EPPP - Abnormal Psychology DSM-IV (OLD) Part 1

The American Psychiatric Association’s Diagnostic & Statistical Manual of Mental Disorders (DSM) Version IV & Text Revision (TR). Published in 2000

The DSM-IV-TR is a diagnostic system that:

Uses a categorical approach (divides the mental D/O’s into types that are defined by a set of Dx criteria) & polythetic criteria sets (for most D/O’s requires the indiv. to present only w/a subset of characteristics from a larger list);

Predominantly a theoretical w/regard to etiology; &

Makes use of a multiaxial classification system that involves describing a person’s condition in terms of 5 dimensions.

The DSM-IV-TR utilizes a categorical approach that divides mental D/O’s into types that are defined by a set of diagnostic criteria:

Involves determining whether or not a person meets the criteria for a given Dx.

Works best when all members of each category are homogeneous, which does not always apply to people w/mental D/O’s.

Used by the DSM-IV-TR

This approach conceptualizes behavior in terms of a continuum that ranges from normal/healthy to pathological & involves rating a person on each Sx or other characteristic (e.g., on a scale 1 to 10)

The DSM includes a Polythetic criteria set for most D/O’s to allow for heterogeneity that requires an indiv. to present w/only a subset of characteristics from a larger list.

Ex: 2 ppl can have somewhat different Sx but receive the same Dx.

The DSM-IV-TR includes a polythetic criteria set.

5 dimensions or axes

biopsychosocial model

The GAF scale is used to rank the indivs. psychological, social, & occupational Fx on a scale from 0 to 100 (w/100 representing superior functioning) on Axis V.

Two factors are considered when assigning a GAF score:

Sx severity and

Level of Fx.

The multiaxial diagnostic system describes a person’s condition in terms of 5 dimensions/axes that “promote the application of the biopsychosocial model in clinical, educational, & research settings” (p. 27):

Axis I:* Clinical Disorders & Other Conditions that may be a Focus of Clinical Attention (v codes).

Axis II:* Personality disorders & Mental Retardation.

Axis III:* General Medical Conditions

Axis IV:* ​Psychosocial and Environmental Problems

Axis V:* Global Assessment of Functioning (GAF scale) a scale used to rank the individuals psychological, social, and occupational functioning on a scale that ranges from 0 to 100.

To ensure that consideration will be given to the possible presence of Personality Disorders & Mental Retardation, NOT because pathogenis or range of appropriate Tx is fundamentally different than Axis I

In the DSM-IV-TR, diagnostic uncertainty about the indivs. condition is indicated by coding on Axis I or II:

Dx (or Condition) Deferred - coded when there is not enough info. to make a definite Dx.

Specific Dx (Provisional) - used when there is sufficient info. for a tentative, but not firm, Dx.

(Class of D/O) Not Otherwise Specified - Class of Dx’s used when there is adequate info. to know that a D/O belongs to a particular category but not enough info. to make a more specific Dx or when features of the D/O do not meet the criteria for a more specific Dx.

The Outline for Cultural Formulation recommends that clinicians consider five elements:

The client’s cultural identity;

The cultural explanation for the CT’s illness;

Cultural factors relevant to the CT’s psychosocial environment & level of Fx;

Cultural factors relevant to the relationship between the client and therapist; and

How cultural factors may impact the client’s Dx & care.

Developmental D/O involving:

Significantly subaverage intellectual Fx (IQ = 7O or below on IQ test)

Impaired adaptive Fx in 2 Areas (Does not meet expected standard of personal Independence for culture/age in at least 2 areas of Fx: communication, self-care, self-direction, social skills, Fx academic skills, work or safety, etc.)

An onset prior to age 18.

Correct Dx: if ppl w/IQ of 71-75 & level of adaptive Fx is subtantially impaired.
4 degrees of severity are:

Mild Mental Retardation (IQ 50-55 to 70):

Moderate Mental Retardation (IQ 35-40 to 50-55);

Severe Mental Retardation (IQ 20-25 to 35-40);

Profound Mental Retardation (IQ below 20-25).

4 degrees of severity are:

1. Mild Mental Retardation (IQ 50-55 to 70): 6th grade level & Adults live independently w/min. sup.;

2. Moderate Mental Retardation (IQ 35-40 to 50-55): 2nd grade level & Adult perform skilled/semi-skilled work w/reg. sup.;

3. Severe Mental Retardation (IQ 20-25 to 35-40): Basic self-care skills & Adults perform simple tasks while closely supervised;

4. Profound Mental Retardation (IQ below 20-25): Need highly structured env. & Indiv. sup.

Delays in motor development

Lack of age appropriate interest in environmental stimuli

a. Lack of eye contact during feeding

b. Less responsive to voice & movement than would be expected

Heredity Causes - 5% (Tay-sachs, Fragile X Syndrome, PKU)

Early alterations of embryonic development - 30% (Down Syndrome, Damage due to toxins)

Pregnancy & perinatal probs - 10% (Fetal malnutrition, anoxia, HIV)

General medical conditions during infancy or childhood - 5% (lead poisoning, encephalitis, malnutrition)

Environmental factors and other mental D/O’s - 15-20% (deprivation of nurturance or stimulation, Autistic Dx)

Unknown causes (Approx. 30-40%)

A rare recessive gene syndrome due to an inability to metabolize the amino acid phenylalanine, found in high-protein foods.

If untreated, produces:

irreversible moderate to profound retardation,

impaired motor & language devel., &

unpredictable, erratic behaviors.

​Sx’s include:

Mental retardation

Microcephaly (condition in which a person’s head is significantly smaller than normal for their age and sex)

Vomiting & Diarrhea

Movement D/O’s

Seizures

D/O can be detected at birth by a blood test & its Sx prevented by a diet low in phenylalanine (milk/dairy,meat, fish)

Due to the presence of an extra 21st chromosome & is estimated to be the cause of 10-30% of all cases of moderate to severe retardation.

