Introduction to Psychiatry 


The Perspectives of Psychiatry

  • Psych has no "Harvey" - no fundamental understanding of how brain works (not like cardio)
  • History of epochs
    • Harvey - mental disorders emerge from a life; employed "psychobiology" (study at psychological level).  Developed history taking, examination; but wrote huge biographies of each patient and didn't know how to treat
    • Freud / psychoanalysis - Mental disorders come bottom-up but not everything is important (just libido).
      • Got really big in pop culture; thought it could fix everything
      • Thought theories could explain thought/motivation/behavior in terms of unconscious mind revealed through slips of tongue & dreams
      • Unconscious mind is repressing natural drives because of culture
    • Empirical psychiatry
      • Drugs modify psychiatry (eg Lithium) - these are particular conditions and not just one universal condition in different manifestations (a la Freud)
      • DSM - field guide (arising from failures of previous symptoms) - just classifying categorically by features
        • Good for diagnostic reliability; often neglects generation & nature
    • Today: "biopsychosocial model" - lists everything, so mental disorders come from there somewhere
      • Subatomic particles to the biosphere and everything in between
      • Just organizes things we know about (not useful)
      • Need disease 'derivative' to reveal how these disorders are arising from some cause

Derivative = expression or formula explaining a clinical event. 
  • For disease derivative, etiology (provocative causes) creates a pathological entity (we call this pathogenesis).  This pathological entity creates a clinical syndrome in a process we call pathophysiology.  These are lawful outcomes of changes
  • Perspectives attempt to see what operation derivatives let us take functional information from biopsychosocial sources to practice & function

Four perspectives and examples:
  • Disease perspective: logic of categories, what the patient has
    • Schema: Etiology, pathogeneisis to create pathology, pathophysiology to make clinical syndrome (like other diseases)
    • Examples: delirium (consciousness), dementia (cognition), memory syndromes, aphasia (language), bipolar disorder (affect), schizophrenia (executive / integrative functions)

  • Dimensional perspective: logic of gradation and quantification, what the patient is
    • Schema: potential (personality) <--> provocation (life circumstances) <--> response (neurotic symptoms)
    • Examples: cognitive capacity, affective vulnerabilities (neuroticism, extraversion/introversion, etc).  

  • Behavioral perspective: logic of teleology and goals, what the patient does
    • Schema: triangle with choice, physiologic drive, conditioned learning
    • Examples:
      • sexual disorders, eating disorders, sleep disorders (disordered innate drive)
      • substance abuse (disordered acquired drives)
      • suicide, anorexia, hysteria, gender identity disorder, crime (social attitudes resting on assumptions or role search)
      • truancy, kleptomania, gambling, pyromania (from emotional arousal or thrill)

  • Life story perspective: logic of narrative, what the patient encounters
    • Schema: setting >> sequence >> outcome with distressing life events occurring throughout
    • Examples: grief, demoralization/discouragement, homesickness, jealousy, PTSD

These all interact, linking psychiatry and neuroscience - four ways to view the same patient.  Can't just look at a patient under one of them.

The Mental Status Exam

Purpose:
  • Confirm symptoms reported in history
  • Elicit/define mental symptoms not elicited in history
  • Describe how patient looked at given time

The components:
  • Appearance & behavior 
    • Appearance: body habitus, grooming, dress, expressiveness
    • Behavior: attitude, posture, movements, unusual activities, eye contact
  • Speech
    • Rate, rhythm, tone, fluency [mute, monosyllabic, telegraphic], spontaneity
    • Logic and associations: verbigeration, word salad (no logical connections), loose associations (can kind of connect), flight of ideas, tangentiality (comes back to question eventually), intact - can tell about thought disorders
  • Mood
    • Stated mood (mood = persistent, pervasive emotional state); rated mood (1-10)
    • Apparent mood = affect
    • Apparent / reported self attitude (self-value)
    • Suicidal / violent thoughts, thoughts of death -> passive death wish ->  planning -> attempting
  • Thoughts / perceptions
    • Hallucinations: perception without stimulus in any sensory modality (vs. illusion, misperception of actual stimulus)
    • Delusions:  fixed false idiosyncratic belief
    • Obsessions/ compulsions: irrational thoughts, worries, behaviors that are repetitive & recurrent despite efforts to suppress
    • Phobias: fear with avoidance of situations or objects
  • Insight / judgement
    • Insight: acknowledgement of problems
    • Judgement: informally = is person seeking help; formally = give scenarios (what would you do if you see a fire in a crowded room)
  • Intelligence / fund of knowledge
    • Intelligence: informal = rough estimate on vocabulary, ability to grasp abstractions, education level; formally = analogies
    • Fund of knowledge: last 5 presidents, etc.
  • Cognitive functioning
    • Level of consciousness (stuporous, drowsy, alert, hyperalert, agitated) and how it varies throughout day
    • Cognitive function: informal = can recall recent events with coherence, logic, good recall?; formal = MMSE & others

MMSE: 30 point scale, screening tool (not diagnostic), results vary based on age & education
  • Orientation (year/season/date/day/month; where are we (state/city/hospital/building/floor)
  • Registration (name 3 unrelated objects & repeat back)
  • Attention & Calculation (serial 7's, world backwards, etc.)
  • Recall (name those three items back)
  • Language / praxis (name pencil/watch, repeat phrase 'no ifs ands or buts,' follow 3-stage command (e.g. take, fold, place paper), read & obey written command, write sentence, copy two-pentagon design)

Psychiatry is Medicine

  • Psychiatry is an exciting field! Whoo-hoo!  Psych conditions cause lots of DALYs!  Psych diseases are stigmatized like cancer used to be.
    • Depression, schizophrenia, Alzheimers have physiological/genetic components being worked out over time
  • What's a physician? Diagnosis (clarifies what's wrong), prognosis (knowing what will happen so you can make decisions), management (what should we do)?
  • Diagnosis can sometimes guide treatment of disease, formulation is much more complete clinical assessment to guide treatment of patient
    • Elements of formulation: what is nature of impairment (disease), who has the illness (personality), does what they do affect it (behavior), what are expectations, fears, hopes (life story)

Perspectives on Cognition (& Dementia)

Take-Home Lessons

  • Cognitive capacities are dimensional traits - for most part universal, smoothly-gradated attributes in population
  • Cognitive capacities are altered by disease - either congenitally or throughout life
  • Cognitive capacities affect behavior - in many ways
  • Cognitive capacities affect life story - in health, in illness

Intelligence is a developmental attribute
  • Constructed but intuitively apprehended; informally assessed via language
  • "Aggregate / global capacity of individual to act purposefully, think rationally, and deal effectively with [his] environment"
    • Aggregate: composed of various elements/features that aren't independent but still differentiable
  • One thing rather than many; reflects ability to acquire knowledge; independent of achievement / what's been learned
  • Ability to learn actually isn't fully independent of what's been learned - over time, achievement/intelligence become intertwined - yet earlier measures aren't always better

Ways to conceptualize:
  • general intelligence (derived from various measures)
  • could break into math, verbal, etc.
  • Or break into verbal/educational (numbers, verbal) and practical (mechanical, spatial, manual, figural)

Intelligence as a spectrum is skewed by people who have physiological mental subnormality - more people at bottom of curve than normal distribution
  • No relationship between achievements of children's parents and IQ for these people

Clinical neuropsychology
  • Study of brain-behavior relationships in health & disease
    • Disease, drugs, experimental conditions
    • Diagnose, characterize phenomenology, learn course (prognosis)
    • Rationale: every individual has basic ability; specialized skills vary around that expectation, deviations may be disease / other interference with normal function
    • Method: establish basic expected level (IQ tests, etc.), survey perceptual, cognitive, motor performances, document pattern of strengths & weaknesses, compare with disease that have been studied & characterized
    • Tests: general intelligence, language, motor/perceptual organization, memory (verbal/figural/recall/recognition), attention/motor function, executive function (planned, purposeful way to be functional & efficient)

Things you can test for:
  • Language: spontaneous talk (circumlocution, paraphasia=abnormality of language), comprehension, naming, fluency, writing, spelling
  • Perceptual organization / motor: non-motor perceptual organization, visual-motor construction, rhythm/musicality
  • Memory: short/intermediate/long term, language vs spatial, recall vs recognition, declarative (who as 39th president) vs source (when did you learn that fact) vs procedure (can you remember to ride a bike), incidental learning (if not asked to do it), prospective memory (remembering to do something

Random terms & presentations:
  • Aphasia - loss of ability to produce / comprehend language (vs. dysarthria - motor speech disorder)
    • Anomia - problem recalling words / names
    • Agnosia - can't recognize objects, people, shapes but no memory or sensory deficit
    • Alexia - lose ability to read
    • Agraphia - lose ability to write
  • Apraxia - loss of learned motor programs, e.g. dressing
  • Amnesia - loss of memory

Delirium vs. dementia
Delirium - clouding of consciousness is key (also cognitive impairment, slowness, drowsiness or manic-like symptoms, hallucinations, delusions)

Dementia
  • Global / multiple deterioration of cognition in clear consciousness
  • Cortical dementias - memory loss; aphasia/apraxia early on (Alzheimer's disease, Lewy body dementia, vascular dementia, frontotemporal dementia)
  • Subcortical dementias - slowing, forgetfulness; visuospatial affected more than verbal functions (Huntington's, Parkinson's, MS, HIV dementia, etc)
  • Small changes in cognitive function can be more significant to pt. life than injury or disease - affects what patients can actually do

Behavior problems in brain injury
  • Stimulus boundedness (obsessiveness/perservation, lack of planning, behavioral apathy, dependency, intolerance to change)
  • Self perception (egocentricity, selfishness, coarseness)
  • Social perception (one perspective at a time, loss of empathy, embarrassing behavior)
  • Self-regulation (unpredictible./random, impatient, impulsive, restless, repetitive)
  • Emotional changes (labile, apathetic, irritable, hypersexual, "silly"

Stress in caregiving for cognitive changes:
  • Patient: physical, behavior changes; devastates self esteem
  • Caregiver: lonely, trapped, depleted, conflicted, avoided
  • Spouses: unsanctioned grief, social limbo, lost intimacy, protect children, old problems exacerbated

The Dimensional Perspective

(Taken from multiple lectures)

Emotive triad:
Potential (traits, vulnerabilities) <--> Provocation (challenges, life circumstances) <--> Response (neurotic symptoms)

Neurotic paradigm: an individual who falls at the extreme on a trait may be especially vulnerable to environmental demand, producing symptom/disorder

Intelligence - aggregate / global capacity of individual to act purposefully, think rationally, deal effectively with his environment
  • Inferred from skills/performance
  • Genes / environment
  • Arbitrary groupings

Personality - individual differences with consistency across time and situations
  • Attributes grouped into traits by factor analysis
  • Arbitrary distinctions between normal and abnormal
  • Extremes can be adaptive or maladaptive based on circumstances

Temperament - "constitutional factors," experienced viscerally, mostly genetic in origin, stable in adulthood (except neuroticism)

Character - experienced cognitively; substantially learned in environment, elaborated in development

Eyesenck: "Super traits" - orthogonal dimensions?
  • Extraversion/Introversion - how active, emotional variable you are
  • Neuroticism/Stability - tendency to have negative emotions & feel vulnerable
  • "Psychoticism(?)" - openness, agreeableness, conscientiousness from McCrae, Costa later

McCrae, Costa: "Five Factor Model" of Major traits
  • Neuroticism - distressed, complaining, poor resilience, poor satisfaction with treatment
    • Assesses adjustment vs. emotional instability; identifies individuals prone to psychological distress, unrealistic ideas, excessive cravings, urges, maladaptive coping responses
    • Facets: anxiety, hostility, depresison, self-consciousness, impulsiveness, vulnerability
    • High scorer: worrying, nervous, emotional, insecure, inadequate, hypochondrial
    • Low scorer: calm, relaxed, unemotional, hardy, secure, self-satisfied (but not necessary happy)

  • Extraversion - "now-focused" tendency, reward-focused
    • Assesses quantity, intensity of intrapersonal interaction, activity level, need for stimulation, capacity for pleasure
    • Facets: warmth, gregariousness, assertiveness, activity, excitement-seeking, positive emotion (hedonic capacity)
    • High scorer: sociable, active, talkative, person-oriented, optimistic, fun-loving, affectionate.  Now-focused tendency can assume that present state will prevail forever; pts high in neuroticism too can be overwhelmed by bad news
    • Low scorer: reserved, sober, unexuberant, stolid, task-oriented, retiring, quiet.  May appear shy, hard to express needs & concerns, sensitive to disapproval from doc - easier to condition, harder to decondition

  • Openness - lively interest (but maybe not adherence) to tx plan
    • Assesses seeking, appreciation of experience for its own sake; toleration for, exploration of unfamiliar things
    • Facets: fantasy, aesthetics, feelings, actions, ideas, values
    • High scorer: curious, broad interests, creative, original, imaginative, untraditional
    • Low scorer: conventional, down-to-earth, narrow interests, unaesthetic, unreflective - may resist doc suggestions if unexpected

  • Agreeableness - like to agree with things
    • Assesses location on continuum from compassion to antagonism in thoughts, feelings, actions
    • Facets: trust, straightforwardness, altruism, compliance, modesty, tender-mindedness
    • High scorer: soft-hearted, good natured, trusting helpful, forgiving, gullible, straightforward - may lead doc to overestimate pt strengths, underestimate weaknesses
    • Low scorer: cynical, rude, suspicious, uncooperative, vengeful, ruthless, irritable, manipulative - may drive doc away from pts even when they need doc most

  • Conscientiousness - low = disorganized/unmotivated, high=obsessive/perfectionistic
    • Assesses degree of organization, persistence, motivation in goal-oriented behavior
    • Facets: competence, order, dutifulness, achievement striving, self-discipline, deliberation
    • High scorer: organized, hard-working, reliable, self-disciplined, punctual, scrupulous, neat, ambitious, persevering - with high neurot. can be obsessive & overwhelmed with tx and disease
    • Low scorer: Aimless, unreliable, lazy, careless, lax, negligent, weak-willed - may be seen as "unmotivated," miss appts, rely on docs to "live their lives"

Traits are heritable - MZ>DZ in twin studies
How to arrive at these categories? "Lexical tradition" - look at how our language has evolved to describe traits; factor-analysis, etc.

Problem with these traits: abstractions, summaries - inherently redundant & circular (e.g. antisocial because you get in fights - self fulfilling)
Problems with types - crudest level of measurement, disjunctive categories

Environment plays a role too - everybody has personality & vulnerability but not everyone has a personality disorder
  • If you can't adapt your personality to the environment, you end up with a personality disorder

Second-Year Medical Student Syndrome

Example of the neurotic paradigm: personality + events (life story) => response
Transient hypochondriasis (preoccupation / fear of being ill but not delusional or body dysmorphic disorder, where you think it's a certain concern about experience)
  • experienced by 70% of 2nd year med students
  • cognition (belief that you're ill) and emotion (fear)

Potential (Vulnerability):
  • self-doubting, introspective, introverted personality
  • OCPD-type qualities often seen in successful professionals
    • Good at deductive reasoning; not as good at inductive math (induce principle and apply)
    • Testing of "essentials" - tend to overinclude / underexclude, focusing on details - oversystematize
      • Tell subject to make groups of things; OCP pts make too many categories
    • Traits good for a doctor in general but can lead to stress, anxiety
Provocation:
  • medical school is stressful - am I good enough? how do I know? do I really want to do this? (plays into introspective personality)
  • old ideas about disease are questioned, new ideas have dire consequences
  • know disease only in abstract, not in actuality yet (not in wards in 2nd year) so you attribute them to yourself
Response: transient hypochondriasis
  • transient because reassurance works, you go to the wards, build mastery, anxiety turns to excitement

Child Development

General issues: continuous/discontinuous, one track vs many tracks, nature vs nurture

Historical development - kids as little adults (medieval), born evil and need fixing (reformation), blank slate (enlightenment - Locke) or noble savages (Rousseau), biological investigation (Darwin - like evolution), mental testing (Binet - IQ developed), conflicts between biological / social (Freud), cultural context (Erikson)

Behaviorism / social learning
  • Watson - classical conditioning (little Albert trained to associate loud noise / crying with furry animals)
  • Skinner - operant conditioning, consequences shape behavior

Cognitive - developmental model: (Piaget) predictable sequence of stages based on what child can understand
  • Stages:
    • Sensorimotor (0-2 years): how body interacts with world; use eyes, ears, hands
    • Preoperational (2-7 years): language, play, and symbolic play but no logic involved
    • Concrete operational (7-11 years): logic present but concrete & rule-bound
    • Formal operational (11+ years): abstract thoughts & symbols present
  • Criticism: Piaget gathered this mostly from just observing his own children; also these stages tend to be less linear & concrete than he conceived them to be

