Behavior Disorders Final

Personality Disorder are ….

• Enduring, inflexible predispositions

• Maladaptive, causing distress and/or impairment

• High comorbidity with other disorders

• Generally poor prognosis

• Patients don't feel that treatment is necessary

Personality Disorder have traditionally been assigned as __________ categories

all-or-nothing

• but DSM-5 retained categorical diagnoses but also introduced an additional dimensional model of personality

Dimensional Model

individuals are rated on the degree to which they exhibit various personality traits

Five Factor Model of Personality (Big Five)

OCEAN

Oppeness

Conscientiousness

Extraversion

Agreeableness

Neuroticism

Prevalence of Personality Disorders

affects about 10% of the general population

Origin and Course of Personality Disorders

• thought to begin in childhood

• tends to run a chronic course if untreated

• may transition into a different personality disorder

Which gender more often shows traits like aggression and detachment in personality disorders?

men

Which gender shows deference to others and insecurity in interpersonal relationships in personality disorders?

women

Antisocial personality disorders shows more often in _____

men

Dependent personality disorder shows more often in ______

women

Comorbidity with Personality Disorders

often have 2+ personality disorders or an additional mood/anxiety disorder

Personality Disorder Cluster A

odd or eccentric

• paraniod, schiziod, and schizotypal personality disorder

Personality Disorder Cluster B

dramatic or erratic

• antisocial, borderline, histrionic, and narcissistic personality disorder

Personality Disorder Cluster C

anxious or fearful

• avoidant, dependent, and obsessive-compulsive personality disorder

Paranoid Personality Disorder

pervasive and unjustified mistrust and suspicion, few meaningful relationships, sensitive to criticism

causes: may involve early learning that people and the world are dangerous or deceptive

cultural factors: more often found in people with experiences that lead to mistrust of others (e.g. prisoners, refugees)

treatment focuses on development of trust; cognitive therapy to encounter negativistic thinking

Schizoid Personality Disorder

Pervasive pattern of detachment from social relationships; Very limited range of emotions in interpersonal situations

Etiology is unclear but may have significant overlap with autism spectrum disorder

Treatment focus on the value of interpersonal relationships and on building empathy and social skills

Schizotypal Personality Disorder

• Features

  • Behavior and beliefs are odd and unusual

  • Socially isolated and highly suspicious

  • Magical thinking, ideas of reference, and illusions (not delusions)

    • “There are signs everywhere” “this is here to remind me of …”

  • Many meet criteria for major depression

  • Some conceptualize this as resembling a milder form of schizophrenia

• Causes:

  • Mild expression of “schizophrenia genes”

  • May be more likely to develop after childhood maltreatment or trauma, especially in men

  • More generalized brain deficits may be present

• Treatment options

  • Address comorbid depression

  • Main focus is combination of medication, CBT, and social skills training

Antisocial Personality Disorder

•  features

  • Failure to comply with social norms

  • Violation of the rights of others

  • Irresponsible, impulsive, and deceitful

  • Lack of a conscience, empathy, and remorse

  • May be very charming, interpersonally manipulative

  • “Sociopathy” and “psychopathy” typically refer to very similar traits 

• Often show early histories of behavior problems, including conduct disorder

  • “Callous-unemotional” type of conduct disorder more likely to evolve into antisocial PD

• Families with inconsistent parental discipline and support

• Families often have histories of criminal and violent behavior 

• Recent research suggests that psychopathy is less reliable predictor of criminality (and there are "successful psychopaths”)

Neurobiological Contributions to Antisocial Personality

theories:

• underarousal hypothesis - cortical arousal is too low

• cortical immaturity hypothesis - cerebral cortex is not fully developed

• fearless hypothesis - fail to respond to danger cues

• Gray’s model - inhibition signals are outweighed by reward signals

Genetic Influences of APD

more likely to develop antisocial behavior if parents have a history of antisocial behavior or criminality

Developmental Influences of APD

high conflict childhood increases likelihood of APD in at risk children

Impaired Fear Conditioning in APD

children who develop APD may not adequately learn to fear aversive consequences of negative actions

