Transcript Developmental Psychopathology

CHAPTER 16
DEVELOPMENTAL PSYCHOPATHOLOGY
Learning Objectives
• What criteria are used to define and diagnose
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psychological disorders?
What is the perspective of the field of
developmental psychopathology?
What sorts of questions or issues do
developmental psychopathologists study?
How does the diathesis-stress model explain
the causes of psychopathology?
What Makes Development Abnormal?
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Mental health professionals use three criteria to
differentiate between normal and abnormal behavior
– Statistical deviance
• Does the person’s behavior fall outside the
normal range of behavior?
– Maladaptiveness
• Does the person’s behavior interfere with
adaptation or pose a danger to self or others?
– Personal distress
• Does the behavior cause personal anguish or
discomfort?
What Makes Development Abnormal?
DSM Diagnostic Criteria
• Professionals who diagnose and treat
psychological disorders use the criteria of the
Diagnostic and Statistical Manual of Mental
Disorders (1994)
– DSM-IV-TR published in 2000
– DSM-V to be published in 2013
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What Makes Development Abnormal?
DSM Diagnostic Criteria
According to the DSM-IV-TR diagnostic
criteria for major depressive disorder, an
individual must experience at least 5 of the
following symptoms, including one of the first
two, persistently within a 2-week period
1. Depressed mood (or irritable mood in children and
adolescents) nearly every day
2. Greatly decreased interest or pleasure in all, or almost
all, usual activities most of the day
3. Significant weight loss when not dieting or weight gain
(or for children, failure to achieve expected weight gains)
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What Makes Development Abnormal?
DSM Diagnostic Criteria
The DSM-IV-TR diagnostic criteria for major
depressive disorder (continued)
4. Insomnia or sleeping too much
5. Psychomotor agitation or sluggishness/slowing of
behavior observable by other people
6. Fatigue and loss of energy
7. Feelings of worthlessness or extreme guilt
8. Decreased ability to think or concentrate or
indecisiveness
9. Recurring thoughts of death, recurring suicidal
ideas, or a suicide attempt or specific plan to
commit suicide
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What Makes Development Abnormal?
DSM Diagnostic Criteria
The DSM-IV-TR diagnostic criteria manual calls
for distinguishing major depressive disorder from
other disorders and requires that the symptoms
cause significant distress or impaired functioning
and are not due to the direct effects of a
substance (an abused drug or a medication) or a
general medical condition
Symptoms should not be described as reactions
to bereavement
– To qualify as major depressive disorder, grief
reactions would need to persist for more than
2 months after a death and involve serious
symptomatology
What Makes Development Abnormal?
Developmental Psychopathology
• Sroufe and Rutter (1984) define
developmental psychopathology as the study
of the origins and course of maladaptive
behavior
– Evaluate abnormal development in relation
to normal development and study the two
in tandem
Caption: Developmental pathways leading to
normal and abnormal outcomes
What Makes Development Abnormal?
Developmental Psychopathology
• March (2009) believes that psychological
disorders should be viewed as lifespan
neurodevelopmental disorders
– This perspective requires looking at normal
and abnormal pathways of brain
development and their implications for
functioning and intervening early with
individuals who are at risk for various
disorders to put them on healthier
developmental trajectories
What Makes Development Abnormal?
Developmental Psychopathology
• Developmental psychopathologists regard
behaviors as abnormal or normal according
to their social and developmental contexts
– Social norms are expectations about how
to behave in a particular social context
– Age norms are societal expectations about
what behavior is appropriate or normal at
various ages
What Makes Development Abnormal?
Developmental Psychopathology
• Two major developmental issues are relevant
to understanding the pathways to adaptive or
maladaptive functioning
– Nature and nurture
– Continuity and discontinuity
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What Makes Development Abnormal?
Developmental Psychopathology
Understanding the developmental pathways of
psychopathology in light of the nature-nurture
issue involves asking questions such as
– How do biological, psychological, and social
factors interact over time to give rise to
psychological disorders?
