Psych Final
Inappropriate Affect
("Disorganized" Symptom) - Emotions out of sync with what is typical or expected in context - Laughing or crying at inappropriate times
Catatonic Behavior
("Disorganized" Symptoms) - Behavioral disturbances ranging from extreme agitation to complete immobility - Odd repetitive behaviors such as grimaces, hand gestures - Waxy flexibility: will remain in any position they are placed in
Emil Kraepelin
(1856-1926) • Most thorough and enduring description and categorization of schizophrenia • Called it Dementia Praecox: premature dementia (mental deterioration) • Distinguished it from Bipolar Disorder (manic-depression)
Eugen Bleuler
(1857-1936) - Introduced term "Schizophrenia" - Greek for "split mind," involving fragmentation and disorganization in perception, thought, and emotion. - Not to be confused with "split personality" (DID)
DSM-5 Criteria for Schizophrenia
(A): Two (or more) of the following, each present for a significant portion of time during a 1-month period: - (1) delusions, (2) hallucinations, (3) disorganized speech, (4) grossly disorganized or catatonic behavior, (5) negative symptoms, i.e., affective flattening, alogia, or avolition - Note: At least one of the symptoms must be (1), (2), or (3) (B) Social or occupational dysfunction (C) Some symptoms persists for at least 6 months - Rule out drugs, medical conditions, and other disorders with psychotic features.
Capgras Syndrome
(Delusion) belief that someone they know has been replaced with a "double" or clone or robot.
Grandeur
(Delusion) belief that they are a famous or highly important person (Jesus, Churchill, King of an alien species)
Cotard Syndrome
(Delusion) belief that they are dead (or have no blood or internal organs)
Persecution
(Delusion) paranoid beliefs that they are the target of a conspiracy to harm them in some way.
Reference
(Delusions) others are talking about them, observing them, trying to communicate with them
DID: Stats
- 1.5% in communities - Ration of females to males (9:1) - onset is almost always in childhood (after 9 development is rare) - high comorbidity rates with other disorders, especially personality disorders. Most have at least 7 other diagnoses - lifelong, chronic course without treamtent
DID: Causes
- 97% cases, histories of horrible, unspeakable child abuse - believed to be a complex defense mechanism to escape from the impact of this early trauma
Negative Symptoms
- Absence or insufficiency of normal behavior Spectrum of negative symptoms - Avolition (or apathy) - lack of initiation of action and/or lack of persistence in goal pursuits - Alogia: relative absence of speech (short answers, if any) - Anhedonia: lack of pleasure - Affective flattening: little expressed emotion, blank stare • Evidence indicates that schizophrenics experience a wide range of emotions, but they do not express the emotions
Side effects of Schizophrenic meds
- Acute: fatigue, blurred vision, dry mouth, dizziness (much like tricyclic anti-depressants) - Tardive Dyskinesia: odd facial tics, grimaces, involuntary tongue protrusion (possibly permanent) - 3-5% will develop TD within 5 years; over 50% by 15 years - compliance with medication is often a problem: over 70% discontinue meds by 18 months
Terminology of DID
- Alters: the different identities or personalities - Host: the central identity that seems to be in control of the body most of the time - Switch: quick transition from one personality to another
Treatment of Bulimia Nervosa: Medical & Drug Treatments
- Antidepressants • Can help reduce binging and purging behavior • Are not efficacious in the long-term
Schizophrenia: Disorganized thought & Speech
- Cognitive slippage: illogical and incoherent thought/speech - Tangentiality (loose associations): "going off on a tangent," conversation goes in unrelated directions
Treatment of Bulimia Nervosa: Psychosocial Therapy
- Cognitive-behavioral therapy (CBT) • The treatment of choice • Change eating habits (behavioral) and attitudes (cognitive) about food and weight - Interpersonal psychotherapy • Social skills, conflict management (remember, many with eating disorders avoid conflict & negative emotions). • Results in long-term gains similar to CBT
Causes of Bulimia & Anorexia: Media & Cultural Consideration
- Cultural imperative for thinness where food is plentiful - Being thin = success, happiness... • Translates into dieting (often the trigger for an eating disorder) • Women's magazines: 10.5 times more weight loss ads/articles than men's • Data from Playboy centerfolds and Miss America contestants: 60-70% weighed at least 15% below normal for their age and height (a previous DSM criterion). - Media standards of the ideal are difficult to achieve
Controversy about DID etiology
- Defense against trauma, or - socially suggested, iatrogenic compliance
Medical Treatment of Schizophrenia
- Development of antipsychotic (neuroleptic) medications in 1950s - often the first line of treatment - most reduce or eliminate positive symptoms, with little effect on negative symptoms
Dissociative Amnesia in the Past
- Dissociative Fugue was a separate disorder - Now a specifier under Dissociative Amnesia - Fugue = flight - Loss of memory in the past, but also sudden travel to a new location (often with no awareness of how they arrived) - often assumed a new identity
Types of delusions
- Erotomanic: belief that another person (often a celebrity) is in love with them. Stalking often involved - Jealous: belief that a spouse or romantic partner is unfaithful. Extreme behaviors to detect or prevent unfaithfulness - Persecutory: paranoid delusions (but no other symptoms) - Somatic: belief in a physical defect or general medical condition (parasitosis- infested with parasite)
Hallucinations
- Experience of sensory events without environmental input - Can involve all senses - Auditory hallucinations: hearing voices • Commands, threats, ridicule, commentary on their behavior • Auditory hallucinations are the most common reported • More than one voice giving running commentary on one's behavior is thought to be particularly disturbing, poor prognosis. - Visual hallucinations: seeing people, animals, angels, demons, moving objects, melting objects, changing shapes - Olfactory (smell), Gustatory (taste), and Tactile (touch) are also reported but less common
Dissociative Amnesia
- Includes several forms of psychogenic (psychological caused) memory loss, especially personal information - Two Types: * Generalized: unable to remember anything, including who they are. * Localized or selective Type: unable to remember specific events, especially of a traumatic nature
Causes of Bulimia and Anorexia: Biological Considerations
- Little is well-established in terms of genetics; recent evidence for some heritability for anorexia. - Evidence for low serotonin associated with binge eating.
