Disorders & Therapies

1. Disorders & Therapies What is abnormal?

2. A little history – Q1 • How has the concept of mental illness changed over time? • Middle ages – often religious or astrology (lunatics) • What was Bethlem Hospital? • Who was Dorothea Dix?

3. Q2 - What is abnormal today? • Atypical behavior - Q3 • Cultural influence • Statistical tools • Maladaptive behavior • Disturbing to others • Irrational

4. Perspectives – Q4 • Applying perspectives to understanding mental illness and to treating it • Cognitive, biological, behavioral, psychodynamic, biopsychosocial • A note on psychoanalytic vs psychodynamic – what’s the difference? • Strengths and limitations of using perspectives

5. Labeling – Q5 • Rosenhan study 1973 • See youtube video • Are there benefits to labeling?

6. DSM IV TR- Diagnostic and Statistical Manual – Q6 • Diagnostic criteria for all American Psychiatric Association disorders • Statistical info on distribution in population • Little etiology • No treatment info • Too many disorders? • Labeling? • www.dsm5.org

7. DSM – Q7 • Axes • Axis I: Mental disorders • Axis II: Personality disorders and mental retardation • Axis III: Physical conditions/Illness • Axis IV: Psychosocial/Environmental • Axis V: GAF • Codes

8. Disorders • Mood disorders • Anxiety disorders • Personality disorders • “Organic” disorders – medical condition • Dissociative disorders • Somatoform disorders • Psychotic disorders

9. Mood • Depression • Mania • Bipolar • Disorders built on episodes - episodes are not disorders • See handouts on Depressive episode, Major Depressive disorder, Bipolar II

10. Types of mood disorder – Q8 • Unipolar • Major depressive disorder • Dysthymic disorder • Bipolar • Bipolar disorder • Cyclothymic disorder

11. Prevalence – Q9 • Bipolar I and II • .5% to 1.6% for men and women • Major depressive disorder • 10 - 25% of women lifetime • 5 - 12% of men lifetime • 120 million worldwide • 5% of Americans at any time

12. Etiology of mood disorders? – Q10 • Genetic - twin and family studies - concordance with MZ = 40 - 70% • Neurotransmitters - serotonin and norepinephrine - evidence may be that receptors are limited or defective - don’t use properly • Sleep abnormalities • 3 stressful events in 60 days - 80% of episodes preceded by stress • Social cognition - vicious cycle

13. Medical therapies for mood disorders – Q11 • Depression • SSRIs increase serotonin availability • MAOIs - prevent breakdown of ser, nor, dop • Teenagers? • Bipolar - lithium reduces the severity of highs and lows

14. Interpersonal therapy – Q12 • Grounded in Freud - depression occurs within interpersonal context - therapy focuses on relationships - some can be fixed, some can’t • Childhood experiences important but not focus of IPT

15. Behavioral therapy – Q13 • Classical Conditioning • Counter-conditioning • Exposure therapy • Systematic desensitization • Aversive conditioning • Operant conditioning

16. Cognitive therapies – Q13 • Ellis and REBT • Beck and cognitive • Designed to change way one thinks about problems

17. Rational Emotive Behavior Therapy – REBT – Q14 • Developed by Albert Ellis - assumes irrational beliefs cause bad emotions • “I have to perform perfectly in today’s game.” When the client fails to perform perfectly, results are negative feelings, depression, etc • Therapist challenges this thought and teaches client skills to think more rationally

18. Cognitive therapy • Developed by Aaron Beck • Widely used to treat depression • Cognitive schemas have become distorted perceptions of the world • Challenge the perceptions - “nobody likes me” • When depressed write down the situation, the emotion, the automatic thought, a rational response, the outcome • Forces cognitive schemata to attention

19. Cognitive behavioral therapy – CBT – Q15 • Combines cognitive and behavioral techniques • Example: OC behaviors - relabel OC thoughts - “my brain is acting abnormally again” • Engage in different, enjoyable behavior for 15 minutes • Relabeling yields a reward

20. Success treating mood disorders? – Q16 • Depression: CBT and interpersonal therapies show about 60% success; with medication: 75% • Chronically/severely depressed adults: CBT or IP: 48%; with meds: 75%

21. Anxiety disorders • Panic attack - see handout • Obsessive Compulsive Disorder • OCPD is different! • Specific phobia

22. Etiology for anxiety? – Q17 • Situational - cues • Cognitive - learned fear from parents • Overreaction to fearful events • More women than men - 2:1

23. Stress and Anxiety • Short term stressors - treat the symptoms • Drugs, relaxation, breathing, yoga

24. Treating anxiety disorders - Q18 • Drugs may treat symptoms • Benzodiazepines - Valium, Xanax

25. CBT – Q19 • Cognitive and behavioral components • Revise thinking processes • What is real threat? • What’s an appropriate response? • Recognizing responses • Practicing responses

26. CBT – Q20 • CBT - • Systematic desensitization – Mary Cover Jones, Joseph Wolpe – exposure plus relaxation • Response prevention • Interoceptive training – simulates physical effects of a panic attack

27. Dissociative disorders – Q21 • Disruption in the usually integrated functions of consciousness, memory, identity • Transient or chronic • Sudden or gradual

28. Dissociative disorders • Dissociative amnesia - inability to recall important personal information • Dissociative fugue - travel to new location, inability to recall personal info / new identity • Dissociative identity - multiple identities, identity fragmentation, not separate personalities

29. Dissociative identity disorder • Different personalities may emerge in different stressful situations • Some reports of severe childhood physical and sexual abuse • Main personality often depressed, passive • Found in many cultures • More common in women (3 or more to 1)

30. Dissociative identity disorder • Women tend to have more personalities - 15 on average vs 8 for men • Not caused by substance abuse

31. Personality disorders – Q22 • Paranoid • Antisocial • Histronic • Narcissistic • OCPD • Borderline

32. Etiology? • Personality - enduring pattern of thinking, feeling, relating to others - when sufficiently maladaptive, it is a disorder • Generally adolescence or early adulthood • APD more frequent in men • Histrionic, dependent more common in women

33. Treatment for personality disorders • ?

34. Somatoform disorders – Q23 • Presence of physical symptoms that seem to suggest a medical problem • Conversion disorders • Pain disorder • Hypochondriasis - preoccupation with fear of having a serious disease • Body Dysmorphic disorder - excessive concern with real or imagined physical flaw, BIID • Koro - SE Asia - concern that the penis, labia, nipples or breasts are shrinking and may disappear into the body, causing death

35. Conversion disorder • May affect 5 in a thousand people • Not intentionally produced • May have secondary gains • Be careful about diagnosis - may be difficult medical case - early years - 1/4 to 1/2 misdiagnosed • Paralysis, anesthesia, seizures that do not record in EEGs

36. Psychotic disorders • Delusions and hallucinations w/o insight • D&H with insight • Loss of ego boundaries • Impairment in reality testing

37. A little history • Freud distinguished between neurotic and psychotic disorders • Generally, neurotic disorders are anxiety disorders with the patient still in contact with reality • Generally, psychotic disorders involve loss of contact with reality

38. Schizophrenia • “split brain” no longer applies • Bizarreness - • Yes - my internal organs were replaced by the FBI • No - the FBI may be watching me • Thought disorder - focus on speech due to difficulty of defining “thought” • Catatonia - complete unawareness of environment, rigid posture, purposeless motor activity

39. Types of schizophrenia – Q24, 25 • Disorganized • Catatonic • Paranoid • Spectrum of disorders • Generally adolescent or later • 1% worldwide, present in some form in most cultures • Women: later, milder, more likely to recover

40. Schizophrenia symptoms • Symptoms include • Delusions and hallucinations • Incoherent speech • Disorganized or catatonic behavior • Poor social and self-care functioning • Attentional difficulties - stimuli flooding • Flat or inappropriate affect

41. Schizophrenia • Enlarged lateral ventricles • Decrease in gray and white matter • Shrinkage of temporal lobe • Decreased activity in frontal lobe • Onset - midteens to late 30s • Socially isolated / impaired? • Worldwide - 1% or so of population

42. Etiology of schizophrenia – Q26 • Genetic • Very strong evidence here - eg 48% for mz twins; adoptee studies • Biological • Excess or over-utilizing of dopamine • Fetal viruses? • Enlarged ventricles; prefrontal cortex • Psychodynamic • Disturbed relationships with mother? • Diathesis-stress model – predisposition plus stress

43. Schizophrenia • Genetic - higher rates for ID, fraternal twins and 1st degree relatives • Women respond to treatment better

44. Treatment of schizophrenia – Q27 • Neuroleptics - block action of dopamine but have risk of tardive dyskinesia, incurable involuntary movements • Clozapine and other anti-psychotics • Social rehabilitation • Social support • Learning theory to adjust behavior • How effective? Varies dramatically

45. Malingering and Factitious disorder – Q28 • Malingering is the intentional presentation of medical symptoms in order to escape duty or gain reward - convicts • Factitious disorder is presenting medical symptoms in order to play the role of a sick person - other rewards are NOT important

46. Organic disorders – Q29

47. http://psychcentral.com/news/2008/10/08/st-johns-wort-can-help-with-depression/3089.htmlhttp://psychcentral.com/news/2008/10/08/st-johns-wort-can-help-with-depression/3089.html • St John’s Wort works for depression

48. Classic Freudian therapyQ30 Psychoanalysis, transference, free association, dreams, defenses, insight

49. Forensic psychology/psychiatry – Q31 • Intersection of psychology and the legal system – can include assessments of individuals to determine ability to stand trial, commitment hearings, custody hearings, treatment of offenders, etc • Note that profiling is a law enforcement specialty

50. Insanity • A legal term, not a psychological one • Inability to take responsibility for actions, not necessarily innocent • John Hinckley and Ronald Reagan