Test 5: Personality, Schizophrenia, and Neurocognitive Disorders Flashcards
What are the three personality disorder clusters? And the disorders?
A) Odd or eccentric: Paranoid, schizoid, schizotypal
B) Dramatic or erratic (emotional): antisocial, borderline, histrionic, narcissistic
C) Anxious or fearful: avoidant, dependent, obsessive-compulsive
What are the statistics of personality disorders?
- Prevalence: ~1% general population
- Origins: thought to begin in childhood
- Course: Chronic if untreated, may transition into a different personality disorder
- Comorbidity: its the rule not the exception
What are the statistics concerning gender for personality disorders?
More common traits:
- Men: aggression and detachment
- Women: submission and insecurity
More common disorders:
- Men: antisocial
- Women: histrionic
What are the personality disorders under study?
- Sadistic: enjoy inflicting pain
- Passive-aggressive: defiant, undermine authority
What are the clinical features of paranoid personality disorder?
- Pervasive and unjustified mistrust and suspicion
- Few meaningful relationships, sensitive to criticism
- Poor quality of life
What are the causes of paranoid personality disorder?
- Not well understood, may involve early learning that people and the world are dangerous or deceptive
- More often found in people with experiences: prisoners, refugees, people with hearing impairments, older adults
What are the treatment options for paranoid personality disorder?
- Few seek professional help on their own
- Focus: development of trust
- Cognitive therapy to counter negativistic thinking
- Lack of good outcome studies
What are the clinical features of schizoid personality disorder?
Pervasive pattern of detachment from social relationships
- Very limited range of emotions in interpersonal situations
- Resembles autism
What are the causes of schizoid personality disorder?
- Etiology unclear (scarce research)
- Childhood shyness or abuse/neglect
What are the treatment options for schizoid personality disorder?
- Few seek professional help on their own
- Focus: value of interpersonal relationships
- Building empathy and social skills
- Lack of good outcome studies
What are the clinical features of schizotypal personality disorder?
- Behaviors and dress is odd and unusual
- socially isolated and highly suspicious
- Magical thinking (superstitious), ideas of reference, and illusions
- Many meet criteria for major depression
- Some conceptualize this as resembling a milder form of schizophrenia
What are the treatment options for schizotypal personality disorder?
- Address comorbid depression (on 30-50% pts)
- Main focus on developing social skills
- Medical treatment is similar to that used for schizophrenia
- treatment prognosis generally poor
What are the clinical features of antisocial personality disorder?
- failure to comply with social norms
- violation of the rights of others
- irresponsible, impulsive, and deceitful
- lack of conscience, empathy, and remorse
- “sociopathy,” “psychopathy” typically refer to this disorder or very similar traits
- charming, interpersonally manipulative
- substance abuse common, 60% diagnosed abuse various substances
What are potential causes of antisocial personality disorder?
- early histories of behavioral problems including conduct disorder
- “callous-unemotional” type of conduct disorder more likely to evolve into antisocial PD
- families with inconsistent parental discipline and support
- families often have histories of criminal and violent behavior
What are neurobiological contributions to antisocial personality?
- Underarousal hypothesis: cortical arousal in too low - so seek stimulation from activities too fearful or aversive for most
- Cortical immaturity hypothesis: cerebral cortex is not fully developed
- Fearlessness hypothesis: fail to respond to danger cues
– Psychopaths less likely to give up when goal becomes unattainable - Gray’s model: inhibition signals are outweighed by rewards signals
What might contribute to the development of antisocial personality?
- Genetic influences: history of antisocial behavior or criminality in parents
- Developmental influences: high-conflict childhood (in at risk children)
- Impaired fear conditioning: children not learn to fear aversive consequences of negative actions
- Biological-environmental: early antisocial behavior alienates peers who would be role models, antisocial behavior and family stress mutually increase one another
What are potential treatment options for 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 (selfish) consequences
What are the clinical features of borderline personality disorder?
- unstable moods, behaviors, and relationships
- impulsivity, depression, fear of abandonment, very poor self-image
- self-mutilation and suicidal gestures
- comorbidity rates are high with other mental disorders, particularly mood disorders
What are the rates of comorbid disorders with borderline personality disorder?
