Three points for day one of schizophrenia:
1. Many misconceptions and popular myths surround the diagnosis of schizophrenia.
2. Schizophrenia’s most prominent feature is a break with reality.
3. Symptoms of schizophrenia are often categorized as
positive, negative, and psychomotor.
Schizophrenia and other psychotic disorders
What is schizophrenia?
--loss of contact with reality
--disorganization of thinking and functioning
--affects 1% of people at some point
--men vs. women
What is schizophrenia not?
--not DID (MPD)
origin of term "schizophrenia"--not associated with violence
--not always chronic
Symptoms of schizophrenia:
sometimes classified as negative
The positive symptoms of schizophrenia
--bizarre vs. nonbizarre
Disorganization of thinking and speech
--loose associations or derailment
Heightened perceptions and hallucinations
Poverty of speech
poverty of content
Loss of volition
Odd repeated gestures
Catatonia—see book for good description
Three points for classification of schizophrenia:
1. Classically, schizophrenia is divided into disorganized, paranoid, and catatonic types.
2. The paranoid type is more supported by research as being a stable and meaningful category.
3. Several other psychotic disorders with similar features
to that of schizophrenia also exist.
Schizophrenia, day two: classification and types of schizophrenia
Diagnostic criteria for schizophrenia:
A. two or more of the following:
--disorganized or catatonic behavior
or any one of the following:
--auditory hallucinations (AH) of a "running commentary"
--AH of "two or more voices conversing with each other."
B. Social/occupational dysfunction.
C. At least 6 months
Types of schizophrenia:
--all of the following:
disorganized speech--not catatonic
flat or inappropriate affect
At least two of the following:
--motoric immobility or stupor
--excessive purposeless motor activity
--extreme negativism or mutism
--peculiarities of voluntary movement
--echolalia or echopraxia (movements)
these types are not terribly supported by research:
--people often change type over time
--people are often not clearly one type
--preoccupation with one or more delusions or frequent auditory hallucinations
--none of the following is prominent: disorganized speech, behavior, or flat/inappropriate affect.
--more clearly supported by research as being different.
--prognosis may be better for treatment and independent living
--nature of disorder may predispose to suicide or violence
--Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior
two or more positive symptoms in a lesser form
Other psychotic disorders:
--nonbizarre delusions for at least one month
--never met criterion A for schizophrenia
--other than the delusion, functioning is not impaired,
behavior is not odd.
Types of delusional disorder:
Brief psychotic disorder
Shared psychotic disorder (Folie a Deux)
Substance-induced, related to gmc, and nos psychotic disorder
Three points for day three of schizophrenia
1. A diathesis-stress model seems most appropriate in attempting to explain the development of schizophrenia.
2. High Expressed Emotion (criticism and hostility) in families is strongly linked to relapse for people with schizophrenia.
3. New frontiers for treatment of schizophrenia include
medication and CBT.
Schizoprenia, day three: causes, aggravators, and the
current state of things.
case of the Genain quadruplets--biochemical abnormalities?
Dopamine--(structural) brain abnormalities?
iatrogenic?--but how much do we really know?
Expressed emotion (EE)
--note on book’s mentioning of it
criticism--camberwell family interview
--research suggests that EE causes relapse
--research does not suggest that symptoms lead to EE
--findings with other disorders
Frontiers in treatment:
--note about the typical antipsychotics
--target serotonin as well as dopamine
--appear to affect positive and negative symptoms
--not as many side effects
CBT for delusions/hallucinations
--some initial studies
--designed to inform
--also to reduce EE
See your textbook for information on history of treatment
The problem of post-deinstitutionalization
--management of people with severe mental illness.
Three points about dissociative disorders
1. Dissociation is a process of "leaving something out" that can be viewed as a defense mechanism.
2. Dissociative fugue can be understood as an extreme case of dissociative amnesia.
3. Dissociative identity disorder is the most severe and
controversial of these disorders.
What is dissociation?
--a process by which something is "left out"
memory for event--a potentially adaptive mechanism
emotions for memory
feelings at the moment
--a potential problem
1. One or more episodes of inability to recall important personal info, usually of a traumatic or stressful nature, that is not just ordinary forgetfulness.
1. Sudden, unexpected travel away from home or one’s customary place of work, with inability to recall one’s past.
2. confusion about personal identity, or assumption of a new identity.
Dissociative Identity Disorder (formerly MPD)
1. The presence of two or more distinct identities or personality states.
2. Control of the person’s behavior recurrently taken by at least two of these identities or personality states.
3. An inability to recall important personal information
that is too extensive to be explained by ordinary forgetfulness.