– What are the important risk factors for
psychological disorders, and what are the
protective factors that keep some individuals
who are at risk from developing disorders?
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What Makes Development Abnormal?
Developmental Psychopathology
Understanding the developmental pathways of
psychopathology in light of the continuitydiscontinuity issue involves asking questions
such as
– Are most childhood problems passing phases
that have no bearing on adjustment in
adulthood, or does poor functioning in
childhood predict poor functioning later in life?
– How do expressions of psychopathology
change as the developmental status of the
individual changes?
What Makes Development Abnormal?
Developmental Psychopathology
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Developmental psychopathologists have proposed
a diathesis-stress model to explain how nature and
nurture contribute to psychopathology
– Suggests that psychopathology results from the
interaction over time of a predisposition or
vulnerability to psychological disorder and the
experience of stressful events
• The predisposition or vulnerability is called a
diathesis, which can involve a particular
genetic makeup, physiology, set of
cognitions, personality, or a combination of
these
Caption: The diathesis-stress model
Learning Objectives
• What are the characteristics, suspected
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causes, treatment, and prognosis for
individuals with autism and its related
syndromes?
In what ways do infants exhibit depressionlike conditions?
How is depression in infants similar to, or
different from, depression in adults?
The Infant – Autism
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Autism is a serious disorder that begins in infancy and is
characterized by
– Abnormal social development
• Difficulty forming normal social relationships,
responding appropriately to social cues, and sharing
social experiences with others
– Impaired language and communication
• May be mute or may have language but be unable to
communicate
– May use flat, robotic tone, reverse pronouns, and
engage in echolalia, parroting of another’s speech
– Repetitive behavior
• Engage in stereotyped behaviors (rocking) or rituals
• Highly distressed when the physical environment is
altered
The Infant – Autism
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Autism is one of the autism spectrum disorders
• Labeled in the DSM-IV as “pervasive developmental
disorders”
• Asperger syndrome is another of the autism spectrum
disorders
– Characterized by normal or above-average
intelligence and good verbal skills
– The individual desires to establish social
relationships but has seriously deficient socialcognitive and social-communication skills
– Affected children are sometimes called “little
professors” because they talk at length about
topics that interest them
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The Infant – Autism
In 2006 the autism spectrum disorders affected
almost 9 of 1,000 8-year-olds
According to 2005 data, autism (in the narrow
sense) affected about 20 of 10,000 children
There are 4 or 5 affected boys for every girl
Researchers believe that the increase in rates of
autistic spectrum disorders is a result of increased
awareness of autism, broader definitions of it to
include the entire autistic spectrum (including mild
cases), and better recognition and diagnosis of
cases that might previously have been diagnosed
as language impairments, learning disabilities, or
even odd personalities
The Infant – Autism
• Autistic children display autistic characteristics
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before age 3 and likely were autistic from birth
Early screening and diagnosis enables early
treatment and improved developmental
outcomes
• The longer autistic infants are undiagnosed
and therefore are not learning about the
social world, the more severe their social
and communicative problems become
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The Infant – Autism
Autistic infants fail to display normal infant behaviors
such as
– Orientation to human voices
– Babbling
– First words
– Preference for human over nonhuman stimuli
– Eye contact
– Visual focus on faces in a scene (autistic babies
tend to focus on objects in the background)
– Joint attention (a key precursor of theory-ofmind skills)
– Reciprocity or taking turns (as in mutual smiling
and peek-a-boo games)
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The Infant – Autism
Suspected causes of autism include the following
- Genes related to neural communication appear to
have been copied incorrectly
• “Copy number variations”
- Environmental contributors
• A virus or chemical could interact with a genetic
predisposition to autism
• Epigenetic influences that turn genes that guide
brain development on or off could be involved
• Prenatal exposure to teratogens can contribute
to ASDs
• Maternal bleeding or pregnancy complications
could be involved
The Infant – Autism
• Suspected causes of autism include the
following conditions (continued)
