Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download WELCOME TO Abnormal Psychology - Buffalo State College Faculty
Document related concepts
Substance use disorder wikipedia , lookup
Mental disorder wikipedia , lookup
History of psychiatry wikipedia , lookup
Sexual dysfunction wikipedia , lookup
Schizophrenia wikipedia , lookup
Glossary of psychiatry wikipedia , lookup
Controversy surrounding psychiatry wikipedia , lookup
Postpartum depression wikipedia , lookup
Major depressive disorder wikipedia , lookup
Mental status examination wikipedia , lookup
Narcissistic personality disorder wikipedia , lookup
Separation anxiety disorder wikipedia , lookup
Dissociative identity disorder wikipedia , lookup
Generalized anxiety disorder wikipedia , lookup
History of mental disorders wikipedia , lookup
Asperger syndrome wikipedia , lookup
Child psychopathology wikipedia , lookup
Behavioral theories of depression wikipedia , lookup
Causes of mental disorders wikipedia , lookup
Transcript
Jill Norvilitis Is he mentally ill? How do you know? What type of mental illness do you think he has? Incorporates Psychological distress—neither necessary nor sufficient Maladaptive—interferes with our well-being, etc. Statistical abnormality or deviancy Violation of the standards of society Social discomfort Irrationality and unpredictability—dangerous at times Nomenclature—a naming system to structure information allows us to study, assess, and treat Shorthand—like a diagnostic system—leads to a loss of information Stigma—people fear what will happen if they reveal a disorder Stereotyping—automatic beliefs based on knowing one thing about someone Labeling Definition of mental disorders A clinically significant behavioral or psychological syndrome or pattern Associated with distress or disability Not a predictable response to a particular event Considered to reflect behavioral, psychological, or biological dysfunction Epidemiology—study of the distribution of diseases, disorders, etc. Prevalence—point, one-year, lifetime Any disorder in lifetime—46.6 % Incidence Comorbidity 1-year MDD 6.7% Alcohol abuse 3.1 Specific phobia 8.7 Lifetime 16.6% 13.2 12.5 Not dysfunctional Thought processes are not seriously disrupted Fewer emotional problems than general population Characteristics: Nonconformity, creativity, strong curiosity, idealism, happy obsession with hobbies, lifelong awareness of being different, high intelligence, outspokenness, noncompetitiveness, unusual eating and living habits, disinterest in others’ opinions or company, nonmarriage, eldest or only child, poor spelling skills 500,000 yrs ago— trephination Later ancient societies indicate possession Babylonians—Idta—spirit who caused insanity Greek and Roman views and treatments Hippocrates—460-377 BC—denied influence of demons Somatogenesis Plato—Criminally insane shouldn’t be held responsible like others Galen—130-200 AD believed disorders could have either physical causes (injury to the head) or mental causes (stressors) After Hippocrates, treatments included pleasant surroundings, giving patients constant activities Increase in power of the clergy, church rejected scientific forms of investigation. Mass madness: group behavior disorders, apparently hysterical. Peak in 14th-15th centuries. Tarantism Lycanthropy Treatment of mental illness was left to clergy. Return of exorcism. Not generally treated as witches, though this did happen. Agrippa -1486-1588-began to speak out against possession Johan Weyer first physician to specialize in mental illness. 16th cent. On—asylums grew in number Gheel, Belgium—first colony of mental patients 1547—St. Mary’s of Bethlehem Hospital— bound in chains, popular tourist attractions, mildly mentally ill were forced to beg on the streets La Bicetre—Philippe Pinel William Tuke—1732-1822—English Quaker— established York Retreat. Moral management—focused on patient’s social, individual, occupational needs—rehabilitation of character. High degree of effectiveness— Buffalo Psychiatric Center—originally Buffalo State Hospital for the Insane. Proposed by physician White in 1864, first received patients in 1880. Followed Kirkbride Model of connected buildings. Mental hygiene movement—focused on physical well being, not treatment Dorothea Dix—1802-1887—champion of the poor and forgotten in mental institutions and prisons. Two opposing views: somatogenic and psychogenic Mental hospitals in the 20th century Syphilis Over 500,000 by 1950s Deinstitutionalization Thorazine Today about 55,000 in state hospitals Criminalization of the mentally ill. By some estimates, 300,000 inmates, 500,000 on probation 28 % psychologists who were female in 1978 52 % female today 75 % female undergrad psych majors 66 % female psych grad students Retrospective vs. prospective Case studies—begin with Hans Correlational method—can correlations be trusted? Epidemiological studies Longitudinal studies Experimental method Control groups Random assignments Blind designs, placebo treatments Quasi-experimental designs Concerns remain New drug studies without adequate informed consent Placebo studies Symptom-exacerbation studies Medication-withdrawal studies Etiology Necessary—must exist for a disorder to occur Sufficient—condition that guarantees the occurrence of a disorder Contributory—increases the probability of a disorder Time frame Distal—in the past Proximal—immediate Diathesis—vulnerability for the disorder Stress—proximal stressor Protective factors Individual Family Community Resilience Biopsychosocial viewpoint Disease or medical model Brain anatomy and abnormal behavior— 100 billion nerve cells called neurons and thousands of billions of support cells called glia. Bottom of the brain—hindbrain— Cerebellum—regulates smooth coordinated movement Pons Medulla—controls heart rate, breathing, digestion Midbrain Forebrain— Hypothalamus—temperature, hunger, thirst, sex Thalamus— Corpus callosum—connects hemispheres Over 100 neurotransmitters discovered to date Those most studied with psychopathology Norepinephrine—emergency reactions in stressful situations Dopamine—schizophrenia and Parkinson’s Serotonin—thinking and information processing, anxiety and depression Gamma aminobutyric acid (GABA)—anxiety and arousal Neurotransmitter imbalances Excessive production and release of neurotransmitter Dysfunction in deactivation process Problem with receptors—abnormally sensitive or insensitive Genetics Behavior genetics—study of individual differences in beh. that are in part attributable to genetic makeup Family history (pedigree) method—we know what % of genes are shared Genotype Phenotype Twin method Adoption Evolution and abnormal behavior Viral infections Temperament—reactivity and self-regulation Biological treatments Behavioral inhibition seems to be innate Psychotropic medications Electroconvulsive therapy Neurosurgery Assessing the Biological Model Lots of valuable new information Treatments bring great relief Shortcomings— 1) some proponents seem to think that everything can be explained by biological terms 2) lots of evidence is incomplete and inconclusive 3) biological treatments can produce undesirable side effects Freud—very deterministic Structure of the personality: Id—comprised of instinctual drives of two types Ego—secondary process thinking—reality principle Superego—conscience Defense mechanisms—control unacceptable id impulses or reduce the anxiety they create Repression Projection Rationalization Reaction formation Sublimation Psychosexual stages of development Oral—birth to 2 Anal—2-3 Phallic—3 to 5 or 6 Oedipus Electra Latency Genital—After puberty How to tap the unconscious? Advantages of Freud’s theory… 1) Helped establish the field 2) Emphasized the importance of childhood for a healthy adulthood Disadvantages… 1) Hard to Research 2) Largely based on case studies 19 % of clinical psychologists describe themselves as psychodynamic (Prochaska & Norcross, 2003) Of course, Freud created his theory over 100 years ago. There have been major updates: Object relations theory: importance of the caregiver is key Melanie Klein Healthy relationships as infants result in healthy relationships as adults Attachment theory: Bowlby, 1969; Ainsworth, 1978 Secure, ambivalent, avoidant, disorganized (in 4/5 abused kids) Classical conditioning Instrumental conditioning AKA operant conditioning Pavlov Important for fears and anxiety Thorndike Law of effect—behavior that is followed by consequences affects repetition Generalization Discrimination Shaping—successive approximations Observational learning Behavior therapies—systematic desensitization, assertion training, token economy, role playing Can be tested in the laboratory We can show that symptoms can be acquired these ways, but is this the way they are ordinarily acquired? Improvements in therapists’ offices do not always extend to real life, nor do they always last without continued therapy Critics argue that it is too simplistic—no cognitions involved; pts. must develop selfefficacy Schemas Observable behavior can be influenced by mental processes Automatic thoughts Cognitive distortions Attributions Assessing the Cognitive Model 24 % of psychologists identify approach as cognitive Appealing because it focuses on a process unique to humans Lends itself to research Precise role of cognitions (cause or effect) has yet to be determined Narrow—deals only with cognitions, not values, meaning, etc. Family Systems Theory Identified patient Homeostasis Family structures (parents in charge) and alliances (parents united) are often disrupted Communication is also often disrupted Can be enmeshed or disengaged Macrosystem—beliefs and values of the culture Exosystem—social structures like family, neighborhood, SES Mesosystem—interconnections between various community systems like peer groups, religious organization, etc. Microsystem—child’s immediate environment, family, school, work Ontogenic Development—the child’s own development and adaptation Neglect and abuse in the home: Parental Psychopathology Authoritative—energetic/friendly Authoritarian—conflicted/irritable—also moody, eating disorders Permissive/Indulgent—impulsive/aggressive—demanding, immature Neglectful/Uninvolved—low s-e, conduct problems, moody, peer and academic problems Divorce Tiffany Field—transmission of depression, even with those as young as 6 mos. Parenting styles: Disorganized and disoriented attachment Problems in all domains 1/3 will go on to repeat the trauma Ongoing stressor—not just one Most (3/4) will be fine But…2x as likely to repeat a grade, report more delinquency, more negative health stuff like smoking, more depression Poverty! Peer Relationships Deviancy training Rejected, neglected, controversial, accepted—neglect is particularly negative Universal vs. culture-specific Schizophrenia—different presentation, more paranoia in Western cultures, also more negative outcome Depression—universal, but different presentation— more somatic in China, for instance Overcontrolled vs. undercontrolled behavior—more under in US, over in Thailand (Weisz et al, 1993) Culture bound syndromes Intake interview— History of present problem Thorough personal and family history Social context Structured vs. unstructured Physical assessment General exam Neurological exam for neurological disorders. For example, may want an EEG if there are memory deficits, etc. Variety of sources in assessment Reliability—consistency or agreement among assessment data Validity—does it measure what it is supposed to measure Test-retest Internal consistency Interrater Content validity—all domains that is supposed to measure Predictive validity Concurrent validity Diagnostic errors—true positives, true negatives, false positives (Type 1), false negatives (Type 2) Sensitivity—correctly diagnose someone with any disorder Specificity—likelihood that people without disorder will be diagnosed that way Life records—school, police, hospital Interviews Observation Psychological tests Standardized Normed Several subtypes: Rating Scales (specific vs. broad) Intelligence Tests WISC-IV, WAIS-III, Stanford-Binet Neuropsychological testing—measure deficits in behavior, cognition, or emotion that correlate with brain damage Personality Tests Projective—Ambiguous stimuli that allow for individual responses Rorschach TAT/RAT Draw A Person Objective MMPI-2 Revised in 1989, first ed. in 1943 (10 clinical scales, + validity scales and special scales 1) Potential for cultural bias of the instrument or clinician 2) Theoretical orientation of clinician 3) Underemphasis on the external situation 4) Insufficient validation 5) Inaccurate data or premature evaluation Efforts go back thousands of years Scientific efforts in 19th century Emil Kraepelin—3 categories—dementia praecox (schizophrenia), manic-depressive psychosis, & organic brain disorders (delirium, dementia, amnestic) 1917—1st American system, didn’t work 30s and 40s—military developed system 1948—Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death—now on ICD 10 1952--Diagnostic and Statistical Manual of Mental Disorders Then DSM-II-in 1968 DSM-III in 1980, III-R in 1987, IV in 1994, TR in 2000 DSM I and II lacked consistency, some criteria were based on theories of causation, others on clusters of sx, little effect on tx Multiaxial Clearly defined diagnostic criteria, Operationally (not theoretically) defined diagnosis 5 Axes I—Major mental disorders II-Developmental and personality disorders III-General medical conditions that affect disorders IV-Psychosocial stressors—topical, labeled acute or chronic V-Global assessment of functioning Polythetic approach—must have some # of criteria out of a larger group Comorbidity Labeling produces stereotypes, prejudices, and harm Self-fulfilling prophecies Gender/ethnic bias— Rosenhan (1973)—voices saying thud, empty, or hollow; kept 7-52 days Antisocial PD more often diagnosed in men, histrionic in women In a study with randomly assigned gender to APD or HPD criteria, psychologists underdiagnosed women with APD and men with HPD People are more likely to diagnose others like themselves with less severe diagnoses, those not like them get more severe diagnoses Disorders are on a continuum, not discrete categories Why do we use categorical? Medical model Easy No one agrees on personality dimensions Not enough attention to validity From Opinion Research Corporation, 2004 67% Am. would not tell their employer that they were seeking mental health treatment 51% would hesitate to see a psychotherapist if a diagnosis were required 41% believe they should be able to handle psychological problems on their own 37% would be reluctant to seek tx because of confidentiality concerns 33% would not seek counseling for fear of being labeled mentally ill 1935 Egaz Moniz—prefrontal leucotomy/lobotomy Won the 1949 Nobel Prize in medicine Originally 18 patients, 6 cured, 6 improved, 6 same. Idea took off. Freeman and Watts—frontal lobotomy—cutting into side of skull and then pivoted Transorbital lobotomy— In 20 yrs, 40,000 pts had lobotomies Side effects—seizures, incontinence, poor judgment, lack of motivation, lethargy, impaired thinking, 5 % died All surgeries were blind 2 procedures are done today. Cingulotomy and stereotaxic subcaudate tractotomy Convulsions to treat mental illness date back to Paracelsus (1493-1591) Today, use of electro shock dates to 1938 Bilateral vs. unilateral About 100,000 per year Injuries in 1/1400 tx Post tx side effects—temporary memory loss, h/a, confusion Used for severe mood disorders—about 80% are severely depressed Antipsychotics—aka major tranquilizers, neuroleptics 60-80% show some improvement Thorazine-1955, Haldol-1960s—less sedation Side effects—extrapyramidal symptoms—Parkinsonism— shuffling gate, tremor, muscular weakness, rigidity Tardive dyskinesia—jerks, tics, twitches of the face and tongue—doesn’t appear for several years and is permanent Atypical antipsychotic—developed in 1980s and beyond—first Clozaril, now Risperdal, Abilify, Geodon, Zyprexa, Seraquel Newer meds are better at treating negative symptoms Side effects—weight gain, drooling, agranulocytosis (drop in white blood cells) Monamine oxidase inhibitors—Parnate, Marplan—dev. as tx for TB, but people became less depressed Tricyclics—Tofranil, Elavil, Anafranil, Pamelor -slow activity of serotonin and norepinphine -work well, but decreases REM sleep, can’t eat foods with tyramine Fewer serious side effects but—fatal in overdose SSRIs—1988-Prozac—most widely prescribed antidepressant in the world, others include Zoloft, Paxil, Celexa, fluvoxamine, Lexapro Less deadly in overdose Better tolerated but nervousness, insomnia, sexual dysfunction, long time to effectiveness 60-70% on antidepressants improve More effective for major depression, less effective for dysthymia Elderly are less able to metabolize Mood stabilizers—lithium--some pts miss the highs Anxiolytics—most prescribed class of psychoactive drugs At times, on top of all drugs prescribed Benzodiazepines—minor tranquilizers—prescribed by length of action or time to onset Long acting—valium, Librium Intermediate—ativan, klonopin Short acting—xanax, halcyon Side effects—rebound, addiction, drowsiness, fatigue, clouded thinking But they work—after 8 wks, 50-60% are free of panic Psychostimulants—ritalin, dexadrine, etc. Why might you not want to prescribe meds? Reliance on drugs Decreased self-efficacy Why does it work? Common factors are not inert or trivial Hawthorne effect Placebo effect—phone call improvement Insight-oriented therapy—assumes beh, emo, and thoughts become disordered because people don’t understand what motivates them, esp. when needs and drives conflict Psychoanalytic therapy—remove repressions that have prevented the ego from helping the individual grow into a healthy adult.