Unit 3 Eating Disorders PDF

10/17/24:  1) Amount of food larger than normal 2) Unhappy moods and may be temporarily comforting Compensatory behavior: - Purging types - Vomiting - Laxative - Enemas - Nonpurging - Restriction periods - Exercise Bulimia nervosa...

10/17/24:  1) Amount of food larger than normal 2) Unhappy moods and may be temporarily comforting Compensatory behavior: - Purging types - Vomiting - Laxative - Enemas - Nonpurging - Restriction periods - Exercise Bulimia nervosa: associated features - Much of daily routine centers on weight, diet and appearance - Sensitive to comments about their weight or appearance  - Often have a history of anorexia Binge eating disorder: - Binge eating once a week on average for three months without compensatory behaviors - People we see at weight loss clinics → but usually still psychological issues - Rapid eating - Feeling uncomfortably full - Binge eating when not hungry - Eating alone because of embarrassment - Negative emotions afterwards Anorexia nervosa: DSM-5 criteria 1) Restriction of energy intake relative to requirements, leading to a significantly low weight a) Approximate is 18.5 BMI 2) Intense fear of gaining weight/becoming fat OR persistent behavior that interferes with weight gain 3) Disturbance in way in which one’s body weight/shape is experiences OR undue influence of body weight or shape on self-evaluation OR persistent lack of recognition of seriousness of current low weight Anorexia: Specifier - Restricting type: - No engagement in recurrent episodes of binge eating or purging behavior - binge-eating/purging type: - Engaged in recurrent episodes of binge eating OR purging - Can be more severe due to purging methods Problems associated with AN: - Preoccupation with food - Struggle for control over hunger - Loss of interest in or sexual difficulties - Medical problems Diagnostic specificity: - A diagnosis of anorexia trumps a diagnosis of bulimia  - A diagnosis of bulimia trumps a diagnosis of binge eating disorder Summary of onset + prevalence of Bulimia and Anorexia: - Onset is the same for both disorders - Sometimes anorexia is earlier (12/13) - Bulimia usually high school or college age - Binge eating sometimes middle-aged (30s/40s) - Rare in general populations - Binge eating + bulimia more common - Disordered behaviors common, but not disorders themselves - Cohort effect - EDs tend to be more recent disorder (vs depression) - Most common in industrialized nations - US - Western Europe - China - Korea - Japan - Higher prevalent in women than men What about men? - Traditionally men with eating disorders often go undiagnosed - Gay men, wrestlers, and jockeys are at elevated risk for eating disorders - Weight class sports Eating disorders in men: - Pressure to be bigger or more muscular - Drive for muscularity - May be 2 dimensions for disordered eating behaviors/symptoms among men: drive for thinness/ “leanness” and a drive for muscularity  - Drive for muscularity present even if disordered eating behaviors/pathology was not? - Satisfaction, internal concerns, ideal male body - Men reported more body image concerns/compulsive exercise - When comparing two group, binge eating men had more relation to excessive exercise + body image concerns/fixations - Drive to lose weight/be thin may trump muscularity drive? - Ideas driving to engage in behaviors, but more so drive for thinness not muscularity - May be more heterogeneity in how body image/weight concerns are constructed in men - Research still being formed Body dysmorphia – muscle dysmorphia.. ED but for men? - What is body (muscle) dysmorphia - Technically body dysmorphia classified under OCD and related disorders… - Muscle dysmorphia is included in DSM-5 as a specifier for body dysmorphic disorder - “I don’t look right” - Can be corrected through surgery - Not technically eating disorder, but still same preoccupation with body looks/diet - Diet, exercises, life weights excessively, use potentially dangerous anabolic steroids - Occurs almost exclusively in men Possible signs to look out for: - Some signs - Following regimented workouts or meals or limiting foods or concentrating heavily on high protein options - Disrupting normal activities to work out instead - Obsessively taking photos of muscles to track improvement - Weighing self multiple times a day - Dressing to emphasis muscular physique or hiding physique because it’s not good enough Growing trend among men: - Nationally representative US sample: 30% of adolescent boys want to bulk up or gain weight - Including 40% objectively normal weight by BMI standards - 22% report muscle building behaviors, including eating differently to build muscle, supplement use, androgenic-anabolic steroid use *No strong boundaries set with regards to when wanting to lose weight or gain muscles becomes disordered! Eating disorders by ethnicity + race: - Eating concerns are recognized as affecting all racial and ethnic groups - Traditionally white upper-class women in western countries  - Now more prevalent in Asian countries - But still some in