Khan: Chapter 161-170 PDF

§ **Delusions of control** -- Belief that one's thoughts or actions are being controlled by outside, alien forces. Common delusions of control include thought broadcasting ("My private thoughts are being transmitted to others"), thought insertion ("Someone is planting thoughts in my head"), and...

§ **Delusions of control** -- Belief that one's thoughts or actions are being controlled by outside, alien forces. Common delusions of control include thought broadcasting ("My private thoughts are being transmitted to others"), thought insertion ("Someone is planting thoughts in my head"), and thought withdrawal ("The CIA is robbing me of my thoughts").  Rare disorder with both biological and environmental etiology (cause/set of causes of a disease).  3 categories of symptoms of Schizophrenia: cognitive, positive, negative symptoms o **Cognitive symptoms**- abnormalities of attention, organization, planning abilities § disorganized thinking, slow thinking, difficulty understanding, poor concentration, poor memory, difficulty expressing thought, difficulty integrating thoughts, feelings and behavior o **Negative symptoms -** blunted emotions, loss of enjoyment "emotional abnormalities" refer to the absence of normal behaviors found in healthy individuals. Common negative symptoms of schizophrenia include: § **Lack of emotional expression** -- Inexpressive face, including a flat voice, lack of eye contact, and blank or restricted facial expressions.  ***Affective flattening*** is the reduction in the range and intensity of emotional expression, including facial expression, voice tone, eye contact (person seems to stare, doesn\'t maintain eye contact in a normal process), and is not able to interpret body language nor use appropriate body language. § **Lack of interest or enthusiasm** -- Problems with motivation; lack of selfcare.  ***Avolition*** is the reduction, difficulty, or inability to initiate and persist in goal-directed behavior; it is often mistaken for apparent disinterest. (examples of avolition include: no longer interested in going out and meeting with friends, no longer interested in activities that the person used to show enthusiasm for, no longer interested in much of anything, sitting in the house for many hours a day doing nothing.) § **Seeming lack of interest in the world** -- Apparent unawareness of the environment; social withdrawal. § **Speech difficulties and abnormalities** -- Inability to carry a conversation; short and sometimes disconnected replies to questions; speaking in monotone.  ***Alogia,*** or poverty of speech, is the lessening of speech fluency and productivity, thought to reflect slowing or blocked thoughts, and often manifested as short, empty replies to questions. o **Positive symptoms**- "psychosis" - hallucinations, delusions (characteristic of psychotic disorders including schizophrenia) "perceptual abnormalities", disorganized speech/thinking, disorganized behavior, catatonic behavior 162 § **Catatonic schizophrenia: Catatonic schizophrenia** is a type (or subtype) of **schizophrenia** that includes extremes of behavior. At one end of the extreme the patient cannot speak, move or respond - there is a dramatic reduction in activity where virtually all movement stops, as in a catatonic stupor.  Our understanding of the cause of schizophrenia very limited. We have a limited understanding on how the limited mental functions occur.  Patients of schizophrenia have the following physical abnormalities observed in the brain (via autopsy or scan examination of structure brain) o Based on autopsy and scan examination of structure brain, we see physical abnormalities in Schizophrenia brain: o Fluid filled regions have been enlarged because there is less tissue of the brain. o **Cerebral cortex** (layer that is outermost part of cerebrum) **seems to have** **decreased size**, in frontal and temporal lobes. These areas have to do with cognitive and perceptual functions which are abnormal in schizophrenia. § Organization of the Cerebral cortex (cortical layers) particularly in frontal and temporal lobes is disturbed. Typically there is a clear organization. Here, there is a disorganization and thinning of layers. o Based on activity studies (by scans that now look at brain activity) § Frontal and temporal lobe activity is also seen in same areas of structural/physical abnormality. o Abnormal development of brain is most likely what leads to this disease. o Some features of schizophrenia also involve **abnormalities in dopamine** **(increase)**. This dopamine plays a role in frontal/temporal lobes. Effects cognitive, emotional, perceptual functions. o A \# of medications that affect dopamine transmission often improve symptoms o The **mesocorticolimbic** pathway Is affected § Meso = "midbrain" - where VTA (Ventrotangmental area). Specifically, the soma of neurons that use dopamine are located