— unresolved, buried conflicts Focus of therapy is not on presenting problems such as anxiety, but conflicts in the psyche from childhood Techniques—free association Resistance—blocks to free association—come late, change subject, miss appointments. Is it effective? Time consuming, expensive, no rigorous, controlled outcome studies of traditional analysis. Appears to have some utility. Newer forms of short-term psychoanalytic have had some outcome studies, look good. Greater emphasis on freedom of choice Free will-most important characteristic—offers pleasure but also pain Carl Rogers’ client centered therapy Techniques— Inconsistent results Gestalt Therapy—Fritz Perls—originally an analyst; we react to people in the context of our needs. Clients are made aware of what is going on now in session. Genuineness-spontaneity, openness, authenticity Unconditional Positive Regard—get rid of conditions of worth Accurate empathic understanding—accept, recognize, and clarify feelings Reflect back statements Techniques—I language; Empty chair; Reversal (beh. opposite) Evaluating Humanistic-Experiential therapies— Many of the ideas have had an impact on psychotherapy However, lack of agreed upon procedures, a bit vague More research these days—looks ok Exposure therapy Systematic desensitization Aversion therapy—pair negative stimuli with stimuli that are inappropriately appealing Token economy Premack principle Modeling Evaluating Behavior Therapy Achieves results in a short period of time—less distress, lower cost Methods are clearly delineated; results easily measured Works better with some problems than others—rarely used for complex personality disorders (except dialectical behavior tx for borderline) Ellis—Rational Emotive Therapy Sustained emotional reactions are caused by internal sentences that people repeat to themselves—irrational beliefs Eliminate self-defeatingness by rational examination Beck—Cognitive therapy Negative beliefs that people have about self, world and future cause disorders. Both behavioral and cognitive. Ellis is more harsh and direct Beck—inductive—seek negative beliefs Social problem solving; skills training, assertion training Efficacy Less research on Ellis’ model—what is there says that it does not work as well as Beck’s approach. Combined use of cog and beh is routine these days. Generally depends 1) therapist’s impression of change 2) client’s report of change 3) reports from clients family or friends 4) pre and post scores on tests 5) changes in overt behaviors Would change occur anyway? After 40 sessions, 75 % have improved; 50 % show significant change after 21 sessions Can therapy be harmful? 5-10% deteriorate in tx. BPD and OCD show the most negative outcomes. What is stress? How we react depends on: When environmental or social threats place demands on people Nature and timing of stressor Psy characteristics and social situation Biochemical variables Types of stress: eustress and distress Frustrations—when strivings are thwarted Conflicts—two incompatible needs or choices 1) Approach-avoidance—a mixed blessing 2) Approach-approach 3) Avoidance-avoidance The nature of the stressor Persons’ perception and tolerance of stress Perception of threat Stress tolerance—ability to withstand stress without becoming seriously impaired—risk factors External resources and social supports Life changes—Holmes and Rahe (1967)—Social Readjustment Rating Scale Chronic or short term # of stressors at once Length of the ordeal Personal involvement Horowitz et al 1979—those with scores of over 300 were at increased risk for major illness in next two years All of these factors can build upon one another and make stress worse Begins in hypothalamus Stimulates sympathetic nervous system Causes adrenal glands to secrete adrenaline and noradrenaline. This causes an increase in heart rate and increased rate of glucose metabolization Hypothalamus also causes the release of corticotrophinreleasing hormone (CRH), which stimulates pituitary gland. Pituitary then secretes adrenocorticotrophic hormone (ACTH) which causes adrenal cortex to produce stress hormone cortisol. Cortisol prepares body for fight or flight. Allostatic load—biological cost of adapting to stress Hans Selye (1936) General Adaptation Syndrome (GAS) 1) First stage—alarm reaction—fight or flight—autonomic nervous system activates 2) If stressor ends, ANS calms down. If it persists or new ones are added, alarm is followed by a stage of resistance. 3) If stressors continue, state of exhaustion begins as a result of long-term resistance. Physical signs: indigestion, loss of wt., insomnia, fatigue. Psychological signs: violence, delusions, stupor. May result in death. Experiencing alarm—heightened vigilance and concentration; dizziness, light-headedness, shakiness Prolonged stress—release of stress hormones can cause chronically high b.p., damage muscle tissues and inhibit healing after injury Innate immunity—1st line of defense; skin, mucus membranes Specific immunity—acquired rather than innate Detection Destruction Once battle is over, suppressor T cells call a halt, if not, body turns on itself. Short term—stress can boost immune system Long term—decrease in immunological strength; can effect some parts and not others Types of coping: Effects: No best way—best to be flexible in type and timing of strategy. Problem-focused: Change the stressor itself Cognitive reappraisal: Change how you think about the stressor Emotion-focused: Change emotional responses Social support: Direct and buffering effects Men: more often active, problem-focused Women: Distraction, venting, social support Pennebaker’s work Sleep disorders Adjustment disorders PTSD and Acute Stress Dis. Dissociative and somatoform disorders Psy factors affecting a medical condition Coronary Heart Disease—more than 500,000 deaths per year Main cause is atherosclerosis Results of CHD include: Angina pectoris and Myocardial infarction Risk factors: men, older people, high bp, parental history of heart problems, cigarettes, high levels of bad cholesterol Hypertension—another correlate of atherosclerosis Stress and cardiovascular disease Manuck et al 1983—monkeys who were exposed to a threatening stimulus Learned helplessness Psych factors: internal, global, stable Perceived control over the situation Belief in coping abilities Social isolation and a lack of social support Hostility component of Type A personality Depression increases risk When a response to common stressor is maladaptive and occurs within 3 months of the stressor. Unable to function as usual Reaction to particular stressor is excessive Dx is discontinued if stressor subsides or if individual learns to cope If it persists beyond 6 mos, change diagnosis Multiple types—depression, anxiety, disturbance of conduct, mixed Difference between the two is timing—Acute Stress occurs right after the event, lasts from 2 days to 4 weeks. After 4 wks after the event, it is PTSD. Onset can also be delayed for PTSD beyond 6 months. Symptoms: Frequent reexperiencing of the event through intrusive thoughts, flashbacks, nightmares, and dreams Persistent avoidance of stimuli associated with trauma and a general numbing or deadening of emotions Increased physiological arousal with an exaggerated startle response Lower rates in areas with less crime and few natural disasters Perception of trauma Social support Those who develop it tend to have preexisting more somatic concerns More social maladjustments and irresponsibility Be more passive and inner directed Be more sensitive to criticism and suspicious of others Short-term crisis therapy—face to face discussion Direct exposure therapy—in vivo or imagined Telephone hotlines Psychotropic medications Anxiety—common features Relative intactness of reality testing Experience of anxiety Recognition that this is not a typical response Affects 25-29% of US population (over 23 million) at some point in life Most common category of disorders for women, second for men Lots of comorbidity in anxiety—suggests common mechanisms Fear or panic activates the fight-or-flight response Anxiety is a complex blend of unpleasant emotions and cognitions that is more oriented to the future and much more diffuse than fear Has cognitive/subjective components “I feel terrified” Physiological components—hr and bp Behavioral components-urge to run Adaptive in that it helps us prepare for a threat. At mild or moderate levels, enhances learning and performance Also has cognitive, physiological, and behavioral components Anxiety and fear can be unconditioned or learned Unrealistic and irrational fears of disabling intensity 7 different disorders in DSM-IV Relatively common (phobias most common) Commonalities in causes Genetic vulnerability—personality trait of neuroticism Limbic system commonly involved Neurotransmitters include GABA, norepinephrine, and serotonin Classical conditioning Those who perceive a lack of control are more vulnerable Commonalities in treatment Graduated exposure—single most effective treatment Cognitive restructuring Benzodiazepines and antidepressants Taijin-kyofushu—Japan—similar to social phobia, fear that they will offend or embarrass, concerned with body odor Nervios—Latino cultures—chronic worrying and negative thinking, expressions of anger, headaches, other somatic ailments. Tied to poverty and poor education. Ataque de nervios—Latino cultures—panic-like attacks dominated by trembling, heart palpitations, numbness. Tied to stress and spiritual causes. Shen-k-vei—China—pattern of severe anxiety or panic, accompanied by bodily complaints. Supposedly tied to excessive semen loss after frequent masturbation or intercourse, a loss believed to endanger the individual’s vital essence Similar to dhat a disorder found in India. Disrupting fear, avoidance out of proportion to the danger posed by a particular object or situation; generally recognized as groundless by sufferer Five subtypes: Animal, Natural Environment, Blood-Injection-Injury, Situational, Other Common ones: claustrophobia, acrophobia (ht), agoraphobia (open, public spaces) Common in women Lifetime prevalence—12% Animal, dental, and blood-injection-injury typically begin in childhood Agoraphobia and claustrophobia—adolescence and early adulthood Animal phobias are most common, but tend to diminish with time, even without treatment Blood-injection-injury—3-4 % of population, but about 15 % of adults have had a blood or injury related fainting spell Disgust is as common as fear Initial heart acceleration, followed by a drop in rate and pressure Leads to nausea, dizziness, and or fainting (don’t find this with other phobias) Psychodynamic viewpoint—look at content of phobia. Today view phobia as defensive in some way, such as fear in place of something else. Behaviorist viewpoint Classical conditioning and generalization Direct traumatic conditioning (think of the dentist) Vicarious conditioning—Mineka and Cook Cognitive factors maintain fear Evolutionary preparedness Cognitive viewpoint Phobics are attuned to stimuli that elicit fear—shadowing studies—phobics attend to ear that they are supposed to ignore and start saying phobia-related words Also—socially anxious—concerned about evaluation Genetic and temperamental— ANS—more easily aroused 1st degree relatives have increased likelihood of all anxiety Behaviorally inhibited toddlers (21 mos) Systematic desensitization—fear hierarchy; in vivo or in session Exposure Modeling Anxiolytics—not effective Cognitive—dispute irrational beliefs—not effective alone, not much incremental benefit Fear of one or more specific social situations—fear is really of scrutiny by others and potential embarrassment About 60% of sufferers are women. Lifetime prevalence rates vary—your book says 12%, I’ve seen as low as 2% Onset is typically in adolescence Culture—in collectivist cultures—fear of offending others or bringing shame to the family; individualist cultures—guilt or embarrassment High comorbidity with GAD, panic, specific, compulsive PD, depression Learning— Direct or vicarious conditioning such as experiencing or witnessing a social defeat More likely to have grown up with parents who were socially isolated or avoidant Evolutionary—a by-product of dominance hierarchies—had to be prepared to flee; had to be attuned to others’ expressions Genetic and Temperamental factors Modest genetic contribution Behavioral inhibition Cognitive variables—expect that others will reject them; preoccupied with their own bodily responses and negative selfimages. Perceptions of uncontrollability and unpredictability Lead to submissive and unassertive behavior Behavioral treatments—exposure Cognitive treatments-challenge negativeautomatic thoughts Antidepressants—may be helpful, but takes a while to build up, can’t just stop taking them Recent research suggests cognitive-behavioral tx has longer lasting effects Short, periodic bouts of panic that occur suddenly, reach a peak in 10 minutes, and then gradually pass. Must include at least 4 symptoms: Palpitations, pounding heart, accelerated heart rate Sweating Trembling or shaking Sensations of shortness or breath or smothering Feeling of choking Chest pain or discomfort Nausea or abdominal distress Feeling dizzy, unsteady, lighthearted or faint Derealization or depersonalization Fear of losing control or going crazy Fear of dying Numbness or tingling sensations Chills or hot flashes Attacks can be cued or uncued Recurrent unexpected panic attacks Month or more of one of the following after at least one of the attacks Persistent concern about having additional attacks Worry about the implications or consequences of the attack Significant change in behavior related to the attacks Often accompanied by agoraphobia Panic is now dx’d with agoraphobia or without About 2.7 % suffer from one or the other pattern in a year, about 5 % lifetime prevalence Likely to develop in late adolescence or early adulthood Twice as common in women as men About 35 % of those with panic disorder are currently in treatment Genetic factors—moderate heritability, overlap in heritability of panic and phobias Biochemical abnormalities No single neurobiological mechanism GABA related to anticipatory anxiety Noradrenergic and serotonergic pathways are implicated Related to mitral valve prolapse Behavioral and cognitive causal factors Fear of fear hypothesis Interoceptive awareness Sense of perceived control or having a safe person may block response Safety behaviors and persistence of panic Safety behaviors need to stop for effective treatment Attentional biases toward threat cues Benzodiazepines—rapid effects, addictive, need gradual withdrawal, rebound panic Antidepressants—high relapse rates Behavioral and cognitive-behavioral tx Prolonged exposure effective in 60-75 % of pts Combined with meds—greater relapse—better to use alone Experience excessive anxiety under most circumstances and worry about anything Sometimes called free-floating anxiety Somatic complaints—sweating, flushing, pounding heart, upset stomach, diarrhea, cold clammy hands, dry mouth, high pulse and respiration Disturbances of skeletal musculature—muscle tension, eyelid twitches, trembling, tire easily, inability to relax Easily startled, fidgety, restless, sighs a lot Generally apprehensive—often imagining and worrying about disasters, losing control, having a heart attack, dying Impatience, irritability, insomnia, distractibility 4-6 % prevalence Twice as common in women Most continue to function despite symptoms Begins in mid-teens, many report problems through life Comorbid with social anxiety and OCD Psychoanalytic view Sx or aggression impulses are in conflict with the ego; ego can’t allow expression because of fear of punishment. Because anxiety source is unconscious, person is in distress and doesn’t know why Learning— Attempts to control thoughts and images actually increases them Classically conditioned to external stimuli—like phobia, only broader Cognitive—control vs. helplessness-in yoking studies, rats with control have less anxiety Biological—small to modest heritability Predisposition to neuroticism Treatment Benzodiazepines—not all that effective, gains often lost Antidepressants, Busipirone may help Muscle relaxation and cognitive restructuring quite effective 1-3 % have OCD-lifetime >90% have both o and c, if include mental rituals, this is 98% Usually begins in early adulthood, often following some stressful event Gradual onset and chronic—poor prognosis 80% may experience depression Early onset—more common in men—checking compulsions Later onset—more common in women—cleaning compulsions Obsessions—intrusive and recurring thoughts, impulses, and images, appear irrational and uncontrollable to pat Doubts—75 % of pts.