Chapter 11: Schizophrenia

Schizophrenia: a psychotic disorder characterized by major disturbances in thought,

emotion, and behaviour: disorder thinking in which ideas are not logically related,
faulty perception and attention, flat or inappropriate affects, and bizarre disturbances
in motor activity
Withdrawn from other people and reality, and fall into a fantasy life of delusions and
hallucinations
Significantly higher in males than females
Prevalence rates of symptoms such as auditory and visual hallucinations are
comparatively higher among people from African nations
Key factors that may vary across cultures include the likelihood of experiencing
adverse life events, degree of social disadvantage, and family differences across
cultures in terms of reactions and interpretations of symptoms of schizophrenia
High in Canada due to: immigration rates and high latitude
Can begin in childhood, but doesnt appear until late adolescence or early adulthood
(earlier for men than women)
Co-morbid substance abuse is a major problem for people who have schizophrenia

Clinical Symptoms of Schizophrenia

Disturbances in several major areas: thought, perception, and attention; motor
behaviour; affect or emotion; and life-functioning
Positive Symptoms
Positive symptoms: excesses or distortions such as disorganized speech,
hallucinations, and delusions
Presence of too much of a behaviour that is not apparent in most people
Disorganized Speech
Formal thought disorder/disorganized speech: problems in organizing ideas and in
speaking so that a listener can understand (incoherent)
Images and fragments of thought are not connected; difficult to understand exactly
what the person is saying
Loose associations/derailment: person may be more successful in communicating with
a listener but has difficulty sticking to one topic. They drift off on a train of
associations evoked by an idea from the past
Delusions
Delusions: beliefs held contrary to reality
The most important delusions:
o Person may be the unwilling recipient of bodily sensations or thoughts imposed by
external agency
o People may believe that their thoughts are broadcast or transmitted, so others
know what theyre thinking
o People may think their thoughts are being stolen from them, suddenly and
unexpectedly, by an external force
o Some people believe that their feelings are controlled by an external force
o Some people believe that their behaviour is controlled by an external force

o Some people believe that impulses to behave in certain ways are imposed on
them by some external force
Hallucinations
Hallucinations: sensory experiences in the absence of any stimulation from the
environment
They include the following:
o Some people report hearing their own thought spoken by another voice
o Some people claim that they hear voices arguing
o Some people hear voices commenting on their behaviour
Negative Symptoms
Negative Symptoms: behavioural deficits; avolition, alogia, anhedonia, flat affect,
and asociality.
Attentional deficits contribute to clear reductions and impairments in working memory
Presence of many negative symptoms is a strong predictor of a poor quality of life;
some evidence that it is associated with earlier onset brain damage and progressive
loss of cognitive skills
Avolition
Apathy/Avolition: lack of energy and a seeming absence of interest in or an inability to
persist in what are usually routine activities
Inattentive to grooming or personal hygiene, difficulty persisting at work or school,
spend time doing nothing
Alogia
Alogia can take many forms
In poverty of speech = sheer amount of speech is greatly reduced
Poverty of content of speech = amount of discourse is adequate, but conveys little
information and tends to be vague and repetitive
Anhedonia
Anhedonia: inability to experience pleasure
A lack of interest in recreational activities, failure to develop close relationships, and
lack of interest in sex
Report that normally pleasurable activities are not enjoyable for them
Flat Affect
Flat Affect: virtually no stimulus can elicit an emotional response
Client may stare vacantly, muscles of the face flaccid, the eyes lifeless
Client talks in a flat and toneless voice
Refers only to the outward expression of emotion and not to the persons inner
experience, which may not be impoverished at all
Asociality
Asociality: severely impaired social relationships
Few friends, poor social skills, and little interest in being with other people
People diagnosed with schizophrenia usually have lower sociability and greater
shyness, and report more childhood social troubles

Interpersonal deficits could reflect related deficits in the ability to recognize emotional
cues displayed by others

Other Symptoms
Catatonia
Catatonia is defined by several motor abnormalities
Some clients gesture repeatedly, using peculiar and sometimes complex sequences of
finger, hand, and arm movements that seem to be purposeful
Others manifest an unusual increase in their overall level of activity, which might
include excitement, wild flailing of the limbs, and great expenditure of energy, similar
to mania
Catatonic Immobility: clients adopt unusual postures and maintain them for very long
periods of time
Wavy Flexibility: whereby another person can move the persons limbs into strange
positions that they maintain for extended periods
Inappropriate Affect
Inappropriate Affect: emotional responses of individuals is out of context
Client is likely to shift rapidly from one emotional state to another for no reason
History of the Concept of Schizophrenia
Early Descriptions
Emil Kraeplin first presented his notion of dementia praecox (Early term for
schizophrenia) He differentiated 2 major groups of endogenous, or internally caused,
psychoses: manic-depressive illness and dementia praecox
Dementia praecox included several diagnostic concepts dementia paranoids,
catatonia, and hebephrenia
Dementia was referred to severe memory impairments. Kraeplins term refers to a
general mental enfeeblement
Bleuer brk with Kraeplin on 2 major points: he believed that the disorder didnt
necessarily have an early onset, and he believed that it didnt inevitably progress
towards dementia
Bleuler proposed his own term schizophrenia Greek word schizein (split) ad phren
(mind)
The metaphorical concept he adopted was the breaking of associative threads
He viewed blocking (total loss of a train of thought) as a complete disruption of the
persons associative threads
Categories of Schizophrenia in DSM-IV and Elimination in DSM-5
Disorganized Schizophrenia: speech is disorganized and difficult for a listener to follow
Clients may speak incoherently, stringing together similar-sounding words and even
inventing new words.
May have flat affect or experience constant shifts of emotions, breaking into
inexplicable fits of laughter and crying

Catatonic Schizophrenia: clients typically alternate between catatonic immobility

and wild excitement, but one may predominate

These clients resist instructions and suggestions and often echo the speech of others

Paranoid Schizophrenia: key to this diagnosis is the presence of prominent

delusions
Delusions of persecution are common but clients may experience grandiose delusions
(exaggerate sense of their own importance, power, knowledge or identity)
Some clients are plagued by delusional jealous (unsubstantiated belief that their
partner is unfaithful)
Clients with paranoid schizophrenia develop ideas of reference: incorporate
unimportant events within a delusion framework and read personal significance into
the trivial activities of others

Additional Ways of Conceptualizing Heterogeneity

Undifferentiated Schizophrenia: applies to people who meet the diagnostic criteria
for schizophrenia but not the criteria for any of the 3 subtypes
Residual Schizophrenia: client no longer meets the full criteria for schizophrenia
but still shows some signs of the disorder
Etiology of Schizophrenia
The Genetic Data
Family Studies
Relatives of people with schizophrenia are at increased risk, and the risk increases as
the genetic relationship between proband and relative becomes closer
Negative symptoms of schizophrenia appear to have a stronger genetic component
A predisposition to schizophrenia may be transmitted genetically
Environment cannot be discounted
Twin Studies
Concordance for identical twins 44.3%, much higher than fraternal which is 12.08%
Less than 100% concordance rate is important: if genetic transmission alone
accounted for schizophrenia then both should have the disorder
A common deviant environment rather than common genetic factors account for
the concordance rates
Adoption Studies
Children of women with schizophrenia were more likely to be diagnosed as mentally
defective, psychopathic and neurotic
Involved more frequently in criminal activity, and had psychiatric issues
Molecular Genetics
Not a single gene for schizophrenia, several multi or polygenic models remain viable
5 disorders that have a common genetic vulnerability: schizophrenia, MDD, bipolar,
autism, and ADHD
Disorders involve single nucleotide polymorphisms in regions on chromosomes 3p21
and 10q24 and in two calcium subunits CACNA1C and CANB2