- Early brain overgrowth
• Neurons in the frontal cortex and/or the
amygdala proliferate wildly during the
early sensitive period for brain
development in infancy and do not
become properly interconnected with
other areas of the brain so that they can
integrate brain signals from these other
areas
The Infant – Autism
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Suspected causes of autism include the following
conditions (continued)
- Malfunctioning of the mirror neuron systems
• Mirror neuron systems allow us to make
sense of other people’s feelings and
thoughts by reacting to them as though they
were feelings and thoughts we have
experienced ourselves
- Malfunctioning of mirror neuron systems
located in a number of brain areas could
account for the deficits individuals with
autism show in imitation, theory-of-mind
skills, empathy, and language
The Infant – Autism
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The autism spectrum disorders involve multiple
cognitive impairments
- Autistic individuals have difficulty with certain
executive functions
• Higher-level control functions based in the
prefrontal cortex of the brain that allow us to
plan, change flexibly from one course of
action to another, and inhibit actions
• This may explain the repetitive behaviors
• The tendency to focus on details is
accompanied by difficulty integrating pieces
of information to get “the big picture” or
overall meaning
The Infant – Autism
• Previously, the long-term outcome for
individuals with ASDs has been poor, especially
if autism is accompanied by intellectual
disability
- Most individuals with autism improve in
functioning, but they are usually autistic for
life
- Positive outcomes are most likely among
those who have IQ scores above 70 and
reasonably good communication skills by
age 5
The Infant – Autism
• The most effective approach to treating autism
is intensive and highly structured behavioral
and educational programming, beginning as
early as possible, continuing throughout
childhood, and involving the family
- The goal is to make the most of the plasticity
of the young brain during its sensitive period
for development
The Infant – Depression
• Infants can exhibit some of the behavioral
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symptoms and somatic (bodily) symptoms of
depression
Depressive symptoms are most likely to be
observed in infants who lack a secure
attachment relationship or who experience a
disruption of an all-important attachment
Infants who display a disorganized pattern of
attachment are especially likely to show
symptoms of depression
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The Infant – Depression
Infants whose mother or father are depressed are at
risk for depression
– They use an interaction style that resembles that
of their caregivers
• They vocalize little, look sad, and show
developmental delays
Infants who are abused, neglected, separated from
attachment figures, or raised in a stressful,
unaffectionate manner may develop failure to thrive
– A life-threatening disorder in which infants fail to
grow normally, lose weight, become seriously
underweight for their age, and often are
developmentally delayed
Learning Objectives
• What are the symptoms, suspected causes,
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treatment, and long-term prognosis for
children with ADHD?
How is depression during childhood similar
to, or different from, depression during
adulthood?
How do interactions of nature and nurture
contribute to psychological disorders? Do
childhood problems persist into adolescence
and adulthood?
The Child –
Externalizing and Internalizing Problems
• Two broad categories are used to refer to
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whether a child’s behavior is out of control or
overly controlled
– Externalizing problems
– Internalizing problems
When children have externalizing problems,
they act out in ways that disturb other people
and violate social expectations
When children have internalizing problems,
negative emotions are internalized or bottled
up rather than externalized or expressed
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The Child –
Externalizing and Internalizing Problems
Externalizing behaviors decrease from age 4 to
age 18
Internalizing difficulties increase during this time
Externalizing problems are typically more
common among boys
Internalizing problems are more prevalent
among girls, across cultures
Children from low socioeconomic homes show
more externalizing and internalizing problems
than higher SES children do, partly because
their environments are more stressful
The Child –
Externalizing and Internalizing Problems
• It is helpful to view developmental disorders
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from a family systems perspective and to
consider how emerging problems affect and
are affected by family interactions
Problems are located not in an individual
family member but in a whole family
– From a family systems perspective,
parents both influence and are influenced
by their children, and the family also
