451

1. 451 • My web site and syllabus: • http://myweb.facstaff.wwu.edu/knecht/ • Topic Questions? • Readings on website: three with cancer: • Read and come up with a question from each to ask Dr. Thompson next week. Turn in your 3 questions to me, either in class on Thursday or by e-mail. • For stepping stone project: • We’ll meet after class to schedule times • www.steppingStonesWhatcom.org

2. Psych 451 Psychiatric Diagnosis and mind- body Mechanisms

3. The Nature of Psychiatric diagnosis – DSM-IV Dia - gnosis “to know and to distinguish between” Purposes of diagnoses: To differentiate those with from those without a condition To enhance communication – a short hand Ensure treatment specificity so a given illness gets the specific treatment This assumes disorders are discrete entities that clearly differ from one another

4. MostPsychiatric Diagnoses differ from Medical diagnoses: • More of social process – • Fashionable diagnoses come and go • Anxiety State decreased, depression and phobia increased • More social consequences – stigma, discrimination • More culturally determined • Culture Bound syndromes such as • AmukPibloktog • Anorexia Nervosa Kayak Angst • Koro Personality Disorders • Taijinkyofusho Factitious Disorders • Few definitive or independent tests to confirm dx

5. Psychiatric diagnoses are mostly syndromes • Signs (observable) and symptoms (reported) that tend to be seen together. • Gr. “Run together” • Used when no clear pathophysiological basis has been defined or identified to explain its occurrence. • Compare Generalized Anxiety Disorder with H1N1

6. Reliability and validity of Psychiatric Diagnosis • Specificity and sensitivity: • Sensitivity – does it include all “real” cases as well as non-cases (false positives) • Specificity: Does it only include “real” cases and reject all non-cases ( but also some false negatives)

7. Study: 168 consecutive admissions to mental hospital • Schizophrenia Criteria sets rxx # Sz • NHSI .97 44 • DSM-III .80 19 • RDC .90 17 • Feigner .84 12 • Taylor-Abrams .65 6 • Who is schizophrenic depends on which set of criteria you use? • Which set would you use to study Sz? Why?

8. Criterion creep makes it fuzzy DSM-V • Veteran’s Administration is currently suggesting changes in PTSD diagnostic criterion A (stressor) for vets to read as follows: • ``a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror.'' A claimed stressor must be consistent with the places, types, and circumstances of the veteran's service.“ •  If you show up in a war zone, you meet criterion A. • What would this change do to Specificity? Sensitivity?

9. How best to characterize Mental disorder • Classical Categorical • E. Kraepelin - 19th C • Sz and manic Depression were discrete entities • Each with a specific etiology • Dimensional • Based on psychological measurement • Sx vary by degree from 0 to …100.. e.g. negative affectivity • Continuum of symptom presence and severity • Prototypical • Describe a prototype • Determine essential criteria • Allow polythetic criteria • Accept blurred boundries

10. . SCHIZOPHRENIA polythetic Diagnosis • A. TWO OR MORE OF: •   1. DELUSIONS • 2. HALLUCINATIONS • 3. DISORGANIZED SPEECH (Derailment, incoherence) • 4. GROSSLY DISORGANIZED OR CATATONIC BEHAVIOR • 5 . NEGATIVE SYMPTOMS • - Flattened affect, alogia, avolition • Only on of 1 or 2 if bizzare

11. B. SOCIAL/OCCUPATIONAL DYSFUNCTION • 1. SOCIAL, INTERPERSONAL • 2. OCCUPATIONAL • 3. SELF-CARE • C, DURATION OF AT LEAST 6 MONTHS • D. EXCLUDE SCHIZOAFFECTIVE AND MOOD DISORDERS • E. NOT DUE TO SUBSTANCE ABUSE OR MEDICAL CONDITION

12. Where are there boundaries between disordersExample: Sz & Bipolar • Sz ………………………………………….. Bipolar I and II Cyclothymia • Schizoaffective ………………………. Unipolar Depression - dysthymia • Personality Disorders • Schizotypy • Schizoid • Paranoid • Schizophrenia Spectrum disorders …

13. Proliferation of diagnostic categories • What does this mean? • 1918 - 59 • DSM-I –1952 - 106 • DSM-II 1968 - 182 • DSM-III 1980 - 265 • DSM-III R 1987 -292 • DSM-IV 1994 -357

14. Five criteria to evaluate a given Diagnosis – rooted in medicine • Describe a set of symptoms for Communication • Suggest pathophysiology – • cause or conditions associated with its occurrence • Suggest a specific treatment plan to address cause • Predict outcome - prognosis • Predict long term sequelae

