Abnormal Psych. Exam 4 Flashcards
Personality
=enduring patterns of thinking and behavior that define the person and distinguish him or her from other people
-expressing emotion patterns of thinking about ourselves and other people
Personality disorder
=persistent pattern of emotions, cognitions, and behavior that results in enduring emotional distress for the person
-enduring, inflexible predispositions
-high comorbidity with other disorders
-generally poor prognosis
-patients don’t feel that treatment is necessary
Countertransference
the emotions of therapists brought out by clients
“Degree”
the problems of people with personality disorders may just be extreme versions of the problems many of us experience temporarily (ex: shy or suspicious)
Dimensional model
individuals are rated on the degree to which they exhibit various personality traits
Five factor model personality (“Big Five”)
-Openness to experience
imaginative, curious, and creative VS shallow and imperceptive
-Conscientiousness
organized, thourough, and reliable VS careless, negligent, and unreliable
-Extraversion
talkative, assertive, and active VS silent, passive, and reserved
-Agreeableness
kind, trusting, and warm VS hostile, selfish, and mistrustful
-Neuroticism
even-tempered VS nervous, moody, and temperamental
Advantages of a Dimensional Model
-retain more information about each individual
-more flexible (categorical AND dimensional differentiations)
-avoid arbitrary decisions involved in assigning a person to a diagnostic category
Categorical Model
“Kind”
Personality disorders that have traditionally been assigned as all-or-nothing categories
“Kind”; Categories
ways of relating that are different from psychologically healthy behavior
Categorical model: An individual’s personality pattern must
-deviate markedly from the expectations of his or her culture
-be pervasive and inflexible across situations
-be stable over time
-have an onset in adolescence or early adulthood
-lead to significant distress or functional impairment
Advantages and Disadvantages of Categorical Model
+Convenient
-Simple
leads clinicians to verify them (make more concrete/reel)
Example of Gender Category vs. Dimension
Category: male or female
Dimension: range between “masculine” and “feminine” expressions
Personality Disorder Clusters
Cluster A: Odd or Eccentric Disorders
Cluster B: Dramatic, Emotional, or Erratic Disorders
Cluster C: Anxious or Fearful Disorders
Cluster A: Odd or Eccentric Disorders includes
Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorder
Cluster B: Dramatic, Emotional, or Erratic Disorders
Antisocial personality disorder
Borderline personality disorder
Histrionic personality disorder
Narcissistic personality disorder
Cluster C: Anxious or Fearful Disorders
Avoidant personality disorder
Dependent personality disorder
Obssessive-compulsive personality diosorder
Paranoid personality disorder
a pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent
Schizoid personality disorder
a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings
Schizotypal personality disorder
a pervasive pattern of social and interpersonal deficits marked by acute discomfort
Antisocial personality disorder
a pervasive pattern of diregard for and violation of the rights of others
Borderline personality disorder
a pervasive pattern of instability of interpersonal relationships, self-image, affects, and control
Histrionic personality disorder
a pervasive pattern of excessive emotion and attention seeking
Narcissistic personality disorder
a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and a lack of empathy
Avoidant personality disorder
a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivty to negative evaluation
Dependent personality disorder
a pervasive and excessive need to be taken care of, which leads to submissive and clinging behavior and fears of separation
Obsessive-compulsive personality disorder
a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency
Gender distribution and gender bias in diagnosis
Men more often show traits like aggression and detachment; women more often show submission and insecurity
Antisocial- more often male
Histrionic & Borderline personality disorders
-equal numbers shown in most recent studies
-before it was slightly more common in women due to psychologists incorrectly diagnosing women (biased against females)
Dependent personality disorder- more often in females
Criterion gender bias
the criteria for the disorder may be biased
Assessment gender bias
the assessment measures and the way they are used may be biased
Comorbidity
condition in which a person has multiple diseases
Overview and clinical features of Cluster A: Paranoid Personality disorder
-pervasive and unjustified mistrust and suspicion
-few meaningful relationships
-behave aggressively or anatagonistically
-sensitive to criticism
-excessive need for autonomy
Causes of Cluster A: Paranoid Personality disorder
Genetic predisposition (related to schizophrenia spectrum of disorders)
Psychological factors may involve early learning that people and the world are dangerous or deceptive
-early mistreatment or traumatic childhood
-parents teaching careful of making mistakes and may impress on them that they are different from others
-vigilance=> focus on signs other people are deceptive and malicious
Cultural factors of experiences that lead to mistrust (ex: prisoners, refugees, older adults, etc.)
Treatment of Cluster A: Paranoid Personality disorder
Focuses on development of trust
Cognitive therapy to counter negativistic thinking
Unlikely to seek due to mistrust and difficulty developing trusting relationships necessary for successful therapy
Triggered by crises in life
Overview and clinical features of Cluster A: Schizoid personality disorder
Pervasive pattern of detachment from social relationships
-social isolation
Very limited range of emotions in interpersonal situations
-limited experience and expression
Indifference to other people
Low interest to sexual experiences + romantic
-don’t desire or enjoy closeness with others
Causes of Cluster A: Schizoid personality disorder
Etiology is unclear
Brainstem inhibitory dysfunction
-more prevalence under fear and sadness
Childhood shyness
-precursor
-abuse & neglect also reported
May have significant overlap with autism spectrum disorder
-possible that a biological dysfunction found in both combines with early learning or early problems with interpersonal relationships to produce social deficits that define schizoid
Treatment for Cluster A: Schizoid personality disorder
Focus on the value of interpersonal relationships and on building empathy and social skills
-modeling, role-playing, and help identify a social network
Rare to request treatment except in response to a crisis
Role-playing
technique that helps patient practice establishing and maintaining social relationships; therapist plays as friend or significant other
Overview and clinical features of Cluster A: Schizotypal personality disorder
Behavior and beliefs odd & unusual
-psychotic-like symptoms, social deficits, sometimes cognitive impairment of paranoia; can’t see illogic to their ideas
Socially isolated and highly suspicious
Magical thinking, ideas of reference, and illusions
-ex: believing they are telepathic
Many meet criteria for major depression
Some conceptualize this as resembling a milder form of schizophrenia
Causes of Cluster A: Schizotypal personality disorder
Mild expression of “schizophrenia genes”?