- 1 in 5: depressed (suicide attempts - 6%)
- 2 in 5: bipolar criteria
- 2 in 3: substance abuse
- eating disorders: 25% bulimia pts have borderline PD
What are the causes of borderline personality disorder?
- strong genetic component: also linked to depression genetically
- high emotional reactivity may be inherited
- may have impaired functioning of limbic system
- early trauma/abuse increase risk
- high shame, low self-esteem
What is the triple vulnerability for borderline personality disorder?
- generalized biological vulnerability: reactivity
- generalized psychological vulnerability: lash out when threatened
- specific psychological vulnerability: stressors that elicit borderline behavior
What are the treatment options for borderline personality disorder?
- few good outcome studies
- antidepressant medications: short-term relief
- dialectical behavior therapy: most promising focusing on
– dual reality of accepting difficulties and need for change
– interpersonal effectiveness - distress tolerance to decrease reckless/self-harming behavior
What are the causes of histrionic personality disorder?
- etiology unknown due to lack of research
- often co-occurs with antisocial PD feminine variant of antisocial trait?
What are the clinical features of histrionic personality disorder?
- overly dramatic and sensational
- sexually provocative (may be)
- impulsive and needs to be center of attention: manipulative (often)
- thinking and emotions perceived as shallow
- more commonly diagnosed in females
What are the treatment options for histrionic personality disorder?
- Focus on attention seeking and long-term negative consequences
- Targets may also include problematic interpersonal behavirors
- Little evidence that treatment is effective
What are the clinical features of narcissistic personality disorder?
- Exaggerated and unreasonable sense of self-importance
- Preoccupation with receiving attention
- Lack sensitivity and compassion for others
- High sensitivity to criticism; envious and arrogant
What are the causes of narcissistic personality disorder?
- Causes largely unknown
- Failure learn empathy as child
- sociological view: product of “me” generation
What are the treatment options for narcissistic personality disorder?
- Focus on grandiosity, lack of empathy, unrealistic thinking
- Emphasize realistic goals and coping skills for dealing with criticism
- Little evidence efficacy
What are the clinical features of avoidant personality disorder?
- Extreme sensitivity to others opinions
- Highly avoidant most interpersonal relationships
- Interpersonally anxious and fearful of rejection
- Low self esteem
What are the causes of avoidant personality disorder?
- May be linked to schizophrenia; occurs more often in relatives of people with schizophrenia
- experiences of early rejection
What are the treatments of avoidant personality disorder?
- similar to social phobia
- focus: social skills, entering anxiety-provoking situations, increase social contact
What are the clinical features of dependent personality disorder?
- Reliance on others for major and minor life decisions
- Unreasonable fear of abandonment
- Avoidance of disagreement
- Unable make decision
- Clingy and submissive
Causes of dependent personality disorder?
- Not well understood/poor research
- Linked to early disruptions in learning dependence
What are the treatment options for dependent personality disorder?
- Efficacy treatment is lacking
- Therapy typically progresses gradually due to lack of independence
- Target skills fostering confidence and independence
What are the clinical features of obsessive-compulsive personality disorder?
- Excessive and rigid fixation on doing things the right way
- Highly perfectionistic, orderly emotionally shallow
- Unwilling to delegate
- Difficulty with spontaneity
- Often interpersonal problems
- Obsessions and compulsions are rare
What are the causes of obsessive-compulsive personality disorder?
Not well known, weak genetic contribution
What are the treatments of obsessive-compulsive personality disorder?
- Little data
- Address fears related to the need for orderliness
- Target rumination, procrastination, and feelings of inadequacy
What is psychosis and how does it relate to schizophrenia?
- Psychosis: gross departure from reality
- Schizophrenia: a pervasive type of psychosis characterized by disturbed thought, emotion, and behavior
What are the types of schizophrenia symptoms?
- Positive: “additional”
– active manifestations of abnormal behavior
– distortions or exagerations of normal behavior - Negative: “absence” of normal behavior
- Disorganized: erratic speech, emotions, and behavior
What are the symptoms in the “positive” symptoms cluster?
1) Delusions: “basic feature of madness”
- gross misrepresentations of reality
- most common: of grandeur or persecution
2) Hallucinations:
- experiencing sensory events without environmental input
- Can involve all senses but most common is auditory
- SPECT: neuroimaging shows that in auditory hallucinations the Broca’s area–involved in speech production (broken speech) is active
What are the symptoms in the “negative” symptoms cluster?