Sociocultural - culture matters

Kids

2 years old: high activity, 1-3 words together, make believe play, big on "no", engages others, illogical
4 year old: pretty still, sentences, friends, concrete stuff (names)
7 year old: sits still, tics; complex structure in language, reciprocity; identifies friends/differences/values, able to abstract sometimes
11 year old: sits still; complex language & conversation; recognizes friends, activities, social context; has ideas/values
13 year old: sits still, fewer tics, complex language & conversation; self-aware & aware of social context, ideas/values
14 year old: sits still (posture), complex language & conversation, very self conscious, larger view of own opinions / comparisons

Rituals

Toddlerhood - routines, rigid, get bossy
Preschool - solitary, less rigid, get upset around transitions (e.g. bedtime)
Elementary school  - group play (rules, rhymes, jinx, cooties); hobbies & collections
Jr/ Sr High - fads, focused interests

Superstitions
Good/bad luck objects, don't want to jinx things, keep safe from harm, wishing (esp. in exams & sports)

Normal rituals & superstitions are good, common, reassuring, social acceptable, diminish after childhood

Obsessions - persistent ideas, thoughts, impulses, images
  • intrusive and inappropriate, cause anxiety or distress
  • e.g. contamination, doubts, ordering, aggression, sexual imagery - try to ignore/suppress/neutralize 
Compulsions - repetitive behaviors to try to reduce anxiety or distress (not produce pleasure);
  • excessive/unconnected to what they're designed to neutralize/prevent
  • washing, checking, counting, repeating

Obsessions/compulsions are distressing, socially isolating, increase after childhood

Autism

Pervasive developmental disorders (PDD)
  • includes autism, PDD-NOS (not otherwise specified), Asperger's syndrome (all autism spectrum disorders, ASD)
  • Spectrum disorder - heritable; autism just means you have more symptoms than Asperger's or PDD-NOS

Some DSM criteria
  • Qualitative impairment in social interaction (peer relationships, nonverbal behaviors, spontaneous sharing of enjoyment, bad emotional/social reciprocity)
    • Affective/gaze information (problems recognizing faces, physical expression of emotion poor, affect not well integrated with gaze/communication)
    • Don't know what to expect from others emotionally / socially
  • Qualitative impairment in communication (poor spoken language, poor sustaining conversation, uses repetitive language, no spontaneous imaginative play)
  • Stereotyped, repetitive behaviors & interests (focus on one thing, inflexible in routines/rituals, repetitive motor mannerisms (e.g. hand flapping), preoccupied with parts of objects (e.g. part of toy))

Things that are spared: attention, attachment (different form), some inhibition, declarative learning, constructive play, visuo-spatial abilities (hyperlexia), object based knowledge

Different from:
MR: uneven cognitive profile (not universal deficit)
ADHD: more social impairment & ADHD doesn't have the communication deficits or repetitive behavior
OCD: different focus/content
Can be comorbid!

Dx of autism: need good communication/parent involvement; 70% have MR, 50% nonverbal after 5yo, most dx > 3yo
Dx based on presence of symptoms, variable presentation across children
Detect early and you can affect trajectory (brain plasticity) - treatable, not curable

Autism is a brain disorder, but currently medical test or cure - need to ID symptoms & highly variable (probably multi-gene, environment interactions)

What causes it?
  • Genes (polygenetics, gene/environment)
  • Brain growth changes in development (big heads - brain develops too fast, too early), overgrowth in various regions

Epidemiology: 1/150 ASD, 1/250 autism, 3:4 males / 1 female
Recurrence risk in subsequent pregnancies probably 10-25% (4-10% observed but with stoppage effects)

Treatment: Applied behavior analysis, environmental restructuring, sensory-motor training
Early is better!

Schizophrenia

Initially "Dementia Praecox" - Kraepelin identified difference between manic depression (mood disordered) and schizophrenic-type disorders
Probably a group of different diseases

Symptoms:
  • Positive: abnormal mental experiences
    • Hallucinations: sensory perception without experience
    • Delusions: fixed, false, idiosyncratic ideas
    • Disorganized thought processes - e.g. loosening of associations, etc.

  • Negative: loss of mental energy/efficiency
    • Limited emotional expression
    • Social withdraw / Indifferent to others
    • Thought/speech poor
    • Lack of motivation / interest

Different from dementia: cognitive impairment across multiple modalities without gross dementia; happens in clear consciousness
Typical: Onset in 20s, chronic course with waxing and waning severity
Diagnosis of exclusion - exclude delirium, dementia, mood disorders (in that order) first after you have these symptoms

Other common positive symptoms
Auditory hallucinations:
  • Patient hearing his/her thoughts being spoken aloud
  • Voices referring to pt in 3rd person or commenting on activity
  • Thoughts being tampered with (inserted/blocked/interrupted/broadcast)
Somatic hallucinations (Bodily sensations being inflicted by outside agent)
Delusional perceptions
Passivity experiences (somebody else is controlling feelings/impulses/experiences)

Epidemiology: 5/1000 prevalence, 0.2/1000 incidence; earlier onset in males
Outcome is worse in developed countries (weird)

Impacts on patients:
  • Suicide, tormenting symptoms & bad medicine side effects, 2-3x greater mortality rates, 20% shorter life expectancy
  • Poverty, homelessness, crime but more likely victimization
  • Substance abuse (37% active at intake)
  • Stigmatized

Social impact:
  • Family (stigma, financial, emotional, physical)
  • Society: $62.7 billion/year

Variants: schizoaffective disorder (with mania or depression), paraphrenia (late-life onset with mostly positive symptoms), delusional disorder (e.g. becoming a stalker but no other schiz features), schizotypal personality disorder (like milder form of schozoprenia without delusions, hallucinations, thought disorder)

Disease?
  • Familial but not simple Mendelian inheritance; highly genetic (twin & adoption studies)
  • Other risk factors: 10% higher winter than summer; 30-40% higher in males, 100% higher if birth complications, 300% higher older fathers, infection? 200-400% greater in urban areas, 200-2500% marijuana use (cause or effect?)
  • Probably tons of factors contributing to multiple overlapping phenotypes
  • Brain studies - enlarged ventricles, volume loss as disease goes on, prefrontal activation decreased, fewer dendritic spines - but all too subtle/variable for diagnostic use

Treatment:
Antipsychotic medication:
  • Typical agents: chlorpromazine first used, others about the same (same side effects)
    • Side effects - parkinsonian movements, other motor abnormalities (striatal D2-receptor blockade)
  • Atypical agents: like clozapine - best effacacy but some bad side effects, others mimicking but not as good
    • Side effects - metabolic (Gain weight)
  • Halperidol (typical) is one of most popular (off-patent, cheap, efficacious)

Comprehensive: psychotherapy (individual, group, family); CBT, social skills, case management, meds as useful

Dementia

Cognitive disorder DDx:

MR
 		Focal disorder
 		Delirium
 		Dementia
Onset
 		Birth
 Anytime
 After birth
 Adulthood
Single/multiple symptom
 		Multiple
 Single
 Usually multiple
 Always multiple
level of alertness
 		Not impaired
 Not impaired
 Impaired
 		Not impaired
Permanent
 		Yes
 usually
 usually not
 Usually permanent

Dementia definition
  • Acquired decline of cognitive function
  • Multiple cognitive functions affected
  • Normal level of consciousness / alertness

Cortical: Normal early motor exam, amnestic (reminding doesn't help), aphasia, normal attention early
Subcortical: abnormal/slow early motor exam, slow memory but improves with reminding, dysarthria, apathetic early

Alzheimer's disease
Diagnosis
  • Slowly progressive dementia
  • No other identifiable etiology
  • Memory impairment plus aphasia, apraxia, and/or agnosia
Pathology: beta- amyloid plaques (extracellular) and neurofibrillary tangles inside cells
Epidemiology: more common in older age, Down's syndrome, family history, female / head injury
Etiology: smaller brain at autopsy; big loss of cholinergic receptors, genetic factors (30% attributable risk)

Delirium

De lira = off the path
Need to know how to assess mental status
Prognosis: 5x higher rate of nursing home patient, bad ability to consent, 50% of all hospital days, doubles inpatient mortality risk
Types:
  • hyperactive/agitated delirium (hyperarousal, hallucinations/delusions, disorientation, agitation - hard to miss),
  • hypoactive/disoriented delirium (hypoarousal, lethargy, confusion, sedation - often mistaken for depression) -
  • and mixed types too

Definition: an acute, transient disturbance in the level of consciousness that is:
  • Characterized by change in mentation, primarily manifested as an impairment in attention
  • with fluctuating symptoms (sine qua non = fluctuation level of inattention)
  • and dirunal variation, usually worse at night (sundowning)

To remember:
Delirium = Clinical diagnosis, state of fluctuating inattentiveness, absence of evidence is not evidence of its absence (don't need etiology to make dx)

Clinical features:
  • instability of mental status findings over time
  • perceptions altered (misperceptions, illusions, 70% visual hallucinations (vs. auditory for schiz) - VH are delirium until proven otherwise)
  • prodrome (restlessness, anxiety, sleep changes, irritability),
  • waxes and wanes, decreased attention, 
  • disorientation (time>place>person),

  • cognitive impairment (perservation = repetition over and over, immediate memory impaired, attention/recall/calculation impaired, mistake familiar for unfamiliar)
  • sleep-wake disturbance
  • emotional lability
  • neurological symptoms (asterixis - flapping hands on extension)
  • autonomic disturbances (vital signs)
Course: sudden onset -> fluctuating intensity -> clouding of consciousness -> stupor, coma, death.
Etiology: final common pathway in neurotransmission disruption (cortical/subcortical) - Ach is major NT involved (anti-Ach medications are very common cause!); also dehydration, drug dependence, fevers for the young, etc.  Common when people have lowered physiologic reserves
Dx: use family, nurse, changes in MSE and MMSE over time, physical and neuro exams
Tx: prevent it; treat underlying causes, use frequent observation & minimize environmental disturbances.  Antipsychotics can help, benzos ONLY if for EtOH (otherwise it would exacerbate situation)

Eating disorders

Spectrum of motivated behavioral disorders
Anorexia Nervosa: self starvation, <85% ideal body wt, fear of fatness & body image dissatisfaction, amenorrhea,
  • Restricting type or with some binge/purge behavior

Bulimia Nervosa: binge eating (2x/wk for 3 mo), sense of loss of control over eating, guilt/shame/discomfort after binging, compensation by purging (vomiting / laxatives / etc) or exercising; body dissatisfaction & fear of fatness but not underweight
  • Purging and non-purging type

Also Eating Disorders NOS (not otherwise specified) e.g. binge eating, subthreshold AN/Bn, atypical disorders

Dieting disorders cycle: Cognitive disturbance (fear of fatness = overvalued idea) <--> Behavioral disorder (disturbance in eating habits)
Why onset at adolescence?  Puberty, menarche, increased fat
Why increasing?  Disorder of our times (thinness, fashion models, social comparison more important in females)
Risk factor: adolescent dieting (for both eating disorders and obesity).

How do they come about?
Birth --(predisposing factors)--> Development of behavioral precursors (dieting) --(precipitating factors e.g. puberty)--> onset --(maintaining factors)--> established eating disorder

Vulnerabilities: (everybody exposed to dieting - why do only some develop ED?)
  • Personality (perfectionism, obsessionality, narcissism, introversion) - psychiatric comorbidity
  • Life experience (dieting / critical parents, peer pressure, stressors)

Pts are often ambivalent in behavior disorders - want treatment on their own terms, battle of wills & rationalization

Treatment: behavioral therapy, nutritional education/rehabilitation, group therapy, family therapy, small role for meds
  • AN: 45% recover wt and menstruation, 75% improve somewhat, 5-10% long term mortality
  • BN: 50% recover long-term

Why are they motivated behavioral disorders?
  • Problem is what patient does;
  • behavior is driven/compelled,
  • appetitive drive modified by social learning,
  • becomes consuming passion,
  • and expression reinforces repetition (disturbs physiology of hunger/satiety & increases reward)

Sleep

Occurs on regular basis:
  • relaxed body habitus
  • eyes closed
  • decreased responsiveness to stimuli
  • physiological / EEG changes
  • reversible (naturally rhythmic)

Regulation of sleep-wake cycle: two processes
  • Homeostatic process: balance of sleep (1/3) /wake (2/3) throughout 24 hr. day, doesn't matter when
    • Acute/chronic deprivation increases homeostatic drive = sleepiness
  • Circadian process: cycle of physiologic systems (endogenous circaidian clock), influences timing of sleep at approximate same nighttime hours
    • Reinforced by daily photoperiod (jet lag interferes); intrinsic periodicity slightly greater than 24 hours
  • Normal process: night: sleep 1st part because we've been up (homeostatic), second part because circadian sleepiness is powerful; day: up 1st part because we slept all night, awake 2nd part because circadian arousal is powerful

Circadian entrainment: rods/cones output to suprachiasmatic nucleus in anterior hypothalamus (SCN = timekeeper) - +/- loops of gene expression

Architecture of sleep: use EEG, EOG (Electro-oculogram), EMG (electromyogram) for brain, eye, muscle (also EKG, airflow, O2sat, penile tumescence monitoring)
Typically cycle (1-2-3/4-2-REM), about 90 minutes, repeated throughout night (REMs longer later in night)
  • REM (15-25%)
    • Distinct physiological state, rapid eye movements on EOG, decreased muscle tone on EMG (dreaming), penile tumescence, dreaming, blood pressure & pulse labile
  • non-REM (75-85%)
    • Stage 1: slower EEG frequency, greater EEG magnitude, alpha waves drop out (wakefulness)
    • Stage 2: Sleep spindles, K-complexes in EEG
    • Stage 3/4 = slow wave sleep/delta sleep: delta waves on EEG (big amplitude & slow = synchronous activity in brain)

Sleep deprivation: need enough to be alert during daytime; 8 hours is usual; consequences include sleepiness, accidents, mistakes, poor academic performance, immune/hormonal disturbance

Sleep wake disturbances
  1. Insomnia - most common; daytime somnolence = more likely to get treatment, can be primary or comorbid, transient (stress) or chronic.  Conditioned aspect of sleeplessness (frustration/arousal associated with bed, reinforced by repetition).  Behavioral management / CBT and hypnotic meds can help.
  2. Excessive sleepiness
    1. Sleep deprivation
    2. Sleep apnea - episodes of decreased airflow, fragmenting sleep
    3. Narcolepsy - genetic disorder - causes daytime sleepiness; associated with cataplexy (sleep paralysis in daytime), sleep paralysis, hallucinations
    4. Med abuse, meds, medical conditions, etc.
  3. Parasomnias - disorders associated with sleep (sleepwalking, sleep terrors, sleep-related eating, nightmares, seizures, asthma, GI reflux during sleep)

Major points:
  • Homeostatic process promotes sleep/wake balance in 1:2 ratio
  • Circadian process organizes timing, periodicity slightly >24hr
  • Peak of internal sleepiness cycle at 4-5 AM, alertness cycle at 7-8PM
  • Sleep-wake cycle is reset/reinforced by photoperiod
  • Sleep is REM/NREM
  • REM includes dreaming, decreased skeletal muscle, tone, heart rate / BP lability, penile tumescence
  • Typical sleep walking does NOT occur during REM sleep

Introduction to Behavior

Behavior: goal-directed purposeful action/activity
  • Classical conditioning: behavior elicited by a previously neutral stimulus that has been paired with another stimulus that would elicit a behavior (e.g. Pavlov's dog) - can be extinguished by repeated unpaired exposure (bell, no food)
  • Law of effect: probability of a behavior can be increased or decreased depending on its immediate consequence (active learning)
    • Exposure-behavior-consequence which increases (positive consequence) or decreases (negative consequence) probability of future behavior
  • Operant conditioning (Skinner) adds idea of positive & negative stimuli.  Reward with good or remove bad stimulus = reinforcement, apply negative stimulus or withdraw good stimulus = punishment. 
    • Deliver positive stimulus = positive reinforcement
    • Withdraw positive stimulus = negative punishment,
    • Deliver negative stimulus = positive punishment
    • Withdraw negative stimulus = negative reinforcement
  • Basically,
    reinforcement = trying to get you to repeat the behavior; punishment = trying to get you to avoid the behavior;
    positive     = delivering     a stimulus; negative = withdrawing a stimulus.