—persistent thought that a completed task hadn’t been adequately completed Thinking—34 %--endless chain of thoughts focusing on future events Impulses-17 %-urges to perform certain acts (whims to assaults) Fears-26 %-afraid of losing control or doing something embarrassing Images-7 %--seen or imagined Compulsions—Five primary types—cleaning, checking, repeating, ordering/arranging, counting. Performance of act reduces tension, increases satisfaction, gives sense of self control Fear that something will happen to them or others because of them Have tendency to judge risks unrealistically Behavioral viewpoint— Biological – Mowrer—two process—in place classically, maintained operantly OCD and preparedness—evolutionarily adaptive in some ways Genetic—moderately high heritability Some abnormalities in brain function that normalize on meds Treatment— Difficult to treat Behavioral treatment that combines exposure and response prevention—effective in 50-75 % Relapse of up to 90% following med discontinuation SSRIs— Combination of meds and therapy not more effective than therapy alone in adults, may be in children Somatoform—pt. complains of bodily symptoms that suggest a physical defect or dysfunction, but no phys. basis Dissociative—disruptions of consciousness, memory, and identity. Individuals with these disorders may be unable to recall events, may forget identity, may assume a new identity. Preoccupied with fears of a serious disease—not reassured by physician Overreact to ordinary physical sensations or minor abnormalities—irregular heartbeat, sweating, coughing, sort spot, stomachache Not faking—sincere Vague and ambiguous symptoms are common Causes— Not well understood Clearly anxiety related—some researchers like term health anxiety Attentional bias for illness-related information Misinterpretations of bodily sensations are seen as causal by cog-beh types Role of secondary reinforcement Treatment Cog-beh SSRIs may be helpful Formerly called Briquet’s Syndrome Multiple somatic complaints for which medical attention is sought, but have no apparent physical cause Most often seen in primary medical care—common complaints include headache, fatigue, abdominal, back and chest pain, genitourinary and sexual symptoms, heart palpitations, gastrointestinal sx, neurological sx 3-10 x more common in women Usually begins in adolescence More often in low SES Lifetime prevalence .2-2% in women, .2% in men Comorbid with anx disorders Causes—Similar to hypochondriasis—hyperattentive to bodily sensations Interaction of personality, cognitive, and learning variables TX-medical management and cog-beh Subjectivity of pain Diagnosed more commonly in women Comorbid with anxiety and mood disorders May allow individuals to avoid some unpleasant activity Diagnosed when onset, severity, and maintenance of pain causes distress with no pathology Can be either psych alone or psych and physical TX—cog-beh; relaxation training, support and validation that pain is real; reinforcement of “no pain” behaviors Symptoms suggest neurological damage, but everything is found to be fine Usually appear in stressful times. Primary and secondary gain. So named because energy of a repressed instinct was diverted into sensory-motor channels and blocked functioning. Thus anx and conflict are converted into physical sx AKA conversion hysteria La belle indifference in about 20-50% of cases 1-3% of those referred for tx. Prevalence in general pop is very low—may be only about .0005 percent 2-10X more common in women. Issues in diagnosis—sx do not conform clearly to the particular diseases simulated; selective nature of the dysfunction; sx may go away under hypnosis or narcosis Distinguishing from malingering and factitious disorder Malingering—fake an incapacity to avoid responsibility—under voluntary control Factitious disorder—fake illness to assume role of pt Tx of conversion—behavioral, hypnosis Preoccupied with an imagined or exaggerated defect in appearance. Often leads to may visits to plastic surgeons. 70% or more of students indicate some dissatisfaction. Would you change something about your appearance if you could? 99% of women, 93 % of men say yes Social and cultural factors play a role. Most common—skin (73%), hair (56%), nose (37%), stomach (22%), breasts, chest, nipples (21%), eyes (20%) No official estimates of prevalence. No gender difference. Onset typically in adolescence. 50% comorbid with depression Over 75% seek non-psych help Related to OCD—similar brain structures implicated; same tx are effective (SSRIs, cog-beh helps in 50-80%) Suddenly unable to recall important personal information, usually after a stressful situation. Most often—for all events in a given period of time. More rarely—selected events in a period; continuous from traumatic event to present; total Behavior looks normal, but may be disoriented Usually person retains ability to read, write, play piano, have knowledge Comes and goes suddenly Not the same as with organic brain disorders or substance use— either a definite cause or fails slowly over time Fugue—new identities may be assumed; may last for days, weeks, or years Similar to conversion in that threatening information becomes inaccessible; suppression is involved in memory loss Two or more personality systems are created from stressful precipitating events Personalities are dramatically different Needs inhibited in one personality are displayed in another Alter identities represent fragments of a single person Some alters may have more knowledge than others Switches can be sudden or gradual Often see depression, self-mutilation, suicide attempts and ideation, BPD, substance abuse, phobias Gaps in memory are common Usually starts in childhood, but not dx’d until 20s or 30s 3-9x more common in women—due to sexual abuse Number of alters has increased over time—50% now show more than ten identities; bizarre and unusual identities have also increased Before 1979, only 200 cases had ever been reported. Post-Sybil and Three Faces of Eve, that has risen to 30-40,000 in North America May have previously been dx’d as schizophrenia Use of DID as a criminal defense is rare—Kenneth Bianchi—The Hillside Strangler Factitious and malingering cases are rare Post-traumatic theory—over 95 % have memories of severe abuse. DID as a way to cope with overwhelming sense of hopelessness and powerlessness. Only some abused kids develop DID—diathesis stress model Escape—dissociation—occurs through a process like self-hypnosis/ Tend to be prone to fantasy, easily hypnotizable, intelligent Sociocognitive theory—DID develops when a highly suggestible person learns to adopt and enact the roles of MPD due to therapist suggestions and reinforcement and because identities allow person to achieve personal goals—unintentional process. Spanos and colleagues—normal college students could be induced by suggestion under hypnosis to show DID sx This is consistent with those who have no sx of DID before therapy, but emerges in tx; also consistent with increase in dx as therapists became aware of dx Tends to focus on integration Psychodynamic and insight based Few outcome studies. Many of those seem to be biased for positive results Recovered memories—real or fake Practitioners more likely to believe in recovered memories but Memory is malleable and memories are subject to modification Intense fear of gaining weight or becoming fat is coupled with a refusal to maintain minimal wt. At least 15 % wt loss without organic cause (usually 25-30%) Active pursuit of thinness Distorted body image Amenorrhea Two types: Restricting and Binge-eating/purging type—about 3050% go from restricting to binge/purge Restrictors are admired Mortality: 3-21%--about 12x higher than other females age 15-24 Normal awareness of hunger, but terrified of giving in to impulse to eat. Distorted perception of satiety. Excessive activity. 90-95 % of cases are in females Peak onset between 14-18 .5-2% prevalence in clinical populations. Higher rates of behaviors when we use an epidemiological approach. Males tend to fall in a few specific groups—jockeys, wrestlers, models So called Golden Girls disease. Most common in industrialized nations (highest rates are here) but increasingly found everywhere. Medical complications: Hair and nails thin and become brittle, dry skin, lanugo, yellowish tinge to skin, cold all the time, low bp, kidney damage, heart arrhythmias, electrolyte imbalances, osteoporosis 40% totally recover 30% considerably improve 20% unimproved, seriously impaired Remainder die Early onset—more favorable prognosis Poor prognosis—chronicity, pronounced family difficulties, poor vocational adjustment Depression in 50-70%, appear to be separate disorders OCD also fairly common Some studies have found increased rates of sexual abuse, but these have generally all been methodologically flawed 1st classified as a disorder in 1980, therefore less research Two types—purging and non-purging Some argue that anorexia with binge/purge is just an underweight form of bulimia Recurrent episodes of binge eating and repeated attempts to lose weight by severe dieting or purging (laxatives, vomiting, exercise) Typical picture: white female begins overeating around 18 and purging a year later, generally vomiting May be over or underweight, typically about average Family hx often includes obesity or alcoholism Prevalence about 1-3 %, higher rates when we look at # with behaviors >90% are female Preoccupied with food, eating, and vomiting so that concentration on other subjects is impaired. May steal food (increased food costs assoc. with binging) Less time socializing, more time alone than non-bulimics Terrified of losing control over eating—all or none thinking Lots of shame, guilt, self-deprecation, and efforts at concealment More extroverted More likely to abuse ETOH, steal, attempt suicide More affectively unstable than depressed Difficulty with self-regulation Some evidence of hx of pica More sexually active than controls, but less interested in sex and enjoy it less Hx of childhood maladjustment; alienated from family Higher rates of borderline 50-75% show full recovery Health risks: Electrolyte imbalances, hypokalemia (low potassium) leading to heart problems, damage to heart muscle, calluses on hands, tears to the throat, mouth ulcers and cavities, small red dots around eyes, swollen salivary glands Risk of anorexia for relatives is 11.4X greater than controls—concordance for MZ twins is about 50%, DZ twins about 5% Risk of bulimia is 3.7x greater Some linkage to chromosome 1 for anorexia, chromosome 10 for bulimia Serotonin—neurotransmitter linked to obsessionality, mood disorders, impulsivity—also modulates appetite and feeding behavior Link is still not entirely clear Set point—90-95% of those who lose weight regain it Peer and media influences Fiji—Becker Objectification theory (Frederickson and Roberts, 1997) --women’s bodies are sexually objectified --use observer perspective when viewing selves --leads to habitual body monitoring-increased shame and anx, fewer peak states, increased depression and eating disorder Hebl et al 2004—swimsuit vs. sweater paradigm 1/3 of pts report that family dysfunction contributed to dev of anorexia No typical family profile with anorexia associated family behaviors—rigidity, parental overprotectiveness, excessive control, marital discord triangulation double message of nurturant affection and neglect of dtr’s need to express her own feelings Many parents have same issues—preoccupied with desirability of thinness, dieting, good physical appearance Bulimia—high parental expectations, other family members’ dieting, critical comments about shape, weight, or eating Fat spurt—more associated with increased body dissatisfaction than age Girls who are underweight are most satisfied with weight Internalizing the thin ideal is associated with Body dissatisfaction, dieting, negative affect Perfectionism—more common in women Sexual abuse in bulimia and binge-eating Anorexia Nervosa Treatable but motivation is a big issue Many have been tried (nutritional counseling, individual and group tx, 12 step, meds, beh. contracts)—most have weak evidence Best results—cog-beh approaches and response prevention; family tx for adolescents Most are outpt-inpt for brief periods Meds—not initial tx of choice, SSRIs used 1st—none has consistently improved wt. maintenance or prevented relapse of anorexia SSRIs are more helpful for bulimia—seem to decrease frequency of binges as well as improving mood and preoccupation with shape and weight Cog-beh is tx of choice—multiple controlled studies show CBT superior to meds and interpersonal tx. Behavioral components focus on meal planning, nutritional education, ending binging and purging cycles by teaching person to eat small amts more frequently Obesity is a widespread epidemic BMI: below 18.5 underweight 2/3 of adult population in US, 31% of those are obese WHO –obesity is one of top 10 global health problems 18.5-24.9—normal 25-29.9—overweight 30 or above—obese To calculate: (weight in pounds*703)/ht in in sq In US—6x more common in lower SES adults, 9x more common in lower SES children Risk factors: low parental education, children who are seriously neglected Associated with diabetes, joint disease, high bp, coronary artery disease, sleep apnea, CA Role of genes Genes assoc with leanness have been id’d in animals Genetic mutation assoc with binge eating Hormones involved in appetite and weight regulation Leptin acts to reduce our intake; inability to produce leptin is assoc with morbid obesity People who are obese tend to have high levels of leptin, but are resistant to its effects Sociocultural influences Culture encourages consumption and discourages exercise Time pressure: on any given day, 30% of Am kids eat fast food In children: peers view obesity more negatively than physical handicaps Peer eating behavior Availability of exercise facilities Family influences Family behavior patterns Food availability (home, neighborhood, school) Parental knowledge and attitudes about food Eating may become an habitual way of alleviating emotional distress Overfeeding young children causes them to develop more adipose cells and may predispose them to weight problems in adulthood Stress and Comfort Food When under stress, people and animals eat foods high in fat or carbohydrates Weight gain as a function of basic learning principles Obese people are conditioned to eat more in response to both external and internal cues than normal-weight individuals Eating is reinforced—food is pleasurable and emotional tension is reduced Binge eating may be a predictor of later obesity Success rates are quite low Weight loss groups— Medications Two types—appetite suppressants and those that prevent some nutrients from being absorbed Meridia—inhibits reuptake of serotonin and norepinephrine—typical weight loss 5-8% Xenical—reduces amt of fat that can be absorbed—not all that effective. Ditto for Alli Gastric Surgery Many exist, but only Weight Watchers has been shown to be effective Groups provide support education, encourage record-keeping Reduces amt that can be consumed Recovery is tough Weight loss can be dramatic—average