HD046

In Adolescence Development

1. Formal Operational Thinking

2. Self-Awareness

3. Moral Reasoning

4. Self-Esteem

Around 11-13 y/o kids are no longer solely bound by concrete, “here & now” thinking. They can consider ideas hypothetically with increased flexibility and possibility and they have more systematic problem solving with potential for:

•  deductive reasoning
•  “if-then” thinking
•  mental hypothesis testing

• Increased awareness of own mental processes
• Metacognition – “thinking about thinking”
• Introspection – thinking turned inward; evaluation of one’s motives, feelings, attitudes toward oneself.
• Increased Egocentrism (obsessive self-focus)

• Shift from conventional to postconventional moral reasoning
• from “law & order”/social approval to social contract and universal ethical principles
• Ex. Why am I ______ religion

Emergence of an “ideal self” and this impacts self-esteem

HD046

Process of Establishing an Identity

James Marcia’s Empirical Approach: Identity Status

1. Early signs of an emerging self
• Need for separateness/autonomy
2. Identity “crisis”
• Experimenting with new roles
3. Resolution of the crisis and movement to the “intimacy” stage

• Identity diffusion
• Foreclosure
• Moratorium
• Identity achievement

[image]

Exploration of alt.:
How much have they actively participated in the process of forming an ID?
Commitment:
How commited are they to a certain value system?

ID diffusion:

• No plans for future (no commitment)
• Little values systems
• Lives at the whim of chance
• Little sense of urgency to explore things

Forclosure:

• Absence of exploration of alternatives
• Never been active in searching for values, goals etc.

Moratorium: Peaks in college years

• Classic adolesence ID crisis problem
• On their way to becoming ID achieved – trying on the different hats
• No commitment yet, but there is the exploration of alternatives
• More experimental, very active in this process

ID Achievement:

• Every one starts off at ID diffusion, and then goes foreclosed route of Moratorium root
• To get to ID achieved you have to go through Moratorium

HD043 - 82 slide very text heavy slide so this is all from JYYS, still re-read the ppt

Personality development

A personality disorder is...

• Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and one’s self that are exhibited in a wide range of social and personal contexts
• Development depends on interaction of many factors
• constitution, innate temperament, family experiences, quality of family attachments, role models, acquisition of coping skills
• Adolescent personality is not rigidly fixed
• Malleable in this life stages within the constraints imposed by temperament, untoward childhood experiences & current familial circumstances

when personality traits are inflexible, maladaptive, and cause significant functional impairment or subjective distress

HD043

Diagnosis of Personality Disorders (PD) (Adolescence)

2 Models for Personality Disorders

• Enduring pattern of inner experience & behaviour that deviate markedly from the expectations of one’s culture at least 2 of the following 4 areas need to be present for diagnosis
• Cognition, affectivity, interpersonal functioning, impulse control
• Pattern is stable, of long duration and can be traced back at least to adolescence or early adulthood
• Not better accounted for by another mental or physical disorder
• Personality appears to have continuity from at least age 3 years

Conflict model: adolescents need to go through a period of crisis to separate themselves from their parents & carve out their own identity

• Adolescents who do not experiment with illegal drugs are often as poorly adjusted as those who overindulge

Continuity theory: stormy, moody, conflict-ridden adolescent is the exception rather than a rule

• Depressive & anxious symptoms in childhood predictive of cluster B disorders in adolescents

HD043

 PD facts in Adolescence

Borderline PD

• Can be diagnosed in adolescents
• predictive of ↑odds of major mental illness diagnosis in young adulthood
• Do not present as complete PD – rather as teens with maladaptive traits whose maladaptive functioning has accentuated in the context of a crisis
• separation/individuation, identity, drug & alcohol, school refusal/failure
• gang activity/delinquency, criminal behaviour
• Sexuality crisis, ex. promiscuity, homosexuality or bisexuality as an identity crisis
• abuse, recent or remote
• suicidality and other psychiatric or non-psychiatric crisis

• Genetics likely a factor
• 11% prevalence of BPD in first degree relatives of probands with BPD
• Symptoms/presentations
• Pervasive pattern of instability of interpersonal relationships, self image, and affects, and marked impulsivity
• Frantic efforts to avoid real or imagined abandonment
• Unstable & intense interpersonal relationships characterized by alternate idealization & devaluation
• Identity disturbance
• Impulsivity (self damaging)
• Aetiology similar to that in adults, beginning around age 14
• history of sexual trauma, disruptive attachments

HD043

Antisocial PD

Narcissistic PD

• Diagnosed at least 18 years of age, conduct disorder before age 15
• Symptoms/presentations
• Disregard for & violation of the rights of others since age of 15 years
• Failure to conform to social norms with respect to lawful behaviours
• Deceitfulness
• Disinhibition (impulsivity, irritability & aggressiveness)
• Reckless disregard for the safety of self or others
• Behavioural inhibition is likely a risk factor for other personality disorders (ex. avoidant PD)

• symptoms/presentations
• grandiosity, need for admiration, lack of empathy
• grandiose sense of self importance
• preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love
• sense of entitlement
• interpersonally exploitative
• often envious of others or believes others are envious of them
• arrogant, haughty behaviour/attitudes
• Aetiology: failure for parents to convey acceptance/approval
• Treatment use a holding environment (ex. psychotherapeutic relationship) → empathy, mirroring (validation)

HD043

DSM IV Personality Disorders Clusters

Personality Disorder Development: Izard

Cluster A: Paranoid, Schizoid, Schizotypal
Cluster B: Antisocial, Borderline, Histrionic, Narcissistic
Cluster C: Avoidant, Dependent, Obsessive Compulsive

Six emotions are considered to be basic…unlearned and universal… preempt consciousness

1. interest
2. joy/happiness
3. sadness
4. anger
5. disgust
6. fear

over time the basic positive and negative emotions are gradually replaced by emotion schemas in which cognitive frames, appraisals, and attributions develop out of the individual's emotional experience and replace the emotions as the predominant motivators. These “motivators” may be seen as temperament in early childhood the schemas combine these emotional states in relatively common/correlated patterns, more or less uniquely across individuals, based on genetic and experiential combinations. Personality differences develop from combinations of individual genetic based differences in the relative strength of these emotions and life experiences that shape the nature of the individual's schema regarding self, others, and the world they live in.

HD047

James Marcia’s identity statuses to each of

the girls in Talk 16

Helen = Foreclosed (the uptight Korean girl)

• More concrete thinking
• Committed to goals
• Listens to external authority
• No exploration of alternatives

Lena = Moratorium (the Russian with huge glasses)

• Change appearance, jobs
• Angst; trying on many things
• A lot of exploration, experimenting with new roles

Rhonda = Moratorium, but closest to identity achieved

• Explored cultural identity
• Committed to exploring acting as a career

Erin = Identity diffuse (the clueless dumb “blond (?)”)

• Not care about school, future
• Sense of invincibility (when get cervical cancer, not too worried)

Astra = Identity diffuse (the blond trouble child)

• Tries out work, school, but not seriously exploring them
• Sense of invincibility (not worried about STIs, pregnancy)
• Present oriented, passive, lack of commitment

HD040

Anxiety Disorder in Adolescence/Children:

What is anxiety?

What is a panic attack?

Emotions such as “afraid”, “scared”, or “nervous” which are associated with a sense of impending danger in the absence of a recognizable adequate external threat.

• Somatic symptoms: lump in the throat, a sense of constriction in the chest or butterflies in the stomach
• Aautonomic disturbances: tachycardia, palpitations, dry mouth, sweating, frequency of micturition or diarrhea

A discrete period of intense apprehension or fear (‘terror’) occurring in the absence of an adequate cause and which is associated with palpitations, sweating, a sense of constriction in the chest, dyspnoea, choking, dizziness, vertigo, paraesthesiae, hot and cold flashes, shaking and clouded thinking. More common in children with the onset of adolescence with sexual maturity.

