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Flashcards in Mental Disorders - Disorders / Criteria Deck (70):
1

Criteria for Schizophrenia - DSM-IV

Pathogenic Symptoms
(1 sufficient)

- Hallucinations in form of running commentary / interlocuting voices
- Bizarre delusions, e.g. loss of control over body

2

Criteria for Schizophrenia - DSM-IV

Characteristic Symptoms
(2 required)

- Delusions
- Regular hallucinations in any sensory modality
- Severely disorganised speech
- Catatonic or disorganised behaviour
- Negative symptoms

3

Criteria for Schizophrenia - DSM-IV

Social / Occupational Dysfunction

Yes

4

Criteria for Schizophrenia - DSM-IV

Duration

6 months, including 1 with characteristic symptoms

5

Criteria for Schizophrenia - ICD-10

Pathogenic Symptoms
(1 sufficient)

- Hallucinations in form of running commentary / interlocuting voices
- Bizarre delusions, e.g. loss of control over body
- Thought echo, thought insertion or withdrawal or thought broadcasting
- Delusional perception

6

Criteria for Schizophrenia - ICD-10

Characteristic Symptoms
(2 required)

- Delusions
- Regular hallucinations in any sensory modality
- Severely disorganised speech
- Catatonic or disorganised behaviour
- Negative symptoms
- Social Withdrawal

7

Criteria for Schizophrenia - ICD-10

Social / Occupational Dysfunction

Not specified

8

Criteria for Schizophrenia - ICD-10

Duration

1 month

9

DSM-IV - Sub-classifications of Schizophrenia

PARANOID type

Delusions or auditory hallucinations are present, but thought disorder, disorganised behaviour or flattening are not

Delusions are persecutory and / or grandiose, but in addition to these other themes such as jealousy, religiosity or somatisation may also be present

10

DSM-IV - Sub-classifications of Schizophrenia

DISORGANISED type

Named hebephrenic schizophrenia in the ICD

Thought disorder and flat affect are present together

11

DSM-IV - Sub-classifications of Schizophrenia

CATATONIC type

The individual may be almost immobile or exhibit agitated, purposeless movement

Symptoms can include catatonic stupor and waxy flexibility

12

DSM-IV - Sub-classifications of Schizophrenia

UNDIFFERENTIATED type

Psychotic symptoms are present but the criteria for paranoid, disorganised or catatonic types have not been met

13

DSM-IV - Sub-classifications of Schizophrenia

RESIDUAL type

Where positive symptoms are present at a low intensity only

14

DSM-V Diagnosis of Schizophrenia

Characteristic symptoms

Two or more of the following, each present for much of the time during a one month period (or less, if symptoms remitted with treatment)

- Delusions
- Hallucinations
- Disorganised speech, which is a manifestation of formal thought disorder
- Grossly disorganised behaviour (e.g. dressing inappropriately, crying frequently) or catatonic behaviour

- Negative symptoms: Blunted affect (lack or decline in emotional response), alogia (lack or decline in speech) or avolition (lack or decline in motivation)

15

DSM-V Diagnosis of Schizophrenia

Social or Occupational Dysfunction

For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care, are markedly below the level achieved prior to the onset

16

DSM-V Diagnosis of Schizophrenia

Significant Duration

- Continuous signs of the disturbance persist for at least six months
- This six month period must include at least one month of symptoms (or less, of symptoms remitted with treatment)

17

What are 'positive' symptoms of schizophrenia?

Excess or distortion of normal function
- adding to behaviour

18

What are 'negative' symptoms of schizophrenia?

Diminution or loss of normal function

19

What are the two categories of positive symptoms for schizophrenia?