Causes of Schizophrenia: Findings from Genetic Research
- Monozygotic twins - risk for schizophrenia is 48-55% - Fraternal (dizygotic) twins - risk drops to 15-17% - Children of one schizophrenic parent, also about 15%, but with two schizophrenic parents over 45%. - Adoption studies - Risk for schizophrenia remains high in cases where a biological parent has schizophrenia
Dissociative Amnesia & Fugue: Treatment
- Most get better without treatment - Most remember all of what they had forgotten
Binge-Eating Disorder Continued
- New diagnosis, so statistics are rare, but prevalence estimates 2% for males, 3.5% for females. - Unlike anorexia and bulimia (rare among African Americans), similar prevalence of binge-eating for African-Americans and Euro-Americans - Many people with binge-eating disorder are obese (they do not compensate for calorie intake) - Often found in weight-control programs (20%) - 50% among candidates for bariatric surgery (stomach size reduction). - Early studies suggest better response to treatment (CBT) than anorexia or bulimia
Causes of Bulimia and Anorexia: Psychological Considerations
- Perfectionistic attitudes - Distorted body image - Mood intolerance: at least a subset of eating disordered patients have difficulty tolerating any negative emotions and conflict • Binging a means of soothing negative feelings
Schizophrenia v. Psychosis
- Psychosis: broad term indicating disorders characterized by extreme loss of contact with reality - Schizophrenia: a type of psychosis
Subtypes of Bulimia
- Purging: most common (90%), vomiting, laxatives, diuretics - Nonpurging: 6-8%, exercise, fasting, or both - no differences in the subtypes in terms of severity of pathology, frequency of binges, or prevalence of co-morbid disorders
Bulimia Nervosa: Defining Features
- Recurrent episodes of binge eating and compensatory actions - Binge eating: eating excessively within a 2 hr period, with a sense of lack of control - Compensatory activity to prevent weight gain: self-induced vomiting, misuses of laxatives, diuretics (increased urination), fasting, excessive exercise, stimulant drugs - Bing/ compensation cycle at least once a week for at least 3 months - also excessive preoccupation with body shape and weight
Anorexia Nervosa: Subtypes
- Restricting: limit caloric intake via diet and fasting - Binge-eating-purging: about 50% of anorexics * smaller amounts of food than bulimics, but more consistent purging * over half of restricting subtypes will eventually begin purging
Causes of Schizophrenia: Neurotransmitter Influences
- The dopamine hypothesis: Schizophrenia caused by excessive dopamine. - Drugs that increase dopamine result in schizophrenic-like behavior (cocaine, amphetamines, LSD, L-Dopa used in treatment of Parkinson's Disease) - Drugs that decrease dopamine function reduce schizophrenic-like positive symptoms (most neuroleptic drugs for treating schizophrenia)
Causes of Schizophrenia: Psychological and Social Influence
- The role of stress - may activate underlying vulnerability (diathesis) - may also increase risk of relapse - Family interactions - families: show ineffective, confusing communication patterns (mixed messages, indirect, "double-blind") - high expressed emotion in families is associated with relapse when schizophrenics return home following hospitalization
Goals of Psychological Treatment of Anorexia Nervosa
- Weight restoration • First and easiest goal to achieve • Frequent, smaller meals (5-6 times/day) with 400- 500 calories per meal • Average gain 1⁄2 lb per day - Behavioral and cognitive interventions • Target attitudes about food, weight, body image, need for perfection, and emotions - Treatment often involves the family - Long-term prognosis for anorexia is poorer than for bulimia
Psychosocial Treatment of Schizophrenia
- behavioral (token economy) methods used in inpatient units (predictable system of reward and punishment) - outpatient community care programs - social and living skills training - family therapy (reduce conflict & stress) - vocational rehabilitation
Overview of Anorexia nervosa and Bulimia nervosa
- both involve extreme fear and apprehension about gaining weight - both involve severe disruptions in eating behavior due to a "drive for thinness" - both have increased since 1960s - strongest etiology seems to be sociocultural rather than psychological or biological - morality rates for eating disorders, especially anorexia are higher than for any other disorder - high morality is due to large extent to the physical consequences of these disorders
Delusional Disorder
