Psychopathology Flashcards
What is normal?
○ Could be:
§ being part of majority (not an ideal definition) (part of normal curve)
§ Autonomous functioning
§ Accurate reality perception
§ Regulated moods
§ Adequate interpersonal relationships
Why is the idea of abnormal difficult to define?
○ Statistical infrequency?
§ Difficult because if someone is abnormal in one domain (eg super smart), they could also be abnormal in a bad domain (eg poor interpersonal skills)
○ Norm violation?
§ In the past, the idea of a social norm has radically changed (eg views on homosexuality), so difficult to base a definition on this
○ Personal distress
§ What causes people to distress varies a lot
§ Very subjective
○ Disability/dysfunction
§ But we can change how we define what determines a disability or dysfunction
What was the early conception of mental illness?
people were a threat to public order
○ Viewed as a moral failing or a spiritual failing, or a physical failing - body or brain
§ No in between - no accpetance of the idea of the psychological or mental - either moral or physical
§ Majority of admissions into asylums were police, 1/3 were family members who couldn’t care for relatives
§ Many aslyums had to close because they became overpopulated
○ Because the focus was on the threat to public safety, there was little care for the wellbeing or recovery of the individual
§ Treatments were very experimental and inhumane
§ Occurrences of ‘shell shock’ (PTSD) in soldiers after WWI showed that ‘normal’ individuals could succumb to nervous illnesses
□ Created desire for more humane treatment
§ Anti-psychiatry movement prompted interest in non-invasive, more humane interventions
Describe de-institutionalisation
○ Amount of people in insititutions in AUS started declining rapidly in 1950s
§ At first this occurred because many facilities started using treatments that actually worked
□ Open-door policies - people could come in, get treatment, and go home
§ Second shift occurred (stage 2) - closing of the asylums because people did not think it was appropriate
□ Treatment moved to community - community hospitals, treatment centres etc
How has treatment of mental illnesses changed since 1950s?
○ Early on, predominantly private specialists managed treamtents in the asylums
○ By 1990, majority of treatment was done by GP (majority) or community providers
What is mental disorder?
○ Clinically significant disturbance in an individual’s cognition, emotion regulation, or behaviour … usually associated with significant distress or disability in social, occupational, or other important activities
§ DSM V
What is not a mental disorder?
○ An expectable of culturally approved response to a common stressor or loss, such as the death of a loved one
§ DSM V
What is the case against diagnoses?
○ Leads to bias or restricted thinking
§ Diagnostic boundaries are rarely distinct and diagnoses change over time
○ Are associated with jargon
§ Are clinicians in fact thinking about the same construct? Jargon may mask what is actually being discussed
○ Inhibit research
§ See the case for the RDoC
§ If we only study conditions meeting specific criteria, we may be missing a larger part of the picture
○ Can be stigmatising and have personal implications
§ How does this effect existing experience? If a brain disorder, is the brain ‘broken’? If it’s not a brain disorder, is something wrong with ‘you’?
○ Some people contend that mental disorder is a myth
§ Thomas Szasz
□ General thesis
® Psychology and psychiatry rely on an assumption that emotional distress, family, and personal turmoil are societal constructions
® This is an unproven hypothesis that is actively promoted by drug companies etc to make people behave in the way they want
□ Response
® Kendler
◊ Few cases seem to be entirely socially constructed
What is the case for diagnoses?
○ Facilitate communication
§ Among clinicians, between science and practice
○ Facilitate care
§ Identification of treatment, and prevention of mental disorders, description of experience, possible etiology and prognosis
○ Researcg
§ Test treatment efficacy and understand etiology
○ Education
§ Teach psychopathology
○ Information management
§ Measure and pay for care
Define sign
○ Objective findings observed by a clinician
Define symptom
○ Subjective complaints reported by a patient
Define syndrome
○ Signs, syndromes, and events that occur in a particular pattern and indicate the existence of a disorder
○ Can be a disorder but doesn’t need to be
Define disorder
○ A syndrome which can be discriminated from other syndromes
○ To be labelled a disorder means there is a distinct course to the syndrome and the age and gender characteristics of the disorder have been described
In some cases, prognosis may also be known
Define disease
○ For a disorder to be labelled a disease, there has to be indications of abnormal physiological processes or structural abnormalities
What are some assessment methods of psychopathology?
- Pen and paper tests
- Clinical interviews
- Behavioural assessment
- Activity diaries
- Psychologial tests
- Medical tests
- Psychophysiological tests
- Neurophysiological tests
- Context is important
What are the dominant classification systems?
• Categorical systems of ICD and DSM
Describe the anti-psychiatry movement
• 1960s movement away from the way in which psychiatry was being practiced
• 1950s was when people started getting institutionalised and treatments
• Foucalt argued that treatment was largely about forcing individuals to conform
• Thomas Szasz believed that psychiatric treatment was a means by which to punish deviance from societal or moral norms
○ Further argued that diagnoses were not meaningful and that they were used to justify inappropriate treatments
• Many advocates for the movement argue that sociocultural factors are a major determinant of problems
○ Ie problems are resulting from shifts within subsections of society that are undesired by others
• This movement has led to the modern lived experience movement
○ There has been a recognition over time that people with a lived experience should be involved in how they’re treated and what they do
What are the three approaches to classification?
○ Categorical
○ Dimensional
○ Hybrid
Describe the categorical approach to classification
§ Divides psychological disorders into categories based on criteria sets with defining features
§ Used by ICD and DSM
§ Better clinical and admistrative utility - clinicians are often required to make dichotomous decisions
§ Clinical resources are limited
§ Easier communication
Describe the dimensional approach to classification
§ Aspects of psychopathology are quantified on a scale
§ Where does a person fall on the continuum
§ Closely model lack of sharp boundaries between disorders and normality
§ Can develop treatment-relevant symtom targets - not simply aiming at resolution of disorder (most treatments target symptoms not disorders)
Describe the hybrid approach to classification
§ A hypothetical combination of categorical and dimensional
§ Could look like: people above this threshold fit into this category, but below that they do not
§ In theory it is the best of both
§ Examples of hybrid
□ MMPI personality inventory
® Have multiple questions on various categories
® Add up those responses and scale it based on normal distribution
® Comes up with a profile of roughly where they stand for each category, so you can see certain areas which might need more support etc
What are the three major movements in clinical psychology?
○ First started with Freud
○ Behaviourist movement
○ Cognition/thoughts
Describe the Freudian paradigm
§ 1856-1939
§ Freudian paradigm
□ Ego
® Main representation of self
® Part of self that interacts with external world
® Influences on ego and superego and id
□ Superego
® Sense of morality
□ Id
® Desires
□ The unconscious has a huge influence on what we do dayy-to-day
□ Only by choosing to become aware of unconscious motivations can individuals choose less maladaptive and more adaptive behaviour
□ Criticism
® Just being aware of unconscious impulses does not necessarily mean the person does anything about them
Describe the behaviourist movement
§ Skinner
§ 1904-1990
§ Focusing on only things we can observe
§ Focusing on objective things
§ Not too worried about thoughts or emotions
§ Behavioural paradigm
□ Approached individuals like input/output machines
□ Didn’t matter what happened in our brains
□ What matters is the stimulus and response pairings
□ Goal of behavioural interventions is to interrupt/change stimulus-response associations
□ Skinner believed we would be best served by doing away with concepts like free will
Describe the cognition movement
§ Beck
§ Don’t have to focus on behaviours - can also focus on the way people think, behave in the world, and use them together
§ Cognitive models
□ CBT:
® The way we think and the way we behave have a fundamental relationship with the way we feel
® Thoughts, behaviour, and feelings are interrelated and to change one, you need to change the other two
What are the biopsychosocial models?
§ Integrates a range of factors
□ Biological
® Normal biology, disease processes, and genetic influences
□ Psychological
® Thoughts, feelings, perceptions
□ Social/environmental
® Culture, ethnicity, social environment
□ The combination of all these things influences what we do and the way we do them
What is the biological paradigm?
