Psy 103- Psychopathology Lectures

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PSY 103

Psychopathology Lect #1 8/8/2013 2:00:00 PM History and Concepts in Psychopathology  Prevalence: 46.4% will have a mental disorder, 26.4% in 12 month period, 5.8% pop will be classified as severe  Mental Illness Distribution: female > male, 18-24yrs > 25-40 > 41+, white, Hispanic > asian, black  Issues in Psychopathology-  Nosology  Assessment  Diagnosis  Treatment  Prevention  Professions Involved in Mental Health-  Psychiatrists (M.D.‟s): o Go to med school o Treat patients with medical means o “bottom” of medical hierarchy o barely above witch doctors o “internests of the mind”- became psychopharmacologist  nowadays, prescibe meds to patients  Clinical Psychologists (Ph.D.‟s): o 5-6 year programs, o psychological research involving mental disorders, methods for diagnosis, therapy on a years internship, clinical training  Social Workers (M.S.W.‟s / D.S.W.‟s): o Applied mental health workers o Front lines in medical realm o 2 year MSW program o case managers in health management system o go out in field, hook clients up with entitlements (food, clean housing, water, therapy)  Psychiatric Nurses (R.N.‟s): o Found in mental hospitals or outpatient mental places o May see patients who need periodic visits  Marriage & Family Therapists (M.F.T.‟s): o 1-2 yr training program o specialize in adjustment disorders (jobs, motherhood, role problems)  Psych Technicians: o Escort patients around mental institutions o Replaced somewhat by nurses aids in mental facilities  MH Intake Workers, Staff: o Insurance, billing, assesments, intake  Primary Care Practitioner M.D.‟s (PCP‟s), Physician‟s Assistants (P.A.‟s), and Nurse Practitioners (N.P.‟s): o PCP- everyday doctor, most likely will prescibe medicine for depression o PA/NP- fastest growing paramedical professions in US  Work for less money, trained more, MD‟s are declining in numbers  PA‟s- work under MD. Develop own patient-case load  NP- are RN who specialize beyond the RN and become individual NP. Prescribe MD, own patients, practice as psychiatrists do.  Mental Health Researchers-  Neuroanatomists:  Neurochemists:  Geneticists: study inheritance of mental disorders and how medication will react  Epidemiologists: how mental disorders might be spread in a population. Prevalence, epidemic, culture, customs.  Psychopharmacologists:  Psychiatrists  Clinical psychologists: Psychopathology Lect #2 8/8/2013 2:00:00 PM  Trephining-  Holes found from ancient skulls  Thought was that people had evil spirits in head and had a hole cut into skull to release the spirits (had neuropsychological diseases)  Earliest believed form of neurosurgery  No evidence that trephining works, more like placebo effect  Most effective treatment for extreme depression is actually convulsive shock therapy o Not the barbaric ways of the past  Humoral Theory (Hippocrates)-  Believed that fluid controlled actions and beliefs  Melancholic- black bile o Deep, dark depression, morose, repetitive dwelling  Choleric- yellow bile o Hair trigger temper o Easily pissed off, irritable  Phlegmatic- excess of plem o Stoic, almost comical, things roll of back,  Sanguine- blood o Extra Cheerful person, upbeat, can be manic  Demonic Possession-  500-1500 AD: Europe hit with famines, plagues  couldn‟t explain natural phenomenon‟s, turned to demonological theories to explain  treatments extremely bizarre o “baking out”- head in oven, go in as rambling, come out quiet and submissive. Therefore, treatment “worked”  Catholic Church  has HUGE influence during the time  Women were considered the heart of corruption  Women could tempt priests etc. became scapegoats  Catholic Church were caretakers of ill o priests became primitive psychologists o nuns became primitive nurses  Malleus Maleficarum (“Witches’ Hammer”) [1486]- first diagnosis of witches o Required that women who were believed to be witches must undergo tests  Diagnosing Witches: o Women were dropped into the water o If sank= innocent, floated= witch  Treating Witches: Exorcism o Various incantations were said to get devil out  Treating Witches: Burning o The devil would leave the woman‟s body at the last second  Mental Illness as Evolutionary Regression: “Mongolism” (Down’s Syndrome): o Evolution was the result of ascendency. o Humans were God‟s gift to world o Darwinism:  Emerged throughout Europe o Mental ill= people who regressed in evolution o Dr. John Langdon Down- 1850  Called it Mongolism  Thought that mental retardation was because they didn‟t evolve past the level of the Mongols (Asians)  Mental Illness as Evolutionary Regression: o Mentally Ill as Animals  Portrayed as inhuman because didn‟t have mental capacity or evolutionary excellence of humans o Mentally Ill Housed as Animals  Literally kept in cages  Goya’s Madhouse (c. 1810)  Elite spectated the mentally ill as if entertainment  Treatment By Restraint  Go in agitated, come out sedated  “Moral Treatment”, or “Unchaining the Insane” o metally ill had somehow degenerated into infantility or