Absence or insufficiency of normal behavior
- Avolition (apathy): lack of initiation & persistence
- Alogia: relative absence of speech
- Anhedonia: lack of pleasure, indifference
- Affective flattening: little expressed emotion
What is more concerning avolition?
This person may experience
- no eye contact in conversation
- limited/halted speech
- stops participating in events or gatherings & no enthusiasm in special occasions/events
- avoids making or receiving phone calls
- trouble starting/completing projects
- fails to make appointments (Dr, tax preparer)
What are the symptoms in the “Disorganized” symptom cluster?
Confused or abnormal
1) Speech
- cognitive slippage: illogical & incoherent speech
- tangentiality: “going off on a tangent”
- loose associations: conversation in unrelated directions
2) Affect:
- inappropriate emotional behavior
3) Behavior:
- variety of unusual behaviors
- Catatonia
What is catatonia?
- immobility or agitated excitement
- considered its own disorder or as a symptom when comorbid
- stuporous (retarded) catatonia:
– Stupor: immobility during which people may hold rigid poses
– Mutism: inability to speak as well
– Waxy flexibility: maintain positions after being placed in them by someone else
– Mimicking: maybe partial and they may repeat meaningless phrases or speak only to repeat what someone else says
– Stereotypy: stereotyped, repetitive movements - Excited catatonia: bizarre, non-goal directed hyperactivity and impulsiveness
- severe and quite rare
What were the subtypes of schizophrenia?
- Previously divided based on content of psychosis
- No longer used
- Included: paranoid, catatonic, residual (minor symptoms persist after past episode), disorganized (many disorganized symptoms) and undifferentiated
What is schizophreniform disorder?
- Psychotic symptoms 1-6 months (>6 mo schizophrenia)
- Associated with relatively good functioning
- Most resume normal life
- Lifetime prevalence: ~0.2%
What is schizoaffective disorder?
- Symptoms of schizophrenia and major mood episode
- Psychotic symptoms occur outside mood disturbance as well
- Prognosis similar to schizophrenia
- No not tend to get better on own
What is delusional disorder?
Key feature: delusions contrary to reality
- lack positive and negative symptoms
- Types:
1) Erotomanic: someone higher is in love or attracted to you
2) Grandiose: they are someone other than who they are (supernatural/celebrity)
3) Jealous: sexual partner is unfaithful
4) Persecutory: they or someone close to them are being mistreated / spied on
5) Somatic: believing bones are glass
- Better prognosis than schizophrenia
- Very rare: 26-60/100,000
- Later onset: 35-55
- Somewhat more common in females (55%)
What is the psychotic disorders due to other causes?
- Psychosis resulting from substance use, medications, or medical conditions
- Knowing the cause is important for treatment of the underlying cause
- Includes:
1) substance/medication-induced psychotic disorder
2) psychotic disorder associated with another medical condition
What is the brief psychotic disorder?
- positive or disorganized symptoms
- lasting less than 1 month
- briefest duration of all psychotic disorders
- typically precipitated by trauma or stress
What is the attenuated psychosis syndrome?
- attenuate = debilitate
- a condition in need of further study
- individuals at high risk for developing schizophrenia or beginning to show signs of schizophrenia
- intention: focus attention on those benefit early intervention
- tend have good insight into own symptoms
What are the prevalence, onset, and life expectancy statistics of schizophrenia?
- Prevalence: 0.2- 1.5% worldwide population
- Onset: often early adulthood (but can develop at any time)
– childhood cases extremely rare but not unheard of
– chronic (generally): moderate-to-severe lifetime impairment - Life expectancy: slightly less than average: increased risk suicide and accidents, self care may be poorer
What are the gender and cultural facture statistics of schizophrenia?
- Affects men and women equally
– Females: better longer long-term prognosis
– Males; slightly earlier onset - Cultural factors: psychotic behaviors not always pathologized, found in similar rates in all cultures
What is the course of schizophrenia?
Prodromal phase (initial symptoms)
- 85% experience
- 1-2yrs before serious symptoms
- less severe, yet unusual symptoms:
– ideas of reference, magical thinking, illusions, isolation, marked impairment in functioning, lack of initiative/interests/energy
What does the research indicate about the causes of schizophrenia?
- Can be inherited: greater risk the closer the family member with schizophrenia
- Healthy environment is a protective factor
What is the dopamine hypothesis of the neurobiological influences of what causes schizophrenia?
Partially caused by overactive dopamine
- Evidence: dopamine agonists (inc) result in schizophrenic-like behavior, antagonists (dec) reduces behavior (neuroleptics, L-Dopa)
- Problem: many neurotransmitters are likely involved
What are the neurobiological influences other than the dopamine hypothesis of what causes schizophrenia?
1) Structural and functional abnormalities in the brain:
- Enlarged ventricles, reduced tissue volume
- Hypofrontality: less active frontal lobes (major dopamine pathway)
2) Viral infections: influenza epidemics during prenatal development (inconclusive)
3) Marijuana: increase risk in at-risk
*Conclusions: reflects diffuse neurobiological dysregulation, but structural and functional brain abnormalities are not unique to schizophrenia
What are the psychological and social influences on schizophrenia?
- Stress: (may) activate underlying vulnerability, increase risk of relapse
- Family interactions: High expressed emotion (EE)–criticism, hostility, and emotional over-involvement/intrusiveness–associated with relapse
What is the medical treatment of schizophrenia?
- Historical: generally ineffective & barbaric: insulin coma induction, psychosurgery, ECT
- Antipsychotic (neuroleptic) medications: 1950s,
– first line treatment
– most reduce/eliminate positive symptoms,
– primarily affect dopamine system but also serotonergic & glutamate - Experimental: Transcranial Magnetic Stimulation (block auditory hallucinations)
What are the common side effects of antipsychotic medications?
DRYNESS
- blurred vision
- dry mouth
- constipation
- drowsiness
- muscle spasms/tremors
- weight gain
What are the development and aspects of antipsychotic medications?
1) first generation medications: acute & permanent side effects are common
- Parkinson’s-like side effects
- Tardive dyskinesia: involuntary movements (face, mouth, hands, etc)
- Problematic compliance (aversion to side effects, finances, dr relationship)
- Injectable antipsychotics may improve compliance
2) Second generation/ atypical psychotics
- may help pts unresponsive to other meds
What was the historical precursors and current psychosocial treatment of schizophrenia?
- Historical: psychodynamic therapy - NOT effective
- Psychosocial approaches
– Behavioral on inpatient units: reward adaptive behavior (self-care & socialization)
– community care programs
– social and living skills training
– behavioral family therapy
– vocational rehabilitation
What is the illness management and recovery psychosocial treatment of schizophrenia?
- Engages pt as active participant in care
- Continuous goal setting and tracking
- Modules: social skills training, stress management, substance use
- Individual social skills training and family interventions reduce schizophrenic relapses (high EE)
What are the cultural considerations for psychosocial treatment of schizophrenia?
- Consider cultural factors that influence individuals’ understanding of own illness (supernatural beliefs)
- Involve family and community as possible
What is the prevention psychosocial treatment of schizophrenia?
- identify at risk children (relatives)
- foster supportive, stable environments
- offer additional treatments at prodromal stages, including social skills training
What are neurocognitive disorders and what are the three types?
- Affected learning, memory, and consciousness
- Most develop later in life
Types:
1) Delirium: temporary confusion and disorientation
2) Mild neurocognitive disorder: early stages of cognitive decline
3) Major neurocognitive disorder: broad cognitive deterioration affecting multiple domains
How has the DSM perspective changed concerning neurocognitive disorders?
- From “organic” mental disorders to “cognitive” disorders
- Broad impairments in cognitive functioning
- Cause profound changes in behavior and personality (what makes these general medical conditions often best treated by mental health professionals)
What is the nature of delirium?
- Central features: impaired conscientiousness and cognition
- Onset: Develops rapidly (hrs, days)
- Appear confused, disoriented and inattentive
- Marked memory and language deficits
What are the facts and statistics of delirium?
- Up to 20% adults in acute care facilities
- Greater prevalence: older adults, undergoing medical procedures, AIDS & Cancer patients
- Full recovery often within several weeks
What are the medical conditions or causes of delirium?
- Dementia (50% involve temporary delirium)
- Head injury/brain trauma
- Infections (UTI)
- Drug intolerance/withdrawal
- Poisons
- Immobility
- Excessive stress
- Sleep deprivation
What are treatment and prevention options for delirium?
