v. mood disorders v. mood disorders it was called as a "depressive disorders" or as an...
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V. V. Mood DisordersMood Disorders
It was called as a "depressive disorders" It was called as a "depressive disorders"
or as an "affective disorders“ or as or as an "affective disorders“ or as "depressive neuroses”."depressive neuroses”.
In DSM-III-R, changed asIn DSM-III-R, changed as "Mood Disorders""Mood Disorders" most common diagnosismost common diagnosis
-> -> major depressive episode Diagnosis criteriaDiagnosis criteria extreme depressive symptoms at least two extreme depressive symptoms at least two
weeksweeks Cognitive symptoms (feeling of Cognitive symptoms (feeling of
worthlessness, difficulty in decision worthlessness, difficulty in decision making)making)
Bodily symptoms Bodily symptoms (change of sleep pattern, (change of sleep pattern, appetite, weight, reduced energy)appetite, weight, reduced energy)
Body symptom is most important Body symptom is most important
componentcomponent General loss of interest in thingsGeneral loss of interest in things Inability to experience any pleasure from Inability to experience any pleasure from
life, including interaction with family or life, including interaction with family or friends or accomplishments at work or at a friends or accomplishments at work or at a schoolschool
Lasts in average 9 months, if not treatedLasts in average 9 months, if not treated Second most common disorderSecond most common disorder
-> -> manic episode
Diagnosis criteria ->Diagnosis criteria -> Symptom lasts at least 1 weekSymptom lasts at least 1 week Require less, if symptoms are severe Require less, if symptoms are severe
enough to require hospitalizationenough to require hospitalization
Elated mood, extreme excitement, euphoria Excessive activities, reduced need of sleep develop grandiose plan believing they can accomplis
h anything they desire flight of ideas : speech is typically rapid and may bec
ome 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
Characteristics of mood disorderCharacteristics of mood disorder
Unipolar mood disorderUnipolar mood disorder experience either depressive or manic symptom, althoexperience either depressive or manic symptom, altho
ugh it is rare that only manic symptoms are presentugh it is rare that only manic symptoms are present
bipolarbipolar mood disorder mood disorder -> experience both depressive and manic symptoms a-> experience both depressive and manic symptoms a
lternatelylternately
depression and elation are relative independent -> an depression and elation are relative independent -> an individual can experience manic symptoms but feel soindividual can experience manic symptoms but feel somewhat depressed or anxious at the same time -> mimewhat depressed or anxious at the same time -> mixed manic episodexed manic episode
feeling of out of control or dangerousfeeling of out of control or dangerous Manic patients experience often depression and anxietyManic patients experience often depression and anxiety
Course of disease Course of disease Individual difference in terms of frequency, severity, and oIndividual difference in terms of frequency, severity, and o
f symptomsf symptoms Unipolarity, bipolarityUnipolarity, bipolarity Different intervention according to courseDifferent intervention according to course Most depression eventually remit on their own within 6 mMost depression eventually remit on their own within 6 m
onthsonths 10% last longer than 2 years10% last longer than 2 years
1. Depressive Disorders1. Depressive Disorders < < clinical description 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 least two months during which the individual was not depressedindividual was not depressed - repeats recovering and relapse lifelong- repeats recovering and relapse lifelong
Relapse in average 4 times in a lifeRelapse in average 4 times in a life and lasts 5 monthsand lasts 5 months High heredityHigh heredity 85% of major depression, single episode 85% of major depression, single episode -> later becomes major depression, recurrent type -> later becomes major depression, recurrent type
(Solomon et al, 2000)(Solomon et al, 2000)
Feeling of worthlessness, difficulty in concentrationFeeling of worthlessness, difficulty in concentration Repeated suicidal ideationRepeated suicidal ideation, sleep difficulties, and loss of , sleep difficulties, and loss of
energyenergy Abraham Lincoln Abraham Lincoln severe depressionsevere depression => postponed his marriage for 3 days=> postponed his marriage for 3 days
< dysthymic< dysthymic disorder > disorder >
Similar to major depressionSimilar to major depression Symptom is weakerSymptom is weaker Duration is far longer (20, 30 years)Duration is far longer (20, 30 years) Lasts at least 2 yearsLasts at least 2 years + should not be without symptoms longer + should not be without symptoms longer than 2 monthsthan 2 months If major depression and If major depression and dysthymicdysthymic disorder are present disorder are present
at the same timeat the same time -> -> double depression
In most cases, it begins as In most cases, it begins as dysthymicdysthymic disorderdisorder -> later develops a -> later develops a major depression major depression in which case the prognosis is not goodin which case the prognosis is not good
After recovery of major depressionAfter recovery of major depression ->-> dysthymic dysthymic disorder disorder -> major depression -> major depression (Akiskal(Akiskal & & Kassano, 1997)Kassano, 1997)
< < onset and duration > >
Average onset of the major depressionAverage onset of the major depression -> general group : -> general group : 2525 age age -> clinical group : -> clinical group : 2929 age age
Recently earlier onsetRecently earlier onset Higher prevalenceHigher prevalence
Born before 1905Born before 1905 -> less than 1 % at the age of 75-> less than 1 % at the age of 75 Born after 1955Born after 1955 -> 6% at the age of 24-> 6% at the age of 24
Confirmed in Puerto Rico, Canada, Italy, Germany, FraConfirmed in Puerto Rico, Canada, Italy, Germany, France, Taiwan, Lebanon, New Zealand that this trend tonce, Taiwan, Lebanon, New Zealand that this trend toward developing depression at increasingly earlier ageward developing depression at increasingly earlier ages is occurring worldwide s is occurring worldwide (Cross National Collaborative (Cross National Collaborative group, 1992)group, 1992)
DysthymicDysthymic disorder with onset before age 21 disorder with onset before age 21 -> more chronic, poor prognosis-> more chronic, poor prognosis -> higher heredity-> higher heredity -> more often comorbid with a personality disorder-> more often comorbid with a personality disorder
According to recent researchAccording to recent research High prevalence of children High prevalence of children dysthymicdysthymic disorder disorder -> 76% of these children develop later a major dep-> 76% of these children develop later a major dep
ressionression Patients with dysthymia are more likely to attempPatients with dysthymia are more likely to attemp
t suicide than major depression patientst suicide than major depression patients It is relatively common for major depressive episoIt is relatively common for major depressive episo
des and dysthymic disorder to co-occur (double ddes and dysthymic disorder to co-occur (double depression) (McCullough et al., 2000)epression) (McCullough et al., 2000)
2. Bipolar2. Bipolar Disorders Disorders
Alternation of manic episodes with major depressive Alternation of manic episodes with major depressive episodesepisodes
-> -> bipolarbipolar I disorder I disorder Alternation of hypomanic episodes with major depresAlternation of hypomanic episodes with major depres
sive episodessive episodes -> -> bipolarbipolar IIII disorder disorder
Similar to major depressionSimilar to major depression only manic or hypomanic symptoms are addedonly manic or hypomanic symptoms are added
cyclothymiccyclothymic disorder disorder -> milder form of bipolar disorder-> milder form of bipolar disorder similar to dysthymicsimilar to dysthymic disorder disorder 1/3 of them develop later a bipolar disorder1/3 of them develop later a bipolar disorder onset onset 12-1412-14 세 세
< onset and duration >< onset and duration >
bipolarbipolar I disorder -> average I disorder -> average 18 age18 age bipolarbipolar IIII disorder -> average disorder -> average 2222 age age Both can begin in childhoodBoth can begin in childhood
Rarely begins later than Rarely begins later than 40 age40 age Earlier onset than major depressionEarlier onset than major depression More abrupt onsetMore abrupt onset
1/3 of them begin in adolescence1/3 of them begin in adolescence Mostly begins as a mild cyclothymicMostly begins as a mild cyclothymic mood swing mood swing 10-13% of bipolar10-13% of bipolar II disorder II disorder -> leads to bipolar-> leads to bipolar II disorder disorder
Unipolar disorder and bipolar disorder are two indepeUnipolar disorder and bipolar disorder are two independent disorderndent disorder
381 patients were observed for381 patients were observed for 10years10years -> only 5.2% of unipolar depression patients experien-> only 5.2% of unipolar depression patients experien
ce ce manic episode (Coryell, Endicott, etmanic episode (Coryell, Endicott, et al., 1995)al., 1995)
Frequent suicidal attempt (19%; Jamison, 1986)Frequent suicidal attempt (19%; Jamison, 1986) Mostly takes place during major depressive episodesMostly takes place during major depressive episodes
symptom specifierssymptom specifiers
1. atypical features specifier (type)1. atypical features specifier (type)
specific features of depressionspecific features of depression excessive sleep, intake of foodsexcessive sleep, intake of foods gain weight during depressive episodegain weight during depressive episode Partial interest in specific objectPartial interest in specific object
2. melancholic features specifiers (type)2. melancholic features specifiers (type)
In case of major depressionIn case of major depression Severe body symptomsSevere body symptoms Wake up early, loss of weight, loss of libidoWake up early, loss of weight, loss of libido Excessive and inappropriate guilty feelingExcessive and inappropriate guilty feeling AnhedoniaAnhedonia
Respond well to physical treatment (ECT)Respond well to physical treatment (ECT) Respond well to drug Respond well to drug (tricyclic antidepressant)(tricyclic antidepressant)
Occur independent of stressOccur independent of stress Can find more among the elderlyCan find more among the elderly
3. Chronic features specifiers3. Chronic features specifiers Continuous symptoms of major depression in lContinuous symptoms of major depression in l
ast 2 yearsast 2 years
4. Catatonic4. Catatonic featuresfeatures specifiersspecifiers
Rare, but in major depression or manic disordeRare, but in major depression or manic disorderr
ImmobilityImmobility, waxy posture, waxy posture Excessive aimless movementsExcessive aimless movements
5. 5. PPsychotic features specifierssychotic features specifiers
major depression or manic disordermajor depression or manic disorder can have hallucination or delusion can have hallucination or delusion bodily delusion bodily delusion (example: part of body (example: part of body decay)decay) mood congruent hallucinationmood congruent hallucination mood incongruentmood incongruent hallucination hallucination (depression (depression -> delusion of grandeur)-> delusion of grandeur) more severemore severe -> likely to develop a schizophrenia-> likely to develop a schizophrenia
5-15% of depressive disorder patients experience hallu5-15% of depressive disorder patients experience hallucination cination
poor premorbidpoor premorbid adjustment -> more likely to experience adjustment -> more likely to experience psychotic symptomspsychotic symptoms
need to be treated with neurolepticsneed to be treated with neuroleptics
6. postpartum onset specifier6. postpartum onset specifier
