10-12

Tuesday, October 12, 2010

12:07 PM

• Common misconceptions
• Schizophrenia is multiple personality disorder
• Ppl with schiz do not suffer
• Ppl with schiz are dangerous criminals/mass murders
• What is schizophrenia?
• Emil Kraplin
○ Dementia Praecox
 b/c the disorder started young, and was progressive
• Eugene Blueler
○ Schizophrenia
• Diagnostic Criteria for Schizophrenia
a. Two or more of the following, each present during a one month period
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms, i.e. affect flatting, alogia, or avolition
○ Only one "A" symptom is required if delusions are bizarre or hallucinations consist of a voice
keeping a running commentary on the person's behavior or thoughts, or two or more voices
conversing with each other
○ Religious traditions should be taken into account when making a diagnosis
○ Must make sure that they are not correct
• Delusions
1. Paranoid delusions or delusions of persecution: person might think that someone is trying to kill
them, someone is watching/following them
2. Grandiose delusions: person thinks they have special powers
3. Thought withdrawal: some outside force is removing a person's thoughts
4. Thought insertion: some outside force is putting thoughts into the person's head
5. Mind reading: person thinks that they can read someone else's mind or vice versa
6. Thought broadcasting: everyone can hear the person's thoughts
7. Ideas of reference: the random things going on around them have a special meaning for them
8. Made feelings: impulses or actions that are not their own
• Hallucinations
• Auditory:
○ Most common form
○ One or more voices
○ Talking to them, talk about them, tell them what to do
○ May or may not know voice
○ Perceived as coming from outside head, or inside head
• Visual:
○ Perceptual alterations
○ Full images
• Tactile:
○ Something touching, crawling
• Gustatory:
○ Smells
• Olfactory:
Tastes

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 ○ Tastes
• Formal thought disorder
1. Derailment: abrupt, sudden shift to another topic where you cannot understand the connection.
They don’t realize it
2. Loss of goal: similar to derailment, but there is no sudden shift in topic. They lose their focus
3. Non-sequitir
4. Tangential response
5. Neologism
6. Word-approximations
7. Incoherence (word salad)
• Diagnostic Criteria Cont'd
• For a significant portion o the time since the onset of the disturbance, one or more major areas of
functioning must be markedly below the level achieved prior to the onset
• Continuous signs of the disturbance persist for at least 6 months. During residual periods, the
signs of the disturbance may be manifested only by negative symptoms or two or more symptoms
listed in criterion A present in attenuated form
1. No major depressive episodes have occurred concurrently with active-phase symptoms
2. Total duration of major depressive or manic episodes occurring during the disturbance has been
brief relative to the total duration of the active and residual phases
• Subtypes of Schizophrenia
• Paranoid type
○ Preoccupied with one or more delusions or frequent auditory hallucinations
○ None of the following is prominent: disorganized speech, disorganized behavior, flat or
inappropriate affect or catatonic behavior
 These ppl have better outcomes
• Catatonic type
○ At least 2 of following:
 Motoric immobility
 Excessive mobility
• Disorganized type
○ All are present:
 Disorganized speech/behavior
 Flat/inappropriate affect
○ Does not meet criteria for catatonic type
• Undifferentiated type
• Residual type
○ Criteria in A
• Other subtyping schemes
• Reactive vs. process
○ Reactive
 Ppl who have good functioning beforehand
 Stressor usually
○ Process
 Gradual process of deterioration
 No stressor
○ Good vs. poor premorbid functioning
 Good - better outcome
○ Paranoid vs. nonparanoid

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 10-14
Thursday, October 14, 2010
11:50 AM

• Diagnostic Criteria for Brief Psychotic Disorder

A. Presence of one (or more) of the following symptoms:!
a. delusions!
b. hallucinations!
c. disorganized speech !
d. grossly disorganized or catatonic behavior!
B. Duration of an episode of the disturbance is at least one day, but less than one
month, with an eventual full return to premorbid level of functioning.!
C. The disturbance is not better accounted for by a Mood Disorder with Psychotic Features,
Schizoaffective Disorder or Schizophrenia and is not due to the direct
physiological effects of a substance (e.g. a drug of abuse, medication) or to a general medical
condition.!

• Specify if: With Marked Stressors: Symptoms occur shortly after and apparently in response to
events that, single or together, would be markedly stressful to almost anyone in similar
circumstances in the personʼs culture!
• Without Marked Stressors: Symptoms do not occur shortly after and apparently in response to
events that, single or together, would be markedly stressful to almost anyone in similar
circumstances in the personʼs culture.
• With Postpartum Onset: in onset within 4 weeks postpartum!
• Prevalence of Schizophrenia
• Roughly 1% overall
• Remarkably similar all over the world
○ Some islands have isolated populations where rates are higher
 Most likely b/c of genetic inbreeding
• True lifetime studies--somewhat higher rate in males than females
• Hospital settings - more men then women
• Women have a later onset for schizophrenia, and women have a better response to treatment,
course and outcome, and are less often hospitalized
• Families find it easier to deal w/ schiz females than males
• Can onset before adolescence - as young as 6 or 7
• Gender differences are similar across psychotic disorders
• Diagnostic Criteria for Schizophreniform Disorder !
1. Criteria A, D, and E of Schizophrenia are met!
2. An episode of the disorder (including prodromal, active and residual
phases) lasts at least one month, but less than six months. (When the diagnosis must be made without
waiting for recovery, it should be qualified as provisional).
• Specify if:
○ Without Good Prognostic Features
○ With Good Prognostic Features: as evidence by two (or more) of the following:
1. onset of prominent psychotic symptoms within four weeks of first
noticeable change in usual behavior or functioning
2. confusion or perplexity at the height of the psychotic episode!
3. good premorbid social and occupational functioning
4. absence of blunted or flat affect
 90% of ppl that met criteria for schizophreniform disorder go on to develop
schizophrenia
• Differences b/t US and Europe in
• Diagnostic Criteria for Schizoaffective Disorder