India + Africa (less common) - We see this in places where thin is the ideal - Seeing more cases rise in POC communities of the US, as much as white women, however, we may not see them in treatment as much/not presenting for treatment - EDs becoming more prevalent across populations - Strong identity related to reduced risk Epidemiology: Bulimia *High amount of crossover with EDs Comorbidity: lifetime psychiatric disorders among ED patients + control women - MDD - PTSD - Alc dependence - Drug dependence - GAD  - OCD - PD “B” *Impulse control/sensation seeking (emotional regulation) → crossover between disorders Anorexia + Bulimia Mortality: - Anorexia - 3% pass away from medical complication - Suicide common - Mortality 12x higher for similarly aged women (not struggling) - Bulimia - Less mortality - More suicide attempts than general population Long-term course: - Bulimia: 10-11 years after diagnosis - 70% in remission - 30% continue to struggle - Anorexia: 21 years after first diagnosis: - 16% deceased - 10% still had disorder - 21% partially recovered - 51% fully recovered (low) Influencing factors/etiology: Etiology: - Social - Cultural context, including high emphasis on the thin ideal Fiji (2002): - 1990s large number of overweight women - “Bigger” was associated with valued qualities  - 1996 TV introduced to Fiji - - 20% cutoff → anyone at score has higher risk for ED - Comments regarding body dissatisfaction 10/22/24: Social Influence: - Culture, media, media, gender and body image - Focus on thinness - Thin = beautiful Internalization of ideal: - “Thin-ideal internalization - extent into which an individual “buys into” socially defined ideals of attractiveness & engages in behaviors to achieve these ideals - Slender women more attractive - Women with toned bodies more attractive - Found EDs more common among young women with greater exposure to media that reinforces thin-ideals beliefs/behaviors/views - family/peers/community reinforce these ideals Culture: - Ideals change with time - Even models/celebrities “not good enough” Rising Media usage, rising body image issues: - 67% of adolescents report feeling worse about their lives as a result of things they see on social media - NEDA - national eating disorders association - American high school students : using social media more than 2 hrs daily were 1.6 times more likely to experience body issues - Engaging with appearance-focused content that idealizes thin bodies, taking selfies and comparing oneself to celebrity images can increase body dissatisfaction and disordered eating among men and women Some findings: - Type of content consumed seems to be strongly associated with negative body image and EDs rather than time spent - Exposure to weight loss content associated with lower body appreciation, greater fear of negative evaluation and more frequent binge eating - Higher BMI associated with this too  - Meta-analysis: social media usage leading to body image concerns/eating disorders/poor mental health mediated by - Engaging in more social comparison, internalization of thin-ideal, self-objectification - Including specific exposures to pro-eating disorder content, appearance focused platforms (i.e. Instagram, Tik Tok) Multiple Social Media Trends and Communities connected to EDs: - “Selfie” culture - Constant focus on outward appearance to others in media → curates obsession with perfection: ideal body image - Comparisons between others’ “selfies” - pro-ED communities - Internet has become source of pro-ED communities to flourish - hard to regulate whole internet - Even influencers simply promoting weight loss content (thinspiration, thigh gap, bikini bridge) - Pro-Ana and pro-Mia websites or blogs - “Girl dinner” - “Body checking” - “What I eat in a day” - Various “challenges (collarbone coin, A4 paper waist) What can we do about it? - Reduce exposure to media images - Reduce internalization of thin-ideal - Dissonance based intervention (create cognitive dissonance) - Critical consumer education - Interrupt social comparison process - Create disconnection - Questioning diet recommendations by some random TikTok influencer - Better treatments (more on that to come) - Weight gain is important… but perhaps MORE important working on underlying issues Biological influences: Minnesota Semi-Starvation Experiment - World War 2 - First 12 weeks, maintenance - Second 24 weeks, semi-starvation (1500 calories or less) - Third 12 weeks, recovery/rehabilitation period - Key point: loss of weight led to extensive obsessions about food and compulsive eating rituals that DID NOT extinguish even when returned to healthy weight - So, act of starvation and food, restriction itself prompts obsessive, food-centered thoughts - Also mentioned extensive concerns about weight and shape - None of the participants had prior history of EDs or other psychological issues Biological influences (anorexia): The Possible Role of Serotonin and Tryptophan - Serotonin: imaging studies show dysregulated serotonin receptor activity in individuals struggling with anorexia (both active