Psychopathology lecture notes.docx

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Department
Psychology
Course
PSY 103
Professor
Fridlund
Semester
Spring

Description
Introduction 4/3/2012 12:23:00 PM  Mental health and the economy  80% Americans say economy is significant source of stress o up from 66% in April 2008 o 49% reported feeling nervous or anxious o 48% reported feeling depressed or sad  1 of 3 people undergoing foreclosure of their homes is clinically depressed  1/3 of Americans report losing sleep over the economy  the odds of violent behavior are 6x higher for people who lose their jobs  Early views of psychopathology  Trephining o Holes in skull indicate that they thought they were possessed by spirits; made holes in skull to let the spirits escape their brain o Mental illness/deviant behavior  possession by evil spirits  ~ 400BCE o humoral theory (Hippocrates)  personality imbalances  melancholic: black bile (very dark, sad, etc.)  choleric: gallbladder (angry, irritable)  phlegmatic: phlegm (stoic, stable, inert)  sanguine: blood (cheerful, can become mania)  Middle Ages o Demonic possession  Catholic church blamed for bad treatment of mental disorders (involved with inquisition)  Talked about most in psychopathology books as very detrimental, etc.  Sisters of Catholic church  more positive outlook  Gracious, kind treatment of patients with mental health issues (baths, etc.)  Aren’t talked about as much compared to negative aspects of Catholic church’s outlook  Demon possessed  Ex: Put head in oven o Malleus Maleficarum “Witches’ Hammer” 1486  Woman behaving bizarrely  if men acting weird… woman caused it  Ex: dunking in water (sink = innocent; float = witch)  Treating witches  exorcism  First manual for treating mental disorders Lecture 1 Continued/Movie 4/3/2012 12:23:00 PM  ~1700-1850 (Victorian/pre-Victorian)  mental illness as evolutionary regression  “mongolism”  down’s syndrome  known as mongoloid children  evolutionary racism  thought hadn’t evolved into British, but were stuck at the Asian level of evolution o hierarchy of human evolution  british male, british female, French, Spanish, eastern European, Slavic, Asians, negro, aboriginals, etc.  mentally ill = animal o housed as animals/human zoo o chained to walls, no drugs, known as insane asylum o Goya’s Madhouse 1810 o treatment by restraint  1800-1900 o “moral treatment” or “unchaining the insane” o Quakers  suggested people with mental disorders should be unchained/allowed a nearly normal life  “state hospital” era 1900-1960 o Napa state = current California state hospital o For mentally ill o Gated facility  Deinstitutionalization 1960-present day o The Hotel California: Camarillo, CA 1936-1997 Turned into: o Cal state University Channel Islands (est. 2003) o Occurred for a number of factors:  Expensive to run  Activist groups thought they were oppressive to the mentally ill (One Flew Over the Cuckoo’s Nest)  Attacked behavioral programs in state hospitals that were intended to get patients ready to transition into the real world o Resulted in many homeless  2/3 of people who were institutionalized then freed when the state hospitals shut down, ended up homeless  Contemporary views of psychopathology  Psychodynamic views  inner psychological conflicts caused people to become mentally ill; must free inner problems that are repressed in order to free your present mental illness o Mesmer (animal magnetism)  Iron filling cabinets, magnetically charged  Invited people to sit next to the cabinets in order to get rid of negative bodily energies (charged people to do it) o Freud  Neuroanatomist  Saw Charcot’s miracle-working seminar; starts practicing hypnosis on patients in Vienna (failed)  Digging into childhood histories of people  Psychoanalysis (conflicts over sex from early childhood that result in later appearance of mental disorder symptoms) o Charcot  Head of psychiatry at leading public hospital in Paris  Demonstrations on hypnosis  Argued the power of suggestion under hypnosis could free negative bodily energies  Made the blind see, made the paralyzed walk  Fraud  had the same patients come in with every new crop of medical professionals watching him  Behavioral views o Pavlov’s dogs  Develop bad habits through classical conditioning  Ex: child abuse o “Little Albert” Watson and Rayner (1920)  what happened to little albert?  investigators on east coast tracked him down  died at age 6  discovered had hydrocephalus at birth (gave him meningitis for experimentation)  Watson and Rayner lied about Albert being a normal child TELL NITZAN  Biological views o Prozac – first medicine safe to prescribe for a multitude of psychological disorders  Early treatment: Kill or Cure?  Lecture 3 4/3/2012 12:23:00 PM  What is a mental disorder?  Why is this issue important? o They’re everywhere  used to be a taboo topic; people now talk about their mental problems with people, on Oprah, etc. (confessional culture)  Concept of “mental illness” depends on basic philosophical assumptions o Monism – mind is equal/reducible to brain  What you do with your brain correlates to your brain itself o Dualism – mind is different from brain  What you do with your brain is different from the brain itself  Brain is a machine: it’s a piece of hardware, but the software is different  Ex: radio = hardware; classical station, rock station, Christian station, etc.  Most historical psychologists were dualists  Philosophical implications for “mental illness” o Monism: mental illness is brain illness – a type of medical illness o Dualism: mental illness is ____?  Aspects of psychopathology  Nosology – the science of disease classification; a set of disease categories within any degree of diseases o Ex: lung disease (know all about different lung diseases); like House M.D. o Scope of mental illness  Originally, “mental illness” was synonymous with “insanity” reserved for psychoses and sudden disabling or bizarre changes in behavior/thinking  Mental illness has been broadened  Now mental disorder rather than mental illness  Mental disorders now span a wide range of severity  Schizophrenia, Alzheimer’s type dementia  Controversially: homosexuality (now declassified), alcoholism, pedophilia, psychopathy, intermittent explosive disorder  Premature ejaculation, premenstrual syndrome, painful intercourse, flying phobias, gambling addiction, voyeurism, exhibitionism, insomnia, sleepwalking, nightmares  Many ways of defining mental disorder have been proposed; all have problems, and there is no consistent, logical way of defining psychopathology o Why worry about how to define mental disorder?  Mental disorder diagnoses are stigmatizing  Some places won’t hire you  Mental disorder diagnoses are sometimes used as tools of political persecution  In foreign countries, one way to get rid of enemies = classify them as crazy (Soviet Union)  Mental disorder diagnoses are used to marginalize dissent  Candidates call each other wing jobs, paranoid, etc.  