HD040

DSM-IV classifies phobias into three major categories

1. Specific phobias:
Animal phobias: Some animal phobias e.g., fears of snakes are universal. Others start in childhood (an event) and may persist into adulthood
Phobias of the natural environment e.g., fear of water, heights and storms.

Blood-Injection-Injury phobias
Phobias of a variety of situations such as flying, heights, elevators, enclosed spaces, driving.

2. Social phobias (or Social Anxiety Disorder)

An excessive fear of being embarrassed in a social situation e.g., public speaking (stage fright), participating in group discussions, dating, and going to a party. Children with social phobia are shy, lack in confidence, shrink from contact with others, do not participate in group activities, are terrified of having to present in front of a group or take a test, and may underachieve academically. Some children with Selective Mutism (children who are mute at school but speak normally at home) probably have a form of social phobia.

3. Agoraphobia is a fear of crowds. Agoraphobic patients are afraid to go out unaccompanied; they are afraid of crowds, shopping centres, buses and travelling. Unlike adults, children do not usually have to go shopping unaccompanied, but they have to go to school. School phobia is the agoraphobia equivalent of childhood

HD040

Separation Anxiety Disorder

• Specific to childhood and occurs when a child develops intense anxiety to the point of panic, as a result of being separated from a parent or another loved one – most often mom.
• The disorder usually develops in children who are conscientious and well behaved and come from close-knit families. It may develop acutely after a psychological stress e.g., death of a grandparent, moving to a new neighbourhood and a new school, or after a medical condition
• The patient may also be afraid to go to school (school phobia), sleep overnight at a friend’s home or go to summer camp
• The child may be afraid that the parent will get sick and die or someone will kill her or that the parent will mysteriously or tragically disappear
• As well, the school phobic complains of numerous somatic symptoms. He has headaches, stomaches, dizziness and other pains and aches; he feels tired. He has difficulty going to sleep alone and may try to sleep with his parents
• In about twenty per cent of patients the mother is also depressed. She clings to her child as much as he is clinging to her
• In their thirties we find that many are still living with their parents, have few social contacts outside their immediate families, and they continue to see a psychiatrist

HD040

Types/causes of anxiety (5)

Treatment of Anxiety Disorders

DSM-IV Anxiety Disorders

1. A normal state

Nearly all children have fears that vary with age.
2. A symptom of a general medical condition

Ex. Generalized Medical Condition such as epilepsy, cardiac arrhythmias, bronchial asthma, phaeochromocytoma, hypoglycaemia, hypocalcaemia, or thyroid disease may be expressed as an anxiety disorder
3. Induced by a substance, either as a symptom of intoxication or withdrawal. Excessive ingestion of caffeine OTC medications, prescription drugs, some psychotropic drugs and illicit drugs
4. A symptom of other mental disorder such as schizophrenia

5. A syndrome

When the above four are excluded we are left with a group of mental disorders in which primary symptoms of anxiety dominate the clinical picture. The aetiology of the idiopathic type is poorly understood, and probably involves and interplay of hereditary, biological, psychological and sociocultural factors. Behavioural inhibition with shyness, fear and a tendency to withdraw in response to new situations are enduring traits linked with the development of anxiety disorders of childhood. Insecure attachment to parents may be related to such behavioural inhibitions

Medications include:

1. Antidepressants: most often the SSRIs 
2. Benzodiazepines e.g. lorazepam
3. Behaviour therapy or cognitive-behaviour therapy are 2 of the psychotherapies commonly used

1. Panic Disorder
2. Panic Disorder with Agoraphobia
3. Agoraphobia without history of Panic Disorder
4. Specific Phobia
5. Social Phobia
6. Generalized Anxiety Disorder
7. Obsessive Compulsive Disorder
8. Acute Stress Disorder
9. Post Traumatic Stress Disorder

Note: Separation Anxiety Disorders are discussed separately

HD040

Depression in Children and Adolescence

Symptoms

Not uncommon in childhood and adolescence. Approximately 1% of preadolescents and 2-3% of adolescents suffer from a clinical major depression at any one time

May be difficult for children to describe

• Many adolescents present following a suicide attempt. Suicidal thoughts and suicidal attempts are less common before puberty. Adult patients with depression usually eat less and sleep less.
• Adolescents with depression usually eat more
• In young people we rarely see the classical insomnia, Oversleeping is more common
• Mood, irritable, loss of interest in activities
• Poor concentration

HD040

Mild chronic depressions

Types of Mood Disorders in Children/Adolescence

Course, prognosis and complications (Mood Disorders)

Anxiety and Depression

Dysthymic Disorders

• Milder, partial chronic depressions lasting more than one year (more than two years in adults).
• They are not uncommon in children
• Show more general social impairment than those with major depression and they are more likely to be seen as being ‘bad’ children.
• A short-lived debilitating illness such as major depression may cause less disruption of a child’s development than the milder but long lasting disturbance of dysthymia

1. Unipolar Disorder (recurrent depressions): Primary or Secondary to other conditions

2. Bipolar Disorder (Mania or Hypomania w/ severe depression): Primary or Secondary to other conditions

Prognosis for the individual episode is good but depression is a relapsing disorder. Approximately 80% of children will have a recurrence of their depression.

Majority of patients we see present with mixtures of both anxiety and depression

HD051

Shamattawa

Suicide Stats

Important Factors

Manitoba Reserve w/ lots of suicide

• Suicide rates have increased since 1960 (esp males)
• Attempts are 20X more frequent
• Girls attempt 3X more than boys
• Boys die 3X more than girls
• Rates are ~15 deaths per 100,000   (or higher)
• Suicide has been the #2 cause of death among teens in Canada
• Aboriginal Populations
• 3 x age specific rates
• 2 x sex specific rates
• Inuit Populations
• 60-75 per 100,000
• Aboriginal Youth
• rates 5-7x higher than non-Aboriginal youth
• Inuit youth approach 11x national average
• Certain Canadian studies put Aboriginal males at a five times greater risk that females
• Aboriginal females 8 times more likely than non-Aboriginal females
• 40-60% have seen a physician in the month prior (Most saw a family doctor)

Important Factors:

• Psychiatric Disorders (80-100%)
• Previous attempts (1/3 try again)
• Family history
• Prozac - Inc risk of Suicide

HD062

Vicarious Traumatization

Intimate Partner Violence (IPV)

What is the harm?

Transformation in the self of a trauma worker or helper that results from empathic engagement with traumatized clients and their reports of traumatic experiences

Infliction of direct physical, sexual, psychological threat or harm by a partner, or the threat of being forced to witness violence against a loved one or pet

Epidemiology:

Women:

• USA 8-13% women per year or in Canada 29% assault by present or past partner
• Violence in 50-60% of couples in counseling

Children:

• In 39% of cases children witness violence against their mothers
• Child witnesses 81% of  IPV
• 63% of witnessing IPV  fair poorly, similar profile to actual abuse
• 40% co-occurance of IPV and physical child abuse

• IPV is the leading cause of physical injury to women aged 15-44
• 1/3 fear for lives when assaulted
• 45% result in physical injuries
• 44% of those sought medical attention
• Women in shelter for severe abuse
• 86% moderate to severe PTSD
• 72% have depression

HD062

Theories on why IPV occurs

Feminist Theory

• Control caused by a social context that supports patriarchal values
• But, no evidence yet that a decrease in abusive behaviour related to change in patriarchal values

Relationship Theories

• Abuse occurs in a coercive hostile relationship system that needs to change
• But, no evidence that changes in hostility, criticism and aversive content results in change in abusive behaviour

Personality Theory

• Caused by a constellation of personality disorders
• Narcissistic, avoidant and angry personality features are common
• Changes in level of anger and alcohol use are each related to changes in abusive behaviour

Alcohol & Drug Use

• 50% of men seeking treatment for alcohol addiction admit physical assault on their partner
• High use the only predictor of male initiated IPV, but not of female initiated IPV

Cognitive Behaviour Theory

• Abuse is learned and then maintained by a lack of nonabusive interpersonal coping skills
• Abusive men are less skilled at emotionally charged problem solving.
• No evidence that communication skills decrease physical abuse

Attachment Theory

• Childhood hx results in unrealistic and unhealthy assumptions about relationships

HD062

Who (males) is abusive?

