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V. Mood Disorders It was called as a "depressive disorders" or as an "affective disorders“ or as "depressive neuroses”. In DSM-III-R, changed as "Mood.

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Presentation on theme: "V. Mood Disorders It was called as a "depressive disorders" or as an "affective disorders“ or as "depressive neuroses”. In DSM-III-R, changed as "Mood."— Presentation transcript:

1 V. Mood Disorders It was called as a "depressive disorders" or as an "affective disorders“ or as "depressive neuroses”. In DSM-III-R, changed as "Mood Disorders" most common diagnosis -> major depressive episode Diagnosis criteria extreme depressive symptoms at least two weeks Cognitive symptoms (feeling of worthlessness, difficulty in decision making) Bodily symptoms (change of sleep pattern, appetite, weight, reduced energy)

2 Body symptom is most important component
General loss of interest in things Inability to experience any pleasure from life, including interaction with family or friends or accomplishments at work or at a school Lasts in average 9 months, if not treated Second most common disorder -> manic episode Diagnosis criteria -> Symptom lasts at least 1 week Require less, if symptoms are severe enough to require hospitalization

3 Elated mood, extreme excitement, euphoria
Excessive activities, reduced need of sleep develop grandiose plan believing they can accomplish anything they desire flight of ideas : speech is typically rapid and may become incoherent, because the individual is attempting to express so many exciting ideas at once Often accompanies anxiety, especially in the ending phase Lasts 6 months, if not treated hypomanic episode => not severe manic no difficulties in adjusting to daily life or work

4 Unipolar mood disorder
Characteristics of mood disorder Unipolar mood disorder experience either depressive or manic symptom, although it is rare that only manic symptoms are present bipolar mood disorder -> experience both depressive and manic symptoms alternately depression and elation are relative independent -> an individual can experience manic symptoms but feel somewhat depressed or anxious at the same time -> mixed manic episode

5 feeling of out of control or dangerous
Manic patients experience often depression and anxiety Course of disease Individual difference in terms of frequency, severity, and of symptoms Unipolarity, bipolarity Different intervention according to course Most depression eventually remit on their own within 6 months 10% last longer than 2 years

6 1. Depressive Disorders - Pure depression without manic or
< clinical description > major depressive disorder, single episode - Pure depression without manic or hypomanic episodes before or during the disorder - An occurrence of just one isolated depressive episode in a lifetime is rare major depressive disorder, recurrent - If two or more major depressive episodes were occurred and were separated by at least two months during which the individual was not depressed - repeats recovering and relapse lifelong

7 Relapse in average 4 times in a life
and lasts 5 months High heredity 85% of major depression, single episode -> later becomes major depression, recurrent type (Solomon et al, 2000) Feeling of worthlessness, difficulty in concentration Repeated suicidal ideation, sleep difficulties, and loss of energy Abraham Lincoln severe depression => postponed his marriage for 3 days

8 < dysthymic disorder >
Similar to major depression Symptom is weaker Duration is far longer (20, 30 years) Lasts at least 2 years + should not be without symptoms longer than 2 months If major depression and dysthymic disorder are present at the same time -> double depression In most cases, it begins as dysthymic disorder -> later develops a major depression in which case the prognosis is not good

9 After recovery of major depression
-> dysthymic disorder -> major depression (Akiskal & Kassano, 1997) < onset and duration > Average onset of the major depression -> general group : 25 age -> clinical group : 29 age Recently earlier onset Higher prevalence

10 Born before 1905 -> less than 1 % at the age of 75 Born after 1955 -> 6% at the age of 24 Confirmed in Puerto Rico, Canada, Italy, Germany, France, Taiwan, Lebanon, New Zealand that this trend toward developing depression at increasingly earlier ages is occurring worldwide (Cross National Collaborative group, 1992) Dysthymic disorder with onset before age 21 -> more chronic, poor prognosis -> higher heredity -> more often comorbid with a personality disorder

11 According to recent research
High prevalence of children dysthymic disorder -> 76% of these children develop later a major depression Patients with dysthymia are more likely to attempt suicide than major depression patients It is relatively common for major depressive episodes and dysthymic disorder to co-occur (double depression) (McCullough et al., 2000)

12 2. Bipolar Disorders Alternation of manic episodes with major depressive episodes -> bipolar I disorder Alternation of hypomanic episodes with major depressive episodes -> bipolar II disorder Similar to major depression only manic or hypomanic symptoms are added cyclothymic disorder -> milder form of bipolar disorder similar to dysthymic disorder 1/3 of them develop later a bipolar disorder onset 세

13 < onset and duration >
bipolar I disorder -> average 18 age bipolar II disorder -> average 22 age Both can begin in childhood Rarely begins later than 40 age Earlier onset than major depression More abrupt onset 1/3 of them begin in adolescence Mostly begins as a mild cyclothymic mood swing 10-13% of bipolar II disorder -> leads to bipolar I disorder

14 Unipolar disorder and bipolar disorder are two independent disorder
381 patients were observed for 10years -> only 5.2% of unipolar depression patients experience manic episode (Coryell, Endicott, et al., 1995) Frequent suicidal attempt (19%; Jamison, 1986) Mostly takes place during major depressive episodes

