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Psychiatry for Medical Students

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Title: Psychiatry for Medical Students


1
Psychiatry
  • IMEC INC.

2
Psycho-analytic Concept
  • Freud and his daughter
  • Ego, Id, Superego
  • Symptom maladaptive defense, or defense breakdown
  • Focus on unconscious mechanism free association
  • Original acceptance of stories of trauma as true
    was reversed

3
Principle of Psychodynamic Psychotherapy
  • Interpretation of transference
  • Therapist not self-revealing or directive
  • Dream interpretation
  • Counter transference requires self analysis and
    supervision

4
Freudian Jargon
  • Permeates mental health culture despite loss of
    dominance paradigm
  • Transference in patients distorted gt feeling
    toward clinician
  • Counter-transference in clinicians gt feeling
    toward patient

5
Defense Mechanism
  • Acting out
  • Repression
  • Suppression
  • Reaction Formation
  • Denial
  • Projection
  • Identification

6
Behavior Therapy
  • Skinner, Watson
  • Operant Conditioning
  • Modeling
  • Social Learning
  • Exposure and response prevention

7
Social Psychiatry
  • Jung did not see Psychiatry as a purely medical
    treatment of disease, but more of a mental and
    physical and spiritual quest for wholeness. He
    points to a sacred journey on which not just the
    sick, but all humanity should embark.

8
Supportive Therapy
  • Empathic listening, may involve some advice and
    problem solving. Idea is to support ego capacity

9
Cognitive Therapy
  • Belief systems and distorted Thinking
  • Cognition effects Feeling
  • Countered Learned Helplessness
  • Controlled Studies show effective less in
    depression

10
Interpersonal Therapy
  • A structure short term therapy shown to be
    effective in controlled studies for depression
  • Focus relationship on one specific problem over
    10-12 sessions

11
Dialectical Behavior Therapy
  • Develop by Masha Linneman, Phd
  • Combined cognitive and behavioral psychodynamic
    and existential concepts in educational approach
  • Documented effective for Para suicidal people and
    borderline personality

12
Family Therapy
  • Many schools of thought
  • Clarify or interpret family dynamics
  • Work with whomever in family will come
  • Needs to be done by different clinician than
    individual therapist

13
Group Therapy
  • May be psycho-educational, like a class
  • Or psych-dynamic, interpreting transference and
    resistances
  • Or supportive

14
Family Psycho-educational
  • Includes family members and identified patient in
    educational problem solving classes on
    vocational, recovery, medical topics
  • Seeks to maximize use community resources and
    support systems

15
DSM IV System of Diagnostics
16
Descriptive Diagnostic Criteria1970s
  • Specific criteria to develop more homogenous
    research samples
  • A move away from psycho-dynamics other theory
  • Getting ready for managed care

17
Expert Consensus plus field testing
  • A big money maker for American Psychiatric Assn
  • Attempts to coordinate the ICD system
  • Attempts to fit subjective distress into the
    medical model which is criticized
  • Some diagnosis is more reimbursable than others

18
AXIS I
  • Most Psychiatric Diagnosis are here
  • Sometimes require for payment eligibility

19
AXIS II
  • Difference form Axis I questioned
  • Mental Retardation Personality Disorder are
    stigmatized as unchangeable
  • Some Axis II may be attributed to AXIS I spectrum
    of disorders

20
AXIS III
  • Non-psychiatric medical diagnosis
  • Neurological, Dementia, Deliria and sleep
    disorders

21
AXIS IV
  • Psychosocial disorders that contribute to
    distress

22
AXIS V
  • Global Assessment of Function 1-100
  • Psychological, social, and occupational
    functioning

23
Appendix Adecision trees
  • Helps to understand Hierarchal structure of
    DSM-IV diagnoses

24
Appendix B Diagnoses for further study
  • Hardly vestigial, this is the growing edge of DSM
  • Premenstrual, Dysmorphic Disorder
  • Post-psychotic depressive disorder of
    schizophrenia
  • Minor and belief disorders
  • Binge-eating disorder
  • Neuroleptic malignant syndrome
  • Other movement disorders due to medication

25
Glossary (appendix C)
  • Helpful in defining terms one might find on a test

26
ICD-9 Codes(appendix H)
  • Used by some insurance systems

27
Anxiety and Adjustment Disorders
28
Overview
  • 15 of people have anxiety
  • Abandonment, fear is Existential
  • Freud classified this as Ego Malfunction with
    conflict
  • Monozygotic concordance with Panic 85

29
Panic Attacks in DSM IV
  • First recognized in 19th century-Soldier Heart
  • Clearly differentiated form chronic anxiety
    states in DSM-III
  • Lactate and CO2 triggers became classic arguments
    for biological etiology
  • 1-2 population has Panic Disorder, gt women
  • Need to rule out cardiac disorder, hyperthyroid,
    pheocromocytoma , vestibular problems

