Clinical Psyc Final

Psychosis

Psychosis

Delusions and hallucinations

-Includes Schizophrenia

Schizophrenia

-Involves psychosis

-Loss of contact with reality

-Affects all the functions we rely on each day

-heterogenous presentation

-Dimensional assessment of symptoms on a 0-4 scale

-Negative and positive symptoms

Schizophrenia: Positive symptoms

-Presence of actively abnormal behaviour, too much of or distortion of normal behaviour

-EX: Delusions, hallucinations

-50-70% of individuals with schizophrenia will experience

Schizophrenia: Negative symptoms

-Loss or reduction of normal behaviour

-EX: Apathy, emotional/social withdrawal, great reduction (“poverty”) in thought or speech

-Spectrum

• Avolition: Inability to initiate/persist in activities

• Alogia: Absence of speech; brief replies

• Anhedonia: Lack of pleasure experienced

• Asociality: Lack of interest in social interactions

• Affective flattening: No open reaction to emotional situations

Avolition

Inability to initiate/persist in activities

Alogia

Absence of speech; brief replies

Anhedonia

Lack of pleasure experienced

Asociality

Lack of interest in social interactions

Affective flattening

No open reaction to emotional situations

Schizophrenia: Disorganized symptoms

-E.g., severe and excess disruptions in speech, behaviour, emotion

-Disorganized speech: Communications problems

• Loose associations or derailment - taking conversation in unrelated directions

• Tangentiality - “Going off on a tangent” and not answering a question directly

-Inappropriate affect and disorganized behaviour: Laughing or crying at inappropriate times

-Catatonic immobility: Keeping body and limbs in the position they are put in by someone else

Catatonic immobility

Keeping body and limbs in the position they are put in by someone else

Schizophrenia causes

-Prodromal

-Age of onset: early adulthood

-highly genetic

-Causes

• Dopamine hypothesis: Too simplistic??

• Hypofrontality: Less active frontal lobes

Agonist

-More

-Drug increases creation of neurotransmitter

-Drug increases release of neurotransmitter

Antagonists

-Less

-Drug interferes with release of neurotransmitter

-Drug sits on the receptors so blocks neurotransmitter from binding

Schizophrenia medication

-Neuroleptics

• Dopamine antagonists

• When effective, neuroleptics help people think more clearly

• Reduce or eliminate positive symptoms

-Effective for 60-70% of persons

-Newer antipsychotics

• Have fewer side effects

• Reduce positive and negative symptoms

• Help in improving cognitive functioning

-Acute and permanent extrapyramidal and Parkinson-like side effects

• Higher rate in conventional antipsychotics

• Lower rate in new antipsychotics

-Medication compliance can be problimatic

Other psychotic disorders

• Schizophreniform disorder

• Brief psychotic disorder

• Delusional disorder

• Schizoaffective disorder

  • Mood + Schizophrenia

• Delusional disorder

• Schizotypal personality disorder

• Schizophreniform Disorder (more than 1 month, less than 6)

• Brief Psychotic disorder (more than 1 day, less than 1 month)

• Delusional Disorder

• Schizoaffective Disorder

  • Mood + Schizophrenia

Schizotypal personality disorder

-Clinical features

• Behaviour and dress is odd, unusual

• Interpersonal and social deficits. Often socially isolated; may be highly suspicious of others

• Magical thinking, ideas of reference, and illusions of common

• Many also meet criteria for major depression

Autism spectrum disorders (ASD) criteria

• Significant and persistent deficits in social interaction and communication skills

• Restricted, and repetitive patterns of interests and behaviours

• Symptoms must be present in early developmental period

• Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning

• Not due to intellectual disability or general delay

ASD (Autism spectrum disorder) prevalence

Estimates are as high as 1 in 68 children in US

Approximately 1 in 66 children and youth diagnosed in Canada

Strengths of autism

-Above-average intelligence

• CDC reports 46% of autistic kids have above average intelligence

-Being able to learn things in detail and remember information for long periods of time

