PSYCH 2SL1: RECOGNIZING PSYCHOPATHOLOGY (PART 2)

BIPOLAR AND RELATED DISORDERS - END OF LECTURE

Bipolar and Related Disorders

• Bipolar I

• Bipolar II

• Cyclothymic

• Substance/Medication induced

Manic Episode

• A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently goal-directed activity or energy

• Lasting at least, 1 wk and present most of the day, nearly every day

Hypomanic Episode

• A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently goal-directed activity or energy

• Lasting at least, 4 consecutive days and present most of the day, nearly every day

• The episode is not sever enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization

Major Depressive Episode

• Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others

• Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day

• 2 weeks period

• F>M

Bipolar I

• At least 1 manic episode

Bipolar II

• At least 1 hypomanic episode

• At least 1 major depressive episode

Cyclothymic Disorder

• At least 2 years

• Chronic fluctuating, mood disturbance involving numerous periods of hypomanic symptoms and periods of depressive symptoms that are distinct from each other

Depressive Disorders

• Disruptive Mood Dysregulation Disorder

• Major Depressive Disorder

• Persistent Depressive Disorder

Disruptive Mood Dysregulation Disorder

• Children with persistent irritability and frequent episodes of extreme behavioral dyscontrol

  • Severe recurrent temper outburst manifested by verbally and/or behaviorally that is out of proportion in intensity or duration to the sistuation

  • Pesistently angry or irritable most of the day, nearly everyday

  • At least 12 mos

  • Age onset 10 yo

• Typically developed unipolar depressive disorder or anxiety disorder in adolesence and adulthood

Persistent Depressive Disorder (Dysthymia)

• At least 2 years

• Depressed mood for most of the day, or more days than not, as indicated by either subjective account or observation by others

• During the 2 year period (1 yr for adolesence and children) of the disturbance, the individual has never been without the symptoms in criteria A or B for more than 2 mos at a time

Etiology of Mood Disorder

• Bipolar and depressive disorders

• Etiology

• Biologic abnormalities

• Alteration of hormonal regulation

• Alteration in sleep neurophysiology

• Structural and functional brain imaging and neuroanatomical considerations

• Genetic factors

Neurotransmitters that are included in the etiology of mood disorders

• Serotonin - decreased in depression; SSRI

• Noepinephrine - decreased in depression; SNRI

• Dopamine - decreased in depression; increased in mania

Genetic Factors of Mood Disorder

• If one parent has a mood disorder, a child will have a risk of between 10 and 25% for mood disorder

• If both parents are affected, the risk doubles

• The more members in the family who are affected, the greater the risk to a child

• The risk is greater if the affected family are first-degree relative

• A family history of bipolar disorder conveys a greater risk for mood disorders in general and, specifically, a much greater risk for bipolar disorder

• Unipolar disorder is typically the most common form of mood disorder in families of bipolar probands

Psychosocial Factors of Mood Disorder

• Personality factors

  • No single personality trait or type uniquely predisposes a person to depression; all humans, of whatever personality pattern, can and do become depressed under appropriate circumstances

• Psychodynamic factors in depression

  • Freuf, expanded by Karl Abraham:

    • Classic View of Depression

      1. Disturbances in infant-mother relationship during oral phase predisposes to depression

      2. Linked to real or imagined object loss

      3. Introjection of the departed object is a defense mechanism invoked to deal within the distress related with loss

      4. Because of lost object is regarded with a mixture of love and hate, feelings of anger are directed towards inner self

Psychodynamic Factors in Mania

• Defense against underlying depression

• May also result from a tyrannical supreego, which cannot tolerate self-criticism

• Ego is overwhelmed by pleasurable or feared impulses

Psychodynamic Factors in Depression

• Edward Bibring

• Silvano Arieti

• Heinz Kohut

• John Bowlby

Edward Bribing

Silvano Arieti

Heinz Kohut

John Bowlby

Cognitive Theory

• Depression results form specific cognitive distortions present in susceptible person

• Aaron Beck - cognitive triad of depression

• view about self - negative

• Environment - hostile and demanding

• Future - expectation of suffering and failure

Learned Helplessness

• Connects depressive phenomena to the experience of uncontrollable events

• Internal causal explanations are thought to produce a loss of self-esteem after adverse external events