Continuous positive reinforcement increases rate and probability of behavior (e.g. cocaine)
Intermittent positive reinforcement increases probability and longevity of behavior (e.g. gambling)

What drives behavior:
  • Operant/classical conditioning
  • Appetite/internal drive
  • Social pressure/modelling

Behaviors express meaning but telling patient meaning might not affect treatment, and the reason to start a behavior often isn't reason it continues
Reciprocal - patients condition doctors, doctors condition patients

Substance abuse = conditioned behavior that becomes self-sustaining
Disordering addictions (use to abuse ratio); non-disordering addictions (nicotine/caffeine), less disordering addictions (methadone < heroin)

Addiction: continued, increasing, repetitive, stereotyped behavior that continues despite mounting consequences that disrupt function in all realms of life
  • Disease model: broken part.  Good because less blame/stigma, emphasizes medical tx.   Bad because no good models, removes pt. responsibility
  • There is a volitional component unlike disease - need to emphasize rehabilitation instead of drugs

Paradigm of motivated behavior:
Behavior --> reward/reinforcement --> satiation --> internal drive/craving --> behavior cycle
  • Environmental exposure & response play into behavior (operant /classical conditioning)
  • Temperament, life experience, disease all play into drive, reward, satiation cycle

Addiction

Definition:
  • Repeated use of a psychoactive drug (often stereotyped, ritualistic fashion) which makes you feel good
  • Apparent (to others) loss of control (use more than report, fail to stop despite stated attempt to do so)
  • Continued use & effort it takes to get drug make problems that would make a reasonable person stop

Risks: anybody can get addicted but more with family history, 2:1 men:women, increasing with generations
Damage: Death (including 50% of suicides - alcohol especially), disease (e.g. hep C), crime, broken lives
Funny "disease":Sufferer seeks out pathogen, acts as if he "wants to be sick" and avoids/fights treatment, appear to be able to choose against drugs when motivated correctly (volitional component), influenced by social attitudes about "symptom"
  • Kind of like sex (don't die if you don't have it, almost everybody has it, if you try not to it's hard to do, optional but would risk life & limb

Addiction: Craving (intense desire for drug, excruciating or pleasant) --> Triggering (stimulus associated with past behavior triggers craving/use) --> Relapse (resumption after period of abstinence: stopping is easy, staying stopped is hard)

Forces at play:
  • Driven behavior (behavior - satiate - wears off - drive) cycle
  • Social learning (peers/conspecifics' behavior influences our behavior)
  • Classical conditioning (eg triggering - irrelevant stimulus passively associated with behavior)
  • Operant conditioning (consequences affect behavior)
  • Behavioral economics (if other behaviors available, can change relative importance of one behavior)
Results in elegant model of behavioral control; drugs short-circuit the control (serves no purpose but reinforces itself so strongly other things become irrelevant - "disorder of behavioral economy")

Addiction pharmocology:
  • Reinforcing properties (pleasurable)
  • Pharmodynamics/-kinetics: rapid onset (more addictive), powerful effect, rapid offset (to encourage repetition & training)
  • Physical dependence (tolerance/withdrawal)

Types of drugs - withdrawal is opposite of effect (developed compensation mechanism now unchecked)
  • Sedatives/hypnotics (EtOH, benzos, barbs, GHB - increase inhibition, unpredictable effects, potentially lethal withdrawal (overexcitation))
  • Stimulants (cocaine, amphetamines, meth - more DA, NE release, more energy/wakefulness, subjective withdrawal)
  • Opiods (morphine, heroin, oxycodone, mu-opiod agonists, analgesics/hypnotics/autonomic effects; OD can = death; withdrawal state torture but not lethal)
  • Hallucinogens (LSD, PCP, peyote, mescaline; grab-bag that disturb perception, not very addictive but big in subcultures)
  • Cannabis derivatives (cannabis, hashish, etc.; becoming more potent; widely used)
  • Inhalants (tolune, glue, gasoline - some kind of drowning reflex)
  • Weird stuff (MDMA = ecstasy - combining stimulant, hallucinogen, empathogen - like people you don't know; ketamine - dissociative anesthetic))
Polysubstance abuse is becoming more common - use drugs to modify others or treat withdrawal (speedball = heroin + cocaine, opiods to come down from ecstasy), bad for prognosis

How do you stop it?
Try to stop drive (e.g. methadone - kill reward of drug)
Reward adherence (increase consequences, encourage other behaviors instead - behavioral economy)
Change environment (models & triggers)

Relapse is a big problem
Differing opinions on Tx - cure (impossible?)? abstain & prevent relapse (AA?)? reduce harm (needle exchange, etc)?

Tx: abstinence can be obtained through sustained effort by patient, support & guidance form care system.  One shot cures don't exist.

Alcohol

  • Carcinogenic, teratogenic, neurotoxic, contributes to violence/suicide/accidents/deaths, worsens medical condition - but people (& societies) tolerate it
  • "Alcohol Attributable Fraction" -  If alcohol disappeared - 45% decrease in violent injury, 28% suicide, 75% esophageal cancer
  • Half of all Americans drink; 20% wt males -> alcohol addiction, 6% overall incidence/year, 1/10 of country consumes 50% alcohol
  • Abuse vs dependence - prefers abuse (pseudodistinction - they don't need alcohol)
  • Never been eradicated from culture successfully

Model (from addiction): models & triggers -> drug use (self-reinforces) -> consequences & other behavior

Facts:
  • Heavy drinking associated with youth; earlier 1st drink increases risk of alcohol addiction (more, longer, more severe)
    • Probably from availability, siblings, peers (via parental monitoring / family style), not genetics or family hx
  • People whose religion / country / culture says no alcohol are less likely to have problems (cultural plasticity)
Alcohol is carrot and stick
  • Stimulant - euphoria, gregariousness, incr. confidence (ascending BAC)
  • Sedative - confused, inattentive, sleepy (descending BAC)
  • May be some genetic vulnerabilities (innate tolerance for children of alcoholics = more time spent on ascending curve than descending; Aldehyde Dehydrogenase Deficiency (immunity altering balance towards punishment), )

Alcohol addiction relatively common - but many "alcoholics" in youth remit spontaneously with no formal treatment.
Behavioral economy - time matters (the longer you're sober, the better chance it'll stick - other behaviors)
Predictors of recovery: females, more time, older = positive; severity = negative.  Tx reduces effects of time, increases prognosis
Social - marriage, parenthood, full-time job help (behavioral economy = crowd out old behaviors).  Bad sign if addiction persists

Pharmacology
  • No specific receptors - interactions with ligand-gated ion chanels (increases GABA-A & Glycine (inhibit cortex, spinal cord); decreases Glutamate NMDA (excitatory))
  • Overall alters inhibitory/excitatory balance to more inhibition diffusely
  • GABA-A receptors may be especially important (benzos, etc. cross-tolerant & good for Tx)
  • Absorption affected by concentration, time in stomach (freshman drinks fast, passes out -> still absorbing from stomach.  Opposite of what pass-out is supposed to do)
  • Peak concentration also depends on body composition (Men<women, younger<older)
  • BAL 30 (1 drink) = euphoric, social, BAL 50 (2 drinks) = jovial, less inhibition, risk, impaired eye movements, BAL 100 (5-6 drinks in 2 hrs) = drunk, slowed rxn time, slurred speech, stagger; BAL 200 = sloppy drunk / lethargic, BAL 300 = deaths from resp. suppression, BAL 400 = LD50, BAL 500 = very high risk of death

Tolerance / withdrawal
  • Tolerance - greater quantities needed to produce same effect over time
    • Mechanisms - receptor effects, metabolic changes, behavioral tolerance (act like not drunk)
    • Tolerance is complex - chronic alcoholics seem sober at BACs that would kill normal person
  • Withdrawal - compensatory mechanisms of tolerance are unopposed
    • State of diffuse cerebral disinhibition / hyperexitation
    • Minor abstinence syndrome (8-48 hrs), withrdarwal-induced seizure (same), Delirium Tremens (2-5 days, delirium, hypersympathetic state - how you die)
    • Tx - give benzos @ tolerance dose then wean off

How to stop it? treatment, recovery programs, job based on abstinence, AA (new social network, etc.) - no good drugs

Intersex

People with indeterminate biological sex (a.k.a. "disorder of sexual development" (prejudicial), historically hermaphrodite)

INSA = advocacy group

Definition: "Biological condition of being between male and female", group of conditions with ambiguous/incomplete sexual differentiation.  


Statistics - 1/100?  Hard to estimate. 


Sex/gender:

  • Sex - genitals, genetic / anatomic
  • Gender- sense of "maleness" or "femaleness" as well as psychological, sociocultural assumptions we make about our sex
  • Sexuality - erotic nature, who / what turns us on, includes sexual orientation

Chromosomes:
  • XX / XY - normal female/male
  • XO - Turner's syndrome (phenotypically female)
  • XXY - Kleinfelter's syndrome (phenotypically male but with female characteristics)
  • XYY - Jacob's syndrome (larger male)
  • XXX - Triple X
  • Fused XXYY - Chimera (some cells XX or XY)

Hormones: more important than chormosomes
  • XX - Congenital Adrenal Hyperplasia (CAH) - more androgens available (corticosteroids not synthesized so adrenals overgrow - need lifelong corticosteroids), masculinizes
  • XY - Androgen Insensitivity Syndrome (AIS) - no androgen reception so feminized
  • XY - 5 alpha reductase insufficiency - no androgens converted early in life; feminized but get androgens @ puberty so "convert to male" 

Gender:
  • Gender Identity = internal, subjective sense of being male/female.  GID, transexuality = variants
  • Gender role - sex-related behavioral expectations, many culturally based (effeminate males, butch females)

Sex development: SRY directs testes development, no SRY = female (deafult).  Hormonal secretions drive rest of structures. 
Intersex - often apparent at birth (genetalia) but sometimes detected at puberty or autopsy

Gonadal intersexuality: usually both gonads contain ovarian/testicular tissue (ovotestes) - female structures dominate (have gender identity of female)
  • Can have XX chromosomal pattern with SRY gene translation, or chimera - gonadal dysgenesis
Non-gonadal intersexuality: much more common, many manifestation - affects genitalia but not gonads
  • Eg large clitoris vs small penis, labia vs scrotum, fused vs open vagina
  • Commonly - epispadius/hypospadius (urethra doesn't fuse

Surgery vs. no surgery (parental distress, good techniques, bonding, less trauma early, confirm gender - but oppositions include long-term trauma, problems with sexual function)
Gender identity - still unsure what factors determine our gender - gender assignment is a guess
Who should decide - parent, physician, child (delayed)?
Parental autonomy with oversight - need to be well informed, diagnosis, all options, understand difficulty predicting gender identity, lack of scientific evidence for traditional practices.

Neuroendocrinology of sexual behavior

Sexual behavior - appetitive & consummatory components (rats, humans) - sex-typical behavior
Sex steroid hormone action is causally related to activation of sexual behaviors in animals.  Individual differences maintained after T replacement in men

Men: Testosterone increases desire, performance in hypogonadal men (higher threshold for desire than intercourse / nocternal erections)
Women: at ovulation, increase in female-initiated sexual interactions - but modified by culture (increased if a partner's around, decreased if don't want to become pregnant, etc)

Steroid hormones - diffuse into cell (lipophilic), bind as ligand to receptor; receptor acts as transcription factor
  • Testosterone can be metabolized to androgen (via 5-alpha-reductase) or estrogen (via aromatase) in brain - happens in both males and females
  • Aromatase inhibitor (no estrogen) blocks T effects on ejaculation in castrated rats (need estrogen for sexual behavior even in males)

Brain stuff: performance/response
  • Pre-optic area is key (males if lesioned lose performance / response)
  • Male circuit known via tract tracing - POA to PAG to nPGi - in some animals
  • Ejaculation generating cells in spinal cord IDd (only in males)
  • PET scans have id'd brain areas associated with ejaculation in men - e.g. Ventral Tegmental Area (VTA) - involved in dopamine / reward (like cocaine); basal ganglia but not hypothalamus, various cortical areas
  • Female mice (study lordosis) - similar to male POA to PAG to nPGi (sexual reflex), Similar forebrain responses
  • Sex difference - males activate hypothalamus, amygdala in desire but not while copulating
  • Orgasm in women - activate various areas (fMRI) - perception in caudate, midbrain; physical response in cerebellum

Monoamines: catecholamines / serotonin;
  • Dopamine released in nucleus accumbens in association with male sexual response (and in POA in response to female)
  • Dopamine agonists enhance male response, as do adrenergic antagonists
  • Fluoxetine treatments inhibit appetitive & consummatory measures of male sexual behavior

Various species differences in brain (e.g. songbirds when learn to sing; also humans  - no females have spinal cord neurons that innervate penis)
Can be acquired - males have bigger pmdAmygdala than females (not at birth) - regulated by hormones
Hypothalamus & INAH-3: females, homosexual males have smaller INAH-3 sizes than straight males
Finger-length: 2nd-4th finger ratio (males longer 4th finger, homosexual women intermediate) - from androgen exposure

Behavior problems in children

Behavioral perspective:
  • Motivated behaviors
  • Goal-oriented behaviors
  • A-B-Cs (antecedent-behavior-consequence

Major problems - only 2 ways to develop:
  • Reciprocal, coercive interactions
  • Monitoring deficits

Coercive interactions - power struggles, escalating
  • negative reinforcement (when behavior decreases noxious stimulus, will re-occur next time)
  • positive reinforcement (behavior followed by experience that makes it more likely for behavior to recur - reward in eye of beholder)
    • Engaging maladaptive behavior increases likelihood it'll happen
Escalation - parents & children get frightened, give hug - rewarding - try new interventions (stronger) - escalates; kids get afraid and resist, "learned helplessness" and parents give up
End stage - physical/emotional abuse for parents, suicide gestures/running away for kids
Talking is bad (usually like nagging) - stable families have fewer verbal interactions

Monitoring: knowing where child is / what doing / who with / attending to details
  • Otherwise kids will lie - you're training them to get what they want - if you just ask them what they're doing
  • Monitoring - knowledge of child, child knows you "get them" parental self-awareness, recognizing patterns of behavior/interaction
  • Poor supervision - accidents, fire-setting in childhood to substance abuse, sexual activity, delinquent behavior as adult
  • Power struggles lead to poor supervision (give up)

Treatment - home is key (parents need to be involved) - also child factors e.g. medical problems, stressors, demographics, etc.

Model - power struggles and lack of supervision facilitate development of maladaptive behavior; neither parent nor child aware of behavioral forces
To decrease behaviors, need to decrease power struggles and increase supervision

How to fix: behavior program (schedule to reduce power struggles, structure + rewards + punishments, prevent relapse)
Parents need to know & feel what it means to be in charge, ignore behavior, set limits, be consistent
  • Decrease verbal interactions, increase predictability & awareness
  • Child feels better, parents can be less involved, task-reward with predictable rewards, child will generalize these principles to rest of life (starts at home)

Summary: power struggles & poor supervision; fix with parent behavior and management training

ADHD


  • 5% school-age children, 50% child psych practice, high comorbidity with disruptive/mood/anxiety disorders
  • 3 types (DSM)
    • Combined/full (ADHD)
    • Predominantly inattentive (ADD)
    • Predominantly hyperactive-impulsive (HI)

Symptoms (DSM): inattention (careless mistakes, easily distracted, difficulty organizing, looses things); hyperactivity/impulsivity (fidgets, on-the-go, talks excessively, interrupts, etc)
Predominantly HI - preschoolers, predominantly ADD - residual in adults or with learning disability; leads to alcoholism /drug abuse

  • Heterogeneous condition: interviews, questionnaires, rating scales are fuzzy; observations are hard, no clinical exam or lab tests to rule in/out - but developmental motor coordination disorders are highly comorbid
  • ADHD diagnosis modified by environmental influences - discordant ratings home/school/clinic, environmental variability, IQ is environmental, socioeconomic status, etc.
  • Most with ADHD can "concentrate" or "focus" on what interests them if it's immediately rewarding
  • Girls harder to diagnose until early (socially unacceptable to be disorganized - compensate by overwork)
  • Can be secondary to other biological disorders

DISORDER OF SELF-CONTROL (impulsivity) - Barkley
  • Inhibition, response preparation (need inhibition to prepare response via working memory) linked
  • Executive function = control processes; no inhibition or response preparation or working memory, problems with education / metacognition

Brain - parallel circuits (frontostriatal), cerebellum/thalamus maybe; EEG problems, fMRI differences, reduced total cerebral volume, volume of cerebellum, abnormal frontal morphology, etc.
Neurotransmitters - DA high in midbrain only, NE system indirectly - could be secondary (DA is neuromodulator), serotonin may be involved (aggressive comorbidity)
Genetic basis? one gene only increases ADHD if mother smokes

Stimulant medications: effective in 75-90% of ADHD cases, few, rarely serious side effects - but response to stimulants is not diagnostic of ADHD
  • Stimulants neither cure nor curse
  • Must individualize meds for target symptoms & times
  • Combination with non-drug methods is better
ABC of CBT / applied behavior analysis- need positive contingency valence (not negative like schools do) - engineer for success (tutoring, coaching, motor skills building).  Pure cognition is not effective (e.g. i need to settle down).  Not great coverage in schools

Take-aways
  • ADHD may be class of related neurobiological/developmental disorders (like epilepsy)
  • Frontal-striatal-cerebellar parallel motor & executive dysfuctions with ADHD
  • Stimulant medication should be separated from biomedical nature of ADHD - neither necessary nor sufficient


Feeding

"Motivated behavior in social context"
Motivated behavior: drive towards goal, stereotyped behaviors to satiate drive; satiation is temporary so makes a cycle (modified by internal/external factors e.g. illness, food availability), leads to learning over time with iteration through cycle

