PSC 168 Notes PDF

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As taught by Professor Schepeler. These notes contain the most essential pieces of information, highly reflective of what you'll find on the midterms and final. I received an A in the course....

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09/26 ● Prehistoric Superstitions: ○ Demon Possession ■ There has always been the idea that people who suffer from mental disorders may have been struck by a demon. ○ Trephining ■ Early surgical approach of treating people who are acting abnormally. We have found skulls which have holes drilled into them. Historians have assumed that this is because people believed the hole allowed demons to escape. ○ Exorcism ● Early Scientific Explanations (Western Perspective) ○ Hippocrates (Greece - ca. 400 B.C.) ■ Theory of the “Imbalance of Humors” (Four: Choleric, Melancholic, Phlegmatic and Sanguinic) ● Melancholia = Depression ● Mania ● Hysteria = Anxiety interacting with physical function ● Dementia, delusions, ■ Hippocrates also recognized the importance of: ● Mental illnesses have biological roots. ● Heredity has important role. ● Psychosocial factors also play role. ■ Treatment ethic: ● First do not do harm! ● Return to Superstitions ○ Dark Middle Ages (5th - 10th Centuries) ■ The demon possession theories became popular again during this time. ○ Mass Madness (13th Century) ■ End of Middle Ages: Fear of the plague, when there is anxiety in a group of people, they’re looking for an explanation ● Tarantism: Dance Mania, people believed that they were bit by tarantulas. ● Lycanthropy: belief to be turning into a wolf. ○ Witchcraft (15th through 17th Century) ■ People who were burned at the stake may have suffered from schizophrenia. ● Renaissance and Rise of Humanism (late 15th Century) ○ Bedlam: first institution for treating the mentally ill. ○ Gradual return to rational, scientific thought ○ Human welfare ● Reform Movements ○ Moral Treatment Movement (Europe 18th Century) ■ Phillipe Pinel (Paris)

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A person with mental illness should be treated kindly. ○ What right do we have to lock up people? Experimented with taking them out of chains and using humane treatment. ■ William Tuke (England, “Retreat at York”) ● Tuke created his own institution. He took in patients with schizophrenia, depression, anxiety, etc. He used only psychosocial treatment methods. ■ American Reformers (19th Century) ● Benjamin Rush ○ “The Father of American Psychiatry” ○ One of the first to argue that alcoholism is a disease and not a moral failure. He is associated with the Pennsylvania Hospital, opened a psychiatric ward in the hospital. Pennsylvania Institute for the Insane was opened by Rush as well. ● Dorothea Dix ○ Originally a schoolteacher in Boston. She realized that a lot of the parents of her students were suffering from substance abuse disorders. She acted as a lobbyist in the 1840s to build thirty new psychiatric hospitals. State Hospitals Proliferate ○ Deterioration of Mental Hospitals (huge, poor are, abuse) ○ New medicalization of treatment (e.g. Hydrotherapy, Malaria therapy, Insulin therapy, Lobotomy, Electroshock) Deinstitutionalization (Starting in 1955) ○ 1955: 560,000 psychiatric beds in “State Hospitals” ○ 1955 - 75: Rapid decrease in psychiatric beds, then leveling off once medication became available. ○ 2000 - 2012: Second wave of rapid decrease in beds. ○ 2010: 43,300 psychiatric beds ○ Reason for Closing State Hospitals (esp. 1955 - 1975) ■ First effective medications available in the mid 1950’s ■ Civil Rights Movement ■ Financial Concerns Return to the “Dark Ages” ○ Homeless Mentally Ill ○ Criminalization of the mentally ill ○ Emergency room “Boarding” ○ Increased violence when untreated