Schizophrenia seems to reflect relatively rare protein altering gene mutations that
have implicated up to 40 genes, including a disruption in DCGR2 (vulnerability for
schizophrenia)
Cells of people with schizophrenia had fewer synapses

Biochemical Factors
Dopamine Activity
Theory that schizophrenia is related to excess activity of dopamine is based
principally on the knowledge that drugs effective in treating schizophrenia reduce
dopamine activity
D2 receptors dopamine receptors that are blocked by first-generation or
conventional antipsychotics
Amphetamines can produce a state that closely resembles paranoid schizophrenia,
and they can exacerbate the symptoms of schizophrenia
Dopamine receptors are greater in number or are hyper-sensitive in people with
schizophrenia
Having too many dopamine receptors = having too much dopamine
Amphetamines worsen positive symptoms and lessen negative ones (opposite for
antipsychotics)
Mesocortical dopamine pathway begins in the same brain region as the mesolimbic,
but projects to the prefrontal cortex which projects onto limbic areas that are
innervated by dopamine
Under activity of dopamine in prefrontal cortex may cause negative symptoms of
schizophrenia
Other Neurotransmitters
Dopamine neurons generally modulate the activity of other neural systems (regulate
GABA)
Similairly serotonin neurons regulate dopamine activity in mesolimbic pathway
Glutamate may also play a role
Decrease in glutamate inputs from either prefrontal cortex or hippocampus to the
corpus striatum can result in increased dopamine activity
Schizophrenia and the Brain: Structure and Function
Enlarged Ventricles
Most consistent finding is enlarged ventricles implies a loss of subcotrical brain cells
Structural problems in subcortical temporal-limbic areas, such as hippocampus and
basal ganglia
Reduction in cortical grey matter in both temporal and frontal regions and reduced
volume in basal ganglia and limbic structures suggesting deteoriation of brain tissue
Large ventricles are correlated with impaired performance on neuropsychological
tests, poor adjustment prior to onset of disorder, and poor response to drug treatment
Pre-frontal Cortex
Known to play a role in behaviours such as speech, decision making, and willed action
Lack of illness awareness is related to poor neuropsychological performance

Reductions of grey matter in prefrontal cortex

Low glucose metabolism in prefrontal cortex

Congenital and Developmental Consideration

Consequence of damage during gestation at birth
Presence at birth/infancy craniofacial midline anomaly that commonly occur as
symptom of CNS anomaly, were associated with doubling risk for schizophrenia
High rates of delivery complications when babies were born, reduced supply of
oxygen, resulting in damage
Virus invades the brain and damages it during fetal development (2nd trimester)
Neurons smaller than normal in prefrontal cortex
3 leading ways of becoming at risk: maternal influenza, toxoplasmosis and genital
infections in mother
Psychological Stress and Schizophrenia
Social Class and Schizophrenia
Highest rates of schizophrenia are found in central city areas inhabited by people in
the lowest socio-economic class
Sociogenic Hypothesis: stressors associated with being in a low social class may
cause or contribute to the development of schizophrenia
Social-selection theory: reverses the direction of causality between social class and
schizophrenia. During the course of developing psychosis, people with schizophrenia
may drift into poverty-ridden areas of the city may chose to move to areas where little
social pressure will be brought on them
Data supports social selection theory more

Family and Schizophrenia

Etiology and the Role of the Family
Schizophrenogenic mother: supposedly cold, and dominant, conflict-inducing parent
who was said to produce schizophrenia in her offspring
Mothers were characterized as rejecting, overprotective, self-sacrificing, impervious to
others feelings, rigid and moralistic about sex, and fearful of intimacy
Family communication pattern of hostility and poor communication predicted later
onset of schizophrenia
Children having a parent with schizophrenia showed a greater increase in
psychopathology than did control participants who were reared in a disturbed family
environment
Relapse and the role of the family
Expressed emotion (EE)
High-EE families = great deal of expressed emotion ; low-EE families = little
Schizophrenia patients returning to low EE families, had greater chances of relapse
High-EE mothers are highly sensitive to excitement and depression in the client and
report a high level of burden associated with the childs illness

Expression of unusual thoughts by the clients elicited higher levels of critical

comments by family members who have previously been characterised as high in EE
In high-EE families, critical comments by family member led to increase expression of
unusual thoughts

Therapies for Schizophrenia

Many clients lack insight into their impaired condition and refuse treatment
Ultimate goal of treatment is to help the individual to remain in or re-enter and
function in the community
Biological Treatments
Shock and Psychosurgery
Prefrontal Lobotomy: a surgical procedure that destroys the tracts connecting the
frontal lobes to the centres of the brain
Used specially for those who behaviour was violent
After surgery, many clients became dull and listless and suffered serious losses in
their cognitive capacities
Drug Therapies
Antipsychotic drugs or neuroleptic were introduced, produce side effects similar to the
symptoms of a neurological disease
First-Generation Antipsychotic Drugs
o Antihistames were used to reduce surgical shock. Saw that they made patients
sleepy and less fearful about impending operation
o Chlorpromazine, calmed people with schizophrenia
o Phenothiazines derie their therapeutic properties from their abilities to block
dopamine receptors in the brain, thus reducing the influence of dopamine on
thought, emotion and behaviour
o They reduce positive symptoms but have much less effect on negative
o Reported side effects of antipsychotics include dizziness, blurred vision,
restlessness, and sexual dysfunction
o Extrapyramidal sife effects resemble the symptoms of Parkinsons disease,
develop tremors of the finger, a shuffling gait, and drooling
o Other side effects include dystonia, and dyskinesia
o Akathisia is an inability to remain still, people pace and constantly fidget
o Tardive dyskinesia: mouth muscles involuntarily make sucking, lip-smacking and
chin-wagging motions
o Neuroleptic malignant syndrome heart races, blood pressure increase, and client
may lapse into a coma
Second-Generation Antipsychotics
o Clozapine produced therapeutic gains in individuals with schizophrenia than
traditional antipsychotics
o Improvements in levels of satisfaction, quality of life, thinking, mood and alertness
o Atypical antipsychotics at effective dose levels, less likely to cause side effects
Psychological Treatments
Social Skills Training
Designed to teach people with schizophrenia behaviours that can help them succeed
in a wide variety of interpersonal situations in their daily life

Focuses on 3 key elements: receiving skills, processing skills, and behavioural

responses in social interaction
Severely disturbed clients can be taught new social behaviour and independent living
skills that may help them function better in their communities

