Psychopathology Flashcards
Erikson’s 8 stages of development
1: trust vs mistrust (infancy to 18 mo)
2: Autonomy vs Shame and doubt (18 mo-3)
3: Initiative vs Guilt (3-5)
4: Industry vs Inferiority (6-11)
5: Identity vs Confusion (12-18)
6: Intimacy vs Isolation (18-40)
7: Generativity vs Stagnation (40-65)
8: Integrity vs Despair (65-)
mood disorder in DSM-5-TR
- Depressive disorders
- Bipolar and related disorders
Depressive disorders
- Disruptive mood dysregulation disorder (in children up to 12 years old)
- Major depressive disorder
- persistent depressive disorder (parenthical alternative wording ‘dysthymia’ removed in DSM-V-TR)
- premenstrual dysphoric disorder
Bipolar and related disorders
- Bipolar I disorder
- Bipolar II disorder
- Cyclothymic disorder
Distinguishing clinical depression from sadness
- More pervasive and persistent; mood doesn’t pick up with activities
usually experienced as pleasant - Mood change may occur apparently without precipitating events or out
of proportion to circumstances - Ability to function is significantly impaired
- Cognitive, somatic & behavioural changes as well as change in mood
- Quality of mood change may be different from normal sadness: feeling
‘strange’, ‘engulfed’ or ‘empty’ or ‘emotionally dead’
Major Depressive episode diagnostic criteria (DSM-5-TR) 1-5
- requires 5 or more of the following for at least two weeks at least one symptom is 1) or 2)
1. Depressed mood most of the day, nearly every day. - Subjective report or observation
- In children and adolescents may be irritable mood
2. Markedly diminished interest or pleasure all or almost all activities, most of the day nearly every day. - Subjective report or observation
3. A significant loss or gain of weight without attempt to diet, or a persistent increase or decrease in
appetite nearly every day (more than 5% body weight in a month).
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day. (Excessive agitation or slowing down of
movement response, observable by others)
Major Depressive Episode
Diagnostic criteria (DSM-5-TR) 6-9
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive or inappropriate guilt nearly
every day (not merely self-reproach or guilt about being sick). - Reduced ability to concentrate or think clearly, or make decisions,
nearly every day.
* Subjective report or observation. - Recurrent thoughts of death (not just fear of dying), recurrent suicidal
ideation without a specific plan, or a suicide plan or attempt.
Major Depressive Episode
Diagnostic criteria (DSM-5-TR) B and C
B. The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a
substance or another medical condition.
Major Depressive episode: Differentiate from:
- ordinary sadness
- grief/responses to significant loss
▫ Consider preoccupation with worthlessness; intensity experienced in waves;
possibility of lighter moments; symptoms (e.g., guilt) not directly related to loss
▫ Clinical judgment re: major depressive episode in addition to grief response - Dementia:
▫ Consider onset and pre-morbid state, temporal sequencing of depressive &
cognitive symptoms, course of illness and treatment response
▫ Dementia will be discussed further later in the unit - Prolonged grief disorder differential diagnosis added in DSM-V-TR
Major Depressive Disorder Diagnostic Criteria (DSM-5-TR)
- one or more depressive episode(s) (single episode/recurrent)
- clinically significant distress or impairment
- never had a manic or hypomanic episode
- specifiers include:
= with peripartum onset
= with seasonal pattern
= with psychotic features
= with anxious distress
Persistent Depressive Disorder
Diagnostic criteria (DSM-5-TR) A and B
A. Depressed mood most of the day, more days than not, for at least 2
years
▫ In children, only one year, and can be irritable mood
B. Presence, while depressed, of two or more of the following:
▫ Poor appetite or overeating
▫ Insomnia or hypersomnia
▫ Low energy or fatigue
▫ Low self-esteem
▫ Poor concentration or difficulty making decisions
▫ Feelings of hopelessness
persistent depressive disorder diagnostic criteria (DSM-5-TR) specifiers include
- with anxious distress
- with melancholic features
- with persistent major depressive episode
- with intermittent major depressive episodes
- mild
- moderate
- severe
premenstrual dysphoric disorder diagnostic criteria (DSM-5-TR)
essential features
- mood lability
- irritability
- dysphoria
- anxiety symptoms
- symptoms occur repeatedly during the pre-menstrual phase of the cycle
- symptoms remit around the onset of menses or shortly after
>significant distress or interference with work, school, relationships etc.
classifiction of bipolar disorders in DSM-5-TR Bipolar I
- one or more manic episodes
- depressive episodes common but not required for diagnosis
classifiction of bipolar disorders in DSM-5-TR Bipolar II
- at least one hypomanic episode
▫ At least one major depressive episode
▫ No manic episodes
classifiction of bipolar disorders in DSM-5-TR Cyclothymic disorder
▫ Chronic but less severe symptoms
Persistent symptoms (at least 2 years; 1 year for children/adolescents)
Numerous periods of hypomanic symptoms not severe enough to meet criteria for hypomanic episode
Numerous periods of depressive symptoms not severe enough to meet criteria for major depressive
episode
Diagnostic Criteria (DSM-5-TR) Manic episode A. B.
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and
abnormally and persistently increased goal-directed activity or energy, lasting at least one week, and
present most of the day, nearly every day (or any duration if hospitalisation is necessary)
B. During the period of mood disturbance and increased energy or activity, three or more of the
following symptoms (four if mood is only irritable) are present to a significant degree and represent a
noticeable change from usual behaviour:
▫ Inflated self-esteem or grandiosity
▫ Decreased need for sleep (e.g., feels rested after 3 hours)
▫ More talkative than usual pressure to keep talking
▫ Flight of ideas or subjective experience that thoughts are racing
▫ Distractibility
▫ Increase in goal-directed activity (socially, at work or school, or sexually) or psychomotor agitation
▫ Excessive engagement in activities with high potential for painful consequences (e.g. spending sprees,
foolish business investments)
Diagnostic Criteria (DSM-5-TR) Manic episode C. D.
C. The mood disturbance is sufficiently severe to cause marked
impairment in social or occupational functioning or to necessitate
hospitalisation to prevent harm to self or others, or there are psychotic
features
D. The episode is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication, other treatment) or to
another medical condition
Diagnostic Criteria (DSM-5-TR) hypomanic episode A. B.
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and
abnormally and persistently increased goal-directed activity or energy, lasting at least four
consecutive days, and present most of the day, nearly every day.