Cycle of violence

Three types of abusive men:

1. Family Only (50%)
   
   • Low level violence
   • Low level of pathology
   • Find intimacy challenging
2. Dysphoric/borderline (25%) 
   
   • High psychological distress
   • Sensitive to rejection
3. Generally violent/antisocial (25%)
   
   • High aggression within and without family
   • Most serious forms of abuse

Tension Escalates

Occurrence of several incidents considered minor by the victim. The victim believes that the situation is temporary and that she will be able to control it
Violence explodes

Total loss of control. Short episode, always serious, lasting up to 24 hours

Calm reconciliation

The perpetrator seeks forgiveness while the victim is hopeful and wishes to forget. The period varies in length and may not occur at all in some couples.
Note: Cycle builds in intesity and risk of harm over time

HD062

IPV Offender Treatment

Why women stay or return in IPV

1. Anger management
2. ‘Violence is a choice’
3. Negative impact on others (empathy)
4. Violence cannot be justified or rationalized

Effectiveness:

• Compliance Issues
• Drop out rates vary 50 to 75%
• 20% - 50% of those court ordered don't attend
• Completers
• 2/3 not re-arrested within 6 months
• 1/3 re-arrested on 1 event, avge 5 others un-reported.
• Issues since 50% in treatement are also in Alcohol Treatement

1. For sake of the children (31%)
2. Give relationship another chance (24%)
3. Partner promised to change (17%)
4. Lack of money (9%)

¾ of those who leave - return

HD062

Reporting of IPV (Stats)

WAST

• 26% lay complaint with police
• More likely if:
• Child witnessed
• Violence severe/Use of weapon
• Ongoing violence
• Less likely if:
• Damage too minor -main
• Privacy, help not wanted, avoid police, fear partner
• Charges are laid in 28% of complaints
• 65% satisfied with police role

Woman Abuse Screening Tool

HD070

Bipolar Disorder (BD) Generally

Types of Bipolar Disorder (Generally)

Definition of a Manic Episode

• Incidence: Bipolar I – 1 %, Bipolar II – 1%, Bipolar Spectrum - 2%
• Early onset (17 – 21 y.o.)
• Comorbidity commonly includes substance abuse, anxiety disorders and personality disorders
• 15 – 20% of patients die by suicide in some studies

1. Bipolar I - recurrent episodes of both mania and depression

2. Bipolar II - hypomania - like mania, but less severe (no marked change in functioning)

3. Cyclothymic disorder

4. Bipolar disorder not otherwise specified (NOS) - episodes of depression accompanied by mood elevations which do not meet criteria of hypomania 

• 1 week period of expansive, elevated or irritable mood
• 3 or more of:
• Grandiosity
• Decreased need for sleep
• More talkative
• Flight of ideas / racing thoughts
• Distractibility
• Increased goal-directed activity or psychomotor agitation
• Excessive involvement in pleasurable activities with high potential for painful consequences (spending sprees, sexual indiscretions, etc.)

HD070

Bipolar II

BDNOS

Both usally present with...

Periods of hypomania typically occur either before or after periods of depression, but also may occur independently

Treatment:

• Quetiapine is only medication with level 1 evidence for acute depression
• Second line evidence includes Lithium (for maitenance)
• Risk of mood elevation from antidepressants is much lower in BPII than BPI

• Not well defined
• Would include episodes of depression accompanied by mood elevations which do not meet criteria of hypomania (too few symptoms or too short a duration) or predictors of bipolarity (ie. Family history)
• Hypomania in DSM-IV requires a 4 day minimum duration
• Clinicians often see it being shorter (1-3 days)

Diagnosis: often diagnosed on the balance of probabilities
Weight given to predictors:

• Atypical depressive symptoms (hypersomnia, hyperphagia, leaden paralysis)
• Psychomotor disturbance
• Psychotic features/pathological guilt
• Positive family history of bipolar disorder

Depression first - look out for the other signs

HD070

Predictors of Bipolar Disorder

Management of Acute Mania

1. Depression below the age of 20 with psychotic symptoms
   
2. Family history of bipolar disorder
   
3. Pharmacologically induced hypomania
4. Episodic anxiety
5. Psychomotor slowing
6. Atypical features: reverse vegetative symptoms
7. Irritability
8. Chronic depression

Assessment: Is it..

Pure or mixed mania
With or without psychosis
With or without rapid cycling

Emergency Management:

• Oral or I.M. antipsychotic +/-Benzodiazepine
• Haldol +/- Lorazepam
• SGA +/- Lorazepam

First Line Treatment:

• Mood stabilizer (Lithium) and/or second generation antipsychotic
• Lithium has a narrow theraputic range and remission is not uncommon
• Antidepressants should be discontinued in all manic patients and stimulants avoided (i.e. Caffeine)

Rationale for Add-On Treatment:

Mood stabilizer monotherapy produces improvement but is frequently too slow or inadequate to achieve remission in acute mania. Hence, atypical neuroleptic medication is generally added  to the mood stabilizer

HD070

 Management of Depression (in BP)

Prophylaxis in BD

Bipolar patients actually spend much more time depressed than manic/hypomanic

1. Monotherapy with Lithium, Lamotrigine or Quetiapine
2. Combination therapy with Lithium plus Divalproex
3. Lithium or Divalproex plus SSRI or Bupropion
4. ECT
5. Cognitive Behavioral Therapy

• Relapse rates in patients who discontinue pharmacotherapy =  60-80%
• Relapse rates in patients who continue medication = 20-50%
• Goal is to prevent relapse

First Line Options:

1. Monotherapy with mood stabilizer (MS):  Lithium, divalproex, Lamotrigine (for depression)
• Good for Rapid Cycling
2. Monotherapy  with second generation anti-psychotics (SGA)
3. Combination of MS and SGA

Second Line Options:

1. Carbamazepine
2. Lithium or Divalproex plus anti-depressant

Third Line Option:

Clozapine

HD070

Major Depression in Adults

Protective and Risk Factors

• Lifetime Incidence of Any Mood Disorder – 20 %
• Lifetime Incidence of Any Major Depression – 8 %
• The leading cause of disability and premature death among 18-44 year olds
• WHO predicts it will be the 2nd leading cause of disability for people of all ages by 2020
• 2 ♀: 1 ♂
• Risk ↑ 1.5-3x if Major Depression in 1st degree relative
• 2 peak ages of onset: 15-25 and 65-75 - possibly

Protective:

• Good social support network consistently shown to be one of strongest protective factors

Risk factors:

• Presence in the home of several young children
• Absence of a confidant with whom the subject could discuss worries
• Lack of full-time or part-time employment
• Loss of mother by death or separation before the age of 11

HD070

DSM IV Criteria for Major Depression

SIG E CAPS (Prescribe Energy Capsules)

A.  Five (or more) of the following symptoms:

1. Depressed mood
2. Markedly diminished interest or pleasure
3. Decrease or increase in appetite
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive or inappropriate guilt
8. Diminished ability to think or concentrate
9. Recurrent thoughts of death or recurrent suicidal ideation

B.  Symptoms present for 2 weeks
C.  Symptoms cause clinically significant distress or impairment

Sleep (Insomnia/hypersomnia)
Interests (Dec)
Guilt       

Energy (loss)

Concentration  (dec or indecisive)
Appetite (Dec, >5% weight loss or gain)
Psychomotor (retardation or agitation)
Suicidality

HD070

Major Depression is believed to result from...

