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PSYC 3604 Final: FinalExam-PSYC3604BV-ChrisMotz
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PSYC 3604
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Chris Motz

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- In class, we discussed the diagnostic criteria for Gender Dysphoria. Describe the essential feature of this diagnosis. In addition, there is a list of six symptoms from which the adult client must have at least two in order to meet the criteria for diagnosis – describe any four of the characteristics on this list (although there are six criteria on this list, you to need to describe any four). (4-6 sentences) - •Essential feature is a strong feeling of incongruence between the assigned gender and their experienced/expressed gender. - –This discrepancy is the core feature. - –The incongruence causes distress. - –Lasting at least 6 months. 6 symptoms: •Marked incongruence between experienced/expressed gender and primary/secondary sex characteristics •Strong desire to be rid of one’s primary/secondary sex characteristics •Strong desire for the sex characteristics of the other gender •Strong desire to be of the other gender •Strong desire to be treated as the other gender •Strong conviction that one has the typical feelings and reactions of the other gender - Although Asperger’s Disorder is no longer considered to be separate from Autism Spectrum Disorder (it is now just a subcategory of Autism), in class we described the two essential symptom categories that defined Asperger’s Disorder, as well as the two symptoms that are absent for Asperger’s. Describe the two essential symptom categories and the two absent symptoms. (4-6 sentences) Taken from lecture slides: “Essential features are severe and sustained impairments in social interaction and the development of restricted, repetitive patterns of behaviour, interests, and activities” And for two absent symptoms: No clinically significant general delay in language or cognitive development” Chapter 10 (lectures) · What are the eating disorders? o Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder · What are the diagnostic criteria for each? o Anorexia: § Essential feature is that the individual refuses to maintain a minimally normal body weight, is intensely afraid of gaining weight, and exhibits a significant disturbance in the perception of the shape or size of her/his body. § The term anorexia (“loss of appetite”) is a misnomer because loss of appetite is rare § When Anorexia Nervosa develops in an individual during childhood or early adolescence, there may be a failure to make expected weight gains (while growing in height) instead of weight loss. § Weight loss may be accomplished through: reduction in total food intake, excluding high calorie foods, purging (i.e. use of laxatives, self-induced vomiting), and increased/excessive exercise. § Symptom manifestation: · Fear of gaining weight or becoming fat · Distortion of own body weight, and the significance of body weight · Experience and significance of body weight and shape are distorted · May realize that they are “thin” but are concerned that certain parts of the body are “too fat.” · Self-esteem is highly dependent upon body shape and weight. o Bulimia: § Essential features are binge eating and inappropriate compensatory methods to prevent weight gain. § Self-esteem is excessively influenced by body shape and weight § Binge eating and compensation must occur, on average, at least once a week for 3 months § The individual should not meet the criteria for the Binging-Purging subtype of Anorexia Nervosa (e.g. when weight is normal). § Binge eating – discrete period of time, an amount of food that is definitely larger than normal (often includes high calorie foods), often with rapid consumption. § Individuals are typically ashamed of their eating problems. An episode of binge eating is also accompanied by a sense of lack of control (an individual may be in a frenzied state when eating). § Compensatory techniques to prevent weight gain (purging is used by 80-90% of individuals with BN). o Binge-Eating Disorder: o The individual regularly engages in a binge, but does not purge what they eat o The binge is accompanied by a sense of lack of control over eating during the episode o May be associated with: eating much more rapidly than normal, eating until feeling uncomfortably full, eating large amounts of food when not feeling physically hungry, eating alone due to embarrassment, feeling disgusted, depressed or guilty 2 o Marked distress regarding binge eating is present o Binge eating occurs, on average, at least 2 days a week for 6 months · What are the subtypes? o Anorexia: § Restricting Type – weight loss is accomplished primarily through dieting, fasting, or excessive exercise. § Binge-Eating/Purging Type – when the individual has regularly engaged in binge eating or purging (or both). o Bulimia: § Purging Type – the person has regularly engaged in self-induced vomiting. § Non-purging Type – this subtype describes presentations in which the person has used other inappropriate compensatory behaviors (fasting or excessive exercise), but has not regularly engaged in self-induced vomiting. · What are the risk factors? • Family Risk Factors - Families with high levels of conflict - Parents who are over controlling - Families that do not allow the expression of emotion (specifically, negative emotion) - Enmeshed families – with extreme interdependence, where the boundaries between the individual and the family are blurred - Parents who do not give enough priority to the child’s needs/schedule (particularly around food) • Personal Risk Factors - “Good girls” who are dutiful toward their parents and who are high achievers (always trying to please their parents) - Excessive perfectionism and obsessive-compulsive features - May lack a sense of self/identity (tied in with family dynamics). Do not accurately identify, or respond adequately, to their own wishes/needs • In response to the parents’ over control - May become angry, defiant, distrustful - May control food intake as a way of exerting control over their lives - May control food intake as a way of eliciting concern from parents • In response to highly enmeshed families - May have a conflicting fear of separation and need for independence – leading to internal conflict & anger & need for control • Compared to families of controls, family environments of individuals who have eating disorders have lower levels of support, empathy, and understanding from parents (Porzelius, Dinsmore, Staffelbach, 2001) 3 • In a community study, families of women who had BN were more likely to diet and to be critical of weight and eating, compared to families of both normal and psychiatric controls (Fairburn, Welch, Doll, Davies, & O’Connor, 1997). • Both AN & BN run in families (Strober, 1991), first-degree relatives have an increased risk for AN & BN. Anorexia refers to loss of appetite, and nervosa indicates that this is for emotional reason. (Although Anorexia does not typically involve a loss of appetite) ● The person must refuse to maintain a normal body weight and weighs less than 85% of what is considered normal for that person's age and height (this has been changed in the DSM-5 to restriction of energy intake resulting in significant low body weight within context of age, sex, and physical health status). ● Intense fear of gaining weight and the fear is not reduced by weight loss ● People with AN have a distorted sense of their body shape. They maintain that even when emaciated, they are overweight or that certain parts of their bodies, particularly the abdomen, buttocks, and thighs, are too fat. ● In females, the extreme emaciation causes amenorrhea , the loss of the menstrual period. This has been removed from the DSM 5. What are the accompanying physical changes/symptoms? ● Brittle hair, loss of hair, lanugo ● Slow heart rate, kidney, GI problems and nails become brittle. Also hormonal issues ● Low levels of Na and K, which affects neural transmission ● Smaller brain size, EEG abnormalities ● Upon recovery white matter abnormalities are restored, but gray matter abnormalities don’t. · What is bulimia nervosa? What are the behaviours, symptoms, and diagnostic criteria? - Bulimia = greek for ox hunger - Episodes of rapid consumption of large amounts of food followed by compensatory behaviours (vomiting, fasting, excessive exercise) to prevent weight gain - Binge eating: eating excessive amount of food for a given period (e.g., 2 hours) - Binge eating episode must also include a sense of lack of control over the behaviour - Binge eating & compensatory behaviour must continue for at least once a week for 3 months - Not diagnosed if the person fits the criteria for anorexia nervosa binge-eating/purging subtype 4 What is binge-eating disorder? What are the behaviours, symptoms, and diagnostic criteria? - Recurrent binges (at least one per week for at least 3 months) - Lack of control during bingeing episode - Distress about bingeing - As well as at least 3 of the following: 1. Eating more rapidly than normal 2. Eating until uncomfortably full 3. Eating alone due to feelings of embarrassment 4. Eating large amounts of food when not feeling hungry 5. Feeling disgusted with oneself or embarrassed or very guilty · What do we know about the etiology of eating disorders? Biological, Socio-cultural, Gender, Cross-cultural, Cognitive-behavioural, Psychodynamic, Family systems, Characteristics of families, Child abuse, Personality. ● Fat talk: tendency of female friends to take turns and make negative comments about their own bodies as a way of fitting in (both average and fat girls were seen as more likeable when they engaged in negative self-talk compared to positive self- talk). Fat talk is