B. During the period of mood disturbance and increased energy or activity, three or more of the
following symptoms (four if mood is only irritable) have persisted, represent a noticeable change
from usual behaviour, and have been present to a significant degree:
▫ Inflated self-esteem or grandiosity
▫ Decreased need for sleep (e.g., feels rested after 3 hours)
▫ More talkative than usual pressure to keep talking
▫ Flight of ideas or subjective experience that thoughts are racing
▫ Distractibility
▫ Increase in goal-directed activity (socially, at work or school, or sexually) or psychomotor agitation
▫ Excessive engagement in activities with high potential for painful consequences (e.g. spending sprees,
foolish business investments)
Diagnostic Criteria (DSM-5-TR) hypomanic episode C. D. E. F.
C. The episode is associated with an unequivocal change in functioning
that is uncharacteristic of the individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable
by others.
E. The episode is not severe enough to cause marked impairment in social
or occupational functioning or to necessitate hospitalisation. (If there are
psychotic features, the episode is, by definition, manic.)
F. The episode is not attributable to the physiological effects of a
substance
Diagnostic Criteria (DSM-5-TR) Cyclothymic disorder A. B. C.
A. For at least two years (at least one year in children and adolescents) there have been numerous
periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and
numerous periods with depressive symptoms that do not meet criteria for a depressive episode.
B. During the above two-year period (one year in children and adolescents), the hypomanic and
depressive periods have been present for at least half the time and the individual has not been
without the symptoms for more than two months at a time.
C. Criteria for a major depressive, manic, or hypomanic episode have never been met.
Diagnostic Criteria (DSM-5-TR) Cyclothymic disorder D. E. F.
D. The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia,
schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia
spectrum and other psychotic disorder.
E. Symptoms not attributable to physiological substance or other medical condition.
F. Symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
Bipolar disorder Course and outcome
▫ Often begins with a depressive episode
▫ Onset 15-24 years
▫ Prognosis mixed (40-50% have sustained recovery)
▫ Remission: two months with minimal or no symptoms
Depressive disorder course and outcome
▫ Data based on samples in treatment
▫ Most recover from initial episode
▫ Variation in long-term course
From rarely in remission
To years of remission between episodes/ single episode
▫ Average episodes over lifetime: 5 or 6
general social determinants of depressive disorder
- Depressive disorder rates higher for those:
▫ Not being married or in a defacto relationship
▫ With lower level of education
▫ Not being in the labour force - Serious stressful life events such as loss
mood disorder statistics
- About 1.5 million (7.5%) Australians aged 16-85 reported having an affective
disorder (e.g., depressive episode) in the previous 12 months - Bipolar Disorder around 2%
- Gender differences
▫ Research consistently shows higher rate of depressive episode in women, Australia
(5.7%) than in men (4.1%)
▫ Minor gender differences for bipolar disorder - Age differences in affective disorders
▫ 10.4% of males and 16.7% of females aged 16-24 years
▫ There is a trend for the prevalence of affective disorders to decrease as people age
https://www.abs.gov.au/statistics/health/mental-health/national-study-mental-h
ealth-and-wellbeing/latest-release
social determinants adolescents 14-17 the mental health of children and adolescents
- Depressive Disorder
▫ Household income threshold, prevalence of major depressive disorder
highest (3.8%) in families in the lowest household income bracket
▫ Higher in families with a sole parent or carer not in employment (6.9%)
compared with families with two parents or carers both in employment
(1.8%)
▫ Higher in step families (4.7%), and families with one parent or carer (5.5%)
▫ Poor family functioning (11.6%)
▫ Area of residence and parent education were not significant
etiology: social factors and severe stress, Brown and Harris’ studies of women
- Depression usually triggered by highly stressful life event(s) (rated as ‘severe’
event)
▫ Why did some women suffer depression after severe event and others did not? - Some women more vulnerable to developing depression: Vulnerability factors:
▫ Loss of parent in childhood
▫ 3 or more children under 14 living at home
▫ Absence of intimate and supportive relationship with partner - Some severe events more likely to trigger depression, i.e. when event involved:
▫ Humiliation
▫ Entrapment
Theoretical Perspectives: cause of depressive disorders Behavioural
- Behavioural
▫ Lewinsohn’s theory: Loss of positive reinforcements, extinction, interpersonal
relationships reinforcing depressed behaviour
Theoretical Perspectives: cause of depressive disorders Cognitive
- Cognitive
▫ Beck: Depressed mood is the product of negative thinking (not vice versa):
distortion and errors in thinking,
selective recall of events with negative consequences,
depressive schemas (revolving around inadequacy, failure, loss, worthlessness)
guide the person’s perceptions and interpretations
▫ Seligman: Learned helplessness - Beck’s negative cognitive triad
Schemas
cognitive frame work which people perceive their life through
Theoretical Perspectives: cause of depressive disorders Psychodynamic
- Psychodynamic
▫ Freud: Anger turned inward, triggered by loss
▫ Early loss experiences may sensitise person to later loss
▫ Harsh expectations internalised early in life leading to self-criticism and
sense of failure
▫ Bibring: Put more emphasis on low self-esteem and helplessness
▫ Blatt: 2 forms of depression:
One precipitated by perceived failure
One precipitated by loss
Theoretical Perspectives: cause of depressive disorders Biological
- Biological
▫ Genetic factors
In major depressive disorder: influence person’s sensitivity to environmental
stress
Greater role in bipolar disorder
▫ Neurotransmitters
Role likely to be complex and interactive
Anti-depressant medications impact on serotonin, norepinephrine, dopamine
▫ Neuroendocrine system
Hormones regulate response to stress
Treatment: Depressive Disorder
- Psychotherapy
▫ Psychodynamic
▫ Cognitive-behavioural
▫ Interpersonal - Medication
▫ SSRIs
▫ Tricyclics
▫ MAO inhibitors - Psychotherapy and medication combined
Treatment: Bipolar disorders
- Medication: Mood stabilisers
- Assistance to maintain steady biological rhythms
▫ Sleep-wake cycle - Evidence based psychological therapies combined with medication
- Seasonal mood disorders: Light therapy
The Nature of Anxiety
Physiological aspects
* Psychological aspects
* Often related to situations of uncertainty
* Anxiety may be adaptive and is normal; serves an alerting function;
arousal aspect can be energising
* Too much anxiety can disrupt thinking and performance
When does anxiety become an anxiety disorder?