15 symptom specifiers 1. atypical features specifier (type) specific features of depression excessive sleep, intake of foods gain weight during depressive episode Partial interest in specific object

16 2. melancholic features specifiers (type)
In case of major depression Severe body symptoms Wake up early, loss of weight, loss of libido Excessive and inappropriate guilty feeling Anhedonia Respond well to physical treatment (ECT) Respond well to drug (tricyclic antidepressant) Occur independent of stress Can find more among the elderly

17 3. Chronic features specifiers
Continuous symptoms of major depression in last 2 years 4. Catatonic features specifiers Rare, but in major depression or manic disorder Immobility, waxy posture Excessive aimless movements

18 5. Psychotic features specifiers
major depression or manic disorder can have hallucination or delusion bodily delusion (example: part of body decay) mood congruent hallucination mood incongruent hallucination (depression -> delusion of grandeur) more severe -> likely to develop a schizophrenia 5-15% of depressive disorder patients experience hallucination poor premorbid adjustment -> more likely to experience psychotic symptoms need to be treated with neuroleptics

19 6. postpartum onset specifier
severe major depression or manic episode Within 4 weeks after delivery (typically within 2-3 days) Experiences psychotic symptoms Could be a beginning sign of a bipolar disorder 1 out of every 1,000 women after a delivery 50% of those who had already experienced one episode experience again In some case, kills their baby

20 Mild depression after delivery excluded
Physical exhaustion through labor A new task to fulfill Change of the identity Change of the environment Burden of child rearing Relationship between childbirth and depression -> comparative study no difference found between the group with childbirth and the group with no childbirth (Whiffen & Gotlib, 1993) postpartum blues tearful, temporary mood swing 50-80% of mother show this symptom 1-5 days after childbirth -> disappears within a few days

21 Specifiers describing course of Mood disorders
3 characteristics that distinguish between recurrent depression and manic disorder - longitudinal course - rapid cycling, - seasonal pattern They differ in the course and time pattern -- needs different intervention strategies

22 1. Longitudinal course specifiers
It is important to know whether the individual had a major depressive episode or manic episode Whether he/she recovered fully from it Whether a major depressive patient had in the past a dysthymia -> if yes, double depression Whether a bipolar disorder patient had in the past a dysthymia or cyclothymia -> if yes, low chance of full inter-episode recovery In case of major depression, bipolar I, bipolar II disorder, it is important to know the course

23 2. Rapid-cycling specifier
It pertains to bipolar I, bipolar II disorder Whether it has a slow or rapid cycling In case of rapid cycling -> more than 4 times per year -> traditional therapy not effective Tricyclic antidepressant -> there is a risk to evoke a rapid cycling 3. Seasonal pattern specifier It pertains to bipolar disorder and recurrent major depressive disorder Changes according to season Mostly begins at late fall and ends early spring

24 During the winter depression, summer manic episode
-> seasonal affective disorder (SAD) In most cases depression during winter -> 5% of American are afflicted -> excessive sleep and eating -> gaining weight diminishing sun light in winter -> increase of the pineal gland hormone melatonin Phototherapy -> exposing to bright light in early morning 2 am effects show up within 3-4 days within 1-2 weeks SAD remit side effect : 19% experience headache 17% eyestrain (Levitt et al., 1993)

25 < Prevalence of mood disorders >
Life time prevalence in US 19% (Kessler, 1994) Female have higher prevalence than men 2 : 1 In case of bipolar disorder, no difference Black people show lower rate compared to whites or hispanics disease last year lifelong major depr % % dysthymia % % bipolar % %

26 < Depression of children and adolescence >
3 month old infants can have also depression Related to mother’s depression (by way of genetics and interaction) Child depression and adults depression are similar in their character There are no difference in regard to developmental stages But ‘look’ of depression changes with age child-> facial expression, eating, sleep disorder adolescence -> low self-esteem frequent suicidal attempt Prevalence rate of childhood lower than adult During adolescence, it increases dramatically

27 In childhood-> dysthymia is more frequent
In adolescence -> major depression is more frequent Bipolar disorder very rare in childhood During adolescence -> dramatic increase of bipolar disorder Adolescence major depression occurs in most cases to girls Childhood major depression -> irritability, mood swing -> easily misdiagnosed as a hyperactivity Childhood depression accompanies aggressive behavior, especially for boys -> easily misdiagnosed as a hyperactivity or conduct disorder

28 Quite often conduct disorder and childhood depression occurs together (comorbid)
32% of ADHD children -> major depression comorbid (Biederman et al., 1987) Adolescence bipolar disorder -> aggressive, impulsive, excessive sexual behavior, traffic accidents < Depression among the elderly > 18-20% of nursing home residents experience major depressive episodes after age 60 mostly become chronic

29 In case of late onset, sleep disorder
hypochondriasis Physical illness, dementia, decrease of social support -> depression prevalence rate in the elderly -> similar to that of general population Physical illness with depression -> needs longer treatment than pure physical illness No sexual difference in terms of prevalence after age 65 < cultural differences > Differences among different cultures Individualistic cultures -> "I feel blue" or "I am depressed"