loss of about 60% of excess weight and loss is maintained over 8 or 9 years Psychological tx Most effective—behavioral management CBT for binge eating Gradual weight loss more effective than low-calorie diets Losing weight is contrary to biology Brownell: Public policy recommendations Improve opportunities for physical activities Regulate food advertising directed at children Prohibit the sale of fast food and soft drinks in school Subsidize the sale of healthful foods Two key moods: Depression (melancholia)—great sadness, apprehension, feelings of worthlessness, guild, withdrawal, loss of sleep, appetite and sexual desire, loss of interest and pleasure in usual activities Often associated with other psych conditions and medical conditions May go 6-8 mos if untreated—tends to dissipate with time In kids—aggression and overactivity, irritability, somatic complaints Mania—emotional state of intense but unfounded elation, hyperactivity, talkativeness, flight of ideas, distractibility, impractical, grandiose plans, spurts of purposeless activity Rare individuals experience only mania Manic stream of thought—loud incessant, full of puns and jokes Comes on relatively suddenly, lasts a few days or months, may be irritable Loss and the grieving process Baby Blues Normal response—Bowlby—1) numbing and disbelief, 2) yearning and searching for the dead person 3) disorganization and despair, 4) reorganization If symptoms haven’t resolved in 2 mos, dx Normal response, experienced by 50-80% of women, lasts just a few days. Caused by stress, sleeplessness, radical change in hormones. Marked by tearfulness, being overwhelmed. Not to be confused with Postpartum depression— Difficulty functioning. More common in those with predisposing factors—social isolation, less family support, history of depression. Depressed mood of mild to moderate intensity Primary hallmark is chronicity Average duration is 5 years (4 years in kids) Chronic stress increases the severity of symptoms Half relapse Lifetime prevalence of 2.5-6 % Two 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 Can be diagnosed with major depression—called double depression 5 symptoms nearly everyday for 2 weeks Must have either sad, depressed mood or anhedonia Difficulties sleeping Shift in activity level Poor appetite with weight loss or increased appetite with weight gain Loss of energy or fatigue Negative self-concept Difficulty concentrating Recurrent thoughts of death or suicide Lifetime prevalence—about 17 %, though some estimates are as low as 45% 90% recover in a year, but ¾ of cases will recur (average duration of an untreated episode is 8-10 months) Typical onset is age 24-29 Symptoms of anxiety are common (not factor analytically distinct in children) Melancholic features—more severe type, loss of pleasure, more of a genetic loading Psychotic features—hallucinations and delusions tend to be content appropriate Atypical features—mood reactivity (brightens at times in response to events). May respond better to MAOIs than other subtypes Seasonal pattern (AKA Seasonal affective disorder) Genetic influences 3x more common among blood relatives MZ concordance—46 %, DZ 20% Biochemical factors Low levels of norephinephrine and serotonin have been linked to depression Some theorists look to a balance of these two, dopamine and acetylcholine Hormonal regulatory systems Hypothalamic-pituitary-adrenal axis --elevated levels of cortisol in 60-80% of severely depressed hospitalized pts Hypothalamic-pituitary-thyroid axis --20-30% of depressed with normal thyroid show dysregulation here. Increasing thyroid hormone levels may help Sleep and other rhythms Greater amounts of REM sleep, enter it earlier in night Circadian rhythms may be out of sync, particularly in SAD Psychoanalytic Freud More recent analytic work—Bowlby’s attachment theory Beck’s cognitive theory Depressogenic schemas/Dysfunctional beliefs Beliefs predispose a person to depression Develop in childhood and adolescences as a function of negative experiences with parents and sig others Activated by current stressors or depressed mood—create a pattern of automatic negative thoughts Negative cognitive triad—self, world and future Negative cognitive biases— Arbitrary inferences Selective abstraction Overgeneralization—overall, sweeping conclusions Magnification and minimization Dichotomous or all-or-none thinking Support for Beck’s theory—strong support as a descriptive theory, mixed but positive support as a causal theory Helplessness and Hopelessness theories of depression Learned helplessness—individual’s passivity and sense of being unable to act and control life is acquired through unpleasant experiences Revisions—attribution theory—Global, stable, internal Hopelessness-expectation that desirable outcomes will not occur. Has generated a lot of research. Interpersonal theory Stressful life events Social support Depressed people elicit negative reactions Depressed people seek other depressed people and bring others down, too Severely stressful life events play a causal role in 20-50% of cases Risk and resilience Personality risk factors Neuroticism Introversion Negative patterns of thinking Cyclothymia—cycles between hypomania and depression Mild form of major bipolar disorder Bipolar Disorders (I and II) Kraepelin 1899—manic-depressive insanity Bipolar I One episode of mania or mixed episode Bipolar II Hypomania More common than bipolar I Symptoms of depression are almost identical to that of major depression Suicide attempts may be more common in bipolar May be misdiagnosed (until first mania appears) Rapid cycling in 5-10% 24 % relapse in 6 mos, 77 % have a new episode in 4 yrs, 82 % by 7 yrs Onset typically in early 20s Genetic influences Neurotransmitters Account for 80-90% of the variance About 70% of heritability is distinct from unipolar Polygenic Increased levels of dopamine may be related to mania Abnormalities in how ions are transported across neural membranes (this is where lithium helps) Some differences in brain structures—enlarged basal ganglia and amygdale Psychosocial causal factors Diathesis stress Low social support Where do depressed people go first? Katon and Walker 1998 41 % initially go to physician with complaints of feeling ill 37 % report pain, 12 % report general fatigue and tiredness Treatments for Unipolar Depression Only about 40 % of people with mood disorders receive minimally adequate care In one study of the depressed poor, only 2/3 said that they had ever received the diagnosis (Bazargan et al 2005) Second most prescribed class of meds (behind blood pressure) 3 of the 12 most prescribed meds are antidepressants (Gitlin, 2002) 74 % of those who are depressed take meds alone or with therapy. In 1990, that was 37 % . Today 60 % receive therapy. In 1990, that was 71 % (Boyles, 2002). Will meds help us all? Knutson et al 1998—Gave nondepressed volunteers antidepressants—noted improvements in negative symptoms like hostility and fear, but did not increase positive feelings like happiness and excitement First class—MAOIs—developed in 1950s Monamine oxidase inhibitors—Parnate, Marplan—dev. as tx for TB, but people became less depressed Slows activity of serotonin and norepinephrin Tricyclics—Tofranil, Elavil, Anafranil, Pamelor Named for molecular structure Created for schizophrenia, but work better for depression Fewer serious side effects but—drowsiness, dry mouth, constipation, decreased sex drive, nausea, tremors, blurred vision, can occas. stimulate mania, increase effects of both when taken with alcohol, fatal in overdose SSRIs—1988-Prozac—most widely prescribed antidepressant in the world Less deadly in overdose Better tolerated but nervousness, insomnia, sexual dysfunction, long time to effectiveness 60-70% on antidepressants improve Course of treatment— Take 3-5 weeks to become effective 50% do not respond to the first drug tried 25 % relapse while on drugs ECT—severely depressed at imminent risk; 6-12 sessions every other day, varying levels of amnesia persist; can be useful in the elderly. Effective for 50-80 % who do not respond to meds Bright light therapy—originally just for SAD, but may help with other types of depression Transcranial magnetic stimulation—brief, intensive pulsating magnetic transmissions Noninvasive, done in awake patients May be more effective than antidepressants without side effects of ECT Psychopharm for biopolar Mood stabilizers—lithium Tegretol, depakote Cognitive-behavioral and behavioral activation therapy Interpersonal therapy Focuses on here and now problems Teaches people how to evaluate their beliefs and automatic thoughts Equally or more effective than antidepressants More effective at preventing relapse Modified CBT may work for bipolar Not as extensively studied or used Also effective Focuses on current relationship issues, trying to help person understand and change maladaptive interaction patterns Modified for bipolar to stabilize daily life Family and marital therapy Unipolar—focus on reducing marital discord is effective Bipolar—focus on reducing ee and increasing coping effective in preventing relapse Cognitive, interpersonal and biological are all effective. Elkin et al 1994, 1989—compared the three with a placebo. Among those who completed tx, sx were almost completely eliminated, compared with 29 % of those on placebo. Drug therapy was faster, but may not prevent relapse as well. Cognitive and interpersonal are not relapse-proof. As many as 30 % of those who respond to these methods may relapse. Continuation or maintenance approaches may help. Behavior therapy alone is not as effective as the other types of tx. Psychodynamic tx is also less effective. Combo of meds and therapy is modestly more effective. ECT acts more quickly than meds, but is equally effective. Myths about suicide People who discuss suicide won’t do it Suicide is committed without warning Only people of a certain class commit suicide Religion prevents suicide (devoutness may, though) People who commit suicide are psychotic People who use low-lethal means aren’t serious Thinking about suicide is rare Improvement in emotional state means decreased risk All suicidal people want to die Estimated that 700,000 people each year, 31,000 in the United States 600,000 unsuccessful attempts in the US each year 11th most common cause of death in the US according to the US National Center for Health Statistics—about 1.3 %of all deaths Depressed individuals are 50X more likely to commit suicide than nondepressed; 40-60% of those who complete suicide are in a depressive episode or recovery phase Only half of those who commit suicide are found to have close friends China—300,000 suicides a year—gender gap—accounts for about 50 % of female suicides around the world Peak age used to be 25-44. Now it is 18-24. Four times as many men as women die from it. But women are 3x as likely to attempt and fail. Highest rate of completed suicides is among the elderly. Method of suicide varies among genders—males—firearms and hanging. Women—pills Other high risk groups—schizophrenia, alcoholics, divorced people, people living alone, people from socially disorganized areas, certain professions (highly creative or successful scientists, physicians, psychologists, businessmen, composers, writers, and artists) Rates in US are about twice as high for whites as for African Americans and Hispanics, but Native American rate are 1.5 times higher than national average Children Adolescents Rates increasing--up 70% for kids 5-14 since 1981 Increased risk if child has lost parent or been abused. Absolute numbers are still low (.7 per 100,000 or about 500) Interviews with school kids find that between 6 and 33 % have thought about suicide. Suicide is the third leading cause of death About ½ of all teens have thought of killing themselves Period of adolescence creates a stressful climate of growth, conflicts, etc. Teens tend to react more sensitively, angrily, dramatically, and impulsively than other age groups. Rate of attempts to completions may be as high as 200:1 Elderly—rate in US is 19/100,000. Accounts for 19% of suicides, but 12% of population Often medically ill Rate also high among those who have lost a spouse One in 4 who attempts succeeds. Depressive disorder and certain other mental disorders Alcoholism and other forms of substance abuse—as many as 70% drink before the act Suicide ideation, talk, preparation Prior suicide attempts Lethal methods Isolation, living alone, loss of support Hopelessness, cognitive rigidity—dichotomous thinking (Suicide was the only thing I could do) Impulsivity and risk taking Being an older white male Modeling, suicide in the family, genetics Economic or work problems Marital problems or family pathology Stress and stressful events— both immediate and longterm Anger, aggression, irritability Psychosis Physical illness—37% in poor health Repetition or combination of the previous factors Biological causal factors— Concordance rates in MZ twins is 19X higher than fraternal twins Reduced serotonergic activity Sociocultural factors Rates vary from one society to another-Lithuania 42, Russia 37, 32/100,000 Japan—suicide long been an acceptable solution to serious problems— death is an appropriate response to shame; death is also freeing oneself from illusion and suffering Communication of intent 40% communicate intent in clear and specific terms Additional 30 % had talked about death and dying 50 % had never seen a mental health professional 15-33% leave notes—typically coherent and legible younger people’s notes express more hostility Emphasis on Goals of person on line (Schneidman & Farberow, 1968) Maintenance of supportive contact with person Helping person realize that distress is impairing judgment Helping person see that distress is not endless Establishing a positive relationship Understanding and clarifying the problem Assessing suicide potential Assessing and mobilizing caller’s resources Formulating a plan Do prevention programs work? Only a small percentage of suicidal people call lines Evidence is mixed for success But, programs do seem to reduce risk among those who call Heterogeneous group Enduring, inflexible patterns of inner experience and behavior Deviate from cultural expectations and cause distress and impairment. Must be of long duration, stable Must lead to clinical distress or impairment in functioning Must be manifested in at least two areas. Little evidence about prevalence—perhaps 13% of the pop at some point in life Axis II—must be considered in all diagnoses Hard to treat because people don’t see selves as disordered Criteria are not sharply defined Dx relies on inferred traits or consistent patterns of beh rather than more objective means There are self-report inventories and semi-structured interviews, but no good assessment device Diagnostic reliability and validity is still low Categories are not mutually exclusive Difficulties in studying causes Comorbidity Little prospective research --almost all is retrospective among people already dx’d Temperamental characteristics are possible biological factors Possible psych factors include maladaptive habits and cognitive styles that may originate in disturbed attachment, ineffective parenting, early emo, phys or sexual abuse Sociocultural factors—social stressors, societal changes, cultural values Cluster A—odd—paranoid, schizoid, schizotypal—odd or eccentric behaviors that are similar to, but not as extensive as those seen in schizophrenia. Often leave person isolated. Cluster B—dramatic—antisocial, borderline, histrionic, narcissistic—dramatic, emotional, erratic. Almost impossible to have a satisfying, giving relationship. More commonly dx’d than others. Cluster C—anxious—avoidant, dependent, obsessive compulsive pd—anxious and fearful behavior, similar sx to anxiety disorders, but no direct link between these and Axis I Suspicious of people, frequently angry, hostile, expects to be mistreated and abused. Prevalence maybe .5-2.5%, males>females Causal factors—little is known, inconsistent findings on genetic transmission Thus—secretive, looking for signs of trickery, reluctant to confide; blaming, bear grudges, way jealous, doubts about loyalty and trustworthiness, may read hidden messages \ High concordance between MZ twins Psychosocial factors are suspected Treatment of Paranoid PD: Do not typically see selves as needing help; few come willingly View role of pt as inferior and distrust/rebel against therapists Therapy has limited effect and moves slowly Central symptoms Inability to form social relationships and an