functions in a larger environment that
influences it
The Child –
Externalizing and Internalizing Problems
• As the diathesis-stress model suggests,
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disorders often arise from the toxic
interaction of a genetic vulnerability and
stressful experiences
Abnormal development, like normal
development, is the product of both nature
and nurture and of a history of complex
transactions between person and
environment in which each influences the
other
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The Child –
Externalizing and Internalizing Problems
The research of Caspi and colleagues (1996)
suggests that there is continuity in susceptibility to
problems over the years and that early problems tend
to have significance for later development
– Children who had externalizing problems (such as
aggression) as young children and were described
as irritable, impulsive, and rough were more likely
than inhibited, overcontrolled children, or welladjusted children to be diagnosed as having
antisocial personality disorder and to have records
of criminal behavior as young adults
– Internalizers – inhibited children who were
extremely shy, anxious, and upsettable at age 3 –
were more likely than other children to be
diagnosed as depressed as young adults
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The Child –
Externalizing and Internalizing Problems
The research of Caspi and colleagues (1996) suggested
that there is continuity in susceptibility to problems over
the years and suggested that early problems tend to have
significance for later development
– Children who had externalizing problems were more
likely to be diagnosed as having antisocial personality
disorder and to have records of criminal behavior as
young adults
– Internalizers – inhibited children – were more likely
than other children to be diagnosed as depressed as
young adults
However, the study also revealed discontinuity
– The relationship between early behavioral problems
and later psychology pathology was weak – most
children with temperaments that put them at risk did
not have diagnosable problems as adults
The Child – Depression
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Children as young as age 3 can meet the same
criteria for major depressive disorder that are
used to diagnose adults
An estimated 2% of children have diagnosable
depressive disorders
Depression may coexist with other distinct
diagnoses such as conduct disorder, attention
deficit hyperactivity disorder, and anxiety disorder
The co-occurrence of two or more psychiatric
conditions in the same individual is called
comorbidity
– Comorbidity is very common throughout the
lifespan
The Child – Depression
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Depression in children may manifest with
behavioral and somatic symptoms of depression
such as losing interest in activities, or eating
poorly
They are prone to be anxious
As early as age 3, children who are depressed
may express excessive shame or guilt (for
example, saying that they are bad)
Some depressed children act out themes of
death and suicide in their play
Depressed children are sad or irritable and show
the same lack of interest in usually enjoyable
activities that depressed adults do
Children as young as age 2 or 3 are capable of
attempting suicide
The Child – Depression
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The carryover of depression problems from
childhood to adulthood is not as strong as
carryover from adolescence to adulthood
However, research has shown that 5- and 6year-olds who report many depression symptoms
are more likely than their peers as adolescents to
be depressed, to think suicidal thoughts, to
struggle academically, and to be perceived as in
need of mental health services
It is estimated that half of children and
adolescents diagnosed as having major
depressive disorder have recurrences in
adulthood
The Child – Depression
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Most depressed children respond well to psychotherapy
– Cognitive behavioral therapy attempts to identify and
change distorted thinking and the maladaptive
emotions and behavior that stem from it
– The category of antidepressant drugs called selective
serotonin reuptake inhibitors (SSRIs) may be used to
correct for low levels of the neurotransmitter serotonin
in the brains of depressed individuals
• However, SSRIs do not appear to be as effective
with children as with adults
• Some research suggested that SSRIs may
increase the risk of suicidal thoughts and behavior
among child and adolescent users, causing the
U.S. government to issue a warning to that effect
in 2004
Learning Objectives
• Are psychological problems more prevalent
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during adolescence than other periods of the
lifespan?
What are the characteristics, suspected
causes, and treatment of eating disorders
such as anorexia nervosa?
What is the course of depression and suicidal
behavior during adolescence?
What factors influence depression during
adulthood?
The Adolescent – Storm and Stress?