gone back to an early non adult stage o “retrained” to childhood then shaped to adolescence then adulthood o restraints, whips, chains like training an animal to behave  habits build civilized aduts  The “State Hospital” Era: o Pastoral communites that used to be run by secular church o Priest= psychiatrists, nuns= nurses o Patients tended own crops, made own clothes, but all done with help of nuns o “NIMBY”- not in my backyard o someone could be committed  never hear from them again, trusted that patients were going ot be taken care of o some turned into torture chambers  priests became power hungry  nurses became control freaks  tortured and abused  Deinstitutionalization: o “The Hotel California” Camarillo, CA 1936-1997 o trying to get schizophrenic patients off meds  a patient hung himself, which lead to investigations and ultimately closure o Now, Cal State Channel Islands o State hospitals had numerous law suits  Most are closed  Civil rights groups fought for many rights for patients  Local community health centers were promised to be set up instead of State Hospitals  Money never found its way to those communitites  Released patients are many of the homeless population  Contemporary Views of Psychopathology: Psychodynamic Views o Psychodynamic- Forces within your mind  Growing up, experiences mould you, which are going to color how you react as an adult  Family interactions, abuse, neglect,  Often takes people outside our everyday circle to observe and explain to us how we act  Mesmer- French dilatants  Forces of magnetism  Rich Parisian women would swoon over the magnetism  “Mesmerized” aka “hypnotized”  Charcot- director of state hospital  Used hypnotism  Performed to scientists  Discovered as a fraud  Freud- Viennese neurologist  Fascinated and took back idea to his own practice  Failed at hypnosis  dream analysis  psychoanalysis  Contemporary Views of Psychopathology: Behavioral Views: o Learning concurrently  Operant  Classical Conditioning:  Can be influenced by early trauma  Watson & Rayner:  Exposed a 9 month old baby to animals  Struck a metal pole behind baby during exposure to each animal until baby cried  Wanted to show that human emotions are conditioned  Extremely audacious and unethical  Found that it was all a fraud, and the baby was severely mentally impaired  Contemporary Views of Psychopathology: Biological Views: o Based on a material reductionist view  Workings of the mind reflect workings of the machine  Leading view for past 20-30 years in neurscience  Mental disorders= physical  What is the best way to reach in and fix? Medicine (as of date)  Prozac- released, best anti-depression med  Family practitioners would prescribe  Meant that psychiatrist became deprived of bread and butter patient  What Is A Mental Illness?  Why Is This Issue Important?  "Our culture is permeated with psychiatric thought. Psychiatry, which had its beginnings in the care of the sick, has expanded its net to include everyone, and it exercises its authority over this total population by methods that range from enforced therapy and coerced control to the advancement of ideas and the promulgation of values.”- Jonas Robitscher  The Concept of “Mental Illness” Depends on Basic Philosophical Assumptions  Monism- o Mind Is equal/reducible to Brain o Any way we behave boils down to hardware  Dualism- o Mind is different from Brain  Think of a radio. One machine but by turning the knob, can play different genres  Philosophical Implications for “Mental Illness” o Monism  Mental illness is brain illness, a type of medical illness. o Dualism  Mental Illness is ?.  "The mind cannot really become diseased any more than the intellect can become abscessed. Furthermore, the idea that mental 'diseases' are actually brain diseases creates a strange category of 'diseases' which are, by definition, without known cause. Body and behavior become intertwined in this confusion until they are no longer distinguishable. It is necessary to return to first principles: a disease is something you have, behavior is something you do.“ -E. Fuller Torrey, M.D.  Scope of Mental Illness-  Originally, “mental illness” was synonymous with “insanity,” reserved for psychoses and sudden disabling or bizarre changes in behavior / thinking. o Insanity= legal term by court of law that defendant was judged incapable of knowing the consequences of actions during a crime  “Mental illness” has been broadened: o Now “mental disorder” rather than “mental illness”  Illnesses are interpreted as things wrong with body  Can‟t demonstrate bady tissue or neurons but can show people behaving in a disorderly way o “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 disorders have been proposed; all have problems, and there is no consistent, logical way of defining psychopathology  Why Worry About How To Define Mental Disorder?  Mental disorder diagnoses are: o Stigmatizing  Goes on record, can‟t get hired in many places o sometimes used as tools of political persecution.  