Mental disorder diagnoses are used to excuse defendants and others from responsibility for their actions (Allan Dershowitz’s “excuse abuse”)  Project X guy’s parents plead mental retardation and he had 0 consequences  Hope: a valid and consistent definition of mental disorder will produce no false positives and no false negatives o Underlying dichotomies that drive attempts to define mental disorder  Is a condition normal or abnormal? Many different criteria:  Deviance (statistical, moral)  Distress (self and/or others)  Dysfunction (inability, efficiency, maladaptation)  Danger (self and/or others)  CHECK PAPER ON GAUCHOSPACE o Is a person ill or evil? (disorder or sin?)  Person commits multiple crimes, psychiatrist says “antisocial personality disorder = born without conscience”; jury decides if he should be sent to a mental hospital to be treated, or should he be locked up as a cold-hearted killer  Born to be bad?  Choose to be bad? o Is the professional response to the condition treatment or oppression?  How a society responds to mental disorders is a way of determining how it regards mental disorders  Ex: Kennedy’s and the younger daughter being lobotomized/turning mute in attempt to save family’s name so John could become president o Current official view (American Psychiatric Association, 1994)  A mental disorder is:  A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual; and that is associated with:  Present distress (ex: a painful symptom) or  Disability (ex: impairment in one or more important areas of function) or  With a significantly increased risk of suffering death, pain, disability, or an important loss of freedom  And must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one th  This view is the basis of the DSM, current in its 4 edition (Diagnostic and Statistical Manual of Mental Disorders) o How do we learn what mental disorders look like? Prototype theory  Theories of meaning  A) Definitional theory of meaning  B) prototype theory of meaning  Definition of disorder  A) semantic definitions of mental disorders  B) prototype definitions of mental disorders  Example: We know that wiener dogs, Chihuahuas, and German shepherds are all dogs, but we think that the shepherd is the “doggiest” dog through our experience (central prototype for a dog)  Example: What’s the fruitiest fruit? Apple has the highest score.  Example: When you ask me what a show is, I picture a sneaker, but someone else can picture a sandal.  Where do people acquire these mental disorder prototypes  Repeated exposure to conditions perceived as necessitating mental health intervention  Personal and indirect (books, films, T.V.) experiences in which people are seen to have unwanted conditions requiring mental health intervention  In training as a mental health professional, through classic case studies or supervises clinical experiences  Read in textbooks, see in training materials/movies  Assessment – gathering information about a patient that may or may not have a disorder (used to diagnose)  Diagnosis – the process of assigning a nosological category to a patient o NOT PATIENT TO A CATEGORY  patients can and usually do have more than one diagnosis  Treatment  Prevention – increased focus  Basic terminology  Etiology = cause o Biology, environment, etc.  Course = trajectory o How it goes over time o Ex: big spurts of OCD then subsides with time  Prognosis = outcome o Some lethal, some end up fine after one episode of disorder  Signs = observable markers o What you see o Ex: You hear your patient yell “Shut the hell up!” to a voice in his/her head.  Symptoms = patient reports o What the symptom sees o Ex: “I hear voices in my head.”  Signs + symptoms = syndrome o hysteria  Syndrome + course = disease Lecture 4 4/3/2012 12:23:00 PM  Basic terminology (Emil Kraepelin)  Etiology = cause o Biology, environment, etc.  Course = trajectory o How it goes over time o Ex: big spurts of OCD then subsides with time  Prognosis = outcome o Some lethal, some end up fine after one episode of disorder  Signs = observable markers o What you see o Ex: You hear your patient yell “Shut the hell up!” to a voice in his/her head.  Symptoms = patient reports o What the symptom sees o Ex: “I hear voices in my head.”  Signs + symptoms = syndrome  Syndrome + course = disease  Why diagnose at all?  Prognosis o Ex: 42 year old woman Alzheimer’s Dementia (able to sign papers for sons, etc.)  Treatment implications  Communication among professions o Psychiatrist referral for medication, etc.  Establish prospects for contagion or other transmission, and possible prevention o Certain mental disorders run in family  Legal reasons o Competence  Is grandma still competent to handle monetary affairs? o Insanity determinations  May be asked as a mental health professional to testify if whether or not a defendant was suffering from a mental disorder while a crime was committed  Financial reasons o Compensation to patient and/or treatment provider o Working conditions lead to post traumatic stress  you can be awarded money from workers’ compensation  Research o Testing treatments for specific disorders  Problems inherent in the act of diagnosis  Sacrifices the uniqueness of individual patient  Can falsely imply etiology (cause) o Dissociative personality disorder  movies and books made it seem like it was always caused by sexual abuse by family member (don’t remember it = repressing it/denial)  Rigidifies treatment alternatives o “This is how this is treated.” o This disorder = this treatment. If it fails, THIS treatment  not everyone is a cookie cutter patient  Iatrogenic illness o Healer in attempting to help you, causes another illness o Risperdol = treating schizophrenia, but 50-80 pounds gained in addition  diabetes  Stigmatization o Employer/future employer looks at medical records and sees a mental disorder = at risk for a future job o Personal stigmatization  “So I hear you’re going to see a shrink, huh?”  Secondary gain o When patients are receiving treatment, they often use it for unfair advantage  Ex: off of work on worker’s comp = sneak in a second job for extra money  Two kinds of diagnosis  Phenotypic o Signs o Symptoms o Course o Outcome o Response to treatment  Genotypic o Causes (genes, germs?)  Phenotypic ---------------- Genotypic o Endophenotypic (lab tests)  In physical medicine, progress consists of moving from phenotypic to genotypic diagnosis  In mental health, nearly all diagnosis is phenotypic, with some endophenotypic evidence emerging  Ingredients of a diagnosis  Symptoms o What does the patient feel?  Signs o What do you see about the patient?  Course of illness o NOTE *Patient might be compromised and can’t tell you accurate history of self/family* o Good days vs. bad days? o When did this start? o Are there things that help you feel better?  Age of onset o How old when this started? o Have you always had these symptoms?  Family history o Depression, suicide, mental health/physical health problems, molestation/rape?  Recent events o Why are you here right now? o Have there been any flare ups that made you decided to come visit me?  Recent behavior o Have you noticed any changes in how you’ve been lately? o Have you been adhering to a normal routine? Work, home, social?  Psychological tests  Lab tests (neuroimaging, hormonal assays, genetic testing) o Always ask when the last time the patient got a physical o NOTE *Physical illness often times masks mental illness*  Response to treatment (prior or current) o Past/current medications? o Have you been to a psychologist/psychiatrist before?  