CH. 11 SUBSATNCE-RELATED-IMPULSE CONTROL DISORDERS

Substance related disorders: use and abuse of psychoactive substances• Wide ranging effects

o Psychophysiological behavioral

• Significant impairment

Impulse-Control Disorders: inability to resist acting on drives or impulses• Levels of involvement:

o Substance use: coffee, cigarettes, occasional marijuana, occasional cocaine, amphetamines, barbiturates, benzodiazepine

Doesn’t do any harm if done in moderationo Substance abuse: when it interferes with your life (work, relationships)

Your attitude is in denial over everything You don’t have dependence, withdrawal or tolerance You are in denial

o Substance dependence: “addiction”

Tolerance developed—take more to get high Experience withdrawal when trying to quite

Types of Substances: • Depressants: alcohol, benzodiazepines, inhalants, marijuana, nicotine

o CNS depressant: Inhibitory centers: their brain doesn’t inhibit what it should (things you shouldn’t say)

Global o Neurotransmitter systems

GABA: fight/flight Glutamate Serotonin: mood

o Primarily affects the frontal lobe of the brain—judgment, impulse, control, decision making. And the cerebellum—balance, posture

o Good correlation with aggression/violence affected by quantity, timing, history, o Positive reinforcement for dependence: activates dopamine (pleasure center) making io Negative dependence: don’t want withdrawal

• Stimulants: “up”—more alert and more focus, though it has a “crash”o Stimulate CNSo Most commonly consumed drugo Reduce appetite o Effects of amphetamines:

Norepinephrine Dopamine Hallucinations and delusions

o Cocaine: increased blood pressure, insomnia, decreased appetite, paranoia

Highly addictive Develop slowly

• Tolerance, Atypical withdrawalo Nicotine: gives sensation of relaxed state, wellness, pleasure

Highly addictive Withdrawal causes irritability, anxiety, difficulty concentrating, restlessness, weight gain

o Caffeine: over 90% Americans take

In small doses wont cause addiction

Can develop a tolerance, withdrawal symptoms both psychological and physiological • Opiates: pain regulation commonly diagnosed by doctors

o Heroin, opium, codeine, morphineo Calm, euphoric, drowsinesso Acts as a depressant too:

Low dose: euphoria, drowsiness, slow breathing High dose: fatal

o Withdrawal symptoms: vomiting (1-3 days)

• Hallucinogens: alter sensory perception, delusions, paranoia, hallucinations, depersonalization o LSD:

Tolerance is rapid Withdrawal is uncommon

o Marijuana “cannabis”: most frequently used drug

Variable, individual reactions Tolerance is questionable Withdrawal and dependence is uncommon Altered sensory perceptions: tactile, visual, and auditory hallucinations, depersonalization, altered

sensory perceptions• Inhalants: fastest. Goes straight to your brain

o Spray paint, hair spray, paint thinner, gasoline, nitrous oxideo Effects are similar to alcohol intoxication o Produce tolerance and prolonged withdrawal symptoms

• Medications Sedative/hypnotic Disorders:

• Barbiturates: can cause comas, similar to alcohol

• Benzodiazepines

• DSM V Criteria: o Maladaptive behavior changeso Impaired judgmento Variable moodso Impaired function

Psychological dimensions• Positive reinforcement

• Negative reinforcemento When you try to quite and you get terrible withdrawal symptoms so you start it back up so that you don’t

go through it anymoreBiological treatment:

• Aversive treatment: make use of drugs extremely unpleasanto Antabuse for alcoholism

• Medications: cope with withdrawal symptoms

• Efficacy: limited when used aloneo Better with psychosocial therapy

Treatment—psychosocial• Inpatient facilities:

o Expensiveo Efficacy is equal to outpatient

• Alcoholics anonymous (12 step)

o Most popularo Social supporto Limited researcho Effective for highly motivated

• Controlled use--o Controlled drinkingo Moderationo Possible benefitso Limited research

Impulse Control Disorder• Intermittent explosive disorder: frequent aggressive outbursts

o Lash out physically o Injury and/or destruction to propertyo Biological: serotonin, norepinephrine, testosteroneo Psychosocial: stress, disrupted family life, parentingo Treatment: CBT, medication (best method)