indifference toward developing them. Demonstrate little emotion Focus mainly on themselves Little affected by praise or criticism Not interested in sex <1%, males > females Causal factors Used to think that this was a precursor to schizophrenia No evidence of hereditary link Parents may have been abusive or unaccepting of children Cognitively—thoughts seem to be vague and empty, unable to pick up emotional cues Treatment—social withdrawal keeps them from entering therapy Generally remain emotionally distant from therapist, seem not to care about treatment, and make limited progress at best. Cognitive therapists—help them focus on pleasurable experiences or think about emotions Behavioral therapists—teach social skills—role playing, exposure therapy, homework assignments Extreme introversion Sensitivity Eccentricity Oddities of thought, perception and speech that are similar to schizophrenia (ideas of reference, bodily illusions –such as having extrasensory abilities or being able to sense external forces 3% prevalence Males>females Perhaps similar causes to schizophrenia. High activity of dopamine Higher rates of this among relatives of those with schizophrenia and those with depression Therapy is difficult—need to reconnect with the world and recognize limits of thinking and powers. Try to set clear limits. Increase positive social contacts. Ease loneliness. Cognitive—try to help them see inaccuracy of thoughts Behavioral methods—speech lessons, social skills training, tips on appropriate dress and manners Low doses of antipsychotics may have some success Overly dramatic and attention seeking Explain emotion extravagantly Very shallow, self-centered Overly concerned with physical attractiveness Uncomfortable when not the center of attention Believe relationships are more intimate than they are Inappropriately provocative Easily influenced by others Speech vague, lacks details 2-3% prevalence Males=females or females slightly greater Psychodynamic Cold and controlling parents left them feeling unloved and afraid of abandonment; to defend against fear of loss, act provocatively so that they have to be rescued Cognitive Less and less interested in knowing about the world because they are so self-focused; must rely on other people or hunches to get direction in life Sociocultural Society encourages girls to be vain, dramatic and selfish— histrionic is just this to an extreme degree Biological Possible genetic link with APD Grandiose view of their own uniqueness and abilities Self-centered is an understatement Require constant attention and admiration Believe only high status people will understand them Lack of empathy Envious Arrogant; take advantage of others <1% prevalence Males>females (up to 75 % male) Psychodynamic—cold rejecting parents lead to children spending lives defending against feeling unsatisfied, rejected, unworthy Support for this—research says that kids who are abused or who lost parents through adoption, divorce, or death are at increased risk Behavioral and cognitive types say just the opposite— people develop this when they are treated too positively early in life. Admiring doting parents teach them to overvalue self worth. Support for this—onlies and firstborns are at increased risk. Sociocultural theorists—link between disorder and eras of narcissism in society. One of the most difficult patterns to treat If they seek, it is because of other disorders, generally depression May try to manipulate therapist into supporting their sense of superiority Psychodynamic—recognize and work through basic insecurities and defenses Cognitive—focus on self-centered thinking, try to redirect onto the opinions of others, to interpret criticism more rationally No approach has had a lot of success 2% females>males (about 3:1) Males with the disorder tend to be more aggressive, disruptive Instability in relationships, mood and self-image Erratic emotions Argumentative, irritable, sarcastic Unpredictable, and impulsive behavior—spending sex No clear sense of self—values, career, loyalty Intense relationships—stormy and transient Emptiness Manipulative attempts at suicide Paranoid ideation and dissociative symptoms (75% show short or transient psychotic-like symptoms) This PD affects job performance more than other PDs High frequency of physical and sexual abuse Comorbidity with other Axis I disorders Disorders ranging from mood and anxiety disorders to substance abuse and eating disorders Comorbidity with other personality disorders, esp. histrionic, dependent, antisocial and schizotypal Self-destructive—self-injurious or self-mutilation behaviors Suicidal behaviors—at last 70% of BPD attempt suicide at least once and 6-10% actually commit suicide Pain to feel alive Genetic factors play a significant role Biological Lowered functioning of serotonin may explain impulsivity and aggression Disturbances in regulation of noradrenergic transmitters may explain their hypersensitivity to environmental changes Psychosocial—negative, traumatic childhood events Diathesis stress model—who are abused are 4x more likely to develop BPD than general pop Biosocial theory—Marcia Linehan—combination of internal forces and external forces If children have intrinsic difficulties identifying and controlling emotions and if parents teach them to ignore emotions, children never learn how to recognize and control emotional arousal, how to tolerate distress, when to trust emotional responses. Psychotherapy can eventually lead to some improvement Tough balance to strike Relational psychoanalytic therapy—fairly effective Dialectical behavior therapy—Marcia Linehan—an integrative treatment approach— considered by many to be treatment of choice. Antidepressants, mood stabilizers, antianxiety, and antipsychotics are controversial, but can help reduce aggression and emotionality. AKA psychopaths or sociopaths 2 components to antisocial pd Psychopathy Conduct disorder before age 15 and Antisocial behavior in adulthood—not working consistently, breaking laws, lying, being irritable, physically aggressive, defaulting on debts, being reckless, impulsive, not planning ahead, no regard for truth, no remorse Cleckley; Hare--two basic dimensions: affective and interpersonal core and behavioral aspects DSM diagnosis may omit those who don’t show violence 3-4 % of men, 1% of women Studied a lot in jails—among urban jails, apd is linked to violent crimes; about 70-80% of prison inmates have apd For many, criminal behavior declines after 40; behaviors change more than psychopathy Higher rates of alcoholism and substancerelated disorders About 50% of kids with ADHD also have CD Psychodynamic Behaviorists Modeling or imitation—lots of parents with the disorder Patterson—coercion theory/reinforcement trap Cognitive view Absence of parental love during infancy leading to a basic lack of trust—respond to early inadequacies by becoming emotional distant, build relationships through power and destructiveness. Support—more likely than others to have had significant stress in childhood, particularly poverty, parental conflict, divorce, family violence Trivialize importance of other people’s needs Genuine difficulty recognizing viewpoint other than their own Biological factors Experience less anxiety than others, lower arousal levels—slow EEG waves, slow autonomic arousal Approximately ¼ of those with APD get tx for it, yet tx is typically ineffective Major obstacle—lack of conscience and lack of motivation Most are forced to attend—work, court, family About 70% leave tx prematurely (Gabbard & Coyne, 1987) Cognitive-behavioral—increasing self-control, selfcritical thinking, social-perspective taking; victim awareness, anger management, curing drug addiction Requires a controlled situation; even the best programs have only a modest improvement Keenly sensitive to criticism, rejection, disapproval Reluctant to enter relationships unless they know they’ll be liked Afraid of being perceived as foolish or being embarrassed by blushing or looking anxious Believe they are incompetent or inferior Avoid school and work Overlap with Dependent PD and BPD .5-2% prevalence Males=females Similar to social phobia; often have both dx Key difference—social phobics fear social circumstances, avoidant pd fear social relationships Assumed to be related to the same causes as anxiety disorder, but this has not yet been shown by research Psychodynamic Cognitive Focus mainly on sense of shame; think punishment for early bowel accidents—may develop negative self-image—leads individual to feel unlovable Harsh criticism and rejection in early childhood lead people to believe that environment will always treat them negatively Expect rejection; misinterpret the reactions of others to fit that expectation; discount positive feedback; generally fear social involvements Support—pts recall feelings rejected and isolated; receiving little encouragement from parents; experiencing few displays of parental love or pride Bio—inhibited temperament Come to tx to experience affection and acceptance Keeping them in tx is a challenge—soon begin to avoid sessions Key—gaining trust Treating much as one would treat social phobia has shown modest success Cognitive—carry on the face of painful emotions; improve self-image; challenge distressing thoughts Behavioral tx—social skills training; exposure tx Group tx—practice in social situations Antianxiety and antidepressants show some success Lacks self-confidence and self-reliance Passively allow spouses/partners to assume responsibility for choice of jobs, housing, even friends Can’t initiate activities Agree even when they know it is wrong Uncomfortable when left alone—even panicky Unable to make demands on others Seek new relationships quickly when old ones end May accept abuse to stay in relationships Both dependent behavior and attachment problems 2%; either males=females or females>males Causes Small genetic influence Psychodynamic—unresolved oral issues; attachment issues; fear of abandonment Behaviorists—parents unintentionally reward clinging and loyal behavior, while punishing acts of independence, perhaps through withdrawal of love Cognitive—two key views: I am inadequate and helpless to deal with the world and I must find a person to provide protection so I can cope. Treatment— Modestly helpful Group therapy can be helpful Also the usual suspects Perfectionist Preoccupied with details, rules, etc Never finish projects Work—not pleasure—oriented Inflexible regarding moral issues Hoard money, may be unable to discard worn out and useless stuff Stubborn, everything must be done today Difference with OCD—those with OCD typically do not want or like their sx, those with OCPD embrace their symptoms 2-5% (your book says 1%) prevalence Males>females by about 2:1 Some overlap with narcissistic, antisocial, and schizoid pd Causes Dimensional approach—high levels conscientiousness and assertiveness, but low level of compliance Psychodynamic—anal regressive or retentive Cognitive—little to say about origin, but illogical thinking keeps it going Treatment Not likely to seek tx unless also have anx or depression Often respond well to cog or dynamic tx Do not respond well to behavioral or meds Axis II dx are often unreliable Personality processes are dimensional Arbitrary decisions are used to define degree of trait Dx are not based on mutually exclusive criteria Need clearer sets of classification rules Nonoverlapping Dimensional approach has been proposed, but which is best? Where is edge between personality and personality disorder? Homosexuality and American Psychiatry Removed from DSM in 1974 However, early sexologists such as Magnus Hirschfeld and Havelock Ellis both believed that it was natural Freud believed that its origins were early and it was unchangeable—nothing to be ashamed of Kinsey said 10 % (but this is wrong)—more like 2.5% Homosexuality around the world Prior to that was considered a disorder Never predominant Always men>women Never above 5% or so Some increased likelihood of stress, anxiety, and depression. More suicidal ideation. Paraphilias Recurrent, intense sexually arousing fantasies that generally involve nonhuman objects, suffering or humiliating oneself or one’s partner, or nonconsenting people Compulsive quality Nearly all male Usually occur in clusters—over half show more than one To dx, must be present for 6 months. There are 8 paraphilias, 5 of which we can dx if people act on them, regardless of whether or not the person experiences distress. Sexual fixation on some object other than another human and attachment of erotic importance to that object Media—type of material Form—particular shape Related—partialism—excessively aroused by a particular body part Transvestic fetishism Cross dressing does not equal transvestism—some men dress in drag for other reasons For the transvestite—sexually arousing Not typically harmful—typically in private or with consent of partner Typically operantly conditioned as children—many were dressed as girls; petticoat punishment Reasons as adults—sexually arousing, relaxing, role playing, adornment 68% are hetero Most keep it secret, even from partners or wives. When wives find out, most are confused or shocked. Most try to be understanding at first, but later become more negative Become sexually aroused from secretly viewing nudes Usually begins by age 15. Almost exclusively found in males Unsuspecting is key—not pornos or strippers Most are nonviolent, but may be violent if provoked More dangerous those who break in those who draw attention to themselves Risk is an element of the arousal Tend to be less sexually experienced, not likely to be married, harbor feelings of inadequacy, lack social skills, less likely to have sisters or female friends Sexual arousal from exposing genitals to others in culturally inappropriate situations Cross-culturally, fewer than 20% are reported to police 1/3 of college women have been victims of this 30% of all arrests for sexual offenses are for flashing About 10% of rapists and child molesters (in one sample) began as flashers Urge to exhibit begins in early adolescence., exhibitionism itself usually begins before age 18. Frequency declines after 40 What they are like: Typically young, unhappily married, timid, unassertive, lacking in social skills, lacking in sexual skills, doubts about own masculinity, suffer from feelings of inadequacy, many report overprotective mothers and poor rel. with fathers Preferred victims are girls or young women Indirect means of expressing hostility toward women, but they aren’t in touch with this About 50% report erections during, usually masturbate later Few are women—women who do this are typically motivated by rage/revenge Males—motivated by desire for sexual excitement Most aren’t dangerous, don’t make repeated calls to the same person Many patterns—obscenities, breathe heavily, sexual overtures, sex surveys, etc. Life exhibitionist-socially inadequate heterosexual male who can’t form intimate rel. Sexual sadism—sexual arousal from inflicting pain on another person Sexual masochism—experiencing pain Masochism is the only paraphilia found with any frequency in women—about 5% of masochists are women Sadomasochism is highly ritualized—not all pain is gratifying In a mild form—not uncommon Pain may be symbolic—like rubber paddle Serious injury is usually avoided Survey from S&M magazine—3/4 male, most married, men interested since childhood, women introduced to it Causes May have bio links to pleasure—pain causes release of endorphins, but this doesn’t explain symbolic pain or sadism Learning theorists—being spanked for masturbation Sociologists—losing control, letting go Problems— Behavior tx 1) Don’t want/seek tx 2) No motivation to change even if in tx (thus cog tx doesn’t work) 3) Should therapist impose own goals? 