Week 32: Psychopathology II & Treatments

• Schizophrenia


  Prevalence rate ~1%

  Typically diagnosed in late adolescence/early adulthood

  Sex differences

  Chronic and often debilitating

  Many aetiologies/underlying diseases
• Positive symptoms


  Behaviours not frequently observed in the healthy population

  • Delusions
  • Hallucinations
• Delusions


  strange beliefs that are rigidly maintained despite absence of evidence

  Belief that thoughts/actions are controlled by someone else, including thought broadcasting, insertion and withdrawal

  Other types

  • persecution (tormented)
  • reference (directed at me)
  • grandeur (importance)
• Hallucinations


  sensory experience in the absence of any input

  auditory hallucinations are most common

  can be visual, olfactory, tactile etc

  Lower order or higher order (sensory - perceptual - cognitive)
• Disorganised Behaviour


  Disorganised speech

  • tangential communication style
  • word salad
  • repetitive speech
  • neologisms

  Disorganised behaviour

  • inappropriate affect or lack of inhibition
  • bizarre behaviour
• Negative symptoms


  absence of behaviour usually evident in the healthy population

  Flattening/cessation of behavioural responses

  • catatonic behaviour
  • anhedonia (lack of interest/pleasure)
  • avolition (motivational impairment)
  • alogia (poverty of speech)
  • Social withdrawal
• Cognitive symptoms


  executive function in schizophrenia (Martin et al., 2015)

  • deficits planning, cognitive flexibility, verbal fluency, ability to solve complex problems, working memory

  Social cognition

  • social cognitive deficits apparent prior to onset of psychosis
  • social cognition best predictor of clinical outcome

  Cognitive problems may contribute to the broader pattern of symptoms typical of schizophrenia

  Consistent with evidence from neuroimaging studies showing prefrontal cortex dysfunction
• Risk factors


  schizophrenia is theorised as a neurodevelopmental disorder and/or neurodegenerative disorder

  Neurodevelopmental - early cognitive or behavioural/personality

  Neurodegenerative - early adolescence onset of frank psychosis

  2 hit hypothesis - e.g. genetic disposition + cannabis abuse
• Schizophrenia Genetic Risk Factors

  Heritability ~80%

  Genomewide Association Studies

  • >30,000 cases -> 45,000 controls
  • NO schizophrenia gene
  • lots of genetic variants that explain a very small increase in risk for SZ
  • structural genetic mutations that can have larger effect but these are rare cases
  • 22q11 deletion syndrome ~6xmore likely to have SZ diagnosis
• Dopamine hypothesis


  SZ associated with abnormally high levels of activity in networks sensitive to the dopamine neurotransmitter

  Evidence from classic antipsychotic drugs

  Effect of overdosing amphetamines
• Social & Psychological risk factors - schizophrenia

  low socioeconomic status

  Urban upbringing

  • rates of schizophrenia are double that of rural areas

  Poverty

  Family environment

  Migration

  Low IQ = common genetic factors
• Anxiety Disorders: DSM criteria

  classified under three chapters

  • anxiety disorders
  • obsessive-compulsive and related disorders
  • trauma- and stressor- related disorders

  Comorbidity

  • all have shared and specific risk factors

  Most common psychiatric disorder

  • 20-30% of population report symptoms of anxiety
• Phobias


  intense irrational fear coupled with great effort to avoid

  Knowledge that the fear is groundless does not diminish the fear

  Different types of phobias

  • specific phobias
  • social phobias
• Social phobias


  social anxiety disorder

  intense fear of being watched and judged by others

  negative evaluation

  emerges in childhood/adolescence

  High risk of substance abuse
• Specific phobias


  extreme, irrational fear of a particular object or situation

  teach the person to relax

  • exposure therapy
  • cognitive therapy
  • relaxation/meditation

  Blood-injection-injury phobia

  • slow pulse, low blood pressure, slack muscles, faint
• Panic Disorder & Agoraphobia


  Occurrence of unexpected panic attacks

  Symptoms

  • restricted breathing, dizziness, tingling feeling, sweating, trembling, heart palpitations, chest pains

  Diagnosed after recurrent unexpected attacks

  Accompanied by agoraphobia

  • fear of being in situations which help might not be available/escape might be difficult
• General Anxiety Disorder


  Continuous and pervasive feelings of anxiety

  Symptoms

  • feeling of inadequacy
  • over sensitive
  • difficulty concentrating
  • questioning of decisions
  • bodily symptoms
• Obsessive-Compulsive Disorder (OCD)


  Obsessions = recurrent unwanted and disturbing thoughts

  Compulsions = ritualistic behaviours to deal with the obsessions

  Surprisingly early onset (often before 10)

