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UNDERSTANDING PSYCHOPATHOLOGY

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Title: UNDERSTANDING PSYCHOPATHOLOGY


1
UNDERSTANDING PSYCHOPATHOLOGY
  • Cognitive Disorders

2
OVERVIEW
  • Assessment
  • Definition of Cognitive Disorders
  • Alzheimers Disease

3
AGING AND MENTAL DISORDERS ECA DATA ON 1-YEAR
PREVALENCE, IN PEOPLE AGES 55YEARS
  • Any anxiety disorder 11.4
  • Severe cognitive impairment 6.6
  • Any mood disorder 4.4
  • Any mental disorder 19.8

4
ASSESSMENT AND DIAGNOSIS IN OLDER ADULTS
CHALLENGES
  • Clinical presentation may differ from that of
    younger individuals
  • e.g., more somatic symptoms
  • Detection is complicated by comorbidity with
    medical disorders
  • somatic disorders may mimic symptoms of mental
    disorders

5
ASSESSMENT AND DIAGNOSIS IN OLDER ADULTS
CHALLENGES
  • Physicians feel ill equipped to detect mental
    disorders in the elderly
  • e.g., in one study, only 55 of internists felt
    confident diagnosing depression, and only 35
    felt confident in prescribing anti-depressants to
    their elderly patients (Callahan et al., 1992).
  • Based on the ECA, it is estimated that up to 63
    of adults 65 years experience an unmet need for
    mental health services (Rabins, 1996).

6
ASSESSMENT AND DIAGNOSIS IN OLDER ADULTS
CHALLENGES
  • Stereotypes about the elderly result in incorrect
    or delayed diagnosis
  • e.g., some believe that depression is an
    unavoidable consequence of bereavement and
    therefore does not warrant clinical attention
  • Cognitive decline makes assessment and diagnosis
    difficult
  • e.g., cognitive deficits may make it difficult to
    obtain an accurate history

7
COGNITIVE DISORDERS IN THE DSM IV
  • A. Clinically significant deficit in
    cognition
  • Intelligence
  • Information processing
  • Problem solving
  • Language
  • Learning
  • Memory
  • B. Represents a change from previous levels of
    functioning

8
AGING AND MENTAL HEALTH
  • With increasing age, cognitive disorders become
    more prevalent. E.g., rates of cognitive
    disorders among the elderly
  • 65 or older 5
  • 80 or older 20
  • Over 80 (50) of the elderly have one (two or
    more) chronic health condition(s)
  • But beware of myths about aging

9
DSM IV COGNITIVE DISORDERS
  • Dementia
  • Delirium
  • Amnesia

10
DSM IV COGNITIVE DISORDERS
  • 1. Dementia Permanent loss of basic cognitive
    functions
  • Memory deficit (required for diagnosis)
  • Language deficit Aphasia
  • Apraxia (impaired ability to execute motor
    behavior)
  • Agnosia (failure to recognize objects or people)
  • Impairment in executive functioning (planning,
    abstract thinking)

11
DSM IV COGNITIVE DISORDERS
  • 2. Delirium
  • A. Disturbance of consciousness reduced
    ability to focus, sustain, or shift attention
  • B. Change in cognition (e.g., memory deficits)
    or development of perceptual disturbances
  • C. Rapid onset fluctuating course

12
DSM IV COGNITIVE DISORDERS
  • 3. Amnestic Disorder
  • A. Memory impairment
  • impaired ability to learn new information
  • impaired ability to recall previously learned
    information
  • B. The memory disturbance causes significant
    impairment and represents a decline from a
    previous level of functioning.
  • C. The memory disturbance does not occur
    exclusively during the course of delirium or
    dementia.

13
DIFFERENTIAL DIAGNOSIS
Feature Delirium Dementia
Clinical course rapid onset insidious
onset short duration long duration fluctuat
ing relatively stable
Cognitive Disturbances Awareness impaired
usually normal Alertness reduced usually
normal Orientation impaired may be
intact Memory recent --impaired recent
remote impaired Thinking slow or
accelerated/ poor abstraction/ dreamlike imp
overished
14
DIFFERENTIAL DIAGNOSIS
Feature Delirium Dementia
Perception often misperceptions typically absent
Sleep-wake cycle always disrupted/ fragmented
sleep often drowsiness during the
day/insomnia at night
Physical illness or drug toxicity usually
present often absent
15
Multiple causes of cognitive disorders in the
elderly
Medical Illness
Medications
COGNITIVE DISORDER
Brain disease
Psychiatric illness
Behavioral Alterations
16
MYTHS ABOUT THE ELDERLY
  • Uniformity (all old people are the same)
  • within group differences increase with age
  • health varies widely
  • lifestyles vary widely
  • due to rapid social change, each generation of
    elderly likely will differ from the next

17
ALZHEIMERS DISEASE
  • Diagnosis is based on cognitive symptoms
  • Behavioral symptoms, however, are common and
    often very disruptive (often prompting
    institutionalization)
  • e.g., 30-50 of Alzheimers patients experience
    delusions
  • Many experience insomnia, incontinence, emotional
    and physical outbursts

18
ALZHEIMERS DISEASE
  • Estimated to affect 8-15 of people over 65
  • Clinical picture involves gradual memory loss,
    deficits in language, planning ability, abstract
    thinking, behavioral symptoms such as agitation,
    and may include depressive and psychotic
    symptoms.
  • Diagnosis is difficult due to lack of biological
    markers, insidious onset, and similarity to
    dementias due to other causes

19
ALZHEIMERS DISEASE
  • Diagnosis depends on clinical features
  • Diagnosis can be confirmed with pathological
    evidence (biopsy or autopsy) characteristic
    malformation of neurons (neuritic plaques and
    neurofibrillary tangles), especially in the
    hippocampus, and loss of brain cells.

20
ALZHEIMERS DISEASE
  • Clinical course involves a gradual decline
  • Memory deficits typically are the first symptoms
  • Depression is common in the early stages
  • Agitation is more common in the later stage
  • Duration of illness averages 8 to 10 years

21
ETIOLOGY OF ALZHEIMERS DISEASE
  • Familial form (accounts for 5 of cases)
    --genetic factors mutations in chromosomes 21,
    14, and 1
  • These mutations appear to result in
    overproduction of the protein found in neuritic
    plaques, beta-amyloid.
  • Onset of the familial form is early, but course
    and nature appear to be influenced by
    environmental factors

22
ETIOLOGY OF ALZHEIMERS DISEASE
  • Approximately 50 of individuals with a family
    history of Alzheimers, if followed into their
    80s and 90s, develop the disorder.
  • Non-familial form--genetic influences possibly
    related to chromosome 19 other genes are under
    study.

23
ETIOLOGY OF ALZHEIMERS DISEASE
  • Biological changes due to aging (these changes
    have led some to speculate that most individuals
    will eventually develop Alzheimers if the human
    life span was extended)
  • neuron and synaptic loss
  • decreased dendritic span
  • lower cortical acetylcholine levels
    (neurotransmitter)

24
ALZHEIMERS DISEASE PROTECTIVE FACTORS
  • Genetic endowment with the ApoE-e2 allele
    (mechanism is not understood)
  • Higher education
  • Use of nonsteroidal anti-inflammatory drugs
    (possibly slow plaque formation)
  • Estrogen replacement therapy
  • Vitamin E and the drug selegiline (deprenyl)
    appear to slow progression

25
MYTHS ABOUT THE ELDERLY
  • Loss of productivity or creativity
  • older workers have fewer avoidable absences form
    work, fewer work accidents
  • Goethe wrote Faust at age 80 years
  • George Bernard Shaw wrote Farfetched Fables at
    age 93
  • A. Rubinstein played at Carnegie Hall at age 90

26
MYTHS ABOUT THE ELDERLY
  • Loss of productivity or creativity
  • older workers have fewer avoidable absences form
    work, fewer work accidents
  • Goethe wrote Faust at age 80 years
  • George Bernard Shaw wrote Farfetched Fables at
    age 93
  • A. Rubinstein played at Carnegie Hall at age 90

27
SUCCESSFUL AGING depends on...
  • Avoiding disease and disability
  • Sustaining high cognitive and physical
    functioning
  • Engaging with life (i.e., maintaining
    relationships and productive activities)
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