▫

- psychology
Schizophrenia spectrum and other psychotic disorders along the
continum
What comes to mind:
• Hallucinations(see, hear or feel things that aren’t real) and
delusions (false beliefs)
• Both are very common
• Psychosis is also a prominent feature (inability to be able to
recognize the difference between reality and fiction)
• common feature of all psychotic disorders
• prevalence of psychotic symptoms: around 5-8% of general
population
• Individual with schizophrenia may believe ex. That there is
conspiracy to harm them that has been created by a
government agency
• Other common symptoms in schizophrenia and other spectrum
psychotic disorders: speaking in coherently, acting unpredicatble,
communication issues, hard time w/ emotion expression, a-
SYMPTOMS, DIAGNOSIS, AND COURSE: typical facial grimaces, ticks and issues with gate
• schizophrenia is a complex neuro-psychiatric disorder • Schizophrenia spectrum: includes group of psychotic disorders
• psychosis is the foundational diagnostic syptom, has a strong impact on perception, cognition. that are similar to schizophrenia but often not as severe and
And emotions persistant
• The DSM-5 uses schizophrenia spectrum to highlight the 5 domains of symptoms • Episodes can be scary, often don’t know who to trust or what
• Duration and severity help distinguish disorders from one another is real
• There are 5 main domains: 4 types of pos: Delusions, hallucinations, disorganized thought and
Speech, and disorganized/abnormal motor behaviour including catatonia
• neg: restricted emotion affect or restricted expression
• often have cognitive deficits, can be associated with declines in functioning, at times they can function well
but often have difficulty taking care of themselves
Positive Symptoms: positive as they are in addition to behaviours that are common
• Positive symptoms of schizophrenia:
Delusions: false beliefs, tend to hold belief with strong conviction even with contradictory evidence (goes against reality)
• content of delusions: persecutory themes, religious, themes of grandiosity
• Some researchers believe that those with delusional thoughts tend to put alot of meaning into irrelevant events (might focus significantly on insignificant events, tribute
importance to events that are inconsequential (ex. People with blue hats are trying to send them a message, blue hat is a significant cue and think about what that means
to them
• - self-deceptions (ex. Thinking that you might win the lottery are different from delusions cause 1. they are possible and 2. aren’t preoccupied by thoughts on daily basis
and 3. Can admit we are wrong
Hallucinations
Disorganized thought and speech
Delusions
• Persecutory delusions (aka paranoid delusions):
The most commonly experienced delusions among individuals with schizophrenia (can occur in severe forms of depression and PTSD ex. Individuals who are in manic state
might believe they are adidy,
• paranoid delusions are distressing and often accompanied by disturbed sleep, anxiety and depression
• very common in first episodes of psychosis and experienced by 70% of individuals in their first psychotic break, the presence of worry tends to predict new
instances of paranoid thoughts
They may believe that others are plotting to cause harm to them and may be convinced that others are watching, harassing, or conspiring against them.
• These beliefs are unshakable and as a result, they cannot be convinced otherwise
• Grandiose delusions:
False beliefs that an individual is more important or powerful than they truly are
• may hold the belief that they are special or have unique powers, wealth, identity, abilities even if evidence exists for the contrary
• pretty common, occur in 50% of patients who are diagnosed with schizophrenia and 66% of individuals with bipolar
• Both harm and distress are common, an individual may believe they are invincible and step into traffic,
• commonly report paranoia and feelings of self-loathing, these are a form of compensation for negative self beliefs
E.g. an individual may believe that they are a God
• Delusions of reference:
Individuals hold the belief that random events or comments that are made by others are directed towards them.
• E.g. holding the belief that a bird flying above you is sending important messages from God
• might result from a heightened attention to irrelevant cues and assigning incorrect importance to neutral stimuli
• Lots of types of delusions can work together in an individuals delusions
 ▫

psychology
Hallucinations
• Hallucinations:
False perceptions
• ex. Might have thought you saw someone when you didn’t, common in dark when seeing shadow, feeling someone touch you when they didn’t
• Common to experience momentary confusion when perceptional systems create a feeling of reality, even if the stimuli doesn’t align with perception
Can occur in all sensory modalities
• Auditory verbal hallucinations are the most commonly reported (70-80% of individuals with schizophrenia)
• The perception of voices can be frightening and distressing
• core symptom of psychotic illness and prediction of poor mental health
• may consist of voices giving command, running commentary on individuals behaviour, voice can seem like its coming from inside head or elsewhere, often have
negative qualities
• It is typical for individuals to report that the voices:
• Speak directly to them
• Are not in their control
• Are evil
Auditory Verbal Hallucinations (AVHs)
• Alterations in brain structure and function are associated with AVHs and these neuro alterations tend to be located in regions of the brain associated with auditory visual
stimuli and also executive functioning
• The presence of spontaneous activation in speech production areas in the right hemisphere may underlie these hallucinations
• speech production areas include: prefrontal cortex, and the auditory cortex and spontaneous activation may lead to a single word or a basic sentence
• hearing voices occurs transdiagnostically, found among individuals with borderline personality disorder, major depression, bipolar, dissociative, PTSD, etc
• around 2-10% of general population report voice hearing experiences but don’t meet the criteria for psychiatric diagnosis
Visual Hallucinations (VHs)
• Visual hallucinations:
Often occur with auditory hallucinations
2nd most common type of hallucination among individuals with psychosis
• Ta ta hallucinations: perception that something is happening to outside of body (common: individuals have bugs crawling on them)
• Somatic hallucinations: perception that something in happening to inside of body (worms eating intestines)
Disorganized Thought and Speech
• Formal thought disorder:
The disorganized thinking that is a common feature of individuals with schizophrenia
• Loose associations (aka derailment): Individuals may slip from one topic to another with little coherence
• when an individual is asked why they are in the hospital they may answer spaghetti looks like worms, I really think its worms, gofers dig tunnels
• neologism common, individuals might make up words that are meaningful to them
• Clangs: individual makes up associations about words based on the sound of the words instead of their content
• Individual may repeat same word or statement lots of times, males with schizophrenia deal with more severe deficits in terms of language cause language is controlled
more bilaterally with women, they can use both sides of brain better to compensate for any deficits they may have
• “Much of abstraction has been left unsaid and undone in these products milk syrup, and others, due to economics, differentials, subsidies,
bankruptcy.. ” (Maher, 1966, p.395)
Disorganized or Catatonic Behavior
• Individuals with schizophrenia may suddenly shout, swear, or pace, usually responses to hallucinations or delusions (ex. Individual may think they are being persecuted, they
might see a hallucination of someone chasing them)
These are typically responses to hallucinations or delusions
Attention and memory issues are common:
• Individuals with schizophrenia tend to have difficulties with daily routines
• bathing, dressing, eating regularly
• Catatonia:
Disorganized behavior that reveals psychomotor disfunction, can range from unresponsiveness to agitation
• negativism: lack of response to instructions, mutism: lack of motor or verbal responses, or catatonic excitement: excessive or purposely motor activity with no reason
Negative Symptoms
• Negative symptoms:
Involve the absence of a capacity
• severe negative symptoms are associated with poor outcomes in comparison to severe positive symptoms, seems to be due to the negative symptoms tend to be more
difficult to treat and more persistent and are less common in other psychotic disorders
Restricted affect and avolition/asociality are common: reduction or absence of emotional expression (might show fewer facial or physical expression or flat vocal tone to
show emotional expression)
• self-report questionnaires: they suggest that individuals with schizophrenia report anhedonia (loss of the experience of pleasure) however lab studies show no
difference in terms of positive affect in response to pos stimuli
• Thought that they might experience intense emotions that they aren’t able to express
• contradictory self-report data might reflect depression
• Avolition : inability to initiate or persist in common goal activites (ex. Work)
• can be expressed a-sociality: lacking desire to interact with others, typically tend to be socially isolated, this may be due to stigma as lots of individuals with
schizophrenia feel rejected from their family
• a-sociality is diagnosed when an individual has a welcoming group of individuals within their lives but the individual with schizophrenia shows no interest to get to
know them
 ▫

psychology
Negative Symptoms cont’d:
Deficits are common in many basic cognitive processes including:
Attention: have hard time focusing and maintaining
Memory: hard time holding info and manipulating it
Processing speed
• because of this, individuals with schizophrenia have a hard time paying attention to relevant info and suppressing unwanted and irrelevant info
• It is thought that these deficits may contribute to hallucinations or delusions, disorganized thinking and behaviours
• Immediate relatives of individuals with schizophrenia might show deficits but to lesser degree
• longitudinal studies show that individuals that go on to develop schizophrenia do suggest that the cognitive deficits might pre-seed the acute symptoms of schizophrennia
Diagnosis
• Schizophrenia has been recognized as a psychological disorder since the 1800s
Emil Kraepelin termed the disorder dementia praecox (precocious dementia) in 1883 thought the disorder was result of premature brain deterioration. He viewed the
disorder as always leading to severe chronic and irreversible deterioration
Eugen Bleuler introduced the term schizophrenia and made the argument that the disorder doesn’t always lead to deterioration
• the term schizophrenia comes from the greek word schizo' (splitting) and 'phren' (mind)
• In order to be diagnosed: the individual must show 2 or more symptoms of psychosis (at least one should be hallucinations, delusions, disorganized speach and symptoms
should be acutely present for at least 1 month and this is apart of the acute stage, some symptoms should be present for 6 months
• Prodromal symptoms:
Exist before the acute phase
• Residual symptoms:
Exist after the acute phase
• during the 6 months before and after the active stage, individuals with schizophrenia might show mainly negative symptoms and milk positive
• If left untreated, schizophrenia is episodic and chronic
• Difficulties in terms of functioning, are heavily tied to negative symptoms and positive symptoms
• Individuals with predominately negative symptoms, tend to have lower education, less success (keeping job), weaker performance on cognitive tasks, worst prognosis in
comparison with individuals with mostly positive
• Negative symptoms tend to be less responsive to medications, even in the DSM-5, no subtypes of schizophrenia are included since evidence noted diagnostic stability and
validity for these subtypes are weak
Course of Schizophrenia
• Global prevalence:
0.33-0.75%
• Risk is significantly higher when relatives have the disorder
• Psychotic features usually emerge during the late teens – mid-30s (the development before adolescents is extremely uncommon)
• early on-set schizophrenia is diagnosed in childhood in adolescent before the age of 13 and occurs in 1 in 10 thousand children (poor outcomes, lots of neg symptoms
and comorbidity with other disorders
• psychotic symptoms can develop rapidly but more commonly develop gradually
• Only 13.5% meet full recovery criteria
• Schizophrenia is one of the top 15 leading causes of disability (globally):
It is associated with impairments in psychosocial functioning which increases the likelihood of:
• Unemployment
• Homelessness
• Poverty
• Difficulty with self care
• the largest economic burden is from individuals from 25-54 years, this age is typically the most economically productive but among individuals with schizophrenia have
significant economic issues due to losses in productivity
• International studies say that around 3% of health care budgets are use to treat individuals with psychotic disorders
• Schizophrenia is associated with higher rates of comorbid illness and mortality rates (due to underlying illnesses like stroke, diabetes, or coronary heart disease)
Prognosis
• Life expectancy: 10-20 years shorter than individuals without schizophrenia
• More likely to suffer from infectious and circulatory diseases, due to higher rates of smoking, overweight, and side effects of meds
• 5-10% of individuals with schizophrenia commit suicide, highest rate of suicide is among those recently diagnosed or those in their first psychotic episode
• Fewer than 1/7 fully recover
• progressive course of schizophrenia explains this
• 70-80% of people with first epsiode will experience remission of their symptoms within a year of treatment, risk of symptom occurance a year after remission
from first episode is around 0-5% among individuals who receive maintenance anti-psychotic treatment but around 78% among those without medication
• medication plays a strong role in whether symptoms will reoccur
• some individuals tend to stabilize within 5-10 years of the first episode and show very little relapses
• research does suggest that cognitive deficits improve in the first year following treatment and can remain stable or improve
 ▫