30
Phenomenological of Panic
  • A discrete period of intense fear or discomfort
    in which 4 of the 13 symptoms appear rapidly and
    peak within 10 minutes
  • Symptoms
  • Palpitation
  • Sweating
  • Trembling
  • SOB
  • Choking
  • Chest pain
  • Nausea
  • Dizzy
  • Derealization
  • Fear of loosing control
  • Fear of Dying
  • Chills/Hot Flashes
  • Parasthesias

31
Panic Disorder Criteria DSM IV
  • Recurrent unexpected panic attacks
  • One month or more of
  • Persistent worry about attacks
  • Worry about the consequences
  • Persistent change in Behavior

32
Behavioral Treatment of PANIC
  • Cognitive Therapy
  • Relaxation/breathing
  • R/O ETOH, Caffeine
  • Stress Management

33
Medical Treatment of Panic
  • SSRI
  • TCAs
  • MAOIs
  • Benzodiazepines
  • Relapse Rate varies with amount of education and
    psycho-therapy

34
Agoraphobia in DSM IV
  • Anxiety about being places or in situations where
    escape of help might not be available in case of
    panic
  • Situations are avoided or endured with marked
    distress

35
Treatment of Agoraphobia
  • Exposure and response prevention
  • Practice and Stopping Paradigms
  • In Vivo Behavior Therapy

36
Generalized Anxiety Disorder
  • Excessive anxiety and worry more days than not
    for 6 months about several events or activities
  • Difficult to control the worry
  • Worry not part of another Axis I disorder
  • Three or more of
  • Restless/on edge
  • Easy Fatigue
  • Difficulty concentrating/mind blank
  • Irritabilty
  • Muscle Tension
  • Sleep Disturbances

37
Treatment of GAD
  • Cognitive Behavior Therapy
  • Most Antidepressants
  • Benzodiazepines
  • Buspirone
  • Non-habit forming
  • Slow acting-a couple of days
  • Low in side effects

38
Specific Phobia in DSM IV
  • Unreasonable/excessive fear of specific object or
    situation
  • Exposure provokes anxiety response, which could
    be panic
  • Fear is recognized as unreasonable
  • Treatment is exposure and response prevention
  • Animal, Natural, environmental, blood etc.
  • 2-1 female predominance

39
Social Phobia in DSM IV
  • Marked Fear or Social Performance
  • Exposure provokes anxiety or Panic
  • Fear unrecognized as excessive
  • Situation are avoided or ended with distress
  • If under age 18, must last 6 months
  • Generalized or specific

40
Treatment of Social Phobia
  • Specific forms mostly fear of public speaking
  • Responds to exposure and support-Toastmasters
  • Beta blocker help
  • Generalized Form more persistent
  • May respond to SSRI
  • CBT
  • Possible overlap with personality disorder
  • 3 in both men and women

41
PTSD in DSM IV part 1
  • Exposed to threat or death or serious injury of
    self/other
  • Response of Fear, Horror, helplessness
  • Trauma is re-experience persistently
  • Intrusive or distressing thoughts
  • Recurrent Bad Dreams
  • Reliving Flashbacks of Events
  • Intense distress at cues
  • Physiological Reactivity with Cues

42
PTSD in DSM-IVpart 2
  • Persistent avoidance of cues and numbing
  • Avoids thoughts, feeling, talk of event
  • Avoids people, places, activities related to
    event
  • Cant remember aspects of trauma
  • Diminished interest/withdrawal
  • Restricted affect
  • Foreshortened future expected

43
PTSD in DSM-IVpart 3
  • Persistent Symptoms of Arousal with 2 below
  • Insomnia
  • Irritability
  • Cant concentrate
  • Hyper-vigilance
  • Exaggerated startle response
  • Disturbances must last 1 month
  • Acute less than 3 months
  • Chronic more than 3 months
  • Delayed onset- gt 6 months later

44
Treatment of PTSD
  • May treat anxiety and depressive symptom with
    medication
  • Support, group therapy with similar patients
  • Gradual desensitization to and reorganization
    traumatic event memories
  • PTSD may be unrecognized if co-occurring with
    other disorders
  • 30 rape victims and Vietnam veterans have PTSD

45
Acute Stress Disorder in DSM-IV
  • Traumatic exposure as in PTSD
  • Three or more during or after event
  • Emotional numbing
  • Dazed
  • Derealization
  • Depersonalization
  • Dissociative amnesia
  • Re-experienced regularly on cue exposure
  • Avoidance of cue or recollection
  • Marked symptoms of Anxiety/arousal
  • Lasts 2-29 days---start within 29 day
  • Lasts short-starts early

