Midterm Review Flashcards
Biomedical Model (definition, cause, treatment, and classification)
Definition: biological dysfunction of the brain/a disease of the brain
Cause: has specific causes - genetic, biological, acquired
Treatment: psychopharmaceuticals, ECT
Classification: Mental health and illness as distinctive, binary, mutually exclusive categories
psychological-behavioural model (definition, cause, treatment, and classification)
Definition: common patterns of thinking, feeling and behaving with adverse consequences on an individual (psychological)
Cause: personal experience and perspectives
Treatment: psychotherapy - trying to change patterns of thinking, feeling and behaving
Classification: mental health and mental illness as two extremes on a continuum
Social model (definition, cause, treatment, and classification)
Definition: mental illness as socially constructed, is defined and redefined based on what counts as socially appropriate
Cause: power and culture, social problems
Treatment: social interventions and social programs; e.g. supported housing and employment, skill building programs, changing social conditions
Classification: mental illness as rational, describing one’s distance from what is ‘normal’
Bio-psychosocial model
- biological factors, social conditions, and individual experiences all contribute
- “social” refers to social determinants of health
- responses try to consider all factors in relation to mental health in an individual, problems are not just psychological but rooted in social environment
What is “madness”?
An elastic concept that helped explain a range of unusual, bizarre, or irrational human behaviours
Factors contributing to the medicalisation of mental illness (asylum era)
- challenges to the authority and power of the Church in Europe
- The scientific revolution - idea that science could solve problems
- The enlightenment - skepticism about religion and the supernatural
- Increased urbanisation - led to increased visibility of people who appeared “mad”
Shifts to become increasingly seen as a medical problem
What is moral treatment?
A philosophy that emphases humane benevolence in treatment rather than restraint and punishment and attempted to restore mental health
- often pointed as the foundation of the asylum movement
what is social control?
Critical perspective on the asylum era by Foucault and Scull as efforts to remove “problematic people” from society (control rather than care)
- individuals deemed problematic due to behaviour violating social norms were defined as mentally ill and then were confined to asylums or prisons
What was the shift to increase regulation of psychoactive substances and how was this accomplished?
Shift: unregulated sales of psychoactive substances led to high levels of use and problems related to opiates and cocaine (late 19th century)
Accomplished through the licensing and regulation of physicians and restricting the legal treatment of illness to physicians
And regulation of pharmaceutical companies
4 Acts that brought stronger regulations for psychoactive drugs (not Kefauver Amendment)
- US 1906 Food and Drug Act
- requirement to disclose substances in labelling - US 1914 Harrison Anti-Narcotic Act:
- physician prescription for sale of cocaine and opiates - Canada Opium and Narcotic Drug Act 1929
- Britain Dangerous Drugs Act 1920
Immediate impact and implications of the regulation of psychoactive substances
Immediate impact: reduced physicians prescribing of psychoactive drugs, “non-medical” sales became illegal and criminalised
Implications: access to psychoactive drugs became officially managed by physicians and medical industry - substances are now fully medicalised
Kefauver Amendment to the federal food, drug, and cosmetic Act
Requires companies to demonstrate not just safety, but that they are “effective”
- BUT not more effect than existing or competing medications, just more effective than a placebo
Case Study 1 - Antidepressants and the placebo effect (Krish)
SSRIs for the treatment of MDD:
- 25% of the response to the drugs was a true effect of medication
- 50% of the response to the drugs was due to the placebo effect
All available data (published and unpublished): placebo effect accounts for 80% of patient response to the medication
75% of published trials show significant benefit of medications compared to placebo
Unpublished trials show only 12% of trials demonstrated benefits
conclusions: prescribing SSRIs is “insufficient” and recommend that psychotherapy, exercise, and acupuncture provide the same benefit, with lower risk of side effects
And relapse rates are higher in relation to ADMs compared to other treatments
Case Study 2 - Is cognitive therapy enduring or are antidepressants iatrogenic (illness caused by medical examination or disease)
Belief that severe depression requires ADMs was tested
After 8 weeks: PLA 25%, ADM 50%, CBT 43% (ADM most effective)
After 16 weeks: ADM 57.5%, CBT 58.3% (CBT was slightly more effective than ADM)
Patients who did CBT were much less likely to relapse
Patients taking placebo were likely to relapse
ADM got strong continuation medication effect & relapse risk reduced 50%
Conclusion:
- CBT has more enduring positive results and a reduced risk of relapse compared to ADMs
- ADM interferes with CBT reducing its enduring effect, but placebo does not have this effect
- Therefore, potential iatrogenic effects of ADM, meaning the medication and side effects may lead to disease or negative outcomes
- This could explain why we don’t see improvements related to the prevalence of depression
- Unmedicated patients typically do better than medicated ones, but those receiving meds may be more unwell or more severe
Case Study 3 - Antidepressant medication and psychotherapy (Benoit Mulsant)
- The high rate of prescription of antidepressants is partially attributable to lack of access to CBT
- wait times to access a psychiatrist in Ontario are 3-12 months
Capacity problem: Ontario is estimated to have 15 psychiatrists per 100,000 population
Access problem: health insurance does not cover psychologists and counsellors - psychotherapy only available through private insurance and for wealthier patients (90 day pills of ADMs costs less than 1 psychotherapy session)
Side effects:
- ADMs can lead to suicide
- poor quality therapy may result in worsening of depression or anxiety
Case Study 4 - Biases in the reporting of antidepressants
- Publication Bias: unpublished results obscure true picture of effectiveness, as these trials more often show negative effects, medications not more effective than placebo
- Outcome reporting bias: negative effects not mentioned in a published paper
- Spin bias: may include negative outcome but focuses on other outcomes/analyses
- Citation bias: publications showing positive results are cited 3 times more often than those with negative results
All 5 Schizophrenia Prevalence Estimates (and their sources)
DSM - 0.3-0.7% - globally
NIMH - 1.1% (changed to 0.3%) - globally
MSDPS 1.8% in the US
WHO 1% Globally
CARMHA 0.36% in BC
Tiered Service Model Pyramid
Tier 1 (very bottom): mental health and wellness promotion/substance use prevention
- population-based health promotion
- example: health literacy
- low service intensity
- high number of people (population-based!)
Tier 2: Targeted prevention & early intervention
- prevention and identification of early symptoms
- motivational approaches
- peer support for people at risk
Tier 3: Assessment and general treatment
- diagnosis
- counselling and basic treatment
- targeted for people w identified problems
Tier 4: specialised intervention
- targeted to people diagnosed w mental disorders and/or substance use disorders
- specialised care
Tier 5: Highly specialised care
- targeted to people w complex and severe mental health and/or substance use
- high service intensity
- low number of people (specialized)
The spectrum of psychoactive substance use
Beneficial - use that has positive health and/or social impacts (prescribed or moderate consumption of alcohol)
Non-problematic - recreational or casual that doesn’t really have health or social effects
Problematic - use at an early age and negative health impacts for individuals, friends/family, or society
Chronic Dependent - use that becomes a habit and compulsive despite negative health and social effects
Major Depressive Disorder (MDD)
- severely low mood
characterised by anhedonia (lack of enjoyment and pleasure and interest) - sense of worthlessness
- changes in appetite
- low energy
- thoughts of death
- symptoms must last at least two weeks to be diagnosed
- WHO: #1 cause of disability globally
- elimination of the bereavement exclusion (previously loss of loved one would NOT be deemed major depression)
Persistent Depressive Disorder (previously called dysthymia)
- chronic low mood over a period of 2 years or more
- symptoms include MDD characteristics, but diagnosis requires the presence of fewer symptoms
Symptoms must last at least two years (persistent):
- feeling low, limited/excess appetite, sleep disruptions, lethargy, sense of failure, lack of hope/faith in self/future
Less intense than MDD, but longer term
Premenstrual Dysphoric Disorder (PMDD)
New to DSM-5
- changing mood and appetite, irritability, during the luteal phase of the menstrual cycle (time between ovulation and menstruation)
- distinguished from premenstrual syndrome by the severity of symptoms and increased impact on daily functioning
some critics note that the addition of “disorder” is overly medicalising a natural biological process and women’s bodies/minds (constructing these as “inherently ill”)
- further controversy: creation of this diagnosis coincides with the extension of a patent for a medication intended to treat it (new medication “Sarafem”, is Prozac renamed - fem used for feminine)
Disruptive Mood Dysregulation Disorder (DMDD)
new to DSM-5
- diagnosis applied to children between the ages of 6-18
- Children w DMDD exhibit extreme anger and irritability that seems disproportional to the triggering situation (unwarranted)
- added to DSM to address (mis)diagnosis of bipolar disorder among children
Controversy - questions validity and utility
- clinical descriptions overlaps with Oppositional Defiant Disorder
- children with DMDD are often treated with antipsychotics (why not antidepressants?)