at VTA. § cortico = "cerebral cortex", axons project to frontal and temporal lobe of cerebral cortex. (axons of the VTA neurons project to other areas of the brain and release dopamine to cerebrum areas). § limbic = "collection of structures inside of the brain" involved in emotions/motivations/etc. § Often divided into mesocortical pathway (VTA to the frontal lobe) and mesolimbic pathway (VTA to limbic structures) § Abnormal activity of mesocorticolimbic pathway. One way of thinking about schizophrenia is abnormal activity is mesocorticolimbic pathway leads to dysfunction in parts of frontal cortex that cause cognitive symptoms, and limbic structure causes negative symptoms, and abnormal activity in temporal cortex causes positive symptoms.  Abnormalities are likely much more complicated. 163  Causes: genes, physical stress during pregnancy (such as infection during pregnancy), and psychosocial factors (negative family interaction styles effect development of brain) o Poverty and schizophrenia link. Causality is not well known. Biological Basis of Depression  Depression, a major Depressive Disorder: major cause of distress, disability, and death from suicide. *Prototype of disorder category of depressive disorders.*  Related symptoms of Depressive mood: feelings of hopelessness, loss of interest in activities. Our understanding of cause of major depressive disorder is limited. No consistent abnormalities in brain tissues, but scans have suggested functional abnormalities in brains. o Areas with abnormal activity involve the **frontal lobe** and **limbic structures**. Decreased activity in frontal lobe and increased activity in limbic structures. Show a role in regulation of emotions and response to stress. o Ex. Stress hormones like cortisol are controlled by the hypothalamus, which communicates with limbic system and frontal lobe. Hormones affect the brain themselves too. § Communication of frontal lobe, limbic system, and hypothalamus may plays a role why there are abnormal hormones in the body. § Stress hormones affect most tissues of the body and the brain (including hypothalamus, limbic system, and frontal lobe)  Unclear which abnormalities of stress hormone are causes and which are effects of the disease.  There are some studies that suggest abnormalities in neural pathways using certain neurotransmitters (molecules that communicate between neurons). Abnormalities in pathways cause abnormal increase or decrease activity in the brain. Collection of neurons have cell bodies in brain stem while axons project into frontal lobe/limbic system. One structure starts in the **raphe nuclei** of the brainstem responsible for **serotonin** release. Another pathway starts in the **locus coeruleus**, which sends long axons to cerebrum and releases **norepinephrine.** Also the **VTA** sends long axons to different areas of cerebrum, supplies **dopamine**.  Medications that affect serotonin, NE, and dopamine often improve symptoms. Ex. monoamine oxidase inhibitors (increase amount of monoamines in synapse) o Monoamines include adrenaline (epinephrine), norepinephrine, dopamine, serotonin, and melatonin (involved in onset of darkness). § Catecholamine (Subclass) includes dopamine, norepinephrine, and epinephrine (2 OH groups on phenyl)  Another newer idea is may be abnormalities of **neuroplasticity** - brain changes in response to experience. But unclear if neuroplasticity abnormalities is a cause or effect. Strength of information/efficiency of flow changes or connections change. Aspects of neuroplasticity appear to be abnormal in animals of major depressive disorder. 164  May include genetics (predisposition can be inherited, increase risk of developing a response to negative or stressful event particularly early in life), but psychosocial factors can also be linked to major depressive disorder such as childhood abuse, stressful events or limited social support during adverse circumstances. So likely combination of biological and psychosocial factors. Anxiety Disorders and Obsessive Compulsive Disorder  5 types  **Generalized anxiety disorder (GAD):** describes a person whose general state is *tense* *and uneasy* to a degree it influences their life (don't eat well or are sleep deprived for example). This anxiety must last for *6 months or more.* o Identifiable physical symptoms: eyelids, twitching eyelids, trembling, fidgeting o Population it affects: women (2/3rd are women) o Source of anxiety: unclear o Can't identify the cause of their stress so they can't deal with it or identify it/cause o Can lead to high blood pressure and other bodily symptoms o Usually have also depression (not part of this disorder but can go along with it) o *Continuous high level of anxiety*  **Panic Disorders** o Sudden burst of *sheer panic and intense fear.