46
Obsessive-compulsive DSM IV part 1
  • Must have obsessions or compulsions
  • Obsessions need ALL 4
  • Intrusive thoughts that cause distress
  • Not just real life worries
  • Attempts to ignore, suppress or neutralize
  • Recognized as a product of own mind

47
OCD--continued
  • Compulsions need both
  • Repetitive behaviors that person feels driven top
    perform
  • Aim is to prevent harm or dreaded event, but not
    in a realistic way
  • Obsessions or compulsions recognized as
    unreasonable at some point
  • Obsession/compulsions cause distress, take over 1
    hour, or mar routine
  • Not just focused on other AXIS I issue.(food,
    hair, weight, drugs, sex, etc.)

48
Treatment of OCD
  • 1-3 of Population in US
  • TLE, Pos-Streptococcal syndromes may mimic
  • Exposure and response prevention
  • WASHERS, CHECKERS, COUNTERS
  • Medications partially helpful
  • Clomipramine
  • High-dose SSRI
  • Possibly anti-psychotics if delusional

49
General Psychiatric Co-morbidities with anxiety
  • Depression?common with GAD
  • Substance Abuse self-treatment
  • Pyschosis

50
Medical Co-morbidities with Anxiety
  • Meds with side effectsXanthines to antibiotics
  • Hypoxia
  • Fear of Illness/Pain
  • Post anesthesia syndrome

51
Adjustment Disorder in DSM IV
  • Emotional or Behavioral Symptoms in Response to a
    stressor within 3 months of onset
  • Either
  • Marked Distress in excess of expected response
  • Significant social or occupational impairment
  • Not bereavement
  • Not an exacerbation of a previous Axis I disorder
  • Acute if less lt 6 months
  • Chronic if greater gt 6 months

52
Sub-types of Adjustment Disorder in DSM IV
  • With Depressed Mood
  • With anxiety
  • With mixed anxiety and depressed mood
  • With disturbances of conduct
  • With mixed disturbances of emotions and conduct
  • Unspecified

53
MOOD DISORDERS
54
Major Depressive Episode DSM IV
  • 5 Symptom for 2 weeks
  • Must include depressed mood or anhedonia (or
    both)
  • 5 weight change in a month or consistent
    appetite change
  • Insomnia/Hyper-somnia
  • Observed psychomotor agitation or retardation
  • Persistent Fatigue or loss of energy
  • Worthlessness inappropriate guilt
  • Decreased concentration or indecisiveness

55
Emil Kraepelin distinguished schizophrenia from
mood disorders in 1899. ECT developed by
Cerletti BiniJohn Cade discovered antimanic
properties of Lithium in 1949 Antidepressant
medications introduced in late 1950s
56
Manic Episode in DSM IV
  • Elevated, expansive or irritable mood for 1 week
  • 3 symptoms (4 if irritable)
  • Grandiosity
  • Less sleep
  • Pressured speech
  • Racing thought/Flight of Ideas
  • Distractibility
  • Increased Goal directed activity or agitation
  • Pursues pleasure at high risk
  • Causes Marked impairment

57
Hypo-manic Episode
  • As Manic-less time around 4 days
  • No Marked impairment

58
Major Depressive Disorder DSM-IV
  • No Mania Allowed
  • With psychotic features
  • With Catatonia-no response
  • With Melancholia-everything is all right
  • With Postpartum onsets within 4 weeks
  • 10-25 women, half as many men
  • Divorce increase risk
  • First degree relatives 2-3X more likely to get it

59
MDD with Catatonia DSM-IV
  • 2 of the listed below-
  • Catalepsy/waxy flexibility or stupor
  • Excessive motor activity
  • Negativism/mutism
  • Posturing-stereotypy
  • Echolalia/echopraxia (mimicking)

60
MDD with Melancholia DSM-IV
  • Must have Anhedonia-loss of pleasure
  • 3 of the following
  • Distinct changemood quality
  • Early AM waking
  • Psychomotor agitation
  • Anorexia or Weight loss
  • Excess Guilt

61
MDD with Atypical Features in DSM-IV
  • Mood Reactivity
  • Two of the following
  • Weight gain
  • Hyper-somnia
  • Leaden paralysis
  • Rejection sensitivity

62
MDD with Post-PartumDSM IV
  • Must be within 4 weeks Postpartum

63
MDD with Seasonal PatternDSM IV
  • Episode and periods of remission follow seasonal
    pattern
  • At least 2 episodes linked to season and none
    out of season within the last 2 years
  • Lifetime episodes tend to be seasonal