- Consider
- Severity/intensity of anxiety
- Duration of anxiety
- Pervasiveness of anxiety
- Extent to which anxiety can be managed or controlled by the person
- Extent to which anxiety is out of proportion to the situation
- Extent to which anxiety leads to a state of self-preoccupation or a
primary focus on the anxiety itself
List of Anxiety Disorders in DSM
- Separation Anxiety Disorder
- Selective Mutism
- Specific Phobia
- Social Anxiety Disorder (Parenthetical alternative name ‘Social phobia’ removed in DSM-V-
TR) - Panic Disorder
- Agoraphobia
- Generalised Anxiety Disorder
- Substance/Medication-induced Anxiety Disorder
- Anxiety Disorder Due to Another Medical Condition
- Other Specified Anxiety Disorder
- Unspecified Anxiety Disorder
Changes from DSM-IV-TR to DSM-V
- Formerly listed under Anxiety Disorders (in DSM-IV-TR)
▫ Obsessive-Compulsive Disorder
▫ Post-traumatic Stress disorder - These diagnoses now listed under categories of:
▫ Obsessive-Compulsive and Related Disorders
▫ Trauma- and Stressor-Related Disorders - Linked diagnosis of ‘Panic Disorder with Agoraphobia’ now removed
- Now listed as separate disorders
▫ Agoraphobia
▫ Panic disorder
Generalised Anxiety Disorder (GAD)
- Excessive anxiety and worry
▫ more days than not for 6 months
▫ about a number of events/issues (such as work or school performance) - Difficulty controlling the worry
- Accompanied by three of:
▫ restlessness or feeling on the edge,
▫ easily tired,
▫ difficult to concentrate,
▫ irritability,
▫ muscle tension,
▫ sleep disturbance - Clinically significant distress or impairment in occupational or social functioning
Panic Attack
(not in itself a disorder)
- Abrupt surge of intense fear or discomfort reaching a peak within
minutes with 4 or more of the list of symptoms (next slide) - Can occur with a range of disorders
Panic Attack - 4 or more of the following symptoms:
▫ Heart palpitations or accelerated heart rate
▫ Sweating
▫ Trembling or shaking
▫ Shortness of breath
▫ Feeling of choking
▫ Chest pain or discomfort
▫ Nausea or abdominal pain
▫ Feeling dizzy, lightheaded or faint
▫ Chills or heat sensations
▫ Numbness or tingling
▫ Derealisation or depersonalization
▫ Fear of losing control, going crazy
▫ Fear of dying
Panic Disorder
- Recurrent unexpected panic attacks (as defined in previous slides)
- Followed by 1 month of concern about
▫ having more attacks
▫ implications of the attack
▫ significant change in behaviour related to the attacks - Not attributable to physiological effects of a substance or another
medical condition - Not better explained by another mental disorder
Agoraphobia
- Marked fear or anxiety about two of:
▫ Using public transport
▫ Being in open spaces
▫ Being in enclosed spaces
▫ Standing in line or being in a crowd
▫ Being outside of the home alone - Fear or avoidance because escape is difficult or help not available if panic or other
embarrassing symptoms - Agoraphobic situations
▫ Almost always provoke fear/anxiety
▫ Are actively avoided or endured with great distress - Typically lasting for 6 months or more
Specific Phobia
- Intense fear or anxiety
- Cued (consistently) by specific object or situation
- Leading to an avoidance of the particular stimulus
- Fear/anxiety/avoidance out of proportion to actual danger & to
sociocultural context - Persistent, typically lasting 6 months
- Clinically significant distress or impairment
Social anxiety disorder (social phobia)
- Marked & consistent fear or anxiety about 1 or more social situations in
which person is exposed to possible scrutiny by others - Fear that actions or anxiety symptoms will be negatively evaluated
(person will feel humiliated or embarrassed) - The social situations are avoided or endured with marked distress
- Anxiety is out of proportion to actual threat
- Persistent, typically lasting for 6 months or more
Etiological Perspectives (Anxiety)
- Evolutionary perspective:
▫ Anxiety and fear adaptive in many situations
▫ Mobilise responses that help person survive danger (fight or flight)
▫ Are anxiety symptoms a product of dysregulation in these response
systems?
A core idea: anxiety related to danger situations
- Evolutionary perspective notes role of anxiety and fear in mobilising
response to external danger - Freud thought anxiety was a signal of an internal danger situation
(signals the likelihood of psychological pain related to inner conflicts,
impulses getting out of control or impending losses) - Anxiety more related to danger (lack of security or lack of control) while
depression more related to loss (lack of hope) – there is some research
to support this
Psychodynamic and attachment perspectives
- Focus on role of early childhood experience in development of
(vulnerability to) anxiety disorders - Psychodynamic: Anxiety precipitated by intrapsychic conflicts &
anticipated danger that someone or something important will be lost - Attachment: Insecure attachment patterns leave person vulnerable to
anxiety (that attachment figure will be unavailable when needed) - Research suggests that:
▫ stressful life events and
▫ childhood adversity - Contribute to the development of anxiety disorders
Behavioural perspectives
Symptoms based on prior learning
* Inappropriate classical conditioning or modeling/observational learning
* People with specific phobias often report learning them from
experience
* Predisposition or preparedness in humans for some fears (e.g., heights,
snakes, storms)
* Learning fear responses through imitation of others
Cognitive perspectives
- Anxiety stems from maladaptive thought patterns and beliefs associated with
▫ vigilant attention to threatening cues and possible dangers
▫ misinterpretations of actions
▫ misinterpretation of body sensations (eg in panic disorder) - Perception of control over events → less anxiety
▫ Sense of uncontrollability → more anxiety - Cycle where fearful expectations → anxious/preoccupied self-evaluation →
more arousal & attention to perceived threat → impaired performance &/or
avoidance - Attempts to suppress a thought (or associated emotion) may make the thought
more intrusive (relevant to OCD?)
Biological Perspectives
- Some evidence of genetic risk factors but not highly specific (not a
different set of genes for each disorder) nor completely non-specific
▫ Heredity plays a role but comparatively modest
▫ GAD, panic & agoraphobia vs specific phobia? - Investigation of neuro-anatomical pathways (especially limbic system)
associated with emotional responses eg fear & panic - OCD seems to involve different areas of the brain
- Neurochemistry:
▫ Role of neurotransmitters eg serotonin seems to dampen stress responses
Obsessive-Compulsive and Related Disorders
DSM-5-TR
- Obsessive-Compulsive Disorder (was in Anxiety Disorders in DSM-IV)
- Body Dysmorphic Disorder (was in Somatoform Disorders in DSM-IV)
- Hoarding Disorder (new disorder added in DSM-V - no longer a subtype
of OCD) - Trichotillomania (Hair-Pulling Disorder)
▫ (Was in Impulse Control Disorders in DSM-IV) - Excoriation Disorder (Skin-Picking disorder) (new in DSM-5)
- A new chapter in DSM-V
▫ Disorders related to OCD through obsessions or compulsions
Obsessive-Compulsive and Related Disorders
- Characterised by:
▫ Intrusive/repetitive internal experiences (these may be thoughts, images
or urges)
▫ Distress related to the intrusive experiences
▫ Compulsive behaviours. - Often the belief about the meaning of the internal experience and the
context in which it occurs are important to the person’s distress and
compulsions.