-some focus as one phenotype of a schizophrenia genotype
-increased prevalence amongst relatives with Schizophrenia
May be more likely to develop after childhood maltreatment (among men) or trauma (PTSD symptoms among women), especially in men
-prospective research says tend to have extreme social anxiety, hypersensitivity, teased for oddness, peculiar thoughts & language
More generalized brain deficits may be present
Treatment for Cluster A: Schizotypal personality disorder
-high risk for major depressive disorder, unsual reason (or anxiety) to seek treatment and part of main treatment
Address comorbid depression
Main focus is combination of medication, cognitive behavior therapy, and social skills training
Overview and clinical features of Cluster B: Antisocial Personality disorder
Failure to comply with social norms
Violation of the rights of others
(ex: stealing from family/friends)
Irresponsible, impulsive, and deceitful
Lack of a conscience, empathy, and remorse
“Sociopathy”, “psychopathy” typically refers to very similar traits
May be very charming, interpersonally manipulative
Substance use disorder is common
Criteria
1-Glibness/superficial charm
2-Grandios sense of self-worth
3- pathological lying
4-Conning/manipulative
5-Lack of remorse or guilt
6-Callous/lack of empathy
“psychopathy”
non-DSM category similar to antisocial personality disorder but with less emphasis on overt behavior
-indicators: superficial charm, laack of remorse, and other personality characteristics
Conduct disorder
A separate diagnosis for children who engage in norm-violating behaviors
Childhood-onset VS. adolescent-onset types
“Callous-unemotional” type of conduct disorder is more likely to evolve into antisocial PD
Predominantly boys
Many become juvenile offenders and tend to be involved with drugs
Conduct disorder Childhood onset
=the onset of at least one criterion characteristic of CD prior to age 10
Conduct disorder Adolescent onset
=the absence of any criteria characteristic of CD prior to age 10
“callous-unemotional” type of CD
a young person presents in a way that suggests personality characteristics similar to an adult with psychopathy
Genetic and Neurobiological influences of Antisocial Personality disorder
Genetic influences
-more likely to develop antisocial behavior if parents have a history antisocial behavior or criminality
adopted offspring of felons had significantly higher rates of arrests, conviction, and antisocial personality disorder
-interaction between genetic predispositions and environmental influences
the adopted children of felons who themselves later become criminals had spent more time in orphanages than either the adopted children of felongs who didn’t becomecriminals and the adopted non-felon children
Neurobiological
-alternations influencing behavior may exist
-epigenetics
Arousal theory of Antisocial Personality disorder
Underarousal hypothesis-cortical arousal is too low
-primary cause of antisocial and risk-taking behaviors; seek stimulation to boost their chronically low levels
People with APD are chronically under-aroused and seek stimulation from the tupes of activities that would be too fearful or aversive for most
-found that the future criminals had lower skin conductance activity, lower heart rate during rest periods, and more slow-frequency brain wave activity=> low arousal
Impaired fear conditioning of Antisocial personality disorder
Fearlessness hypothesis- fail to respond to danger cues
Children who develop APD may not adequately learn to fear aversive consequences of negative actions (e.g. punishment for setting fires)
Grays model of Antisocial Personality disorder
Inhibition signals outweighted by reward signals
Behavioral Inhibition System (BIS) is responsible for slowing us down when faced with punishment
-Reward system: responsible for how we behave (approach to positive rewards; involved with pleasure pathway)
Behavior of psychopaths
-imbalance between both systems may make fear and anxiety produced by BIS less apparent and the positive feelings with the reward system more prominent
Psychological, social, and developmental influences
Psychological and social influences
-In reserch studies, psychopaths are less likely to give up when goal becomes unattainable- may explain why they persist with behavior (e.g. crime) that is punished
Developmental influences
-high-conflict childhood increases likelihood of APD in at-risk children
Treatment of Antisocial Personality Disorder
Few seek treatment on their own
Antisocial behavior is predictive of poor prognosis
Emphasis is placed on prevention and rehabilitation
Often incarceration is the only viable alternative
May need to focus on practical (or selfish) consequences (e.g., if you assault someone you’ll go to prison)
Most common treatment strategy for children involves parent training
-parents are taught to recognize behavior problems early and to use praise & privileges to reduce problem behavior and encourage prosocial behaviors
-factors placing families at risk for not suceeding-> cases with a high degree of family dysfunction, socioeconomic disadvantage, high family stress, a parent’s history of antisocial behavior, and severe conduct disorder on the part of the child
Overview and clinical features of Borderline Personality Disorder
Unstable moods and relationships
-dysfunction in the area of emotion is sometimes considered one of the love features & best predictor of suicide
Impulsivity, fear of abadonment, very poor self-image
Self-harm and suicidal gestures
-10% die by taking their own lives
Comorbidity rates are high with other mental disorders, particularly mood disorders, substance use disorders, and eating disorders (instability -> impulsivity)
Causes of Borderline Personality Disorder
Strong genetic component
High emotional reactivity may be inherited
May have impaired functioning of limbic system
-emotion regulation & dysfunctional serotonin neurotransmission
Hyperattentive to negative emotional stimuli in the environment
Early trauma/abuse increase risk
-significant particularly for girls/women (2-3x more likely to be sexually abused than boys)
Triple Vulnerability model for BOrderline Personality Disorder
Generalized biological vulnerability
-genetic vulnerability to emotional reactivity & ways it affects specific brain function