not correlated with BMI but it is associated with negative views of self and unhealthy eating habits. Social comparison orientation: judge yourself in relation to others. Biological ● Genetics: the focus used to be on Socioeconomic status it’s within the last ten years we looked at genetics more closely. ○ First degree relatives of AN are 4x more likely to develop it too ○ Twin studies also support genetic involvement ○ MZ twins > FT ○ Key features of disorders like : dissatisfaction of one’s body and wanting to be thin also are heritable ○ Genetic basis for the internalization to be thin ○ About 56% genetic component ● Brain: hypothalamus and paraventricular nucleus implicated (since they regulate appetite and eating behaviors). ○ Higher levels of cortisol, but that’s a consequence rather than cause to an ED, also hypothalamus changes appetite, but AN people still are interested in the food (despite the name of the disorder). ○ Starvation increases levels of endogenous opioids (positive reinforcement) ○ On the other hand in BN you see low levels of endogenous opioids (the more severe the case the lower the levels too). Might explain the comorbidity with self-harm. 5 ○ Low 5-ht ● Sociocultural: ○ Scarlett O Hara: eat lightly to look feminine ○ Activity anorexia: don’t try to be thin, try to be fit. But physical activity suppresses appetite. Dancers more anorexic than models. ○ Anorexia show interest in food but don’t get positive incentives for actually eating the food. ● Gender: ○ Culture affects women more. ● Cross-cultural ○ Fear of fat does not work in china ○ In Fiji they have another type of BN ● Cognitive-Behavioral ○ Emphasis on fear of fat and body image disturbance as motivation that leads to starvation and weight loss (which now act as powerful positive reinforcements) ○ Another positive reinforcement is mastery of self control they create ○ Perfectionism and feeling you are inadequate make things worse ○ Thinspiration effect: dieters initially feel thinner when they look at thin bodies which motivates them to diet. Ultimately this will lead to distress for those who can’t attain this idealized body type. ○ Criticism by peers and parents also makes things worse ■ Obesity correlated with being teased, which is correlated with negative view image, which promotes ED symptoms. ○ A lapse in diet (i.e. binging) will be worse the stricter the diet is. So the purge afterwards will be worse too. Clients with anorexia who do not binge and purge may have more intense preoccupation and fear of weight gain, or may be able to exercise more self control. ● Psychodynamic ○ Child-parent relationship and core personality traits at the center. ○ Symptoms fulfill needs (need to increase effectiveness), or avoid growing up and becoming sexual. ○ Nowadays they focus more on a deficit perspective, and put emphasis on symptoms as a way to compensate for deficits in the self. ○ Anorexia is a way of children who have been raised to feel ineffectual to ward off those feelings of incompetence and helplessness. Parenting style where parent imposes their wishes on the child without taking into consideration what the child wants. Also those children don’t know how to identify their own internal states and are not self-reliant ● Family system 6 ○ Enmeshment ○ Overprotectiveness ○ Lack of conflict resolution ○ Rigidity: maintain status quo regardless of events that require change. ● Characteristics of Family ○ Parents of people with ED lack some communication skills like asking for clarification when their child tells them something ambiguous. ● Abuse: ○ Correlates with sexual/physical and emotional abuse ● Personality: ○ Starvation can alter personality ○ Retrospectively, before the onset of the disorder individuals were shy, compliant and perfectionist. ■ For bulimia + histrionic, affective irritability and outgoing disposition ○ Anorexia + BN = high in neuroticism, and low in self esteem. Also high on traditionalism ○ AN + BN= high on narcissism, but not always. ■ Narcissistic “poor me” defense is associated with higher levels of dropping out of treatment. ○ Specifically we see elevated self orientated and socially prescribed perfectionism ■ For bulimia perfectionism works on three levels. We have more symptoms in those who score high on perfectionism and on body dissatisfaction and low self esteem. ■ Perfectionistic self presentation: try to create an image of perfection and be highly focused on minimizing mistakes you make in front of others. · What sorts of treatments are available? How do they work? Biological and Psychological. ● About 70% of them recover, it may take about 6-7 years though. We see a lot of relapse. ● 90% of people with an ED are not in treatment ● Biological treatments ○ BN: use of antidepressants ○ Not very successful with helping after weight restoration and a lot of people drop out of them ● Psychological treatments for AN ○ First goal is to get them to gain weight (operant conditioning works well) 7 ○ With operant conditioning you isolate the client and reward them when they eat with meal time company, tv time etc ○ Cognitive behavioral: ■ Treatment should focus on self control ■ Works ○ Ego-analytic therapy ■ Promotes greater autonomy, is done through family therapy and has positive results ○ Maudsley approach ■ Teaches parents creative ways to feed their kids. ■ Family therapy> any other therapy, but no therapy works very well for those who have the disorder for more than 3 years, so early intervention is critical. ○ In BN the best treatment is CBT ■ First step challenge beauty standards ■ Uncover and change beliefs that make them starve themselves ■ Alter all-or-nothing POV ■ Also use schema focused behavioral therapy ● How does prevention work for eating disorders? (this is the Canadian Perspectives 10.1 on page 322-323) ○ Multiple sessions, to only female groups that are 15 and older, are interactive and aimed at high risk individuals ○ Make peer support groups, educating teachers in preventative efforts and focus on prevention through a dissonance interaction ● Chapter Summary ○ The two main eating disorders are anorexia nervosa and bulimia nervosa. The symptoms of anorexia nervosa include refusal to maintain normal body weight, an intense fear of being fat, and a distorted sense of body shape. Amenorrhea in females is no longer a required symptom in the DSM-5. Anorexia typically begins in the mid-teens, is 10 times more frequent in women than in men, and is comorbid with several other disorders, notably depression. Its course is not favourable, and it can be life-threatening. The symptoms of bulimia nervosa include episodes of binge eating followed by purging, fear of being fat, and a distorted body image. Like anorexia, bulimia begins in adolescence, is much more frequent in women than in men, and is comorbid with other diagnoses, such as depression. Prognosis is somewhat more favourable than for anorexia. ○ Biological research in the eating disorders has examined both genetics and brain mechanism. Evidence is consistent with a possible genetic diathesis, but adoption studies have not yet been done. Endogenous opioids and serotonin, both of which 8 play a role in mediating hunger and satiety, have been examined in eating disorders. Low levels of both these brain chemicals have been found (see Steiger et al., 2001). ○ On a psychological level, several factors play important roles. As cultural standards changed to favour a thinner shape as the ideal for women, the frequency of eating disorders increased. The prevalence of eating disorders is very high among people who are especially concerned with their weight, such as models, dancers, and athletes. ○ Psychodynamic theories of eating disorders emphasize parent-child relationships and personality characteristics. Bruch’s theory, for example, proposes that the parents of children who later develop eating disorders impose their wishes on their children without considering the children’s needs. Children reared in this way do not learn to identify their own internal states and become highly dependent on standards imposed by others. Research on characteristics of families with an eating-disordered child have yielded different data depending on how the data were collected. Reports show high levels of conflict, but actual observations of the families do not find them especially deviant. Studies of personality have found that people with eating disorders are high in neuroticism and perfectionism and low in self-esteem. ○ Cognitive-behavioural theories of eating disorders propose that fear of being fat and body-image distortion make weight loss a powerful reinforcer. Among people with bulimia nervosa, negative mood and stress precipitate binges that create anxiety, which is then relieved by purging. ○ The main biological treatment of eating disorders is the use of antidepressants. Recent data suggest that drugs are not effective. Dropout rates from drug treatment programs are high and relapse is common when people stop taking the medication. Treatment of anorexia often requires hospitalization to reduce the medical complications of the disorder. Providing reinforcers for weight gain, such as visit from friends, has been somewhat successful, but no treatment has yet been shown to produce long-term maintenance of weight-gain. ○ Cognitive-behavioural treatment for bulimia focuses on questioning society’s standards for physical attractiveness, challenging beliefs that encourage severe food restriction, and developing normal eating patterns. Outcomes are promising, at least in the short term. Chapter 11 (lectures) What are the foundations of the psychotic disorders? Psychoses: A class of psychological disorders where reality contact is impaired. Psychotic: delusions or prominent hallucinations, with the hallucinations occurring in the absence of insight