4) Perceived responsibility—client must know he can change Systematic desensitization—pair relaxation with arousing images Aversion tx—shock, nausea inducing drugs Social skills training Orgasmic reconditioning—begin with old images, then switch to appropriate ones Drugs Prozac—some effectiveness for exhibitionism, voyeurism, fetishism (OCD-type beh) Anti-androgen drugs—depo provera—decreases sexual desire in those at risk for sexual offenses. Decreases desire—not urges or behavior in a particular direction. High refusal and drop out rates for this treatment. Money (1978)—8 variables of gender Chromosomal (xx vs. xy) Gonadal (testes vs. ovaries) Prenatal hormonal gender Prenatal and neonatal brain hormonalization Internal accessory organs External genital appearance Pubertal hormonal gender Assigned gender identity 1) Persistent cross-gender identification 2) Profound discomfort or disgust with biological sex In kids Girls—tomboys Boys—less interest in rough and tumble play, lower activity levels, more creative, theatrical. More often described as beautiful or feminine babies. Typically show cross-gender preferences as early as 2 or 3—around that age— boys will seek dolls, may tuck away penis when playing. Typically ostracized in school. Transsexualism, also known as transgender—people with GID who do something about it Male to female 3x as common ; 1/30000 males, 1/100,000 females seek surgery. Also more effective Don’t consider selves to be homosexual Found throughout history Typically show cross gender preferences in play and dress early in childhood. Many say they have felt this way forever. There is no clear cause or understanding of this disorder. Sexual reassignment surgery—long process Psychotherapy typically fails. May be influenced by prenatal hormonal imbalances Also possibility that they are treated inappropriately or ambiguously by parents Counseling to assure adjustment (ie not someone who is lonely or schizophrenia) Hormone tx Real life test—live 1-2 yrs as new gender Surgery—male—remove genitalia without severing nerves. Then artificial vagina is created with skin of penis. Use device to dilate it for next 6 mos so it doesn’t close. Female—penis and scrotum are created from tissues in genital area. Need implants to stiffen penis. Largely cosmetic. Hormones for life. Outcome—Lundstrom et al (1984)—international literature—90% happy with surgery, positive results. Less unhappy with life. Those with better looking results have more positive outcome. Links between childhood sexual abuse and many negative outcomes PTSD, low self-esteem, depression, anxiety, sexual precocity, sexual withdrawal About 1/3 show no signs Prevalence—depends on definition, but about 10-12% men and 1520% of women Recovered memories—induction of false memories Effects are more negative Ongoing Penetration Threat or force Step or bio father Most cases—know victim Boys are more likely to be abused in public and by strangers Brother-sister is most common and not always harmful Father-daughter is second most commonYounger daughters—more socially inept, dependent fathers Older daughters—more authoritarian, angry fathers Fathers who are actively involved in child care are less likely to abuse General family disruption—conflict, abuse, alcoholism Recurrent intense sexually arousing fantasies, urges, and behaviors involving sexual activity with a prepubertal child Nearly all pedophiles are male; 2/3 of victims are girls Pedophiles are more likely to believe that children benefit from sexual contact Begins in adolescence and persists over a person’s life Tend to be shy, introverted, yet still desire to have mastery or control over someone How common? Definitions vary and way info is gathered varies, leaving wide estimates in how common this is. Somewhere between 14% and 25% of women in US are raped in their lifetimes. Reported rapes are 20x greater than Japan, 13x greater than GB Types of rape— Stranger—4% Spouse—9% (often a part of other violence in the home, rarely reported, marital rape exemption laws have all been repealed in this country) Acquaintance—19% Know well—22% In love with—46% Some studies have found rates of 80% by acquaintance or known person—these #s are hard to call because they may not perceive themselves as victims. Perhaps 5-16% of acquaintance rapes are reported. 1) Might not fit her idea of what a real rape is, even though she still feels the trauma 2) Might blame herself or be aware that others will 3) Might not recall incident well because of alcohol or drug use 4) Mistrust of police or legal system 5) Fear reprisals from rapist, his friends or his family 6) Fear publicity Both. 1970s—big thing about power, but sex seems to be a part of it Victims tend to be in teens/early 20s Rapists cite sexual motives Rapists share similarities with some of the paraphilias 60% are under 25 Hypersexual peer group Sexually active, but actually know little about sex Low SES Prior criminal record Accepting of rape myths Date rapists—tend to be more middle to upper middle class Poor cognitive appraisal of women (believe women lie) Poor social and communication skills Impulsive Sexually aroused by depictions of rape May have hx of sexual abuse Use strength to get what they want Difficult to treat successfully Meta-analyses show modest effects Cognitive-behavioral techniques are most effective Nonpedophile child molesters and exhibitionists respond better than pedophiles and rapists Repetitive, planned activity rather than a single event Immediately after—trouble sleeping, crying, fear of being alone, fear of sex, eating problems, headaches, irritability, withdrawn Distress peaks about 3 wks after, stays high for a month, then begins to decline Physical trauma combines with psychological factors (rape trauma syndrome) PTSD Negative impact on victim’s intimate relationships STDs Human sexual response Masters and Johnson Vasocongestion Myotonia 4 stages—Excitement, Plateau, Orgasm, Resolution Model was missing a cognitive piece—most sex researchers now consider a desire phase Disorders can occur in desire, excitement, or orgasm or pain Laumann, Paik, and Rosen (1999) 43% of women and 31% of men (18-59) experience sexual problems for women, problems decrease with age, except problems with lubrication for men, problems with decreased desire and erection increase with age pre and post marital (divorced, separated, widowed) increased risk for problems higher educational attainment is negatively corr. with sex problems for men and women Lack of desire or interest/aversion to sex, increasing in frequency over past generation Hypoactive Sexual Desire Disorder—little or no interest in sex, absence of fantasies More common among women Hard to define low desire, difficult to treat successfully Often brought in by other member in couple Causes Bio—testosterone deficiencies, thyroid, diabetes, medication for hypertension, CA, heart, and others Psych—anxiety, fatigue, lifestyle Sexual Aversion Disorder—phobia or panic level May be related to a hx of erectile problems in men; also to rape or sexual abuse Previously called impotence and frigidity Male erective disorder— Situational vs. generalized; primary vs. secondary Performance anxiety—big cause; also depression, s-e, etc. 10% of men experienced erectile problem in last 12 mos—varies with age 50-80% are due to organic factors—vascular problems, diabetes, spinal cord injury Exercise, wt loss, lower cholesterol all improve sexual functioning Female sexual arousal disorder—both subjective arousal and lubrication 19% of women have problems with lubrication often goes with other sexual disorders like HSDD usually situational more commonly has psych causes—anger and resentment toward partner, sexual trauma, anxiety, guilt, ineffective stimulation but physical causes also possible—vascular damage, decreased estrogen Male orgasmic disorder—cannot have orgasm even when highly aroused and had a great deal of stimulation Female orgasmic disorder 8% in last year –not necessarily dx most often is limited to intercourse bio causes-MS or neuro condition, side effect of meds, ETOH abuse also psy causes—hostility, anxiety, guilt 24% of women in last 12 mos accts for 25-35% of cases of female sex tx may be related to education, also to spectatoring Premature ejaculation—hard to define—but too rapid to permit selves or partner to enjoy sex fully. Def varies--<30 sec, <1min, or no voluntary control Dyspareunia—painful coitus 14% women, 3% men In women, most common cause—lack of lubrication Can also be caused by allergies to spermicides etc., vaginal infections, STDs, PID Psych causes—guilt, anx, sex trauma In men—genital infections, smegma Vaginismus—involuntary contraction of the pelvic muscles that surround outer 1/3 of vaginal barrel. Intercourse is painful or impossible. 12-17% of women seeking sex tx. Not conscious. Not bio based. Always have a physical first! Poor general health is related to most of these problems. Alcohol—interplay of expectancy and actual effects Cocaine—can decrease sexual desire, cause erectile or orgasmic dis. Vascular problems Cultural influences—cultures that have more negative attitudes toward sex have more dysfunctions Ineffective sexual techniques Irrational beliefs Performance anxiety Sexual trauma Sexual orientation 5 goals Therapy usually involves both partners Bio tx also available—viagra Sensate focusing Masters and Johnson—pioneered behavioral tx—focus on problem beh, not cause Cognitive-behavioral tx—teach script flexibility—novelty is good 1) change self-defeating beliefs and attitudes 2) teach sexual skills 3) enhance sexual knowledge 4) improve sexual communication 5) reduce performance anxiety Need to make sure that relationship out of bed is a good one Restructure negative thoughts—all or none thinking Evaluation –success varies by dx—vaginismus 80%; premature ejaculation 90%; HSDD—most difficult to treat successfully Tx works best when couples are motivated and get along well in other areas Two types of substance disorders in three classes (alcohol; sedativehypnotics, opioids) About 9.4 % of US adults meet criteria in a year Abuse—person uses a drug to the extent that he/she is often intoxicated and fails to meet obligations; no physiological dependence To dx—1 of Failure to fulfill major obligations Exposure to physical dangers such as operating machinery or driving drunk Legal problems Persistent social/interpersonal problems Dependence—aka addiction—physio dependence—tolerance and withdrawal sx Tolerance—greater and greater to achieve same effect Withdrawal—cramps, restlessness, even death—both psych and phys 3 of the following to dx Tolerance Withdrawal or taking drug to avoid withdrawal Uses more or more often than intended Tried and unable to reduce use Lots of time in obtaining or recovering from substance Use continues despite phys problems causes or worsened Activities given up or reduced b/c of use Course of alcoholism is erratic and fluctuating Often don’t seek help but appear in hospitals and jails. About 25,000 highway deaths per year—1/2 of total. ½ of all murders. Losses dues to medical treatment, lost productivity, losses due to death cost society about 200 billion annually Lower levels of ETOH abuse associated with ---marriage, being older, and higher levels of education Comorbid with antisocial, mania, other drug use, schizophrenia, panic Short term effects: Doesn’t undergo digestion. Instead into small intestine and into blood. Absorption is rapid; removal is slow. Depressant on CNS—sedation, sleep Expectancy effects Commonly: Low levels—stimulate brain cells activating pleasure areas of brain Higher levels—depress brain functioning inhibiting glutamate—leads to impaired learning, judgment, and self-control Effects of alcohol vary by drinker depending on tolerance, amt of food in stomach, physical condition, duration of drinking Physical effects of chronic use: Decreased sexual inhibition Lowered sexual performance Lapses of memory Hangover Cirrhosis in 15-30% of chronic drinkers; 27,000 deaths per year High caloric content can reduce the consumption of other foods leading to malnutrition Can cause nutritional deficiencies—interferes with ability to utilize nutrients Delirium tremens—disorientation, hallucinations, fear, tremors—lasts 3-6 days, death rates have declined due to drugs that help Korsakoff’s—memory, confabulation Fetal alcohol syndrome— Bio—2 keys 1) Ability of addictive drugs to activate areas of the brain that produce intrinsic pleasure and immediate powerful reward 2) Person’s biological makeup including genetic inheritance Psychosocial causes Psychological vulnerability Emotionally immature; impulsive, aggressive; require an inordinate amt of praise; expect a great deal of the world; low frustration tolerance Stress, tension reduction Expectations of social success Family relationship factors Presence of an alcoholic father Acute marital conflict Lax maternal supervision, inconsistent discipline Many family moves during early years Lack of attachment to father Lack of family cohesiveness Medications—block the desire to drink or reduce the side effects of withdrawal Psychological treatments Group therapy Environmental interventions—alleviate aversive life situation Behavior and cognitive behavior Aversive conditioning Skills training for younger drinkers Self-control training Controlled drinking—about 15-18% succeed with controlled drinking AA—dropout rates of about 50%; better than no tx Outcome studies and issues in treatment Low rates of success among hard-core substance abusers Recovery rates of a 70-90% with modern tx and aftercare Favorable outcomes—motivation to change and a positive relationship with therapist Drinking Check Up sessions—early stages help Relapse prevention Recognize indulgent behaviors Recognize apparently irrelevant decisions that serve as early warning signals Opium in use for thousands of years Morphine—powerful sedative and pain reliever—treated with acetic anhydride, you get heroin—more rapid and intense Commonly smoked, snorted eaten, skin popped or mainlined Withdrawal occurs after extended use within 8 yrs Withdrawal—many withdraw without help; others experience runny nose, tearing eyes, perspiration, restlessness, etc Social effects—centered on obtaining drug; leads to lying, stealing, etc.; disease like AIDS Three most common reasons cited: pleasure, curiosity, peer pressure Narcotics subculture Withdrawal does not reduce craving Methadone tx—newer bupenorphine—fewer side effects Similar psych to alcoholism Cocaine creates 4-6 hr euphoric state Amphetamines Abuse—acute toxic psychotic sx—visual, auditory, tactile hallucinations Sleeplessness Some meds to reduce cravings Must address feelings of tension and depression Used to treat ADHD and for appetite suppression Effects—psychologically and physically addictive Rapid tolerance High bp, enlarged pupils, unclear/rapid speech, loss of appetite, sweating, confusion, sleeplessness Withdrawal is physically painless; can be some cramping, nausea, diarrhea; depression may be a sx of abrupt withdrawal Effects—calming, induce sleep; excessive use leads to tolerance and dependence but tolerance does not increase the amt needed to cause death Brain damage and personality deterioration may occur Middle aged and older persons are susceptible to dependency when used as sleeping pills— silent abusers Alcohol is often used with the barbiturates Withdrawal can be dangerous and severe LSD and related drugs—hallucinogens Chemically-synthesized—discovered in 1938 Ineffective as a psychological tx—thought it would be a model for psychosis Trips can be pleasant or traumatic Flashbacks are involuntary recurrences Ecstasy (MDMA) Both hallucinogen and stimulant—feel hypersexual and uninhibited Originally developed as a diet pill in 1913 Increasingly popular as party drug Recreational use is associated with impulsivity and poor judgment Negative psychological and health consequences Dried and crushed leaves of the cannabis sativa plant Until the 1970s, marijuana rarely led to abuse or dependence, but it is now 4x stronger than it used to be, with 4x as much thc— more addictive Physically dependent—withdrawal includes flu-like sx, restlessness, and irritability Dangers—can cause panic reactions that last for 3-6 hrs Can interfere with sensorimotor tasks and cognitive fx— dangerous while driving Memory problems that persist beyond use, particularly for heavy users Lung disease—reduces ability to expel air Lower sperm count, abnormal ovulation Today, about 6% of hs seniors smoke marijuana daily and fewer than 55% believe that is harmful (Johnston et al, 2005) Poisonous alkaloid Dx—nicotine dependency syndrome or nicotine withdrawal disorder Higher rates in less educated Almost ½ of all smokers have quit Health risks decline 5-10 yrs after cessation Kills 1000 people a day, 1/6 deaths Tx of withdrawal— social support groups replace cigarette smoking with safer forms of nicotine self-directed change professional assistance all show about a 25 % success rate higher rates of success among those hospitalized for cancer, cardiovascular or pulmonary disease Schizophrenia is a group of psychotic disorders characterized by major disturbances in thought, emotion and behavior No one essential symptom Lifetime prevalence of 1% Higher risk in some groups—children of