30 -> "my heart is broken" "our life has lost its meaning"
Collectivistic cultures -> "my heart is broken" "our life has lost its meaning" American Indian Prevalence rate men 19.4% ; women 36.7% (Kinzie et al., 1992) < creativity > Relationship between Mood disorder and creativity In the New Oxford Book of American Verse of the 36 poet enlisted, 8 were bipolar disorder ( 5 committed suicide ) Virginia Wolf was also bipolar disorder and committed suicide

31 < Anxiety and depression >
Anxiety and depression are closely related to each other Most of the depressive patients experience anxiety But not all the anxiety disorder patients experience depression Pure depression component -> anhedonia Lowered cognitive and motor functioning most depression begins with anxiety

32 cause It is very complex
biological, psychological and social factors interacting with each other 1. Biological dimensions Family research Family members of mood disorder patients have higher prevalence rate -> 2-3 times higher than general population Family members of bipolar disorder -> higher only in major depressive symptoms Family members of the major disorder patients -> higher prevalence only in major depressive symptoms

33 Is bipolar disorder -> an extension of unipolar disorder
Is bipolar disorder -> an extension of unipolar disorder ? (Blehar et al., 1988) Adoption study Parents prevalence of the adopted mood disorder children - compared with the parents of the adopted children without mood disorder symptom : Mendlewicz & Rainer(1977) -> higher prevalence Von Knorring et al(1983) -> no difference Twin research Identical twin are likely to present 3 or more times with mood disorder than fraternal twins, if the first twin shows a mood disorder.

34 If the first twin has a bipolar disorder, then even higher concordance rate
-> if he /she is a bipolar I disorder -> then the rate that the other twin shows a mood disorder (not bipolar) is over 80% in case of severe mood disorder if the first twin is severe major depression -> identical twin : 59% -> fraternal twin : 30% concordant In case of not severe major depression -> identical twin : 33% -> fraternal twin : 14% concordant

35 Neurotransmitter systems
Close relationship between mood disorder and neurotransmitter serotonin’s function of emotion regulation - by way of norepinephrine and dopamin if serotonin level diminishes => get impulsive and fluctuation of emotions Absolute quantity of a single neurotransmitter is not so much important as the balance with other neurotransmitters The importance of dopamine in the etiology of the mood disorder gets attention The relationship between L-dopa and hypomania (Van Praag & Korf, 1975)

36 The endocrine system Mood disorder-> related to endocrine system
hypothyroidism (Cushing’s disease) -> excessive secretion of cortisol -> depression HPA axis (brain circuit) hypothalamic-pituitary-adrenalcortical axis DST (dexamethasone suppression test) dexamethasone is a glucocorticoid that suppresses cortisol secretion in normal subjects. -> however, when this substance was given to depressive patients, much less suppression was noticed => 50% of depressive patients showed reduced suppression

37 Sleep and circadian rhythms Sleep patterns of depressive patients
In depressive patients the adrenal cortex secreted enough cortisol to overwhelm the suppressive effects of dexamethasone In recent study anxiety disorder patients demonstrated also non-suppression on DST Sleep and circadian rhythms Sleep patterns of depressive patients sleep time before REM phase is shorter than the normal (90min) Lack of deep sleep (slower wave sleep) More intensive REM sleep than the normal

38 More often awake in the middle of night
If being waked up in the later phase of the sleep -> improves depressive symptoms -> relationship between depression and biorhythm (Wehr & Sack, 1988) Depression which came after stressful event -> didn’t show REM sleep disorder -> better responded to psycho-social treatment

39 2. Psychological dimensions
Stressful life events Stress events prior to onset of mood disorder context and meaning of the stress is more important than stress event itself In most research was proven : The relationship between mood disorder and stressful event Mood disorder following a severe stress event => takes longer time for treatment

40 Etiology of mood disorder
-> related to stressful events -> its own dynamic after outbreak Only % of the normal population who experienced a severe stress event develop a mood disorder -> interaction between stressful event, biological and psychological vulnerability Learned helplessness and dysfunctional attitude Seligman’s(1975) rat experiment

41 If electric shocks are not avoidable
-> develops a depression First reacts with anxiety -> learns that it is uncontrolable -> depression The depressive attributional styles a) internal (“it is all my fault”) b) stable (“additional bad things will always be my fault”) c) global (“the bad situations is all my fault”)

42 The causality of depressive attributional style
Is that the cause or the result ? Child study of Nolen-Hoeksema, Girgus & Seligman (1992) Life stress events explained more variance than attributional style - but childhood attributional style explained much of the variance in adult depression - childhood stress event influences children’s attributional style

43 Beck’s cognitive theory of depression (1967)
Negative attributional style is to be found not only in depression but also in anxiety disorder Abramson, Metalsky and Alloy -> revised the importance of the attributional style in the etiology of depression -> the sense of hopelessness is more important Both anxiety disorder patients and depressive disorder patients experience helplessness, but, only depressive patients give up -> hopelessness about regaining the control Beck’s cognitive theory of depression (1967) cognitive errors of the depressive patients

44 1) Arbitrary inference -> fails to see various aspects of things (A high school teacher infers that he is a terrible teacher, because one student out of 20 students fell asleep) 2) Over-generalization -> when a professor makes a critical remark on your paper, you then assume you will fail the class despite a long string of positive comments and good grades on other papers The depressed always makes thinking errors -> they think negatively about themselves, their immediate world, and their future => depressive cognitive triad

