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(index to be inserted)

Section 4: Mental Illness

Diagnostic and Statistical manual of mental disorders

DSM -IV

Multi-axial Assessment

Axis 1 - Clinical disorders
Axis 2 - Personality Disorders
    Developmental Disorders
Axis 3 - General Medical Conditions
Axis 4 - Psychosocial/Environment
Axis 5 Global Functioning

        Benefit: - universal classifications of a person

        Draw Back – Stigmatize a person.
            Tools of the insurance company.

Example of a person’s Assessment

Axis I – mood disorder
        depressive
        due to hyperthyroid
Axis II – No diagnosis
Axis III – Hypothyroidism
Axis IV – None
Axis V – 45 (1-100) – worked their way up to a 65 on discharge.
                    91 – 100 perfect handling of their life.

NOTE TO STUDENTS: MEMORIZE DISORDERS BY CLASS

Anxiety Disorders –

Phobic Disorders – (phobia – fears)
       Irrational Fears – for example the fear of balloons.
                it is possible to treat a fear whether or not you know where it came from.
        Claustrophobia - fear of small places
        Acrophobia – fear of heights

Example:  Desensitization to a Phobia

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Flooding
        Reducing most of your fear all at once
        Facing your fear all in one day
      First applied in late sixties.

Freud believed that these phobias were related to the first years of life, some problem with one of the first stages of psychosexual development

Symptom substitution - When you loose one fear you replace it with another
        theory of Freud - found to be false.

Panic Disorder

An additional fear is that of
    Agoraphobia
        this can be a conditioned fear - fear that you will have a panic attack out in a public place - you then fear even going out all.

        Fear of being in a situation from which you might not escape or might be difficult

Anxiety Disorders –
      Social phobia
        fear of situations that may lead to embarrassment
        speaking in public
agoraphobia

Tranquilizers – not to be longer than a 3 month period. – because they are addictive.

Gaba – inhibitory neurotransmitter
        or the valerian root – increases (corrected 3/13/01) Gaba transmission

Obsessive compulsive disorder
        obsession – repetitive thought
        compulsion – behavior. – repeats

    Some people will be obsessive compulsive about washing hands – they ‘ll wash so much that their hands chap and bleed.

This can be treated with SSRI – example to treat OCD is clomipramine
        Selective Serotonin Re-uptake Inhibitors – example – Prozac

MOVIE NOTES:
        Boys have a 1 in 100 chance in getting OCD
        But once adult hood comes around, women to men is roughly equal.

post traumatic stress disorder.
        Recurring nightmares are a symptom of PTSD
        It is possible that the trauma causes physical changes in the brain...
        or maybe some people are susceptible to having this reaction.
                not all people that undergo a trauma end up with PTSD

    some of the changes are in the hypocampus - involved in memory.. it decreases in size for people who come down with PTSD during war time.

Some people ARE more vulnerable to stress than others.
        The person should have a social support network.. so that they feel stabilized

Affective Disorders
   Major Depression
        SAD – Seasonal Affective Disorder – Uni-polar (depression) only during a certain season – typically during the beginning of winter until beginning of summer.
                Caused by light exposure and the corresponding melatonin release. – primarily found in the northern and southern extremes of the globe.. from about Washington state North but rarely around the equator
        Bipolar Disorders (Click here to go to description)
        Dysthymia – Mild Uni-polar Depression (Click here to go to description)
        Cyclothymia – mild mood swings

Taking too much melotonin can make you depressed…to cure seasonal depression -
        increase the amount of daylight that you have (artificially) or move towards the equator.

Psychology – IF it interferes with a person’s life, then it’s a problem

MOVIE NOTES:
    Sever winter depression – living in high latitudes
        Wanting to sleep lots
        Depressed
        Difficulty working
in the back of the eyes, there is a structure which tells the body whether or not it is day or night.

The lights help to take a person out of hibernation..

Uni-polor Depression  - DSM - IV criteria (5 or more symptoms over a 2 week period)

  • Depressed mood
  • Diminished interested or pleasure (anhedonia)
  • It's hard to help a depressed person because they aren't really that responsive.
  • Weight or appetite increase or decrease
  • Sleeping too much or too little
  • Feeling either agitated or physically slowed
  • Loss of energy
  • Feelings of worthless ness or guilt
  • Difficulty concentrating or making decisions
  • Thoughts of death or suicide

Uni-polar depression continued

        Left frontal love = Approach/joy
        right frontal lobe = withdrawal/distress
        underachieve left frontal EEG in adults and in children

---

Uiversity of Washington Research (Dr. Dawson)
    Children of mothers: frontal EEG activity during play at one year of age left lobe activity is about equal to right lobe activity
    children of non-depressed mothers: left is greater than right.