schizophrenia, schizophrenia in family, older father (45+) at birth, people of Afro-Caribbean origins living in UK Vast majority begin in late adolescence or early adulthood Prodromal phase—sx not obvious, but deterioration has begun; social withdrawal Males tend to have an earlier onset and more severe form; perhaps the female hormones are protective An excess or a distortion—hallucinations, delusions, bizarre beh. Disorganized speech: aka formal thought disorder Person fails to make sense despite seeming to conform to the semantic and syntactic rules governing verbal communication; aka cognitive slippage, derailment, loosening of associations, incoherence Clang Word salad Perseveration Neologisms—words that have meanings only to them May appear long before dx of schizophrenia Not exclusive to schizophrenia Delusions— From Latin verb ludere—“to play” tricks are played on the mind Beliefs that the rest of soc would disagree with or view as misinterpreting reality Not exclusive to schizophrenia 97% in one study of schizophrenia had delusions Lack insight that beh is odd Common types… Delusions of bodily changes Hallucinations Sensory experience in the absence of any external perceptual stimulus Auditory are the most common—75% of those with schizophrenia have these Imaging studies show increased activity in Broca’s area—area of the temporal lobe involved in speech production. Perhaps pts misinterpret their own self-generated inner speech as coming from another source Types: Audible thoughts Voices arguing Voices commenting Can also be visual, gustatory (food tastes strange), olfactory, tactile (tingling, burning, bugs), somatic (inside body) Inappropriate affect Negative symptoms—absence or deficit Poverty of speech—alogia Blunted or flat affect—66% of schizophrenia, but report feeling just as much + and – emotion. Further, display greater skin arousal Avolition—apathy—particularly common in those who have had schizophrenia for years. Anhedonia—lack of interest in recreational activities; inability to experience pleasure Social withdrawal Catatonia—may grimace, adopt strange facial expressions or bodily positions. May exhibit increase in activity or catatonic immobility Unusual postures are adopted and maintained for long periods. Waxy flexibility. Delusions of persecution and grandeur are common Ideas of reference—unimportant or trivial events have personal significant The “paranoid constitution” gives some sense of purpose and integrity Tend to function at a higher level and have more intact cognitive skills Prognosis generally better (in the west) More common style in the west—less common in less developed countries Diffuse symptoms Hallucinations and delusions—sex, hypochondriacal, religious, persecutory Incoherent speech Frequently deteriorates to the point of incontinence Earlier, more gradual onset Pattern of severe disorganization progressing into emotional indifference and infantile behavior Prognosis is poor Alternate between catatonic immobility and wild excitement, though one may be predominant— pronounced symptoms are apparent Can be violent Echolalia or echopraxia (mimic actions) Negativistic—resist instructions Onset pretty sudden comparatively May recall actions of stupor later on Used to be a more common subtype, now less so here; still more common in less industrialized areas Stupor has been interpreted as way of coping or maintaining control Undifferentiated— Wastebasket category May be in acute, early stages Residual type Suffered at least one episode of schizophrenia, but not currently exhibiting any prominent positive or disorganized symptoms Prominent symptoms are negative Social withdrawal, impaired role functioning, blunted or inappropriate affect, lack of initiative, vague and circumstantial speech, impaired hygiene or grooming, odd beliefs or magical thinking Schizoaffective disorder Schizophreniform Features of schizophrenia and a mood disorder (either bipolar or unipolar) Prognosis better than for schizophrenia alone Schizophrenia-like psychoses that last at least one month, but not as long as 6 months Most often seen in an undifferentiated form May or may not be related to subsequent psychiatric disorder Prognosis better than for schizophrenia Delusional disorder Other than delusions, behave normally Generally nonbizarre (could happen but aren’t) Brief psychotic disorder Sudden onset of psychotic, grossly disorganized, or catatonic sx Often lasts only days; less than a month Often triggered by stress Returns to normal functioning Shared psychotic disorder (folie a deux) Dx when individual in a close relationship with a psychotic individual begins to believe same delusions May spread to an entire family Concordance rates: General pop Spouse First cousin Grandchild Kids Siblings DZ MZ 2% 2% 5% 6-9% 9% 12-17% 44-48% 1% Studies of discordant MZ twins show that children of the well twin are at a significantly higher risk of developing schizophrenia (17% or so) Twin studies overestimate importance of genes because of shared environment. Adopted kids or schizophrenia parents—still at higher risk Multiple gene disorder—regions on chromosomes 22, 7, 8, and 1 Currently looking for candidate genes—genes known to be involved in some of the processes that are known to be problematic in schizophrenia Prenatal viral exposures—in Northern hemisphere, more are born in spring Rhesus incompatibility 1957 flu epidemic in Finland—elevated rates of schizophrenia in children whose mothers had been in their second trimester Increased risk—for males, about 2.1% Mechanism may involve oxygen deprivation Prenatal birth complications Early nutritional deficiency Dutch hunger winter—conceived at ht of famine—2x increase in risk Unclear if this is general hunger or a specific nutrient Brain volume—larger ventricles—3% reduction in brain volume Males more affected than females Not specific to schizophrenia Cortical tissue loss increases over time Specific brain areas Problems in frontal and temporal lobes as well as neighboring (medial temporal) areas such as hippocampus and thalamus Not specific to schizophrenia, not shown in all schizophrenia Abnormally low frontal lobe activity associated with negative sx Neurochemistry Dopamine hypothesis Pharmacological action of Thorazine Amphetamine induced psychosis Drugs increasing dopamine may create psychotic sx Dysregulated dopamine may create aberrant salience (pay more attn to stimuli that are not relevant or important) But no strong evidence that pts with dopamine are producing more dopamine than controls Focus is on receptor sensitivity Social class—more schizophrenia in lowest class Why? Poor tx from others, poor ed, no opportunity Or social selection theory (most, not all variance, by this) Urban environment—2.7x risk Family—expressed emotion (critical, hostile, and overinvolved) increases relapse No evidence for schizophrogenic mother Immigration—migrants are at 2.7x risk Black skin migrant have higher risk than migrant with white skin Appears to be related to stress and discrimination Clinical outcome 15-25 yrs after developing schizophrenia, about 38% have a favorable outcome, but this does not mean a return to premorbid functioning 16% recover to point that they no longer need tx 12% need long term institutionalization 1/3 show signs of continued negative sx Spontaneous improvements late in life sometimes occur First generation—thorazine, haldol—neuroleptics Block action of dopamine by blocking D2 receptors Work best for + symptoms Side effects—drowsiness, dry mouth, wt gain, tardive dyskinesia, extrapyramidal side effects( involuntary movements, such as shaking or rigidity) Second generation Clozaril, Risperdal, Seroquel, Geodon, Abilify Fewer extrapyramidal side effects Decrease in both + and – sx Block a wider array of receptors, including D4 Side effects include drowsiness, drooling, wt gain, diabetes, agrunulocytosis (drop in white blood cells) Family therapy Goal to reduce EE Involves education, coping, problem solving, communication Case management Social skills training Cognitive-behavioral—goal is to decrease intensity of + sx, reduce relapse, decrease social disability. Results promising. Think A Beautiful Mind Individual treatment Psychodynamic can make some pts worse Coping skills tx is effective in enhancing social adjustment Ageism 80% of the elderly report having experienced ageism, such as people assuming they have memory or physical impairments due to age 31% report being ignored or not taken seriously because of their age 58% report being told jokes that make fun of older persons (Palmore, 2005, 2004, 2001) Positive ageism—emphasize that there are no disadvantages to growing old. Elderly are a growing population: 1900 2000 2040 4% were over 65 13% 21-25%--baby boomers Number of people over 80 will double in the next 10 years—fastest growing segment of the population Three groups Young old 65-74 Old-old 75-84 Oldest old 85 and up Over 95: more clear-headed, agile, and healthy than those in their 80s and early 90s. Many of these are sexually active, working, enjoying the outdoors and the arts. Resistant to disabling and terminal infections. People themselves credit good frame of mind and healthy regular behaviors (diet and exercise, not smoking) Age effects—consequences of being a given age Cohort effects—consequences of being born at a particular time Time of measurement—events at a particular point in time affect research, too People often blame age for the problems of the old, but 10-20% have psych problems Depression in later life Overall as many as 20% of people experience depression in old age—highest rates in older women Some studies indicate that depression decreases with age Depression increases risk of developing significant medical problems Also risk of secondary depression—30% of those with chronic health problems are depressed Increased risk for suicide—even more than among the young 19/100,000 (compared to 12/100,000 for other adults). Among white men over 85 it is 65/100,000 Risk factors for suicide: physical illness, hopelessness, social isolation, loss of loved one Depression may be confused with cognitive problems—those who are depressed complain more of memory problems than the demented do. Tend to underestimate their abilities. Make more errors of omission Treatment does work Antidepressants—side effects—drugs break down differently later in life ECT—back in favor Cognitive tx Interpersonal tx Insomnia is more common among older than younger people At least 40% of those over 65 experience some measure of insomnia Prone to this because of medical ailments, pain ,medications, depression, anxiety Also normal physical changes—as we age, we spend less time in deep and REM sleep; sleep is more readily interrupted, we have trouble falling back asleep Maybe 10% of elderly have sleep apnea At any given time 6% of elderly men and 11% of elderly women (Fisher et al 2001) GAD is particularly common—up to 7% of all elderly Prevalence increases with age—higher among those over 85 May be related to declining health—see higher rates in those with medical problems Have not been able to identify why some get anxious and others stay generally calm Treated with cognitive tx, benzos, prozac—just like younger people, but side effects are a risk Prevalence of such patterns declines after 60—perhaps declining health or reduced financial status. Accurate abuse data are hard to come by 4-7% of older people, particularly men—alcohol related disorders in a given year Men under 30 are 4X as likely to exhibit a behavioral problem assoc with alcohol Higher rates in those who are institutionalized in general medical and psych hospitals among the elderly—estimates range 15-49% Among those who begin drinking in old age—reaction to negative events, pressures of growing older such as living alone, unwanted retirement, death of a spouse Prescription drugs are another issue Elderly make up 13% of the population, but consume ¼ of prescription drugs Risk of confusing medications, missing doses is high Overprescription is also a problem Psychosis is often associated with delirium or dementia Schizophrenia actually decreases a bit— symptoms tend to diminish some with age Delusional disorder which typically has a prevalence of about 3/100,000—increases in the elderly Unclear about why this increase is there— researchers guess that it is related to deficiencies in hearing, social isolation, greater stress, or heightened poverty Brain impairment in adults For the most part, cell bodies and neural pathways do not regenerate Impairment may involved acquired and customary skills or anosognosia—capacity or realistic self-appraisal Impairment depends on Nature, location, and extent of neural damage Premorbid competence and personality of the individual Individual’s life situation Amount of time since the first appearance of the condition Diffuse vs. focal damage Mild to moderate diffuse damage—may impair attention; would see this type of damage with oxygen deprivation or ingestion of toxic substance like mercury Person may complain of memory problems due to difficulty focusing Focal damage is to a specific region—defined trauma, stroke Frontal lobes—one of two patterns: 1) behavioral inertia, apathy 2) impulsivity, distractibility Right parietal lobe—visual-motor coordination Temporal lobe—memory, eating, sexuality, emotions (depending on part) Left parietal lobe—language, writing, reading, arithmetic Problems we see with brain disorders Impairment of memory; including confabulation Impairment of orientation (unable to locate self in time or space) Impairment of learning, comprehension, and judgment Impairment of emotional control or modulation Apathy or emotional blunting Impairment in the initiation of behavior Impairment of controls over matters of propriety and ethical conduct Impairment of receptive and expressive language Impaired visuospatial ability Affects 2 million in US each year Often misdiagnosed More common in kids and older adults When elderly enter hospital for general medical condition, 1/10 shows symptoms of delirium. Another 10% will develop delirium in hospital. But—studies show that admission docs detect only about 1/15 cases of delirium (Cameron et al 1987) Acute confusional state with sudden onset, fluctuating state of awareness Cognitive changes like impaired informational processing Disturbances of the sleep cycle—worse at night—vivid dreams May slur Make perceptual errors—unfamiliar for familiar Paranoid delusions in 40-70% Swings in activity and mood May be fever, flushed face, dilated pupils, increased heart and bp Do have lucid intervals—fluctuation is key for diagnosis Mortality is high—up to 40% die In elderly, people often assume that state can’t be fixed and so don’t look into it May be superimposed on another diagnosis Drug intoxication (including prescriptions) Infections Fever Malnutrition Head trauma Pneumonia Congestive heart failure Cancer Uremia Dehydration Stroke Treatment: medical emergency Usually reversible May involve medications (neuroleptics or benzos for drug withdrawal) May involve environmental manipulations such as orienting techniques Senility Gradual deterioration of intellectual abilities to the point that social and occupational functioning are impaired. Onset is typically gradual Memory for recent events is affected in early stages. With time, increasingly marked comprehension, motor control, problem solving and judgment Often accompanied by impairment in emotional control or moral or ethical sensibilities Dementia may be progressive or static Occasionally reversible if underlying cause can be treated Causes: stroke, degenerative diseases (Alzheimer’s, Huntington’s, Parkinson’s), infectious diseases (syphilis, meningitis, AIDS), intracranial tumors and abscesses, dietary deficiencies (B vitamins), head injury, anoxia, toxic substances 30 % of those over 80 3-9% of world’s adults 5 million Americans 70 forms identified Most common form of dementia. Accounts for 50-66% of all cases. Sometimes occurs in middle age (called early onset), but most often after age 65 (late onset). Prevalence markedly increases in late 70s and early 80s. Problem may be underestimated. Women have a slightly higher risk. May survive for 20 years, but time between onset and death is usually 8-10 years. Begins with mild memory problems, lapses of attention, difficulties in language and communication. As symptoms worsen, difficulty completing complicated tasks. Eventually, sufferers have difficulty with simple tasks, distant memories are forgotten, changes in personality are very