- some claim it medicalises what may be normal phases of emotional development among children, and labelling influences processes related to identity
- Allen Frances (chairperson of DSM-4) encourages practitioners to ignore DMDD and refuse to diagnose it
Bipolar Disorder
Involves experiencing episodes of mania (high energy) and episodes of depression, previously termed “manic depression”
- mania is a key diagnostic feature
- mania episodes: elevated moods and increased engird lasting at least a week
- some people w mania report decreased need for sleep, inflated self esteem, flight of ideas, distractibility, may engage in compulsive and potentially harmful activities (substances, sex, gambling)
Bipolar Disorder and its complicated phenomena
- some people find manic episodes frightening and may end up being hospitalised
- others enjoy the emotional high
- some descriptions over-emphasise the mania, overlooking the depressive component
What are the different forms of mania in bipolar disorder?
Hypomania: refers to milder forms of mania - elevated mood w lesser degrees of functional impairment than true episodes of mania
- decreased need for sleep, high energy, self-confidence, very optimistic
True mania: is more severe compared to hypomania, and may include psychosis and lead to incarceration or hospitalisation
Different types of bipolar disorder (3)
Bipolar 1 (I): features depression and mania
Bipolar 2 (II): hypomania and more severe depression (less mania, more depression)
Cyclothymic disorder: The most mild form, with swings between mild depression and hypomania
Anxiety Disorders - Specific phobia (what is it?)
Specific phobias are the most diverse, most common, and most recognised forms of anxiety disorder - many subvareities
- estimated 5-10% of the general population suffers
- twice as prevalent in women
Can involve:
- fear of specific situations
- fear of objects
- fear of biological entities
Specific situational phobias
- acrophobia (fear of heights)
- claustrophobia (fear of small confined spaces)
- aerophobia (fear of flying)
- thanatophobia (fear of death)
- autophobia (fear of abandonment)
specific object-related phobias
- trypanophobia (fear of needles)
- aquaphobia (fear of water)
- trypophobia (fear of holes)
Biological entity related phobias
- arachnophobia (fear of spiders)
- mysophobia (fear of germs)
- gynophobia (fear of dogs)
Specific phobia - where it may stem from, and symptoms
- usually developed/anchored in childhood or associated with previous trauma
- irrational nature of the specific fear is distinct feature, individuals usually can see that its irrational, but this does not lessen worry
Physical Symptoms: shortness of breath, rapid breathing, irregular heartbeat, sweating, nausea
Psychological Symptoms: panic, fear, dread, feeling scared or “anxiety”
Avoidance: people with phobia often take steps to minimise their exposures to the feared situation, which can have social or health impacts
Agoraphobia (non-specific phobia)
- fear of situations from which one cannot escape - and/or a fear of entrapment
- can include fear of crowds, open spaces, leaving home, unfamiliar environments
Often results in panic attacks
- acute feelings of helplessness and embarrassment
- avoidance of triggering situations: (which can be almost anything) can be very problematic - and become more extreme and limiting some people may rarely leave home
- fear of experiencing the panic increases the severity of the phobia - feedback loop of avoidance and anxiety
Prevalence is approx 1%
Social Anxiety Disorder
Fear of being judged negatively or rejected by others
- also includes fear of this being recognised or being judged for having this worry or fear
People may avoid situations that trigger the fear
- public speaking, sports, team activities
- meeting new people
- anywhere they might be the focus of attention
Symptoms include those common to other anxiety disorders
- may lead to substance use (often alcohol), to “help” manage anxiety in social situations and limit symptoms (but this may have further negative repercussions and lead to risk/harm)
Prevalence: Approx 12% of American population
Panic Disorder
recurring panic attacks
- may be triggered by stressful situations, but may be unexpected/spontaneous too
Physical and emotion reactions:
- fear/discomfort
- dizziness, sweating, shortness of breath
- feelings of suffocation
- feelings of losing control
Can lead to avoidance - very disabling because of the wide variety of situations that a person may feel they need to avoid
May also involve social and emotional distancing in order to avoid attacks (relationships may suffer)
Prevalence: approx 15% of Americans
General Anxiety Disorder
Defined as low-level, but non-specific worries of everyday events and situations, with few evident triggers or causes
- may be about potential situations and the future, often revolve around work, finances, relationships, health (what if BLANK happens?!)
