Transcript presentation source

Melting Pot in the
Diagnosis of
Psychopathology
Mental disorder: DSV-IV
A mental disorder is conceptualized as a
clinically
significant
behavioral
or
psychological syndrome or pattern that
occurs in an individual and that is
associated with present distress (e.g. a
painful symptom) or disability (I.e.
impairment in one or more important
areas of
functioning) or with a
significantly increased risk of suffering
death, pain, disability or an important
loss of freedom.
DSM-IV, continued
• In addition, this syndrome or pattern must not
be merely an expectable and culturally
sanctioned response to a particular event, for
example, the death of a loved one. Whatever
its original cause, it must currently be
considered a manifestation of a behavioral,
psychological, or biological dysfunction in the
individual.
DSM-IV
• Neither deviant behavior (e.g. political,
religious or sexual) nor conflicts that are
primarily between the individual and
society are mental disorders unless the
deviance or conflict is a symptom of
dysfunction in the individual as described
above.
Problems with DSM-IV
Distress and disability do not recognize the
role of outside judgment in deciding what is a
disability or how serious distress has to be to
become a mental disorder.
Loss of freedom could logically include all
criminal behavior.
Social approbation is one sign of mental
disorder--without mentioning who
disapproves of whom.
Reformulated definition:
A
mental disorder is essentially an involuntary,
organismic impairment in psychological functioning
(i.e., cognitive, affective and/or behavioral).
Persons who are hindered in their ability to adapt
flexibly to stress, to make optimal life decisions, to
fulfill desired potentials, or to sustain meaningful or
satisfying relationships as a result of an impairment
in cognitive, affective, and/or behavioral functioning
over which they have insufficient control, have a
mental disorder.
Problems with re-formulated definition
 Definition includes many conditions considered by
others to represent simply problems in living
 This would suggest that everyone goes through life
suffering from and /or tolerating a variety of mental
disorders some of which are chronic (personality)
 Disorder is located in the individual, does not
recognize context or environment
 Does not help sort out severity of illness nor ability to
function.
Bases of developing a system of
classification
• Symptoms
– many symptoms cross disorders
• Behaviors
– many behaviors similar among disorders
• Prognosis
– Frequently individualized
Bases of classification
• Individual
genetics
biology (uterine environment, virus,
etc)
Trauma
• Interrelationships with people
• Events/passage of time
• Society/cultural aspects
Schizophrenia/Psychosis
Mental disorder is a micro-social crisis situation in
which the acts and experience of a certain person are
invalidated by others for certain intelligible cultural
and micro-cultural (usually familial) reasons, to the
point where he/she is elected and identified as being
‘mentally ill’ in a certain way, and is then confirmed
(by a specifiable but highly arbitrary labeling process)
in the identity “schizophrenic patient’ by a medical or
quasi-medical agents.
Micro-social: a finite group of persons in face-to-face
interaction.
Cooper, David (1967) Psychiatry and Anti-Psychiatry Ballantine Walden, NY
How do we know mental illness?
• Why do we diagnosis?
• Who does it benefit?
• What about the stigma?
• How can we (as individuals and professionals)
best support our patients?
SDV MODEL: DIATHESIS
• A constitutional disposition, or predisposition, to some anomalous or
morbid condition ‘which no longer belongs with the confines of
normal variability, but already begins to represent a potential
disease condition
• Broadened: can include cognitive or social predispositions that
make a person vulnerable to disorders (coping or confidence (Zubin)
SDV MODEL: Personality
The organization of traits that characterize
individuals
Traits: relatively enduring dispositions of persons to
react in relative consistent ways in certain kinds of
situations which are prototypical for the trait.
Stress vulnerability model
Three critical factors responsible for the development of a psychiatric disorder
and its course over time. These factors are interactive.
1. Biological vulnerability
2. Stress
3. Protective factors
Biological Vulnerability
• A persons vulnerability is thought to be
determined from genetic factors and early
biological factors (exposure to viral infection in
uterus)
• The amount of vulnerability varies from one
person to the next
• The severity of the disorders varies also
• Biological vulnerability is worsened by alcohol or
drug use
Stress
• The imposition of strain on a person or the effects of the strain on him;
both physical and psychological factors can be stressful. Prolonged stress
may impair functioning or trigger mental illness
– external factor: stressor
– internal: response to stress
• Stress can be thought of as a response to life situations that require the
individual to adapt or change.
• If the person cannot adapt or change then psychiatric symptoms will
appear or worsen
• Stress can trigger the onset of the disorder
• Stress can worsen its course
• Stressors: Example of stressors include: life events, tense relationships,
interpersonal difficulties (frequent arguments, strong feelings of anger or
resentment in the family
Interventions based upon the stress vulnerability model of schizophrenia
Stress-vulnerability-family coping skills model of adaptation to Psychiatric Disorders, Mueser & Glynn, 1990)
Risk Factors
• Early childhood trauma
– Sexual abuse
– Physical violence
– physical abuse
– Parental death
– Parental absences (divorce)
– Parental psychopathology
– Parental substance abuse
Protective factors
• Protective factors reduce the person’s
biological vulnerability and/or stress.