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• Diagnostic Criteria for Schizoaffective Disorder
1. An uninterrupted period of illness during which, at some time, there is either a Major Depressive
Episode (which must include depressed mood), a Manic or a Mixed Episode concurrent with
symptoms that meet Criterion A for Schizophrenia.
2. During the same period of illness, there have been delusions or hallucinations for at least two
weeks in the absence of prominent mood symptoms.
3. Symptoms meeting criteria for a mood episode are present for a substantial portion of the total
duration of the active and residual periods of the illness.
4. Not due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or to
a general medical condition.
• Specify Type:
○ Bipolar type (current or previous Manic or Mixed Syndrome) or
○ Depressive type (no current or previous Manic Syndrome)
• Ppl with schizoaffective disorder are very similar in brain function, cognitive tests to those with
schizophrenia
• Diagnostic Criteria for Delusional Disorder
1. Nonbizzare delusions (i.e., involving situations that occur in real life,
such as being followed, poisoned, loved at a distance, having a
disease or being deceived by oneʼs spouse or lover) of at least one
monthʼs duration.
2. Has never met criterion A for Schizophrenia. Note: Tactile and
olfactory hallucinations may be present in Delusional Disorder if they
are related to the delusional theme.
3. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired
and behavior is not obviously bizarre or odd.
4. If mood episodes have occurred concurrently with delusions, their total duration has been brief
relative to the duration of delusional periods.
5. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse,
medication) or to a general medical condition.
• Delusional Disorder Subtypes
• 1) Persecutory: delusions that one (or someone to whom one is close) is being malevolently
treated in some way
• 2) Jealous: delusions that oneʼs sexual partner is unfaithful
○ more common in men
• 3) Erotomanic: delusions that one is loved by another person, usually of higher status
○ more common in women
• 4) Somatic: delusions that one has some physical deficit or general medical condition
• 5) Grandiose: delusions of inflated worth, power, knowledge, identity, or of special relationship to
deity or famous person
• 6) Mixed: delusions characteristic of more than one of the above types, but no one theme
predominates the delusional beliefs
• 7) Unspecified Type
• Personality Disorders associated with Schizophrenia
A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as
malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by
four (or more) of the following:
a. suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or
her - always assuming the worst about every situation
b. is preoccupied with unjustified doubts abut the loyalty or trustworthiness of friends or
associates!
a. is reluctant to confide in others because of unwarranted fear that the information will be
used maliciously against him or her!
a. reads hidden demeaning or threatening meanings into benign remarks or events!
B. persistently bears grudges, i.e., is unforgiving of insults, injuries or slights!

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 B. persistently bears grudges, i.e., is unforgiving of insults, injuries or slights!
C. perceives attacks on his or her character or reputation that are not apparent to others and
is quick to react angrily or to counterattack !!
D. has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner!
Does not occur exclusively during the course of Schizophrenia, a Mood Disorder with Psychotic
Features, or Schizoaffective Disorder and is not due to the direct physiological effects of a
general medical condition.!
• More common in men
• Almost impossible to treat - they see everyone else as the source of the problem
• Criteria for Schizoid Personality Disorder
A. A pervasive pattern of detachment from social relationships and a restricted range of expression of
emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as
indicated by four (or more) of the following:!
1. neither desires nor enjoys close relationships, including being part of a family!
2. almost always chooses solitary activities!
3. has little, if any, interest in having sexual experiences with another person!
4. takes pleasure in few, if any, activities!
5. lacks close friends or confidants other than first-degree relatives!
6. appears indifferent to the praise and criticism of others!
7. shows emotional coldness, detachment, or flattened affect!
B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder
with Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder, and is not
due to the direct physiological effects of a general medical condition.
• No evidence that it is linked to schizophrenia
• Criteria for Schizotypal Personality Disorder
A. A pervasive pattern of social and interpersonal behavior marked by acute discomfort with, and reduced
capacity for, close relationships as well as by cognitive and perceptual distortions and eccentricities of
behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or
more) of the following:
1. ideas of reference (excluding delusions of reference)
2. odd beliefs or magical thinking, influencing behavior and inconsistent with subcultural norms
(e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense,” “others can feel my
feelings”; in children and adolescents, bizarre fantasies or preoccupations)
3. unusual perceptual experiences, including bodily illusions
4. odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or
stereotyped)
5. suspiciousness or paranoid ideation
6. inappropriate or constricted affect
7. behavior or appearance that is odd, eccentric or peculiar
8. lack of close friends or confidants other than first-degree relatives
9. excessive social anxiety that does not diminish with familiarity, and tends to be associated with
paranoid fears rather than negative judgments about self
B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder with Psychotic
Features, another Psychotic Disorder, or a Pervasive Developmental Disorder.
○ Risk factor for schizophrenia - depends on age
 Younger person can still develop schizophrenia, older person probably won't
○ NOT psychotic
• Disagreement on how disorder should be classified