□ Focus on genetics
® Alteration in a single gene, part of a gene, or interaction between genes contributes to why individuals may develop a psychiatric illness
® Myth that we can idenitfy a single gene connected to a signle disorder
® In reality, genes probably play a role, but it is much more complicated than we thought
□ Structural brain damage (hard lesion)
□ Disordered physiology (eg inflammation processes and depression)
□ Neurochemistry
® Myth: a lack of neurotransmitter/too much of it can lead to mental disorder
® Reality: there can be different amounts of neurotransmittters across the brain, so there might be one area that has to little, and another that has the right amount, so treating the disorder with drugs that target the whole brain might not help
□ Functional connectivity impairments (soft lesion: eg schizophrenia)
® Idea is that we can look at how different areas of the brain interact with each other
® However, over decades of research, within the same person, the way the brain may speak to itself is not reliable
What are the social determinants of mental health?
§ Issues in broader society that may contribute to poor mental health in groups of people
§ Proximal factors
□ Most closely related to the individual
® Eg age, gender, ethnicity
§ Distal factors
□ Furhter away from the individual either in physical space or in concept
® Eg community, population, diversity,
§ It is really important to look at how these factors interact with the individual over the course of their life
What is the diathesis stress model?
§ Based on certain things, there is a diathesis (vulnerability, often in terms of personality). That vulnerability interacts with stress (not necessarily negative stressful things).
§ Resilience is particularly important factor - if someone is highly resilient, they are less likely to be affected by the stressor
Describe Research Domain Criteria (RDoC)
§ Intorduced in response to issues happening in research context of the National institutes of Mental Health in America
§ Was meant as a reform for how we do research
§ Wasn’t meant to be a clinically-oriented model or a classification model, but meant to allow us more freedom in the way we study mental disorders
§ Focus not on disorders but on problems
§ Domains
□ Negative valence
□ Positive valence
□ Cognitive systems
□ Systems for social processes
□ Arousal/regulatory systems
□ Sensorimotor
§ The way the model suggests we should focus on the domains is in the contet of time
§ All of the domains are situated in an environmental context
§ Within the individual, there are a range of focuses
§ The idea is to focus on all these elements within a particular domain to try to understand the whole process
§ Could then use this to come up with a profile for the individual
§ Example fo how it is used:
□ Tamminga et al.
□ Took people with schizophrenia, schizoaffective disorder, and bipolar disorder (psychosis is the common symptom)
□ Put them all together, and focused on their cognitive control and sensorimotor activity
□ Measured genetics, brain activity etc
□ Looked for different patterns in association with the symptoms
□ Could then group people based on similarities rather than their diagnosis
□ Idea is to classify people more specifically
§ Limitation
□ Hasn’t yielded any actionable activity yet
What is the hierarchical taxonomy of psychopathology?
§ Idea is that you can work at different levels to understand different aspects of the disorders and how they link to other disorders
§ Cam from the idea that having a certain genetic profile seems to confer generic vulnerability for psychopathology
§ People may exhibit problems across multiple domains
Describe the clinical staging model
§ Model adopted from cancer (stages reflecting the disease - progression)
§ Based on observations by Pat McGorry and Henry Jackson in schizophrenia
§ Focus on identifying those at risk and facilitating early intervention
§ Different from Stepped Care approach
□ Setpped care is an escalation of treatment
□ Clinical staging suggests you get treatment according to stage of disorder
§ Very clinical
§ Also aims to use more universal interventions that are less costly, less harmful, and less intense at earliest stages
§ Limitation
□ Only implies that people progress in a worsening way, rather than getting better, then relapsing etc
What is the transdiagnostic model?
§ Goal is to say that there is no unique underlying factor that is specific to any given disorder
§ Recognition of shared aetiological and maintenance factors
§ May account for high levels of comorbidity between disorders - such as anxiety and depressive disorders
§ May also provide an explanation for why diagnostic specific therapies are not effective for all sufferers
What is anxiety?
- Generally characterised by fear and negative affect
* Internalised
Explain how anxiety links to behaviour
○ Historically anxiety disorders have been thought of as disorders of avoidance
§ Avoiding some experiece/threat
○ Fight, flight, freeze
§ The freeze response is often overlooked
§ Sometimes people with anxiety feel like they don’t know what to do - overwhelmed by things
○ Approach-avoidance conflict
§ Wanting to go somewhere/do something (approach motivation), conflicts with the fear of going
§ This conflicts manifests in freezing behaviour
Explain the link between anxiety and fear
○ Thought they were the same
○ Fear describes feelings that occur when a source of harm is immediate or imminent
○ Anxiety describes feelings that occur when the source of harm or threat is uncertain or distant in space or time (anticipatory)
○ The Fear Center model
§ Original idea: there is a clear fear cicuit in the brain (amygdala)
§ The fear response happens automatically to environemtnal stimulus with no cognition attached
What is the Two-System model of anxiety
§ If you recognise that fear and anxiety are different, than the Fear Center Model doesn’t make sense
§ Our understanding of the amygdala is now much more nuanced
§ Now think that the amygdala is responsible for knowing recognising valence - what should we be paying attention to, what is relevant?
§ This model suggests two circuits:
□ Defensive-survival circuit
® Engaging in automated escape/defense response
□ Cognitive circuit
® The evaluation of the circumstance leads to the fear, not the behaviour we engage with
® This brings in also the prefrontal cortex in underlying the fear experience as well as the amygdala
◊ Prefrontal cortex = consciousness, and did not used to be thought of a relevant in terms of the fear response
○ Rather than being automatic, conscious processing associated with threat/harm is critical to the understanding of anxiety disorders
Provide a brief overview of anxiety disorders in general
• Anxiety disorders are the most common disorders globally
○ Most common is specific phobia, followed by GAD
• 15-20% of people are likely to have experienced an anxiety disorder in the past year
• Disproportionately effect women
○ Roughly twice as many
• While they are considered to be relatively mild, anxiety and depression account for the largest number of Disability Adjusted Life Years within mental disorders
○ Because the impact may not be as big as schizophrenia or psychosis, but when you combine the fact that they can cause major distress and disruption with the fact that a lot fo people experience this disorder, it adds up
• Generic treatment
○ Anxiety disorders tend to respond better to psychotherapy than to medication, however, in certain circumstances, medication is favourable
○ Generic treatment for:
§ At risk of anxiety or mild anxiety
□ Watchful waiting
□ CBT (inc. internet-based/computer-based CBT) if worsening
§ Moderate anxiety
□ CBT or pharmacotherapy (antidepressant) or both
§ Severe or treatment-resistant anxiety
□ CBT and pharmacotherapy
Describe specific phobia
• Avoidance category
• DSM 5 description
○ Marked fear, anxiety or avoidance of specific circumscribed objects or situations
○ Fear is out of proportion to the actual threat posed
○ The individual recognises the symptoms are excessive or unreasonable
§ In ICD, but not in DSM - people don’t always recognise the unreasonableness
○ Typically persists for a least 6 months
○ Subtypes include animal, natural environment (eg heights or storms), blood-injection-injury (eg needles), situational (eg planes), or other phobias
• Lifetime prevalence from 3-15%
• In youth, it is much more common, and then dies down until about 65/70 when it spikes up again for women
What is the aetiology of specific phobia?
○ Tend to develop through classic associative learning
§ The fear may generalise to other similar objects
○ Most people don’t recall the direct exposure triggering the fear
○ People can indirectly learn fear through social learning
§ Watching someone else fear something
○ Some people also overrepresent memories of certain events (Flashbulb memories), where details of a trauma may be remember with much more clarity than other memories
What is the treatment of specific phobia?
○ Exposure therapy
§ Present the person with the thing they fear
§ Help them feel relaxed/calm in that situation
§ Trying to break link between fear and the stimulus itself
§ Types
□ In Vivo
® In real life
□ Imaginary
® Picturing the object
□ Virtual Reality
® Simulation
□ Gradual
® Progressing to see the actual thing
® Might start by imagining, then drawing, then watch a video, then hold spider
□ Flooding
® Go straight to direct exposure ie suddenly putting spider on them
§ Difficult to do this therapy because many people don’t like it, but it is 70-85% effective
§ Premature termination of therapy is not uncommon
What is panic disorder?