• Tx: improvement of depression contingent on the patient’s learning a sense of control and mastery of the environment

Treatment for Mood Disorders

• Guarantee safety

• Pharmacotherapy - mood stabilizaers

• Transcranial magnetic stimulation

• Psychotherapy

Anxiety Disorders

• Excessive feat and anxiety and related behavioral disturbances

  • Separation anxiety disorder

  • Selective mutism

  • Social anxiety disorder

  • Panic disorder

  • Agoraphobia

  • Generalized anxiety disorder

Normal Anxiety

• Diffuse, unpleasant, vague sense of apprehension, often accompanied by autonomic symptoms and restlessness

• Alerting signal that warns of impeding danger and enables us to take measures to deal with threat

• Adaptive

2 Components of Normal Anxiety

• Awareness of physiological sensation

• Awareness of being nervous or frightened

Pathological Anxiety

• 17.7%

• F>M

• Prevalence decreases with higher socioeconomic status

Psychosocial Sciences

• Psychoanalytic theory

• Developmental issues

• Developmental issues

• Behavioral theories

• Existential theories

Psychoanalytic Theory

• Signal of danger in the unconscious

• Result of psychic conflict between unconscious sexual or aggressive wishes and corresponding threats from the superego or reailty

• Treatment: Not eliminate but increases tolerannce

Disintegration Anxiety

• Developmental issue

• Feat that self will fragment because others are not responding hand needed and validation

Persecutory Anxiety

• Self is being invaded and annihilated by an outside malevolent force

Castration Anxiety

• Oedipal phase in boys in which a parental figure (usu father) may damage the boy’s genitals or cause bodily harm

Superego Anxiety

• Guilt feelings about not living up to internalize standard derived from parents

Behavioral Theories

• Or learning theory of anxiety

• Conditioned response to a specific stimulus thus developing mistrust

Existential Theories

• No specifically identifiable stimulus

• Person experience feelings of living in a purposeless universe

• Anxiety is their response to perceived void in existence and meaning

Biological Sciences

• ANS

• Neurotransmitters

• Genetic Studies

• Neuroanatomical Considerations

ANS

• Increased sympathetic tone

• Adapt slowly to repeated stimuli

• Respond excessively to moderate stimuli

Neurotransmitters

• NE: increased

• GABA

• Serotonin

• HPA axis: increased cortisol during stress but altered in anxious patients

• CRH: increased during stress thereby activating HPA axis and increases cortidol

Genetic Studies

• Almost half of all patients with panic disorder have at least one affected relative

• Higher frequency in first degree relative

Neuroanatomical Considerations

• Limbic system

• Cerebral cortex

Panic Disorder

• Recurrent unexpected panic attacks

• A significant maladaptive change in behavior related to the attacks

• F>M (2:1)

Panic Attacks

• Abrupt surge of intense fear or intense discomfort that reaches a peak within minutes

Agoraphobia

• Marked fear or anxiety triggered by real or anticipated exposure to:

  • Using public transportation

  • Being in open spaces

  • Being in enclosed spaces

  • Standing in line or being in a crowd

  • Being outside or home alone

• Escape might be difficult or help might not be available in the event of development of symptoms

Generalized Anxiety Disorder

• Excessive anxiety and worry (apprehensive expectation) occurring more days than not for at least 6 months, about a number of events or activities

• Individual finds it difficult to control worry

Obsessive Compulsive Disorders

• Obsessive Compulsive Disorder

• Body Dysmorphic Disorder

Obsessive Compulsive Disorder

• Adolesence / Childhoos

• 20 y/o

• Time consuming (more than 1 hr per day)

• Cause distress

• Impairment in social, occupation, functioning

Body Dysmorphic Disorder

• One or more perceived defects in physical appearance that are not observable by others

• Performs repetitive behavior in response to appearance

• Clinically significant distress or impairment in social, occupation, and functioning

• Not explained by weight concerns

Trauma and Stress-Related Disorders

• Reactive Attachment Disorder

• Disinhibited Social Engagement Disorder

• Posttraumatic Stress Disorder

• Acute Stress Disorder

• Adjustment Disorder

Reactive Attachment Disorder

• At least 9 mos of age (disturbance is evident <5 y/o)