• Kleptomania: failure to resist urge to steal unnecessary itemso They feel a tension when in the store, and when they have it with them (without paying) they feel a

release Considered an antidepressant because stealing regulates their mood in a sense

o Some say that they are amnesiac to the event. There has been some brain imaging proving it as wello High comorbidities: mood disorders, substance abuse/dependenceo Treatment: antidepressants

• Pyromania: irresistible urge to set fireso Usually younger kids, short livedo NOT Arsonistso Little etiological and treatment research—CBT in that it can identify what the triggers are

• Pathological gambling: MOST ADDICTIVE OUT OF ALLo Even when they’ve lost all their money and their family wont speak to them anymore, they will still

believe that if they gamble one more time, it will fix everything and they’ll make their money backo Biological influences: poor impulse regulation, dopamine (pleasure), serotonin (moods) o Treatment: similar to substance dependence—go to meetings, get social support

• Trichotillomania: irresistible urge to pull hair (eyelashes, head) to relieve anxietyo The unattractiveness wont even bother themo Treatments: SSRIs, CBT

Video: mother says that people put her down for not being there. She claims that she was always there and that she had her child in “everything”. This seems to look like a perfectionistic family, pressuring the child to be perfect and do what the parent wants. As a clinician, you must keep your ears perked to hear certain things so that you have ALL of the information to properly diagnose and treat the patient.

CH 12 PERSONALITY DISORDERS

Personality disorder: inflexible ,maladaptive way of perceiving the world and relationships and themselves. So they are very difficult to treat. They feel that any internal difficulties they have are because of others and there is nothing wrong with them, its everyone else’s fault Enduring and pervasive predispositions: these disorders develop very early on in life, thus altering

• Perceiving, relating, and thinkingInflexible and maladaptive: much like mental retardation, thus the both of them get mixed up and put into the same categories

• Distress, impairment

—High comorbidity with many other disorders—Poorer prognosis—Prevalence = 0.5-2.5%

• Outpatient = 2-10%

• Inpatient = 10-30%—Gender: differences in diagnostic rates

• Borderline—75% female

• Clinician bias

• Criterion biaso Histrionic = extreme “stereotypical femaleo No ‘macho” disordero Comorbidity

Cluster A: Odd or eccentric• Paranoid Personality Disorder: mistrust and suspicion, paranoid

o They view the world as a dangerous place and believe people will stab them in the back, so being their doctor can be very difficult

o Have very few relationships, sensitive to criticism, vulgar, antisocial, parents can be criminalo Treatment: unlikely to seek help, there must be a crisis

Focus on developing trust CBT: assumptions, negative/distorted beliefs

• In a movie theater, when teenagers are noisy and talking, they believe that the teenagers are doing it on purpose to upset them.

No empirically-supported treatments o Etiology:

Possible relationship to schizophrenia—they might have a predisposition to think this way Possible role of early experience: trauma, abuse, learning (“world is dangerous”)

o Prognosis: not good, especially if not treatedo Course: chronic if not treated

• Schizotypal Personality Disorder: psychotic-like symptoms o Magical thinking (you can read peoples minds), Ideas of reference (see a message on the TV and think its

about/for you), illusionso Odd/unusual behavior and appearance—but you can still understand them clearly…o Socially isolatedo Highly suspicious o Etiology :

Lack full biological or environmental contributions: Preserved frontal lobes Cognitive impairments: left hemisphere, more generalized

o Treatment: treatment of comorbid depression

Multidimensional approach: social skill training, antipsychotic medications, community treatment• Schizoid Personality Disorder:

o Appear to neither enjoy nor desire relationshipso Limited range of emotions: Appear cold, detachedo They don’t notice/care for social cues (things that make you laugh, smile, frown…)o Appear unaffected by praise: Unable or unwilling to express emotiono No thought disordero As children, they grow up shy, don’t participate, like to observeo They are high functioning—choose to work in places where they are on their owno Etiology: limited research, precursor—childhood shyness, abuse, neglect, autism, dopamine

o Treatment: unlikely to seek on own, must be a crisis

Focus on relationships Social skills therapy: empathy training, role playing, social network building No empirically-supported treatments