• e.g. punishment for setting fires

Arousal Theory in APD

People with APD are chronically under-aroused and seek stimulation from the types of activities that would be too fearful or aversive for most

Psychological and social influences in APD

In research studies, psychopaths are less likely to give up when goal becomes unattainable - may explain why they persist with behavior (e.g. crime) that is punished

Biological-Environment influence in APD

• Early antisocial behavior alienates peers who would otherwise serve as corrective role models

• antisocial behavior and family stress mutually increase one another

T/F: APD is the result of multiple interacting factors

true

Treatment for APD

• Few seek treatment on their own 

• Antisocial behavior is predictive of poor prognosis

• Emphasis is placed on prevention and rehabilitation

• Often incarceration is the only viable alternative 

• May need to focus on practical (or selfish) consequences (e.g. if you assault someone you'll go to prison)

Neurodevelopmental Disorders include

• Attention deficit hyperactivity disorder

• Specific learning disorders

• Autism spectrum disorder

• Intellectual disability 

• Communication and motor disorders

Nature of Developmental psychopathology

• Study of how disorders arise and change with time 

• Disruption of early skills can affect later development

• Caution: do not excessively pathologize childhood behavior that is part of normal development

Communication and and Motor Disorders

• childhood-onset fluency disorder

• language disorder

• social communication disorder

• tourette’s disorder

Childhood-onset Fluency Disorder

• Often called stuttering

• Occurs twice as often in boys as girls

Language Disorder

• Limited speech in all situations

• Occurs in 10-15% of children younger than 3 years of age

Social Communication Disorder

Difficulties with the social aspects of verbal and nonverbal communication

Tourette’s Disorder

• Motor and vocal tics

• High comorbidity with ADHD and OCD

ADHD

• Central features as inattention, overactivity, and impulsivity

• Associated with behavioral, cognitive, social, and academic impairments

• 3 subtypes:

  • Predominantly inattentive presentation

  • Predominantly hyperactive/impulsive presentation

  • Combined presentations

Prevalence of ADHD

• Occurs in ~ 5% of school-aged children throughout the world

• is most commonly diagnosed in the US, although the prevalence is fairly constant worldwide

• In general population, 5-9% meet criteria

Which Gender is ADHD more prevalent?

boys outnumber girls 3:1

• Some suggest girl’s symptoms less likely to be disruptive, thus less likely to be diagnosed

Course of ADHD

• Symptoms usually appear around age 3-4

• Half of children with ADHD continue to have difficulties as adults

• Impulsivity decreases, but inattention remains

• Brain development progresses in a more typical fashion in children receiving medication

Neurobiological Contributions of ADHD

• Smaller brain volume 

• Inactivity of the frontal cortex and basal ganglia

• Abnormal frontal lobe development and functioning

Genetic Contributions of ADHD

• ADHD seems to run in families

• DAT1 - dopamine transporter gene has been implicated, as have norepinephrine, GABA, and serotonin

Role of Toxins in ADHD

• Food additives may play very small role in hyperactive/impulsive behavior among children

• Maternal smoking increases risk

ADHD represents a _______, not a deviation, in brain developement

delay

Psychosocial Factors of ADHD

• Children with ADHD are often viewed negatively by others leading to frequent negative feedback from peers and adults 

  • Peer rejection and resulting social isolation may lead to low self-esteem (therefore, increased risk for depression)

Biological Treatments of ADHD

• Goal of treatments: reduce impulsivity and hyperactivity, improve attention

• Stimulant medications

  • Currently prescribed for ~3.5% of American children

• Newer non-stimulant medications also available

• Genes affect individual’s responses to meds

  • Some trials and error is necessary 

• Effects of medications

  • Improve attention/focus (do not affect learning/academics directly)

  • Decrease negative behaviors 

  • Benefits are not lasting following discontinuation

Behavioral and Combined Treatments of ADHD

• Reinforcement programs increase appropriate behaviors, decrease inappropriate behaviors

• May also involve parent training

• Adults: cognitive behavioral therapy to increase attention and organization

• Combined bio-psycho-social treatments

  • May be superior to medication or behavioral treatments alone, but more research is needed