o used to marginalize dissent (S. Halleck, The politics of therapy, 1971). o used to excuse defendants and others from responsibility for their actions (i.e., Allan Dershowitz‟s “excuse abuse”).  Person commits crime not personality  Hope: A valid and consistent definition of “mental disorder” will produce no false positives and no false negatives.  Underlying Dichotomies That Drive Attempts to Define “Mental Disorder”  Is a condition normal or abnormal? Many different criteria: o Deviance (statistical, moral):  Repetitive actions over and over causing fear and anxiety  Checking alarm clock o Distress (self and/or others):  When is misery is justified or excessive  When do we say this is a disorder?  Also disorders where patients are fine but cause stress and chaos to others o Dysfunction (inability, efficiency, maladaptation) :  Life is just awful for them  Maladaptive actions  “shooting themselves in their foot repeatedly”  sometimes self recognition, spouse, parental, court o Danger (self and/or others):  Is a person ill or evil? (Disorder or sin?) o What about a pedophile?  Some say that “they are not evil but they have a miswiring of the nervous system”  Others say that “they are evil”  Others say that “they are sick and need help”  Is the professional response to the condition treatment or oppression? o How a society responds to mental disorders is a way of determining how it regards mental disorders o Incarceration? Prison? Therapy and rehab?  What do we do to people with mental disorder?  How we react show our deepest feelings towards mental disorders  Current Official View- (American Psychiatric Association, 1994)  A mental disorder is: o a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual; and that is associated with:  present distress (e.g., a painful symptom), or  disability (i.e., 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. o this view is the basis of the Diagnostic and Statistical Manual of Mental Disorders, current in its 4th Edition.  How do we learn what mental disorders look like?  Prototype Theory o Theories of meaning: Definitions of Disorder: o Definitional theory of meaning  Semantic definitions o Prototype theory of meaning  Prototype definitions o Semantic Definition-  The study concerned with the relations between signs and their referents;  the relations between the signs of a system;  human behavioral reaction to signs, including unconscious attitudes, influences of social institutions, and epistemologic and linguistic assumptions. o Prototype Definition-  Making typical identifications based on characterizations  However, not all subjects in that category have all those characteristics  EX: a dog= fur, tail, 4 legs, bark, loyal. But some dogs don‟t have these traits  Where do people acquire these mental disorder prototypes?  Repeated exposure to conditions perceived as necessitating mental health intervention  Personal and indirect (books, films, TV) experiences where people are seen to have unwanted conditions requiring mental health intervention  In training as a mental health professional, through classic case studies or supervised experiments  Nosology-  Science or scheme of disease categorization and classification  Process of coming up with classification  Scheme of possible lables  Ex: if lung nosologist, study all the causes and diseases  Neural Nosology: List of mental disorders that people are diagnosed with  Diagnosis-  Act of assigning a nosological category to a patient  Collection of all the possible labels from nosology  Basic Terminology:  Etiology: cause o All the risk factors added together  Course= trajectory o Some have a smooth course: chronic o Others: acute flair ups, chronic deteriorating, acute course then never again  Prognosis- outcome o Endpoint of disorder o Normally good or poor prognosis o EX: alzheimers type dementia= poor prognosis  Signs= observable markers o Signs patients give off  Symptoms= patient reports o What patient tells you  Signs + symptoms= syndrome  Syndrome + course= disease Psychopathology Lecture #3 8/8/2013 2:00:00 PM  Why Diagnose At All?  Prognosis: o good prognosis or poor  Treatment implications: o different medications, predict better responses, different counseling approaches  Communication among profession: o shorthand communication, gives medical/ psychological jargon, understand condition  Establish prospects for contagion or other transmission, and possible prevention:  Legal reasons (e.g., competence, insanity determinations): o judge wants to know if accused or juror or persons involved in the case are mentally stable  Financial reasons (compensation to patient and/or treatment provider): o worker‟s comp, insurance companies have big interest  Research: o can work towards a cure  Problems Inherent in the Act of Diagnosis  Sacrifices the uniqueness of individual patient: o people get fed into the system, life stories/ special factors are lost, fit into categories  Ex: Bipolar I, 23 yr old male.  Can falsely imply etiology (cause): o went looking for causes that psychologists believed were true. If wasn‟t there, must be repressed.  