Gender and Age Factors

• Men tend to present with:
- psychology
Earlier age of onset
More negative symptoms including social withdrawal and blunted affect
Lower social functioning
More comorbid substance abuse
• studies show that males with schizophrenia have more abnormalities in neural structure and functioning in comparison to females
• Women tend to present with:
Later age of onset (3-5 years later than males)
More affective symptoms (mood disturbances and depressive symptoms)
• women that have late onset of schizophrenia tend to have less severe negative symptoms and more positive
• Women overall have a better prognosis (reason: unclear, thought that women are more likely have better history (education, social, relationship) and less likely to
show cognitive deficits)
• Also thought that estrogen might regulate dopamine in ways that might be protective for women
• Peak onset for males: early to mid 20s (1 peak at 20-25 years), peak onset for females: late 20s (2 peaks, 1st between 25-30 and 2nd after 45)
Cultural Influences
• Types of hallucinations and delusions are similar across cultures but the specific contents of hallucinations and delusions differs across cultures
• themes of delusions tend to relate to cultural beliefs and social background (ex. Religious delusions are common in christian societies and more rare in Buddhist or hindu
societies)
• delusional content in US was highly focused on Germans in the second world war, strongly focused on communists during the cold war, and technology in recent eras
OTHER PSYCHOTIC DISORDERS: schizophrenia is most common and well known, heavily depicted on television and media
Schizoaffective disorder
• Schizoaffective disorder:
Combination of schizophrenia and a mood disorder
Psychotic symptoms:
• Delusions, hallucinations, disorganized speech and behavior, negative symptoms
Mood symptoms:
• These meet the criteria for a major depressive or a manic episode
Diagnosis: requires the person experiences 2 weeks of hallucinations or delusions with no mood symptoms
Schizophreniform disorder
• Individuals meet Criteria A, D, and E for schizophrenia
They show symptoms that last only 1-6 months (represents intermediate between schizophrenia and brief psychotic disorder)
• functional impairments are not necessary for diagnosis
• Good prognosis is associated with quick onset of symptoms previously functioning well and experiencing confusion but not blunted affect
• 2/3 of individuals with this go on to be diagnosed with schizophrenia or schizoaffective disorder
Brief Psychotic Disorder
• Individuals diagnosed with Brief Psychotic Disorder have a sudden onset of:
Delusions
Hallucinations
Disorganized speech
Disorganized behavior
Episode lasts 1 day-1 month (after this, symptoms remit completely)
• symptoms will sometimes reoccur after a stressor (like an accident)
• 1 in 10 thousand women tend to experience brief psychotic episodes after birth, relapse tend to be high but outcomes tend to be quite good
Delusional Disorder
• Individuals with delusional disorder:
Delusions lasting at least 1 month (these delusions pertain to events that happen in real life, like having a disease, being follow)
Only show delusions: no other psychotic symptoms (different from schizophrenia) they don’t act oddly in terms of functioning
• less likely to seek help with mental health functioning and will usually only seek assistance if pushed to do so by family/friends
• Age of onset: 40 years, but range 18-90
• Males: persecutory and jealous subtypes common
• Females: erotomaniac is common
• Symptoms tend to improve with psycho-therapy and anti-psychotic medication
Prevalence: 0.05-0.2%
Good prognosis is associated with:
• Early onset of symptoms (before 30 years)
• Higher occupational functioning
• Higher social functioning
• Sudden onset of symptoms
 ▫
Schizotypal Personality Disorder
• Schizotypal Personality Disorder:
A personality disorder, NOT a psychotic disorder
• On the continuum of schizophrenia spectrum of disorders psychology
Lifelong pattern of unusual behaviours (have an impact on personality, self-concept, thinking and interpersonal relationships)
Exhibit pathological personality traits such as:
• Psychoticism
• Eccentricity (eccentric behaviours and disturbed thought and affect is similar to schizophrenia but the development tends to align better with personality disorders)
• Cognitive dysregulation
• Perceptual dysregulation
• Restricted affect
• Emotional withdrawal
• prevalence around 1.9%
• these individuals tend to have very few close relationships and challenges in understanding others (often perceive others as being deceitful and hostile and suspicious)
• Might also believe that random circumstances are significant (accident happened at intersection that they were at yesterday, they would find significance in that
intersection)
• Neurological tests: show challenges with working memory, learning and recall tend to be pervasive and they will go on to develop schizophrenia
BIOLOGICAL THEORIES: since symptoms and prevalence are similar, many researchers state that biological explanations are the best for the development of schizophrenia
Genetic Contributors to Schizophrenia
• Family, twin, and adoption studies: support the argument that genetic transmission is a critical risk factor for schizophrenia
• overall, genes tend to strongest risk factor, schizophrenia is strongly impacted by susceptibility genes, epigenetic processes and environmental factors
• Environmental factors that may increase the risk of schizophrenia:
Pregnancy and birth complications
Childhood trauma
Social isolation
Substance abuse
• both genes and environment are associated with the development, but the nature of this interaction is unclear
• Family Studies:
Genetic relatedness is strongly associated with the risk of developing schizophrenia
• the risk of developing schizophrenia to the general population is less than 1 %
• Family history is associated with higher risk of schizophrenia, also mood disorders, mood disorders and bipolar disorders
• Adoption Studies:
Biological relatives of adoptees with schizophrenia:
• Are approximately 10 times more likely to have schizophrenia in comparison to biological relatives of adoptees without schizophrenia
- one study: kids who were given up for adoption were tracked, around half had biological mothers with schizophrenia and half didn’t, around 10% of the kids whos
biological mother had schizophrenia went on to develop it, or another psychotic disorder. Only 1% of those kids whose biological mother did not have schizophrenia went on
to develop schizophrenia or another psychotic disorder
• Twin Studies:
Have revealed high rates of heritability (up to 81%)
• quadruplets who shared genes and family environment all went on to develop schizophrenia (the specific symptoms and outcomes varied)
Concordance rate for MZ (monozygotic) twins = 46%
Concordance rate for DZ (dizygotic) twins = 14%
• epigenetic: when you compare MZ twins, discordance for schizophrenia (so when one has it and other doesn’t), to MZ who both have it, researchers found that MZ
twins who are discordance to schizophrenia, tend to show differences in molecular structures of DNA, especially on genes that regulate dopamine systems
• the MZ twins that were concordant for schizophrenia tended to show fewer differences
• reasons for epigenetic is unclear, likely that it might involve stress
Structural and Functional Brain Abnormalities
• most researchers believe that schizophrenia is a neuro developmental disorders where many factors are related to abnormal development of the brain during
gestation and also in early life
• Most consistent finding:
Significant reduction in gray matter in the cortex of individuals with schizophrenia
• reduction tends to be pronounced in the medial, temporal, superior temporal and prefrontal regions
• individuals at risk for schizophrenia due to family history, tend to show abnormal activity in prefrontal cortex
• neural imaging studies of individuals who have gone on to develop schizophrenia in adolescence, have gone on to show structural changes within prefrontal
cortex from before to after symptom development
• Other findings have shown differences in:
Prefrontal cortex
Hippocampus: some studies show that individuals with schizophrenia tend to show abnormal activation in the hippocampus when completing tasks that require the
encoding on information, and the retrieval of info
white matter: found in areas of the brain associated with working memory
ventricles: enlargement if often seen (means atrophy or deterioration in other brain tissue)
• Damage to the Developing Brain:
• the neuro developmental theory of schizophrenia suggests that there is damage that happens during neuro development that can have long-term impacts on the
brain
Birth complications:
• E.g. hypoxia
• birth complication where the baby doesn’t get enough oxygen to brain before, during or after delivery
• research has shown neuro abnormalities among individuals with schizophrenia who have experienced hypoxia
• this might contribute to a reduction in grey matter or enlarged ventricle regulations
• infants with perinatal hypoxia, they are 2 times more likely to develop schizophrenia later on in life
 ▫

Structural and Functional Brain Abnormalities

• Damage to the Developing Brain:
psychology
Maternal illness and prenatal exposure:
• High rates of schizophrenia are found among individuals whose mothers were exposed to diseases and infections throughout pregnancy or delivery
• ex. Influenza, rubella, toxoplasmosis, and herpes
• Individuals with schizophrenia are more likely to be born in spring, and the exposure to the flu in the fall/winter when critical phases of fetal development is taking
place might be a risk factor
• Maternal and fetal inflammatory responses to the infections are having a strong impact on fetal neuro development
• Anti-inflammatory diets: leafy green vegetables (kale or broccoli) for pregnant women with infections might reduce those risks
• Localized bacterial infection tends to be associated with 1.6 fold increased risk for developing a psychotic disorder, system Y bacterial infection is associated with a 3
fold risk in terms of developing a psychotic disorder
Neurotransmitters
• Dopamine: plays a critical role in schizophrenia
• original dopamine theory: schizophrenia is caused by too much dopamine in the prefrontal cortex and the limbic system
• Diathesis stress model: argues that HPA (hypothalamic pituitary adrenal) access triggers a cascade of events that results in neural circuit disfunction which impacts
dopamine reproduction
• The stress induced HPA action tends to be associated with dopamine release (this is supported by the utility of anti-psychotic drugs that work by blocking dopamine
• Dopamine doesn’t;t fully explain the negative schizophrenia symptoms, many individuals who take anti-psychotic drugs do show relief from positive symptoms but
often show little relief from negative
Medications that reduce schizophrenia symptoms:
• Block dopamine receptors
Medications that increase dopamine levels (like amphetamines):
• Typically lead to an increase in positive symptoms of schizophrenia
• Serotonin:
regulates dopamine neurons within the mesolimbic system
• interaction between serotonin and dopamine is important in understanding schizophrenia symptoms
• Glutamate (excitatory) and GABA (inhibitory):
Deficiencies may be associated with emotional and cognitive symptoms
• drugs like ketamine that block glutamate receptors can cause delusions and hallucinations in individuals with no psychological disorders
PSYCHOSOCIAL PERSPECTIVES:
Social Drift, Trauma, and Urban Living
• Social drift theory:
• `the symptoms of schizophrenia typically interfere with individuals ability to complete education and job and can drift to lower economic status
• some research supports, some research supports the opposite
• social status and environmental factors might impact schizophrenia, but likely bidirectional relation
Cumulative exposure to environmental risk factors in deprived and urban areas can increase the likelihood of psychological disorders (especially among those with
genetic risk factors):
• Common risk factors:
• Lack of social support
• Poverty
• High neighborhood crime rates
• Low access to health care
• Trauma and social adversity:
Childhood adversity is associated with a higher risk of psychosis in adulthood (might include sexual abuse, physical abuse, emotional abuse, psychological abuse, neglect,
parental death or bullying)
• among those with schizophrenia the most common adversity is emotional neglect
Childhood abuse and neglect are associated with the later development of schizophrenia
Individuals have an increased risk for schizophrenia when they grow up and/or live in urban environments that have higher levels of deprivation or poverty
• theories like social deprivation, income inequality and social fragmentation have all been proposed but none have been conclusive
• overcrowding is another explanation (this would increase the risk of pregnant women and also newborns being exposed to infectious agents)
• Trauma and social adversity:
Childhood adversity is associated with a higher risk of psychosis in adulthood
Childhood abuse and neglect are associated with the later development of schizophrenia
Individuals have an increased risk for schizophrenia when they grow up and/or live in urban environments
Stress and Relapse
• Stress can trigger new episodes of schizophrenia among individuals with the disorder (higher levels of stress will often occur before the onset of a new episode
Stressful life events (e.g. adult trauma, conflict, bereavement, financial difficulties) worsen psychotic symptoms
• one significant stressor that is associated with increased risk of new episodes is immigration. Recent immigrants leave behind a support system and may
experience financial stress. First and second generation immigrants have a higher rate of acute symptoms of schizophrenia in comparison to individuals from the same
ethnic group who have been in the country for a longer time
• risk might be especially higher for refugees in comparison to non-refugee migrants
• Protective factor that reduces the risk for developing schizophrenia:
Household pets (particularly dogs) throughout infancy and early childhood
• exposure pet dog in pregnancy, infancy, and childhood is associated with less inflammation and fewer immune mediated disorder example, Asthma, allergies and it
might be doing this because of cortisol release, so exposure can change intestinal micro biom of family members and suggests that pet dogs can impact intestinal
inflammation and can alter the risk of schizophrenia through changes in the gut brain access
 ▫