10/01 ● Two Forces in the History of the Treatment of the Mentally Ill

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Medical/Biological Explanations ■ Hippocrates: Humors ■ Lobotomy ■ Medication, etc. Psychological Explanations (including spiritual, social, environmental) ■ Exorcism ■ Moral Treatment ■ Freud’s Psychoanalysis Biological Models ■ Genetics ● Genetic component to a lot of psychological disorders. Addiction: how fast the dopamine pathway of your brain becomes hooked. ● Even personality traits have some genetic markers ● Life experiences can alter gene expression ■ Endocrine (Hormonal) System ● Low thyroid levels can often masquerade as depression. ● People who are chronically stressed will have an imbalanced levels of stress hormones. ■ Immune System ● Early abnormalities in the immune system, while the fetus is still in the womb, can make the individual much more vulnerable to diseases like schizophrenia and autism. ■ Brain Structures ■ Biochemistry ● Frontal lobe is newest addition to the cortex. ○ Impulse control, planning, etc. ● ADHD: Not enough dopamine supplied to the Frontal Lobe ● Schizophrenia & Autism: Shrinkage, loss of brain matter. ● OCD: Overactivity, dysfunctional feedback loop w/ limbic system. ● The Limbic System ○ Thalamus: big role in schizophrenia. They can no longer discern between important and unimportant stimuli. ○ Amygdala: Fear and negative emotion. ■ Neurotransmitter (NT) ● Norepinephrine ○ Very general NT, function depends on where it occurs in the brain ● Serotonin ○ Related to calmness ○ SSRIs, the Prozac family, increase the level of serotonin in the brain (Mood) ○ Sleep ○ Regulation of impulses (e.g., aggressive behaviors, selfdestructive tendencies, suicidal urges, obsessive-

compulsive behaviors) Dopamine ○ outgoing, exploratory behavior ○ All pleasure seeking behaviors (including chemical addictions) involve the dopamine systems ○ excess of dopamine in brain can cause hallucinations and delusions ● GABA (Gamma-aminobutyric acid) ○ inhibitory neurotransmitter, reduces overall arousal Biological Forms of Treatment ○ Psychotropic Medications, main classes: ■ Anti-anxiety drugs ● benzodiazepines: you need more and more pretty quickly. They’re pretty addictive ■ Anti-depressants ● They’re not addictive and treat more than just depression. They also work for anxiety. ■ Mood stablilizers ● Used for treatment in manic-depressive disorder. ■ Antipsychotic drugs Socio-Cultural / Multicultural models ○ prevention of psychological disorders in the first place ○ Early interventions ○ Community education ○ Self-help and support groups ○ Understand the meaning of symptoms within cultural context Bio-Psycho-Social Model ○ Integration of various approaches Diathesis-Stress Model ○ What are the precursors that will lead to a disorder? ○ Looks at predispositions in genes, biological weaknesses or psychological traits. When paired with stressors, they tend to create a mental disorder. Intake Assessment ○ Reasons for referral and assessment. ○ History of current problem ○ Client Social History ■ Socio-economic status ○ Family History ○ Legal History ○ Support Network ○ Medical and Psychiatric History ○ Substance Abuse History ○ Mental Status Exam ○ Diagnostic Impressions (DSM-IV - on all 5 axes) ●

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○ Recommendations Mental Status Exam ○ General Appearance and Behavior ○ Behavior Observation ○ External Sources (e.g., records) ○ Psychological Tests ○ Neurological Tests Projective Personality Tests ○ Subjecs are asked to respond to ambiguous stimuli while being unaware of the true purpose of the test. ○ Projective Hypothesis: Subjects will project aspects of their personality onto the ambiguous materials. TAT - Thematic Apperception Test Sentence Completion Test Draw-A-Person Test House-Tree-Person Test Analysis takes into account: ○ Size of drawing ○ Placement of figures ○ Pencil pressure ○ Line quality ○ Amount of detail Objective Personality Tests ○ Most frequently administered “objective” personality inventory is the MMPI-2 (Minnesota Multiphasic Personality Inventory) ■ 567 True/Flase Questions ■ 10 Clinical Scales Neuropsychological Tests Definitions of Abnormality ○ Deviance ○ Distress ○ Dysfunction ○ Danger ○ How do we diagnose in clinical practice? ■ Diagnostic and Statistical Manual of Mental Disorders ■ DSM-IV (1994) 2000 Revision ● Must meet minimum number of specified symptoms for each disorder. ● Symptoms cause either subjective distress or dysfunction ● Symptoms are not considered normal in individual’s culture ● Time Marker to indicate how long client has dealt with a given issue. Mental Disorder in the US ○ Leading cause of disability