-----

Treatment of uni-polar depression

Uni-polar depression

  • low levels of norepinephrine and or serotonin
  • Biochemical treatments raise these neurotransmitters
  • Amino acids: phenylalanine and or tyrosine can raise norepinephrine
  • 05 -hydroxy-tryptophan can raise serotonin
  • St. John's Wort (a herb) can raise serotonin

Uni-polar depression
      MAO - Inhibitors raise both norepinephrine and serotonin
            you need MAO to have an reaction to tyromines
                so if you have an inhibitor, you may wish to not eat certain foods

SSRI'S (selective serotonin re-uptake inhibitors) raises serotonin (e.g., Prozac, Paxil, Zoloft.)
---

9-26% females lifetime will get uni-polar depression
5-12% males will get uni-polar depression

for both m/f only 1 % will come down with Bipolar disorder.

ECT (Electro Convulsive Shock Therapy) – Seizure induction – creates a form of amnesia, and helps to dissipates the depression report for people.
        People then have permanent in memory.
        Although there is no major brain damage.

Sleep Differences

Normal Sleep
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Depressed Sleep
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Prozac – makes some people worse.

MOVIE NOTES:
        Depressed family – vociferous
        Medications have their limitations.
        Prozac will not change everything.. simply help people become more functional in society.

        Prozac is a part of life, not just a medication
End of Movie Notes.

DSM IV Criteria for Mania (Bipolar)

  • Elevated, expansive, or irritable mood
  • Inflated self-esteem
  • Decreased need for sleep
  • More talkative than usual
  • Feeling that thoughts are racing
  • Easily distracted
  • More activity
  • Negative outcomes (e.g. gambling shopping)

MOVIE NOTES:
        Certain families only would suffer from disorders
        Genetic markers for depression on chromosome #11 – on the short arm.

Figure: 1
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Figure: 2
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First line of defense of manics are lithium and anticonvulants
    The transmitters involved are norepinephrine and seritonin
    Manic is associated with norepinephrine

Treatment of Manic Depression: You need to treat both manic and depression stage. You need lithium, to add seritonin re-uptake inhibitors to prevent recycling into mania.

        These medications have side affects
        Lithium and anticonvulants – nausea, lowering immune system, and liver affects when the dosage is too high.

Article –

The use of cannabis as a mood stabilizer in bipolar disorder: anecdotal evidence and the need for clinical research

By Lester Grinspoon, MD. And James B Bakalar

Abstract –
      The authors present case histories indicating that a number of patients find cannabis (marijuana) useful in the treatment of their bipolar disorder. Some used it to treat mania, depression or both. They stated that it was more effective than conventional drugs, or helped relieve the side effects of those drugs. One woman found that cannabis curbed her manic rages: she and her husband have worked to make it legally available as a medicine. Others describe the use of cannabis as a supplement to lithium (allowing reduced consumption) or for relief of lithium’s side effects. Another case illustrates the fact that medicinal cannabis users are in danger of arrest, especially when children are encouraged to inform on parents by some drug prevention programs. An analogy is drawn between the status of cannabis today and that of lithium in the early 1950’s., when it’s effect on mania had been discovered but there were no controlled studies. In the case of cannabis, the law has made such studies almost impossible, and the only available evidence is anecdotal. The potential for cannabis as a treatment for bipolar disorder unfortunately can not be sully explored in the present social circumstances.

Schizophrenia

Psychosis involves loss of contact with reality, symptoms included:

  1. Disorganized and deluded thinking
  2. Disturbed perceptions (hallucinations)
  3. Inappropriate emotions and actions

Neurotic = maladjusted
Psychosis = such a large discrepancy with reality, the person actually has problems serving while in a schizophrenic episode

Delusions: false beliefs not based on reality
Hallucinations: perceptions in the absence of sensory stimulation, often hearing non existence voices.

Schizophrenics are near impossible to hypnotize because their attention is not able to be directed.

(s)he = she or he

Since when a person thinks, (s)he is almost talking to (his)herself.
    If a schizophrenic is thinking, (s)he may think that when (s)he hears (his)her own thoughts (vividly) (s)he will think that (s)he is hearing voices.