psychology
Schizophrenia and the Family
• Individuals with schizophrenia who have families that are high in expressed emotion:
Are more likely to suffer relapses of psychosis
Are more likely to be rehospitalized
• individuals and families who are high in expressed emotions, tend to overly involved with each other, protective of member who has schizophrenia, and tends to be
critical, hostile and resentful towards them (found cross culturally)
• lower levels of expressed emotions are often found in families in developing countries and there tends to be lower relapse rates among individuals with schizophrenia
within these countries
• Families have tendency of being more understanding of positive than negative symptoms (might view positive symptoms as uncontrollable and negative as controllable)
• Interventions that reduce family expressed emotions often lead to reduction in relapse rate among family members with schizophrenia
Cognitive Perspectives
• Beck and Rector (2005):
Argued that individuals with schizophrenia have fundamental difficulties in:
• Attention
• Inhibition
• Adherence to rules of communication
*Because of these difficulties, they may use different thinking styles in order to cope with the overwhelming information they are trying to process
• it is thought from this perspective that delusions happen when a person tries to explain bizarre perceptual experiences and jump to conclusions with little
evidence
• thought that hallucinations might happen when a person is hyper-sensitive to perceptual input and might attribute experiences to external sources
• from a cognitive perspective, negative symptoms might result from expectations that interactions with others might be negative and the need to conserve limited
cognitive resources, which might lead them to withdrawal
• cognitive therapies have been beneficial in terms of helping patients cope with stressful factors that are associated with their symptoms and helping them to
dispute delusions and hallucinations, negative symptoms tend to be treated by helping individuals with schizophrenia develop an expectation that there are positive benefits to
interacting more with others
TREATMENT: typically involves medications, therapies and social services
• medications typically help in reducing psychotic symptoms and reduce the likelihood of relapse
• Therapy: helps individuals cope with impacts of the disorder
• Social services: helps to provide support with community integration and resource access
Biological Treatments
• (First Generation) Typical Antipsychotic Drugs: historically, most individuals with schizophrenia were warehoused
Chlorpromazine (Thorazine):
• In the 1950s (50% of individuals housed in psychiatric hospitals were diagnosed with schizophrenia. These individuals were fed, bathed, and often restrained from hurting
themselves using physical restraints. No treatment was provided that improved functioning) French researchers found that this drug could reduce agitation, hallucinations,
and delusions among individuals with schizophrenia
• anti-psychotic drugs (neuroleptics), currently a-typical antipsychotic are most useful in terms of relieving positive symptoms while having few intolerable side
effects
• From a class of antipsychotic drugs called phenothiazines (block dopamine receptors, tends to reduce impact on brain but don’t help with neg symptoms)
• Other types of phenothiazines became widely used
• Other classes of antipsychotic drugs have been introduced:
• Butyrophenones (e.g. Haldol)
• Thioxanthenes (e.g. Navane)
• Individuals with schizophrenia usually need to take an antipsychotic drug all the time to prevent new episodes
• if these drugs are discontinued, around 70% relapse within 1 year, around 98% will relapse within 2 years
• around 30% of people who continue their medication will relapse
• There are many side effects associated with these drugs including:
• grogginess, blurred vision, sexual disfunction, visual disturbances, depression
Akinesia (slowed motor activity, expressionless face, monotonous speech
Akathesis (agitation that causes people to be unable to sit still)
• Parkinson’s disease: caused by too little dopamine in the brain, side effects highlight that the drugs reduce functioning levels of dopamine within the brain
• Tardive dyskinesia:
Permanent side effect of typical antipsychotic drugs
• involves involuntary movements of the tongue, mouth, face, jaw
• individuals might involuntarily make sucking sounds, smack their lips, or might stick out tongue repeatedly (happens in around 20% of people who have long-term
use of phenothiazines
• side effects of neuroleptics can be lowered by reducing dosages and most doctors will prescribe the lowest dose possible that will keep active symptoms
controlled (maintenance dose)
• issue with maintenance dose: neg symptoms might be strongly present and mild pos might persist, could make it hard for a person to function in their day
to day lives
Neurological disorder
 ▫

psychology
• (Second Generation) Atypical Antipsychotics:
More effective than neuroleptics in treating schizophrenia
• Do not cause the neurological side effects that first generation drugs tend to cause
• clozapine is most common and it impacts both dopamine and serotonin receptors
• research has shown that clozapine is effective in treating schizophrenia spectrum disorders and is as effective in reducing both negative and positive
symptoms
• side effects: dizziness, nausea, sedation, seizures, tachycardia, agranulocytosis (deficiency of granulocytes, which fight infections, it can be fatal so patients need
to be heavily monitored)
• Limitations:
10-60% of individuals have little or no response to first- or second- generation antipsychotics
• higher rates of non-response tend to be associated with earlier onset of schizophrenia, and early onset is a strong predictor of poor response to antipsychotic
treatment
• benefits of antipsychotics in terms of symptom reduction, tend to be the greatest in patients that have the most severe symptoms
• antipsychotic use is associated with lower mortality in comparison to no antipsychotic use in individuals with schizophrenia
• the vast majority of those with psychotic disorders don’t benefit from rehab programs without the use of psychotic drug therapies
Behavioral, Cognitive, and Social Treatments: the need cant be overstated
• A comprehensive approach to treatment tailored to the individual should consist of:
Cognitive treatments : help people with schizophrenia to help identify and change negative attitudes towards their mental illness, also help them seek help and
participate socially when possible
Behavioral treatments : make use of operant conditioning and modelling to teach skills like starting and ending conversations, asking help from physicians and completing
activities like cooking, cleaning and self-care
Social interventions: helps increase contact between those with schizophrenia and support resources like support groups
Family Therapy:
• Family therapy approaches focus on:
Basic education concerning schizophrenia (families will be taught about the biological causes, symptoms, medications associated with schizophrenia (goal is to reduce self-
blame in families and increase tolerance for uncontrollable symptoms, they will also learn how to communicate more effectively, to reduce harsh interactions and to increase
problem solving symptoms
• outcomes: ofer increased carer well-being and reduction in terms of patient directly criticism and hostility
Training family members in coping with inappropriate behaviors
Training family members in coping with the disorder’s impact upon their lives
Stigma
• individuals with a mental illness are often subjected to stigmatizing, discriminative behaviours in social situations and even within families
• Negative impacts of stigma: lower quality of life, lower likelihood to seek help, discontinuation of treatment
• Across cultures, individuals are more likely to believe that schizophrenia is caused by biological factors in comparison to depression
• individuals who contribute biological causes to psychological disorders tend to be more likely to have a greater desire for social distance from those individuals
• Individuals with psychotic disorders are more likely to experience stigma and isolation because of public judgement in comparison to other mental health disorders
• Individuals in the general population often perceive people with psychological disorders as:
Dangerous
Unpredictable
Out of control
psychology
DSM-5 types of delusions:

DSM-5 for schizophrenia

DSM-5 diagnostic criteria for schizoaffective disorder

DSM-5 for schizophreniform disorder

DSM-5 diagnostic criteria for brief psychotic disorder

DSM-5 diagnostic criteria for delusional disorder

DSM-5 for diagnostic criteria for schioztypal personality disorder

As genetic similarity to an individual with schizophrenia increases, an

individuals risk for developing schizophrenia also increases
 Two-hit model: psychiatric conditions result from disturbance in
neural development in the weeks before or after birth
• this impacts neural circuits and creates vulnerability
• Then psycho-social stressors experiences later on in life
can end up triggering symptoms onset

Areas of abnormal dopamine activity:

• in terms of the original theory of dopamine: revises theory is that there
are different types of dopamine receptors and different levels of
dopamine in a variety of neural regions that can explain schizophrenia
• Excess levels of dopamine have been found in the mesolimbic pathway,
this part is critical for processing the salience of stimuli and reward
• Abnormal function in mesolimbic pathway can be associated with
attributing importance to insignificant stimuli and associated with
hallucinations and delusions
• Abnormal low levels of dopamine in the prefrontal cortex might lead to
neg symptoms like low motivation, restriction of affect, and inability to
care for self (this explains why dopamine antagonists don’t tend to
alleviate negative symptoms of schizophrenia
• disregulation within the dopamine system has been implicated in form of
psychosis and mood disorders

Psychological and social treatments:

• many individuals who can control the positive symptoms of schizophrenia with medication will see experience a lot of negative symptoms, issues with motivation and social
interactions
• psychological interventions can really help increase social skills and can reduce social isolation and feelings of apathy
• Lack of effectiveness of anti-psychotic drugs is in part associated with the discontinuation of the drugs because, often, individuals feel like they don’t need them or
because they find the side effects to be intolerable
• Psychological interventions can help people understand the need to maintain on these medications persistently and help manage their side effects as well
• Because schizophrenia is so severe, lots of people can have a difficult time keeping a job, sheltering themselves and maintaining proper medical attention and care

In terms of what happened, experiencing prodromal or early symptoms of

schizophrenia, which were negative and given anti-psychotic medication
• He remained apathetic and isolated, stopped taking meds, and 2 months
Interaction of biological and psychosocial factors in terms of impacting the later had horrible thoughts that he thought was put there by his father,
development of schizophrenia grabbed a knife and threatened to kill his father if he didn’t stop torment
him, positive symptoms after medication declined and negative persisted
 ▫
Persoanlity disorders along the continuum
One core aspect of personality is our sense of
identity
• functional end: stable sense of self, distinct
from others as it can adapt to social situations
Another core: How we relate to people
• Adaptive personalities: empathize with others,
cooperate
In healthy personalities, traits are not fixed or rigid
but they fluctuate depending on social context
If personality traits are inflexible they usually cause
lots of social and personal disfunctions and
psychological distress