noticeable. Typically early on deny they have a problem. Then become anxious or depressed about state of mind. Many become agitated. As sx worsen, show less and less awareness of limitations. During late stages, may withdraw. Also late stage—wandering, confused about time and space. Eventually fully dependent. Fail to remember close relatives. Uncomfortable at night (sundowners). Late phase may last 2-5 yrs. Stay physically healthy until later stages of disease. Often succumb to opportunistic infections—spend a lot of time lying— prone to pneumonia. Can only be officially diagnosed after death Marked by neurofibrillary tangles Twisted protein fibers found within the cells of the hippocampus and other areas. Occur in all people as they age, but Alzheimer's patients have lots Senile plaques Sphere-shaped deposits of a small molecule called betaamyloid protein that form in the spaces between cells in the hippocampus, cerebral cortex, and other areas. Normal part of aging, Alzheimer's patients have lots. In most people, these are comprised of 40 amino acids with a few that have 42. In Alzheimer's, there are many more AB42s. Plaques may interfere with communication between cells and so cause cell breakdown or cell death. Genetics Many, but not all cases, run in families. Distinguish between familial vs. sporadic Alzheimer's Early onset—three rare genetic mutations that can cause this (about 5% of cases)—on chromosomes 21, 14, 1 Late onset—chromosome 19 MZ twins are not perfectly concordant. Genetic risks interact with environment—diet, exposure to metals such as aluminum, experiencing head trauma Exposure to ibuprofen may be protective No effective treatment exists Medications such as Cognex and Aricept and Namenda help delay Work on vaccines continues Behavioral techniques to control wandering, incontinence, inappropriate sexual behaviors, and poor self-care Treating caregivers—social death of the patient; anticipatory grief Caregivers are at risk for depression Counseling and support are effective About 70% live at home ¾ of caregivers are women Caring for a loved one takes an average of 69-100 hours per week Major worries of caregiver—54% -cost of help, 49%-Alzheimer's related stress on family, 49%-lack of time to attend to own needs; Alzheimer's Assoc, 1997, Thomas et al 2002 Vascular dementia—multi-infarct dementia Similar clinical picture to Alzheimer's Series of infarcts destroy neurons over expanding brain regions After 50; more common in men About 19% of all dementia cases Vulnerable to death from stroke Mood disorders more common than in AD Can manage cerebral arteriosclerosis to some extent Creutzfeld-Jakob Disease—slow acting virus that may live in the body for years; then rapid course Dementia from HIV-1 infection HIV can result in destruction of brain cells May lead to psychotic phenomena Damage may occur throughout brain, but tends to be localized in subcortical regions 30-60% of untreated pts with HIV will develop AIDS-related dementia; with current antiviral tx, rate reduces to 20% Central feature is strikingly disturbed memory or amnesia Immediate recall and memory for remote events is usually preserved Short term memory is typically very impaired Confabulation is common Overall cognitive functioning is relatively intact Korsakoff’s Syndrome—follows severe alcohol abuse May also be caused by head trauma, stroke, surgery in the temporal lobe, hypoxia Depending on cause, may abate wholly or partially Affects more than 2 million per year Most common cause—MVA, followed by falls, assaults, sports injuries Men 15-24 are at greatest risk Three types of head injury—closed, penetrating, skull fractures Immediate acute reactions—unconscious, disruption of circulatory, metabolic, and neurotransmitter regulation Retrograde and anterograde amnesia are common Person typically passes through stupor and confusion on way to recovering clear consciousness Coma may occur Treatment—prompt medical attention is required Mild concussions improve quickly Minority—personality change Severe injury—poor prognosis 24% of TBI develop post-traumatic epilepsy, presumably because of the growth of scar tissue Take a developmental perspective Tasks a child should be handling and see how they’re doing All of this is culturally related. Often an attempt to adapt to negative circumstances. Issues in working with children: 1) Limited capacity to understand in children 2) More difficulty coping as cannot put problems into perspective of a past and future 3) Use unrealistic concepts to explain things (don’t understand death, etc) 4) Dependent on others for help Adultomorphism 1/5 children has a disorder that disrupts functioning. 1/10 has a disorder that severely impairs functioning. Loosely categorized into externalizing and internalizing. Inattention—doesn’t pay attention/makes careless mistakes Hyperactive Fidgets Can’t stay seated Runs or climbs excessively/inappropriately Can’t play quietly On the go/driven by a motor Girls tend to have PI, boys PH or C; 2-3X more common in boys (not 6-9x as text says) Other issues: 7-15 points lower IQ Doesn’t listen when spoken to Doesn’t follow through on instructions Difficulty getting organized Avoids things that require concentration Social problems Emotional competence Those with PI are more likely to have internalizing problems, LD, slow pace of problem solving Prevalence is 3-5% of school aged kids 50-70% continue to have problems into adolescence and adulthood; less hyperactivity with age Poorer prognosis when comorbid with CD As adults—more car accidents, higher risk of substance abuse Causes: Multiple biological and psychological causes. Frontal lobe deficits Runs in families Mothers report more stress; negative parenting Not caused by diet, additives Treatments: 70-80% on stimulants improve Side effects: decreased appetite, insomnia, abdominal pain, headaches, crying spells, stunts growth—drug holidays. Don’t improve social skills or academics. Behavior modification Combination most effective Social skills training, cognitive-behavioral effective after sx under control Typically kids 3-7 Poor control of emotions Noncompliant Argumentative with parents and teachers Conflicts with peers Tantrums Problem with ODD: some sx are very common Majority of kids with ODD will go on to show conduct problems. Risk factors: family discord, low SES, antisocial beh. in parents More serious behavior problems Repetitive, persistent problems with behaviors that are potentially harmful to child, others, or property Sx—physical fights, weapons, stealing with or without confrontation, fires, sexual aggression, truancy, lying, running away overnight, breaking into house, bldg or car, bullying, cruelty to animals or people Demographics vary greatly. More common in boys. Boys have more aggressive subtypes. Girls tend toward less confrontational sx. Prognosis factors Childhood onset vs. adolescence-limited Degree of callous-unemotional traits Big three sx: fires, cruelty to animals, cruelty to people Socialized vs. unsocialized Early onset is linked to APD (25-40%) Even if not APD, often associated with life problems such as divorce, joblessness, and abusive parenting Biological Danish adoption study—parent history of criminality and % of kids convicted of conduct offense Bio Yes No Adop yes 25 14 No 20 13 Generally lower levels of adrenaline—low arousal Psychosocial causes— Gerald Patterson—coercive cycles—kid is obnoxious until parent relents; parents engage in negative parenting Parents of CD kids more likely to behave in ways that encourage development of coercive styles; criticize more, issue more commands Adverse environmental factors make it harder to use positive child rearing skills—substance abuse, marital distress, violence, poverty, social isolation, death of a family member Self-perpetuating—deviancy training Difficult temperament leads to poor attachment Hostile attribution bias Society picks punitive rather than treatment based approaches but… Must be multimodal Need to address family issues Behavioral programs All most effective at young ages SAD—characterized by worry that caregiver will get hurt/child hurt if not with caregiver Normal in young kids—not a disorder until past normal period, generally 6-9 School avoidance present in ¾ Often have specific phobias as well May be acute onset following big life changes; may wax and wane More common in girls Generalized Anxiety Disorder Pervasive diffuse worry 95% worry all the time ½ meet MDD criteria Seems to be chronic Selective mutism— Persistent failure to speak in specific social situations Can speak and understand language Rare, most common at school entry More common in families where taciturn behavior is prominent Stress and family environmental factors Phobias—simple—consider in context of kids’ normal fears Fears can be adaptive, but can become phobias Unusual age of onset Intensity Persistence of fear Type of fear—rational or not Morris and Kratchowill (1989) Toddlers—separation, animals, dark Preschool—strangers, bodily harm, toddler fears School age-being alone, imaginary beings, violence, death, dark, injury, storms, teasing Teens—peer rejection, achievement, family problems, war, poverty, AIDS Causal factors in anxiety disorders: Modeling of anxious parents Indifferent or detached parent may instill insecurity Temperament Cultural factors Genetic link—anxiety in parents predicts anxiety in kids Treatment: Meds—common, not yet well established. Possibly prozac Behavior therapy—focused on assertiveness training and desensitization Cognitive-behavioral tx Adult criteria are used, but there are limitations in this Kids are less adept at expressing the cognitive symptoms Childhood depression is not factor analytically distinct from anxiety Ability to feel and express shame and guilt does not emerge until age 7 or so Many more somatic complaints in kids Social withdrawal is common, but this looks different in children—not able to choose to stay home Irritability is common instead of overtly depressed mood Hallucinations are more common in children than adults Wt. issues may be failure to make expected gains instead of wt. loss Younger kids—depression is more common in boys or equal in boys and girls By adolescence—more common in girls Prevalence==.4-2.5% in children, 4-8.3% for adolescents Causal factors Treatments— Genetic component –higher risk if parent is depressed Early exposure to traumatic events, including death of a parent Parent-child interaction in transmission of depressed affect Cognitive—global, internal, stable Antidepressants are not well established. Some studies show no effect, others show a moderate effect. Concern about side effects and suicidal thoughts. Suicide appraisal is important—longitudinal study of 8-13 yo who were depressed found that 1/3 made suicide attempts in the next 7 yrs. Perhaps 7%-1/10 of all teens make a suicide attempt Cognitive behavioral techniques are effective 75 outcome studies Average outcome for a treated child was 2/3 of an SD better than untreated kids Beh>nonbeh Play or non-play did not matter Parents or no parents did not matter Experience, education and sex of therapist did not matter Greatest improvements for specific problems, global issues like self-esteem and social adjustment improved less Group of severely disabling conditions Result of structural differences in the brain Examples include Asperger’s and Autism Prevalence unclear, but increasing, maybe 3.2% of clinic cases Three primary features: noncommunicative speech, social isolation, need for sameness Appears as early as 1 yr to 18 months when kid are not making eye contact Social deficit-do not want physical contact, do not show affection Self-stimulation—stereotyped movements Panic if routine is changed Intellectual ability—have thought that most have IQs in MR range. New studies questions whether this is so or whether it is an artifact of testing. Theory of mind deficits Less time in symbolic play Not the same as schizophrenia 4x more common in boys About 5% of autistics are savants—isolated skills of great talent with no known cause or training Not caused parents actions (refrigerator mothers—retreat in autistic fortress) Not caused by vaccines. Multiple big studies. Precise cause is unknown. Based on twin studies, 80-90% is based on genetic factors. Fragile X in 8% of autistic males. Increased frequency of pre and perinatal complications Many brain abnormalities Poor prognosis No medications— Behavioral tx work best Eliminate self-injurious behavior Social skills training Development of language skills Hard to find reinforcers Don’t like change Self-stimulation interferes with teaching Difficulty generalizing learning Lovaas—highly positive results Intensive, in home 47% achieved normal intellectual functioning Disorders of receptive and expressive language and reading, writing, mathematics Reading disorder Word recognition, reading comprehension Typically spelling too Difficulty with oral reading—either omit or add Phonological awareness! 2-8% of kids (5% sounds about right) Mathematics disorder Two groups are highly comorbid All are more common in boys Look for discrepancy between expected and actual achievement Difficulty with variety of skills including coding written problems into math symbols; perceptual organization skills like recognizing symbols Less common than reading, maybe 1% of kids Written expression Impairment of ability to write words, spelling, grammar, punctuation, ,handwriting Write less complex and less interesting essays <1% of kids Less research on this Receptive-expressive language disorder Trouble producing and understanding spoken language Those with receptive may appear deaf Phonological disorder Able to comprehend and use substantial vocabulary, but actual sounds are disturbed. Later acquired speech sounds are more difficult—r, sh, th, f, z, l, ch, j May need speech therapy May recover Causes Treatment Genetically influenced Neurological deficits Instruction on listening, speaking, reading, and writing skills in a logical, sequential manner. Hands on instruction. Time in seat on task. Not discovery-based. Long term Some deficits continue to adulthood. Lower occupational attainment than would be expected. Cover for deficits by listening to news instead of reading, etc. Significantly subaverage intellectual functioning Deficits in adaptive functioning Occurring prior to age 18 Intelligence testing—2 sds below Adaptive functioning About 2.5% of population in theory, 5% in practice Problem—what is adaptive in some places isn’t in others Time of onset—can’t occur from an accident later in life Dx often in infancy or before birth Mild cases most often dx’d in school—no obvious phys or neuro manifestations Only about 25% have known organic cause. Most mild cases have no known cause Mild—50/55 to 70 AKA EMI Moderate—35/40 to 50/55 AKA TMI 10% of ID pop May have phys defects that hinder fine motor skills (pencils) and gross motor (running, climbing) skills Learn to about 2nd grade level Learn some self-care skills Partial independent living—group homes Severe—20/25 to 35/40 85% of ID pop By late teens can learn to about 6th grade level Unskilled jobs or sheltered workshops May marry, have kids Often no brain pathology, just kids with parents with low SES, low IQ 3-4% of ID pop Limited sensorimotor control. Some congenital physical abnormalities May be friendly, but can communicate only at a concrete level Profound—IQ below 20/25 1-2% of ID pop Require total supervision and often nursing care High mortality in childhood Can improve skills with training All ID have deficits to some degree in Communication Academics Sensorimotor skills Self-help Vocational skills Etiology Lack of exposure to reading materials; poor parenting Down syndrome (1/1000 births). Most < 50. PKU 1/14000 FAS Infectious diseases (German measles, syphilis) prenatally Prematurity Malnutrition Accidents Radiation in pregnancy Lead poisoning Anoxia Treatment Families are satisfied with choice of institutionalization or not Community-oriented care has positives for adolescents Mainstreaming vs. self-contained-- Children do well in mainstreaming—modest gains in social skills No particular academic advantage (except for mild MR who may not have rec’d enough attn in self-contained room) Other children are not harmed by ID kids in room Child’s inability to seek assistance Parental consent is needed except for mature/emancipated minors, emergencies, court order Risk factors for kids Need to address family issues Placement issues Juvenile detention Boot camps Deviancy training
