A Multidimensional Life-Span Approach to Psychopathology

    1. Biological Forces
            Health problems increase with age and can provide clues about psychological difficulties (e.g., reduced appetite as a symptom of depression)
   2. Psychological Forces
            Normative changes in attention, memory, and intellectual performance can mimic mental disorders; likewise, changes can make it difficult to tell when an older adult has a given pathology.   
    3. Sociocultural Forces
            Social norms and cultural factors play a role in helping to define psychopathology. Social norms and customs vary across cultures, so we must ask if the behaviors are appropriate for a particular person or culture.   
    4. Life- Cycle Forces
            How a person behaves is influenced by one's past experiences.  

Developmental Issues in Assessment and Therapy
    Assessment- a formal process of measuring, understanding, and predicting behavior.
        1. Multidimensional Assessments
        2. Mental Status Exams
    Negative and Positive biases along with non-optimal environmental conditions can influence accuracy of assessment.

    Assessment Methods
        1. Self reports (interviews)
        2. Report by others (family members)
        3. Psychophysiological Assessments (electroencephalogram)
        4. Direct Observation (systematic or naturalistic)
        5. Performance-Based Assessments (mental status exam)

Here is a link that shows the mini mental status exam: http://www.chcr.brown.edu/MMSE.PDF
Here is a link that explains more about the electroencephalogram :http://www.scholarpedia.org/article/Electroencephalogram
   
    Developmental Issues in Therapy
            Medical Treatments
            Psychotherapy: http://www.aboutpsychotherapy.com/
                    Both require one to be sensitive to developmental issues of older adults.

Symptoms and characteristics:

    1. Dysphoria- the general feeling of feeling down or blue

    2.  Physical symptoms- can include insomnia, changes in appetite, headaches, trouble breathing, fatigue, loss of concentration
        (*Note*)These symptoms should be carefully evaluated as they can also be signs of other disorders

    3.  The problems must last at least 2 weeks

    4.  Other causes such as medication, alcoholism, neurological, etc. must be ruled out

    5.  These symptoms must negatively affect the persons daily living

Here is a good resource to read if you think you or a friend may be experiencing any of these symptoms clicky

Factors that increase risk for depression:

    1.  Being female, unmarried or widowed, experiencing stressful life situations, and lacking social support.

    2.  Having a chronic illness, living in a nursing home, or being a caregiver for someone

    3.  Ethnicity also affects depression.  Hispanics have an overall high rate of depression compared to other ethnicities

Gender and Depressive Symptoms:

    1.  Women are diagnosed with depression more often than men

    2.  Depletion syndrome of the elderly - A form of depression in older women in which dysphoria and self blame are usually not present

Assessment scales:

    1.  Beck Depression Inventory - this test is often used on adults that has questions pertaining to overall feelings and physical symptoms

    2.  Geriatric Depression Scale - physical symptoms have been removed and the format is easier for older adults

    (*Note*)A diagnosis of depression should never be based solely a test score alone

Here is links for more information on the BDI and GDS
    BDI:  BDI
    GDS: GDS

Causes of Depression:

    1.  biological-physiological theories- Focus on genetic predispositions and changes in neurotransmitters

    2.  psychosocial theories
       
        i.  Behavorial theories- argue that depressed people do less pleasurable activities and receive less pleasure from those activities

        ii. Behavorial-cognitive theories- focuses on internal belief systems which people interpret as uncontrollable

        iii. Another psychosocial theory argues that it is a balance between  biological dispositions, stress, and protective factors

Treatment of Depression:

        1. Drug Therapies

            i.  SSRI's (Selective Serotonin Reuptake Inhibitors)-boosts levels of serotonin and generally have lower side effects

            ii.  HCA's (Heterocyclic Antidepressants)- includes common tricyclic antidepressants and are effective in at least 70% of people, but                    have a rate of side effects esp. in older adults who are taking other medications

            iii.  MAO inhibitors (Monoamine Oxidase Inhibitors)- interfere with transmissions between neurons, but can produce deadly side effects                 when they interact with food that contains tryamine or dopamine (i.e. cheddar cheese, wine, chicken liver)

            iv.  Lithium- used for bipolar disorder, which involves mood swings between mania (extremely high activity) and depression

Here is a good cite for information on these and other Antidepressant medications medicinenet

    2.  Electroconvulsive therapy (ECT)- Used for treating very severe forms of depression that do not respond to medication

    3.  Psychotherapy-  based on the idea that talking to a therapist about one's problems can help; there are over 100 types of psychotherapy

        i.  behavioral therapy-  focuses on changing current behavior without focusing on the underlying causes

        ii.  cognitive therapy-  focuses on changing how people think

Delirium:  characterized by disturbances of consciousness and changes in cognition that develop over a short period of time

    i.  Caused by a number of medical conditions, medication side effects, substance intoxication or withdrawl, exposure to toxins, or some     combination of the above

    ii.  The most important aspect in diagnosis of this disease is to differentiate between it and depression and dementia

    iii.  Most cases of delirium can be cured

Dementia:  is a not a single disease but is instead a cluster of conditions.

    i.  About 4 million people, 6-8% of adults over 65 have dementia
       
        1.  At the age of 65 the rate is less than 1%, but for those over 85 the rate increase to about 50%

    ii.  The families of dementia
           1.  Dementia can literally mean losing one's mind, and is characterized by cognitive and behavioral deficits involving some form of permanent              brain damage

    iii.  Alzheimer's Disease:  is the most common form of progressive, degenerative, and fatal dementia accounting for as much as 70% of         dementia cases
       