severe major depression or manic episodesevere major depression or manic episode Within 4 weeks after delivery (typically within Within 4 weeks after delivery (typically within 2-3 days)2-3 days) Experiences psychotic symptomsExperiences psychotic symptoms Could be a beginning sign of a bipolar disorderCould be a beginning sign of a bipolar disorder 1 out of every1 out of every 1,0001,000 women after a delivery women after a delivery 50% of those who had already experienced one episod50% of those who had already experienced one episod
e experience againe experience again In some case, kills their babyIn some case, kills their baby
Mild depression after delivery excludedMild depression after delivery excluded Physical exhaustion through laborPhysical exhaustion through labor A new task to fulfillA new task to fulfill Change of the identityChange of the identity Change of the environmentChange of the environment Burden of child rearingBurden of child rearing
Relationship between childbirth and depressionRelationship between childbirth and depression ->-> comparative study comparative study no difference found between the group with childbirth ano difference found between the group with childbirth a
nd the group with no childbirth (Whiffennd the group with no childbirth (Whiffen & & Gotlib, 1993)Gotlib, 1993) postpartum bluespostpartum blues tearful, temporary mood swingtearful, temporary mood swing 50-80% of mother show this symptom 1-5 days after c50-80% of mother show this symptom 1-5 days after c
hildbirth hildbirth -> -> disappears within a few daysdisappears within a few days
Specifiers describing course of Mood disorders Specifiers describing course of Mood disorders
3 characteristics that distinguish between 3 characteristics that distinguish between recurrent depression and manic disorder recurrent depression and manic disorder
- - longitudinal courselongitudinal course - rapid cycling, - rapid cycling, - seasonal pattern- seasonal pattern
They differ in the course and time pattern They differ in the course and time pattern -- needs different intervention strategies-- needs different intervention strategies
1. Longitudinal course specifiers1. Longitudinal course specifiers
It is important to know whether the individual had a mIt is important to know whether the individual had a major depressive episode or manic episodeajor depressive episode or manic episode
Whether he/she recovered fully from itWhether he/she recovered fully from it Whether a major depressive patient had in the past a Whether a major depressive patient had in the past a
dysthymiadysthymia -> if yes, -> if yes, double depressiondouble depression
Whether a bipolar disorder patient had in the past a Whether a bipolar disorder patient had in the past a dysthymia ordysthymia or cyclothymiacyclothymia
-> if yes, low chance of full -> if yes, low chance of full inter-episodeinter-episode recovery recovery In case of major depression,In case of major depression, bipolar bipolar I, bipolar I, bipolar IIII disord disord
er, it is important to know the courseer, it is important to know the course
2. Rapid-cycling specifier2. Rapid-cycling specifier
It pertains to bipolarIt pertains to bipolar I, I, bipolarbipolar IIII disorder disorder Whether it has a slow or rapid cyclingWhether it has a slow or rapid cycling In case of rapid cyclingIn case of rapid cycling -> more than 4 times per year-> more than 4 times per year -> traditional therapy not effective-> traditional therapy not effective Tricyclic antidepressant -> there is a risk to evoke a rapiTricyclic antidepressant -> there is a risk to evoke a rapi
d cyclingd cycling
3. Seasonal pattern specifier3. Seasonal pattern specifier
It pertains to bipolar disorder and recurrent major depreIt pertains to bipolar disorder and recurrent major depressive disorderssive disorder
Changes according to season Changes according to season Mostly begins at late fall and ends early springMostly begins at late fall and ends early spring
During the winter depression, summer manic episodeDuring the winter depression, summer manic episode -> seasonal affective disorder (SAD)-> seasonal affective disorder (SAD) In most cases depression during winterIn most cases depression during winter -> -> 5%5% of American are afflicted -> excessive sleep and of American are afflicted -> excessive sleep and
eating -> gaining weighteating -> gaining weight diminishing sun light in winter -> increase of thediminishing sun light in winter -> increase of the pineal g pineal g
land hormone melatoninland hormone melatonin
PPhototherapyhototherapy -> exposing to bright light in early morning 2 am-> exposing to bright light in early morning 2 am effects show up within effects show up within 3-43-4 days days within within 1-2 weeks 1-2 weeks SAD remitSAD remit side effect : side effect : 19% experience headache19% experience headache 17% eyestrain (Levitt et17% eyestrain (Levitt et al., 1993)al., 1993)
< Prevalence of mood disorders < Prevalence of mood disorders >>
Life time prevalence in US 19% (Life time prevalence in US 19% (Kessler, 1994)Kessler, 1994) Female have higher prevalence than men 2 : 1Female have higher prevalence than men 2 : 1 In case of bipolar disorder, no differenceIn case of bipolar disorder, no difference Black people show lower rate compared to whites or hiBlack people show lower rate compared to whites or hi
spanicsspanics
disease last year lifelongdisease last year lifelong ---------------------------------------------------------------------------------------------------- major deprmajor depr 6.5% 16.1%6.5% 16.1% dysthymiadysthymia 3.3% 3.6% 3.3% 3.6% bipolarbipolar 1.1% 1.3% 1.1% 1.3%
< Depression o< Depression of children and adolescence f children and adolescence >>
3 month old infants can have also depression3 month old infants can have also depression Related to mother’s depressionRelated to mother’s depression (by way of genetics and interaction)(by way of genetics and interaction) Child depression and adults depression are similar in their Child depression and adults depression are similar in their
charactercharacter
There are no difference in regard to developmental stagesThere are no difference in regard to developmental stages But ‘look’ of depression changes with ageBut ‘look’ of depression changes with age child-> facial expression, eating, sleep disorder -> facial expression, eating, sleep disorder adolescence -> low self-esteem -> low self-esteem frequent suicidal attempt frequent suicidal attempt Prevalence rate of childhood lower than adultPrevalence rate of childhood lower than adult During adolescence, it increases dramaticallyDuring adolescence, it increases dramatically
In childhood-> In childhood-> dysthymiadysthymia is more frequent is more frequent In adolescence In adolescence -> major depression is more frequent -> major depression is more frequent Bipolar disorder very rare in childhood Bipolar disorder very rare in childhood During adolescence -> dramatic increase of bipolar diDuring adolescence -> dramatic increase of bipolar di
sordersorder Adolescence major depression occurs in most cases tAdolescence major depression occurs in most cases t
o girlso girls
Childhood major depression Childhood major depression -> irritability, mood swing-> irritability, mood swing -> easily misdiagnosed as a hyperactivity-> easily misdiagnosed as a hyperactivity Childhood depression accompanies aggressive behaviChildhood depression accompanies aggressive behavi
or, especially for boysor, especially for boys -> easily misdiagnosed as a hyperactivity or-> easily misdiagnosed as a hyperactivity or conduct diconduct di
sordersorder
Quite often conduct disorder and childhood depressioQuite often conduct disorder and childhood depressio
n occurs together (comorbid) n occurs together (comorbid)
32% of ADHD children 32% of ADHD children -> major depression comorbid-> major depression comorbid (Biederman(Biederman etet al., 1987)al., 1987)
Adolescence bipolar disorderAdolescence bipolar disorder -> aggressive, impulsive, excessive sexual behavior, tr-> aggressive, impulsive, excessive sexual behavior, tr
affic accidentsaffic accidents
< Depression among the elderly >
18-20% of 18-20% of nursing home residents experience major dnursing home residents experience major depressive episodesepressive episodes
after age after age 60 mostly become chronic60 mostly become chronic
In case of late In case of late onset, sleep disorderonset, sleep disorder hypochondriasishypochondriasis Physical illness, dementia, decrease of social support -> dePhysical illness, dementia, decrease of social support -> de
pressionpression prevalence rate in the elderly -> similar to that of general poprevalence rate in the elderly -> similar to that of general po
pulationpulation
Physical illness with depressionPhysical illness with depression -> needs longer treatment than pure physical illness-> needs longer treatment than pure physical illness No sexual difference in terms of prevalence after age 65 No sexual difference in terms of prevalence after age 65
< cultural differences >< cultural differences >
Differences among different culturesDifferences among different cultures Individualistic culturesIndividualistic cultures -> "I feel blue" or "I am depressed"-> "I feel blue" or "I am depressed"
Collectivistic culturesCollectivistic cultures -> "my heart is broken"-> "my heart is broken" "our life has lost its meaning""our life has lost its meaning"
American Indian American Indian Prevalence rate Prevalence rate men men 19.4% ; women19.4% ; women 36.7% (Kinzie36.7% (Kinzie etet al., 1992)al., 1992)
< creativity >< creativity >
Relationship between Mood disorder and creativityRelationship between Mood disorder and creativity In the New Oxford Book of American Verse In the New Oxford Book of American Verse of the of the 36 poet enlisted, 8 were bipolar disorder ( 5 co36 poet enlisted, 8 were bipolar disorder ( 5 co
mmitted suicide )mmitted suicide ) Virginia Wolf was also bipolar disorder and committed Virginia Wolf was also bipolar disorder and committed
suicidesuicide
< Anxiety and depression >< Anxiety and depression >
Anxiety and depression are closely related to each otherAnxiety and depression are closely related to each other Most of the depressive patients experience anxietyMost of the depressive patients experience anxiety But not all the anxiety disorder patients experience depreBut not all the anxiety disorder patients experience depre
ssion ssion
Pure depression component Pure depression component ->-> anhedonia anhedonia Lowered cognitive and motor functioningLowered cognitive and motor functioning most depression begins with anxietymost depression begins with anxiety
cause cause
It is very complexIt is very complex biological, psychological and social factors biological, psychological and social factors
interacting with each otherinteracting with each other
1. B1. Biological dimensionsiological dimensions
FFamily researchamily research Family members of mood disorder patients Family members of mood disorder patients
have higher prevalence ratehave higher prevalence rate -> 2-3 times higher than general population-> 2-3 times higher than general population Family members of bipolar disorderFamily members of bipolar disorder -> higher only in major depressive symptoms-> higher only in major depressive symptoms Family members of the major disorder patientsFamily members of the major disorder patients -> higher prevalence only in major depressive -> higher prevalence only in major depressive
symptomssymptoms
Is bipolar disorder -> an extension of unipolar disordeIs bipolar disorder -> an extension of unipolar disorder r ? (Blehar? (Blehar etet al., 1988)al., 1988)
Adoption studyAdoption study Parents prevalence of the adopted mood disorder chilParents prevalence of the adopted mood disorder chil
drendren - compared with the parents of the adopted - compared with the parents of the adopted children without mood disorder symptom :children without mood disorder symptom : MendlewiczMendlewicz & Rainer(1977) & Rainer(1977) -> higher prevalence-> higher prevalence Von KnorringVon Knorring etet al(1983)al(1983) -> no difference-> no difference
Twin researchTwin research Identical twin are likely to present 3 or more times wiIdentical twin are likely to present 3 or more times wi
th mood disorder than fraternal twins, if the first twin th mood disorder than fraternal twins, if the first twin shows a mood disorder.shows a mood disorder.