Rigidifies treatment alternatives: o “cookbook treatment styles”  Iatrogenic illness: “healer” “beginnings” o The healer causes the patient to become ill o Therapy backfires (psychologists), medicine backfires (psychiatrists) o Fail to understand cultural differences and advice gives rise to new problems  Stigmatization: o People don‟t want others to know they are getting help  Secondary gain: o Benefits patients get from diagnosis o Disability is more profitable than working  Two Kinds of Diagnosis  Phenotypic: o Signs: observable traits o Symptoms: what patient feels o Course: how long symptoms and signs persist o Outcome: o Response to treatment: how successful was recovery using prescribed treatment  Genotypic: o Cause: genes and germs o Laboratory tests  In physical medicine, progress consists of moving from phenotypic to genotypic diagnosis.  In mental health, nearly all diagnosis is phenotypic.  Ingredients of a Diagnosis-  Symptoms:  Signs:  Course of illness:  Age of Onset:  Family History  Recent events  Recent behavior:  Psychological tests  Laboratory tests (eg neuroimagins, hormonal assays, genetic testing)  Response to treatment (current or prior):  Multifactorial nature to Diagnosis-  No one sign/symptom defines a mental disorder o Ex: hearing voices can be found in schizophrenia, or drug users, alcohol bouts, urinary infection patients  Diagnosis based on pattern of signs and symptoms  The patterns of syndromes and courses of illness, that define mental disorders are spelled out in Nosology of mental disorders  Nosologies for Mental Disorder:  Diagnostic and Statistical Manuals for Mental Disorder (DSM series)  1952- DSM-I (100 disorders in 8 categories) o consisted of brief paragraphs containing “horoscopic” descriptions of each disorder (both DSM-I and II) o deciding which disorder fit a particular patient was highly subjective and proved statistically unreliable.  1960 DSM- II (100 disorders in 10 categories)  1980 DSM- III (230 disorders in 19 categories) o research oriented psychologists and psychiatrists that came up with whole new manual of diagnoses o got rid of anything neurosis or unconscious  1989 DSM –IIIR (750 in 40 categories)  1994 DSM – IV  2000 DSM –IV-TR  Features of DSM- III, IIIR, IV, IV-TR: o Phenotypic diagnosis:  Based only on observable signs/ symptoms  Abandoned intrapsychic conjectures and terms like neurosis and reaction  “Chinese-menu” decision-tree approach  inclusion/ exclusion criteria  field tested for reliability  multiaxial diagnosis  DSM-IV Multiaxial Diagnosis: o Axis I: major mental disorders and V-codes o Axis II: personality disorders and mental retardation o Axis III: general medical conditions o Axis IV: psychosocial/ enviro problems o Axis V: global assessment of functioning  Clinical Interview: Types of Information and Goals  ~1 hr; most valuable single source of info leading to a diagnosis  personal and family history: medical, mental health, social, occupational, financial problems  treatments that have worked/ not worked in past  symptomatology: o what brings you here today? What have you been feeling?  signs from patient‟s presentation: o attire & grooming, o posture, o physical characteristics (skin tone, weight, stature, symmetry, bodily anomalies), o mannerisms, spasms/tics, o speech (articulation, prosody), o consciousness (level of alertness, fogginess, hypervigilance), emotional state, o general attitude (defiant, compliant, guarded, defensive, sincere, plaintive, resistant, apathetic) o thought content (solicited by free inquiry) o thought processes (thought broadcasting, removal, insertion) o general knowledge (facts, pop culture)  Ex: what is your opinion of _____? o abstract thinking:  ex: is your life how you imagined it would be when you were 10? o social judgment: o insight o cognitive functioning o goals:  suitability and readiness for psychotherapy (self or another therapist)  determined need for referral to:  psychiatrist or PCP for medication  neurologist for neurological testing and/ or neuroimaging  social worker, vocational counselor, physical therapist  Mini Mental Status Exam-  Orientation: (up to 3x) o Time, place, person  Registration: o Names of 3 common objects, ask patients to repeat them  Attention & calculation: o Serial 7‟s or WORLD backwards  Recall: o Ask for the names of 3 common objects  Language: o Write a sentence o Copy a design  Family history= important b/c it influences the risk of specific mental disorders  Highest genetic disorder: Alcoholism Depression-  Clinical features:  Cognitive: o Pervasive sadness, guilt, or feelings of worthlessness  Guilt is main factor in European definition o Recurrent thoughts of death or suicide  Motivational: o Pervasive anhedonia  Nothing brings you pleasure or enjoyment  Neurovegetative: o Significant change in weight  15-20 lbs average loss  Exceptions: carbohydrate cravers o Sleep disturbance  Go to bed at normal time but wake up at odd hours  Feel wrung out, exhausted, can‟t go back to sleep  Exceptions: hypersomnias o Psychomotor agitation or retardation  Can‟t sit still  Others cant move at all, almost