Drive = construct, element of behavioral model that provides "motive force" - embodied in physiological control mechanisms
  • drive to eat serves energy homeostasis; act is hedonic (rewarding) to ensure repetitive feeding
    • Homeostasis = maintenance of stable internal state despite changing environment (e.g. body temp in mammals)
Feeding cycle: food consumption, satiety, hunger, food acquisition, food consumption.  Repeated over time, leads to learning
  • Leads to stereotyped meal patterns, frequency/timing, size, social context, content
  • Physiological satiety signals, meal initiation signals, long-term homeostatic signals, GI physiology
  • Overdetermined - layers and layers of redundancy to ensure feeding happens

CCK - prototypic peripheral satiety signal.
  • peptide released from gastric/duodenal mucosa when stimulated by food
  • Plasma level peaks 10-30 min post-meal, subsides over 3-5 hrs
  • Signals via vagus to brainstem satiety centers; also functions as NT

Ghrelin - hunger signal
  • Neuropeptide synthesized in stomach
  • Levels increase with food deprivation, peak prior to meals
  • Receptors in hypothalamus = homeostasis
  • Levels increase after weight loss but pattern stays the same

Hedonic control - meal size is function of food palatability & macronutrient content (Better something tastes, more you eat)
  • Nucleus accumbens - important reward locus, has opiod receptors (eating affects DA + opiod systems)
    • Gets input from feeding centers
    • Opiod antagonists block sweet food intake (naloxone)

External factors:
  • Population's energy balance shifting (much more obesity, incl. child/adolescence)
  • Increased energy in, decreased energy out
    • Supersizing - high calorie, cheap foods esp. using HFCS (less effective at reducing subsequent intake in people trying to diet
    • Homeostasis normally defended against perturbation (e.g. meal size - big/small pieces, eat same amount - but bigger portions, don't defend portion size)
  • High, energy-dense food is everywhere, leads to decreased locomotor activity

Review:
  • Eat to maintain energy homeostasis; complex, overdetermined system of physiological elements drive behavior
  • Eat high-energy-dense food because they taste good; lots of HFCS so they don't satiate, available everywhere; then less likely to exercise

Biological Studies of Sexual Orientation


Definition of sexual orientation: thoughts/fantasies, sexual activity, inner identity/subjective sense, public social role - may be incongruent
Differs from gender dysphoria (think they're wrong sex)

Kinsey scale - 0-6 with 0 heterosexual, 6 homosexual, huge data set from interviews.  Around 5% exclusively homosexual; peaks in adolescence & declines; majority heterosexual

Natural history of homosexuality:
  • gender nonconformity is key (not predictive of effeminate males but rather gay males, for instance)
  • Aversion to aggressive behavior is one of most highly correlated factors for males
  • Prospective studies of effeminate boys (highly correlated) - 68% male vs. none in control group

Mechanisms (all but genetics are causally ambiguous; genetics wouldn't be only relevant one probably):
  • Psychosocial (classic unloving father/doting mother, small role only)
  • Anatomic differences
  • Neuroendocrine
  • Genetics

Biology:
  • Early awareness of orientation (age 10) & stability - suggests biological trait
  • No reliable physical/hormonal differences - but some subtle physical variations (e.g. finger length); INAH-3 data are suggestive but not compelling.  Some brain imaging (click-evoked otoacoustic emissions) big difference for homosexual/heterosexual females
  • Early hormonal response may be critical
  • "Fruitless" fly - one gene causes male courtship behavior (splice variants).  If male gets female splice, tries to mate with males

Genetics
  • Family studies - heterosexuals 4% homosexual brothers; homosexuals 20% homosexual (single males interviewed)
  • Twin studies (homosexual proband) - suggests about 50% genetic loading (50% monozygotic twins discordant = important nongenetic factors)
  • Pedigree evidence - maternal transmission (X-linkage, maternal effects, imprinting - or decreased reproductive rate in homosexual males)
  • Linkage analysis - 33/40 pairs of "affected sibs" shared markers at Xq28 vs expected 20/40; later researchers couldn't confirm

Obsessive-Compulsive Disorder

Characterization of OCD
  • Generally, psychiatric disorders are different in children - but OCD is an exception (has a very similar presentation)
  • Patients have feelings they need to fulfill (not just thoughts but also behaviors)
    • In adults, there's more thought around the behaviors (i.e. I need to get the germs off of my hands)
    • Children have same feelings without explanations
  • Different than psychosis or a thought disorder:
    • The person with OCD fights with themself about the behavior. 
    • Part of the brain knows that they don't have to do the behavior; the other part tells them to do it. 
    • They know on some level that the behavior is illogical
  • OCD is the 4th most common disorder in psychiatry but often hidden
  • OCD is familial, maybe connected to Tourette's syndrome
    • Often, females in a family have OCD while males have Tourettes

Related conditions
  • "OCD spectrum disorders" include pathological gambling, compulsive shopping, sex addiction, binge-eating, Trichotillomania (hair pulling), kleptomania - but there's no evidence that they're related biologically or that such a spectrum exists
  • Body dismorphic disorder (think some part of the body doesn't look right and gets worried about it) and grooming disorders (nail-biting, skin-picking) look like they might be associated with OCD (family studies)

Symptoms & definitions
  • Obsessions: intrusive ideations, urges, or images
  • Compulsions: repetitive, ritualistic behaviors performed in a rigid fashion
  • Ego-dystonic: unpleasant, want to get rid of it
  • Cause distress, impairment, or last > 1 hr
  • Insight is not required in children but usually the norm in adults (about 5% of adults have no insight though)
  • Five common groups of symptoms (as determined by factor-analysis):
    • Contamination/cleaning
    • Aggressive/sexual/religious ("Taboo" group)
    • Ordering/symmetry/repeating/counting ("Perfectionism" group)
    • Hoarding
    • Checking/responsibility

3 main subtypes:
  • Predominantly obsessive (obsessions, anxiety disorders)
  • Predominantly compulsive (compulsions, tics, ADHD, assoc. OCPD)
  • OCD in which both are notable (associated with basal ganglia insults & tics, ADHD)

Commonly present to: pediatricians (behavioral), dermatologists (dry hands), school (trouble, homework - behaviors taking up time), work
Common comorbidities: depression, tic disorders (esp. children), generalized anxiety, separation anxiety (esp. children)
Classes: Simple (just OCD) or Complex (OCD + co-morbidity); in children OCD +/- ADHD is major distinguishing factor

Tourette Syndrome (may be related to OCD)
  • Tics: stereotypic, sudden motor and vocal movements; suppressible, suggestible
  • 'Just right' feeling to performing a tic - perceptually tinged mental phenomena (like tension being relaxed)
  • 'Sensory' compulsions: incompleteness, bodily sensation, visceral, muscular
Both Tourette's & OCD have waxing/waning courses

Biology of OCD:
  • Triune Brain theory: basal ganglia (hierarchy, territory/ritual, grooming), limbic system (affiliative behaviors, emotion), cortical system (inhibition, planning, insight)
  • May be a dysfunction or hyperfunction in the cortico-striate circuits
  • Functional brain imaging shows overactive orbit of frontal cortex (OFC) - which reverses with treatment (drugs or CBT)
  • People with Sydenham's Chorea (movement disorder of basal ganglia) often have OCD - may be connection
  • OCD can also result from traumatic brain injury
    • Obsessions - mesial, basal ganglia injury = risk; orbitofrontal injuries are protective
    • Compulsions - weakly predicted by mesial, orbitofrontal injuries
    • Helps confirm the cortico-striate circuit theory - but suggests obsessions may be more neurally determined than compulsions
  • Genetics: OCD is familial (11.7% vs 2.7% general pop)
    • Obsessions are more familial
    • OCD spectrum may also be genetic (body dysmorphic disorder, somatoform disorders, grooming disorders more frequent in relatives of OCD probands)
    • Obsessive Compulsive Personality Disorder (OCPD) = a personality (often referred to as "anal-retentive") - higher in relatives of OCD pts (maybe a common gene)
    • Tic disorders more prevalent in relatives as well; earlier onset OCD predicts tic disorders in family
    • Greater penetrance of gene effect in female probands

Treatment:
  • Type of CBT: Exposure-response prevention (ERP) -
    • Make hierarchy of feared situations/thoughts from less to more severe
    • Expose sequentially starting at less frightening
      • Note response / anxiety 
      • Encourage pt. to stay focused, think about the worst possible consequence (cognitive)
      • Refrain from washing or mental compulsions (e.g. counting)
      • Repeat, increase duration; increase severity of feared situation/thoughts
    • "Overdo" it - get them to the point where they can go beyond what they're likely to face in normal life
    • Use imaginal exposure for thoughts (listen, read, write)
  • Pharmacology: SSRIs can help - any drug that increases serotonin availability
    • Neuroleptics can help too (DA agonists)
  • About 2/3 will respond to medication (symptoms resolve and gain function)
    • Medicine reduces symptoms 30-50%
  • Another 2/3 respond to CBT (requires hard work, cooperation from pt and experience from clinician - combo is best
  • About 1/3 stay chronic with comorbidities (e.g. ADHD, generalized anxiety, Tourette, autism)

Clinicians should know:
  • OCD is common (1-2%) and secretive
  • Suspect OCD if you notice repetitive behaviors and anxiety
  • Tx is CBT +/or meds (SSRIS or clomipramine & augment with narcoleptics)
  • Pay attention to comorbid disorders (anxiety, depression, others)

Development of Sexuality

Definitions:
Sex: genitals/reproductive organs, genetic/anatomical
Gender: "maleness" or "femaleness", psychological/social
Sexuality: erotic (Lovemaps)

Human sexuality is:
  • developmental (the product of specific events at specific times)
  • acquired/learned (based on input from the senses)
  • there are no fixed "releasers" in humans, unlike other species

Prenatal factors:
  • include chromosomes, prenatal environment, fetal gonads & hormones, genital differentiation, M/F differentiation in brain development
  • different effects have different impacts at different times.
  • Internal sexual differentiation: M/F are the same until the 2nd/3rd month, then interplay of inhibiting/releasing hormones
  • External genital differentiation: female by default, need testosterone & proper response to it to masculinize

Postnatal factors:
Sex:
  • Chromosomes & hormones (see previous sexuality lecture for descriptions of hormonal / chromosomal disorders)
  • Sex organs = most common birth defects - there's more diversity to sex than most people realize
  • Males are more complex / vulnerable to this variability
Gender
  • Gender identity (internal sense) and gender role (social behavior & biology)
  • Develop in terms of identity, gender constancy (boys become men, girls become women, etc.) and the identification/complementation process (look at other genders and determine "what is me", "what is not me").
Sexuality
  • "Lovemaps" - representations in brain of ourselves as gendered, sexual people; characteristics of others that we're attracted to; sexual activities that arouse us

Development:
  • Sexual rehearsal play: normal sex learning; learning about M/F & adult/child differences, age-graded sex learning through experience; sex role rehearsals
    • No real professional consensus about optimal sexuality development
  • Early learning of gender differences:
    • Age 1: 75% infants recognize M/F faces & voices;
    • Age 2: 25% can ID their own gender
    • Ages 2-4: children learn about their gender from adult teaching
  • Gender identity development (ages 2-4)
    • Age 3: 85% correctly ID gender of self & adults
    • Age 3-4: children learn about gender content from culture
    • Age 4: 100% can ID gender
  • Gender constancy development
    • Ages 3-5: children learn about genital differences
    • Ages 4-6: children learn about gender constancy (boys-->men, girls--->women)
  • Show me play
    • more common in a sex positive society; includes sexuality rehearsal
    • subject to taboos, prevention, prohibition, punishment

  • Normal in early childhood:
    • Learning about M/F & adult/child differences, 13-17 mo interested in urinary stream of parents, direct exploration (playing doctor/nurse), ask questions about differences
    • Ages 2-6: 25% boys, 19% girls touch sex parts in public; 43% boys, 48% girls intentionally feel mother's breast
    • Kindergarten teachers report 50% kids use sex words often; 90% of teachers observe kids seeking body contact
    • First kiss around these ages; normal behavior incl. masturbation w/o penetration, imitating seduction, kissing/flirting/telling dirty jokes
    • "First date" and "wedding invitation" rehearsals (and childbirth rehearsals in other countries where children are more exposed to childbirth) start around ages 5-8

    • Yellow flags (kindergarten-2nd grade) - preoccupied with masturbation/sex language, mutual/group masturbation, simulating foreplay with dolls/peers, peeping/exposing self/others, pornography, precocious sexual knowledge, sexual graffiti
    • Red flags (kg-2nd grade) - sex explicit conversations with large age differences, touching/exposing others' genitals, degrading, humiliating, inducing fear or forced sexual activity, chronic peeping/exposing/frottage/obscenities/pornography, compulsive masturbation that interferes with tasks, simulating intercourse with clothing on - but need to check against developmental context (e.g. do they live in a house where they share room with parents?)
    • Require intervention - oral/vaginal/anal penetration, forced touching of genitals, simulating intercourse with clothes off, any evidence of genital injury/bleeding

  • Modesty increases with age (exposure to parental nudity, sleeping in parental bed is positively related to self esteem, decreased discomfort with body, physical contact in college students)

Masturbation (child/adolescent)
  • Starts around 10 mo for males, 12 mo for females (reach for genitals; includes erections for males)
  • 16-19 mo infants have true masturbation with excitement, pleasure, etc. - after 19 mo, 2/3 females continue to masturbate while 1/3 stop
  • 2-6 yo 35% boys, 19% girls touching sex parts in public; 50% of 3-4 yo boys have orgasms
  • Does puberty start at age 6? Boys 6-10 get erections when they see erect penis; feel guilty for dirty mind about fantasies, 50% get spontaneous erections by age 10-12
  • Increases with age for boys (14% at age 8 to 98% by age 15), girls tend to masturbate alone, re-learn masturbation from boyfriend

Adolescent sexuality:
  • for college bound boys, heterosexual play drops off after age 10 (not for non-college bound boys);
  • by age 12, 1/5 of boys have tried intercourse with females (prior to puberty); black males in East Baltimore often report 1st intercourse before puberty

Paraphilias (before age 8) - result from "vandalized lovemaps"
  • Social issue: sex negativism vs sex positivism; prevention, prohibition, punishment & shame, traumatization - different events have different impacts at different times

Gender variance in childhood
Boys:
  • prefer girls as playmates; avoid rough & tumble play / team sports, like dramatic play,
  • ID with female heroines, interested in hair, jewelry, clothes
  • play with Barbie dolls (not baby dolls - engage in romantic rehearsal on "how to get a man" not "how to be a mother" - high concordance with becoming gay men, not transsexuals)
  • Express dissatisfaction with sex, desire to be other sex (ages 3-5)
  • Sissy boy syndrome: treatment for adjustment, not change; 75% males are gay
Girls: tomboy girls, rough play, team sports, etc. - most are heterosexual and a few transsexual, but on the whole have better self-esteem & self confidence than "normal" girls

Generational changes: ages of puberty, 1st sexual experience, coming out as gay going down; age of marriage going up (24 for F, 26 for M)
  • Puberty: growth spurt around 11 in F, 13 in M
    • Hormonal influence - pubertal eroticism (sex drive, energize prior sexual interests/fantasies); change in body = self image changes
  • Intercourse by age 19 - 1/5 to 2/3 by the end of the 20th century
  • By age 16, about 50% of teens are having sex

Gay youth:
  • About 6-14% of adolescents engage in exploratory behavior; frequency of homosexuality stays pretty constant over generations (4-6%)
  • Constant from 1970s-2000: age of 1st same sex attraction (12-13), 1st same sex experience (13-15)
  • Coming out as gay has started happening at earlier age (mid-20s to 16)
  • Bi-curious / confused have heterosexual sex sooner

Summary: human sexuality comes from diversity across people, specificity within the person, events at critical periods of time, input from senses

Adult Sexuality

Intimate relationships important in adult years
Various styles have emerged - Sexual revolution (70s') has led to more & more acceptance of alternative lifestyles
Singlehood: more adults today single than ever before (advanced education, women have careers = not as dependent, attitudes more accepting - people choose to not marry)

Sexual behaviors, relationships are placed in moral context - shaped by family, religion, culture
  • Sexual relationships, activities are chosen based on a person's moral code
  • Traditional: sex acts that can't lead to pregnancy are bad
  • Relational: major purpose of sex is to cement relationships

Sexual relationships motivated by: physical attraction, romantic love, sexual arousal, desire for status/security/profit, desire to please others/conform/be nonconformist, desire to bear/rear children, transactional in nature.

Attitudes vary with gender, age, education, region, race/ethnicity, sexual orientation, religion.  Younger, more educated, urban, homosexual generally means more open.