Scope of Learning Disorders

• Academic problems in reading, math, and/or writing

• Performance substantially below expected levels based on age and/or demonstrated capacity

• Problems persist for 6+ months despite targeted intervention

Prevalence of Specific Learning Disorders

• -15% prevalence across youth of various age and cultures

• Highest rate of diagnosis in wealthier regions, but children with low SES more likely to have difficulties

• Reading difficulties most common, affect 7% of the general population

Students with learning disorders are more likely to:

• Have negative school experiences

• Drop out of school

• Be unemployed

• Have suicidal thoughts

Genetic and Neurobiological Contributions to Specific Learning Disorders

• Learning disorders run in families, but specific difficulties are not inherited

• Evidence for subtle neurological difficulties is mounting (e.g. decreased functioning of areas responsible for word recognition)

Psychosocial Contributions to Specific Learning Disorders

Some languages are more difficult to read so have higher rates of reading impairment

Treatment for Specific Learning Disorders

• Requires intense educational interventions

  • Remediation of basic processing problem, cognitive skills, and compensatory skills

• Data support behavioral educational interventions

• Biological interventions (e.g. Ritalin) usually used only for those individuals who also have ADHD

Autism Spectrum Disorder

problems occur in language, socialization, and cognition

Autism is _______

pervasive ==> problems span many life areas

2 Main Areas of Impairment in Autism

1. Communication and social interaction

• 10-33% don't acquire effective speech 

2. Restricted, repetitive patterns of behavior, interests, or activities

Autism includes

Asperger’s disorder, childhood disintegrative disorder, and Rett disorder

Impairment in Social Communication and Interaction

• Defining characteristics: failure to develop age-appropriate social relationships

  • Trouble initiating and maintaining relationships

  • Trouble with nonverbal communication

    • May lack appropriate expressions, tone

  • Trouble with social reciprocity

Deficits in joint attention

Joint Attention

the ability to communicate interest in an external stimulus and another person at the same time

With Autism there is a Preference for the …

status quo – maintenance of sameness

Severe forms of Autism

stereotyped or ritualistic behavior 

• E.g. spinning, waving hands, rocking

Less severe forms of Autism

intense, circumscribed interest in very specific subjects

• Having restricted areas of interest may compound difficulties relating to others

Prevalence of Autism

• 1 in 68 8-year-old children meet criteria

• Majority of recent rise in rates due to changes in diagnostic criteria

• More commonly diagnosed in males

  • Gender ratio: 4-5 to 1

• 31% also have intellectual disabilities

• Previously thought to be very rare, but this is not the case

Historical Views of Autism

• Failed parenting

• Originally thought to be lack of self-awareness

  • Later research showed some individuals with ASD have self-awareness

Genetic and biological Contribution of ADHD

Familial component: if you have one child with autism, the chance of having a second child with autism is 20%

• Numerous genes on several chromosomes involved

• Oxytocin receptor genes

  • Bonding and social memory 

• Older patents associated with increased risk

• Amygdala larger at birth

T/F: Vaccinations increase the risk of autism

False

Behavioral Treatments of Autism

• Behavioral approaches

  • Skill building in communication and socialization

  • Reduce problem behaviors

  • Naturalistic teaching strategies (at home and in the community in addition to at school with, e.g. child-initiated activities)

  • early intervention is critical

Biological treatments for Autism

• Medical intervention has had little positive impact on core dysfunction

Preferred approach to Autism Treatment

integrates early intervention, education, and psychological support

Intellectual Disability

• Below-average intellectual and adaptive functioning

• First evident in childhood

• Range of impairment varies greatly

• IQ typically below 70-75

Prevalence of Intellectual Disability

1-3% of general population

• 9 in 10 people with ID have mild impairment (IQ 50-70)

Course of of Intellectual Disability

• Chronic course

• Highly variable individual prognosis 

  • Independence is possible for many individuals with mild impairment when provided with appropriate resources

Genetic causes of Intellectual Disabilities

• Chromosomal disorders (e.g. down syndrome)