            1. Neurological changes in Alzheimer's disease
           
                1.  The changes in the brain are microscopic and, thus it can only be definitively diagnosed at autopsy

                        i.  Rapid cell death- occurs in the hippocampus (the part of the brain involved in memory), the cortex (the part of the brain                             involved in higher level cognitive abilities), and the basal forebrain (the lower portion of the front of the brain)

                        ii.  Neurofibrillary tangles- accumulations of pairs of filaments in the neuron that become wrapped around each other

                        iii.  Neurotic plaques- are spherical structures consisting of a core of beta-amyloid surrounded by degenerated fragments of                             dying or dead neurons

Here is an interesting article on how fast neurotic plaques and Alzheimer type neuronal changes can arise Science Daily

                        iv.  Decreases in certain neurochemicals may also be a possible cause of Alzheimer's disease

Symptoms and diagnosis:

    1.  The major symptoms of Alzheimer's disease are gradual changes in cognitive functioning including:
        i.  Declines in memory, learning, attention, and judgement
        ii.  disorientation in time and space
        iii.  difficulties in word finding and communication
        iv.  declines in personal hygiene and self-care skills
        v.  inappropriate social behavior
        vi.  changes in personality

    2. Sundowning- symptoms of Alzheimer's disease are generally worse in the evening than the morning

    3.  the rate of symptom progression is highly variable across patients, however the progression is generally faster the earlier the disease onsets

    4.  Diagnosis of probable Alzheimer's disease is based on a comprehensive evaluation of physical and psychological functioning that rules out     other potential causes

Searching for a cause:

    1.  Autosomal Dominant pattern- only one gene from one parent is necessary to produce the disease;  that means there is a 50% chance that     a child of an affected parent will have the disease

*Intervention Strategies:

-Alzheimer's disease is incurable, but research has been done to find ways to alleviate the cognitive deficits and behavioral problems that characterize the disease.
    -the drugs being researched to help improve memory are only options for treating the cognitive impairments in mild to moderate Alzheimer's
-pharmacological interventions have focused on easing the cognitive symptoms, by increasing cerebral blood flow or levels of neurotransmitters
*The more recent research is looking at ways to prevent, or at least delay, the onset of the disease.

        (10.) using outside services as needed.

-dealing with difficult behavior can be an issue for caregivers, but a successful approach is a technique called the differential reinforcement of incompatible behavior (DRI)
    -DRI is an effective approach that reinforces appropriate behaviors which cannot be done at the same time as problem behaviors

-behavioral interventions for cognitive problems...here are 2 that are extremely effective:
    (1.) spaced retrieval: a technique that helps patients with Alzheimer's learn and remember new information
    (2.) Montessori method: a teaching approach first developed for the use with children

-caregiving is very stressful for families...but two options are:
    (1.) respite care: designed to follow family members to get away for a time
        -can be in-home or temporary placement in residential facilities
    (2.) adult day care: provides placement and programming for frail older adults during the day

*Other forms of dementia:

A helpful site with more information on dementia is, http://alzonline.phhp.ufl.edu/en/reading/memory/guide_ch1.php. It is very helpful for visual people who like to see pictures and charts of parts of the brain.

-vascular dementia: results from a series of small infarcts (CVA's) and accounts for 10-15% of all cases of dementia
    a.) the onset is sudden and the course of the disease is more stepwise than Alzheimer's

-Parkinson's disease: a cluster of motor problems including slow walking, stiffness, difficulty getting in and out of chairs, and a slow tremor
    a.) the behavioral problems are caused by a deterioration in neurons in the mid-brain that produce the neurotransmitter dopamine
    b.) between 14 and 40% of Parkinson's patients develop dementia
    c.) brain tissue at autopsy reveals changes in Lewy bodies that differentiate this type of dementia from Alzheimer's disease


-Huntington's disease: an autosomal dominant disorder that generally manifests itself through involuntary flicking movements of the arms and legs, the inability to sustain a motor action, psychiatric disturbances, personality changes, and cognitive impairments
    a.) usually onsets between the ages of 35 and 50
    b.) cognitive impairments begin gradually and don't develop until late in the disease
    c.) there is a genetic test with a positive result indicating that the patient will get the disease...which is fatal :(

-Alcohol dementia...Wernicke-Korsakoff's syndrome: a consequence of long-term chronic drinking due to a deficiency in thiamine, which causes memory loss
    a.) this disorder can be treated if caught early and alcohol consumption is stopped

-AIDS dementia complex (ADC): protein gp 120, a byproduct of HIV causes death in neurons, which is responsible for this dementia
    a.) early symptoms of ADC include the inability to concentrate, problems performing complex sequential mental tasks, and memory loss
        -there are also motor and behavioral symptoms
    b.) ADC is progressive with mental and motor problems continuing to degenerate

*Other Mental Disorders and Concerns:

(1.) anxiety disorders: includes anxiety states with no specific trigger; phobic disorders characterized by irrational fears of objects or circumstances; and obsessive-compulsive disorders, in which thoughts or actions are performed repeatedly
    a.) diagnosed in as many as 33% of adults

-symptoms of anxiety disorders:
    -all anxiety disorders include a variety of physical changes that interfere with daily functioning to some degree
        --physical changes are particularly common among older adults and include dry mouth, sweating, dizziness, headaches, chest pain, insomnia, etc.
        --anxiety responses need to be evaluated in context
-treating anxiety disorders:
    -drug therapy with benzodiazepines is common
        --however, drug therapies must be used carefully in older adults because they can cause