• One important protective factor in
schizophrenia is medication
• Good coping skills in the patient and their
family (such as communication or problemsolving skills)
• A supportive environment can reduce stress
(social support)
• Providing meaningful structure
Interventions
• Schizophrenia develops in a person with a
biological vulnerability for the disorder which is
triggered by life stress.
• Protective factors such as antipsychotic
medications and avoiding alcohol and substance
use reduce biological vulnerability
• good communication and problem-solving skills,
and a supportive home environment can reduce
life stress
• family can support the patient to take meds, avoid
substances, develop communication and problem
solving, praise patient for small recovery steps and
PTSD: normal response
• PTSD normal response to abnormal
situations
– the incident that causes PTSD is abnormal or
extraordinary
– all of the reactions seen are within the limits of a
normal response to such a stressor and would be
expected to be seen in the majority of people
experiencing the event.
– Assumes that PTSD is a failure to recover from mental
traumatization, however recovery is always possible.
– Effects of the traumatization (all survival based):
•
•
•
•
Activation of SNS
Activation of HPA
Strong engraving of memory traces of the event
Promotion of startle response (orientation)
PTSD: abnormal alternative
• PTSD is an abnormal response
• symptom logy can occur after ordinary as well as
extraordinary events
• results from more than just event/response
paradigm
Predictors of PTSD
•
•
•
•
•
Pretrauma Vulnerability
Magnitude of Stressor
Preparation for Event
Immediate and Short-Term Responses
Post Trauma Responses
Pretrauma vulnerability
• Genetic and biological factors
• Family history of mental disorders and or alcohol
abuse
• Gender
• Neuroendocrine vulnerability (cortisol)
• Personality traits (neuroticism, intr5oversion)J
• Prior psychiatric disorders
• Early traumatization (child abuse (sexual or
physical))
• Repeated exposure to trauma
• Negative parenting behavior
• Early separation from parents
• Parental poverty
• Rearing environment (attachment)
Magnitude of stressor
General characteristics:
Intensity of traumatic event
Duration of traumatic event
Frequency of traumatic event
Dangerousness of event (perceived threat to
existence)
7 genetic dimensions of traumatic stress
1. Threat to one’s life and body integrity
2. Severe physical harm or injury
3. Receipt of intentional injury/harm
4. Exposure to the grotesque
5. Witnessing or learning of violence to loved
ones
6. Learning of exposure to a noxious agent
7. Causing death or severe harm to another
Preparation for the Event
• “IF POSSIBLE”
• . . . . adequate preparation for a stressful event
helps protect individuals from the effect of stress
Immediate or short-term responses
• Peritraumatic responses:
– Observable behavior of symptoms
• Conversion, agitation or stupor
– Emotional or cognitive experience
• Anxiety, panic, numbing confusion
– Mental processes
• Psych. Defenses
– Dissociation,
• freezing/surrender and or disorganization
and the perception of events as
uncontrollable or unpredictable have longterm effects
Immediate or short-term responses
– All coping efforts seem to have same
effect (lessening impact), what is
important is that person feels they have
some ability to cope.
–
• Survivors of terrorist attack: (Israel)
• Actively rescuing other survivors
• Sharing important information with the rescuers
• Preserving one’s dignity by covering one’s body
• Controlling the disclosure of information about the
event to one’s relatives
Post trauma responses
• Intrusive symptoms
– 48 hours after the event
– For many the repeated memories are
intolerable
– Survivors may be judging themselves
and reevaluating their actions
– The reevaluating may lead to the
formation of negative beliefs about
oneself and others
• PTSD and rape victims (Rothbaum, 1989)
– 94% had symptoms of PTSD within 1
week of trauma
– 52% - 2 months later
– 47% - 9 months later
• Serin Gas release in Tokyo subway
– Seen for first two year-no signs of PTSD
– PTSD symptoms appeared 5 to 6 years
Children and trauma
• Children exposed to early adverse
experiences are at increased risk for the
development of depression or anxiety
disorders
• 1.5 million verified cases of child
maltreatment reported annually in US
• A large number of children experience the
loss of a parent
• A large number of children live with a
mentally ill parent unable to provide
continuous parental care
Mental disorders and childhood
• Relationship between disorganized
attachment and psychopathology in
childhood
– Increase in ADHD, behavior problems, social
problems, Oppositional Defiant disorder in
boys, difficult temperament (predictor of
aggressive behavior), cognitive immaturity
Resilience
•
•
•
•
GxE-study team-Kings College, London
Work of Sir Michael Rutter
Terrie Moffitt
Avshalom Caspi
• Stems from the work of:
• Norman Garmezy (1960’s) and Ann Masten
(1970’s) at University of Minnesota
Resilience
• Resilience-springing back from serious
adversity.