Common clinical errors in treating Depression

The disruption of normal brain neurochemistry:
Norepinephrine →  motivation, energy, anxiety, irritable

Serotonin → impulsivity, mood, appetite, sex, aggression
Dopamin  → reward circuits

Medications, ECT, and depression-focused psychotherapy can all affect neuronal growth and regional brain metabolism

third to half of patints receive appropriate treatment b/c:

1. Insufficient questioning
2. Failure to consult a family member
3. Making a diagnosis of depression when only depressed mood is present
4. Exclusion of a diagnosis or failure to treat despite presence of symptom complex

HD070

Antidepressant Medication

Pharmacotherapy Failure

Maintenance Treatment for Depression

• Preferred treatment in moderate to severe depression
• 60-70% response rate (vs 30% for placebo)
• Vegetative symptoms often improve prior to mood
• Symptoms typically begin to resolve after 2-4 weeks 
• Full resolution may take up to 4 months

• 60% of patients show a response after 3-6 weeks BUT if no response in 3 weeks, likelihood of response is 20%
• Switch to a different SSRI or newer anti-depressant if no response
• Generally reserve TCA or MAOI until at least 2 failed trials

• 70% lifetime recurrence rate
• Continue for at least 6 months after recovery
• Consider indefinite treatment for high risk patients
• Taper gradually
• Minimum of 6 – 9 months of continuation pharmacotherapy (at full dose) in patient without recurrent episodes of depression
• Minimum of 2 years for patients with recurrent depression or with risk factors for recurrence
  
  

HD070

Risk Factors of Recurrence for Depression

What is the most effective treatment for depression?

• Older age
• Episodes which are chronic, severe, psychotic or difficult to treat
• Significant medical or psychiatric comorbidities
• Residual symptoms
• A history of recurrence with antidepressant discontinuation

ECT

• 60-80% response rate
• Typical course:  6-12 treatment, 2-3 treatments/wk
• First line for psychotic, actively suicidal and medication-resistant depressions

HD070

Cognitive, Behaviour and Interpersonal Therapy

Comparison

Cognitive Therapy

• Attempts to change automatic and maladaptive ways of thinking
• Teach pt. to identify and respond in more adaptive ways

Behaviour Therapy

• Targets social withdrawal and anhedonia
• Increase activity levels and engage pts. In activities to increase feelings of mastery and pleasure
• Train in social skills, assertiveness, and problem solving

Interpersonal Therapy

• Focuses on relationship issues
• Encourages affective expression
• Improved communication and dispute resolution with significant others
• Social skills training to reduce social isolation

• CBT, BT, IPT all about equally effective in studies (60-70%)
• All are equal to medication in studies for mild to moderate depression
• Pharmacotherapy is more effective for severely ill patients

HD074

Different Stages of Grief/Bereavement

RFs for poor Bereavment Outcome

1. Anticipatory grief – in anticipation of death of another
2. Acute grief

• Somatic distress
• Preoccupation with images of the deceased
• Guilt
• Hostile reactions
• Loss of patterns of conduct/activity
• Appearance of traits of the deceased (starting to act like the deceased)

3. Pathological Grief

Phases of grief after death

• Usually in stages: denial → disbelief → acceptance → resolution
• People grieving regard their feelings as normal – normal & uncomplicated bereavement does not present like severe depression - eventually regain lost functions

• Poor social support
• Few religious resources
• Being very dependant on the deceased
• Ambivalent marital relationship
• Minimal funeral ceremony associated with denial of impact of death
• Previous psych history/Depression
• Low socioeconomic status
• Short terminal illness with little warning of impending death
• Multiple life crises
• Reactions of distress, yearning, anger of
• Self-reproach
• Alcoholism/tobacco/drugs

 HD076

Gender identity disorders

 Paraphilias

Key diagnostic features:
1. Evidence of cross-gender identification. In children, manifested by four (or more) of the following:

1. Repeatedly stated desire to be, or insistence that he or she is, the other sex
2. In boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing
3. Strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex
4. Intense desire to participate in the stereotypical games and pastimes of the other sex
5. Strong preference for playmates of the other sex

2. Evidence of persistent discomfort about one’s assigned sex

3. There must NOT be any physical intersex condition

4. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

“Recurrent, intense sexual urges, fantasies, or behaviors that involve unusual objects, activities, or situations and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning"

1. Exhibitionism - want to expose self
2. Fetishism - inanimate object
3. Frotteurism - Rub against people
4. Sexual masochism - Be degraded
5. Sexual sadism- Degrade others
6. Transvestic fetishism - focus involves cross-dressing by a male in women’s attire
7. Voyeurism - watch unknowing people undress/have sex
8. Paraphilia NOS – paraphilias that don’t meet any criteria listed above.  Examples: necrophilia, telephone scatologia (obscene phone calls), coprophilia (feces), klismaphilia (enemas), zoophilia (animals)

HD076

Possible contributory factors in the development of paraphilias

Psychodynamic

• Paraphilias protect the ego from repressed fears and memories
• Represent fixations at pregenital stages of psychosexual development
• “Castration anxiety” – by showing his genitals to others, the exhibitionist is reassuring himself about his own masculinity/manhood

Behavioural and Cognitive

• Paraphilias arise from classical conditioning that has linked sexual arousal with stimuli that have been labeled by society as inappropriate
• Due to troubled childhood and other social-developmental factors leading to insecure attachment, individuals substitute paraphilias for conventional relationships
• Cognitive distortions (e.g., the voyeur observing a woman who has left her blinds open while undressing believes that she did it intentionally)

Biological

• Speculation that since the majority of people with paraphilias are male, androgen plays a role

HD081

Schizophrenia before DSM

Schizophrenia (DSM)

Bleuler

• 1º symptoms: Autism, flat Affect, thought disorder (loose Association), Ambivalence
• 2º symptoms: delusions, ideas of reference, hallucinations

Schneider

• 1st rank: thoughts out loud, thoughts broadcast, thoughts controlled, actions controlled, delusions
• 2nd rank: affective changes, hallucinations (other), emotional blunting, perplexity

Crow et al. (1900s)

• Type 1 (+) excess: delusions, hallucinations, thought disorder, bizarre behaviour
• Type 2 (-) absence: alogia, blunted affect, asocial, decreased attentionMeds work better againts the + symptoms, so people will end up behaving with the - symptoms

1. Characteristic Symptoms (>2), for a significant period, during a 1-month period…
          1)   Delusions
          2)   Hallucinations
          3)   Disorganized Speech (derail/incoherent)           4)   Behavior (grossly Disorganized/Catatonic)
          5)   Negative Symptoms (flat affect, alogia,             avolition)
   Only 1 symptom if bizarre delusions/ or voices
2. Social/Occupational Dysfunction
3. Duration - >6 months..at least 1 as A., with negative +/or mild positive signs
4. Rule out Schizoaffective/Mood Dis.
5. Rule out Substance/General Medical
6. Not  Pervasive Developmental Disorder

HD081

Schizophrenia Sub-types

Other Schizophrenia-like diagnosis

1. Paranoid -  Delusions or Hallucinations - common
2. Disorganized -  …Speech, Behavior, and                  Affect disturbances
3. Catatonic  -  Motor abnormalities
4. Undifferentiated
5. Residual

Schizophreniform Disorder

• Essentially schizophrenia, but when symptoms are have present for 1-6 months – diagnosis changes to schizophrenia after 6 months

Schizoaffective Disorder

•  Concurrent Mood Episodes - not well understood

Brief Psychosis

• Time:  1 day – 1 month

Psychotic Disorder

• due to … GMC (General Medical Condition)

Hallucinations/Delusions in context of evidence of direct physiologic effect (not Delirium) – not delerius

• Ex smelling burnt toast pre-stroke

Substance-Induced Psychotic Disorder

• Not all psychosis are schizophrenic

HD081

Delusional Disorder

Shared Psychosis Disorder

Criteria:

• Nonbizarre Delusions, > 1month (real-life situations)
• Never met Criterion A) of Schiz.
• Functions OK, behavior not obviously odd or bizarre (apart from delusion’s impact or its’ ramifications)
• Ex thinking someone is after you after small car accident

Subtypes:

• Erotomanic - another is in love w/ them
• Grandiose – inflated worth, power, etc
• Persecutory – being treated badly
• Somatic - physical defect, or condition – think they have a disease
• Mixed, Unspecified