Multifactorial nature of diagnosis  No single sign or symptom defines a mental disorder o i.e. is pathognomonic of a mental disorder  diagnosis is based on a pattern of signs and symptoms o i.e. syndrome  the patterns of syndromes and courses of illness that define mental disorders are spelled out in the nosology of mental disorders o nosologies for mental disorder: diagnostic and statistical manuals for mental disorder (DSM series); American psychiatric association  1952 DSM 1 (100 disorders 8 categories)  1968 DSM II (100 disorders 10 categories)  1980 DSM III (230 disorders in 19 categories)  1989 DSM IIIR (revised) (750 disorders in 40 categories)  1994 DSM IV  2000 DSM IV TR (text revision/update)  2013 DSM V (www.dsm5.org) o DSM 1 and II diagnosis  Consisted of brief paragraphs containing “horoscopic” descriptions of each disorder o Features of DSM III, IIIR, IV, IV-TR  Phenotypic diagnosis  Based only on observable signs/symptoms  Abandoned intrapsychic conjecture and terms like “neurosis” and “reaction”  Chinese menu decision-tree approach  Inclusion criteria  Exclusion criteria  “Must have 3 of the following 4, but can’t have any of the following 5.”  Field tested for reliability  Everyone agreed with the diagnoses, but the diagnoses weren’t necessarily valid  Multiaxial diagnosis  DSM-IV  5 axes  1: major mental disorders and V-codes o ADHD, depression, bipolar disorder, etc.  2: personality disorders and mental retardation o dependent, avoidant, unstable moods, no conscious/anti-social  3: general medical conditions o cancer, arthritis, diabetes, broken leg, etc. (chronic back pain more often than not leads to depression on axis 1)  4: psychosocial/environmental problems o recently lost job  5: global assessment of functioning o 100 point scale on which you rate how well they’re doing o DSM-V (Due May 2013)  Many disorders now considered separate categories now defined as part of disorder spectrum  ex: Asperger’s syndrome and autism  Behavioral addictions  Shopping, porn and internet  More stringent definitions based on absolute severity of signs and symptoms are used to diagnose disorders  Right now = very subjective  More quantitative features to make less subjective  There is greater recognition of “cross-cutting” symptoms that span multiple disorders  Anxiety and depression  Bipolar disorder and schizophrenia  Certain “risk syndromes” are defined as predictive of later disorders such as dementia and psychosis  Controversial  If you see _____ at young age, there’s a high chance it’ll develop into _____ at an older age.  “pre-psychotic” o clinical interview: types of information and goals  lasts about 1 hour; most valuable single source of information leading to a diagnosis  personal and family history re: medical, mental-health, social, occupational, financial problems  treatments that have worked/not worked in past  symptomatology  signs from patient’s presentation  goals:  suitability and readiness for psychotherapy (self or another therapist)  determine need for referral to:  psychiatrist or PCP primary care practitioner) for medication  neurologist for neurological testing and/or neuroimaging  social worker, vocational counselor, physical therapist, etc.  signs noted in clinical interview  attire and grooming  posture  physical characteristics  skin tone/complexion  weight/stature  symmetry/atrophy/bodily anomalies  mannerisms, spasms, or tics  speech  articulation  prosody  consciousness  level of alertness, fogginess, hypervigilance  emotional state  general attitude  defiant, compliant, guarded, defensive, sincere, plaintive, resistant, apathetic, etc.  thought content  solicited by free inquiry  thought processes  thought broadcasting, removal, insertion  general knowledge  general facts, pop culture, politics  abstract thinking  what would you do if you found a fresh piece of mail just lying in the street?  social judgment  insight  why do you think you’ve developed the problems that brought you here today?  cognitive functioning  usually, current mental status via MMSE  neuropsychological screens like clock drawing  MMSE  orientation (up to 3x)  time (year, season, date, month, etc.)  place  person  registration  slowly say the names of 3 common objects (apple, table, penny) and ask them to repeat them  attention and calculation  serial 7’s or WORLD backwards  recall  ask for names of 3 objects above  what’s round crunchy fruity juicy  language  name a pencil and a watch when pointed to  repeat “no ifs, ands, or buts”  follow a 3-stage command: “Take a paper in your right hand, fold it in half, and put it on the floor.”  Read and obey the following: close your eyes  Write a sentence  Copy the following design  Clock drawing as a neurological screen  “I’d like you to draw a clock, put in all the numbers, and set the hands for ____”  helpful ancillary diagnostic information  info from family members, physicians, employers  medical charts  family history is important in diagnosis because it influences the risk of specific mental disorders Affective Disorders - Depression 4/3/2012 12:23:00 PM  affective:  mood, motivation, emotion  depression  clinical features of major depression o cognitive  pervasive sadness, guilt, or feelings of worthlessness  recurrent thoughts of death or suicide  most people who are very depressed are too depressed to actually go through with the suicide  when people get better/medication kicks in, they think “I never want to be this depressed again” and that’s when they actually commit suicide o motivational  pervasive anhedonia  anhedonia: nothing gives you pleasure anymore  favorite foods, sex, favorite movies, etc.  pervasive: throughout entire life o neurovegetative  significant change in weight (+ or – 10 pounds/month)  sleep disturbance  usually not difficult to get to sleep, but difficult to stay asleep  psychomotor agitation or retardation  really shaky/crawling out of skin  slowly moving body through molasses  pervasive fatigue or loss of energy  getting out of a chair/bed is a huge ordeal  difficulty concentrating  usually because so preoccupied with depressive thoughts  so fatigued = hard to maintain concentration  prevalence o occurrence of a disease within a time frame  point prevalence: ~5% of U.S. population are diagnosably depressed  1 yr. prevalence: ~10%  lifetime prevalence: 15-20% (26% W 12% M)  15-20% U.S. population at any time may suffer from subsyndromal depression, with nearly equal disability  depression that doesn’t meet 5/9 DSM criteria  4/9? Still question in psychodiagnosis  have just as many issues with substance abuse, work, home, social, etc.  setting the bar too high?  depressions in non-Western countries differ from those in Western countries  western = sadness, guilt, hopelessness, moral wretchedness (U.S. = only country accordance with sadness)  religious undertones; idea that slothfulness/retreat from community duties = sin in protestant theology  non-western = don’t feel well, liver bothering them, fatigued, under the weather, spirits getting to them, etc.  risk factors for depression o genetic predisposition  evidence from adoption and twin studies  animal models  breeding animals that are much more prone to depression due to breeding/parents o personal loss  or gain! No silver lining without a cloud  lost parent, sibling, etc. early on = vulnerable to depression o prolonged psychological stress  depression = collapse?  