Paranoia and Disorganised

20

Schizophrenia - Positive Symptoms - Paranoid

- broadly describes the distortion of reality

- includes hallucinations and delusions

Delusions - some are internally consistent and could be true however that is very unlikely in the specific case

- Hallucinations can occur across a wide range of disorders BUT certain types that reflect the feeling of being controlled lean towards ScZ

21

Schizophrenia - Positive Symptoms - Disorganised

- can be inferred from patients language or behaviour

- patients may talk incoherently, frequently change topic, give unrelated answers to questions and come up with new words / word combinations

- harder to define - mere violation of social norms is not sufficient

- if it is inappropriate or clearly dysfunctional, this is symptomatic
> e.g. of wearing several overcoats on a hot day

22

Schizophrenia - Positive Symptoms

DELUSIONS

An idiosyncratic belief or impression that is firmly maintained despite being contradicted by what is generally accepted as reality

- overpowering, intense feeling you are being watched, followed and spied on (tracking devices, implants, hidden cameras)
- thinking that someone is trying to poison your food
- thinking people are working together to harass you
- thinking that something is controlling you, i.e an electronic implant
- thinking that people can read your mind / or control your thoughts

REQUIRES clinical skill to assess the degree of conviction!

23

Schizophrenia - Positive Symptoms

HALLUCINATIONS

Perception of visual, auditory, tactile or olfactory or gustatory experiences without an external stimulus and with a compelling sense of their reality

a) Second person auditory hallucinations
- "you are not going to smoke the cigarette the way you want to"

b) Third person auditory hallucination
- "He is an astronomy fanatic. Here's a taste of his medicine. He's getting up now. He's going to wash. It's about time"

24

Schizophrenia - Negative Symptoms

- have a considerable impact on quality of life and the prospect of long-term social integration of the individual
- associated with disruptions to normal emotions and behaviours

- Flat Affect - a person's face does not move or he/she talks in a dull, monotonous voice
- lack of pleasure in everyday life
- lack of ability to begin and sustain planned activities
- speaking little, even when they are forced to interact

25

Schizophrenia - Symptoms

Changes in self-experience

Thought insertion
- 'thoughts come into my mind from outer space'

Thought withdrawal
- 'it doesn't allow me to think about what i want to think about. it blocks my mind'

Delusions of control
- 'they inserted a computer in my brain - it makes me turn to the left or the right'

Somatic passivity experiences
- 'i have tingling feelings in my legs caused by electric currents from an alternator'

Made emotions
- 'it puts feelings into me: joy, happiness, embarrassment, depression. it just puts it in and i feel the glow spread over me

26

Schizophrenia - Symptoms

Thought Disorder

- involves a disturbance of speech, communication or content of thought

- poverty of thought, flight of ideas, perseveration, loosening of associations, neologisms

- unusual or dysfunctional ways of thinking

- P has trouble organizing their thoughts or connecting them logically

27

Schizophrenia - Epidemiology

Prevalence - fairly uniform across regions and cultures
- 0.5 - 1%
- social and cultural factors may influence diagnosis?

Age of onset - between 16-35

Lower social class and IQ - not really influential factors but higher proportions of lower social class P's and harsh effect on IQ

MZ concordance = 50%
DZ concordance = 17%
Non-twin siblings = 9%

28

Schizophrenia - Outcome

More likely for no remission (no ending of symptoms) vs remission

Lots of studies show that no remission is much higher than remission

29

Schizophrenia - Outcome

Harrow et al

- 25 year follow up study
- ScZ vs Mood disorder
- 2, 4.5, 7.5, 10, 15, 20 years
- mood was always higher than ScZ
- longer follow up periods - better complete recovery (normally?)

30

Schizophrenia - Outcome

Tiihonen et al (2009)

- introduction of second-generation anti-psychotic drugs - affected mortality of ScZ P's
- examined the LT contributions of anti-psychotics to mortality
- found that LT treatment with anti-psychotics is associated with lower mortality compared to no A-P use

Clozapine - lower mortality than other drugs!