If the first twin has a bipolar disorder, then If the first twin has a bipolar disorder, then
even higher concordance rateeven higher concordance rate ->-> if he /she is a bipolar if he /she is a bipolar I disorder I disorder -> then the rate that the other twin shows a -> then the rate that the other twin shows a
mood disorder (notmood disorder (not bipolar bipolar) is over 80%) is over 80%
in case of severe mood disorderin case of severe mood disorder if the first twin is severe major depressionif the first twin is severe major depression -> identical twin : -> identical twin : 59% 59% ->-> fraternal twin : fraternal twin : 30% concordant30% concordant In case of not severe major depression In case of not severe major depression -> identical twin : -> identical twin : 33%33% ->-> fraternal twin : fraternal twin : 14% concordant14% concordant
Neurotransmitter systemsNeurotransmitter systems Close relationship between mood disorder and neurotrClose relationship between mood disorder and neurotr
ansmitteransmitter serotonin’s function of emotion regulationserotonin’s function of emotion regulation - by way of norepinephrine and dopamin - by way of norepinephrine and dopamin if serotonin level diminishes => get impulsive and fluctif serotonin level diminishes => get impulsive and fluct
uation of emotionsuation of emotions
Absolute quantity of a single neurotransmitter is not sAbsolute quantity of a single neurotransmitter is not so much important as the balance with other neurotrano much important as the balance with other neurotransmitterssmitters
The importance of The importance of dopaminedopamine in the etiology of the moo in the etiology of the mood disorder gets attentiond disorder gets attention
The relationship between The relationship between L-dopaL-dopa and hypomania and hypomania (Van Praag(Van Praag & & Korf, 1975)Korf, 1975)
The endocrine systemThe endocrine system
Mood disorder-> related to endocrine systemMood disorder-> related to endocrine system hypothyroidism (Cushing’s disease)hypothyroidism (Cushing’s disease) -> excessive secretion of cortisol-> excessive secretion of cortisol -> -> depressiondepression HPA axisHPA axis (brain circuit)(brain circuit) hypothalamic-pituitary-adrenalcortical axishypothalamic-pituitary-adrenalcortical axis
DST (dexamethasone suppression test)DST (dexamethasone suppression test) dexamethasone is a glucocorticoiddexamethasone is a glucocorticoid that suppresses cortisol secretion in that suppresses cortisol secretion in
normal subjects.normal subjects. -> however, when this substance was given to depressive patients, muc-> however, when this substance was given to depressive patients, muc
h less suppression was noticedh less suppression was noticed =>=> 50% of depressive patients showed reduced suppression50% of depressive patients showed reduced suppression
In depressive patients the adrenal cortex secretIn depressive patients the adrenal cortex secret
ed enough cortisol to overwhelm the suppressive ed enough cortisol to overwhelm the suppressive effects of dexamethasoneeffects of dexamethasone
In recent study anxiety disorder patients demonstIn recent study anxiety disorder patients demonstrated also non-suppression on DSTrated also non-suppression on DST
Sleep and circadian rhythmsSleep and circadian rhythms
Sleep patterns of depressive patientsSleep patterns of depressive patients sleep time before REM phase is shorter than the sleep time before REM phase is shorter than the
normal (90min)normal (90min) Lack of deep sleep (slower wave sleep)Lack of deep sleep (slower wave sleep) More intensive REM sleep than the normalMore intensive REM sleep than the normal
More often awake in the middle of nightMore often awake in the middle of night If being waked up in the later phase of the sleIf being waked up in the later phase of the sle
epep -> improves depressive symptoms-> improves depressive symptoms -> relationship between depression and biorh-> relationship between depression and biorh
ythm (Wehr & Sack, 1988)ythm (Wehr & Sack, 1988)
Depression which came after stressful event Depression which came after stressful event -> didn’t show REM sleep disorder -> didn’t show REM sleep disorder -> better responded to psycho-social -> better responded to psycho-social treatmenttreatment
2. 2. Psychological dimensionsPsychological dimensions
SStressful life eventstressful life events Stress events prior to onset of mood disorderStress events prior to onset of mood disorder context and meaning of the stress is more context and meaning of the stress is more
important than stress event itselfimportant than stress event itself In most research was proven :In most research was proven : The relationship between mood disorder and The relationship between mood disorder and
stressful eventstressful event Mood disorder following a severe stress event => Mood disorder following a severe stress event =>
takes longer time for treatmenttakes longer time for treatment
Etiology of mood disorderEtiology of mood disorder -> -> related to stressful eventsrelated to stressful events -> -> its own dynamic after outbreakits own dynamic after outbreak
Only Only 20 - 50%20 - 50% of the normal population of the normal population who experienced a severe stress event who experienced a severe stress event develop a mood disorderdevelop a mood disorder
-> interaction between stressful event, -> interaction between stressful event, biological and psychological vulnerabilitybiological and psychological vulnerability
Learned helplessness and Learned helplessness and dysfunctionaldysfunctional attitude attitude
Seligman’s(1975) Seligman’s(1975) rat experimentrat experiment
If electric shocks are not avoidableIf electric shocks are not avoidable -> develops a depression-> develops a depression First reacts with anxietyFirst reacts with anxiety -> learns that it is uncontrolable-> learns that it is uncontrolable -> depression-> depression
The depressive attributional stylesThe depressive attributional styles a) internal (“it is all my fault”)a) internal (“it is all my fault”) b) stable (“additional bad things will always b) stable (“additional bad things will always be my fault”)be my fault”) c) global (c) global (“the bad situations is “the bad situations is all my fault”)all my fault”)
The causality of depressive attributional styleThe causality of depressive attributional style Is that the cause or the result ?Is that the cause or the result ? Child study ofChild study of Nolen-Hoeksema, Girgus Nolen-Hoeksema, Girgus & & SeliSeli
gman (1992) gman (1992)
Life stress events explained more variance thLife stress events explained more variance than attributional style an attributional style
- but childhood attributional style- but childhood attributional style explained much of the varianceexplained much of the variance in adult depressionin adult depression -- childhood stress event influences childhood stress event influences children’s attributional stylechildren’s attributional style
Negative attributional style is to be found not only in dNegative attributional style is to be found not only in d
epression but also in anxiety disorderepression but also in anxiety disorder
Abramson, MetalskyAbramson, Metalsky and Alloy and Alloy -> revised the importance of the attributional style-> revised the importance of the attributional style in the etiology of depressionin the etiology of depression -> -> the sense of hopelessness is more important the sense of hopelessness is more important Both anxiety disorder patients Both anxiety disorder patients and depressive disorder patientsand depressive disorder patients experience experience helplessness, helplessness, but, only depressive patients but, only depressive patients give up give up -> hopelessness about regaining the control-> hopelessness about regaining the control
Beck’s cognitive theory of depression (1967)Beck’s cognitive theory of depression (1967) cognitivecognitive errors of the depressive patients
1) Arbitrary inference1) Arbitrary inference -> fails to see various aspects of things -> fails to see various aspects of things (A (A
high school teacher infers that he is a terrible high school teacher infers that he is a terrible teacher, because one student out of 20 teacher, because one student out of 20 students fell asleep) students fell asleep)
2) Over-generalization2) Over-generalization -> when a professor makes a critical remark -> when a professor makes a critical remark
on your paper, you then assume you will fail on your paper, you then assume you will fail the class despite a long string of positive the class despite a long string of positive comments and good grades on other paperscomments and good grades on other papers
The depressed always makes thinking errorsThe depressed always makes thinking errors -> they think negatively about themselves, -> they think negatively about themselves,
their immediate world, and their futuretheir immediate world, and their future => => depressive depressive cognitive triadcognitive triad
Negative cognitive schema of the depressive patients
1) self-blame schema1) self-blame schema individuals feel personally responsible forindividuals feel personally responsible for every bad thing that happens.every bad thing that happens. 2) 2) negative self-evaluation schemanegative self-evaluation schema individuals believe they can never doindividuals believe they can never do anything correctly.anything correctly.
