substance abuse.
• Treatment is with stimulants and psychotherapy to help
with compensating for the symptoms. Cardiovascular side
effects of stimulants are of concern.
Bipolar Disorder
• A medical condition in which people have mood
swings out of proportion, or totally unrelated to
things going on in their lives.
• These swings affect thoughts, feelings, physical
health, behavior, and functioning.
• The present view is that the mood swings are
secondary to an illness that creates a wide range
of vulnerabilities, not just of mood, but also of
arousal, motivation, impulsivity, and behavioral
sensitization.
Sleep Disruption
• Decreased need for sleep is one of the criteria for
bipolar mania and the ability to maintain energy
without sufficient sleep is seen in few other disorders.
• Sleep disturbance escalates just before an episode and
continues to worsen during an episode. It is the most
common prodrome before mania.
• Induced sleep disruption is associated with the onset
of hypomania and mania. An increase in bed rest or
sleep is associated with an onset of depression.
The Manic Phase
• Hypomania
– Energetic, extroverted, assertive, hypersexual, selfconfident, rapid speech
• Mania
– Poor judgment, euphoric, grandiose, paranoid,
irritable, hyperactive, manipulative, demanding,
pressured speech
• Psychosis
– Delusional, labile, distractible, confused, combative.
Hallucinations are relatively rare. May mimic
schizophrenia.
Rates of Violence
(Fazel S et al, Arch Gen Psych Sept 2010)
Bipolar Depression
• Very difficult to treat and prevent
• Usually the first and most frequent episode,
causing the most impairment.
• Patients with depression onset have a more
unstable course, more mixed states, and more
suicidal behavior. This may in part be due to
early treatment with antidepressants.
Natural History
• Onset can occur at any time, from childhood to
old age, but it is usually in adolescence. Early
onset of depression, anxiety, substance abuse,
and behavioral disorders are all linked to eventual
bipolar disorder.
• Depression is the most frequent episode.
• Depressive episodes last longer (25.4 weeks) than
manic episodes (5.5 weeks).
• The time between episodes is usually 12-14
months.
Evaluation Questions
• Has there ever been a time when you were not
your usual self and:
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You felt so good or so hyper that you got into trouble?
You were very irritable?
You were more self-confident than usual?
You needed less sleep than usual?
You were more talkative than usual?
Your thoughts raced in your head?
You had more energy than usual?
Spending money got you into trouble?
Treatment
• In evaluating the effectiveness of treatment in
bipolar disorder, you must consider three
different phases:
– Treatment of mania
– Treatment of depression
– Prevention of relapse
Rhythms in Bipolar Disorder
• Disrupted social and circadian rhythms, life
events, and medication non-adherence can all
precipitate a manic episode. The final
common pathway may be sleep disruption.
• Psychoeducation, family-focused treatment,
interpersonal and social rhythm therapy, and
CBT have all proven to be useful, reducing
relapse rates by 30-40%.
Early Warning Signs of Mania
• Sleep disruption
• Sudden drop in anxiety (devil-may-care attitude),
or sudden lifting of depression
• Overly optimistic in absence of problem solving
• Overly social, poor listening
• Loss of concentration
• Increased sexuality
• Increased activity – hyper focus or no focus
Psychotherapeutic Interventions
• Principles of treatment are:
– Identify signs of relapse and make plans for an early
response
– Use education to increase the likelihood of adherence
– use mood charting
– Practice stress management and problem solving,
improve capacity to manage stressors
– Maintain regular rhythms for exercise, sleep, and
eating
– Keep negative expressed emotion in the family at a
minimum, improve communication
– Don’t make important decisions while symptomatic
Improving Stress Management
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Activity scheduling
Distraction techniques
Relaxation exercises
Problem-solving
Insomnia activities
Stimulus control
Cognitive restructuring
Coping cards
Schizophrenia
• The most current view is that schizophrenia is a
syndrome rather than a disease, i.e. individuals
diagnosed with schizophrenia may have substantial
differences in psychopathology, in the same way that
individuals with congestive heart failure will have
different causes for their condition.
• Schizophrenia is associated with marked social and
occupational dysfunction and a course of chronic
remissions and exacerbations. The three major
dimensions of schizophrenia are psychotic symptoms,
deficit symptoms, and cognitive symptoms.