31

DSM-IV criteria for Manic episode

Distinct period of abnormally & persistently elevated, expansive or irritable mood lasting at least 1 week (or any duration is hospitalization is necessary)

During mood disturbance, three or more of the following have persisted and present to a significant degree
- inflated SE, decreased need for sleep, more talkative than usual, subjective experience that thoughts are racing, distract-ability, increase in goal-directed activities, excessive involvement in pleasurable activities that have a high potential for painful consequences

Symptoms don't meet criteria for a mixed episode

Mood disturbance is severe enough to cause marked impairment in occupational functioning or in usual activities OR to necessitate hospitalization to prevent harm to self or others

Symptoms are not due to direct physiological effects of a substance or a general medical condition

32

Criteria for Mania in DSM-IV

Core Symptom
- elevated mood (but may be irritable and suspicious instead)

Important symptoms for diagnosis
- over activity
- pressured speech
- decreased need for sleep
- inflated self esteem
- flight of ideas
- distract-ability
- reckless spending and other pleasurable activities with likely adverse consequences

Criteria - distinct period for at least one week plus other symptoms

33

Criteria for Mania in ICD-10

Core Symptom
- elevated mood (but may be irritable and suspicious instead)

Important symptoms for diagnosis
- over activity
- pressured speech
- decreased need for sleep
- excessive optimism
- inflated self esteem
- flight of ideas
- distract-ability
- perceptual disturbance
- extravagant or inappropriate behavior
- reckless spending and other pleasurable activities with likely adverse consequences

34

Bipolar Disorder

Alternation between episodes of depression and mania
- periods of recovery in between
- Kraeplin > a manic episode is defined groundlessly and abnormally elevated mood
- additionally, increased energy - over-activity, fast talking, decreased need for sleep
- also common for loss of social inhibition & inflate SE

35

Bipolar Disorder - Mania

Can occur with or without frank psychotic symptoms
- if they are present, can include grandiose, religious or persecutory delusions

Many BD P's don't experience psychotic symptoms but it is commonly classified as an affective psychosis

Some P's with BD only have recurrent manic episodes without intervening depressive episodes

36

Bipolar Disorder - Epidemiology

- less common than unipolar depression
- lifetime prevalence is approximately 1%
- peak age of onset - adolescence through early 20's
(red flag if manic episode onset is after 40 years!)
- commonly between 15-30 years
- M are equally as affected as W

Bipolar II disorder - more common
- approximately 5% lifetime prevalence
- milder form OR separate disease?

37

Bipolar Disorder - Manic Episodes

- rare for them to be singular events
- 90% are followed by further manic episodes (which equals diagnosis)
- these often alternate with depressive episodes
- pattern - regular to the P

38

Bipolar Disorder - Manic vs Depressive Episodes

Manic - median = 4 months
Depressive - median = 6 months

39

Bipolar Disorder - Recovery?

BD - can lead to cognitive decline and residual states

BD P's who have 4+ episodes in the course of one year:
- fulfill 'rapid cycling' criteria
- have a poorer prognosis than those with fewer episodes and longer periods of remission

Seasonal variation
- depression - more common in Spring and Autumn
- mania - more common in Summer

40

Bipolar Disorder - Heritability

Much stronger for bipolar than unipolar disorders!

Specific genetic association - not been consistently replicated
- family studies have found a particularly strong genetic associated for BD
- first degree relatives of P's with BD - 5-10x increased risk of developing compared to general population

Concordance for MZ = 60%

Relatives of BD P's also have an increased risk of developing other affective disorders:
- Bipolar II, recurrent depressive, schizoaffective disorder

41

Depression

CLINICAL SYNDROME
- characterized by low mood
- lack of pleasure and even interest in normally enjoyable activities
- lack of motivation or drive
- variety of non-specific symptoms associated - disturbed sleep, difficulty concentrating, loss of appetite
- normally quite slow and unresponsive
- sometimes can be quite agitated?
- severe episodes - wracked by thoughts of guilt and hopelessness
- suicidal thoughts - may or may not act upon them
- single most common cause of suicide!

