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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?