Generalized psychological vulnerability
-tend to view the world as threatening and react strongly to real & perceived threat
Specific psychological vulnerability
-early trauma/abuse
Treatment options of Borderline Personality Disorder
Antidepressant medications provide some short-term relief
Dialectical behavior therapy is most promising treatment
Dialectical behavior therapy
helping people cope with stressors that seem to trigger suicidal behaviors and other maladaptive responses
Focus on dual reality of acceptance of difficulties and need for change
Focus on interpersonal effectiveness
Focus on distress tolerance to decrease reckless/self-harming behavior (priority treatment)
Overview and clinical features of Histroinic Personality disorder
Overly dramatic and sensational
May be sexually provocative
-often care about looks
Often impulsive and need to be the center of attention
-vain, self-centered, and uncomfortable when not in spotlight
-constantly seek reassuance/approval constantly, and become upset/angry when others don’t attend/praise them
Thinking and emotions are perceived as shallow
More commonly diagnosed in females
-may lead to overdiagnosis in women due to fitting Western “Stereotypical female”
Causes of Histronic Personality Disorder
Etiology unknown due to lack of research
Often co-occurs with antisocial PPD, suggesting it may be a sex-typed variant
-women with the underlying condition may be predisposed to exhibit a predominantly histronic pattern, while an antisocial pattern for men
Overview and clinical features of Narcissistic Personality Disorder
Exaggerated and unreasonable sense of self-importance
Preoccupation with receiving attention
-require & expect a great deal of special attention
Lack sensitivity and compassion for other people
-exploit others for their own interests and show little empathy
HIghly sensitive to criticism; envious and arrogant (when comforted with other successful people)
-often depressed since can’t live up to onw expectations
Grandiosity
Treatment options for Histrionic Personality Disorder
Focus on attention seeking and long-term negative consequences
Targets also include problematic interpersonal behaviors
Little evidence that treatment is effective
Grandiosity
exaggerated feelings and fantasies of greatness
Causes of Narcissistic Personality Disorder
Failure to learn empathy as a child=> remains in a self-centerd, grandiose stage of development
-endless & fruitless search for ideal person who will meet unfulfilled empathetic needs
Sociological view (LAsch)-product of the “me” generation (“baby boomers”)
Treatment of Narcissistic Personality disorder
Focus on grandiosity, lack of empathy, unrealistic thinking
Emphasize realistic goals and coping skills for dealing with criticism
Little evidence that treatment is effective
Overview and clinical features of Avoidant Personality Disorder
Extreme sensitivity to the opinions of others
Highly avoidant of most interpersonal relationships
-individuals who are asocial because apathetic, affectively flat, and relatively uninterested in interpersonal relationships
OR
-individuals who are asocial because interpersonally anxious and fearful of rejection
Interpersonally anxious and fearful of rejection
Low self-esteem
Causes of Avoidant Personality Disorder
May be linked to schizophrenia; occurs more often in relatives of people with schizophrenia
Experiences of early rejection
-difficult temperament=> parental rejection=> low self-esteem & social alientation
Childhood experiences of neglect, isolation, rejection, and conflcit with others
Treatment of Avoidant Personality Disorder
Similar to treatment for social phobia (Benzodiazapines or SSRIs)
Focus on social skills, entering anxiety-provoking situations
Good relaitonship with therapist is important (predictor of success)
Overview and clinical features of Dependent Personality Disorder
Reliance on others to make major and minor life decisions
Unreasonable fear of abandonment
Clingy and submissive in interpersonal relationships
-desire to obtain and maintain supportive & nurturing relationships
Sometimes agree with other people when their opinion differs so as not to be rejected
Feelings of inadequacy, sensitivity to criticsm, need for reassurance
-similar to avoidant personality disorder
(except they avoid instead of cling)
Causes and Treatment of Depedent Personality Disorders
Causes
-Not well understood but may be linked to failure to learn indepedence
-disruptions like death of a loved one or neglect or rejection could => fear of abandonment
Treatment options
-Therapy typically progresses gradually due to lack of independence
-careful of overdependence developing on therapist
Overview and clinical features of Obsessive-compulsive personality disorder
Excessive and rigid fixation on doing things the right way
Highly perfectionistic, orderly, and emotionally shallow
Unwilling to delegate tasks because others will do them wrong
Difficulty with spontaneity
Often have interpersonal problems
-rigidity=> poor interpersonal relationships
Obsessions and compulsions are rare
-unlike for obsessive-compulsive disorder (type of anxiety disorder)
Often afraid that what they do will be adequate, so procastinate and excessively ruminate about important issues & minor details alike
One of the most common personality disorders in general population
Theory that many serial killers have this
-“masters of control” in manipulating their victims
-combo of disoder + unfortunate childhood experiences
Also, sex offeders and gifted children
Causes and Treatment on Obsessive-compulsive Personality disorder
Causes are not well-known
-moderate genetic contribution
Treatment
-targets include cognitive reappraisal techniques to reframe compulsive thoughts
-target rumination, procastination, and feelings of inadequacy
Schizophrenia
Characterized by a broad spectrum of cognitive and emotional dysfunctions including delusions and hallucinations, disorganized speech and behavior, and inappropriate emotions
Distrupts daily functioning
Psychotic symptoms: the individual has lost touch with reality
“Split mind” reflects Eugen Bleur’s belief that all the usual behaviors shown was an associative splitting of the basic functions of personality
-inspired incorrect use of term to mean multiple personalities
What are the three types of symptoms of Schizophrenia?