Family Therapy and Reducing Expressed Emotion

Educate clients and families bout biological vulnerability that predisposes people to
schizophrenia
Provide information about antipsychotic medication
Encourage family members not to blame themselves or the client for the disorder
Help improve communication and problem-solving skills in the family
Encourage clients and families to expand social contacts
Instill a degree of hope that things can improve
Cognitive Behavioural Therapy
People with schizophrenia can benefit form techniques designed to address their
delusions and hallucinations
CBT can facilitate motivation and engagement in social and vocational activities
People who have been psychotic for some time incorporate their psychotic beliefs into
their broader cognitive schemas
Hallucinations and delusions probably result not from perceptual distortion but from
cognitive styles that encourage the psychotic person to live in fictional narratives as if
they were real
Defeatist beliefs distinguish a group of schizophrenia people with a particularly
troubling form of negative symptoms called the deficit syndrome
The presence of defeatist beliefs is associated with greater neurocognitive impairment
and the defeatist beliefs also seem to mediate the links that cognitive impairment has
with negative symptoms and with poor vocational functioning
Treatment Focus on Basic Cognitive functions
People with schizophrenia have deficits in virtually all facets of cognitive functioning
and show performance deficits on a range of simple and complex tasks
More molecular approach focuses on trying to normalize such fundamental cognitive
functions as attention and memory
Cognitive Enhancement Therapy: a computer-based training in attention, memory and
problem-solving, as well as social-cognitive skills
CET proved successful in improving cognition and processing sped and there was
evidence to suggest that it also had a positive effect on functional outcomes
Structural MRIs indicated that CET preserved grey matter in areas such as the left
hippocampus
Chapter 12: Substance-Related Disorders
Substance Dependence: characterized by the primary symptoms of tolerance and
withdrawal
Tolerance: indicated by either (1) larger doses of the substance being need to
produce the desired effect or (2) the effects of the drug becoming markedly less if the
usual amount is taken
Withdrawal: negative physical and psychological symptoms that develop when the
person stop taking the substance or reduces the amount

Substance Abuse: person must experience one of the following as a result of the
recurrent use of the drug
o Failure to fulfill major obligations
o Exposure to physical dangers
o Legal problems
o Persistent social or interpersonal problems
Polydrug (polysubstance abuse): alcohol abuse or dependence combined with other
drugs

Alcohol Abuse and Dependence

Patient is often anxious, depressed, weak, restless and unable to sleep. Tremors of the
muscles, especially of the small musculatures of the fingers, face, eyelids, lips and
tongue, and pulse, blood pressure and temperature are elevated
A person who has been drinking heavily for a number of years may also experience
delirium tremens when the level of alcohol in the blood drops suddenly. The person
becomes delirious as well as tremulous and has hallucinations that are primarily
visual, but may be tactile as well
Increased tolerance is evident following heavy, prolonged drinking
Tolerance results from changes in the number or sensitivity of GABA or glutamate
receptors. Withdrawal may be the result of increased activation in some neural
pathways to compensate for alcohols inhibitory effects in the brain
Some cravings may be so powerful that they are forced to ingest alcohol in a nonbeverage form, such as hair tonic
Nature of the Disorder
Disease model: view that problems such as excessive drinking are due to
vulnerabilities that reside within a person
Moral Model: the view that excessive drinking reflects personal failings and personal
choices of the afflicted individual
o Reject moral view and show ambivalence toward disease model
Course of the Disorder
The male alcohol abuser passes through 4 stages: beginning with social drinking and
progressing to a stage at which he lives only to drink
Difficulties with alcohol usually begin at a later age in women than in men and often
after an inordinately stressful experience, such as a serious family crisis
Women with drinking problems tend to be steady drinkers who drink alone and are
more unlikely than men to binge
Costs of Alcohol Abuse and Dependence
People who abuse alcohol constitute a large proportion of new admission to mental
and general hospitals
Problem drinkers use health services four time more often than do non-abusers, and
their medical expenses are twice as high as those of non-drinkers
Alcohol may contribute to other injuries as well. Rape, assault, and family violence are
alcohol-related crimes, as is homicide. Over half of all murders are committed under
the influence of alcohol
Short-Term Effects of Alcohol

Alcohol is metabolized by enzymes after being swallowed and reaching the stomach.
Most of it goes into the small intestines where it is absorbed into the blood. It is then
broken down, mostly in the liver, which can metabolize about 30 ml of 100 proof
whisky per hour.
Effects of alcohol vary with the level of concentration of the drug in the bloodstream,
which in turn depends on the amount ingested in a particular period of time, the
presence of absence of food in the stomach to retain the alcohol and reduce its
absorption rate, the size of a persons body, and the efficiency of the liver
This mean that the initial effect of alcohol is stimulating the drinker experiences an
expansive feeling of sociability and well-being as the blood alcohol level rises, but
after blood-alcohol level peaks, alcohol acts as a depressant that may lead to
negative emotions
Large amounts of alcohol interfere with complex thought processes, motor coordinate
balance, speech and vision; some people become depressed and withdrawn
Stimulates GABA receptors, which may be responsible for reducing tension
Alcohol also increases levels of serotonin and dopamine, may be the source of its
pleasurable effects
Alcohol inhibits glutamate receptors, which may cause the cognitive effects of alcohol
intoxication

Long-Term Effects of Prolonged Alcohol Abuse

Almost every tissue and organ of the body is affected adversely by prolonged
consumption of alcohol
Malnutrition may be severe. Since alcohol provides calories, heavy drinkers often
decrease intake of food
Alcohol also contributes directly to malnutrition by impairing the digestion of food and
the absorption of vitamins.
A deficiency of B-complex vitamins can cause amnestic syndrome, a severe loss of
memory for both recent and long-past events
Prolonged alcohol use also contributes to the development of cirrhosis to the liver
(liver cells become engorged with fat and protein, impeding their function)
Other common physiological changes include damage to endocrine glands and
pancreas, heart failure, hypertension, stroke, and capillary hemorrhages (responsible
for redness in the face)
Prolonged use of alcohol seems to destroy brain cells. Alcohol also reduced the
effectiveness of the immune system and increases susceptibility to infection and
cancer
Heavy alcohol consumption during pregnancy is the leading cause of mental
retardation
Fetal Alcohol Syndrome: growth of fetus is slowed, and cranial, facial and limb
anomalies are produced due to the mother consuming alcohol when pregnant
Light drinking especially of wine, is related to decreased risk for coronary heart
disease and stroke
Inhalant Use Disorders
Alarming number of young people begin their substance abuse by inhaling such
substances such as glue, correction fluid, spray paint, cosmetics, gasoline, household
aerosol sprays, and nitrous oxide
Peak age of inhalant use is 14-15 years, with initial onsets in children as young as 6

Inhalant use disorder can involve behaviours such as sniffing, huffing, and bagging
Most inhalants act as depressants and can be seen as similar to alcohol and
sedatives. The inhaled substance can result in feelings of euphoria and psychic
numbing, but inhalants can cause damage to the central nervous system. Nausea and
headaches are experienced eventually in almost all cases.

Nicotine and Cigarette Smoking

Nicotine: addicting agent of tobacco. It stimulates receptors, called nicotinic receptors in
the brain.
The main receptor mediating nicotine dependence is the nicotinic acetylcholine
receptor subtype
Exposure to nicotine influences brain nicotinic cholinergic receptors to facilitate
neurotransmitter release thus producing stimulation, pleasure and mood modulation
Addictive effects of smoking start very shortly after ones first puff
Female smokers have substantially greater changes in cognitive activity after nicotine
exposure
Health Consequences of Smoking
Single most preventable cause of premature death
Health risks of smoking are significantly less for cigar and pipe smokers because they
seldom inhale the smoke into their lungs, but cancers of the mouth are increase
Medical problems caused by smoking: lung cancer, emphysema, cancer of the larynx
and esophagus, number of cardiovascular disease
Most probably harmful components in the smoke from tobacco are nicotine, carbon
monoxide, and tar (consists of hydrocarbons including know carcinogens)
Smoking contributes to erectile problems in men
Consequences of Second-Hand Smoke
Second-hand smoke: or environmental tobacco smoke, is smoke coming from the
burning end of a cigarette, contains higher concentrations of ammonia, carbon
monoxide, nicotine and tar than does the smoke that is inhaled by the smoker
Effects can be found in terms of health outcomes and behavioural tendencies
Marijuana
Marijuana: dried and crushed leaves and flowering tops of the hemp plan, Cannabis
sativa. Can be smoked, chewed, prepared as tea, or eaten in baked goods
Hashish: stronger than marijuana, produced by removing and drying the resin exudates
of the tops of high-quality cannabis plants
Effects of Marijuana
Psychological Effects
Depend in part of its potency and size of dose
Smokers find it makes them feel relaxed and sociable, large doses have been reported
to bring rapid shifts of emotion, to dull attention, to fragment thoughts, and to impair
memory
Increases likelihood of psychotic disorders due to the interactions that relate to the
levels of dopamine

