Mental Disorder
Syndrome characterized by clinically significant disturbance in ones cognition, emotions, behaviour that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Usually associated with distress or disability in social, occupational, and other important activities.
What type of assessment system does the DSM-5 use?
Nonaxial assessment system
What does ‘Polythetic Criteria Set’ mean in relation to the DSM-5?
For each diagnosis, a person may only have some of diagnostic criteria
What are the 3 ways to handle diagnostic uncertainty?
- Provisional: full criteria will eventually be met, but not enough info currently
- Other specified disorder: symptoms don’t meet full diagnostic criteria and clinician wants to provide reason why
- Unspecified Disorder: client’s symptoms don’t meet full criteria but clinician doesn’t want to indicate why
Level 1 Assessment Tool in DSM-5
Assesses 13 adult domains, 12 child domains
Identifies areas for further evaluation
Level 2 Assessment Tool in DSM-5
Detailed info on specific domains to assess with diagnosis, treatment planning, and follow up
WHODAS 2.0
WHO Disability Assessment Schedule
- Understanding/communication
- Getting around
- Self-care
- Getting along with people
- Life activities
- Participation in society
Personality Inventory Domains (5)
- Negative affect
- Detachment
- Antagonism
- Disinhibition
- Psychoticism
Cultural Formation
3 components that assess cultural features of a clients concerns
Outline for Cultural Formation
Includes identity, cultural conceptualizations of distress, cultural features affecting relationships between client and therapist, over all cultural assessment
Cultural Formation Interview (CFI)
Semi-Structured, 16 questions that assess impact of culture on client’s presenting concerns & treatment
- Cultural definition of concern
- Cultural perception of cause/context
- Cultural factors affecting coping
- Cultural factors affecting past/present help seeking
Cultural Concepts of Distress
Ways that a cultural group experiences, understands and communicates suffering, behavioural problems, or troubling cognitions.
Ataque de Nervios
Latino syndrome. Symptoms of intense emotional upset, uncontrollable crying, heat rising from chest to head, aggression, inhibition
Kufungisisa
South African. Depression.
Susto
Latin. Chronic somatic suffering stemming from emotional trauma. “spirit attack”
Neurodevelopmental Disorders
Onset during developmental period
- Intellectual disability
- Global Developmental Delay
- ASD
- ADHD
- Specific Learning Disorder
- Communication Disorder
- Movement Disorder
Intellectual Disability
Intellectual reasoning deficit
Adaptive Functioning deficit
2+ standard deviations below mean (70)
Severity rating is determined by…conceptual, social, practical domains. Not IQ
Vineland Adaptive Behaviours Scale
Assessment of adaptive functioning
Assesses what kids can DO, not necessarily their capabilities
1. Conceptual/Academic: memory, language, reading, writing
2. Social: empathy, interpersonal, social judgment
3. Practical: personal care, money, organization
Etiology of Intellectual Disability
75% prenatal 5% heredity 30% chromosomal abnormalities 10% pregnancy/perinatal complications 5% Childhood medical conditions 15-20% Environmental factors, comorbid conditions 30-40% unknown Low birth weight is strongest predictor
Borderline Intellectual Functioning
IQ 70-85
Global Developmental Delay
Under 5 yo
Not meeting developmental milestones
Too young for standardized testing
ASD previous conditions
Encompasses the previous: Autistic disorder, aspergers, childhood disintegrative disorder, pervasive developmental disorder NOS
ASD Diagnosis
- Social communication deficit (NV, V, Peer, reciprocity)
- Restricted & repetitive behaviour, interest, activities
- Onset in early developmental period (2yo)
- Impaired social, occupation, and other
- Language abnormalities (echolalia, pronoun reversal)
ASD Severity Ratings
These are so dumb
Level 1-requires support
Level 2-substantial support
Level 3-very substantial support
Etiology of ASD
Amygdala abnormality Cerebellum (repetitive movements) Corpus callosum Serotonin, GABA abnormalities Genetic
Differential diagnosis for ASD
Rett Syndrome
- Female predominated
- Normal pre/perinatal development
- Normal psychomotor until 5mo
- 5-48 months=deceleration of cranial growth, stereotyped hand movements, loss of social engagement
- After this period, there is an improvement
ADHD
Diagnosis:
- Symptoms for at least 6 months
- Onset before 12yo
- Evident in ~2 settings
- Social, academic, occupational impairments
Child: minimum 6 symptoms of inattention and/or 6 symptoms of hyperactivity
Adult: minimum 5
5% children; 2.5% adults
Mostly male
Disinhibition Hypothesis of ADHD
Barkley
Inability to adjust activity levels to the requirement of the situation
E.g. issues with doing tasks that have limited interest to them, or tasks that have inconsistent reinforcement
Common meds for ADHD
- Ritalin (methylphenidate)
- Concerta (methylphenidate)
- Adderall (amphetamine)
- Dexedrine (dextroamphetamine)
- Straterra (atomoxetine) nonstimulant
Most common comorbid conditions with ADHD
ODD
CD
Learning Disorder
Specific Learning Disorder
Diagnosis:
- Difficult using academic skills for at least 6 months
- Reading difficulties, spelling/writing difficulties, mathematical difficulties
- Skill must be far below average for chronological age
- Interferes with academic/occupational performance, daily living
- Can’t be accounted for by other condition
Three areas and severities of Specific Learning Disorder
- Reading impairment
- Written expression impairment
- Mathematic impairment
Mild/Moderate/Severe
Dyslexia
Difficulties with word recognition, poor decoding and spelling abilities
Due to phonological processing abilities
Discalculia
Difficulties in numerical processing, accurate calculations
Etiology of Specific Learning Disabilities
Toxins (lead)
Early malnutrition/food allergies
Hemispheric abnormality
Cerebellar-vestibular dysfunction (inflammation of middle ear)
Communication Disorders
- Language disorder (4yo–> adulthood)
- Speech sound disorder (phonology & articulation, may not be lifelong)
- Social (pragmatic) communication disorder (V and NV communication)
- Childhood onset fluency disorder (stuttering)
Childhood Onset Fluency Disorder
Diagnosis:
- Impairment in normal fluency and time patterning of speech
- Repetitions, prolongations, pauses, word substitutions and avoidance
Prognosis:
- 65-85% of children recover
- Symptom severity at 8yo a good indicator
Treatment:
- Reduce stress
- Habit Reversal Training
Movement Disorders
- Developmental Coordination Disorder: delays in motor milestones
- Stereotypic Movement Disorder: repetitive and nonfunctional
- Tic Disorders: Tourettes, persistent motor or vocal tic disorder
Tourette’s Disorder
Diagnosis:
- At least 1 vocal tic
- Multiple motor tics, simultaneously or at different times
- Persisted for more than a year
- 4-6 yo develops
- Usually improves in adolescence
Treatment:
- Antipsychotics
- Comprehensive behavioural treatment
What 5 symptoms accompany psychotic disorders?