Positive symptoms
Negative symptoms
Disorganized symptoms
Positive symptoms of Schizophrenia
symptoms around distorted reality
-including delusions and hallucinations
Negative symptoms of Schizophrenia
deficits in normal behavior
They involve the loss of certain qualities of the person
They may intitially be more subtle or difficult to recognize than positive
The strong presence is associated with poor outcome
Tend to be persistent and more difficult to treat
Improve over time
May affect approx. 60% of individuals with schizophrenia; many different types
Disorganized symptoms of Schizophrenia
rambling speech, erratic behavior, and inappropriate affect
-don’t easily fit into positive or negative type
-understudied
-disorganized speech
-erratic speech & emotions
-include giving irrelevant reponses to questions, expressive disconnected ideas, and using words in peculiar ways
-may relfect a disturbance in the thought patterns that govern verbal discourse
Diagnosis of Schizophrenia
=the presence of two or more positive, negative, or disorganized symptoms for at least 1 month
dimensional assessment of symptom severity
Catatonia
=alternating inmobility and excited agitation; unusual motor responses, particularly immobility or agitation, and odd mannerisms
Tends to be severe and quite rare
May be present in psychotic disorders or diagnosed alone and may include:
-stupor, mutism, maintaining the same pose for hours
-opposition or lack of response to instructions
-repetitive, meaningless motor behaviors
-mimicking others’ speech or movement
Now recognized by DSM-5 as a distinct schizophrenia spectrum disorder
Hebephrenia
silly and immatur emotionality
Paranoia
delusions of grandeur and persecution
Delusions
=beliefs that are highly unlikely
-often impossible; seen by most members of society as a misrepresentation of reality
-people tend to be preoccupied with delusions
-delusional patients express and defend their beliefs with utmost conviction
“disorder of content”
Delusion of grandeur
beliefs that one is a special being or possesses special powers
Delusions of persecution
beliefs that others watch or torment them
Delusions of thought insertion
beliefs that one’s thoughts are being controlled
Delusion of reference
beliefs that random events or comments by others are directed at the individual
Capgras syndrome
beliefs that someone they know has been replaced by an imposter
Cotard’s syndrome
beliefs that they are dead
Motivational theory (Delusions)
=delusions are coping mechanisms to alleviate stress and anxiety
-look at these beliefs as attempts to deal with and relieve anxiety & stress
-helps make sense of uncontrollable anxities
-distracts from upsetting aspects of the world
Deficit theory (delusions)
=delusions stem from brain dysfunction
-views these beliefs as resulting from brain dysfunction that creates these disordered cognition or perceptives
Hallucinations
=the experience of sensory events without any input from the surrounding environment (not caused by actual external stimuli_
-persistent and real
-can vary in terms of both duration and severity
-Broca’s area (involved in speech production) being the most active => intrusive thoguhts that they believe are coming from somewhere or -one => meta-worry
Meta-worry
worrying about worrying
Emotional prosody comprehension (hallucinations)
-one possible explanation
-prosody is aspect of our spoken language that communicates meaning and emotion through pitch, amplitude, pauses, etc.
-research suggests emotional prosody is deficient in people with auditory verbal hallucinations
Auditory hallucinations
the most common hallucinations
hearing voices
Visual hallucinations
the second most common form
visual obviously XD
Tactile
perceptions outside of the person’s body
Somatic hallucinations
perception inside the person’s body
Metacognition
thinking about thinking
-hallucinations are connected to
The different types of Negative symptoms of Schizophrenia
-Avolition
-Alogia
-Asociality
-Anhedonia
-Affective flattening
Avolition
=inability to initiate and persist in activities
-known as apathy
-little inclination towards engaging in even the most basic daily tasks (e.g. personal hygiene
Ex: sit listlessly in a chair all day, not washing or combing hair for weeks
Alogia
=absence of speech
-remarkable reductions in the amount of speech or an apparent disinterest in conversation
-a negative thoguht disorder-> difficulties in articulating thoughts
Asociality
=lack of interest in social interactions
-develops before the onset of symptoms
-might be a strategy to deal with the other symptoms-> to reduce levels of stimulation
-may be the result of the stigma of schizophrenia
Anhedonia
=presumed lack of pleasure
-it may also be an early marker of the oneset of the disorder
Affective flattening
=don’t show emotions when emotions would normally be expected
-blunted affect
-show fewer expressions, maintain a vacant stare & avoid eye contact, and are less likely to use gestures to communicate emotional information
-their tone of voice may be flat
-may internally experience emotions
-may stem from difficulty in expressing rather than feeling
-may help identify schizophrenia risk in children
Loose associations (Derailment)
the tendency to slip from one topic to an unrelated topic with little coherent transition
Responding tangentially
replying to a question with an irrelevant response
Perserveration
repeating the same word or phrase over & over
Word salad
totally incoherent
Inappropriate affect and disorganized behavior in Disoganized symptoms
=emotional displays that are improper for the situation
-incongruity and lack of adaptability in emotional expression
-may show laughter or tears at inappropriate moments
-peculiar or “unconventional” behaviors
Catatonic immobility
disturbance of motor behavior in which the person remains motionless
-sometimes in an awkward posture, for extended periods
Waxy-inflexibility
the tendency to keep their boodoies and limbs in the position they are put in by someone else
Development of Schizophrenia
Risk increases between the ages of 15 and 35
More severe symptoms -> late adolescence or early adulthood
Early childhood indications
-mild physical abnormalities, poor motor coordination, mild cognitive and social difficulties
Generally, have a poor prognosis
-following trrratment there is improvement for many
-others may experience a pattern of relapse and recovery
Stages of Schizophrenia
Prodronal stage
Active stage
Residual stage
Prodronal stage of Schizophrenia
=less severe yet unusual behaviors begin to manifest
-daily functioning deteriorates
-ideas of reference, magical thinking, illusions, social isolation, lack of interests, or energy, unusual perceptual experiences, outcursts of anger, increased tension, and restlessness
Active Stage of Schizophrenia
=psychotic symptoms start to occur
Residual stage of Schizophrenia
=symptoms (mainly negative symptoms) similar to prodromal stage
-dramatic symptoms of psychosis have improved
Early subtypes of schizophrenia
Paranoia= delusions of grandeur or persecution
Disorganized (hebephrenia)= immature emotional expression
Catatonia= alternatig between immobility and agitation
Mild to moderate form of psychosis on a continuum