into their pathological nature. Or could also include prominent 9 hallucinations that the individual realizes are hallucinatory experiences. An even broader definition would also include other positive symptoms of Schizophrenia (i.e. disorganized speech, grossly disorganized or catatonic behaviour) What is schizophrenia? It is a psychotic disorder characterized by major disturbances in thought, emotion, and behaviour: distorted thinking in which ideas are not logically related, and bizarre disturbances in motor activity. People with schizophrenia withdraw from other people and reality, often into a fantasy life of delusions and hallucinations. What are the key features/symptoms of schizophrenia? Positive symptoms which appear to reflect an excess or distortion of normal functions and Negative symptoms appear to reflect diminution or loss of normal functions. Positive symptoms have two dimensions psychotic which includes delusions and hallucinations, and disorganized which includes disorganized speech and grossly disorganized or catatonic behaviour. Delusions: erroneous beliefs that usually involve a misrepresentation of perceptions or experience, and are resistant to change even in the face of conflicting evidence. Content may include a variety of themes. ❖ Persecutory delusions (most common) - people belief they are being tormented, followed, tricked, spied on or ridiculed. ❖ Referential delusions- are beliefs that certain gestures, comments, passages from books/newspapers, song lyrics (etc.) are directed at them ❖ Grandiose delusions- believe they have exceptional abilities, wealth or fame ❖ Erotomanic delusions - believes that another person is in love with him/her ❖ Nihilistic delusions - believes as major catastrophe will occur i.e. the end is near ❖ Somatic delusions - believes that their health or organ functions are at risk Delusions can be bizarre if they are clearly implausible, do not derive from ordinary experience, and are not understandable to peers. Bizarre - belief that an outside force has removed my internal organs and replace them with someone else’s organs (without leaving scars) or losing control of their mind or someone is taking thoughts or putting thoughts in their mind. Nonbizarre - belief that I am being watched by the police or government Hallucinations: Perception-like experiences that occur without an external stimulus. Vivid and clear. Not under voluntary control. Can occur in any sensory modality (auditory, visual, olfactory, gustatory, tactile). Auditory are most common usually experienced as voices (familiar or unfamiliar) that are perceived as distinct from the person’s own thoughts. 10 Disorganized thinking: (“thought disorder”) -due to difficulty in diagnosing “thought disorder” and because this is usually based on the individual’s speech, the emphasis here is on disorganized Speech. ➢ Derailment or loose associations ➢ Tangentiality - responses to questions/answers are off track or have no connection to the question ➢ Incoherence or “word salad” - structure of sentence has become compromised Grossly Disorganized Behaviour: may manifest in a variety of ways, including childlike silliness to unpredictable agitation. ➢ May involve difficulties in performing goal-directed behaviours Catatonic Motor Behaviours: include a marked decrease in reactivity to the environment ➢ Negativism - resistance to instruction ➢ Catatonic mutism and stupor - complete unawareness ➢ Catatonic rigidity - rigid posture ➢ Catatonic posturing - assuming bizarre postures ➢ Catatonic excitement - purposeless excessive motor activity Negative Symptoms: ➢ Diminished emotional expression - (expression in voice may not be there and same as with face) ➢ Avolition - lack of motivation, self initiated, voluntary behaviour ➢ Alogia - poverty of speech - lack of any kind of speaking - brief replies & empty of meaning ➢ Anhedonia - inability to experience pleasure ➢ Asociality - lack of any kind of social interactions What are the diagnostic criteria for schizophrenia? ● Essential features - range of cognitive, behavioural, and emotional dysfunctions that have been present for a significant portion of time during a 1 month period, with some signs of the disorder persisting for at least 6 months. ● Two (or more) of the following, present for a period of at least 1 month. At least one of these must be 1, 2, or 3: 1. Delusions 2. Hallucinations 3. Disorganized speech (e.g. Frequent derailment or incoherence) 4. Grossly disorganized or catatonic behaviour 5. Negative symptoms 11 ● Since onset, level of functions in one or more areas (self-care, work, interpersonal relations, etc.) must be markedly below the level achieved prior to onset. ● Continuous signs of disturbance must be present for at least 6 months ● Not better accounted for by Schizoaffective Disorder or a Mood Disorder with psychotic features, and is not due to a general medical condition or substance induced. What are the subtypes? What are the criteria for each (how do we tell them apart)? 1. Catatonic - at least two of the following: motor immobility excessive motor activity, extreme negativism (motiveless resistance to all instruction or attempts to be moved), peculiarities of voluntary movement (posturing) 2. Disorganized - all of the following are prominent: disorganized speech, disorganized behaviour, flat or inappropriate affect (criteria are not met for catatonic type) 3. Paranoid - preoccupation with one or more delusions or frequent auditory hallucinations (but not disorganized speech, disorganized or catatonic behaviour, flat/inappropriate affect) 4. Undifferentiated - some of the characteristic symptoms are present (i.e delusions, hallucination, etc.) but does not meet the criteria for the first three subtypes 5. Residual - absence of prominent delusions, hallucinations, disorganized speech/behaviour. Continuing evidence of the disturbance as indicated by the presence of negative symptoms (or limited characteristics symptoms - e.g. odd beliefs) What is the course of schizophrenia (the phases)? Development & Progress ➢ Prodromal phase – In some cases, onset may be sudden (“reactive” or “good premorbid”). However, in other cases the onset may be protracted over years (“process” or “poor premorbid”) (can cycle back & forth). ➢ Active phase – patient shows prominent symptoms of schizophrenia ➢ Residual phase – (active phase is usually followed by residual phase) patient shows symptoms similar to prodromal phase (i.e. blunted affect) ➢ Typical pattern is to fluctuate between Residual phase and Active phase. What are the other psychotic disorders? What are the diagnostic criteria for each? How do we tell them apart? • Delusional Disorder: The presence of at least one delusion. Duration of at least 1 month. • Characteristic symptoms for Schizophrenia have never been met. - If hallucinations are present, are not prominent and are related to the delusional theme. • Other than the impact of the delusion(s), functioning is not significantly impaired, and behaviour is not odd/bizarre. • If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods. 12 • The disturbance is not due to the direct physiological effects of a substance or a general medical condition. Delusional Disorder Subtypes 1. Erotomanic – delusions that another person, usually of higher status, is in love with the individual. 2. Grandiose – delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person. 3. Jealous – delusions that the individual’s spouse or lover is unfaithful. 4. Persecutory – delusions that the person (or someone to whom the person is close) is being malevolently treated in some way 5. Somatic – the central theme of the delusions involve bodily functions or sensations. 6. Mixed – delusions characteristic of more than one of the above types, but no one theme predominates. 7. Unspecified – the dominant delusional belief cannot be clearly determined or does not fit with one of the other types. Brief Psychotic Disorder • Brief Psychotic Disorder: Presence of at least one of the following symptoms (one of these must be 1, 2, or 3): 1. Delusions 2. Hallucinations 3. Disorganized speech (frequent derailment or incoherence) 4. Grossly disorganized or catatonic behaviour • Duration of an episode is at least 1 day, but less than 1 month, with eventual full return to premorbid level of functioning. • Not better accounted for by another Psychotic Disorder or a Mood Disorder with psychotic features, and is not due to a general medical condition or substance-induced. Schizophreniform Disorder • Two (or more) of the following, present for a period of at least 1 month (or less if successfully treated). At least one of these must be 1, 2, or 3. 1. Delusions 2. Hallucinations 3. Disorganized speech (e.g. Frequent derailment or incoherence) 4. Grossly disorganized or catatonic behaviour 5. Negative symptoms • An episode lasts at least 1 month, but less than 6 months. • Not attributable to a substance or medical condition. Not better accounted for by Schizoaffective or Mood Disorder (because no mood episodes). 13 Schizoaffective Disorder • Schizoaffective Disorder: An uninterrupted period of illness during which there is a major mood episode (either depressive or manic), plus the main criteria for Schizophrenia are met. Two (or more) of the following, present for a period of at least 1 month. At least one of these must be 1, 2, or 3. 1. Delusions 2. Hallucinations 3. Disorganized speech (e.g. Frequent derailment or incoherence) 4. Grossly disorganized or catatonic behaviour 5. Negative symptoms • During same period, there have been delusions or hallucinations for at least 2 weeks in the absence of the mood episode. • Mood symptoms are present for a majority of the total duration of the illness. • Not attributable to a substance or medical condition. What do we know about the foundations of the psychotic disorders? (genetics, prenatal & postnatal factors, environmental stressors, neurotransmitters & drugs) The Genetics of Schizophrenia (Research is very much focussed on diathesis stress model) • Research indicates that the vulnerability to the illness can be inherited. 