illness and in recovery) - But opposite activity: reduced receptor activity in actively ill individuals, increased/overactive activity in recovery individuals - Connection to tryptophan - Receptors become even more sensitive to any serotonin, anything eaten activates receptors → eat less - *serotonin may play role in development of AN Psychological/cognitive risk factors: - General risk factors - Stressful life events - Familial experiences - Negative emotionality - Specific risk factors - Shape and weight-related concerns (body dissatisfaction, negative self-evaluation) - Both BN and AN tend to have excessive concern (more intense) - More risk factors → more likely to develop disorder - Across all three eating disorders  - Dietary restraint - Dieting → contributes to onset + maintenance of disorder - Family history + certain familial experiences - Genetic factors account for 40-60% of liability - Environment + genetics - Set point theory Distorted body image: - Greater gaps in what they look like versus their ideal (perception issues) Family factors besides genetics: - Direct factors - “Cut down on chips” from parent - Indirect factors - Watching parents either binge or restrict Final general summary of risk factors: - When comparing EDs to control with other psychiatric disorders: - Family overeating, teasing (by both peers and family), high parental demands - Some disorder-specific risk factors - AN: perfectionism, feeding problems (picky eating, digestive problems), obsessionality + ties to OCD/OCPD - BN: escape/avoidance coping style, high neuroticism, some evidence of high levels of impulsivity, being overweight in childhood Keep in mind: - You can’t tell whether someone has ED by looking at them - EDs not lifestyle choice - EDs not only affecting white, middle/upper class teenage and young adult women - EDs not only about having bad body image - EDs not just a “phase”; it is not easy for someone to “snap out of it” - When someone is back to healthy weight, it does not mean that they are definitely “fully recovered/cured” - EDs are not always something that people struggle with forever Medical management: - EDs associated with physical complications - Comprehensive care should include medical management Evidence-based treatments for bulimia and BED: - BN - CBT - Targets core features of disorder - How symptoms cycle to perpetuate themselves - Goals - Stop behaviors - Challenge dysfunctional beliefs - Develop realistic expectations - Individual is most effective - 70-80% reduction in binge eating + purging - 33-50% show no signs of BN - Some evidence for group and self-help forms  - IPT (interpersonal psychotherapy) - Focuses on difficulties in close relationships - Antidepressants - Seen as supplement not stand-alone treatment - BED - CBT for BED - IPT for BED Outcome + course of Bulimia: - More favorable outcome than AN - Predictors of continued binge eating: - Longer illness duration - Emphasis on shape + weight - Childhood obesity - Poorer social adjustment - Persistent compensatory behavior - Comorbid alcohol use disorder Evidence -based treatments EBTs for Anorexia: - AN - Family based treatment for FBT for adolescents/children is most successful - CBT - Modest support bc adults can’t have this - Two goals for treatment: - At least minimal amount of weight gain - Address broader eating difficulties 10/24/24: FBT for AN: - Family-based therapy - Developed at Maudsley Hospital, London - Focus on treatment without hospitalization - Outpatient intervention - Abt 20 sessions over 12 months - Views parents as resource for resolving disorder Treatment for adults with AN… needs work - CBT used but… not as successfully as FBT for adolescent - New studies on open-dialectical behavior therapy - Emotional loneliness - Inflexibility - Potential usefulness for adults, but we do not know yet Treatment of anorexia: - Predictors of successful treatment - Early onset combined with rapid diagnosis, less parent-child conflict, early treatment, less weight loss, and absence of binge eating and purging, development of strong therapeutic alliance - Challenges - Fear of weight gain often propels anorexia patients into defensive positions - Health professional often seen as dangerous or threatening - Easier to treat kids and adolescents as parents have a little more control than when the patient is an adult Current support (or lack of) for other treatment: - Psychotropic medication - I.e. depression meds - Antipsychotics → contradictory evidence - Nothing targeted for AN - Nutritional counseling Long term outcome of AN: - Long term outcomes (10-20 years following treatment) - Abt 50% within normal weight range  - Abt 20% remain significantly underweight - Mortality rate of 5% - From starving or related complication - Suicide - Anorexia far more difficult to treat than bulimia Treatment gaps for EDs: - Data on receipt of any treatment for EDs is dire - Abt 20% of college students with EDs report receiving treatment - Individuals from racial/ethnic minority backgrounds with EDs are significantly less likely than their white