64
Rapid Cycling Mood Disorderin DSM-IV
  • 4 Episodes in one year with 2 months remission
    between each

65
Mixed Mood EpisodeDSM-IV
  • Meets Criteria for both Manic and Major
    Depressive episode nearly every day for 7 days

66
Dysthymic Disorder in DSM-IV
  • Most days depressed for 2 years (adult) Children
    need to show irritability-1 year
  • 2 symptoms from list
  • Appetite disturbances
  • Sleep disturbances
  • Low energy/fatigue
  • Low self-esteem
  • Problems concentrating, decisions
  • Hopeless feelings
  • No MDE for 2 years
  • No mania, hypomania, or cyclothymia
  • No 2 month period between episodes
  • Effects about 6 of people-women 2-3X men. Less
    than ½ develop MDD or Bipolar

67
Double Depression (not DSM)
  • Refers to superimposed Dysthymic Disorder and
    Major Depression
  • Effects 25 with MDD
  • Must be Dysthymic first

68
Bipolar I II
  • Bipolar I with Mania in DSM-IV
  • Bipolar II with hypomania, requires some
    depressive episodes in DSM-IV
  • More worse depression in Bipolar II
  • Bipolar I gender neutral
  • Bipolar I inherited at higher rate than MDD or
    Schizophrenia

69
Cyclothymia in DSM-IV
  • 2 years of hypomanic and depressive symptoms that
    do not make MDE
  • No 2 month period of remission for 2 years
  • No MDE first 2 years
  • After 2 years, may occur with major mood disorder
  • 1/3 Cyclothymics Progress to Bipolar
  • 2/3 Remain Stable

70
ECT for Depression and Mania
  • Often works faster than medication
  • Indication for psychotic depression
  • Memory loss usually transient, not a therapeutic
    effect
  • Stigma reduces access
  • 8-12 sessions in most cases
  • Bi-frontal stimulation

71
Course Outcomes of Mood Disorders
  • 10-15 of Mood disorders patients suicide
  • Episodes get worse and more frequent over time if
    untreated
  • 6 months therapy in first episode
  • 50 bipolar do well on lithium
  • 60-70 response in major depression to
    antidepressants
  • Placebo better in depression than mania

72
Antidepressants
  • Tricyclics-late1950s
  • (Tofranil,Pamalor, Doxapin)
  • Dry mouth, Constipation, sedation are common
  • Can cause mild withdrawal
  • Toxic if overdose
  • MAOIs
  • Require care with diet, serotonergic medications
    and indirect acting stimulants contraindicated
  • May be more effective with Bipolar Depression
  • Weight gain, hypotension
  • Avoid Tyramine (Wine, Cheese)
  • P450 OXIDATION Decreased with MAOI

73
Antidepressants Cont-SSRI
  • Less toxic in overdose
  • May be more effective in pre-menopausal women
  • Cognitive and sexual side effect
  • Rare but significant akithesia
  • Interact with TCAs and MAOIs
  • Serotonin Syndrome
  • Increased TCA levels do to p450 effect
  • Overlapping can cause mild Serotonin
    Syndromestiffness, nausea, diarrhea, fever
  • SIGNIFICANT HYPERTHERMIA-

74
Other Antidepressants
  • Bupropian?Ziban or Wellbutrin (antichol)
  • May reduce smoking---no wgt gain or sexual
    effects
  • Caution regarding pro-ictal effects
  • Venlafaxine
  • Dual agent SSRI-like and Noradrenergic-May cause
    mild increase in BP
  • Nefadozone
  • Lack of sexual side effect (but significant p450)
  • Bad with Statins
  • Mirtazepine
  • Newer

75
Mood Stabilizers
  • LITHIUM CARBONATE
  • Weight gain, tremors, polyurea, THYROID disorders
  • Toxicity confusion, diarrhea, delirium, nausea
  • CARBAMEPAZINE (Tegretol)
  • May cause rash, decreased WBCs
  • High maintenance-revs up p450
  • SODIUM VALPROATE
  • Can be loaded fast
  • Weight gain, amenorrhea, tremor
  • Thrombocytopenia at HIGH doses

76
Mood Stabilizers in Pregnancy
  • Thorazine (Chlorpromazine)
  • A phenothiazine with antiemetic properties no
    specifics known adversely for pregnancy
  • Melleril (Thioridazine)
  • Good in combative states-hyper excitability
  • Also has antiemetic properties, phenothiazine
  • Both dopamine blockade, are extrapyrimidal
    (another is Stelazine)

77
Anti-psychotics a mood stabilizers
  • Dopamine blocking neuroleptics can restrain mania
    acutely and chronically-long acting shots or
    oral versions
  • SIDE EFFECT-TARTIVE DYSKINESIA
  • New Atypical antipsychotics may have mood
    stabilizing effect
  • Olanzapine
  • Risperidone
  • Quetiapine
  • Ziprasidone
  • These agents are very expensive compared to other
    mood drugs