These cognitive errors and schemas are These cognitive errors and schemas are automatic, that is, not necessarily conscious.automatic, that is, not necessarily conscious. Beck’s cognitive theory of depression Beck’s cognitive theory of depression (1967)(1967)
=> => automatic thoughts automatic thoughts
DDysfunctionalysfunctional attitude and hopelessness attitude and hopelessness attribution (negative outlook)attribution (negative outlook) -> high risk for depression -> high risk for depression (M. Seligman)(M. Seligman) Temple-Wisconsin study of cognitiveTemple-Wisconsin study of cognitive vulnerability of depression vulnerability of depression Student group longitudinal study Student group longitudinal study (2.5year) (2.5year)
->-> high risk group -> 17%high risk group -> 17% low risk group -> 1% low risk group -> 1% developed a major depression
High risk group -> 39%High risk group -> 39% Low risk group -> 6% Low risk group -> 6% developed a minor depression (Gotlib(Gotlib & & Abramson, 1999)Abramson, 1999)
Psychological vulnerabilityPsychological vulnerability + biological + biological vulnerability vulnerability -> -> slippery path to depression slippery path to depression
social and cultural dimensionsocial and cultural dimension
Influence of divorce on depressionInfluence of divorce on depression study of study of Bruce and Kim(1992)Bruce and Kim(1992) 695 women and695 women and 530530 men were re-interviewed men were re-interviewed 1 year after divorce1 year after divorce
21% of divorced women showed severe depression21% of divorced women showed severe depression -> 3 times as much as women who were not -> 3 times as much as women who were not
divorceddivorced 17% of divorced men showed severe depression17% of divorced men showed severe depression -> 9 times as much as men who were not divorced-> 9 times as much as men who were not divorced
Marital support have a significant impact on deMarital support have a significant impact on developing a depressionveloping a depression
- high marital conflict + low marital support- high marital conflict + low marital support -> susceptibility of depression -> susceptibility of depression (Gotlib(Gotlib & Beach, 1995) & Beach, 1995)
Depression -> endangers maritalDepression -> endangers marital relationship relationship ( in men )( in men ) Marital problem Marital problem ->-> depression (in women) depression (in women) => treatment of marital problem is important f=> treatment of marital problem is important f
or treating depressionor treating depression (Fincham(Fincham etet al., 1997)al., 1997)
Mood disorders in womenMood disorders in women Bipolar disorder -> no gender difference in terms Bipolar disorder -> no gender difference in terms
of prevalenceof prevalence Major depression-> Major depression-> 70% are women70% are women similar distribution worldwidesimilar distribution worldwide the same with anxiety disordersthe same with anxiety disorders
Low controllability of womenLow controllability of women MenMen are are expected to be independent, self asserti expected to be independent, self asserti
ve, whereas women to more passive, to be sensitve, whereas women to more passive, to be sensitive to other people, and perhaps to rely on others ive to other people, and perhaps to rely on others more than males domore than males do (Hammen(Hammen etet al., 1985) al., 1985)
Men are at greater risk in the process of divorMen are at greater risk in the process of divor
cece Women are more disadvantaged in the societyWomen are more disadvantaged in the society
More discrimination, poverty, sexual harassmMore discrimination, poverty, sexual harassment, and abuseent, and abuse
Full time working womenFull time working women ->-> no difference compared to control no difference compared to control men groupmen group
Men group Men group ->-> higher rate on the problem related with agg higher rate on the problem related with agg
ressivity, hyperactivity, drug abuseressivity, hyperactivity, drug abuse
Social supportSocial support
Existence of social support has great influence Existence of social support has great influence on the development of depressionon the development of depression
Severe life stressSevere life stress When there is social supportWhen there is social support -> 10% developed a depression-> 10% developed a depression when there is no social supportwhen there is no social support -> 37% developed a depression-> 37% developed a depression (Brown et(Brown et al., 1978)al., 1978)
Social support have also influence onSocial support have also influence on the recovery of a depression (Keitnerthe recovery of a depression (Keitner etet al., 1al., 1
995)995)
Integrative theoryIntegrative theory
Anxiety and depression may share a commonAnxiety and depression may share a common genetically determined biological vulnerabilitygenetically determined biological vulnerability -> excessive neurophysiological response to -> excessive neurophysiological response to stressstress Stress event-> stress hormon-> influence on neurotraStress event-> stress hormon-> influence on neurotra
nsmitter, especially on snsmitter, especially on serotonin and erotonin and norepinephrinenorepinephrine
New theoryNew theory stress hormone "turn on" certain genesstress hormone "turn on" certain genes -> atrophy of neurons in the hippocampus-> atrophy of neurons in the hippocampus that help regulate emotions.that help regulate emotions.
Childhood stress experienceChildhood stress experience -> cognitive vulnerability -> cognitive vulnerability -> influences on adult stress response-> influences on adult stress response
Problem Problem : cannot explain specific psychologica: cannot explain specific psychological disordersl disorders
- need a theory that differentially explains bet- need a theory that differentially explains between anxiety, depression, bipolar and unipolar ween anxiety, depression, bipolar and unipolar disorderdisorder
TTreatment of mood disordersreatment of mood disorders
Drug therapyDrug therapy Change in the level of neurotransmittersChange in the level of neurotransmitters or in neuro-chemical structuresor in neuro-chemical structures - inhibition of reuptake of specific- inhibition of reuptake of specific neurotransmitters in the synapsesneurotransmitters in the synapses - down regulation of specific- down regulation of specific neurotransmittersneurotransmitters
TTricyclicricyclic antidepressants antidepressants
Imipramine (Tofranil)Imipramine (Tofranil) Amitriptyline (Elavil)Amitriptyline (Elavil) -> down-regulate norepinephrine-> down-regulate norepinephrine -> down-regulating process take 2-8 -> down-regulating process take 2-8 weeksweeks Side effectsSide effects - - blurred vision, dry mouth, constipationblurred vision, dry mouth, constipation difficulty urinating, drowsiness, weight gaindifficulty urinating, drowsiness, weight gain (at least 13 pounds on average)(at least 13 pounds on average) sexual dysfunctionsexual dysfunction -> 40% of patients-> 40% of patients drop outdrop out
50% of the patients benefit50% of the patients benefit Placebo effect -> Placebo effect -> 25-30% 25-30% For patients who stayed to the end of the tre
atment
->-> 65-70% 65-70% benefitbenefit
Excessive use of tricyclic antidepressants -> danger of death
-> needs attention when prescribed to a -> needs attention when prescribed to a suicidal patientssuicidal patients
MAO inhibitorsMAO inhibitors Block the MAO enzyme that break down such nBlock the MAO enzyme that break down such n
eurotransmitters as norepinephrine and serotoeurotransmitters as norepinephrine and serotoninnin
-> down-regulate the two neurotransmitters-> down-regulate the two neurotransmitters -> have less side effects than -> have less side effects than tricyclicstricyclics
More effective to the More effective to the atypical feature depressioatypical feature depressionn
Interacts with foods that contain tyramine (cheInteracts with foods that contain tyramine (cheese, red wine, beer )ese, red wine, beer )
-> might induce high blood pressure-> might induce high blood pressure -> interact with other drugs and risk of fatal sid-> interact with other drugs and risk of fatal sid
e effectse effects
SSRIs (selective serotonergicSSRIs (selective serotonergic reuptakereuptake inhibitors) inhibitors) Inhibit reuptake of serotoninInhibit reuptake of serotonin
Enhance serotonin level in the receptor siteEnhance serotonin level in the receptor site - exact mechanism is still not clear- exact mechanism is still not clear - most well known - most well known SSRISSRI -> -> fluoxetine (Prozac).fluoxetine (Prozac). was regarded as a break throughwas regarded as a break through (newsweek 3/26/90 cover story)(newsweek 3/26/90 cover story) side effect become known to publicside effect become known to public physical agitation, sexual dysfunction or low desire (7physical agitation, sexual dysfunction or low desire (7
5%), insomnia, and gastrointestinal upset5%), insomnia, and gastrointestinal upset
But less side effects compared to those of tricyclic antiBut less side effects compared to those of tricyclic antidepressantsdepressants
< Two new antidepressants >< Two new antidepressants >
VenlafaxineVenlafaxine -> related to tricyclic -> related to tricyclic antidepressants, but less side effectsantidepressants, but less side effects and less damage to the cardiovascularand less damage to the cardiovascular systemsystem NefazodoneNefazodone -> similar to -> similar to SSRIsSSRIs improve sleep efficiencyimprove sleep efficiency
Great deal of interest in the antidepressant properties Great deal of interest in the antidepressant properties of the natural herb of the natural herb
-> St. John's Wort (hypericum)-> St. John's Wort (hypericum) alters serotoninalters serotonin function function
Drug therapy of childhood depressionDrug therapy of childhood depression -> difference between children and adults-> difference between children and adults -> side effects of tricyclic antidepressants-> side effects of tricyclic antidepressants
Risk of death due to cardiac side effectsRisk of death due to cardiac side effects (Tingelstad, 1991)(Tingelstad, 1991)
Drug therapy of depression of the elderlyDrug therapy of depression of the elderly - - - side effects such as memory impairment, - side effects such as memory impairment, physical agitationphysical agitation
Prevention and delay of the next Prevention and delay of the next
depressive episode are more important depressive episode are more important than treatment of depression itselfthan treatment of depression itself
Because most of the depression remit Because most of the depression remit after some timeafter some time
Need medication further Need medication further 6-12 month 6-12 month after the recoveryafter the recovery
Women who are going to plan to have a Women who are going to plan to have a baby needs caution when considering baby needs caution when considering drug therapy, because the fetus can be drug therapy, because the fetus can be affectedaffected
40-50% of the patients didn’t benefit 40-50% of the patients didn’t benefit from drug therapyfrom drug therapy
LithiumLithium
In treatment of depression and bipolarIn treatment of depression and bipolar symptomssymptoms More side effect than other antidepressantsMore side effect than other antidepressants - toxicity, lowered thyroid functioning- toxicity, lowered thyroid functioning - intensify lethargy associated with depression- intensify lethargy associated with depression - substantial weight gain- substantial weight gain