Obsession
- Recurrent and persistent ideas, thoughts, urges or images that are
experienced as intrusive and unwanted - Usually cause anxiety or distress
- The individual attempts to ignore or suppress the thoughts, urges or
images, or to neutralise them with another thought or action
(performing compulsion)
Compulsion
- Repetitive behaviors or mental acts performed in response to
obsessions or according to rules that must be applied rigidly. - Aimed at reducing or preventing anxiety or distress, or preventing a
dreaded event or situation. Not connected in a realistic way with what
they are designed to neutralize or prevent, or are clearly excessive
High anxiety ensues if prevented from completing the action
Obsessive-Compulsive Disorder DSM-5-TR
- Presence of obsessions or compulsions (often both)
- Symptoms are time-consuming (e.g., more than 1 hour a day), cause marked
distress and/or impairment in social, occupational or other important functioning - Not due to a substance, or medical condition
- Nor better explained by another mental disorder
▫ Specify if
Good or fair insight
Poor insight
Absent insight/delusional beliefs
▫ Specify if tic-related
OCD
- Common types of obsessions and compulsions:
▫ Symmetry/exactness
▫ Forbidden thought aggressive/sexual/religious
▫ Cleaning/contamination - Mean age of onset (US data) 19.5 years
▫ 25% by 14 years; onset after 35 years is unusual - Onset is typically gradual
- Chronic without treatment
▫ reduces quality of life - Common comorbidities:
▫ Anxiety, depressive disorder, tic disorder
OCD Components
- Not-Just-Right (NJR) (Coles et al. 2003)
- The sense that an error is occurring (“it’s not juuuust right”)
- Common with order and symmetry but not restricted to this
- Difficult to describe (error-detection process may be outside awareness)
- Thought-Action Fusion (TAF) (Thompson-Hollands et al. 2014)
- Moral TAF – having the thought is morally equivalent (or almost!) to the act that the thought represents e.g. an intrusive
thought about sex with a child is morally equivalent to having sex with a child. - Likelihood TAF – having the thought increases the likelihood of the thought actually happening.
Neurobiology/anatomy of OCD
- Early observation of obsessions/
compulsions after encephalitis
lethargica
▫ basal ganglia lesions - Dysregulation of serotonin implicated
in formation of obsess/comp - Increased frontal and subcortical
activity
▫ Orbitofrontal Cortex, Anterior Cingulate
Cortex, Thalamus and Caudate
“brain lock” Schwartz et al especially
in right hemisphere
“a prefrontal cortico-striato-thalamic brain
system”
Cognition in OCD
- Not-Just-Right (NJR) (Coles et al. 2003)
- The sense that an error is occurring (“it’s not juuuust right”)
- Common with order and symmetry but not restricted to this
- Difficult to describe (error-detection process may be outside awareness)
- Thought-Action Fusion (TAF) (Thompson-Hollands et al. 2014)
- Moral TAF – having the thought is morally equivalent (or almost!) to the act that the thought represents e.g. an intrusive
thought about sex with a child is morally equivalent to having sex with a child. - Likelihood TAF – having the thought increases the likelihood of the thought actually happening.
Neurobiology/anatomy of OCD
- Early observation of obsessions/
compulsions after encephalitis
lethargica
▫ basal ganglia lesions - Dysregulation of serotonin implicated
in formation of obsess/comp - Increased frontal and subcortical
activity
▫ Orbitofrontal Cortex, Anterior Cingulate
Cortex, Thalamus and Caudate
“brain lock” Schwartz et al especially
in right hemisphere
“a prefrontal cortico-striato-thalamic brain
system”
Cognition in OCD
- Deficits generally related to fronto-striatal dysfunction
- Deficits seen in tasks mediated by frontal lobes executive dysfunction
▫ Set shifting; idea generation; inhibition difficulties - Little evidence of basic attentional deficits
▫ “Deficits” on attention tasks driven by slow speed of processing - Visuospatial dysfunction including reduced visual-spatial memory
- Verbal working memory and declarative memory unimpaired
▫ Memory performance reduced on tasks requiring higher level organisation/ strategies to
encode information
executive aspects of memory
OCD Components
- Personal Implications (Tolin et al., 2003)
- Beliefs about safety (“Things/I must be dangerous…”)
- Beliefs about morality/character (“What kind of a person….”)
- Beliefs about perfection/errors (“I must do things a certain way…”)
- External Implications (Tolin et al., 2003)
- Beliefs about the safety of others (“If I don’t act, someone will get hurt…”)
- Beliefs about responsibility (“I am responsible for others…”
Body Dysmorphic
Disorder
- Preoccupation with perceived
defects. - Repetitive behaviours in response to
concerns. - Distress and impairment.
Trichotillomania
- Recurrent, automatic or irresistible hair pulling.
Excoriation Disorder
- Recurrent, automatic or irresistible skin-picking.
Schizophrenia Spectrum and Other Psychotic Disorders in DSM-
5-TR
- Schizotypal (personality) disorder
- Delusional disorder
- Brief psychotic disorder
- Schizophreniform disorder
- Schizophrenia
- Schizoaffective disorder
- Substance/medication-induced psychotic disorder
- Psychotic disorder due to another medical condition
- Catatonic features/disorders
- Other (specified/unspecified)
Key Features of Psychotic Disorders
- Positive Symptoms:
▫ Delusions
▫ Hallucinations
▫ Disorganised thinking
▫ Grossly disorganised/abnormal motor behaviour (including catatonia) - Negative symptoms
- Note that a diagnosis of a psychotic disorder requires a pattern of
symptoms, not just one symptom
Concept of Positive and Negative Symptoms
- It is usual today to think about two sets of psychotic symptoms, positive
and negative. - Positive symptoms are active manifestations of abnormal experience.
These include hallucinations, delusions and thought disorder. - Negative symptoms, on the other hand, are deficits in normal
behavior/experience, such as less emotional expression, less speech,
less interest or motivation.