Issues with capacity of interpersonal relationships or

identity are sometimes diagnosed with a personality
disorder

PERSONALITY:
• Personality: enduring patterns of feeling, perceiving, thinking about, and relating to yourself and to your environment
• might describe others as emotional, outgoing etc
5 factor model: dimensional perspective that everyone’s personality exists along 5 personality traits, each factor has many dimensions and they vary
Significant among of research supports 5 factor models and these traits capture variation in terms of personalities, research has also been replicated across cultures,
numerous facets of personalities are impacted by genes
• Personality trait:
A core element of personality that tends to be consistent across settings and time (e.g. being caring, outgoing)\

GENERAL DEFINITION OF PERSONALITY DISORDER

• The DSM-5 uses a categorical perspective of personality disorder but importantly in the section for further study it does have a continuum model
• the general criteria for personality disorder is that the individual deviates significantly from expectations of culture, styles of thinking, emotional experiences,
interpersonal functioning and/or impulse control
• This personality pattern should be pervasive and inflexible across situations, onset in adolescents or early adulthood, lead to significant distress or functional
impairment
• Pattern of functioning shouldn’t be better explained by other mental disorders, medical or substance abuse
• Personality disorder to be diagnosed in kids younger than 18, personality patterns need to be present for 1 year, anti social personality disorder cannot be diagnosed
before 18 years
• Personality Disorder: an enduring pattern of feeling, thinking, and behaving that is fairly stable over the course of time
Personality features of concern must be displayed by early adulthood
Clinicians need to assess personality traits across time and across situations while considering ethnic, cultural and social factors

CLUSTER A: ODD-ECCENTRIC PERSONALITY DISORDERS:

• Behavior of individuals with odd-eccentric personality disorders:
Similar to the behavior of individuals with schizophrenia, main difference is they know reality
• Difference: they retain their grasp on reality to a greater extent
• ex. Common to be paranoid, speak in weird ways that make it difficult to understand, challenges relating to others, bizarre beliefs or perceptual experiences
• Part of schizophrenia spectrum, specifically schizotypal
• Symptoms are below threshold of psychotic disorder
• Can be pre to schizophrenia in a small proportion of individuals
• More common among people who have first degree relatives with schizophrenia or a persecutory type of delusion disorder

PARANOID PERSONALITY DISORDER:

• Characterized by a pattern of suspiciousness and distrust of others
Frequently preoccupied with concerns that they are being mistreated or victimized, hyper vigilant and look among environment
• ex. Much more likely to notice a sudden grimace on partners face or slip of the tongue, spend a lot of time trying to understand them
• Sensitive and angrily reactive to criticism, even if it is perceived or real, also hold grudges
• Because this has a strong effect on social relationships, they are likely to experience challenges in social settings which can lead to withdrawal or isolation
• In romantic relationships, hard to maintain without accusing partner of being disloyal, tend to be resistant to rational arguments against suspicions and see argument
as evidence that their partner is apart of a conspiracy against them
• Individuals with paranoid personality disorder are suspicious and distrustful of others, often believing that unrelated events have personal significance to them
• There is a dearth of research examining PPD and many embers of the psychiatric community have called for its removal from the DSM-5
• Known, really hard to treat since the primary characteristics include suspicions, rumination, jealousy which can limit treatment
• Symptoms don’t include psychotic symptoms like paranoid delusions and hallucinations, rates: 1.2-4.4% of individuals in general pop
• Overall, challenging to get along with and unstable relationships
• Strong predictor of aggressive behaviour and strongly associated with violence, stalking and litigation
• Comorbidity: people diagnosed are at higher risk for major depression, anxiety, substance abuse and psychotic episodes
• suicide risk is unclear due to limited data
 ▫
THEORIES OF PARANOID PERSONALITY DISORDER: not strong enough evidence to link paranoid personality disorder in schizophrenia
• Genetic theories:
Currently there is not strong enough evidence to demonstrate a linkage between PPD and schizophrenia
• Family studies show that it tends to be more common in relatives with unipolar depression in comparison to schizophrenia effected individuals
• Children of parents with schizophrenia are at high risk for avoidant and schizotypal disorder but not paranoid personality
• Cognitive theories:
PPD results when individuals hold the underlying belief that others are malevolent and deceptive and when individuals believe they are unable to defend themselves
against others
• tend to focus on signs of hostility and danger, personalize blame and tends to leave them with the belief of being alone and unprotected in a dangerous world
TREATMENT OF PARANOID PERSONALITY DISORDER
• Because they have a fundamental distrust of others, individuals with PPD usually only access mental health resources when they are in crisis
• limited knowledge of best therapeutic options, research on CBT, psychoanalysis, transference focus therapy, conditioned avoidance response and dialectical behavioural
therapy do show promise in helping, but not enough evidence shows the most effective
• Cognitive therapy approach tends to focus on increasing sense of self efficacy in terms of facing challenging situations, this tends to decrease fear and hostility
towards others
• Suspicious approach to thinking can often undercut the development of trusting therapeutic relationships and also a therapist attempts to challenge paranoid thinking
can be misinterpreting in line with the paranoid belief system

SCHIZOID PERSONALITY DISORDER

• People with Schizoid Personality Disorder:
> Tend to be indifferent to developing close relationships with others
> Seem to derive little to no pleasure from social interactions
> Show a pattern of detachment from social relationships
> Tend to display a restricted range of emotional expression in their social interactions
> Emotional coldness and detachment might be associated with an inability to process emotions
> Research has shown higher rates of alexithymia: impaired ability to recognize and express emotions > Emotional dysregulation, suicide ideation, and comorbity
> At a high risk for major depression
> Inescapable feeling of loneliness and also social withdrawal; weaken their ability to cope with mental pain and increase suicide attempts > Violent crime is more likely
among Cluster A, specifically schizoid personality and schizotypal
• SPD is highly treatment-resistant:
> These individuals are typically indifferent to others’ praise or criticism > Take pleasure in very few actives
> View relationships as messy, unrewarding, and intrusive
• One of the most understudied, also least common
• 5% of general population, no strong consensus
• More common in men than women
• Function adequately in society that don’t require frequent interpersonal interactions

THEORIES AND TREATMENT OF SCHIZOID PERSONALITY DISORDER

• Genetic theories:
> There is a slightly higher rate of SPD among relatives of individuals with schizophrenia > Sociability, low warmth might be inherited
• Treatment:
> Individuals with SPD are not often motivated to seek treatment
> Interpersonal closeness of therapy is stressful instead of being supportive
> Psychosocial treatments tend to focus on increasing the individuals awareness of their feelings, social skills, and social contract
> Model the expression of feelings for a client, identify and express these feelings
> Social skills training is done using role play with therapist and homework assignments
> Group therapy, model interpersonal relationship and practice social skills with other group members
SCHIZOTYPAL PERSONALITY DISORDER
• Individuals with schizotypal personality disorder (STPD):
> Have enduring patterns of peculiar behaviours and/or appearance that have a strong impact upon their behaviour, thinking, and interpersonal functioning > Only personality
disorder included in schizophrenia spectrum; display similar symptoms
> Symptoms development and course can be quite different
> Socially isolated, uncomfortable with interpersonal interactions, limited range of emotions, odd and magical thinking
• Symptoms:
> Social interaction challenges are very common among individuals with STPD > lead to isolation and socially anxious behaviour
> Cognitive and perceptual distortions (but they maintain their grasp on reality)
> easily lost in thought and fantasy, believe that random events are strongly related to them
> Tangential speech
• Men more affected, likelihood is higher among those who are separated, divorce, widowed, and those with low income
• Comorbidity is really complicated and important to understanding the course of the behaviour
PERSONALITY DISORDER
THEORIES OF SCHIZOTYPAL PERSONALITY DISORDER
• Biological factors:
> Research supports heritability of STPD
> Family history, adoption, twin studies show genetic
> .81 which is very high, significantly more common among first degree relatives with schizophrenia > STPD is mild form of schizophrenia
> On neuropsychological tests individuals with STPD have difficulties with working memory, learning and recall (less severe than individuals with schizophrenia)
> People with both STPD and schizophrenia show grey matter reduction in areas of the temporal lobe, but reductions are less severe among those with one or the other
> Dysregulation of dopamine in the brain
> High levels on dopamine in striatal and cortical that play a strong role in the develop of the symptoms
• Environmental factors:
> Childhood trauma and adversity (sexual, physical, emotional)
> More likely to have a parent who has battered, abused substances, or been incarcerated
> Disruption in interpersonal and social functioning
> Exposure to this trauma has an impact on long-term outcomes including: > Paranoid ideation
> Social cognitive abilities
> Working memory, verbal fluency, and visual learning

TREATMENT OF SCHIZOTYPAL PERSONALITY DISORDER

• Typically treated with the same drugs used to treat schizophrenia (neuroleptics and a-typical antipsychotics)
> reduce psychotic like symptoms (distorted ideas of references, magial thinking, illusions)
> Antidepressants sometimes used for those who have significant distress
• In psychotherapy the focus is on establishing a good relationship with client and social skills training
> very few close relationship sand struggle with social anxiety and paranoid thoughts
> learn socially appropriate behaviour and increase social contracts
• Cognitive therapy focuses on assisting individuals with STPD to look for objective evidence in their environment to support their thoughts and disregard bizarre and odd
thoughts

CLUSTER B: DRAMATIC-EMOTIONAL PERSONALITY DISORDERS

• Individuals with Cluster B personality disorders:
> Have a hard time regulating their emotions and behaviours
> Show challenges in impulsivity, inflated sense of self, tendency to seek stimulation, strong disregard for personal safety or the safety of others > Hostile, dramatic,
impulsive
> Others perceive their behaviours as dramatic, emotional, and impulsive

BORDERLINE PERSONALITY DISORDER

• This disorder is characterized by:
> Instability of emotions, relationships, and image
> Strong impact on personals ability to function
> Regulate emotions; emotional extremes in boats of anger, depression, or anxiety (can last for a few hours or a few days
> Go from content, to feeling suicidal in a matter of hours > Difficulty regulating their emotions
> often experience emotional extremes revealed in bouts of anger, depression and anxiety > Volatile emotionality: extreme sensitivity to perceived emotional slights
> In combination in a unstable sense of self and impulsivity can lead to destructive actions
• Typically emerges during early puberty
• The symptoms: progressively impact numerous areas of an individuals life
• Interpersonal relationships are very unstable
> Idealizing others to disposing them without being provoked
• Feelings of emptiness; lead to cling onto new acquittances and therapists to fill that void
• Worry about abandonment
• Understands typical actions as rejection; therapist cancelling appointment when they are sick is taken by the patient as rejection and they become very angry