- Delusions
- Hallucinations
- Disorganized thinking
- Disorganized/abnormal motor behaviour
- Negative symptoms
Each symptom ranked on 5 point scale for severity
Delusional Disorder Diagnosis
Diagnosis:
- Delusion (false beliefs maintained despite evidence) May be bizarre or non-bizarre
- Delusions present for 1 month or more
- Functioning is not impaired by delusion
Onset in middle to late adulthood
Types of Delusions (7)
- Erotomanic: someone famous is in love with them
- Grandiose: inflated self-worth, power, knowledge
- Jealous
- Persecutory
- Somatic: abnormal bodily functions/sensations
- Mixed: more than one of them
- Unspecified: doesn’t fit in other categories
Schizophrenia Diagnosis
- Requires two + active symptoms for at least one month
- Must include one of: delusions, hallucinations, disorganized thinking/speech
- Continuous signs of disorder for at least 6 months
- Must cause impairment in functioning
Schizophrenia Prognosis
Onset: early to mid-twenties for men; late twenties for females
Chronic condition; can be managed but remission is unlikely
Good prognosis linked to:
- Late onset
- Brief active symptom phase
- No family history of schizophrenia
Schizophrenia and Culture
Do African Americans get it more?
-They may have delusions and hallucinations as part of MDD, Bipolar
In developed countries, clients more likely to experience…
- Acute onset
- Shorter clinical course
- Complete remission
- May be met with better social support and acceptance
Schizophrenia Etiology
Brain Abnormalities:
- Increased volume in lateral and third ventricles
- Reduced size of hippocampus and amygdala
- Lower activity and flow to PFC…this causes negative symptoms
Dopamine Hypothesis: linked to elevated dopamine levels/over sensitive dopamine receptors.
Schizophrenia Treatment
1st gen antipsychotics
- Chlorpromazine
- Thioridazine
- Haloperidol
- Use: for positive, not negative symptoms
- Risks: tardive-dyskenesia
2nd gen antipsychotics:
- Clozapine
- Risperidone
- Olanzapine
- Ariprazole
- Use: both + and - symptoms
- Risk: tardive dyskenesia less likely
Schizophreniform Disorder
Exactly the same as schizophrenia, but differing timeline
Minimum 1 month, but less than 6 months
Impaired functioning not required for diagnosis
Brief Psychotic Disorder
Requires 1+ of:
- Delusions
- Hallucinations
- Disorganized speech
- Disorganized movement
- Catatonia
Duration: 1 day-1 month…eventually return to their unique normal
Usually preceded by stressor
Schizoaffective Disorder
Concurrent psychotic and MDD/manic episodes
-Must have at least 2 weeks of ONLY psychotic symptoms with no mood symptoms
Specifiers:
- Bipolar type
- Depressive type
- With Catatonia
Bipolar I Diagnosis
- Manic episode: elevated/irritable/swinging mood, excessive goal directed energy, inflated self-esteem and grandiosity, decreased need for sleep, flight of ideas
- Requires at least one manic episode that lasts for minimum one week
- May include 1+ episodes of hypomania or depression, but not required for diagnosis
- Causes marked impairment in functioning
- Requires hospitalization the the safety of self or others
Bipolar I Diagnostic Specifiers
- In partial/full remission
- Mild/moderate/severe
- With anxious distress
- With mixed features
- With rapid cycling (4+ mood episodes in last year)
- With mood-congruent or mood-incongruent psychotic features
- With catatonia
- With peripartum onset
- With seasonal pattern
Bipolar I Etiology
Heredity is the strongest factor
Biologically:
- Neurotransmitter dysfunction
- Brain abnormalities
- Psychosocial
Risk for relapse:
-Perfectionist, goal driven
Bipolar I Treatment
Mood stabilizers
- Lithium: good for when there is both mania and MDD
- If intolerant to lithium…valproate, carbamazepine, other anti-seizure meds
Meds + Psychosocial support the best
Therapies:
- CBT and Interpersonal & Social Rhythm Therapy
- FFT
Bipolar II Diagnosis
- One hypomanic episode (3-4 days)…does not cause significant impairment nor hospitalization
- One MDD episode…depressed mood + anhedonia
- Increase creativity, productivity, efficiency (without impairment)
Bipolar II Diagnostic Specifiers (9)
- Mild/Moderate/Severe
- With anxious distress
- With mixed features
- With rapid cycling
- With congruent mood/mood incongruent psychotic features
- With catatonia
- With peripartum onset
- With seasonal pattern
Cyclothymic Disorder
- Multiple episodes of hypomanic symptoms
- Multiple episodes of depressive symptoms (not meeting MDD)
- Must last for 2 years in adults, 1 year in children
- Cause significant distress + impaired functioning
- Symptoms present for at least half the time; can’t be without symptoms for 2+ months
Can’t meet criteria for manic/hypomanic/MDD episode
Separation Anxiety Disorder Diagnosis
- Developmentally inappropriate fear/anxiety related to separation from the home or attachment figures
- Distress when anticipating separation from home and/or attachment figure
- Persistent worry about losing the attachment figure
- Refusal to leave home without the attachment figure
- Refusal to go to sleep without being near the attachment figure
- Nightmares about separation
- Physical symptoms even at thought of separation
Causes significant distress and impaired functioning
Symptoms present for 4 weeks in children, 6 months in adults
School Phobia + School Refusal
May be related to Separation Anxiety
In children aged 5-7 this is due to separation anxiety
In adolescents, it may be more indicative of another underlying mental illness
Separation Anxiety Etiology
- Parental over protectiveness
- Previous trauma
- Past separations
- Life stressors
Separation Anxiety Disorder Treatment (according to the DSM)
- Behavioural therapies such as systematic desensitization, contingency management
- CBT with the goal of fostering adaptive thinking
Selective Mutism Diagnosis + Treatment
- Consistent failure to speak in specific social situation where speaking is expected
- They can speak in other situations
- Impairs educational and occupational achievement or social occupation
- Onset before age 5
- Underlying feeling is fear and anxiety, not counterwill
Treatment:
- Behavioural and cognitive
- Desensitization and relaxation
Specific Phobia Diagnosis
- Fear/anxiety about a specific object or situation
- This situation ALWAYS causes the distress
- Avoidance or endures the stimuli with great distress
- Fear is not proportionate to the danger actually present
- Impaired functioning
Specific Phobia Etiology
- Most start in childhood
- Hereditary
- Neurotransmitter abnormalities
- Dysfunctional cognitions
- Observational learning
- Classical conditioning (John Watson and poor little Albert)
Specific Phobia Treatment
Exposure with response prevention
Relaxation exercises
Social Anxiety Disorder Diagnosis
- Marked anxiety about one + social situation where a person is exposed to the scrutiny of others
- Avoidance or endures situations with marked distress
- Symptoms must last for 6+ months
- Causes impaired functioning and high distress
Social Anxiety Disorder Etiology