Hostage situation o History of early abuse or neglect  Childhood/adolescence  Infidelity in relationship o Being in an industrialized nation  People = less depressed in non-industrialized  Could be pace? Could be effects of crowding? Still not 100% sure o Overall, not race or social class o Age of first onset in latter 20’s o Physical illness/chronic pain  Need to exclude undiagnosed other illnesses  May be causes of depression o Giving birth  Frequent “baby blues” can lead to post-partum depression  Baby blues usually lasts a couple days  Post-partum depression can lead to psychotic episodes of thinking the baby is the devil/wanting to kill it, etc. o Female: male ratio is 2:1 after puberty  In children the ratio is 1:1 o Previous depression “kindles” later depressions  Depression is a recurrent disorder  A single episode will go away by itself in 3-4 months (usually)  Odds of having another episode is 50%  Odds of having a third episode is 75%  Odds of having a fourth episode is 85-90%  Harry Harlow’s monkey depression research o Artificial mothers made of terrycloth vs. chicken wire o “bottom of a bottomless pit with no way out”  put baby monkeys at the bottom  monkeys became immensely depressed, internalized, less responsive to environment  became clingy and immature o could mainstream them back with normal monkeys  if put stressor in cage, would regress and freak out  “kindling” increases risk of later depression, regardless of life stress o depressive episodes  higher risk for depression in future o stressful life events matter to some extent, but it plateaus  previous depressive episodes = more important than stressors in life  why are women diagnosed with depression twice as much as men? o Some possibilities  X-linked depression gene(s)  Premenstrual symptoms  Statistical problem  Prevalence of depression = same as finding prevalence of any disorder  Elevation in depressive symptoms linked to PMS  Quality of female vs. male life  F is more responsibilities, but less power and choice on how to handle them  M has more power/choice  Female masochism (Freud)  Regarded depression as part of female nature  M naturally rule world because have penis, anatomy is destiny; clitoris is shrunken penis that mirrors F’s lesser subordinate relationship in the world  Cognitive style  Females dwell on problems  Males ignore or escape them  Male depression masked by alcohol/drug abuse (Amish study) st  1 line depression treatments o psychotherapy  especially interpersonal or cognitive therapy  interpersonal  central themes in interpersonal therapy o grief – delayed mourning, developing replacement relationship o fights – building skills in communication, negotiation, and assertiveness o role transitions – reevaluating the lost role, building a new role, developing new social supports  ex: leaving home, divorce, retirement o social deficits – using role playing to learn new behavior in relationships  ex: failure patterns in past relationships  cognitive  invented in 1960’s Aaron Beck  uncovering automatic self-defeating thinking patterns  developing new ways to interpret setbacks o normalization, analyzing logically, decastrophizing  replacing old “automatic” thoughts with new ones  prime areas of concern: o self o life events o future  ex: yell hi at Kristen from across the street; she ignores you o she hates me, I’m worthless, everyone doesn’t like me, etc. o normalization/analyzing logically: there was traffic, she was wearing headphones, maybe it wasn’t Kristen, she’s late and not paying attention, maybe she thinks you don’t like her, maybe she’s depressed o decastrophizing: you’ll meet plenty of people in your lifetime that like you/don’t like you… so what?  Issues: you can be too depressed to make cognitive therapy work o antidepressant medication  general use  effective for both anxiety and depression  do not cure depression, only hold it in check for so long as they are taken  take 2-3 weeks after first dose to produce an antidepressant response  not addictive or habit-forming, but must be tapered slowly to avoid rebound symptoms  are not euphoriants  all have some unpleasant side effects  no known “time bomb” effects or damage to fetus  can be taken for life  recovering patient must be watched for suicidal or other violent behavior  work only so long as taken  depression may relapse afterward  can precipitate manic episodes in bipolar patients  feeling better with medication should take 2-3 weeks; if better in 2-3 days, red flags should go up for bipolar disorder  wide use throughout the U.S.  antidepressants are the most frequently prescribed medications in the U.S.  antidepressant use has tripled from 1988 to 2000  over 12% of people in the U.S. obtain prescriptions for antidepressants each year  highest usage state is Utah at 18.4% and lowest usage state is New York at 9.1%  CA’s usage rate is 9.9% o phototherapy for seasonal depression o ECT for treatment-refractory depression  Neurochemical theories of depression o Neurotransmitter theories  Major transmitters implicated  Norepinephrine, epinephrine  Dopamine  Serotonin (5HT)  Also  Substance P  NMDA  Neurosteroids  Endocrine  Hypothalamus-pituitary  Thyroid  Adrenal (cortisol)  Sex hormone  Neurotrophic (neuronal growth) factors such as BDNF *brain-derived Neurotrophic factor) that promote neuronal growth and axonal and dendritic sprouting o Neurochemical disturbances in depression  Neurotransmitter abnormalities in depression represent just one part of the neurobiological changes in depression; they probably account for the side effects of antidepressant medications more than the main effects  Depression is also associated with  Reductions of BDNF and other growth factors  Altered levels of activity in the limbic system, prefrontal area, and other brain regions, observable by neuroimaging  Increased levels of neurosteroid hormones, which promote neuronal death and glial cell damage  Regardless of the mode of action, remission of depression with antidepressant medication results in restoration of normal levels of BDNF and neurosteroids, and return of normal neural activity  Reduced gray matter volume is seen in chronic depression, and appear to be restored with successful antidepressant therapy; people with lower amounts of gray matter in the right-hemisphere neocortex carry a greater risk of later depression o Physical conditions that can masquerade as major depression  Hypothyroidism  Blood test  Low testosterone or estrogen levels (both M and F)  Undiagnosed illness  Ex: infectious mononucleosis  Anemia  Chronic fatigue syndrome  Suicidality and antidepressants o 40% of people with major depression make at least one suicide attempt, and 50%-60% have suicidal ideation  F used to use pills (ineffective) while M used to use guns (effective) o as of 2004, all antidepressants in U.S. must now carry warnings about suicidality o although some studies show that suicidal ideation is increased with antidepressant medication, various studies have shown no link between antidepressant