-Being strong visual and auditory learners

-Excelling in math, science, music, or art

Autism and gender

-4-4.5 times more common among boys

-Gendered concept

• Early cases studies and theories “extreme male brain”

• Differential male-to-female ratio

• New interest in females

• Co-occurrence of autism and transgender or non-binary identities

ADHD types

-ADHD-IA

-ADHD-HY

-ADHD-C

ADHD-IA

6 or more inattentive symptoms

ADHD-HY

-6 or more hyperactive/impulsive symptoms

-6 months or longer

ADHD-C

Met both criterion A (inattention) and B (hyperactive)

ADHD treatment

-Biological (medication)

• Stimulant medication works in 70-80% of cases

• Improves motor planning, response inhibition, compliance

• Decreases negative behaviours

• Effects not long term

-Psychological (behavioural)

• Goal setting and reinforcement

Specific learning disorder

-Performance substantially below what would be expected given age, IQ, and education

-Deficits in reading, math, and written expression

-Problems persist despite intervention

Specific learning disorder treatment

-Education intervention

• Remediate directly the underlying basic process of problems

• Improve cognitive skills

• Improve behavioural skills

Intellectual disability

-Intellectual functioning significantly below average

• Language and communication impairments

-Wide range of impairment in daily activities (mild to profound)

-Individuals with ID have difficulty learning

-DSM-5 excludes numeric cut-offs for IQ scores

-Criteria

• Person must have significantly subaverage intellectual functioning (IQ 70)

• Concurrent deficits or impairments in adaptive functioning

• Age of onset (deficits evident before age of 18)

Personality disorder

-Persistent pattern of emotions, cognitions, behaviour resulting in enduring emotional distress for affected person and others

-Distress may (or may not) be subjective

-Causes difficulties with work and relationships

-The DSM-5 lists 10 specific personality disorders

Personality disorder clusters

-DSM-5 divides personality disorders into groups (clusters)

• Cluster A: Odd or eccentric

• Cluster B: Dramatic, emotional

• Cluster C: Anxious, fearful

Cluster A: Odd or eccentric

-Paranoid

-Schizoid

-Schizotypical

Cluster B: Dramatic, emotional

-Histrionic

-Narcissistic

-Antisocial

-Borderline

Cluster C: Anxious, fearful

-Avoidant

-Dependent

-Obsessive compulsive

Antisocial personality disorder

-Aggressive, lying, cheating, no remorse, substance abuse, unnatural death in boys with this disorder

-Moral insanity, egopathy, sociopathy, and psychopathy

-50% to 80% of male offenders diagnosed with this disorder

-Conduct disorder in children

DSM-5 Conduct Disorder

• Aggression to People and Animals

• Destruction of Property

• Deceitfulness or Theft

• Serious Violations of Rules

• Subtypes

• Childhood onset (symptoms began <10 years old)

  • Adolescent onset (symptoms began >10 years old)

  • Unspecified onset

  • Specifier: with Limited Prosocial Emotion

Limited prosocial emotion is the same thing as: (important)

“CU traits” callous-unemotional traits or low prosocial emotion

CU traits

-Lack of empathy, shallow affect

-Severe and chronic aggressive/antisocial behaviour

-Low emotional responsiveness to others

ASPD / Conduct disorder / CU trait treatment

-Prevention is key

-Parent training for diagnosed children

• Parent-child interaction therapy

• Mostly behavioural focused

-Multifaceted for juvenile offenders

-CBT has limited impact

-Not much for adults

Borderline personality disorder

-Turbulent relationships, fear abandonment, self-mutilating behaviours, no control over emotions

-Often engage in suicidal or self-mutilating behaviours

-Approximately 10% die by suicide

-75% achieve remission six years after initial treatment

Borderline personality disorder (BPD) treatment (important)

-Antipsychotics and antidepressants

-Dialectical behaviour therapy (DBT)

Dialectical behaviour therapy (DBT) (Important)