Schizophrenia Schizoaffective Disorder
Schizophreniform Disorder
Brief Psychotic Disorder
Delusional Disorder
Schizotypal Disorder
Schizophreniform Disorder
psychotic symptoms lasting beween 1-6 months (>6 months would be diagnosed as schizophrenia)
-associated with relatively good functioning
-most patients resume normal lives
-lifetime prevalence: approx. 0.2%
**If don’t recover in 6 months=> schizophrenia
Schizoaffective disorder
symptoms of schizophrenia + additional experience of a major mood episode (depressive or manic)
-psychotic symptoms must also occur outside the mood disturbance
-prognosis is similar for people with schizophrenia
-differential diagnosis is important between Schizoaffective Disorder & Major depressive Disorder with psychotic features
Delusional disorder
=characterized by delusions that are contrary to reality
Lack other positive and negative symptoms
Types of delusions include
-Erotomanic
-Grandiose
-Jealous
-Persecutory
-Somatic
Better prognosis than schizophrenia
Erotomanic delusions
irrational belief that one is loved by another person, usually of higher status
Grandiose delusions
believing in one’s inflated worth, power, knowledge, identity, or special relationship to a deity or famous person
Jelous delusions
believes that the sexual aprtner is unfaithful
Persecutory delusions
believing oneself (or someone clsoe) is being malovently treated in some wa7
Somatic delusions
the person feels afflected by a physical defect or general medical condition
Shared psychotic disorder
the condition in which an individual develops delusions as a result of a close relationship with a delusional individual
Substance/medication-induced psychotic disorder
psychosis caused by the ingestion of medications, psychoactive drugs, or toxins
Psychotic disorder assocaited with another medical condition
condition characterized by hallucinations or delusions and that is the direct result of another physiological disorder (ex: stroke or brain tumor)
Brief psychotic disorder
=characterized by positive symptoms of schizophrenia (e.g., hallucinations or delusions) or disorganized symptoms
-lasts less than one month
-briefest duration of all psychotic disorders
-typically precipitated by trauma or stress
Attenuated psychosis syndrome
idetified as a condition in need of further study in DSM-5
=individuals who are at high risk for developing schixophrenia or beginning to show signs of schizophrenia
-label designed to focus attention on these individuals who could benefit from early intervention
-tend to have good insight into own symptoms
-may be at early stage of Schizophrenia (prodromal)
Cultural Formulation Interview (CFI)
a guide that helps clinicians examine any biases they may have when interviewing people from other cultures
Genetic influences of Schizophrenia
Genes contribute but no single gene; multiple gene variances combine to produce vulnerability
Inherit tendency, not specific forms
-risk increases with genetic relatedness; risk varies acccording to how many genes shared
Monozygotic (100% shared) have greater concordance than dizygotic twins
De novo mutations in germ cells or post-conception, can contribute to phenotypic diversity
Unshared environments
-even identical siblings can have different prenatal and family experiences and can therefor be exposed to varying degrees of biological & environmental stress
Gene-environment interaction
-adoptee risk for developing high if a biological parent has
-protective factor- risk is lower than for those raised by biological parent with schizo.
De novo mutations
=genetic mutations that can occur as a result of a mutation in a germ cell (egg or sperm) of one of the parents or in the fertilized egg after conception
Marker genes
=location of genes of these traits
Linkage and association studies
-endophenotypes
-schizophrenia is likely to involve multiple genes
Behavioral marker (endophenotype): Smooth pursuit eye movement
Schizophrenia patients show reduced ability to track a moving object with their eyes
Relatives of schizophrenic patients also have deficits in this area
Three of the most reliable genetic influences of Schizophrenia, sections on:
Chromosome 8 (Neuregulin 1; NRG1)
Chromosome 6 (dystrobrevin-binding protein 1 or DTNBP1)
Chromosome 22 (catecholamine o-methyl transferase; COMT)-> role in dopamine metabolism, seen disrupted in those with the disorder
The Dopamine Hypothesis of Schizophrenia
=schizophrenia is partially caused by overactive dopamine
Evidence
-drugs that increase dopamine (agonists) result in schizophrenic-like behavior
-drugs that decrease dopamine (antagonists) reduce schizophrenic-like behavior
Whats the problem with the Dopamine Hypothesis of Schizophrenia?
Problem: over-simplistic
-May neutrotransmitters are likely involved (at least 3 specific neurochoemical abnormalities simultaneously at play
1-Significant # not helped by dopamine antagonists
2-Although neuropletics block reception of dopamine quickly, symptoms subside after several days/weeks (more slowly than expected)
3-These drugs only partly helpful in reducing negative symptoms
Other neurobiological infleunces of Schizophrenia
Structural and functional abnormalities
-Enlarged ventricles and reduced tissue volume
indicates that adjacent parts of the brain either have not developed fully or atrophied, thus allowing the ventricles to become larger
more often in men
enlarge in proportion to age & duration
-Hypofrontality= less active (frontal lobes)
a major dopamine pathway
Viral infections during early prenatal development
-brain damage=> Schizophrenia
-findings are inconsistent
-possible for the genes that make vulnerable to Schizophrenia may themselves contribute to the birth complications
Marijuana use also increases the risk for developing Schizophrenia in at-risk individuals
-for those with COMT and AKT1 genotypes
-people with Schizophrenia more likely to have a cannabis use disorder
Psychological and Social influences of Schizophrenia
The role of stress
-may activate underlying vulnerability
-may also incerase risk of relapse
Family interactions
-Unsupported theories (Schizophrenogenic mother, Double bind communication)
-High expressed emotion (EE)- associated with relapse
Schizophrenogenic mother
a mother whose cold, dominant, and rejecting nature was thoguht to cause Schizophrenia in her children
Double bind communication
=a communication style that produced conflicting messages, which in turn, caused Schizophrenia to develop
-presumably communicates messages with two conflicting meanings
ex: “do you love me anymore” when child lets go after a hug
Expressed emotion (EE)
hostility, criticism, and overinvolvement demonstrated by some families toward a family member with a psychological disorder
Development of antipsychotic medications
Often first line treatment for schizophrenia
Began in the 1950s
Most reduce or eliminate positive symptoms
Primarily affect dopamine system, but also affect serotonergic and glutamate system
When effective, neuropletics help people think more clearly and reduce hallucinations & delusions
-affecting positive symptoms and lesser the negative & disorganized ones
-earliest kind called convensional or first-generation
Medical treatment of Schizophrenia