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○ One year prevalence: 26% Most Common Mental Disorders in the US (Lifetime Prevalence) ○ Anxiety Disorders: 28.8% ○ Mood Disorders: 20.8% ○ Substance Use Disorders 14.6%

Anxiety Disorders ○ Panic Disorder ■ Panic Attack ● “Discrete period of intense fear or discomfort, in which four or more of the following symptoms developed abruptly and reached

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a peak within a few minutes.” ○ Pounding heart or palpitations ○ Sweating ○ Trembling ○ Shortness of breath ○ Feeling of choking ○ Chest pain ○ Nausea ○ Feeling dizzy ○ Depersonalization ○ Fear of going crazy, dying ○ Numbness ○ Chills or hot flashes ■ Recurrent and unexpected panic attacks ■ Fear of future panic attacks or losing control ■ Duration of symptoms at least 6 months ■ Symptoms cause significant distress or dysfunction ● Agoraphobia is coded as an additional disorder Etymology of Panic Disorder ○ Pan: Greek/Roman god of nature, fertility, sexuality Prevalence ○ One year prevalence: 2.7% ○ Life-time prevalence: 5% Etiology of Panic Disorder ○ often biological predisposition (genetic; hypersensitive NS, oversensitive locus ceruleus) ○ higher acidity (lactic acid is produced at higher rates) in the brain ○ first panic attack may be triggered by drugs, medications, medical condition or trauma Education about ○ Panic attack as a normal fight-flight response ○ Conditioning Process: Catastrophic thoughts to bodily sensations trigger panic attacks ○ Encourage moderate aerobic exercise ○ Regular eating (often borderline hypoglycemics) ○ Reducing caffeine, etc. ○ Breathing exercises (to prevent hyperventilating) Cognitive Behavior Therapy ○ Cognitive Exercises: ■ Identify negative thoughts and learn to combat them ■ Devise coping statements (e.g., “I won’t die”) ■ Distraction techniques ■ Humor, distanciation Panic Disorder

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Medications for Panic Attacks: ■ SRI’s (e.g., Paxil, Lexapro); Effecor; Tricylics ■ Taken daily, start working after ca. 3 weeks ■ not addictive ■ Benzodiazepines: (Anti-anxiety drugs) e.g., Xanax, Klonopin ■ effective after 20-60 minutes ■ addictive Phobias ○ Agoraphobia ○ Specific Phobia ○ Social Anxiety Disorder (Social Phobia) ○ Biologically wired to become scared of them and trying to avoid them. Etymology ○ Agora = marketplace ○ Gender Ratio: 5:2 (females:males) ○ Onset: 20 - 35 years Treatment ○ Exposure Therapy ○ Cognitive Therapy ○ Antidepressants (especially SSRI’s) - also to treat any comorbid Specific Phobias ○ Animal Type ○ Natural Environment Type ○ Situational Type ○ Blood-injection / Injury Type ■ Sudden drop in blood pressure (fainting), whereas all other phobias cause sympathetic NS to activate ■ Most genetically correlated phobia ○ Young children often have phobias, many of them are outgrown without therapy Onset and Course ○ Usually in childhood but can start at any age Prevalence ○ One year prevalence: 8.7% ○ Lifetime prevalence: 11% Treatment ○ Behavior Therapy ■ Extinction of avoidance behavior through exposure therapy (flooding/systematic desensitization/virtual exposure) ○ Cognitive Therapy ■ Usually straight behavior therapy sufficient for simple, specific phobias. Add cognitive techniques if more generalized phobias. ○ Medications ■ Preferably none or only as adjunct Social Anxiety Disorder