THEORIES OF BORDERLINE PERSONALITY DISORDER

• Individuals with BPD:
> have significant challenges with regulating emotion
> Are hyperattentive to negative stimuli
> It is thought that these issues may stem from childhood instability, neglect, and psychopathology among their caregivers
> Sexual and physical abuse, lead to challenges in terms of emotional regulation and in terms of attaining a positive and stable identity
• Marsha Linehan:
> argues that a history of exposure to emotional invalidation, abuse, and neglect inhibits proper learning of emotion-regulation skills
> dialectal behaviour therapy
> tend to rely on others to help them in terms of coping, but don’t have confidence to request help in mature ways: manipulative and immature (injuring themselves) >
extreme emotional reactions to situations often lead to impulsive actions
• Psychoanalytic theories:
> Object relations theorists have argued that individuals with BPD never learned to differentiate their perspectives of themselves from their perspectives of others
> This leads to extreme reactivity to others opinions and fears of abandonment
> Perceive others as rejecting them, then they reject themselves; results in self-punishment or self mutilation
> Hard time integrating positive and negative qualities; early caregivers tend to reward them when they remained dependent and punished when trying to separate >
Tend to see themselves and others as either all good or all bad, splitting: vasolating between the two
> Can view their partner as incredibly caring and kind, but when the partner is late for dinner they are selfish and uncaring
THEORIES OF BORDERLINE PERSONALITY DISORDER CONT’D:
• Biological theories:
> Amygdala and hippocampus among individuals with BPD are smaller in volume in comparison to individuals without this disorder > Amygdala: emotion
> Hippocampus: stress and memory
> Individuals with BPD have stronger activation in the amygdala in response to emotional faces
> There are structural and metabolic abnormalities in the prefrontal cortex of individuals with BPD > Prefrontal important for regulating of emotions and critical in
controlling impulsive behaviour > Impaired functioning tend to be associated with emotional dysfunction and emotionalbility
> Might be due to genetic factors in part, does run in families, twin studies support heritability > Early abuse and early maltreatment

PERSONALITY DISORDER
TREATMENT OF BORDERLINE PERSONALITY DISORDER
• Dialectical Behavior Therapy (DBT):
> This form of therapy shows the best support for treatment of BPD including reductions in: > Nonlethal self-injury
> Hospitalization
> Anger
> Gain a more realistic and positive sense of self, learn how to regulate their emotions, and also to correct their inclinations towards dichotomous thinking > Therapists
teach clients to monitor self discouraging thoughts, black and white analyzing, and challenge these thoughts
> This form of therapy also reduces anxiety, depression and increases interpersonal functioning
> Assertiveness skills: helps them to express emotions in a mature manner
> Monitoring situations that are most likely to lead to those behaviours and learning to cope
• Cognitive Therapy:
> Systems training for emotional predictability and problem solving (STEPPS) > Group intervention for individuals with BPD
> Uses both cognitive and behavioural techniques
> Cognitive techniques used to challenge the maladaptive and irrational cogntions
> Behavioural address problem solving and self-management
> STEPPS: reduce negative affect, impulsivity, and increases functioning
• Psychodynamic approaches:
> Transference-focused therapy:
> Uses the relationship between therapist and client to help them develop a stronger understanding of healthy relationships and themselves
> Reduce suicide, impulsivity, aggression, and anger > Mentalization-based treatment:
> Provides clients with validation and support
> Individuals with personality disorder have a fundamental challenge in terms of understanding the mental states of themselves and others due to early trauma and
attachment issues
> Appreciate alternatives to sense of self, focus on relationship between client snd therapist
> Make fewer suicide attempts and improve mood
• First-line treatment: > Psychotherapy
> Some medications may be useful though
> Mood stabilizers and A-typical antipyschotics
> SSRI’s not effective
> Medication only typically recommended for co-morbid disorders

HISTRONIC PERSONALITY DISORDER

• Individuals with histrionic personality disorder (HPD):
> Hav rapidly shifting emotions
> Have intense and unstable relationships
> Are often described as dramatic, excitable, erratic and volatile
> Are excessive in attention-seeking behavior
> BPD form HPD, BPD show self destruction and chronic feelings of emptiness whereas HPD behave in ways that draw attention to themselves > Use emoitla displays,
inappropriate sexual conduct, emotionality, provacative
> BPD hang onto others because of self doubt and negative self image, HPD want flattery, nurturing and attention
• Prevalence:
> HPD affects 1-3% of the general population
• Sex difference:
> Women are 2x as likely to be diagnosed
• They have an increased risk for:
> Depression and substance use disorders
• More likely to be separated or divorced
• Tend to exaggerate medical problems, more medical visits
> Higher risk for somatic disorder, panic attacks, and conversion disorders
• Attention seeking behaviour associated with suicidal threats and acts
• Not enough information, debates about validity of HPD, proposed to be eliminated in DSM because of proposed support against it

TREATMENT OF HISTRIONIC PERSONALITY DISORDER

• Psychodynamic psychotherapy:
> Helps clients to uncover repressed emotions and needs
> Helps clients to express themselves in a more socially appropriate manner
• Cognitive therapy:
> Focuses on helping clients to reduce dramatic evaluations of situations and adopt more adaptive ones
> Helps clients to formulate goals and plans that don’t depend on the approval of others
• Group and family are not recommend, they want attention so this approach distracts them
NARCISSITIC PERSONALITY DISORDER
• Individuals with Narcissistic Personality Disorder (NPD):
> Believe they are better than everyone else and walk over others to achieve their goals
> They act in a dramatic manner, tend to be shallow in emotional expressions, and seek admiration from others
• Grandiosity, preoccupied with own self importance, lack empathy, strong belief that others should admire them
• In relationships, make entitled demands of others to support their own wishes and ignore the needs of others, also exploring them
• Individuals with NPD can be very successful in societies that value assertiveness and self confidence (e.g. United States, Canada)
> High functioning NPD display their traits of self-confidence as workaholics, express as perfection but failure to reach can become overbearing and controlling
> Alienate others in their lives
• They tend to seek treatment for:
> Depression
> Challenges adjusting to life stressors
• Prevalence: 6.2% (in the US)
• Males: 7.7%, Females: 4.8%
• NPD tends to be more prevalent among younger adults, suggests that NPD on the rise due to social and economic environments that support extreme self-foucs
• High rates of mood and anxiety, as well as substance abuse
• Higher rates pf physical and violent aggression, suicidal thoughts, and suicidal behaviours

PERSONONALITY DISORDER
THEORIES OF NARCISSISTIC PERSONALITY DISORDER
• Psychodynamic oriented theorists argue that individuals with NPD rely on dominating others for their self-esteem since they didn’t develop adaptive strategies
for managing distress as children
• Two main subtypes
> GRANDIOSE: cope with challenges by thinking of themselves as superior and unique, exploitative, manipulative, particularly when they feel distressed,
sometimes engage in violent action
> VULNERABLE: cope by ending in grandiose fantasies to reduce their own feelings of shame, hypersensitive to criticism, tend to avoid others
> Interpersonal antagonism: common in both types
• Associated with childhood adversity (abuse and neglect)
• Overly permissive or overly controlling could cause grandiose or vulnerable NPD, respectably

TREATMENT OF NARCISSISTIC PERSONALITY DISORDER

• Individuals with NPD typically don’t seek treatment except when they experience:
> Depression
> Significant interpersonal challenges > Therapists using cognitive techniques:
> Help clients to develop more realistic expectations concerning abilities and more sensitivity to the needs of others
> They teach clients to challenge their self-aggrandizing methods of interpreting situations
• Individuals with NPD tend to view their issues as being weaknesses within others
> Make it hard for therapists to form a working alliance
• Don’t have an easy time challenging their self-serving biases, usually don’t stay in therapy once their acute symptoms are reduced

CLUSTER C: ANXIOUS-FEARFUL PERSONALITY DISORDERS

AVOIDANT PERSONALITY DISORDER (AVPD)
• Individuals with avoidant personality disorder tend to:
> Excessively avoid interpersonal interactions
> Have low self-esteem, are very anxious about being criticized by others and tend to experience a lot of shame > Symptoms overlap with social anxiety
disorder
> Choose occupations that are socially isolated or have less interactions with others
> When they do have to interact with others, they feel nervous, inhibited, and hypersensitive to being criticized > View themselves as being inferior, socially
inept, isolated and lonely
> The 2 pathological personality traits that highlight this disorder are:
> Negative affectivity
> Detachment
> *They crave relationships with others, but feel unworthy of these relationships and end up isolating themselves
> 2.4%, more common in females
> Co-morbid with depression, substance abuse, and anxiety
> Co-morbid with cluster C disorders
> So much overlap between social anxiety and AVPD, if individuals have both they are highly self-critical of themselves
> AVPD more chronically impaired than social anxiety, and tend to have fantasies about having these types of relationships
THEORIES OF AVOIDANT PERSONALITY DISORDER
• Biological theories:
> Twin studies suggest that genes play a role in AVPD (the same genes are likely implicated in both AVPD and SAD)
• Cognitive theories:
> Individuals with AVPD adopt dysfunctional beliefs about being worthless because of rejection by caregivers early in life
• AVPD does not have a relation to sexual or physical abuse, but do report more emotional neglect
• Describe parents as less affectionate, more rejecting, less encouraging, and guilt in gendering
> Could be recall bias due to hypersensitivity
• “If my own parents don’t like me, how could anyone” nervous when talking to others, believe criticism is inevitable
TREATMENT OF AVOIDANT PERSONALITY DISORDER • This disorder is chronic and begins early in life
• Cognitive and behavioral therapies are useful
> Increases in social contacts, reduction in avoidance behaviours, and more comfort engaging in social situations
> SSRI’s sometimes used to reduce social anxiety
• Gradual expose to social settings along with social skills training and challenging negative thoughts about self and situations
DEPENDENT PERSONALITY DISORDER
• Individuals with dependent personality disorder (DPD):
> Have a pathological and excessive need to be taken care of by others > They tend to be clingy, and they strongly fear separation
> Lead to issues in social interactions and cause psychological distress
> Worry about displeasing others and losing the approval from others
> Submit to unreasonable demands in an attempt to avoid seperation
> Difficulty making decisions and rely on others for advice and reassurance
> Tend to crave continual reassurance and emotional support
> They tend to have pathological attachments to particular individuals. They often display significant insecurity and separation anxiety
• Prevalence: 0.78%
> Higher rates are found in self-report methods rather than interviews, suggests that people have these disorders but clinicians don’t diagnose
• More women are diagnosed than men
• Common comorbidities:
> Depressive and anxiety disorders, often triggered by interpersonal conflict or disruption in relationships
• Increased risk for physical illness, child abuse, partner abuse, suicidal behaviour, and functional impairment

THEORIES OF DEPENDENT PERSONALITY DISORDER

• Biological theories:
> DPD tends to run in families, .81
> Adolescent with separation anxiety or chronic illness are more likely to develop
• Cognitive and behavioural theories:
> Behavioral:
> Pathological dependence may be learned behaviours that are used to elicit care > Learned behaviours generalized into adult relationships
> Cognitive:
> Individuals with DPD have inflexible beliefs concerning their dependence, which drive their dependent behaviours > Believe they are needy and week, can drive their
behaviours to reflect these beliefs
• Early attachment theories:
> Anxious-insecure attachment style in infancy can lead to anxious attachment in adulthood
> Dependency characterized with high levels of anxiety and insecurity and low levels of risk taking and perceived competence