AKA Folie a Deux

• Delusion develops in one, in context of close relationship with another who has an established delusion
• Delusion is similar to 1st person’s
• Not better accounted for by other

HD086 - Psychotic Disorders II (no answers, ask someone)

 HD088 -Psychotropics - Look at Coop notes/Tutorial

HD126

Eating Disorders Epi

Anorexia Nervosa & Bulimia Nervosa Similarities

Prevalence 4%
90-95% female
Age of onset generally teens & early adulthood

Both have:

• Preoccupation with weight
• Desire to be thinner

Not mutually exclusive

• 50% of anorexic pts will also have bulimia

HD126

DSM Criteria for Anorexia Nervosa

 2 types

Associated Behavious

Epidemiology of Anorexia Nervosa

Outcome

• Refusal to maintain body weight at or above a minimally normal weight for age and height (<85% of expected weight)
• Intense fear of gaining weight or becoming fat, even though underweight
• Absence of at least three consecutive menstrual cycles

1. Restricting Type:

Person has not regularly engaged in binge-eating or purging behavior

2. Binge-eating/purging Type: (Higher Mortality)

Person has regularly engaged in binge-eating or purging behavior

Self induced vomiting or the misuse of laxatives, diuretics or enemas

1. Markedly restrict calories
2. Strange dietary rituals
3. Compulsive exercise

• 0.5% lifetime prevalence in women for narrowly defined disorder
• 3.7% for more broadly defined anorexia nervosa
• Male-female prevalence ranging from 1:6 to 1:10
• Incidence is increasing (from upper to middle class too)
• Japan is the only non-Western country with figures comparable to US
• Onset is 12-25 with bimodal peaks 14 and 18
• Increasing cases in minorities, prepubertal children, women of all ages

• Prognosis: modest % (30-50%) recover, 20% = ongoing, remitting illness, 20% relapse, 5-10% death
• Medical complications related to weight loss – cachexia, cardiac, digestive/GI, reproductive, dermatologic, hematologic, neuropsychiatric, electrolyte imbalance (esp. hypokalemia)
• Some FX are irreversible – ex. calcium deficiency in late teens → brittle bones
• Medical complications related to purging – dental, metabolic, digest/GI, neuropsychiatric
• Physical signs – dry skin, lanugo, brittle hair & nails, orthostatic changes, hypotention, cold & cyanotic periphery, ↓body temperature, ↓pulse rate, edema
• Co-morbid axis 1 diagnoses
• depression, substance abuse, OCD, anxiety disorder, panic disorder, psychotic disorder (though rare)
• Causes of death – suicide, sudden cardiac arrhythmias, starvation

HD126

Bulimia Nervosa (DSM)

Prevalence

Outcome

• Binge eating and inappropriate compensatory behaviors occur at least twice a week for 3 months
• Bulimia people are usually in the normal weight range
• Purging type and Non-purging type (ex someone that over-exercises)

Females:  Lifetime prevalence 1.1 to 4.2%
Males:  Lifetime prevalence 0.1%

Onset late adolescence to early adulthood

• Physical signs: Russell’s sign, hypertrophy of salivary glands, ↑ serum amylase, dental complications, ↑ temperature sensitivity, ↑ rate of caries development, muscle weakness, edema
• Medical complications (related to purging): dental, metabolic, digest/GI, neuropsychiatric
• Prognosis: Long term little known, 50-70% short term success rate
• Comorbitities: Depression and Dysthymia, Bipolar disorder, Substance abuse, Personality disorder

HD126

Aetiology of Eating Disorders (3 Theories)

Look at HD89, 90 for tutorial Qs

5 Axis of DSM

Biological theories – hypothalamic abnormality, variants of a mood disorder (esp. bulimia), genetics, autointoxication with endogenous opioids, starvation & malnutrition
Psychological theories – maladaptive learned responses (→ ↓anxiety), cognitive distortions, distortions of perceptiosn & interoceptions, way of putting off tasks of adolescence, weak sense of self & low self-worth, family factors
Social & cultural factors – society’s attitudes on beauty & fashion

Axis I    Clinical Syndromes
Axis II   Personality Disorders (put on seperate access from axis I b/c of the FX they have on axis I)
              Specific Developmental Disorders
Axis III  General Medical Conditions
Axis IV  Psychosocial  Problems
Axis V   Global Assessment of Functioning

HD093

Personality Disorder Overview

Cluster A, B and C

Personality is:

• Totality of emotional and behavioral traits that characterize the person in day to day living under ordinary conditions
• Relatively stable and predictable

Personality Disorder (PD):

• Variant of those character traits that goes beyond the range found in most people
• Inflexible and maladaptive and cause functional impairment or subjective distress
• Deeply ingrained, inflexible, and maladaptive patterns of relating to and perceiving both the environment and themselves
• Traits must be long-standing with a longitudinal history of reactions/actions in certain situations

Epidemiology:

• 10-20% of the general population meet criteria for one or more personality disorders
• Prevalence far greater in psychiatric samples
• Axis II disorder affects response to treatment and presentation of Axis I disorder (esp Depression)

CLUSTER A  “odd, eccentric”

Paranoid
Schizoid
Schizotypal

CLUSTER B “dramatic, emotional, erratic”

Histrionic
Narcissistic
Antisocial
Borderline

CLUSTER C  “anxious, fearful”
Avoidant
Dependant
Obsessive-compulsive

HD093

Paranoid PD

Characteristics:

• Longstanding suspiciousness and mistrust of people
• Self-fulfilling prophecy
• If patient acts suspicious towards doctor because patient believes doctor is out to get him. The doctor will feel the hostile environment and suspicion towards self, and react in a way that confirms the patient’s original suspicion/belief
  
  
• Often hostile, irritable and angry
• Refuse responsibility for their own feelings and assign responsibility to others (projection)
• Lack warmth, appear unemotional

Epi:

• Prevalence 0.5 – 2.5%
• Males > females
• Believed to be more common among minority groups, immigrants, deaf
• Relatives of people with schizophrenia show increased incidence of paranoid personality disorder

Etiology:

• Specific causes unknown
• Early childhood deprivation or child abuse alone or with genetic susceptibility

Course and Prognosis:

• Lifelong problems living and working with others
• Occupational and marital problems common (Due to Paranoia)
• Vast majority don’t develop schizophrenia – most stay in the paranoid personality realm
• No thought disorder because able to rationalize paranoia

Management:

• Be straightforward, honest, explain all procedures fully
• Don’t argue, agree to disagree
• Don’t be defensive
• Control/set limits on threatening behavior

HD093

Schizoid Personality Disorder

Characteristics:

• Lifelong pattern of social withdrawal
• No desire to have close relationships with other people
  
• Solitary type jobs
• Non-competitive
• Discomfort with human interaction, introversion
• Lifelong inability to express anger directly
• Bland, constricted affect
• Appear cold and aloof
• Won’t even be closely tied or feel much towards family
  

Epi:

• Prevalence unknown – uncommon in clinical settings
• Little evidence linking this disorder to schizophrenia (unlinke other cluster As)

Etiology:

• Unclear if there is a genetic predisposition
• Psychological factors (retrospective studies) – cold, unempathetic, emotionally impoverished childhood

Course and Prognosis:

• Onset in early childhood
• Once established, disorder is stable

Management:

• Avoid intimate personal contact, therefore minimizing conflict
• Appreciate need to privacy
• Long term psychotherapy helpful in small number (mostly they won't seek help since they are not in distress)

HD093

Schizotypal Personality Disorder

Characteristics:

• Odd or strange
• Magical thinking, peculiar ideas, illusions
• Don’t usually have auditory hallucinations or frank psychotic symptoms (unless very stressed)
• May be superstitious or claim clairvoyance
• Show poor interpersonal relationships or act inappropriately, isolated, few friends
• Stand out in a crowd – present as very unusual
• Can realize that most people don’t believe what they do and can somewhat accept that 
• EX Doc from Back to the Future

Epi:

• 3% of general population (seems high)
• Relatively stable course
• Incidence of schizophrenia is increased in first degree relatives - familial factor strongest link of cluster A
• Shares a genetic relationship with schizophrenia in twin and adoption studies

Management:

• Similar to schizoid patients
• Must be able to help patient differentiate fact from fantasy
• May need antipsychotics

HD093

Histrionic Personality Disorder

Characteristics:

• Colourful, dramatic, extroverted
• Excessive emotionality and attention seeking
• Exaggerate thoughts and feelings
• Seductive behavior common (coy, flirtatious)
• Superficial relationships
• Temper tantrums if not centre of attention

Epi:

• estimated 2-3%
• Females more than males
• Female familial incidence
• Association with somatization and alcoholism

Management:

• Self esteem heavily centered in body image, therefore, threatened when ill
• Men become “macho”, may act seductively
• Women reaffirm self worth by increasing dependence, flirtatious behaviors
• Doctor must provide emotional support, but not become too personal

Treatment:

• Long term psychotherapy – develop insights into reasons for problems in relationships
• Help patient think more clearly and systematically

HD093

Narcissistic Personality Disorder

Characteristics:

• Grandiose sense of self importance
• Handle criticism poorly – may be enraged or indifferent
• Want their own way, frequently ambitious
• Unable to show empathy
• Fragile self esteem, prone to depression
• Very vulnerable – self-esteem is nothing like what they present to people
• If something happens to them (ex: loss of job; relationship)
• Have falsely built themselves up, and when something bad happens they are crushed

Epi:

• No data
• May be increased in offspring of parents with this disorder

Course and Prognosis:

• Handle growing older poorly, vulnerable to “midlife crisis”

Management:

• First need to build a therapeutic relationship – need the patient to believe that you accept them unconditionally
• Really begin to change when they are depressed and distress is high enough (due to loss, etc.) and realize that things might need to change in order to survive
• Physical illness causes panic (not perfect)
• Similar to histrionic, but narcissist often holds therapy in contempt

Treatment:

• Psychotherapy
• Lithium and other mood stabilizers
• Antidepressants

HD093

Borderline Personality Disorder

Characteristics:

• Extraordinarily unstable affect, mood, behavior, object relations and self image
• Almost always in a state of crisis
• Mood swings common
• Behavior unpredictable
• Repetitive self destructive acts
  
• Feel both dependent and hostile (tumultuous relationships)
• Reject people and are very mean to them
  
• But are very fearful of others leaving them
  
• “I hate you.  Don’t leave me.”
• Splitting  “all good” / “all bad”
  

Epi:

• 1-2% of population (2 female:1 male)
• Increased prevalence of major depression, alcoholism and substance abuse in first degree relatives

Etiology:

Biological Issues:

• Depression increased in first degree relatives
• Chemical basis to affective instability?

Psychological issues:

• Defect in separation-individuation
• Masterson hypothesized that things that happen around the age of 2 help contribute to development of borderline personality disorder
• Age of 2 is natural age of exploration and separation from parent
• When they feel uncomfortable, come back to mother, and then go back to exploring
• Parents with BPD will have baby to fill void, but then when the baby becomes 2 they start to explore and mom clings. When baby returns mom is cold. Messes the kid up.

Course and Prognosis:

• Little change over time
• High incidence of Major Depression
• Suicide rate more than 5% (highest suicide risk out of all personality disorders)

Management:

• More frequent checkups may reassure patient of doctor’s empathy and interest
• Minor health problem may be perceived as life-threatening

Treatment:

• Long term psychotherapy with a reality oriented approach
• Medications: 
• Antipsychotics
• Antidepressants
• Mood stabilizers

HD093

Antisocial Personality Disorder

Characteristics:

• Continual antisocial or criminal acts
• Inability to conform to social norms
• Often present a normal and even charming
• Only personality disorder where you have to be able to identify a conduct disorder in childhood (< 15) in order to give them antisocial personality disorder diagnosis at 18/older
• If you can’t determine conduct disorder in childhood, then say individual has antisocial personality traits
• Cannot be trusted EVER  (lie, lie, lie)
• Super ego lacunae
  
• Have big holes in their super ego where they consider nothing to be wrong
• Lack of remorse; appear to lack a conscience

Epi:

• Onset before age 15
• 3% male: 1% female
• Prevalence increases in lower socioeconomic groups
• Family history often positive for antisocial personality disorder
• Diagnosed in 75% of prison inmates

Etiology:

Genetic:

• Increased sociopathic behavior and alcoholism in fathers
• Twin studies suggest genetic component
• Criminals had lower heart rates, decreased skin conductance, increased slow waves on EEG

Psychological:

• Maternal deprivation in first 5 years of life
• Parent shows lack of consistent discipline, lack of affection, increased incidence of alcoholism, impulsiveness

Course and Prognosis:

• Tends to remit with time
• After 21, remission rate of 2% per year
• As destructive social behavior decreases, tends to develop hypochondriac and depressive disorders
• Approximately 5% commit suicide; death by accident is common

Management:

• May feign symptoms to get narcotics
• Group therapy most effective

HD093

 Start of Cluster C:

Avoidant Personality Disorder

Characteristics:

• Extreme sensitivity to rejection
• Show great desire for companionship, but are shy
• Need unusually strong guarantees of uncritical acceptance
• High anxiety level
• Overlap with social anxiety disorder
• Lack of self confidence
• No close friends or confidants (mostly family)

Course and Prognosis:

• Function in a protected environment (often live w/ parents)
• If supports fail: depression, anger, anxiety

Management:

• Increased shyness and increased insecurity when ill
• Often downplay symptoms and delay seeking help
• Don't rush them

Treatment:

• Individual psychotherapy – exquisitely sensitive to rejection
• Group therapy—overcome social anxiety
• Social skills training
• Cognitive therapy

HD093

Dependent Personality Disorder

Characteristics:

• Get others to assume responsibility for major areas of their lives
• Lack of self confidence
• Don’t like to be alone
• Have very hard time making decisions
• Tend to want to be in a relationship because they don’t like being alone – even in abusive relationships
• Submissive

Epi:

• Females more than males
• More common in the youngest child in the family

Etiology:

• Persons with chronic illness in childhood may be prone
• Maternal deprivation?

Course and Prognosis:

• Impaired occupational functioning (rely on others)
• Risk major depression if lose person on whom dependent

Management:

• May have inappropriate demands for immediate attention
• Angry outbursts if don’t get prompt attention
  Illness provides secondary gain

Treatment:

• Psychotherapy – focus on patient’s exaggerated fears of damaging others or oneself by pursuing autonomy
• Group therapy
• Assertiveness training
• Social skills

HD093

Obsessive Compulsive Personality Disorder

Characteristics:

• Do NOT have OCD
• Emotional constriction, orderliness, stubbornness
• Pervasive pattern of perfectionism and inflexibility
• Formal, serious, lack sense of humor

Epi:

• Prevalence 1%
• Males more than females
• More common in oldest children

Course and Prognosis:

• Good workers
• Some episodes of full blown OCD
• Prone to depression, especially as they get older

Management:

• Particularly troubled by loss of control when ill
• Reassured by scientific approach and thoroughness of physician
• Want documentary evidence
• Encourage self monitoring

Treatment:

• Cognitive therapy –address illogic
• Thought stopping –for ruminations

HD091

What is Dissociation?