• There is a definite genetic component of schizophrenia

• Rates of schizophrenia in MZ were the same and increased compared to general populatoin, even
though only one parent had it
• Living with schizophrenic parents can't cause disorder

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• Living with schizophrenic parents can't cause disorder
• Type of Concordance
•  SUBTYPE CONCORDANCE: Whether or not sets of twins have the same subtype of
schizophrenia
•  SEVERITY CONCORDANCE: The more severely disturbed the proband, the more likely the co-
twin or relative is to have the disorder.
• Particular subtypes/symptoms are not inherited
• Polygenic model - a large number of genes contribute to a vulnerability to schizophrenia. The more
genes you inherit, the more likely ou are to get schizophrenia or the more sever eit will be

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 10-19
Tuesday, October 19, 2010
11:44 AM

• Guest Lecturer: Sharon Lyons

• Many people have families w/ mental illness
• Had diagnosis in 3-'s
• As teenager, she felt shy, quiet, few friends
• Good good grades
• Experienced date rape as teenager. Had kid at 15 yrs
• She went to college, majored in business @ fontbonne
• 1994 - she was fired from Irs
• She couldn't keep job,
• Job was stressful, had trouble sleeping, had strange dreams
• In counseling, things got worse @ work couldn't concentrate at work. She took off work called in
sick
• She became more paranoid - thought things were in code
• She developed delusions- tended to come after periods of depression. Tries to keep depression
low
• Never had hallucinations just delusions
• Told her employees that she was getting married - total lie

• Dopamine Hypothesis of Schizophrenia

• Excess of dopamine at certain synpases in te brain causes or at least influences schizophrenia
• This excess amount of dopamine could occur in several ways
• The transmitter neurons could actually produce too much dopamine.
•  The mechanisms that either breakdown the dopamine once it has
been released or re-uptake the dopamine in the transmitter neurons
are dysfunctional. therefore, too much dopamine may remain at the
synapses.
•  The receptor neurons may be overactive, either because there are too
many or because they are too sensitive.
• evidence for dopamine hypothesis
1. Amphetamines: large doeses of amphetamines cause symptoms similar to paranoid schizphrenia.
Make symptoms worse in ppl who already have schizophrenia
2. Phenothiazines - relieve schizophrenic symptoms. Produces parkinsonian symptoms
3. Levadopa: precursor of dopamine. Levadopa increases, schizophrenic symptoms get worse
4. Disulfiram: chemical that prevents dopamine from converting into norepinephrine. When
conversion is prevented, schizophrenic symptoms get worse
5. MAO levels: MAO deactivates dopamine. Therefore, if dopamine activity is ecessive, ppl with
schizophrenia should have lower levels. Studies have confirmed this
• How to Measure dopamine release
• Inject radionucleotide that binds to dopamine 2 receptors
○ Measure the amount of IBZM binding
• Give amphetamine
○ Causes endogenous relase of dopamine (and norepinephrine)
○ Endogenous dopamine bumps IBZM off of D2 receptors (called displacement)
• Measure IBZM
Schizophrenia Genetics
Dopamine Hypothesis of Schizophrenia
 An excess of dopamine at certain synapses in the brain causes or at least influences

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 An excess of dopamine at certain synapses in the brain causes or at least influences
schizophrenia
 This excess amount of dopamine could occur in at least three ways:
o The transmitter neurons could actually produce too much dopamine
o The mechanisms that either breakdown the dopamine once it has been released or re-
uptake the dopamine in the transmitter neurons are dysfunctional. Therefore, too much
dopamine may remain in synapses
o The receptor neurons may be overactive, either because there are too many or because
they are too sensitive
What Evidence is There for the Dopamine Hypothesis?
 Amphetamines: large doses of amphetamines cause symptoms similar to paranoid
schizophrenia. They also make symptoms worse in people who already have
schizophrenia. Amphetamines increase the amount of dopamine and norepinephrine
that are present at the synapse.
 PHENOTHIAZINES: These are a class of drugs that relieve schizophrenic symptoms.
However, they also produce parkinson's disease-like symptoms. Parkinson's disease is
a moter deterioration occurring in one's 40s or 50s. We know that parkinson's disease
is caused, at least in part, by low levels of dopamine.
 LEVADOPA: This is a chemical that is a precursor of dopamine. In other words, it is a
substance that is synthesized into dopamine. When levadopa increases, schizophrenic
symptoms get worse.
 DISULFIRAM: This is a chemical that prevents dopamine from converting into
norepinephrine. When the conversion is prevented, schizophrenic symptoms get
worse.
 MAO LEVELS: MAO deactivates dopamine. Therefore, if dopamine activity is excessive,
people with schizophrenia should have lower mao levels that people without
schizophrenia. Numerous studies have been done looking at mao levels in the blood
platelets of people with schizophrenia and lowered levels are frequently found.
How to Measure Dopamine Release
 Inject radionucleotide that binds to dopamine 2 (D2) receptors (IBZM)
o Measure the amount of IBZM binding
 Give amphetamine
o Causes endogenous release of dopamine (and norepinephrine)
o Endogenous dopamine bumps IBZM off of D2 receptors (called displacement)
 Measure IBZM binding again
o Calculate difference in IBZM binding before amphetamines and after amphetamine
 Bigger release of dopamine in response to amphetamine -> bigger decrease in IBZM
binding
Two main dopamine systems in the brain (areas where dopamine is concentrated)
 Mesocortical system
o Coritical areas, frontal areas
 Too little?
 Mesolimbic system (midbrain and in substantia nigra with projection to accumbens, olfactory
tuberble and amygdala), subcortical
o Too much?
What is dopamine doing?
 Influencing brain structure and functioning
Schizophrenia - Brain Structure and Activity
Ways to Compare Brains
 Neuropsychological exams:

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 Neuropsychological exams:
o Different parts of the brain are used for different tasks. If patients with schizophrenia are
bad on the certain tasks, maybe they have a problem with the functioning of that brain
area.
 Structural Brain Imaging Techniques:
o These techniques allow you to measure the size of different brain structures
 Computerized axial tomography
 Magnetic resonance imaging
 Functional Brain Imaging Techniques:
o These techniques allow you to measure how much activity there is in different parts of the
brain
 Positron Emission Tomography (PET) scanning
 Functional Magnetic Resonance Imaging (fMRI)

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 10-21
Thursday, October 21, 2010
11:41 AM

• Kids with schizophrenia show reduced white matter growth in the brain
• Dorsal prefrontal cortex
• Other ways for genes to influence brain structure and functino in schizophrenia
• Glutamate hypothesis
• Problem with DA hypothesis: time course
• Phencyclidine (PCP): dissociative anesthetic -->
○ Auditory hallucinations
○ Depersonalization
○ Delusions
○ Concompetitive NMDA antagonist (blocks Ca2+ channel)
• 2 weeks PCP in monkeys --> schiz.-like symptoms
○ Including poor performance on frontal lobe-sensitve task
• Ketamine (NMDA)
• Seizures can be caused!!
• Tring more indirect ways of enhancing glutamate function
• Gaba hypothesis
• Impaired Gaba input to pyramidal cells
• Impairs generation of oscillatory signals that drive active maintenance of information
• Reflected in reduced gamma and decreaesd DLPFC activity
• Viral Hypothesis
• Medinick
○ Mothers pregnant during influenza epidemics
 Chuldren developed shizophrenia at a higher rate than the general population
○ More specifically,
 Mothers with influenza during second trimester
□ Children developed schiz at a higher rate than mothers who had influenza
during first or third semester
 2nd trimester critical period for cortical development
□ Influeza may alter cortical development
• Other causes of brain damage in schiz
• The neurological symptoms of schizophrenia may be caused by
○ Birth trauma
○ Nutritional issues
○ Maternal stress
• Schizophrenia and Social Class
• Sociogenic hypothesis: being in a low social class causes schizophrnia
○ The degrading treamtent a person receives from others, low levels of education and lack of
rewards/opportunities make bing in the lowest social class very stressful
○ Immigrants who live in area where they are the minority - higher risk for schizophrenia
 Environemnt may do something to your brain
 i.e. nutrition
• Social drift theory: during the course of developing schizophrenia, people drift into the poverty
ridden areas
○ The cognitive, emotional, ad motivational problem often associated with schizophrenia
impair their leanring abilities so that they cannot afford to live anywhere else
• Family and Environment
• Expressed emotion paradigm
Conduct interview with parent about child

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 ○ Conduct interview with parent about child
• Critical comments
• Hostility
○ Usually if you find critical comments you will find hostility
• Emotional overinvolvement
• Relapse rates were much higher for kids that lived in hostile/critical homes
○ But maybe the kids were just difficult
○ They controlled for that, still found this effect
• Contact with the family - if you spend more time with hostile/critical family, higher risk
• Gunderson (1984)
•  Reality Adaptive Supportive (RAS)
–  Focused on problems in current living situation of the patient. Little
attempt was made to explore past or to seek correlates between present
and past experiences. The exploration of the present was intended to
identify problems that could be solved or that could be expected to
reoccur so that more effective coping strategies could be developed.
–  They got .6 hours of therapy a week for two years.
•  Psychodynamic
–  A form of analytic therapy that was aimed at increasing insight. They
sought correlates between present and past experiences.
–  They got two hours a week for two years.
• Results
○ Found that psychodynamic was worse than RAS on 3/4 outcome criteria:
1. Rehospitalization
2. Vocational adjustment
3. Social adjustment
○ Didn’t differ on impact on symptoms
• Pharmacological Treatments
•  “Typical” antipsychotics (also called neuroleptics)
–  haldol
–  prolixin
–  thorazine
–  chlorapromazine
• Newer, “Atypical” antipsychotics
–  clozapine (Clozaril®)
○ Can't be a drug of first choice because it can lead to fatal condition
 Have to try 2 other ones 1st
 Weight gain & drooling are side effects
–  olanzapine (Zyprexa®)
–  quetiapine (Seroquel®)
–  risperidone (Risperdal®)
–  sertindole (Serlect®)
–  ziprasidone (Zeldox®)
–  aripiprazole (Abilify®)
»  Different partial agonist of D2
• Cognitive Remediation Treatment
• Wykes et al, 2002 - 12 week trial
○ Compared control treatment (occupational therapy techniques such as relaxation training)
○ Cognitive Remediation Therapy ( information processing
strategies in
domain of working memory, cognitive flexibility and planning
• Hogarty et al. 2004
• Cognitive enhancement Therapy
• Compared:

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• Compared:
1. Family treatment
2. Social skills training
3. Family treatment and social skills training
4. Drug controls
• Family treatment and social skills --nobody relapsed after a year
○ Even after 2 years, it was 25% compared to 62%

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 10-26
Tuesday, October 26, 2010
11:45 AM

• Eating Disorders
• Diagnostic Criteria for Anorexia Nervosa
a. Refusal to maintain body weight at or above a minimally normal weight for age and height,
e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or
failure to make expected weight gain during period of growth, leading to body weight less
than 85% of that expected.
b. Intense fear of gaining weight or becoming fat, even though underweight.
c. Disturbance in the way in which one's body weight, size, or shape is
experienced, undue influence of body weight or shape on self evaluation, or
denial of the seriousness of the current low body weight.
a. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive
menstrual cycles. A woman is considered to have amenorrhea if her periods occur only
following hormone, e.g., estrogen, administration.)
• Specify Type:
○ Restricting type: person has not regularly engaged in binge-eating or purging behavior (i.e.,
self-induced vomiting or the misuse of laxatives, diuretics, or enemas).
○ Binge-Eating/Purging Type: during the current episode of Anorexia
Nervosa, the person has regularly engaged in binge-eating or purging
behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or
enemas).
• Diagnostic criteria for bulimia nervosa
A. Recurrent episodes of binge eating. An episode of binge eating is
characterized by both of the following:
○ eating, in a discrete period of time (e.g., within any 2-hour period), an
amount of food that is definitely larger than most people would eat during a similar period
of time and under similar circumstances
○ a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop
eating or control what or how much one is eating
B. Recurrent inappropriate compensatory behavior in order to prevent weight
gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications;
fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behavior both occur, on
average, at least twice a week for 3 months.
D. Self evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of Anorexia
Nervosa.
• Specify Type:
○ Purging Type: during the current episode of Bulimia Nervosa, the person has regularly
engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of
laxatives, diuretics, or enemas).
 Health consequences: dehydration, acid on the teeth, etc
○ Nonpurging Type: during the current episode of Bulimia Nervosa, the person has used
other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has
not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the
misuse of laxatives, diuretics, or enemas
• Nervosa - mental illness
• They can't stop eating during their binge eating episodes
• Anorexia trumps bulimia in terms of diagnosis!!
• Bulimia has higher prevalence than anorexia

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• Bulimia has higher prevalence than anorexia
• Research Criteria for Binge Eating Disorder
A. Recurrent episodes of binge eating. An episode of binge eating is
characterized by both of the following:
○ eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that
is definitely larger than most people would eat during a similar period of time and under
similar circumstances
○ a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop
eating or control what or how much one is eating
B. The binge-eating episodes are associated with three (or more) of the
following:
• eating much more rapidly than normal
• eating until feeling uncomfortably full
• eating large amounts of food when not feeling physically hungry
• eating alone because of being embarrassed by how much one is eating
• feeling disgusted with oneself, depressed, or very guilty after overeating
C. Marked distress regarding binge eating is present.
D. The binge eating occurs on average, at least 2 days a week for 6 months.
E. The binge eating is not associated with the regular use of inappropriate
compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur
exclusively during the course of Anorexia or Bulimia .
○ Highly associated with obesity
 But not every obese person has binge eating disorder
• Binge eating is the most common eating disorder

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 10-28
Saturday, November 06, 2010
7:35 PM

TREATMENT FOR EATING DISORDERS

• ED - eating disorder
• AN - anorexia nervosa
• BN - bulimia nervosa

• ESTs - empirically supported treatments

• CBT - cognitive-behavioral therapy
• IPT - interpersonal psychotherapy
• FBT - family-based therapy

• EDNOS is the most commonly diagnosed ED

• Key ED info
• Heightened emphasis on;
○ Food, eating, body shape/weight
○ ED behaviors = unhealthy coping strategy
• BED: in the EDNOS category, but proposed as a formal diagnosis in DSM-V
• In treatment-seeking individuals:
○ Binge eating = most common symptom
○ Purging = next most common
• Treat EDNOS symptoms like the full syndrome diagnoses
• Binge:
○ Large amount of food within a 2hr period (larger than most ppl would eat in the same
situation)
○ Sense of loss of control (LOC): cannot stop
• Considerations for Youth
• Symptoms often develop in youth; treatment should consider:
○ Early intervention = better
○ Role of parents/family (modeling, stimulus control, positive reinforcement)
○ Cognitive development
○ Peer relations and social context
• ESTs for BN: CBT
• CBT: most researched, best established
• Reduces core features of BN
• Compared to pharmacotherapy and other psychotherapy
• Binge-purge cycle:
○ Extreme distress
○ Decreased self-esteem
 Perpetuates dietary restraint
• Primary treatment goal: eliminate binge-purge cycle
○ Restore normal diet
○ Modify dysfunctional thoughts about shape/weight
• Shown to improve:
○ ED symptoms
○ Mood
○ Social functioning
• Effects usually maintained thru 1 year follow up
• Stage 1 treatment goals:
Therapeutic relationship