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Adolescence is a period of risk-taking, of problem
behaviors such as substance abuse and
delinquency, and of heightened vulnerability to
some forms of psychological disorder
– Among adolescents, there is a 20% rate of
diagnosable psychological disorder at a given
time
– Most adolescents cope with the challenges of
teenage life remarkably well and maintain the
level of adjustment they had when they entered
adolescence
– However, for a minority of adolescents, a buildup
of stressors can precipitate serious
psychopathology
The Adolescent – Eating Disorders
• Anorexia nervosa (“nervous loss of appetite”)
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has been defined as a refusal to maintain a
weight that is at least 85% of the expected
weight for the person’s height and age
Anorexic individuals are also characterized by a
strong fear of becoming overweight, a distorted
body image (a tendency to view themselves as
fat even when they are emaciated), and, if they
are females, an absence of regular menstrual
cycles
The Adolescent – Eating Disorders
• Another eating disorder is bulimia nervosa (the
so-called binge-purge syndrome), which
involves recurrent episodes of consuming huge
quantities of food followed by purging activities
such as self-induced vomiting, use of laxatives,
or rigid dieting and fasting
The Adolescent – Eating Disorders
• Approximately 3 in every 1,000 adolescent girls
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experience anorexia
There are about 11 female victims for every 1
male victim
Anorexia is evident at all socioeconomic levels
and in all racial and ethnic groups
The Adolescent – Eating Disorders
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Both nature and nurture contribute to eating
disorders
– On the nurture side, cultural factors are
influential, especially the Westernized ideal of
thinness as the standard of physical
attractiveness
– On the nature side, researchers believe that
genes serve as a diathesis, predisposing certain
individuals to develop eating disorders
• Genes may contribute to low levels of the
neurotransmitter serotonin, which is involved in
both appetite and mood and has been linked to
both eating disorders and mood disorders
The Adolescent – Eating Disorders
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Both nature and nurture contribute to eating
disorders
– On the nature side (continued)
• The neurotransmitter dopamine has also been
implicated, as it is involved in the brain’s
reward system, and some evidence suggests
that eating disorders, like alcohol and drug
addiction, involve compulsive behavior that is
reinforcing
• Genes also may contribute to a personality
profile that puts certain individuals at risk
– Females with anorexia tend to be highly
anxious and obsessive perfectionists
The Adolescent – Eating Disorders
• The interaction of nature and nurture
– However, anorexia may not emerge unless a
genetically predisposed girl living in a weightconscious culture experiences stressful
events
• Genes and environment interact to produce
a disorder
The Adolescent – Eating Disorders
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Treatment for individuals with anorexia begins with
behavior modification programs designed to bring
their eating behavior under control, help them gain
weight, and deal with any medical problems they
may have
Then the individual may begin psychotherapy
designed to help her understand and gain control of
the problem
– Possibly family therapy designed to change
parent-child relationships
• The Maudsley approach to family therapy
views the family as part of the treatment team
and requires cooperation of all family members
– Medication for depression
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The Adolescent –
Substance Abuse Disorders
Substance abuse and dependence take heavy
tolls on development
– Substance abuse occurs when use of a
substance has adverse consequences such
as putting the person in physically dangerous
situations, interfering with performance in
school or at work, or contributing to
interpersonal problems
– Substance dependence refers to continued
use despite significant problems, as indicated
by such signs as compulsive use, increased
tolerance for the drug, withdrawal symptoms if
use is terminated, and inability to quit
Caption:
Percentage of
adolescents in
grades 8, 10,
and 12 who
report ever
using various
substances
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The Adolescent –
Substance Abuse Disorders
The University of Michigan Monitoring the Future study has
tracked adolescent substance use
– The reported rates of usage were highest in the 1970s
and early 1980s, lower in the 1990s, and increased
again in 2008
– There is an increase with age in use of most substances
(except inhalants)
– The use of alcohol is widespread
• 8th graders, 10th graders, 12th graders, and college
students report binge-drinking
– Native-American youth have high rates of use, Hispanic
white and non-Hispanic white youth have medium rates,