- Heredity
- Behavioural inhibition
- Direct conditioning
- Observational learning
- Cognitive biases
Social Anxiety Disorder Treatment
- Exposure
- Social skills training, cognitive restructuring
- Medication
Panic Attack Symptoms
An abrupt surge of intense fear that reaches a peak within minutes. Includes at least 4 symptoms
- Heart palpitations
- Sweating
- Trembling, shaking
- SOB
- Dizziness
- Chest pain
- Parethesias (pins and needles)
- Depersonalization/derealization
- Fear of losing control & dying
Panic Disorder Diagnosis
-Recurrent and unexpected attacks with at least one attack being followed by one month of persistent concern about having another attack and significant maladaptive change in behaviour related to them
Must first rule out:
- Hyperthyroidism
- Seizure disorder
- Cardiac arrhythmia
- Other medical disorders
Onset:
-20-24 years
Risk:
-Increase risk of suicide
Panic Disorder Etiology
Genetic
Classical conditioning
Cognitive biases (especially regarding body related cues)
Panic Disorder Treatment
-CBT + meds
Common meds:
- Imipramine
- Other TCA
- SSRI
- Benzodiazepine
- *High risk of relapse when med not taken**
Therapies:
- Panic control therapy: brief form of CBT developed by David Barlow. Includes exposure, restructuring, relaxation
- Interoceptive Exposure: used with CBT. Exposure to physical sensations associated with panic attack
Agoraphobia Diagnosis
-Presence of anxiety in at least 2 situations
LA TOE (Lines, Alone, Transport, Open, Enclosed)
-Situations are avoided for fear of having no escape if they have embarrassing or incapacitating symptoms
-Situations always have:
Anxiety, require the presence of a safe companion, and are endured with intense anxiety
-Anxiety is not proportional to danger present
Must first rule out:
- Specific phobia (they are likely to have ~one agoraphobic situation and it is more related to the situation itself, not embarrassment)
- Social Anxiety Disorder (mostly related to negative evaluation, they are often fine when left alone)
Agoraphobia Treatment
- In vivo exposure
- Success rates boosted when significant others are involved in treatment
Generalized Anxiety Disorder Diagnosis
-Excessive worry about events/activities that lasts for ~6 months Includes 3 or more symptoms (1 or more for children) -Restlessness/feeling on edge -Easily fatigued -Difficulty concentrating -Irritability -Muscle tension -Sleep disturbance
Onset:
30+ years
Most common MI in older adults
Difficulties with controlling the worries
Significant distress and impairment
Many have comorbid disorders, such as depression and other anxiety disorders
GAD Etiology
Genetic
Behavioural inhibition
Neuroticism
Cognitive Theory: automatic catastrophic thoughts maintain anxiety and cause avoidance behaviours
OCD Diagnosis
Obsessions: recurrent and persistent thoughts, urges or images that are intrusive and unwanted and cause marked anxiety and distress
Compulsions: repetitive behaviours and mental acts that a person feels compelled to perform in response to an obsession or rigid rules. The purpose is to reduce anxiety, but it doesn’t actually work
Must be time-consuming (more than 1 hour per day) and/or cause distress and impairment
Symptoms for 12+ months
Affects both genders equally
Presents in males before females (10 years for males)
OCD Specifiers (related to insight)
- Good/fair insight
- Poor insight
- Absent insight/delusional beliefs
OCD Etiology
- Heredity
- Low 5-HT
- Brain abnormalities: orbitofrontal cortex, caudate nucleus
OCD Treatments
Exposure with ritual prevention + CBT Medications: -Clomipramine (TCA) -Fluvoxamine -Sertraline
Therapy + Meds is the best
Body Dysmorphic Disorder
Diagnosis:
- Preoccupation with defect or flaw in appearance that are hardly noticeable by others
- Repetitive behaviours or mental acts related to defect (checking, grooming, hiding)
Onset:
- A bit more common in women
- Begins in teens
Specifiers
- Good/fair insight
- Poor insight
- Absent insight/delusional beliefs
Hoarding Disorder
Diagnosis:
-Difficulty throwing out or giving up possessions, regardless of their value
Specifiers:
- Good/fair insight
- Poor insight
- Absent insight/delusional beliefs
Trichotillomania
- Pulling of one’s hair
- Repeated attempts to stop, but to no avail
- Distress and impairment
Reactive Attachment Disorder
Summary: child doesn’t develop attachments, mood is erratic, stuck in 3 F’s
Symptoms (start before 5yo):
- Emotionally withdrawn
- No connection seeking towards CG
- Low positive affect
- Unexplained irritability, sadness, fearfulness, withdrawal
- Little smiling
- No asking for support
- Lack of response to connect seeking from CG’s
- No interest in play
- Changes in routine & unsolicited comfort may be met with external or internal rage
Requires child to have extreme developmental trauma such as neglect, repeated separations, unusual rearing that disrupts attachment
Child must developmentally be at least 9 months
Disinhibited Social Engagement Disorder
Summary: low boundaries with everyone
Has ~2 of:
-Low restraint in approaching & interacting with unfamiliar adults
-Over familiar behaviour with strangers
-Low checking with CG after venturing away from them
-Willingness to go with unfamiliar adults
Child must have history of developmental trauma
- Neglect
- Repeated separations
- Unusual rearing
Must have developmental age of 9mo
PTSD Diagnosis
Different criteria for all age groups, but all include 4 symptoms:
- Intrusive: reexperiencing trauma
- Avoidance: avoid memories, thoughts, reminders
- Negative cogs/mood: guilt, shame, fear
- Increased arousal: hypervigilance, reckless
Adults/kids/teens exposure occurs:
- direct
- witnessing it happen
- Learning it happened to close person
- Repeated exposure to details
Kids >6 yo exposure occurs:
- Direct
- Witnessing it
- Learning it happened to P-CG
Symptoms for longer than 1mo
w/ Delayed expression = full diagnosis not met until 6mo after event
PTSD Treatment
Therapy:
- Multicomponent CB intervention
- Cognitive processing therapy
- Psychological debriefing NOT WORK
- EMDR
Acute Stress Disorder
-Similar to PTSD Must have min 9 symptoms from 5 categories: -Intrusion -Negative mood -Dissociation -Avoidance -Arousal
Symptoms last 3 days-1 month
Adjustment Disorder
Development of symptoms in response to 1+ psychosocial stressors within 3 months of said stressors
- Distress is disproportionate to stressor
- Symptoms remit within 6 months
Specifiers:
- With depressed mood
- With anxiety
- With mixed anxiety and depressed mood
- With disturbance of conduct
- Unspecified
Not diagnosed when symptoms are due to bereavement
Dissociated Disorder Commonality
Include a disturbance in normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control and behaviour
Dissociative Identity Disorder
2+ distinct personalities, with gaps in recall of events, personal info, personal traumas. Cannot be explained by typical forgetfulness
Not related to accepted cultural/religious practices
Clients typically unaware of their symptoms
Childhood abuse is a risk factor