45 Negative cognitive schema of the
depressive patients 1) self-blame schema individuals feel personally responsible for every bad thing that happens. 2) negative self-evaluation schema individuals believe they can never do anything correctly. These cognitive errors and schemas are automatic, that is, not necessarily conscious. Beck’s cognitive theory of depression (1967) => automatic thoughts

46 Dysfunctional attitude and hopelessness
attribution (negative outlook) -> high risk for depression (M. Seligman) Temple-Wisconsin study of cognitive vulnerability of depression Student group longitudinal study (2.5year) -> high risk group -> 17% low risk group -> 1% developed a major depression

47 High risk group -> 39% Low risk group -> 6% developed a minor depression (Gotlib & Abramson, 1999) Psychological vulnerability + biological vulnerability -> slippery path to depression

48 social and cultural dimension Influence of divorce on depression
study of Bruce and Kim(1992) 695 women and 530 men were re-interviewed 1 year after divorce 21% of divorced women showed severe depression -> 3 times as much as women who were not divorced 17% of divorced men showed severe depression -> 9 times as much as men who were not divorced

49 - high marital conflict + low marital support
Marital support have a significant impact on developing a depression - high marital conflict + low marital support -> susceptibility of depression (Gotlib & Beach, 1995) Depression -> endangers marital relationship ( in men ) Marital problem -> depression (in women) => treatment of marital problem is important for treating depression (Fincham et al., 1997)

50 Mood disorders in women
Bipolar disorder -> no gender difference in terms of prevalence Major depression-> 70% are women similar distribution worldwide the same with anxiety disorders Low controllability of women Men are expected to be independent, self assertive, whereas women to more passive, to be sensitive to other people, and perhaps to rely on others more than males do (Hammen et al., 1985)

51 Men are at greater risk in the process of divorce
Women are more disadvantaged in the society More discrimination, poverty, sexual harassment, and abuse Full time working women -> no difference compared to control men group Men group -> higher rate on the problem related with aggressivity, hyperactivity, drug abuse

52 Social support Existence of social support has great influence on the development of depression Severe life stress When there is social support -> 10% developed a depression when there is no social support -> 37% developed a depression (Brown et al., 1978) Social support have also influence on the recovery of a depression (Keitner et al., 1995)

53 Integrative theory Anxiety and depression may share a common
genetically determined biological vulnerability -> excessive neurophysiological response to stress Stress event-> stress hormon-> influence on neurotransmitter, especially on serotonin and norepinephrine New theory stress hormone "turn on" certain genes -> atrophy of neurons in the hippocampus that help regulate emotions.

54 Childhood stress experience
-> cognitive vulnerability -> influences on adult stress response Problem : cannot explain specific psychological disorders - need a theory that differentially explains between anxiety, depression, bipolar and unipolar disorder

55 Treatment of mood disorders
Drug therapy Change in the level of neurotransmitters or in neuro-chemical structures - inhibition of reuptake of specific neurotransmitters in the synapses - down regulation of specific neurotransmitters

56 Tricyclic antidepressants
Imipramine (Tofranil) Amitriptyline (Elavil) -> down-regulate norepinephrine -> down-regulating process take 2-8 weeks Side effects - blurred vision, dry mouth, constipation difficulty urinating, drowsiness, weight gain (at least 13 pounds on average) sexual dysfunction -> 40% of patients drop out

57 50% of the patients benefit Placebo effect -> 25-30%
For patients who stayed to the end of the treatment -> 65-70% benefit Excessive use of tricyclic antidepressants -> danger of death -> needs attention when prescribed to a suicidal patients

58 MAO inhibitors Block the MAO enzyme that break down such neurotransmitters as norepinephrine and serotonin -> down-regulate the two neurotransmitters -> have less side effects than tricyclics More effective to the atypical feature depression Interacts with foods that contain tyramine (cheese, red wine, beer ) -> might induce high blood pressure -> interact with other drugs and risk of fatal side effects

59 SSRIs (selective serotonergic reuptake inhibitors)
Inhibit reuptake of serotonin Enhance serotonin level in the receptor site - exact mechanism is still not clear - most well known SSRI -> fluoxetine (Prozac). was regarded as a break through (newsweek 3/26/90 cover story) side effect become known to public physical agitation, sexual dysfunction or low desire (75%), insomnia, and gastrointestinal upset But less side effects compared to those of tricyclic antidepressants

60 < Two new antidepressants >
Venlafaxine -> related to tricyclic antidepressants, but less side effects and less damage to the cardiovascular system Nefazodone -> similar to SSRIs improve sleep efficiency Great deal of interest in the antidepressant properties of the natural herb -> St. John's Wort (hypericum) alters serotonin function

61 Drug therapy of childhood depression
-> difference between children and adults -> side effects of tricyclic antidepressants Risk of death due to cardiac side effects (Tingelstad, 1991) Drug therapy of depression of the elderly - - side effects such as memory impairment, physical agitation

62 Prevention and delay of the next depressive episode are more important than treatment of depression itself Because most of the depression remit after some time Need medication further 6-12 month after the recovery Women who are going to plan to have a baby needs caution when considering drug therapy, because the fetus can be affected 40-50% of the patients didn’t benefit from drug therapy