Actute and permanent side effects may occur with both 1st and 2nd generation antipsychotics
-Parkinson’s-like side effects
(similar motor difficulties)
ex: trapyramidal symptoms
most common is Akinesia
-Tardive dyskinesia
Compliance with medication is often a problem
-Aversion to side effects
ex: grogginess, blurred vision, and dryiness of the mouth
-Financial cost
-Poor relationship with doctors
Transcranial magnetic stimulation
Tardive dyskinesia
=involuntary movements of tongue, face, mouth, or jaw
-can include protrusions
Transcranial magnetic stimulation
=wire coils repeatedly generate magnetic fields that pass through the skull to the brain
-stimulate the area of brain involved in hallucinations for individuals with Schizophrenia
Psychosocial treatment of Schizophrenia
-Behavioral methods like the token economy that reward adaptive behavior
-Community care programs
-Social and living skills training
therapists divide social skills into parts (model), roleplay, and then practice in “real world”
-Virtual reality-based interventions
-Behavioral family therapy resembles classroom education
-Vocational rehabilitation
ex: supportive employment
providing coaches who give on the job-training
Behavioral family therapy resembles classroom education
when the family is informed about the illness and treatment, relieved of the myth that they caused the disorder, and taught practical facts about antipsychotic medications and their side effects + communication skills + problem solving skills
Illness management and recovery of Schizophrenia Psychosocial treatment
Engages patient as an active participant in care
Continuous goal setting and tracking
Modules include social skills training, stress management, substance use disorder
Token economy
social learning behavior modification system in which individuals each items they can exchange for desired rewards by displaying appropriate behaviors
Preventing Schizophrenia
Identify at-risk children
-relatives of individuals with Schizophreniz
Foster supportive, stable environments
-focus on instability of early family rearing environment; environment factors may trigger onset
Offer additional treatment at prodromal stages, including social skills training
True or False: Most medications for Schizophrenia affect the dopamine system
True: most medications for Schizophrenia and other psychotic disoders are dopamine anatagonists, althoguh some also affect serotonin and glutamate
True or False: Even the newer antipsychotic drugs have significant side effects
True: Although it had been hoped that the second-generation medications would be more aceptable, they have similar side-effect profiles to the first-generation drugs
True or False: Psychodynamic therapy is useful in the tratment of psychotic disorders
False: Psychodynamic approaches are not only not helpful in treating people with psychotic disorders, they may be harmful
True or False: Illness management and recovery engages the person with Schizophrenia as an active participant in treatment
True: illness management and recovery focuses on helping the indicidual become an active participant in treatment, including providing education about the disorder, teaching effective use of medication strategies for collaborating with clinicians, and coping with symptoms when they reoccur
Delirium
Nature
-central features- impaired consciousness and congnition
-develops rapidly over several hours or days
-appear confused, disoriented, and inattentive
-marked memory and language deficits
Full recovery often occurs within several weeks
-transient condition
-may lead to an increase in the mortality rates
(40-50% die within 1 year)
Neurocognitive disorders
=affect learning, memory, and conscientiousness
-Most develop later in life
Types:
-delirium
-Major or mild neurocognitive disoder
Shifting DSM perspectives of Neurocognitive disorders
From “organic” mental disorders to “cognitive disorders
-“organic” indicated brain injury or dysfunction involved
-meaningless distinction due to covering so many disoders
-“cognitive” to signify that predominant feature is the impairment of such cognitive abilities
Board impairments in cognitive functioning
Cause profound changes in behavior and personality
Delirium is most prevalent in what certain populations:
Older adults
Those undergoing medical procedures
People with AIDS or cancer
People in hospitals/critical care
Medical conditions related to Delirium
Dementia (50% of cases)
Drug intoxication, poisons, withdrawal from drugs
-designer drugs (ex: ectasy, molly,etc.) can cause substance-unduced delirium
Infections
Head injury and several forms of brain trauma
Sleep deprivation, immobility, and excessive stress
Treatment and Prevention of Delirium
Treatment
-Attention to underlying causes
ex: caused by alcohol withdrawel=> antipsychotic meds
necessary and appropriate medical intervention often revolves accompanying delirium
-Psychosocial interventions
first line of treatment
reassurance/comfort, coping strategies, inclusion of patients in treatment decisions
Prevention
-Address proper medical care for illnesses, proper use of and adherence to therapeutic drugs
Major neurocognitive disorders (dementia)
Nature
-gradual deterioration of brain functioning
-deterioration in judgment and memory
-deterioration in language/advanced cognitive processes
-has many causes and may be irreversible
Mild neurocognitive disorder
draws attention to early-stage cognitive decline
Symptoms of Neurocognitive disorders
Aphasia
Apraxia
Agnosia
Executive dysfunction
Aphasia
difficulty with language
Apraxia
impaired motor functioning
Agnosia
failure to recognize objects
-one of the most familiar symptoms of NCD
Facial agnosia
inability to recognize even familiar faces
Executive dysfunction
difficulties with planning, organizing, sequencing, abstracting information
Causes of Major and Mild Neurocognitive Disorders
Include several medical conditions and the use or misuse of drugs or alcohol that provide negative changes in cognitive functioning
-Due to Alzheimer’s disease
include multiple cognitive deficits that develop gradually and steadily
-Prion disease
-Parkinson’s disease
-Huntington’s disease
-Frontrotemporal
Vascular
-With Lewy bodies
Due to traumatic brain injury
-Substance/medication induced
-HIV infection
-Another medical condition
-Multiple etiologies
-Unspecified
Subcortical dementia
=primarily affects the inner areas of the brain, below the outer layer called the cortex
-People are more likely to experience severe depression and anxiety than cortical dementia
-In general, motor skills including speed and coordination are impaired early
Cortical dementia (Alzheimer’s type) vs. Subcortical dementia
Aphasia
Impaired recall and recognition
Impaired Visuospatial skills
Less severe depression and anxiety
Normal motor speed
Normal coordination until late in the progression
———————————————————–
No aphasia
Impaired recal; normal or less impaired recognition
Impaired Visuospatial skills
More severe depression and anxiety
Slowed motor speed
Impaired coordination
Alzheimer’s Disease Clinical features
Typically develop gradually and steadily
Mmeory, orientation, judgment, and reasoning deficits
Range of cognitive deficits
Aphasia, Apraxia, Agnosia, Executive dysfunction