Dissociative Experiences Scale (DES)

Dissociativity

• Dissociation is a process (mental) that produces a discernible alteration in a person's thoughts, feelings, or actions so that for a period of time certain information is not associated or integrated with other information as it normally or logically would be
• In its extreme, dissociation gives rise to a set of particular psychiatric problems known as the dissociative disorders
• the process of dissociation acts in a continuum fashion, spanning the range from minor and common forms of dissociation to significantly major or pathologic forms

• DES scores can range from 0 to 100 with such normal individuals having a median score of about 7
• 5% of these large general samples have DES scores of 30 or greater, which is an empirical threshold often associated with the development of significant dissociative pathology

The tendency for a person to experience dissociation in a spontaneous fashion in naturally occurring situations

HD091

Factors that may positively or negatively affect

capacity for dissociativity

4 types of DSM Pathological Dissocaition

• dissociativity has a slow and steady decay as people get older
• begin to lose their capacity for dissociation as they enter into their early adolescent years, and the decay or loss of dissociativity continues into adulthood
• Presence severe childhood sexual abuse

1. Depersonalization Disorder
2. Dissociative Amnesia
3. Dissociative Fugue
4. Dissociate Identity Disorder (DID)

HD091

Depersonalization Disorder (DSM)

Dissociative Amnesia (DSM)

• Depersonalization has been reported to be the third most common complaint among psychiatric patients, following depression and anxiety.
• Many people have variations of depersonalization as part of the normal range of experience in human life.
• Diagnostic criteria include:
• a) an experience of feeling detached from or as if one is an outside observer of one's own mental processes or body; or an experience of feeling like an automaton of as if in a dream
• b) During the depersonalization, reality testing remains intact
• c) The depersonalization is sufficiently severe and persistent to cause marked distress or interfere in a person's life.
• d) The experience is the predominant disturbance and is not a symptom of another disorder such as schizophrenia, panic disorder, anxiety disorder or depression. Furthermore, it is not part of any organic disturbance or related to substance abuse

Criteria:

a) one or more episodes of inability to recall important personal information, usually about traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness

b) the disturbance is not due to dissociative identity disorder or to any organic mental disorders (e.g., epilepsy, black-outs from drug or alcohol intoxication, et cetera)

HD091

Dissociative Fugue (DSM)

Dissociate Identity Disorder (DID) (DSM)

a) the predominant disturbance is sudden, unexpected, travel away from or one's customary place of work, with inability to recall one's past and/or an assumption of a new identity

b) The disturbance is not due to dissociative identity disorder or any organically-mediated process.

Dissociative fugue is often reported in newspapers from time to time when we find someone showing up in a city not knowing his or her name, not knowing anything of their history

c) occasionally having assumed a new identity for a brief period of time

a) the existence within the person or patient of two or more distinct personalities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and of the self)

b) At least two of these personalities or personality states recurrently take full control of the patient's behaviour

There has been some discussion as to the need for amnesia between the two personalities or personality states; suffice it to say that there are those with full complex DID who do not have amnesia between states

Prevelence: Maybe as high as 1-2%

HD098

Physical complaints but no physical findings.  What are the possible diagnoses? (4)

What is Illness Behaviour?

Somatoform D/O – person doesn’t know what they are doing, really do believe they have a problem (diffnt from malingering)

Factitous D/O – person comes in just because they want to be a patient

Malingering – Intentionally presenting with the objective of getting secondary gain (attention, insurance money, substances) – act is entirely concious of actions

Missed Diagnosis

The manner in which individuals monitor their bodies, define and interpret their symptoms, take remedial action, and utilize sources of help. It is affected by a wide range of social, psychological, and cultural factors

Abnormal if:

• Inappropriate or maladaptive mode of perceiving, evaluating or acting in relation to one’s own health status
• This persists despite education
• May be illness-affirming or illness-denying

HD098

Somatosensory Amplification

Somatization is prominent in...

Bordline "somatitization"

• Hypervigilance to bodily sensations
• Predisposition to select out and concentrate on weak or infrequent bodily sensations
• Reactions to sensations with cognitions and affect that intensify them

Anxiety disorders
Substance abuse
Depression
Psychotic disorders

Fibromyalgia
Chronic fatigue syndrome
Functional gastrointestinal disorders (IBS)
Noncardiac chest pain
Chronic headache
Medically unexplained syncope
Chronic unexplained pelvic pain

HD098

Somatization D/O

Undifferentiated Somatoform D/O

Conversion D/O

• Multiple symptoms without adequate physical explanation
• Early onset (before age 30), fluctuating course
• Women: 0.2 to 2%     men <0.2%
• Familial pattern
• Dx: multiple organ systems/ early onset / chronic course / lack of physical and lab findings

• One or more physical c/o without adequate physical explanation
• Lower threshold dx than somatization d/o
• Varying onset, varying course
• No particular epidemiological factors

• Symptoms or deficits affecting voluntary motor or sensory function
• La belle indifference – A naive, inappropriate lack of emotion or concern for the perceptions by others of one's disability
• Do not conform with normal anatomy and physiology
• Rural, lower ses, no medical training
• Women:men   2:1 up to 10:1
• Familial
• Late childhood to early adulthood
• Short duration, recurrence common

HD098

Somatofrom Pain D/O

Hypochondriasis

Body Dysmorphic Disorder

• Medically unexplained pain, with psychological factors (must be present) contrib’g
• Depression and substance abuse are very common
• Prevalence unknown; women somewhat higher
• Any age of onset; duration variable

• Fear of serious disease b/o misinterpretation of bodily sx.
• Not delusional
• Prevalence:  1-5%;   men=women
• Any age, but often younger
• Chronic course, waxes and wanes

• Preoccupation with a defect in appearance – imagined or excessive
• Frequent careful checking / camouflage / reassurance / isolation
• Women = men
• Early onset, continuous course
• Focus may change

HD098

Conditions confused with somatoform disorders (7)

Organic Mental Disorders - Definition

Medical Condition that is the main cause
of secondary Depression 

1. Multiple sclerosis
2. CNS tumour or syphilis
3. Hyperparathyroidism
4. Porphyria
5. Lupus
6. Hyperthyroidism
7. Myasthenia gravis

• Refers to mental disturbances that have a underlying medical cause
• DSM-IV reclassifies these disorders as “Secondary to”   or “Substance- Induced”
• Mood Disorder Secondary to General Medical Condition

Stroke - especially near Left frontal pole

HD101

Frontal Lobe Syndrome

Dementia Criteria

• Lesions to the pre-frontal or orbito-frontal area
• Characterized by combinations of:
• Disinhibition
• Affective changes (euphoria, irritable, depression)
• Perseveration – stick to same thing over and over without moving onto the next topic
• Problems planning ahead, decisions
• Loss of social graces, manners

A.  The development of multiple cognitive deficits manifested by both:

• Memory impairment (new learning OR recall)
• + One or more additional cognitive impairments
• Aphasia – can’t speak properly
• Apraxia – inability to move things
• Agnosia – inability to name
• Disturbance of executive functioning

B.  Cognitive impairments cause significant impairment in social or occupational functioning and represent a significant decline from a previous level.
C. This criteria is specific to the type of Dementia (4 of them)

• Gradual onset and continuing decline:  Alzheimer type
• Vascular type - Focal neurologic signs
• Direct consequence of medical condition
• Substance Induced Persisting Dementia

D. Does not occur exclusively in the context of delirium
E. Not better accounted for by another illness

HD101

Delerium Criteria

4 Cs of Delerium

A. Disturbance of consciousness with reduced ability to focus, sustain or shift attention
B. A change in cognition or development of perceptual disturbance (often visual)
C. Develops over short period of time and fluctuates over course of the day
D. evidence of medical cause

Consciousness
Cognition
Course (fluctuates)
Cause (has one)

HD101

Table comparing Dementia and Delerium

HD101

Delirium - Clinical Features

Epi

• Confusion
• Dazed, unclear about surroundings
• Poor attention and concentration
• Poor short term memory
• Disorientation
• Delusions, illusions may occur (Visual Hallucinations)
• Speech may be circumstantial, tangential, incoherent
• Repetitive picking at bed sheets
• Sleep reversal

Agitated Delirium:

• Unable to stay in bed
• Pull out IVs
• Refuse care because of delusions
• Fight off staff who are trying to help
• Frightened, scared, screaming

Quiet Delirium:

• May not draw any attention
• Listless, uncomplaining and compliant
• All the while having no idea what is going on around them