painful, energy expending, exhausting o Pervasive fatigue or loss of energy  Even small activities are going to exhaust them o Difficulty concentrating  Too much of an effort, so can‟t complete thoughts  Prevalence:  About 5% of US at all time  One- year prevalence: ~10%  Lifetime prevalence: 15-20% (26% women, 12% men)  Subsyndromal depression: just below the criteria to be diagnosed to be depressed o 15-20% of US pop at anytime suffer  in western countries, depression varies than non-western o find guilt and worthlessness in western countries o in non-western: treated as physical illness  Risk Factors-  Genetic predisposition: evidence from adoptions and twin studies  Personal loss: or gain, no silver lining w/o a cloud  Prolonged psychological stress  History of early abuse or neglect  Being in an industrialized nation  Not race or social class o Social class predicts everything about social health except depression st  Age of 1 onset in later 20‟s  Physical illness/ chronic pain  Giving birth: Baby Blues o Depression can follow because of how exhausting the process is. o Post- partum depression: see baby is a demon or possessed  Emerges most when mother has genetic risk of schizophrenia  Female: Male Ratio- 2:1 after puberty  Previous depression kindles later depression  Harry Harlow-  Abused as a child, became perpetrator of abuse to monkey subjects  Monkey Depression Research- o Put monkeys in bottomless pit, became to chew own limbs, curled in ball o Released them with other monkeys who were abused o Clung to each other o Conclusion: Effects of early abuse are deep and pretty much irreversible  Never as resilient, much more vulnerable  Can live a normal life if have adequate social support  “kindling”-  each depression increases the risk of later depression, regardless of life stress  Woman Dominance in Depression-  Could be due to: o X-linked depression genes o Premenstrual symptoms  Elevate to some degree the prevalence of depression of women o Quality of female vs male life  Men have more privileges in society while women have more responsibilities, fewer freedoms  Problems with sociological critic: female lifespan= longer than males o Female masochism (Freud):  Early in upbringing, realized that they did not a male genitals which meant they don‟t have the thing to make it in the world.  Instead had a consolation prize: a baby o Cognitive style  Females dwell on problems  Males ignore of escape them o Male depression masked by alcohol/drug abuse (Amish Study) Psychopathology Lecture #4 8/8/2013 2:00:00 PM “Depression”- st  1 Line Depression Treatments- o psychotherapy: esp, interpersonal or cognitive therapy  more expensive, takes longer  still have postive results but insurance doesn‟t usually pay for it o antidepressant medication:  cheaper, more positive results over a wider range of patients  quicker results o phototherapy for seasonal depression  in places where winters are dark, cold, lonely, long  almost like a hibernation response  much more effective and quicker than medication  Symptoms: carb cravings, put on weight, sleep o ECT for treatment- refractory depression  Tends to be extremely effective for many types of depression  Cognitive Therapy-  Uncovering automatic self-defeating thinking patterns o Believed this is why patients were depressed  Developing new ways to interpret setbacks (normalization, analyzing logically, decatastrophizing) o Goal of Cognitive Therapists: counter negative self-thinking, taking sting out of the situation  Replacing old “automatic” thoughts with new ones  Prime areas of concern: o the self- see themselves as worthless o life events- victims of bad luck o the future- see future as hopeless and powerless to change it  Became popular after the World War I o Focused on symptom removal and goal specification  Focuses on thinking to combat depression  Interpersonal Therapy-  Central Themes- o Grief- delayed mourning, developing replacement relationships o Fights- building skills in communication, negotionation and assertiveness  Need to know how to “fight” o Role transitions- reevaluating the lost role, building a new role, developing new social supports  Ex: leaving home, divorce, retirement  Saying goodbye to people and behaviors that characterize the old position o Social deficits- using role playing to learn new behavior in relaitonships  Failure patterns in past relationships  Focuses on social support to combat depression  Neurochemical Theories of Depression-  Neurotransmitter Theories- Basically discarded, not central implication of why antidepressants work o Major transmitters implicated: NO, EP, DA, 5HT o Also: Substance P, NMDA, Neurosteroids  Endocrine Theories- o Hypothalamus- pituitary  Pituitary= master gland and released different hormones and amounts when depressed o Thyroid  Regulates basic metabolism  Controlled by pituitary o Adrenal (cortisol)  Secreted by adrenal glands on top of kidneys  Usually secrete high amounts when depressed o Sex hormone (testosterone, estrogen)  Low in both are depressed  Neurotrophic factors- o Promote neuronal