peers to be diagnosed, receive care or even be asked by a doctor about ED symptoms What about prevention of EDs? - Successful efforts have not focused on: - Body image - Disordered eating - Eliminating unhealthy eating habits - Successful efforts have focused on: - Promoting healthy eating habits - Dissonance tasks to combat internalization of thin ideal Substance Use Disorders: Myths vs facts Common myths: - Just say no– willpower! - Substance use is brain disease and changes brain chemistry, not as easy as just saying no - Addiction only affects certain people - Can affect anyone regardless of age, gender SES, or ethnicity - You have to hit rock bottom - Treatment at early stages associated with better outcomes - Criminal behavior - Most common substance use disorders are legal substances, places emphasis on legal consequences and away from treatment Substance use disorder (SUD) and Stigma: - Cause of illness key factor influencing level of stigma - Brain disorder vs. just need willpower to quit - SUDs → highly stigmatized - Leading cause of not pursuing treatment  - Stigma within medical field: violent, manipulative, not motivated - Lack of training, lower paying specialty, often underfunded Language matters: - Substance abuser/addict - Needs punishment - At fault for substance related difficulties - More likely to be dangerous - Lacks willpower - Person with SUD - Brain based - Deserving of treatment - More concern, empathy - Can recover - Results: wanted more distance from Jane (addict) vs Mary (SUD) - Negative connotation = addict - Positive connotation = SUD Changes in language: What counts as a substance? - Substance that alters a person’s thoughts, emotions, behaviors or perception - Can be over the counter, prescriptions, legal or illegal substance - Can be used to increase a person’s comfort or levels of consciousness Common categories of substances: - Depressants - Slow down activity in brain and body - Relax, calm in small doses - Examples: alcohol, benzodiazepines - Stimulants - Speed up body; cause excitement/euphoria - Cocaine, nicotine, caffeine  - Opiates - Block pain, increase pleasure (increase dopamine) - heroin , oxycodone - Cannabinoids - Triggers dopamine release - Both depressant and stimulant - Marijuana, hashish - Hallucinogens - Alter our brain function – neurotransmitter functioning - Alter our perceptions of reality - MDMA, LSD, psilocybin (lab made and natural substances) US college students substance use Fall 2023: Use vs. disorder: - Use is not the same as disorder - How do we know when it turns into a disorder? - Defined by amount? - Problematic? - Different tolerances - Too high of amount, but “i’m fine” - Does it cause problems in daily life? - Current continuum of use model Use vs. disorder: Important symptoms - Craving - Amount of time spent planning or thinking about drug/substance - Tolerance - Larger doses of drug needed to produce desired effect - Effects of drug decrease if usual amount is taken - Tolerance varies by substance (i.e. heroin vs LSD) - Withdrawal - physical/psychological effects from stopping substance - Effects are specific to substance - Caffeine → headaches, hand tremor - Xanax → seizure, hallucinations, tremor, racing heart DSM-5: substance use disorder criteria - Problematic pattern of use that impairs functioning is associated with 2+ symptoms from following symptoms - Craving - Tolerance - Withdrawal - Failure to meet obligations - Repeated use when potentially dangerous - Repeated relationship problems - Continued use despite problems caused by substance - Taken for longer time or in larger amounts than intended - Efforts to reduce or control use unsuccessfully - Much time spent trying to obtain the substance - Social, hobbies, or work activities given up or reduced due to use SUDs facts and stats: - Age of onset - Peaks around college age, declines over time, slight peak at 45 - Transgender kids and adults have higher substance use disorder rates than cisgender people - Substance use disorders seen across world (not just Western world, but higher rates in US) - Worldwide deaths from alcohol and drug use disorders - Number of deaths in US due to illegal drug overdose - US very high rates of Fentanyl - Worldwide: tobacco and alcohol most deaths Comorbidity: - Comorbidity is high - Between 40-65% of those with SUD have another mental illness - High rates of SUD in mood disorders (depression and bipolar), anxiety and schizophrenia - Disentangling disorders is hard: - Substance use → mood or anxiety - mood/anxiety → substance use to cope Behavioral addiction (new, controversial area): - What about non-substance related behaviors that we may become “addicted” to? - I.e. shopping, gaming, sexual behavior - Lots of debate on whether this should be included - Why or why not? Behavioral addiction: for or against - Reasons for: - Behaviors activate similar reward pathways in brain - Impair quality of life  - Increase awareness and treatment/validate experience - Against: - Doesn’t involve exposing brain to substance - No tolerance or withdrawal - Cultural context? Gambling disorder – only behavioral addiction included currently - Not social gambling or professional gambling - Disordered gambling – takes over one’s life, financial and interpersonal consequences Symptoms specific to gambling disorder: - Chasing losses – betting more money after loss - Feel compelled to gamble and increase stakes – tolerance? - Feelings of anger, guilt when try to stop – withdrawal? 