Negative impact on social and occupational functiong
Additional symptoms may include
-agitation, confucsion, or combativeness
-depression and/or anxiety
Prevalence of Alzheimer’s disease
More common in less educated individuals
Slightly more common in women
Post-diagnosis survival= 8 years
Onset= 60s-70s (early onset= 40s-50s)
60-70% of the cases of neurocognitive disorder result from Alzheimer’s disease
Vascular Neurocognitive disorder
-Caused by blockage or damage to bllod vessels
no longer carry oxygen and other nutrients to certain areas of brain tissue, damge results
-Second leading cause of neurocognitive disorder after Alzheimer’s disease
-Onset is often suggen (ex: stroke)
Patterns of impairment are variable
because multiple sites in teh brain can be damaged, profile of degeneration differs by person
-Most require formal care in later stages
until they succumb to an infectious disease to which they are susceptible because weakening of the immune system
-Prevalence 1.5% in people 70 to 75 and 15% for people over 80
-Risk slightly high in men
possibly accounted by the relatively high rate of Cardiovasuclar disease
Frontotemporal Neurocognitive Disorder
=damage to the frontal or temporal regions of the brain, affecting personality, language, and behavior
Two types:
-declines in appropriate behavior
-declines in language
Pick’s disease
Pick’s disease
Rare neurological condition
Produces a cortical dementia like Alzheimer’s
Occurs relatively early in life (around 40s-50s)
Course believed to last 5-10yrs and appears to have a genetic component
Neurocognitive disorder due to Traumatic brain injury
Accidents leading cause
-assaults, falls, suicide attempts
Symptoms last for at least one week after head injury, including problems with executive function, learning, and memory
-ex: difficulty planning complex activities
-memory loss is the most common symptom
Risk factors include age (most common among teens and young adults), excessive alcohol use, and lower SES
Lewy Body Disease
Lewy bodies: microscopic protein deposits that damage the brain over time
Symptoms onset gradually
-impaired attention and alertness, visual hallucinations, motor impairment
Parkinson’s Disease
Degenerative brain disorder
-principally affecting motor performance associated with reduction in dopamine
(maybe also major neurocognitive disorder)
Dopamine pathway damage
1/1,000 affected worldwide
Chief difficulty: motor problems
-stooped posture, Bradykinesia (slow body movements), tremor, jerkiness in walking, speech (soft monotone)
Not all with PD will develop dementia
75% survive 10+ years after diagnosis
HIV infection
Causes AIDS
Can cuase neurological impairments and dementia in some individuals
-cognitive slowness, impaired attention, and forgetfulness, clumsy, repetitive movements (tremors & leg weakness)
Apathy and social withdrawal
Typically occurs in later disease stages
Now occurs in <10% of individuals with HIV; HAART decreases risk because of new medications
Huntignton’s disease
=a genetic disorder that initially affects motor movements, typically in the form of Chorea, involuntary limb movements;
A genetic autosomal dominant disorder
-50% of offspring of someone with the disease will develop it
-caused by a gene on Chromosome 4
Manifests initially as involuntary limb movements (chorea), usually later in life
Somwehere between 20-80% display enurocognitive disorder
Dementia follows a subcortical pattern
Prion Disease
=disorder of proteins in the brain that reproduce and cause damage
No known treatment, always fatal
Can only be acquired through cannibalism or accidental transmission (ex: contaminated blood transfusion)
Ex: Creutzfeldt-Jakob disease
Creutzfeldt-Jakob disease
Affects one out of 1,000,000 people
Linked to mad cow disease (bovine spongiform encephalopathy)
-might be transmitted from infected cattle to humans
Hydrocephalus
characterized by excessive cranial water due to brain chrinkage
Hypothyoidism
inadequate thyroid gland function
Substance/Medication-Induced Neurocognitive Disorder
50-70% of chronic heavy alchol users show some cognitive impairment; 7% of those meet criteria for neurocognitive disorder
Results from prolonged drug use, especially incombination with poor diet
May be caused by alcohol, sedative, hypnotic, anxiolytic, or inhalant drugs
Brain damage may be permanent
Symptoms similar to Alzheimer’s
Deficits may include memory impairment, aphasia, apraxia, agnosia, disturbed executive functioning
Genes identified as deterministic=
having one you are nearly 100% likely of developing the disorder
i. rare
Genes identified as suceptibility=
slightly increase risk
i. more common in general population
Causes of Neurocognitive Disorder
Each of them have biological origins
Contributions of Psychosocial Factors in Neurocognitive Disorders
-Psychosocial factors like education, coping skills, and social support don’t cause dementia directly (may influence onset and course)
-Lifestyle factors include drug use, diet, exercise, stress
-Risk for certain conditions vary by ethnicity
Medical Treatments of Neurocognitive Disorders
Few primary treatments exist
Most treatments attempt to slow progression of deterioration, but can’t stop it
Some drugs target cognitive deficits
-cholinesterase-inhibitors
modest impact on cognitive abilities in some patients
-long-term effects not well demonstrated
continue to experience cognitive decline
lose small gain once stop taking drugs (which most due because of side effects)
Exploratory Medical Treatments
Gingkgo biloba (herb) to improve memory-findings are mixed
Slowing down progression through taking vitamins, doing exercise
Drugs to treat associated symptoms
-SSRIs for depression and anxiety
-Antipsychotics for agitation
All are only modestly effective for short periods
Tests of vaccines on genetically altered mice
-mice are good subjects due to aging rapidly, allowing researchers to study how the brain reacts to the potential vaccine if it has already started the progression
Transgenic mice
mice in which the DNA has been altered
Aims of Psychosocial Treatments for Neurocognitive Disorders
Enhance lives of patients and their families
Teach compensatory skills
Use memory enhancement devices, if needed
ex: “memory wallets” containing statements about one’s life
Cognitive stimulation can delay onset of more severe symptoms
-practice learning and memory skills
Psychosocial Treatments: Caregivers of Neurocognitive disorders
They get instructions on how to hangle problematic behavior like
-Wandering
-Socially inappropriate behavior
because no longer aware of social stigma
ex: masturbation in public
-Impact of care on their own health
They are also under a great deal of stress, may need mental health treatment
Early on, need basic information on causes and treatment of disorder, fianncial & legal issues, and locating help for the patient & family
Prevention of Neurocognitive disorder
Through interviews and medical history, 3 major factors individuals can change
1-Control your blood pressure
2-Don’t smoke
3-Lead an active physical & social life
Civil commitment
=detail when a person can legally declared to have a mental illness and be placed in a hospital for treatment
Involves legal definition of mental illness
In the US date back to the 19th century