medication and actual suicides  more likely to commit suicide while recovering, whether on medication or not o suicidality is associated with improvement from depression, regardless of the presence of antidepressant medication  suicide and antidepressant use in Sweden  1990’s = skyrocketed sales of antidepressants  suicide = slightly negative slope  teen suicide in U.S. 2000-2005  2004, FDA demanded that “black box” warnings be included with all anti-depressants, resulting in a downturn in medication prescriptions to adolescents  stopped prescribing anti-depressants as willingly  suicide rate skyrocketed  started prescribing again  suicide went way down  classes of antidepressant medication o monoamine oxidase inhibitors (MAO inhibitors) – marplan, parnate, nardil  introduced in late 1950’s  had severe dietary restrictions and very unpleasant side effects  rich in amino acids = blood pressure skyrockets  can stroke out and die o tricyclics – Elavil, norpramin, tofranil, anafranil  introduced in early 1960’s  eliminated the dietary restrictions of the MAO inhibitors but still had very unpleasant side effects (weight gain, dry mouth, constipation, dizziness, blurred vision) and are cardiotoxic  dry gut  constipation  weight gain  very poisonous medicines of OD on them  “cardiotoxic” o selective serotonin reuptake inhibitors (SSRI’s) – Prozac/serafem, Zoloft, celexa, Lexapro, paxil, luvox  30-40% patients on SSRI’s suffer from sleep and sexual symptoms  older people especially, younger people not so much  insomnia problems (insomnia caused by depression, but when depression is lifted, insomnia left by SSRI)  female orgasmic difficulty  male ejaculation difficulty (more intense and longer stimulation)  F/M slight loss of sexual interest  children on paxil may develop suicidal ideation (but not suicide)  paxil = worst withdrawal symptoms because it goes in and out of your system very quickly; heavy agitation  people who do not respond to one SSRI have a 40-70% chance of responding to a second one; answer may lie in pharmacogenomics (matching medications to your genome)  Prozac = very safe  People have swallowed 4-8 GRAMS of prozac, and don’t die… o atypical antidepressants – Effexor, Cymbalta, wellbutrin, pristiq, remeron, trazodone  together, the most prescribed “class” of current antidepressants  fewer sexual side effects; varied in actions and side effects o atypical depression – hysteroid dysphoria (reversed neurovegetative signs/symptoms)  weight gain/carbohydrate binging  hypersomnia  leaden paralysis  feeling like slogging through the day  moving through life = a lot of effort  interpersonal rejection sensitivity  hypersensitivity to compliments, rejection, etc.  often  histrionic traits  always imagine you’re on a stage and everyone is watching you perform  acutely aware of “do I look okay? Am I acting okay?” o history of being performers (choir, drama, theater, etc.)  self-medication with caffeine or chocolate  sometimes  uniquely responsive to MAOI’s o special use antidepressants  wellbutrin  very stimulating and it used to treat adult ADHD and nicotine cravings  sold as Zyban for nitotine cravings  Cymbalta  Activating but has good anti-anxiety effects and helps in patients with chronic pain  Current best-selling antidepressant  Trazodone and Remeron  Both sedating and are used widely in elderly patients with insomnia  Remeron promotes appetite and is especially indicated in patients with excessive weight loss o How long should people take antidepressant meds?  Most depressions remit with no treatment in 3-4 months st nd  However adds are >50% of 1 recurrence, >75% 2 recurrence, etc.  Each recurrence tends to be longer and leaves the person with greater disability  Ex: depression is often progressive  Depression that is aggressively controlled early (by high doses and multiple, or multiple-action, medications) predicts less recurrence  Medication can be tapered and then resumed if depression re-emerges, but there  is a slight risk of acquired medication immunity if the medication is tapered then resumed  Medication for life? Medication is “unnatural”, but so is depression? o Increased risks associated with antidepressant meds?  Modern antidepressants are quite safe, but  SSRI’s may be associated with heart and long defects in the infants of mothers taking some SSRI’s while pregnant  Serotonin syndrome (confusion, hallucinations, fever, seizures) can occur in people who are taking SSRI’s along with MAOI’s or other serotonin-raising drugs  Abruptly stopping any antidepressant can result in a discontinuation syndrome:  Zaps, tremors, etc. o Alternative depression treatments  Medications  Lithium augmentation of antidepressant therapy  St. John’s Wort  Sam-e  Thyroxin  Testosterone (M/F)  Estrogen (F, in menopausal and post-partum depression)  Phototherapy (seasonal depression)  Exercise (mild depression)  Sleep deprivation (temporary) o Conditions associated with major depression and often treated with antidepressant meds  Chronic pain  Binge eating disorder  Bulimia nervosa  Migraine headache  Misc. anxiety disorders (panic disorder, OCD)  Trichotillomania  Compulsive zit-popping  Compulsive shopping  Compulsive gambling o ECT – old and new  Old  Retrograde amnesia  Caused seizures  1930’s-1950’s  medieval, traumatizing, etc.  New  Anesthetics, sedatives to lessen seizures  Facts  Works fastest of any therapy for depression  Mechanism of action unknown  Has fewest side effects of any therapy for depression (very high satisfaction ratings)  Sometimes causes spotty memory losses (episodic > semantic)  Usually applied only to right hemisphere to minimize speech disturbance  Abused in past, and now used only as a last resort, and for most severe cases  Comparative efficacy of depression treatments  ECT works fastest, for most people, and with fewest side effects  Meds and psychotherapy work equally well for most adults, but medication works faster  For adults, a combo of therapy and medication seems no more beneficial than either one alone  Adolescents, current recommendation is an SSRI plus cognitive-behavior therapy  Medication is the least expensive single mode of treatment  Treatment resistant depression  Up to 305 of patients do not respond to standard treatments  Strategies  Medication augmentation o Lithium or abilify o A second antidepressant o Thyroid medication o Stimulants (Ritalin, Straterra) o Side-effect management (sleep, sexual response) o Estrogen, testosterone  Risks of medication augmentation o Serotonin syndrome (agitation, euphoria/delirium, fevers, muscle contractions, seizures) o Precipitation of manic states  Medication + ECT  Vagal nerve stimulation  Experimental therapies for treatment-resistant depression  Transcranial magnetic stimulation/magnetic seizure therapy o Stimulate brain with magnetism o Some + effects from magnetic stimulation (repeated every day) o Could replace ECT within the next decade  ECT is reliable/has been studied/can be predicted = reluctant to give it up  Vagus nerve stimulation o Most confident of experimental therapies o Pacemaker device wires wrapped up and around vagus nerve o Only side effect observed = person immediately gets raspy voice o Use for when already tried combos, augmented