• DSM 5 characteristics
○ Recurrent unexpected (eg occurring without a cue) and unavoidable panic attacks
○ Concern or worry about having more panic attacks or maladaptive behavioural changes
○ Persists for at least 1 month
• Epidemiology
○ 13.2% of population are likely to experience a panic attack in their lives
§ Among those with panic attacks, 66.5% report recurrent attacks
§ 4.9% past-year panic attacks
§ 12.8% of those with panic attacks meet for panic disorder
○ 1.7% of the population are diagnosed with panic disorder at some point in their lives
○ 1% of people were diagnosed with panic disorder in the last year
○ Most develop panic disorder between 18-29
○ Women 1.8x more likely than men
○ Low household income increases odds ratio 1:5
What is the aetiology of panic disorder?
○ Cognitive theories
§ Underpinned by catastrophic misinterpretations of somatic and other experiences
§ Counter arguments
□ Can induce panic attacks
□ Nocturnal panic attacks
□ Both of these indicate that cognition is not necessary
○ Anxiety Sensitivity Theory
§ Certain people are likely to be predisposed to be more sensistive to kinds of somatic experiences associated with panic attacks
§ Counter arguments
□ It is difficult to separate Anxiety Sensitivity from panic - does sensisitvity precede the panic attack?
○ Learning theory
§ Something people learn over time
§ Alarm theory
□ Start to sound the alarm the minute anything close to a panic attack happens
Eg exercising (increased heart rate, sweating, difficulty breathing)
What is the treatment of panic disorder?
○ Responds equally well with psychotherapy and pharmacotherapy ○ Approaches that work § CBT § Antidepressants § Benzodiazepines (antianxiety)
What is agoraphobia?
• Characteristics
○ Marked fear, anxiety, or avoidance of situations such as public transportation, open spaces, enclosed places, lines or crowds, or outside the home alone
○ Fears that escape might be difficult or help is not available in the event of panic-like symptoms or other incapacitating or embarrassing symptoms
○ Fear is out of proportion to the actual threat posed
○ Individual recognises symptoms are excessive or unreasonable
○ Typically persists for at least 6 months
• Epidemiology
○ Lifetime prevalence of 0.6-1.1%
○ Prospective studies have estimated closer to 5.3%
§ Following people over time - seeing if they end up fitting into the diagnosis
○ Debate about relationship between panic attacks and disorders
○ 46-85% of people with agoraphobia do not experience panic attacks
○ Course is usually chronic (only 10% experience full remission)
○ Most likely in people who are 45-59
What is the treatment of agoraphobia?
○ Very similar to panic disorder and specific phobias
What is social anxiety disorder?
• Characteristics
○ Marked fear, anxiety or avoidance of social interactions and situations in which one is scrutinised, or situations in which one is the focus of attention (eg being observed while speaking, eating, or performing)
○ Fear of negative judgement from others, in particular, fear of being embarrassed, humiliated, rejected, or offending others
○ Fear is out of proportion to the actual threat posed
○ Individual recognises the symptoms are excessive or unreasonable
○ Physical symptoms and symptoms of blushing, fear of vomiting, or urgency of/fear of micturition (peeing) or defaecation
○ Typically persists for at least 6 months
○ Social anxiety can be limited to performance situations only
• Epidemiology
○ 4% lifetime prevalence
○ 2.4% past-year prevalence
○ 1.3% past-month prevalence
○ 75% developed before age 20
○ 47% lifetime comorbidity with mood disorder
○ 59.8% lifetime comorbidity with another anxiety disorder
○ 26.7% lifetime comorbidity with substance use disorder
○ 38% receiving some treatment
What is the aetiology of social anxiety disorder?
○ Diathesis stress model
§ Genetic factors and environmental factors interact with proximal factors (behavioural and cognitive)
§ This interaction leads to the development of social anxiety
What is the treatment of social anxiety disorder?
○ Exposure therapy
§ Assumption is that the client has to experience the feared situation to change the affective-behavioural patterns and associative ideation
§ Can fail via mental distancing - “it’s just role play”
§ Safety behaviours (eg rehearsed speaking) can also be maladative
○ Applied relaxation
§ Progressive muscle relaxing may work
○ Social skills training
§ Can be helpful if there is a deficit
○ Cognitive restructuring
§ I must not appear nervous when public speaking -> I’d prefer not to appear nervous when public speaking
What is generalised anxiety disorder?
• Characteristics
○ Excessive anxiety and worry about various events that have occurred more days than not for at least 6 months
○ Difficulty controlling the worry
○ Anxiety and worry are associated with at least 3 of the following 6 symptoms (only one is required for children)
§ Restlessness or a feeling of being keyed up or on edge
§ Easily fatigued
§ Difficulty concentrating
§ Irritability
§ Muscle tension
§ Sleep disturbance
○ The anxiety, worry, or associated physical symptoms cause significant distress or impairment in important areas of functioning
○ The disturbance is not due to the physiological effects of a substance or medical condition
○ The disturbance is not better accounted for by another mental disorder
• Epidemiology
○ Global prevalence:
§ Lifetime - 3.7%
§ 12-month - 1.8%
§ Lifetime high-income countries = 5%, middle = 2.8%, low = 1.6%
○ Lifeitme comorbidity = 81.9% (Mood disorder = 63%, other anxiety disorder = 51.7%)
○ Severe role impairment in 50.6% of people with GAD
§ 28% at home, 32.1% at work, 31.1% relationships, 34.9% social
○ 49.2% seek treatment
○ Typical onset in late 20s/early 30s
§ 50% of casesappear prior to age 39, 75% by age 53
○ Chronic course: ~50% of people with lifetime GAD met criteria in past year
What is the aetiology of GAD?
○ Avoidance model of worry
§ Suggests that worry was an ineffective cognitive attempt to problem solve - removing a perceived threat while avoiding aversive somatic and emotional experiences
§ Counter arguments (after study)
□ Worry does not facilitate avoidance of emotions
□ Rather, worry does sustain negative emotionality (ie restricts affects)
® It may restrict the emotions you feel, so you generally may feel not great, but that means that there is not a huge drop in emotions when you start worrying
○ Intolerance of uncertainty model
§ Uncertain or ambiguous situations are stressful and upsetting. Belief that worry will serve to either help cope with feared events more effectively or to prevent those events from occurring at all
§ Problem
□ People don’t always believe that worry is helpful
○ Meta-cognitive model
§ People initially develop belief that worry helps (and perhaps it does), but subsequently begin to worry about their worrying (meta-worry). Efforts at thought control fail and people feel helpless
○ Emotion dysregulation model
1. Presence of more intense emotions, 2. poor understanding of emotion, 3. negative attitudes about emotions, 4. maladaptive emotion regulation
What is the treatment of GAD?
○ Only 50% respond to medications and/or psychotherapy
○ Insufficient evidence for meds vs CBT
○ Combined methods recommended in complex cases
○ Substance abuse comorbidity (35%)
○ Sleep problems comorbidity
○ Physical illness comorbidity
○ These comorbidities may explain why it is so hard to treat
What is the difference between unipolar and bipolar?
○ One step up from depression is dysthymia - a bit sad/persistently down or irritable
○ Euthymia = normal mood
○ Hypomania = slightly less than manic episode: feeling good but not amazing
○ Normal people have experiences between hypomania and dysthymia
○ Difference between bipolar and unipolar is that people with unipolar mood disorders only experience the negative dip - no presence of a positive affective state
○ Bipolar has this dip as well as experiencing a manic state
What is depression?
○ Can be a normal human emotion
§ Characterised by feelings of sadness, despair, unhappiness
○ Can be normal depending on the proportion of it
§ Grief
□ Appropriate sadness response to a recognised external loss
□ Uncomplicated bereavement - will end at some point
○ Complicated bereavement
§ Continue to be depressed/grieve for longer than what is seen as culturally appropriate
§ Difficult to diagnose - no two people grieve in the same way
When does normal depression become clinical depression?
○ Based on
§ Intensity
□ The mood change pervades all aspects of the person and impairs social and occupational function
§ Absence of precipitants
□ Mood may develop in the absence of any discernable precipitants or be grossly out of proportion to precipitants
§ Quality
□ Mood change is different from that experienced in normal sadness
§ Associated features
□ Mood change might be accompanied by a cluster of signs and symptoms including somatic and cognitive features
What is Disruptive mood diregulation disorder (DMDD)?