1. overwhelming trauma
2. "someone else" to cope with trauma
self-hypnosis3. alters arise
state dependent learning
--similar alter themes:
Host4. there is switching between alters
--signs of switching
1. Still thought to be rare, although many more recent cases.
2. Large % have been abused.
3. 5:1 females to males.
Is it "real"?
1. Seen clinically by people who aren’t looking for it.
2. Some evidence of physiological changes between alters.
3. For some, documentation of their early abuse.
1. Societally created?
2. Increase since 1970
3. Why so many alters?
4. Why same clinicians reporting most?
5. Why is it just in North America?
Three points about "organic" memory disorders
1. The DSM-IV places these disorders along with other "cognitive" disorders, such as dementia and delirium.
2. Memory loss can include events before the loss, after the loss, or combinations of the two.
3. A rare, but increasingly concerning form of cognitive
disorder may be caused by specific types of proteins called prions.
--DSM-IV does not call them "organic disorders"
--three types of disorders:
delirium--caused by either
a GMC--a note about delirium and dementia
--due to substances
korsakoff’s--due to head traumaalcohol use and deficiencies in thiamine
Unusual dementias: BSE, Creutzfield-Jakob Disease, and Kuru
--caused by "proteinaceous infectious particles"
genetic material?no proofincubation period
action on brain
sheep and goatsKuru
animals become irritable
scrape off own fur
-- Fore Highlanders of Papua New Guinea
--discovery of cause
--becomes evident as dementia.
--one person in a million
--around age 60.
--10 to 15 percent of cases are inherited,
--some are iatrogenic
implantation of dura matter
electrodes in the brain,
contaminated surgical instruments
injection of growth hormone derived from human pituitaries
Mad Human Disease?
--noted in book
--cannibalism is bad, even if you are a cow
--new versions of CJD have been noted
--higher incidence than normal
--lessons from kuru
Three points about Odd Personality Disorders
1. When a person has an inflexible personality style, across a variety of contexts, and gets in trouble because of it, we call it a personality disorder.
2. Paranoid personality disorder is characterized by intense, but nondelusional paranoia and suspicion.
3. Although both schizoid and schizotypal personality
disorders have been historically linked with schizophrenia, schizotypal
actually seems related, whereas schizoid seems not to be.
1. An enduring pattern of inner experience and behavior that differs markedly from the expectations of the person’s culture, with at least two of the following areas affected:
2. Pattern is inflexible and pervasive across a broad range of personal and social situations.
3. Pattern is stable and long-lasting, and its onset can be traced back to at least adolescence or early adulthood.
The five axes system:
The "Odd" Personality Disorders
Paranoid personality disorder:
A. Pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four or more of the following:
1. suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her
2. is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
3. is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her
4. reads hidden demeaning or threatening meanings into benign remarks or events.
5. persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights
6. perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack
7. has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.
B. Not accounted for by another disorder (such as schizophrenia)
Parents are. . .
--distant, rigid fathers and overcontrolling moms?
--sadistic or unprotective?
--concerned with errors and believe the child is unique?
--or, are they one of three ways for three different subtypes
of paranoid personality disorder?
Difficult to study because. . . .
Schizoid personality disorder:
A. Pervasive pattern of detachment from social relationships and restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four or more of the following:
1. neither desires nor enjoys close relationships, including being part of a family
2. almost always chooses solitary activities
3. has little, if any, interest in having sexual experiences with another person
4. takes pleasure in few, if any, activities
5. lacks close friends or confidants other than first-degree relatives
6. appears indifferent to the praise or criticism of others
7. shows emotional coldness, detachment, or flattened affectivity
term "schizoid" often used to characterize:
--relatives of people with schizophrenia
--those likely to develop schizophrenia.
However, research has not backed this up:
--study of schizoid children
--studies of relatives of people with schizophrenia
--theorists continue to pursue
Problem: avoidant personality disorder.
Schizotypal personality disorder:
A. Pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following:
1. ideas of reference (not delusions)
2. odd beliefs or magical thinking that influence behavior and are inconsistent with subcultural norms.
3. unusual perceptual experiences, including bodily illusions.
4. odd thinking and speech
5. suspiciousness or paranoid ideation
6. inappropriate or constricted affect
7. behavior or appearance that is odd, eccentric, or peculiar
8. lack of close friends or confidants other than first-degree relatives
9. excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.
Historically "schizotype" and "schizotypal" have been used in relation
--the "schizophrenic genotype"
--as a personality configuration
--personality disorder does not explicitly refer to either.
Problem (theoretically): borderline personality disorder.
Three points about dramatic personality disorders:
1. People with dramatic personality disorders tend to be more erratic, exploitive, or emotional, and to get into more trouble than people with the other personality disorders.