Major chemical in marijuana is delta-9-tetrahyrdrocannabinol (THC) (2-3x higher than

2 decades ago)
Neurocognitive deficits are greater among adults who began cannabis use in early
adolescence and adolescents seem much more susceptible than adults to
neurocognitive deficits
Being high on marijuana impairs the complex psychomotor skills needed for driving

Somatic Effects
CB (cannabinoid) receptors in the brain are located in various regions, and it is
believed that receptors in the hippocampus account for the short-term memory loss
that sometimes follows smoking
Short-term side effects of marijuana include: bloodshot and itchy eyes, dry mouth and
throat, increase appetite, reduced pressure within the eye, and somewhat raised
blood pressure
Growing evidence that smoking marijuana is associated with a host of respiratory
diseases and related ailements and seriously impairs lung functioning. Symptoms
include coughing, wheezing, bronchitis, injury to airway tissue and impaired
functioning of immune system components
Most marijuana smokers inhale the smoke more deeply and retain it in their lungs for
much longer periods of time
Dependence susceptibility: notion that some people are much more sensitive and
prone to becoming addictive than are other people
Therapeutic Effects
THC and related drugs can reduce the nausea and loss of appetite that accompany
chemotherapy for some cancer patients
Marijuana is also a treatment for the discomfort of AIDS as well as glaucoma,
epilepsy, and multiple sclerosis
Sedatives and Stimulants
Sedatives
Sedatives: downers, slow the activities of the body and reduce its responsiveness
Opiates
Opiates: group of addictive sedatives that relieve pain and induce sleep when taken in
moderate doses
Opioids synthetic or semi-synthetic version of opiates
Oxycontin opioid with the active ingredient oxycodone that produces a swift and
powerful high
History
Begin when morphine was created (powerful sedative and pain reliever)
Morphine was use in patient medicines, by being injected directly into veins to relieve
pain
Found morphine can be converted into another drug that they called heroin
Heroin was a substituted for morphine in cough syrups and other patent medicines,
but proved to be more addictive and more potent that morphine, acting more quickly
with greater intensity

Psychological and Physical Effects

Produce euphoria, drowsiness, reverie, and a lack of coordination
Heroin has an additional effect: the rush, a feeling of warm, suffusing ecstasy
immediately following an intravenous injection
User sheds worries and fears and has great self-confidence for 4-6 hours, but then
experiences letdown, bordering on stupor
Opiates produce their effects by stimulating neural receptors of the bodys own opioid
system
The body produces opioids, called endorphins and enkephalins, and opium and its
derivatives fit into their receptors and stimulate them
They are clearly addicting, increased tolerance of the drugs and withdrawal
symptoms. Reactions to not have a dose may begin within 8 hours after the last
injection.
Individual typically has muscle pain, sneezes, sweats, becomes tearful and yawns a
lot over the next few hours
Withdrawal symptoms become more severe within 36 hours; may be uncontrollable
twitching, cramps, chills alternating with excessive flushing and sweating, and a rise
in heart rate and blood pressure
Person is unable to sleep, vomits and has diarrhea
Synthetic Sedatives
Barbiturates: another major type of sedative, were synthesized as aids for sleeping and
relaxation
These drugs were initially considered highly desirable and were frequently prescribed
Sedatives relax the muscles, reduce anxiety, and in small does produce a mildly
euphoric state
They are thought to produce these psychological effects by stimulating the GABA
system.
With excessive doses, speech becomes slurred and gait unsteady
Judgement, concentration, and ability to work may be severely impaired
The user loses emotional control and may become irritable and combative before
falling into a deep sleep
Very large doses can be fatal because the diaphragm muscles relax to such an extent
than an individual suffocates
Stimulants
Stimulants: act on the brain and the sympathetic nervous system to increase alertness
and motor activity
Amphetamines

Isolated an alkaloid from the plant belonging to the genus Ephedra, and the result,
ephedrine, proved highly successful in treating asthma. But relying on the shrub for
the drug wasnt efficient, so they developed a synthetic substitute -> Amphetamine
Amphetamine produces its effects by causing the release of norepinephrine and
dopamine and blocking their reuptake
They are taken orally or intravenously and cab be addictive
Wakefulness is heightened, intestinal functions are inhibited, and appetite is reduced

Heart rate quickens, and blood vessels in the skin and mucous membranes constrict
The individual becomes alert, euphoric, and outgoing and is possessed with seemingly
boundless energy and self-confidence.
Larger doses can make people nervous and confused, subjecting them to palpitations,
headaches, dizziness, and sleeplessness
Large doses taken over time can induce a state similar to paranoid schizophrenia,
including its delusions
As tolerance increases, user stops taking pills and injects methedrine (meth) directly
into the veins

Cocaine
Alkaloid cocaine was extracted from the leaves of the coca plant
Cocaine has effects in addition to reducing pain. It acts rapidly on the brain, blocking
the reuptake of dopamine in mesolimbic areas that are thought to yield pleasurable
states, dopamine is left in synapse and facilitates neural transmission and results in
positive feelings
Cocaine increases sexual desire and produces feelings of self-confidence, well-being,
and indefatigability
An overdose may bring on chills, nausea and insomnia, as well as a paranoid
breakdown and terrifying hallucinations
Chronic use leads to changes in personality, includes heightened irritability, impaired
social skills, paranoid thinking, and disturbances in eating or sleeping
Cocaine, a vasoconstrictor, causes the blood vessels to narrow. It increases persons
risk for stroke and causes cognitive impairments
Cocaine poses special dangers in pregnancy, for the blood supply to the fetus may be
compromised

LSD and Other Hallucinations

History
LSD was first referred to as a psychotomimetic because it was thought to produces
effects similar to the symptoms of psychosis
Term in current use for LSD is a hallucinogen
4 other important hallucinogens are mescaline, psilocybin, and synthetic compounds
of MDA and MDMA
Mescaline: an alkaloid and an active ingredient of peyote, was isolated from small,
disc-like growths on the top of the peyote cactus
Psilocybin: a crystalline power that Hofmann isolated from the mushroom Psilocybe
Mexicana
Each of the substances is structurally similar to several neurotransmitters, but effects
are thought to be due to the stimulation of serotonin receptors
Ecstasy: refers to 2 closely similar synthetic compounds, MDA and MDMA, is
chemically similar to mescaline and the amphetamines and is the psychoactive agent
in nutmeg
Drug enhances intimacy and insight, improves interpersonal relationships, elevates
mood, and promotes aesthetic awareness

It can also cause muscle tension, rapid eye movements, increase heart rate and blood
pressure, nausea, faintness, chills or sweating, and anxiety, depression, and confusion
Lasting side effects include paranoia, confusion and memory complaints