Cohabitation:
  • increasing in prevalence; about 7% of men/women cohabitating, about 50% will either marry or split up within 1 yr
  • can be casual or formalized by contract (domestic partnerships / civil unions); older generation doing it as well (baby boomers)
  • older generation - may need to do it for financial reasons (taxes higher with marriage; remarry and lose previous partner's pension / social security)

Marriage:
  • 50-60% American adults married, living with spouses
  • Younger people marrying later & more likely to divorce, remarry
  • Married men & women more physically and emotionally sexually satisfied than singles; have more sex too
  • Women have sex less frequently, less oral sex, less reliable orgasms (men report same but have reliable orgasms)
    • Lower levels of sexual satisfaction for married women - may need to feel that they're wanted/attractive; won't speak up about what they want, need more time to be aroused
  • Sexual satisfaction positively correlated with marital quality - esp. initiation of sex by both partners & frequency of sex (couples who schedule sex on regular basis = have sex for whole life)
  • Why do couples stop having sex in marriage? familiarity, habituation, loss of passion, becoming less physically attractive to self or partner, birth of children, age-related decline, partners may have other sexual interests, sex might only be satisfying for one or neither but don't communicate (faking it = bad)
  • Sexless marriages not uncommon - lack of interest common (fast pace, 2 income families = not enough time or energy)
  • Extramarital relationships: more common 18-30 yo, more permissive attitudes, greater interest in sex, more opportunities (e.g. travel a lot) - 25% men, 15% women between 18-59 yo
    • Some couples have open relationships - swinging or polyamory

Lovemaps: "a developmental representation in the mind/brain of our idealized lover, idealized love affair, idealized program of sexuo-erotic activity projected in imagery, ideation, and behavior"
  • Develop from prenatal brain influences, early childhood experiences, pubertal hormonalization

Autoerotic behavior:
  • Kinsey: all males, 2/3 females have erotic dreams
  • 95% of people have erotic fantasies (daydreams, during masturbation, with partner) - often fantasize things they wouldn't act out (lovemaps)
    • Good way to get at their actual "lovemap" interest = ask about fantasies
  • Masturbation: historically subject of anxiety, belief that it means you can't get sex
    • 50% men, 16% women masturbate 2+ times/wk; 12% men/40% women never masturbate (college students)
    • Incidence of women masturbating rises with age, peaks in 40s
    • Married women masturbate more; males & females with higher education masturbate more

Interactive sexual behaviors:
Linear model taught in society; may need more variation:
  • kissing, petting/fondling, manual stimulation, oral stimulation, anal play/intercourse, coital positions (man on top traditional; women's movement brought in others),
  • 95% sexual encounters end in intercourse for heterosexual couples; varies for gay/lesbian
Differences in sexual behavior: may pose problems in relationship if couple doesn't share same interests (e.g. fetishes, BDSM, role play, talking dirty)

Successful relationships:
  • "opposites attract but don't last" -similarity is important (race, ethnicity, religion, intelligence, attractiveness, etc.) - "Homogamy"
  • Communication is key factor - reciprocal self-disclosure to build intimacy and trust
    • Good predictor of durability is how they handle conflict, anger (e.g. many more positive than negative interactions)

Marital disruption:
  • Divorce / separation: linked to passage of time, age at marriage, ethnicity
    • 1:5 ends within 5 years, 1:3 ends within 10 years, 1:2 ends within 20 years
    • Marriage during teen years increases risk of disruption
    • African-American couples more likely to break up than whites/Hispanics; Asian-American couples less likely than other groups
    • Virgins at marriage, religiously observant = longer marriages
    • Most divorced men/women marry again

Important to not just focus on sexual disorders, but sexual health as well

Somatization Disorder


Somatization is a behavior in which a patient complains of many unexplained symptoms in many bodily systems
  • Definition: "a polysymptomatic condition in which patients complain of multiple medically unexplained symptoms in many symptoms of review"
  • What patient does, not something they "have"
  • Behavior = complaining; mimic or imitate bona fide conditions without actually having them
    • Not a motivated behavior - acquired culturally
  • Used to be called "hysteria

Patients are hurting and get hurt by having the condition
  • See themselves as very disabled and act like it
  • Have extra surgeries, e.g. hysterectomies
    • somat. pts have 3lbs more healthy tissue removed vs. gender/age matched surgical controls
    • ~2x number of surgeries vs. sick people, ~4x more surgery vs healthy people
  • In one study, 9% of admissions had somatization disorder (docs don't recognize it well)
  • Costly to society & medical system - and $$ doesn't help pt
    • Somat. pts spend 7 days in bed / yr (vs. 0.5 for avg person)

Features:
  • Usually starts before adolescence
  • Pt background: unhappy, distressed, commonly hx of physical/sexual abuse
  • Family links:
    • 20% female relatives show same behavior
    • Male relatives more likely to be alcoholic or anti-social
    • Children have high incidence of ADHD
  • Incidence:1-7/1000 in general pop; M:F ratio of 1-3:10 
    • By nature overrepresented in hospitals though (9% of admissions?)
    • Criteria biased to make Dx in women
    • Males use disability services more often, females hospital services

Sick role:
  • Tallcott Parsons: "sick role" is a socially defined, legitimate role with:
    • Responsibilities (cooperate with docs, try to get well)
    • Relief of obligations; conferral of benefits (release from work, others concerned, victimhood, deliverance from demands) - creates positive reinforcement cycle
    • Also reinforced by the fact that their behavior creates real medical problems eventually
  • Somat. behavior is more or less unconscious: unusual goal of seeking the sick role / appearing ill
    • Patients driven to stay ahead of docs, avoid disapproval - avoid judgments about irresponsibility, failure to do things, etc.

  • Culture: Pts. imitate symptoms in a situation where certain privileges, considerations, attitudes can be expected from others
    • Behavior made available by fact that sick role exists, shaped & reinforced by benefits of sick role
    • If in a culture where no docs - complain to priests, others (culturally bound)
    • Culture determines form of symptoms, stress on pt. determines timing
    • Historically "hysteria" in the 19th c included paralysis, fainting - but as medicine got better at Dx of those motor problems, shifted to sensory side (no tests for pain)
    • Media reinforcement - "disease of the month" (e.g. chronic fatigue, food allergies, fibromyalgia)
  • Analogous to "supplier-induced demand" - docs / medical system used to having patients
    • Doctor role - admission can reinforce behavior; docs can become allies
  • Pt needs: ally helping to promote sickness (e.g. doc), predicament which has no other solution in their mind, model of sickness, social skills to pull it off

Diagnosis:
  • Identify by providing opportunity for behavior to be demonstrated
    • Medical history & evaluation
    • Review of symptoms
      • DSM III/IV - "symptom count" criteria, which changes from version to version - hard to use; biased to Dxing females
  • Short symptom screening test for somatization disorder
    • 100% specific if they say yes to 4 symptoms; 87% if 3 symptoms; 2 means more screening should be done
    • "Somatization Disorder Besets Ladies And Vexes Physicians"
      • Shortness of breath (respiratory)
      • Dysmennorhea (female reproductive)
      • Burning in sex organs (psychosexual)
      • Lump in throat (pseudoneurological)
      • Amnesia (pseudoneurological)
      • Vomiting (gastrointestinal)
      • Painful extremeties (skeletal muscle)
  • Psychiatric co-morbidity common
    • Relationship between # medically unexplained symptoms and # psych diagnoses
    • Common traits: histrionic, obsessional, dependent, neurotic/unstable, anti-social
    • Almost dose-response relationship between neurotic scores & # somatic complaints; also "harm avoidance)

Treatment
  • Murphy's principles: visit is more important than Tx; if you don't see pt. they'll find somebody who will - and that person will hurt them
    • Suggests routine, scheduled visits every few weeks; pay attention to person more than symptoms, don't inquire about details, avoid meds & manage behavior; lengthen time between appts until pt. starts causing, then go shorter
  • Smith's principles: need a gatekeeper (e.g. primary care physician); regularly scheduled, brief visits, look for signs not symptoms of disease; avoid tests, surgery unless clearly indicated and reassure pt you'll be watching for any developments
  • The four C's of behavioral treatment
    • Control - stop it
    • Confrontation - say what's going on (identify)
    • Conversion - persuade pt that life can be lived otherwise
    • De-conditioning - systematically undo/counter rewarding consequences (change reward system)
  • McHugh:
    • Diagnose (recognize pseudo-symptoms)
    • Separate pt from all pathogenic involvements
    • Counter-suggestion - remove attention, confrontation
    • Treatment & rehab directed at pt. vulnerabilities:
      • Co-morbid conditions, et.g. medical or psychiatric
      • Demoralization (feelings of defeat)
      • Personality vulnerabilities
  • Why? - spend less on care, don't waste, improve pt. behavior in sustainable manner with tx, increase physical capacity, functioning, mental health with tx.
    • Physical recovery is fast, mental recovery takes more time

Perspectives on Emotion

Key points:
  • Emotion is a useful psychobiological concept
  • Emotion links experience, physiology to motivate behavior
  • Maladaptive / painful emotional experience is:
    • the outcome of some disease processes
    • the manifestation of life story, dimensional processes
    • the cause of many behavioral problems

Definition of emotion: "an intense mental state that arises subjectively rather than through conscious effort and is often accompanied by physiological changes"
  • Primal, experiential, not like emoting or acting, needs to have physiological changes or otherwise it's just an idea

Other definitions:
  • Affect: outward manifestations of emotion
  • Mood: persistent/pervasive emotional state (mood:emotion::climate:weather - mood constrains emotions)
  • Feeling: emotional states refined at a higher level by cognitive processes
    • Feeling is "about" something; emotion is primary
    • Emotions are made known as feelings, moods, behaviors - can't be described directly

Some older models of emotion:
  • Folk psychology: emotional experience followed by emotional expression (event --> feeling --> response)
  • James-Lange: emotional expression followed by emotional experience (event --> response --> feeling) - physiology then response
  • Cannon-bard: emotional experience derives from brain activity; expression not required (event-->brain activation = feeling) 

Two-factor: currently the predominant model
  • Emotional experience combines context and expression
  • Event --> (brain activation + context) --> feeling
  • Fits with ABC model - integrated model of emotion
    • Antecedent (sensory data) --> behavior (brain activation, conditioning via context) --> Consequence (internally mediated, physiological)
Simplified model of emotional experience (feeling)
  • amygdala & other emotional areas of the brain, hippocampus combine with stimulus to give rise to the immediate conscious experience (emotional)

Physiological arousal is necessary but not sufficient to explain an emotional response
  • Expt: give people a stimulant and then either tell them about it or not, then put them in a happy or angry environment to take a "personality test" with somebody who's in on the experiment setting the tone
  • Results: much less of a strong response (either anger or happiness) if the pt is informed about the stimulant (context matters)

Qualities of emotion: two axes

less arousal
 more arousal
negative valence
 sadness, apathy
 anger, anxiety
positive valence
 contentment, relief
 elation, excitement

  • Valence - positive or negative experience or connotation
  • Arousal - intensity of experience or motivation that it inspires
    • Affects function: degree of arousal improves performance up to a point, then inhibits
      • Too low = not motivated; too high = distracted
      • For easy task, need more arousal (get bored easier)
  • Can map various stimuli for valence, arousal - predictable results across subjects

Two major motivational systems:
  • Satiety: detect + valence objects relative to appetitive drives, act to acquire object; valence resets to neutral once object acquired
  • Safety: detect high arousal, - valence objects and act to diminish arousal (e.g. escape)

Emotion and memory: emotional facts are normally recalled best (e.g. need to find water in desert to keep from dying, you remember where the oasis is)
  • if you block arousal / lesion amygdala, get loss of preferential recall of emotional facts
  • Amygdala - @ front end of hippocampus; crossroads in functional neuroanatomy of memory & behavior
    • Connects to cognitive, behavioral, physiological areas of brain
    • Blocking amygdala - can change reward-seeking or fear/avoidance behavior

Fear circuits
  • Long (cortical ) path goes from eyes to thalamus to visual cortex to amygdala, etc. - conscious thought of "this is a snake, get away" => can modulate response based on context
  • Short-cut for fear - directly from thalamus to amygdala - triggers freezing behavior (deer in headlights), primes sympathetic activation

Human tests (hard to get good data from animals' emotions)
  • Have subjects view pictures, read passages with emotionally provocative content => amygdala lights up
  • Stroop test: read the color of a word , e.g. the word "blue" colored in red, subject says "red" (modified version - use emotionally provocative words)
    • Longer response time for emotionally provocative words - need additional cognitive steps to process response
  • Specific facial features associated with emotional states across cultures; can lose (e.g. amygdala lesion)
  • Humans use emotion to interpret others' experiences - e.g. watch two shapes chase each other around; interpret romantically and you remember it more than just a series of movements

Disease perspective:
  • Known etiologies / pathophysiologies: traumatic brain injury (esp. temporal, frontal lobes), subcortical dementia, intoxicating substances, delirium
    • Phineas Gage - lost L. frontal lobe - emotional, behavioral changes
      • Frontal lobe - way station for all three mental functions (emotion, cognition, behavior are linked)
    • Drug use / intoxication - can increase arousal (stimulants) or decrease (opiods); can change emotional function (e.g. alcohol) although sometimes it can be adaptive (introverts loosening up with alcohol)
  • Depression, mania, panic, apathy, anhedonia - have emotional components
    • Idiopathic changes in emotion - mood disorders, etc.
      • Inappropriate elation, sadness, anxiety, irritability 
    • Loss of emotional response - apathy / anhedonia, or loss of emotional modulation - manic euphoria or lability
  • Pts. where amygdala has been knocked out - big emotional changes

Dimensional perspective:
  • Temperament: emotional disposition
    • "an individual's character, disposition, tendencies as revealed in his reactions"
    • "the characteristic way an individual behaves, esp. towards other people"
    • "consistent, basic dispositions inherent in the person that underlie and modulate the expresison of activity, reactivity, emotionality, sociability"
  • Early theory (hippocrates / galen): melancholic, choleric, phlegmatic, sanguine

    		Unstable
    		 Stable
    Introverted
    		 Melancholic
    		 Phlegmatic
    Extroverted
    		 Choleric
    		 Sanguine
  • Modern theory: Eysenck, essentially the same
    • Stable/unstable, introverted/extroverted axes - spectrum.
  • Emotional disposition vs emotional disorder
    • Disorder (disease) - inappropriate, unmodulated, diminished emotions
    • Disposition (dimensions) - probability of having strong emotional response in given situation
      • Problems arise when normal (in form) emotional reactions are maladaptive in function

Behavioral perspective
  • Emotions = subjective, experiential aspect of motivation (appetitive or defensive)
  • Behavior seeks to change valence / arousal level of emotion: flight from threat to reduce arousal, improve valence; riding roller coaster to increase arousal and valence (have fun), eating to increase valence (pleasure) and decrease arousal (hunger)
  • Disturbance motivates pathological behavior
    • Suicide: folk wisdom = "understandable negative emotional response"  to something
      • Reality: most are pathological emotional states (inappropriate, unmodulated, etc) incl. disease, e.g. depression
    • Addictive behaviors (substances, self-injury, bulimia, gambling) - conditions pt to seek behavior for instant, transient relief of any negative emotion
    • Downward spiral - maladaptive behavior creates negative emotional consequences which produce more maladaptive behavior (craving itself can be unpleasant emotion)

Life story perspective
  • Narrative - how we accept narrative as true is colored by emotional state
    • Revision of life story from tragic to something more hopeful begets positive emotions
  • Understanding somebody means knowing emotional life, not just facts (e.g. does height, weight tell you more about somebody than the fact that they're excited about an upcoming vacation or sad because their pet just died?)