* o "Panic attacks" -- sudden, intense. Might be in response to any stimuli § Heart palpitations or sweating or chest pain or shortness of breath. o Panic attacks are in response to situations that typically don't warrant that level of stress. § There are situations where a high level of panicking is appropriate ex. If you are being attacked by someone, someone breaks into your house. o There are physical symptoms as well.  **Phobias:** irrationally afraid of specific objects or specific situation. *Focused anxiety* o Can be debilitating (ex. Phobia of leaving your home) or can have a normal life (ex. Phobia of snakes) o Tend to form a pattern. People tend to have phobias of specific subtypes of things typically § Generally associated with fear of animals, insects, blood, heights, or enclosed spaces. These are common but there are more. § People get by by avoiding the source of their phobia o Social Phobias: Fear of different social situations. not as easy to avoid. § Ex; shyness, or intense fear of being scrutinized by other § People avoid talking to people or places where they might be judged or situations that might lead to embarrassment  **OCD** o Characterized by obsessions and compulsions 165 o Obsessions: Unwanted repetitive thoughts o Compulsions: Unwanted repetitive actions o These obsessions and compulsions persistently interfere with everyday life. Ex. Continuously watching your hands through multiple times throughout the day to the point your skin becomes rock. § For normal people, once you perform the action the worry goes away and doesn't interfere with your life. The worry doesn't continue to occupy the brain. Ex. Checking if door is locked, or washing your hands shortly after touching something gross. o Common obsessions: dirty, bad future (something terrible is about to happen, ex. Someone in your family is about go get sick to the point that they don't think about other things), need for symmetry (feel uncomfortable unless things around them are ordered to the point they continue thinking about it ex. A book is slanted and you think about it till you fix it, if you don't something bad will happen) § Remember: these must invade your everyday life and the obsessions are an extreme. o Common compulsions: washing (intense need to wash hand, to bathe, or groom), check doors/appliances (constantly/repeatedly), movement ritual (feeling the need to repeatedly sit down/stand up, leave room and come back, tap on a desk). o 2-3% of people. Typically, teen and young adult.  **Post-Traumatic Stress Disorder (PTSD)** o When a person have lingering memories and nightmares about a past event that it impact them in daily life (haunting/bad memories/repeated nightmares) Includes physical symptoms like insomnia o Have a trigger that leads to the disorder. § Ex. Soldiers coming home from the war, survivors of terrible accidents, violent/sexual assault victims, natural disaster victims. o Described as PTSD if symptoms persist for over 4 weeks after an event. § Ex. A normal person might have a nightmare after something terrifying but these nightmares stop/become infrequent after some time. For someone with PTSD they don't stop. o Acronym: § **Posttraumatic stress disorder** **TRAUMA** **T**raumatic event **R**e-experience **A**voidance **U**nable to function **M**onth or more of symptoms **A**rousal increased 166 o **Repressed memories /memory** are hypothesized memories having been unconsciously blocked, due to the memory being associated with a high level of stress or trauma. The theory postulates that even though the individual cannot recall the memory, it may still be affecting them consciously. The existence of repressed memories is a controversial topic in psychology; some studies have concluded that it can occur in victims of trauma, while others dispute it. According to some psychologists, repressed memories can be recovered through therapy. Other psychologists argue that this is in fact rather a process through which false memories are created by blending actual memories and outside influences. Furthermore, some psychologists believe that repressed memories are a cultural symptom because there is no written proof of their existence before the nineteenth century.\[2\] § **Some believe that they can be "recovered"** years or decades after the event, most often spontaneously, triggered by a particular smell, taste, or other identifier related to the lost memory, or via suggestion during psychotherapy. Dissociate Identity Disorder  Formerly called multiple personality disorder  Two or more distinct personalities exist in a single body. Both identity have influence on persons thoughts and behaviors  The two identities are *distinct* from each other. Each has its own: o mannerisms, o emotional responses, o distinct "physical changes" -not actually different physical differences but one identity could identify as right handed and another as left handed o Denial -- denying the existence of the other identity. Not aware of other distinct personalities exist within that person.  