Three Aspects of Schizophrenia
Cognitive Symptoms
Deficit
Symptoms
Psychotic
Symptoms
Deficit Symptoms
• Restricted emotional expression, reduced
initiative, poor rapport, poor hygiene
• These may be the most distinctive feature of
schizophrenia
• They appear earlier, are harder to treat, and
worsen over time, unlike positive symptoms
• Antipsychotics cause these symptoms in
healthy volunteers.
Psychotic Symptoms
• Reality distortion (hallucinations, bizarre
delusions - most frequently of prosecution, or of
being controlled by outside forces, x-rays, outer
space)
• Disorganized thought (autistic language, mutism,
echolalia, word salad, autistic logic, thought
blocking)
• Less a cause of disability than negative symptoms
• 5% of people without schizophrenia experience
auditory hallucinations
Cognitive Symptoms
• Disorganized and dissociative thinking
• Loss of attention, memory, executive function,
verbal skills, motor skills
• Generalizations are incorrect
• Trouble with abstraction
• Difficulty with understanding the main idea
• May be the most disabling aspect of the
illness
Rates of Violence
(Fazel S, et al. JAMA May 20, 2009)
Natural History of Schizophrenia
• The illness begins with genetic vulnerability, and
lies dormant until the premorbid phase:
neurological soft signs, minor physical anomalies,
mild cognitive, sensory, and motor deficits. These
are too non-specific to be of diagnostic value.
• The prodromal phase begins in puberty: anxiety,
blunted affect, depression, irritability, poor sleep,
social withdrawal, cognitive decline. 30-50%
progress to schizophrenia within a year.
Natural History
• With the onset of the illness, the disease
enters the progressive phase. If treated 86%
will recover, but the vast majority will relapse
within 3 years.
• In the chronic/residual phase, people with
schizophrenia experience repeated episodes
and relapses. The illness often becomes
resistant to medication.
Natural History and Relapse
• Prediction of poor outcome
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Poor premorbid adjustment
Early and gradual onset
Absence of affective features
Male gender
Duration of psychosis before treatment
More psychotic episodes
• Discontinuing medication increases the relapse
rate by 5x.
• Noncompliance after the first episode is 75%.
Biological Treatment
• Antipsychotic drugs treat psychosis but not
schizophrenia. Efficacy for negative symptoms and
cognitive problems is modest, at best. The primary
benefit of the drugs is to prevent relapse of psychosis.
• Some provocative recent studies suggest that
antipsychotics may exert a neuroprotective effect if
given early enough in the illness.
• Nonetheless, medications seem to be most effective
early in the illness. Psychosocial interventions can be
added to medication to improve relapse prevention.
Psychosocial Treatments
• Assertive community treatment (ACT) reduces frequency of
hospitalization, increases housing stability, shows high
satisfaction from clients and families.
• Integrated dual disorders treatment
• Supported employment - individual placement and support
(IPS) is effective
• Family psychoeducation reduces relapse, improves
symptomatic recovery, enhances family outcomes.
Programs must > 9 months.
• Social skills training improves social skills in group but not
necessarily in the community.
• Personal/Cognitive therapy may help with delusions,
hallucinations, social functioning
Vocational Needs
• Interpreting the behaviors of co-workers
• Understanding how “personal” work
relationships should be
• Recognizing how their behavior effects others
• Problems with substance abuse
• Transportation and clothing
• Performance of job tasks
• Dependability
Training Modules
•
•
•
•
•
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Identifying how work changes your life
Learning what the job expectations are
Identifying personal strengths and preferences
Learning to cope with stress
Learning to manage symptoms and medications
Learning to manage health concerns and
substance abuse
• Learning how to interact with supervisors/peers
• Learning how to socialize successfully
• Learning how to recruit social support
Description of Borderline PD
• Interpersonal problems
– Turbulence, fear of abandonment, self-esteem dependent
on important others
• Affective instability
– Reactivity, intense negative emotions, pervasive dysphoria
• Behavioral difficulties
– Impulsive, self-destructive, addictions, recklessness
• Cognitive problems
– Lack of stable sense of self, psychosis and dissociation
• Comorbidity
– Substance abuse, impulse control disorders, mood
disorders, eating disorders, anxiety disorders, PTSD, ADHD
The Fundamental Pathology
• Gunderson: primarily a disorder of attachment,
with excessive fear of aloneness and
abandonment, and mentalization failure
• Linehan: a disorder of emotional dysregulation
• Zanarini:
– “hyperbolic” temperament (overly sensitive) +
traumatic experience results in chronic, intense inner
pain.