63 Lithium In treatment of depression and bipolar symptoms More side effect than other antidepressants - toxicity, lowered thyroid functioning - intensify lethargy associated with depression - substantial weight gain Advantageous to treat manic symptoms Tricyclic antidepressants -> can induce manic symptoms

64 Can be prescribed to patients without bipolar disorder
Mechanism are not known probably influences the level of dopamine and norepinephrine Influences the production and availability of sodium and potassium, which is electrolytes found in body fluids 30-60% of bipolar patients respond (Prien & Potter, 1993) Prevents relapse for 66% of the patients Manic symptoms -> euphoric -> compliance problem

65 Electroconvulsive Therapy(ECT)
In the past, immature ECT technique -> recently improved For the patients who don’t respond to drugs well and those who have psychotic depression or are at risk of suicidal attempt -> 50-70% benefit from ECT After anesthesia -> electric shock to brain - shocks last shorter than 1 second each time - once every two days 6-10 times per day

66 Side effects relatively small temporary memory disturbance -> recover within 1-2 weeks Mechanisms -> not known functional and structural change in brain

67 < psychotherapy of major depression >
A.T. Beck’s cognitive behavior therapy Once a week and sessions monitoring thought process while depressive symptoms come up -> find out "depresssive errors in thinking" -> replace with a more realistic thinking Negative cognitive schemas -> find out them with the therapist as a team -> test them as a home work

68 Hypothesis testing (as to responses of other people)
Reactivating the patients -> compensate the patients through activity -> improve self concept Peter Lewinsohn, Gotlib & Clarke Focused on reactivating patients in the beginning Recently they deal with cognitions too

69 Interpersonal Psychotherapy; IPT
Klerman, Weissman, Rounsaville, Chevron, Markovitz et al A structured therapy like that of CBT brief therapy with sessions Mainly focuses on the interpersonal relationship and coping style Focuses on one of the following 4 problems

70 Preventing relapse Interpersonal disputes The loss of a relationship
Acquiring new relationships Identifying and correcting deficits in social skills Similar effects as medication, CBT (Elkin et al., 1989) Preventing relapse Medication -> rapid response Psychotherapy -> improve social functioning and relapse prevention

71 medication + psychotherapy
-> combined effects After medication offer a psychotherapy For the bipolar disorder, combined therapy of psychotherapy and family therapy are effective Family conflict -> related to relapse When treated with psycho-social therapy relapse rate decreased up to 50% compared to drug therapy alone (Miller et al., 1991)

72 5-6 graders of elementary school
social skill training teaching cognitive strategies - was effective in the prevention of depression (Gilham et al., 1995) 50% of depression patients relapsed within 4 months, if medication was stopped (Hollon et al., 1990) after 24months medication stop group % relapsed medication cont. group % CBT group % CBT + drug therapy %

73 psychotherapy -> biophysiological change
Medication > pcychological change Both of them lead to the DST change after treatment The level of tyroid hormone thus, psychotherapy and medication combined brings an integrative change (Joffe, segal & Singer, 1996)

74 VI. Schizophrenia and Related Psychotic Disorders
Complex disorder Disorders in perception, thought, emotion, language, movement, behavior 16-19 billion dollars annually spent for the treatment in US 2.5% of total medical costs (Rupp & Keith, 1993) 1801, Pinel, 1809, John Haslam 1899, German psychiatrist Emil Kraepelin combined three symptoms

75 “catatonia”, “hebephrenia” and “paranoia” that were regarded at that time as independent conditions into one category => dementia praecox Catatonia (alternating immobility and excited agitation) Hebephrenia (silly and immature emotionality) Paranoia (delusions of grandeur or persecution)

76 These three symptoms shared similar underlying features
Early onset is at the heart of the three symptoms that will eventually lead to “mental weakness” -> a diagnostic system that was focusing on the onset and course of a disease He pointed out that dementia praecox is different form manic depressive illness in their onset and course

77 < Clinical description > positive symptoms
In 1908, swiss psychiatrist Eugen Bleuler introduced the term schizophrenia The core problem of schizophrenia is according to him -> associative splitting of the basic functions of the personality -> breaking of associative threads < Clinical description > positive symptoms -> more active manifestations of abnormal behavior or an excess or distortion of normal behavior -> delusions or hallucinations

78 Negative symptoms Deficits in normal behavior like in speech and motivation Disorganized symptoms Rambling speech, erratic behavior, inappropriate affect At least two of three symptoms must be present at least longer than a month to be diagnosed as a schizophrenia

79 Positive symptoms Delusions Unrealistic thoughts
“squirrels are aliens sent to Earth on a reconnaissance mission" “I can end starvation for all of the world’s children.” “I will set up a base in the moon and evacuate children there." “My opponent will spray my bicycle with chemicals that would take my strength away.” Individuals with delusion - different emotion from depression - less depressive but less wise

80 Hallucinations The experience of sensory events without input from the surrounding environment Can involve any of the senses But auditory hallucination is most common “It’s too damn loud. Turn it down." “Good day for fishing. Got to go fishing.” “You are strange. You are out.” People tend to experience hallucinations more frequently, when they are unoccupied or restricted from sensory input