2. Although these disorders overlap, they differ in terms of the character, target, and extent of their impulsiveness, exploitiveness, and emotionality.
3. Of the personality disorders, only borderline personality disorder has a treatment tailored specifically to it that actually seems to work fairly well.
Dramatic personality disorders
Antisocial Personality Disorder:
A. A pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three or more of the following:
1. [repeatedly breaking the law]
2. deceitfulness: repeated lying, use of aliases, conning others for profit or pleasure
3. impulsivity/failure to plan ahead
4. irritability or aggressiveness: repeated physical fights or attacks
5. reckless disregard for safety of self or others
6. consistent irresponsibility: failure to sustain consistent work behavior or honor financial obligations
7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.
B. at least 18
C. evidence of Conduct Disorder
Note about conduct disorder
"psychopath" and "sociopath"
completely manipulativeNote about punishment.
i.e., movie "psychopaths"
Psychodynamic point of view.
More men than women (3% vs. 1%).
Borderline Personality Disorder
A. Pervasive pattern of instability in personal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following:
1. frantic efforts to avoid abandonment (other than in criterion 5)
2. pattern of unstable and intense personal relationships characterized by alternating between extremes of idealization and devaluation
3. identity disturbance: markedly unstable self-image or sense of self
4. self-damaging impulsivity (spending, sex, substance abuse, binge eating—not including criterion 5)
5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
6. affective instability due to a marked reactivity of mood (intense moods lasting a few hours and rarely more than a few days)
7. chronic feelings of emptiness
8. inappropriate, intense anger, or difficulty controlling anger
9. transient, stress-related paranoid ideation or severe
--"GO AWAY! DON’T LEAVE ME!!"
3/4 are women.
--theoretical conflict with schizotypal
Dialectical Behavior Therapy
Histrionic Personality Disorder
Pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following:
1. is uncomfortable if not the center of attention
2. interacts with others is often inappopriately sexually seductive or provocative
3. rapidly shifting and shallow expressions of emotions
4. consistently uses physical appearance to draw attention to self
5. has a style of speech that is excessively impressionistic and lacking in detail
6. shows self-dramatization, theatricality, and exaggerated expression of emotion
7. is suggestible
8. considers relationships to be more intimate than they
Note about treatment.
Narcissistic Personality Disorder
Pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following:
1. grandiose sense of self-importance
2. preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
3. believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
4. requires excessive admiration
5. sense of entitlement
6. interpersonally exploitive
7. lacks empathy—unwilling to recognize or identify with the feelings and needs of others.
8. often envious of others or believes others are envious of him/her
9. shows arrogant, haughty behaviors or attitudes
More common in men.
May seek treatment because of depression
--use of defenses
Three points about anxious personality disorders
1. Avoidant personality disorder involves extreme avoidance of most or all social contact due to fear of criticism.
2. Dependent personality disorder involves a sense of helplessness and sense of needing to be taken care of.
3. Obsessive compulsive personality disorder involves
a rigid pursuit of "perfection" to the exclusion of practical goals or
Anxious personality disorders
Avoidant personality disorder
Pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four or more of the following:
1. avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection
2. is unwilling to get involved with people unless certain of being liked
3. shows restraint within intimate relationships because of the fear of being shamed or ridiculed
4. is preoccupied with being criticized or rejected in social relationships
5. is inhibited in new interpersonal situations because of feelings of inadequacy
6. views self as socially inept, personally unappealing, or inferior to others
7. is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.
Generalized social phobia
How do we differentiate this from schizoid?
Dependent personality disorder
A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following:
1. has difficulty making everyday decisions without an excessive amount of advice and reassurance from others
2. needs others to assume responsibility for most major areas of his or her life
3. has difficulty expressing disagreement with others because of fear of loss of support or approval (not including realistic fears of retribution)
4. has difficulty initiating projects or doing things on his or her own (not due to lack of energy)
5. goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant
6. feels uncomfortable or helpless when alone because of exaggerated fear of being unable to care for himself or herself
7. urgently seeks another relationship as a source of care and support when a close relationship ends
8. is unrealistically preoccupied with fears of being left to take care of himself or herself
Why is it an "anxious" personality disorder?
Obsessive compulsive personality disorder
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four or more of the following:
1. is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost
2. shows perfectionism that interferes with task completion
3. is excessively devoted to work and productivity to the exclusion of leisure activities and friendships
4. is overconcientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by culture or religion)
5. is unable to discard worn-out or worthless objects even when they have no sentimental value
6. is reluctant to delegate tasks or to work with others unless they submit to exactly his way of doing things
7. adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes
8. shows rigidity and stubbornness
[day nine is the personality disorders game]
Three points about disorders of childhood:
1. Developmental psychopathology is, in essence, the study of how psychopathology develops and changes across the lifespan.
