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Week 1: History and Theories of Psychopathology Functions of Brain Regions Brainstem and the thalamic reticular activating system provide arousal and set up attention posterior cortex integrates perceptions and generates language frontal cortex generates programs and executes plans like an orchestra conductor (the highest level) Cerebrum - Higher cognitive functions such as judgment, imagination, perception, thought and decision-making o cerebral cortex is especially important for personality and intelligence o two symmetrical hemispheres that each play slightly different roles regarding speech, language learning, and vision Cerebellum - voluntary motor movements, balance, equilibrium, and muscle tone o Damage to the cerebellum can result in loss of motor control, weak muscles, abnormal eye movements, slurred speech, and staggering Diencephalon - thalamus and the hypothalamus o Hypothalamus – control of appetite, temperature, blood pressure, perspiration, and sexual drive o relay point between subcortical areas of the brain and the cerebral cortex o Autonomic nervous system “fight or flight” o relays information about the auditory, visceral, visual, somatic and gustatory systems o control of immune responses, blood pressure, digestion, and body temperature Brainstem - main junction between the brain and the rest of the body o brain joins with the spinal cord to send and receive information from every inch of our bodies o breathing, heart rate, digestion, and our body’s natural rhythms o includes the medulla oblongata, pons, and midbrain Pathophysiology neurotransmitter involvement with mental health disorders Serotonin - o involved in the regulation of various activities (e.g. behavior, mood, and memory, sleep, and appetite, encouragement of socialization) o has some influences on learning, memory, and other cognitive abilities o primary treatment target for many psychiatric and neurological disorders (e.g. major depressive disorder, post-traumatic stress disorder, bulimia nervosa, obsessive-compulsive disorder, anxiety, aggressive behavior, premenstrual
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dysphoric disorder, panic disorders, social phobia, bipolar disorder, atypical depression, and migraine Dopamine – o Too much – positive symptoms of schizophrenia and psychosis o Too little – Parkinson’s disease, depression, ADHD, anxiety o Mesolimbic pathway – pleasure and reward pathway; overstimulation of NAc leads to euphoria and risk for cravings and withdraw (addiction) involved in cognition, working memory and decision making in the prefrontal cortex o Nigrostriatal dopamine pathway – Motor planning: lack of dopamine in this pathway results in motor control impairment (i.e. EPS, movement disorders, parkinsonism, TD, spasms) o Tuberoinfundibular dopamine pathway – Inhibits prolactin release Prevention of these functions increases prolactin affecting menstrual cycles, libido, fertility, bone health or galactorrhea Norepinephrine and Epinephrine Acetylcholine Theories of Personality and Psychopathology (theorist and stages of theories) Sigmund Freud – o psychosexual development o The Ego and the Id o Defense mechanisms o Theory of anxiety as “dammed up libido” and ego’s partial failure to cope with distressing stimuli o Character traits as result of successful repression to the defense system Erikson – o Dilemmas or polarities in the ego’s relations with family and larger social institutions at nodal points in childhood, adolescence and early, middle and late adulthood o Psychological development o Concept of identity, identity crisis and identity confusions
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reversibility by inversion of reciprocity; operations; class inclusion and seriation o Formal operations (11 years to end of adolescence) – Combinatorial systems, whereby, variable is isolated and all possible combinations are examined, hypotheticodeductive thinking Building Therapeutic Relationships/Rapport with clients Empathy – understanding what the patient is feeling and thinking, the provider being able to put themselves in the clients shoes while also remaining objective Head nodding, putting aside one’s pen and leaning forward are nonverbal ways of showing interest and building rapport (in an interview many empathetic responses are nonverbal) Remaining objective is crucial to a therapeutic relationship; differentiates empathy from identification o Identification - provider loses ability to remain objective due to experiencing client’s emotions too deeply – blurring the boundaries and causing distress in the client and burn out in the provider Building a patient-provider relationship entails: o Providers demonstrating, they understand what the patient is stating and emoting o Recognition by the client that the provider cares – increasing trust and stronger therapeutic alliance The psychiatric interview, history, and examination Interview is a not one single funnel of open-ended questions leading to close ended questions, rather it is a series of funnels, each beginning with open-ended questions, with closed questions to clarify Initial psychiatric interview: o Identifying data o Source and reliability o Chief compliant o Present illness (use psychiatric ROS) o Past psychiatric illness o Drug and alcohol abuse/use o Past medical history o Family history