▫ Often significant in schizophrenia but less prominent in other psychotic
disorders
Delusions (***)
- False beliefs which are held in a very fixed way, not amenable to
argument - Typically personal - not shared by other members of the person’s family
or cultural group; often the person is quite preoccupied with these
beliefs - Note that delusions involve a disorder of beliefs
Types of Delusions
- Paranoid/persecutory - unrealistic belief that someone is plotting against you, trying to harm
you; evidence for the belief is very personalised or idiosyncratic - Grandiose - belief that one has special powers, special significance or has been given a
special mission - Somatic - clearly unrealistic, often bizarre belief about one’s body (not just a
hypochondriacal concern) - Delusions of reference – belief that events, communications etc are referring to you
- Delusions of control - belief that one is controlled by mysterious, external forces
- Thought insertion – belief that someone is putting thoughts into one’s head
- Thought withdrawal – belief that thoughts have been removed by an outside force
- Thought broadcasting – belief that others can hear one’s thoughts
- (bizarre vs non bizarre)
Hallucinations
- The person sees, hears, feels, smells or tastes something which is not actually there:
▫ Visual
▫ Auditory
▫ Tactile
▫ Olfactory
▫ Taste - Note that hallucinations involve a disorder of perception
- Auditory hallucinations are particularly common in psychosis, and often take the
form of voices - Person is generally unaware that the hallucinations are not real
Disorganised Thinking
- This is generally inferred from the person’s speech
- Derailment /Idiosyncratic associations: The way one idea or thought
follows another is unusual and idiosyncratic - Tangential speech: Answers to questions only obliquely related to
question - Incoherent speech
- Must be severe enough to substantially impair effective communication
and ability to concentrate
Disorganised Motor Behaviour and/or Catatonia
- Grossly disorganised or abnormal behaviour
▫ Unpredictable agitation
▫ Childlike ‘silliness’
▫ Difficulties with goal-directed behaviour & ADL - Catatonia
▫ Unusual immobility or rigidity, posturing
▫ Mutism
▫ Excitement/ apparently purposeless overactivity
▫ Stereotyped movements
▫ Echoing/mimicking of speech (echolalia) or movement (echopraxia)
▫ DSM-5 argues catatonia is under-recognised & introduces use of a catatonia specifier
across a wider range of disorders
Negative Symptoms
- Diminished emotional expression (blunted affect or affective flattening)
– reduced expression of emotion
▫ Facial; tone of voice; eye contact; gesture - Avolition - difficulty getting motivated or initiating activities
- Alogia (poverty of ideas) – diminished speech output
- Anhedonia – decreased capacity to experience pleasure
- Social withdrawal
DSM-5-TR Diagnostic Criteria for Schizophrenia
A. Two or more of the following, each present for a significant portion of time during
a one-month period (or less if successfully treated). At least 1 of these must be (1),
(2) or (3):
1. Delusions
2. Hallucinations
3. Disorganised speech (e.g., frequent derailment or incoherence)
4. Grossly disorganised or catatonic behavior
5. Negative symptoms (diminished emotional expression or avolition)
B. Significant impairment in social/occupational functioning or self-care
C. Continuous signs persist for at least six months
(D & E: differentiate from other disorders and effects of a substance)
Phases of an Episode of Schizophrenia (***)
- Prodromal (onset stage, early signs, some changes in feelings, thoughts, perceptions)
* Attenuated psychotic symptoms
* 85% go through 1-2 year prodromal phase - Active or acute (clear psychotic symptoms)
- Residual (acute symptoms have resolved but still attenuated signs of disorder or
negative symptoms remain)
* Depression is common in residual stage - Remission or recovery (50% of people will reach this stage)
Delusional Disorder
- Presence of delusion(s) persisting for at least 1 month
- Never met Criterion A for schizophrenia
- Apart from impact of delusions, functioning not markedly impaired and
not obviously bizarre or odd - Mood episodes have been brief or absent compared with duration of
delusions - Not due to physiological effects of a substance (e.g., cocaine) or a
general medical condition (e.g., Alzheimer’s disease) and not better
explained by another mental disorder
Delusional Disorder- Types (Specifiers)
- Based on central theme of delusion
▫ Erotomanic: That another person is in love with you
▫ Grandiose: Having great (but unrecognised) worth, powers, knowledge etc
▫ Jealous: That the person’s spouse /sexual partner is unfaithful
▫ Persecutory: That someone is conspiring against or being malevolent
towards you or a loved one
▫ Somatic: Delusion of a physical defect or disease
▫ Mixed: Characterised by more than one delusion
▫ Unspecified - Specify if ‘with bizarre content’
Brief Psychotic Disorder
- Psychotic symptoms last for at least one day but less than one month
- Eventual return to premorbid level of functioning
- Replaced an earlier diagnostic category of Brief Reactive Psychosis
which referred to psychotic symptoms which were a reaction to
significant stress. - Specify:
▫ With or without marked stressor(s) (brief reactive psychosis)
▫ Without marked stressor(s)
▫ With peripartum onset
▫ With catatonia
Schizophreniform Disorder
- Symptoms as for schizophrenia but different duration
▫ The episode lasts at least 1 month but less than 6 months - The term ‘first-episode psychosis’ may be used early in illness states to
avoid ‘labelling’ young adults with schizophrenia.
