Diagnosis and Psychopathology 2

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Axis II disorders: MR and Personality DO, also defense mechanisms and/or maladaptive personality traits not sufficient for personality DO
DSM-IV-TR approach: categorical - divides DOs based on criteria sets with defining features. Meets or doesn't meet criteria.
polythetic criteria sets: To receive a DO, ind only has to present with a subset of symptoms from a longer list
Mild MR: IQ - 50-55 to 70
"Educable MR"
Majority (85%)
Not noticed until late childhood
Up to 6th grade level educ.
Live/work independently
Moderate MR: 35-40 to 50-55 IQ
"trainable"
10% of MR
2nd grade level
live/work under supervision
Severe MR: 20-25 to 35-40
3-4% MR
poor motor skills, limited communicative speech
live with others under close supervision
Profound MR: below 20-25
1-2% of MR
severe limitations motor/sensory
highly structured environ/constant aid & sup
MR etilogy, two most common: 1. Developmental alteration in embryo 30% (ex. Down's/FAS)
2. Environmental influences & other d/o (ex. deprivation or Autism)
Autism: Before age 3
social interaction
communicative language
repetitive/stereotyped beh
75% get co-dx of MR
poor prognosis
echolalia: echoing words/phrases of others. Common in Autism
Autism rates/gender: 2-5 in 10,000
2-5x more in males
unrelated to schizophrenia
Autism etiology: -NOT related to SES or parental characteristics
-genetic/neurological explanations more valid
Autism Tx: -Behavioral therapy (operant) found effective
-Most effective when initiated young age & intensive
-Drugs little effect, except Haloperidol for certain beh
Rett's DO: -Developmental regression before age FOUR (# letters)
-Normal development for at least 5 mos
-Females only
Childhood Disintegrative DO: -Normal dev. until 2+ yrs
-Before age 10 significant loss of developed skills in two areas
-very rare
Asperger's DO different from Autism: no delay in:
language, self-help skills, cognitive dev, or curiosity about environ
Frequent Co-Dx in learning disorders: ADHD (20-50%)
Also: conduct, ODD, MDD
Phonological DO: Does not use speech sounds expected for age and dialect
Stuttering: -abnormalities in fluency/time pattering of speech
-Remits on own by age 16 in 60% of cases
ADHD onset, duration, gender: onset before age 7
duration at least 6 mos
4-9x more common in boys
Co-Dx for ADHD: Conduct 50%
Emotional Dx 25%
Learning Dx 20%
70% exhibit signs through life
ADHD etiology: biological
Abnormalities in prefrontal cortex
Caudate Nucleus
57% parent to offspring
twin studies show .80 heritability for hyper/impuls
Behavioral disinhibition hypothesis: Barkley
ADHD not attention deficits but inability to adjust activity levels to setting
TX for ADHD: TX suppress symptoms not cure
Typically drugs (stimulants) and cog/beh modalities
Ritalin (Methylphenidate) side effects: somatic complaints
motor and vocal tics
obsessive compulsive symptoms
growth suppression
Conduct DO vs. Oppositional Defiant DO: defy society rules/norms vs. defiance to authority figures, negativistic
Conduct DO Dx: -3 signs, for at least 12 mos, with one sign in past 6 mos
Conduct DO childhood vs. adol onset: -childhood: 1 sign prior 10yo, more overt aggression, more likely antisocial
-Adol: signs after age 10, less severe & better prognosis
ODD DO Dx: 4 signs persist for at least 6 mos
Pica: Eat nonnutritive subs persistently for at least 1 mo.