- delusions that are contrary to reality but stubbornly maintained - In previous DSM, "non-bizarre delusions" were specified; in DSM-5, " non-bizarre" has been dropped (too difficult to define) - Delusions persist for at least one month - No other positive or negative symptoms that are associated with schizophrenia - Extremely rare; better prognosis than schizophrenia
Anorexia Nervosa: Medical Consequences
- dry skin - brittle hair or nails - sensitivity to cold temperature - Lanugo: downy hair on face, chest, back and/or limbs - low blood pressure -Amenorrhea (lack of menstruation)
Dissociative Identity Disorder: An Overview
- formerly multiple personality disorder - dissociation of personality or identity - extensive memory lapses not due to normal forgetfulness - not due to drug or medical condition - in children, not imaginary play - multiple identities vary from as few as 2 to as many as 100 (avg 15) - identities display unique behaviors, voice, postures, and even handwriting
Anorexia: Facts & Stats
- majority are female and white (rare among african american) - usually middle to upper class - develops around 13 or early adolescence - most anorexics are 25-30% underweight by time they seek treament
Bulimia: Facts & Stats
- majority females (90-95%) - onset around 16-19 years of age - lifetime prevalence is about 1.1% for females, 0.1% for males - 6-8% of college women suffer from bulimia - Tends to be chronic if left untreated
Anorexia Nervosa: Associated Features
- most are comorbid for other psychological disorders - OCD higher in anorexia than in bulimia
Bulimia Nervosa: Medical Features
- most are within 10% of target body weight - purging can result in medical problems including: * Erosion of dental emanel (stomach acid from vomiting) * enlarged salivary glands ("chubby face") * laxative abuse can cause intestinal problems and permanent colon damage * Electrolyte imbalance (loss of sodium & potassium) which causes kidney failure, cardiac arrhythmia, and seizures
Bulimia Nervosa: Psychological Features
- most have comorbid psychological feature - 80% have anxiety disorder at some point in life - 50-70% have a mood disorder during the course of their eating disorder; 33% have substance abuse problems - Depression usually follows eating disorders and is a response to the eating disorder
DID: Treatment
- no controlled research - possibly long-term talking therapies (psychodynamic) - focus is on facing early trauma and reintegration of identities - success rates: 20-25% achieve full integration of personality
Other disorders with psychotic features: schizoaffective disorder
- symptoms of both schizophrenia and a mood disorder (major depression or bipolar disorder) - prognosis is similar for people with schizophrenia - treatment usually involves both neuroleptic (antipsychotic) meds and mood stabilizers or antidepressants.
Previous DSM Diagnostic Criteria for Anorexia
- used "refusal to maintain normal body weight" - specified 15% underweight as a criterion - also included symptom of amenorrhea (missing periods) for 3 cycles
Types of Schizophrenic Symptoms
-Positive Symptoms: Characteristics not found in mentally healthy people (or extreme exaggerations of normal functions). The most obvious signs of schizophrenia. - Negative Symptoms: Absence or deficits in normal behavior (lacking in something) - Disorganized Symptoms: Erratic behaviors, speech, movement, and emotional responses.
Prodromal Phase of Schizophrenia
-Possible signs before a full-blown psychotic break with reality. • Most schizophrenics have had contact with the mental health profession before their "break." • Vague complaints: "not myself lately," "can't get my act together," "feel off-key somehow." • Most misdiagnosed as depressed, anxious, etc., often given meds that don't help.
Primary difference between Bulimia & Anorexia
1. anorexics are successful in keeping weight dow 2. bulimics ashamed of their condition, while anorexics often proud of their "achievements" and sense of control
Epidemic of DID
Book Sybil (1974); film 1976: Shirley Mason (at least 16 personalities); treated by Cornelia Wilber, MD for 11 years beginning in 1954. - Diagnosis greatly increased following this book and subsequent film: • 200 cases in history as of 1980 • 20,000 between 1980-1990 • 40,000 between 1985-1995 • Most diagnoses in United States
Results of Fallon & Rozin Study
Females rated their ideal, and the figure they thought males would find attractive (Females attractive) lower than figure males actually find attractive (Males attractive) and much lower than their current figure. Males rated their ideal, the figure they thought females would find most attractive, and their current figure about the same. These were actually larger than the figure females actually found most attractive.