Test 2 Page 15
 ○ Therapeutic relationship
○ Psychoeducation on BN
○ Orientation to treatment structure and rationale
○ Behavioral techniques: weekly weighing and self-monitoring of food intake
• Stage 2 treatment goals:
○ Continue behavioral techniques
○ Cognitive techniques: problem solving, cognitive restructuring
• Stage 3 treatment goals:
○ Relapse prevention
○ Prepare for future setbacks and high risk situations
• ESTs for BN: IPT
• IPT: improve social functioning to reduce ED symptoms
• Compared to CBT
○ Post-treatment, follow-up
○ Maintenance of treatment effects at 5 year follow up
• Underlying theory: interpersonal functioning <---> psychological adjustment/well-being
• Focuses on resolving problems in 4 domains:
1. Grief
2. Role dispute: conflict b/t patient and significant others
3. Role transition
4. Interpersonal deficits
• Use of group setting
• Initial phase:
○ Identify problem area(s) to target
• Intermediate phase
○ Work on problem area(s)
• Termination phase
○ Discuss gains made thru treatment
○ Prepare patients for future work on their own
• ESTs for BED: CBT
• Modified version of CBT for BN
○ Focuses on chaotic eating patterns (involve over-restriction and under-restriction)
• Focus: establish patterns of healthy restraint
○ Normalize eating patterns
○ Moderate caloric intake
○ Modify dysfunctional thoughts/cognitive distortions related to diet-binge cycle
• Phase 1:
○ Behavior strategies
○ Self-monitor patterns of over- and underrestriction
• Phase 2:
○ Identify/challenge beliefs that perpetuate binge cycle
○ Cognitive skills
• Phase 3:
○ Discuss treatment progress
○ Relapse prevention skills
• ESTs for BED: IPT
• Group format
○ Powerful for patient and other members
○ Use the group to practice social skills and communication techniques
• ESTs for AN
• Less research
○ Participant recruitment and retention are problems
• Little support for specialized psycho- or pharmacotherapy
Re-feeding to regain weight, address medical complications

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• Re-feeding to regain weight, address medical complications
• FBT is effective
○ Adolescents
• FBT:
○ Maudsley approach
○ Empower the family
○ Help patient to:
 Regain weight
 Regulate disordered eating behaviors
 Promote development and independence
○ So far, it shows the most promise compared to other treatments
○ "train" family to

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 11-2
Tuesday, November 02, 2010
12:00 PM

• Classes of Drugs
• Sedative-hypnotic drugs!
–  barbituates!
–  Benzodiazepines!
» induce relaxation and sleep
•  Act by stimulating GABA receptors
•  Can result in tolerance and severe withdrawal reactions
•
•  Opioids!
–  opium!
– morphine!
–  heroin!
»  attach to receptors for endorphins!
»  intoxication associated with pleasant, calm feelings!
»  withdrawal - anxiety, restlessness, twitching, aches, fever!
»  overdose - shuts down respiratory system!
• Stimulants
○ Increase central nervous system
○ Cociane
 Euphoric rush of well-being, confdence
 Increaes dopamine in system
 co
○ Other stimulants
 Amphetamines
 Caffeine
○ Hallucinogens
 Change sensory perception
 LSD
 No withdrawal or tolerance, but risk from one use
 Flashbacks
○ Cannabis
 Marijuana
 Hallucinogenic, depressant and stimulant effects
 More abuse and dependence now than in 60s
 Memory impairment
 Lung disease
 May interfere with human reproduction
 However, powerful anesthetic
• A. Cessation of (or reduction in) alcohol use that has been heavy or prolonged.
• B. Two (or more) of the following, developing within several hours to a few days after Criterion A:
• (1) autonomic hyperactivity (e.g., sweating or pulse rate greater than 100)
• (2) increased hand tremor
• (3) insomnia
• (4) nausea or vomiting
• (5) transient visual, tactile, or auditory hallucinations or illusions
• (6) psychomotor agitation
• (7) anxiety
• (8) grand mal seizures - can kill people
• C. The symptoms in Criterion B cause clinically significant distress or

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• C. The symptoms in Criterion B cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
• D. The symptoms are not due to a general medical condition and are not better accounted for by
another mental disorder.
• Specify if: With Perceptual Disturbances
• Gender
• – Gender Differences :
○ » Fewer women develop alcoholism compared to men.
○ » The disparity is narrower today than 50 years ago.
○ » Social disapproval of women drive solitary drinking.
○ » A single standard dose of alcohol, measured in proportion to total body weight, will
produce a higher peak blood alcohol level in women than in men.