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○ Fear of Social or performance situations ○ Concern about rejection or embarassing oneself ○ Duration of symptoms at least 6 months ○ Symptoms cause significant distress or dysfunction Predisposition: ○ Shyness, cautiousness, introverted temperament, sensitive NS Onset and Course: ○ Early adolescence ○ Typically worse when young, but may get worse over time and/or becomes chronic ○ 10-20 years, peak of onset around age 13 Prevalence ○ One year: 6.8% ○ Lifetime: 9% Medication Treatment: ○ Antidepressants (especially SSRI’s) ○ Beta Blockers (lower blood pressure) Psychological Treatment ○ Social Skill Training ○ Group Therapy (if tolerated) ○ Assertiveness Training ○ Cognitive Therapy ○ Treat comorbid disorders (panic attacks? depression?) ○ Explore: Childhood issues of domestic violence, abuse, shaming. Generalized Anxiety Disorder ○ Excessive anxiety and apprehension over a number of things, not limited to specific situations. ○ The worry is difficult to control ○ Symptoms such as muscle tension, restlessness, difficulty concentrating, feeling “on edge” ○ Duration of symptoms at least 6 months ○ Distress or dysfunction Onset and Course ○ 0 - 20 years ○ Often a chronic course ○ Worsened by increase in life stressors Prevalence ○ One year: 3.1% ○ Lifetime: 5% Gender Ratio: 2:1 (females:males) Etiology: ○ GAD tends to run in families: ■ modeling of anxious behavior by overprotective & anxious parents ■ and/or genetic factors (e.g., short serotonin transporter gene)

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Treatment ○ Psychological ■ Cognitive Therapy (obstacles: poor insight & somatization) ■ See textbooks for other interventions for GAD ○ Medication ○ Antidepressants (not addictive) ○ Benzodiazepines ○ Buspar ( = nonaddictive antianxiety medications which, by the way, is not helpful for panic) ○ Neurontin ( = gabapentin, an anti-seizure medication with antianxiety effects; non-addictive)

10/10 ● Obsessive-Compulsive Disorder ○ Obsession: Intrusive, repetitive anxiety-arousing thought or image ■ Common Themes ● Contamination ● Harming somebody ● Driving off bridges ● Sexual ideas ● Order ● Symmetry

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Compulsion: Need to perform acts to reduce anxiety ■ Common behaviors involve: ● Cleaning and washing ● Checking ● Counting ● Ordering ● Touching ● Licking ● Praying ● Seeking reassurance ■ DSM-V definition includes ● Recurrent intrusive thoughts/images and/or compulsions ● Attempts to suppress the thoughts or behaviors ● Symptoms present for at least 6 months ● Symptoms cause significant distress or dysfunction ■ Specifiers: ● good/fair insight; poor insight; absent insight/delusional ■ Onset: ● 4 - 25 years ● rare after age 40 ■ Course: ● “waxing and waning” chronic course if not treated ■ Prevalence: ● Lifetime: 2.5% ■ Gender Ratio ● 1:1 ■ Comorbidity (Co-occurrence) ● Depression ● Other anxiety disorders ● Alcohol and cannabis abuse ■ Etiology ● Biological (genetic predisposition, etc.) ○ Feedback loop in the left hemisphere, limbic system and basal ganglia which causes improper function. Serotonin is the necessary neurotransmitter. ● Conditioning Process Behavior Therapy ■ Exposure with Response Prevention ● Response you are preventing is engaging in the compulsive behavior. Cognitive Therapy ■ Habituation Training Medications ■ Medications increasing Serotonin levels, like:

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● Clomipramine (Anafranil) ● SSRI’s including Prozac, Paxil, Luvox, Zoloft, Celexa and Lexapro OCD Spectrum Disorders: ○ DSM-V lists: ■ OCD ■ Hoarding Disorder (Compulsive Hoarding) ■ Excoriation Disorder (Skin Picking Disorder) ■ Trichotillomania (Hair Pulling Disorder) ■ Body Dysmorphic Disorder ■ Other OCD Type Disorders: ● nail biting ● lip biting ● cheek chewing ● obsessional jealousy Hoarding Disorder ○ Need to accumulate possessions ○ Distress associated with discarding ○ Cluttering the home ○ Sense of emotional security from “stuff” Trichotillomania Disorder ○ Compulsive hair pulling, resulting in hair loss ○ May involve scalp, eye brows ○ Hair pulling has soothing effects and is used to reduce anxiety or stress Body Dysmorphic Disorder ○ Focus on an imagined or grossly exaggerated bodily defect (e.g., nose, teeth, ears, a mole, spots on skin, hands, breasts, etc). ○ Onset: ■ Usually begins adolescence ○ Prevalence: ■ 2% of US Population ■ 4% of US College ○ Gender Ratio: 1:1 (females:males) ○ Etiology ■ Family History ■ Shyness and social phobia ■ Cultural emphasis on perfection and beauty ○ Treatment: ■ SSRI Medication ■ Exposure with Response Prevention ■ Cognitive Therapy ■ Cosmetic Surgery does not work. Stress Disorders ○ Acute Stress Disorder ○ Post-Traumatic Stress Disorder (PTSD)