rare, = boys&girls
associated with MR
Tourette's DO: onset 2-18 yo
motor AND vocal tics
tics must occur multiple times/day, daily or periodically for at least one year (no more than 3 mos break from tics)
Chronic Motor or Vocal Tic: either motor or vocal tics, not both like Tourette's
Encopresis (not due GME): passage of feces
1x month for 3 mos
At least age 4
Enuresis (not due GME): passing of urine (awake-diurnal or sleep-nocturnal)
2x week for 3 mos
At least age 5
more common boys than girls, but shrinks with age
Reactive Atachment DO of infancy or early childhood: extremely disturbed and dev inappropriate social relatedness
-onset before age 5
-inhibited and disinhibited type
Stereotypic Movement DO: -repetitive, apparently driven motor behaviors
-cause harm
-often resist behaviors
-assoc. w/MR
Childhood Depression (how presents): -young children show separation anxiety resulting in school phobias
-adol (esp. boys) antisocial behaviors
Differential diagnosis between Substance Intox/Withdrawal and Substance-Induced disorder: Intox/Withdrawal tend to account for most presentations but when symptoms are IN EXCESS of typical intox/with than warrant substance-induced do diagnosis and therefore independent clinical attn.
Hallucinogen Persisting Perception DO: hallucinogen flashbacks that occurred during hallucinogen intox. Occurs when s.o. is not currently using.
DO caused exclusively by GME or substance use, with impairment in cognition or memory: Delirium
Dementia
Amnestic DO
Delirium def: disturbance of consciousness
marked change in cognition or perception
Rapid and usually brief (less than 1 mo)
Typicallly 60+, but children more vulnerable than adults
Risk groups for Delirium: 1. older Px 60+
2. Px with decreased "cerebral reserve" (ex. stroke, dementia etc.)
3. Postcardiotomy Px
4. Px in drug withdrawal, esp. alcohol and benzos
Dementia def: multiple cognitive impairments:
1. memory
and 1 of following:
2. aphasia
3. apraxia
4. agnosia
5. disturbance exec function
Dementia vs. Delirium: Dementia Px are alert, course is more variable, tend be 85+, rare in adol/children
Dementia vs. pseudo-dementia (depression impairs cognitive functioning): In pseudo-dementia px tend to show improved functioning as mood improves.
Can date the onset of cognitive deficits more precisely (more sudden).
More concerned with cognitive deficits than in dementia.
Dementia vs. depression as related to cognitive symptoms: Depression: transitory
involve only procedural & recall (not recognition).
Dementia: widespread
involve recall AND recognition
Alzheimer's Dementia: impaired declarative memory(semantic & episodic) but procedural is intact
Alzheimer's Disease: 50% of Dementia Px
duration from onset to death: 8-10 yrs
clinical course: gradual & progressive
Women overrepresented
3-4x likely to have first degree relative with illness
Vascular Dementia: 10-20% of Dementia Px
due to cerebrovascular disease (stroke or infarction) tha causes decreased blood supply to brain
clinical course: variable and progressive
onset is abrupt
Substance-Induced Persisting Dementia/Amnestic DO: PERSISTING effects of substance use, not direct effects of intox/with - develops long after substance has been eliminated from body
Anterograde amnesia: inability to learn new information
Retrograde amnesia: inability to recall learned info or events from past
Substance Dependence: use despite significant substance-related problems
12-month period
tolerance and withdrawal
N/A for caffiene
Substance Abuse: less severe than dependence
maladaptive pattern of use
12-month period
N/A for caffiene or Nicotine
Korsakoff's Syndrome: a.k.a. Alcohol-induced persisting Amnestic DO
due to thiamine deficiency causing damage to thalamus
impairment in recent memory (ability to txfr short to long term)
confabulation
Cannabis: No physical dependence
no sig withdrawal symptoms
inhibits aggression
Abstinence Violation Effect (AVE): Marlatt & Gordon:
Attributions for cause of relapse affect abstinence.