Effects of Hallucinogens
A persons set is widely held to be an important determinant of his or her reactions to
hallucinogens
A bad trip can sometimes develop into a full-blown panic attack and is far more likely
to occur if some aspect of taking the drug creates anxiety
Flashbacks: a recurrence of psychedelic experiences after the physiological effects of
the drug have worn off
Etiology of Substance Abuse and Dependence
Social Variables
Various aspects of the social world can affect peoples interest in and access to drugs
Cultural attitudes and patterns of drinking influence the likelihood of drinking heavily
and therefore, abusing alcohol
Rates of alcohol are higher among bartenders or liquor store owners - alcohol is
readily available
Rates of smoking increase if cigarettes are perceived as being easy to get and
affordable
Lack of emotional support from parents is linked with increase use of cigarettes,
cannabis and alcohol
A lack of parental monitoring leads to increased association with drug-abusing peers
and subsequent use of drugs
The social milieu in which a person operates can also affect substance abuse. Having
friends who smoke predicts smoking. Peer influences are also important in promoting
alcohol and marijuana use.
Those who have high self-efficacy are influenced less by peers
Psychological Variables
Mood Alteration, Situations and the role of cognitions
Why do people drink?
Drinking occurs if the perceived benefits outweigh the costs
Drinking motives vary along 2 dimensions: the valence of reinforcement and locus,
that is, people can drink to obtain pleasurable outcomes or avoid negative outcomes,
and they can drink in response to external, social stimulation in response to internal,
personal cues
4 combinations involving these two dimensions are possible. Drinking for positive,
internal reasons = drinking to enhance positive mood (enhancement scale). Drinking
for negative, internal reasons = drinking to reduce or avoid experiencing negative
emotions (coping scale). Drinking for positive, external reasons = drinking to obtain
social rewards (social scale). Drinking for negative, external reasons = drinking to
escape punishment or to avoid being embarrassed by people (conformity scale)
Self-medication theory of addiction: drinking is done with the goal of reducing an
aversive state

Cognitive Factors in Drinking

Alcohol may produce its tension-reducing effect by altering cognition and perception
Alcohol impairs cognitive processing and narrows attention to the most immediately
available cues (Resulting in alcohol myopia intoxicated person has less cognitive
capacity to distribute between ongoing activity and worry)
Positive alcohol expectation predict higher levels of consumption and alcohol-related
problems, while negative expectations tend to inhibit consumption
Explicit cognition: controlled thought processes that can be deliberated upon
Implicit cognition: automatic appraisal of cues that is more uncontrolled and perhaps
not subject to conscious awareness
Focus on implicit cognition reflects the reality that behaviour is often not a product of
conscious cognitive reflection but is instead due to cognitions spontaneously
activated during periods of temptation or periods of stress
Drug-Stroop Task can be used to assess vulnerability to addiction, but it can also be
used to evaluate remission and treatment-improvements
Personality and Drug Use
Personality variables attempt to explain why certain people are drawn to substance
abuse
Personality variables are stable individual differences that can be detected early in
childhood and are believed to be relatively stable across the lifespan
Brain systems associated with behavioural activation and behavioural inhibition are
associated with 3 genetically inherited dimensions of personality: novelty seeking,
harm avoidance, and reward dependence
Substance abuse are likely among people characterized by high levels of neuroticism
and psychotism
Maturing out phenomenon: overall tendency for peak drinking levels to occur when
people are in their mid-20s and there is a sharp drop in drinking levels when people
reach their late 30s
Biological Variables
Twin studies revealed greater concordance rate in identical twins for alcohol abuse,
caffeine use, heavy use of cannabis, and drug abuse
Genetic component of drinking may be stronger in males than females
Some people may be genetically programmed to be able to quit smoking (heritable
component)
Appears that (1) neuroadaptations following continued brain exposure remain even
after alcohol exposure stops (2) there is substantial individual variability in
neuroadaptations based on genetic factors
Corticotrophin-releasing factor system within the amygdale is central factor in the
neuroadaptive changes that accompany problem drinking
Conditioning Theory of tolerance: underscores the need to jointly consider biological
processes and environmental stimuli that may be involved in the acquisition and
maintenance of addictive behaviours
Feed-forward mechanism: anticipatory regulatory responses made in anticipation of a
drug
Therapy for Problem Drinking

Admitting the Problem

Substance abuses of all kinds are adept at denying they have a problem and may
react angrily to any suggest that they do
Current heavy drinkers were significantly less likely than moderate drinkers to believe
that they need treatment
Enabling the drinker to take the first step t betterment can be achieved through
questions that get at the issue somewhat directly (page 396)
Traditional Hospital Treatment
Detoxification: the withdrawal from alcohol
Can be difficult both physically and psychologically, and usually takes about one
month
Tranquilisers are sometimes given to ease the anxiety and general discomfort
To help get through withdrawal, alcohol abusers also need carbohydrate solutions, B
vitamins, and sometimes anticonvulsants
Biological Treatments
Antabuse: a drug that discourages drinking by causing violent vomiting if the alcohol
is ingested
It blocks the metabolism of alcohol so that noxious by products are created
The drinker must already be committed to change. If an alcohol abuser is able or
willing to take the drug every morning as prescribed, the chances are good that
drinking will lessen because of the negative consequences of inhibiting.
Alcoholic Anonymous
Largest and most widely known self-help group in the world
Regular meetings where new-comers rise to announce that they are alcoholics, and
older members give testimonials telling stories of their lives and how they are better
now
The belief is instilled in each AA member that alcohol abuse is a disease that can
never be cured, so continuing vigilance is necessary to resist taking even a single
drink lest uncontrollable drinking begin all over again
Couples and Family Therapy
Alcohol abusers often abuse their family members
Behaviourally oriented marital or couples therapy has been found to achieve some
reductions in problem drinking, as well as some improvements in couples distress
generally
A focus of this therapy is involving the spouse in helping the drinker take his or her
Antabuse on a regular basis
Husbands who drink excessively often have wives who drink to excess
Cognitive and Behavioural Treatment
Aversion Therapy
Problem drinkers are shocked or made nauseous while looking at, reaching for, or
beginning to drink alcohol

Covert sensitization: problem drinkers are instructed to imagine being made violently
and disgustingly ill by their drinking

Contingency-Management Therapy
Involves teaching clients and those close to them to reinforce behaviours inconsistent
with drinking
This therapy also includes teaching job-hunting and social skills, as well as
assertiveness training for refusing drinks
Behavioural self control emphasizes patient control and includes one or more of the
following:
o Stimulus control one narrows situations in which one allows oneself to drink
o Modification of the topography of drinking
o Reinforcing abstinence
Moderation in Drinking
Controlled Drinking: a moderate pattern of alcohol consumption that avoids the
extremes of total abstinence and inebriation
Some alcohol abusers can learn to control their drinking and improve other aspects of
their life
Guided Self-change: an outpatient approach, emphasizes personal responsibility and
control
As stated in the GSCP manual the goals of the program are to (1) help clients help
themselves (2) allow clients to make informed choices (3) teach a general problemsolving approach (4) strengthen client motivation and commitment to change (5)
encourage self reliance, empowerment and personal competence
Harm reduction therapy: complete abstinence from alcohol
Clinical considerations in treating alcohol abuse
A comprehensive clinical assessment considers what place drinking occupies in the
persons life
Depression is often co-morbid with alcohol abuse and that suicide is also a risk
Alcohol researchers recognize that different kinds of drinkers may require different
treatment approaches
The challenge is to determine which factors in the drinkers should be aligned with
which factors in treatment
Aptitude-treatment interaction is a critical issue in the development of better
interventions for problem drinking
Therapy for the use of Illicit Drugs
Detoxification is the first way in which therapists try to help an addict or drug abuser,
and it may be the easiest part of the rehab process
Biological Treatments
2 widely used drug-therapy programs for heroin addiction involve heroin substitutes
(drugs chemically similar to heron that replace the bodys craving for it) or heroin
antagonists (drugs that prevent the user from experiencing the heroin high)
The first category includes methadone synthetic narcotics designed to take the
place of heroin