TREATMENT OF DEPENDENT PERSONALITY DISORDER

• Individuals with DPD often seek treatment and show a significant degree of insight and self-awareness in comparison to other PDs • Goal in psychotherapy:
> Increase client self-confidence
> Teach appropriate independence skills
> How early experiences with caregivers impacted their dependent behaviours
> Assessing relationship style that exists between patient and therapist
> CBT: assert supportive behaviours and reduce anxiety, challenge client assumptions
> Making decisions, hierarchy, move up this hierarchy from easiest to hardest decisions
• Marital and family therapy can sometimes be useful to see how nuture patterns plays a role in anxiety
• Useful: short term dynamic psychotherapy, psychodynamic therapy, cognitive therapy, CBT, and logo therapy: not one is the best approach

OBSESSIVE-COMPULSIVE PERSONALITY DISORDER (OCPD)

• Individuals with OCPD tend to display:
> Rigidity
> Perfectionism
> Dogmatism
> Rumination
> Emotional and interpersonal difficulties
> They also tend to be compulsive and preoccupied with rules > Inflexibility, cause impairment and interpersonal difficulties
• Not related to high occurrences of disabilities
• Individuals are productive and base their feelings of self-esteem on productivity
• Have issues interpersonally in terms of appreciating others and tolerating the quirks of other people
• This disorder shares some features with OCD but only has a small to moderate comorbidity with OCD
> OCPD, more general manner, prone to rigidity, not as much one specific thought
> Individuals with OCD view thoughts as intrusive, whereas OCPD view as facets of thier personalites > OCPD come across as grim, strict, and tightly in control of thier
emotions
> rarely spontaneous and workaholic, don’t appreciate friendships or leisure time
• Some researchers have argued that OCPD may be a subtype of OCD
• OCPD is the most prevalent PD: 2-8%
• Some studies show that men are twice as likely as women to be affected, other show no sex differences
• More likely in individuals over the age of 30, but traits often begin in childhood
• High risk for depression, anxiety, and eating disorders
• Majority of OCD do not have OCPD, but when they do occur OCD and OCPD with depression symptoms tend to be more severe
THEORIES OF OBSESSIVE COMPULSIVE PERSONALITY DISORDER
• OCPD is related to genetic factors which are similar to those in OCD
> OCPD is more common among relatives of individuals with OCD > Reduced grey matter in the prefrontal cortex, singulet, and insula
> Abnormalities in the prefrontal cortex among individuals with OCD and OCPD suggest there is a shared mechanism that relates to decision making in both
of these disorders
• Individuals with OCPD have a stronger history of neglect
TREATMENT OF OBSESSIVE-COMPULSIVE PERSONALITY DISORDER
• Individuals with OCPD often seek treatment. (feel psychological distress and impairment) Treatments that seem effective include:
> Behavioral therapies:
> can reduce their compulsive behaviors
> client given assignment of altering rigid schedule, taught to use relaxation techniques
> Cognitive therapies:
> can help to evaluate and challenge negative automatic thoughts
> provide evidence for and against negative automatic thoughts, eventually the hope is that rigid expectations will be replaced with more flexible > *Sometimes SSRIs are use
to reduce obsessionally
The big 5 personality factors
• within each factor there are facets that are under factors
• Description of individuals who are high and low on the facte
• Ex. Extroversion vs introversion one facet here is gregariousness
• individuals who are highly gregarious are outgoing and sociable and
individuals who are low gregarious are withdrawn and isolated

In the DSM-5 there are two different models of personality disorders, the first is
categorical and defines 10 personality disorders in terms of really specific criteria
The dimensional model is in DSM-5 for further study and uses the continuum model
of personality disorders which is similar in the big 5 model
• this approach makes the fundamental assumption that the normal and
abnormal personality falls along a continuum within personality disorders
representing extreme and maladaptive personality trait variants

Personality Disorder Clusters:

• The DSM-5 groups 10 PDs into 3 clusters based upon their similarities.
• The DSM-5 recognizes the limitations to the cluster system, not validated,
doesn’t account the fact that people display co-occurring personality
disorders from diff clusters
Cluster A: display odd eccentric behaviours and thinking, paranoid personality
disorder, schizo personality disorder, schizotypal personality disorders
• All have some features of schizophrenia but not out of touch with reality,
instead, suspicious of others
Cluster B: dramatic, erratic and emotional behaviour and erratic interpersonal
relationships, includes anti-social personality disorder, histrionic, boarder line and
narcissistic personality disorder
Cluster C: anxious, fearful and chronic self doubt
• dependent personality disorder, avoidant personality disorder, and obsessive
compulsive
• Tend to have little self confidence and difficulty in relationships

Cluster A: Odd eccentric personality disorders

 Felix

Therapist and ann

• Therapist doesn’t directly challenge ann’s beliefs about her co workers
intentions but instead tries to reduce the sense of danger ann was feeling by
defining the situation as aggravating instead of threatening
• IN order to gain the trust of a person with paranoid personality disorder, the
therapist has to remain calm, respectful and straight forward, indirectly raise
questions about how the client may be interpreting situations

Roy case study

• schizoid personality disorder

41 year old case study

• schizotypal personality disorder
•

Schizotypal personality disorder:

• men are slightly more effected rate 4.2%
• Women 3.7%
• Likelihood tends to be higher in separated, divorced or widowed individuals and
those with low income
• Some have episodes of brief psychotic disorder and some go on to develop
schizophrenia
• Common differentials diagnoses: ADHD, social anxiety, and autism spectrum
• comorbidities: complicate the understandings of the course and treatment
 Cluster B personality disorders: dramatic-emotional:
• borderline and antisocial have been focus of research

Cindy case study:

• cindy symptoms highlight intense out of control emotions that cannot
be managed
• Hyper sensitivity to abandonment
• The tendency to cling to others, and strong history of self harm
• Individuals who have borderline personality disorder will often engage
in para-suicidal gestures (non-lethal but intentional self-harm, lethal
suicide attempts)
• 70-75% of people with borderline personality disorder have
engaged at least once with self harm
• Greatest risk for suicide is within the first 2 years of diagnosis
• suicide rates among individuals with borderline personality disorder
tend to be 8-10%, around 50% higher than general pop
• most common personality disorder and uses intensive use of mental
health services

Borderline Personality Disorder:

• more likely to experience long-term negative outcomes including severe and
persistent functional disability, physical illness and reduced life expectancy
(due to suicide and natural causes)
• Diagnosed with other mental disorders like depression, generalized anxiety
disorder, specific phobia, PTSD, agoraphobia and psychotic disorders
• Studies show the symptoms will usually decrease with age and spontaneous
remission will happen in about 25-41% of people with borderline,
schizotypal, avoidant, and obsessive-compulsive personality disorders
• Stabilization will often occur with age but some features persist in older
patients including emotional disregulation and challenges in interpersonal
relationships
• In over 85% of diagnosed will end up show remission within 10-15 years and
only a minority in remission will relapse
Amygdala and
the prefrontal
cortex have
been implicated
in borderline
personality
disorder

Debbie case study on histrionic personality disorder

 Cluster C: Anxious-fearful personality disorders:
• all of these are characterized by a strong sense of anxiety or fearfulness as
well as behaviours that are meant to reduce the fear
• all three are characterized by diff fears but all result in personal distress and
dysfunction

Avoidant Personality Disorder:

• comorbid with depression, anxiety and substance abuse
• Elevates risk of suicide aviation and suicide attempts
• Comborbid with cluster C
• Overlap between avoidant and social anxiety that they might be alternate
forms of the same disorder, both highly self-critical of social interactions
• have more generalized anxiety and more severe anxiety about social
situations in comparison to those with social anxiety
• More chronically impaired by anxiety
• Desire affection and fantasize about ideal relationships

Ruthann case study on avoidant personality

Francesco case study on dependent personality

Ronald case study on obsessive-compulsive personality disorder (OCPD)

Biological and environmental factors collectively work together to either

increase or decrease the likelihood of an individual developing a personality
disorder
 ▫
• human brain changes dramatically cross life
• Infancy/childhood: significant growth in size and
complexity
• Early adulthood: further changes and maturation
• Changes are strongly impacted by health, life style
and experiences
• Older: gradual decline in structural and functional
integrity of the brain but the brain still adapts (allows
people to function well in older age)
• Lots of variability in development of the brain and
related cognitive, emotional and behavioural functioning
• Some kids, significant challenges in academic skills
(reading, writing, math) and others have more global
cognitive deficits that make it hard to function
• Some have deficits in regulating emotion and
behaviours
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER: • Many differences and are strongly impacted by
• There are 3 subtypes of ADHD in the DSM-5: environmental experiences and biological factors
Combined presentation:
> requires that an individual experiences 6 of more symptoms of inattention and 6 or more symptoms of hyperactivity impulsivity
Predominantly inattentive presentation
> requires experiences 6 or more symptoms of inattention but less than 6 symptoms in hyperactivity impulsivity
Predominantly hyperactive/impulsive presentation
> requires experiences 6 or more symptoms of hyperactivity impulsivity but less than 6 symptoms of inattention
• Prevalence: 3.4-6% of school-aged children (increasing)
> ADHD starts in childhood and the symptoms must be present before the age of 12 in a variety of settings
> challenges can continue into adulthood
• Males are more than 2x as likely to be diagnosed with ADHD in childhood and adolescence (the sex difference narrow with age as individuals move into adulthood)
Females tend to present with inattentive features and have less disruptive behavior than boys
> females might be under-diagnosed because they primarily have inattentive features
> parents underrate impulsive and hyperactive symptoms in girls and overrate in boys, bias may have a strong impact on sex ratio and diagnostic rate of AHDH
• ADHD is found globally
• Most kids with ADHD are diagnosed in elementary school
• Symptoms of ADHD are strongly correlated with:
Challenges in school performance
> ex. Children with ADHD tend to have lower scores on achievement tests, lower GPA and more likely to repeat grades
Difficulties in peer relationships
> tend to be disrupted and kids with ADHD are more likely to experience rejection and teasing because of impulsivity and hyperactivity
> when engaging with other kids, kids with ADHD tend to be irritable, intrusive and demanding
• Learning disorders are commonly comorbid with ADHD
> particularly reading disorder, disorder of written expression and developmental coordination disorder
> around 20-25% of kids with ADHD have a specific learning disorder that makes in hard to focus and learn in school
• Behavioral challenges can become worse over development
> sometimes, the increasing behavioural issues are eventually diagnosed as conduct disorder (most likely among children diagnose with combined ADHD presentation)
> between 45-65% of children with ADHD develop a conduct disorder, abused drugs or alcohol or break the law
• Challenging symptoms which interfere with everyday functioning tend to persist into adulthood in 50-78% of individuals
> adults who were diagnosed with ADHD as children, are at a high risk for antisocial personality disorder, substance abuse, mood and anxiety disorder, marital issues,
traffic accidents and frequent job changes
>ADHD has a significant impact on the quality of life of the child, parents and siblings and can double the change of premature death from unnatural causes like accidents