and Asian- and African-American youth have lower rates
– Traditionally, males have had higher rates of substance
use and abuse than females, but the gap has been
narrowing
The Adolescent –
Substance Abuse Disorders
• The developmental pathway to adolescent
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substance use and abuse begins in childhood
Dodge and others (2009) developed a
cascade model of substance use to illustrate
that adolescent problem behaviors and
psychological disorders grow out of the
accumulating effects of transactions between
an individual and parents, peers, and other
aspects of the social environment over many
years
Caption: A cascade model of substance use
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The Adolescent –
Substance Abuse Disorders
The cascade model of substance use illustrates
the chain of influences, starting with
(1)A child who is at risk due to a difficult
temperament,
(2)Born into an adverse family environment
characterized by such problems as poverty,
stress, and substance use, who is then
(3) Exposed to harsh parenting and family
conflict,
(4) Develops behavior problems, especially
aggression and conduct problems, as a
result, and
The Adolescent –
Substance Abuse Disorders
• The cascade model of substance use illustrates
the chain of influences (continued)
(5) Is therefore rejected by peers and gets into
more trouble at school, causing
(6) Parents, perhaps in frustration, to give up
trying to monitor and supervise their now
difficult-to-control adolescent child, which
contributes to
(7) Involvement in a deviant peer group, where
the adolescent is exposed to and reinforced
for drug taking and other deviant behaviors
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The Adolescent –
Substance Abuse Disorders
Substance use disorders are often comorbid
with other disorders such as depression and
anxiety disorders
– Some of the same genes seem to contribute
to both substance abuse and internalizing
disorders like depression
– It is likely that substance abuse develops as a
way to cope with emotional problems through
self-medication
Preventive interventions to delay drinking and
drug use in adolescence can deter problematic
substance use in adulthood
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The Adolescent –
Depression and Suicidal Behavior
Before puberty, boys and girls have similarly low
rates of depression
After puberty, rates climb and the rate for girls
becomes higher than that for boys
Up to 35% of adolescents experience depressed
moods at some time, and as many as 7% have
diagnosable depressive disorders at any given
time
Symptoms are mostly like those displayed by
depressed adults, although depressed
adolescents sometimes act out and look more
like delinquents than like victims of depression
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The Adolescent –
Depression and Suicidal Behavior
Genetic influences on symptoms of depression
seem to become stronger in adolescence than they
were in childhood
The changes of puberty and the timing of puberty
may be factors
Teens (especially females) who have experienced
family disruption and loss in childhood may be
especially vulnerable to interpersonal stress after
they reach puberty
– Stressful events, especially interpersonal ones
such as family disruption, predict increases in
depressive symptoms
Girls are more likely than boys to use ruminative
coping, or unproductively dwell on their problems
The Adolescent –
Depression and Suicidal Behavior
• Suicidal thoughts, suicide attempts, and
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completed suicides become more common from
childhood to adolescence
Suicide is the third leading cause of death for the
15- to 24-year-old age group
– The annual rate is 10 per 100,000 for this age
group
Although more adults commit suicide,
adolescents attempt suicide more frequently
Caption: Number of suicides per 100,000 people by
age and sex among European Americans, African
Americans, and Hispanic Americans in the United
States
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The Adolescent –
Depression and Suicidal Behavior
Suicidal behavior in adolescence is the result of diathesisstress
Four key risk factors are
– An existing psychological disorder
• Such as depression, substance-related disorder,
anxiety disorder, or another diagnosable psychological
condition
– Family pathology and psychopathology
• Such as a history of troubled family relationships or a
family history of psychopathology and suicide
– Stressful life events
• Such as deteriorating relationships with family and
peers, academic and social failures, problems with the
law
– Access to firearms
• Which makes it easy to act on suicidal impulses
Learning Objectives
• What factors contribute to the onset of major
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depressive disorders in adulthood?
What factors make it challenging to diagnose
of major depressive disorder among older
adults?
What are the characteristics and causes of
dementia?