Synthetic narcotics are cross-dependent, by acting on the same CNS receptors, they
become a substitute for the original dependency
Clonidine an antihypertensive medication, may ease withdrawal from a variety of
addicting drugs
Bromocriptine also shows some promise in reducing craving, perhaps by reversing the
depletion of dopamine that is believe to underlie cocaines addicting properties

Psychological Treatments
Patients receiving cognitive treatment learned how to avoid high-risk situations,
recognize the lure of the rug for them, and develop alternatives to using cocaine
Cocaine abusers in this study also learned strategies for coping with the craving and
for resisting the tendency to regard a slip as a catastrophe
Motivational interviewing: combines CBT principles with the humanistic principles by
Rogers. The central premise is that people must be motivated and ready to change in
order for psychological interventions to work and motivation needs to be enhance
among ambivalent clients
3 key motivational concepts that are related to whether someone with a drinking
problem can overcome it are readiness to change, ambivalence, and resistance
Treatment of Cigarette Smoking
Biological Treatments
Attention to nicotine dependence is clearly important because the more cigarettes a
person smokes daily, the less successful attempts to quit will be
Gum containing nicotine may help in quitting, the nicotine in the gum is absorbed
much more slowly and steadily than in tobacco
Nicotine patches are applied to the skin that slowly and steadily release the drug into
the bloodstream and thence to the brain
Vareicline is a nicotine receptor partial agonist that seems effective in reducing
smoking when used over a period of 3 months. It not only reduces withdrawal
symptoms, it tends to reduce the urges to smoke among those who have quit
smoking
Psychological Treatments
Variations in smoking may help. Such as rapid puffing, focused smoking, and smoke
holding
Use various coping skills such as relaxation and positive self-talk, when confronted
with a tempting situation
Combined approach with counselling and pharmacotherapy is the best
Relapse Prevention
People who smoked the most and more addicted to nicotine, relapse more often and
more quickly
So called booster or maintenance sessions help, and represent a continuation of
treatment, but when they stop, relapse happens
Self-efficacy is a smokers most difficult challenge

Chapter 16: Aging and Psychological Disorders

Subjective Age Bias: presence of negative aging stereotypes may account for the fact
that most people report that they feel younger than they actually are
Younger subjective age is linked with greater life satisfaction and a host of other
positive outcomes
Positive health experiences and greater health satisfaction are linked with lower
subjective age
Physical realities of aging are complicated by ageism
Ageism: discrimination against any person, young or old, based on chronological agee
The old are usually defined as those who are over the age of 65. This was set largely
by social policies.
Diversity in Older Adults
The word diversity is well suited to the older population
Old people are more different from one another than are individuals in any other age
group
Age, Cohort, and Time of Measurement Effects
Must be cautious when we attribute differences in age groups solely to aging 3 kinds
of effects:
o Age effects: consequences of being a given chronological age
o Cohort effects: consequences of having been born in a given year and having
grown up during a particular time period with its own unique pressures, problems,
challenges and opportunities
o Time-of-measurement effects: confounds that arise because events at an exact
point in time can have a specific effect on a variable being studied over time
Two major research designs are cross-sectional and longitudinal studies
Cross-Sectional studies: investigator compares different age groups at the same
moment in time on the variable of interest
They allow us to make statements about age effects in a particular study or
experiment, not about age changes over time.

Longitudinal Studies: researcher selects one cohort and periodically retests it using
the same measure over a number of years
Allows researchers to trace individual patterns of consistency or change over time and
to analyze how behaviour in early life relates to behaviours in old age
Selective mortality: least-able people drop out, leaving a non-representative group of
people who are usually healthier than the general population

Diagnosing and Assessing Psychopathology in Later Life

Measures of cognitive functioning is often included as standard practice in research to
determine whether the elderly respondent has experienced declines in cognitive
ability
One goal is to develop short but reliable measures suitable for screening purposes
(elderly have diminished attention spans)
Another goal is to create measures whose item content is tailored directly to the
concerns and symptoms reported by elderly people, not to those of younger
respondents
Range of Problems
Old age individual have all problems: physical decline and disabilities, sensory and
neurological deficits, loss of loved ones, the cumulative effects of a life of many
unfortunate experiences, and social stresses
Elderly people with a mental disorder may suffer from a double jeopardy suffer
stigma from being old and from being mentally ill
Old Age and Brain Disorders
Dementia
Dementia: a general descriptive term for gradual deteoriation of intellectual abilities to
the point that social and occupational functions are impaired
Difficulty remembering things or events in the most prominent symptoms and
memory problems in people who objectively have normal cognition predict
subsequent dementia
May leave tasks unfinished; poor hygiene and appearance because they forget to
bathe or how to dress
Get lost, even in familiar settings; judgement may be fault and difficulty
comprehending situations
They relinquish their standards and lose control of their impulses; may use coarse
language, tell inappropriate jokes, or shoplift
Trouble recognizing familiar surroundings or naming familiar objects
Episodes of delirium a state of great confusion may also occur
Course of dementia may be progressive, static or remitting, depending on the cause,
many people with progressive dementia become withdrawn and apathetic
Causes of Dementia
Alzheimers Disease
Alzheimers Disease accounts for 50% of the cases of dementia
The brain tissue deteoriates irreversibly, and death usually occurs 10-12 years after
the onset of symptoms

Women with Alzheimers Disease live longer than men, but more women than men die
as a result of the disease
The person may at first have difficulties only in concentration and in memory, and
may appear absent minded and irritable
Well before the onset of clinical symptom, subtle deficits in learning and memory are
revealed by neuropsychological tests
As the disease develops, the person often blames others for personal failings and may
have delusions of being prosecuted. Memory continues to deteoriate and the person
becomes increasingly disoriented and agitated
The main physiological change in the brain, evident at autopsy, is an atrophy of the
cerebral cortex, first the entorhinal cortex and the hippocampus and later the frontal,
temporal, and parietal lobes
As neurons and synapses are lost, the fissures widen and the ridges become narrower
and flatter and ventricles also become enlarged
Plaques: small, round areas making up the remnants of the lost neurons and bamyloid, a waxy protein deposit are scattered throughout the cortex
Tangled abnormal protein filaments Neurofibrillary Tangles accumulate within the cell
bodies of neurons.
These plaques and tangles are present throughout the cerebral cortex and
hippocampus
Volume loss in the medial temporal lobes was the most sensitive measure when
identify patients with Alzheimers disease
Alzheimers disease has a structural effect on the entorhinal and hippocampal
regions, and functionally, it impacted the inferior parietal lobules and precuneus
Strong evidence for a genetic basis for Alzheimers disease
Gene appears to be related to the development of both plaques and tangles, and it
seems to increase the likelihood that the brain will incur damage from free radicals
Environment is also likely to play a role in most cases
Remaining active at the cognitive level may buffer or protect an individual in terms of
the degree of cognitive decline experienced
Cognitive Reserve Hypothesis: notion that high education level delays the clinical
expression of dementia because the brain develops backup or reserves neural
structures as a form of neuroplasticity
A related protective factor is being bilingual; they engage in more stimulating mental
activities and more extensive cognitive practice that contribute to a cognitive reserve
that becomes ultimately reflected in brain plasticity
Frontal-Lobe Dementias
Accounts for 10-15% of dementia cases
Typically begins in a persons late fifties
Frontal-temporal dementias are marked by extreme behavioural and personality
changes
Sometimes people are very apathetic and unresponsive to their environment; other
times, they show an opposite pattern of euphoria, over-activity and impulsivity
Serotonin neurons are most affected, and there is widespread loss of neurons in the
frontal and temporal lobes
Picks disease is one cause of frontal-lobe dementia; it is a degenerative disease in
which neurons are lost. It is also characterized by the presence of Pick bodies,