growth and axonal and dendritic sprouting o EX: BDNF (brain derived neurotrophic factor)  Spur growth of connections between neurons  A depressed brain= loses connections, brain gets lighter, brain wastes away, less active  Neurochemical Disturbances in Depression-  Depression associated w/: o Reductions of BDNR and other growth factors o Alter levels of activity in limbic system, PFC, other brain regions o Regress into states of vegetation, muteness, unable to feed themselves in severe depressive states o Increased levels of neurosteroid hormones  Promote neuronal death and glial cell damage  Both fast and slow communication in brain stopped  Antidepressant medications: o Results in restoration of normal levels of BDNF and neurosteroids o Restores connections within the brain and returns to normal neural activity o Restores gray matter volume in brain  Physical Conditions that Masquerade as Major Depression-  Hypothyroidism  Low testosterone or Estrogen levels  Undiagnosed illness (infectious mononucleosis)  Anemia  Chronic fatigue syndrome  Antidepressant Medications-  Chemicals that are effective for both anxiety and depression  Don‟t cure depression, just hold it in check  2-3 weeks after initial dose to see response  not addictive or habit forming  have unpleasant side effects  no known “time bomb” effect or fetal damage  must watch patients for suicidal or violent behavior  work only so long as taken  can precipitate manic episodes in bipolar patients o switched from the depression phase of bipolar disorder to manic phase o meds start working 2-3 days, patients talk a mile a minute, bounce off the walls  how long should they be taken? o Most depressions remit w/ no treatment in 3-4 months o odds are >50% of 1 recurrances, >75% of 2 nd o medication is unnatural but so is depression  Suicidality and Antidepressants-  40% of people w/ major depression make +1 suicide attempt  50-60% have suicidal ideation  antidepressants in US must carry warnings about suicidality  suicidality is associated w/ improvement from depression, regardless of the presence of antidepressant medication  more teen suicides in 2004 when FDA made “black box label” mandatory for all antidepressants. o Psychologists stop prescribing them to adolescents o More suicides  Classes of Antidepressant Meds-  Monoamine Oxidase Inhibitors (MAO Inhibitors)- Marplan, Parnate, Nardil o late 1950‟s o severe dietary restrictions and extremely unpleasant side effects o not as popular as could‟ve been  Tricyclics- Elavil, Norpramin, Tofranil, Anafranil o 1960‟s o eliminated dietary restriction of MAO inhibiors o side effects: 30-40 lb weight gain, dry mouth, blurred vision o cardiotoxic  Selective Serotonin Reuptake Inhibitors (SSRI’s)- Prozac/ Serafem, Zoloft, Celexa, Paxil, Luvox o Sleep deficit (insomnia) and sexual symptoms (slows down sexual response)  30-40% of patients o children on Paxil can develop suicidal ideation (not suicide) o people who don‟t respond to SSRI have 40-70% chance of responding to a second one  Atypical Antidepressants- Effexor, Cymbalta, WEllbutrin, Pristiq, Remeron, Trazodone o Most prescribed class of current antidepressants o Fewer sexual side effects o Varied actions and side effects  Atypical Depression- Hysteroid Dysphoria  Reversed neuroveegetative signs and symptoms  Symptoms: o Weight gain/ carb binging o Hypersomnia o Leaden paralysis (sluggishness) o Interpersonal rejection sensitivity  Super intuned to other people‟s facial expressions, comments, actions  Often: o Histrionic traits o Self medication w/ caffeine or chocolate  Keep mood propped up o Sometimes, uniquely responsive to MAO- inhibitors  Alternative Depression Treatments-  Medications: o Lithium augmentation of antidepressant therapy o St. John‟s Wort o Sam-e o Thryoxin o Testosterone  Phototherapy: seasonal depression  Exercise: mild depression  Sleep Deprivation: temporary  Other Disorders Treated with Antidepressant Meds-  Chronic pain  Binge eating disorder  Bulimia nervosa  Migraine headaches  Misc. anxiety disorders  Trichotillomania  Compulsive zit popping, shopping, gambling  Hypochondria  Sexual addition  Premature ejaculation  Electroconvulsive Therapy (ECT)-  Fastest of any depression therapies  Mechanism of action unknown  Fewest side effects of any depression therapy o Very high satisfaction ratings  Spotty memory losses (episodic >> semantic)  Applied only to right hemi to minimize speech disturbance  Abused in past, now only last resort and most severe cases  Comparative Efficacy of Depression Treatments-  ECT= fastest w/ fewest side effects  (adults) Meds and psychotherapy work equally well but meds= fster  Combo of therapy and meds are no more beneficial than one alone  (adolescence) current prescription is SSRI‟s and cognitive therapy  Treatment resistant depression  30% of patients to not respond to standard treatments  Strategies: o Medication augmentation-  Risks of medication augmentation:  Serotonin syndrom (agitation, euphoria/ delirium, fevers, muscle contractions, seizures)  Precipitation of manic states o Medication + ECT