78
Mood Stabilizers as Antidepressants
  • Lithium, Carbamepazine, Lamotrigine all have
    antidepressant properties, especially in bipolar
    disorder

79
DEPAKOTE (valproic acid)
  • Primarily a seizure medication that can be used
    in absence seizure, as well as associated
    Migraines

80
How long to treat bipolar disorder?
  • Indefinitely, if clear recurrent symptoms
  • Psychotherapy can help with acceptance of illness
  • Strong relationships with support group
    counteracts loss of insight
  • 50 usually dually diagnosed with substance abuse

81
Stress, Sleep, and Substances
  • All can exacerbate moods
  • Normalizing sleep and addressing psychotic and
    suicidal thinking top priorities
  • Get drugs and alcohol out of the way
  • Steroids and thyroid can provoke manic picture

82
Social Learning and Reinforcement Theories in
Depression
  • Work, recreation, exercise may all have
    antidepressant effect
  • Change in routine, loss of supports may trigger
    depression
  • First episode of depression may be stressor
    related
  • But recurrent episodes may be of kindling

83
Schizophrenia and Dissociative Disorders
84
DSM-IV criteria for Schizophrenia
  • At least 2 of the following (6 months)
  • Delusions
  • Hallucinations
  • Disorganized speech
  • Grossly disorganized or catatonic behavior
  • Negative symptoms
  • Running commentary (voices)-fixed

85
DSM IV Schizophreniform
  • Same criteria as schizophrenia, except symptoms
    last from 1-6 months
  • Good prognostic features
  • Psychiatric features begin within 4 weeks of
    behavioral change
  • Confusion/perplexity with psychosis
  • Good premorbid function
  • Affect not flat or blunted
  • Does not require a decline in function

86
DSM IV Brief Psychotic Disorder
  • One of the symptom list for schizophrenia other
    than negative symptoms
  • Lasts one day to one month
  • May specify with or without marked stressors, or
    post-partum if within 4 weeks of delivery

87
OLD ANTI-PSYCHOYIC MEDS-NEUROLEPTICS
  • D2 blocking neuroleptics
  • Chloropromazine (Thorazine)
  • Haldoperodol (Haldol)
  • Thifluoroperazine (Stelazine)
  • Fluphenazine (Prolixin)
  • Molindone (Moban)
  • Haldol and Fluphenazine may be given in long
    lasting injection

88
Chlorpromazine (Thorazine)
  • Phenothiazine with D2 blockade. 3 sedative
    effectvery moderate extra-pyramidal effects
  • Used in psychosis and mania
  • Also used in acute intermittent porphyria
  • Migraine headache
  • SE-SEDATION

89
Haldoperol
  • Heterocylic compound with low anticholinergic
    effects, yet high extra-pyramidal side effects
  • Considered a butyrophenone-

90
Perphenanazine (Trilafon)
  • Phenothiazine with low to moderate
    anticholinergic and low to moderate
    extrapyrimidal
  • D2 phenothiazine-
  • Used with Hiccoughs
  • Used in Hemi-ballismus
  • Tourettes

91
Fluphenazine (Prolixin)
  • D2 Phenothiazine with low anticholinergic and
    high extra-pyrimidal side effects
  • Can be given in long acting IV
  • Considered a depot drug for Torrettes

92
Molindone (Moban)
  • A heterocyclic compound with moderate
    anticholinergic and moderate extra-pyramidal
  • Least likely to cause seizure

93
Side effects of Older Antipsychotics
  • Akinethesia
  • Dystonia
  • Tardive Dyskinesia
  • Neuroleptic Malignant Syndrome
  • Parkinsonism
  • Cognitive and mood disorders

94
Akithesia
  • Subjective-inner restlessness
  • Pacing-cant sit still
  • Also associated with SSRIs
  • Responds to Beta-blockers or benzodiazapines

95
Dystonia
  • Opisthotnos, Oculgyric crisis common
  • May effect any muscle group
  • Anticholinergics and antihistimine may be given
    IM or IV
  • Atropine or Neostigmine
  • Life threatening if it effects the tongue or
    Respiration

96
Tardive Dykinesia
  • Occurs in 50 of patients with chronic Dopamine
    D2 Blockade
  • Spastic twitching of mouth, tongue, fingers, but
    may be truncal or ballistic
  • Movement disorder may be part of another disorder
    as well
  • May improve with lower doses or switch to an
    atypical

97
Parkinsonism
  • Idiopathic
  • Mask faces, stiff gait, reduced arm swing
  • Need to distinguish from depression
  • Very common with Thorazine
  • Give Dopa/Carbidopa