• Multiple genetic mutations 

• Signal genes can be responsible but dominant genes are less often responsible than recessive genes

Lesch-Nyhan Syndrome

Intellectual disability, symptoms of cerebral palsy, self-injurious behavior 

Phenylketonuria (PKU)

• Cannot break down phenylalanine, which is found in some foods

• Results in intellectual disability when the individual ear phenylalanine

Chromosomal Disorders

• down syndrome

• fragile x syndrome

Down Syndrome

• Most common chromosomal cause of intellectual disability 

• Extra 21st chromosome (trisomy 21)

• Distinctive physical symptoms

Fragile X Syndrome

• Symptoms include learning disabilities, hyperactivity, short attention span, gaze avoidance, perseverative speech 

• Primarily affects males

Cultural-familial intellectual disabilities:

• refers to intellectual disability influenced by social environmental factors, such as:

  • Abuse

  • Neglect

  • Social deprivation

• These factors likely interact with existing biological factors

• Very rare today because of better child-care systems and early identification of at-risk families

Treatment of Intellectual Disability

• Goals are similar across severity; level of assistance differs

• Behavioral interventions teach:

  • Basic self-care skills

  • Social skills

  • Practical skills

Neurocognitive Disorder Affect …

Affect learning, memory, and consciousness

T/F: Most Neurocognitive develop later in life

true

Types of Neurocognitive Disorders

Delirium and Major or Mild Nuerocognitve disorder

Delirium

temporary confusion and disorientation

Major or Mild Neurocognitve disorder

broad cognitive deterioration affecting multiple domains

There was a shift from “organic” mental disorders (due to brain injury/dysfunction to a _________ disorder

cognitive

• broad impairment in cognitive functioning

• causes profound changes in behavior and personality

Nature of Delirium

• Central features ⇒ impaired consciousness and cognition

• Develops rapidly over several hours or days

• Appear confused, disoriented, and inattentive

• Marked memory and language deficits

• Drugs such as Ecstasy, “Molly”, and “bath salts: can cause substance-induced delirium

Delirium Prevalence

• Affects up to 20% of adults in acute care facilities (e.g. ER)

• More often in certain populations, including:

  • Older adults

  • Those undergoing medical procedures

  • People with AIDS or cancer

  • People in hospitals/critical care

• Full recovery often occurs within several weeks

Medical Conditions Related to Delirium

• Dementia (50% of cases involve temporary delirium)

• Drug intoxications, poisons, withdrawal from drugs

• Infections

• Head injury and several forms of brain trauma

• Sleep deprivation, immobility and excessive stress

Treatment for Delirium

• Attentions to underlying causes

• Psychosocial interventions 

  • reassurance/comfort, coping strategies, inclusions of patients in treatment decisions

Prevention for Delirium

• Address proper medical care for illnesses, proper use of, and adherence to, therapeutic drugs 

Nature of Dementia

• Gradual deterioration of brain functioning

• Deterioration in language and advanced cognitive processes

• Has many causes and may be irreversible

New Neurocognitive Cases are identified every ________

7 seconds

Dramatic rise in ____________ disease cases predicted through 2050; more people expected to live to > 85 years

Alzheimer's disease

How many people with major neurocognitice disorders in the US?

5 million

Alzheimer’s disease clinical features

• Typically develops gradually and steadily

• memory , orientation, judgement, and reasoning deficits

• Additional symptoms may include

  • Agitation, confusions, or combativeness

  • Depression and/or anxiety

Alzheimer’s is more common in ___________

less educated individuals

• People who attain a higher level of education decline more rapidly once the symptoms become more severe

• Cognitive reserve hypothesis

Cognitive reserve hypothesis

the more synapses a person develops throughout life, the more neuronal death must take place before the signs of dementia are obvious

Alzheimer’s disease is slightly more common in ________

women - Possibly because women lose estrogen as they age, estrogen may be protective

Post-diagnosis survival of Alzheimer’s

8 years

Onset of Alzheimer’s

60s or 70s

early = 40s to 50s

What percentage of cases of neurocognitive disorder result from Alzheimer's disease?

60-70%