meds, anti-depressants, ECT o Delivers ~20 pulses per second to electrodes wrapped around vagus nerve in back of throat, stimulator implanted in chest  Direct brain stimulation o Still very experimental, but could eventually be an alternative for these others Affective Disorders – Mania 4/3/2012 12:23:00 PM  Clinical features of mania  Euphoria or irritability o Intensity at any emotional state  Purposeless or reckless behavior  Persistent insomnia  Pressured speech, flight of ideas o Brain switches back and forth from ideas VERY quickly o Can’t follow their thoughts “do you have a pen I need a place to put my cattle”  Poor insight or frank psychosis  Sometimes, assaultiveness or suicidality o “I want to see what’s after death”  not time to think before plunging off a bridge  major depression and bipolar disorder  depression only = major depression (unipolar depression)  depression + mania = bipolar disorder o almost always find that patient has had background of deep, dark depression  unipolar and bipolar disorders  unipolar mood history o unipolar (major) depression o hypomania (mild mania)  very creative, write a lot very quickly, can’t slow down (people say they should get some rest)  sometimes goes undiagnosed  usually a judgment call o unipolar mania (rare)  ex: spotting UFO  bipolar mood history o cyclothymia  mild depression with hypomania o bipolar I disorder (worst)  bipolar depression with mania  very frank manic periods with deep, dark depressions o bipolar II disorder  bipolar depression with hypomania  deep, dark depressions; manic periods restrained o mixed episodes  bipolar depression and mania simultaneously  bipolar disorder  point prevalence (historically) ~ 1-1.5% but more recent studies suggest 3.5%  probably no sex difference in prevalence  associated with high rates of alcohol/drug abuse (40-50% higher than any other axis I disorder), criminal behavior, and anxiety disorders (~40%) o many people try to drown/sedate depression/mania with alcohol and drugs  age of first diagnosis ranges from 15-45 with most people diagnosed in their 20’s o college age = many first diagnoses  but sometimes seen in children (pediatric bipolar disorder) o spells of being rev’d up/slowing down with no explanation o SPELLS is what differentiates between BPD and ADHD  runs in families o family history of bipolar disorder in 30% of B.D. patients o 65% concordance rate in MZ twins, 14% in DZ twins o 20% of MZ twins in which one has BPD, the other will have major depression, suggesting some common inheritance o 10% concordance rate in 1 -degree relatives o probably multiples routes of genetic involvement  bipolar depression compared to major (unipolar) depression  depression is the more problematic state in bipolar disorder  most cases of bipolar disorder first appear as depressed phase  40% persons with bipolar disorder are initially diagnosed with major depression o must be very safe while diagnosing o if given antidepressants, will quickly become manic o how do you tell?  Usually ask about family history (bipolar/mania/talking fast, staying up all night?)  Watch very carefully to see if they start to switch  average age on onset is below age 25 compared to late 20’s for major depression  bipolar depression lasts longer, recurs more frequently, is more likely to reach psychotic levels, and can take twice as long to obtain remission with treatment  people with bipolar disorder spend up to 1/3 of their adult lives in depression  more likely to include reversed neurovegetative signs/symptoms and psychomotor retardation  ~1:1 sex ratio of diagnosis, as opposed to ~2:1 F:M ratio in major depression  more than 10% of people with bipolar disorder eventually suicide, mostly in depressed phase  many gene loci have been associated with bipolar disorder  shared loci between BPD and schizophrenia (2007)  manic vs. paranoid schizophrenic? o Ex: idea of aliens implanting in brains and stealing thoughts o Sometimes can only tell from family history o Responds to anti-manic depression (lithium, etc.)  bipolar… otherwise schizophrenic  Brain mechanisms in bipolar disorder  Brain mechanism is unknown, but may reflect defects in the metabolism of protein-kinase C (PKC), an enzyme involved in the calcium metabolism of neurons in specific brain areas; result is unstable levels of neurotransmitter release by these neurons  PKC activity is increased in manic patients and is thought to be normalized by anti-manic medications o Anti-manic medications AKA mood stabilizers  Specific PKC inhibitors (ex: tamoxifen, used to treat breast cancer) quickly bring acute mania under control  Many other hypotheses are under investigation  Pediatric bipolar disorder  Occurs in about 1% of children, sometimes as early as infancy o Infant bipolar: mood instability  rages, deep crying spells, Hypersexuality, pressures speech, racing thoughts, impaired judgment, delusions and hallucinations (imaginary friends NOT CONSIDERED delusional/psychotic for kids)  Up to ½ of severe childhood depressions become adult bipolar disorder  About ½ of children treated for depression with SSRI’s develop manic or hypomanic episodes  Typically a 10-year lag between occurrence of first signs/symptoms (sx) and onset of treatment  Often confused with ADHD due to shared symptoms (sx) of distractibility and hyperactivity o Distinction between episodic nature o ADHD = there all the time o PBD = more spell-like (come on and go away)  Mixed episodes (mania and depression ARE NOT opposites)  Crying  Irritability/anger  Suicidal ideation  with  euphoria  Hypersexuality  Racing thoughts  Severe insomnia  Auditory hallucinations  NOTE: many mixed episodes are actually “switches” or manias emerging out of depressions (half way point between switching) o Many suicides occur during mixed episodes o Handle mixed episodes with sedatives (mellow them out as quickly as possible)  Rapid cycling bipolar disorder  DSM IV: four or more episodes (depression or manias/hypomanias) per year  Cycling can occur within days or hours  About 15% of bipolar patients are rapid cyclers, more frequent in women  Treatments for bipolar disorder st  Medication is 1 -line treatment, but med compliance only ~30% o Acute management (with antipsychotic medications) followed by introduction of a mood stabilizer for chronic management  Psychotherapy o Usually requires prior medication response to be valuable o Builds compliance to medication o Helps patient (and family) understand impact of disorder o No effect on disorder itself  ECT (rarely used, but somewhat effective) o Rely on ECT to get over deep, dark depression  Induced sleep (very rarely) o Sleeping med in height of mania  keep them asleep for 2-3 days = wake up no longer manic; yet awake for 1-2 days = manic again  Medications for chronic management of bipolar disorder  Antimanic action (top of list)  antidepressant action (bottom of list) o Lithium carbonate (strong antimanic and anti-suicide but weak antidepressant actions)  Toxic to kidneys long term (must have kidney dr. watch your kidneys for functionality)  Deforms fetuses (don’t take if pregnant)  Cardiotoxic (can’t have much lithium around suicidal patients) o Anticonvulsants (moderate antimanic and antidepressant actions/ decent mood-stabilizing qualities)  Lamictal – has uniquely strong antidepressant properties, and appears weight-neutral (favored med for bipolar disorder)  Tegretol, Neurontin  For rapid cycling bipolar disorder, Depakote and Topamax (typically give good mood stabilizer, along with antidepressant)  Antimanic med 1 st nd  Antidepressant med 2 o Antipsychotic agents (moderate antimanic and antidepressant actions)  Abilify (weight-neutral), Zyprexa, Risperdal o Antidepressants (strong antidepressant actions but increase risk of “switching” into mania or mixed states) o Standard of care: Polypharmacy (more than one medication)  Affective disorders may be associated with creativity  “no one has ever written, painted, sculpted, modeled, built, or invented except literally to get out of hell.” – Artaud  bipolar disorder and creativity o Nancy Anderson  study of writers at Iowa’s writing workshop o Kate Jamison  study of writers and artists  70% of writers cyclothymia  likely sufferers of bipolar disorder o Lincoln, etc.  