Who have this disorder? People typically have a history of child abuse or other extreme life stressor. o Perhaps develops under cases of extreme stress, which leads to a person's conscious awareness dissociating/separating from painful memories, thoughts or feelings.  How common is this disorder? It is extremely *rare.* o Only popularized by news (usually fake/extreme cases) and movies o Hillside strangler was a fake case, a person who claimed that his crimes was because of this disorder  Controversy surrounds DID due to its rarity. For the following reasons: o Rare in North America, but even more rare in other parts of the world. Some experts think it's a social construct more than a disorder. o Can the disorder be induced by therapists? Leading questions by therapists. 167 § Individuals of therapy might play along with the leading questions of the therapist or lie. o We all to an extent role-play. We all play different roles in many different circumstances (we are a son, and father, and boss at the same time). So we all to a degree have DID. In extreme stress, you might lose yourself in these roles, much like an actor can lose himself while playing a part. Somatic Symptom Disorders and Other Disorders  Medical conditions typically result in physical symptoms. o Medical conditions can also result in psychological symptoms. In the case of autoimmune conditions, cardiovascular disease, and diabetes. People with these conditions can have symptoms of depression, anxiety (like mental disorders)  Mental disorders (disorders effecting the mind such as depression, schizophrenia, anxiety disorders) can result in psychological conditions. o Mental disorders can also manifest into physical conditions. Ex. Depression can manifest in disturbances of sleep. o In some mental disorders, the manifestations of physical symptoms can become a big deal. Mental disorders can exacerbate existing physical conditions or can directly lead to their own physical symptoms. **These are called somatic symptom** **disorders.**  **Somatic Symptom Disorder:** mental disorders manifesting in physical (somatic) symptoms. o *Can be any symptom.* Wrist pain or general feeling of fatigue o *May or may not be able to explain what we see* (the physical condition)*.* May or may not be related to a physical condition o Must cause *functional impairments.* Stops them from going to school or enjoying life. These individuals have excessive levels of all of the following symptoms: *worried* (excessively), have extreme levels of *anxiety*, and spend lots of time and energy worrying/stressing about these symptoms, etc.  **Conversion Disorder** o Must look like *Neurological symptoms only* -- like problems with speech, swallowing, seizures, paralysis o Neurological symptoms that we see are incompatible with any known neurological or mental condition. *We cannot explain these symptoms* based on test or clinical exam. o Sometimes have a level of psychological stress or traumatic event resulting in manifestation of neurological symptoms o The DSM-5 criteria for conversion disorder states the individual Must exhibit at least one symptom of altered voluntary motor or sensory function that shows internal inconsistency, causes distress or impairment, and cannot be explained by another mental or medical disorder. The ICD-10-CM categorizes by symptom 168 type, with weakness (or paralysis) and abnormal movement (tremor) listed as specific symptom types.  **Factitious Disorder** o Patients want to be sick. The patient will falsify or disease their signs or symptoms to get a diagnosis/treatment. Ex. They might injure themselves, falsify tests. This is often called Munchausen's syndrome. o Munchausen's by proxy -when one person makes another person look ill so medical attention/treatment provided further for another individual. o People do this to be in sick roll (not for money) Personality Disorders  Personality is how we experience the world (our inner experience) and how we behave outwardly.  **Personality disorder:** marked deviation from how we expect the people to behave or how the person is experiencing the world. This difference leads to distress/functioning.  **This category is controversial.**  There are 10 personality disorders which are split up into three clusters. Cluster A (odd and eccentric traits), Cluster B (dramatic, emotional, erratic traits), and Cluster C (anxiety and fearful). There is an overlap between the clusters. One person might have one or more types of personality disorders out of the 10 that there are.  