-Effective in reducing suicide attempts

-Creator: Marsha Linehan

-Traditional components: individual outpatient therapy, skills training, phone consultation, case consultation for therapists

Levels of substance us involvement

• Substance use

• Substance intoxication

• Substance abuse

• Substance dependence

• Substance withdrawal

Substance use disorder

-Disorder described as an “addiction”

-Physiological dependence

• Tolerance: greater amounts of drug needed to experience same effect

• Withdrawal: negative physical response when the substance is no longer ingested

-Psychological dependence: Behavioural reactions to substance dependence

Substance categories

-Depressants

-Stimulants

-Opioids

-Hallucinogens

-Other drugs

Opioids

-Natural chemicals in opium poppy having a narcotic effect

-Sleep-inducing, pain-relieving (analgesic)

• Canada in grip of opioid crisis: prescription and illegal; high in First Nation adults

• Withdrawal is unpleasant

• Intravenously taken: risks of HIV

• High morality rates

• Dopesick

Substance abuse treatments

-Substance abusers arrive at treatment at different stages to change substance use behaviour

-Motivational enhancement therapy (MET): increase motivation to change behaviour

Medication

• Agonist substitution (e.g., Buprenorphine, Nicotine patches)

• Antagonist treatments (e.g., Naltrezone)

• Aversive treatment (e.g., Antabuse)

Psychosocial treatments

-Inpatient facilities

-Alcoholics anonymous (AA)

-Controlled use

-Component treatment

-Relapse prevention

Civil commitment

-Most provincial legislation permits commitment when the person

• Has a mental disorder

• Poses danger to himself/herself or others

• Is in need of treatment/other treatments have failed

-Differences in definition/interpretation

-Right to refuse treatment

Deinstitutionalization and Homelessness

-Conditions leading to homelessness

• Younger people, women, families, First Nations people, refugees, ethnic minorities

-Downsizing/closure of mental hospitals

• Transinstitutionalization

• Deterioration in care

Transinstitutionalization

Moving people to nursing homes, group residences, jails prisons

Criminal commitment

-Criminal commitment is the process by which people are held because:

• They have accused of committing a crime and are detained in a mental health facility until fit to participate in legal proceedings

OR

• They have been found not criminally responsible on account of a mental disorder (NCRMD)

Insanity defence

-M’Naghten rule, adapted by Canadian law in 1894

-Not guilty by reason of insanity (NGRI)

-Not criminally responsible on account of mental disorder (NCRMD)

-Not fit to stand trial

-Reactions to NCRMD

Duty to warn and protect

-Mental health practitioners abide by Canadian Psychological Association (CPA, 2017) guidelines

• Stop lethal consequences of client’s actions

• Report to appropriate authorities

• Limits to condentiality

• Risks to patient not to be undervalued

Patients’ rights

-Canadian citizens are constitutionally protected

-The right to treatment

-The right to refuse treatment

The right to treatment

Least restrictive setting possible

The right to refuse treatment

-Drugs’ side effects

• e.g., antipsychotics

-Controversial

Delusions

-Gross misrepresentations of reality

-EX: Delusions of grandeur or persecution

-Cotard’s syndrome and Capgras syndrome

Hallucinations

-Have sensory experience even though not actually there

• Can involve any or all senses

-Auditory most common

Schizophrenia criteria

A. “Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less iff successfully treated):

• Delusions*

• Hallucinations*

• Disorganized speech*

• Grossly disorganized or catatonic behaviour

• Negative symptoms (ie. diminished emotional expression or avolition)”

B. Impairment in functioning (eg. work, self-care, interpersonal relations)

C. Duration: continuous signs of disturbance for 6+ months

Schizophrenia stats

• 0.2% to 1.5% in general population

  • 1.3% Canadians over age 15 have received diagnosis

• Less than average life expectancy

• Men and women affected at same rate

• Can be suicidal

Development of schizophrenia

• Age of onset: symptoms can begin early

  • Prodromal stage: unusual behaviours before serious symptoms occur

  • Takes 2-10 years for person at high risk

• Relapse possible even after early treatment

Cultural schizophrenia factors

• Universal; occurs in all races and cultures

• Cultural variations to treatment

  • Treatment outcomes are better in poorer countries

• Stereotypes and bias: misdiagnoses

Genetic schizophrenia factors

• Multiple gene variances combine to produce vulnerability

• Family studies

  • Children of schizophrenic parents likely to have it too

  • Seen within families; see figure 14.2

  • Predisposition may be inherited

• Gene-Environment Interactions

  • Genes may act as vulnerability factors

  • Interact with specific environmental pathogens at crucial deveopmental stages

    • Leading to development of schizophrenia

Potential Causes of Schizophrenia: Neurotransmitter Influences

• Dopamine Hypothesis

• Drugs that increase dopamine (agonists), can result in schizophrenia-like behaviour

  • Eg. L-dopa for Parkinson’s disease

• Drugs that decrease dopamine (antagonists) , reduce schizophrenia-like behaviour

• Can lead to side effects that look like Parkinson’s disease

• Evidence against dopamine hypothesis → too simplistic

• Current theories emphasize that some dopamine sites might be hyperactive, others hypoactive. Also that glutamate may be implicated

Neurobiological influences

• Dopamine

  • Clues to the role of dopamine in schizophrenia

    • Neuroleptics (dopamine antagonists) effective in treating

    • Neuroleptics produce negative side effects

    • L-dopa (agonist) produces schizophrenia-like symptoms

    • Amphetamines, which activate dopamine, can worsen some symptoms in schizophrenia

Potential Causes of Schizophrenia: Neurobiological Influences

• Brain: Structural and Functional Abnormalities

  • Majority have enlarged ventricles

  • About 50% have hypofrontality-less active frontal lobes

• Viral infections during early prenatal development

  • Relation between early viral exposure and schizophrenia is inconclusive

Schizophrenia Psychological and Social  Influences

• Role of stress

  • May activate underlying vulnerability nad/or increase risk of relapse

• Family interactions (not thought to be casual)

  • High levels expressed emotion (criticism, emotional overinvolvement/intrusiveness, low tolerance of the disorder) in the family is associated with relapse

    • Also likely to be a reciprocal process

  • Role of psychological factors

    • Psychological factors likely exert only a minimal effect in producing schizophrenia

  • Psychosocial interventions include medication-taking compliance

  • Transcranial magnetic stimulation (TSM) treatment for hallucinations

    • TMS also improves auditory hallucinations: effect is brief

Psychosocial Interventions for Schizophrenia

• Psychosocial Approaches

  • Behavioural (ie. token economies) on inpatient units

  • Social and living skills training

  • Stress management, identifying relaspse_waring signs

  • Behavioural family therapy

  • Vocational rehabilitation

  • Technology

• Early intervention

• Psychosocial approaches are usually a necessary part of medication therapy

Schizophrenia treatment across cultures

• Treatments vary from culture to culture: herbal medicines, acupuncture, oral treatments, imprisonment, ancestor worship. Etc.

• Prevention

  • Identify and treat children who may be at risk for developing schizophrenia

  • Identify instability in early family-rearing environment

  • Treat persons in prodromal stages of disorder

Schizotypal personality disorder

• Clinical Features

  • Behaviour and dress is odd, unusual

  • Interpersonal and social deficits. Often socially isolated; may be highly suspicious of others

  • Magical thinging, ideas of reference, and illusions common

  • Many also meet criteria for major depression

• Causes?

  • Schizotypal personality – A phenotype of a schizophrenia genotype?

    • Higher prevalence of this PD in relatives of people with schizophrenia

Schizophreniform Disorder (Partial Criteria)

A. “Two (or more) of the following each present for a significant portion of time during a 1-month period (or less if successfully treated):

• delusions*

• hallucinations*

• disorganized speech*

• Grossly disorganized or catatonic behaviour

• Negative symptoms (ie. diminished emotional expression or avolition)

B. Duration: more than 1 month, less than 6

C. Rule out other psychological disorders (esp. Schizoaffective; depressive, bipolar with psychotic features)

D. Rule out effects of substance, medical condition

• Estimated 0.2% prevalence

• Associated with good premorbid functioning; most resume normal lives

Brief psychotic disorder (partial criteria)

A. Presence of 1+ of following symptoms

• delusions*

• hallucinations*

• disorganized speech*

• Grossly disorganized or catatonic behaviour

B. Durination: more than 1 day, less than 1 month. Return to premorbid functioning

C. Rule out other psychological disorder, effects of substance, medical condition

• Specify if:

  • With marked stressor(s)

  • Without marked stressor(s)

  • With peripartum onset

  • With catatonia

Schizoaffective disorder

A. “An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A for Schizophrenia.

• Note: Major Depressive Episode must include Criterion A1: depressed mood.

B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness.

C. Symptoms that meet criteria for a major mood Episode are present for the majority of the total duration of the active and residual periods of the illness.”

D. Rule out substance or medical condition

• Specify whether: bipolar or depressive type

• Specify if: with catatonia

Delusional disorder

• Delusions that are contrary to reality without other major symptoms of schizophrenia

  • But may be socially withdrawn

• Type of delusions: erotomanic, grandiose, jealous, persecutory, and somatic

• Rare (<0.5% of population).

• May have late onset (e.g., first admission to psychiatric facility > 40 years of age)

• Better prognosis than schizophrenia

Schizotypical personality disorder

• Clinical Features

  • Behaviour and dress is odd, unusual

  • Interpersonal and social deficits. Often socially isolated; may be highly auspicious of others

  • Magical thinking, ideas of reference, and illusions common

  • Many also meet criteria for major depression

• Cause?

  • Schizotypal personality - A phenotype of a schizophrenia genotype?

    • Higher prevalence of this PD in relatives of people with schizophrenia

Summary of schizophrenia and psychotic disorders

• Schizophrenia includes a spectrum of cognitive, emotional, and behavioural dysfunctions

  • Positive, negative, and disorganized symptoms clusters

• Other DSM-5 disorders include psychotic features

• Several causative factors have been implicated for schizophrenia

• Unfortunately, successful treatment rarely includes complete recovery

Overview of DSM-5 criteria for autism spectrum disorders

A. Significant and persistent deficits in social interaction and communication skills

B. Restricted, and repetitive patterns of interests and behaviours

C. Symptoms must be present in early developmental period

D. Symptoms cause clinically significant impairment of social, occupational, or other important areas of current functioning

E. Not due to intellectual disability or general delay

Male prototype of ASD

• Are clinicians biassed towards a more “male prototype”?

• Are diagnostic criteria primarily developed on male-centric description?

• Are families and primary care providers “missing” girls if they don’t fit into a “male prototype”?

Social camouflage hypothesis

• Females with ASD may develop social skills and coping mechanisms that allow them to blend in or camouflage themselves into society

Autism symptoms in girls

• Social scripts (overly rehearsed?)

• Imaginative play -more scripted/ obsessive

• Making symptoms

  • At school, polite and make eye contact; meltdown at home

• Socially acceptable interests (eg. horses, princesses, cats…)

Characteristics associated with autism

• Self-injurious behaviours

• Sleep disturbances

• Gastrointestinal symptoms

• Epilepsy

• Co-morbid mental health concerns

  • ADHD, anxiety and fears, mood

• Cognitive abilities

Risks for development of autism

• Genetic and biological factors

• Environmental risk factors

  • Compromised fetal or neonatal development

  • Parental age

  • Environmental toxins

• Genetic - environment interactions

• Abnormalities in brian development, not localized

Adolescence and adulthood considerations with Autism

• Anxiety – socializing, changes, public places...

• Need emotional support

• Need access to special interest

• Need downtime

• Need social participation, establish support networks

• Questions about valid indicators of Quality of Life

• Transitions

• Out of educational system, health care systems

• Greater self-directed time

• Develop increased independence (decision making, etc.)

• New social situations and peer groups

What might be some challenges or issues for parents of autistic children?

• Obtaining diagnosis

• Caregiving demands

• Shaping expectations

• Acceptance

• Parenting efficacy

• Parenting stress

• Parent mental health concerns

• Parent-child relationships – few differences

• Marital impact

• Sibling impact – mixed

• Family resources and quality of life

Functional impairment: WFIRS

• Family (eg. fights with parents, siblings)

• School (eg. learning: needs extra help, behaviour: detention)

• Life skills (eg. problems getting ready for school)

• Self-concept (eg. feels bad about self)

• Social Activities (eg. is tested, teases others, problems making friends)

• Risky Activities (eg. conduct problems, drugs, aggression)

ADHD stats

• ADHD: 3.4% children and adolescents worldwide

• Boys outnumber girls 4:1

• 2.6% canadians overall; more men than women

• Problem of overdiagnosis of ADHD in North America

• Comorbid with disruptive behaviour disorders

• Between 5% and 15% youth of various ages and cultures

• 18% disabled Canadians over age 15 have a learning disability

• Boys and girls equally affected

• Related to later development of other mental health problems

  • Less education, underemployment, unemployment

• Approximately 90% have mild intellectual disability (IQof 50-70)

• Occurs in 1%-3% of general population

• Chronic course: people do not recover

• Less severe forms relatively independent and productive with training and support

• Male-to-female ratio is 1.6:1 in mild form; no gender differences in severe forms

ADHD causes

• Thought to be highly genetic

  • 80% heritable

• Multiple genes responsible (25-45 identified)

• Inhibition of dopamine gene (DAT1)

• Prenatal smoking, stress, alcohol use

• Abuse, neglect

• Prenatal: eg exposure to substance use

  • Fetal alcohol syndrome: heavy alcohol consumption during pregnancy

• Perinatal: issues with labour and delivery (eg. lack of oxygen)

• Post-natal: head injury, infections

ADHD associations

• Subtle brain differences; reduced with medication

• Volume (size) of brain is slightly smaller

• Sleep problems

• Negative responses by others create low self-esteem

Specific learning disorder causes

• Genetic: found in identical twins, relatives

• Neurobiological: subtle brain damage

  • Phonological processing problems and reading disabilities linked in both children and adults

• Environmental factors: SES, cultural expectations, parental interactions and expectations, child management practices, support (lack of) provided in school

Specific learning disorder treatment

• Education intervention

  • Remediate directly the underlying basic process of problems

  • Improve cognitive skills

  • Improve behavioural skills

• Combination of programs effective

Cluster A disorders

-Paranoid personality disorders

-Schizoid personality disorder

-Schizotypal personality disorders

Cluster C disorders

• Avoidant personality disorder

• Dependent personality disorder

• Obsessive-compulsive personality disorder

Cluster B disorders

• Histrionic personality disorder

• Narcissistic personality disorder

• Antisocial personality disorder

Paranoid personality disorders

• Suspicious, mistrustful of others without justification

• Argumentative, may complain, quiet, hostile toward others, suicidal

• Bears relationship to:

  • Paranoid type of schizophrenia

  • Delusional disorder

Schizoid personality disorders

• Detachment from social relationships, no desire to enjoy closeness with others, cold, aloof

• Homelessness

• Extreme social deficiencies

• Social isolation, poor rapport, and constricted affect

Schizotypal Personality Disorder

• Social deficits, psychotic-like symptoms, cognitive impairments/paranoia

• “Magical thinking”

• Report unusual perceptual experiences

• Hypersensitive to criticism as children

Avoidant Personality Disorder

• Interpersonally anxious

• Views self as socially inept, unappealing

• Fear of rejection/ shame

• Pessimistic about their future

• Restraint in personal relationship

Dependent Personality Disorder

• Interpersonally dependent, anxious

• Submissive, timid, and passive

• Feelings of inadequacy, sensitive to criticism, need reassurance

• Cling to relationships