1. Twin, adoption & family history methods indicate an elevated risk of the disorder for family members of someone with Schizophrenia 2. MZ twins = 25-50% 3. DZ twins = 10-15% 4. Adoption studies provide evidence that the tendency for Schizophrenia to run in families is primarily due to genetic factors, rather than the environmental influence of being exposed to a mentally ill family member. • Hall et al. (2006) 1. Examined variations in the NRG1 gene (coding for neuregulin1 – a protein that has a variety of effects on the nervous system) 2. Longitudinal study of those with the variant (TT), those with one variant (CT) and controls (CC) 3. Particular variations in the NRG1 gene were linked to: 1. decreased activation of frontal and temporal lobe regions, 2. increased psychotic symptoms, and 3. decreased premorbid IQ 14 • However, research indicates that genetic influences act together with environmental factors (a diathesis-stress model). Tienari, Wynne, Moring & Lahti (1994) • Genetic studies lead to the conclusion that the disorder involves multiple genes, rather than a single gene. - Specifically, the Serotonin Type 2a receptor gene (5-HT2a), and the Dopamine (D3) receptor gene, and several chromosomal regions (regions on chromosomes 6, 8, 13 & 22) Prenatal & Postnatal Factors • There is evidence that Obstetrical Complications (OC) have an adverse impact on the developing fetal brain – numerous studies show that Schizophrenia patients are more likely to have a history of OCs • Labour & delivery complications, which are often associated with hypoxia (fetal oxygen deprivation) are strongly linked with later Schizophrenia • Another risk factor for Schizophrenia is maternal infection. - Risk rate for Schizophrenia is elevated for individuals born shortly after a flu epidemic. - This is consistent with “season-of-birth” effect on Schizophrenia. - A disproportionate number of Schizophrenic patients are born during the Winter months – possibly reflecting a seasonal exposure to viral infections during the second trimester (an important time for brain development) - Stressful events during pregnancy (i.e. death of a spouse) are associated with greater risk for Schizophrenia Environmental Stressors • Research indicates that stressful life events can worsen the course of Schizophrenia - The number of stressful life events increases in the months immediately preceding a relapse • Stress exposure can also contribute to the onset of symptoms in vulnerable individuals - The offspring of Schizophrenic parents manifest significantly greater increases in behaviour problems if they are exposed to abuse/neglect - High-risk offspring are more likely to develop Schizophrenia if they are raised in an institutional setting rather than by family Neurotransmitters & Drugs • Epinephrine, norepinephrine, serotonin, glutamate & GABA have all been hypothesized to play a role in Schizophrenia • Dopamine seems to play a central role: - Drugs that reduce Dopamine activity also diminish psychotic symptoms - Drugs that heighten Dopamine activity exacerbate or trigger psychotic episodes 15 - Antipsychotic drugs block Dopamine receptors (the D2 subtype) – the newer “atypical” antipsychotic drugs have the same effect but cause fewer side effects. • The NMDA receptor is a crucial receptor for Glutamate. - Administration of NMDA receptor antagonists (blocking the effects of Glutamate on the NMDA receptors) produce Schizophrenic symptoms in normal patients. What sorts of treatments/therapies are available? What is COPE? Therapy & Treatment • (in addition to medication) • Research supports the use of Family Therapy - Including educational & behavioural components. - Reduces caregiver burden & improves coping, thereby reducing the risk of relapse (better support) • Therapy on patient – social skills training to improve functioning, increase interpersonal interactions, and involvement in leisure activities • Cognitive-Behavioural Therapy – to help patients deal directly with their symptoms. Can be effective at reducing hallucinations and delusions. • Cognitively Oriented Psychotherapy for Early Psychosis (COPE) (Big trend in the past 15 yrs which has been on prevention instead of treatment.) -Jackson, McGorry & Edwards (2001)- - Individuals may experience a “first episode” of psychosis – and for many this may not necessarily lead to the development of Schizophrenia - Intervention needs to be delivered at the earliest opportunity in order to give the patient resources to manage the event and cope with the subsequent cognitive and emotional consequences • COPE - Focus of treatment is that the individual (their thoughts and emotions) is critical in their own recovery - After patient experiences psychosis, they are at risk of having this one event negatively influence their definition of “self” (who am I?) and their expectations for self development (what will I become?) - Some people with severe mental illness may self-stigmatize – and this has been linked to a decreased success rate of returning to work, housing, & relationships - “Possible selves” become “feared or undesired selves” instead of “future positive possible selves” • Goals of COPE - Help client preserve a sense of self – this includes positive future selves (going to school, having a job, having a relationship) – even if the specific nature of these goals need to be adjusted 16 - Help client find meaning in the experience (can take positives out of negative) - Promote mastery over the experience - give individual a sense of control - attributions - scepticism - Mastery of - Therapist needs to identify possible cognitive targets that need intervention (possible selves, coping skills, attributional style, core schemata, appraisals about the psychosis itself, etc.) Chapter 11 (text) · But you will need to know the “Categories of schizophrenia” section (page 335-337). This \\includes Disorganized, Catatonic, Paranoid, and the “Additional ways of conceptualizing heterogeneity.” - Disorganized: · Speech is disorganized, often accompanied by silliness & laughter · May have flat affect or experience constant shifts in emotions · Behaviour = generally disorganized & not goal-oriented - Catatonic: · Catatonic symptoms · Alternate b/w cationic immobility & wild excitement but one of these symptoms may predominate · Often resist instructions & often echo speech of others - Paranoid: · Delusions § Persecution = most common § Grandiosity § Jealousy (believe partner is being unfaithful) · Vivid auditory hallucinations § Ideas of reference (find personal meaning in unimportant ideas) · Personality is often agitated, argumentative, angry, sometimes violent · Remain emotionally responsive but may be stilted, formal, and intense · More alert & verbal than other schizos · Language, although filled with delusions, not disorganized - Additional ways of conceptualizing heterogeneity · Subtyping is not useful way of dealing with the disorder so added the following: - Undifferentiated schizo: · Fit criteria of schizo but none of the subtypes - Residual schizo: · When no longer meets the full criteria for schizo but still shows some signs of the disorder Etiology 17 Genetics Factors - Genetic predisposition · Negative symptoms have stronger genetic component · Relatives = increased risk of other disorders (e.g., schizotypal personality disorder) · If twin has schizo but you didn’t get it, you can be carrier of schizo gene but just didn’t turn on · Possible “deviant environment” could account for some of the concordance rates b/w twins with & without schizo § Adoption studies helped counter this: babies born from schizo moms but raised by non-schizo adoptive parents à more of these babies ended up with schizo than not - Molecular Genetics focused on 5 disorders that appear to share common genetic vulnerability · Schizo, major depressive disorder, bipolar disorder, autism spectrum disorder, and ADHD · Involve single-nucleotide polymorphisms in regions on chromosomes 3p21 and 10q24, and two calcium subunits: CACNA1C and CANB2 · Sporadic cases of schizophrenia (ppl who develop it without any family history of schizo) seem to reflect rare protein-altering gene mutation that have implicated over 40 genes, including disruptions to DCGR2 § Gene found in 22q11microdeletion region known for vulnerability to schizo - Cells of schizos also have fewer synapses so make fewer connections · Points towards usefulness of antipsychotic drugs to help nerve function return to normal levels Biochemical Factors - Dopamine Theory · Excess activity of dopamine (DA) so drugs that treat schizo reduce DA activity · Antipsychotics’ side effects = similar to symptoms of Parkinson’s Disease · 1 generation/conventional antipsychotics block D2 receptor nd · 2 gen/atypical antipsychs block D3 and D4, as well as S2, S3 · New research suggests that rather than excess of DA in the system, there’s an excess of oversensitive DA receptors · Another study found that maybe there is underactive DA neurons in PFC, thus failing to exert inhibitory control over DA neurons in limbic area resulting in over-activity in mesolimbic DA system · DA theory does not appear to be a complete theory for schizo - Other NTs · Newer drugs implicate Serotonin 18 · Glutamate may also play a role à low levels have been found in schizo’s cerebrospinal fluid · PCP (street drug) can cause negative & positive symptoms in regular ppl by interfering with one of glutamate’s receptors Brain structures/functions - Enlarged ventricles - Pre-frontal cortex is important - Many other areas in the brain Psychological stress - Social class – ppl with schizo tend to be lower in socioeconomic class - Sociogenic hypothesis suggests that stressors associated with lower social class may contribute to development of schizo - Social-selection theory explains that correlation b/w low social class and schizo could be because while developing psychosis, may have harder time making money and may drift into poverty-ridden areas of the city Family & Schizophrenia - Family relationships, esp b/w mother and child = crucial in development of schizo · What do we know about the development of schizophrenia from Developmental Studies (also known as High-risk studies)? ● In childhood they had lower IQs and were described as delinquents, withdrawn and with decreased motor skills and more expressions of negative affect. ● Teachers described the girls as passive and the boys as disagreeable. ● Negative symptoms was predicted by a history of pregnancy complications and by a failure to show electodermal responses to stimuli. ● Positive symptoms were associated with a history of family instability ● Also found low gray matter volume · What are the therapies for schizophrenia? How do they work? o What are the biological treatments? Prefrontal lobotomy: destroys the tracts connecting the frontal lobes to lower centres of the brain. It was used with patient having violent behaviour. Not used anymore as it was associated with loss of cognitive capacities. How do they work? What are the types of drugs (types, effects, side effects, etc.)? You will need to know the general types/categories of drugs (i.e. first-generation antipsychotics/neuroleptics, second-generation atypical antipsychotics), but you will not be tested on any specific drug names (i.e. chlorpromazine, Thorazine, butyrophenones, haloperidol, Haldol, etc.). 19 First generation drugs (conventional/traditional antipsychotics): Block dopamine receptors reducing dopamine influence (thought, emotions and behaviour) Made patients more calm, less fearful and sleepy but have many side effects. They also seem to work on the positive side effects not the negative ones. Side effects include dizziness, blurred vision, restlessness, sexual dysfunction. There was also extrapyramidal side effects affecting the nerve tract: Parkinson’s disease symptoms; tremors of the fingers, shuffling gait, drooling, dystonia (muscular rigidity), dyskinesia(abnormal motion of all muscles) chewing movement, kip, fingers, legs. AKathisia (can’t stay still) Tardive dyskinesia (sucking, lip-smacking, chin wagging motions and whole body involuntary motor movement in extreme case. May cause neuroleptics malignant syndrome which can be fatal; severe muscular rigidity with a fever, increased heart rate and blood pressure and may go into a coma. Second generations drugs (Atypical antipsychotics): Help both negative and positive symptoms. Are known to have greater therapeutic gains, less side effects and reduce relapse rates. One of the drug also decreases suicidal attempts compared to the traditional drugs. These drugs impact on serotonergic neurotransmitters and 5HT receptors. These drugs have lowered the amount spent in hospitals and increase well being compared to the traditional drugs. o What are the psychological treatments? Psychosocial treatments and cognitive behavioural interventions How do they work? Psychosocial treatments; This includes social skills training: teach behaviours to help with interpersonal situations such as conversations with psychiatrist, ordering meals in a restaurant, filling out job applications, saying no to offers to buy drugs on the street. Theoretical basis of this is by Robert Liberman and his associates: 3 key elements. 1. Receiving skills, 2. Processing skills 3. Behavioural responses in social interaction. Done by modelling, role playing and training in goal setting. Helps with living in the community, employment, cognitive deficits and negative symptoms. Family therapy, reducing expressed emotion: calming things down for the family once the patient is out of hospital by; -educating clients and families about the disorder, vulnerabilities, symptoms and signs of relapse. - provide information about how to deal with effects of the medication. - encourage to not put blame on anyone. -improve communication and problem solving. -encourage to expand their social contacts and support networks. -instill hope that things can improve. Study found that families that express their emotions highly have negative effects (relapse).Research indicates that one clear benefit is a lasting reduction in family distress and dysfunction. 20 Cognitive-behavioural therapy: Addresses delusions and hallucinations. It also motivates clients to engage in social and vocational activities. Claims that itis attributions and beliefs that cause distress and dysfunction from cognitive styles. Grant and Beck focused on a cluster of dysfunctional attitudes in a factor described as ‘defeatist beliefs’ ex: If you cannot do something well, there is little point in doing it at all. Clients have found to have ‘the deficit syndrome’ who have those beliefs. Cognitive Therapy and Command Hallucinations (CTCH) figure 11.6 p358. The extent to which voice hallucinations are seen as strong for a client. Power beliefs (100% powerful). How the voices are perceived will dictate if the client will comply. CBT address and remove these beliefs therefore limit the command hallucinations from occurring. Although may not be the optimum treatment for hallucinations and delusions. CBT seems to be effective at reducing negative symptoms, feeling less negative about oneself and less hopeless.CBT benefited the most were clients with medication- refractory positive symptoms. Focusing on basic cognitive functions: Cognitive enhancement therapy (CET). Since it is known that individual with schizophrenia have deficits in cognitive functioning and performance deficits on simple and complex tasks, there is an attempt to improve these functions; attention and memory, social adaptation and other deficits. The CET specific focus is on computer-based training in attention, memory, and problem solving as well as social cognitive skills (starting a conversation) Also used is the scaffolded instructions (current development zone) then learn from that zone on to develop general problem solving skills. This improves their self regulation and self conceptualization. Practice accounted for the improvements. · What are the Contemporary Trends and Issues in Treatment? Contemporary view is that biological factors predispose a person to develop schizophrenia and that stressors, principally of a psychological nature, trigger the disorder in a predisposed individual and interfere with that person’s adaptation to community living. Both pharmacological and psychosocial interventions are important. Things to keep in mind: medication is necessary, blaming and guilt is counterproductive, effort is needed in treatment programs, family-oriented treatment needed especially for after discharge, CBT interventions helps clients with control of stress, early intervention is important, multi-faceted campaigns aimed at the general public and key professionals are needed, teach clients social skills and reality based thinking, and join support groups. · How does early detection relate to prevention? (the Canadian Perspectives 11.1, page 362) First Episode Psychosis Clinic at the Centre for ADDiction and Mental Health (CAMH): early intervention will help people function at the highest level possible, despite their disorder. Most are outpatient services for young people and most treatment is done in the participant's’ home. 21 PRIME clinic: Prevention through Risk Identification Management and Education: established to facilitate early identification and treatment of people aged 12-45 who are possibly in the earliest stages of a first episode of psychosis (prodromal phase) and are at risk of ‘transitioning’ to the active phase. The goal is to intervene during the prodromal phase to prevent 1, onset of active phase symptoms and 2, the decline in cognitive, social and occupational functioning associated with schizophrenia. By educating and raising awareness about schizophrenia in the medical community and general public, early signs such as confusion, exaggerated self-opinion, suspiciousness, altered perceptions, odd thinking and speaking processes, lack of close friends, flat emotions, can bring individual to treatment as soons as possible which gives them the best possible chance of recovery. ● Chapter Summary ○ The symptoms of schizophrenia are typically divided into positive and negative types. Positive symptoms refer to behavioural excesses, such as delusions, hallucinations, and disorganized speech. Negative symptoms refer to behavioural deficits, such as flat affect, avolition, alogia, and anhedonia. Individuals with schizophrenia also show deterioration in functioning in occupational and social roles. ○ The diagnosis requires that symptoms be present for at least one month and that a prodromal or residual phase, in which some symptoms are present but at a lower level of severity, lasts for at least five months. ○ Schizophrenia, as described in diagnostic systems, has historically been divided into subtypes, such as paranoid, catatonic, and disorganized. These subtypes are based on the prominence of particular symptoms (e.g., delusions in the paranoid subtype) and reflect the considerable variations in behaviour found among people diagnosed with schizophrenia. These distinctions were dropped in DSM-5, though dimensional symptom ratings have been added to capture the heterogeneity of symptom expression. ○ The concept of schizophrenia arose from the pioneering efforts of Kraepelin and Bleuler. Kraepelin’s work fostered a descriptive approach and a narrow definition, whereas Bleuler’s theoretical emphasis led to a broad diagnostic category. Bleuler had a great influence on the American concept of schizophrenia, making it extremely broad. By the middle of the twentieth century, the differences between the diagnosis of schizophrenia in the United States and the diagnosis of schizophrenia in Europe were vast. ○ Research has tried to determine the etiological role of specific biological variables, such as genetic and biochemical factors and brain pathology, as well as of stressors, such as low social class and family conflict. The data on genetic transmission are impressive and new research increasingly highlights the complex 22 array of genetic factors and processes that may be involved. Adoption studies, which generally escape the criticisms levelled at family or twin studies, show a strong relationship between having a schizophrenic parent and the likelihood of developing the disorder. Perhaps the genetic predisposition has biochemical correlates, although research in this area permits only tentative conclusions. ○ It appears that an increased sensitivity of dopamine receptors in the limbic area of the brain is related to the positive symptoms of schizophrenia. The negative symptoms may be due to dopamine underactivity in the prefrontal cortex. Research into biochemical factors in schizophrenia is beginning to examine the possible role played by other neurotransmitters, such as serotonin. ○ The brains of people with schizophrenia, especially those with negative symptoms, have enlarged lateral ventricles and prefrontal atrophies, as well as reduced metabolism and structural abnormalities in the frontal and limbic areas. Some of these structural abnormalities could result from maternal viral infection during the second trimester of pregnancy or from damage sustained during a difficult birth. ○ Vague communications and conflicts are evident in the family life of people with schizophrenia and probably contribute to their disorder. A high level of expressed emotion (EE) – criticism, hostility, and emotional overinvolvement – in families has been shown to be an important determinant of relapse. Increases in general life stress have also been shown to be important precipitants of relapse. These stressors may increase cortisol levels, which, in turn, stimulate dopamine activity. ○ Much of the available information is consistent with a diathesis-stress or biopsychosocial view of schizophrenia. Investigators have turned to the high-risk method, studying children who are particularly vulnerable to schizophrenia by virtue of having a schizophrenic parent. Mednick and Schulsinger found that circumstances predicting maladjustment in adulthood differ depending on whether positive or negative symptoms are most prominent. ○ There are both biological and psychological therapies for schizophrenia. Insulin and electroconvulsive treatments and even surgery were in vogue in the early twentieth century, but they are no longer much used, primarily because of the availability of antipsychotic drugs, in particular, the phenothiazines. In numerous studies, these medications have been found to have a major beneficial impact on the disordered lives of people with schizophrenia. Newer medications such as clozapine and risperidone are at least as effective as the phenothiazines and produce fewer motor side effects. Drugs have also been a factor in the deinstitutionalization of hospital clients. ○ Drugs alone are not a completely effective treatment, as clients with schizophrenia need to be taught or retaught ways of dealing with the challenges of everyday life. Furthermore, most antipsychotic drugs have serious side effects, 23 especially after long-term use, and many clients with schizophrenia do not benefit from them. ○ Good evidence for the efficacy of psychoanalytic treatments does not exist, although case studies of dramatic cures have been presented in both the professional and the popular literature. ○ Family therapy, aimed at reducing high levels of expressed emotion, has been shown to be valuable in preventing relapse. In general, evidence is accumulating and showing the benefits of psychosocial interventions. ○ Behavioural treatments, such as social skills training, have helped clients discharged from mental hospitals meet the inevitable stresses of family and community living or, when discharge is not possible, lead more ordered and constructive lives within an institution. ○ Recent efforts to change the thinking of people with schizophrenia are showing much promise and there is growing support for cognitive theories of schizophrenia and associated interventions. ○ The most effective treatments for schizophrenia are likely to involve both biological and psychological components. ○ A significant proportion of people who are homeless suffer from mental illness. Canada has implemented important initiatives such as the At Home/Chez Soi Project led by the Mental Health Commission of Canada. Chapter 12 (lectures) · What are the components/features of the substance-related disorders? Addiction, tolerance, physical and psychological dependence Addiction: body requires substance for normality Tolerance: as use continues, amount needed to achieve “high” rises Physical Dependence: withdrawal effect is experience in absence of drug Psychological Dependence: desire for emotional effects of drug, user’s tendency to focus life around drug What is a substance use disorder? What are the diagnostic criteria, symptoms and specifiers? 10 Classes: alcohol, cannabis, caffeine, hallucinogens, inhalants, opioids, sedatives, stimulants, tobacco, other. Also includes gambling disorder. All used in excess, cause activation in brain reward system (the “high). Essential feature: cluster of cognitive, behavioural and physiological symptoms, including continued use of substance despite many substance related problems. Also important: underlying change in brain structure which may go beyond detoxification. Contributes to relapse and cravings (when exposed to environmental stimuli). What are the effects of nicotine How does nicotine work? Effects on the Nervous System: first puff releases dopamine into reward pathways. 24 Increases NE in amygdala (porcess and storage of emotional memory), then decreases amount of NE released (decreases pleasure). Also implicates serotonin, glutamate, GABA, acetylene, Endogenous Opioids Barr, Pizzagalli et all Study: nicotine on non-smokers. Single dose increased positive response to environmental cues. Withdrawal: irratability, depressive mood, insomnia, frustration, anger, difficulty concentrating, restlessness, increased heartrate, decrease in reward functions. Impulsivity, Study: high and low impulsive smokers asked to quit for a day, then recorded thoughts before allowed to smoke again. Same negative experience reported but high impulsive recorded more feelings of positive expectation from resuming smoking. What are the effects of alcohol? How does alcohol work? How do genes influence susceptibility? Effects on Nervous System: increases dopamine and serotonin, increases reward, positive expierence, feelings of pleasure. More NE released, activating and enlivening. GABA reduces stress/anxiety and relaxes. Endogenous Opioids increase pleasure, decrease stress. Glutamate blocks NMDA receptor, slower cerebral reaction and memory problems Chronic Effects: Vitamin B deficiency causes neurological impairments. Encephalopathy: cognitive, motor, and visual deterioration. Korsakoff’s syndrome: involves amnesia. Gastrointestinal problems: cirrhosis of liver, pancreatitis, hypertension (high blood pressure). Rapid increase in rate of frontal lobe shrinkage. Genetic Susceptibility: Diathesis-Stress model. Study on High Risk Environments. Type 1: relatively mild addiction, minimal criminality. Type 2: early onset, violence and criminality. High risk environments had an effect on Type 1 but not Type 2. Same environment presents different risks depending on genotype. What sorts of treatments are available? Psychosocials: inpatient hospitalization, AA, Controlled Use, Aversion Therapy, continguency and behaviour management, Relapse Prevention Biological: agonist substitution substitutes one drug with a similar one, example methadone replaces heroine. Antagonist substitution: block one drug’s effect with another. Adversive Therapy (unpleasant)/ Drugs for treating withdrawal. . Chapter 12 (text) · What are the components/features of the substance-related disorders? Tolerance, Withdrawal, etc. What are substance abuse and substance dependence, and how are these now part of the substance-related and addictive disorders? Historically, the pathological use of substances was represented in 2 categories: substance dependence. Substance dependence was characterized by the primary symptoms of tolerance and withdrawal. 25 Tolerance is indicated by either: (1) larger doses of the substance being needed to produce the desired effect or (2) the effects of the drug becoming markedly less if the usual amount is taken. Withdrawal symptoms: 1)negative physical and psychological effects develop when the person stops taking the substance or reduces the amount. 2) The person may also use the substance to relieve or avoid withdrawal symptoms. substance abuse, the person must experience one of the following as a result of recurrent use of the drug: 1)Failure to fulfill major obligations 2)Exposure to physical danger (operating machinery when intoxicated) 3)Legal problems 4)Persistent social/interpersonal issues What is alcohol abuse and dependence? What do we know about the features, symptoms, characteristics, etc.? Alcohol abuse- The person who abuses alcohol, in contrast to the person who is physically dependent on it, experiences negative social and occupational effects from the drug but does not show tolerance, withdrawal, or the compulsive drinking patterns seen in the person who is alcohol dependent. Alcohol dependence- Alcohol dependence may include tolerance or with- drawal reactions. People who are physically dependent on alcohol generally have more severe symptoms of the disorder. Withdrawal of alcohol and Tolerance- The effects of the abrupt withdrawal of alcohol in a chronic, heavy user may be dramatic because the body has become accustomed to the drug. Subjectively, the patient is often anxious, depressed, weak, restless, and unable to sleep. Tremors of the muscles, especially of the small musculatures of the fingers, face, eyelids, lips, and tongue, may be marked, and pulse, blood pressure, and temperature are elevated. Although changes in the liver enzymes that metabolize alcohol can account to a small extent for tolerance, most researchers now believe that the central nervous system is implicated Withdrawal delirium tremens 26 In relatively rare cases, a person who has been drinking heavily for a number of years may also experience delirium tremens (the DTs, which involve alcohol withdrawal delirium) when the level of alcohol in the blood drops suddenly. The person becomes delirious as well as tremulous and has hallucinations that are primarily visual, but may be tactile, as well. o What is the nature of this disorder? What is the course of this disorder? Jellinek describes that male drinkers have four stages from social drinking and progressing to a stage at which he lives only to drink. Although considerable fluctuations are found in drinking patterns; heavy drinking, abstinence or lighter drinking at times. There is no single pattern of alcohol abuse. For women they usually begin at a later age and usually after stressful experiences. The time interval between the onset of heavy drinking and alcohol abuse is briefer than it is for men. They are also steady drinkers who drink alone and are more unlikely than men to binge. o What are the short-term effects: it depends on the concentration of the drug in the bloodstream, amount ingested in a period of time, presence of food, size of a person and efficiency of the liver. Alcohol is metabolized by enzymes after reaching the stomach. Most is in the small intestines and gets absorbed into the blood. Broken down in the liver. If the amount exceeds the amount able to metabolize (30 mililitres 50% alcohol) per hour then effects are felt. It has a biphasic effect; initially it stimulates. The drinker feels sociable, and increased well-being. When the blood level of alcohol peaks and begins to decline, then it acts as a depressant and may lead to negative emotions (depressed and withdrawn). Large amounts interferes with complex thought, motor coordination, balance, speech and vision are impaired. The stimulation of GABA receptors reduce tension (major inhibitory neurotransmitter.). Serotonin and dopamine levels increases and produce pleasurable effects. Glutamate receptors are inhibited which causes cognitive effects such as slurred speech and memory loss. and long-term effects of alcohol?: creates severe biological damage and psychological deterioration. Body tissue and organs are almost all affected. Signs of malnutrition; heavy drinkers often reduce their intake of food impairing the digestion of good and absorption of vitamins. Deficiency of B-complex vitamins which can cause memory problems. Decreased amounts of protein intake contributes to the development of cirrhosis of the liver. Damage to endocrine glands and pancreas, heart failure, hypertension, stroke, capillary hemorrhages (swelling and redness in the face). Brain cells destroyed by prolonged use; loss of grey matter from the temporal lobes. Reduction of immune system, women who drink has a risk for breast cancer. Drinking while pregnant can affect the baby such as fetal alcohol syndrome; mental disability, 27 growth of fetus is slowed, cranial, facial and limb anomalies. There are psychological, biological and social consequences of prolonged consumption of alcohol. · What do we know about the features, symptoms, characteristics, etc. of Inhalant Use Disorder? ● Many young people begin their substance abuse by inhaling such substances as glue, correction fluid, spray paint, cosmetics, gasoline, household aerosol sprays, and the nitrous oxide found in spray cans of whipped cream ● Peak age of use is 14-15 beginning as young as 6 ● Inhalants are inexpensive and readily available ● Inhalant use disorder can involve: sniffing, huffing (breathing in fumes from a small rag in mouth) and bagging (breathing fumes from a plastic bag held up to mouth) ● High rate of gasoline sniffing in Indigenous communities ● Most inhalants act as depressants - and cause damage to nervous system ● High levels of suicide, criminal behaviour and family problems · What do we know about the features, symptoms, characteristics, etc. of Nicotine use? What are the health consequences? ● Settlers imitated the Indigenous people in the Americas ● It can be smoked, chewed or ground into small pieces and inhaled as snuff ● Nicotine: addicting agent of tobacco which stimulates pleasure receptors and mood modulation ● Nicotine is VERY addictive and a robust and highly effective reinforcer of drug taking behaviour ● Addictive effects begin very shortly after first puff (for some all it takes is one puff) ● Female smokers have substantially greater changes in cognition than males Health Consequences ● Responsible in some way for ⅕ deaths in the US ● Single most preventable cause of premature death ● Less dangerous for cigar/ pipe smokers because they seldom inhale the smoke into lungs (but increased cancers of the mouth) ● Consequences of extended smoking: lung cancer, emphysema, cancer of the larynx, and esophagus and many cardiovascular diseases ● Smoking health risks significantly decline 5-10 years after quitting · What do we know about the features, symptoms, characteristics, etc. of Marijuana use? What are the psychological, somatic, and therapeutic effects? ● Marijuana (crushed leaves and flowers of the hemp plant) can be smoked, chewed, prepared as tea, or eaten 28 ● Hashish: (stronger than Marijuana) is produced by removing and drying the resin exudate of the tops of high-quality cannabis plants ● Effects include relaxation and sociable behaviours, ○ Larger doses bring rapid shifts to emotions, to dull attention, to fragment thoughts, and to impair memory ○ Time seems to move slowly ○ Heavy doses could include hallucination and other effects similar to those of LSD (eg. panic) ● Increases likelihood of psychotic disorders in some young people ● Much more potent now than it was 20 years ago ● Drop in IQ for heavy smokers, no changes for occasional smokers ● Marijuana plays a role in a significant proportion of accidents and arrests ● Can last in the system for up to 8 hours and people will not realise they are still impaired when they drive or fly ● Short term effects: bloodshot and itchy eyes, dry mouth and throat, increased appetite, reduced pressure within the eye, raised blood pressure ● Habitual use of MJ does produce tolerance ● Dependence susceptibility: some people are much more sensitive and prone to becoming addictive than other people (starting young, anxiety disorder) ● THC and related drugs can reduce effects of chemotherapy (nausea & appetite) ● MJ treats: AIDS, glaucoma, epilepsy, and multiple sclerosis ● 2001: legal for medicinal purposes · What do we know about the features, symptoms, characteristics, etc. of Sedatives and Stimulants? Sedatives: Slow the activities of the body and reduce its responsiveness ● Includes: opiates (opium and its derivatives), morphine, heroin and codeine (and the synthetic barbiturates and tranquilizers: secobarbital & diazepam) ● OPIATES: group of addictive sedatives that relieve pain and induce sleep when taken in modern doses ○ Opium is one of the most common form - when synthetic it is referred to as opioids ○ OXYCONTIN: a very popular and addictive painkiller in Canada that produces a swift and powerful high ○ Prescription Opioid Related Misuse (PORM) Canada is among the highest in the world ● MORPHINE: Separated from raw opium and used as a powerful painkiller and sedative ○ Used in patent medicines & directly into the vein to relieve pain ○ Soldiers in the American Civil War were treated with morphine and returned home to the addictive drug 29 ● HEROIN: researched that morphine could be converted into another powerful pain- relieving drug, heroin. ○ Originally used as a cure for morphine addiction ○ Then proved to be even more addictive and more potent than morphine, acting more quickly and with greater intensity ● Psychological and physical effects: euphoria, drowsiness, reverie, lack of coordination ○ Rush, feeling of warm, suffusing ecstasy immediately following an intravenous injection ○ Sheds worries and fears and has great self-confidence for 4-6 hours - then has a letdown, bordering on stupor ○ Reactions to not having a dose may begin within 8 hours of last injection ○ Users show increased tolerance to the drug and withdrawal symptoms (muscle pain, sneezes, sweats, tearful, yawning) then around 36 hours they become more severe (uncontrollable muscle twitching, cramps, chills alternating with excessive flushing and sweating, and a rise in heart rate and blood pressure, insomnia, vomiting and diarrhea) ○ Symptoms persist for about 72 hours and gradually decrease over a 5-10 day period ○ Often spend upwards of $200 on these drugs/ day either they are wealthy or acquire money through illegal means (eg. prostitution or selling drugs) ● BARBITURATES (benzodiazepines):another major form of sedative is a synthetic sedative. ○ They were frequently prescribed until it was discovered that they were addictive ○ Sedatives: relax the muscles, reduce anxiety, mildly