i.e. if internal and stable - hinder recovery, if external and unstable than higher recover rates and coping w/lapses
Tx for Nicotine Dependence: Most stop on own or with minimal professional help
-multimodal behavioral approach
-replacement tx effects maximized w/behavioral intervention
Relapse Prevention Therapy: Marlatt and Gordon
-not disease model
-maladaptive, over-learned habit patterns
-include cognitive therapy, coping skills training, lifestyle mods (meditation/exercise)
According to Marlatt and Gordon, name 3 high-risk situations associated with 75% of relapses: 1. negative emotional states
2. interpersonal conflict
3. social pressure
Duration Schizophrenia vs. Schizophreniform: Schizophrenia - active phase for 1 month, signs persist fofr at least 6 months
Schizophreniform - less than 6 months
alogia: restricted fluency/productivity of thought and speech
Schizophrenia age onset/gender/course: onset late teens to mid-30's
equally common in males/females (community)
males>females in hospital
course is chronic
Factors associated w/better prognosis for Schizophrenia: 1. late and acute onset
2. precipating event
3. female
4. good premorbid adjustment
5. brief duration of active-phase symptoms
6. family history of mood disorder
7. NO family history of Schizophrenia
General Etiology of Schizophrenia: genetics and biological factors, but also psychosocial factors
Dopamine hypothesis (neurotransmitter imbalance): Schizophrenic reactions associated w/excess or sensitivity to dopamine (imbalance of norepinephrine and dopamine)
Lifetime probabilities for developing schizophrenia: unrelated 1%
Biological siblings 10%
Dizygotic twins 16%
Monozygotic twins 48%
Author diathesis-stress theory of Schizophrenia: Mednick
Schizophrenia in industralized vs. non-industralized (developing) countries: industralized countries had higher rate of continuous or episodic illness w/o full remission (65%) vs. developing countries (39% - hypothesize more family/community support
Tx for Schizophrenia: 1. antipsychotic meds with social skills training during acute
2. day tx following acute that includes occupational therapy
3. education of family (familiy therapy and meds more effective than meds alone)
Schizoaffective DO: both mood disorder and schizophrenia (active phase symptoms)
-period of two weeks where psychotic symptoms are present AND mood syms are absent (otherwise Mood DO w/psychotic features)
Delusional DO, types: non-bizarre delusions persistent for at least 1 mo
1. erotomanic
2. grandiose
3. jealous
4. persecutory
5. somatic
6. unspecified/mixed
Brief Psychotic DO: one psychotic symptom
Sudden onset/brief
hours to NOT exceed one month
full return to premorbid level
w/ or w/o marked stressor, postpartum onset
Loose associations vs. circumstantiality: loose assoications more vague, unfocused and bizarre. Main point is lost.
Circumstantiality is more excessive detail but main point never lost.
% Bipolar I/Unipolar depression die by suicide: 10-15%/15%
Cyclothymic D/O: lasts at least 2 yrs
hypomanic/depression cycles
both milder than MD or Mania
daily functioning not impaired
% of those with one major depressive episode experience another: 50-60% within a 2 year period
change diagnosis to MDD, recurrent
Women and depression: 2x higher than men
onset with menses in adol.
different coping than men (brood/dwell vs. action/mastery)
multiple roles lowers risk
women more extreme levels of well-being (neg and pos)
Postpartum Depression, % and course: 50-80% "baby blues"
onset first few days through 2-8 wks, could last 1 year
only 10-20% develop into Mood D/O
catecholamine hypothesis for depression: depression=low norepinephrine
mania=excess norepinephrine
(while dopamine is a catecholamine this theory only addresses norepi)
permissive theory for depression: implicates serotonin and norepinephrine
dep= low both
mania=high norepi, low sero
Rehm Self-Control Theory of depression: structured group therapy
help px self-monitor mood/activity, self-evals, and administer healthy self-reinforcement
MAO inhibitors vs. tricyclics/SSRI's in treating depression: MAO = atypical depression including anxiety, OC, hypochondria
Tricyclics/SSRI's = classic symptoms
Cognitive therapy vs. IPT for depression: cognitive therapy most effective for mild dep
IPT with meds most effective with severe dep
TX for depression: combination of therapy and drugs greater than either alone
Bipolar I vs. II: BI does NOT require a Major Depressive Episode, but BII does
Panic D/O vs. Social/Specific Phobia: In Panic D/O the panic attacks are not bound to a specific situation
Tx phobias: agoraphobia - antidepressant & in-vivo w/response prevention (flooding, group therapy w/imp. people
Specific phobias - longer periods of exposure more effective (either in-vivo or imaginal)
Social Phobia - meds, beta-blockers
Tx OCD: In-vivo exposure w/response prevention
PTSD vs Acute Stress D/O: PTSD symtptoms must last for >1 mo, Acute Stress symptoms occur w/i 1 month and last from 2 wks to 1 mo - beyond 1 mo consider PTSD
Acute vs. Chronic PTSD: symptoms last <3mos=Acute
>3mos=Chronic
EMDR efficacy in PTSD: more effective compared to no tx or non-exposure tx, but no more effective than exposure techniques
Conversion d/o vs. somatization d/o: Conversion symptoms are motor or sensory and appear to be due to psychological need/conflict.