Advantageous to treat manic symptomsAdvantageous to treat manic symptoms Tricyclic antidepressantsTricyclic antidepressants -> can induce manic symptoms-> can induce manic symptoms
Can be prescribed to patients without bipolar diCan be prescribed to patients without bipolar di
sordersorder Mechanism are not knownMechanism are not known probably influences the level of probably influences the level of dopaminedopamine and and nn
orepinephrineorepinephrine Influences the production and availability of Influences the production and availability of sodisodi
umum and and potassium, which is electrolytes found ipotassium, which is electrolytes found in body fluidsn body fluids
30-60% of bipolar patients respond (Prien30-60% of bipolar patients respond (Prien & Pot & Potter, 1993)ter, 1993)
Prevents relapse for 66% of the patients Prevents relapse for 66% of the patients Manic symptomsManic symptoms -> euphoric -> euphoric -> compliance problem-> compliance problem
ElectroconvulsiveElectroconvulsive Therapy( Therapy(ECT)ECT)
In the past, immature ECTIn the past, immature ECT technique technique -> recently improved-> recently improved For the patients who don’t respond to For the patients who don’t respond to
drugs well and those who have psychotic drugs well and those who have psychotic depression or are at risk of suicidal depression or are at risk of suicidal attemptattempt
-> 50-70% benefit from ECT-> 50-70% benefit from ECT
After anesthesia After anesthesia -> electric shock to -> electric shock to brainbrain
- shocks last shorter than 1 second each - shocks last shorter than 1 second each timetime - once every two days - once every two days 6-10 times per day6-10 times per day
Side effectsSide effects relatively smallrelatively small temporary memory disturbancetemporary memory disturbance -> recover within 1-2 weeks-> recover within 1-2 weeks
Mechanisms Mechanisms -> not known-> not known functional and structural changefunctional and structural change in brainin brain
< psychotherapy of major depression >< psychotherapy of major depression >
A.T. Beck’s cognitive behavior therapyA.T. Beck’s cognitive behavior therapy Once a week and 10-20 sessionsOnce a week and 10-20 sessions monitoring thought process whilemonitoring thought process while depressive symptoms come updepressive symptoms come up
-> find out "depresssive errors in thinking"-> find out "depresssive errors in thinking" -> replace with a more realistic thinking-> replace with a more realistic thinking
Negative cognitive schemas Negative cognitive schemas -> find out them with the therapist as a team-> find out them with the therapist as a team -> test them as a home work-> test them as a home work
HHypothesis testing (as to responses of other people)ypothesis testing (as to responses of other people)
Reactivating the patientsReactivating the patients -> compensate the patients through activity-> compensate the patients through activity -> improve self concept-> improve self concept
Peter Lewinsohn, GotlibPeter Lewinsohn, Gotlib & Clarke & Clarke Focused on Focused on reactivating patients in the beginningreactivating patients in the beginning Recently they deal with cognitions tooRecently they deal with cognitions too
Interpersonal Psychotherapy; IPTInterpersonal Psychotherapy; IPT
Klerman, Weissman, Rounsaville, Chevron, MaKlerman, Weissman, Rounsaville, Chevron, Markovitz et alrkovitz et al
A structured therapy like that of CBTA structured therapy like that of CBT brief therapy with 15-20 sessionsbrief therapy with 15-20 sessions
Mainly focuses on the interpersonal relationshiMainly focuses on the interpersonal relationship and coping stylep and coping style
Focuses on one of the following 4 problemsFocuses on one of the following 4 problems
Interpersonal disputesInterpersonal disputes The loss of a relationshipThe loss of a relationship Acquiring new relationshipsAcquiring new relationships Identifying and correcting deficits in Identifying and correcting deficits in
social skillssocial skills
Similar effects as medication, CBT Similar effects as medication, CBT (Elkin(Elkin etet al., 1989)al., 1989)
Preventing relapsePreventing relapse
Medication -> Medication -> rapid responserapid response Psychotherapy Psychotherapy -> improve social -> improve social
functioning and relapse preventionfunctioning and relapse prevention
medicationmedication + psychotherapy + psychotherapy -> -> combined effectscombined effects After medication offer a psychotherapyAfter medication offer a psychotherapy
For the bipolar disorder, combined therapy of For the bipolar disorder, combined therapy of psychotherapy and family therapy are effective psychotherapy and family therapy are effective
Family conflict Family conflict -> related to relapse-> related to relapse When treated with psycho-social therapyWhen treated with psycho-social therapy relapse rate decreased up to 50% comparedrelapse rate decreased up to 50% compared to drug therapy alone to drug therapy alone (Miller (Miller etet al., 1991)al., 1991)
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 24month
s -------------------------------------
medication stop group 50% relapsed
medication cont. group 32% CBT group 21% CBT + drug therapy 15%
psychotherapy -> biophysiological changepsychotherapy -> biophysiological change Medication Medication -> pcychological change-> pcychological change Both of them lead to theBoth of them lead to the DST change after trDST change after tr
eatmenteatment The level ofThe level of tyroidtyroid hormone hormone thus, psychotherapy and medication combinethus, psychotherapy and medication combine
d brings an integrative change d brings an integrative change (Joffe, segal(Joffe, segal & & Singer, 1996)Singer, 1996)
VI. Schizophrenia and Related VI. Schizophrenia and Related Psychotic DisordersPsychotic Disorders
Complex disorder Disorders in perception, thought, emotion, langu
age, movement, behavior 16-19 billion dollars annually spent for the treat
ment in US 2.5% of total medical costs (Rupp & Keith, 199
3) 1801, Pinel, 1809, John Haslam 1899, German psychiatrist Emil Kraepelin combined three symptoms
“catatonia”, “hebephrenia” and “paranoia” that were
regarded at that time as independent conditions into one category
=> dementia praecox
Catatonia (alternating immobility and excitedCatatonia (alternating immobility and excited agitation)agitation) HebephreniaHebephrenia (silly and immature (silly and immature emotionality)emotionality) Paranoia (delusions of grandeurParanoia (delusions of grandeur or persecution)or persecution)
These three symptoms shared similar These three symptoms shared similar
underlying featuresunderlying features Early onset is at the heart of the three Early onset is at the heart of the three
symptomssymptoms that will eventually lead to “mental that will eventually lead to “mental
weakness” weakness” ->-> a diagnostic system that was focusing a diagnostic system that was focusing
onon the onset and course of a disease the onset and course of a disease
He pointed out that dementia praecox is He pointed out that dementia praecox is different form manic depressive illness in different form manic depressive illness in their onset and coursetheir onset and course
In 1908, swiss psychiatristIn 1908, swiss psychiatrist EugenEugen BleulerBleuler introduced the term schizophrenia introduced the term schizophrenia The core problem of schizophrenia is according to himThe core problem of schizophrenia is according to him -> -> associative splitting of the basic functionsassociative splitting of the basic functions of the personality of the personality ->-> breaking of associative threads breaking of associative threads
< < Clinical description Clinical description >>
positive symptomspositive symptoms
-> more active manifestations of abnormal behavior -> more active manifestations of abnormal behavior or an excess or distortion of normal behavioror an excess or distortion of normal behavior -> delusions or hallucinations-> delusions or hallucinations
Negative symptomsNegative symptoms
Deficits in normal behavior like in speech and motivationDeficits in normal behavior like in speech and motivation
Disorganized symptomsDisorganized symptoms
Rambling speech, erratic behavior, inappropriate affectRambling speech, erratic behavior, inappropriate affect
At least two of three symptoms must be present At least two of three symptoms must be present at least longer than a month to be diagnosed as at least longer than a month to be diagnosed as a schizophreniaa schizophrenia
Positive symptoms
DelusionsDelusions
Unrealistic thoughtsUnrealistic thoughts ““squirrels are aliens sent to Earth on a squirrels are aliens sent to Earth on a
reconnaissance mission"reconnaissance mission" ““I can end starvation for all of the world’s I can end starvation for all of the world’s
children.”children.” ““I will set up a base in the moon and evacuate I will set up a base in the moon and evacuate
children there."children there." “ “My opponent will spray my bicycle with My opponent will spray my bicycle with
chemicals that would take my strength away.”chemicals that would take my strength away.”
Individuals with delusionIndividuals with delusion -- different emotion from depression different emotion from depression -- less depressive but less wise less depressive but less wise
HallucinationsHallucinations
The experience of sensory events without input from the The experience of sensory events without input from the surrounding environmentsurrounding environment
Can involve any of the sensesCan involve any of the senses But auditory hallucination is most commonBut auditory hallucination is most common
“ “It’s too damn loud. Turn it down."It’s too damn loud. Turn it down." “ “Good day for fishing. Got to go fishing.”Good day for fishing. Got to go fishing.” ““You are strange. You are out.” You are strange. You are out.” People tend to experience hallucinations more People tend to experience hallucinations more
frequently, when they are unoccupied or frequently, when they are unoccupied or restricted from sensory inputrestricted from sensory input
SPECT (single photon emission computed tomSPECT (single photon emission computed tomography)ography)
Cerebral blood flow of men with schizophrenia Cerebral blood flow of men with schizophrenia Were tested when they are hearing auditory halWere tested when they are hearing auditory hal
lucinationlucination -> Broca's-> Broca's area was being activated area was being activated
Broca’s area is in charge of Broca’s area is in charge of speechspeech productionproduction The area that involves languageThe area that involves language comprehension iscomprehension is Wernicke'sWernicke's area area
This is a surprising discovery, because it meaThis is a surprising discovery, because it mea
ns that auditory hallucination is not hearing thns that auditory hallucination is not hearing the voices of others but are listening to their owe voices of others but are listening to their own thoughts or their own voices (Hoffman, Rapon thoughts or their own voices (Hoffman, Rapoport, Maure, & Quinlan, 1999)port, Maure, & Quinlan, 1999)
Negative symptomsNegative symptoms
Absence or insufficiency of normal behaviorAbsence or insufficiency of normal behavior Emotional and social withdrawalEmotional and social withdrawal ApathyApathy Poverty of thought or speechPoverty of thought or speech
AvolitionAvolition
Volition means aVolition means act of willing, choosing or decisionct of willing, choosing or decision Avolition means inability to initiate and persist in activAvolition means inability to initiate and persist in activ
ities.ities.