15. How should we think of Diagnoses? • An entity? • A social construction? • Convenient construct? • Are they useful? • Reification of psychiatric Diagnoses • Don’t label the person

16. Mediating Mechanisms • How do we get from mental distress (Dx) to physical systems breaking down or being damaged? • Or from physical disorders or systems malfunctioning to cause specific mental/emotional disorder? • Several Systems: • Autonomic Nervous System -sympatho-adrenao-medullary • SAM • Hypothalamic – Pituitary – Adrenocortical Axis : HPA • Neurotransmitter systems and pathways • Neuroanatomical structures

17. Autonomic Nervous System: • Sympathetic division • Active defense system • – fight or flight – activation adrenaline/epinepherine, norepinepherine – • depletion of energy resources • Parasympathetic division- • Conservation, withdrawal, build up of energy resources and healing – Acetylcholine • When functioning properly together they promote Homeostasis among bodily systems when in balance

18. ANS

19. Examples of disorders that could involve SNS activation or dysregulation?

20. Examples of disorders • - CHD Hostility • Surges of adrenalin • Arterial tears – plaques attach • blood clots more readily • GAD .. Chronic Gastric distress • Asthma attacks: • SNS activation in strong emotion can trigger attacks.

21. SAM and HPA-C axis CRF/H

22. Hypothalamic – pituitary – Adrenocortical Axis - HPA • Stress perceived – • Hypothalamus - Corticotropin Releasing factor (CRF/H) • CRF goes to anterior Pituitary – Adreno-corticotropic Hormone (ACTH) • ACTH cortex of the Adrenal gland – Cortisol • Into blood system to organs • Feeds backs to hypothalamus to regulate production • Cortisol had many effects on body • Good in short term, bad in long term activation

23. Paraventricular Hypothalamus Anterior pituitary Negative Feedback to hypothalamus Adrenal cortex cortisol

24. Long term Corticosteroids • Affects viability of immune function, reduces it • High blood pressure • Possible atrophy of hippocampus • Memory difficulties • The HPA axis neurobiology of mood disorders, anxiety disorder, bipolar disorder, insomnia, post-traumatic stress disorder, borderline personality disorder, ADHD, major depressive disorder, burnout, chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, and alcoholism.[1] • Antidepressants, routinely prescribed for many of these illnesses, serve to regulate HPA axis function.[2]

25. Hypothisized relationships depression normal Ptsd

26. Neurotransmitters associated with various diagnoses • Dopanergic: Schizophrenia, substance abuse, Bipolar mania • Noradrenergic: Depression, mania • Serotonergic: depression, OCD, schizophrenia • Gabanergic: Anxiety disorders

27. Neurotransmitter systems regulation and dysregulation - malfunction

28. Neuroanatomical areas associated with certain diagnoses

29. Basal ganglia – cognition, emotion, motor activity

30. Brain Areas mediating OCD • Thought to be “locked in unison” during disorder • Orbito-frontal cortex – error detection • Caudate Nucleus • – regulate “worry” between thalamus and frontal cortex hyperactive • -SSRI reduces CN activity • Cingulategyrus : “something is deadly wrong” (surgery) • Releases “Fixed Action Patterns” • territoriality (checking). • Mating (urges), • Washing

31. Caudate nucleus

32. Neuroanatomy of OCD ?? • Straddling the fence between cognition and emotion, Anterior Caudate has been suggested to be involved in the pathophysiology of : • attention deficit/hyperactivity disorder (Bush et al., 1999), • post-traumatic stress disorder (Shin et al., in press), • depression ( Drevets, 2001; Davidson et al., in press), • obsessive-compulsive disorder (Jenike et al., 1991), • schizophrenia, • bipolar disorder, • panic disorder, • Tourette’s Syndrome (Benes, 1993), and Alzheimer’s Disease (Vogt et al., 1997).

33. Neuroanatomical sites of Alzheimer‘s Disease deterioration

34. Anatomical regions use certain neurotransmitters • Serotonin pathways • Norepinepherine pathways • Dopamine pathways

35. Genetics • Many disorders have some genetic contributions to etiology • How would that work?

36. Multiple causation – Diathesis Stress Schizophrenia: • Factors in order of predictive power • Cotwin Sz 50 • Parent Sz 13 • Sibling Sz 9.6 • Premorbid pers. • EP P50 • Continuous prefor. • Eye tracking • Hippocampal volume • Obstetric complication • Stressful life events • Maternal influenza

37. PTSD: Diatheses/correlates • Given a life threatening trauma, what predicts PTSD? • Social support network • Negative affect/neuroticism • Poor coping skills • Prior traumas • Lower IQ • Nature of the stressor • Perceived controllability

38. Fear Circuitry - J. LeDouxPeripheral NS CNS SNS

39. Others?