spherical inclusions within neurons

Frontal-Subcortical Dementias
Types include:
o Huntingtons Disease: caused by a single dominant gene located on chromose 4
and is diagnosed principally by neurologists on the basis of genetic testing. Its
major behavioural feature is the presence of writhing movements
o Parkinsons Disease: muscle tremors, muscular rigidity, and akinesia (an inability
to initiate movement) and can lead to dementia
o Vascular Dementia: now referred to as major or mild neurocognitive disorder.
Diagnosed when a patient with dementia has neurological signs, such as
weakness in arm or abnormal reflexes, or when brain scans show evidence of
cerebrovascular disease
Other Causes of Dementia
Number of infectious diseases can produce irreversible dementia
Encephalitis is caused by viruses that enter the brain from other parts of the body or
from the bites of mosquitoes or ticks
Meningitis caused by bacterial infections
Organism that produces the venereal disease syphilis can invade the brain and cause
dementia
Head traumas, brain tumours, kidney or liver failure, nutritional deficient and
endocrine-gland problems can result in dementia
Treatment of Dementia
Biological Treatments of Alzheimers disease
Various studies have attempted to increase the levels of acetylcholine
Tetrahydroaminoacridine (Tacrine) inhibits the enzyme that breaks down
acetylcholine, which produces mild improvement or slows the progression of cognitive
decline
Tacrine cannot be used in high doses because it has severe side effects
5 drugs have been approved thus far: tacrine, donepezil, rivastigmine, galantamine,
and memantine
These drugs have not stopped progression of Alzheimers disease though they may
slow down the progression of symptoms
Psychosocial Treatments for the individual and Family
Overall goal is to minimize the disruption caused by the persons behavioural
changes. Achieved this by allowing the person and the family the opportunity to
discuss the illness and its consequences, providing accurate information about it,
helping family members care for the person in the home, and encouraging a realistic
attitude in dealing with diseases specific challenges
Psychotherapy provides little long-term benefit for those with severe deteoriation
Depression is twice as evident among caregivers
Depression and feelings of being burdened are highly correlated among caregivers

4 significant burden areas were identified: emotional burden, physical burden,

financial burden, and employment burden
Resilience promotes well-being among caregivers experiencing significant burden
3 best predictors of making the difficult decision to institutionalize a loved one are the
elderly persons level of aggression, incontinence, and the presence of psychiatric
disturbance

Delirium
Delirium: implies being off track or deviating from the usual state; a clouded state of
consciousness
Great trouble concentrating and focusing attention and cannot maintain a coherent
and directed stream of thought
Early stage: Frequently restless, sleep-waking cycle is disturbed, vivid nightmares and
dreams are common
May be impossible to engage in conversation because of their wandering attention
and fragmented thinking
Speech is rambling and incoherent; lose sense of time and place
In the course of a 24 hour period, delirious people have lucid intervals and become
alert and coherent. This distinguishes delirium from other syndromes
Fever, flushed face, dilated pupils, tremors, rapid heartbeat, elevated blood pressure,
and incontinence are common
Causes of Delirium
Drug intoxications and drug-withdrawal reactions, metabolic and nutritional
imbalances, infections or fevers, neurological disorders, and the stress of a change in
the persons surroundings
Delirium may also occur following major surgery (most commonly hip surgery), during
withdrawal from psychoactive substances, and following head traumas or seizures
Common physical illnesses that can cause delirium are congestive heart failure,
pneumonia, urinary tract infection, cancer, kidney, or live failure
Treatment of Delirium
Generally takes one to four weeks for the condition to clear
If the underlying cause is not treated, permanent brain damage and death can ensue
Primary prevention strategies appear to reduce the high rates of delirium, as well as
the duration of delirium episodes in hospitalized older adults
The intervention addresses such risk factors for delirium such as sleep deprivation,
immobility, dehydration, visual and hearing impairment, and cognitive impairment
Old Age and Psychological Disorders
Depression
Major depression is less prevalent among adults age 65 and older, relative to younger
people
Depression and other disorders are still quite evident in the elderly
Greater prevalence of depression was associated with female gender, the presence of
dementia, and the presence of physical health problems
At least half of depressed older adults are experiencing depression for the first time
(late-onset depression)

Those with early-onset depression are more likely to have a family history o
depression and personality dysfunction that renders them vulnerable
Early-onset depression have comparatively greater depression and less social
support, and have more severe cognitive and neurological changes
Older adults are less likely to demonstrate impaired social and occupational
functioning because they are less likely to be working
Depletion syndrome depression without sadness; loss of pleasure, vitality and
appetite; hopelessness and somatic symptom; self-blame, guilty, and dysphoric mood
a

Causes of Depression in Older Adults

Decreases involvement in daily activities and maintained by self-critical thoughts
Elderly with health problems and depression dont know whether if depression or the
health problem came first
As we age, experience a lot of life events that could cause depression
Bereavement after the loss of a loved one has been hypothesized to be the most
important risk factor
Women with ill husbands anticipate the loss and may become depressed prior to their
spouses death
People who were optimistic and found meaning in their lives had better psychological
adjustment
Importance of social support as a stress buffer for elderly people facing life challenges
Treatment of Depression
Quality of the alliance between elderly and his/her therapist is a key factor in
determining whether there is a positive treatment response
Depressed elders with negative self-views had less positive responses to the cognitive
interventions
CBT was effective in reducing levels of depression as assessed by Beck-Depression
Inventory
Interpersonal psychotherapy (IPT) is a short-tem psychotherapy that addresses
themes such as role loss, role transition, and interpersonal disputes, which are
problem areas prominent in the lives of many older adults
A form of treatment known as reminiscence therapy can also be effective for treating
depression the elderly. It is also known as life review therapy. It is as cognitive therapy
that requires individuals to reflect on previous negative events and address any
remaining conflicts. It also requires that they strive to find lifes meaning while
examining the present situation and the past
Helps the person address the conflict between ego integrity and despair. Ego integrity
refers to a process of finding meaning in the way one had led ones life, and despair
reflects the discouragement that can come from unreached goals and unmet desires.
Electroconvulsive therapy is also back in favour among many geriatric psychiatrists
ECT has many risks, and should only be considered when other treatments have not
been effective, or when a rapid response is needed
Anxiety Disorders
Can be a continuation or re-emergence of problems experienced early in life, or they
can develop for the first time in senior years

Risk factors for anxiety in older people are: being female, several chronic medical
conditions, not being married, having lower levels of education, adverse childhood
experiences, and elevated neuroticism
Anxiety among people with dementia is linked with poorer quality of life, behavioural
disturbances, and poor outcomes
Elderly report more worries about health and fewer worries about work
Differences exist in the structure of affect, with elderly people placing less emphasis
on feelings of guilt and self-blame
Elderly people emphasize the somatic aspects of anxiety rather than the cognitive
Symptoms of anxiety may be more closely intertwined with symptoms reflecting sleep
difficulties and decline in cognitive capabilities
PTSD and acute stress disorder may be especially relevant in the lives of older adults
CBT consisting of relaxation training, cognitive therapy, and exposure-based
procedures; is useful for older adults because it is time-limited, symptom-focused, and
collaborative