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Both require exposure to life-threatening traumatic event. Symptoms are roughly the same. Both require symptoms cause distress or impairment. Difference: length of time symptoms have lasted ● ASD: 2 - 30 days ● PTSD: More than 30 days ■ 40% of those with ASD develop PTSD ■ 50% of those with PTSD recover within 3 months Symptoms of PTSD ○ Must have been exposed to life-threatening traumatic event AND have developed the following symptoms ○ (1) Re-experiencing a traumatic event through ■ recurrent & intrusive memories or dreams ■ feeling as if traumatic event were recurring ■ dissociative flashbacks ■ Strong psychological and physiological response to cues resembling trauma ○ (2) Avoidance behaviors ■ Avoid cues or situations associated with the trauma ○ (3) Emotional distress, negative thoughts and impaired functioning ■ Persistent negative thoughts and emotions ■ Feeling detached or estranged from others ■ Feeling numb inside ■ Not being able to remember (aspects of) trauma ■ Not functioning effectively ○ (4) Heightened arousal ■ Difficulty falling or staying asleep ■ Irritability or outbursts of anger ■ Difficulty concentrating ■ Hypervigilance ■ Exaggerated startle response ■ Reckless, self-destructive behavior With Delayed Expression: ○ Full criteria not expressed until at least 6 months after trauma ○ More likely if: PTSD in Children ○ Overall the same as in adults ○ Anxiety is likely to be more generalized ○ More somatic symptoms are reported ○ Prone to “act out” and play out the trauma through repetitive play and actions Trauma Factors ○ Human-caused (vs. nature-caused) trauma ■ Human-caused trauma is more likely to cause PTSD ■ Easier to generalize in a world where social interaction is a necessary

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function of everyday life as opposed to something like a natural disaster ■ Natural disasters are discussed and understood to be traumatic events ■ Talking to others is like therapy (communal experience) ○ Severity of trauma ○ Prolonged/repeated trauma (vs. isolated trauma) ○ if person was/felt immobilized (vs. able to take some action) Social Factors ○ lack of social support (family, society at large) ○ lack of resources ○ further victimization through stigmatization Medications for PTSD: ○ No one specific PTSD medication but can treat symptoms ○ Benzodiazepines: may be prescribed in the first days after trauma ○ Beta blockers (Propranolol) to prevent PTSD after trauma ■ Blood pressure lowering medications which help reduce general physical symptoms of anxiety ○ Antidepressants: for anxiety, panic, sleep and depression ○ Topomax (anti seizure medication) may be helpful for flashbacks and nightmares ○ Antipsychotics or mood stabilizers to reduce anger Psychological Treatment for PTSD ○ Create safe space and rapport ○ Facilitate client talking about the event (to express feelings) ○ Empower client (to shed the victim role) ○ Teach coping skills (e.g., relaxation, breathing; coping statements) ○ Desensitization procedures including EMDR (Eye Movement Desensitization and Reprocessing) ○ Cognitive Therapy ○ Group Therapy / support groups ○ Body Therapies, movement therapies (“complete the action”) ■ People who were immobilized often experience the same thing when they have flashbacks. In therapy, they need to learn to take action. Possibly roleplay the situation that they were in. ○ With Children: Art therapy & play therapy: physical exercises to help children regulate their emotions. P...