How to memorize: A= 3, B=4, C=3. A= weird, B = wild, C = worried. A= PSS acronym, B/C = ABHNADO -- gibberish words that work for me)  Cluster A has three personality disorders: (Acronym: PSS: **P**sych &**S**ociology **S**ection) o **Paranoid**: profound distrust + suspicion of other people. \[paranoid of others\] o **Schizoid**: emotionally detached in relationships and shows little emotion. (what people sometimes incorrectly consider as antisocial) \[DISTANT, can spell as DiZtant. D and Z in schizoid and D and Z in distant\] o **Schizotypal**: odd beliefs/ magical thinking (t in typical = think of magical hat)  Cluster B has four personality disorders: (Acronym including B and C clusters: ABHNADO) o **Antisocial**: little or no regard for others. Commit crimes and show no remorse. Inconsiderate of others. \[Self-explanatory. Hates/ANTI society\] o **Borderline**: Unstable relationships, emotions are unstable, variable self-image and compulsive (which can put them in danger). People at the borderline are at the brink of an emotional/relationship issue. Ex. Displays characteristics of a stereotypical teenager. \[acronym: 13 year old Borderline Brenda\] o **Histrionic**: Are very attention seeking. Display emotions outwardly, wear bright clothes. Ex. \[H for Hollywood Actresses\] o **Narcissistic**: huge egos, need for admiration and praise, grandiose. ex. Dr. House (in TV show House...House is a show that is on **N**etflix), Hitler, his documentary is also on **N**etflix  Cluster C has three personality disorders (ADO) 169 o **Avoidant**: inhibited, feel inadequate and try to *avoid* putting themselves in a situation where they can be criticized. \[self-explanatory\] o **Dependent**: submissive and clingy. Ex. Those who stay in physically abusive relationships, \[imagine: Dependent Debby clings and is submissive to her husband Dan) o **Obsessive-Compulsive Personality Disorders** (OCPD). (do not mix with OCD). Very focused on life being ordered and things being perfect and for them being in control to an extent where it annoys other people. It is a personality! On the other hand, in OCD the focus is on order, things in control, having to wash hands.  Large degree of controversy of Personality disorders. xSleep Disorders See above notes Sleep Wake Disorders Breathing Related Sleep Disorders / Breathing Related Sleep Disorders  Sleep problems occur in three areas: brain, upper airways, or lung/chest walls o Brain - which regulates respiratory center of the lung § **Central Sleep Apnea**- central (brain is part of CNS)), sleep (at night), apnea (effects airflow).  Looking for apnea without obstructions. Looking at 5+ apneas/hour during sleep.  Problem with the brains control system for ventilation (that control brain for breathing)  **Cheynes-Stroke breathing** -- crescendo then decrescendo breathing followed by stop in breathing. Normal breathing pattern is inhale/exhale changes from a normal fixed pattern.  Believed heart failure/stroke/renal failure is the cause. o Upper Airways- obstruction from mouth to the lungs § **Obstructive Sleep Apnea** -- when airways are obstructed. Soft tissues around our neck can relax at night and potentially cause obstruction of airflow for a short period of time. Gets worse as people get older.  At nighttime, this causes snoring or gasping or pauses in breathing.  At daytime, people are tired/sleepy and unrefreshed 170  Diagnosed by: Sleep study (a polysomnography) and looking for 15+ "apneas"/hour (Apnea -- lack of airflow). o Lungs or chest walls -- stops lungs from being able to expand § **Hypoventilation Disorder** -- When we are not able to ventilate our lungs fully and remove all CO2. Results in a buildup of CO2, and a decrease in O2. Can occur due to medications that repress respiratory functions (narcotic pain killers such as opioids) or if there is a problem with the lungs or chest wall. A common occurrence is due to obesity.  High CO2 can cause right sided heart failure  Low O2 effects all organs/tissues of bodies. Cognitive impairment, heart problems (arrhythmias - abnormal heart rhythms), and polycythemia (elevated RBC in blood) xReward Pathway in the Brain See above notes xDrug Dependence and Homeostasis See above notes xTolerance and Withdrawal See above notes xSubstance Use Disorder See above notes Biological Basis of Alzheimer's disease  Most common disorder in dementia category, or neurocognitive disorders. Loss of cognitive functions. Memory also decreases. But normal motor functions are fine until later stages where they lose basic **activities of daily living (ADL)** -- toileting, eating, bathing, etc.  Cause of disease is limited.  Brain tissue has decreased in size significantly -- shrivelled up, **atrophy**. o It's the **cerebrum** that often dramatically decreases in size. Severity of atrophy correlates with severity of dementia. o Starts in temporal lobes, important for memory. o Later, atrophy spreads to parietal and frontal lobes. Many other cognitive functions.  Under microscope, 3 main abnormalities: **loss of neurons**, **plaques** (amyloid, because plaques are made of beta-amyloid. Occur in spaces between cells, outside of neurons in abnormal clumps), and **tangles** (neurofibrillary tangles, clumps of a protein **tau**. Located