Alcohol and Substance Abuse/Dependence

Overview
• DSM-IV-TR uses two terms to describe substance use disorders, and these terms reflect
different levels of severity (in theory…):
○ Substance dependence
○ Substance abuse
• Drug of abuse - a chemical substance that alters a person's mood, level of perception, or brain
functioning
• Polysubstance abuse - abuse/dependence of several types of drugs
What is Substance Abuse?
• Substance abuse is characterized by:
○ Failure to fulfill major obligations (e.g., work or child care)
○ Exposure to physical dangers (e.g. driving while intoxicated)
○ Legal problems brought on by drug use
○ Persistent social or interpersonal problems (e.g., arguments with spouse)
Diagnostic Criteria for Substance Abuse
• A maladaptive pattern for substance use, leading to clinically significant impairment or distress,
as manifested by three or more of the following, occurring at any time in the same 12 month
period:
○ Recurrent substance use resulting in failure to fulfill major role obligation at work, school,
or home (e.g., repeated absences or poor work performance related to substance abuse;
substance related absences, suspensions, or expulsions from school; neglect of children or
household)
○ Recurrent substances use in situations in which it is physically hazardous (e.g., driving an
automobile or operating a machine when impaired by substance use)
○ Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly
conduct)
○ Continued substance use despite having persistent or recurrent social or interpersonal
problems caused by or exacerbated by the effects of the substance (e.g., arguments with
spouse about consequences of intoxication, physical fights)
• The symptoms have never met the criteria for substance dependence for this class of substance
What is substance dependence?
• Substance dependence is characterized by:
Tolerance to drug action occurs (greater doses, diminished drug action)

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 ○ Tolerance to drug action occurs (greater doses, diminished drug action)
○ Withdrawal symptoms occur with drug cessation
○ Person recognizes excessive use of the drug
○ Much of the person's time is spend getting the drug or recovering from its effects
○ Substance use continues despite physical or psychological problems caused by the drug
Diagnostic Criteria for Substance Dependence
• Maladaptive pattern of substance use, leading to clinically significant impairment of distress, as
manifested by three or more of the following, occurring at any time in the same 12 month
period:
○ Tolerance, as defined by either of the following:
 A need for markedly increased amounts of the substance to achieve intoxication or
desired effect
 Markedly diminshed effect with continued use of the same amount of the substance
○ Withdrawal, as manifested by either of the following:
 The characteristic withdrawal syndrome for the substance
 The same or closely related substance is taken to relieve or avoid withdrawal
symptoms
○ The substance is often taken in larger amounts of over a longer period than was intended
○ There is a persistent desire or unsuccessful efforts to cut down or control substance use
○ A great deal of time is spend in activities necessary to obtain the substance or recover
from its effects
○ Important social, occupation, or recreational activities are given up or reduced because of
substance use
○ The substance use is continued despite knowledge of having a persistent or recurrent
physical or psychological problem that is likely to have been caused or exacerbated by the
substance
• Specify if:
○ With psychological dependence: evidence of tolerance or withdrawal
○ Without psychological dependence: no evidence of tolerance or withdrawal
Classes of drugs
• Depressants
○ Slows activity of central nervous system
○ Alcohol
 Stimulates GABA receptors (reduces tension)
 Increases dopamine/serotonin levels (pleasurable aspects of intoxication)
 Inhibits glutamate receptors (cognitive actions)
• Alcohol
○ Intoxication associated with decreased inhibition, slowed reaction times, memory
impairment
○ Abuse can follow different patterns (continual use, bingeing, etc.)
○ Withdrawal
 Delirium tremens (DTs)
○ Long term effects of alcohol dependence
 Cirrhosis of liver
 Lowers immune system
 Korsakoff's syndrome (confusion, memory loss)
 Fetal alcohol syndrome (MR, slow growth)
• Sedative-hypnotic drugs
○ Barbituates
Benzodiazepines

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 ○ Benzodiazepines
 Induce relaxation and sleep
□ Act by stimulating GABA receptors
□ Can result in tolerance and severe withdrawal reactions
• Opioids
○ Opium
○ Morphine
○ Heroin
 Attach to receptors for endorphins
 Intoxication associated with pleasant, calm feelings
 Withdrawal - anxiety, restlessness, twitching, aches, fever
 Overdose - shuts down respiratory system
• Stimulants
○ Increase central nervous system
○ Cocaine
 Euphoric rush of well-being, confidence
 Increases dopamine in system
 Cocaine-induced psychosis
 Cheaper forms (free-basing, crack) have increased abuse and dependence problems)
 Risk of overdose, suicide, heart problems, brain seizures
• Other stimulants
○ Amphetamines
○ Caffeine
• Hallucinogens
○ Change sensory perception
○ LSD
○ No withdrawal or tolerance, but risk from one use
○ Flashbacks
• Cannabis
○ Marijuana
○ Hallucinogenic, depressant and stimulant effects
○ More abuse and dependence now than in 60s
○ Memory impairment
○ Lung disease
○ May interfere with human reproduction
○ However, powerful anesthetic
Diagnostic Criteria for Alcohol Withdrawal
• Cessation of (or reduction in) alcohol use that has been heavy or prolonged
• Two or more of the following, developing with several hours to a few days after criterion A ^
○ Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100)
○ Increased hand tremor
○ Insomnia
○ Nausea or vomiting
○ Transient visual, tactile, or auditory hallucinations or illusions
○ Psychomotor agitation
○ Anxiety
○ Grand mal seizures
• The symptoms in criterion B cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning
The symptoms are not due to a general medical condition and are not better accounted for by

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• The symptoms are not due to a general medical condition and are not better accounted for by
another mental disorder
• Specify if:
○ With perceptual disturbances
Gender
• Gender differences
○ Fewer women develop alcoholism compared to men
○ The disparity is narrower today than 50 years ago
○ Social disapproval of women drive solitary drinking
○ A single standard dose of alcohol, measured in proportion to total body weight, will
produce a higher peak blood alcohol level in women than in men
What is going to change in DSM-IV
• No more distinction between abuse and dependence
• XX use disorder
○ Alcohol
○ Nicotine
○ Etc.