2. Some disorders, such as conduct disorder in children, appear to (sometimes) lead to specific adult disorders (APD), while others, such as ADHD, tend to become less severe.
3. Other disorders, such as autism, may remain relatively
unchanged across the lifespan, except when treatment can intervene.
1. kids are not adults.
2. disorders that have a developmental course; that is:
a. childhood disorders may relate to adult disorders
b. the childhood "version" of an adult disorder may look very different
c. you can’t expect something that is "like" an adult disorder necessarily to lead to one
d. children may go on "trajectories"
e. there may be risk and protective factors that can help us understand how these trajectories may be modified
ODD à CD à
--have tempers, argue, defy, annoy, blame, etc.
--Aggression to people and animals
cruel to people and animals.
--Serious rule infraction
APD (previously discussed)
Some other disorders of childhood that are important for
Must have a total of six of the below, with at least two from (1) and one each from (2) and (3):
(1) impairment of social interaction
a. delay in or lack of spoken language and attempts to communicate(3) restricted/stereotyped patterns of behavior, interests, and activities
b. or else marked impairment in being able to carry on a conversation
c. stereotyped and repetitive use of language/ideosyncratic language
d. lack of make-believe play or social imitative play
a. preoccupation with one or more stereotyped and restricted patterns of interestAlso must have: delays or abnormal functioning in at least one of the following, with onset prior to 3 years: social interaction, language (social communication), symbolic or imaginative play.
b. inflexible adherence to specific, nonfunctional routines or rituals
c. stereotyped/repetitive motor mannerisms
d. preoccupation with parts of objects
Description of "interests"
A. Either (1) or (2)
(1) six or more symptoms of inattention, below, for six months, in a way that is maladaptive and not at developmental level.
--often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
--often has difficulty sustaining attention in tasks or play activities
--does not seem to listen when spoken to directly
--often does not follow through on directions/ does not finish duties, chores, work
--often has difficulty organizing tasks and activities
--often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
--often loses things necessary for tasks or activities
--often distracted by extraneous stimuli
--often forgetful in daily activities
(2) six or more symptoms of hyperactivity-impulsivity, same restrictions above
--often fidgets with hands or squirms in seat
--often leaves seat in classroom or in other situations in which remaining seated is expected
--often runs about or climbs excessively in situations in which it is inappropriate (in adults, may be limited to subjective feelings of restlessness)
--often has difficulty playing or engaging in leisure activities quietly
--is often "on the go" or acts as if "driven by a motor"
--often talks excessively
--often blurts out answers before questions have been completed
--often has difficulty awaiting turn
--often interrupts or intrudes on others
--some sx present before age 7
--sig. impairment in two or more settings
types of ADHD.
Three points about disorders of old age:
1. As the population of elders continues to grow in the US, it is more apparent how little we know about this population, due to various problems with current research.
2. Disorders of adulthood, such as schizophrenia, may display unforeseen changes as adults get older.
3. Delirium and dementia are two disorders that appear
to affect the elderly at higher rates than they
Psychological disorders in older folks
Issues affecting the study of abnormality in this population:
--appropriateness of measures
how measures are normed--normal aging process
"normal" at different ages
memory/cognitive ability--generational effects
general body changes
different "language"/meanings--previous thinking: progressive CNS disease
For example: schizophrenia
Some disorders that are largely related to old age (not exclusively):
Delirium due to (indicate the GMC, substance, multiple etiologies, etc.)
A. Disturbance of consciousness—reduced clarity of awareness of the environment—with reduced ability to focus, sustain, or shift attention.
B. A change in cognition (memory deficit, disorientation, language disturbance) or perceptual disturbance not better accounted for by a dementia.
C. Disturbance develops over a short period of time (hours to days) and tends to fluctuate during the day.
D. There is evidence that the delirium is due to the GMC, substance, multiple etiologies, etc.
Dementia of the Alzheimer’s type
1. development of multiple cognitive deficits manifested by both memory impairment and at least one of the following cognitive disturbances:
--disturbance in executive functioning
2. significant impairment in social or occupational functioning, along with significant decline from a previous level of functioning.
3. gradual onset and continuing cognitive decline.
What are we going to do with all of our old folks?
Legal Issues [no three points, as most of class will be discussion]
[class evaluations first]
What do mental disorders have to do with responsibility?
What is the purpose of punishment?
What is the purpose of treatment?
Confidentiality and its limits:
Purposes of confidentiality
Limits of confidentiality