NS 48 Psychological disorders II

Somatoform disorders Physical ailments that cannot be explained by organic conditions. 3 types:- 1) Somatization 2) Conversion 3) Hypochondriasis Differential diagnosis of a somatoform disorder that mental factors are a large contributor to the symptoms onset, severity and duration. Somatoform disorders are not the result of conscious malingering or factious disorder. Malingering- fabricating or exagerating the symptoms of metal or physical disorder for a variety of secondary gain motives, which may include financial compensation (often tried to fraud), avoiding school, work or military service; obtaining drugs; getting lighter criminal sentences; or simply attracting attention or sympathy. External incentives present. Factitious disorder- No external incentives rae present, rather the motivation is a desire to maintain the sick role.

CULTURE: Symptoms differ across cultures (example: Africa burning hands and feet, worms in the head etc)

2) -

Conversion disorder- characterised by a significant loss of physical

function (with no apparent organic basis), usually in a single organ. The physical symptoms usually sugest neurological problems. Sensory impairment any modality? Paresthesias and paralysis. May be sudden onset, sudden reappearance and sudden termination. Common in women, and men in combat. Often misdiagnosed. 0.01-0.5% 2-10 times more common in women. AGE: Late childhood- early adulthood [rarely before 10 or after 35] COURSE: Onset is typically acute or sudden, symptoms remit in about 2 weeks, symptoms will recur in cases. CULTURE: More common in rural areas, lower socio economic developing areas and lower educational levels.

1) -

Somatization disorder marked by a history of diverse physical

complaints that appear to be psychological in origin. A: A history of many physical complaints that occur over a period of several years and result in treatment being sought or significant impairment in functioning beginning before age of 30. B: Each of the following must have been met, with the individual symptoms occurring at any time during the course of the disturbance 2 GI problems 1 sexual problem 4 pain symptoms 1 pseudoneurological symptom. After appropriate investigation each of the symptoms in criterion B cannot be explained by a known GMC or substance. When there is related GMC, the physical complaints ro resulting social or occupational impairment are in excess of what would be expected from history, physical exam or lab findings. Symptoms are not intentionally produced or feigned. 0.2-2.0 % in women. And <0.2% in men. commoner in women. AGE: Initial symptoms adolescence; Criteria mid 20s. COURSE: Chronic, rarely remits completely.

3) -

Hypochondriasis- characterized by excessive preoccupation with health

concerns and incessant worry about developing physical illness. No physical symptoms are necessary. These people are preoccupied with the possibility that normal sensations are symptoms of a serious disease. They pay frequent visits to the physicians and persists on medical reassurance. They tend to over-report bodily sensations. 1-5% Equal rates in genders. AGE: any age, most common in early adulthood. COURSE: typically chronic, waxes and wanes. ASSOCIATED with: fears of aging and death, doctor shopping, poor relationships with physicians, past experience with disease, family and work problems.

4) -

Pain disorder- main symptom is pain.

Main symptom is pain may be exacerbated by psychosocial factors. May be maintained by gain: Primary gain elevated physical difficulty; secondary gain monetary compensation. Appear to be at equal rates in men and women, although women have more chronic sort of pain. AGE: any age can be onset age. Associated with unemployment, disability, family problems, substance abuse/dependence, depression, suicide, sleep disturbance, etc.

Etiology of somatoform disorders

1) Psychoanalytic theory

Controlling repressed sexual urges displaced anxiety or secondary gain. They deny knowledge but use information. 2) Behavior theory Malingering Social learning and reinforcement Secondary gain get out of confrontation and get sympathy. One sign of anxiety is an increased level of cortisol (stress hormone) cortisol levels are elevated in patients with somatisation disorder. But there is no concordance in twin studies for any somatoform disorders. The right hemisphere may be implicated in conversion disorder, symptoms of which are more likely in the left half of the body. The right hemisphere is involved in emotional experience and expression.

5) Body dysmorphic disorder - Excessive concern with real or imagined defects in appearance, especially
facial marks or features.