Movie Notes: on schizophrenics
        10% will suicide in 10 years
        15% will not respond to the medication
End of Movie

Schizophrenia:

  • Positive symptoms: talk is disorganized and deluded, emotional expression (e.g., laughter, tears, or rage) often inappropriate
  • Negative symptoms: toneless voices, expressionless faces (flat affect), or mute and rigid bodies

Discrimination between Chronic and Acute

  • Chronic (process) develops gradually
  • Acute (reactive) develops rapidly in response to particular life stresses

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Movie Notes -

Hipocampus – some clear cut organic pathological changes… the nerve cells are usually lined up like slats of a picket fence.. but in schizophrenics, these slats are in "every which way" – during 2nd trimester (possibly due to flue virus)
These cells are supposed to migrate during the 2nd trimester. – but they don’t completely migrate.
The flue virus has a special enzyme that has neuro menedase, specifically affects the adhesive ness of these nerve cell adhesion molecules.
Normal: Lined up, dendrites are organized.
abnormal: Neruons are all over, and the dendrites are located in every direction
Agent – thorozine (promozine) – anti psychotic drugs – normalize the chemistry of the brain.
Anti-psychotics drugs reduce the dopamine activity.
Schizophrenia is in theory too much dopamine

End of Movie Note

Schizophrenia
        Biological observations include
                Increased receptors for dopamine
                Frontal lobe under activity
                Enlarge ventricles (less cerebral tissue)
        Biological causes implicate
                Genetic Predisposition
                Mid-pregnancy viral infection of the fetus

Schizophrenia
        Relapse frequency is related to stress and to double-blind situations.
        Treatment:
                Drugs that decrease dopamine (chlorpromazine (thorazine), clozapine)
                Skills training, family support
                Tardive dyskenisia can be a side effect of chlorpromazine
                        Example: Parkensisns – not having enough dopamine

                Command hallucinations are some of the worse

Discsociative disorders
    Dissociative amnesia

  1. inability to recall important personal information
  2. that is traumatic or stressful
  3. reversible
  4. not due to other disorders
    (e.g., post tramatic stress)
  5. causes distress or impairment

Dissociative Fugue

  1. Sudden unexpected travel from home with inability to recall one’s past
  2. Identity confusion or new or partial identity
  3. Not due to drugs or dissociative identity disorder
  4. Causes distress or impairment

When one’s identity returns there is no memory of fugue state

Dissociative identity disorder

  1. two or more distinct identities – each has its own patterns of perceiving, thinking and relating
  2. inability to recall personal information (not explained by ordinary forgetfulness.)

Dissociative Identity Disorder
        Loss of childhood memories
        Stress can trigger identity switches
        Half of cases have 10 or fewer identities
        Patients score high on measures of hypnotizability
        Several times more likely in adult females than in males

Differences in acting vs. "The real thing"
   Different for each personality
        Brain Waves
        Allergic Reactions

Movie Notes (multiple personalities)
    When another personality, there is now way to retake control
        Childhood – is when DID begins.. because a child feels they need to flee from psychological or sexual abuse.
            The brain is constantly generating activity, if you stimulate the person with a should, sight or shock, you get a vot: vot potential - used in EEG

Each personality can show different brain wave patterns.

Heart rate, cerebral blood flow
Sight
Temperature

 

Movie Notes: Intro to tomorrows Therapy Lecture
    A problem that interferes with life
    Psychotherapy helps to resolve problems that interfere with life.
        Some Methods:

  • Providing a safe relationship

Trust
Therapeutic alliance
Support: helps the therapeutic alliance
Suggestion – helps to bring out symptoms

  • Working through

Clarification of what must be dealt with
<outbursts at a person – transference reaction>
Flux – flexible enough to display positive signs of advancement.

  • Developing new patterns

Positive adjustments
Encouragement from the psychotherapist

Dissociative identity Disorder continued

Hostile, controlling, or protective personalities have more complete memories passive itdentiies
identities can didffer in usual acuity, pain tolerance, allergy symptoms, insulin response

it's a strange combinateon between a real disorder vs

it is possible that a child developes multiple personalities as a defense mechanism, if the child does not shed this habit, it can become a disorder when they are an adult.

One potential for this disorder is that people simply "fake it" and are trying to get attention

Personaity Disorders

there are a number of personality disorders that may impare one's social functioning

-

Two examples are:
   Borderline personality involves unstable identity; emotions and relationships
        More females
    Antisocial personality involves lack of conscience
    - unstable relationhsips (high rate of suicide - self muulation kinds of things)
        More Males

    Antisocial - similar - psychopath

    Very manipulative
        1% of the population has these anti social tendencies, and they don't feel empathy as most people do, less guilt
                Asburger syndrome - similar in the sense that it doesn't allow for empathy

Movie Notes:
    Psychopaths don't process sounds on the left as the rest of us,
        they process equally on each side of the brain.
        Typically responds to the stimulus of emotional words and other words.
                Also psychopaths have been described as machines.
        They feel able to rationalize behavior
    Very difficult to study a psychopath.. simple description - they are wired up differently
END OF MOVIE NOTES

Behavior Therapy:
True gestalt theory was absent

Psycho analysis is so epileptic - (pulls in ideas from all over)

Active Listening
    The therapist listens to the client
        SHUT UP and Listen
        Be understanding regardless
        To verify that you understand what they are saying, Ask "is that you said?"
        Don't give cues of what you want to hear!