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o Developmental and social history o ROS o Mental status exam o Physical exam o Formulation o DSM5 diagnosis o Treatment plan Be familiar with how to conduct a mental status exam Observation, with direct questioning to augment the MSE Parts of an MSE: o Appearance and Bx o Motor activity o Speech o Mood o Affect o Thought content o Thought process o Perceptual disturbances o Cognition (see table 5.1-5) o abstract reasoning o Insight
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o Montreal Cognitive Assessment (MoCA o Young Mania Rating Scale (YMRS) o Quality of Life Enjoyment and Satisfaction Questionnaire—Short Form (Q-LES-QSF) o The Modified Overt Aggression Scale (MOAS o Positive and Negative Symptom Scale (PANSS) o Adverse Childhood Experience Week 3: Mood Disorders Depression:
- Twice as common in females as male
- MDD criteria 5 or more of the following symptoms a. Depressed mood b. Sleep Changes c. Interest loss (anhedonia) d. Guilt (worthlessness) e. Energy loss f. Concentration Reduction g. Appetite Change h. Psychomotor change i. Suicide ideation/thoughts i. i.e. SIGECAPS ii. Must last for 2 weeks or more iii. Must not be caused by other condition i. Including substance use iv. Treatments include i. Psychotherapy ii. Medications (SSRI, SNRI, MAOis, TCAs) iii. ECT for refractory (Electroconvulsive therapy)
- Mania – 3 or more of the following a. Distractability b. Irresponsibility/irritability/impulsiveness c. Grandiose d. Flight of Ideas e. Activity increase f. Sleep decrease
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g. Talkative i. DIGFAST ii. For at least 1 week for an episode iii. Must cause significant impairment iv. Not attributable to substances Hypomania – 3 or more of DIGFAST
- For at least 4 days
- No significant impairment – able to function Bipolar 1 - Requires 1 episode of mania, and may include episodes of depression and hypomania Bipolar 2 – Requires at least one episode of hypomania and an episode of major depression Treatment includes mood stabilizers (lithium/valproate first line. Also, lamotrigine, quetiapine, and atypical antipsychotics for acute mania) Cyclothymic disorder – alternates between hypomania and depression. Suffer some symptoms of DIGFAST, but not for 4 days. Also suffers criteria of SIGECAPS, but not enough to diagnose.
- Symptoms present for 2 years or more
- Treat with CBT and lithium, atypical antipsychotics Persistent depressive disorder (aka dysthymic d/o).
- Decreased mood and SIGECAPS symptoms without meeting full MDD criteria for 2+ years; described as baseline sadness; still enjoy some things
- Treat with CBT first and then SSRIs Adjustment disorder
- Mood/anxiety symptoms < 3 months after a stressor, typically resolving within 6 months
- Treat with supportive therapy and meds for symptoms (insomnia, nausea etc) Week 4: Anxiety Disorders, PTSD, and
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Separation anxiety d/o
- Definition: Excessive anxiety regarding separation from home or form people to whome the individual has a strong emotional attachment. a. Children > 4 weeks b. Adults > 6 months c. May include anxiety/fear/distress when separated: reluctance to be alone/leave home/school/work; worry about harm to attachment figures
- Symptoms cause dysfunction in society
- Treat with CBT, family therapy, possibly adjunct SSRI
- Similar to anxiety during normal child development a. Stranger anxiety at 6mo b. Separation anxiety at 1 year Selective mutism (commonly comorbid with anxiety/attachment disorder)
- Consistent failure to speak in specific social situations in which there is an expectation for speaking despite speaking in other situations
- The disturbance interferes with educational or occupational achievement or with social communication
- Duration of disturbance is at least 1 month (not limited to the first month of school)
- The failure to speak is not attributable to lack of knowledge of, or comfort with, the spoken language required in the social situation.
- The disturbance is not better explained by a communication disorder and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder. Panic Attacks
- 4% lifetime prevalence. 2:1 women vs men
- Definition: sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something bad is going to happen. a. Occurrence of at least one attack b. Constant worry about recurrence c. Other symptoms: trembling, unsteadiness, personalization, palpitations, abdominal pain, chest pain
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3. Must rule out medical etiologies which include a. Hyperthyroidism b. Atrial fibrillation c. Pheochromocytoma d. Drugs (amphetamines, sympathomimetics)
- Treatment a. Psychotherapy: CBT b. Pharmacotherapy: SSRI >? TCA i. Short term benzos Social Anxiety Disorder
- Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions, being observed, and performing in front of others a. In children, the anxiety must occur in peer settings and not only during interactions with adults.
- The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (will be humiliating/embarrassing etc.)
- The social situations almost always provoke fear or anxiety a. In children, the fear or anxiety may be expressed by crying, tantrums, freezing etc.)
- The social situations are avoided or endured with intense fear/anxiety
- The fear/anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context
- The fear/anxiety/avoidance is persistent, typically lasting 6 months or more.
- The fear/anxiety/avoidance causes clinically significant distress or impairment in social/occupational/other area of function
- The fear/anxiety/avoidance is not attributable to the physiological effects of a substance/condition
- More common in males than females (believed to be d/t normal work requirements of men vs women) OCD
- 2-3% - equal b/t men/women
- Obsessions: recurrent thoughts that persist despite trying to ignore them and/o
- Compulsions: explicit rituals that either reduce anxiety or that patients feel they have to
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iv. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event v. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event
- Persistent avoidance of stimuli associated with the traumatic event beginning after the traumatic event occurred aeb one or both of the following a. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic events b. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic events
- Negative alterations in cognitions and mood associated with the traumatic events, beginning or worsening after the traumatic events occurred, aeb 2 or more of the following a. Inability to remember an important aspect of the traumatic events (typically d/t dissociative amnesia and not to other factors such as drugs/alcohol) b. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g. I am bad. No one can be trusted, etc) c. Persistent, distorted cognitions about the cause or consequences of the traumatic events that lead the individual to blame himself/herself or others d. Persistent negative emotional state (fear, horror, anger, guilt) e. Markedly diminished interest or participation in significant activities f. Feelings of detachment or estrangement from others g. Persistent inability to experience positive emotions
- Marked alterations in arousal and reactivity associated with the traumatic events beginning or worsening after the traumatic events occurred aeb 2 or more of the following a. Irritable behavior and angry outbursts typically expressed as verbal or physical aggression toward people or objects b. Reckless or self-destructive behavior c. Hypervigilance d. Exaggerated startle response e. Problems with concentration f. Sleep disturbance
- Duration of the disturbance is greater than 1 month
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- Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
- The disturbance is not attributable to the physiological effects of a substance (medication, etoh, etc)
- Specify whether a. With dissociative symptoms
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b. Limited positive affect c. Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers
- The child has experienced a pattern of extremes or insufficient care as evidenced by at least one of the following a. Social neglect/deprivation in the form of persistent lack of basic emotional needs/comfort/stimulation/affection b. Repeated changes of primary caregivers that limit opportunities to form stable attachments c. Rearing in unusual settings that severely limit opportunities to form selective attachments
- Criteria are not met for ASD
- Disturbance is evident prior to age 5
- Child must be at least 9 months old for diagnosis Disinhibited social engagement disorder
- A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least 2 of the following a. Reduced/absent reticence in approaching and interacting with unfamiliar adults b. Overly familiar verbal/physical behavior that is not consistent with culturally sanctioned, age appropriate social boundaries. c. Diminished/absent checking back with adult caregiver after venturing away d. Willingness to go off with unfamiliar adult without hesitation
- Not limited to impulsivity
- Child has experienced a pattern of extremes of insufficient care as evidenced by at least 1 of the following a. Social neglect/deprivation by not having emotional needs met b. Repeated changes in primary caregiver c. Rearing in unusual settings that limit opportunities to form selective attachments Week 5: Disruptive, Impulse-Control, and Conduct Disorders; Dissociative and Somatic Symptom-Related Disorders Disruptive, Impulse Control, and Conduct Disorders
- These disorders involve problems in emotional/behavioral regulation that violate the
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rights of others and/or bring individual into significant conflict with societal norms or authority figures Oppositional Defiant Disorder criteria – reduced basal cortisol level and abnormalities in the PFC and amygdala
- A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months aeb at least 4 symptoms from any of the following categories a. Angry/irritable mood i. Often loses temper ii. Often touchy/easily annoyed iii. Often angry and resentful. b. Argumentative/defiant behavior i. Often argues with authority figures or, for children and adolescents, with adults ii. Often actively defies or refuses to comply with requests from authority figures or with rules iii. Often deliberately annoys others iv. Blames others for his or her mistakes/misbehaviors c. Vindictiveness i. Has spiteful or vindictive at least twice within the last 6 months
- The disturbance in behavior is associated with distress in individual or others in his/her immediate social context, or it impacts negatively on social, educational, occupational, or other important areas of functioning
- Do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. a. Mild: symptoms are confined to only 1 setting b. Moderate: Some symptoms are present in at least 2 settings c. Severe: Some symptoms are present in 3 or more settings Intermittent Explosive Disorder – specifically affects anterior cingulate (limbic system) and orbitofrontal cortex – Amygdala responses to anger stimuli are higher Definition: Recurrent behavioral outbursts representing a failure to control aggressive impulses as manifested by either of the following
- Verbal aggression (tantrums, tirades, verbal arguments, fights) or physical aggression toward property, animals, or other individuals.
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i. Serious violations of rules m. Often stays out at night despite parental prohibitions, beginning before age 13 n. Has run away from home overnight at least twice while living in the parental or parental surrogate home or once for a lengthy period o. Is often truant from school, beginning before age 13
- Disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning
- If the individual is age 18 years old, criteria are not met for antisocial personality disorder
- Specifiers a. F91.1 (312.81) – Childhood-onset b. F91.2 (312.82) – Adolescent onset c. F91.9 (312.89) – Unspecified onset
- Further specifiers a. With limited prosocial emotions b. Lack of remorse or guilt c. Callous – lack of empathy d. Unconcerned about performance e. Shallow or deficient affect
- Severity a. Mild – few if any conduct problems in excess of those required to make diagnosis are present b. Number of conduct problems and the effect is between mild and severe c. Many conduct problems in excess of those required to make the diagnosis are present, or conduct problems cause considerable harm to others Pyromania Diagnostic criteria A. Deliberate and purposeful fire setting, on more than one occasion B. Tension or affective arousal before the act C. Fascination with, interest in, curiosity about, or attraction to fire and its subsequent contexts D. Pleasure, gratification, or relief when setting fires or when witnessing or participating in their aftermath E. Fire-setting is not done for monetary gain, as an expression of sociopolitical ideology or other rationale F. Fire setting is not better explained by conduct disorder, a manic episode, or
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antisocial personality disorder Kleptomania Steals shit Dissociative Disorders Characterized by a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior. Very often a sign of trauma response. Dissociative Identity Disorder A. Disruption of identity characterized by 2 or more distinct personality states which can be described in some cultures as an experience of possession. a. Involves marked discontinuity in sense of self and sense of agency accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory- motor functioning B. Recurrent gaps in the recall of everyday events, important personal information and/or traumatic events that are inconsistent with ordinary forgetting. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The disturbance is not a normal part of a broadly accepted cultural or religious practice a. Also not better explained by imaginary friends in children. E. Symptoms are not attributable to the physiological affects of substancesw a. Over 70% of patients with DID have attempted suicide Dissociative Amnesia F44.0/300. A. An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting a. Most often consists of localized or selective amnesia for a specific event or events; or generalized amnesia for identity and life history B. The symptoms cause clinically significant distress or impairment in social or other area of functioning. C. The disturbance is not attributable to the physiological effects of a substance D. The disturbance is not better explained by DID, PTSD, Acute Stress Disorder, somatic symptom disorder, or major or mild neurocognitive disorder