98
Neuroleptic Malignant Syndrome
  • May be life threatening
  • Ridgitity, increased CPK
  • Hyperthermia and confusion
  • Possible common pathway in Catatonia
  • GIVE DANTROLENE

99
Cognitive and Mood effects of Dopamine Blockers
  • Dysphoria-mental slowing
  • May be partially relieved by smoking tobacco
  • Leads to discontinuation
  • Reduces PLEASURE Principle

100
Newer Antipsychotic and Side Effects
  • Clozapine-(Clozaril)
  • Aplastic anemia, seizures, weight gain
  • Olanzapine-(Zyprexa)
  • Weight gain
  • Resperidone-(Risperdal)
  • Increased Prolactin
  • Quetiapine-(Seroquel)
  • Cataracts in Beagles
  • Ziprasidone-(Geodan)
  • QTc Interval worry

101
Other Interventions
  • Mood Stabilizers
  • Benzodiazapines-helpful in Catatonic State
  • ECT-(First Year)
  • Cognitive Therapy may be helpful

102
Mental Status in Schizophrenia Spectrum
  • Affect may be flat, blunted or inappropriate
  • Hallucinations, usually auditory, formed or
    unformed, like a sound, not just a thought
  • Thought content may be delusional, ideas of
    reference
  • Though form includes a word salad, echolalia,
    loose associations
  • Orientation and memory usually intact
  • Poor insight common

103
Prognosis of Schizophrenia
  • Majority live independently in community
  • Family, employment, housing, positive symptoms,
    late onset and female gender improve outcomes
  • Improved medications more effective with less
    side effects
  • Prognosis has improved relative to affective
    disorder
  • Still, 15 die of suicide lifetime

104
Prognosis of Acute Psychotic Disorder
  • Precipitating trauma or stressor is good sign
  • Treatment improves prognosis
  • Preserved affective tone is a good sign

105
About hallucinations
  • Frequently are uniformed
  • Usually auditory
  • May be tactile, gustatory or visual
  • May be experienced as coming inside or outside
    person
  • May be the voice of a known person
  • Hearing a name called or voice of a dead relative
  • May be part of a normal religious experience
  • There are false sensory perception

106
Affect vs. Mood
  • Affect describes range of mood and how it is
    globally expressed to observer verbally or
    non-verbally
  • Blunted, labile, shallow, flat
  • Mood is specific feeling tone from sad to
    euphoric, may have a distinct abnormal quality in
    melancholia

107
Delusions
  • False beliefs that reject evidence
  • Organized persistent delusions tend to persist
    despite treatment
  • Do not assume unlikely belief is false or without
    some truth

108
Illusions
  • Misperception of normal sensory function
  • Common in children and delirium

109
Recovery/Survivor Movement
  • Government support in US
  • Skeptical toward forced treatment
  • Believes symptoms need not be barrier to work or
    independence
  • Favors self help/mutual help
  • Questions medical model
  • Supports closing hospitals

110
Epidemiology of Schizophrenia Spectrum
  • 50 monozygotic concordance
  • 1 of population across cultures
  • Schizotypal personality in families12 of 1st
    degree relative get schizophrenia
  • Seasonal patterns of birth suggest infectious
    etiology
  • Onset is later in women
  • African-americans may be over-diagnosed

111
Psychological Theories
  • Ambiguous parental communication largely
    discounted now
  • High expressed emotionexacerbates endogenous
    condition
  • Inadaquate ego development or stimulus
  • Fundamental cognitive problems, neural networking
    under investigation now

112
Differential Diagnosis
  • Mood disorders with psychosis
  • Borderline Personality may hear voices, brief
    psychosis
  • Schizotypal personality old mannerisms, thoughts
    short of criteria
  • Paranoid disorder/personalitylack formal thought
    disordernot bizarre
  • Drug induced disorders

113
Schizophrenia Terms
  • Thought broadcasting others can hear/know pts
    thoughts
  • Catatoniaecholalia
  • Thought insertion another person thought in
    patients head
  • Delusions of reference unrelated experience has
    special meaning
  • Loose associations thoughts do not usually
    follow each other
  • Clang associationswords associated by sound not
    meaning
  • Neologism a made up word

114
Dissociative Identity Disorder DSM IV
  • Two or more distinct personalities-Three Faces of
    Eve
  • At least two take control of behavior at times
  • Inability to recall extensive personal
    information
  • Not due to alcohol, medical issues, or in
    children fantasies

115
Depersonalization DisorderDSM IV Criteria
  • Feeling of being outside of self
  • Intact reality testing
  • Causes significant distress or problems in
    function
  • Not part of other Medical or Psychiatric disorder