    Psychotherapy - goal - increases self awareness

 

Psychotherapy

  • Psychotherapy is education
  • Education can mean learning a new viewpoint, new information, or practicing a new skill
  • 1.) Insight
  • 2.) New information
  • 3.) Skill development
  • 4.) feed back and support

Two key concepts are:

  • Transference – patterns of relating from previous relationships are repeated and transferred to the therapist
  • Resistance – an important part of therapy - the client subverts the therapeutic process to avoid threatening material.
    There are three primary ways of dealing with resistance
  1. Confront the resistance - hit it head on, make the patient see their own resistance.
  2. Dodge the resistance – It will come up again later in the session
  3. Support the resistance – Increase security, so the client resists less (in a paradoxical fashion)

 

Psychological Therapies
    Psychoanalytic:
            Emphasizes etiology – Sigmund Freud
    Humanistic:
            Person-Centered –Carl Rodgers
            Gestalt – Fritz Perls
   Cognitive – Albert Ellis, Aaron Beck
   Behavioral
        Systematic desensitization – Mary Cover Jones
        Operant conditioning

Humanistic Therapy – Creation of an informative session where the person learns from
        Gestalt therapy – constant confrontation –

Hakomi – resistance is dealt with in a different way than gestalt therapy

  1. Establish mindfulness (similar to a meditative state)
    Very present moment focus – like gestalt
  2. It supports the resistance.
    Helps the patient in resisting the therapy, therefore making the client feel more secure and more willing to confront threatening material.

In Hakomi – the idea is to increase security: "if you want to fight me, I’ll help you fight me so you no longer feel threatened" – supporting of the patient

Eating Disorders:

    Binge Eating followed by either

  • Purging
  • Excessive exercise

Can be any weight

  • About 5% of high school females
  • About 14% of college females (seniors)
  • Often appears with depression

Anorexia Nervosa

  • Self induced starvation
  • Abnormal fear of being fat feeling fat even though they are thin. (distorted body image).
  • About 1% of adolescent females

    80% to 90% of bulimic and anorexic are women

In an experiment where there were 3 schools, all of which had a littering problem, there were 3 methods of handling the situation.

  1. Scolding the children in an assembly
    showed no true signs of improvement.
  2. Giving rewards for throwing away trash
    Worked while the system was in place
    After returning to the school 6 months later, the students returned to their previous habits.
  3. Supporting the children, praising them for not littering (even though they do litter)
    Worked because it changed the mind set of the children
    After 6 months they continued to refrain from littering, because of the change in the mindset.

Stress

Stress is physiological response to noxious stimuli.

Effects include:

  • Enlarged adrenal Glands
  • Reduced thymus
  • Ulceration of the Stomach

Stress is affected by one’s appraisal of the Situation. What is stressful verses challenging varies across individuals

General adaptation syndrome (Hans Selye)

    3 phases

  1. Alarm reaction
  2. Resistance
  3. exhaustion

Effects if stress:

Can increase adrenaline and norepinehprine
Raises cortisol
Lowers interferor
Reduces the number of lymphocytes

Movie Notes
    General Adaptation Syndrome (Hans Style)
    Gluco-cordacoides are released from a gland near Kidney – causes stress – too much exposure may destroy brain cells
End of Movie Notes

Theory from some new research is that:
Stress early in life can reduce the size of the hypocampus.
    Verses the idea of stress killing brain cells.
            Neuro-plasticity – how the brain re-grows it self

 

Things that suppress the immune system:

  • Surgery
  • Sleep Deprivation
  • Learned helplessness
  • Bereavement i.e. any loss (e.g., friend, intellectual skills, memory, self esteem, home, land, physical attractiveness, status)

Life-Stres Scale
            Event                         Score

  • Death of Spouse    100
  • Divorce                     73
  • Marriage                   15
  • Financial Change   38
  • Vacation                   13

Factors that influence stress are:

  • Appraisal
  • Perceived control (eg. Dentist, nursing home study)
    being told by your physican that there will be a certain type of pain for a limited amount of time, the fact that you know reduces your stress.
        An experimental example would be:
               
    There would 2 rats
  • Intensity
  • Duration
  • Predictability
  • Competency
  • Motivation - less modivartion = more stress
  • Physiological State - going through surgery, and if you have psycho logical stress - divorce, the 2 will add together
  • Social Support - the more social support/friends the less stress you will experience.

 

 

 

 

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