10/29/24: Neurotransmitters and the Brain: - Reward pathway in the brain - Ventral tegmental area (VTA): primary dopamine producing area of brain - N Accumbens: motivation and rewards - Frontal cortex: planning Neurotransmitters and the brain: - Reward pathway in the brain - Actions we need to survive (i.e. food, sex, etc.) are reinforced by release of dopamine Neurotransmitters: dopamine - Previously assumed that dopamine was released when we consume reward (liking) - However, cues that predict reward or anticipate reward (wanting) → dopamine release - Over time, cues that predict reward produce a greater response in the reward pathway than the reward itself → craving  - Liking reward decreases, but wanting remains intense (especially in response to cues) - As substance use increases, dopamine receptors become less sensitive (tolerance) – need to increase drug amount to avoid withdrawal or have any positive feelings What does this mean for substance use disorders? - Dopamine system becomes sensitive to drug and associated cues that predict reward - Smoking - Football - Bar Biological factors: - Vulnerability model - Vulnerability in individual dopamine system → substance use - Toxic effect model - Substance use → problems in individuals dopamine system (keep you in cycle of abuse) - Research supports both Brain volume differences? - After substance usage – less brain volume - 4 drinks per day – more volume loss - Quantity matter - Smaller brain volumes (in children) can also predict substance use disorder Psychological factors - Personality - Risk taking - Impulsivity - Emotion regulation - Heightened negative emotionality - Difficulty regulating - Comorbidity - Medicating self/dampen other symptoms Social/environmental factors: - Social - Peer pressure - Lack of social connection - Family environment - Early life experiences  - Family history of substance use – access - Community - Stressors – trauma/poverty - advertisement/media Abstinence vs. harm reduction: - Abstinence: - Treatment requires no substance use - Some say not substance of choice others say no substance of any kind - Can be very punitive → failure if you slip up and low retention rates - Harm reduction: - Reduced use aimed at improving function and quality of life (primarily CBT) Medications: - Substitution - Substitutes drug with similar drug thought to be less dangerous - Examples: methadone, nicotine gum/patch - Methadone (heroin/opiate addicts) - Highly controversial - Reduce dose overtime - Antagonistic treatment - Drugs that block or counteract pleasurable drug effects - Naltrexone for opiate and alcohol problems - Overtime people stop taking substance bc they aren’t getting response they want - Aversive treatment - Makes use of drugs extremely unpleasant - I.e. antabuse for alcoholism - Feel sick when you drink alcohol very quickly → associate alcohol with horrible sensations - Only works for people really motivated to stop - Efficacy of biological treatments? - Step down approach - Need to be combined with talk therapy Treatment: - Inpatient care - For detox (withdrawal from substance under medical supervision) - Some drugs tougher to detox from - I.e benzodiazepines (unsafe on their own) → hallucinations, etc. - Team approach  - Nursing staff, psychologists, social workers, psychiatrist, peer counselors - Community support programs/self-help groups - 12 step programs: alcoholics anonymous/ narcotics anonymous - Disease model – “I am powerless” - Religious component – higher power - Social support system – key component? - Led by peers with actual experience - Some studies show AA participation → better outcomes than other treatments; some suggest AA no more effective than other forms of therapy? - Is this the right fit? - Location, i.e. New York (support every other) - Some people don’t like religious or label aspect of it - SMART recovery - Groups guided by trained facilitator - Same group for all substances - Structured - Internal locus of control vs. spiritual higher power - Discourages label (“I am an addict” vs. “I have a substance use disorder”) - AA models/SMART both involve peer support - Group therapy - Led by therapist - CBT based skill building - Mindfulness - Peer support still important - CBT - Learn how to avoid high risk situations - Recognize triggers - Cue exposure - Develop alternative to use - Motivational enhancement therapy - Motivational interviewing (MI) - Helps people discover their own reasons for change - Developed as alternative to interventions that are: - Not client-centered - Persuasion based - Often used in drug treatment settings because… - Historically used coercive, non-mutually agreed-upon interventions - But used in many different settings - 5 principles of motivational interviewing  - Express empathy - Develop discrepancy - Avoid arguments - Roll with resistance - Support self-efficacy Efficacy of treatment? - Treatment of substance use is not great - Motivated persons tend to do better - Important to incorporate comprehensive treatment approach - Important to keep client’s reasons for change in mind - What is your ‘why?’ - Ex: my why is to be able to meet my grandkids 10/31/24 - As substance use increases, dopamine receptors become less sensitive and need more drug to increase reward Substance Use treatments - Medications– substitution, aversive, antagonistic - AA/SMART recovery models - Group therapy - CBT - Motivational interviewing Case examples: - Peer support (lonely) - CBT to look at feelings + fears, can we retrain that? - Heroin addiction - Maybe inpatient safe detox - Motivational interviewing → get him to want to stop heroin Prevention – SUDs - DARE– scare kids not to use drugs - Not effective, may have opposite effect - “This is your brain on drugs” → egg cracking add Prevention via public policy: - Use laws/public policy aimed at advertising substances?  - 1998 Master Settlement Agreement - Lawsuit with 4 large tobacco companies - Government prohibited targeting cigarette sales to youth - Banned payments to promote tobacco products in movies, music, video games - “Healthy cigarette recommended by doctor or dentist” - Advertisements of menthol cigarettes (more addictive) to black communities - After 1991, pretty substantial decline of cigarette usage by kids - However, no ban on e-cigarettes - Vaping use by kids increasing - Advertised as cool + colorful, tasty (geared towards kids + young adolescents) - Similar to candy and food flavors → increase usage in teens - Social influence approach: - Education re. The prevalence of substance use among peers - Refusal skills training - Social competence or life skills - Modest outcomes – will need more research and commitment to prevention Dopamine detox: - Dopamine detox - Fast from things that trigger dopamine (i.e. social media, gaming, sugar, etc.) - Is there any science behind “detoxing” from dopamine? - Not that she could find - Sure, it can be nice to give yourself downtime or distance from activities like social media - However, our brains don’t stop releasing dopamine because of a detox from some things Schizophrenia: Myths about Schizophrenia: 1. dissociative identity/multiple personalities 2. Violence/danger a. No more likely than those of us without schizophrenia) 3. Schizophrenogenic mother a. Cold distant mother I never had) b. Blamed mom for causing it  c. Mom this is your fault, we need to treat you + your family d. Not as common of story line today History: - Kraepelin - “Dementia praecox” - Meaning premature dementia – early onset, progressive - Cognitive disorder - Bleuler - Broke with Kraeplin’s description - Introduced the term “schizophrenia” - Meaning “split mind” - Split between patient’s thoughts and reality, not split personality Today’s definition: - Schizophrenia impacts virtually every aspect of a person from how we think, feel and behave - It is chronic and a severe illness - 3 major categories of symptoms: - Positive symptoms: excesses - Disorganized symptoms - Negative symptoms: reductions Positive symptom domain (aka psychotic symptoms) - Delusions - Firmly held beliefs contrary to reality and usually very unlikely - Common types - Grandeur – exaggerated sense of power, knowledge, identity - Example: world famous author - Reference – insignificant remarks, events, or objects are meant for them - Ex: president is speaking to me through tv; song is about me - Thought broadcasting – belief that thoughts can be heard or known by people around them - Ex: all of you can hear my thoughts - Persecutory – belief that person is being mistreated, spied on, planned harm - Example: my husband is trying to kill me; the FBI is tapping my house through the radiator - Hallucinations  - Sensory experiences in the absence of sensory stimulation - Person can see, hear, feel, smell or taste something that isn’t there - Most often seeing or hearing things: - Hearing thoughts spoken by another voice - Voices commenting on behavior - Often negative and threatening - Seeing people, objects, creatures - Note: these symptoms can be present in other disorders (i.e. bipolar disorder, dementia, tend to be less developed) Negative symptoms: - Behavioral deficits in motivation, pleasure, social closeness, and emotion expression - Two domains: 1. Motivations and pleasure (MAP): motivations, emotional experience, sociality 2. Expression: outward expression of emotion, vocalization Motivations and pleasure (MAP): - Asociality: diminished interest/motivation in being around others and having close relationships, however.. - When they are with others they report just as much enjoyment as those without disorder - High levels of loneliness: want more connection with others →doesn’t fit with idea of asociality - Anhedonia: people with