Schizoaffective Disorder
- Mixture of mood and psychotic symptoms
▫ Period during which there is a major mood episode concurrent with
Criterion A of schizophrenia - Psychotic symptoms do not only occur in the context of a mood episode
Substance/Medication-Induced Psychotic Disorder
- Presence of (prominent) hallucinations and/or delusions
▫ Developed during, or soon after, substance intoxication or withdrawal
▫ The substance/medication is capable of producing the symptoms - Not better explained by a psychotic disorder that is not
substance/medication-induced
▫ e.g., Substance/medication-induced disorder will normally resolve within a
month after intoxication or withdrawal - Distinguish from:
▫ Substance withdrawal ‘with perceptual disturbances’
Mood Disorders with Psychotic Features
(listed under Mood disorders in DSM-5-TR)
- Bipolar disorder, with psychotic features
- Major depressive disorder, with psychotic features
- Psychotic symptoms (hallucinations and/or delusions) only occur in the
context of a mood episode
▫ (i.e., during manic or depressive states)
Epidemiology
Schizophrenia and Related Psychotic Disorders
- Lifetime prevalence: approx 0.8 to 1%
- Onset is typically (but not only) between 15-28
- Recent evidence suggests men may be more likely than women to
develop schizophrenia (contrary to long-held view of equal prevalence) - Occurs in cultures/countries across the world
Gender Differences
- Males more likely to have:
▫ Earlier onset
▫ Poor premorbid social functioning
▫ Pattern of negative symptoms
▫ Chronic course
▫ Note ‘more likely’ does not mean always
Schizophrenia: Course and Recovery
- Long term follow-up studies suggest:
▫ Approx 50% acute onset (vs gradual onset)
▫ Approx 50% undulating course - exacerbations and remissions (vs stable or
simple course) - Long-term outcome is variable, ranging from recovered or mild
impairment through moderate to severe impairment - Problematic issue:
▫ How to measure/assess outcome
▫ Aspects of outcome (e.g. symptoms, social function, work) not highly
correlated
Course and Recovery (continued)
- More favourable outcome associated with:
▫ Acute onset
▫ Shorter duration of untreated psychosis
▫ Undulating course
▫ Fewer relapses
▫ Female gender
For long-term outcome
No clear difference for recovery from first episode
▫ In developing countries (vs developed)
Treatment – Antipsychotic Medication
- 1st generation antipsychotics (e.g., Chlorpromazine/Largactil)
▫ In approximately 25% of sufferers, symptoms not improved
Term ‘treatment-resistant’ refers to condition not person
▫ Side effects:
Extrapyramidal symptoms (muscular rigidity, restlessness)
Tardive dyskinesia after long-term use - 2nd generation/Atypical antipsychotics (e.g., Clozapine)
▫ Symptom relief for many who found earlier antipsychotics ineffective
▫ Fewer motor side effects
▫ But other side effects (e.g., weight gain and medical risks)
Treatment (continued) Schizo
- Maintenance medication reduces relapse rates
▫ How long to maintain for? - Anti-psychotic medications tend to subdue positive symptoms, but have
less impact on negative symptoms. Negative symptoms seem to
respond better to intensive psychosocial treatment - Hospitalisation – quite common in acute episode
Treatment - Psychosocial interventions (Schizo)
- Psychoeducation
▫ Including medication compliance - Psychosocial rehabilitation
▫ Social skills and assisted living - Case management services
- Housing/occupational assistance
- Cognitive behavioural therapy for voices and information processing
- Supportive therapy
- Treatment of comorbid or “dual diagnosis”
- Family interventions
Treatment - Issues (Schizo)
- Importance of early intervention
- Prodromal phase may be 1-2 years
- Delay between onset and treatment may be 1-2 years
- Most improve when treated
- Most ~ 75% will experience relapse and recovery
- High risk of suicide
- Non compliance with medication
- Consent to treatment
- Psychological therapy only when stable
Schizophrenia and the brain
- Although results vary, most studies have found that the brains of
people with schizophrenia weigh less than the brains of others - Enlarged ventricles
- Lower volume of grey matter
- Reduction in the number of neurons in the PFC
- Thinner cortex in the medial temporal regions
- Abnormalities in the organization of neurons in the hippocampus
Schizophrenia:
a neurodevelopmental disorder
- Subtle physical abnormalities indicative of early (foetal) developmental
disturbance
Schizophrenia more likely in those with adverse pre- or perinatal events - Pregnancy complications
- Foetal growth retardation; low birth weight
- Delivery complications/interventions
- Correlation b/w Scz and serologically confirmed maternal infections like flu
- Prenatal hypoxic-ischaemic damage
- Neuronal loss in temporal lobes/hippocampus
- Synaptic pruning in adolescence may reduce connections in already affected areas
- Interaction of environmental and genetic factors
Genetics of schizophrenia
- Sekar et al., (2016)
- Complement component 4 (c4) gene
- Increased c4 activity associated
with greater pruning of
synapses postnatally - Mediated by an immune
response? - Pruning associated with grey
matter loss during adolescence - coinciding with onset?
- Greater grey matter loss seen
in young people with
schizophrenia
Brain morphology in schizophrenia
- No one “schizophrenic” lesion in the brain
- Slight decrease in overall grey matter and
white matter volume - Ventricular enlargement
- Reduced hippocampal volume
- Malformations of midline structures
- Cavum septum pellucidum
- Abnormalities of cingulate gyrus
- Abnormalities evident in 1st episode
patients
Suggest a neurodevelopmental basis to
illness
Relationship between Brain
structure & symptoms in
schizophrenia
- Severity of auditory hallucinations
associated with degree of grey
matter loss in auditory cortex &
PFC (Gaser et al., 2004). - Functional abnormalities present
in at risk adolescents who later
develop Sz (Whalley et al., 2006) - Reduced activation of frontal
regions both at rest and during
cognitive tasks during fMRI (Hill
et al., 2004) - Reduced blood flow in the
anterior cingulate during
attentional tasks seen on PET
(Yucel et al., 2002)
Cognitive effects of schizophrenia 1
- Present at onset of illness
- Appear unrelated to positive symptoms
- Do not appear to change substantially over
time - State dependent?
- Decline over time?
- Static/neurodevelopmental?
- Not just related to medication
- Atypical antipsychotics may be neuroprotective
- Attention, EF and memory dysfunction
common - Greatest impact on ADLs
Cognitive effects of schizophrenia 2
- The prodromal period (Brewer et al., 2005)
- Ultra high risk study of 98 young people 38 later developed psychosis; cf. 34 controls
- Overall lack of impairment in UHR group general cognitive impairment not part of
prodrome - BUT lower non-verbal IQ abilities and impaired verbal memory
- Frontally mediated memory processes affected before onset of psychosis
- First episode psychosis
- Associated with acute functional deterioration in cognitive functioning
- Magnitude of impairment similar to that seen in chronic illness
- Association between negative symptoms and cognitive deficits at first episode
Cognitive effects of schizophrenia 3
- Chronic schizophrenia
- Generally believed that cognition does not appear to decline significantly over time
- Cognitive effects of neuroleptic/ antipsychotic drugs make such judgments difficult
- Polydrug Tx greater cog impairment, but ?? causative
- Sponheim et al., (2010)
- 41 recent onset vs 106 chronic patients
- Most cognitive abilities comparable over time
- Some timed problem solving and fine motor tasks appear to decline
- Chan et al., (2014)
- 26 patients with chronic severe Sz vs 34 patients with behavioural variant
frontotemporal dementia - Performance on 6 cognitive domains compared
- > 85% overlap between groups in most cognitive domains
What is Personality and Personality Disorder?