Delusions
Gross misrepresentations of reality Other: belief that their minds are being controlled, thoughts being read, they are invisible or made of substances such as glass or plastic.
Schizophrenia: Postive Symptoms
Primarily delusions and hallucinations
Dissociative Amnesia & Fugue: Causes
Stats: - onset usually in adulthood - shows rapid onset and dissipation - occurs most often in females Causes: - little is known - trauma and stress can serve as triggers
Prodrome
early symptoms or signs of an illness before a full-blown syndrome occurs. - e.g., achy and tired before full-blown attack of flu symptoms
Tardive dyskinesia
odd facial tics, grimaces, involuntary tongue protrusions
DID is controversial
• 1/3 of Psychiatrists believe DID should not have been included in DSM • Sociocognitive model of DID: DID is iatrogenic, i.e., caused by the treatment. - Symptoms are reinforced by overly eager therapists • People with DID are often highly suggestible, creative, and hypnotizable, so perhaps easily influenced by therapists to adopt roles. • Some therapists want to believe they have such fascinating cases.
Identifying "at-risk" individuals
• Bonn Scale for the Assessment of Basic Symptoms (BSABS): scale assessing subtle phenomenology (over 60 items; German). • This scale has improved diagnostic accuracy in many studies comparing prodromal schizophrenia to bipolar, depressed and other disorders. • Might help catch budding schizophrenics before "thematization" of odd experiences occur—i.e., when a delusional story is formed to "make sense" of a myriad of bizarre experiences. • Earlier treatment of schiz. is assoc/w less treatment resistance, better outcomes, and more complete remissions.
Males & Females Body Rating
• Fallon & Rozin (1985), J. Abnormal Psych. • Asked male and female college students to look at pictures and rate - Their current figure - Their ideal figure - Figure they believe would be most attractive to opposite sex - Opposite sex figure they find most attractive.
Westernization
• Nassar, 1988 - 60 Egyptian women at universities in Cairo, Egypt: 0 eating disorders - 50 Egyptian women at universities in London: 12% eating disorders • Becker at al., 2002 - Television introduced to Fiji islands in 1995 - After 3 years, rate of self-induced vomiting rose from 0 to 11%.
Louis Sass & Josef Parnas: Schizophrenia Study
• Negative symptom list not very helpful. • Need more careful phenomenology of prodromal experiences, which includes: • Diminished sense of ownership of experience: - Perplexity over the source of experience (what is me vs. not me) - Internal vs. external: images v. perceptions; inner speech v. outer speech by self v. speech of others - My control of my actions vs. my control of others' actions v. others' control of my actions v. uncontrolled movements. • Hyper-reflexivity - Extreme self-consciousness of all experience (thoughts, feelings, actions) - Attention to things that are normally automatic, tacit, unnoticed (loss of "common sense"). - Hyper-awareness of body sensation: growing/shrinking, electrical sensations
Binge-Eating Disorder
• New to DSM-5 • Marked distress because of binge eating (defined as with bulimia) • But do not engage in extreme compensatory behaviors and therefore cannot be diagnosed with bulimia. • Three other symptoms must be present as well: e.g., eating rapidly, regardless of hunger, until uncomfortable; eating alone because of embarrassment; or being disgusted or depressed by one's binging.
Schizophrenia: Facts & Stats
• Onset and prevalence of schizophrenia worldwide - About 0.2% to 1.5% (or about 1% population) - Often develops in early adulthood, but can emerge at any time • Schizophrenia is generally chronic - Most suffer with moderate-to-severe lifetime impairment - Life expectancy is less than average * Schizophrenia affects males and females about equally - Females tend to have a better long-term prognosis -Onset differs between males and females • Males earlier (18-25); females later (25-35; plus an additional spike in later life).
Genetic and Behavioral Markers of Schizophrenia
• Search for genetic markers is still inconclusive - Schizophrenia is likely to involve multiple genes • Behavioral markers: Smooth-pursuit eye movement - The procedure - eye-tracking a moving object - Only 8% of general population has trouble smoothly following a moving object on a screen - Tracking deficits in schizophrenics (50-85%) and their non- schizophrenic 1st degree relatives (45%).
Anorexia Nervosa: Defining Features
• Successful weight loss - hallmark of anorexia - Restriction of energy intake leading to failure to maintain body weight at or above expected weight for sex, age, and health. • Intense fear of - obesity and - losing control over eating - Distorted body image. - Often begins with reasonable dieting, but becomes an obsessive pursuit.