Demoralization - a "persistent failure to cope" marked by feelings of impotence, isolation, despair - most frequent symptoms of pts in psychotherapy are anxiety and depression, direct expressions of demoralization

Grief: a "profound, prolonged, stereotypic emotional response to a significant loss"
  • Disease: syndrome but adaptive, not pathological
  • Dimension: differs in vulnerability & expression across individuals
  • Behavior: can choose how to grieve but not whether or not you'll feel grief; may be antecedent for other behavior
  • Life story: normal emotional response to involuntary interruption of one's life story; grief is best understood in life story context

Post-Traumatic Stress Disorder (PTSD)
  • General criteria:
    • Exposure to traumatic event (incl. witness)
    • Re-experience event
    • Avoid stimulus & emotions that recall event
    • Increased emotional arousal
  • Disease: reduced hippocampal volume (not known cause v. effect)
  • Dimension: higher neuroticism scores = more vulnerable
  • Behavior: avoidance (conditioned by unpleasant recalls)
  • Life story: people consider themselves damaged by the event

Summary:
  • Emotions are physiologic & cognitive as well as experiential phenomena
  • Two main dimensions: valence & arousal
  • Response is widespread in brain but most directly dependent on amygdala functioning
  • Diseases of emotion (incl. brain damage, intoxication, mental illness) are problems of emotional absence, modulation, or appropriateness
  • Temperamental dimensions describe emotional propensities - can produce clinical problems under predictable sources of stress
  • Valence and arousal are the currency of behavioral motivation, reward, satiety
  • We use our emotional experience to make sense of experiences of other people; it's also an efficient way to describe complex activities

Suicide and Violence

Suicide

Completed suicide vs. attempted suicide vs. self injury


Lethality vs. intent

 


 Low lethality
 High lethality
High intent
 OD on Prozac with note
 Gun in motel room
Low intent
 Wrist scratch with boyfriend after argument
 OD of tylenol after argument with mom

Females tend towards lower lethality / intent (but higher rates of attempts); males towards higher lethality / intent (so higher completion rates)

Epidemiology
  • Rate: 11 per 100,000 in US; 2.9% lifetime prevalence of attempt
  • Completion: Males > Females (3:1)
  • Attempt: Females > Males (4:1)
  • Older > Younger (but rates rising in young)
  • Native American / White > Asian/African-American/Hispanic

Mood disorders (major depression, bipolar) present in majority of completed suicide - although popular culture tends to think of suicide more in terms of life events than disease
  • 6-19% lifetime risk of suicide for people with mood disorders
  • Depression with "agitated / energized quality" can be especially dangerous - imparts a "driven" quality to self-destructive impulse

Disease Perspective: Biology
  • Serotonin deficit? more receptors in frontal cortex, less 5-HIAA (serotonin metabolite) in CSF
  • Genetic influence?  Suicide runs in families (even after controlling for psychiatric illness increase)
    • Higher suicide rates among biologic relatives of adoptees who commit suicide
    • Higher concordance for MZ twins vs DZ

Behavioral Perspective
  • Substance use disorders are second most common risk factor after mood disorders
    • Increased substance use disorders may be behind the increased suicide rates in young people
    • Can be complicated: alcohol can lead to secondary depression, or mood disorder could be primary and complicated by secondary alcoholism

Dimensional Perspective
  • Completed suicide more common in those with erratic / dramatic / emotional temperaments - unstable extroverts / "Cluster B"
    • Attempted suicide especially overrepresented
    • Sometimes see malingered suicidality in this group on presentation to ER - claim to be suicidal even if they're not

Life Story Perspective
  • Provocative factors: individual self-absorption, social disintegration / loss of status, social encouragement (romanticization via literature, movies, etc)
    • We often think about these factors first, media dwells on them, etc.
    • History of suicide in a family member also increases risk (people think it's OK if somebody close to them has done it)
    • Medical illness can cause suicidality - e.g. physician-assisted suicide
      • If fears about death dealt with in caring, knowledgeable way by physician, request for death usually disappears
      • The more physicians know about palliative care, the less they favor assisted suicide
      • Fears about pain and death need to be resolved first
  • Protective factors: religious beliefs (e.g. going to hell if I commit suicide); parental role (if they have young children)

Management of suicidality

1. Assessment:
  • Has it gotten so bad that you've thought about not wanting to go on? (passive death wish)
  • Have you thought that you might actually harm yourself?
  • Have you thought about how you might actually do it
  • Do you have the means available?
  • Have you tested it out?
  • Use collateral informants - patient might not tell you everything

2. Plan
  • Refer to psychiatrist whenever needed
  • Treat underlying causes (depression, substance use disorders)
  • Mobilize support & plan  - confidentiality is secondary if pt at risk
  • Psychotherapy helps - stigmatize self-destruction, affirm pt's sense of self-worth / hope, emphasize capacity for choice
  • Consider hospitalization if thoughts can't be controlled

3. Prevention
  • Patients: education about mood disorders (adolescents as well as adults)
  • Providers: need to get pts. on proper tx regimen with adequate antidepressant doses

Violence

  • Pts with major mental illness at higher risk for violence (esp. those with schizophrenia; substance abuse also increases risk substantially; substance abuse + major mental illness is biggest risk factor)
  • Suicide can be conceptualized as violence against oneself - common factors
  • Schizophrenia:
    • One study: 19% had committed violence in past 6 mo
    • Serious violence associated with psychotic (persecutory delusions - like a pre-emptive strike) and depressive symptoms, childhood conduct problems, victimization
  • Violence on the job more common for those who are mental health professionals
  • Neurobiology
    • Decreased serotonin function (like suicidality)
      • Less serotonin transporter in anterior cingulate cortex; less metabolite in CSF
    • Low MAOA activity associated with violence (opposite of what you'd expect - could be developmentally related)

Managing violence:
  • Think PREVENTION
  • YOUR behavior - keep your distance, position yourself for escape
  • Use MEDICATIONS: give liberally before interview - antipsychotics in large doses, benzos in large doses
  • Call SECURITY (before interview) - may need one for each limb
  • RESTRAINT and SECLUSION as needed - using stretcher or bed, or a seclusion room

Conclusions:
Suicide
  • Suicide is powerfully influenced by disease factors (mood disorders, biology of serotonin)
  • Behavioral factor (substance misuse) plays a role
  • Dimensional factors: emotional, impulsive temperament
  • Life story factors: availability of means, cultural attitudes, family / economic instability
  • Management: inquire explicitly about suicidal thinking, treat depression, stigmatize suicide, emphasize choice & value of pt's life
Violence
  • Increased risk for violence in pts with mental illness, especially those with schizophrenia & substance use disorders
  • Low availability of serotonin, low activity of MAO may be risk
  • To be safe: keep your distance, give high dose antipsychotics, call security, consider restraint/seclusion

Sexual Function & Aging

Statistics
  • Steep drop in sexual activity with age; lower for women
    • Men - intercourse; women - masturbation with age
  • Of those who are sexually active, there's less of a drop-off in frequency - "people who have good sex lives have good sex lives"
  • Age 70+: 18% women, 41% men sexually active, regardless of partner status
  • Reasons for inactivity: women = no desire, no partner; men: ED, no partner
  • 48% perfectly happy not having sex at all

Factors affecting sexual function at, after midlife:
  • Physiological changes: endocrine, cardiovascular, neurovascular
  • Medical problems for self & partner
  • Medications (polypharmacy)
  • Environment (hard to find privacy in a nursing home)
  • General well-being
  • Relationships (history, length, lack of)
  • Primary sexual problems & previous sexual history (if somebody had problems when younger, probably won't bring it up after all these years)

Medical history factors:
  • Direct/indirect damage, functional limitations, fatigue
  • Cardiovascular diseases
  • Diabetes - more problems type II (unhealthy lifestyle, etc)
  • Neuromuscular: parkinsonism, seizures, MS, neuropathies
  • Psych problems, sleep disorders, pain, autoimmune problems
  • Huge list of medications that can be implicated (e.g. SSRIs, sleep agents, alcohol, etc)

Psychosocial issues
  • Previous sexual function problems;
  • Changes in interest, motivation, relationship quality, history; Socio-economic pressures, changing roles & social expectations
  • Decrease in opportunities, changing self image, body image with age
  • Religious beliefs
  • Fear of STDs

In women:
  • Sexual function changes with aging process - both with and independent of menopause
  • Social mis-expectations about older women, sexuality; opportunities decrease
  • Pts and providers feel uncomfortable discussing sexual function/dysfunction ("women shouldn't talk about sex") - esp. aging women
  • Core group of people having sex live longer (increase in sexual activity from 60s to 70s)
  • Common problems (most -> less common): lack of interest, difficulty with lubrication, inability to climax, sex not pleasurable, pain during intercourse (goes down with age), anxiety about performance
  • Menopause
    • Avg age 49-51; genetics, history, natural or surgical
    • Perimenopausal women: >20% dissatisfied sexually; only 10% seek tx
    • Tissue atrophy, reduced lubrication, pH increase -> more microbial infections (increases STD risk), changes in body fat distribution, muscle strength, bone structure, etc. --> self image changes
    • Other changes: slower arousal, reduced intensity; pelvic floor changes (e.g. childbirth), reduced libido
    • Symptoms: night sweats, hot flushes, sleep / mood disturbances & disorders, breast tenderness, lack of energy, stiff/aching joints, anxiety, palpitations, urinary symptoms, vaginal dryness
      • Risk factor for depression
      • Perimenopause can last for 10yrs + (symptoms)
  • Hysterectomy/oophorectomy (surgical menopause)
    • 1/2 million women per year; after c-section, hysterectomy is most commonly performed major surgery among reproductive-aged women in USA
    • (55% hysterectomies also include bilateral oophorectomy)
  • Estrogen - premenopausal ovaries produce 90-95% circulating estradiol; gradual decline starting at puberty then steep decline to almost no production @ menopause
    • Impacts genital/pelvic function (local arousal) and systemic impact too (desire)
  • Testosterone - "hormone of desire" but not a linear relationship
    • Premenopausal levels for women = 1/10th to 1/20th male levels
    • Ovarian, adrenal production reduces with age (not with menopause)
    • If you're going to measure it, measure free T (not total - need to know what's available) - and threshold levels are important
  • Hormone therapy
    • WHI (Women's Health Initiative) scared a lot of people - studied women, showed increased cardiovascular risk
      • Problem with study - studied women had been off estrogen (postmenopausal) for years
      • Safer if hormones started @ time of menopause
    • Cardiovascular risk, breast cancer risks are pretty low (obesity is higher risk factor than hormones for breast cancer, for instance)

In men:
  • Common problems (most->less common): erectile dysfunction, climaxing too quickly (decreases with age), lack of interest, anxiety about performance, inability to climax (increases greatly with age), sex not pleasurable
  • ED and cardiovascular problems are highly comorbid
    • 26% Americans have 1+ forms of cardiovascular disease (contributors: hypertension, diabetes, high cholesterol, obesity, smoking, family hx, sedentary lifestyle, drugs)
    • 20%+ have hypertension; 90% lifetime risk by age 80-85 
    • Small vessel diseases too
    • ED risk is a good way to get people to stop smoking (threatens their sex lives)
  • Physiological changes
    • Tissue atrophy, reduced lubrication, pH increase, related microbial shifts
    • Vasomotor symptoms
    • Dyspareunia (= painful sexual intercourse)
    • Diminished inevitability period, increased refractory period (probably from less frequency)
    • Changes in body fat distribution, muscle strength, bone structure, skin integrity, hair, self-image, etc.
    • Cardiovascular changes, pelvic floor changes (e.g. incontinence), reduced libido
  • But males actually get more satisfied as they get older with their sexual functioning (although function itself goes down)
  • More ED, more severe ED with age (complete ED is much harder to treat)
    • If you involve women in ED dx/tx, better results
    • 1/2 men stop using ED meds @ 12 mo - not working - need to keep checking up
  • Testosterone:
    • Affects sexual function in brain and in local tissue
    • Normal gradual decrease over lifetime in T levels (also have annual, daily shifts as well)
    • Wide range of normal: 200-900 ng/dL (300+ is better)
    • Threshold levels for sexual function - consistent for an individual but variable between individuals (vary between 100-900 ng/dL between males)
      • Mean threshold drops from age 50s to 80s (251 - 156 ng/dL)
  • Adult onset hypogonadism
    • < 325 ng/dL T is abnormal - ~20% older men
    • Primary, secondary causes (chonic disease, obesity, meds, more)
    • Treat with T; desire increases

Men and women:
  • Dysfunction is multidimensional
    • "use it or lose it" - If you're abstinent for a long time, you can have physiological problems (ED, vaginal dryness, etc)
    • Endocrine balance, vascular status, relationship/stress/depression/"learned disability" all contribute & interact with function, frequency, quality of sexual activity
  • Guys have increasing emotional sex satisfaction with age, women decrease
  • Communication with healthcare providers is important - few pts (less women than men) initiate discussions; few physicians initiate - but 32% women, 86% men >70yo feel physicians should initiate the conversation about sex
    • Make it open-ended; make sure they know that it's normal to talk about this stuff

Treatment:
  • Med changes if meds are interfering
  • Use meds & education (off label for women especially?)
  • Hormones?  guys have shorter life expectancy with lower T
  • Exercise (women more orgasmic afterwards), more sex helps too
  • Refer: center for sex med, regional centers, psych / endocrinology / gyn / urology consults, couples counseling, sex therapy

The Life Story Perspective (Demoralization & Meaning)

  • Logic: setting --> sequence --> outcome

  • Everybody in the room uses it all the time, but not always as a professional
  • Strengths: source of empathy; limitation: implies greater knowledge (e.g. I know why you...)
  • Empathy: powerful tool, but can have unwanted side-effects and adverse outcomes (like meds)

Demoralization: "an emotional state characterized by discouragement, a feeling of being overwhelmed, and hopelessness"
  • Represents a clinical application of the life story perspective
  • Prevalence - 3x higher in medically ill (25-40%) but not everyone experiences it
  • People don't see other options when they're demoralized - docs can help them see what other choices exist so that they can choose well

Re-moralization: major goal of life story method
  • Identify the problems (is it demoralization or depression)
  • Help the patient act (not choosing is a way of making a choice - pts need to choose)
  • Review successes and failures (what could I have done better?  what did I do well?)

Applying the life story method:
  • Life story reasoning is universal; need to recognize strengths and limitations as a professional
  • Part of doctoring is to help pts distinguish between facts (disease reasoning, for instance) and stories
  • Power of therapeutic relationship - based on life story relationships
  • Listening is a powerful clinical tool - don't always have to 'do' something
  • Clarification can be a helpful intervention - "do you mean..."
  • Meaning without action rarely helps - doesn't help to say "well, you feel this way because..." unless you have a way to help

Diagnosis and Treatment of Sexual Dysfunctions

Female Sexual Dysfunction

Female sexual response is complex (psychological, neurological, vascular, endocrine systems); Male response is less so. 
  • Women have more sexual complaints than men (43% vs 31%)
  • Female risk factors: age, health status, depression, meds, quality of relationship
  • M&J model of female sexual response cycle: desire, arousal, plateau, orgasm(s), resolution
    • Composite model (may not match any one woman)

Categories of female sexual dysfunction: can have disorder in any of the above areas
  • Sexual desire disorder, arousal disorder, orgasmic disorder, pain disorders
    • All interrelated (highly comorbid but not always)
    • Can become inductive (E.g. no desire > leads to arousal problems > leads to no orgasm, pain eventually - reinforces lack of desire)

  • Hypoactive sexual desire disorder: Persistent or recurrent deficiency (or absence) of sexual fantasies/thoughts and/or desire for, or receptivity to, sexual activity, which causes personal distress 
    • (need distress for disorder - many people lose desire with age but it's not pathological if it's not distressing)

  • Female sexual arousal disorder: absence or markedly diminished feelings of sexual arousal (sexual excitement/pleasure) form any form of sexual stimulation
    • Can be lack of subjective excitement (cognitive), genital response (physiological - lubrication/swelling), or both.
    • Unlike men, cognitive / physiological sides can be disconnected (can be aroused physically but not emotionally)

  • Desire (biological) vs. motivation (psychosocial - interest) - overlap often but not always
    • Libidinal dysfunction: low desire, normal motivation (e.g. love my husband but don't want to have sex with anybody; low T could be a cause)
    • Sexual anergia: low desire, low motivation (e.g. chronic medical conditions, breast cancer pts, aromatase inhibitors, etc)
    • Sexual disaffection: normal desire, low motivation (e.g. not with husband but with other guys - psychogenic)

  • Risk factors: clinical depression, antidepressant drugs (SSRIs cause inhibition of orgasm, not usually desire), age, chronic illness (e.g. diabetes, cardiovascular, lower urinary tract syndromes / LUTS, oophorectomy makes sex drive vanish if no exogenous T)
    • Combination of medical, psychological, sociocultural, interpersonal/relational influences -  multidetermined

  • Treatment - nothing really FDA approved for women yet; lots of studies going on - currently any rx is off-label
    • Often, female disorders are considered "lifestyle disorders" so FDA doesn't approve as readily as for males' "medical disorders" (in opinion of lecturer)
    • Testosterone does work (transdermal is safer but FDA didn't approve - increases activity, satisfaction, desire, arousal, orgasm, self-image, etc)
    • Viagra / other PDE-5 inhib work for arousal but most females have desire disorders
    • Wellbutrin has least side effects of antidepressants
    • Best tx is information - for females and for physicians

Male sexual dysfunction


Male sexual response: libido/desire > erection > ejaculation > satisfaction/resolution > libido/desire... (cycle)
Common dysfunctions:
  • Erectile dysfunction
  • Hypogonadism (>60yo especially - docs afraid to give T, thinking that prostate cancer might increase, but there's not much evidence)
  • Ejaculatory problems (premature, retrograde, anorgasmia (really rare in men not to have orgasms)
  • Also can have diminished or excessive libido

ED - 40% vascular, 30% diabetes, 15% meds in origin
  • If ED increases, desire can diminish - so if somebody complains about lack of desire, screen for ED
  • ED increases greatly in prevalence & severity with age (more ED, more complete ED)
  • Meds : SSRIs and antihypertensives / diuretics are the big two (but can be others too)
  • Emotional predictors (greatest->lesser): emotional problems/stress, depression, dissatisfaction with partner, >20% decrease in income
  • Lifestyle risk factors: lack of excercise, obesity, heavy drinking, drug use, smoking
  • Psychogenic vs. organic ED:
Psychogenic
 Sudden onset
 Complete, immediate loss of function
 AM erections present
 Erectile function varies with partner, circumstance
 Typical presentation: young guy
Organic
 Gradual onset
 Incremental progression
 Lack of AM erections
 Lack of erections under most sexually stimulating circumstances
 Typical presentation: older guy with partner of decades
  • Psychogenic causes - depression, performance anxiety, relationship problems, psychosocial problems, psych diseases