Cluster B: Dramatic, emotional, erratic• Antisocial Personality Disorder: noncompliance with social norms

o “Social predators”: violate rights of others, irresponsible, impulsive, deceitfulo Can be criminals, or day-to-day workers o Don’t feel fearful, don’t consider consequenceso Nature of psychopathy:

Glibness/superficial charm Grandiose sense of self-worth Proneness to boredom/need for stimulation Pathological lying Conning/manipulative Lack of remorse, empathy, and consciousness

o Etiology:

Inconsistent parenting, learn from parents in how they think and act, variable support, history of criminality and violence

Early histories of behavioral problems Gene-environmental interaction: genetic predisposition, environmental triggers

• Amygdala is overactive and they are under-aroused

Arousal hypotheses: under-arousal, fearless Gray’s model of brain functioning:

• Behavioral inhibition system (BIS)—lowo Whatever they think about doing, they do it. Nothing holds them back

• Reward system (REW)—high

• Fight/flight system (F/F)

Interactive, integrative model: genetic vulnerability (neurotransmitters), environmental factors o Treatment: unlikely to seek own

High recidivism, incarceration, early intervention—parental trainingo Prevention: Rewards for pro-social behaviors, skills training, improve social competence

• Borderline Personality Disorder: clinicians have the most difficulty with these peopleo Patterns of instability: CANNOT regulate their emotions, don’t have an emotional skin

Labile—intense mood swings, cutting Turbulent relationships—go from person to person and always put the blame on them

o Very impulsive, extreme fear of abandonment, self mutilating, very suspiciouso Many attempts at suicidal. They aren’t looking for attention, they truly feel empty inside and don’t know

how to fill that void so they look for people to help them. They will create relationships with people that doesn’t exist. They assume way too much

o They come in with crisis after crisiso Comorbid disorders: depression (suicide), bipolar, substance abuse, eating disorders o Etiology:

Genetic/biological components: overactive amygdala, low BIS Early childhood experience: problem in mother child relationship, usually connected to abuse.

Very bad abuse. The mother is very rejecting and unaffectionate o Treatment: highly likely to seek treatment

First get them healthy, then help them deal with everyday things that they normally get upset about. Teaching them how to deal with them so they can function on a day-to-day basis

Antidepressant medications:

Dialectical behavioral therapy (DBT): o Outcomes: demonstrated efficacy, cortical activation changes

• Histrionic: overly dramatic o Attention seeking, like to be in the spotlight, overly seductive, o Don’t think about the long-term consequences of behavioro Etiology : little research

Links with antisocial personality: Sex-typed alternative expression Childhood—may be reinforced by accident if they liked to act

o Treatment: problematic interpersonal behaviors

Little empirical support because it is hard to identify them and bring them in because they don’t think anything is wrong with them

• Narcissistic: exaggerated and unreasonable sense of self-importanceo Expect to be treated differently. They are very entitled. Over exaggerated sense of importance o Requires attentiono Hypersensitivity to evaluationo Co-occurring depressiono Etiology: parental reinforcement. They praise their parents maybe a little too much

Not taught empathyo Treatment: not much. Teach them what they hadn’t learned as a child

Cluster C: Fearful or anxious• Avoidant:

o Extreme sensitivity to opinions of others, of being evaluated by others o Avoids most relationships because they are afraid of being dumped…they want them thougho Interpersonally anxious, fearful of rejection, low self esteemo In a relationship, they are very careful and passive about how they feel. They don’t want to rock the boato Etiology: difficult temperament, early parental rejection, interpersonal isolation and conflict o Treatment: similar to social phobia

• Dependento Rely on others for major and minor decisions. Like others to make decisions for them o Unreasonable fear of abandonmento Clingy, submissive, timid, passive, feelings of inadequacyo Sensitivity to criticismo High need for reassuranceo They will create relationships with people who are very stable and independent (have a job with money,

home, normalcy)….like looking for your dado Etiology: little research

Early experience: death of a parent, rejection, attachment o Treatment: limited empirical support

Caution: dependence on therapist, they say and do what the therapist wants to hear/see to please them

Gradual increases in: independence, personal responsibility, confidence • Obsessive-compulsive: fixation on doing things the “right way”

o Rigid, perfectionistic, orderly, preoccupation with details—most important things in their life