- PERSONALITY: ‘enduring patterns of thinking and behaviour that define
the person and distinguish him or her from other people’ including
‘ways of expressing emotion’ and ‘patterns of thinking about ourselves
and other people’ (Oltmanns & Emery, 2012, p.219) - When enduring personality patterns interfere with the person’s ability
to get on with others and to carry out social roles including work roles –
these patterns can be viewed as a form of psychological dysfunction ie
as a mental health problem
General Personality Disorder defined in DSM-5-TR
- Enduring pattern of inner experience and behaviour that deviates markedly from
expectations of the individual’s culture. Pattern is manifested in 2 or more of:
▫ Cognition (ways of perceiving or interpreting)
▫ Affectivity (emotional responses)
▫ Interpersonal functioning
▫ Impulse control - Inflexible and pervasive over many situations
- Clinically significant distress or impairment in functioning
- Stable over time and of long duration, with onset in adolescence or early adulthood
- Not better accounted for by another disorder, effects of a substance or a general
medical condition
DSM-5-TR (Personality)
- The DSM has typically had a categorical approach to personality
disorders
▫ What are some limitations of this? - However, an alternative dimensional model was proposed in the DSM-5
(in Section III), involving:
▫ Level of personality functioning
▫ Pathological personality traits
▫ Pervasiveness and stability
▫ Alternative explanations for personality pathology
Alternative Model Listed in DSM-5-TR as ‘Emerging’
- Greater emphasis on personality functioning, core self and personality traits
- Rating of impairment on Self and Interpersonal Functioning (Identity, Self-direction,
Empathy & Intimacy) - Six personality disorder types
▫ Antisocial/Psychopathic
▫ Avoidant
▫ Borderline
▫ Obsessive-Compulsive
▫ Schizotypal
▫ Narcissistic - But diagnosis can also be based on patterns of personality traits (e.g. Detachment;
Antagonism; Disinhibition)
Challenges in Diagnosis
- Personality disorders could be seen as involving maladaptive or extreme
variations on the ordinary range of personality characteristics
▫ When does a “quirk” or variation become a personality disorder? - Personality disorders
▫ Are a controversial diagnostic category
▫ Can be difficult to define and identify reliably
Can have significant overlap with each other
▫ Can lead to significant stigma, even amongst mental health professionals
Controversy: Gender Differences
- Men diagnosed with a personality disorder tend to display traits
characterized as more aggressive, structured, self-assertive and detached - Women tend to present with characteristics that are more submissive,
emotional and insecure - Criteria gender bias
▫ For instance, histrionic PD may be thought of as extreme “stereotypical female”,
▫ No “macho” disorder
▫ Dependent personality disorder but no independent personality disorder
Arguments for Change in Approach to Personality Disorder
Diagnosis
- Excessive co-morbidity among current DSM personality disorders
- Limited validity for some existing types
- Arbitrary diagnostic thresholds in DSM (i.e., number of criteria necessary)
- Current DSM PD diagnoses not particularly stable over time (personality
traits more stable than disorders) - Replacement of behavioural PD criteria with traits is anticipated to result
in greater diagnostic stability - Use of a dimensional rating of types recognizes that personality
psychopathology occurs on continua
ICD-11 Classification of PDs (Bach & First, 2018)
- Takes an alternative approach to the categorical model of the DSM
- Focuses on the impairment of self and interpersonal personality functioning
▫ SELF - sense of identity, self worth, accuracy of personal evaluation, & capacity for self-direction
▫ INTERPERSONAL - interest in engaging in r/ships with others, ability to understand and appreciate
others’ perspectives, develop and maintain close and mutually satisfying relationships, and manage
conflict - Classified according to severity
▫ “Personality Difficulty”, “Mild PD”, “Moderate PD”, “Severe PD” - May also be specified with one or more prominent trait qualifiers “Negative Affectivity”,
“Detachment”, “Dissociality”, “Disinhibition” and “Anankastia” (excessive preoccupation with
orderliness, perfectionism and control) - Suggested as helpful in informing clinical prognosis and intensity of treatment, and trait
classifiers characterized as helpful in selecting focus and style of treatment.
Other Perspective on Personality: Five Factor Model
- “Big Five”; one of the most researched personality models:
▫ Openness to experience (imaginative, curious, creative
▫ Conscientiousness (organised thorough, reliable)
▫ Extraversion (talkative, assertive, active)
▫ Agreeableness (kind, trusting, warm)
▫ Neuroticism (even-tempered) - Cross-cultural research establishes the universal nature of the five
dimensions
DSM-5-TR: 10 Personality Disorders in 3 Clusters
- Cluster A (Odd or eccentric)
▫ Paranoid
▫ Schizoid
▫ Schizotypal - Cluster B (Dramatic, emotional or erratic)
▫ Antisocial
▫ Borderline
▫ Histrionic
▫ Narcissistic - Cluster C (Anxious or fearful)
▫ Avoidant
▫ Dependent
▫ Obsessive-compulsive
Cluster A (personality)
- Paranoid Personality Disorder
▫ Pervasive distrust and suspiciousness of others such that their motives are
interpreted as malevolent - Schizoid Personality Disorder
▫ Pervasive pattern of detachment from social relationships and a restricted
range of emotional expression - Schizotypal Personality Disorder
▫ Pervasive pattern of social and interpersonal deficits marked by acute
discomfort with reduced capacity for close relationships, as well as by
cognitive or perceptual distortions and eccentricities of behaviour
Cluster A: Paranoid Personality Disorder
- A pervasive distrust and suspiciousness of others
▫ The motives of others are interpreted as malevolent,
▫ beginning by early adulthood
▫ present in a variety of contexts, as indicated by four (or more) of list (next slide) - Not occurring only during a psychotic disorder such as Schizophrenia or
mood disorder with psychotic features - Not due to the direct physiological effects of a general medical condition
- Criteria may be met prior to the onset of Schizophrenia, in this case -
Paranoid Personality Disorder (Premorbid)
Paranoid Personality Disorder (cont.) Criteria
- Four or more of the following:
▫ Suspects, without sufficient basis, that others are exploiting, harming or deceiving him or
her
▫ Preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or
associates
▫ Reluctant to confide in others because of unwarranted fear that the information will be
used maliciously against him or her
▫ Reads hidden demeaning or threatening meanings into benign remarks or events
▫ Persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights
▫ Perceives attacks on his or her character or reputation that are not apparent to others
and is quick to react angrily or to counterattack
▫ Recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner
Paranoid Personality Disorder: Presentation and Treatment
- Unlikely to come for help due to lack of trust
- Unlikely to stay in therapy due to difficulty making an alliance
- Little research available
- Presentation:
▫ May be argumentative, complaining or quiet
▫ Sensitive to criticism
▫ Increases any risk of suicide or violent behaviour
▫ Often poor quality of life
Anatomy of the frontal cortex 1 Lateral view
Anatomy of the frontal cortex ventral view
Anatomy of the frontal cortex medial view
Symptoms of frontal lobe dysfunction
Motor symptoms
Primary motor area
Impaired ability to move contralateral
part of body specific to lesion
Premotor and Supplementary
motor areas:
Acute-impairment of voluntary
movement
Residual deficits in rapid planned
movements
Frontal eye fields:
Oculomotor deficits (eye movement)
Broca’s area
Broca’s aphasia
Sensory and perceptual
symptoms
Orbitofrontal cortex: impaired
odour memory/discrimination
Behavioural symptoms of PFC
damage
Summary of Major symptoms of frontal lobe damage
THE EMOTIONAL BRAIN:
LIMBIC SYSTEM
CORTICAL STRUCTURES
AND EMOTION
Frontal areas involved in
“higher” cortical processing
of social emotional
experience secondary
emotions
Highly personal/
individualised
Shame, embarrassment, anxiety
Require a personal evaluation
of situation at the cortical
level before being assigned
an emotional response
thalamo-cortico-amygdala
circuit
MULTIPLE MEMORY
SYSTEMS
TEMPORAL PROFILE OF
MEMORY DISORDER
Anterograde Amnesia
Inability to acquire new memories
Post-Traumatic Amnesia
Global Anterograde Amnesia
Impairment in the ability to form new memories across a variety
of areas
Retrograde Amnesia
Inability to access old memories
May be incomplete—older memories accessible
but more recent memories are not
Time-Dependent Retrograde Amnesia
Commonly produced by traumatic brain injury
Severity of injury determines how far back in time
the amnesia extends
The “temporal gradient” aka Ribot’s Law
More recent memories affected more than older memories
LONG TERM EXPLICIT
MEMORY
Explicit memory
Events, facts, and episodic
memories
Conscious intentional remembering
“Top-down” processing
Episodic memory
Autobiographic
Person’s recall of singular personal
events
H.M. and M.L. (see text) could not
make new episodic memories
Semantic Memory
All nonautobiographical knowledge
—knowledge about the world
Intact in H.M.