The Adult
• Stressful experiences in childhood and
adolescence increase a person’s chances of
psychological disorder later in life
– Psychological problems then emerge
when a vulnerable individual faces
overwhelming stress
– The greatest number of life strains occur in
early adulthood and then decrease from
early to middle adulthood
The Adult
• Rates of affective disorders (major
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depression and related mood disorders),
alcohol abuse and dependence,
schizophrenia, anxiety disorders, and
antisocial personality all decrease from early
adulthood to late life
Cognitive impairment is the only category of
disorder that increases with age
Overall, about one-fourth of American adults
experienced a psychological disorder in the
past year (reported in 2005)
The Adult – Depression
• The average age of onset of major
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depression is in the early 20s
About 28% of Americans will experience a
diagnosable mood disorder by age 75
Compared to young or middle-aged adults,
older adults tend to be less vulnerable to
major depression and other affective
disorders
Unless older adults develop physical health
problems that contribute to depression or
experience increasing (rather than
decreasing) levels of stress as they age,
their mental health is likely to be good
The Adult – Depression
• Reports of depression symptoms, if not
diagnosable disorders, increase when people
reach their 70s and beyond
– Possibly this is because depression can
be difficult to diagnose in later adulthood
– Symptoms of depression may be
interpreted as normal aging, as chronic
illness, or as signs of dementia
The Adult – Depression
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In many cultures, beginning in adolescence, females are
more likely than males to be diagnosed as depressed by
a margin of about 2 to 1
– This gender difference probably results from a variety
of factors
• Hormones and biological reactions to stress
• Levels of stress
• Ways of expressing distress
– Women more likely to express classic
depression symptoms; men more likely to
become angry or overindulge in alcohol and
drugs
• Styles of coping with distress
– Women tend to engage in more ruminative
coping; men tend to distract themselves from
problems
In late life, the rates of depression become similar for
males and females
The Adult – Depression
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Many adults who have major depression are
undiagnosed and untreated
– Especially elderly adults and those who are
African American and other minority group
members
Failure to diagnose and treat may occur because
– Depression and anxiety may be seen as a normal
part of getting older or of becoming ill
– Mental health problems are stigmatized (seen as
shameful)
– Mental health professionals may underdiagnose
or misdiagnose the problems of elderly individuals
– Mental health professionals may believe that
elderly adults as less treatable than younger
adults
The Adult – Aging and Dementia
• Dementia is a progressive deterioration of
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neural functioning associated with cognitive
decline
– Includes memory impairment, declines in
tested intellectual ability, poor judgment,
difficulty in abstract thinking, and possibly
personality changes
Rates of dementia increase steadily with age
– Overall, dementia affects 6-8% of elderly
adults age 65 and older
– Rates climb steeply with age, from less
than 1% in the 60-to-64 age group to
around 30% for people 85 and older
The Adult – Aging and Dementia
• Alzheimer’s disease is one form of dementia
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– In the DSM-IV-TR, the disease is referred
to as dementia of the Alzheimer’s type
Alzheimer’s disease has two characteristic
features in the brain
– Senile plaques – masses of dying neural
material with a toxic protein that damages
neurons, beta-amyloid, at their core
– Neurofibrillary tangles – twisted strands of
neural fibers within the bodies of neural
cells
The Adult – Aging and Dementia
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The first noticeable signs of Alzheimer’s disease
emerge 2-3 years before diagnosis is possible
– For example, difficulties in learning and
remembering recently encountered verbal
material such as names and phone numbers
In the early stages, free recall tasks are difficult,
but memory is good if cues to recall are provided
With progression of the disease, people may
have trouble remembering both new and old
information, forget mid-way through a task, or
lack orientation to time and place
The Adult – Aging and Dementia
• Eventually those with Alzheimer’s disease
•
•
become incapable of self-care, no longer
recognize loved ones, and lose all verbal
abilities
Death occurs, on average, 8 to 10 years after
onset of the disease
Other symptoms may include agitation and
uncontrollable behavior, depression, and
possibly psychotic symptoms such as a
hallucinations
The Adult – Aging and Dementia
•
•