81 SPECT (single photon emission computed tomography)
Cerebral blood flow of men with schizophrenia Were tested when they are hearing auditory hallucination -> Broca's area was being activated Broca’s area is in charge of speech production The area that involves language comprehension is Wernicke's area

82 This is a surprising discovery, because it means that auditory hallucination is not hearing the voices of others but are listening to their own thoughts or their own voices (Hoffman, Rapoport, Maure, & Quinlan, 1999) Negative symptoms Absence or insufficiency of normal behavior Emotional and social withdrawal Apathy Poverty of thought or speech

83 Avolition Volition means act of willing, choosing or decision Avolition means inability to initiate and persist in activities. Show no interest in carrying out basic life functioning Neglects personal hygiene Alogia Relative absence of speech Respond to questions with brief replies that have little content and appear uninterested in the conversation

84 Reflect a negative thought disorder rather than inadequate communication skills
Have trouble finding the right word to formulate their thoughts Delayed comments or slow response to questions Anhedonia Lack of pleasure Not interested in the activities that bring pleasure -> sex, food, social activity

85 Affective flattening Flat affect 2/3 of the patients show this symptom As if one has a mask on Looks pointlessly Speaks monotonously Uninterested in what happens in the surrounding

86 Have feelings inside -> difficulty expressing emotions, not a lack of feeling (Berenbaum & Oltmanns, 1992) -> emotional responses through physiological recordings Facial expressions of schizophrenic patients in childhood displayed -> less positive and more negative affects

87 Disorganized symptoms
Disorganized speech - difficult to get informations when talking - lack of insight about one’s illness - associative splitting - cognitive slippage - inconsistent in speaking - illogical language

88 -> cogintive slippage Dr: why are you here in the hospital ?
Tangentiality -> cogintive slippage Dr: why are you here in the hospital ? Pt: I don’t want to stay here. I’ve got other things to do. The time is right, and you know, when opportunity knocks. Loose association, Derailment Dr: I was sorry to hear that your uncle Bill died a few years ago. How are you feeling about him these days ?

89 < Inappropriate affect and disorganized >
Pt: Yes, he died. He was sick, and now he’s gone. He likes to fish with me, down at the river. He’s going to take me hunting. I have guns. I can shoot you and you’d be dead in a minute. < Inappropriate affect and disorganized > Emotional expression not fitting in the situation Bizzare actions like hoarding objects or acting strangely in public catatonia -> wild agitation or immobility pace excitedly or move finger or arms in stereotyped ways

90 Hold unusual postures waxy flexibility -> tendency to keep the body and limbs in the position they are put in by someone else Schizophrenia subtypes Three divisions have persisted as subtypes of schizophrenia catatonic, hebephrenic, paranoid type DSM-IV-TR

91 - Delusion, hallucination being main
1. Paranoid type - Delusion, hallucination being main symptom - Cognitive skills and affects are relatively intact - Better prognosis - Delusions and hallucinations usually have a theme such as grandeur or persecution

92 2. Disorganized type Flat or inappropriate affect such as laughing in a silly way at the wrong time Delusion or hallucination not organized around a central theme as in the paranoid type, but are more fragmented Early onset, chronic lacking the remissions

93 3. Catatonic type Waxy flexibility Excessive movement Defiant attitude Odd mannerism stereotypical body movement, grimacing Echolalia Echopraxia Relatively rare, because of recent success of neuroleptic medications

94 4. Undifferentiated type
People who have the major symptoms of schizophrenia but who do not meet the criteria for paranoid, disorganized, or catatonic types 5. Residual type People who have had at least one episode of schizophrenia but who no longer manifest major symptoms are diagnosed as residual type of schizophrenia

95 They may display residual or “left over” symptoms
Such as negative beliefs, or they may still have unusual ideas that are not fully delusional Residual symptoms can include social withdrawal, bizarre thoughts, inactivity, and flat affect

96 Schizophreniform Disorder
< Other psychotic disorders > There are other psychotic disorders that don’t fit under the hading of schizophrenia Schizophreniform Disorder Symptoms of schizophrenia for a few months only Good premorbid social and occupational functioning absence of blunted or flat affect Schizoaffective Disorder People who have both schizophrenia and mood disorder at the same time. Mood disorder + delusion or hallucination longer than 2 weeks

97 Delusional Disorder A persistent belief that is contrary to reality in the absence of other characteristics of schizophrenia -Different from schizophrenia, the delusions of delusional disorder are theoretically possible Not organically caused delusion Not caused by drugs or alcohol either There are no negative symptoms such as flat affect, anhedonia

98 Brief Psychotic Disorder
Late onset (age 40-49) subtypes => erotomanic, grandiose, jealous, persecutory, somatic Brief Psychotic Disorder Characterized by the presence of one or more positive symptoms such as delusions, hallucinations, or disorganized speech or behavior lasting 1 month or less Often precipitated by extremely stressful situations Shared Psychotic Disorder - An individual develops delusions simply as a result of a close relationship with a delusional individual

99 1. Statistics Lifelong prevalence 0.2% - 1.5% Similar prevalence world wide, and no gender difference Onset of male begins earlier than that of female More men before age 36, more women after age 36