o Ketamine Infusion (NMDA Receptor Antagonism) o Vagal Nerve Stimulaiton & TMS  VNS-  Approved July 2005  ~20 pulses per sec to electrodes wrapped around vagus nerve in back of throat, stimulator implanted in chest  Mania-  Characteristics- o Euphoria or irritability o Purposeless or reckless behavior o Persistent insomnia o Pressured speech, flight of ideas o Poor insight or frank psychosis o Sometimes assaultivenss or suicidality Psychopathology Lecture #5 8/8/2013 2:00:00 PM  Mania- o Mr. Jones (1993)  Clinical Features- o Euphoria or irritability o purposeless or reckless behavior o persistent insomnia o pressured speech and flight of ideas o poor insight or frank psychosis o assaultivenss or suicidality  Major Depression & Bipolar Disorder-  Depression only (aka Unipolar Depression)  Depression + mania= bipolar disorder  Unipolar & bipolar disorders-  Unipolar Mood History- o Unipolar (major) depression o Hypomania (mild mania) o Unipolar mania (rare)  Bipolar Mood History- o Cyclothymia:  Mild depression w/ hypomania o Bipolar I Disorder:  Bipolar disorder w/ mania o Bipolar II Disorder:  Bipolar depression w/ hypomania o Mixed episodes:  Bipolar depression + mania  Bipolar Disorder-  recently ~3.5%, previous ~1.5%  no sex difference in prevalence  associated with high rates of alcohol/ drug abuse (40-50%), criminal behavior, and anxiety disorders (~40%)  age of first diagnosis ranges from 15-45, normally around 20‟s o in children- pediatric bipolar disorder  runs in family o family history of BD in 30% of B.D patients o 65% concordance rate in MZ twins, 14% in DZ twins  in 20% of MZ twins with BPD, other will have major depression o multiple routes of genetic involvement  Bipolar Depression Compared to Major (Unipolar) Depression-  Depression= more problematic state in BPD  BPD ususally 1st appears as depressed phase  40% of people with BPD are initially diagnosed w/ Major Depression o delusions, voices in their mind  ave age of onset= below 25  lasts longer, more frequently, more likely to reach psychotic levels  BPD patients spend up to 1/3 of adult lives in depression  more likely to include reversed neurovegetative signs/ symptoms and psychomotor retardation  ~1:1 sex ratio diagnosis BPD, ~2:1 f:m ratio in major depression  +10% of people with BPD commit suicide  Brain Mechanisms in BPD-  May reflect defects in the metabolism of Protein-Kinase C (PKC) o PKC- calcium metabolism of neurons  unstable levels of neurotransmitter release by these neurons  PKC activity is increased in manic patients o Normalized by anti-manic meds  Specific PKC inhibitors (eg tamoxifen) quickly bring acute mania under control  Pediatric BPD-  ~1% of children, sometimes as early as infancy  manifested by: o mood instability (rages, despondency) o hyper-sexuality o pressured speech o racing thoughts o impaired judgment o delusions/ hallucinations  ~1/2 of severe childhood depressions become adult bipolar disorder  ~1/2 of children treated for depression w/ SSRI's develop mania or hypomanic episodes (switching)  10 yr lag between occurrence of 1st signs/ sx and onset of treatment  often confused with ADHD o show distractibility and hyperactivity o ADHD- show symptoms all the time o PBPD- episodic  Mixed episodes-  Mania and depression are not opposites  crying, irritability, anger, suicidal ideation AND  euphoria, hypersexuality, racing thoughts, insomnia, auditory hallucinations  Treatments for BPD-  Medication= 1 line treatment o Med compliance only ~30% o acute management (w/ antipsychotic medications), followed by introduction of a mood stabilizer for chronic management o Medications  Lithium carbonate: strong antimanic and antisuicide  weak antidepressant actions  meant for impulsive people  calms them down  prevents homicidal and suicidal tendencies  disadvantages:  narrow therapeutic window of efficacy o too little= uneffective o too much= toxic  tremors, nausea  anticonvulsants: moderate antimanic and antidepressant actions  treat seizure disorders mainly but treat BPD beautifully  Lamictal: uniquely strong antidepressand properties and appears weight- neutral  can get Steven Johnson‟s syndrome  tegretol, neurontin  Depakote and Topamax- for rapid cycling BPD  Antipsychotic agents: moderate antimanic and antidepressant actions  Abilify (weight neutral), Zyprexa, Risperdal  Antidepressants: strong antidepressant actions but increase risk of “switching” into mania or mixed states  Psychotherapy- o Usually requires prior medication response to be valuable o builds compliance to meds o helps patients and family understand impact of disorder o no effect on disorder itself o doesn‟t do anything for BPD per say but helps create understanding and compliance skills  ECT (rarely used, but somewhat effective)- o can be remarkably effective when used with manic medications  induced sleep (very rarely)  Affective Disorders may be linked to creativity  Upsides of BPD-  The “well” relatives of people with BPD appear to have higher rates of achievement, success and creativity ANXIETY-  Signs/ Symptoms-  Cognitive: o Objectless