Dissociative Amnesia
-Inability to recall important autobiographical information…not explained by forgetfulness
Specifier: dissociated fugue (purposeful wandering away from home and forgets one identity and other important details)
Risk: trauma
Forms of Dissociative Amnesia
- Localized Amnesia: forget ALL events related to a period of time
- Selective Amnesia: Forget SOME events related to a period of time
- Generalized Amnesia: Uncommon, but may include forgetting personal identity and semantic/skill knowledge
Depersonalization Disorder
Sense of unreality, detachment, being an outsider observing one’s own thoughts, feelings and actions
Actual sense of reality is intact
Recurrent
Derealization Disorder
Sense of unreality or detachment from one’s surroundings
Actual sense of reality is intact
Recurrent
Somatic Symptoms Disorder
-1 or more somatic symptom that cause distress and impairment with excessive thoughts, feelings and behaviours associated with symptoms
At least one of three symptoms:
- Excessive time/energy devoted to symptoms and concerns about health
- Persistently high levels of anxiety about health
- Disproportionate and persistent thoughts about the seriousness of the symptoms
More than 6 months, though symptoms may not be continuously present
More common in females
Specifiers:
-With predominant pain
Illness Anxiety Disorder
Preoccupation with having a serious illness
Absence of somatic symptoms or presence of mild symptoms
High level of anxiety about health
Performance of excessive health related behaviours or maladaptive avoidance of medical care
Symptoms last for 6 months or longer…the feared illness may change over this time
Conversion Disorder (Functional Neurological Symptoms Disorder)
-At least 1 symptom that involved an alteration in voluntary motor and sensory function. Not related to neurological/medical conditions
Specifiers:
- With weakness or paralysis
- With attacks or seizures
- With anesthesia or sensory loss
Factitious Disorder Diagnosis
2 types:
- FD imposed on self
- FD imposed on other
Summary: falsifying physical/psychological symptoms, but it is all deception with no external reward
- Exaggerating
- Simulating
- Inducing
Munchausen Syndrome is most severe presentation of this
Munchausen Syndrome
Falls under diagnosis of FD
-Predominantly ‘physical issues’
Can include extensive travel and seeking of unnecessary invasive procedures
-Impersonation and fabrication
Factitious Disorder Differential Diagnosis
Malingering: intentional production of exaggerated physical/psychological symptoms for personal gain (e.g. legal reasons)
Discrepancy between symptoms and objective findings
Person is uncooperative during evaluation and treatment
Person may have antisocial PD
Factitious Disorder Treatment
Symptom management
Need strong therapeutic alliance, support and consistent care
Confrontational techniques not recommended due to premature termination
Inpatient treatment may just support the persons deception related to symptoms
Pseudocyesis
Woman has all symptoms of pregnancy except the fetus
Sleep Wake Disorder Summary
Involves problems related to quality, timing and amount of sleep that causes daytime distress and impaired functioning
Insomnia Disorder Diagnosis
Dissatisfaction with sleep quality or quantity due to one more more symptoms:
- Difficulty getting to sleep
- Difficulty maintaining sleep
- Early morning awakening and inability to return to sleep
- Causes SD/IF
- 3+ nights per week
- Ongoing for 3+ months
- Occurs even with sufficient opportunities for sleep
Insomnia Etiology
- Major life events
- Less severe but chronic daily stresses
Insomnia Treatment
Meds:
- Benzodiazapine
- Antihistamine
Therapies:
- Sleep restriction: restrict time in bed
- Stimulus control: strengthen bed and bedroom cues for sleep
- Sleep hygiene education
- Relaxation training
- Cognitive restructuring
Hypersomnolence Disorder
Diagnosis:
-Excessive sleepiness despite sleeping minimum 7 hours
w/ at least one of the following occurring:
-Recurrent daytime sleep episodes
-Prolonged sleep for more than 9 hours that is nonrestorative
-Difficulty being fully awake after abrupt awakening
Occurs min 3x per week for 3 months
Narcolepsy
Diagnosis:
-Recurrent periods of irresistible need to sleep, lapsing into sleep, that occur in same day
-3+ times per week for ~3 months
Required for diagnosis:
-Cataplexy: brief loss in muscle tone, triggered by emotional arousal
-Hypocretin Deficiency: hormone involved in regulation of sleep
-REM Latency: less than or equal to 15 minutes
-May experience hallucinations
Hypnogogic (falling asleep)
Hypnopompic (waking up)
Obstructive Sleep Apnea Hypopnea Diagnosis
Requires polysomnographic evidence of:
- 15< obstructive apneas per hour or 15< hypopneas (airflow reduction) per hour
- Sleep with disturbance in nocturnal breathing (snoring, snorting, breathing pauses)
- Daytime sleepiness, fatigue, unrefreshing sleep despite enough sleep
Sleep Apnea Etiology
- Genetic disorders that disrupt upper airway
- Menopause
- Obesity
- Endocrine disorder
- Medications
Sleep Apnea Treatment
Mild symptoms:
- Positional therapy (pillows, etc)
- Nose strips
- Oral/dental appliances
Moderate symptoms:
-CPAP (continuous positive airway pressure)
Circadian Rhythm Sleep-Wake Disorder
Recurrent pattern of sleep disruptions due to alteration of circadian system
Results in insomnia or excessive sleepiness
Non-REM Sleep Arousal Disorder
Diagnosis:
- Recurrent episodes of incomplete awakening that occur during Stage 3 or 4 in the first 1/3 of a sleep episode
- Sleep walking OR night terrors (no recall once awake)
- Occurs mostly in childhood then reduces
Specifiers:
- Sleep walking type
- Sleep terror type
Nightmare Disorder
- Recurrent, extended, dysphoric and well remembered dreams that involve efforts to avoid threats to survival, security or physical integrity
- Usually occur during REM in second half of major sleep episode
- After awakening, anxiety may linger
REM Sleep Behaviour Disorder
Diagnosis:
- Recurrent episodes of arousal during REM, usually during later sleep period
- Vocalizations, complex motor behaviour consistent with the dream
- Wake up alert and not confused, remember dream
Etiology:
- Nerve pathways that are supposed to paralyze you during sleep are being lazy
- May co-occur with narcolepsy
Restless Leg Syndrome
- Sensorimotor neurological sleep disorder that involves urge to move legs in response to unpleasant sensation in them
- Worsens during inactivity and is relieved by activity
- Worse in evening/night
- 3x per week for min 3 months
Feeding and Eating Disorders-Summary
Persistent disturbance of eating behaviour, leading to altered consumption/absorption of food that impairs physical health and psychosocial functioning
Pica
- Persistent eating of non-nutritious, non-food substances
- Lasts at least one month
- Most common in young children, and pregnant women
- Common w/ intellectual disability (severity worsens as disability does)
Rumination Disorder
RUMI Barfs it Up
Diagnosis:
- Repeated regurgitation of food for at least one month