- clinicians describe episodes of irrationality involving unrealistic views and assessments
Psychological Symptoms:
- tension
- restlessness
- problems focusing
Physical Symptoms:
- muscle tension
- general stress response
Global Prevalence: about 4% worldwide
Naming and Classifying drugs
All drugs have a chemical name, generic name, and a trade name
example: sertraline (generic name), zoloft (trade name)
Trade name: intentionally selected to describe the medication or effect (Effexor - effect, effectiveness. Abilify - able, ability)
Drugs can be classified by:
- diagnostic symptoms they target
- chemical structure of the medication
- neuro-receptors, action and mechanism
definition of psychosis
a serious mental illness (such as schizophrenia) characterised by defective or lost contact with reality often with hallucinations or delusions
May involve:
- hearing a voice others cannot hear
- believing something that others would think impossible
- difficulty navigating daily life due to these altered perceptions
Psychosis is a central feature of schizophrenia, and can be one of the most debilitating forms of mental illness
What kind of mental disorders can psychosis be found in? (other than schizophrenia)
- bipolar disorder
- severe forms of depression
- schizoaffective disorder (blend of schizophrenia and mood disorders)
- delusional disorder (delusions similar to schizophrenia but not featuring other typical characteristics/symptoms)
3 symptoms of schizophrenia
- postive symptoms (hallucinations, delusions)
- negative symptoms (deficits in “normal” behaviour)
- cognitive disturbances (symptoms of “disorganised” speech/cognition)
“positive” and “negative” are not interpreted the way we view pos and neg
positive symptoms (plus): experiencing new or additional mental phenomena, thought to be episodic or acute
negative symptoms (minus): existing behaviours or feelings decline or disappear, thought to be chronic or persistent (present for years)
4 main forms of delusions
- Persecutory delusions: a person believes that others are “out to get them”, or that they are being targeted for mistreatment
- Grandiose delusions: the person believes themselves to be in a position of great power, such as deity, celebrity, or a head of government
- Delusions related to control: a person may believe that an external force is controlling their thoughts or body or that thoughts are being implanted or broadcasted aloud
- Delusions of reference: believing that they are being communicated with in code (receiving secret hidden messages) through media or other sources
Negative Symptoms
The negative symptom domain consists of five key constructs:
- blunted affect (facial expressions and tone of voice is less expressive)
- alogia (reduction in quantity of words spoken)
- avolition (reduced goal-directed activity due to decreased motivation)
- asociality
- anhedonia (reduced experience of pleasure)
Disturbances in Cognition
deficits in:
- memory
- attention
- learning
These interfere greatly with functioning and disrupt a persons life significantly - impeding employment or education
Some researchers believe these are actually the primary hallmark of schizophrenia rather than psychosis
Emil Kraepelin Debates and Controversies on Schizophrenia
Idea that “dementia praecox” (premature dementia or precocious madness) was a specific disorder, not just a group of disconnected syndromes
Created the dominant framework: a scientific pursuit to discover and treat mental diseases along categorical lines
- “dementia”: deterioration of mental facilities, difficulty distinguishing between false perceptions and reality (cognitive disturbances, psychosis)
- “praecox”: very early onset, emerging in late adolescence
- distinct from “manic depression” (now bipolar disorder)
Eugen Bleuler (Swiss Physician) Debates and Controversies of Schizophrenia
Disagreed with Emil Kraepelins ideas of dementia praecox, and used the term schizophrenia
- progressive mental decline was not inevitable, raging a diversity of outcomes was possible
- rather than seeking the condition as “hopeless”, thought treatment like talk therapy could be beneficial
- also not all affected individuals first experience symptoms in adolescence
Diagnostic priority given to communication and emotional “deficits” and “fragmentation of the personality”, rather than psychosis and psychotic symptoms (which Kraepelin thought were the key features)
Advantages of direct-to-consumer marketing of psychopharmaceutical medications
May raise awareness to pharmaceutical options for those suffering from mental illness are seeking help with medical professionals
Allows consumers to recognise symptoms, learn about disease, and seek medical attention for conditions that might otherwise go unidentified or untreated
Disadvantages of direct-to-consumer marketing of psychopharmaceutical medications
- In the past pharmaceutical marketing companies have under-reported harmful side effects of drugs (example: OxyContin). The average consumer - without background in medicine in research - may not understand nor seek out the list of full side effects
- illegal / black market demand for these drugs may go up
- research has found that physicians may feel pressure to prescribe patients drugs that they request, even if they are ambivalent about the choice of treatment
What is direct-to-consumer (DTC) advertising?