As a child, you can get rewarded for thiso Poor interpersonal relationshipso Obsessions and compulsions are rare—just feel the need to be perfecto Etiology: limited research

Weak genetic contributions Predisposed to favor structure

o Address fears related to the need for orderlinesso Decrease: rumination, procrastination, feelings of inadequacyo Limited efficacy data o Treatment: don’t want to be treated

CH. 13 SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS

Psychosis: active manifestations, distortions of normal behavior, exaggerations or excesseso Positive symptoms: men @ 19, women @ 20/21. Exaggeration of normal behavior

o Hallucinations: sensory experience in absence of environmental stimuli or input

Can involve all senses: visual, olfactory, auditory Most common: auditory (hear voices)

• Meta-cognition, own vs. others voice, Broca’s area

• Temporal part of the brain is mostly affectedo Delusions: disorder of thought, grandeur, persecution

Cotard’s Syndrome: believe that they are dead, the walking dead. Believe the entire world is made of just shells. They are very depressed and just cant die

• Abnormality in the brain

Capgras: brought about by changes in brain chemistry. They have a distinct feeling that the people in their lives have been replaced by imposters

• Can be brought on by dissociation due to characteristics about the person that we don’t like. So instead of looking at the person differently, you just say it isn’t them at all anymore

Gross misrepresentations of reality Strongly held false beliefs

o Negative symptoms: absence or insufficiently of normal behavior. Deficit of normal behavioro System cluster: Abolition (problem initiating and sustaining activities), Algolia (difficulty thinking, slow

thoughts and thus slow speech), Anhedonia (no pleasure in activities), Affective flattening (facial expressions)

Disorganized symptoms: erratic behaviors that affect many domainso Disorganized speech: cognitive slippage or loosening of associations, tangentially

Disjointed words, cant make sentences, but can write it down. They just cant vocalize ito Inappropriate affect/emotional expressiono Unusual behaviors: catatonia—rigid in posture, or fluid in movement

Schizophreniao Paranoid Type:

o Delusions and hallucinations: grandeur or persecutiono Intact cognitive skillso Cannot function at all, so you will never see them at worko Intact affecto Little to no disorganized behavioro BEST PROGNOSIS

o Disorganized Type: o Marked disruptions: speech, behavioro Flat or inappropriate affecto Hallucinations and delusions: fragmentedo Develops earlyo Chronico Few remissions

o Catatonic Type: unusual motor responseso Rigid, catatonic, don’t react/move. o Odd mannerisms: echolalia, echopraxia

Repeat what people say or do Keep a position held for odd amounts of time

o Undifferentiated Type:o At one time had symptoms, but then they stop or change and don’t fall under one category o Do not fit into other subtypes, major symptoms, fail to meet criteria

o Residual Type: o Must have one or more past episodeso No major symptomso Persistent, less extreme symptoms

o Genetic influences: o Inherited vulnerability for schizophreniao Polygenetic influenceso Risk increases with genetic relatednesso Risk is transmitted independently of diagnosiso Interaction with environment o Twin studies: Genian quadruplets: same genetics and environment (general) but different schizophrenia

Differences: age on onset, symptoms, diagnoses, courses, outcomes Importance of a shared environments

o Family studies:

Parents severity increases likelihood for children Do inherit: general predisposition Do no inherit: specific forms Risk increases with genetic relatedness

o Etiology: prenatal and perinatal influences. Purely biological, genetic, family history. Brought on by stressoro Psychological and social influences: Stress, family and relapse o Genetic influences: o Dopamine imbalance

o Treatment: biological interventionso Historical treatments

Insulin coma therapy Psychosurgery: prefrontal lobotomies Electroconvulsive therapy

o Antipsychotic medications (neuroleptics) o Transcranial magnetic stimulation

Magnetic fields Possible benefits: auditory hallucinations

o Psychosocial approaches: behavioral

Inpatient units Community care programs Social and living skills training Behavioral family therapy Vocational rehabilitation

o Necessary adjunct to medication o Prevalence = 0.2% to 1.5% (life)o Course : moderate-to-severe lifetime impairment

o Life expectancy = less than averageo Suicide

o Female : male 1:1 o Development:

o Through virus in mother in her second trimester o Early childhood clinical featureso Prodromal stage—14-15 years oldo Diagnosis and treatment typically occur 1-2 years after symptom onseto Relapse and recoveryo Most (78%) experience several episodeso Poor overall prognosiso High suicide rates