euphoric state ○ With excessive use: slurred speech, unsteady gait, impaired judgement, concentration, and ability to work loss of emotional control, irritability, combative and falling into a deep sleep ○ Very large doses: fatal because the diaphragm muscles relax to such an extent that the individual suffocates ○ Large doses of sedatives are often chosen as a means of suicide Stimulants: uppers, act on the brain and the sympathetic nervous system to increase alertness and motor activity ● AMPHETAMINES: originally developed to help with asthma it became commercially available in the 1930’s and soon after discovered its stimulating effects ○ Prescribed for depression and appetite and in war to combat fatigue. Currently it is used for hyperactive children ○ They can be taken orally or intravenously and can be addictive ○ Symptoms: wakefulness, reduced appetite, increased heart rate, constricted blood vessels, alert, euphoric, outgoing, self-confidence 30 ○ Large doses: make people feel confused, nervous with palpitations, headaches, dizziness and sleeplessness, can become suspicious and hostile * over a long time it can induce a state similar to paranoid schizophrenia ○ Tolerance develops rapidly ○ Can inject several times: resulting in days without eating or sleeping resulting in an exhausted and depressed state with sleep ● COCAINE: Sigmond Freud promoted the drug to combat his depression but then realised it has negative effects as well ○ It reduces pain, creates a state of euphoria, increases sexual desire, self- confidence, well-being, and indefatigability ○ Overdose: chills, nausea, insomnia, paranoid breakdown, hallucinations of insects crawling under the skin ○ Chronic use: changes in personality: heightened irritability,impaired social skills, paranoid thinking, dangers in pregnancy, memory and attention, · What do we know about the features, symptoms, characteristics, etc. of LSD and Other Hallucinogens? What are the effects and side effects of hallucinogens? ● Hallucinogens: a drug that has one of its main symptoms of hallucinations ● A bad trip: can lead to panic attacks, and in worst case scenario they can go into a psychotic states that can require hospitalization and extended treatment ● Flashbacks: recurrence of psychedelic experiences after the physiological effects of the drug have worn off · What do we know about the etiology of substance abuse and dependence? What are the social, psychological, and biological variables? How do they work? ● Substance abuse is a developmental process (positive attitude toward the substance- experiment with it- use it-use it heavily- become dependant) Social Variables: peers, parents, media portrayals affect people's interest in and access to drugs ● Cultural attitudes and patterns of drinking thus influence the likelihood of drinking ● Ready availability is another factor ● Smoking increases if cigarettes are perceived as easy to get and affordable ● Chronic disease behavioural factors (smoking, drinking) are more prevalent among those who have caregivers who smoke and peers who smoke and drink ● Protective factors: high self esteem and from a home with someone who went to post secondary ● Higher connection between siblings than parent-child ● High self-efficacy = less influenced by peers Psychological Variables ● Why do people drink: cost vs. benefits --> drinking occurs if perceived benefits outweigh the perceived costs 31 ● Other researchers believe drinking motives vary along 2 dimensions ○ Valence of reinforcements (positive vs. negative) – drink to obtain pleasurable outcomes & avoid negative outcomes ○ Locus (external reasons, vs. internal, personal reasons) – drink in response to external, social stimulation, or internal, personal cues ○ 4 drinking motives are possible between the 2 dimensions ● Self-medication theory of addiction – exactly what it sounds like Cognitive Factors · Reduces tension · Alcohol myopia: intoxicated person has less cognitive capacity to distribute between ongoing activity & worry --> activities = distractions from anxiety Personality · High sensation seekers tend to be more into drugs · Alcohol/Durg use believed to be associated with behavioural inhibitions, which is associated with people high on novelty seeking, harm avoidance, reward dependence o Novelty seeking dimension is most relevant to alcohol dependence · Eyeseck believed people with substance dependence are most likely those high on neuroticism & psychoticism · Study on kindergartners o Anxiety and novelty-seeking in kindergartners predicted onset of getting drunk, using drugs, and smoking o Depression was related to smoking · Maturing out phenomenon: shit ton of drinking in early-twenties followed by sharp drop in late thirties (~20 solid years of getting lit fam) LOLLL What are the therapies for Problem Drinking? Hospital Treatments, Biological Treatments, Psychological Treatments How is admitting the problem helpful, and how does this work? - Because once the person admits they have a problem, they can seek help from treatments available to them - Enabling drinker to taking first step to betterment – contemplation stage – can be achieved through questions that get at the issue somewhat indirectly · E.g., “do you sometimes feel uncomfortable when acohol is not available?” etc. How has traditional hospital treatment worked? What are the biological treatments? What is Alcoholics Anonymous and how does this work as treatment? How does couple/family therapy work? How does cognitive-behavioural treatment work? Traditional Hospital Treatments - Tranquilizers are sometimes given to ease anxiety & general discomfort of withdrawal 32 - Due to tranquilizer abuse, some places will try gradual tapering off without tranquilizers, rather than sudden cut-off of alcohol · Works for most problem drinkers - Also need carb solutions, B vitamins, and sometime anticonvulsants Biological Treatments - Disulfiram, or Antabuse: drug that discourage drinking by causing violent vomiting if alcohol is ingested - Blocks metabolisms of alcohol so that noxious by-products are created - Biological treatments work best when used along with psychological intervention - Naltrexone and Naloxone add to overall treatment when combined with CBT Psychological - Alcoholics Anonymous o 12-Step Program - Couples & family therapy o Behaviorally oriented therapies to help abstain or reduce excessive drinking o Works o Focus is for loved one to help drinker take Antabuse on regular basis - CBT o Aversion therapy: problem drinkers are shocked or made nauseous while looking at, reaching for, or beginning to drink alcohol § Covert sensitization – instructed to imagine being made violently and disgustingly sick by their drinking § Lacks empirical support o Contingency-Management Therapy: teaching the drinker & those close to them to reinforce behaviours inconsistent to drinking (like operant conditioning): e.g., taking Antabuse and avoiding situations associated with drinking § Also includes teaching job-hunting & social skills as well as assertiveness to refusing drinks § Behavioural self-control training – emphasizes patient control & one or more of: · Stimulus control: limits situations in which one allows oneself to drink (e.g., special occasion) · Modification of topography of drinking: e.g., only mixed drinks & taking small sips rather than taking shots or big gulps · Reinforcing abstinence: e.g., allowing oneself a non-alcoholic treat if one resists the urge to drink o Moderation in Drinking § Controlled drinking: moderate pattern of alcohol consumption that avoids extremes of total abstinence and inebriation 33 § Guided self-change: outpatient approach that emphasizes personal responsibility & control · Early intervention program for ppl with mild to moderate drinking problems · Helps clients help themselves · Allows client to make informed choices · Teaches general problem-solving approach · Strengthens clients’ motivation & commitment to change · Encourages self-reliance, empowerment, and personal competence § Harm reduction therapy: · Considers addictions an adjustment problem that needs intervention rather than a crime deserving of punishment · Abstinence is ideal outcome, but is not the only outcome – striving for more extreme goals might be self-defeating · Bottom-up approach in line with needs of addict & is focused on reducing their level of suffering · More access to “lower threshold” services that will meet you where you are, not where you should be – since some programs kick you out if you are not abstinent… but that’s the end goal so y’all fucked up · Based on compassionate pragmatism rather than moralistic idealism – non-judgmental & acknowledges realistic struggles as ppl attempt to manage everyday affairs What are the clinical considerations when treating alcohol abuse? ● Many different types of drinkers, individual differences will affect how they respond to treatment ○ Same treatment won’t work for everyone What are the therapies for the abuse of illicit drugs? Biological, Psychological. How do these work? Biological Treatments - Heroin substitutes: drugs chemically similar enough to heroin to reduce cravings - Heroin antagonists: drugs that prevent user from experiencing the high from heroin - Methadone, levomethadyl acetate, buprenorphine: synthetic narcotics designed to take place of heroin (is still addictive so turns heroin addict into addict of one of these) § Happens cuz these drugs are cross-dependent on heroin – act on same receptors but substitute original dependency 34 - Naloxone or cyclazocine: first weaned off of heroin, then given gradually increasing doses of these drugs, so that even if they take heroine later they won’t get the high § Down side: takes responsibility, motivation and control on addicts part, and
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