Treatment of ED
  • Med, sex, psychosocial history > physical exam (genitalia, secondary sex characteristics), lab tests as needed
  • Care:
    • 1st line = viagra, lifestyle therapy, counseling, hormones
    • 2nd line
      • Vacuum constriction devices - use negative pressure to mechanically create penile blood filling; downsides are that it ruins the romance & is artificial (cold penis)
      • Intercavernosal injection: alprostadil (induces corporal smooth muscle relaxant effects) - inject right into corpora cavernosa - painful, can cause fibrosis but works often
      • Can also use transurethral alprostadil (painful too), topical creams/gels
    • 3rd line: penile prosthesis surgery, including hydraulic implants (switch pumps things up or deflates - but it's a surgical procedure; the valve can stick open)

Affective Disorders

Classically known as "mood disorders"


 Mania
 Depression
Mood changes
 Elevated, expansive, or irritable
 Depressed or irritable
Vital sense
 Increased
 Decreased
Self-attitude
 Increased, at times grandiose
 Decreased
Why do we think affective disorders are diseases?
  • clinical syndromes (similar symptoms across individuals, cultures, history)
  • genetic evidence (1% gen pop, 10% 1st degree family, 50% MZ twins)
  • biological changes (specific brain injury can cause depression - L. frontal cerebral cortex, basal ganglia strokes especially)
    • Major depression higher in CNS diseases (Parkinson's, MS, migraines, Alzh), no increase in ALS or other PNS diseases - just more demoralization

Major Depressive Disorder (MDD)

Clinical syndrome
  • Mood changes - depressed or irritable
  • Vital sense changes (neurovegetative symptoms) - decreased
  • Self-attitude changes - decreased
    • The first two could be demoralization, but this is key for depression
    • Ask: Do you think you're a good mother/father/provider, burden to family (if old), attractive, cool (if young girl/boy)

Symptoms
  • Depressed or irritable mood or feeling nothing - 50% people with MDD lack "sad" feeling (esp. teens - irritable)
  • Anhedonia - decreased interest, pleasure in activities
  • Physiological changes (can go either way)
    • Change in appetite, weight (seek comfort from food)
    • Sleeping more or less than usual (classic - wake up early in morning)
    • Feeling restless or slowed down (generally slowed down, but restless - drug/alcohol use can be used for short-term relief when restless)
  • Fatigue / loss of energy
  • Decreased concentration (grades / work performance goes down, or other aspects of life as they focus everything on work)
  • Feelings of guilt or worthlessness
  • Recurrent thoughts of death, suicide (a potentially fatal disease)
  • Psychotic symptoms (hallucinations, delusions) possible but rare - when present, delusions & moods link up in somewhat consistent/sensible ways

Intense feelings - often family members don't "get it"

Classic def'n of depression:
  • 5+ symptoms during a 2 wk period, causing clinically significant distress/impairment in functioning,
  • not due to alcohol or other substances or med condition (although comorbidity possible)
  • and only depressive episodes (no manic or hypomanic episodes).
    • If manic too - Bipolar I
    • If hypomanic too - Bipolar II

Epidemiology of MDD
  • Lifetime prevalence: 10-25% for women, 5-12% for men (one of most common disorders in all of medicine)
  • rates equal for pre-pubertal boys & girls, then women 2x as often post-menarche (hormonal effect?)

Mania

Symptoms
  • Elevated, expansive, or irritable mood
  • Inflated self-esteem or grandiosity (paranoia is like a type of grandiosity - think that everybody's paying attention to you)
  • Decreased need for sleep
  • More talkative or pressure to keep talking
  • Racing thoughts
  • Distractibility
  • Increased activity or agitation
  • Excessive involvement in pleasurable activities
  • Engages in risky behaviors - e.g. think that they can fly, lose judgement (risky sex, drive fast, jump off of buildings)
  • Psychotic symptoms (hallucinations and delusions) are possible, but rare - associated with more severe cases

Bipolar Disorder - Type I
  • Manic-depressive illness, both depressive and manic episodes
    • Manic episodes - at least 3 symptoms for at least 1 week
  • Prevalence ~1% of population
  • Equal rates men/women (increased a bit in females for BPD II)

Bipolar Disorder - Type II
  • Hypomanic episodes instead of manic
    • Difference is that judgment isn't so severely impaired; not so much energy, etc.

Treatment of mood disorders

  • Medications - antidepressants or mood stabilizers
  • Individual psychotherapy
  • Education, support
  • Control of behaviors - alcohol abuse, substance abuse, eating disorders, cutting
  • Other Tx: electroconvulsive therapy (ECT - not so bad these days), bright light therapy if seasonal component (seasonal affective disorder = SAD)
  • Best is meds + other treatment (like other diseases, e.g. diabetes, hypertension)


Depression:
  • Goal: elevate mood back to baseline
  • Challenges: delay in meds' effectiveness, side effects, compliance

Bipolar disorder
  • Goal: mood stabilization
  • Challenges: potential to destabilize mood (e.g. antidepressants triggering "overshooting" > manic episodes; compliance falters esp. when manic)

Antidepressant medications:
  • Selective Serotonin Reuptake Inhibitors (SSRIs) - fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa)
    • Block re-uptake but we don't know what happens after that
  • Tricyclics - Nortripyline, desipramine, imipramine
  • Selective Serotonin-Norepinephrine Inhibitors - venlafaxine, duloxetine
  • MAO inhibitors - phenelzine, tranylcypromine
  • Others - bupropion (Wellbutrin), mirtazapine, trazodone

Mood stabilizers
  • Lithium (best evidence for this one)
  • Divalproex sodium (Depakote) - evidence for this one too
  • Carbamazepine (Tegretol), lamotrigine (Lamictal), gabapentin (Neurotonin), topriamate (Topamax), atypical neuroleptics e.g. seroquil
    • these are seizure meds but lots of marketing to use them as antidepressants (scant evidence)

Is current Tx adequate?
  • Study of gen. practitioners (not enough psychiatrists to provide care)
    • Really low rates of pts receive antidepressants (11% of mild depression cases, 29% with severe depression)
    • Only 41% of those getting meds got an adequate dose
  • Another study: 68% with depression detected by GP; 52% of those got antidepressants (still missing 1/3 for Dx, 1/2 of those for Tx)
    • Only 27% completed an adequate trial - so less than 10% got adequate treatment
  • Need follow-up and good education for physicians & pts
    • Inform ahead of time & monitor side-effects to increase compliance
    • Need to get pt above tx threshold or else the meds have no effect
  • Goal: adequate doses for sufficient time periods - up to 8wks at therapeutic dose
    • Increase compliance - discuss availability of multiple options, ask about side effects, educate about time needed for benefits, follow up in 1-2 wks for brief visit

Mood disorders & the perspectives:
  • Disease: established clinical syndromes, building evidence but not conclusive about etiology
  • Dimensional: individuals vulnerable with different responses to illness, challenges of tx - harder to pick up introverts with depression or extroverts with mania, for instance
  • Behavioral: associated with motivated behaviors, can be a potential trigger or sustaining factor
  • Life story: individual response to having illness fits into pt's life

Conclusions:
  • Mood disorders = common, treatable diseases
  • Need antidepressant, mood stabilizer trials to be of adequate length at therapeutic doses
  • Treatment requires collaborative effort between pt and physician

Anxiety Disorders

Components of anxiety
  • Psychic anxiety
    • Apprehensive expectation (affective experience, cognitions - e.g. worry)
    • Vigilance and scanning (hyperalertness, difficulty concentrating, insomnia)
  • Somatic anxiety
    • Autonomic hyperactivity (cardiopulmonary, GI symptoms - e.g. parasympathetic; bowel & bladder need to be emptied)
    • Motor tension (muscular tension, fidgeting, tremor)
  • AVOIDANCE - big symptom of anxiety disorders - what do you avoid doing?

Arousal vs. performance (Verkes-Dodson law)
  • Performance increases with anxiety(arousal) to a point, then you start underperforming when you're overanxious. 
  • Way out at the end of the curve = panic attack - paralyzed with fear (extreme arousal, extremely low performance)

Fear circuit
  • Sensory perception (potential threat, e.g. see snake) + hippocampus (remembering specific aspects of fear reaction) + prefrontal cortex (inhibits amygdala) + thalamus, sensory association cortex
  • All go to amygdala - center of this reaction
    • amygdala affects lots of fear-response areas (details below FYI)
    • amygdala in turn affects striatum (motor activation), PAG (escape, analgesia), dorsal motor nucleus of vagus (parasymp arousal), locus ceruleus (norepi), dorsal raphe (serotonin), ventral tegmental area (VTA>dopamine), paraventricular nucleus of hypothalamus + extrahypothalmic areas for CRF secretion (corticotropin releasing factor -> stress hormones; more cortisol released from adrenal gland)

Anxiety disorders: panic disorder, phobias (agoraphobia, specific phobia, social phobia), OCD (see previous lecture), PTSD, generalized anxiety disorder (GAD)

Panic attack - sudden build-up of intense anxiety with 4+ symptoms
  • Physical: palpitations (pounding heart, acc. heart rate), sweating, trembling, shaking, shortness of breath, smothering, choking feeling, chest pain, discomfort, nausea / GI distress, dizzy/lightheaded/faint, chills/hot flushes
  • Cognitive/perceptual: "derealization" / "depersonalization" - feel removed from reality; fear of losing control/going crazy; fear of dying; paresthesias

Panic disorder - condition characterized by recurrent, "spontaneous" panic attacks with associated interference (e.g. avoidance or always going to doctor, etc.)
  • Disease perspective: panic attacks seem to pt. to be "foreign" phenomenon, can be caused by certain medical conditions
    • Heritable but could be via personality (which is itself heritable) - not necessarily "broken part"
    • Biological effects - increased sensitivity to variety of chemicals (like CO2), decreased cardiac variability ("autonomic inflexibilty")
  • Dimensional perspective: personality traits (e.g. high neuroticism), anxiety sensitivity are risk factors
  • Life story perspective: stressful life events can be precipitating factors

Phobias - unreasonable, disabling fears that are consistently cued by the presence or anticipation of specific objects or situations which are avoided or endured with intense distress
  • "fear with avoidance" - causes impact on person's life

Agoraphobia - fear of places/situations in which help might not be available or where escape could be difficult/embarrassing
  • e.g. being away from home, crowds/lines, bridges/tunnels, traveling in bus/train/plane/automobile (not fear of traveling per se but rather fear of being unable to escape
  • Often with panic disorder

  • Disease perspective: heritable, partially separable from panic disorder (probably via. introversion)
  • Dimensional perspective: high neuroticism, low extroversion, avoidant/dependent personality as risk factor
  • Behavioral perspective - important for natural history & treatment
    • Try to get people to do the things they're avoiding, break the cycle of negative reinforcement (opposuite of treating substance abuse, where you're trying to get them to avoid things they're doing to break a positive reinforcement cycle)

Specific Phobia:
  • Animal type (e.g. dogs, mice, insects)
  • Natural environment (storms, heights, water)
  • Blood/injection/injury (associated with decreased heart rate, vasovagal responses unlike others - so pts tend to faint)
  • Situational (public transport, tunnels, bridges, elevators, flying, driving, enclosed places, etc.)
  • Others (choking/vomiting, "space," costumed characters)

  • Disease perspective: heritable (overlap with personality), biological correlates (severe vasovagal response to blood, etc. in BII phobics)
  • Behavioral: important for natural history & treatment - choices about what to do impact recovery

Social Phobia
  • Fear of embarrassment / humiliation in social situations
  • Performance types (public speaking, recitals, using public restrooms, writing/eating with others around) - affects choices; people will give up promotions, etc.
  • Intrapersonal types (initiating, maintaining conversations, participating in small groups, dating, attending parties) - higher if high neuroticism / introversion
  • Dimensional/behavioral perspectives:
    • Personality vulnerabilities (high neurot, low extrovers.) - maybe shy around age 13
    • Traumatic experiences (teased, humiliated)
    • Respond by facing social situations (increased discomfort / opportunity) or avoiding social situations (decrease discomfort / embarrassment, reinforces cycle of restricting activities / isolation)

Post-Traumatic Stress Disorder (PTSD)
  • Requires severe stress (actual or threatened death, serious injury) with attendant intense fear as well as chronic associated symptoms:
    • Re-experiencing - e.g. nightmares, flashbacks
    • Avoidance / numbing - less responsive to loved ones, etc.
    • Increased arousal - overlap with other anxiety disorders

  • Disease perspective: heritability, small hippocampus (cause/effect?)
  • Dimensional perspective: personality traits are risk factors for exposure (risk-taking) or development/persistence of symptoms (e.g. high neurot, low extrovers more likely to be symptomatic)
  • Behavioral perspective: exposure to the memories & situations the person is avoiding for Tx
  • Life story perspective: defining characteristic of PTSD

Generalized Anxiety Disorder
  • Condition characterized by chronic anxiety and worry about several aspects of one's life
  • Typical symptoms: feeling restless/keyed up/on edge, fatigue, poor concentration, irritability, muscle tension, poor sleep (e.g. difficulty falling asleep)
  • GAD pts often have high lifetime h/o other anxiety d/o & depression

  • Disease perspective: symptoms seem "foreign" to pt, heritable, decreased cardiac variability
  • Dimensional perspective: anxiety is a normal phenomenon but these people have it more; high neurot. is risk factor
  • Life story perspective: stressful life events cause worse, more symptoms

Epidemiology of anxiety disorders
  • 1:5 prevalence; almost 20% of psych service use - very common, lots are in primary care settings
  • Course: anxiety disorders usually chronic, fluctuating conditions with early onsets (childhood / adolescence)
    • Panic, agoraphobia, sit. phbia often in early adulthood
  • More common in women
  • Anxiety disorders have high comorbidity with each other; also with depression & substance use disorders
  • Onset usually precedes that of comorbid depressive, substance use disorders
  • Genetic links - higher prevalence in 1st degree relatives

Therapy
  • Psychotherapy
    • Supportive/education first
    • CBT:
      • Cognitive: Relaxation during panic attack; exposure exercises; cognitive exercises to combat negative thoughts
      • Behavioral: avoidance, learning to tolerate anxiety symptoms - break negative reinforcement cycle of risk avoidance
    • Group - support or other (e.g. social phobia)
    • Psychodynamic- have to understand origins of panic, GAD
  • Meds
    • Work immediately:
      • antihistamines (sedating),
      • benzodiazepines (e.g. acute stress; quick & effective but don't want to give them for chronic conditions: abuse potential)
      • beta-blockers help control sympathetic hyperactivity, can help performance anxiety & peripheral symptoms; not helping thoughts but helps break cycle
    • Don't work immediately
      • For chronic/frequent anxiety - start at low dose, advance slowly (treat pt. as if elderly to avoid agitation)
      • SSRIs, tricyclics, MAOIs (antidepressants) can help for anxiety too - not wellbutrin, which actually agitates many pts
      • Venlafaxine, buspirone

Personality Disorders

  • Personality ~ totality of traits (shaped by nature, nurture, situation, self) - dimensional
  • Personality disorder present when:
    • same situations repeatedly cause distress in a person (traits inflexible, non-adaptive to experiences)
    • traits cause difficulty in all/most domains of life - work, school, sex, relationships
    • provocations leading to distress are minor
  • Personality disorder diagnosis identifies something typical in a person, giving a general formation of that person's vulnerabilities - their tendencies - helping understanding

DSM IV groupings
  • Cluster A - Odd / Eccentric
    • Paranoia - sensitive, distrustful, suspicious
    • Schizoid - socially detached, emotionally constricted
    • Schizotypal - interpersonally uncomfortable / awkward, cognitively awkward, behaviorally eccentric
  • Cluster B - Dramatic / Emotional / Erratic
    • Antisocial - selfish, callous, belligerent (M>>F)
    • Borderline - impulsive, emotionally/interpersonally unstable (F>>M)
    • Histrionic - emotionally reactive, attention-seeking (F>M)
    • Narcisssistic - grandiose, admiration-seeking, unempathetic (M>F)
  • Cluster C - Anxious / Fearful
    • Avoidant - socially inhibited, emotionally fragile, fearful of evaluation
    • Dependant - submissive, clinging, care-seeking
    • Obsessive-compulsive - excessively orderly, perfectionistic, controlling (M>>F)

Categorical approaches of typologies (as DSM above) are traditional, can sometimes be validated, are more efficient but more subjective / can be changed as concepts
  • Oriented to "pathology" trying to formally explain tendencies of pts
  • Way of dealing with near endlessness of traits
  • but can change with time & cultural understanding
Dimensional approaches are statistical, more valid, but complex & can miss essential points, stable as concepts, emphasis on population not individual
  • Universal approach, reflecting psychology
  • Predispositions/tendencies - e.g. mood lability (life calls for steadiness in most things) but too labile = histrionic, too steady = obsessional
Tension between the two reflects tension throughout medicine - both are clinically useful and valid (e.g. newtonian, quantum physics)