Show no interest in carrying out basic life functioningShow no interest in carrying out basic life functioning Neglects personal hygieneNeglects personal hygiene
AlogiaAlogia
Relative absence of speechRelative absence of speech Respond to questions with brief replies that have little Respond to questions with brief replies that have little
content and appear uninterested in the conversationcontent and appear uninterested in the conversation
Reflect a negative thought disorder rather than inadequate coReflect a negative thought disorder rather than inadequate communication skillsmmunication skills
Have trouble finding the right word to formulate their thoughtsHave trouble finding the right word to formulate their thoughts
Delayed comments or slow response to questionsDelayed comments or slow response to questions
AnhedoniaAnhedonia Lack of pleasureLack of pleasure Not interested in the activities that bring pleasure -> sex, fooNot interested in the activities that bring pleasure -> sex, foo
d, social activityd, social activity
Affective flatteningAffective flattening
Flat affectFlat affect 2/3 of the patients show this symptom2/3 of the patients show this symptom As if one has a mask onAs if one has a mask on Looks pointlesslyLooks pointlessly Speaks monotonouslySpeaks monotonously
Uninterested in what happens in the Uninterested in what happens in the surroundingsurrounding
Have feelings insideHave feelings inside ->-> difficulty expressing emotions, not a lack of difficulty expressing emotions, not a lack of
feeling (Berenbaumfeeling (Berenbaum & & Oltmanns, 1992) Oltmanns, 1992) ->-> emotional responses through physiological emotional responses through physiological recordingsrecordings
Facial expressions of schizophrenic patients in Facial expressions of schizophrenic patients in childhood childhood displayeddisplayed
->-> less positive and more negative affects less positive and more negative affects
Disorganized symptomsDisorganized symptoms DDisorganized speech
- difficult to get informations when talking- difficult to get informations when talking - lack of insight about one’s illness- lack of insight about one’s illness - - associative splitting associative splitting -- cognitive slippage cognitive slippage - inconsistent in speaking - inconsistent in speaking - illogical language- illogical language
Tangentiality -> cogintive slippage-> cogintive slippage
Dr: why are you here in the hospital ?Dr: why are you here in the hospital ? Pt: I don’t want to stay here. I’ve got other thingsPt: I don’t want to stay here. I’ve got other things to do. The time is right, and you know, to do. The time is right, and you know, when opportunity knocks.when opportunity knocks.
Loose association, Derailment
Dr: I was sorry to hear that your uncle Bill died a fewDr: I was sorry to hear that your uncle Bill died a few years ago. How are you feeling about him theseyears ago. How are you feeling about him these days ?days ?
Pt: Yes, he died. He was sick, and now he’s gonPt: Yes, he died. He was sick, and now he’s gon
e. He likes to fish with me, down at the river. He’e. He likes to fish with me, down at the river. He’s going to take me hunting. I have guns. I can shs going to take me hunting. I have guns. I can shoot you and you’d be dead in a minute.oot you and you’d be dead in a minute.
< Inappropriate affect and disorganized > Emotional expression not fitting in the situationEmotional expression not fitting in the situation BizzareBizzare actions like hoarding objects actions like hoarding objects or acting strangely in public or acting strangely in public catatoniacatatonia -> wild agitation or immobility-> wild agitation or immobility pace excitedly or move finger or arms pace excitedly or move finger or arms in stereotyped waysin stereotyped ways
Hold unusual posturesHold unusual postures waxy flexibilitywaxy flexibility ->-> tendency to keep the body and limbs in tendency to keep the body and limbs in
the position they are put in by someone the position they are put in by someone elseelse
Schizophrenia subtypesSchizophrenia subtypes
Three divisions have persisted as Three divisions have persisted as subtypes of schizophreniasubtypes of schizophrenia
catatonic, hebephrenic, paranoid typecatatonic, hebephrenic, paranoid type
DSM-IV-TRDSM-IV-TR
1. Paranoid type1. Paranoid type
- - Delusion, hallucination being main Delusion, hallucination being main
symptom symptom
- Cognitive skills and affects are- Cognitive skills and affects are
relatively intact relatively intact
- Better prognosis- Better prognosis
- Delusions and hallucinations usually- Delusions and hallucinations usually
have a theme such as grandeur orhave a theme such as grandeur or
persecutionpersecution
2. Disorganized type2. Disorganized type
Flat or inappropriate affectFlat or inappropriate affect such as laughing in a silly way at the such as laughing in a silly way at the
wrong timewrong time
Delusion or hallucinationDelusion or hallucination not organized around a central themenot organized around a central theme as in the paranoid type, but are moreas in the paranoid type, but are more fragmentedfragmented
Early onset, chronicEarly onset, chronic lacking the remissionslacking the remissions
3. Catatonic3. Catatonic type type
Waxy flexibilityWaxy flexibility Excessive movementExcessive movement Defiant attitude Defiant attitude Odd mannerismOdd mannerism stereotypical body movement, grimacingstereotypical body movement, grimacing EcholaliaEcholalia EchopraxiaEchopraxia Relatively rare, because of recent Relatively rare, because of recent success of neuroleptic medicationssuccess of neuroleptic medications
4. Undifferentiated type4. Undifferentiated type
People who have the major symptoms of People who have the major symptoms of schizophrenia but who do not meet the criteria schizophrenia but who do not meet the criteria for paranoid, disorganized, or catatonic typesfor paranoid, disorganized, or catatonic types
5. Residual type5. Residual type
People who have had at least one episode of People who have had at least one episode of schizophrenia but who no longer manifest major schizophrenia but who no longer manifest major symptoms are diagnosed as symptoms are diagnosed as residual type of residual type of schizophreniaschizophrenia
They may display residual or “left over” symptomsThey may display residual or “left over” symptoms Such as negative beliefs, or they may still have Such as negative beliefs, or they may still have
unusual ideas that are not fully delusionalunusual ideas that are not fully delusional
Residual symptoms can include social withdrawal, Residual symptoms can include social withdrawal, bizarre thoughts, inactivity, and flat affectbizarre thoughts, inactivity, and flat affect
< Other psychotic disorders >< Other psychotic disorders >
There are other psychotic disorders that don’t fit under the haThere are other psychotic disorders that don’t fit under the hading of schizophreniading of schizophrenia
SchizophreniformSchizophreniform Disorder Disorder Symptoms of schizophrenia for a few months onlySymptoms of schizophrenia for a few months only Good premorbid social and occupationalGood premorbid social and occupational functioningfunctioning absence of bluntedabsence of blunted or flat affect or flat affect
SchizoaffectiveSchizoaffective Disorder Disorder People who have both schizophrenia and mood disordePeople who have both schizophrenia and mood disorde
r at the same time. r at the same time. MMood disorder + delusion or hallucination longer than ood disorder + delusion or hallucination longer than
2 weeks2 weeks
Delusional DisorderDelusional Disorder
A persistent belief that is contrary to reality in A persistent belief that is contrary to reality in the absence of other characteristics of schizothe absence of other characteristics of schizophreniaphrenia
-Different from schizophrenia, the delusions of -Different from schizophrenia, the delusions of delusional disorder are theoretically possibledelusional disorder are theoretically possible
Not organically caused delusion Not organically caused delusion Not caused by drugs or alcohol eitherNot caused by drugs or alcohol either There are no negative symptoms such as flat There are no negative symptoms such as flat
affect, anhedoniaaffect, anhedonia
Late onset Late onset (age 40-49)(age 40-49) subtypes subtypes =>=> erotomanic, grandiose, jealous, persecutory, erotomanic, grandiose, jealous, persecutory, somatic somatic
Brief Psychotic DisorderBrief Psychotic Disorder Characterized by the presence of one or more positive symptoms Characterized by the presence of one or more positive symptoms
such as delusions, hallucinations, or disorganized speech or behsuch as delusions, hallucinations, or disorganized speech or behavior lasting 1 month or lessavior lasting 1 month or less
Often precipitated by extremely stressful situationsOften precipitated by extremely stressful situations
Shared Psychotic DisorderShared Psychotic Disorder
- - An individual develops delusions simply as a result of a An individual develops delusions simply as a result of a close relationship with a delusional individualclose relationship with a delusional individual
1. 1. StatisticsStatistics
Lifelong prevalence 0.2% - 1.5%Lifelong prevalence 0.2% - 1.5% Similar prevalence world wide, and Similar prevalence world wide, and
no gender differenceno gender difference Onset of male begins earlier than Onset of male begins earlier than
that of femalethat of female More men before age More men before age 36, more 36, more
women after age 36women after age 36
< Development< Development >>
Children show some abnormal signs before they displaChildren show some abnormal signs before they display the characteristic sympotomsy the characteristic sympotoms
(cf: (cf: 조승희조승희 , Virginia College of Technology. Massacre in April 17. 2007 killin, Virginia College of Technology. Massacre in April 17. 2007 killing 32 students and injuring 15 students)g 32 students and injuring 15 students)
Negative affects domineeringNegative affects domineering Bad adjustmentBad adjustment 40 years follow up study of 40 years follow up study of 52 schizophrenic patients52 schizophrenic patients Symptoms decreased as getting oldSymptoms decreased as getting old (Winokur(Winokur etet al., 1987)al., 1987)