- Treatment:
– attention to precipitating medical problems
– psychosocial interventions: reassurance/comfort, coping strategies, inclusion of pts in treatment decisions - Prevention:
– address proper medical care for illness, and proper use and adherence to therapeutic drugs
What is the nature of major and mild neurocognitive disorders?
- Gradual deterioration of brain functioning: judgement, memory, language, advanced cognitive processes
- Has many causes and may be irreversible
What is the difference between major and mild neurocognitive disorders?
- Major: new DSM-5 term for dementia
– 1+ cognitive deficits that represent a decrease from previous functioning
– substantiated by clinical assessment
– interfere with daily independent activities - Mild: New DSM-5 classification for early stages of cognitive decline: able to function independently with some accommodations
What is the prevalence and statistics of major neurocognitive disorders?
- New case every 7 seconds
- 65+: 5%, 85+: 20%
- Mild: 70+, 10%
What are the initial stages of major neurocognitive disorder?
- memory and visuospatial skills impairments
- Facial agnosia: inability to recognize familiar faces (aka prosopagnosia/facial blindness)
- Other symptoms: delusions, apathy, depression, agitation, aggression
What are the later stages of major neurocognitive disorder?
- Cognitive function continues to deteriorate
- Total support needed for daily activities
- Increased risk of early death because of inactivity and other illnesses
What are the causes of neurocognitive disorders?
- Frontotemporal
- Vascular
- With Lewy bodies
- Substance/medication induced
- Unspecified
Due to: - TBI
- HIV infection
- Another medical condition
- Multiple etiologies
- Alzheimer’s Disease
- Prion disease
- Parkinson’s Disease
- Huntington’s disease
What are the clinical features of neurocognitive disorder due to Alzheimer’s disease?
- Nearly half of neurocognitive disorders
- Gradual and steady development (typically)
- Memory, orientation, judgment, and reasoning deficits
- Additional symptoms: agitation, confusion, combativeness, depression, anxiety
- Definitive diagnosis only by autopsy
What is the nature and progression of Alzheimer’s? (Survival, onset)
- Early and later stages: slow
- During middle stages: rapid
(“Nun study” - analysis of nun’ journal writing over many years shows pattens of deterioration) - Post-diagnosis survival: 8 yrs
- Onset: 60s/70s (“early onset” = 40s & 50s)
What is the prevalence of Alzheimer’s disease?
- 5 million Americans, several million worldwide
- more common in less educated individuals
– more educated declines more rapidly after onset
– suggests education provides a buffer period of better initial coping - slightly more common in women:
– possibly estrogen is protective
What are the extent of deficits in Alzheimer’s Disorder?
- Aphasia: difficulty with language
- Apraxia: impaired motor functioning
- Agnosia: failure to recognize objects
- Difficulties with: planning, organizing, sequencing, abstracting information
- Negative impact on social and occupational functioning
What are the aspects of the vascular neurocognitive disorder?
- Cause: blockage/damage to blood vessels
- 2nd leading cause of neurocognitive disorder
- Onset: sudden (ie stroke)
- Variable patterns of impairment
- Most require formal care in later stages
- Cognitive disturbances
- Obvious neurological signs brain tissue damage
- Prevalence: 70-75, 1.5% 80+, 15%
- Risk slightly higher in men
What are the aspects of frontotemporal neurocognitive disorder?
- Damage to frontal or temporal regions of the brain: personality, language, behavior
- 2 Types of Impairment:
1) decline in appropriate behavior
2) declines in language
ie: Pick’s disease: pick bodies/cells inside nerve cells in the damaged areas of the brain
What are the aspects of neurocognitive disorder due to Pick’s disease?
- Rare: 5% all dementia diagnoses
- Cortical dementia like Alzheimer’s
- Early onset: 40s-50s
- Little known about cause
What are the aspects of neurocognitive disorder due to traumatic brain injury?
- Leading cause: accidents
- Symptoms at least 1 week after injury including executive functioning, learning, memory- most common
- ie athletes experiencing repeated head blows
What are the aspects of neurocognitive disorder due to Lewy Body Disease?
- Lewy body: microscopic protein deposits that damage brain over time
- Onset: gradual
– impaired attention/alertness, visual hallucinations, motor impairment
What are the aspects of neurocognitive disorder due to Parkinson’s Disease?