Antisocial Personality Disorder
  • Traits: little conscience, remorse, shame; cold, destructive, cold, callous, low empathy, low personal loyalty, manipulates love, loyalty; poor social impulse control, rebellion, irresponsibility, low social role-taking, selfish, egocentric, self-aggrandizing, impervious to influence, doesn't learn from experience, doesn't tolerate constraints, risk-taking, stimulus seeking, if sad, sad that they have to pay consequences for their actions - Shotgun Joe
  • DSM criteria biased towards poor people - same intrinsic problem as those who manipulate Wall Street
  • Correlates with criminiality (30-80% prison inmates), over-represented on trauma services, 70-90% drug addicts
  • Delinquency correlated with decreased upward mobility as adult outcome - personality as a determinant of future social class
  • Heritable and environmental: reduction in rates for those children of antisocial fathers adopted out of but increase if adoptive father also antisocial

Neurotic Paradigm: traits = potential, circumstances = provocation, emotional reaction = response
  • E.g. paranoid person reacts with hurt, anger, suspicion to perceived threats that others might not perceive, dependant person > fear & anxiety to perceived threats of abandonment

Gender Identity Disorder

New ideas:
  • Notion of 2 sexes being challenged - transgendered identity emerging (male, female, and "other" - androgynous / in between / different)
  • Transvestites / cross dressers / transsexuals not separate categories but Dx may just represent a point in time
  • Patients demanding right to make more choices; changing gender identity tx - why do I have to get a note from a psychiatrist to get surgery?
    • Provider can often learn much from patients' experiences

GID Diagnosis (DSM IV)
  • Strong, persistent cross-gender identification
  • Persistent discomfort with sex / sense of inappropriateness in gender role of that sex
  • Not intersex (not physiological in that sense)
  • Causes clinically significant distress or impairment in social, occupational, other important functions

Transgender - all individuals who experience some form of cross-gender identification or cross culturally defined categories of gender
  • Culturally bound - e.g. females can wear suits today and it's acceptable, wouldn't have been a century ago; men can't wear dresses
  • Continuum of behaviors: costuming, female/male impersonators, drag queens/kings, homosexual cross dressers, heterosexual cross dressers, transgenderists, transsexual
    • Cross-dressing: majority are heterosexual
    • Transgender vs transsexual: "gender is between the ears, sex is between the legs" - depends on patient's perception
    • "Camping & vamping" - camp has sense of parody, "vamp" indicates extreme feminine acts (e.g. dress up with big breasts, very outlandishly feminine)

Incidence:
  • Officially 1:11,900 M->F, 1:30,000 F->M - but this is from surgical applications (reflects transsexuals, not other transgender)
  • Other estimates (Janus): 6% men, 2% women have some experience with cross-dressing

Etiology:
  • Current evidence inconclusive
  • Biology? genital differentiation explains intersex; could brain differentation explain GID? 
    • Some studies indicate BSTc (central subdivision of bed nucleus of stria terminalis) may be female sized in M-F transgender but small studies (n=5) and pts had been on hormones for treatment - not conclusive
  • Social learning? exposure to conditioning experiences could support behaving in manner traditionally associated with opposite sex; identify with parent of opposite sex
  • Normal variant? Maybe gender identity is a continuum?  Gender transposition?
  • Psychopathology? Maybe form of body dysmorphic disorder?

Integrated theory:
  1. Genetic predisposition
  2. Prenatal hormones support genetic heritage, stimulate behaviors/internal feelings, neural pathways change
  3. Socialization patterns shape manifestation

History:
  • Early 20th c. Magnus Hirschfeld, Havelock Ellis coin term "transvestism" to apply to cross-dressers; "sex transformation" expts in early 20th c (animals, then humans), first sex-change operations in 20s and 30s in Berlin (Hirschfeld); Harry Benjamin (endocrinologist colleague of Hirschfeld) brings to America, US attorney general nixed his desire to do 1st sex change surgery in USA
  • 50s-60s: Ex-GI George Jorgenson gets sex change, returns to US as Christine, applies for marriage license to man - big news.  Harry Benjamin publishes "Transsexual Phenomenon" in 1966. 
  • Hopkins Gender Identity Clinic: Opened 1966, legitimized sex reassignment surgery, paved way for opening of other programs although few surgeries performed.  1979: Meyer, Reter publish study showing no objective (relationship status, economic status, etc) improvement in M-Fs post-surgery (but didn't look at happiness, etc.).  Hopkins closed GID clinic in 1979, other clinics closed later
  • Today: GID tx has changed, no comprehensive programs - individual providers with interest, expertise instead; World Professional Association for Transgender Health (WPATH) sets standards of care

Why do people seek therapy? Can't deal with feelings anymore, want to transition and just want blessing/letter, have questions about gender - who am I, what's wrong, want diagnosis, want to know options, want to be "fixed", family can bring

Evaluating a case: must learn about population (very knowledgeable), can't come with own agenda: each case is unique so keep an open mind, take a thorough gender history (developmentally) and background history, look at here and now - what's going on, what problems ahead, what transitional steps have been taken, what do they know, what resources do they need?

Role of mental health professional:
  • Look for coexisting psychopathology: psychosis, alcohol/drug abuse, etc. that might make it hard to identify where desire is coming from
  • Make diagnosis
  • Assist person in choosing course of action - serve as support-guide-educator through decision making / transitional process

Common thought now: person doesn't have to go the whole way to male or female but could stop at some androgynous point (no longer based on how well you pass but rather pt's comfort in gender identity in role - e.g. take hormones but don't get surgery)

Explore options:
  • what does person want (live full time, part-time, make it go away, just talk to someone)
  • what is possible (passing/not passing, TG vs M/F identity, family/friends/employment issues)
  • learning to live with it: most important message is that it won't go away - easier to change body than mind; can stay closeted / cross-live on part-time basis / let few people know

Case study (M->F): cross-dressing, uncomfortable with genitals, fantasizing about being penetrated while masturbating, sexless marriage, feeling "out of whack" or uncomfortable.  Tx with hairdresser to give more androgynous style, hair removal, voice training, more cross dressing and going to gay bars, eventually hormones (smooth skin, breast development), gender change at DMV for driver's license, go full time, then surgery.  Support from friends, family, employers very important

the stuff below wasn't covered explicitly in lecture but was in the slides

Standards of care
  • Hormones: 18yo with exceptions, 3mo real-life experience or in psychotherapy, informed consent, 1 letter from behavioral clinician/physician
  • Genital reconstructive surgery: legal age of majority, 12mo continuous hormone therapy, 12mo real life experience, informed consent, 2 letters

Transition process: can be full or part time; cross-dressing (undergarments, unobtrusive clothes, unisex), further cross dressing (breast forms, wigs, breast binding, more explicit clothing); hair removal; grooming changes (wardrobe, makeup, hair); lifting weights / losing / gaining weight, M-F speech therapy / vocal coaching; support groups (internet); sexual orientation exploration
  • procedures: hormones (F-M very effective, less for M-F), facial reconstructive surgery, breast augmentation / mastectomy, silicone injections, tracheal shave, vocal cord tightening
  • genital reconstructive surgery: many options, M-F have better outcomes, more affordable (orchidectomy, vaginoplasty, labiaplasty); F-M less frequent, costly, poorer overall results (hysterectomy, metoidoplasty, scrotoplasty, urethroplasty, phalloplasty)
  • disclosure - to significant others, children, employers, friends; start with most accepting person, must learn to respect other peoples' reactions
    • Spouses/SOs: four major issues: shock - partner was dishonest about something intimate, left-out or competing with SO's other side, questioning own sexual attraction  and attractiveness, how far will this go?
    • Parents: grieve loss of son/daughter, trouble accepting / relating to child in new gender, fear for their happiness/safety
    • Children: depends on age/developmental stage, can change as child grows older, many accept / are good allies, some embarrassed or fear losing parents through divorce
    • Siblings, friends, co-workers: change in relationship (how to relate?), can be good advocates, depends on values/views/how they're affected
    • Employers: can they do the job, how does it look to others / impact on business, discrimination laws

Paraphilias

No powerpoint, so here's what I got

I. Evaluation of someone whose sexual behavior has been problematic

Take-home point #1: Individuals behave in similar ways for a variety of reasons

  • Law defines sex offender based on behavior alone: e.g. illegal for adult to have sexual contact with people under age of consent, coerce individual into sexual activity - that behavior can have multiple causes, though
  • Is person behaving in sound mind, or is there a psychiatric abnormality?
    • Non-paraphilic sex offender: somebody who breaks into home, finds woman home alone, sexually assults her - not a sexual craving at root. Or if someone is mentally retarded: if no partner available, etc. could coerce a child of same mental age into sexual activity.  If competent enough, could be found guilty in court but this is not a paraphilic disorder

DSM: paraphilic disorder = intense, recurrent, erotically arousing fantasies about something (ongoing struggle to prevent behavior; problematic / distressing)

4 ways people differ from one another sexually (we're taught that everyone's created equal - but we're not the same)
  • behavior, partners, intensity, attitudes (see below for details)

  • Kinds of behavior they do or don't find sexually exciting

    • Transvestitic fetishism: person gets aroused by putting on clothes of opposite sex, usually M->F.  Not an issue of gender identity but rather of sexual arousal.  E.g. outed cross-dressing pediatrician depressed, triggered by worries about losing wife / career but still not certain that he can stop doing it.
    • Exhibitionism: expose yourself; people do it many, many times despite legal, other consequences
    • Sexual masochism: person turned on, excited by own pain, humiliation, degradation, etc.
      • Can occur as frequently in women as men (others more biased - more men). 
      • E.g. autoasphyxiation -> accidental death by hanging, etc., very traumatic for family & others; can lead to victimization
    • Sexual sadism: recurrently craving sex in a way that results in pain, humiliation, degradation, or even death of others
      • Opposite end of coin from masochism; uses much more force than would be necessary (e.g. rape vs. rape by sexual sadist)
      • Can be very problematic: serial sexual assults resulting in murder are often committed by sexual sadists (e.g. Ted Bundy)
    • Don't make dx on behavior alone (e.g. get drunk & naked, not exhibitionist - don't have intense, recurrent features)

  • Kinds of partners they find appealing or don't

    • Zoophilia: partner that somebody gets turned on by is an animal. 
      • Thought rare but may be more prevalent than known before. Internet - many hits on zoophilia websites; can't tell anything about other peoples' sexual makeup even if you're sitting next to them

    • Necrophilia: arousal by having sex with corpse or dead body
      • E.g Jeffery Dahlmer, killed people & had sex with their dead bodies. Unplanned killings at first. Tried very hard not to kill again (surrogate ways to fulfill urges: tried to dig up corpses from cemetaries, used male mannequin to pretend as corpse, went to gay bathhouses & slipped sleep meds in their drinks).  Then developed a quasi-religous, almost psychotic devotion to killing - but all stemming from his necrophilia.
      • Very rare - but people may get jobs in funeral parlors, etc. or steal corpses

    • Pedophilia: sexually attracted to pre-pubescent children as partners
      • Don't diagnose just because somebody has sex before age of consent - e.g. someone gets drunk, has sex with older-looking minor is not pedophilic
      • How to diagnose? Everybody can describe a gender, age-range of partner that we're sexually attracted to.  Most of us aren't attracted to younger children - don't need to repress feelings because feelings aren't there.  Other people would tell us a very different age range (e.g. pre-pubescent children)
      • Classification by gender of child: Same-gender pedophilia (e.g. M adult, M child), opposite-gender pedophilia (e.g. M adult, F child), bi-gender pedophilia (e.g. M adult, M or F child)
      • Classification by exclusivity: Exclusive pedophilia: just children, not adults; non-exclusive: children and adults. If non-exclusive, can't just "turn off" child part - driven by intense, biological cravings - adult craving doesn't erase craving for child
      • Man with exclusive, homosexual pedophilia isn't gay - just pre-pubescent children (e.g. many of the catholic priests involved in scandals)
      • This doesn't mean that somebody is terribly flawed in their character or temperament - doesn't tell you introvert/extrovert, kind, cold, etc. - need to see if there are characterological problems too (often not the case). 
      • Not about lacking social skills (myth: people are insecure with adults so they turn to kids) or power-control issues (myth: not about sex, just because they wan't to be in control). 
        • False because if man with pedophilia is alone, fantasizing - fantasize about children, not adults (don't just need socialization)
      • M>F but still exists in females

    • Kind of person that turns one person on can turn another person off

  • Intensity of sexuality - is sex a pressing issue or less so?

  • Attitudes of sexual desires
    • ego-dystonic: when sexual desires conflict with personal values & attitudes, needs & goals
    • ego-syntonic: when sexual desires are in harmony with personal values & attitudes, needs & goals

II. Etiology


III. Rationale for treatment

  • Law assumes that everyone can control behavior by applying free will - need this presupposition to prevent society from devolving into anarchy. 
    • But how does this apply to highly motivated, appetitive behaviors?  E.g. weight loss - all you have to do is eat less, but the drive is so strong people still can't lose weight after New Year's Resolution.  Behavior "cheating" on diet looks almost pathological / voluntary on surface, but not really a "choice" per se.
  • Volitional impairment, e.g. in pedophilia.  If somebody puts a gun to your head and asks for your wallet, it seems like a choice but fear, etc. makes the choice just an illusion.  Pedophilia, etc. lie somewhere between choice and this total impairment of choice - volition is impaired.
  • Why should pedophiles be liable for their behavior, then? 
    • If an alcoholic gets into a car and kills somebody, they're still responsible for controlling their behavior

IV. Treatment concepts

  • Group therapy (and other therapies)
    • Therapeutic confrontation: Confront self-deceptive rationalizations, look at damage they're really causing - increase motivation to do the right thing
    • Therapeutic support: people with similar problems, can talk about problems openly
    • Relapse-prevention strategies: how do you change your lifestyle?  Don't go work with children, etc.
    • Development of support systems

  • Biologically-based treatments
    • Don't know currently what exactly is driving all of this in the brain
    • Can't go in and take out the part that's broken in the brain
    • Can try to reduce the intensity of sexual hungers: lower testosterone - decreases sexually motivated behaviors, sex drive
      • Originally done by castrating - remove testes to lower testosterone (not like cutting off the hand of the crook - not just punitive)
        • Remove penis, keep testes in rat - try to respond to female but can't
        • Remove testes, keep penis in rat - could respond but don't try
      • Now done with meds - lowers rates of recidivism, can successfully treat the condition.  Not necessarily "once a sex offender, always a sex offender"
        • Sex offenders actually have lower rates of recidivism than some other crimes - data not always the driving factor in policy decisions like registration, etc.

Treatment

Perspectives and therapeutics:

 


Aim
Hazard
Disease
Cure (biological tx)
Side effects
Dimension
Guide (insight - anticipate & prepare pt for challenges)
Paternalism
Behavior
Interrupt (behavior change is goal)
Stigmatization (want to stigmatize behavior to encourage change but not patient)
Life Story
Rescript
"all interpretations are hostile"

Four types of treatment:
  1. Supportive: minimize harm while illness runs its course
  2. Symptomatic: minimize suffering while illness runs its course
  3. Empiric: illness remedy with proven efficacy
  4. Rational: remedy aimed at pathology or etiology

Practical problems of mental life:
Modes of therapy: biological, psychological, social.

Biological
Psychological
Social

History of pharmacotherapy: bromides, other sedatives as tranquilizers (pre 50s); 1940s-50s lithium chlorpromazine and other symptomatiic treatments evolved, 1960s-80s expansion of same types; 1990s/now new generation of designer drugs aimed at specific neurotrans systems

Pharmacology: symptomatic

Pharmacology: syndrome-specific

Pharmacology: behavioral

Caveats of psychopharm: it's a big business (e.g. antidepressant treatment in $$ and % of tx); drug ads have gone from targeted at physicians to targeted at patients; "indication creep" means that drugs are gaining more and more "uses" but may not have great evidence

Electroconvulsive therapy (ECT)

Other current biological treatments:

Psychosurgery:

Under development:

Psychotherapy: art/technique of rescripting a life story and/or providing guidance with the aim of altering behavior

Three components of psychotherapy according to Jerome Frank

Supportive psychotherapy: least technique-driven; practical approach to helping pts with severe dysfunction, generally with severe mental illness.  Healing involves developing therapist/pt trust (therapist may be only reliable, caring, undemanding person they know)

Behavioral psychotherapy - therapist coaches patient to change behavior

Psychodynamic psychotherapy - insight-oriented psychotherapy;

Psychoanalysis - originated with Freud; involves 3-5x/wk frequent therapy with psychoanalyst for several years, unguided free-association (lay on the couch so you can't see reaction of therapist); aim is to explore more subtle patterns of attchment, emotional response, behavior than can be detected in psychodynamic therapy - but not often done anymore ($$, time)

Social therapy - at times, mentally ill may commit unpredictable violence, obstruct family/social functioning, threaten the social order e.g. suicide.

Confinement, restraint: dangerous pts can be and generally are hospitalized (danger to self/others); laws vary by state

Rehabilitation:

The Future:

Summary: