Chapter 16: Specific Disorders and Treatments

Miss Crossman

Module 16.1-Anxiety Disorders

Essential questions: What are the different anxiety disorders? How do they compare to one another? How are they different?

Anxiety: an apprehensive feeling that something might go wrong (not in response to a specific threat)

If a person has heightened anxiety for their circumstance and it interferes with their life, they likely have an anxiety disorder

Generalized anxiety disorder: a person suffers from constant worrying

Ex: I might get sick,I might lose my job. Lots of focus on the “what ifs”
	
5% of all people have GAD sometime in their life
	Often comorbid with other disorders like depression, panic
disorder, phobias,
	Responds well to anti-depressant drugs and cognitive behavior therapy (CBT)

Generalized anxiety disorder

Healthy anxiety

•An individual with hypochondriasisis known as ahypochondriac.

•Hypochondriacsbecome unduly alarmed about any physical or psychological symptoms they detect, no matter how minor the symptom may be, and are convinced that they have, or are about to be diagnosed with, a serious illness.

Panic disorder

• Panic disorder: characterized by frequent periods of anxiety and occasional periods of attack: rapid breathing, increased heart rate, chest pains, sweating, faintness, trembling

• Panic attacks typically only last a few minutes but are extremely distressing to the person experiencing it

• Ex: migraine medication

• Occurs in about 1-3% of adults worldwidesometime throughouttheir life • More common in women than men
• More common in young adults than older adults • Anxiety tends to decrease with age
• Not any super clear link to genetics with anxiety

heories on panic disorder:
Panic disorder cont.

One theory: person hasTstrong autonomic response (increased heart rate)→braininterprets as either heart attack or an emergency→anxietyabout attack leads to more arousal→increasedanxiety even more

• Ex: migrainemedication side effect

Hyperventilation theory: panic attacks begin with hyperventilation, which causes the body to act as though it were suffocating, which then triggers other sympathetic nervous system responses

People who have repeated panic attacks start to associate them with places, events, activities, and internal states. Any situation that resembles those of previous panic attacks may trigger a new panic attack as a conditioned response

Treatment: CBT

Controlled breathing, pleasant imagery, relaxation techniques

Identifying triggers and dealing with them

Can take several months, but 75% can eventually stop their panic attacks all together after therapy

Panic disorder related phobias

• Social phobia: severe avoidance of other people and fear of doing anything in public
• Many peoplewithpanicdisorderalsohavethis

• Ex: fearof talking to strangers, fearof talking to large groups • Partly relatedtooverprotective, critical families (environment)
• Treatments include:CBT, antidepressants, and antianxiety medications

• Agoraphobia: excessive fear of open or public places

• Some people with panic disorder have this too, not all agoraphobes have panic disorder though

• Panic disorder patients may develop these phobias because they areafraid of having a panic attack in public, so they stay home

Disorders with exaggerated avoidance

• Avoidance behaviors:behaviors learned to avoid punishment • Avoidance behaviors are highly resistant to extinction

• Phobias: extreme persistent fear that interferes with daily living

• “irrational fear” does not refer to it being irrationalthat a person is afraid of that thing. The level of fear is considered irrational

• Exposureto the trigger can lead to panic attack like symptoms • About 11% of people experiencea phobia sometimein their life
• More common in women than men • ALL phobias are acquired

• Somefears are learned easier than others-we may be evolutionarily wired to learn them easier than other ones

Therapy for phobias

• Behavior therapy-systematic desensitization is a method of reducing fear by small exposure to the object of their fear, one step at a time

• first, teaches them how to relax. Then exposes them to a triggering thing (image of the feared object). Has patient visualize the object in different levels of intensity, and eventually will be exposed to a real version of their fear (ex: bird)

• Many therapists will use virtual reality to do this

• Flooding/intensive exposure therapy: a treatment that exposes the person to the object of the phobia suddenly ratherthan gradually

• Sympathetic nervous system can only be aroused so long, so eventually calm down even among the disturbing images

Obsessive-compulsive disorder

• Obsessive-Compulsive disorder: people suffering from this deal with both obsessions(repetitive, unwelcome streams of thought), and compulsions(repetitive, almost irresistible actions)

• Obsessions often lead to compulsions. Compulsions are createdto reduce the stress created by obsessions

• Someone obsessed with dirt and cleanliness washes their hands excessively as a compulsion

• 2-3% of people suffer from OCD sometime in life. ½ of people have obsessions without compulsions

• Develops between ages of 10 and 25 most typically

• Affects hardworking, perfectionistic, intelligent individuals

• Trying NOT to think about something makes it nearly impossibleto not think about it • Most common compulsions: cleaning and checking

• Therapy: exposure therapyand antidepressants

Module 16.2-Substance related disorders

What is addiction? How does it affect the brain? How does Alcoholism compareto other dependencies?

Dependence/addiction: when a person finds it difficult or impossible to quit a self-destructive habit

“Does the substance cause troublesin my life, and do I often take more thanI had decided I would?”

Almost all drugs that cause dependency stimulate dopamine receptors in the nucleus
accumbens(area critical for attention and habit formation)	addiction Addiction is something that monopolizes a person’s attention

Why do people keep using drugs?

To seek pleasure

The “high” can be very pleasurable

To escape unpleasant feelings

• Withdrawal symptoms include:sweating, nausea, sleepiness, anxiety, restlessness, vomiting, diarrhea

Physical dependence: a person who uses a
drug to reduce unpleasant withdrawal	Ex: alcoholism symptoms

Psychological dependence: strong repetitive desire for something without physical symptoms of withdrawal

Sometimes, peoplestill have intense cravings after withdrawal symptoms

Ex: marijuana use, gambling addiction

a druguser learnsto associate the drug with	Addiction Cont. relief from internal distress. (support:

relapses often happen during distress of somesort)

The processof becoming addicted changes the organization of several brain areas that are important for motivation, attention, and learning

Is addiction a disease?

• Calling substance abuse a diseasemakes it seem like people can either have it or not have I

• The evidence shows there is quite a continuum from people having no problem to severe problems

• diseaseconcept suggests that alcoholism or drug dependence becomes worse over time. In fact the outcome varies. Some people get worse, some stay the same, some get better

• Disease implies there is a need for medical intervention. In some cases, therapy is the best method, which is not a medical intervention

• Can be helpful in destigmatizing addiction, but isn’t necessarily a disease

alcoholism

• Alcoholism: the habitual overuse of alcohol • Genetic factors:
• Twin studies show a strong genetic factor for addictive behaviors

• Type 1 alcoholism: develops gradually over the years, affects about as many women as men, is generally less severe, and depends more on life experiences than genetics.

• Type 2 Alcoholism: develops rapidly, usually by age 25, is much more common in men than women, is usually more severe, and showsa stronger genetic basis

• Alcoholism more likely among people who grew up in families marked by conflict, hostility, and inadequate parental supervision of the children • Culture is a big determinant as well
• Thereare individual differences. Not all kids of alcoholics become alcoholics themselves. Not a clear picture all the time

Treatments for alcoholism

People who try to quit drinking on their own, about 10-20% people succeed, but not necessarily on the first try

Antabuse: Disulfiram, available under the trade name Antabuse, is now sometimesused in the treatment of alcoholism, for which it is regarded as only moderately effective

• A personwho takes this will get very ill whenthey drink

Many people though find that they cannot get better on their own

Harm Reduction approach: concentrates on decreasing the frequency of drug use and minimizing the harmful consequences to health and well-being (doesn’t require full giving up)

Alcoholics Anonymous (AA) is the most popular treatment in North America

• imposes no requirements on itsmembers other than making an effortto quit alcohol, newmembers are strongly encouraged to attend 90 meetings during the first90 days

• AA members say it helps them, thereisn’tmuchresearchon its effectiveness though

Contingency management: people monitor their alcohol levels with a breathalyzer and when they are alcohol free, they are given small rewards

Opiate dependence

• Opiate dependence=rapid onset versus alcohol, which often takes longer time • Opiate abuse shows a genetic tendency
• Treatments:

• Cold turkey • CBT
• Self-help groups

• Contingency management • Methadone
• buprenorphine

Module 16.3-mood disorders

What isdepression? What are the various forms of it? What are the causes and treatments? What isbipolar disorder?

depression

• Major depression: more extreme condition than occasional sadness, persisting most of the day for at least 2 weeks, while the person experiences little interest, pleasure, motivation, or activity

• Profound sadness, but more so a lack of happiness

• People with depression experience sleepabnormalities

• Fall into REM sleepincrediblyfast, have more eye movements during REM • Wake up early, cantgo back to sleep
• Depression feels usually worst in the morning

• Prettycommon. 10% of adults will experience depression in any given year, and 20% will experience it in their lifetime • Few people remain permanentlydepressed

Seasonal affective disorder

• Seasonal affective disorder (SAD)

• Depression associated with a particular seasonof the year is called seasonal affective disorder.

• It is most common in areas that have little sunlight in the winter →Pacific NW

• Light therapy, which requiresthe person to sit in front of a bright light for a few hours each day, is effective for treating SAD

Bipolar disorder

• Bipolar/manic-depressive disorder: someonealternates between periods of depression and periods of mania, which are oppositeextremes

• Mania is a state of extreme exuberanceand agitation.

• Bipolar I disorderinvolves the experience of at least one episode of mania.

• Bipolar II disorderinvolves alternation between major depressionand hypomania, a milder form of mania. • Affects about 1% ofthe population
• Hereditary influenceson bipolar disorder

• Drug therapies:

• Lithium-naturallyoccurring chemical that is used to treatmania. • Anticonvulsants also used
• How it works is not well understood (may block arachidonic acid, which is producedduring brain inflammation) • Lithium is toxic at high dosesso patients must be carefully monitored.

Genetic predisposition to depression

Having closebiological relatives whowere diagnosedwith depression increases one’sprobability of becoming depressed.

Having adoptive relatives whowere depressed also increases that probability, but not as much.

The probability is especially highif one has biological relatives who were diagnosed with depression before age 30.

Genetics on
depression	There is probably no one gene that causes depression.

Genes influence temperament thus also the way people respond to events in their lives.equally

Before adolescence, boys and girls are equallylikely to develop it. After, women are 2X more likely experience depression than men

Depression cont. sex differences

• Hormones:

• Women experience more rapid hormonal changes than men do (menstrual cycles, pregnancy, childbirth and menopause).

• Yet the hormone levels of depressed women arenot significantlydifferent that those of non-depressed women.

• Coping

• Men generally try to distract themselves when they are feeling depressed. Women tend to dwell on their feelings more

Cognitive aspects of depression

• Explanatory style: a tendency to accept one kind of explanation for success or failure more often than others.

• Internal attributions: cites causes within a person • External attributions: cites causes outside a person

• Pessimistic explanatory style: when you consistently blame yourself for failures (it is global and stable)

• Pessimists more likely to have experienced depression and to experience depression

Treatments for depression

•Psychotherapy

• Interpersonal therapy:focuses on improving interpersonal relationships and on coping with difficulties someone has faced in the present or recent past, such as death of a loved one, divorce,
unemployment, and lack of social skills

• Cognitivetherapy-focuses on changing people’s thoughts and beliefs and encouraging a more active life

• “negative cognitive triad of depression”: • I am deprived or defeated.
• The world is fullof obstacles. • The future is devoid of hope.

antidepressants Antidepressant medications:

• Tricyclic drugs (e.g., imipramine, trade name Tofranil) block the reabsorption of the neurotransmittersdopamine, norepinephrine, and serotonin after they are released by an axon’s terminal

• Work well for most people but have not great side effects: they produce unpleasantside effects, including dry mouth, difficultyurinating, heart irregularities, and drowsiness (Horst & Preskorn, 1998). Many people quit the drugs or reduce the dosage because of the side effects

• Selective serotonin reuptake inhibitors (SSRIs) ex: Prozac, Zoloft. They block the reuptake of the neurotransmitter serotonin. • side effects are usually limited to mild nausea or headache
• Monoamine Oxidase Inhibitors:block the metabolic breakdown of released dopamine, norepinephrine, and serotonin by the enzyme monoamine oxidase ( allow the neurotransmitter to stimulate the neuronlonger)

• Atypical antidepressants: act primarily on dopamine or norepinephrine synapses rather thanserotonin, althoughtheir mechanism of effect is not entirely certain. (Wellbutrin)

St. John’s Wortis an herb that has antidepressant effects. It should not be used with other medications.

• Can interfere with other medications, including birth control

serotonin

• Serotonin

Of all the neurotransmitters, serotonin is perhaps the most implicatedin the cause and treatment of major psychological and physiological disorders.These disorders include depression, anxiety, obsessive-compulsive disorder, schizophrenia, stroke obesity, hypertension, and vascular disorders.

Many studies have found that the flow of the neurotransmitter serotonin is defective in people with depression. The serotonin molecules flow back to their originating site on the axon, instead of to receptors on the dendrite. This means the electricalimpulse isn’t transmitted properly along the neural pathway. That's why many antidepressantmedications aim at enhancingserotonin activity at the nerve synapse.

Electroconvulsive therapy (ECT or EST)

• ECT: A brief electrical shock is administered across the patient’s head to induce a convulsion similar toone produced by an epileptic

• Started in the 30s, popular 40s-50s, then fell out of favor

• ECT had sometimes been used as a punishment to patients rather than a treatment

• In the 70s, ECT made a comeback for depressed patients who didn’t respond well to therapyand medication

• Can be very helpful for suicidal patients (doesn’t have long lasting effects without other treatments though)

• How it works is not completely understood

Module 16.4-Schizophrenia

What are the symptoms of schizophrenia? How is it different than other disorders?

Schizophrenia

Comes from the Greek words meaning “split mind”

NOT thesame thing as DID

Means a split from reality, not two personalities

The DSM-V diagnosis requires a complete deterioration of daily activities and at least two of the following symptoms:

Hallucinations

Delusions or thought disorders Incoherent speech
Grossly disorganized behavior

Loss of normal emotional responses and social behaviors

a therapist must rule out other conditions that produce similar symptoms, including drug abuse, brain damage, neurological diseases, niacin deficiency, and food allergies

Positive & Negative symptoms of schizophrenia

Positive symptoms: refer to those that are behaviors that are noticeable by their presence

Negative symptoms: behaviors notable for their absence

Ex: hallucinations and delusions

Ex: lack of speechor emotional expression Lack of ability to feel pleasure
Inability to care for oneself

People with mostly negative symptoms tend to be different than those with a mixture or positive symptoms. Condition is often worse for negative symptoms (longer lasting, harder to treat)

Hallucinations & Delusions Hallucinations: perceptions that do not correspond to anything in the objective world

• Most common: hearing voices or other sounds no one else hears • Sometimes they know its not real, sometimes they do not

Delusions are unfounded beliefs that are strongly held despite a lack of evidence for them

• Delusions of persecution-belief that dangerous enemies are persecuting you • Ex: a schizophrenic man thinks spies are watching his every move
• Delusions of grandeur: a belief that you are unusually important, • Ex: a woman believes she is the prophetess for God
• Delusion of reference: a tendency to interpretall sorts of messages as if they were meant for oneself. • Ex: Sees a commercial, thinks it was purposely sent to them as some sign

Schizophrenics often perform poorer than averageon selective attention tasks or executive function tasks

Schizophrenics often have loose associations

• Ex: jesus, sex, cigars

People with schizophrenia are impaired at reading other people’s facial expressions

Sometimes have a hard time with abstract concepts (use very concrete thinking)

• Tend to interpret things very literally

Disordered thinking

Catatonic schizophrenia

• Catatonic schizophrenia:prominent movement disorder, including rigid inactivity or excessive activity

• Periods of extremely rapid, repetitive activity alternate with periods of total inactivity.

• During inactivity: periods of rigid posture, will resist attempts to change it • Brain is still alert during the inactivity though

• Diagnosed much less frequently than in the past

• Catatonia can still occur in patients with other disorders

Disorganized schizophrenia: incoherent speech, absence of social relationships, and “silly” or odd behavior

Disorganized	Often have “clang associations” schizophrenia       • Ex: “the train brain rained on me”
Also display “word salad”

• The sheep languished blue trains suffer. Windows books dogshands run. Run desk making dinner sunglasses menu. Folders pile swimming red clouds.

Paranoid schizophrenia

•Paranoid schizophrenia:haveelaborate hallucinations and delusions, especially delusions of persecution and delusions of grandeur.
• Tend tobemorecognitivelyintactthanother types

• Can carry on jobs and relationships at times

Undifferentiated and residual schizophrenia

• Undifferentiated: person has basic symptoms: deterioration osdaily functions plus some combo of delusions, hallucinations, disordered thinking, etc.

• Nothing distinct enough to categorize in the other 3

• Residual schizophrenia: people who have had an episode of schizophrenia and who are partly recovered. the person has some mildlingering symptoms but nothing severe

• Many people fall on the margins of several types, and can switch between two

Schizoaffective disorder

• Schizoaffective disorder: schizophrenia plus periodic symptoms of disordered affect or mood.

• Will have hallucinationsand/or delusions, plus a major mood episode (depression or mania)

prevalence

Schizophrenia affects about 1% of people worldwide

Less prevalent in third world countries

More prevalent in cities than rural areas

• What could be the reasons for this?

Much more common in men than women-7:5 ratio

• Men have more severe symptoms typically

People typically diagnosed in their early 20s

Causes

• Genetics:

• Twin studies show if one monozygotic twin has it, 50% chance the other will too

• Brain damage

• Mild brain abnormailitiesare present in many schizophrenics • Hippocampus andcortexsmallerthanaveragebrains
• Cerebral ventricles are bigger

• Smaller numbersofneurons, less synapses in prefrontal cortex

The neurodevelopmental hypothesis

neurodevelopmental hypothesis: schizophrenia originates with nervous system impairments that develop before or around the time of birth, for either genetic or other reasons

Incidences of schizophrenia are higher under these conditions:

Mother had a hard labor and delivery of the baby Mother was poorly nourished during pregnancy Mother had an infection during pregnancy
Baby was unusually small at birth

Patient has serious head injury during childhood

Patient infected with parasite toxoplasma gondii during childhood, which attacks the brain

The mother had anRh-negative blood type and her baby was Rh-positive

Neurodev. Hypothesis cont.

• Season of birth effect: person born in the winter or earlyspring is slightly more likely to develop schizophrenia

• Examined this only in northern climates

• The cold must have some effect. This affects no other disorder

• The flu and other epidemics more probably in the colder weather

Therapies for Schizophrenia

• Antipsychoticdrugs were first introduced in the 1950s

• Thorazine and Haldol helpedpeoplemanage their schizophreniaand live active lives • Are most effective when given early in the onset of the disease
• Most block dopaminereceptors in the brain

• Drugs that stimulate dopamineactivity (ex: meth, cocaine) can cause the positive symptoms of schizophrenia

• dopaminehypothesis of schizophrenia—thatthe underlyingcause of schizophreniais excessive stimulation of certain types of dopamine synapses.

• People with schizophrenia have increased release or increased numbers of dopamine receptors in certainbrain areas

• Dopamineregulated by glutamate, and schizophrenics often have underproduction of glutamate

Side effects and

Antipsychotics can create tardive dyskinesia: a condition characterized by tremors and involuntary movements

By altering dopamine, it also alters movement, which dopamine is partly responsible for

alternative drugs

Atypical antipsychotics (Risperidone, Clozapine): relieve schizophrenia without tardive dyskenisia

Produce effects on dopamine and serotoninsynapses
	Clozapineis regarded by most psychiatrists as themost effective drug forrelieving the symptoms of schizophrenia

• Addressed negative symptoms of schizophrenia many drugs fail to address

Other disorders You need to know

Neurodevelopmental disorders

Neurodevelopmental disorders: conditions associated with central nervous system functioning that begin in early childhood

• Includedevelopmental deficits that affect social, intellectual, academic, and personal functioning

Intellectual development disorder: general mental deficits in intellectual functioning and adaptive behaviors

Autism spectrum disorder: centers on repetitive behaviors and impairments of social communication and interaction

• Impairments include:social and emotional interaction/exchange, understanding and using nonverbal communication (eye contact)

• Development & maintenance of social relationships

ADHD

• Sometimes have repetitive motions or speech, use of objects, ritualized patterns of behavior.

• Sometimesextreme sensitivityto sensory stimulation

Trauma and stress related Disorders

• PTSD

• Acute stress disorder: characterizedby symptoms that develop shortly after people experience or witness a traumatic event • Often get uncontrollableflashback memories and nightmares
• Dissociativesymptoms • Sleep disturbances
• Hypervigilance

• Problems processing traumatic event

• Typically violent traumatic events

• If these symptoms persist for more than a month or develop 6 months after trauma, may be diagnosedwith PTSD

Dissociative disorders

• Dissociative Identity Disorder

• Dissociative amnesia: the inability to remember parts of the past as a result of trauma

• Localized amnesia” inability to rememberevents during a specific stretch of time is the most common type of memory loss • Selective amnesia:involves loss of only certain specific memories
• Generalized amnesia: total loss of memory of one’s life, including learned skillsand acquired knowledge (rare) • Often will wander aimlessly so has to be sent to law enforcement or psychiatric care
• Dissociative fugue: complete loss of awareness of one’s identity and the assumption or development of another identity

Somatic symptom disorder and related disorders

Somatic symptom disorders are physical disorders caused by psychological stress

Somatic symptom disorder: characterized by extreme anxiety about physical symptoms that are interpreted as evidence of illness.

Used to by called hypochondriasis

Symptoms arereal for these patients, not imagined

Ex: person experiences chest pain (acid reflux) interprets it as a heart attack or cancer

Illness anxiety disorder: severe obsession with having or getting a serious illness despite no indication of illness following a medical exam
Absenceof actual physical symptoms (why its different from somatic symptom disorder)

A personmust have distorted thinking,
pattern of distrust and
people’s motives
schizophrenia because
symptoms, or loss of
Personality disorders
eccentric	erratic
interpersonal difficulties, problems with	Cluster A: “odd, suspicious and	Cluster B: dramatic, emotional, impulse control, and problems with emotional
personalitydisorder
• Paranoid personality disorder:
responses to be classified as having a	• Borderline personalitydisorder: significant and disruptive pattern on instability in
and impulse ontrol
suspiciousness about other	 interpersonal crelationships, mood, self-image • Histrionic personality disorder is characterized
• Different than
by constant attention-seeking, emotional overreaction, and suggestibility. A person with this condition tendsto over-dramatize
and lead to depr ssion.
doesn’t have psychotic	 situations,whichemay impair relationships • The hallmarks of Narcissistic Personality

touchwith reality
Disorder (NPD) aregrandiosity, a lack of empathy for other people, and a need for admiration. People with this conditionare frequently described as arrogant, self-centered, manipulative, and demanding.

• Antisocial personality disorder: inability to feel empathy or guilt, leading to a pattern of manipulation and disregard for the rights of others

Cluster C: “Anxious and Fearful”

• Avoidant personality disorder is a psychiatric condition characterized by a lifelong pattern of extreme social inhibition, feelings of inadequacy, and sensitivity to rejection.

• People with avoidant personality disorder may avoid work activities or decline job offers because of fears of criticism or disappointment from others.

Neurocognitive disorders

• Neurocognitive disorders: a group of disorder is which the primary problem is in cognitive function. It is an acquired disorder

• Alzheimer’s disease

• Lewy body-related dementia:causes neurocognitive impairment but also includes hallucinations

• Delirium: cognitive dysfunction in attention or awareness, limited attention span, and confusion