Characterized by:

Moderate to severe Mental Retardation

Delayed motor devel. & physical growth

Assoc. w/physical abnormalities including:

Slanted, almond-shaped eyes,

Broad flat face

Cataracts,

Respiratory defects

Tend to age more rapidly than other ppl,

Life expectancy below normal,

At higher risk for Alzheimer‘s disease/dementia, leukemia & heart defects/lesions.

Approp. Dx for people with IQ’s in the 71-84 range.

Persons who fall into this categorization have:

A relatively normal expression of affect for their age, though their ability to think abstractly is rather limited.

Reasoning displays a preference for concrete thinking.

Others may describe such a person as “simple” or “a little slow”.

They are usually able to Fx day to day w/out assistance, including holding down a simple job & the basic responsibilities of maintaining a dwelling

If s/he has substantial deficits in adaptive functioning.

Due to a deletion on chromosome 15

Sx’s include:

Mental Retardation

Decreased muscle tone

Short stature

Insatiable appetite

Morbit obesity

(Etiology of MR)

Dx when a person’s:

Score on a measure of academic achievement is substantially below (usually 2 SD’s or more) his/ her score on a(n) IQ test & the discrepancy cannot be fully explained by a sensory deficit.

The most common co-diagnosis is ADHD (20-30%); evidence that LD associated w/high risk for antisocial behavior & arrest/conviction for antisocial behaviors.

More common in Boys.

(Communication D/O) is characterized by:

Disturbance in normal fluency and

Time patterning of speech that is inapprop. for the individual’s age;

Connot be completely explained by a speech-motor or sensory deficit.

Onset:* Btwn ages of 2-7

Effective Tx*: Habit reversal, which combines regulated breathing, awareness training, & social support.

Etiology:* 3 times more common in males, & in 60% of cases it remits spontaneously by 16 y.o.

Reduction of psychological stress at home, stop reprimanding child for stuttering & teach coping strategies for frustration

Regulated breathing:

Involves reassuring the individual that s/he can speak without stuttering

Incorporates breathing & vocalization exercises & graded speech assignments

Habit reversal, which combines regulated breathing, vocal exercises, awareness training (aware of situations words that evoke stuttering), & social support (parents encourage & reinforce childs efforts to speak w/out stuttering)

Involve severe & pervasive impairments in communication & social interaction &/or the presence of stereotyped behaviors & activities.

Included in this category are:

Autistic Disorder,

Rett's Disorder,

Childhood Disintegrative Disorder,

Asperger‘s Disorder.

(Pervasive Devel. D/O) Dx criteria includes 6 characteristic Sx's by age 3:

1. Impairment in social interactions* (Min. 2 Sx's)

Babies avoid eye contact; limited facial expressions (dont smile); resist physical contact

Older children have trouble interpreting meaning of gesture & facial expressions, indifferent to other ppls feelings, impaired nonverbal behavior that helps regulate social interactions, fail to devel. normal peer rel. & may seem oblivious to others).​​

2. Impairment in communication* (Min. 1 Sx) (Do not speak at all or varying degree of limited speech that contains a # of abnormalities. Such as: Pronoun reversal - saying "you" insted of "I", Echolalia - echoing words/phrases of others, inappropriate tone of voice).

3. Restricted, repetitive, & stereotyped behavior, interests & activities* (Min. 1 Sx) (Preoccupied w/narrow interests, parts of an object instead of entire object, & engage in repetative body movements - arm flapping or rocking).

Course/Prognosis:* (poor but best) outcomes as adults assoc. with:

Ability to communicate verbally by age 5/6,

IQ over 70, &

Later onset of Sx. (Small % of adults able to live/work independently)

Etiology:

Biogenic D/O & has a genetic component

Linked to CNS brain abnormalities including: A smaller-than-normal cerebellum, enlarged ventricles; corpus collosum & limbic system

Assoc. w/abnorm. levels of norepinephrine, serotonin, & dopamine.

4-5 x more common in males

Most effective are:

Behavioral techniques (e.g., shaping & discrimination training for communication) by Lovaas.

improving daily living, communication, and social skills

Reducing undesirable behaviors

Used behavioral technique for Autism, one found to be most effective:

Shaping & discrimination training to teach non-speaking children to immitate others verbally & improve communication skills.

Originally described by Lovaas (1960) & continue to be used to improve communication skills.

(Pervasive Devel D/O) Characteristic devel. pattern of multiple Sx following a period of normal devel. for 5 + mos. Sx's include:

Head growth deceleration;

Loss of previously acquired purposeful hand skills

Loss of expressive language

Devel. of stereotypical movements (e.g., hand-wringing);

Impairments in the coordination of gait or trunk movements; -

Loss of interest in the social environment;

Severely impaired language development; and

Psychomotor retardation.

DSM-IV-TR states that this D/O “has been reported only in females"; yet is evidence it's occasionally occurs in males but that males w/this D/O often die shortly after birth (e.g., Kerr, 2002).

(Pervasive Developmental D/O) is characterized by distinct pattern of developmental regression after 2 yrs. of normal devel. in at least 2 areas of Fx. Sympotms include:

Loss of previously acuired language (expressive or receptive), motor, social skills, play, self-help skills & bowel or bladder control

Characteristic abnormalities in social interactions, communication & adaptive behaviors

(Pervasive Developmental Disorder) Essential features include:

Severe impairment in social interactions

Restrictive, repetative paterns of behavior, interests & activity, w/no substantial delays in cognitive, language, or self-help skills.

(Disruptive Behavior D/O) Dx criteria includes Sx in at lease 2 settings (Ex home & School):

Onset of some Sx prior to age 7

Persistent Sx 6 mos. or more

Developmentally-inappropriate:

Inattention may involve forgetfulness, distracability, difficulty w/organization, completing tasks, & following instructions and/or

Hyperactivity-impulsivity may include difficulty remaining seated, inappropriate running & jumping, excessive talking & frequently interrupting others

3 sub-types:

Predominatly Inattentive: 6+ Sx of inattention, but less than 6 Sx of Hyperactivity-impulsivity.