• Occurs in 10-30% hospitalized medically ill
• 10-40% hospitalized elderly
• 25% hospitalized cancer patients
• 51% post-operative patients
• Up to 80% terminally ill
• Typically symptoms resolve in 10-12 days
• Elderly may have prolonged symptoms (>1 month)
• Elderly less likely to have full recovery by discharge ( 4-40%)
• May even have persisting cognitive deficits
• Increased risk of complications (pneumonia, Ulcers)

HD101

Causes of Delerium (Acronym)

Infection: Encephalitis, meningitis, syphilis, HIV, sepsis

Withdrawal: Alcohol, barbiturates, sedative-hypnotics

Acute metabolic: Acidosis, alkalosis, electrolyte disturbance, hepatic failure, renal failure

Trauma: Closed head injury, heatstroke, postoperative, severe burns

CNS pathology: Abscess, hemorrhage, hydrocephalus, subdural hematoma, infection, seizures, stroke, tumors, metastases, vasculitis

Hypoxia: Anemia, CO poisoning, hypotension, pulmonary or cardiac failure

Deficiencies: Vit B12, folate, niacin, thiamine

Endocrinopathies: Hyper/hypoadrenocorticism, hyper/hypoglycemia, myxedema, hyperparathyroidism

Acute vascular: Hypertensive encephalopathy, stroke, arrhythmia, shock, dehydration

Toxins or drugs: Medications, illicit drugs, pesticides, solvents

Heavy metals: Lead, manganese, mercury

HD101

Delirium - Pathophysiology

Damage to prefrontal cortex:

• Loss of higher and executive function
• Dorsolateral prefrontal cortex
• Associated with executive function
• Orbitomedial prefrontal cortex
• Damage associated with disinhibition
• Anterior cingulate gyrus
• May account for loss of language

Thalamus and Caudate:
Account for the changes in level of consciousness of patients with delirium

Neurotransmitters: Ach, DA, SER, GABA, NE, Glu, His

HD101

Delirium Screening Tests

1. Confusion Assessment Method (CAM) - Best

+ for delirium if 1 and 2, AND either 3a or 3b are +:
1. Acute Onset and Fluctuating Course 
2. Inattention
3a. Disorganized Thinking
3b. Altered Level of Consciousness

Sensitivity: 94%-100%; Specificity: 90%-95%

2. Folstein Mini Mental State Examination
Screens several functions:

• Orientation (time, place)
• Registration
• Recall
• Attention, Concentration
• Language
• Naming, reading, repeating, follow commands, writing, copying complex figure

3. Montreal Cognitive Assessment (MoCA)
Tests different areas of function including:

• Visuospacial/executive (Trails test)
• Naming
• Memory
• Attention
• Language
• Abstraction
• Delayed recall
• Orientation

HD101

Delirium Treatment

Male:Female ratio for Alcohol/Drug Dependance

Monitering

• Dectect/treat underlying cause and eliminate causitive meds
• Prevent self harm or harm to others but avoid restraints

Environment:

• Reduce factors that aggravate confusion
• Improve Day- Night recognition, and sleep-wake cycles
• Reduce overstimulation/avoid understimulation
• Reduce sensory impairments
• Clock and calendar in room
• Photos of family
• Reduce number of staff to work with the patient
• Encourage family visits
• Night light if room dark at night

Biological:

• Antipsychotic Medication
• Typical (Haldol)
• Atypical (Risperidone)

2:1 (4% males: 2% females)

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ASAM Definition of Addiction

Addiction is a primary disease, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic  biological, psychological, social and spiritual manifestations. This is reflected in an individual psychologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death

HD104

DSM IV substance abuse

A. A maladaptive pattern of use leading to clinically significant distress – at least 1 criterion met within a 12 month period

• Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home
• Recurrent substance use in situations in which it is physically hazardous
• Recurrent substance-related legal problems
• Continued substance use despite having persistent or recurrent social or interpersonal problems caused by the effects of substance use

B. Has never met the criteria for Substance Dependence

3 or more criteria met:

1. Tolerance
2. Withdrawal; or use of substances to relieve or avoid withdrawal symptoms
3. Substance is often taken in larger amounts or over a longer period of time
4. There is a persistent desire or unsuccessful efforts to cut down or control substance use
5. A great deal of time is spent in activities necessary to obtain substances, use substances, or recover from their effects
6. Important activities are given up or reduced because of alcohol
7. Substance use is continued despite knowledge of having problem that is likely to have been caused or exacerbated by it

Proposed for DSM V

• Craving
• Assess severity according to the 3 of criteria met:
  0-1 = no diagnosis
  2-3 = mild
  4-6 = moderate
  7+ = severe

HD104

The 4 Cs of Addiction

CAGE

Screening in pregnancy - TACE

1. Loss of control
2. Compulsion to use or preoccupation  with using
3. Craving
4. Continued use despite consequences

Cut down feelings?
Annoyed by people criticizing your drinking?
Guilty about your drinking?
Eye-opener

2 or more responses suggests alcoholism

Same but T is Tolerance w/ No G

HD104

Wernicke – Korsakoff Syndrome

General Symptoms of Substance Abuse

• Ataxia
• 6th Nerve Palsy
• Confusion with drowsiness & memory deficit
• Caused by Thiamine Deficiency
• If untreated may result in permanent memory deficit
• Give Thiamine prior to any glucose as glucose metabolism may deplete any thiamine reserve

• Gastritis, Ulcers G.I. bleeds, pancreatitis, liver disease
• Headaches (hang overs) codeine dependence, peripheral neuropathy, seizures
• Trauma
• Hypertension, palpitations due to tachycardia or arrythmia cardiomyopathy ,endocarditis, MI
• Anemia - bone marrow suppression, blood loss, nutritional deficiency
• Pneumonia, chronic cough with freebasing cocaine, rhinitis with snorting cocaine
• Menstrual irregularities

HD104

Addiction Cycle

Signs of Substance Abuse

Lab Tests

Using -> Withdrawal -> Remorse -> Craving

1. Track marks, abscess at injection site
2. Damaged nasal cartilage
3. Skin excoriations with met-amphetamines
4. Signs of liver disease- hepatomegaly telangectasia, palmar erythema
5. Signs of withdrawal- agitation, tremor, tachycardia, hypertension

The least sensitive method of assessment, but can be used to sow someone in drinking denial actual FX:

• Low rbc, High MCV Low platelets
• Increased GGT elevation of other liver enzymes or signs of liver failure
• Low Mg.
• Hepatitis B & C & HIV

HD104

Alcohol Withdrawal

Treatment

Mild  - tremor, nausea, tachycardia, hypertension, agitation, elevated temp., sweating. Onset within a few hours of the last drink, peak at 24-36hrs

Moderate – more severe symptoms of sympathetic nervous system hyperactivity plus:

Seizures – onset at 7-48 hours occur in

Alcoholic Hallucinosis - onset 24hrs - several days

Severe - Delirium Tremens

Onset at 3-4 days  – severe sympathetic system hyperactivity plus agitation, disorientation, confusion & hallucinations.
Mortality rate for withdrawal-1-5% up to 10% for D.T.s

Fisrt choice Diazepam
Lorazepam (if liver problems)
Also Haloperidol 2-5mg prn for psychosis
Anticonvulsants are not indicated

HD104

Benzodiazepine  Withdrawal

Opiate Withdrawal

Stimulant Withdrawal

Mild: Tremor, anxiety, insomnia, tachycardia
Severe: Seizure, psychosis
Treatment:

Gradual tapering with a long-acting benzodiazepine – Diazepam or Clonazepam

Headache, Nausea, vomiting, cramps & diarrhea, Bone pain, Chills, sweats, piloerection, Anxiety, emotional lability, craving
Not life threatening - like a bad flu
Treatment:

Symptomatic treatment - Clonidine, Immodium, Gravol, Ibuprofen & Acetaminophen
Tapering dose of a long-acting Opioid (Methadone) - BUT there is a high rate of relapse with abstinence based programs

Fatigue, hypersomnia, agitation, depression, increased appetite, drug craving
Treatment
Emotional support, avoidance of triggers for cravings, antidepressants