Prodromal stage: first stage, you are aware that something isn’t right and so you try to muffle it or mask it and hope that it goes away. It is the negative symptoms and there might be a little bit of psychosis, but not enough to be sent to an institution. Maybe for about a year or two until their first psychotic break

Schizophreniform Disorder: o Few months only, no more than 6 months. By the 5th or 6th,they go back to baseline and are pretty much fineo Associated with good premorbid functioningo Most resume normal liveso Prevalence = 0.2% life

Schizoaffective Disorder:o Symptoms of schizophrenia plus a mood disorder (depression, or bi-polar)o Disorders are independent: delusions for 2 weeks in absence of moodo Prognosis = similar to schizophrenia: persistent, no improvement without treatment o One of the worst things you could haveo They have large suicidal rates

Delusionsal Disorder: delusions contrary to realityo Lack other positive and negative symptomso Types: erotomaniac, grandiose, jealous, persecutory, somatico Rare, better prognosis than schizophreniao Derek fisher—symone fisher was convinced she was his wife and she changed her name to his last nameo Age of onset = 40-49o Female > male 55-45%o Prognosis: better than schizophreniao Rare: better than schizophrenia, worse than other psychotic disorders

Brief psychotic Disorder: o One or more positive symptomso **Lasts 1 month or lesso Usually precipitates from and extreme stress or trauma, other disorders, drugs/alcohol

o Can end up in ERo Typically return to premorbid baseline

Shared Psychotic Disorder: delusions from relationship with delusional persono 50% female dyads: mother-daughter or sister-sistero Cognitive impairment in secondary member o Because they are so close together, they will take on the other’s delusions

Schizotypal Personality Disorder: o Symptoms less severe but similar to schizophreniao Genetic relationship to schizophrenia: “Schizophrenia spectrum”

Impact on current thinkingo Kraepelin: combination of symptoms, distinction from bipolar, dementia praecoxo Bleuler: associative splitting, cognitive impairmentso Importance of onset and course

Neurobiological Influenceso Current Theories:

o Several neurotransmitterso Striatial D2 receptors (excess)o Prefrontal D1 receptors (deficit)o Glutamate

Development: early childhood clinical featureso Prodromal Stage o Diagnosis and treatment typically occur 1-2 year after symptom onseto Relapse and recoveryo Most 78% experience several episodeso Poor overall prognosiso High suicide rates

CH. 15 COGNITIVE DISORDERS

Perspectives on cognitive disorders• Affect multiple cognitive processes

o Learning, memory, consciousness

• Most develop later in life

• 3 classes: delirium, dementia, Alzheimer’sDelirium:

• Global impairmentso Consciousnesso Cognition

• Develop rapidly over several hours to days

• Comes on quickly, acute

• Confusion, disorientation, attention, memory, language deficits, out of touch with surroundingso Can be due to fever, trauma to head

• Course: not for very long, a few days at most or hours. But you WILL come out of it

• Statistics: o 10%-30% in acute care (ER)o Highest prevalence: Older adults, AIDS patients, medical patientso Full recovery = several weeks

• Drug intoxicationo Medication: forget when they took it if they did at all and overdose by accidento Illicit drugs: MDMAo Poisonso Withdrawal from drugs

• Conditions related to: Fever, Infections, Head injury/brain trauma, Sleep deprecation, Excessive stress, Withdrawal from alcohol

• DSM-IV subtypes: o Delirium due to a general medical condition

o Substance-induced deliriumo Delirium due to multiple etiologieso Delirium not otherwise specified

• Treatment: o Treat underlying medical problems/causeo Psychosocial interventions: friends and family