Somatization - multiple physical complaints not fully explained medically
Genetic basis for personality d/o: Antisocial well-established - 5-10x greater w/1st degree relatives
Also, schizoid, schizotypal and paranoid genetic component.
What not predictive of personality d/o: level of education
social class
alcoholism
(what is? poor childhood adaptive behavior)
schizotypal vs. schizoid personality d/o: schizotypal - deficits interpersonally but also peculiar thoughts & behaviors (t in typal=thoughts).
schizoid - indifference socially, limited emotional expression (no t =no thought concerns)
Who pioneered use of "family lunch" for tx of Anorexia?: Minuchin
Ganser's syndrome: "syndrome of approximate answers" - answers close to truth but not completely true
Dissociative Disorder NOS
assoc w/hallucinations, disorientation, amnesia and lack of insight
hynopompic vs. hypnagogic hallucinations: hypnopompic - awakening
hypnagogic - "go-ing" to sleep
Primary vs. Secondary impotence: "secondary" means impotence occurs after period of normal functioning
Dissociative Fugue vs. Amnesia: Fugue involves travel away from home or adoption of new identity.
Amnesia involves forgetting important personal info
delusions: false beliefs firmly held despite clear evidence to contrary.
represent beliefs not widely accepted by one's culture
illusions vs. hallucinations: misperceptions of actual external stimulus vs. perceptions seemingly real but w/o presence of external stimulus
magical thinking: belief one's thoughts/actions can control specific outcome
generalized tonic-clonic seizures: a.k.a. grand mal
last up to 1 hour
followed by deep sleeep
generalized absense seizures: a.k.a. petit-mal
brief, no deep sleep after
complex-partial seizures: confused, stare blankly, walk like in a daze
a.k.a. psychomotor seizures or temporal lobe seizures
(tori lynn)
simple partial seizures: affect one side of body
uncontrollable jerking/trembling of arm/leg
tonic-clonic seizure may follow
Types of biofeedback tx for tension vs. migraine headaches: muscle/tension = EMG
migraine = thermal hand warming
tx for tension and migraine headaches: relaxation as effective as biofeedback therefore relaxation is recommended because easier to apply
Tx for pain: -operant treatments which reorganize environ rewards/pun so pain behavior is no longer reinforcing
-cognitive tech
-relaxation training
essential or primary vs. secondary hypertension: secondary - result of known GME
primary - cause is unknown, 80% of cases
general adaption syndrome (Selye): Alarm reaction - mobilization of sympathetic nervous sys
Resistance - defenses stabilizes, symptoms disappear
Exhaustion - depletion of energy, organ failure, collapse from prolonged resistance
(ARE)
Aspects of Type A linked to medical disorders (including heart disease): anger, hostility and aggression more predictive than job involvement or time urgency.
depession equally associated w/heart disease
Sickness Impact Profile (SIP): Quality of life measurement used to assess impact of disease on physical and emotional functioning.
higher score, greater level dysfunction
Schizophrenia disorganized vs. undifferentiated: disorganized - disorganized behavior/speech and flat or inappropriate affect (laughter/grimaces etc.)
Undifferentiated - can have aspects of other types (ex. paranoid delusions and inappropriate affect) or not clear

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