  Awareness of irrational behaviour
• Stress Disorders


  triggered abruptly by an identifiable and horrific event

  psychological effects similar across events
• Stress disorder psychological effects


  period of numbness

  dissociation
• Acute stress disorder


  recurrent nightmares/waking flashbacks
• Post-traumatic stress disorder (PTSD)


  enduring reaction to the trauma, persistent for 1 month after the stressor
• Post-traumatic stress disorder


  chronic sometimes lifelong disorder following a traumatic experience

  Symptoms

  • re-experiencing symptoms
  • arousal symptoms
  • avoidance symptoms
  • emotional numbness
  • loss of interest
  • angry outbursts
  • "survival guilt"
• Anxiety Genetic Risk Factors


  Heritability ~30-40%

  no "gene" for anxiety

  number of genes that explain a vary small amount of variance
• Anxiety biological basis


  Malfunctioning autonomic nervous system

  Despite their commonality neuroimaging studies show anxiety disorders have common and unique biological underpinnings

  Specific and social phobias

  • hyperactivation in amygdala and insula
• PTSD biological basis


  Hypoactivation in the Anterior Cingulate Cortex and Prefrontal cortex

  Re-experience and avoidance severity associated with decreased activity of ACC

  • unable to inhibit old memories

  Dissociation and the prefrontal cortex
• Psychological risk factors of phobias

  Specific phobias may be the result of "classical conditioning"

  • experienced a negative event (US), leading to fear (UR)
  • Object/cue linked to the event (CS)

  Vicarious conditioning

  • a person acquires a conditioned response merely by observing someone else's fear
• Psychological risk factors of PTSD

  only 1 in 10 Vietnam war veterans developed PTSD

  Why?

  • severity of trauma
  • level of social support
  • early trauma
  • diathesis-stress model?
• Psychodynamic Approaches


  overcome neurosis by "working through" unconscious psychological conflicts (catharsis)
• Psychodynamic approaches - transference

  patient's tendency to respond to the therapist in ways that recreate their responses to major figures in their life, while therapist maintains neutrality

  Freud insisted on at least 3 sessions/week

  Modern-day psychotherapists endorse many of Freud's claims, but have modified the treatments
• Psychodynamic Approaches - interpersonal therapy


  time limited (12-16 sessions) and structures

  psychological symptoms are a response to social isolation and impact the quality of relationships

  Often used to treat depression

  Focuses on

  • conflict with another person
  • life changes that affect the self and interaction with others
  • grief and loss
  • difficulty in starting/maintaining relationships
• Humanistic Approaches


  Client-centred therapy (Carl Rogers, 1950s)

  • non directive approach
  • people must take responsibility and live in the present
  • people need to accept themselves, solve their problems
• Client-centred therapy


  methods

  • active listening
  • reflecting back
  • challenge

  Factors for successful therapy

  • empathetic understanding
  • unconditional positive regard
  • genuineness
• Behavioural therapies


  focus on overt behaviours which can be identified and solved

  Lab studies and empirical basis

  Behaviours themselves are treated

  New learning to replace old habits

  • classical conditioning
  • operant conditioning
  • modelling
• Behavioural Therapies - Classical Conditioning


  Applied to treat specific phobias

  • Negative event (US) = Fear (UR)
  • Object cue linked to event (CS) = Fear (CR)

  Need to break connection between phobic stimuli and associated fears

  Exposure therapy

  • break connection and create new one using a relaxation response

  In vivo desensitization

  • extend the exposure to a real or virtual world
• Behavioural therapies - operant conditioning

  change behaviour through reinforcement (Act and consequence)

  Token economy

  • positive behaviours are reinforced with tokens which can be exchanged for desirable items
  • reinforcement changes gradually to encourage more higher level functions

  Contingency management

  • certain behaviours are reliably followed by well-defined consequences

  Modelling

  • learn new skills/behaviour patterns by imitating another person
• Cognitive-Behavioural Therapies


  seek to change maladaptive beliefs and modes of thinking

  Most commonly used to treat anxiety and depression

  Also used to treat OCD, panic disorder, eating disorders, insomnia and substance abuse
• Rational-Emotive Behavioural Therapy (Albert Ellis, 1950s)


  A -> B -> C sequence

  • people believe that an activating event (A) leads to a consequence (C) (i.e. A directly causes C)
  • But, a belief (B) is what translates A into C

  Beliefs are the cause of problems

  Therapy challenges irrational beliefs

  • dispute these irrational beliefs (D)
  • substitute them with more effect beliefs (E)
  • teacher-like manner
• Cognitive Therapy (Aaron Beck, 1970s)


  Dysfunctional cognition plays a key role in development of mental disorders

  Cognitive restructuring: change a person's thought processes (e.g. persuasion, confrontation, provide strategies)

  Beliefs may not cause depression but can certainly sustain it

  1. Identify unhelpful thinking habits
  2. challenge and distance yourself from these
  3. find alternative and more realistic thoughts
• Cognitive-Behavioural Therapy


  Hybrid of Ellis and Beck's work

  Present focused

  concerned with identifying and solving problems the patient wishes to address (direct approach)

  ~5-20 sessions, highly structured

  requires motivation from the patient