Download Psych 451 -2 - Western Washington University

451
My web site and syllabus:
1.
1.
http://myweb.facstaff.wwu.edu/knecht/
2. Topic Questions?
3. Readings on website: three with cancer:
1. Read and come up with a question from each to ask Dr.
Thompson next week. Turn in your 3 questions to me,
either in class on Thursday or by e-mail.
4. For stepping stone project:
1. We’ll meet after class to schedule times
2. www.steppingStonesWhatcom.org
•Dia - gnosis “to know and to distinguish between”
•Purposes of diagnoses:
•To differentiate those with from those without a condition
•To enhance communication – a short hand
•Ensure treatment specificity so a given illness gets the specific treatment
•This assumes disorders are discrete entities that clearly differ from
one another
Most Psychiatric Diagnoses differ from Medical diagnoses:
• More of social process –
• Fashionable diagnoses come and go
• Anxiety State decreased, depression and phobia increased
• More social consequences – stigma, discrimination
• More culturally determined
 Culture Bound syndromes such as
 Amuk
Pibloktog
 Anorexia Nervosa
Kayak Angst
 Koro
Personality Disorders
 Taijin kyofu sho
Factitious Disorders

• Few definitive or independent tests to confirm dx
Psychiatric diagnoses are mostly
syndromes
 Signs (observable) and symptoms (reported) that tend
to be seen together.
 Gr. “Run together”
 Used when no clear pathophysiological basis has been
defined or identified to explain its occurrence.
 Compare Generalized Anxiety Disorder with H1N1
Reliability and validity of Psychiatric Diagnosis
 Specificity and sensitivity:
 Sensitivity – does it include all “real” cases as well as
non-cases (false positives)
 Specificity: Does it only include “real” cases and reject
all non-cases ( but also some false negatives)
Study: 168 consecutive admissions to mental hospital
 Schizophrenia
Criteria sets
 NHSI
 DSM-III
 RDC
 Feigner
 Taylor-Abrams
rxx
# Sz
.97
.80
.90
.84
.65
44
19
17
12
6
 Who is schizophrenic depends on which set of criteria
you use?
 Which set would you use to study Sz? Why?
Criterion creep makes it fuzzy DSM-V
 Veteran’s Administration is currently suggesting changes
in PTSD diagnostic criterion A (stressor) for vets to read
as follows:
 ``a veteran experienced, witnessed, or was confronted with an event or
circumstance that involved actual or threatened death or serious injury, or a threat
to the physical integrity of the veteran or others, such as from an actual or potential
improvised explosive device; vehicle-imbedded explosive device; incoming
artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper
fire; or attack upon friendly military aircraft, and the veteran's response to the
event or circumstance involved a psychological or psycho-physiological state of
fear, helplessness, or horror.'' A claimed stressor must be consistent with the places,
types, and circumstances of the veteran's service.“
 If you show up in a war zone, you meet criterion A.
 What would this change do to Specificity? Sensitivity?
How best to characterize Mental disorder
 Classical Categorical
 E. Kraepelin - 19th C


Sz and manic Depression were discrete entities
Each with a specific etiology
 Dimensional
 Based on psychological measurement


Sx vary by degree from 0 to …100.. e.g. negative affectivity
Continuum of symptom presence and severity
 Prototypical
 Describe a prototype
 Determine essential criteria
 Allow polythetic criteria
 Accept blurred boundries
. SCHIZOPHRENIA polythetic Diagnosis
 A. TWO OR MORE OF:

1. DELUSIONS
 2. HALLUCINATIONS
 3. DISORGANIZED SPEECH (Derailment,
incoherence)
 4. GROSSLY DISORGANIZED OR CATATONIC
BEHAVIOR
 5 . NEGATIVE SYMPTOMS

- Flattened affect, alogia, avolition
 Only on of 1 or 2 if bizzare

 B. SOCIAL/OCCUPATIONAL DYSFUNCTION



1. SOCIAL, INTERPERSONAL
2. OCCUPATIONAL
3. SELF-CARE
 C, DURATION OF AT LEAST 6 MONTHS
 D. EXCLUDE SCHIZOAFFECTIVE AND MOOD
DISORDERS
 E. NOT DUE TO SUBSTANCE ABUSE OR MEDICAL
CONDITION
Where are there boundaries between disorders
Example: Sz & Bipolar
 Sz
………………………………………….. Bipolar I and II
Cyclothymia
 Schizoaffective ………………………. Unipolar Depression
- dysthymia
 Personality Disorders
 Schizotypy
 Schizoid
 Paranoid
 Schizophrenia Spectrum disorders …
Proliferation of diagnostic categories
 What does this mean?
 1918
- 59
 DSM-I –1952
- 106
 DSM-II 1968
- 182
 DSM-III 1980
- 265
 DSM-III R 1987
-292
 DSM-IV 1994 -357
• Five criteria to evaluate a given Diagnosis – rooted in medicine
1. Describe a set of symptoms for Communication
2. Suggest pathophysiology –
• cause or conditions associated with its occurrence
3. Suggest a specific treatment plan to address cause
4. Predict outcome - prognosis
5. Predict long term sequelae
• How should we think of Diagnoses?
• An entity?
• A social construction?
• Convenient construct?
•
Are they useful?
• Reification of psychiatric Diagnoses
• Don’t label the person
Mediating Mechanisms
 How do we get from mental distress (Dx) to physical
systems breaking down or being damaged?
 Or from physical disorders or systems malfunctioning to
cause specific mental/emotional disorder?
 Several Systems:
 Autonomic Nervous System -sympatho-adrenao-medullary