BIOLOGICAL FACTORS:
• Abnormal activity has been documented in a variety of neural regions:
Prefrontal cortex
> cognitive, motivation and behaviour
Striatum
> working memory and planning
Cerebellum
> motor behaviours
Cerebral cortex
> smaller in volume in comparison to kids vs adults and there is less conductivity between the frontal region of the cortex and regions of the brain that impact motor
behaviour, emotional reactions and attention
> continues to develop into adolescence
> kids with ADHD have brains that are slower to develop, which may lead to them unable to control their behaviour and maintain attention at an age appropriate level
> this helps to explain why some kids with ADHD show a reduction in symptoms, particularly hyperactivity, with age
• challenges such as impulse control, attention among those with ADHD tend to related to fundamental abnormalities in the prefrontal cortex, striatum, cerebellum and the
cerebral cortex
 ▫
BIOLOGICAL FACTORS CONT’D
• Catecholamine neurotransmitters (particularly dopamine and norepinephrine) function abnormally among individuals with ADHD
These neurotransmitters play an important role in:
• Sustained attention
• Inhibiting impulses
• Processing errors
> drugs that target levels of dopamine and norepinephrine seem to be useful in terms of treating ADHD)
• ADHD is highly heritable:
Genes that impact dopamine, noradrenaline, and serotonin may have abnormalities among individuals with ADHD
>siblings of children with ADHD are 3-4x more likely to develop ADHD in comparison to children without siblings with ADHD
> autism spectrum disorder and ADHD often co-occur and research has suggested a genetic linkage
• Prenatal and birth complications are associated with ADHD
> ADHD tends to be associated with low birth weight, difficult delivery leading to oxygen deprivation and premature delivery

PSYCHOLOGICAL AND SOCIAL FACTORS:

• Children with ADHD are more likely to belong to families in which:
Parents engage in hostile and sometimes aggressive behavior
Parents engage in substance abuse
• thought that the genetic factors associated with ADHD may catalyze disruptive behaviour in kids and this may lead to hostile parenting, even in adoptive parents

TREATMENTS FOR ADHD:

• Most children diagnosed with ADHD are treated with stimulant drugs (e.g. Ritalin, Dexedrine, Adderall)
> around 70-80% of kids with ADHD respond well the drugs and show decreasing results of demanding, non-compliant, and disruptive behaviour and increases in positive
mood, gaol-directed behaviour, and quality of social interactions
> it is thought that these work to increase dopamine in the synapses in the brain, but they also come along with side effects
• Side effects of stimulants:
Reduced appetite
Insomnia
Edginess
Gastrointestinal upset
Increased frequency of tics
> concern that stimulates might stunt growth, kids with ADHD who take stimulants sometimes have a decreased growth rate
> risk of abuse from individuals who want the high, money on resale or for individuals who want an edge for school or work
• Antidepressant medications:
Often prescribed to children and adolescents with ADHD since both anxiety and depressive disorders tend to be quite common among this population
> anti depressants help with cognitive performance but they are not as effective as stimulus
> bupropion is an antidepressant with strong impact on dopamine levels and seems to be more effective for ADHD in comparison to other anti depressants
> as soon as these medications are stopped, symptoms will almost always return
• Behavioral therapies can be effective
Parents and teachers will often work collaboratively to alter both rewards and punishments for a child
• strong focus on pro-social, goal-directed and attentive behaviour, and on extinguishing hyperactive and impulse behaviours.
• Ex. A child and parent may have an agreement that they will earn a chip every-time they obey a request to put away toys or clothes, and at end of week they can
exchange the chips for fun activities, if they refuse to comply with a request, they will lose a chip
• kids learn to anticipate the consequences of behaviours and tend to make less impulse behaviours, also taught appropriate social interaction skills (like listening to
others, waiting their turn, expressing frustration in non-aggressive ways)
• For adults with ADHD, cognitive behavioural therapies and treatments tend to focus on planning and time management skills and this is quite effective

AUTISM SPECTRUM DISORDER (ASD):

• ASD involves impairment in 2 behavioral domains:
Social interactions and communication
Restricted and repetitive patterns of behaviors, activities and interests
• Deficits in communication and social interaction sometimes first appear in infant and toddler interactions with their caregivers
> in comparison to typically developing kids, infants with ASD might not smile or coo when responding to caregivers
> they also might not cuddle even when scared, may rarely make eye contact and joined attention
> other early symptoms: delayed language development (when older, kids with ASD might prefer solitary play and don’t seem to react typically to other peoples
emotions
• Approximately 25-30% of people with ASD do not develop useful speech by school age
> those who do, often don’t use it as expected for age
> often use a small number of single words or fixed phrases
• Children with ASD tend to be preoccupied with one feature of a toy or an object
> might engage in repetitive or odd behaviours with their toys ex. Instead of playing regularly with a car, a child with ASD might take off a wheel and pass it in hands
• Routines and rituals tend to be very important to children with ASD
> when routine is changed, can become distressed and frightened ex. If a parent stops at grocery store from school it can cause distress if its not normal
• Stereotyped and repetitive behaviours are common (often use part of body, ex banging head on wall, flapping arms and hands (self-stimulatory behaviours)
>self-stimulatory behaviours: assumptions that kids engage in these behaviours for self stimulation, it really remains unclear what purpose is
 ▫
AUTISM SPECTRUM DISORDER (ASD) CONT’D:
• Children with ASD often have challenges on measures of intellectual ability
> ex. IQ tests - around 50% of children with ASD showing at least a moderate intellectual disability
> some children only show challenges with skills like require language and understanding of peoples perspectives
> language skills and the ability to engage socially significantly contribute to academic performance
• Verbal skills: tend to be a strong predictor of long-term outcomes for children with ASD
> particularly with psychosocial adjustment and overall well-being
> often, in popular media, children with special talents with ASD will be highlighted
>ex. The ability to draw extremely well or exceptional memory (these children are referred as savants) these are quite rare
• For an ASD diagnosis:
Symptoms must have onset in early childhood (typically seen by 2 years of age)
> variability in terms of severity and outcomes of ASD, best predictor of ASD outcomes is the IQ of the child and the language development of the child before 6 years
of age

CONTRIBUTORS TO AUTISM SPECTRUM DISORDER:

• Leo Kanner (1943): the psychiatrist who was the first to describe autism
> believed that autism was caused by poor parenting and biological factors
> many psychoanalytic theorists argue that parents with children with ASD were uncaring, distant and cold and children’s symptoms were viewed to as a retreat
inward bc of unavailable caregivers
> research has shown that unresponsive parenting plays little to no role of the development of ASD
• Biological factors:
Genes play a role in the development of ASD
> family and twin studies have strongly supported the role of genetics
> siblings of children with ASD are 50x more likely to have the disorder
> concordance rates for ASD are around 60% for monozygotic twins and 0-30% for dizygotic twins
> children with ASD have a higher rate of other genetic disorders that are associated with cognitive impairment like fragile X syndrome and PKU
> no single gene causes ASD but abnormalities in many genes have been found to be associated with ASD
> differences have been found in terms of the levels of neurotransmitters of serotonin and dopamine
• Neurological factors seem to play a role in ASD
> around 30% of kids with ASD develop seizure disorders by the time they reach adolescence and this suggests neurological dysfunction
> greater head and brain size is found in children with ASD compared to children without it
• Structural abnormalities have been documented in:
Cerebellum
Cerebrum
Amygdala
Hippocampus
• Studies have shown that children with ASD: have a higher rate of prenatal and birth complications
• Imbalance of maternal gut microbiome is associated with neural abnormalities in offspring (occurs in response to infection, changes in diet and stress in pregnancy)
• Maternal immune activation (activation of the immune system due to stress, inflammation, infection, asthma or allergies and thought to be a vulnerability factor for
ASD) and inflammation are associated with many neurodevelopmental disorders (ASD, schizophrenia, cerebral palsy, depression and epilepsy)
• Microbiota-gut-brain axis:
Children with ASD tend to have more gastrointestinal (GI) symptoms in comparison to children without ASD
> GI symptoms are strongly associated with ASD symptom severity

TREATMENTS FOR AUTISM SPECTRUM DISORDER:

• Drug treatments are often used to improve symptoms of ASD such as:
Overactivity
Stereotyped behaviors
Sleep disturbances
Tension
> SSRI’s tend to reduce repetitive behaviours and aggression and might improve social interactions in some
> Atypical antipsychotics are used to reduce repetitive and obsessive behaviours and can also improve self control
> Stimulants tend to be used to improve attention
> overall, these drugs can make it easier for individuals with ASD to participate in behavioural treatments and school
*Evidence for utility of the drugs is very mixed
• Psychosocial therapies:
Behavioral techniques and structured educational services are often used
> operant conditioning can reduce repetitive and ritualistic behaviours, aggression, and tantrums
> challenges that the child portrays will be targeted and materials that reduce distractions will be used
> parents are sometimes taught to implement these techniques at home, *importantly these techniques must be implementing consistently
> research has found improvements in cognitive skills and behavioural control among children who were treated with behavioural therapy applied both parents and
teacher *especially effected if applied at an early age
Behavioral treatment models are often based on applied behavior analysis
> using this, attempt to reinforce good behaviours and decrease undesirable
> early intensive behavioural interventions tend to be strongly recommended and they can dramatically improve developmental outcomes
>ex. Daily living skills, communication and social skills
> many options for treatment using this approach and no universal approach works since developmental levels and symptoms vary drastically among individuals with ASD
 ▫
INTELLECTUAL DEVELOPMENT DISORDER (INTELLECTUAL DISORDER)
• The DSM-5-TR classifies ID into 4 different levels based on severity:
Mild
> children and adults have limitations with academic or job-related skills, mature with social interactions, can care for themselves except for complex occasions like legal or
health decisions
> hold jobs that don’t require complex conceptual skills
Moderate
> children have language delays like using 4-10 words by the age of 3, physically clumsy, challenges dressing and feeding themselves, usually don’t achieve past 2nd grade
level in terms of academic levels
> adults can hold jobs that require elementary level of skills but might require lots of assistance, with significant training they are able to care for themselves like hygiene,
eating *social interactions ate often impaired due to communication issues
Severe
> Limited vocabulary and speak 2-3 word sentences
> as children, tend to show significant deficits with motor development, adults can feed themselves with spoon, can dress themselves if clothing is straightforward (less
buttons), cannot shop or cook for themselves
> some may be able to learn unskilled manual behaviour, but many are unable
> socially they lack awareness of risk and require significant support for all elements of daily living
Profound
> sensory and motor impairments that can prevent the functional use of objects and tend to limit participation in activities to watching
> socially they can understand simple and concrete instructions and gestures, but strong degree of dependence that is characteristic of profound intellectual disorders
where even into adulthood they are fully dependent on others for their physical care and safety
• Intelligence tests measure: individually given in order to figure out the intellectual functioning of an individual who is suspected of having and intellectual disorder
Verbal comprehension
Working memory
Perceptual reasoning
Quantitative reasoning
Abstract thought
Processing speed
> individuals with intellectual disorder typically have scores that are 2 standard deviations below the average IQ for the general pop
> most IQ assessments have an IQ of 100 and standard deviation of 15 so the IQ score would be 70 or below
DSM-5-TR deemphasizes IQ scores in diagnostic criteria and instead puts them in focus of the individuals level of adaptive functioning across conceptual, practical, and social
domains - this is because IQ scores can be misleading and misused
Prevalence: 1-3% of the population has an intellectual development disorder