Most of the patients kept their symptoms lifelong,Most of the patients kept their symptoms lifelong, ((moderate to sever symptoms)moderate to sever symptoms)
Group1 (22%) -> one episode only, no Group1 (22%) -> one episode only, no
impairment impairment Group2 (35%) -> several episodes with Group2 (35%) -> several episodes with
no or minimal impairment no or minimal impairment Group3 (8%) -> impairment after the Group3 (8%) -> impairment after the
first episode with subsequent first episode with subsequent exacerbation and no return to normalityexacerbation and no return to normality
Group4 (35%) -> impairment increasing Group4 (35%) -> impairment increasing with each of several episodes and no with each of several episodes and no return to normalityreturn to normality
Schizophrenia found in all culturesSchizophrenia found in all cultures Differed in terms of prevalence rate or recovery rDiffered in terms of prevalence rate or recovery r
ateate In US more African Americans receive the diagnoIn US more African Americans receive the diagno
sis of schizophrenia than whites.sis of schizophrenia than whites. People from devalued minority groups maybe victiPeople from devalued minority groups maybe victi
ms of bias and stereotyping.ms of bias and stereotyping. Blacks were more likely to be detained against thBlacks were more likely to be detained against th
eir will, brought to the hospital by police, and giveir will, brought to the hospital by police, and given emergency injections (Goater et al., 1999)en emergency injections (Goater et al., 1999)
2. Cause2. Cause
< Genetic influences >< Genetic influences >
19381938 Franz KallmannFranz Kallmann Examined family members of more than 1,000 people Examined family members of more than 1,000 people
diagnosed with schizophrenia in a Berlin Psychiatric Hdiagnosed with schizophrenia in a Berlin Psychiatric Hospitalospital
The severe the symptoms, the higher concordance ratThe severe the symptoms, the higher concordance rate of family memberse of family members
Various subtypes found in the same familyVarious subtypes found in the same family -> general predisposition for schizophrenia,-> general predisposition for schizophrenia, not specific predispositionnot specific predisposition
The closer genetically the higher concordance rateThe closer genetically the higher concordance rate Identical twin Identical twin 49%49% Fraternal twin Fraternal twin 17%17% Sibling Sibling 6%6% Cousin Cousin 2%2% (Gottesman, 1991)(Gottesman, 1991)
Quadruplets schizophrenia observed over the years and all Quadruplets schizophrenia observed over the years and all 4 sisters developed schizophrenia4 sisters developed schizophrenia
But they showed all very different courses the same parentBut they showed all very different courses the same parents and family-> individually different experiencess and family-> individually different experiences (Rosenthal, (Rosenthal, 1963)1963)
Adoption studies Adoption studies
1. adopted child research1. adopted child research
firstfirst, identify schizophrenic patients, identify schizophrenic patients nextnext, find their children given , find their children given to other familiesto other families
2. 2. Relatives studiesRelatives studies
firstfirst, , schizophrenic patients who were adopted schizophrenic patients who were adopted areare
identifiedidentified nextnext, find their parents and siblings, find their parents and siblings
Research in Finland Research in Finland (Tienari, 1992)(Tienari, 1992) Adoption studiesAdoption studies
Of the Of the 20,000 female schizophrenic patients20,000 female schizophrenic patients 164 were identified who gave their children aw164 were identified who gave their children aw
ay for adoptionay for adoption => 155 children of these patients were identifi=> 155 children of these patients were identifi
ed who were brought up in foster homeed who were brought up in foster home 185 children of the normal parents were comp185 children of the normal parents were comp
ared as a control group who were also brought ared as a control group who were also brought up in foster homeup in foster home
Of the patients’ children, Of the patients’ children, 16 were diagnosed either schizophrenia 16 were diagnosed either schizophrenia or other psychosis or other psychosis -> -> 10.3% 10.3% Of the normal parents’ children,Of the normal parents’ children, 2 were diagnosed as psychosis 2 were diagnosed as psychosis -> -> 1.1% 1.1%
GottesmannGottesmann’s research ’s research (1989)(1989) Children of identical twin patients Children of identical twin patients ->-> 16% 16% Children of identical twin patient’s sibling Children of identical twin patient’s sibling
who are not patients -> who are not patients -> 17%17%
Children of fraternal twin patients -> Children of fraternal twin patients -> 16%16% Children of fraternal twin patient’s sibling Children of fraternal twin patient’s sibling
who are not patients -> who are not patients -> 1.7%1.7%
The fact that the probability of outbreak The fact that the probability of outbreak of schizophrenia in children of patient of schizophrenia in children of patient twin and in normal twin are the same twin and in normal twin are the same proves high heredityproves high heredity
But it is only But it is only 17% 17% -> the rest can be -> the rest can be attributed to other causes attributed to other causes
Defects of not a single but several genes Defects of not a single but several genes combined together -> severe pathologycombined together -> severe pathology
Search for markersSearch for markers Characteristics common to schizophrenic patientsCharacteristics common to schizophrenic patients => =>
will lead to a discovery of related geneswill lead to a discovery of related genes
One of them is :One of them is : Smooth-pursuit eye movement or eye trackingSmooth-pursuit eye movement or eye tracking
The ability to track objects with eye movement The ability to track objects with eye movement keeping head still.keeping head still. schizophrenic patients lack in this abilityschizophrenic patients lack in this ability And this independent of drug And this independent of drug or hospitalization or hospitalization (Liebermann(Liebermann etet al., 1993)al., 1993)
< Neurobiological factors< Neurobiological factors >>
Dopamine over-activity hypothesisDopamine over-activity hypothesis It is still controversial, but long lived It is still controversial, but long lived
hypothesishypothesis
Evidences that support dopamine Evidences that support dopamine hypothesishypothesis
1. Antipsychotic drugs that are often1. Antipsychotic drugs that are often
effective in treating people witheffective in treating people with
schizophrenia are dopamine antagonistsschizophrenia are dopamine antagonists
2. These drugs can produce negative side 2. These drugs can produce negative side
effects similar to those in Parkinson’s effects similar to those in Parkinson’s disease, a disorder known to be caused disease, a disorder known to be caused by insufficient dopamine. by insufficient dopamine.
3. The drug L-dopa, a dopamine agonist 3. The drug L-dopa, a dopamine agonist used to treat people with Parkinson’s used to treat people with Parkinson’s disease, produces schizophrenia-like disease, produces schizophrenia-like symptoms in some peoplesymptoms in some people
4. Amphetamines, which also activate4. Amphetamines, which also activate dopamine, can make psychotic dopamine, can make psychotic
symptoms worse in some people with symptoms worse in some people with schizophreniaschizophrenia
In other words, when drugs are In other words, when drugs are
administered that are known to administered that are known to increase dopamine (agonist), there is increase dopamine (agonist), there is an increase in schizophrenic behavior;an increase in schizophrenic behavior;
when drugs that are known to when drugs that are known to decrease dopamine activity decrease dopamine activity (antagonists) are used, schizophrenic (antagonists) are used, schizophrenic symptoms tend to diminish.symptoms tend to diminish.
(mostly drugs that block the activity of(mostly drugs that block the activity of D2D2 receptor receptor))
< Evidences that contradict the dopamine theory < Evidences that contradict the dopamine theory >>
1. A significant number of people with schizophre1. A significant number of people with schizophrenia are not helped by the use of dopamine annia are not helped by the use of dopamine antagoniststagonists
2. Although the neuroleptics2. Although the neuroleptics block the reception block the reception of dopamine quickly, the relevant symptoms of dopamine quickly, the relevant symptoms subside only after several days or weeks, musubside only after several days or weeks, much more slowly than researchers would expecch more slowly than researchers would expectt
3. These drugs are only partly helpful in reducing 3. These drugs are only partly helpful in reducing the negative symptoms (e.g., flat affect, anhethe negative symptoms (e.g., flat affect, anhedonia) of schizophreniadonia) of schizophrenia
4. There is no evidence that schizophrenic patients 4. There is no evidence that schizophrenic patients
have more D2 receptors than normals.have more D2 receptors than normals.5. The research haven’t proved yet that there is ab5. The research haven’t proved yet that there is ab
normality in D2 receptors of schizophrenic patiennormality in D2 receptors of schizophrenic patients.ts.
6. Clozapine6. Clozapine is effective to those patients who don’ is effective to those patients who don’t respond well to the traditional drugs. But this drt respond well to the traditional drugs. But this drug is very weak in blocking D2 receptors.ug is very weak in blocking D2 receptors.
Dopamine is related to schizophrenia, but its role Dopamine is related to schizophrenia, but its role is very complexis very complex
Dopamine has a different effect in combination wDopamine has a different effect in combination with serotoninith serotonin
Appropriate proportion of dopamine and serotonin Appropriate proportion of dopamine and serotonin is important in regulating positive symptoms such is important in regulating positive symptoms such as hallucination or delusionas hallucination or delusion
CClozapine plays a role in mediating these two neurlozapine plays a role in mediating these two neurotransmitters.otransmitters.