Laws vary by state
In emergency situations, clearly immediate danger, a short-term commitment can be made without the formal proceedings required
Court-ordered Assisted outpatient treatment (AOT)
person agrees to receive treatment as a condition for continuing to live in the community
General criteria of Civil Commitment
1-Person has a mental illness and needs treatment
2-Person is dangerous to self or others
3-Person is gravely disabled (inability to care for self)
The Civil Commitment Process
Governamnetal authrotiy over civil commitment
-Police power
-Parens patriae
Person fails to seek help
Others feel that help is needed
Petition is made to a judge on the behalf of the person
Individual must be notified of the commitment process
Determination is made by a jduge
Decision informed by expert opinion
Police power
Police are responsible for the health, welfare, and safety of society
They can create laws and regulations to ensure it
Criminal offenders in custody if a threat
Parens patriae
=state acts as a surrogate parent
-a person receives care to prevent them from being in danger
ex: custody of children with no parents
ex: commit individuals with severe mental illness to mental health facilities when believed they might be harmed because unable to secure basic necessities of life (grave disability- food & shelter) or because they don’t recognize their need for treatment
Mental Illness as a legal concept
=typically defined as severe emotional or thoguht disturbances that impact health and safety
Definitions vary by state
Often exclude:
-cognitive disability
-substance-related disorders
Definition is not synonymous with having a psychological diagnosis
-benefit: flexibility
-disadvantage: vulnerable to bias
Dangerousness to self or others
=tendency to violence that, contrary to opinion, is not more likely among mental patients
Central to commitment proceedings
Violence and mental illness
-misconception that people with mental illness are much more likely to be dangerous- perpetuated by sensational media portraysals
-substance use disorder and recent victimization increase likelihood of violence
-people with mental illness are more likely to be victims of violent crimes than those without
Assessment tools are best at identifying persons at low risk of being violent, not good at long term prediction
-functional imaging technologies reveals that injury to prefrontal cortex (“empathy” towards others in distress area) prevents people from using empathy to make moral decisions
Ultimately, professional cannot predict whether any given individual will become violent
Changes affecting Civil Commitment
Supreme court has placed restrictions on involuntary commitment
-A non-dangerous person cannot be involuntarily commited (O’Connor V. Donaldson)
(when the superintendent of the hospital refused to release Dondaldson for almost 15 years, during which received no treatment)
Addington v. Texas(1979), the U.S. Supreme Court said that more than just a promise of improving quality of life is required to commit someone involuntary
-if nondangerous people with mental illness can survive in the community witht he help of tohers, they shouldn’t be detained against their will
Consequences of Supreme rulings
-Criminalization of the mentally ill
living within the community with no mental health services, eventually runnning wild in the legal system because of behavior
-Deinstitutionalization
-Transinstitutionalization
Deinstitutionalization
=movement of people with mental illness out of institutions
Policies to severly limit who can be involuntarily commited, the limits placed on the hospital stays of people with severe mental illness, and the concurrent closing of large psychiatric hospitals were held responsible for the substantial increase in homelessness during the 1980s
Problem= led large number of ill people to become homeless
2 goals
-to close the large state mental hospitals
-to create a network of community mental health centers where the relased invidividuals could be treated
Transinstitutionalization
=in practice, people with mental illness have been moved out of large mental hospitals to other institutions, including prisons and nursing homes
-instead of alternative community care
Criminal commitment
=accussed of commiting a crime
Detained in mental health facility
-evaluation determines fitness to stand trial
Can be found guilty, not guilty, or not guily by reason of insanity
Nature of insanity defense plea
Accused not guilty because of insanity at time of crime
Diagnosis of a disorder is not the same as insanity
Frequently protrayed in popular media but actually very rare
Definitions of insanity: M’Naghten rule
instability to distinguish right from wrong
Definitions of insanity: Durham rule
crime was the product of a mental illness
Definitions of insanity: American Law Institute standard
knowledge of right vs.wrong; self-control; diminished capacity
Diminished Capacity
Evidence of abnormal mental condition would be admissible to affect the degree of crime for which an accused could be convicted
Specifically, those offenses requiring intent or knowledge could be reduced to lesser include offenses requiring only reckless or criminal neglect
Requirements for Competence to Stnd trial
Understanding of legal charges
Ability to assist in one’s own defense
Essential for trial or legal processes
Burden of proof is on the defense
Consequences of a determination of incompetence
Loss of decision-making authority
Results in commitment, but with limitations
Identifying malingering in insanity plea
Research indicates that the Minnesota Multiphasic Personality Inventory test is mostly accurate in revealing malingering
The examiners look for true symptoms but those that people with mental illness rarely report
They tend to have a rush to fake their illness, often overreport these problems, perhaps to convince others
Mental health professionals also appear capable of providing reliable information about a person’s competence, or abiltiy to understand & assist with a defense
Malinger
to fake or grossly exaggerate symptoms, usually to be absolved from blame
Expert witness
Person with specialized knowledge and expertise
Assist in competency determinations
Assist in making reliable DSM diagnoses
Advise the court regarding psychological assessment and diagnosis
Assess malingering
Duty to Warn
Tarasoff v. Regents of the University of California
-must warn individual in danger
Thompson v. County of Alameda
-threats must be specific
When in doubt, consult with colleague
Evidence-based and Clinical Practice Guidelines and Standards
Increased cost of health care leads governments to study effectiveness of treatment
Past 15 years- Evidence Based Practice (EBP) formally identified as systematic method of delivering clinical care
Agency for Health Research and Quality
-efficient and cost-effective mental health services
-dissemination of relevant state-of-the-art information
-Clinical efficacy axis
-Clinical utility axis
Clinical efficacy axis
=thorough consideration of scientific evidence to determine whether intervention is effective compared to alternative treatment
Clinical utility axis
=concerned with the effectiveness of the intervention in the practice setting