Treat underlying medical problems Education: reassurance, coping strategies, help with their memory by reinforcing things in their

lives• Prevention:

o Proper medical care and use

Dementia: • Gradual deterioration of brain functioning

• Affects multiple domains: Judgment, memory, language

• Course: chronic

• Prognosis: bad, unless there is something to cure it

• May or may not be reversible

• Progressive dementia: initial stageso Memory impairmento Visio-spatial deficits: wont be able to identify normal day-to-day thingso Agnosia: facial agnosia…cant recognize peoples faceso Delusions, depression, agitation, aggression, apathy

• Progression later stages: worse symptoms to identify people and objects. Symptoms worsen….o Continued cognitive declineo Assistance with activities of daily living: independent, basico Death: pneumonia o Middle stage is rapid as apposed to the early and late stages which are long onset

• DSM-IV-TR Classeso Dementia of the Alzheimer’s typeo Vascular dementiao Dementia due to other general medical conditionso Substance-induced persisting dementiao Dementia due to multiple etiologieso Dementia not otherwise specific

• Treatment: o Early intervention is criticalo 3 areas of focus

Prevention, delaying onset, symptom managemento Multidimensional treatmento Focus on slowing the progression

• Prevention: o Reducing risk of dementia

Controlling blood pressure Staying socially active Staying physically active

o Other prevention efforts

Head trauma Neurotoxins exposure Drug and alcohol use

Dementia of the Alzheimer’s type• Multiple cognitive deficits: memory, orientation, judgment, reasoning

• Range of cognitive deficits: aphasia, apraxia, agnosia, executive function

• Significant social and occupational impairments

• Develop gradually and steadily

• Confusion, agitation/combativeness, depression, anxiety, sundowner syndrome o Sundownder syndrome: worse at night because they get tired and cranky and cant keep up and cant deal

with their agitation as well as during their day

Alzheimer’s Disease: • Nature and progression of the disease: deterioration

o Early and later stages = lowo During middle stages = rapido Post diagnosis survival = 8 yearso Onset = 60s or 70s

Early onset = Before 65• Statistics:

o Prevalence: 5 million Americans, several million worldwideo Higher:

Poorly educated Women: estrogen?

o Lower:

Higher education: cognitive reserve theory• Causes:

o Early, Unsupported Views

Aluminum (coating on cans and pans), smokingo Neurobiological influences: neurofibrillary tangleso Amyloid plaques: cortical atrophy o Genetic: polygenetic, chromosomes 21, 19 (late onset), 14 (early onset), 12, 1

Vascular Disease• Progressive brain disorder

• Blockage or damage to blood vesselso Clogged vessels breaks the oxygen flow to the brain

• Onset is often sudden: stroke

• Apepar disorganized

Vascular Dementia: • Obvious neurological problem because of the strokes which affect physical abilities

• DSM-IV Criteriao Cognitive disturbances: identical to Alzheimer’so Obvious neurological signs

Greater motor problems Weakness in limbs

o Significant impairments

• Statistics: o Prevalence:

1.5% in age 70-75

15% in age 80 or older Men > Women higher rates of cardiovascular disease

o Most will require formal nursing careo Death from infection

Pneumonia Weak immune system

• Course: some treatments that can thin blood and facilitate it. But if not treated quickly and early enough, not prognosis is not good

Dementia: Head Trauma• Accidents are most common cause

• Memory loss in primary symptom

• Post concussive syndrome

• Poly-trauma: additive effects

HIV: • Causes neurological impairments and dementia

o Cognitive impairmento Impaired attentiono Forgetfulnesso Clumsinesso Repetitive movements, Tremors/leg weaknesso Apathyo Social withdrawal

• Later stages of HIV infection

• 29% to 87% of those with AIDS

• Sub-cortical dementiao Motor sill impairmentso Slowing, anxiety, depression, no aphasia

Parkinson’s Disease: • Degenerative brain disorder

• Dopamine pathway damage

• 1/1,000 people worldwide

• Motor problems: tremors, posture, walking, speech

• Sub-cortical impairments pattern

Huntington’s Disease:• Genetic disorder: chromosome 4

• Early onset = 40 or 50s

• Motor symptoms: Chorea

• Sub-cortical dementia pattern: 20% to 80%

Subcortical dementia: more severe agitation and depression. It will be worse

Reduce risk of dementia: keep up exercise, good social and intellectual life, keep active mentally and physically. Bring down blood pressure