Frequent visits to plastic surgeons!!! (Michael Jackson :D R.I.P) This is culturally influenced by not culture-bound (like in Korean culture it quite normal for a person to want a nose job! So obviously in a culture so obsessed with people attaining perfection in terms of looks more likely to have people with BDD). May be a symptom of more pervasive disorder such as Obsessive compulsive disorder or delusional disorder. About 5-40% with this disorder also have anxiety/depressive disorder. 6-15% of these patients get cosmetic surgery and/or are dermatology clients. Equally common in both sexes. AGE: Onsets around Childhood- adolescence. COURSE: Chronic, continual, may wax and wane. Associated with excessive checking/grooming, removal of mirrors, social isolation, surgery, suicide!!!!!

Dissociative disorders people lose contact with portions of their consciousness or memory resulting in disruptions in their sense of identity. 1) Dissociative amnesia sudden loss of memory for important personal information that is too extensive to be due to normal forgetting. 2) Dissociative fugue- people lose their memory for their entire lives along with their sense of personal identity. 3) Dissociative identity disorder- involves the coexistence in one person of two or more largely complete, and usually very different personalities.

NS 49 Psychological disorders III

What are mood disorders?

They are a class of disorders marked by emotional disturbances of varied kinds that may spill over to disrupt physical perception and social thought process. Symptoms include emotional, cognitive and motor elements. Types:-

1% is population and equally common in male and female. Age of onset usually 20s. Etiology of Genetic disorders:1) Genetic vulnerability although heretidy can create a predisposition, environmental factors are important. 2) Neurochemical and neuroanatomical factors NT abnormalities (NA and 5-HT) Depression also associated with reduced hippocampal volume. 3) Cognitive factors learned helplessness and pessimistic explanation of negative life events hopelessness and excessive rumination. 4) Interpersonal factors inadequate social skills. 5) Precipitating stress moderately strong link between stress and onset mood disorder.
Symptoms of mania:Elation Euphoria Extreme sociability Impatience Racing thoughts Flight of ideas Impulsive behaviour Over-talkative Self-confident Delusions of grandeur Hyperactive Unable to sleep or eat Increased libido

1) Major depressive disorder (unipolar)

Persistant feelings of sadness and despair and a loss of interest in previous sources of pleasure. 7-17% prevelance. Onset can occur at any time but mostly before age 40. Most have recurrent episodes of this. Prevalence is twice as high in women then men.
Symptoms of depression:Depressed mood Loss of interest Worry Somatic symptoms of anxiety Insomnia Suicide Guilt Weight loss Retardation Agitation Hypochondriasis Loss of insight Paranoia Obsessions Depersonalisation Diurnal Vision

What is schizophrenia?

2) Bipolar disorder (maniac-depressive disorder)

Experience of both depressed and maniac periods. They experience very low and very high moods periods of prolonged and profound depression alternative with periods of elevated mood.

It is a class of disorders marked by delusions, hallucinations, disorganized speech and deterioration of adaptive behaviour. Extremely debilitating illness.

Types:1) Paranoid type- delusions of persecution and delusions of grandeur. 2) Catatonic type- Striking motor disturbances, ranging from muscular rigidity to random motor activity. 3) Disorganized type- severe deterioration of adaptive behaviour is seen incoherence, complete social withdrawal, delusions entering on bodily functions. 4) Undifferentiated type- dont fit into any of the above. NEW MODEL Positive Vs Negative symptoms. Positive symptoms- behavioural excesses or peculiarities, such as hallucinations, delusions, bizarre behaviour and wild flights of ideas. Negative symptoms- behavioural deficits, such as flattened emotions, social withdrawal, apathy, impaired attention, and poverty of speech.

Expressed emotion how family dynamics influences course of illness after onset. Precipitating stress stress may be a trigger in pre-existing vulnerability.

NS 56 Emotional and cognitive aspects of addiction

Substance of abuse Alcohol Nicotine Cocaine Designer drugs Related problems. RTA, foetal alcohol syndrome, heart disease. Lung cancer, cardiovascular disease. Psychosis, brain damage, death, crime. Unknown risks, contamination, unwanted effects.

Factors that influence substance misuse Course of the disease! 1) May be treated successfully and full recovery (milder versions) 2) May make partial recovery with relapses 3) Or may be a chronic illness- often need of long term hospitalization. Availability Peer pressure Deprivation Personality disorders Pre-existing psychopathy Pharmacological properties of the drug Neurobiology dopamine release in nucleus accumbens leading to sensation of PLEASURE ;) Conditioned learning (things such as positive and negative reinforcement, classical conditioning) Iatrogenic factors (listening to the doctor!!!!!)