100 < Development > Children show some abnormal signs before they display the characteristic sympotoms (cf: 조승희, Virginia College of Technology. Massacre in April killing 32 students and injuring 15 students) Negative affects domineering Bad adjustment 40 years follow up study of 52 schizophrenic patients Symptoms decreased as getting old (Winokur et al., 1987) Most of the patients kept their symptoms lifelong, (moderate to sever symptoms)

101 Group1 (22%) -> one episode only, no impairment
Group2 (35%) -> several episodes with no or minimal impairment Group3 (8%) -> impairment after the first episode with subsequent exacerbation and no return to normality Group4 (35%) -> impairment increasing with each of several episodes and no return to normality

102 Schizophrenia found in all cultures
Differed in terms of prevalence rate or recovery rate In US more African Americans receive the diagnosis of schizophrenia than whites. People from devalued minority groups maybe victims of bias and stereotyping. Blacks were more likely to be detained against their will, brought to the hospital by police, and given emergency injections (Goater et al., 1999)

103 2. Cause < Genetic influences > 1938 Franz Kallmann Examined family members of more than 1,000 people diagnosed with schizophrenia in a Berlin Psychiatric Hospital The severe the symptoms, the higher concordance rate of family members Various subtypes found in the same family -> general predisposition for schizophrenia, not specific predisposition

104 The closer genetically the higher concordance rate
Identical twin 49% Fraternal twin 17% Sibling % Cousin % (Gottesman, 1991) Quadruplets schizophrenia observed over the years and all 4 sisters developed schizophrenia But they showed all very different courses the same parents and family-> individually different experiences (Rosenthal, 1963)

105 Adoption studies 1. adopted child research first, identify schizophrenic patients next, find their children given to other families 2. Relatives studies first, schizophrenic patients who were adopted are identified next, find their parents and siblings

106 Research in Finland (Tienari, 1992)
Adoption studies Of the 20,000 female schizophrenic patients 164 were identified who gave their children away for adoption => 155 children of these patients were identified who were brought up in foster home 185 children of the normal parents were compared as a control group who were also brought up in foster home

107 Of the patients’ children,
16 were diagnosed either schizophrenia or other psychosis -> 10.3% Of the normal parents’ children, 2 were diagnosed as psychosis -> 1.1% Gottesmann’s research (1989) Children of identical twin patients -> 16% Children of identical twin patient’s sibling who are not patients -> 17%

108 Children of fraternal twin patients -> 16%
Children of fraternal twin patient’s sibling who are not patients -> 1.7% The fact that the probability of outbreak of schizophrenia in children of patient twin and in normal twin are the same proves high heredity But it is only 17% -> the rest can be attributed to other causes Defects of not a single but several genes combined together -> severe pathology

109 Search for markers Characteristics common to schizophrenic patients => will lead to a discovery of related genes One of them is : Smooth-pursuit eye movement or eye tracking The ability to track objects with eye movement keeping head still. schizophrenic patients lack in this ability And this independent of drug or hospitalization (Liebermann et al., 1993)

110 < Neurobiological factors >
Dopamine over-activity hypothesis It is still controversial, but long lived hypothesis Evidences that support dopamine hypothesis 1. Antipsychotic drugs that are often effective in treating people with schizophrenia are dopamine antagonists

111 2. These drugs can produce negative side effects similar to those in Parkinson’s disease, a disorder known to be caused by insufficient dopamine. 3. The drug L-dopa, a dopamine agonist used to treat people with Parkinson’s disease, produces schizophrenia-like symptoms in some people 4. Amphetamines, which also activate dopamine, can make psychotic symptoms worse in some people with schizophrenia

112 In other words, when drugs are administered that are known to increase dopamine (agonist), there is an increase in schizophrenic behavior; when drugs that are known to decrease dopamine activity (antagonists) are used, schizophrenic symptoms tend to diminish. (mostly drugs that block the activity of D2 receptor)

113 < Evidences that contradict the dopamine theory >
1. A significant number of people with schizophrenia are not helped by the use of dopamine antagonists 2. Although the neuroleptics block the reception of dopamine quickly, the relevant symptoms subside only after several days or weeks, much more slowly than researchers would expect 3. These drugs are only partly helpful in reducing the negative symptoms (e.g., flat affect, anhedonia) of schizophrenia

114 4. There is no evidence that schizophrenic patients have more D2 receptors than normals.
5. The research haven’t proved yet that there is abnormality in D2 receptors of schizophrenic patients. 6. Clozapine is effective to those patients who don’t respond well to the traditional drugs. But this drug is very weak in blocking D2 receptors. Dopamine is related to schizophrenia, but its role is very complex Dopamine has a different effect in combination with serotonin

115 Appropriate proportion of dopamine and serotonin is important in regulating positive symptoms such as hallucination or delusion Clozapine plays a role in mediating these two neurotransmitters. Blocking only dopamine isn’t effective Dopamine and serotonin must be blocked simultaneously to be effective (more dopamine should be blocked)

116 < Psychological and social influence >
Even the identical twins show different prevalence rate Environmental and experiential influences Research with high risk children In 1960, longitudinal researches of Danish researchers Mednick & Schulsinger 207 children of schizophrenic mothers were observed 104 control group children The research is still being done