pharmaceutical companies market their products directly to patients rather than to health care professionals
- Ads describe a disease and tell the viewer about specific drugs that can treat it
- Ads must also include the risks of taking this medication
- Only allowed in US and New Zealand - prohibited in Canada under the Food and Drug Act
Antidepressants - the generic and trade names
- Prozac (fluoxetine)
- Zoloft (sertraline)
- Effexor (venlafaxine)
- Seroquel (quetiapine)
- Abilify (aripiprazole)
- Zyprexa (olanzapine)
Anti-Anxiety (anxiolytics) - the generic and trade names
- Prozac (fluoxetine)
- Zoloft (sertraline)
- Effexor (venlafaxine)
- Valium (diazepam)
- Ativan (lorazepam)
- BuSpar (buspirone)
Antipsychotics - the generic and trade names
- Risperdal (risperidone)
- Zyprexa (olanzapine)
- Abilify (aripiprazole)
- Seroquel (quetiapine)
- Clozaril (clozapine)
Mood Stabilizers
- Lithium
- Epival (divalproex)
- Lamictal (lamotrigine)
- Seroquel (quetiapine)
What are medications are benzodiazepines?
- Valium (diazepam)
- Ativan (lorazepam)
- Xanax (alprazolam)
Difference between typical and atypical antipsychotics
Typical - first generation (1950s-60s)
Atypical - second generation (end of 20th century)
What disorder does antipsychotics treat?
- mainly schizophrenia
- bipolar disorder
- MDD
what disorder does mood stabilisers treat?
Bipolar disorder
3 main ways they increased medical regulation of substances
- raising educational and licensing standards for physicians
- creating legal monopoly on treatment of illness for physicians
(monopoly - the exclusive possession or control of the supply of or trade in a commodity or service) - regulations for the pharmaceutical industry
What is Miltown?
minor tranquilliser specific effect on anxiety rather than being a general sedative - claimed to treat anxiety without the risks of barbiturate medications
- overshadowed antipsychotics and antidepressants
lessons: benefits overstated, risks/side effects harms understated, extensive sales and profits, large consumer demand
what were the important changes to psychiatry in the 50s and 60s?
- shifts from institution to community: partially due to use of thorazine and antidepressants to reduce severe symptoms, even seriously ill individuals could be cared for outside hospital
- increasing predominance and adoption of the biological model among some psychiatrists: effectiveness of medications encouraged support for neurochemical basis of mental illness, BUT psychodynamic (and freudian) beliefs continued (emphasis on psychotherapy)
- marketing depicted medications as an adjunct for physicians: to help patients make progress in psychotherapy, not an inherent cure
What’s one reason why more people were getting prescribed medicine?
Because health system pressure on physicians to treat more patients in shorter amounts of time led to higher rates of prescribing as a response to mental illness
What is disease mongering?
(Introduced by psychiatrist David Healy in 1997): a marketing strategy increasingly shifting away from selling specific medications toward marketing the idea of particular diseases to consumers
- selling disease to grow patient population and develop markets, maximising perceived prevalence and severity of mental illness by subtly redefining who was deemed to have psychiatric symptoms
- some critics point to this as the medicalisation of normal human experience and the range of experiences and emotions
Example: FDA approved Xanax for social anxiety disorder, thus transforming shyness into a “disorder”
Barbiturates and amphetamines
Consumption of opiates and cocaine declines, new types of substances became popular
- Barbiturate sedative (1900s)
- Amphetamines stimulant (1930s)
In the 1950s, 25% of all prescriptions included one or both in the US (consumed by adults and children)
Large market and profit potential due to popularity leading to more industry interest and sales
Thought to be relatively safe, despite high rates of barbiturate overdose