Etiology of schizophrenia Genetic vulnerability Neurochemical factors DA, 5-HT, and glutamate related. Structural abnormalities of the brain enlarged ventricles are associated with schizophrenia but no one knows why. The neurodevelopmental hypothesis- disruptions in maturational processes of the brain before or at the time of birth caused by prenatal viral infections obstetrical complications and other brain insults.

Acute intoxication Transient phase that is substance induced. It leads to alteration of:Consciousness Cognition Perception Affect Behaviour

Using larger amounts or over longer period than intended Persistent desire and unsuccessful efforts to cut down or control use Lot of time spent in activities needed to obtain substance Important activities given up Substance use continued despite knowledge of having a problem caused by it

Substance Abuse Substance abuse I It is maladaptive pattern of substance use leading to clinically significant impairment or distress. Substance abuse II Having one or more of the situations below in 12 months period:Recurrent substance use leading to failure to fulfil major role obligations. Recurrent substance use in physically hazardous situations. Recurrent substance-related legal problems. Continued substance use despite persistent recurring social or interpersonal problems caused or exacerbated by the substance

Substance dependence III Specify if with or without physiological dependence (tolerance or withdrawal) Course specifiers: Early full remission Early partial remission Sustained full remission Sustained partial remission On agonist therapy In controlled environment Withdrawal criteria Development of a substance-specific syndrome due to stopping or reducing substance use that has been heavily prolonged. The syndrome causes clinically significant distress or impairment in social, work or other important areas of functioning. Symptoms not due to general medical condition and not better accounted for by another mental disorder.

Substance abuse III The symptoms have never met the criteria for substance dependence for this class of substance.

Dependence leads to 1) Tolerence with continued use increased dose will be needed to maintain effect. 2) Withdrawal unpleasant physical and psychological symptoms on discontinuing or decreasing a heavily used substance. 3) Psychological dependence need developed through learning (example- it reduces anxiety) can lead to physical dependence as it is with alcohol. Managing addictions

Substance dependence Substance dependence I Maladaptive pattern of substance use leading to clinically significant impairment or distress. Substance dependence II Three or more of these occurring at any time in a 12 month period: - Tolerance - Withdrawal

Support Rehabilitation Drug treatment centres Cognitive behaviour therapy Motivational interviewing HIV risk management (needle exchange) Pharmacology specific antidotes for use in overdose, medications to reduce

Unable to regulate drinking Altered tolerance (higher than normal im guessing?) Withdrawal symptoms (doh!) Persistence even after attempted abstinence (ahem !!!)

May even lead to further complicationsAcute intoxification More withdrawal Medical complications Wernickes encephalopathy Korsakoffs psychosis Social complications (embarrassment) Foetal alcohol syndrome if you are pregnant No physical dependence Marked psychological dependence Feelings of euphoria, space and time distortion, relaxation, well being, increased appetite.

withdrawal, and long term replacement medications.

1) Marijuana- Tetrahydrocannabinol
Also memory change: consolidation, apathy feeling, transient psychosis, lung disease, psychomotor impairment.

2) Alcohol
Men 21 and women 14 units safe. Binge consumption physical, neuro-psychiatric and social damage. Physical signs of alcohol are Intoxication ataxia, nystagmus, slurred speech, decreased concentration, psychological/behavioural changes, stupor. Alcohol on breath Red sclera/conjunctivae Liver disease Tremor, sweating -

Alcohol can be managed by:0 Acute detoxification nutrition, support, benzodiazepines, rehydration and electrolyte balance. Practise: abstinence vs controlled drinking. (smarter sense!) Maintainence group psychotherapy: motivation relapse prevention, new social routines, self help treatment of anxiety and depression (so the victims do not go running back to booze).

Psychiatric problems associated with alcohol: Suicide (10-15%, similar to bipolar and schizophrenia) Associated with 1/3 deliberate self-harm acts Depression (40%) Antisocial personality and violence Anxiety disorders (25-50%) Alcoholic hallucinations, sexual and sleep problems.

