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MENTAL ILLNESS. ADULT PSYCHOPATHOLOGY Definitions of mental health vs. illness vary: culture: great variability SES (a rich man is eccentric, a poor one is mad) age: more acceptance of ‘odd’ behaviours in the elderly

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  1. MENTAL ILLNESS ADULT PSYCHOPATHOLOGY Definitions of mental health vs. illness vary: • culture: great variability • SES (a rich man is eccentric, a poor one is mad) • age: more acceptance of ‘odd’ behaviours in the elderly • gender: different cultural expectations, less tolerance of deviance in women

  2. ADULT PSYCHOPATHOLOGY (Cont’d) Ideal vs. real mental health (e.g. text) • Difference between stress and coping mechanisms, which can sometimes be maladaptive, and full blown mental illness. • Change is always stressful, individual variation in optimal levels of stress. • Summation of stresses as we age: depletion of coping resources vs. development of better coping strategies.

  3. ADULT PSYCHOPATHOLOGY (Cont’d) Important personal variables: • past history • personality • social supports • SES • locus of control (women, poor and elderly more external) • longevity (higher incidence)

  4. ADULT PSYCHOPATHOLOGY (Cont’d) Bottom line criterion for mental illness: • inability to function Importance of label, stigma Relative influence of nature vs. nurture (heredity/environment): • the higher the genetic predisposition, the fewer environmental insults needed to produce mental illness.

  5. ADULT PSYCHOPATHOLOGY (Cont’d) Most common model of mental illness: • medical model Medical model: • a series of culturally unacceptable behaviours is ‘packaged’ into a diagnostic category. DSM: • no uniform, testable criteria.

  6. ADULT PSYCHOPATHOLOGY (Cont’d) Each category has: • Symptoms (mix of behavioural and physical) • Underlying cause (etiology) • Treatment (can be just palliative or geared to eradicate the cause) Approaches: • biological • psychological • combination of both

  7. ADULT PSYCHOPATHOLOGY (Cont’d) Biological approach: • organic causes (brain) • treatment: drugs, ECT, surgery Psychological approach: • causes: stress, emotions, personality, childhood experiences, poor coping strategies • treatment: psychotherapy (rare for the elderly) Combination approach: • causes: both organic and environmental • treatment: usually drugs and some level of psychotherapy

  8. ADULT PSYCHOPATHOLOGY (Cont’d) Etiology of mental illness: • organic, e.g. Alzheimer's • functional or psychic, e.g. phobias • organic + environment, e.g. most • “problems in living” (Szasz) Treatments: • drugs • ECT • psychotherapies • out vs. inpatient

  9. stroke heart attack malnutrition trauma tumors infections electrolite imbalance diabetes thyroid dysfunction liver dysfunction drugs alcohol (Korsakoff syndrome) surgery (anesthesia) Brain disorders (delirium in text – covers only acute disorders) can be acute or chronic. Acute: rapid onset, reversible with treatment. Chronic: slow and gradual onset, degenerative, irreversible. Acute Brain Disorders: Many possible causes: • agitation • changes in sensation and perception • Some symptoms: • confusion • disorganized thinking

  10. Unfortunately, the reversible illnesses are treated as irreversible in the elderly, therefore depriving them of a possible cure. Chronic Brain Disorders Schizophrenia: • onset between ages 13 and 30, chronic • Delusions: • thought disorders, belief system • Hallucinations: • sensory perceptions not based on actual, real stimuli • Inappropriate Affect • Managed with drugs

  11. Depression: Very high incidence all ages. Two types: • Unipolar: depression only, more common in older adults. • Bipolar: alternating depression and mania, also called manic-depression. More common in the young. Depression can also be: • Reactive: acute, short duration, due to events, responds to psychotherapy alone, support. • Chronic: long term, resistant to psychotherapy, often need physical therapies, e.g. drugs, ECT.

  12. Drugs: • tricyclics, MAO inhibitors, lithium (for bipolar, very toxic to liver and kidneys, increases blood pressure), SSRIs: selective serotonin reuptake inhibitors, e.g. Prozac, Zoloft, Paxil, etc. • Side effects of drugs leads to low compliance. Also danger of drug interactions (potentiate or decrease effect when combined with other drugs) often dangerous.

  13. ECT: • electroconvulsive therapy, “shock”, memory deficits, brain damage possible. Nobody knows how it works. Psychoactive drugs for the elderly: • Elderly need lower doses!! • More problematic, as dosages have to be more carefully adjusted, usually downward. Also problem of interaction with other drugs taken for other problems. Polypharmacy.

  14. Some Signs of Depression: • dysphoria • insomnia • fatigue • inability to enjoy things that were liked • changes in appetite • crying jags • despair • apathy • pessimism • differences between young and old: young may cover it up better • impaired daily functioning • negative thoughts, suicidal ideation

  15. People with chronic illnesses very vulnerable to depression • Some diseases of middle/old age can also cause depression: • CV disease • brain disorders (Parkinson’s, MS, dementias, etc.) • metabolic disturbances (e.g. diabetes, thyroid) • cancer • post-operatory period • many drugs can cause depression and suicide

  16. Gender Issues: • Gender: women socialized to self-blame, more prone. • Age: depletion syndrome of the elderly, somewhat similar to depression. It increases with age, depression proper decreases. Role of marital status: • Before age 65: higher incidence for single men and married women. • After age 65: reverse

  17. Gender Issues (Cont’d): • Marriage improves men’s mental health. It negatively affects women’s mental health. This is reversed after age 65. • Men more likely to show: • ‘acting out’ • alcoholism • drug abuse • criminal behaviour • reluctance to seek help • but, because of social male stereotypes, more tolerance for the above and less likely to be labelled and stigmatized.