schizophrenia seem to have largely intact ability to experience pleasure (liking) - Ability to anticipate future pleasurable things (wanting) seems to be impaired - Inability to experience pleasure - People with schizophrenia have more difficulty with anticipating pleasure (wanting) rather than experiencing pleasure (liking) - Avolition: reduced motivation can be for goal directed activities but also for pleasurable activities - “I’m supposed to care about my family but I’m not motivated to go see them” - “I miss having friends but it takes so much work to have friends” - “I got in trouble at work because I didn’t go” - On behavioral tasks in lab– less willing to work for effort for more money - In daily life: - Fewer steps - Fewer times leaving home - Fewer anticipated goal directed activities  - But, when engaged in goal directed activities, report similar amount of pleasure/satisfaction - Disconnect between liking something and taking steps to do things Expression domain: - Blunted affect: reduced outward expression of emotion - Facial expression - Vocal fluctuations - Hand gestures - Emotion recognition task - Decreased ability to recognize emotional expressions - Alogia: reduction in amount of speech - These symptoms are especially linked to poor social functioning/connections Negative symptoms summary: - MAP: - Avolition - Asociality - Anhedonia - ED - Blunted affect - Alogia - Negative symptoms relate to increased functional impairments + reduced recovery - Predictive of poor outcomes more than positive symptoms Disorganized symptoms: - Disorganized speech - Problems in organizing ideas and in speaking coherently - Loose associations (derailment) - Difficulty sticking to one topic - “Word salad” - Motivation to go to work? - “I submitted paper but the tracker is going off I’m trying to trick them into thinking I left” - Catatonia: peculiar, increased, repeated gestures or immobility - Seldom seen today due to effective medications DSM-5: Schizophrenia  - At least 2 of the following symptoms, at least one of which is delusions, hallucinations, or disorganized speech - Delusions - Hallucinations - Disorganized speech - Disorganized (or catatonic) behavior - Negative symptoms (diminished motivation or emotional expression) - Anhedonia - anticipations - Asociality - Flat affect - Symptoms must last at least 6 months Case Study: What symptoms did you notice? - Flat (talking about getting shot or murdered) - Delusions - Disorganized speech/behavior - Hallucinations - Heard eagle telling her things (US government representations) Timeline of schizophrenia: - Premorbid phase– before positive symptoms - Home movie study: - Fewer expressions of positive emotions (smiles, laughs) - Reduced responding to peers - Involuntary hand/body movement - Prodrome – early adolescence - Functional decline – begin having trouble at school, attention, getting homework done - More social withdrawal - Hearing whispers/seeing shadows - Disheveled - Psychotic & stable phase - Psychotic phase - Active positive symptoms - Stable phase (chronic) - Positive symptoms managed/less severe - Negative symptoms - Cognitive symptoms *Note: people can cycle between psychotic and stable phase; aging associated with less psychosis Other schizophrenia spectrum disorders: - Schizoaffective disorder - Symptoms of both schizophrenia and mood disorders - Psychotic symptoms must be independent of mood episodes - Brief psychotic disorder - Same symptoms but shorter duration (1 day to 1 month) - Can be triggered by stress - Delusional disorder - Persistent delusions lasting at least 1 month - No other schizophrenia symptoms Facts and stats: - Top 10 leading cause of disability worldwide - Abt 1% of population - Typical age of onset for men 18-25; can begin later for women - Gender differences widely debated. Most recent literature suggests equal rates or only slightly higher rates in men - Elevated rates of suicide, substance use, depression Epidemiology: biological - Heritability estimate abt.77 - Higher concordance in MZ (45%) vs DZ (12%) twins - Overlapping genetic risk factors with other diagnoses (i.e. bipolar, autism) Biological: neurotransmitters - Dopamine hypothesis: SZ caused by too much dopamine - Evidence: meds that increase dopamine (Parkinson’s meds) cause psychotic symptoms - Cocaine → psychotic symptoms - Problem: doesn’t explain cognitive and negative symptoms, decreasing dopamine doesn’t take it all away Dopamine in schizophrenia and those in prodrome: - Increased dopamine in limbic system of schizophrenic patients - Dopamine is a part of the disorder, but it’s not the whole thing Neurotransmitters:  - It’s complicated - Take home: not just a dopamine problem, it likely involves several neurotransmitters (serotonin, glutamate, etc.) Biological: brain - Brain structure, - Ventricles – enlarged - Reduced volume – frontal and temporal, hippocampus (worse memory) - Brain function – reduced activation - Prefrontal - Limbic (during anticipation) - Hippocampus *note: this is not an exhaustive list! Social/environmental: - Stress – genes x