Alzheimer’s disease has a genetic basis, but
there is no single “Alzheimer’s gene”
Alzheimer’s disease may be characterized as
“early onset” or “late onset”
– A gene on the 21st pair of chromosomes may
be associated with the early onset form of the
disease
– Genetic contributors to late-onset Alzheimer’s
disease are more common than the earlyonset variety and are not as clearcut or strong
• Rather than making Alzheimer’s disease
inevitable, a number of genes only
increase a person’s risk slightly
The Adult – Aging and Dementia
•
One variant of a gene on chromosome 19 has
been associated with late-onset Alzheimer’s
disease
– The gene is responsible for the production of
ApoE, a protein involved in processing
cholesterol
• It is believed that the ApoE4 gene may
increase the buildup of beta-amyloid – the
damaging substance in senile plaques – and
therefore speed the progression of
Alzheimer’s disease
– Having two of the risk-inducing ApoE4 variants
of the gene means having up to 15 times the
normal risk of Alzheimer’s disease
• Signs of brain atrophy can be detected in
people with two ApoE4 genes before they
show cognitive impairment
The Adult – Aging and Dementia
• Chromosome 19, ApoE4 gene (continued)
•
– Having another specific variant of the
ApoE gene means having a good
chance of maintaining good cognitive
functioning into very late adulthood
However, not everyone with the ApoE4
gene, or even a pair of them, develops
Alzheimer’s disease, and many people
with Alzheimer’s disease lack the gene
– Apparently other genes and
environmental factors apparently play a
role
Caption: Alzheimer’s disease emerges
gradually over the adult years; brain cells are
damaged long before noticeable cognitive
impairment results in old age
The Adult – Aging and Dementia
•
The risk for developing Alzheimer’s disease is
influenced by the following factors or conditions
– Head injuries in earlier adulthood increase the risk
– Obesity and a diet that increases the odds of high
blood pressure, high cholesterol, and cardiovascular
disease also contribute
– Cognitive reserve is important.
• Extra brain power or cognitive capacity that some
people can fall back on as aging and disease
begin to take a toll on brain functioning
• People who have advanced education and high
intelligence and have been mentally, physically,
and socially active over the years have more
cognitive reserve than less active people and, as
a result, are less likely to be impaired as
Alzheimer’s disease begins to damage their
brains
The Adult – Aging and Dementia
• Prevention and treatment of Alzheimer’s
disease focuses on early detection in
hopes that drugs can prevent or delay the
associated changes in the brain
– Current medications modestly improve
cognitive functioning, reduce behavioral
problems, and slow the progression of
the disease in some people
The Adult – Aging and Dementia
• Although deterioration leading to death is
inevitable, there are options for both
patients and their caregivers to help them
understand and cope with dementia and
function better
– Memory training and memory aids
– Behavioral management techniques
and medications to address behavioral
problems
– Educational programs and
psychological interventions
The Adult – Aging and Dementia
• Vascular dementia is the second most
•
•
common form of dementia and often occurs
in combination with Alzheimer’s disease
– Multi-infarct dementia is caused by a
series of minor strokes that cut off the
blood supply to the brain
Vascular dementia may do its greatest
damage to executive functions or the
functions that reside in the area of the brain
that is damaged by the stroke or brain injury
Vascular dementia is closely associated with
environmental risk factors for cerebrovascular diseases that affect blood flow in the
brain, such as smoking or eating a fatty diet
The Adult – Aging and Dementia
• Other possible causes of dementia are
•
Huntington’s, Parkinson’s disease, AIDS, and
multiple sclerosis
Reversible or curable problems such as
alcoholism, toxic reactions to medication,
infections, metabolic disorders, and
malnutrition can cause symptoms of
dementia
The Adult – Aging and Dementia
•
•
Sometimes elderly adults who are experiencing
delirium are mistakenly diagnosed as having
dementia
– Delirium emerges more rapidly than dementia
and comes and goes over the course of the
day
– Delirium is a disturbance of consciousness
characterized by periods of disorientation,
wandering attention, confusion, and
hallucinations
Many hospital patients experience delirium in
reaction to any number of stressors such as
illness, surgery, drug overdoses, interactions of
different drugs, or malnutrition
The Adult – Aging and Dementia
• It is critical to distinguish among irreversible
•
dementias (including dementia of the
Alzheimer’s type and vascular dementia),
reversible dementias, delirium, depression,
and other conditions
To accurately distinguish and diagnose
requires a thorough assessment, including a
medical history, physical and neurological
examinations, and assessments of cognitive
functioning