  18. Gender Issues (Cont’d): • Women more likely to show: • anxiety • depression • self-blaming • intense emotional expression • Women more likely to acknowledge problems and seek help, and more likely to be labelled, stigmatized and given psychotropic medication. Influence of feminine stereotypes, powerlessness.

  19. Psychotherapy for the elderly: • Not common. Most therapists not trained to deal with problems of the elderly. • Higher tolerance for deviant behaviour. • Therapists more interested in YAVIS: (young, attractive, verbal, intelligent, successful) • Expense (private or public) • Many elderly suspicious or reluctant

  20. Organic Brain Disorders: • Alzheimer’s • Multi-infarct dementia • Huntington’s chorea • Parkinson's • Lewy body dementia

  21. Alzheimer’s Disease: • Chronic, irreversible, degenerative disease of brain. • No known cause, some genetic markers – iffy • Type of dementia – brain syndrome • Parts of brain involved: • amygdala (emotions) • hippocampus (memory) • cerebral cortex (reason, judgment)

  22. Alzheimer’s – Histological Changes • Amyloid plaques: clusters of protein bits that accumulate, causing inflammation and damaging neurons. • Neurofibrillary tangles: dendrites change structure and disintegrate, leading the neuron to wither and die.

  23. Alzheimer’s Affects Amygdala Hippocampus Cortex Personality Memory Reasoning Appetites Works Back- Judgment Energy wards Decisions Drives ex: Irritable Fussy Chronic, Irreversible Death Usual Cause: Pneumonia 8 mo. – 20 years

  24. 4 Phases: • Early Changes: • Irritability • “Something Wrong” • Memory • Cover-Ups & Compensations Hard to Assess • Retrospective

  25. 4 Phases (Cont’d): 2. • Memory Worse • Paranoia • Odd, Inappropriate Social Behavior • Needs Help (eg. banking, bills) • Personality Change 3. • Unsafe to Leave Alone • Poor Concentration • Memory Gone 4. • Terminal • No Coordination • Swallowing difficult or impossible • Agitation • Bed Ridden

  26. Usual Course Functionality Time

  27. Assessment methods: • Clinical interview (most common) • Self-report (reliability and validity?) e.g. questionnaire • Other’s report (relatives, neighbours) • Psychophysiological (psychological stimulus, physiological response) e.g. fearful stimulus-situation and EEG or heart rate

  28. Assessment methods: • Direct observation in situ (e.g. nursing home dining room) • Performance test (e.g. remembering list, drawing a picture after looking at it for 10 seconds)

  29. Critical areas: • cognitive functioning • social cognition • personality Must be preceded by medical exam to rule out diseases or medication effects, and assessment of nutritional status.

  30. Genetics important only in early onset of Alzheimer’s (age 30-60) • Increased evidence of some prevention factors: • exercise • folate • low cholesterol • low blood pressure MCI: • mild cognitive impairment, different from Alzheimer’s and different from normal age-related memory decline. • Drugs may prevent progression to Alzheimer’s

  31. Multi-Infarct or Vascular Dementia: • Reduced blood flow to brain areas, due to either an arterial blockage (+85%) or a hemorrhage (+15%) • Either ‘regular’ stroke or ‘mini’ stroke. The latter can go undetected, very brief symptoms: transient ischemic attack (episode) TIA • E.g. brief fainting, acute brief headache

  32. Huntington’s Chorea: Autosomal disorder, dominant gene. Test available. Expresses between ages 35 and 50. Physical and mental manifestations (see text) • involuntary movements of limbs • difficulty with voluntary movement • hallucinations • paranoia • mood swings • eventually unable to care for self

  33. Parkinson’s disease: Characteristic: involuntary movements, cannot control but also cannot move some voluntary movements, rigidity. • hallucinations • paranoia • depression • mood swings • eventually, cognitive decline • genetic test available L-dopa (medication)

  34. Neurons in the substantianigra in the midbrain do not produce enough dopamine, an important neurotransmitter. • Initially physical symptoms only. Eventually, up to 40% develop dementia, could be due to the illness or to the drugs given. L-dopa, a synthetic dopamine, causes hallucinations and other psychotic symptoms at certain dosages.

  35. Lewy Body Dementia: • abnormal brain structures • progressive loss of memory, language, reasoning • faster progression than Alzheimer’s • more ups and downs than Alzheimer’s in early stages • psychotic symptoms as illness progresses

  36. Substance abuse: • In young adults, mostly by choice, though some by prescription medications. • In middle-aged (particularly women) and old adults, by prescribed medications (tranquilizers, pain-killers, etc.) • Very widespread in our society • Males: alcohol most common • Females: sedatives, hypnotics, psychotropic drugs most common

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