Slowly leads to dependenceThere is a compulsion to drink Constant preoccupation with alcohol

3) Stimulants
Nicotine Caffeine Amphetamines speed oral or i.v euphoric feelings, increased concentration and energy followed by depression, lethargy and fatigue. (high followed by a low). Chronic use of speed schizophreniform psychoses. Cocaine crack Sniffed, chewed or injected. Results restlessness, increased energy, abolition of fatigue and hunger, visual and tactile hallucinations. Might also lead to paranoid psychoses, post cocaine dysphoria sleeplessness and depression. Highly addictive. MDMA Ecstasy synthetic amphetamine analogue. Causes 5-HT release and blocks 5-HT reuptake! (sweet!) Leading to hyperactivity, dehydration and hyperpyrexia. Opiate withdrawal: 24-48 hours Craving Flu-like symptoms: (muscle cramps, chills, lacrimation, rhinorrhoea); sweating, yawning. 7-10 days mydriasis, cramps, diarrhoea, agitation, restlessness gooseflesh.

Effects of cognition on drug addiction - Frontal cortex is very important in things such as decision making, response inhibition, planning and memory. - Drugs lead to frontal cortex damage leading to impaired decision making and behavioural inhibition. - Addiction involves not only pleasure circuits, but also motivational centres. - Frontal cortex effects may last long after dopaminergic effects have worn off and may explain the relapse may make it difficult to look beyond the immediately reinforcing and pleasurable aspects of the drug to the long term consequences.

4) Hallucinogens
LSD Psychological and physiological effects but does not cause dependence. Effects flashbacks, schizoid psychoses, seizures Treatment of drug abuse residential therapy, medication therapy, drug-free outpatient therapy, methadone maintenance, residential therapy community treatment. Drug replacement therapy methadone, buprenophine, mainly opiate dependence, works best with psychotherapy and counselling. Therapeutic communities where clients stay in a residence for 6- 12 months and they focus in re-socialization of a person to a drug-free and crime free society.

5) Opiates heroin, morphine, methadone.

Smoked, sniffed, oral, i.v, i.m or subcutaneous. Initial dysphoria, buzz rush histamine release, peace tranquillity, detachment, CNS depression. Leads to rapid tolerance and withdrawal.

NS 61 Treatment of psychological disorders

Biomedical Psychotherapy Behavior therapies Who looks for help? Usually female, young, urban, lives with a partner, willing to talk associated with higher levels of psychological well being. Cultural differences important when asking for help. Individuals of asian cultures for instance think that social support is less helpful that individuals from European cultures. Treatment is provided by clinical psychologists, counselling psychologists, psychiatrists, clinical social workers, psychiatric nurses and counsellors. 1) Biomedical therapies This assumes that psychological disorders are caused atleast in part by biological malfunctions. Psychopharmacotherapy Antianxiety drugs Antipsychotics Antidepressants tricyclics, MAO inhibitors, SSRIs Mood stabilizer Lithium Electroconvulsive therapy electroshock seizures are induced in an anesthesized patient for therapeutic effect. Used to treat major depression.

Freuds view unconscious conflicts between the id, ego, and superego sometimes lead to anxiety. This discomfort may lead to the use of defence mechanisms, which may temporarily relieve anxiety. b) Client centred therapy - Goal restructure self-concept to better correspond to reality. - therapeutic climate genuineness unconditional positive regard - empathy. Rogers theory anxiety and self-defeating behavior are rooted in an incongruent self-concept that makes one prone to recurrent anxiety, which triggers defensive behaviour, which fuels more incongruence.

c) Rational emotive therapy (RET) Depression caused by errors in thinking Goal change the way client thinks. Becks theory depression is caused by negative thinking.

d) Cognitive behaviour therapy (CBT)

2) Psychotherapy insight therapies. a) Psychoanalysis Goal discover unresolved unconscious conflicts. Free association, dream analysis, interpretation, resistance and transference.

NS 63 Cognitive Behavioural Therapy for psychological disorders

What is depression? Depression is persistent sad, anxious or empty feelings. Feelings about hopelessness and /or pessimism, guilt, worthlessness and/or helplessness. Also feelings of irritability, restlessness. Loss of interest in activities or hobbies once pleasurable including sex. Fatigue and decreased energy. Having difficulty concentrating, making decesions and remembering details.