Predominatly Hyperactive-Impulsive: 6+ Sx of Hyperactivity-impulsivity, but less than 6 Sx of Inattention.

Combined Type: 6+ Sx of both.

Etiology:

Bio. basis but may be exacerbated by env. factors; unknown.

Strong genetic component that increases w/genetic similarity

Linked to lower than normal levels of activity in prefrontal cortex (Frontal lobe/Processing) & basal ganglia, reduced size in region of cerebellum, smaller-than-normal caudated nucleus (Striatum/Motor), globus pallidius &

Abnormalities in dopamine & serotonin levels.

In children, 4-9 x more common in boys than girls; In adults rates are similar

Prognosis:* Even w/Tx up to 60% of children w/ADHD continue to have Sx's as adults & the primary adult Sx is inattention

Tx:* Involves CNS stimulant (e.g., methylphenidate), social-academic skill techniques, CBT, & family intervention.

Prevalence:* 3 to 7%; CDC (2005) 7.8% of US children between 4 to 17 have received a diagnosis of ADHD…lowest rates for kids 4-8

At least 60% of children w/ADHD continue to have some Sx as adults.

For most adults, inattention is the predominant Sx & includes inconsistency in the ability to concentrate, difficulty establishing and maintaining routines, and an inability to prioritize and complete important tasks & activities.

Hyperactivity is less apparent & manifests itself as fidgiting & restlesness.

Similar associated Sx's as child/adolesc. related to social relations & ED & Occupational Fx

Prevalence of ADHD in Adults 1-5%

conduct disorder (30 to 90%)

learning disorder (up to 50%)

oppositional defiant disorder

anxiety disorder

major depression

Dx criteria requires the presence of at least 3 Sx during the past 12 mos.:

Theft or decitfulness

Rules; serious violation of rules

Agression to people or animals

Property destruction

Other charateristics include:

Persistent pattern of behaviors that violate the rights of others &/or age appropriate social rules

Little concern for well-being of others

Blame others for own misbehaviors

Little or no guilt or remorse

In ambiguous situations may misinterpret actions of others as hostile/threatening

2 sub-types of Conduct D/O:

Childhood-Onset Type - Dx when the onset of Sx is prior to age 10. (Assoc. w/ a higher degree of aggressivness & greater risk of a Dx of Antisocial Personality D/O &/or Substance related D/O.)

Adolescent-Onset Type - Dx when Sx begin at age 10 or later.

Moffitt’s (1993) distinguishes btwn 2 types of Conduct D/O:

Life-course persisting type - Begins early (Age 3), involves a pattern of increasingly serious transgressions, & is due to a combo of neurological deficits, a difficult temperament, & adverse environmental circumstances.

Offenders engage in a wider range of crimes including more victim oriented offenses.

Adolescence-limited type - A temp. form of antisocial behavior that reflects a “maturity gap” btwn the adolescent’s biological maturation & lack of opportunities for adult privileges.

Offenders are limited to those that represent adult privilege or autnomy from parents.

Essential features are a recurrent pattern of:

Negativistic, defiant, & hostile behaviors toward authority figures.

Sx include (Min. 4 Sx's - BAD AVATAR):

Blames others for own mistakes or misbehaviors;

Argues with adults;

Deliberately annoys people;

Angry & resentful

Vindictive or spiteful

Actively defies or challenges the rules or requests of adults;

Temper; often losses temper;

Antagonistic

Rule Refusal

(Tic D/O) Characterized by at least:

1 vocal tic (Clicks, grunts or barks) &

Multiple motor tics (Deep knee bends, facial grimaces & eye blinks).

Onset of Sx's before 18

Duration of Sx's 1yr. +

Onset:* 6-7 years old; more common in males

Etiology:*

May share a genetic basis w/OCD & abnorm. in the basal ganglia & frontal lobes.

Linked to abnorm. (elevated) levels of dopamine.

Comorbidity:

Most common assoc. Sx are obsessions & compulsions

Sx of ADHD, reason they often do poorly in school.

Tx:*

Antipsychotic drugs - Haloperidol & compliance a problem due to adverse side effects.

Transient Tic Disorder

Sx's began before age 18

An individual w/tics that do not meet the criteria for a specific Tic disorder & onset after 18 w/ a duration less than 4 weeks.

(Elimination D/O) Characterized by:

Incontinence by a child that has reached an age where continence would be expected or

Repeated voiding of urine during the day or night into the bed or clothes that is usually involuntary &

Not due to a general medical condition or substance use.

Tx:

Bell-and-pad (aka night alarm) w/

Pharmacotherapy:

Antideprssant Imipramine (reduces wetting frequency in 85% of cases, suppresses wetting entirely in 30% of cases--most kids relapse within 3 mos. after discontinuing the drug)

Desmopressin (synthetic version of an antidiuretic hormone, good short term, but poor long term effects).

The research has shown that bell & pad is most effective while drug therapy have good short-term effects the relaps rates are higher than the bell & pad.

Bell-and-pad (aka night alarm) effective in up to 80% of cases; -causes a bell to ring when the sleeping child begins to urinate

1/3 of kids exhibit some degree of relapse within six months of the initial treatment

effectiveness increased when combined with other behavioral techniques (e.g., behavioral rehearsal or overcorrection)

(Anxiety D/O) of childhood that involves:

Developmentally inappropriate, excessive levels of anxiety related to separation from home or attachment figures.

Anxiety Sx's beyond what is normal for child's developmental level

Duration of Sx's for at lease 4 weeks

Onset befor 18 y.o.

Recurrent & ongiong distress when separated from caregiver

Persistent fear something terrible will happen to caregiver during separation

Repeated nightmares related to separation

Persistent fears of being alone

Frequent physical complaints when separation occurs or is anticipated including headaches, stomach aches or other physical sx's

It is often manifested as school refusal, or refusal to go to bed w/out someone staying w/them

Often develops after an experience of a life stressor (Parental divorce or death of family relative or pet)

Early childhood D/O involving:

Developmentally inappropriate social relatedness caused by pathogenic care,

Evidence the Sx's are the result of pathogenic care.

Begins before age 5.

There are 2 subtypes:

Inhibited - Persisiten failure to initiate & respond to most social interactions in a developmentally approp. way (Excessively inhibited, hypervigilant or highly ambivalent response).

Disinhibited - Indescriminate sociability or lack of selectivity in choice of attachment figures (doesn't discriminate btwn familiar & unfamiliar ppl & act in excessively familiar way toward strangers)

Disclosure - Open communication w/child about illness; cope better if told early on in Devel. appropriate way.

Hospitalization - Hospitalized children are at increased risk for emotional & behavioral problems (Dependency, disrputive behaviors, anxiety, depression or severe withdrawl).

Physical Disabilities - Children with physical disabilities are at increased risk for emotional & behavioral problems.

School-Related Problems - Children & adolescents with chronic medical conditions have higher rates of school-related problems (e.g., CNS irradiation & intrathecal chemotherapy for leukemia have been linked to impaired neurocognitive functioning and learning disabilities).

Compliance - with medical regimens is a particular difficulty for adolescents.

Involves:

Persistent eating of nonnutritive substances (e.g., paint, plaster, insects, and clay) for at least 1 month w/out an aversion to food.

Behavior is inappropriate for the person‘s developmental level &

Is not part of a culturally-sanctioned practice.

Onset: Btwn ages of 12-24 months; occasionally found in pregnant women.

A maladaptive reaction to 1 + psychological stressors in excess of what would be expected given nature of stressor(s).

Sx's devel. w/in 3 mos.. of onset of stressor

Sx's do not persist for more than 6 mos. after the stressor has ended

Types:

Adjustment D/O w/ Anxiety

Adjustment D/O w/ Depressed Mood

Adjustment D/O w/Disturbance of conduct

Adjustment D/O w/mixed anxiety & depressed mood

Adjustment D/O w/mixed disturbance of emotion & conduct

Specifiers:

Acute (less than 6 mos.)

Chronic (6 + mos.)

Dx Criteria:

Disturbance in consciousness involving

Reduced clarity/awareness of the env.,

Excessive distractability &

Inability to appropriatly focus/shift attention

Accompanied by cognitive changes or perceptual disturbances

Cog. changes include lang. & memory impairment & disorientation especially to time & place.

Perceptual disturbances include illusions & hallucinations

Causes: By a # of conditions including:

fever,

nutritional dificencies &

head injuries,

Sx's usually develop rapidly & fluctuate over time.

It is most common in children & older adults & older age especially when combined w/medical illness & change in Meds.

Memory impairment, & disorientation can be caused by a general medical condition or substance use

​Certain substances such as alcohol, cocaine & PCP = Substance Intoxication Delirium or Sub. w/drawl Delirium.

Tx: Tx has 2 primary components:

Target the underlying cause

Reduction in agitation & disorientation by a combo of environmental manipulation (providing an environment that min. disorientation) & psychosocial interventions (e.g., having a calm, friendly family or staff member stay with the patient).

Haloperidol or other antipsychotic drugs may help reduce agitation, delusions, and hallucinations.

Involves:

Disturbance in consciousness & other Cog. Fx

Autonomic Hyperactivity

Tremors

Insomnia

Nausea & vomiting

Confusion

Vivid Hallucinations & Delusions

Seizures potentially fatal form

Following a period of prolonged heavy use.

Dx Criteria includes:

Onset is deceptive (insidious) & course progressive

Multiple cognitive deficits including:

Some degree of memory impairment (loss);

Both anterograde (Diff. acquiring new info) & retrograde (Inability to recall previously learned info) amnesia. (Retrograde may not be apparent in early stages of D/O)

Denial of cognitive problems

Impairment in recall & recognition memory & greater impairments in declarative memory

At least 1 other cognitive impairment including:

Aphasia - Inability to express oneself thur speech

Apraxia - Inability to carry out voluntary purposeful movements not due to motor deficits, lack of understanding or motivation.

Agnosia - Inability to recognize familiar objects, tastes, sounds (sensations)

Impaired executive functioning (Abstraction).

Causes:* General Medical Condition or Substance use

Various types of Dementia categorized as:

Cortical dementias - Anterograde Amnesia apparent initally (Dementia of the Alzheimer’s type)

Subcortical dementias - Retrograde amnesia more prominent initally (Dementia Due to Huntington‘s/Parkinson's Disease)

Diff. btwn 2 types most apparent in early stages of D/O.

Vascular Dementia - caused by arteriosclerosis or cerebrovascular disease

Major Depressive Disorder that involves prominent cognitive Sx that may be mistaken for Dementia (especially in older adults) & is referred to as pseudodementia.

Onset:

Usually abrupt,

Exaggeration of cognitive problems

Person is concerned about his/her impairments,

Greater impairment in recall & procedural memory (vs. declarative) but intact recognition memory

Person is likely to emphasize failures & be uncooperative during testing.

.

Dx criteria Involves (cortical Dementia):

A gradual onset of Sx &

Slow, progressive decline in memory/cognitive Fx that can be described in terms of 3 stages:

Stage 1: (1-3yrs.) Anterograde amnesia, impaired visuospatial skills, anomia, changes in personality that include irritability, indifference or sadness.

Stage 2: (2-10 yrs.) Increased retrograde amnesia, flat/liable mood, restlesness & agitiation, delusions, wandering aphasia, agnosia & idiomotor apraxia.

Stage 3: (9-12 yrs.) Severely deteriorated cognitive Fx & communication, apathy, limb rigidity & urinary & fecal incontinenece.

Due to a degeneration of cells in the medial temporal lobe that includes the amygdala, hippocampus & enthrhinal cortex (memory & sense of location & direction)

A definitive Dx requires an Atopsy or brain biopsy to confirm neuron loss & plaques & tangles.

Memory impairments have been linked to low levels of Actetylcholine (ACh) in the hippocampus.

More common in Females than Males Average Duration 8-10 yrs.

Late onset after 65 yrs old most common

Tx combo:

Group therapy (emphasizes reality orientation & reminiscence);

Antidepressant to alleviate depression & drugs that slow memory loss by increase Ach.

Behavioral techniques & antipsychotic drugs to reduce agitation;

Environmental manipulation & pharmacotherapy to enhance memory & cognitive Fx.

Most effective when include family members.

Dx Criteria:

Caused by cognitive impairments plus

Evidence of Arteriosclerosis or other cerebrovascualr disease

Abrupt onset of Sx followed by a stepwise or fluctuating decline in Fx & a "patchy" pattern of Sx that is determined by the location of brain damage.

Cognitive impairment include:

Focal neurological signs - Behavioral & perceptual impairments due to lesions in the brain & take the prom of weakness in 1 side of the body, abnormal reflexes ro sensory deficits.

Labrastory signs including CT or MRI scan showing liesons in cortical or subcortical areas of the brain.

Recovery depends on cause.

Ex: Recover from cerebrovascular accident (stroke) improvement occurs in 1st 6 mos., w/physical disabilities resolving more quickly than cognitive deficits.

Risk factors include: hypertension, diabetes, cigarette smoking, & atrial fibrillation.

(Subcortical Dementia)

Includes:

Retrograde Amnesia initally prominent

Parkinsonism

Hallucinations

Frontal & visospatial deficits

Fluctuating course

Sx depend on location & extent of brain injury.

Usually the subcortical type & likely to involve:

Changes in personality,

Deficits in executive cognitive Fx,

Altered experience &

Expression of emotion (Frank, 2005).

If Head Trauma is cause of a single brain injury, it is usually non-progressive; yet, repeated injury (e.g., from boxing) can result in a progressive form of dementia referred to as dementia pugilistica.

Early signs include:

forgetfulness

impaired attention

psychomotor slowing

Sx include:

Cognitive impairment (forgetfulness, impaired attention/concentration, prob. solving skills),

Psychomotor slowing,

Psychiatric Sx (depression & anxiety),

Motor Sx (ataxia, tremors & clumsiness),

Apathy & social withdrawal,

Loss of initiative, &

Saccadic eye movements.

Involves 6 stages:

Stage 0 (Normal): Indiv. mental & motor Fx; normal.

Stage 0.5 (Equivocal/Subclinical): Indiv. has min. or equivocal Sx w/no impairment in performance of work/activities of daily living (ADL). Mild signs may be present (e.g., slowed ocular or extremity movements).

Stage 1 (Mild): Unequivocal evidence of Fx, intellectual, or motor impairment, but indiv. is able to perform all but the most demanding aspects of Work/ADL & can walk w/out assistance.

Stage 2 (Moderate): Indiv. can't work but can perform basic activities of self-care & is ambulatory but may require assistance.

Stage 3 (Severe): Indiv. exhibits signs of major intellectual incapacity (e.g., cannot sustain complex conversations) or motor disability (e.g., cannot walk without assistance).

Stage 4 (End Stage): Indiv. is nearly vegetative. Intellectual & social fx are rudimentary & the indiv. is nearly or completely mute, has paraparesis or paraplegia, & has urinary and fecal incontinence.

Dx criteria:

Memory impairment w/some degree of Anterograde amnesia (Inability to acquire & recall new info.) w/or w/out Retrograde amnesia (impairment in the ability to recall previously acquired info.

Appropriate Dx when memory loss is known to be due to a general medical condition or substance use & usually has no difficulty learning new info. or recalling personal info. from prior to the occurrence of the trauma/stressor.

Does not occur exclusively during the course of Delirium or Dementia

Alcohol-Induced Persisting Amnestic Disorder (Korsakoff Syndrome) is characterized by:

Due to alcohol/sibstance abuse

Retrograde amnesia,

Anterograde amnesia, and

Confabulation (Fill in memory gaps w/inaccurate or imagined info & believe it's real)

Effects recent long-term memory more than remote memory (trouble recalling events that happened before D/O than events earlier in life)

Believed to be due to a thiamine deficiency.

involves 1 or more episodes of an inability to recall important personal info. that cannot be attributed to ordinary forgetfulness

The gaps in memory are often related to a traumatic event

Most common types are localized & selective

Retrospective gaps in the recall of aspects of the indiv. past often related to a trauma/stressor

Alcohol withdrawal involves:

Autonomic hyperactivity,

Hand tremor,

Insomnia,

Nausea or vomiting,

Anxiety,

Transient illusions or hallucinations, and

Grand mal seizures following cessation of prolonged or heavy alcohol use.

Alcohol-Induced Sleep Disorder is usually of the Insomnia Type and can be the result of Alcohol Intoxication or Withdrawal.

Dx criteria:

Involves the continued use of a substance despite significant substance-related problems as evidenced by the presence of at least 3 characteristic Sx during a 12-mo. period.

Sx's Include:

It may or may not involve tolerance & withdrawal (physiological dependence).

substance frequently taken in larger amounts or over longer periods of time than intended

persistent desire or unsuccessful attempts to control or cut down substances use

a great deal of time spent in activities related to obtaining the substance, using the substance, or recovering from its effect

important social, occupational, or recreational activities reduced or stopped because of substance use

continued use of the substance despite persistent or recurrent psychological or physical problems caused or exacerbated by its use

The term "addiction" is sometimes used to refer to condition that involves a compulsion to use a drug w/the devel. of tolerance for the drug & withdrawal Sx when the drug is not taken.

Conger (1956) Proposed that alcohol reduces anxiety, fear & other states of tension & ppl drink alcohol to reduce tension which leads to addiction. Thus, the addiction is the result of negative reinforcement.

(substance Dependence/Addiction)

They proposed that addictive behaviors are acquired and that addition is an "overlearned, maladaptive habit pattern" and focus on relapse prevention which involves teaching strategies for dealing w/high-risk situations (Env. cues that elicit strong negative emotions)

Refer to the typical reaction to relapse as an “abstinence violation effect” that involves:

Self-blame,

Guilt,

Anxiety, and

Depression,

Lead to an increased susceptibility to further drinking.

Propose the potential for future relapse is reduced when the person views the episode of drinking as a mistake resulting from specific, external, and controllable factors.

38% of incidents of relapse are due to negative emotional states

The Relapse Prevention Therapy (RPT) involves:

ID circumstances that increase the indiv. risk for relapse (situations that elicit negative emotional states, expose the indiv. to alcohol/alcohol-related cues, or cultivate social pressure to drink)

Then implementing a variety of behavioral & cognitive strategies that will help the indiv. prevent future lapses & deal more effectively w/them if they occur (e.g., coping skills training, cognitive restructuring, self-efficacy enhancement, and lapse management).

Predictors of successful smoking cessation attempts include:

Male gender,

Older age (35+)

Later age at the initiation of smoking, and

Low nicotine dependence.

Live in girfriend or Married

Interventions are most effective when they include a combo of:

Nicotine replacement therapy;

Multicomponent behavior therapy; and

Support & assistance from a clinician.

Sx include:

Resemble a moderate-severe case of the flu (e.g., sweating, nausea, abdominal cramps, and fever)

Occur following cessation of or a substantial reduction in the use of an opioid following prolonged or heavy use.

Sx occur following abrupt cessation of or reduction in the use of nicotine after daily use for at least several weeks and include:

Depressed mood,

Insomnia,

Irritability,

Anxiety,

Restlessness,

Impaired concentration,

Decreased heart rate, and

Increased appetite.

1. Duration: 6+ months of disturbance

2. Includes 1+ month of active-phase symptoms

3. Must have 2+ symptoms from active phase

4. Positive symptoms (Type I - THREAD)

5. – Delusions (false, fixed beliefs)

6. – Hallucinations (auditory most common)

7. – Disorganized speech (word salad)

8. – Disorganized/catatonic behavior

9. Negative symptoms (Type II - LESS)

10. – Flat affect (emotional dullness)

11. – Alogia (limited speech/thought)

12. – Avolition (lack of motivation)

13. Subtypes: Paranoid, Disorganized, Catatonic

14. Also: Undifferentiated, Residual types

15. Onset: 18–25 (males), 25–35 (females)

16. Prevalence: 0.5–1.5% (more in males)

17. Causes: Genetic (48% MZ twins), brain abnormalities

18. Dopamine hypothesis: excess dopamine

19. Treatment: Antipsychotics, CBT, family therapy

20. African Americans at higher risk of misdiagnosis

Sx's (Type 1) - Excess of Normal Fx includes:

Thinking may become disturbed (Delusions)

Hallucinations (usually Auditory)

Reduced contact w/reality

Emotional control affected (Incongruent Affect)

Arousal may lead to worsening Sx's

Disorganized Speech (word salad) & Behavior

Appears to reflect an excess/distortion of normal Fx including delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior. (Type I)

THREAD

Sx's (Type 2) - Restriction in ramge & intensity of emotions & other Fx's:

Loss of volition (Avolition: reduction in goal directed behavior)

Emotionally Flat (Affective flattening)

Speech Reduced

Slowness in movement & thought; psychomotor agitation (Alogia: poverty of thought/speech)

Involve a restriction in the range & intensity of emotions & other Fx & includes affective flattening, alogia (poverty of thought & speech), and avolition (restricted initiation of goal directed behavior). (Type II)

LESS

Rates of Schizophrenia are higher among those with genetic similarity,

more similarity = higher concordance rates.

Bio. siblings 10%

Identical twins 48%

Fraternal twins 17%

A better prognosis for Schizophrenia is associated with:

Later age at onset

Presence of a precipitating event

Good premorbid adjustment

An acute & late onset,

Female gender,

Absence of structural brain abnormalities

Brief duration of active-phase symptoms,

Insight into the illness,

A family Hx of a Mood Disorder, and

No family Hx of Schizophrenia

Prognosis better when indiv. is aware of thier illness

Attribute Schizophrenia to elevated levels/oversensitivity in dopamine receptors.

Also can be abnormalities on other neurotransmitters such as elevated dopamine, norepinepherine &/or serotonin

High levels of expressed emotions by family members (open criticism and hostility toward the patient, or alternatively, overprotective, symbiotic relationships) are associated with a high risk for relapse and rehospitalization for individuals with Schizophrenia.

From best (1) to worst (5) prognosis:

SchizoiD Personality D/O = Distant (Avoids)

SchizoTypal Personality D/O = Magical Thinking (Not your Typical)-ME PECULIAR

SchizophreniFORM D/O = Form from stress (1-6mos.; 6+ mos. Schizophrenia)

Schizophrenia D/O = +(THREAD)/-(LESS) (6+ mos. w/1 mo. 2 active phase Sx's)

Schizoaffective D/O = Schizophrenia(psychotic) + Mood D/O (Except 2 weeks w/psychotic; no mood Sx's)

(Psychotic D/O) identical to Sx of Schizophrenia except for:

Involving active-phase psychotic Sx with

A duration of symptoms for at least 1 month but less than 6 months.

Involves delusions, hallucinations, disorganized speech, &/or grossly disorganized behavior that has:

a duration btwn 1 day to 1 month &

Eventually returns to premorbid Fx.

Onset follows an overwhelming stressor.

Characterized by:

An uninterrupted period of active phase illness involving (Psychotic & Mood Sx)

Concurrent Sx of Schizophrenia & symptoms of Major Depressive, Manic, or Mixed Episode that includes:

A period of at least 2 weeks w/out prominent mood Sx

Onset:* Early adulthood

Prognosis:* Somewhat better than for Schizophrenia, but worse than a Mood D/O.

Schizophrenic + Mood D/O

Involves 1 or more nonbizarre delusions that last for at least 1 month & do not substantially impair functioning.

2 types:

Erotomanic (belief that someone is in love with the individual of higher status) and

Unspecified (which is appropriate when the indiv. dominant delusions do not clearly fit the criteria for a specific type; delusions of reference).

Other Types:

Grandiose (inflated sense of self worth, power, knowledge)

Jealous

Persecutory (belief one is being attacked, harrased, persecuted, etc)

Somatic

Dx criteria Involves (DEAD SWAMP):

1 or more Major Depressive Episodes w/out a Hx of Manic, Hypomanic, or Mixed Episodes

Presenceof charaterized Sx's such as:

Depressed mood &/or

Loss of interest/pleasure in ones usual activities

for at least 2 weeks

Depressed Mood most of the day

Energy Loss or Fatigue

Anhedonia (inability to exp. pleasure from activities usually found enjoyable).

Death or Suicide (thoughts or act of)

Sleep Disturbances (insomnia/Hypersomnia)

Worthlessness or Guilt

Appetite or weight changes

Mentation Decrease (inability to think/concentrate)

Psychomotor Aggitation or Retardation

Age-related Sx:

In children Dep. accompanied by anxiety & may involve irritability, aggression, social withdrawl & somatic complaints.

In Adolesc. Dep. w/aggression & other anti-social behaviors are prominent and may lead to a mis-Dx of conduct D/O.

Older adults Dep. w/prominent cognitive Sx., anxiety, aggitation & feelings of hopelessness , along w/physical Sx's.

Etiology:

Catecholamine Hypothesis: Depression due to low levels of norephinepherine,

Linked to several neurotransmitter abnormalities, including low levels of norepinephrine & serotonin.

Highly linked to genetic components

In adults 2x as common in females as males; begining in adolesc.

In children equal among boys and girls

Tx: Commonly involves the use of antidepressant &/or CBT or interpersonal therapy

Depression has been linked to a number of alterations in sleep quality & quantity:

Assoc. w/ decreased sleep continuity

Reduced slow-wave sleep

Shortened/Decreased REM Latency (Earlier onset of REM sleep)

Increased REM Density (Increased frequency of rapid eye movements)

Requires the presence of characteristic symptoms:

Depressed mood and/or

Loss of interest or enjoyment in customary activities

For at least 2 weeks

That represents a change from previous functioning w/sufficently severe impaired Fx

Episode can last 3-6 months, Sx's remit at 6 months & may or may not return

Prior to puberty, rates are about equal for males and females

In adolescence, the rate for females is about 2x the rate for males and continues into adulthood

Lifetime risk of D/O in community samples ranges from 10-25% for women & 5-12% for men.

Strong genetic component:

Twin Studies Identical .50 & Fraternal .20

1.5 to 3 times more common in 1st degree bio. relatives

Dx Criteria (DIG FAST):

Involves a period of 1 week or longer w/psychotic features w/significantly impaired functioning (occupational/social) or need for hospitalization:

The prevailing mood is abnormally & persistently elevated, expansive or irritable.

Distractibility

Indiscrection (excessive involvement in pleasurable activities)

Grandiosity

Flight od Ideas

Activity Increases

Sleep Deficit (Decreased need for sleep)

Talkativness (Pressured Speech)

Dx Criteria (TAD HIGH):

Characterized by a distinct period of abnormally & persistently elevated, expansive or irritable that:

lasts for 4 days &

Accompanied by 3 Sx of a Manic Episode.

There is a clear change in mood & Fx but not severe enough to cause marked impairment in (occupational/social) Fx or require hospitalization & absence of psychotic Sx.

Talkative

Attention Deficit

Decreased need for sleep

High self-esteem/Grandiosity

Ideas the race

Goal directed activity increased

High-risk activity

Dx Criteria: Lasts for 1 week and involves rapidly alternating Sx of Manic & Major Depressive Episodes. * Disturbance is severe enough to cause marked impairment in social & occupational Fx or requires hospitalization or alternatively includes psychotic Sx.

The specifier with Postpartum Onset is applied to Major Depressive D/O, Bipolar I Disorder, Bipolar II Disorder, or Brief Psychotic Disorder when:

Onset of Sx is w/in 4 weeks postpartum.

10-20% of women experience Sx that are sufficiently severe to meet the Dx criteria for Major Depressive D/O &

Addl. Sx's include preoccupation w/infant's weel-being that can range from excessive concern to unplesant fears & thoughts about harming the child

Up to 70%-85% experience milder symptoms ("baby blues").

In Northern Hemisphere, Major Depressive D/O is linked to winter mos. for some CT's.

Sx include:

Decreased activity

Hypersomnia (Sleep disturbances)

Loss of libido,

Increased appetite & weight gain, and

Cravings for carbohydrates.

Tx: Phototherapy - exposure to bright light that mimics sunlight is an effective.

Seligman's original (1970) model proposes that:

Depression is due to repeated exposure to uncontrollable negative life events &

attributions of the negative events are internal, stable, & global (Attribution theory - believe his/her own fault).

Abramson, Metalsky, and Alloy (1980) revised the original theory to:

emphasize the role of hopelessness

predicts that exposure to negative life events leads to depression and attributions of those events to internal, stable & global factors contribute to a sense of helplessness and an inability to control those events.

(Beck) Depression is related to a negative cognitive triad that consist of negative beliefs about:

onself,

the world (situation), &

the future

that devel. during childhood as the result of negative life experiences.

Ex: A Dep. person may believe that she is a failure, that no one can do anything to help her suceed & nothing is going to change in the future.

Dx criteria (HES 2 SAD):

presence of a chronically depressed mood present most of the time

that is not severe enought to meet the criteria for a Major Dep. Episode &

lasts for at least 2 years in adults or 1 year in children/adolescents.

Hopelessness

Energy loss or fatige

Self-esteem low

2 years min. of Depressed mood most of day for more days than not

Sleep (increased/decreased)

Appetite (increased/decreased)

Decision-making or concentration impaired

Tx: Interpersonal therapy & CBT are both useful but may be less effective than for Major Dep. D/O. Outcome improve when CT goes for maintenence session & Tx combined w/antidepressants.

Lewinsohn (1974) operant conditioning.

Attributes Dep. to a low rate of response-contingent reinforcement for social & other behaviors (e.g. as the result of the death of a partner or change in social environment), which results in:

extinction of those behaviors as well as

pessimism,

low self-esteem,

social isolation, &

other features of depression that tend to reduce the likelihood of positive reinforcement in the future

Compared 3 Tx types:

CBT,

Interpersonal therapy (IPT), &

The tricyclic imipramine for depression.

Inital res. results found all 3 were effective & their effects did not differ significantly overall, but imipramine was somewhat better for CT's w/severe Sx.

A follow up study indicated that only 30% of CT's receiving CBT remained Sx free 18 mos. later compared to:

26% receiving IPT,

19% receiving imipramine, and

20% in the placebo group

Dx criteria requires (BI-POLAR FAMILY):

1 or more Manic or Mixed Episodes w/or w/out a Hx of 1 or more Major Depressive Epsiode.

Brevity of episodes

Impulsivity

Pre-morbid Hyperthymic Personality (polarity switch in response to anti-dep)

Overeating & over sleeping

Liability of mood

Anxiety D/O & Sub. Use D/O usually comorbid

Relatively resistnat to Tx

Family Hx of Schizophrenia or Bi-Polar D/O

Abrupt onset, aggitation & behavioral abnorm

Mixed episode

Instability in job & marriage relationships

Lithium recommended 1st line of Tx

Young age (onset early 20's)

Strong evidence of a genetic component, 2/3 of ppl w/Dx have a relative w/Bi-polar D/O

Gender: Equally common in males and females

Tx: Lithium or anti-seizure drug is usually effective for reducing mania/hypomania

Dx criteria (BI-POLAR FAMILY):

Combo 1 or more Major Depressive Episodes & 1 or more Hypomanic Episodes w/out a Manic or Mixed Episode

Brevity of episodes

Impulsivity

Pre-morbid Hyperthymic Personality (polarity switch in response to anti-dep)

Overeating & over sleeping

Liability of mood

Anxiety D/O & Sub. Use D/O usually comorbid

Relatively resistnat to Tx

Family Hx of Schizophrenia or Bi-Polar D/O

Abrupt onset, aggitation & behavioral abnorm

Mixed episode

Instability in job & marriage relationships

Lithium recommended 1st line of Tx

Young age (onset early 20's)

Gender: More common in females

Strong evidence of a genetic component, 2/3 of ppl w/Dx have a relative w/Bi-polar D/O

Tx: Lithium or anti-seizure drug is usually effective for reducing mania/hypomania

Dx criteria:

Periods of fluctuating hypomanic Sx (periods) &

numerous periods of depressive Sx for

at least 2 years in adults or 1 year in children/adolescence.

High risk for suicide is associated with:

A warning,

Previous attempts,

A plan (especially involving a lethal weapon),

Male gender,

Being divorced/separate and

Feelings of hopelessness

Rates are highest for Whites, an exception is for American-Indian/Alaskan Native adolescents & young adults

Related to mental D/O's the highest risk is associated w/Major Dep.

Suicide attempters (vs. completers) are most likely to be female & under the age of 35

Dx criteria includes alterations in perception, depersonalization & derealization(PANICS):

Involves 2 or more unexpected panic attacks

w/at least 1 of attack followed by 1 mo. of persistent concern about having another attack,

worry about the consequences of the attack &/or

a significant change in behavior related to the attack

4 Sx's for 10-25 min.

Palpitations Heart

Apprehension, or terror that devel. abruptly & usually peak w/in 10 min.

Nausea, Numbness

Intense fear of death, terror

Chocking, chest Pain, chills

Shortness of breath, sweating, shaking

Must be able to rule out being due to a medical condition

Sx may mimic a heart attack or hyperthyroidism

3 Types:

Unexpected (uncued)

Situationally Bound (cued)

Situationally Pre-disposed

Tx Includes:

in vivo exposure with response prevention most effective, &

in some cases, a TCA or SSRI or benzo. relapse increases when only drugs are used.

PANICS

Dx Criteria:

Involves excessive anxiety about being in situations or places from which escape might be difficult or embarrassing or in which help might not be available in case of panic attack or if other Sx's occur

If a panic attack or other symptoms occur - it can occur with or without panic attacks

Indiv. restrict places willing to go & eventually wont leave the house

More common in females

Tx of choice:

in vivo exposure with response prevention - involves exposing the person to the feared stimulus while preventing usual avoidance response

Exposure can be gradual or can involve flooding - whic involves initally exposing the person to stimuli that produce maximal anxiety

Indiv. may want a friend to accompany them in order to help alleviate anxiety

Characterized by:

Persistent fear of of being in social/performance situations that may cause embarrassment or humiliation as the result of scrutiny or evaluation by others

In adults, there is a realization that the fear is excessive and unreasonable

Situations commonly associated w/Social Phobia include:

public speaking,

attending parties,

initiating conversations, and

speaking to authority figures

Tx:

In-vivo exposure, enhanced w/social skills training

Cognitive techniques

Characterized by:

A marked & persistent fear of a specific object or situation other than those associated w/Agoraphobia or Social Phobia

In adults, there is recognition that the fear is unreasonable or excessive

5 Types

Blood-Injection-Injury Type differs from the other types in terms of physical reaction to feared stimuli.

For ppl w/this type, feared stimuli produce an initial increase in heart rate & blood pressure that is immediately followed by a drop in both &, as a consequence, fainting

Other Specific Phobias experience only an increase in heart rate and blood pressure

Animal

Natural Environment

Situational