42

ICD-10 and DSM-IV criteria for Depression

Symptoms
* Depressed mood
* Loss of interest and enjoyment
* Increased fatigue
Reduced concentration and attention
Ideas of guilt and unworthiness
Ideas or acts of self-harm or suicide, thoughts of death
Sleep disturbance
Disturbed appetite / weight change
Pessimistic view of the future
Reduced SE and self-confidence

Features associated with somatic (ICD-10) or melancholic syndrome (DSM-IV)
- early morning awakening
- mood worse in the morning
- psycho motor retardation or agitation
- weight loss
- loss of libido

* = most typical symptoms

43

Depression - Symptoms and Severity

MILD = two typical and two other symptoms
MODERATE = two typical and three or four others
SEVERE = three typical and four or more others

44

Depression - a clinical syndrome?

Diagnosis is based on the presence of a sufficient number of symptoms that commonly co-occur

- depressive episodes - part of a long-term pattern of affective changes
- up to 90% of P's with one episode will experience another

Normally there are intervals of recovery between episodes
BUT - Dysthymia - milder form of low mood often accompanied by feeling tired and exhausted - chronic?

45

DSM-IV Criteria for a Major Depressive Disorder

- two main symptoms
- what are the other criteria

Five (or more) of the following symptoms have been present during the same 2 week period and represent a change from previous functioning

At least one of the symptoms is either:
1) Depressed mood
2) Loss of interest or pleasure

*do not include symptoms that are clearly due to general medical conditions, mood-incongruent delusions or hallucinations*

46

DSM-IV Criteria for a Major Depressive Disorder

- five or more of the following symptoms

Depressed mood most of he day, nearly every day as indicated by either subjective report or observation made by others
(note in children or adolescents - can be irritable mood)

Markedly diminished interest or pleasure in all, or almost all activities of the day, nearly every day (subjective account or observation by others)

Significant weight loss when not dieting or weight gain or decrease/increase in appetite nearly every day
(in kids - consider failure to make expected weight gains)

Insomnia or hypersomnia nearly every day

Psychomotor agitation or retardation nearly every day - observed by others, not merely subjective feelings of restlessness or being slowed down

Fatigue or loss of energy nearly every day

Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

Diminished ability to think or concentrate or indecisiveness, nearly every day (subjective account or observed by others)

Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

47

Depression - Prevalence

5-25% (DSM-IV-TR, 2000)

- 70% of cases - depression persists for about 1 year
- 15% of us suffer from depression at some point during their lifetime
- typically lasts 4-8 months - frequently people relapse!

48

Depression - World Wide View

- it is a major public health problem in industrialised countries
- growing problem in the developing world

WHO
- every year about 120 people throughout the world suffer from depression
- only 25% of these have access to effective treatment

49

Depression - Heritability

Most family studies of recurrent or unipolar disorder found a relative risk for UD in first degree relatives of 1.5-3
- weaker genetic contribution than other disorders

- Common and moderately heritable
- Recurrence and early age of onset characterise the cases with greatest familial risk

Earlier age of onset:
- (before 30) have a higher likelihood of suffering from UD too - genetic liability leads to earlier onset?
- associated with higher rates of relatives with alcoholism - weak genetic association?

50

Depression - Twin studies

Sullivan et al (2000)

Twin studies - shared environment plays a small role
Estimates of 37% + for heritability

51

Depression - Genetic links

Small positive associations have been suggested between the polymorphism in the serotonin transporter promotor regions (5-HTTLPR) and:
- bipolar, suicidal behaviour, depression related personality traits
- not MDD yet!

52

Depression - Neuroticism links!

- overlaps with the neuroticism (personality dimension) with regards to genetic susceptibilities
- useful quantitative trait or endophenotype

53

Depression - development of a depressive episode

A genetic predisposition, individual stressors and other aspects of the person's unique environment play equally important parts

54

Personality Disorders

"An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individuals culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time and leads to distress or impairment"

55

Personality Disorders - Criteria / Manifestations

The pattern is manifested in two (or more) of the following areas:
(1) Cognition - i.e. ways of perceiving & interpreting self, other people and events
(2) Affectivity - i.e. the range, intensity, liability and appropriateness of emotional response
(3) Interpersonal functioning
(4) Impulse Control

B. The enduring pattern is inflexible & pervasive across a broad range of personal and social situations

C. The enduring pattern leads to clinically significant distress or impairment in social, occupational or other important areas of functioning

D. The pattern is stable and of long duration & its onset can be traced back at least to adolescence or early adulthood

56

Personality Disorders - ICD-10 and DSM-IV

Both take a categorical approach to personality disorders

Assume that groups of commonly coinciding symptoms yield qualitatively distinct syndromes

57

Personality Disorders - DSM-IV

- Based on the symptoms that are present in addition to the general criteria
- Recognises 10 different personality disorders which are grouped into 3 clusters
- Cluster A, B and C

58

Personality Disorders - What is Cluster A and the personality disorders in it?

'Odd-Eccentric'

Paranoid Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder

59

Personality Disorders - Cluster A

Paranoid Personality Disorder

Characterised by irrational suspicions and mistrust of others

0.5 - 2.5%

60

Personality Disorders - Cluster A

Schizoid Personality Disorder

Lack of interest in social relationships, see no point in sharing time with others, anhedonia, introspection

Less than 1%

61

Personality Disorders - Cluster A

Schizotypal Personality Disorder

Characterised by odd behaviour or thinking

Ideas of reference, odd beliefs, unusual perceptual experience, odd speech / behaviour

3%

62

Personality Disorders - What is Cluster B and the personality disorders in it?

'Dramatic, Emotional or Erratic'

Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder

63

Personality Disorders - Cluster B

Antisocial Personality Disorder

Pervasive disregard for the rights of others, lack of empathy and (generally) a pattern or regular criminal activity

Deceitfulness, impulsivity, aggressiveness, recklessness, lack of remorse

3% in Males, 1% in Females

64

Personality Disorders - Cluster B

Borderline Personality Disorder

Extreme 'black & white' thinking, instability in relationships, self-image, identity & behaviour often leading to self-harm and impulsivity

Affective instability, anger, feels empathy, dissociative symptoms

3% in Females, 1% in Males

65

Personality Disorders - Cluster B

Histrionic Personality Disorder

Pervasive attention-seeking behaviour including appropriate seductive behaviour and shallow or exaggerated emotions

Centre of attention, suggestibility

2-3%

66

Personality Disorders - Cluster B

Narcissistic Personality Disorder

A pervasive pattern of grandiosity, need for admiration and a lack of empathy

Characterised by self-importance, pre-occupations with fantasies, belief that they are special, including a sense of entitlement and a need for excessive admiration and extreme levels of jealousy & arrogance

Less than 1%

67

Personality Disorders - What is Cluster C and the personality disorders in it?

'Anxious-Fearful'

Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive-Compulsive Disorder

68

Personality Disorders - Cluster C

Avoidant Personality Disorder

Pervasive feelings of social inhibition & social inadequacy, extreme sensitivity to negative evaluation and avoidance of social interaction

Preoccupation with criticism, inhibition when making new contacts, inferior self-image, low risk taking

0.5 - 1%

69

Personality Disorders - Cluster C

Dependent Personality Disorder

Pervasive psychological dependence on other people

Doesn't take responsibility, needs for reassurance, lack of confidence in own judgements, actions & opinions, needs company, submissive & clingy behaviour

Unknown %

70

Personality Disorders - Cluster C

Obsessive-Compulsive Personality Disorder

Not the same as OCD - personality!!!!

Characterised by rigid conformity to rules, moral codes and excessive orderliness

Perfectionism, dedication to work, conscientiousness, lack of flexibility and efficiency

1%