117 Most of the researches are retrospective studies, the effects of which are limited
Ventura et al (1989) 30 patients were observed for one year Interviewed every two weeks Relapse often after stress events But 55% of the relapsed hadn’t had a considerable stress, which means there are factors other than stress that impact relapse

118 < The influence of the family and culture on the relapse >
Schizophrenogenic mother (Fromm-Reichmann, 1948) double bind (Bateson, 1958) induces guilty feelings of the parents -> which has negative impact on family Recent research The influence of the interaction among the family members on the relapse Brown et al (1959)

119 Expressed emotion (EE)
Patients who were restricted in their contact with family members showed lower relapse rate Criticism, hostility and emotional intrusiveness of the family members had impact on relapse (Brown et al., 1962) High expressed emotion in family -> a good predictor of relapse (Bebbington et al., 1995) Patients who lived in high EE family showed 3.7 times higher relapse rate than those who lived in low EE family (Hooley, 1985)

120 2. Treatment < Biological intervention > In 1930s injection of massive doses of insulin -> insulin coma therapy serious side effects, risk of death psychosurgery -> prefrontal lobotomies In the late 1930s Introduction of ECT Today it is known to have no effect

121 Dramatic change after inventing neuroleptics in 1950
=> control delusion and hallucinations (mainly positive symptom) class example degree of extra- pyramidal effects (side effects) Conventional antipsychotics phenothiazines Fluphenazine / Prolixin high Trifuluoperazine / Stelazine high Perphenazine / Trilafon high Mesoridazine / Serentil low Chlorpomazine / Thorazine moderate Thioridazine / Mellaril low

122 Butyrophenone haloperidol / Haldol high
others Thiothixene / Navane high Molindone / Moban low Loxapine / Loxitane high New Antipsychotics Clozapine / Clozaril low Risperidone / Risperidal low Olanzapine / Zyprexa low Serindole / Serlect low Quetiapine / Seroquel low

123 These drugs influence mainly dopamine
but also have influence on serotonin system It is only recently that we come to understand better the mechanism of drugs - Drugs are effective for some patients, but not for other patients. Clinicians and patients often must go through a trial and error process to find the medication that works best

124 Conventional antipsychotics are effective for approximately 60% of people who try them (APA, 2000)
Mostly many side effects Some people respond well to newer medications The most common are clozapine, risperidone, and olanzapine These medications tend to have fewer serious side effects than the conventional antipsychotics (Davis, Chen, & Glick, 2003)

125 Noncompliance of the patients is a significant problem
Approximately 7% of the patients refuse to take medication 3 out of 4 patients refused to take the antipsychotic medication for at least 1 week (Weiden et al., 1991) Negative side effects are a major factor in patient refusal grogginess Deterioration in the ability to concentrate (18%) Dry mouth (16%) Blurred vision (16%)

126 - one of the common side effect
Akinesia - one of the common side effect it includes an expressionless face, slow motor activity, and monotonous speech Tardive dyskinesia - involuntary movements of the tongue, face, mouth or jaw - results from long-term use of high doses of antipsychotic medication - often irreversible and may occur in as many as 20% of people who take the medications over long periods

127 The new antipsychotics such as clozapine produce fewer side effects, but even clozapine brings undesirable effects and must be monitored closely The compliance problem is serious Psychosocial intervention can help to increase compliance by helping patients communicate better with professionals about their concerns

128 < Psychosocial intervention >
Psychological intervention could be combined with medications Improving patient’s socialization Participation in group sessions self care such as bed making Token economy, in which residents could earn access to meals and small luxuries by behaving appropriately Deinstitutionalization - growth of human rights, integration into community - ill conceived policy produced many homeless people

129 < Social skill training >
Basic conversation Assertiveness Relationship building Maintaining eye contact while talking to another person Making friends Relapse prevention Utilizing social support system

130 < Family education >
Educating the family about the symptoms of schizophrenia Educating about the cause of the illness Teaching the family members to communicate more effectively (learn more constructive way to express negative emotions, listening more empathically) Teaching practical facts about antipsychotics (effects, side effects etc) Teaching about support system Teaching about problem solving strategies

131 < Vocational rehabilitation >
Enhancing the vocational ability Supportive rehabilitation Multilevel treatment -> contribute to reducing relapse rate Relapse rate of schizophrenia (after 2 year) 1. drugs + support or education -> 62% 2. drugs + social skills training -> 35% 3. drugs + famil stress management -> 38% (Falloon, Brooker & Graham-Hole, 1992)

132 < Self help groups >
Recently change from large mental hospitals to family homes in local communities Self help groups of former patients Fountain House in New York City (Beard et al., 1982) Most of the Psychosocial club have differing models, but all are "person centered“ and focus on obtaining positive experiences through employment opportunities, friendship, and empowerment.

133 25,000 New Yorkers have participated in club-houses sponsored by New York Association of Psychiatric Rehabilitation Services. Participation in club houses may help reduce relapse (Beard, Malamud & Rossman, 1978) But it is difficult to interpret the improvement, because it is possible that those who have participated may belong to a special group of individuals (Mueser et al., 1990). You’ve done a great job ! I appreciate very much your efforts to come along ! Have a good time during vacation !!


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