Does not depend on medial-
temporal lobe–ventral-prefrontal-
lobe memory system that subserves
episodic memory
NEURAL SUBSTRATES
OF IMPLICIT MEMORY
Basal ganglia
Reduced habit learning procedural
memory
Huntington’s and Parkinson’s Diseases
Amygdala
Fear conditioning
Premotor cortex (procedural)
Cerebellum (procedural)
Diencephalon
Thalamic nuclei; Mammillary bodies
Basal forebrain Numerous
small nuclei
Different types of dementia
Risk and protective factors of Alzheimer
How does the brain respond to injury?
MOTOR SYSTEM: NOT JUST PRIMARY
MOTOR CORTEX
Cortico-spinal tract
Projects from cortex to spinal
cord
Basal Ganglia
Cerebellum
Brainstem
Spinal Cord
Also called the pyramidal tract
90-95% of fibres decussate (cross
over to the other side) at the level
of the medulla in the “pyramids”
(lateral corticospinal tract pic)
Other 10% cross over lower in the
spinal cord (anterior or medial
corticospinal tract)
THE NEOCORTEX: INITIATING
MOVEMENT
Medial structures
- Supplementary motor area
- Cingulate cortex
EXTRAPYRAMIDAL AND
SUBCORTICAL STRUCTURES
“Extrapyramidal” systems
Additional motor systems
that do not travel through
the pyramidal structures of
the medulla
Important for involuntary
movements
Reflexes
Postural control
“Readiness” activation of
muscles
Cerebellum
Basal ganglia
CEREBELLUM INPUTS
AND OUTPUTS
THE BASAL GANGLIA
NEUROANATOMY OF
BROCA’S APHASIA
Frontal operculum “motor
speech area”
Articulation deficits
If only damage here, most
likely to resolve
Precentral gyrus
Underlying WM
Subcortical structures incl. BG
and thalamus
Insula
Dronkers et al: insula damage
required for speech apraxia
Prosody affected
Foreign Accent Syndrome
NEUROANATOMY OF
WERNICKE’S APHASIA
Primary auditory cortex
Heschl’s gyrus
Wernicke’s area
2° auditory processing area
Evaluates input from 1° auditory
cortex with reference to semantic
word knowledge stored in
auditory-verbal memory (L
temporal lobe)
L Wernicke’s area
Verbal, semantic information
Homologous R hem area
Analogical reasoning Eureka
moments
Subordinate, related meanings of
ambiguous words
i.e. bank river vs money
OTHER APHASIA
SUBTYPES***
Fluent
Conduction aphasia*
Normal speech comprehension/
production, with impaired
naming/repetition of non-words
Lesion in arcuate fasciculus*
disconnecting Broca’s and Wernicke’s
areas
Transcortical sensory aphasia
Disconnection of W’s area from
parietal association cortex
Speech spontaneous and fluent
sounding
Nonfluent
Transcortical motor aphasia
Disconnection of B’s area from SMA
Transient mutism; prosody affected;
telegraphic speech
Dual Language Pathway***
Dorsal language pathways (phonemes)
Ventral Language pathways (semantics)
THE VISUAL SYSTEM 1 –
STRUCTURES OF THE EYE
THE VISUAL SYSTEM 2 –
RETINA
Remember: Cells
found in the retina
Rods – specialised
for:
low light levels and
B&W tones
Low spatial acuity
Cones –
specialised for:
Higher light levels
and colour vision
Responsible for
higher spatial acuity
THE VISUAL SYSTEM 3 –
BRAIN PATHWAY
Geniculostriate pathway (via lateral geniculate nucleus
tectopulvinar pathway (via superior colliculus)
THE VISUAL SYSTEM 4 –
BRAIN STRUCTURES
V1: striate cortex
Retinotopic map
V2-V5: prestriate (2°
association) cortex
Basic interpretation of visual
information
V2: light, line orientation,
features of shapes
V3: movement of objects (no
colour)
V4: colour
V5 (area MT): direction of
movement
APPERCEPTIVE
VISUAL AGNOSIA***
Inability to recognise objects
due to deficit in forming stable
perceptual (mental)
representations of the visual
stimulus
Most commonly as a result of
damage in the RIGHT parietal or
temporal region
Patients are unable to copy
even simple drawings or match
objects although are able to
identify individual objects or
drawings
Difficulty identifying objects
from unusual perspectives
ASSOCIATIVE VISUAL
AGNOSIA ***
Inability to associate
perceptual information
with semantic info
Usually modality specific
Can copy pictures, but
cannot draw from memory
Identification of line drawing
or picture of an object is
more difficult than
identification of actual object
Left hemisphere lesions
most frequent cause
VISUAL SPATIAL NEGLECT***
Failure to respond, report
or attend to stimuli or
events in the hemifield
contralateral to brain injury
Damage usually temporal-
parietal***
Can occur with either L or
R hem strokes
Usually involves neglect of
personal or body space
Anosognosia (unawareness
of deficit) common in
neglect
Classification of seizure types
Tonic - muscle rigidity
Clonic - uncontrolled jerking
Focal- focused
Generalised - unspecific
Focal seizures with awareness
retained (formerly Simple partial seizures)
Focal seizures with impaired awareness
(formerly complex partial seizures)