Kay Redfield Jamison Touched with Fire (1993)  Bipolar I  Many suicide attempts  Discovered bipolar disorder in college  The upside of bipolar disorder  The “well” relatives of people with BD appear to have higher rates of achievement, success, and creativity Anxiety Disorders – Formerly “Neurosis” 4/3/2012 12:23:00 PM  Midterm Stuff  SQ3R method of studying o Look it up  Parscore pink 100 ? size  Common signs/symptoms of anxiety  Cognitive o Objectless fear or feeling apprehensiveness o Heightened sense of vulnerability o Worrying and rumination (obsessive thinking of something) o Going blank or spacing out o Irritability, impatience, distractibility o Hypervigilance  Physiological o Trembling, twitching, feeling shaky o Fatigue, restlessness o Muscle tension, jitteriness o Dizziness, lightheadedness o Fast heartbeat, breathing rate, can describe heart palpitations (skipping a beat) o Sweating, cold or clammy hands o Dry mouth, nausea, diarrhea o Altered appetite and sleep  Typically getting to sleep = issue  Signs/symptoms of panic attack (acute anxiety episode)  Palpitations, pounding heart, or accelerated heart rate  Sweating  Trembling or shaking  Sensations of shortness of breath, choking, smothering  Chest pain or discomfort  Nausea or abdominal distress  Feeling dizzy, unsteady, lightheaded, or faint  Derealization (feelings of unreality)  Depersonalization (being detached from oneself) o Out of body experiences  Fear of dying, losing control or going crazy  Paresthesias (numbness or tingling sensations)  Chills or hot flushes  Autonomic arousal and the brain  Amygdala – registers situations as threatening  Locus Coerculeus – governs activation of neocortex, hypothalamic- pituitary axis, and autonomic nervous system (“get ready for an emergency” message sent out)  Anxiety-related actions of the sympathetic nervous system  Pituitary release of ACTH  Adrenal secretion of epinephrine and norepinephrine  Pupillary dilation  Drying of mucosal linings (mouth, stomach, intestines, etc.)  GABA and anxiety  Sites related to anxiety in animals involve the neurotransmitter GABA (gamma-amibonutyric Acid)  Anxiety-prone people have deficits in GABA  Chemically blocking GABA increases anxiety  GABA is only one of many neurotransmitters involved in anxiety o GABA and 5HT (serotonin) inhibit anxiety o Epinephrine, norepinephrine, and dopamine provoke the physiological changes that can lead to anxiety  Ethyl alcohol (ETOH) and common anti-anxiety medications bind to GABA receptor areas and mimic GABA  Major anxiety disorders  Most frequently occurring psychiatric problems in the general population  Overall, they run strongly in families, and are co-morbid (multiple disorders simultaneously) with depression and stress disorders (50- 70% of people with lifetime depression also have lifetime anxiety disorders) – suggesting a common “distress” inheritance  Carry increased risk of alcoholism/drug abuse and “self-medication”  DSM-IV-TR classification of anxiety disorders o Generalized anxiety disorder o Panic disorder, with and without agoraphobia o Social anxiety disorder (social phobia) o Specific phobias o Obsessive-compulsive disorder o Stress disorders  Acute  Post-traumatic  Some common physical disorders that can mask as “anxiety disorders”  Hyperthyroidism  Pheochromocytomas (adrenal tumors that over-secrete adrenalin)  Inner ear disease  Angina pectoris  Hypoglycemia  Mitral valve prolapse  Cardiac arrhythmias  Drug effects (caffeinism, nicotine addiction, nasal decongestants, asthma inhalers or other stimulants)  General diagnostic criteria for generalized anxiety disorder (GAD)  Description o Debilitating worry, fretfulness o Worry is hard to control o Varied anxiety symptoms: restlessness, fatigue, difficulty concentrating or mind going blank, irritability, muscle tension, insomnia o Often arises with, or just before or after, major depression  Facts about GAD o 1-year prevalence 3-4% o usually emerges during adolescence o F > M 2:1 ratio o 75% of GAD sufferers have another mental disorder, usually major depression o affects 10-20% of the elderly, who are beset with frailty, medical illness, and losses – which lead to vulnerability and fear o 36% of GAD sufferers self-medicate with ethyl alcohol (ETOH) and other drugs (marijuana, for example) o substance use often develops with GAD and so causality may be bi-directional  symptomatic treatments for anxiety o habit control (ex: coffee, cigarettes, stimulant medications) o anxiolytic (anti-anxiety) medications  for acute use  benzodiazepines (Xanax [habit forming], Ativan, klonopin, valium)  rarely: beta-blockers (Tenormin, Inderal)  help with body issues of anxiety, not mind issues  for chronic use  most often SSRI’s (Prozac, Lexapro, etc.) or atypical antidepressants (Cymbalta, Effexor)  occasionally for intense, psychotic anxiety:  atypical anxiolytics (buspar)  antipsychotics (abilify, Seroquel, Risperdal, zyprexa)  psychotherapy  supportive, cathartic  relaxation and medication techniques  stress management training  biofeedback  exercise  for mild – moderate anxiety  support groups  panic disorder  description o occurrence of panic attacks without warning o pattern of avoidance and disability as a result o ritualized avoidance becomes panic disorder with agoraphobia (when avoiding, automatically diagnoses agoraphobic)  home or room within the home, becomes “safety zone”  reluctance to venture outside safety zone without “escape route”  facts o one year prevalence ~ 2.3% o lifetime prevalence ~ 3/5% o develops mostly during late teens (15-19) o female : male ratio ~ 2:1 o increased risk with background of child abuse/neglect, and with mitral valve prolapse o panic attacks can be triggered in susceptible people by:  yohimbine (sympathetic NS stimulant)  sodium lactate (exercise waste-product)  caffeine, nicotine (sympathetic NS stimulant)  marijuana st  1 line panic disorder treatments o dietary/medication control (caffeine, nicotine, marijuana) o anxiolytic medications (benzodiazepines, mainly Xanax) – for acute use only o antidepressant medication (mainly, SSRI’s), chronically as preventative o psychotherapy  cognitive therapy  make sure don’t have cardiac med issues FIRST  normalization, de-catastrophizing, paced