– The person is insistent and persistent that this anguish
be recognized and acknowledged by others (“I am in
the worst pain in the history of the world.”) This
contributes to their sense of isolation and alienation.
Zanarini Description: Two Key Features
• Intense inner pain
– Dysphoric affect
• I feel grief stricken. I feel panicky.
– Distorted cognition
• I am damaged beyond repair.
• Behavioral responses (partly communicative)
– Self-injury, manipulative suicidal behavior
– Substance abuse, eating disorders, promiscuity
– Interpersonal patterns: devaluation, manipulation,
entitlement, rage. They may overact to criticism and
negatively personalize disinterest. Basic trust is not achieved.
Demographics and
Natural History
• 2.7% of the population, seen worldwide
• Most prevalent personality disorder in clinical
settings: 10% of psychiatric outpatients, 20% of
psychiatric inpatients.
• 75% female in clinical settings, 50% in general
• Onset is in adolescence with chronic instability
and high use of mental health resources
• Diagnosis is unstable, improvement over time is
the norm, hospitalization is uncommon after the
first few years of illness.
Interpersonal Agenda of the
Borderline Personality
• The person’s primary concern is to find someone
who can understand them perfectly enough so that
their sense of isolation will abate and their misery
will stop. It is a kind of “Golden Fantasy” – by finding
the one person who can help them, all of their needs
will be met.
• A strong fear of abandonment arises when
something seems to disrupt the developing
relationship. Abandonment fear is expressed with
“rage” as a kind of hostile dependence.
Caveat About Self-Injury
• There are many reasons why people do things
to their bodies that may seem deviant to
mainstream observers. Not everyone is
manifesting psychiatric pathology.
• Causes for concern:
– Injury to face or genitals
– Carving words or messages on the body
– Indifference or odd affect
– Severe injury
Borderline Personality Disorder
• BPD is the only disorder that includes recurrent
suicidal behavior as part of the disorder.
• 70% will attempt suicide with an average of 3
attempts per person. 3-10% will die of suicide,
40% men.
• Most attempts occur early in the 20’s, but most
deaths will happen later in the illness (mean age
of 37), so during the most alarming stage of the
illness, there is less chance of death.
• How is a clinician to manage this?
Borderline Personality Disorder
• Most predictors of suicide death (previous
attempts, depression, SIB, substance abuse) are
not helpful because they are so common in the
disorder.
• Two recent studies suggest that risk increases
with the cumulative consequences of chronic
illness, including impaired functioning and
progression of suicidal behavior. In addition, PTSD
and cognitive-perceptual symptoms, like
dissociation may increase risk.
Boundaries
• Clients will consciously and unconsciously
manipulate to get what they think they need. The
sense of entitlement can lead therapists to grant
favors and cross boundaries that they normally
would not.
• Impulsivity may precipitate therapists having to
act immediately with phone calls, extended
sessions, etc.
• The traumatic history may bring out rescue
fantasies fed by the borderline’s idealizing
transference.
Individual Psychotherapy
• The best way to avoid transference and
countertransference disasters with a BPD is to
keep very firm boundaries, both physical and
verbal.
Pharmacological Treatment
• No medication has been approved by the FDA for
BPD or BPD traits, although MSAD showed 40% of
clients on 3+ medications, 20% taking 4+
medications, 10% taking 5+ or more medications.
• Medication is hard to use with these clients because
of their extreme reactivity, transference problems,
suicidality, comorbidity, and variety of symptoms
among clients.
• Clients with impulse disorders often exhibit a strong
initial transient response to placebo treatment.
Common Ingredients of Successful
Therapies (Paris 2008)
• Emphasize getting a life in the present – a job, going
to school, having a relationship, etc
• Managing emotional dysregulation – learning and
labeling feelings, then modifying them through
mindfulness, distress tolerance, problem solving
• Dealing with impulsivity – using behavioral analysis,
teaching patients to slow down before reacting
• Manage bad interpersonal relationships – get
patients to broaden their sources of satisfaction and
support