Pasted from <https://mail.google.com/mail/?ui=2&view=bsp&ver=ohhl4rw8mbn4>

Test 2 Page 22
 11-4
Thursday, November 04, 2010
11:40 AM

• What are the most important risk factors for alcoholism among adolescents?
• Experimentation
• Parental modeling
• Having alcoholic parents
• High levels of negative affect in the ome
• Girls with opposite-sex friends
• Expectations play a role in response to drugs

Screen clipping taken: 11/4/2010 11:50 AM

• Biological Factors
• Twin studies Adoption studies
•  Data from a large sample of twins in Australia found concordance rates for alcohol dependence of
56% in male MZ twins and 33% in male DZ twins.
•  MZ and DZ female twin pairs were 30% and 17%, respectively.
•  The offspring of alcoholic parents who are reared by nonalcoholic adoptive parents are more likely
than people in the general population to develop drinking problems of their own.
• Type 1 - you need both adopted and biological parents to be alcoholics to have severe risk
• Type 2 - only your biological parents need to be an alcoholic for you to have severe risk

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• Type 2 - only your biological parents need to be an alcoholic for you to have severe risk
• Alcoholism Subtypes
• Type 1:
1. Later onset
2. Prominent psychological dependence
3. Absence of antisocial personality traits
4. Present in both men and women
1. Type 2:
1. Earlier onset
2. Co-occurrence with antisocial traits
3. Present primarily in men
• What do these genes influence?
– Dopamine and Reward pathway
»People may become dependent on psychoactive drugs because they stimulate areas of the brain
that are known as “reward pathways.”
• Drugs cause your brain to lose some of its dopamine
• Medial forebrain bundle
» This may be a “final common denominator”
• Cocaine blocks the reuptake of dopamine
• Endogenous Opioid Peptides
• Endorphins - endogenous endorphins, short chains of amino acids, or
neuropeptides.
• Anything that activates the opiod system are very addictive
» Appear to be important in the activities associated with systems that control pain,
emotion, stress, and reward.
–  It is theorized that alcoholism is associated with activation of this system in
response to alcohol.
• Psychological Factors
•  Tension-reduction Hypothesis
– Avoiding or reducing unpleasant stress
•  Expectations About Drug Effects
– Longitudinal studies: adolescents who are just beginning to experiment with alcohol and who
initially have the most positive expectations about the effects of alcohol go on to consume greater
amounts of alcoholic beverages.
– Expectations play a role in the onset of the problem
rather than being consequences of heavy drinking.
• Substance abuse disorders are a huge strain on society
• Tension-reduction hypothesis
• Avoiding or reducing unpleasant stress
• Biological Treatment of Substance-Related Disorders
• Agonists substitution
○ Safe drug with a similar chemical composition as the abused drug
○ Examples include methadone for heroin addiction, and nicotine gum or patch
 Methadone patches for heroine
• Antagonistic Treatment
○ Drugs that block or counteract the posititve effects of substances
○ Examples include naltrexone for opiate and alcohol problems
 Person must be aware
 When on these treatment are used the person feels sick when they
• Aversive Treatment
–  Drugs that make the ingestion of abused substances extremely unpleasant
–  Examples include antabuse for alcoholism and silver nitrate for nicotine addiction
•  Efficacy of Biological Treatment
–  Such treatments are generally not effective when used alone

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 –  Such treatments are generally not effective when used alone
• Debate Over Controlled Use vs. Complete Abstinence as Treatment Goals
•  Inpatient vs. Outpatient Care
– Data suggest little difference in terms of overall
effectiveness
•  Community Support Programs
– Alcoholics Anonymous and related groups
• Self-Help Groups and Alcoholics Anonymous
•  Fundamentally spiritual
•  The original12-step program
• Difficult to evaluate its efficacy.
– Long-term follow-up difficult; early dropout
• Appears to help people, it is not clear how it helps, or why
• Psychosocial Treatment
• Components of Comprehensive Treatment and Prevention Programs
– Individual and group therapy
– Aversion therapy and covert sensitization
– Contingency management
– Community reinforcement
– Relapse prevention
– Preventative efforts via education
• TREATMENT
•  Outcome Results and General Conclusions
– Project MATCH
» Evaluated three forms of psychological treatments:
• Cognitive behavior therapy
• 12-step facilitation therapy
• Motivational enhancement therapy
○ Long-term outcome is best predicted by the person’s coping resources, social support
•

Test 2 Page 25
 Review Session 11-7
Sunday, November 07, 2010
4:18 PM

• Catatonia and disorganized speech is less commonly see n today than before
• Probably b/c of better medication that reduces symptoms
• Schizotypal is much more similar to schizophrenia than schizoid
• Schizoid ppl aren't interested in social interactions
• Schizophrenia - slightly higher in men
• Age of onset - men's onset is earlier
• Women have better respone to treatment
• Less frequently hospitalized
• All eating disorders are more common in women
• All forms of substance abuse/dependence are more common in men
• Gap is narrowing, esp with alcoholism

Test 2 Page 26