116
Dissociative Fugue DSM IV criteria
  • Sudden travel away from home
  • Forgetting past, taking on a new one in a new
    place
  • Culture bound syndromes of AMOK, PIBLKLOG, GRISI
    SIKNIS fall into this category

117
Dissociative disorderNOS in DSM IV
  • Dissociative trance disorder an unusual loss of
    identity interpreted as possession
  • Dissociative states brought on by torture or
    brainwashing
  • Situations where criteria for dissociative
    disorder is only partially met
  • Derealization without depersonalization

118
Atypical Psychotic Syndromes
  • Shared Psychotic disorder sicker one dominates
  • Capgras syndrome delusions that people one
    knows are imposters
  • Coutards syndrome nilhilistic delusions that
    the world or body parts are gone
  • Autoscopic pyschosis illusion that ones own body
    part
  • Koro delusion that genitalia are being absorbed
    into ones body

119
Delusional Disorder DSM IV
  • Non-bizarre Delusions involving real life
    possibilities, lasting one month or more
  • Does not meet criteria for schizophrenia
  • Outside of delusions functioning not impaired
  • Mood problems brief relative to periods of
    delusions

120
Types of delusions
  • Erotomanic delusions that another loves them
  • Grandiose delusions of wealth or inflated worth
  • Jealous delusion that partner is unfaithful
  • Somatic delusion of persecution
  • Mixed form above
  • Unspecified

121
Personality Disorder, Substance Abuse and Eating
Disorders
122
Overview of Personality Disorders
  • Longstanding, stable pattern of behavior
  • Causes Distress or impairment
  • Not explained by Axis I disorder
  • Pattern of inner experience and behavior deviates
    markedly from cultural expectation

123
Cluster A Odd
  • Paranoid PD
  • Schizoid
  • Schizotypal

124
Paranoid PD Distrust and suspicion
  • Need 4 from list
  • Suspects other exploit or harm them
  • Unjustified doubts about others loyalty
  • Reluctant to confide in others
  • Reads insults or threats into benign events
  • Unforgiving
  • Perceives attacks on reputation reacts
  • Suspects infidelity of partner for no reason

125
Schizotypal PDOdd, Cognitive, distortions
  • Need 5 from list (THINK OF STORY TELLER)
  • Ideas of reference
  • Odd or magical beliefs
  • Perceptual distortions
  • Odd thinking or speech
  • Suspicious/paranoid ideas
  • Inappropriate or constricted affect
  • Eccentric Behavior
  • Lacks Friends
  • Social Anxiety

126
Schizoid PD Detached
  • Needs 4 from list
  • Does not desire relationships
  • Solitary
  • Little sexual activity
  • Few pleasures
  • Lacks friends
  • Indifferent to critics
  • Detached or cold

127
Cluster B
  • Antisocial PD
  • Histrionic PD
  • Borderline PD
  • Narcissistic PD

128
Antisocial PD Criminal
  • After age 15, has 3 criteria
  • Repeated law breaking
  • Deceitful lies
  • Impulsive
  • Irritable and aggressive
  • Disregard for safety
  • Irresponsible
  • No remorse

129
Borderline PD Unstable
  • Needs 5 of these
  • Frantic to avoid abandonment
  • Unstable relationships
  • Unstable identity
  • Impulsive
  • Suicidal/cutting
  • Mood shifts
  • Feels empty
  • Inappropriate rage
  • Brief Paranoia/Dissociation

130
Histrionic PDexcess emotion
  • Needs 5 below
  • Seeks attention
  • Seductive
  • Shallow mood shifts
  • Uses physical appearance
  • Vague speech
  • Dramatic
  • Suggestible
  • Imagine intimacy

131
Narcissistic PD Grandiose
  • Needs 5
  • Self Important
  • Fantasies of Glory
  • Feels special
  • Seeks admiration
  • Entitled
  • Exploitative
  • Lacks empathy
  • Envious
  • Arrogant

132
Cluster C
  • Obsessive-Compulsive
  • Dependent
  • Avoidant

133
Obsessive-Compulsive
  • Needs 4 of list
  • Preoccupied with details
  • Perfectionism
  • All work, no play
  • Over scrupulous
  • Cant delegate
  • Miserly
  • Stubborn

134
Dependent PD Clinging
  • Needs help deciding
  • Wants other responsible
  • Cant say no
  • Afraid to start things
  • Seeks nurturance
  • Feels helpless alone
  • Always in relationship
  • Fears solitude

135
Avoidant PD Fears risk
  • Avoids activities or relationships that might
    involve rejection or criticism
  • Low self-esteem