- It may be re-chewed, re-swallowed, spit out
- Not bc of a medical disorder
- Onset: 3-12 months
- May result in weight loss and/or malnutrition
Etiology:
- Neglect
- Stress
- Parent-child issues
Avoidant Restrictive Food Intake Disorder (ARFID)
Afraid of Food
Diagnosis: -Don't eat adequately with one or more of the following... Weight loss/not meeting weight gains Nutritional deficiency Dependence on feeding tube/supplements Psychosocial functioning impairments
- No medical condition
- Linked to FAILURE TO THRIVE
- Like AN, but no dysmorphia
- Pathological Picky Eating
ARFID Etiology
- More likely in those with ASD, ADHD, Intellectual Disability
- More likely in children who don’t outgrow picky eating
- Comorbid with anxiety disorders
Anorexia Nervosa Diagnosis
More psychological than ARFID
Diagnosis:
- Restriction of food = low body weight
- Fear of gaining weight
- Distortions in: self image, importance given to body weight or shape through self-evaluation, denial of seriousness of the problem
Subtypes:
- Restricting type
- Binge-eating/purging type
Specifiers:
- In partial remission
- In full remission
Severity:
- Mild (BMI = 17+)
- Moderate (BMI = 16-16.99)
- Severe (BMI = 15-15.99)
- Extreme (BMI <15)
AN Comorbid Conditions
Bipolar
Depression
Anxiety
Alcohol + SU disorders
AN Etiology
- Onset: adolescence/young adulthood
- Earlier onset = shorter duration
- More common in females
- Associated with cultures that encourage thinness (modelling, athletics, etc)
- Upper/middle class backgrounds
- Common in overprotective or depressed mothers, uninvolved fathers
- Parenting that focuses on ‘perfect children’
- May have higher 5-HT (anxiety, irritablity, obsessional thinking) Food restriction lowers 5-HT
AN Treatment
- Multidisciplinary
- Family therapy (structural family therapy shows good evidence)
- CBT = moderate support
- Goal is to mitigate health problems and treatment may often require hospitalization
Bulimia Nervosa Diagnosis
Weight is within normal range unlike AN Binge/Purging Type
LACK of control, whereas AN is TOO MUCH control
Diagnosis:
- Recurrent episodes of binge eating followed by compensatory behaviours
- Occur ~once a week for 3 months
Specifers:
- In partial remission
- In full remission
Severity (based on # of compensatory beh)
- Mild = 1-3
- Moderate = 4-7
- Severe = 8-13
- Extreme = 14+
BN Etiology
Onset: adolescence/young adulthood More common in females Associated with: -Childhood obesity -Early puberty -Low self esteem -Childhood sexual abuse -Life stressors
BN Comorbid Illnesses
- Higher risk of suicide
- Bipolar
- Depression
- Anxiety
- PD’s, esp BPD
- SUD’s
BN Treatment
- CBT
- Interpersonal therapy
- Meds: antidepressants
- High 5-HT
Binge Eating Disorder
No compensatory behaviours
Diagnosis: -Recurrent episodes of binge eating with at least 3+ of... Eating rapidly Eating until uncomfortably full Eating a lot when not hungry Eating alone out of embarrassment Disgusted/guilt after -Binges occur at least once a week for 3 months
Specifiers:
- In partial remission
- In full remission
Severity (based on episodes per week)
- Mild = 1-3
- Moderate = 4-7
- Severe = 8-13
- Extreme = 14+
Atypical Anorexia (other specified/unspecified disorder)
Anorexic behaviours but with normal BMI
Bulimia Nervosa of low frequency/duration (other specified/unspecified disorder)
Occurs less than once a week for less than 3 months
Purging Disorder (other specified/unspecified disorder)
Purging in absence of binge eating
Night Eating Syndrome
- Waking up throughout the night to eat
- Eat a quarter of your daily calories after dinner, which causes you distress
- Related to insomnia
Enuresis Diagnosis
- Repeated peeing into bed or clothes (intentionally or involuntarily)
- Occurs 2x a week for ~3 months, or causes SD/IF
- Must be chronologically/developmentally ~5 yo
- Not always a medical thing
Subtypes:
- Nocturnal only (most common)
- Diurnal only
- Both
Characterizations:
- Primary: child is 5 and never established continence
- Secondary: disturbance develops after period of continence
Prognosis: 99% of clients remit by adulthood
Enuresis Etiology
- Lax toilet training
- Psychosocial stress
- Delays in development of circadian rhythm of urine production
- Most common in children with enuretic fathers
Enuresis Treatment
- Urine alarm bell and pad technique (classical conditioning). More effective than meds
- Family/individual therapy esp if it’s related to a stressor
Encopresis
- Recurrent pooping in inappropriate places, intentionally or not
- At least once a month for 3 months
- Chronological/developmental age of 4yo
Specifiers:
- With constipation and overflow incontinence
- Without constipation and overflow incontinence
Characterizations:
- Primary: person never established continence
- Starts after a period of continence
Encopresis Treatment
No evidence based treatment
Medical management helpful when constipation is the underlying problem
When deliberate, ODD and CD may be involved
-Behavioural and family therapies
Sexual Dysfunctions Overview
Disturbance in sexual response or sexual experience
Symptoms cannot be explained by:
- Another mental illness
- Relationship distress
- Other stressors
- Medical condition
- Substance use/medication
Must persist for ~6 months
Specifiers:
- Life long: since onset of sexual activity
- Acquired: after period of sexual functioning
- Generalized: occurs with all types of stimulation, situations, partners
- Situational: only with certain types of stimulation, situations, partners
Severity coded based on distress
- Mild
- Moderate
- Severe
Premature Ejaculation
Diagnosis:
- Jizzing within one minute of penetration
- Happens before person wishes it
- Occurs 75-100% of the time
Treatment:
- Squeeze and stop-start techniques
- Female superior position recommended
- SSRI’s & topical desensitizing agents
Delayed Ejaculation
Diagnosis:
- Marked delay, infrequency, absence of ejaculation
- 75-100% of the time
Erectile Disorder
Diagnosis: -One of the three... Can't achieve erection Difficult maintaining erection Decrease in erectile rigidity -75-100% of the time -Rule out: Diabetes MS Smoking Alcohol
Treatment:
- CBT (Master & Johnson)
- Medication (viagra)
Female Orgasmic Disorder
Diagnosis:
- Marked delay, infrequency or absence of orgasm
- Reduced sensation of orgasm
- 75-100% of the time
Treatment:
- Sensate focus
- Directed masturbation
- Kegel exercises
Female Sexual Interest/Arousal Disorder
Diagnosis: -Lack or reduced sexual interest/arousal evidence by ~3 of... Absent/reduced sexual interest A/R sexual thoughts/fantasies Reduced sexual initiation Low receptivity to partners initiation A/R pleasure (75-100% of time) A/R interest/arousal to sexual cues A/R sensation during sexual activity
Genito-Pelvic Pain/Penetration Disorder
Diagnosis:
-Recurrent difficulties with 1 or more of…
Penetration
Pain during penetration attempts
Anxiety about pain
Tensing of pelvis during attempted penetration
Treatment:
- Relaxation training
- Manual stimulation
- Progressive dilation of vagina
Male Hypoactive Sexual Desire Disorder
Diagnosis:
-A/R sexual thoughts/fantasies/desires
Substance/Medication Induced Sexual Dysfunction
Substances that can cause it…
- Alcohol
- Opioids
- Sedatives
- Hypnotics
- Anxiolytics
- Stimulants
Gender Dysphoria Diagnosis Children
-Marked incongruence between assigned gender and experienced/expressed gender
-At least 6 of the following…
Desire to be of other gender/insistence that they are
Preference for cross dressing
Preference for cross gender roles in play
Preference for activities, toys, games that are stereotypically of the other gender
Preference for playmates of other gender
Rejection of things that are stereotypically of the same gender
Dislike of ones sexual anatomy
Desire sex characteristics of other gender
Lasts for ~6 months
Gender Dysphoria Diagnosis Adults
-Incongruence between assigned and experienced/expressed gender
-At least 2 of the following…
Shown in ones experienced/expressed gender and sex characteristics
Desire to be rid of ones sex characteristics
Want sex characteristics of other gender
Desire to BE the other gender
Desire to be treated as the other gender
Believe that one has feelings/reactions of the other gender
Gender Dysphoria Etiology
More common in bio males
Onset 2-4yo in kids, persistent rates 2-50%
Late onset occurs at puberty or later, more common in males
Paraphilic Disorders Summary
Intense and persistent sexual urges, fantasies, behaviours that involve non-human objects, the suffering of ones self or one’s partner, children or other nonconsenting persons
It causes distress or impairment to the individual, or whose satisfaction involves personal harm or risk or harm to others
Specifiers:
- In a controlled environment: person living in an institutional setting, opportunities to engage in paraphilia are limited
- In full remission: has not acted on urges, has not experiences distress or impairment while in an uncontrolled environment
Voyeuristic Disorder
Diagnosis:
- Observing an unsuspecting person who is naked and/or engaging in a sexual activity
- Client is 18+
- Must occur for minimum 6 months
Exhibitionist Disorder
Diagnosis:
Exposing one’s genitals to a stranger
Frotteuristic Disorder
Diagnosis:
-Rubbing or touching a non-consenting person
Sexual Masochism Disorder
Diagnosis:
-Being humiliated, beaten, bound, made to suffer
Sexual Sadism Disorder
Diagnosis:
-Sexual excitement resulting from physical or psychological suffering of another
Pedophilic Disorders
Diagnosis:
- Sexual contact with prepubescent child (>13 yo)
- Perp must be min 16 years old, and at least 5 years older than the object of desire
Fetishistic Disorder
Diagnosis:
-Use of non-living objects for sexual gratification
Transvestic Disorder
Sexually aroused by wearing women’s clothing
Occurs mostly in men
Most of the men identify as het, thought some engage in sexual activity with other men while “cross dressed”
Personality Disorders Summary
Enduring patterns of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture
They must have symptoms by adolescence or early adulthood
Cause SD & IF
Can be diagnosed in minors if symptoms present for >1 yr Not ASPD
Affects three areas:
- Cognition
- Affect
- Interpersonal functioning
- Impulse control
Cluster A Personality Disorder
Odd, eccentric
- Paranoid
- Schizoid
- Schizotypal
Cluster B Personality Disorders
Dramatic, emotional, erratic
- Antisocial
- BPD
- Histrionic
- Narcissistic
Cluster C Personality Disorders
Anxiety, fearfulness
- Avoidant
- Dependent
- OCD PD
Paranoid Personality Disorder
Diagnosis:
-Pattern of suspiciousness towards others due to interpreting their motives as malevolent
-Must have 4+…
Suspects-without evidence-that others are exploiting, harming, deceiving them
Preoccupied with doubts about peoples loyalty
Reluctant to confide in others in case its used against them
Misinterprets benign remarks
Persistently bears grudges
Perceives attacks on reputation and reacts with anger
Unjustified suspicion about fidelity of partner
-May be argumentative, complain a lot, hostile aloofness
-Interpersonal difficulties
Schizoid Personality Disorder
Diagnosis:
-Pattern of detachment from interpersonal setting
-Must have 4+…
Doesn’t want or enjoy close relationships
Prefers solitude
Little interest in sexual experiences with another
Pleasure in few activities
Lacks close friends other than first degree relatives
Appears indifferent to praise/criticism
Cold, flattened affect
-Appears introverted & preoccupied
-Social contact may impair work, but they are fine working in solitude
Schizotypal Personality Disorder
Diagnosis:
-Interpersonal deficits…discomfort in social situations and reduced capacity for close relationships
-Must have 5+…
Belief that irrelevant things are aimed at them
Odd beliefs that influence behaviours
Unusual perceptual experiences (not delusions)
Odd thinking and speech
Paranoid ideation
Inappropriate/flat affect
Odd behaviour & appearance
Lack of close friends
Social anxiety
-They may want close relationships, but their behaviour suggests otherwise
Antisocial Personality Disorder
Diagnosis: -Pattern of disregard and violation of the rights of others -Occur since ~15yo -History of CD before 15yo -Must have 3+... Not confirm to norms for lawful behaviour Deceitfulness Impulsivity Irritability/aggressiveness Reckless disregard for safety Irresponsibility Lack of remorse -Chronic, but may reduce with age
ASPD Etiology
- Heredity
- Family (parenting with high negativity, low warmth, inconsistency)
- Personality traits: low empathy, lower than normal autonomic response to threatening stimuli
ASPD Treatment
Therapies:
- Multisystemic therapy: targets chronic violence, substance use. Often done in high risk, out of home placements
- Home based family therapies, child-family therapies, CBT interventions
BPD
Diagnosis: -Pervasive instability in: Interpersonal relationships Self image Affect (+ impulsivity) -Symptoms occur in multiple contexts -Must include 5+ Efforts to avoid real/imagined abandonment Unstable interpersonal relationships (idealization to devaluation) Identity disturbance Impulsivity Suicidal behaviours Affective instability Chronic feelings of emptiness Inappropriate anger Transient paranoid ideation/dissociative symptoms
BPD Etiology
- Object Relations Theory (Mahler): issues in the separation-individuation that lead to a fixation; vacillate between need for separation and fear of abandonment; good CG/bad CG
- Kernberg: inconsistent parenting that switches from nurturing to avoidant to punitive. This results in splitting
- Linehan: pervasive dysregulation caused by biological vulnerability to high emotionality + inability to regular, and exposure to invalidating parenting with inconsistent parenting
BPD Treatment
DBT very evidence based
- Group skills training
- Individual outpatient therapy
- Telephone coaching
Histrionic Personality Disorder
Histrionic Horny Harriet