environment - Suggestion that stress triggers onset of psychosis and future episodes - Complications during pregnancy or birth - Infection during pregnancy - Prenatal malnutritions Environmental factors: - What about marijuana? - For people who have schizophrenia already, use is associated with worsening symptoms - Emerging research suggesting MJ use can be a trigger particularly among those who are vulnerable to schizophrenia - Still need more research to understand this link better – need better understanding of directionality - Urbanicity: higher rates (abt 3x) among people living in urban areas relative to rural areas) - Poverty: higher rates among urban poor Social factors: expressed emotion (EE) - Hostile, critical, overinvolved comments - EE is associated with greater relapse, does not cause schizophrenia - “You look like such a slob! Clean your clothes!” - “I will do it for you – you can’t do it right!” - Bidirectional  - Expression of unusual thoughts by persian with schizophrenia → increase critical comments by family - Critical comments by family → increase thoughts by person with schizophrenia Treatment: antipsychotic medications - Act by blocking dopamine receptors, also impacts serotonin, norepinephrine - Treat positive symptoms – do not really touch other symptoms - Positive symptoms may linger but tend to be less severe - First generation – 1950s (i.e. Thorazine) - Tardive dyskinesia: lip smacking, tongue sticking out, uncontrollable facial/body movements - Second generation - 1990s (i.e. Seroquel) - Lots of side effects → willingness to take meds - High blood pressure - Weight gain - Drooling - Tremor Treatment: psychological - Family therapy: - Education - Help communication/manage frustrations/decrease expressed emotions - Cognitive behavioral therapy: - Daily life skills/medication management - Relaxation strategies/coping with stress - Work with delusions/hallucinations - Note: some studies show reductions in delusions via therapy results in feelings of hopelessness - Question: what would life be like without delusional belief? - “All for nothing, sadness, wrong” - Case example: psychotic break during PhD, frequent writing in journals with breakthroughs - Social skills training: - Interpersonal situations/role playing - Self care - Daily life skills - Cognitive enhancement training: - Can we boost people’s cognitive functioning? - Minimal support for this right now  - Does not translate over time Prevention/resilience: - Can we prevent development of schizophrenia? - Recent years a lot of work has examined risk and prediction of schizophrenia - Risk factors: - Those with genetic risk - Social withdrawal/isolation - “Psychotic like experiences” - DSM-5 Proposed: Attenuated Risk Syndrome - Diagnosis for those at high risk - However, most people don’t develop psychosis; risk: label of psychosis 10/7/24: - Denied hallucinations - Facial expressions - Organized fashion of story - Delusions Current prevention work: - First Episode clinics set up around the country for those early in course of schizophrenia (18-30-year-olds) - Goal: slow progression, prevent decline - Question: what is effective? - Resilience factors that can apply broadly - Stress management, social support, sleep, physical activity - Community resources: education, prenatal care (infection/malnutrition issues), nutrition Do symptoms of schizophrenia differ across cultures? - Negative symptoms appear largely consistent across demographic groups, SES, cultures, etc. - Hallucinations + delusions - Some have found that voices are less negative/threatening outside of Western cultures – but mixed feelings - Delusions primarily persecutory across countries Outcomes of schizophrenia across world - Favorable outcome hypothesis in developing countries  - View: developing countries have a larger % of patients with a good outcome - Results: several older studies support this, unclear if this trend continues - Developed countries largely associated with worse social outcomes - Ex: study comparing Nigeria and India to US → tolerance, acceptance, care for family - Case example: woman from Senegal US view of schizophrenia: - Before 1960s - SZ viewed through lens of white, middle-class patients - Associated with creativity/genius - Patient notes: - “Talked to loudly + embarrassed husband” Schizophrenia : late 1960s - Ionia State Hospital in MI - Disproportionate number of black men sent to hospital after petty crimes + participation in civil-rights protests - Increase in number of black men diagnosed with schizophrenia - Medical record: - “Danger to society if not in institution” - DSM II (1968) - Added hostile/”aggressive attitude” to schizophrenia symptoms - Unintentionally reflected social tension of the 1960s, influencing link between protest and mental illness - Argument that this change resulted in structural racism - Biases are historically “structured into clinical interactions” Schizophrenia: Current - Aggression and hostile symptoms no longer in DSM - However, still pervasive view in society that schizophrenia associated with violence