Selective abstraction forming conclusions based on isolated event. Overgeneralization generalizing beliefs based on a single incident. Magnification or minimization perceiving a situation in a greater or lesser light than it deserves. Personalization tendency to relate external events to yourself. Labeling and mislabelling portraying your identity based on imperfections and mistakes made in the past, and allowing them to define your true identity. Polarized thinking thinking in all or nothing, black or white extremes.

Cognitive Behaviour Therapy

Goal Change the way a client thinks by using their automatic thoughts (notions that are triggered by particular stimuli that elicit emotional responces) using their core beliefs. The way people feel and behave is determined by how they perceive and structure their experience. Peoples internal communication accessible to introspection & peoples beliefs have highly personal meanings which can be explored by one. To understand nature of an upsetting emotional event the focus must be on cognitive content of the persons reaction.

Early experiences develop core beliefs of client. -Core beliefs unhelpful assumptions generated that organize perception and govern behaviour. - Critical incident trigger assumption leads to negative automatic thoughts (NATs) which have knock on effect o mood, behaviour physiology. Objective develop a shared formulation of depression with a client elicit negative automatic thoughts with a client use downward arrow technique to explore core beliefs. Cognitive distortions - Faulty assumptions and misconceptions - Arbitary inferences make conclusions without support evidence.

1) First session Socialize to the model previous experience of therapy and expectations Contratcting Assessment Problem list Goal setting Agenda setting

4) Interventions a) Behavioural activation demonstrate link between mood and activity. Monitor activities in a diary Rate each activity out of 10 for pleasure and mastery (sense of achievement) Rate level of depression. Schedule activities based on information from the diary. b) Thought challenging Use thoughts identified on thought record and rate how much believe the thought List all evidence that supports the thought List all evidence that suggests the thought is not true 100% of the time Based on the evidence re rate how much you believe the original thought, an alternative thought and re-rate emotion

Problem client cant think of a goal? - Magic/miracle question (solution focused therapy) use the line: if I had a magic wand and i could use that wand to change everything for you over night so that everything was better for you what would be the first thing that you would notice in the morning that would tell you things had changed? this helps client to start to think of life without this problem of theirs. 2) Eliciting Negative Automatic Thoughts hot thought Aim encourage the client to notice what is going through their mind when they have a strong reaction to a situation. Link this thought to an emotion and rate the emotion. Thought is an interpretation of the situation and it is this thought that governs the emotional response. Thought with the highest emotional responce hot thought. Requires client to practice in session and to complete thought record at home (usually for a week).

c) Behavioral experiments - Identify belief to be tested - Rate conviction in this belief - Design experiment - Identify any problems with the experiment and ways to overcome it - Record expected outcome - Usually do experiment as homework but can be done in session - Record actual outcome - Create alternative belief based on new evidence

3) Downward arrow technique Identify underlying assumptions and core beliefs that drive negative automatic thoughts exploration of what NAT means to the individual. Example:-

Becks Cognitive Therapy - Active - Directed - Time-limited - Present-centered - Recognize and change negative thoughts and maladaptive beliefs Therapists role and function - Emphasis on therapeutic relationship - Genuine - Warm

Empathetic Accepting Creative Active Knowledgeable of cognitive and behavioural strategies Guide Help client understand how their beliefs and attitudes influence the way they feel and act. Promote cognitive change. Assist client in acquiring new skills. Clients bring up topics to explore- must identify distortions in their thinking. Devise homework assignments Teach the client how to be their own therapist

Client role and function - Active - Participate - Do homework - Complete outside readings - Bring up topics to explore - Identify distortions in their thinking - Summarize important points in the sessions.

What are the applications of cognitive behaviour therapy? - Used to treat depression and anxiety disorders, as well as other disorders. - Therapist assists individuals in making alternate interpretations of daily events. - Therapist has client become aware of distortions in your thinking patterns by examining your automatic thoughts. - Therapist assists client in learning how you disregard important aspects of situation - Asess rigid or simplified thinking - Overgeneralization from a single incident of failure - Challenging - Cognitive reframing/restructuring