Diagnosis: -Pattern of emotionality and "attention-seeking" -Begins in early adulthood -Present in multiple contexts -Must have 5+... Discomfort when not center of attn Inappropriately seductive Rapidly shifting & shallow affect Consistent use of physical appearance to draw attention Excessive impressionistic speech Self dramatization Highly suggestible Considers relationships more intimate than they are
Narcissistic Personality Disorder
Diagnosis: -Pattern of grandiosity in fantasy or behaviour -Need for admiration -Lack of empathy -Symptoms present in multiple contexts -Must include 5+... Grandiose sense of self Preoccupation with fantasies of unlimited success, power, beauty Believe they are unique, understood by high status peoples Requires excessive admiration Sense of entitlement Interpersonally exploitive Lacks empathy Envious of others Arrogant
-Symptoms cause interpersonal strain
Avoidant Personality Disorder
Diagnosis:
-Pervasive pattern of:
Social inhibition
Feeling inadequate
Hypersensitivity to negative evaluation
-Symptoms occur in multiple contexts
-Must include 4+…
Avoids activities requiring high interpersonal contact (fear of criticism, rejection, disapproval)
Unwilling to get involved unless certain they will be liked
Restraint in intimate relationships
Preoccupied with being criticised/rejected
Inhibited in new interpersonal situations
Views self as socially inept, inferior
Reluctant to take risks
-No close relationships outside of immediate family
-Long for relationships and fantasize about ideal ones
Dependent Personality Disorder
Diagnosis:
-Pervasive need to be cared for
-Submissive, clingy, fear separation
-Begins in early adulthood
-Occurs in multiple contexts
-Must have 5+ symptoms…
Indecisive without reassurance from others
Needs others to take responsibility for their lives
Difficult disagreeing with others
Difficulty initiating their own projects
Goes to lengths to receive nurturance
Uncomfortable/helpless when alone
Urgently seeks new relationships when one ends
Preoccupied with fear of being left to care for themselves
Must be excessive & not a cultural norm
OCD Personality Disorder
Diagnosis:
- Pervasive preoccupation with:
1. orderliness
2. perfectionism
3. Mental/interpersonal control - Symptoms result in limited:
1. Flexibility
2. Openness
3. Efficiency - 4+ of…
1. Preoccupation with details/rules/lists
2. Perfectionism interferes
3. Devoted to work and productivity above all else
4. Over conscientious
5. Scrupulous
6. Inflexible morals and values
7. Can’t get rid of old items
8. Hesitant to delegate or work with others
9. Frugal spending style
10. Rigidity and stubbornness
No obsessions or compulsions. Not related to OCD though they can coexist
Personality Change due to Medical Condition
Causes:
- CNS neoplasm
- Head trauma
- Stroke
- Huntington’s
- Seizures
- Infection (HIV)
- Endocrine disorders (hypothyroidism)
- Autoimmune conditions (Lupus)
Disruptive Impulse-Control and Conduct Disorders Summaries
Violate rights of others, low control of emotions, conflict with societal norms or person’s in authority
ODD, CD, Intermittent Explosive Disorder
ODD
Diagnosis:
- Pattern of…
- Angry mood
- Argumentative/defiant
- Vindictiveness - 4+ in interactions w/ other than siblings…
- Loses temper
- Easily annoyed
- Often angry/resentful
- Argues with authority figures
- Refuses to comply with rules
- Deliberately annoys others
- Blames others for mistakes
- Spiteful - Min 2x in last 6 months
- Causes distress for others or self
- Negative impact on individuals functioning
Specifiers:
- Mild-one setting
- Moderate-two settings
- Severe-three or more settings
ODD Etiology
- More common in families with inconsistent parenting style, especially when harsh, inconsistent and/or neglectful
- Comorbid with ADHD and CD
Intermittent Explosive Disorder
Diagnosis:
- Recurrent behavioural outbursts
- Can’t control aggressive impulses
- Criteria
1. Verbal/physical aggression 2x week for 3 months OR
2. 3 behavioural outbursts in 12 months that have caused damage of property or physical assault that injured people or animals - Reaction not appropriate to stressor
- No premeditation or end goal
- Must be ~6 yo
Conduct Disorder Diagnosis
Pattern of behaviours that violate others rights Symptom groups 1. Aggression to people/animals 2. Property destruction 3. Deceitfulness 4. Violation of rules
Specifiers:
- Childhood onset: ~1 symptom >10yo
- Adolescent onset: no symptoms before 10 yo
- Unspecified onset: age unknown
Childhood onset has most severe symptoms and worst prognosis
Conduct Disorder Etiology
- Life course persistent path
- Symptoms start at 3-4 yo
- Increasingly serious transgressions
- Combo of: neurological deficits, difficult temperament, hyperactivity, adverse social environment - Adolescent-limited oath
- After puberty
- Due to maturity gap between biological & social maturity
- Deviancy is nonconfrontational and inconsistent
- Often peer related
- Begins to decline in later adolescence
Conduct Disorder Treatment
Most effective when began in adolescence and has family involvement
FFT, multisystemic treatment, parent management trainings
Within what timeframe must symptoms occur for an illness to be considered substance induced?
Within 1 month of intoxication, withdrawal or taking meds.
Substance Use Disorder
Applicable to all substances except caffeine
Diagnosis:
- Cognitive, behavioural, physiological symptoms that show client continues to use the substance despite problems
- 2+ symptoms for 12 months
1. Impaired control
2. Social impairment
3. Risky use
4. Pharmacological Criterion
What are the 2 types of remission
- In early remission: sober 3-12 months
2. In sustained remission: 12+ months
Etiology of Substance Use Disorders
- Incentivization-Sensitization Theory
- Tension-Reduction Hypothesis
- Self-Medication Hypothesis
Relapse Prevention Model for SUDs
CBT approach focused on the factors that precede relapse
- Environmental and emotional factors that may increase relapse
- Self monitoring for immediate situation
- Global life style changes (i.e. develop positive addictions)
- Focus on situational rather than internal reasons for relapse (AVE-abstinence violation effect)
Substance-Induced Disorders
Substance Intoxication
- Reversible, caused by ingestion of substance
- Has physiological effects on CNS
- Can occur with all substances except tobacco
Substance Withdrawal
- Substance specific changes due to stopping or reducing heavy use
- Doesn’t occur with hallucinogens and inhalants
Alcohol Withdrawal
- Autonomic hyperactivity
- Psychomotor agitating
- Generalized tonic-clonic-seizure
- Transient hallucinations
Alcohol Withdrawal Delirium
- Delirium tremens
- Disturbance in attention, awareness and cognition
- May include vivid hallucinations, delusions, autonomic hyperactivity, agitation
Alcohol Induced Major Neurocognitive Disorder
- Significant decline in ~1 cognitive domain that interferes with independence
1. Non-amnestic confabulatory type
2. Amnestic confabulatory type - Anterograde and retrograde amnesia
- Procedural, LT, WM memory intact. ST impaired
-Related to thiamine deficiency
Opioid Use
- Withdrawal is not life threatening.
- Dysphoria
- Nausea, diarrhea
- Muscle aches
- Lacrimation
- Rhinorrhea
- Piloerection
- Sweating
- Fever
- Yawning
- Insomnia
Sedative or anxiolytic Withdrawal
- Autonomic hyperactivity
- Transient hallucinations or illusions
- Seizures
Stimulant Withdrawal
- Vivid, unpleasant dreams
- Insomnia or hypersomnia
- Increased appetite
- May be followed by a crash
6 Cognitive Domains of Neurocognitive Issues
- Complex attention (sustained, divided, processing speed)
- Executive function
- Learning and memory
- Expressive and receptive language
- Perceptual motor
- Social cognition
Delirium
- A disturbance in attention and awareness that develops rapidly over a short period of time
- ~1 disturbance in cognition: Memory deficit, Language impairment, Disorientation, Perceptual abnormalities
- Must be medical evidence that symptoms are resultant from something physiological
Specifiers:
- Substance intoxication delirium
- Substance withdrawal delirium
- Medication-induced delirium
- Delirium due to medical condition
- Delirium due to multiple etiologies
Etiology: age, dementia, depression, male, visual/hearing impairment, dehydration/malnutrition, alcohol, medication, functional dependence, severe illness
Triggers: infection, electrolyte imbalance, acute stroke, surgery, pain, withdrawal, some drugs
Treatment: education, environment control, haloperidol
Major and Mild Neurocognitive Disorders
- Major Neurocognitive Disorder
- Formerly dementia
- Sig. decline from a prior level of functioning in ~1 cog. domain that interferes with independence
- Does not just occur during delirium - Mild Neurocognitive Disorder
- Modest decline from prior level of functioning in ~1 domain that does not interfere with independence but may require additional effort, compensations
Specifiers:
- Alzheimers
- Frontotemporal lobar degeneration
- Lewy body disease
- Vascular disease
- TBI
- Substance/medication use
- HIV
- Prion disease
- Parkinsons
- Huntingtons
- Other medical condition
- Multiple etiologies
- Unspecified
Major/Mild CD due to Alzheimers (symptoms)
- Criteria for mild/major NCD met
- Symptoms have insidious onset
- Impairment in 1 cog domain for mild, 2 for major
- Early Stage
- Anterograde amnesia (no new memories)
- Impaired attn and judgment
- Becoming lost
- Apathy
- Depression
- Irritability
- Anomia - Middle stage
- Antero and retrograde amnesia
- Problems reading and writing
- Inability to remember names, family, etc
- Mood swings, personality changes
- Sleep disturbance
- Fluent aphasia
- Restlessness
- Difficulty with complex and sequential tasks - Late stage:
- Severe impairment of most functions
- Need daily assistance
- Respiratory infection common
Alzheimer’s Etiology and Treatment
Etiology:
- Genetic
- Structural brain abnormalities
- Early onset: chromosomes 1, 14, 21
- Late onset: chromosome 19
Treatment:
- Behavioural interventions
- Antipsychotics, antidepressants
- Cholinestrase inhibitors to enhance cognitive functioning (keeps ACh high). Only helpful in early stages and is temporary
- Better outcomes when kept at home
Vascular Neurocognitive Disorder
- Criteria for mild/major NCD met
- Symptoms consistent with vascular etiology
- Caused by cerebrovascular disease (affect blood supply to brain)
- Not progressive…a stepwise decline with fluctuations
- Prevention: hypertension, hypotension, heart disease, diabetes, heavy smoking
Traumatic Brain Injury
- Critera for major/mild NCD met
- TBI with ~1: loss of consciousness, post traumatic amnesia, disorientation/confusion, neurological sign
- Onset of symptoms after injury or after regaining consciousness
- Symptoms persisted past post-injury period
- Processing speed heavily impacted
HIV Infection Related NCD
-Criteria for mild/major NCD met
-Symptoms due to damage in subcortical areas: difficulty learning new things, impaired executive functions, psychomotor slowing, apathy, social withdrawal. decline in IQ
Early symptoms:
-Forgetfulness
-Concentration issues
-Mental slowing
-Apathy
-Irritability
-Loss of balance/coordination
Later symptoms:
- psychomotor slowing
- ataxia
- tremors
Prion Disease related NCD
- Criteria for mild/major NCD met
- Insidious and rapid progression
- Myoclonus: jerky muscle contractions
- Ataxia
- Biomarker evidence: Creutzfeldt-Jakob Disease is common
Hypertension
- Primary (essential) hypertension
- Age
- Obesity
- Chronic stress
- Family history
- Cigarette smoking
- High sodium intake - Secondary hypertension (related to other disorder)
- Kidney disease
- Artery blockage
- Diabetes
- Endocrine disorders
- Pregnancy
- Sleep apnea
Treatment:
-Life style changes and medication (anti-hypertensive meds, diuretics, anti-adrenergics, vasodilators, beta blockers, calcium channel blockers, angiotensin-receptor blockers, ACE inhibitors
Stress Definition
When an individual perceives that the environmental demands tax or exceed their adaptive capacity
General Adaptation Syndrome to Stress
- Chronic stress = contributor to disease bc cortisol suppresses immune system
- People have same physical response to all types of prolonged stress
- 3 stages:
1. Alarm (physiological, FFF)
2. Resistance (prolonged stress): pituitary release ACTH = adrenal cortex releases cortisol. Increases blood glucose levels, metabolism of fats and proteins
3. Exhaustion: pituitary and adrenal lose capacity to maintain elevated hormone levels and physical reserves are depleted. Leads to: mental/physical exhaustion, illness, collapse, death
Transactional Model of Stress
- Events are not inherently stressful or nonstressful, but its how we appraise the event
1. Primary appraisal: relevance of event to wellbeing based on values, beliefs. May be irrelevant (no stress), positive (no stress) or challenging (stress…second appraisal)
2. Secondary appraisal: are my resources/abilities sufficient to cope with this threatening situation? If yes, no stress response. If no, stress response.
3. Cognitive reappraisal: monitors situation and uses new info to modify primary/secondary appraisals. This can increase or decrease the stress response
Types of Headaches
- Migraine (classic or common)
- Tension
- Cluster (O2 therapy, anesthetic, the usual migraine meds)
- Sinus headache
Major Depressive Disorder
- Requires 5+ syptoms (1 must be depressed mood or anhedonia)
- May also include:
- Appetite changes
- Weight changes
- Sleep changes
- Psychomotor changes
- Loss of energy
- Worthlessness/guilt
- Decreased concentration
- Suicidal ideation - Present every day for ~2 weeks
- Cause distress + impaired functioning
* Children: physical complaints, irritable, social withdrawal
* Older adults: looks like dementia - May have: anxious distress, congruent/incongruent psychotic features, atypical features (weight gain, hypersomnia, leaden paralysis, rejection sensitivity)
Peripartum onset (during pregnancy or 4 weeks post partum)
Seasonal pattern
Catatonia: catalepsy (holding in odd postures, rigidity of limbs), stereotypy (repetitive non-goal directed movements), mutism
Prevalence and Etiology of MDD
Prevalence:
- 7% 12 month prevalence
- Peak onset in 20’s
- Initially triggered by stress
Etiology:
- Biopsychosocial
- High genetic cause
- Neuroticism, ACEs
- Catecholamine hypothesis: low NE
- Permissive theory: low NE and 5-HT
- Stress: high cortisol damages hippocampus
Seligman’s Learned Helplessness Model of Depression
- Repeated exposure to uncontrollable negative life events + tendency to attribute life events to internal structures
- Seligman uncontrollably slides down the inside of a volcano*
Abramson, Metalsky & Alloy Theory of Depression
Hopelessness is the root cause of depression
Lewinsohn Behavioural Theory of Depression
Low rate of response contingent reinforcement for adaptive behaviours
I’m doing everything right, but everything is still shit