• Unipolar
• Epidemiology
○ Don’t know much about it because it’s relatively new
○ Estimated 3-month prevalence 0.8-3.3%
○ Highest rate in preschoolers
○ Co-occurrence with another psychiatric disorder 62-92% of the time
○ Very difficult to diagnose because it’s so common in young children and their moods fluctuate so much
• Characterised by
○ Extreme irritability
○ Anger
○ Frequent, intense temper outbursts
○ Not just being moody
○ Created in response to rise in diagnosis of bipolar disorder among children/adolescnece and inappropriate treatment of medication
What are the DSM5 criteria for DMDD?
○ Severe recurrent temper outbursts mnifested verbally and/or behaviourally that are grossly out of proportion in intensity to the situation or provocation
○ Temper outbursts are inconsistent with developmental level
○ Temper outbursts occur, on average, 3+ times a wek
○ The mood between temper outbursts is persistently irritable or angry most of the day nearly every day, and is observable by others
○ 12 month + duration - cannot have symptom-free interval of 3months+
○ Age of onset prior to 10 years
What is major depressive disorder?
• Gets diagnosed as an episode - get diagnosed with the disorder if they've had a depressive episode first • Major Depressive episode (MDE): 5/9 symptoms during 2 week period (most days) ○ Depressed mood* ○ Diminished pleasure & interest* ○ Weight or appetites change ○ Sleep disturbance ○ Psychomotor disturbance ○ Fatigue or loss of energy ○ Feeling worthlessness or guilt ○ Trouble concentrting or making decisions ○ Recurrent thoughts of death ○ *One of these two must be present
What is the epidemiology of major depressive disorder?
○ 12 month prevalence ~6% globally
○ Lifetime prevalence of 20.6%
○ 39.7% of cases = moderate severity
○ 49.5% of cases = severe
○ Ajusted odds ratio of also having generalised anxiety disorder: 5.7
○ 74.6% of cases were anxious distressed
§ Condition of the symptoms were best described by MDD - didn’t make sense to make diagnosis of both MDD and GAD, but also secondary to the depression is an anxious affect presentation which exacerbates the depressive symptoms
○ Depression was 2nd leading cause of Years Lived with Disability in 2010
○ Depression was leading cause of Disability Adjusted Life Years (DALY)
○ No real difference in how common it is in high or low socio-income countries
What are the associated problems and course of major depressive disorder?
○ Heart disease (rr=1.8) ○ Diabetes mellitus (rr=1.6) ○ Obesity (rr=1.6) ○ Cognitive impairement (rr=1.8) ○ Disability (rr=1.7) ○ Cancer (rr=1.3) ○ Mortality (rr=1.8) ○ rr= risk ratio • Course ○ 40-60% of people with depression exhibit stable recovery ○ As many as 50% of individuals relapse within 5 years ○ ~15% of individuals exhibit chronic course ○ 30-60% exhibit recurrent course
What is the treatment of major depressive disorder?
• Treatment
○ CBT
○ Behavioural action therapy
§ Getting people to be active
○ Psychodynamic therapy
§ Inspired by Freudian approaches
○ Problem-solving therapy
§ Methods to identify particular problems and coming up with greater responses to them
○ Interpersonal therapy
§ Thinking about relationships, an getting people to engage socially
○ Mindfulness-based therapy
○ Medications
§ Insufficient amount, or too much of a particular neurotransmitter
□ Big three for depression
® Serotonin
® Dopamine
® Noradrenaline
§ Most common medical treament of depression is a selective serotonin reuptake inhibitor
□ Creates more serotonin in the brain
○ Treatment response
§ STAR*D study
□ Started people off with an SSRI
□ Then if they didn’t respond to that, progressed them to another form of treatment
□ Problem was, as people went to more and more stages, more people dropped out
□ The other problem, was that the likelihood of responding to a medication reduced as they got further along the progression
® This describes treatment-resistant depression: once you have tried a certain number of treatments, you start getting treatment-resistant
Describe suicide
• As many as 60% of people who commit suicide have MDD
• 12-month prevalence of suicidal ideation is ~2.0%
• 12-month prevalence of suicide attempts is ~0.3%
• Risk factors
○ Family history (OR 1.7-10.6)
○ Early life adversity
○ Psychiatric illness - esp depression, anxiety (90% of those who suicide)
○ Impulsivity
○ Substance misuse
○ Sense of hopelessness/helplessness
• Three stages of factors
○ Distal or predisposing
§ Eg family history/genes
○ Developmental or mediating
§ Eg personality traits, or elevated anxiety
○ Proximal or precipitating
§ Suicidal behaviour
What is persistent depressive disorder?
• DSM 5 Criteria
○ Depressed mood more days than not for at least 2 years
○ Presence of 2+ of the following
§ Change in appetite or weight
§ Change in sleep
§ Low energy or fatigue
§ Low self-esteem
§ Poor concentration or difficulty making decisions
§ Feelings of hopelesness
○ Previously known as dysthymia - low level, chronic depression
○ Proposed alternative to MDD
What is the treatment of persistent depressive disorder?
○ Generally the same as MDD
○ More likely to be treatment resistant
○ Physical and psychiatric comorbidities common
○ Undertreatment is likely as many people present to GPs
What is premenstrual dysphoric disorder?
Depressive disorder
• Minimum of 5 total (at least 1 each from A and B) in final onset of menses
• A)
○ Marked affective liability (eg mood swings, sudden sadness, increasing sensitivity to rejection)
○ Marked irritability, anger, or increased interpersonal conflict
○ Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts
○ Marked anxiety, tension, or feelings of being keyed up or on edge
• B)
○ Decreased interest in usual activities
○ Difficulty concentrating
○ Lethargy, easily fatigued, lack of energy
○ Change in appetite, eating, cravings
○ Change in sleep
○ Being overwhelmed or out of control
○ Physical symptoms
• Prevalence rates range from 1-8% of women
• Heritability of premenstrual symptoms 30-80%
• History of interpersonal trauma may increase risk of PMDD
• Prevalence of non-fatal suicidal behaviours increased in a graded fashion according to PMDD status
• Treatment
○ SSRIs, hormones, CBT
What is the genetic aetiology of depressive disorders?
○ Heritability of unipolar depression: 40-70%
○ First degree relatives of depressed individuals have risk of 5-25%
○ Not just presence of genes but actually the way in which the genes express themselevs
§ Diathesis and environmental factors
What is the neurobiological aetiology of depressive disorders?
○ A number of neural regions are implicated (including hippocampus)
○ There are suggestions of alterations to dopamine, serotonin, and noradrenaline
What is the immune aetiology of depressive disorders?
○ Some forms of depression may be related to immune activity
○ Suggestions that inflammation of the brain may account for some episodes of depression in some people
○ Enhancing inflammatory response leads to depressive-like symptoms
○ Anti-inflammatory medications may be helpful
○ This may only be a subset of cases
What is the stress aetiology of depressive disorders?
○ Stressors are 2.5 times more likely in depressed patients
○ 80% of MDEs preceded by major life event
○ Stress leads to more stress (helplessness/hopelessness)
What is the personality aetiology of depressive disorders?
○ Neuroticism linked to depression (and anxiety)
○ Introversion linked to depression
○ Negative self-esteem/poor self-scheme linked to depression
○ Interpersonal sensitivity may be a risk factor
What is the cognition aetiology of depressive disorders?