• Consistent pattern inhibited, emotionally withdrawn behavior

• Experienced extreme insufficient care

  • Social neglect, lack of basic emotional needs

  • Repeated changes of caregivers

  • Limited opportunity to form an attachment

Disinhibited Social Engagement Disorder

• At least 9 mos of age

• Culturally inappropriate, overly familiar with STRANGERS

• Extreme insufficient care

Posttraumatic Stress Disorder

• More than 1 mos

• Begin within the first 3 mos after trauma

• ½ of adults, recovery in 3 mos

• Others remain symptomatic

  • For >1 year & so >50 yrs

1. Exposure

2. Intrusion symptoms

3. Avoiding distressing stimuli related to trauma

4. Negative alterations in cognition/mood

5. Altered arousal/reactive state

6. More than 1 mos

Active Stress Disorder

• 3 days to 1 mos

1. Exposure

2. Presence of symptoms (5 categories)

   1. Intrusion symptoms

   2. Negative mood

   3. Dissociative symptoms

   4. Avoidance symptoms

   5. Arousal symptoms

Adjustment Disorder

• Occurs within 3 mos of the onset of stressors

• Once stressor/consequences are terminated

  • Symptoms do not persist for additional 6 mos.

  • Presence of emotional or behavior symptoms in response to an identifiable stressor

Dissociative Disorder

• Unbidden intrusions to awareness, lack of continuity, inability to access info

• Depersonalization/Derealization Disorder

• Dissociative Amnesia

• Dissociative Identity Disorder/Multiple Personality Disorder

Depersonalization/Derealization Disorder

• Clinically significant persistent or recurrent depersonalization and/or derealization

• Intact reality testing

Dissociative Amnesia

• Inability to recall autobiographical information that is inconsistent with normal forgettin

Types of Dissociative Amnesia

1. LOCALIZED - unable to remember an event (MOST COMMON)

2. SELECTIVE - unable to remember a specific aspect of event

3. GENERALIZE - complete loss of identity/life history

Dissociative Identity Disorder / Multiple Personality Disorder

• Presence of 2 more distinct personality states

• RECURRENT episodes of AMNESIA

• Also experience

  • Recurrent, inexplicable into sense of self

  • Alteration in sense of self

  • Odd changes of perception

Somatic Symptoms and Related Disorder

• Prominence of SOMATIC SYMPTOMS associate with significant distress and impairment

• Somatic Symptom Disorder

• Illness Anxiety Disorder

• Conversion Disorder (Functional Nerological)

• Factitious Disorder (Imposed on Self and to Another)

Somatic Symptoms Disorder

• More than 6 mos

• Not the symptom itself - the way the person interprets them

• One or more somatic symptom that is DISTRESSING → disruption of daily life

• Excessive thoughts, feelings, behavior related to somatic symptom

  • Persistent, high level anxiety, time and energy devoted to thinking

    • Duration (symptomatic): More than 6 mos

Illness Anxiety Disorder

• At least 6 mos

• Preoccupation with having/acquiring serious illness

• Somatic symptoms are NOT PRESENT (if present, mild)

• High level anxiety

• Performs EXCESSIVE HEALTH RELATED BEHAVIORS

Conversion Disorder (Functional Neurological)

• Altered VOLUNTARY motor or sensory function

• INCOMPATIBILITY of symptom and recognized medical/neurological condition

Factitious Disorder (Imposed to Self and to Another)

• Deception

• Falsification of physiological/psychological symptoms

• Present himself/another person (victim) as ill

Feeding and Eating Disorders

• Persistent disturbance to eating > altered consumption > impaired physical/psychosocial health

• PICA

• Rumination Disorder

• Avoidant/Restrictive Food Intake Disorder

• Anorexia Nervosa

• Bulimia Nervosa

• Binge-eating Disorder

PICA

• At least 1 month

• Non-food substances

Rumination Disorder

• At least 1 month

• Repeated REGURGITATION after eating

Avoidant/Restrictive Food Intake Disorder

• Avoidant, restriction of food intake > failure to meet requirements for nutrition