SAM
 Hypothalamic – Pituitary – Adrenocortical Axis : HPA
 Neurotransmitter systems and pathways
 Neuroanatomical structures
Autonomic Nervous System:
 Sympathetic division
 Active defense system
 – fight or flight – activation adrenaline/epinepherine,
norepinepherine –
 depletion of energy resources
 Parasympathetic division Conservation, withdrawal, build up of energy resources
and healing – Acetylcholine
 When functioning properly together they promote
Homeostasis among bodily systems when in balance
ANS
Examples of disorders that could
involve SNS activation or dysregulation?
Examples of disorders
 - CHD Hostility
 Surges of adrenalin
 Arterial tears – plaques attach
 blood clots more readily
 GAD .. Chronic Gastric distress
 Asthma attacks:
 SNS activation in strong emotion can trigger attacks.
SAM and HPA-C axis
CRF/H
Hypothalamic – pituitary – Adrenocortical Axis - HPA
 Stress perceived –
 Hypothalamus - Corticotropin Releasing factor (CRF/H)
 CRF goes to anterior Pituitary – Adreno-corticotropic




Hormone (ACTH)
ACTH cortex of the Adrenal gland – Cortisol
Into blood system to organs
Feeds backs to hypothalamus to regulate production
Cortisol had many effects on body

Good in short term, bad in long term activation
Paraventricular
Hypothalamus
Anterior pituitary
Negative Feedback to hypothalamus
Adrenal cortex
cortisol
Long term Corticosteroids
 Affects viability of immune function, reduces it
 High blood pressure
 Possible atrophy of hippocampus
 Memory difficulties
 The HPA axis neurobiology of mood disorders, anxiety
disorder, bipolar disorder, insomnia, post-traumatic
stress disorder, borderline personality disorder,
ADHD, major depressive disorder, burnout, chronic
fatigue syndrome, fibromyalgia, irritable bowel
syndrome, and alcoholism.[1]
 Antidepressants, routinely prescribed for many of
these illnesses, serve to regulate HPA axis function.[2]
Hypothisized relationships
depression
normal
Ptsd
Neurotransmitters associated with
various diagnoses
 Dopanergic: Schizophrenia, substance abuse,
Bipolar mania
 Noradrenergic: Depression, mania
 Serotonergic: depression, OCD, schizophrenia
 Gabanergic: Anxiety disorders
Neurotransmitter systems regulation and
dysregulation - malfunction
Neuroanatomical areas associated
with certain diagnoses
Basal ganglia
– cognition, emotion, motor activity
Brain Areas mediating OCD
 Thought to be “locked in unison” during disorder
Orbito-frontal cortex – error detection
2. Caudate Nucleus
1.
1.
– regulate “worry” between thalamus and frontal cortex
hyperactive
2.
-SSRI reduces CN activity
Cingulate gyrus : “something is deadly wrong” (surgery)
4. Releases “Fixed Action Patterns”
3.
1.
2.
3.
territoriality (checking).
Mating (urges),
Washing
Caudate nucleus
Neuroanatomy of OCD ??
 Straddling the fence between cognition and emotion,








Anterior Caudate has been suggested to be involved in the
pathophysiology of :
attention deficit/hyperactivity disorder (Bush et al., 1999),
post-traumatic stress disorder (Shin et al., in press),
depression ( Drevets, 2001; Davidson et al., in press),
obsessive-compulsive disorder (Jenike et al., 1991),
schizophrenia,
bipolar disorder,
panic disorder,
Tourette’s Syndrome (Benes, 1993), and Alzheimer’s Disease
(Vogt et al., 1997).
Neuroanatomical sites of Alzheimer‘s
Disease deterioration
Anatomical regions use certain
neurotransmitters
 Serotonin pathways
 Norepinepherine pathways
 Dopamine pathways
Genetics
 Many disorders have some genetic contributions to
etiology
 How would that work?
Multiple causation – Diathesis Stress
Schizophrenia:
 Factors in order of predictive power
 Cotwin Sz
50
 Parent Sz
13
 Sibling Sz
9.6
 Premorbid pers.
 EP P50
 Continuous prefor.
 Eye tracking
 Hippocampal volume
 Obstetric complication
 Stressful life events
 Maternal influenza
PTSD: Diatheses/correlates
 Given a life threatening trauma, what predicts PTSD?
 Social support network
 Negative affect/neuroticism
 Poor coping skills
 Prior traumas
 Lower IQ
 Nature of the stressor
 Perceived controllability
Fear Circuitry - J. LeDoux
Peripheral NS
CNS
SNS
Others?