Substance-Related Disorders
Alcohol Abuse and Dependence
Heavy drinking was linked with depression, anxiety, and health problems
Binge drinking among men was linked with being separated, divorced or widowed
Problem drinking in older adults may be a continuation of a pattern established earlier
in life; but many drinkers begin having alcohol-related problems after the age of 60
(late-onset alcoholism)
Tolerance for alcohol diminishes with age (ratio of body water to body mass
decreases; results in higher blood alcohol concentration per unit of alcohol inhibited)
Older people metabolize alcohol more slowly. Drug may cause greater changes in
brain chemistry and more readily bring on toxic effects (such as delirium)
Cognitive deficits associated with alcohol abuse, such as memory problems, are more
likely to be more pronounced in the aged alcoholic than in younger individuals
Residual cognitive effects may remain long after the older person has stopped
drinking
Medication Misuse
Elderly people have a higher overall rate of legal drug intake than any other group
Abuse of prescription or legal drugs is often inadvertent but can be deliberate
Older adults may abuse tranquilizers, antidepressants, or sleep aids, to deal with
postoperative pain or the grief and anxiety of losing a loved one
These drugs often create physical as well as psychological dependency
Slurred speech and memory problems caused by drugs may be attributed by others to
old age and dementia
Sleep Disorders
Insomnia is a frequent complaint among older adults
1 in 5 of people over 65 experience insomnia
The prevalence of insomnia goes up steadily as age increases
Insomnia in the elderly Is both more frequent and severe that in younger people and
is associated with more complications

Need for help is indicated by insomnia being linked with lower self-reported levels of
physical health and psychological health
The most common sleep problems experienced by older adults are waking often at
night, frequent early-morning awakenings, difficulty falling asleep, and daytime
fatigue
Older adults spend less time in REM sleep, and stage 4 sleep (deepest stage) is
virtually absent
Older men experience it more than women

Causes of Sleep Disorders

Various illnesses, medications, caffeine, stress, anxiety, depression lack of anxiety,
and poor sleep habits may make insomniacs of older adults
Depressed mood has been shown to be related to sleep disturbances in older adults
too
It is worsened by self-defeating actions such as ruminating over it and counting the
number of hours slept and those spent waiting to fall asleep
Sleep apnea: respiratory disorder in which breathing ceases repeatedly for a period of
a few seconds to as long as 2 minutes as the person sleeps. It disrupts normal sleep
and can lead to fatigue, muscle aches, and elevation in blood pressure over a period
of time
Disruption is due to markedly reduced airflow caused by relaxation produced
obstruction from excessive tissue at the back of the throat
Treatment of Sleep Disorders
Pharmacotherapy is most common form of treatment for sleep disorders for elderly,
receive one-third of the sedatives and hypnotics that are used
Sleep drugs rapidly lose their effectiveness with continuous use, and may make sleep
light and fragmented
Medications can even bring about a drug-dependent insomnia gives people drug
hangovers and increase respiratory difficulties
CBT is an effective long-term treatment for insomnia
Tranquilizers are not appropriate for elderly to treat insomnia
Melatonin, a hormone secreted by the pineal gland plays an important role in
regulating sleep and is known to decrease with aging; therefore it has been used to
treat sleep disorders
Suicide
Several factors put people in general at especially high risk for suicide: serious
physical illness, feelings of hopelessness, social isolation, loss of a loved one, dire
financial circumstances, and depression
Suicide rates for people over 65 are high, approximately 3x higher than younger
individuals
Older white men are more likely to commit suicide, peak ages are 80-84
Elderly men more than elderly women, were more likely to use lethal methods as a
means of committing suicide (Ex using a gun)
Older people are less likely to communicate their intentions to commit suicide and
make fewer attempts as the most often kill themselves with lethal methods
Elderly people are often more socially isolated and less likely to be rescued prior to
death

Suicide acts themselves are more planned and determined in older people and are
less impulsive
As more people survive longer, the number of suicides as people age is almost certain
to increase
Individual differences in loneliness and feelings of isolation predicted suicide ideation
in elderly
Poor cognitive functioning, depression, general hopelessness, and interpersonal
hopelessness were predictors of suicide ideation
Feeling like a burden tends to have a negative impact in protective factors such as the
meaning of life
Link between physical illness and suicide
Elderly suicides were more violent and alcohol was more likely to be involved

Treatment and Care of Older Adults

Treatment of Older Adults
Clinicians tend to expect less success in treating older people than in younger people
The views of psychotherapists are paralleled by equally negative views of the elderly
endorsed by people in the general population
If older clients were viewed has having limited possibilities for improvement, they
may not be treated
Admissions of older adults to hospitals and psychiatric units have decreased
substantially in recent years due to changes in mental health policy
Nursing and Home care
Most older people needing mental health treatment now live in nursing homes or
receive community-based care
Significant and ongoing concerns about the quality of care in nursing homes and this
has been exacerbated by some horrific stores of abuse and neglect towards elderly
Alternative Living Settings
Dramatic rise in assisted-living or retirement homes, a viable alternative to placement
in a nursing home for many older adults who require assistance
Assisted-living facilities resemble hotels with separate rooms and suites for the
residents, as well as dining rooms and on-site amenities
Philosophy of assisted living stresses autonomy, independence, dignity and privacy
Many residences are quit luxurious with attentive staff, nursing and medical
assistance readily available, daily activities such as bingo and movies, and other
services all designed to provide assisted care for older adults too infirm to live on their
own

Issues Specific to Therapy with Older Adults

Guidelines for Psychological Practice with Older adults agreed on six areas: (1)
attitudes (2) general knowledge about adult development, aging, and older adults (3)
clinical issues (4) assessment (5) intervention, consultation, and other service
provision (6) education

Content of Therapy
Incidence of brain disorders increases with age but other mental health problems of
older adults are not that different from those experienced early in life
Medical illnesses can create irreversible difficulties in walking, seeing and hearing.
Finances may be a problem.
Therapy with older adults must take into account the social contexts in which they
live, something that cannot be accomplished merely by reading the professional
literature
Mental health care workers need to know and understand the social environments in
which their older patients live in. many neglect to consider this in older adults
The social needs of older people often different from those of younger people. There is
no link between level of social activity and psychological well-being among old people
As we age, our interests shift away from seeking new social interactions to cultivating
those few social relationships that really matter to us
Process of Therapy
Traditional individual, group, family and marital therapies are effective with older
adults
Therapists hold that therapy with older people needs to be more active and directive,
and thus they provide information and take the initiative in seeking out agencies for
necessary services
Certain kinds of thinking in therapy simply take longer for many older people. Older
people also tend to experience some diminution in the number of things that can be
held in mind at any one time
Therapists may find that it helps to move with greater deliberation when seeing an
older adult
Older adults often receive must more social reinforcement for dependent behaviours
The growing specialization of behavioural gerontology emphasizes helping older
people to enhance their self-esteem by focusing on specific, deceptively motor
behaviours, such as controlling toileting better, increasing self-care and mobility, and
improving telephone skills in order to enhance social contacts
One development though hardly a formal therapy, involves teaching older adults
computer skills so that they can access the internet and expand their social contacts
Therapists must be able to interpret the facial expressions of these adults and
understand the meaning of their words and reactions