Blocking only dopamine isn’t effectiveBlocking only dopamine isn’t effective
Dopamine and serotonin must be blocked simultaDopamine and serotonin must be blocked simultaneously to be effective (more dopamine should be neously to be effective (more dopamine should be blocked)blocked)
< Psychological and social influence< Psychological and social influence >>
Even the identical twins show different prevaleEven the identical twins show different prevalence ratence rate
Environmental and experiential influencesEnvironmental and experiential influences Research with high risk childrenResearch with high risk children In 1960, longitudinal researches of Danish reIn 1960, longitudinal researches of Danish re
searchers Mednicksearchers Mednick & & SchulsingerSchulsinger 207 children of schizophrenic mothers were o207 children of schizophrenic mothers were o
bservedbserved 104 control group children 104 control group children The research is still being doneThe research is still being done
Most of the researches are retrospective Most of the researches are retrospective
studies, the effects of which are limitedstudies, the effects of which are limited Ventura et al (1989) Ventura et al (1989)
30 patients were observed for one year30 patients were observed for one year
Interviewed every two weeksInterviewed every two weeks Relapse often after stress events Relapse often after stress events But But 55% of the relapsed hadn’t had a 55% of the relapsed hadn’t had a
considerable stress, which means there considerable stress, which means there are factors other than stress that impact are factors other than stress that impact relapserelapse
< The influence of the family and culture on the r< The influence of the family and culture on the r
elapseelapse >>
SchizophrenogenicSchizophrenogenic mother mother (Fromm-(Fromm-Reichmann, 1948)Reichmann, 1948) double bind (Bateson, 1958)double bind (Bateson, 1958) induces guilty feelings of the parents induces guilty feelings of the parents -> -> which has negative impact on familywhich has negative impact on family
Recent researchRecent research The influence of the interaction among the famiThe influence of the interaction among the fami
ly members on the relapsely members on the relapse Brown Brown et al et al (1959)(1959)
Expressed emotion (EE)Expressed emotion (EE) Patients who were restricted in their contact with familPatients who were restricted in their contact with famil
y members showed lower relapse ratey members showed lower relapse rate
Criticism, hostility and emotional intrusiveness of the Criticism, hostility and emotional intrusiveness of the family members had impact on relapse family members had impact on relapse
(Brown et(Brown et al., 1962)al., 1962)
High expressed emotion in familyHigh expressed emotion in family -> a good predictor of relapse -> a good predictor of relapse (Bebbington(Bebbington etet al., 1995)al., 1995)
Patients who lived in highPatients who lived in high EEEE family showed 3.7 times family showed 3.7 times higher relapse rate than those who lived in low EE famhigher relapse rate than those who lived in low EE family ily (Hooley, 1985)(Hooley, 1985)
2. 2. Treatment Treatment
< < Biological intervention Biological intervention >>
In 1930sIn 1930s injection of massive doses of injection of massive doses of insulininsulin -> insulin coma therapy-> insulin coma therapy serious side effects, risk of deathserious side effects, risk of death psychosurgerypsychosurgery -> prefrontal-> prefrontal lobotomies lobotomies In the late 1930sIn the late 1930s Introduction of ECTIntroduction of ECT Today it is known to have no effectToday it is known to have no effect
Dramatic change after inventingDramatic change after inventing neurolepticsneuroleptics in 1950in 1950 => control delusion and hallucinations=> control delusion and hallucinations (mainly positive symptom)(mainly positive symptom)
class example degree ofclass example degree of extra- extra- pyramidal effectspyramidal effects (side effects)(side effects)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------- ConventionalConventional antipsychoticsantipsychotics phenothiazinesphenothiazines Fluphenazine / ProlixinFluphenazine / Prolixin high high Trifuluoperazine / StelazineTrifuluoperazine / Stelazine
highhigh Perphenazine / TrilafonPerphenazine / Trilafon high high Mesoridazine / SerentilMesoridazine / Serentil lowlow Chlorpomazine / Thorazine Chlorpomazine / Thorazine moderatmoderat
ee Thioridazine / Mellaril Thioridazine / Mellaril lowlow
Butyrophenone Butyrophenone haloperidol / Haldolhaloperidol / Haldol high high
others others Thiothixene / NavaneThiothixene / Navane high high Molindone / MobanMolindone / Moban lowlow Loxapine / LoxitaneLoxapine / Loxitane highhigh
NewNew Antipsychotics Antipsychotics Clozapine / ClozarilClozapine / Clozaril lowlow Risperidone / RisperidalRisperidone / Risperidal lowlow
Olanzapine / ZyprexaOlanzapine / Zyprexa lowlow Serindole / SerlectSerindole / Serlect
lowlow Quetiapine / SeroquelQuetiapine / Seroquel lowlow
These drugs influence mainly dopamineThese drugs influence mainly dopamine
but also have influence on serotonin but also have influence on serotonin systemsystem
It is only recently that we come to It is only recently that we come to understand better the mechanism of understand better the mechanism of drugsdrugs
- Drugs are effective for some patients, - Drugs are effective for some patients, but not for other patients.but not for other patients.
Clinicians and patients often must go Clinicians and patients often must go through a trial and error process to find through a trial and error process to find the medication that works bestthe medication that works best
Conventional antipsychotics are effective for apprConventional antipsychotics are effective for appr
oximately oximately 60% 60% of people who try them of people who try them (APA, 200 (APA, 2000)0)
Mostly many side effectsMostly many side effects Some people respond well to newer medicationsSome people respond well to newer medications The most common are clozapine, risperidone, anThe most common are clozapine, risperidone, an
d olanzapined olanzapine These medications tend to have fewer serious siThese medications tend to have fewer serious si
de effects than the conventional antipsychotics de effects than the conventional antipsychotics (Davis, Chen, & Glick, 2003)(Davis, Chen, & Glick, 2003)
Noncompliance Noncompliance of the patients is a significant of the patients is a significant problemproblem
Approximately Approximately 7% of the patients refuse to tak7% of the patients refuse to take medicatione medication
3 out of 4 patients refused to take the antipsy3 out of 4 patients refused to take the antipsychotic medication for at least 1 week (Weidenchotic medication for at least 1 week (Weiden etet al., 1991)al., 1991)
Negative side effects are a major factor in patiNegative side effects are a major factor in patient refusalent refusal
grogginessgrogginess Deterioration in the ability to concentrate Deterioration in the ability to concentrate (1(1
8%) 8%) Dry mouth (16%)Dry mouth (16%) Blurred vision (16%)Blurred vision (16%)
AkinesiaAkinesia
-- one of the common side effect one of the common side effect it includes an expressionless face, slow motor it includes an expressionless face, slow motor activity, and monotonous speechactivity, and monotonous speech
TardiveTardive dyskinesiadyskinesia
-- involuntary movements of the tongue, involuntary movements of the tongue, face, mouth or jawface, mouth or jaw - results from long-term use of high doses of - results from long-term use of high doses of antipsychotic medicationantipsychotic medication - often irreversible and may occur in as many- often irreversible and may occur in as many as as 20% of people who take the medications 20% of people who take the medications over long periodsover long periods
The new antipsychotics such as clozapine The new antipsychotics such as clozapine
produce fewer side effects, but even clozaproduce fewer side effects, but even clozapine brings undesirable effects and must bpine brings undesirable effects and must be monitored closelye monitored closely
The compliance problem is seriousThe compliance problem is serious Psychosocial intervention can help to increPsychosocial intervention can help to incre
ase compliance by helping patients commuase compliance by helping patients communicate better with professionals about their nicate better with professionals about their concernsconcerns
< P< Psychosocial intervention sychosocial intervention >>
Psychological intervention could bePsychological intervention could be combined with medicationscombined with medications Improving patient’s socializationImproving patient’s socialization Participation in group sessionsParticipation in group sessions self care such as bed makingself care such as bed making
Token economy, in which residents could earn Token economy, in which residents could earn access to meals and small luxuries by behaving access to meals and small luxuries by behaving appropriatelyappropriately
DeinstitutionalizationDeinstitutionalization - growth of human rights, integration- growth of human rights, integration into communityinto community - ill conceived policy produced many- ill conceived policy produced many homeless peoplehomeless people
< Social skill training< Social skill training >>
Basic conversationBasic conversation AssertivenessAssertiveness Relationship buildingRelationship building Maintaining eye contact while Maintaining eye contact while
talking to another persontalking to another person Making friends Making friends Relapse preventionRelapse prevention Utilizing social support systemUtilizing social support system
< Family education< Family education >>
Educating the family about the symptoms of schizophrEducating the family about the symptoms of schizophreniaenia
Educating about the cause of the illnessEducating about the cause of the illness Teaching the family members to communicate more eTeaching the family members to communicate more e
ffectively ffectively (learn more constructive way to express negative emot(learn more constructive way to express negative emot
ions, listening more empathically)ions, listening more empathically)
Teaching practical facts about antipsychotics Teaching practical facts about antipsychotics (effects, (effects, side effects etc)side effects etc)
Teaching about support systemTeaching about support system Teaching about problem solving strategiesTeaching about problem solving strategies
< < Vocational rehabilitation Vocational rehabilitation >>
Enhancing the vocational abilityEnhancing the vocational ability Supportive rehabilitationSupportive rehabilitation Multilevel treatment Multilevel treatment -> contribute to reducing relapse rate-> contribute to reducing relapse rate
Relapse rate of schizophrenia (after 2 yearRelapse rate of schizophrenia (after 2 year))
1. drugs + support or education 1. drugs + support or education --> 62%> 62%2. drugs + social skills training 2. drugs + social skills training --> 35%> 35%3. drugs + famil3. drugs + famil stress management -> 38% stress management -> 38% ((Falloon, BrookerFalloon, Brooker & Graham-Hole, 1992) & Graham-Hole, 1992)
< Self help groups >< Self help groups >
Recently change from large mental Recently change from large mental hospitals to family homes in local hospitals to family homes in local communitiescommunities
Self help groups of former patientsSelf help groups of former patients Fountain House in New York City (Beard etFountain House in New York City (Beard et
al., 1982)al., 1982)
Most of the PsychosocialMost of the Psychosocial club have differing club have differing models, but all are models, but all are "person centered“ and "person centered“ and focus on obtaining positive experiences focus on obtaining positive experiences through employment opportunities, through employment opportunities, friendship, and empowerment.friendship, and empowerment.
25,000 New Yorkers have participated in club-houses 25,000 New Yorkers have participated in club-houses
sponsored by New York Association of Psychiatric Rehsponsored by New York Association of Psychiatric Rehabilitation Services.abilitation Services.
Participation in club houses may help reduce relapse Participation in club houses may help reduce relapse (Beard, Malamud & Rossman, 1978)(Beard, Malamud & Rossman, 1978)
But it is difficult to interpret the improvement, becauBut it is difficult to interpret the improvement, because it is possible that those who have participated may se it is possible that those who have participated may belong to a special group of individuals belong to a special group of individuals (Mueser(Mueser etet aal., 1990).l., 1990).
You’ve done a great job ! You’ve done a great job ! I appreciate very much your efforts to come along !I appreciate very much your efforts to come along ! Have a good time during vacation !!Have a good time during vacation !!
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