○ The way we think about things can influence the way we feel about them and how we behave
○ There can be a trigger (antecedent event), which leads to a belief/thought, which leads to behaviour
§ ABC model
○ Negative triad
§ People have negative views about the world, themselves, and the future
§ This pattern is particularly probelmatic in a lot of people with depression and can be helped by cognitive therapy in particular
○ Dissogenic schemas
§ Depressive thinking/styles of thought
§ Fear of losing control
§ Fear of abandonment
§ Feeling like you’re undesirable
§ Feeling incompetent
§ Feeling deserved to be punished
§ Perfectionism
Describe mania
• Abnormally and persistently elevated, expansive or irritable mood
• Expansive quality of mood characterised by unceasing and indiscriminate enthusiasm for interpersonal, sexual, or occupation interactions
• Inflated self esteem (ranging from uncritical self-confidence to delusional intensity grandiosity)
• Decreased need for sleep
• Pressured speech
• Racing thoughts
• Distractability
• Increased goal-oriented activities
• Psychomotor agitation
• Diagnosing mania
○ A distinct period of abnormally and persistently elevated, expansive or irritable mood, lasting at least 1 week (or any duration if hospitalisation necessary)
○ During the period of abnormailty, 3 or more of the following symptoms have persisted (4 if mood is only irritable) and have been present to a significant degree
§ Impaired regard for consequences
§ Agitated, excessively goal-directed
§ Flight of ideas
§ Distractability
§ Inflated self-esteem or gradiosity
§ Decreased need for sleep
○ The mood disturbance causes marked impairement in social or occupational functioning or necessitates hospitalisation to prevent harm to self or others, or there are psychotic features
What is the difference between mani and hypomania?
• Main difference between Bipolar I and Bipolar II is whether there is a manic episode involved
• In both you see a major depressive episode typically
• In bipolar I you see a manic episode as well, whereas Bipolar II only has hypomanic episodes
• In both, it is common for mixed features to occur
○ Someversion of mania and depression occurring at the same time
• Hypomanic episode
○ Abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting 4+ consecutive days
○ During this period, three or more of the following symptoms have been present
§ Agitated, excessively goal-directed
§ Flight of ideas
§ Distractability
§ Inflated self-esteem or gradiosity
§ Decreased need for sleep
§ More talkative than usual or pressure to keep talking
§ Excessive involvement in activities that have high potential in painful consequences
What are bipolar disorders?
• Bipolar I
○ One or more manic episodes usually (but not always) accompanied by major depressive episodes
○ Lifetime prevalence of 0.6%
• Bipolar II
○ One or more depressive episodes accompanied by at least on hypomanic episode
○ Lifetime prevalence 0.4%
• Cyclothymic disorder
○ At least 2 years of numerous periods of hypomanic and depressive symptoms that do not meet threshold for manic or depressive episodes
○ Lifetime prevalence of 2.4%
• Age of onset for all ~20 years
• Not usually a single episode (5.9%) or continuous presentation of features (17.9%)
Multiple episodes are common
What are the specifiers of bipolar disorders?
○ Mixed features ○ Anxious distress § Significnt anxiety ○ Catatonia (unusual movement ○ Melancholic features ○ Atypical features ○ Rapid cycling § Very fast switches between depression and mania
What is the relationship between bipolar disorders and psychosis?
○ Australian survery
○ 89% of pp with bipolar in study experienced psychotic symptoms
○ 20.5% had experienced hallucinations
○ 85.7% had experienced delusions
What is the course of illness for bipolar disorders?
○ Distinct manic and depressive phases vs mixed phases
○ Clear restoration of functionning between episodes not uncommon
○ Some exhibit rapid cycling
§ Difficult to treat
○ If untreated, four findings are very consistently reported
§ Length of normal periods between episodes decreases
§ Length of each episode increases
§ Depressed phases become more likely
§ Suicide a major risk factor
What is the aetiology and treatment of bipolar disorder?
• Aetiology
○ Similar to that of depression
• Treatment
○ Mood stabilisers or antipsychotics are common
○ CBT also effective though not by itslef
What is the general background of schizophrenia and other psychotic disorders?
- Low prevalence disorders
* Associated with high levels of stigmatisation and poor recognition by the general public
What is psychosis?
○ umbrella term - can refer to variety of syndromes or symptoms
○ At the disorder level, it refers to a group of disorders distinguished from one another in terms of
§ Symptom configuration (eg delusional disorder vs schizophrenia)
§ Duration (eg schizophrenia vs schizophreniform disorder)
In psychosis, what domains must individuals have abnormalities in at least one of?
§ Delusions § Hallucinations § Disorganised thinking (speech) Grossly disorganised or abnormal motor behaviour (including catatonia) § Negative symptoms
Describe delusions
□ Fixed beliefs that are not amenable to change in light of conflicting evidence
□ Persecutory delusions
® Most common
® Belief that one is going to be harmed, harrassed and so forth by an individual, organisation, or other group
□ Referential delusions
® Beliefs that certain gestures, commens, or environmental cues are directed at oneself
□ Grandiose delusions
® Beliefs that the individual has exceptional abilities, wealth or fame
□ Nihilistic delusions
® The conviction that a major catastrophe will occur
□ Somatic delusions
® Preoccupations regarding health and organ functions
□ Bizarre vs non bizarre
® Bizarre delusions are something that is completely implausable and not understandable to other same cultured-peers, don’t derive from ordinary experience
® Non-bizarre are not as easily able to be disconfirmed eg being surveilled by the police
□ Primary vs secondary
® Primary: formed without a prior event or pathological process linked to that delusion
® Secondary: secondary to other changes in mood, memory, or perception
Describe hallucinations
□ Percpetion-like experiences that occur without external stimulus
□ Auditory is most common, but they may occur in any sensory modality
□ Hallucinations may be a normal part of religious experience in certain cultural contexts
□ For diagnostic purposes, they need to occur in the context of clear sensoriums - can’t occur when someone is asleep/waking up
□ Not always distressing
□ A lminority of the population report experiencing hallucinations which are not distressing and therefore don’t seek assitance for them
□ Need to have insight - understand that what they’re hearing is a hallucination
□ Mere presence of hallucination is not sufficient to indicate a mental illness
Describe disorganised thinking/speech in psychosis
□ Also referred to as Formal Thought Disorder
□ Typically inferred from the individual’s speech:
® Clanging
◊ Speech pattern based on phonological association rather than semantic or syntactic
® Circumstantiality/tangentiality
◊ Speech including unnecessary or irrelevant detail
® Flight of ideas
◊ Sequence of loosely associated concepts are articulated . Sometimes rapidly changing from topic to topic
® Derailment
◊ Speech train steers off topic to unrelated things
® Incoherence
◊ Word salad
◊ Incomprehensible speech
® Pressure of speech
◊ Excessive spontaneuos speech production and rapid rate. Difficult to interrupt
□ Can be difficult to evaluate if the person making the diagnosis comes from a different linguistic background
Describe abnormal motor function in psychosis
□ May manifest itself in different ways, ranging from child-like ‘silliness’ to unpredictable agitation
□ Catatonia
® A marked decrease in reactivity to the environment
® Can range from a resistance to movement, or the individual maintaining a rigid, bizarre posture
Describe negative symptoms in psychosis
□ Reductions in some level of communication or human experience
□ Diminished emotional expressions
□ Avolition
® Decrease in motivated self-initiated purposeful activities
□ Alogia
® Diminished speech output
□ Anhedonia
® Decreased ability to experience pleasure
□ Asociality
® Lack of interest in social interactions and may be associated with avolition, but can also be a manifestation of limited opportunities for social interaction
□ Similar to symptoms of depression
What are the two groupings of symptoms in psychosis
§ Positive symptoms
□ Delusions, hallucinations, disorganised thinking
§ Negative symptoms
□ Catatonia (absence of movement)
Is it true that you are either psychotic or you’re not?
No
• Continuum of psychosis in the community
○ Psychotic sx (hallucinations and delusions) are present - at various degrees of severity
§ In about 5% of the general population who are not seeking help
§ In about 25% of people with non-psychotic common mental disorders such as anxiety and depression
§ In around 80% of patients with psychotic disorders
What is schizotypy?
○ Theoretical concept that psychotic symptoms lie on a continuum raning from normal dissociative, imaginary states that we all have, to extreme states related to diagnostic criteria
○ Model of personality type
○ Approach is in direct contrast to a categorical approach Describes four types of experiences
§ Impulsive non-conformity
□ Disposition to unstable mood and behaviour, particularly through guard to rules and social conventions
□ All of us lie on some place on a continuum of compulsive non-conformity
§ Introverted anhedonia
□ Tendency to introverted, emotionally flat, and unsocial behvaiour
□ Associated with the deficiency in the ability to feel pleasure from social and physical stimulation
§ Cognitive disorganisation
□ Akin to disorganised speech
□ Tendency for thoughts to become derailed, disorganised or tangential
□ All of us somewhat experience this
□ Not a fixed position - can experience this more sometimes than others
§ Unusual experiences
□ Disposition to have unusual perception, hallucinations, magical beliefs
○ Schizotypy often assessed using OLIFE measure (Oxford-Liverpool inventory of feelings and experiences)
What is brief psychotic disorder?
○ Presence of one or more of the following symptoms (at least one of these must be the first, second or third options):
§ Delusions
§ Hallucinations
§ Disorganised speech
§ Grossly disorganised or catatonic behaviour
○ Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning
○ The disturbance is not better explained by major depressive or bipolar disorder with psychotic features or another psychotic disorder such as schizophrenia or catatonia, and is not attributable to the physiological effects of a substance or another medical condition
○ Specifiy if
§ With marked stressors (brief reactive psychosis): If symptoms occur in response to events that, singly or together would be markedly stressful to anyone in similar circumstances in the individual’s culture
§ Without marked stressors: If symptoms do not occur in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the individual’s culture
§ With postpartum onset: if onset during pregnancy or within 4 weeks postpartum
How is delusional disorder characterised?
Characterised by the presence of one (or more) delusions with a duration of 1 month or longer
Describe schizophreniform disorder
○ Two (or more) of the following, each present for a significant portion of time during a one month period (or less if successfully treated). At least one must be one of the first three
§ Delusions
§ Hallucinations
§ Disorganised speech
§ Grossly disorganised or catatonic behaviour
§ Negative symptoms
○ An episode of the disorder lasts at least 1 month but less than 6 months. When the diagnosis must be made without waiting for recovery, it should be qualified as ‘provisional’
○ Approximately 1/3 of those diagnosed recover, but the remaining 2/3 progress to schizophrenia or schizoaffective disorder
What are the diagnostic criterion for schizophrenia?
○ A: Two (or more) of the following, each present for a significant portion of time during 1 month period (or less if successfully treated). At least one must be one of the first three
§ Delusions
§ Hallucinations
§ Disorganised speech
§ Grossly disorganised or catatonic behaviour
§ Negative symptoms
○ B: For a significant portion of the time since onset, the level of functioning in one or more major areas is markedly lower than prior to the onset
○ C: Continuous signs of the disturbance persist for a least 6 months
○ D: The disturbance is not attributable to the physiological effects of a substance or another medical condition
What is schizoaffective disorder?
○ An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with criterion A of schizophrenia
○ Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode during the lifetime duration of the illness
○ Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of illness
○ The disturbance is not attributable to the effects of a substance or other medical condition
○ similar to bipolar, but any time a manic episode occurs with psychosis, it is schizoaffective, not bipolar
Explain the details of schizophrenia
• Typically begins in early adulthood: 15-25
• Males tend to develop it slightly earlier than females (males between 16 and 25)
• Incidents in women is noticeably higher after age of 30
• Later onset in women could be associated with hormonal changes around menopause
• Av age of onset
○ Men: 18
○ Women: 25
• Onset under the age of 10 or over 40 is quite rare
• Lifetime prevalence of schizophrenia is 1-2%, delusional disorder is 0.2% and schiozaffective is 0.3%
• Higher prevalence amongst migrants, developing countries and 2-fold risk urban vs rural dwellers
• Approximately 1:1 male:female ratio, although McGrath suggested 3:2
• Associated features
○ Depression
○ Suicide (5-10% of people with sz commit suicide)
○ Anxiety
○ PTSD - trauma may be the experience of psychosis itself or associated with treatment (eg seclusion, restraint)
○ Substance use problems
○ Poor quality of life in general - occupational, relationship, social and emotional functioning
○ Stigma
○ Shorter lifespans
What is the link between psychosis and violence?
○ The vast majority of people with psychosis are not violent and do not display violent or dangerous behaviours
○ The vast majority of people experiencing psychosis withdraw from others when they become unwell
○ The origins of violence/aggression and psychosis are hetergenous - but factrs that may increase risk of violence/aggressive behaviour by individuals with psychotic disorders include
§ Past history of violence
§ Certain personality traits
§ Social circumstances
§ Content of auditory hallucinations
§ Substance use
§ Paranoid beliefs
§ Being male
§ Being young
○ The risk of an individual with a psychotic disorder becoming a victim of violence is up to 14 times higher than the rate of being a perpetrator
○ Yet, most studies focus on the perpetrators of violence rather than victims
○ Also, im media, stories about violent acts perpetrated by people with psychotic disorders far outweigh stories that are more sympathetic about disorder, or indicate that people with psychotic disorders are victims
What are the historical conceptions of schizophrenia?
○ Benedict Augustine Morel 1860 - demence precoce
§ The first attempt at a rigorous description of what we now know as schizophrenia
§ Based on observations of individuals displaying a set of symptoms and experiencing early onset and deteriorating course
○ Emil Kraepelin 1898- dementia praecox
§ A refined more formal definition
§ Emphasised early onset and deteriorating course
§ Differentiated from manic-depressive psychosis and other psychotic illnesses based on clusters of symptoms, onset, course, and outcome
□ Created first early ideas around different diagnoses of different psychotic illnesses
§ Symptoms emphasised were hallucinations, delusions, negativism, attentional difficulties, stereotypes, and emotional dysfunction
§ Dimentia praecox means senility of the young
□ Referencing early onset
○ Eugen Bleuler 1911 - schizophrenia
§ Conceptualised manic depression and schizophrenia on a continuum
§ Identifies that schizophrenia and bipolar were not always characterised by early onset or deteriorating course
§ His conceptualisation was adopted around the world
§ ‘Breaking the associative threads’ loosening of connections between thought structures seen as the core of the disorder
§ Primary symptoms: five ‘A’s
□ Disturbances in thinking
□ Disturbance in affect
□ Ambivalence
□ Autism
□ Avolition
○ Kurt Schneider 1959
§ Emphasised symptoms specific to schizophrenia - first rank sx (symptoms)
□ Hearing one’s voice out loud
□ Hallucinate voices talking about them
□ hallucinations in the form of running commentary
□ Somatic hallucinations produced by external agencies
□ Thought withdrawal
□ Thought insertion
□ Thought broadcasting
□ Delusional perception (ideas of reference)
□ Made feelings
□ Made actions
□ Made impulses
§ Issues with Schneiderian first rank symptoms - not specific to schizophrenia
□ But still impacted the development and refinement of diagnostic criteria in texts such as DSM
○ US-UK Cross-National Project (1972) and WHO multi-centre collaborative study (1974)
§ Varying rates of schizophrenia between countries due to lack of standardised criteria
○ Late 1970s
§ Development of the Feighner criteria and Research Diagnostic Criteria - precursors to the landmark and expansive DSM-III
□ Primarily for affective disorders, such as depression, but also for schizophrenia, anxiety and neurosis, antisocial personality disorder, and also homosexuality (which was seen as a mental illness)
○ 1980: DSM-III diagnostic criteria for schizophrenia was published
§ Narrow (neo-Kraepelinian view)
§ Changed the way diagnostic criteria were depicted
□ Developed inclusion and exclusion rules, and duration criteria
§ Included that the experience of symptms interferes with life functioning
§ Five subtypes of schizophrenia were identified
□ Paranoid
□ Disorganised catatonia
□ Undifferentiated
□ Residual
○ McGorry (late 1980s-present)
§ Realised that Kraepelin’s writing was based on an asylum setting - focused on chronic samples
§ There was an over-focus of chronic samples who are only representative of very poor outcome patients and are contaminated by institutionalisation, medication side-effects etc
§ Realised the need to prospectively study first-episode patients and prodromal (in the developing phases) patients
§ Diagnosis is not stable in first episode
○ Richard Bentall (1990s-present)
Need to study psychotic symptoms individually, not schizophrenia as a construct
What are the findings of family studies on psychotic disorders?
○ Risk of developing sz increases as a degree of genetic relatedness increases:
§ Spouse: 1% (no genetic relationship, population rate)
§ Grandchild: 2.8%
§ Sibling: 7.3%
§ One parent: 9.4%
§ Both parents: 46.3%
§ Identical twin: 45-50%
□ They share exactly their genetic makeup, and the concordance rates in not 100% - suggests there is something else going on beyond just genetics
What are the findings of adoption studies on psychotic disorders?
○ Higher concordance rates among adopted children who had one biological parent with disorder than adopted children with no affected biological relatives
What are the findings of epigentics studies on psychotic disorders?
○ Used to think there was a single gene responsible
○ Now know there are many genes involved, and most likely need to understand better Gene-environment interactions
§ People with COMT gene are more at risk for developing sz than those without it if they use cannabis (heavy use only) (Caspi et al., 2005)
• Psychosis and genetics
○ Not simple
○ Approx 1000 genes are involved
What are the biological factors of psychotic disorders?
○ Neurotransmitters
§ Dopamine hypothesis
□ Excessive dopamine function in CNS
§ Other neurotransmitters proposed to have role: norepinephrine, seratonin
○ Brain structure
§ Enlarged ventricles (indicating potential loss of brain tissue)
□ Not diagnostic, because ventrical sizes vary hugely in normal population
§ Reduced grey and white matter in prefrontal cortex - particularly associated with negative symptoms
§ Hippocampal volume seems to be larger amongst normal people than people experiencing first ep of psychosis, people who are at risk of psychosis, and larger than people with chronic schizophrenia
□ Group-based differences
□ Problem: studies are conducted in samples of people who have been unwell for a long time, and on medication fo ra long time - we don’t know if the brain structure evidence occurs for the duration of the illness
○ Brain function
§ During hallucination, there is activity in the left auditiory and visual areas of the brain, but not in the frontal lobe, which is normally involved in organised thought processes
□ Not super useful for diagnostic purposes - need more longitudinal evidence
○ Neurocognition in schizophrenia
§ Deficits in sustained auditory and visual attention
§ Problematic initial processing of information into sensory memory
§ Impaired detection of relevant stimuli that are embedded in irrelevant noise
§ Problematic organisation of information in working memory
§ Executive function
§ Language - thought disorders
§ Cognitive set changing (switching)
§ IQ deteriorated
§ Psychomotor speed
§ Not specific enough though - not diagnostic
○ Social cognition
§ Emotion perception - the ability to comprehend emotional cues in a social context
§ Social perception - the ability to comprehend communicative cues in a social context - may not be emotional
□ Predictive of relapse, and poorer illness course in general
□ Useful to target this
® Hasn’t had a lot of focus - most focus on treatment has been symptom reduction, and this treatment has oftentimes come from drug companies
What are the psychological factors of psychotic disorders?
ological factors
○ Role of family
§ Schizophrenogenic mother
□ Cold, aloof, overprotective, domineering, strips child of self-esteem, stifles independence
□ Particularly a risk if father is passive
§ This was discredited
□ Mothers of individuals with schizophrenia do not, by large, fit this definition
○ Social
§ Living in urban environment
§ Migration
§ Being socially excluded
§ If you are a member of a minority groupliving in high density environment , and particularly if you use cannabis, you’re risk of developing psychosis
○ Childhood trauma
§ Significant proportion of people with psychotic disorders have experienced traumatic childhood experiences, such as sexual and physical abuse
§ Numerous published clinical case studies whose authors suggest that these traumatic experiences may play a causal role in psychosis
§ John Reid, Richard Bentall, Tony Morrison - outspoken in criticising mainstream psychiatry/psychology for ignoring the role of chilhood sexual assault and abuse
○ Stress
§ Stress vulnerability model:
□ Everyone has a vulnerability to psychosis, someone may have a higher vulnerability than others, and added stress increases chances of having a psychotic experience
□ Buffer is coping and resilience
□ Can instil hope for patients
○ Cognitive
§ Eg Morrison, Bentall, Birchwood, Garety
§ Core model - culturally unacceptable interpretations of intrusions into awareness
§ Role of appraisal is central
§ Culturally unacceptable interpretations result from faulty knowledge of self - leads to misattribution of thought to external source
§ Response serves to increase likelihood of future intrusions
□ Disturbance in mood eg anxiety
□ Physiological arousal eg lack of sleep
□ Behavioural change
□ Cognitive change
§ Model suggests that we can work with people from a psychological/cognitive behavioural point of view to challenge those appraisals and reduce the likelihood that they will experience the appraisals, or will change their behaviour
§ Movement towards cognitive treatments rather than medication
Explain the relationship between substance use and psychosis
§ Substance-induced psychosis
□ Short-term: during intoxication or withdrawal phase
□ Ie amphetamines, cocaine, hallucinogens
§ Cannabis
□ Swedish conscipt study (Andreasson et al., 1987)
□ Those who used cannabis by 18 were 2.4 times more likely to develop schizophrenia than those who had not
□ Comparison with those who had not used cannabis by 18:
□ Problems:
® Cannabis useage was only enquired about at 18 years - no further enquiry about later usage
® Other factors were also not taken into consideration
□ Zammit et al. (2002) did further 27-year follow up on original cohort
® Relationship between cannabis use and schizophrenia persisted when controlling for other factors such as other drug use, psychiatric symptoms at baseline
® Estimated that the attributable risk of cannabis use to schizophrenia was 13%
□ Have been other further studies showing consistent findings
□ Schoeler et al. 2016: cannabis use and the risk of relapse
® Prospective cohort study followed up for at least 2 years after onset of psychosis 220 patients who presented to psychiatric services in South London with first-episode psychosis
® Change in cannabis age status (eg from user to non user) and change in pattern of continues cannabis use within the first two years after onset are risk factors for relapse
® These associations were independent of the effects of other potential confounders that vary o ver time, such as medication adherence and other illicit drug use
® The longer the period of continued (monthly) cannabis use after onset of psychosis, the more likely a patient is to experience relapse
® Cannabis use status and pattern of continued cannabis use after onset of psychosis are predicitive of subsequent relapse but not vice versa
What are the relapse rates of people with psychotic disorders?
○ Up to 80% of FEP (first-episode psychosis) patients will experience a psychotic relapse within 5 years of remission from the initial episode
○ EPPIC 7 year follow-up study
§ Symptomatic remission 37-59% of cohort
§ Social/vocational recovery: 31%
§ ~25% both social/vocational recovery and symptom remission
• Risk factors for relapse
○ Yes:
§ Substance use, medication non-adherence, carer critical comments, poor premorbid adjustment showed a consistently positive association with relapse
○ No:
§ Duration of illness, duration of positive symptoms, positive, negative, affective symptoms, age of onset, insight, gender , marital status, education, and employment
Explain Camberwell’s study looking into emotional expression and psychotic disorders
○ Brown 1950’s and 1960’s noticed many relapsing patients shared common family environments - conflict, criticism, hostile, over-involved
○ Developed Camberwell Family interview to assess patterns of family interaction
○ Relapse at 9 months and 2 years associated with:
§ High EE (expressed emotion)
§ More than 35 hours face to face with high EE family
§ Not taking neuroleptics
What are the potential impacts of relapse/chronic illnesses in psychotic disorders?
○ Unemployment ○ Housing difficulties ○ Poor physical health ○ Side-effects of anti-psychotic medication ○ Neglect of children ○ Premature death
Describe the relationship between psychosis and hospitalisation/treatment
• Psychosis and hospitalisation
○ In Australia, preference is to treat people as outpatients, so people who are admitted to hospitals are those with more complex presentations
• Treatment
○ Pharmacological treatment - primary approach in acute phase of illness
○ Best practice: low dosage approach
○ ‘Atypical anti-psychotics’ fewer side effects than ‘typicals’
○ Soteria model
§ Highly supportive care, usually medication free, living in a community
§ Comparable results to treatment as usual
• Psychotic treatment
○ CBT - addressing hallucinations, delusions, negative symptoms
○ Substance use
○ Family education
○ Psychoeducation of patient
○ Relapse prevention
○ Occupational and social functioning
What are some ongoing issues with psychotic disorders?
• Ongoing issues
○ No biological markers or physiological tests to diagnose schizophrenia
○ Aetiology continues to be uncertain
○ No clear evidence that the concept of schizophrenia is a valid construct
○ Contiuum vs categorical models
○ Emphasis of hallucinations and delusions in diagnositc criteria
○ Accurate idenitification and treatment in prodromal or ‘ultra high risk (UHR)’ phase
○ What is the meaning of positive symptoms for the person’s self - that is their self-evaluation? Is the content important or irrelevant? What purpose do they serve?
What are somatic symptom disorders?
- Share a common feature: the prominence of somatic symptoms associated with significant distress and impairment
- Mental disorders that take the form of physical disorders
- Overlap between mind and body
- Individuals present with prominent somatic symptoms for which there is no explanation
- People are commonly seen in primary care (GPs) or other medical settings, less commonly in psychiatric or more general mental health settings
What are dissociative disorders?
• Dissociative disorders are chractrised by a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behaviour. Dissociative symptoms can potentially disrupt every area of psychological functioning
Why consider somatic symptom and dissociative disorders together?
• It is thought that there may be a common mechanisim underlying these disorders - specifically a dissociation or disconnect between mental awareness and another part of the usually integrated mental system
○ Somatic symptom disorders - the part of mental function that is ‘split off’ involves the sensory or motor system and affects physical functioning
○ Dissociative disorders - higher mental functions such as memory or identity are ‘split off’
What is the history of somatic symptom disorders?
○ Ancient egyptians (Kahun Medical Papyrus - 1900 BC) and hippocrates - hysteria - non-fatal bodily symptoms experienced by women (thought to be result of a wandering uterus)
○ 17th century - hypochondriasis
§ Males also
§ Relates to the experiences of medical or physical symptoms without any medical cause
○ 19th century - Briquet, Charcot, Janet
§ Wrote descriptions of people experiencing these types of difficulties
§ Anna O - first case of psychoanalysis (Freud/Breuer)
□ Father was chronically unwell - she nursed him through his illness and his death
□ Over that time, she herself became bedridden at times, developed double vision, headaches, neck weakness, loss of sensation in arms and legs, became mute at one point, disturbed speech, erratic moods, range of non-specific symptoms
□ Breuer and Freud coined the term ‘conversion’
® Her symptoms were a direct expression of her distress in being with her father
® Conversion: transformation of psychical [mental] excitationinto chronic somatic symptoms
§ In DSM-III, clear attempt to move away from psychodynamic and psychoanalytic descriptions of the disorders, but this part of the DSM retains these links
§ Briquet’s syndrome
□ Based on 430 cases who had multiple physical symptoms with no known medical rationale for developing them
§ Charcot experimented with hypnosis in treating hysteria
□ Freud worked with
§ Janet continued this work
□ Interpreted physical symptoms as being a direct representation of traumatic events through bodily memory
§ Freud initially believed that hysteria was caused by early sexual experiences - early child abuse
□ Seduction theory
□ Later discarded this theory - found that the experiences weren’t realy but were imagined
What is the aetiology of somatic symptom disorders?
○ Biological
§ Hypothalamic-Pituitary-Adrenal axis involvement?
§ Neurobiological factors
§ Gate-control theory (a model of pain)
○ Trauma
§ Individuals with somatic symptom disorders more likely than medical patients or health controls to have experienced adverse events in childhood
§ Van der Kolk - memory of trauma is not stored in declarative memory but in emotions and bodily sensations (controversial)
○ Family factors
§ Learned illness behaviour
○ Environmental factors during adulthood reinforcing illness behaviour (secondary gain)
§ Attention etc
What are the general cognitive factors of somatic symptom disorders?
○ Tendency to experience symptoms as intense and distressing (somatosensory amplification)
○ More sensitive to physical sensations
○ Selective attention to bodily sensations
○ More likely to attribute cause of physical symptoms to physical cause (rather than situational or psychological)
○ Abnormal illness behaviour - seeking treatment, tests etc
○ Vicious cycle: treatment seeking heightens anxiety which heightens physical symptoms and vigilance for symptoms, new symptoms noted, anxiety increases etc
What is the impact of somatic symptom disorders?
○ Huge levels of disability
○ Costs to the community in terms of days off work/incapacity to work
○ Compensation seeking
○ Problems for family members eg separation of children from afflicted parent is often difficult given the become care providers for the patient-patient. Secondary consequences - missed schooling, reduction of social opportunities for children
○ Burden on health care system
What is somatisation?
• Process underlying all of somatic disorders
• Distress is experienced as physical symptoms or altered bodily function
• Not necessarily ‘abnormal’ - despite DSM assuming a clear demarcation between normal and abnormal
○ Possibly used as a coping process
• Sometimes difficult to distinguish between physical disorder and somatoform disorder - questions used to try and distinguish between them:
○ How many physical symptoms are being described and for how long?
○ What degree of bodily preoccupation is there?
○ How intensely does the individual worry about their health and illness?
○ How forcefully do they seek health care?
○ Is there any history of disgruntlement with the health care system?
• Sometimes difficult to distinguish these disorders from other psychological conditions
○ Heart palpitations and upset stomach - not uncommon in relation to anxiety
○ Fatigue - not uncommon in depression
○ Vomiting and weight change - not uncommon in eating disorders
• Western countries - somatisation is viewed as abnormal
• Some Eastern countries - soatisation is viewed as the norm, expressing psychological distress is abnormal
• Physical illnesses of unknown origin - highlight the ongoing debate about mind-body split
○ Western countries: chronic fatigue, IBS
○ China: Shenjing shuairuo
○ Korea: Hwa-byung
What are some DSM-V characteristics of somatic symptom disorders?
• Suffering is authentic regardless of whether it is medically explained
• Can have these symptoms as well as having a legitimate diagnosed medical condition
○ They are not mutually exclusive
What are some associated features of somatic symptom disorder?
○ High levels of medical care - rarely alleviate’s the individual’s concerns
○ Cogntive features include:
§ Attention on somatic symptoms
§ Attribution of normal bodily sensations to physical illness (possibly with catastrophic interpretations)
§ Worry about illness
§ Fear that any physical activity may damage the body
§ Denial of psychological factors
○ Behavioural features may include
§ Repeated bodily checking for abnormalities
§ Repeated seeking of medical help and reassurance,
§ Avoidance of physical activity
○ High comorbidity with depression and increased suicide risk
○ Persistent somatic symptoms are associated with:
§ Being female
§ Older age
§ Fewer years of education
§ Lower socioeconomic status
§ Being unemployed
§ A reported history of sexual abuse or other childhood adversity
§ Concurrent chronic physical illness or psychiatric disorder (depression, anxietyy, persistent depressive disorder, panic)
§ Social stress
§ Reinforcing social factors such as illness benefits
What is illness anxiety disorder?
- A preoccupation pattern with having or acquiring a physical illness
- Easily alarmed by hearing about illness
- Do not respond to appropriate medical reassurance, negative dianostic tests or benign course
- Attempts by doctors to reassure do not generally alleviate the individual’s concerns and may heighten them
- Illness concerns assume a prominent place in the individual’s life, affecting daily activities, and may even result in invalidism
What is the difference between Illness Anxiety Disorder and panic disorder/agoraphobia?
○ Illness anxiety
§ Aniticipated harm is less imminent than in panic - individual has time to prevent anticipated disaster by seeking medical attention
§ Concerned about lumps and bumps/blemishes
§ Health anxiety fears are persistent and enduring, may experience panic attacks triggered by illness concerns
○ Panic
§ Misinterpretations of bodily sensation –> avoidance of situations which are likely to trigger PA
§ Avoidance is an attempt to cope with or avert catastrophe
§ Misinterpret signs of anxiey
§ May be concerned panic attacks reflect a medical illness, but anixety is acute and episodic
What are the cognitive and psychological aspects of Illness Anxiety Disorder?
○ Hypersensitivity to bodily sensations
○ Heightened focus on bodily sensations
○ Heightened anxiety regarding health/illness
○ Biased thinking about threat or reality of serious disease
○ Excessive reassurance seeking
○ More distrust of medical opinion BUT higher rates of help-seeking
○ Childhood learning experiences of illness behaviour
○ Catastrophic interpretations of benign signs
○ Optimistic bias towards making judgements about own health risk