- Degenerative brain disorder
- Dopamine pathway damage
- 1/1,000 worldwide
- Chief difficulty: motor problems - tremors, posture, walking, speech
- Not all with PD develop dementia
- 75% survive 10+ yrs after diagnosis -
What are the aspects of neurocognitive disorder due to HIV infection?
HIV-1 can cause neurological impairments and dementia in some individuals
- cognitive slowness, impaired attention, & forgetfulness
- apathy & social withdrawal
- typically occurs in later disease stages
- now occurs in <10% of individuals with HIV; because HAART (highly active, antiretroviral therapies) decrease risk
What are the aspects of neurocognitive disorder due to Prion disease?
- Misfolded protein sin the brain that reproduce and cause damage
- No known treatment, always fatal
- Can only be acquired though cannibalism or accidental transmission (blood transfusion)
- ie: Creutzfeldt-Jakob disease
– 1/1M - eating nerve tissue of mad cow diseased cows
- MCD: slowly destroys brain and spinal cord of in cattle (Bovine Spongiform Encephalopathy)
What are the aspects of substance/medication-induced neurocognitive disorder?
- Prolonged drug use, especially in combination with poor diet
- May be caused by alcohol, sedative, hypnotic, anxiolytic, or inhalant drugs
- Brain damage may be permanent
- Symptoms similar to Alzheimer’s
– memory impairment, aphasia, apraxia, agnosia, disturbed executive functioning
What are the brain features of Alzheimer’s disease?
- Neurofibrillary tangles (strandlike filaments)
- Amyloid plaques (gummy protein deposits between neurons)
- Atrophy
What are the biological processes and genetic Factors of Alzheimer’s Disease?
- Many preliminary findings that need further research
- Genes: Chromosome 21,19 (late onset), 14 (early onset), and 12
- Deterministic genes: rare & inevitable (Beta-amyloid precursor gene, Presenilin-1 and -2 genes)
- Susceptibility genes: more likely but not certain to develop Alzheimer’s
What is an example of a susceptibility gene for Alzheimer’s disease?
ApoE4 gene
- chromosome 19
- late onset
- More prevalent in those with family history of Alzheimer’s
- More likely to produce cognitive decline in the context of a stressful environment
What are the contributing psychosocial factors in Neurocognitive Disorders?
- Psychological and psychosocial factors do not cause dementia directly but they may influence onset and course
- Lifestyle factors: drug use, diet, exercise, stress
- Environmental stressors: repeated head trauma
- Cultural factors: ethnicity and lower SES
- Educational attainment, coping skills social support
What are the general facts about medical treatments for neurocognitive disorders?
- Few primary treatments exist
- Most attempt to slow progression of deterioration, but cannot stop it
- Most not effective because we have no way to replace extensive brain damage
What are specific medical treatments for neurocognitive disorders?
- Future: glial cell-derived neurotropic factors, stem cells: may slow deterioration, vaccines
- Some drugs target cognitive deficits:
– Cholinesterase-inhibitors: Aricept, Exelon, Reminyl
– long-term effects not well demonstrated - Exploratory: Ginkgo biloba to improve memory (findings mixed)
- Associated symptoms: SSRIs (depression/anxiety), antipsychotics (agitation)
- All: only modestly effective, short periods
What are the effects of medical treatments of neurocognitive disorders?
- Any gains in a person’s abilities are only temporary
- Any improvement is to 6 months prior
- Many patients discontinue medications because of expense or severe side effects
What are the psychosocial treatments of neurocognitive disorders?
Aim:
- enhance lives of patients and families
- teach compensatory skills
- memory enhancement devices (memory wallets with statements about ones life)
*Cognitive stimulation can delay onset of more severe symptoms
What are the psychosocial treatments for caregivers of neurocognitive disorders?
- Instructions on how to handle problematic behavior: wandering, socially inappropriate behaviors, aggressive or rebellious behaviors
- Treatment of mental health due to stress
What are prevention measures for neurocognitive disorders?
- Reduce risk in older adults:
– use anti-inflammatory medications
– control blood pressure
– don’t smoke, active social life - Other targets:
– increasing safety behaviors to reduce head trauma
– reduce exposure to neurotoxins and use of drugs