metronomic breathing  supportive therapy o in vivo desensitization if agoraphobia is present  master things that are just outside comfort zone  in vivo = real life  social anxiety disorder (social phobia)  most common anxiety disorder o 1 year prevalence of ~8%; lifetime prevalence up to 15% o more common in females ratio of 1.5 : 1 o develops in late adolescence or young adulthood o grossly under-diagnosed in managed care population  occurs when people become disabled by o intense, persistent, and chronic fears of being watched and judged by others, and of doing things that will be humiliating or embarrassing o can be generalized or occur in specific situations (non- generalized) o 1/3 are sufferers are very disabled, and are more likely to be depressed, divorced, unemployed or under employed  awareness that fears are excessive  common “performance situations”  life is constantly a performance “Did I say good morning okay? Did I seem cheerful enough?” Etc. o public speaking (toastmasters) o public restroom use o going to parties o eating in front of others o bedroom (some erectile dysfunction, some orgasmic dysfunctions)  most commonly treated with medications (benzodiazepines and/or SSRI’s) plus supportive and proactive psychotherapy  specific phobias  description o persistent fears or panic attacks out of proportion to situation o compelling desire to avoid phobic stimulus o insight that fear is excessive o symptoms are unrelated to another disorder  facts o have a one year prevalence of ~7% and a lifetime prevalence of ~9% in the U.S. o mean duration of a specific phobia is about 20 years o females > males 2:1 to 3:1 ratio  types of specific phobias o animal type o natural environment type (storms, heights, water) o situation type (claustrophobia, tunnels, bridges, flying, driving) o bodily reactions (vomiting, headache, fever) o blood-injury-injection type (vasovagal reaction)  light headed, faint, blood pressure drop, nausea o nature of phobic stimuli undercuts a straightforward conditioning view of specific phobia  treatment for specific phobias o all treatment are complicated by avoidance behavior o anxiolytic or antidepressant medication (preferably SSRI) o systematic desensitization o in vivo desensitization – effective, but low treatment acceptance and high therapy dropout rates o applied tension for blood-injection phobias o experimental: VR therapy for flying and height phobias o self-help groups  Obsessive Compulsive Disorder (OCD)  Description o Debilitating, unwanted (ego-dystonic)  Obsessions (intrusive thoughts, impulses, images)  Compulsions (repetitive behavior to ward off anxiety or an unwanted impulse) o Recognition that one’s obsessions and compulsions are excessive or unreasonable o Significant distress or impairment for one hour per day  Facts o One year prevalence ~ 2% o About 80% ocd sufferers have coexisting major depression o ½ of OCD cases begin in childhood, and these childhood cases are mostly males and are more severe o ocd cases beginning in adolescence of adulthood are less severe, and females = males in prevalence o 20% of ocd cases have 1 degree relatives with ocd  Causes? o Basal ganglia + frontal cortex = areas of brain involved  Usually regulates brain thought “listening to professor, what’s my homework? Remember to check the mail.”  OCD = stuck on what’s my homework? o Frontal cortex and ocd  Prefrontal areas of brain with OCD = massively overworking  Cannot smoothly shift attention from one item to the next item  Common obsessions and compulsions o obsessions  Multiple obsessions  Contamination, excessive doubt  Fear of causing harm to self or others  Fear of being sexually inappropriate  Need for symmetry or exactness  Other (praying, repeating words, etc.) o Compulsions  Multiple compulsions  Checking  Washing  Counting  Arranging/organizing  Collecting/hoarding o 98% of OCD sufferers have both obsessions and compulsions  disorders related to OCD (OCD spectrum disorders) o Gilles de la Tourette syndrome  Anxiety (great deal of anxiety building, and if they don’t let the tic or involuntary sound out, the anxiety will be unbearable)  tics (mild form)  coprolalia (involuntary uttering sounds/cuss words) o trichotillomania (pulling/twisting of hair, picking scabs on scalp, etc.) o onychophagia (severe, chronic nail-biting) o hypochondriasis (obsessing you have a disease; repeatedly go to doctor for it) o bulimia nervosa, anorexia nervosa (resemble OCD cycle)  desire to binge, purge, etc.  obsessive counting of calories, foods, etc. o body dysmorphic disorder  obsessive concern about appearance and body parts (skin, hair, nose)  compulsions (mirror checking, camouflaging, grooming, skin picking)  half of BDD individuals are delusional  pattern of anxious avoidance of others  body integrity identity disorder (BIID) – an OCD spectruym disorder? o Belief, usually from early childhood, that one or more limbs (usually legs) do not “belong” to one’s body, and that amputation of the limbs will achieve “wholeness” o Certainly regarding the limbs involved and the level of amputation desired o Rehearsal activity (pretending) during which they imitate the amputated state in private and in public o Pursuit of elective amputation or attempts at self-amputation o BIID can include non-amputation bodily changes, such as beliefs that one “should” be deaf  Streptococcus and OCD: PANDAS o Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections o Seen in school age children who develop strep throat or strep rash, usually with fever and urinary incontinence o Sudden onset of tic disorder, or ocd signs/symptoms, most commonly hand washing and preoccupation with germs o Rapid remission of symptoms usually occurs with antibiotic therapy o PANDAS accounts for only a small % of childhood ocd  1 line ocd treatments o antidepressant therapy with serotonin-boosting medications  ssri’s  tricyclics (especially clomipramine) o behavior therapy  thought stopping  response prevention  knock stack of books over, but tie their hands behind their back o psychosurgery (cingulatomoy) for otherwise intractable cases Leftover 4/3/2012 12:23:00 PM  Reactions to Extreme Trauma  Intrusive recollections (daytime flashbacks, nightmares, illusions) and acute distress upon cues suggestive of the trauma  Dissociative symptoms (psychic numbing) o Emotional detachment o Being in a daze o Dropping out of usual activities o Avoidance of topics related to trauma o Forgetting or “fogginess” re: key aspects of trauma o Feeling that the current setting is not real (Derealization) o Feeling detached from one’s body (depersonalization)  Chronic hyperarousal: exaggerated startle, insomnia, hypervigilance, motor restlessness  Irritability and aggressiveness (esp. males)  Survival guilt (suffer trauma with people  best friend dies in war, should’ve been you)  Traumas that can precipitate stress disorders  Most common traumas: o Rape, attempted rape, an assault (>300,000 rapes and attempted rapes per year in U.S. 15:1 W:M) o Military combat (usually men)  Other precipitants: o Accidental human calamities (motor vehicle accidents, plane crashes) o Floods, earthquakes, fires o Deliberate human calamities (bomb
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