• Insufficient energy via oral route

  • Weight loss, nutritional deficiency, dependent on enteral feeding and oral supplements

Anorexia Nervosa

• Persistent energy intake restriction

• INTENSE FEAR OF GAINING WEIGHT OR BECOMING FAT

• Disturbance in perceived weight

Bulimia Nervosa

• Recurrent episodes of BINGE EATING > INAPPROPRIATE COMPENSATORY behaviors to prevent weight gain

Binge-eating Disorder

• At least once per week for 3 mos

• Recurrent binge eating with NO COMPENSATORY

Elimination Disorders

• Enuresis

• Encopresis

Enuresis

• At least 5 yrs of age

• Voiding in appropriate places

• Bedwetting

Encopresis

• At least 4 yrs old

• Elimination of feces in inappropriate places

• Self-limited

Sleep Wake Disorders

• Sleep Deprivation

Sleep Deprivation

Lack of sleep causing:

• Ego disintegration

• Hallucinatio

• Delusion

• Irritability

• Lethargy

Sleep Hygiene

• Sleep schedule

• Allow body > wind down

• Avoid naps

• Exercise

• Optimum environment

• Avoid alcohol, heavy dinner

Sexual Dysfunctions

• Heterogenous > inability to experience sexual pleasure

Gender

Public lived role

Gender Assignment

Natal gender (genitalia at birth)

Gender identity

Gender dysphoria

• Distress due to incongruence of expressed from natal

Transgender

Gender is different from natal

Transexual

• Social transition; gender reassignment surgery

Disruptive, Impulse Control, Conduct Disorder

• MEN > problems c self control of emotions and behaviors, violate the rights of others

• Oppositional Defiant Disorder

• Intermittent Explosive Disorder

• Conduct Disorder

• Pyromania

• Kleptomania

Oppositional Defiant Disorder

• At least 6 mos

• Angry/irritable mood

• Argumentative, vindiciveness

  • Argues with authority

  • Refuses to comply

  • Blames others for his mistakes

• Associated with individual distress or immediate social context

• Negatively impacts function

Intermittent Explosive Disorder

• At least 6 yrs

• Recurrent behavioral outburst

  • Verbal/physical aggression (2x for 3 mos)

  • Physical injury/Destruction of property (within 12 mos)

• Not premeditated (impulsive)

• NO TANGIBLE OBJECT

• Distress in individual problems in interpersonal relationships, legal/financial consequences

Conduct Disorder

• Before age 13

• At least 1 criteria for 6 mos

• Bullies, threatens, intimidates

• Cruel to people and animals

• Forces sexual activity

• Obtain goods or favors

Pyromania

• Deliberate, purposeful fire setting

• Tension before act

• Attraction to fire

• Pleasure, relief after fire setting

• Not done for any other reason

Kleptomania

• Failure to resist impulses to steal objects not needed for personal use

• Tension before, pleasure while committing theft

Substance Related and Addiction Disorders

• Cluster of cognitive, behavioral, physiological symptoms

• Continues to use substance despite problems

• Underlying change in brain circuits, beyond detox (RELAPSE, INTENSE CRAVING)

• Intoxication

• Withdrawal

Intoxication

• REVERSIBLE syndrome

• Affects memory, judgement, mood, orientation, behavioral, social, occupational

Withdrawal

• Occurs ATER STOPPING A DRUG that has been used for a prolonged period

• Physiological + psychological signs and symptoms

Neurocognitive Disorders

• Delirium

• Dementia

Delirium

• Acute decline in consciousness, cognition, affects attention

• May be life threatening REVERSIBLE THOOOO

• Perceptual disturbance, abnormal psychomotor, impaired sleep-cycle

Dementia

• Progressive cognitive impairment

• Clear consciousness

• Impairment in social and occupational

Dependence

• Behavioral dependence - substance seeking activities, related evidence of pathological use patterns are emphasized

• Physical dependence - physiological effects of substance use

Habituation

• Continuous or intermittent craving for the substance to avoid a dysphoric state

Amnestic Disorders

• Impaired ability to create new memories

Personality Disorder

• Separated into 3 clusters

PD - Cluster A

• Old, aloof features

• Schizophrenia

• Schizoid

• Paranoid