136
Treatment of Personality Disorder
  • Medication may help depression, anxiety or mood
    stability
  • Building insight through relationship with
    therapist
  • Setting limits/confronting acting out/impulsive
    acts
  • Borderline PD responds to dialectical behavior
    therapy
  • Avoid Hospitalization

137
Eating Disorders
  • Bulimia Nervosa
  • Anorexia Nervosa
  • Obesity

138
Bulimia Nervosa in DSM-IV
  • Binging
  • Eating too much in a specific time
  • Lack of controlled eating
  • Compensatory Behavior for weight purge, fasting,
    and exercise
  • Behaviors occur twice a week for three months
  • Focus on body shape weight
  • Separate from Anorexia Episodes, if any
  • Purging and non-purging types may be specified

139
Anorexia Nervosa in DSM IV
  • Refusal to keep body weight at 85 or more
  • Fear of gaining weight distorted awareness of
    body weight

140
Dementias
141
Dementia Types
  • Alzheimers Dementia
  • Vascular Dementia
  • Picks Disease
  • Creutzfield-Jakobs
  • Huntingtons Chorea
  • Parkinsons Disease
  • Wilsons Disease

142
Alzheimers Dementia
  • Memory loss that effects job skills
  • Difficulty with familiar tasks
  • Problems with language
  • Disorientation to time place
  • Problems with abstract thought
  • Poor judgment
  • Changes in personality, mood and behavior
  • Loss of initiateve
  • ACCULMULATION OF AMYLOID PLAQUES ON
    NEUROFIBRILTORY TANGLES

143
Vascular Dementia
  • Patchy deterioration in cognitive function post a
    cerebovascular accident
  • Men gt women
  • 15 of all dementias
  • Most prevalant between 60-70 Years

144
Picks Disease
  • Atrophy of the frontal and temporal lobes
  • Very rare
  • Personality changes due to frontal lobe

145
Creutzfield-Jakobs
  • Dementia causes by an unknown prion-some
    indicators suggest similarities with Mad Cow
    disease
  • Rapidly progressive, onset in the 40s
  • Fatal within 2 years

146
Huntingtons Chorea
  • Autosomal dominant
  • Defect in Chromesome 4
  • Males Females
  • BASAL GANGLIA AND CAUDATE
  • Chorionic movements and dementia
  • Onset between 30-40
  • Psychosis progresses to infantile state
  • Death in 15-20 years

147
Parkinsons Disease
  • Decreased dopamine in substantia nigra
  • Symptoms
  • Bradykinesia
  • Tremors
  • Masklike face
  • Shuffling gait
  • Cogwheel rigidity
  • TX- L-Dopa, Carbidopa, and deprnyl

148
Wilsons Disease
  • Defect in Chromosome 13
  • Ceruloplasmin deficiency
  • Abnormal copper metabolism
  • Kaiser-Fleischner rings

149
Defense Mechanism
150
Defense mechanism types
  • Mature
  • Altruism
  • Humor
  • Sublimation
  • Suppression

151
Altruism
  • Guilty feelings are subdued by honost unsolicited
    generosity of time and money to others

152
Humor
  • Appreciating the amusing nature of an anxiety
    provoking stimuli

153
Sublimation
  • Process where one replaces an unacceptable wish
    with one that fits ones moral beliefs

154
Suppression
  • A voluntary (unlike other defense mechanisms) in
    which one withholds an idea or feeling awareness

155
Defense mechanism types
  • Immature
  • Acting Out
  • Dissociation
  • Displacement
  • Fixation
  • Identification
  • Isolation
  • Projection
  • Rationalization
  • Regression
  • Repression
  • Splitting

156
Acting Out
  • Unacceptable feeling or thought are expressed via
    obtuse actions

157
Dissociation
  • Temporary, changes in personality, consciousness,
    and memory, sometimes to a drastic level, in a
    avoidance of the emotional stressor

158
Displacement
  • Avoidance of the awareness of some painful reality

159
Fixation
  • Partially remaining at a more childish level of
    developement

160
Identification
  • Modeling behavior after another person who is
    more powerful

161
Isolation
  • Separation of the feelings from ideas of events

162
Projection
  • An unacceptable internal impulse attributed to an
    external source

163
Rationalization
  • To proclaim some sort of a logical reason for
    actions that would appear morally unacceptable,
    in order to actually a avoid self-blame

164
Reaction- Formation
  • Warding off an idea or feeling which is replaced
    (unconsciously) with emphasis on the opposite
    idea or feeling

165
Regression
  • Turning back to a lesser mature state or earlier
    time to deal with stressor in todays world

166
Repression
  • Involuntary withholding an idea from conscious
    awareness. The precursor mechanism to other
    immature defences

167
Splitting
  • Belief that people are either good or bad, ie
    saying all physicians are cold and insenstitive

168
THE END
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