– highly subjective definition
• Reviewing the literature of the long term
effect of physical and/or sexual child abuse,
20 to 40% of the maltreated children show
few signs of behavioral or mental health
problems in later life.
• Why are some people able to experience
extreme adversity and yet lead
successful/satisfying lives?
GxE
• Interplay between particular genes and
environment.
• A particular variant of a gene can promote
resilience and perhaps buffer against the ruinous
effects of adversity.
• In the absence of the aversive environment the
gene does not express itself.
5-HHT Promotor Gene
• 5-HHT gene is critical for regulation of serotonin
in brain.
• 5-HHT gene has two alleles and each allele
occurs in either a short or a long version.
• People with at least one Short allele are more
prone to depression.
Moffitt and Capsi-Influence of life stress on depression: moderation by a polymorphism in the 5-HTT
gene Science, vol: 301, July, 2003.
Types of variation
• 33% of (US-white population) have two copies
of the protective long allele.
• 50% have one long allele and one short allele
• 17% have two short alleles
• (africian-americans are less likely to have short
allele, Asians are more likely)
Prospective study of 847 adults
• Found link (correlation) among having at least
one short 5-HHT allele and elevated rates of
depression in adults who had experience
mistreatment as children or significant
stress/adversity.(moderate risk)
• Having two short 5-HHT alleles increased the
likelihood of depression as an adult.
• Two long alleles the link was low for
subsequent depression.
Conclusions
• In other words:
• “children with two risky alleles lost out badly
when their environments failed them, children
with one risky allele were at some increase
(sic) risk and children with good resilience
alleles (two long, sic) carried a shield. “
•
Emily Baxelon, New York Times, April 30th, 2006.
Stephen Suomi, NIMH
• Two groups of monkeys (rhesus).
– One group raised by Mom in Laboratory but similar to “wild”
experience.
– Second group created to mimic experience of a neglected or
abused child. Never see mother, spend two weeks in an
incubator and then moving into small groups of peers.
• Rhesus monkeys hare 96% of their genes in common
with humans, including the long and short variations of
5-HHT.
Shannon •
C, Schwandt
ML, Champoux are
M, ShoafDNA
SE, Suomi SJ,
Linnoila M, Higley
JD. Maternal
absence
and stability of individual
differences
in CSF 5Monkeys
tested
and
one
short/long
and
two
HIAA concentrations in rhesus monkey infants. AM J Psychiatry. 2005 Sep;162(9):1658-64.
long monkeys can be categorized.
Christina S. Barr, Timothy K. Newman, Melanie Schwandt, Courtney Shannon, Rachel L. Dvoskin, Stephen G. Lindell, Julie Taubman,§ Bill Thompson,¶
Maribeth Champoux, Klaus Peter Lesch, David Goldman, Stephen J. Suomi,and J. Dee Higley. Sexual dichotomy of an interaction between early
adversity and the serotonin transporter gene promoter variant in rhesus macaques. Proc Natl Acad Sci U S A. 2004 August 17; 101(33): 12358–12363.
Findings
• In motherless, peer raised monkeys who have one
short/long pairs 5-HHT alleles are more likely to
experience fear, panic, aggression (low serotonin acid
in CSF) when a strange monkey in placed in a cage
next to them.
• motherless, peer raised monkeys who have a 2 long
5-HHT alleles are more likely to take the presence of
the stranger monkey in stride (similar to mother
raised monkeys).
• (since it is rare to find a rhesus monkey with two
short alleles for 5-HHT their conditions was not
tested.
Conclusions
• Findings are similar to Australian study by
Moffitt/Caspi.
• Suomi:
“How you grow up affects your hormonal output
and the structure and function of the brain. And
these effects are tempered by the kind of gene
the monkeys carry, so it is a true interaction?
Behavioral description
The group is in a caged together, mother raised and nonmother raised. When people walk in (even Suomi who
goes in daily) some of the monkeys stay in the middle of
the cages and ignore the stranger. Another group races to
the back of the cage and huddles together in the farthest
corner their small fingers wrapping around one another’s
fur. They twitter and turn their faces away in distress.
Middle of the cage monkeys were mother raised, the ones at
the back were motherless.
After a few minutes some of the peer raised monkeys begin to
dart forward to peers, and after a few more minutes they
settle in with the mother-raised group. But others never
move from the back. The monkeys who raced to the back
but eventually came forward and mirror human resilience
How do you
distinguish
Stress from Trauma?