fear or feeling of apprehensiveness o heightened sense of and vulnerability o worrying and rumination o going blank or spacing out o irritability, impatience, distractibility o hyper vigilance  Physiological: o Trembling, twitching, feeling shaky o fatigue, restlessness o muscle tension, jitteriness o dizziness, lightheadness o fast heartbeat, breathing rate  Panic Attack (acute anxiety episode)  Signs and symptoms: o Palpitations, pounding heart, or accelerated heart rate o sweating o trembling or shaking o sensation s of shortness of breath, choking, smothering o chest pain or discomfort o nausea or abdominal distress o feeling dizzy, unsteady, lightheaded or faint o derealization (feelings of unreality) o depersonalization (being detached from oneself) o fear of dying, losing control or going crazy o paresthesias (numbness or tingling sensations) o chills or hot flushes  Autonomic arousal and the Brain-  Amygdala- o Registers situations as threatening o sends signals to locus coeruleus  Locus Coeruleus- o Governs activation of neocortex, hypothalamic-pituitary axis and ANS o sends signals all throughout brain to go on red alert based on signals from the amygdala  GABA and Anxiety-  Most common neurotransmitter in brain  anxiety prone people = GABA deficient  blocking GABA chemically= +anxiety  Other neurotransmitters inovled in anxiety: o GABA and 5HT inhibit anxiety o EP, NO, DA provoke the physiological changes that lead to anxiety  Ethyl Alcohol (EtOH) and common anti-anxiety meds bind to GABA receptor areas and mimic GABA  Major Anxiety Disorders-  Most frequent psychiatric problem in general population  run strongly in families and are co-morbid w/ depression & stress disorders (50-70%) o suggests common “distress” inheritance  carry increased risk of alcoholism 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  common physical disorders that can mask as anxiety disorders: o hyperthyroidism- enlarged thyroid o pheochromocytomas (adrenal tumars that oversecrete adrenalin) o inner ear disease o angina pectoris- diminished circulation to heart  confuse tightened chest w/ anxiety o hypoglycemia- low blood sugar o mitral valve prolapse- o cardiac arrhythmias o drug effects- caffeinism, nicotine addiction, nasal decongestants, asthma inhalers or other stimulants  Generalized Anxiety Disorder- GAD o Debilitating worry, fretfulness o worry= 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 o 1 yr prevalence, 3-4% o usually emerges during adolescence o females > males, 2:1 ratio o 75% of GAD sufferes have another mental disorder, usually major depression  Symptomatic Treatments for Anxiety-  Habit control (e.g coffee, cigarettes, stimulant meds)  "Anxiolytic" anti-anxiety meds o for acute use:  benzodiazepines- context and reasons for taking them can make them addictive  handle anxiety for up to a month for best management  too long can start to become a depressant  rarely: beta-blockers- control blood pressure  act peripherally on blood vessels  kill wanted responses o for chronic use:  most often: SSRI’s or atypical antidepressants   occasionally: atypical anxiolytics, antipsychotics  Psychotherapy o Supportive, cathartic o relaxation and meditation techniques o stress management training o biofeedback  exercise  support groups Psychopathology Lecture #6 8/8/2013 2:00:00 PM PANIC DISORDER-  Panic Disorder- o occurrence of panic attacks without warning o pattern of avoidance and disability as a result  should I go shopping? Should I leave the house?  walking around with apprehensiveness that characterizes panic disorder  ritualized avoidance becomes panic disorder with agoraphobia o home or room within the home now becomes a safety zone o reluctance to venture outside safety zone without “escape route”  1 yr prevalence ~2.3%, lifetime prevalence ~3.5%  female: male ratio ~2:1  increased risk w/ background of child abuse/ neglect, and with mitral valve prolapse  triggered by: o yohimbine (sympathetic NS stimulant) o sodium lactate (exercise waste product) o marijuana  Treatment- o First Line Treatment-  Dietary/ medication control (e.g. caffeine, nicotine, marijuana)  anxiolytic medications (benzodiazepines, mainly Xanax) for acute use only  Antidepressant meds (SSRI's) chronically as preventative  Psychotherapy:  teach people about what a panic attack is  process of runaway fear that they can gain mastery of (normalization)  metronomic breathing: teach patients to suppress runaway breathing and learn to enforce a rhythm of their panic attack to gain control  supportive therapy  In vivo desensitization if agoraphobia is present  Take them step by step out of their house to face the things they fear  Social Anxiety Disorder (Social Phobia)-  Most common anxiety disorder o 1-yr prevalence ~8%, lifetime ~15% o common in females 1.5:1 o late adolescence 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 other, and of doing things that will be humiliating or embarrassing o generalized or occur in specific situations o 1/3 sufferers are disa
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