BIOLOGICAL CAUSES OF INTELLECTUAL DEVELOPMENT DISORDER:

• Numerous biological factors can cause ID:
Chromosomal disorders
Gestational disorders
Exposure to toxins prenatally
Exposure to toxins in early childhood
Infections
Brain injury
Brain malformations
Metabolism problems
Seizure disorders
• Genetic Factors:
Approximately 300 genes are implicated in the development of ID
> these genes tend to lead to one or more of the deficits seen within ID
> families of children with ID tend to have high rates of intellectual issues including intellectual disorder and autism
Genetically transmitted metabolic disorders can lead to ID
1. fenal ketonuria (PKU)
> individuals who are effected can not metabolize phenylalanine (amino acid) a build up of this amino acid in the body can lead to brain damage, but children that receive
a diet free of this can score average levels on intelligence tests
> if left untreated, children with PKU typically have IQ scores below 50 and severe or profound intellectual disorder
2. tay sachs disease
>primarily occurs in jewish populations
> when an infected child is 3-6 months old, a degeneration of the nervous system starts and lead to mental and physical deterioration, typically die before age of 6
and no known use of treatment
• Many types of chromosomal disorders result in ID:
Down syndrome
> born with 23 pairs, 22 are called autosomes and the 23rd pair contains the sex chromosomes
> down syndrome occurs when chromosomes 21 is a triplicate instead of duplicate (trisomy 21) occurs is 1 in every 800
> severity level of intellectual disorder varies from mild to profound, the ability to care for self and keep a job is contingent on the degree of intellectual deficits and
the support they receive
>. Almost all individuals with down syndrome live past 40 years develop thinking and memory issues that are characteristic of Alzheimer’s disease and they lose the
ability to care for themselves
• Many types of chromosomal disorders result in ID:
Fragile X syndrome: risk of chromosomal abnormalities increasing with age of parents, older the parent is the more likely degeneration of chromosomes have occured
and the more likely the chromosomes have been damaged by toxins
> occurs when a tip of the X chromosome breaks off and this tends to affect males more as they don’t have a second X chromosome to balance the mutation
> severe to profound intellectual disorder and severe deficits in terms of interpersonal connections
 ▫
BIOLOGICAL CAUSES OF INTELLECTUAL DEVELOPMENT DISORDER CONT’D:
• Brain Damage During Gestation and Early Life:
Diseases that the mother contracts during pregnancy can impact the risk of offspring developing ID
> ex. During pregnancy, if the mother contracts rubella, syphilis or herpes there is a chance that damage to the fetus can lead to ID
Chronic maternal disorders (diabetes and high blood pressure) are associated with ID
> can have a strong impact on fetal nutrition and development and if the disorder is treated throughout pregnancy, risk to the fetus is quite low
Exposure to alcohol can lead to fetal alcohol syndrome (FAS)
> alcohol can pass through the placenta barrier and can be associated with still birth, miscarriage, low birth weight and prematurity
> children with fetal alcohol syndrome have a below average IQ of around 68, easily distracted, poor judgement, challenges understanding social cues
> As adolescents, academic functioning is usually between 2nd and 4th grade levels - they will often experience academic failure, substance abuse, challenges with
independent living and difficulty holding down job
> 2-15 children per 10 thousand have fetal alcohol syndrome and 3x this are born with alcohol related neurological and birth defects
• Brain Damage During Gestation and Early Life:
Severe head traumas can lead to ID (e.g. shaken baby syndrome - results in inter-cranial injuries and retinol hemorrhaging)
> babies heads are large and heavy and neck muscles are weak and cannot control head with shaking, quick movement can lead brains to bang against inside of skull and
lead to bruising - bleeding inside and around brain and behind eyes can lead to seizures, blindness, paralyses, intellectual disorders and sometimes death
> can occur with 1 shake
Exposure to toxic substances
> toxic substances like lead, mercury, arsenic
Accidents
> motor vehicle

SOCIOCULTURAL FACTORS:
• Low socioeconomic backgrounds are a risk factor for ID
> parents have also had ID and haven’t been able to get employment
> social disadvantages of poverty can also lead
> poor mothers are less likely to receive optimal prenatal care and higher risk of premature births
> children in low SES areas are at higher risk for lead exposure (older buildings have lead paint and can chip off)
> poor children less likely to have caregivers read to them and more likely to have parents less involved in their schooling

TREATMENTS OF INTELLECTUAL DEVELOPMENTAL DISORDER:

*interventions have to be comprehensive, intensive and long-lasting in order to be effective
• Drug therapy:
Medications can be used in order to:
• Reduce seizures
• Control aggressive behavior
• Control self-injurious behavior
• Improve mood
* neuroleptic medications can reduce anti-social and aggressive behaviour but come with neurological side effects leading to controversy
> atypical antipsychotic can reduce self-injurious and aggressive behaviour in adults without having significant neurological defects
> anti-depressant can reduce self-injurious behaviour and minimize depressive symptoms and improve sleep
• Behavioral Strategies:
Behavioral strategies that increase positive behaviors and reduce negative behaviors can be implemented by caregivers and teachers
Communication and social skills can be taught
> ex. Individuals may be taught to initial conversations by asking questions and learn to communicate what they wnat to say more effectively
> rewards might be given as they get closer to mastering a skill
> most behavioural methods focus on a comprehensive program that is reared towards maximizing an individuals ability to function in community instead of only focusing
on isolating skills
• Social Programs: focus on integrating child into mainstream as much as possible, and sometimes placing individual into group home that can provide comprehensive care
> the earlier the intervention, the greater likelihood of positive outcomes
Early Intervention Programs
> intensive 1 on 1 interventions that nurture the development of basic skills and ensure proper medical care, nutrition, and reduction in any social conditions that may
negativity impact child development
Mainstreaming
> providing as many opportunities for inclusion as possible for students with ID and special education needs
> many kids spend time in special education and receive training to learn critical skills and spend time in reg. Classrooms as well
> research has shown the students who are placed in mainstream perform as well or better than students in self-contained special education classrooms
> possibly due to higher expectations on academic achievement
> social outcomes: research shown better relationships, others show more stigma (research has been mixed)
Group homes
> many adults with ID live in group home, in these contexts they receive assistance with daily tasks as well as training in social and vocational skills
> work in workshop performing unskilled or semiskilled labour, but more are being mainstreamed into general workforce, primarily in service related jobs (ex. Bagger in
grocery store or in fast food restaurants)
 ▫
LEARNING, COMMUNICATION AND MOTOR DISORDERS: instead of having deficits in larger ray of skills, kids with this disorder have challenges with specific skills or
behaviours and these disorders are not a result from intellectual disability, developmental delay, neurological disorders or environmental factors like economic disadvantage
• severity ranges from mild to severe
Specific Learning Disorder
• Individuals who have specific learning disorder have performance in one or more academic domain that is significantly lower than expected for their age, level of
intelligence, or schooling.
Academic domains that are commonly affected:
• Reading
• Written expression
• Mathematics
> have unexpected low performance on standardized tests and these tests have to be administered individually and must be culturally and linguistically appropriate and
usually used amongst school aged individuals
> threshold for diagnosis is to some degree arbitrary but often 1-1.5 standard deviation below age based population means is used as cut off
• Dyslexia:
Difficulties in reading
Typically apparent by 4th grade
The most common specific learning disorder
> challenges: poor reading accuracy, reading comprehension weakness, and slow reading rate
> prevalence: around 7% children, more common among male
• Challenges in math include issues of understanding math terms, recognizing numerical symbols, counting
> around 1% of kids are effected
• Challenges in written expression
> encompasses weakness in spelling, grammar and punctuation, creating sentences and paragraphs
• Children with learning disorders:
Tend to struggle with low academic performance
They often must put in extremely high levels of effort in order to achieve average grades
• Because of the challenges they sometimes become
demoralized
disruptive
• if untreated, at high risk for dropping out of school
• Around 40% of these individuals will never finish high school
• Adults might have challenges getting and keeping a job and often avoid major work activities that require reading, writing, or arithmetic
• Emotional side effects might impact social relationships

COMMUNICATION DISORDERS:
• Communication disorders are characterized by persistent challenges in acquiring and using language and other forms of communication
• Common communication disorders include:
Language disorder
> includes challenges with spoken, written and sign language
> symptoms/challenges with grammar, vocabulary, narrative (knowing how to put stories together) and other pragmatic language skills
Speech sound disorder
> challenges with producing speech
> might not use speech sound in an appropriate way for their age or dialect
> They will sometimes substitute one sound for another (ex. Might use a T for K sound, or omit sounds like the final consonant at the end of words)
> words come out sounding like baby talk (wabbit)
> most children with this disorder improve significantly with treatment and shortens duration of disorder
Childhood-onset fluency (stuttering)
> children who stutter have challenges speaking fluently and evenly
> often voice frequent repetition of sounds like (I..I. I see him) some repeat whole phrases (other children are mean because of because of because of…)
> severity is variable and contingent on situation but tends to be worse when pressure to speak well (providing oral report)
> start gradually and typically before the age of 10
> prevalence 0.3-5% with around 2x prevalence among males
> approx. 80% of children recover on their own by 16, but some continue into adulthood
> can have significant negative impact on self-esteem and limit person’s activities and goals
Social communication disorder
> children have challenges using verbal and non-verbal communications in social interactions (Ex. Sharing info in a way appropriate for context)
> challenges altering the communication in order to match need of listener or conversation rules
> as a result, their social relationships and participate tend to be neg. Impacted
> diagnosis only given if communication issues are not better explained by ASD and so kids cannot have restricted, repetitive patterns of behaviour, activities or interest
for this diagnosis
 ▫
CAUSES OF LEARNING AND COMMUNICATION DISORDERS:
• Genetic factors:
Associated with all learning and communication disorders but there isn;t specific change responsible for specific disorders
> genetic abnormalities may explain many different learning disorders
• Abnormalities in brain structure and functioning:
> ex. Individuals with reading difficulties seem to have difficulties functioning in 3 different regions of the brain
>1st is broca’s area: involved in ability to analyze and articulate words
>2nd: parietotemporal region: requires for mapping visual perception of printed words onto the structure of language
>3rd: occipitotemporal region: requires for quick, automatic, fluent identification of words
> dyslexia: neuro imaging revealed low activity in the parietotemporal and occipitotemporal regions
Implicated in learning disorders
• Many environmental factors have been implicated: ex. Lead poisoning, sensory deprivation, birth defects and low socioeconomic status(create risk for damage of critical
neural regions, when enviornmentals offer few enriching opportinutiies for langauage skill development, they are less likely to overcome biological contributors to these
challenges

TREATMENT OF LEARNING AND COMMUNICATION DISORDERS:

• Treatment involves therapies that focus on building on the relevant skills
• In Alberta, Individualized Program Plans (sometimes referred to as Individual Educational Plan) are mandatory for children with learning disabilities and special needs
> These will detail the specific learning challenges, appropriate teaching methods and goals for academic year
> these are revised, contingent upon child’s progress (ex. A child with dyslexia might receive systematic instruction for word recognition from school and at home they
might practice with caregivers and potentially given computerized exercises for further learning
> programs have a positive impact on skill development among kids with learning disorders
> can change neuro functioning - in one study, kdis with dyslexia who received individuals tutoring for 1 year showed more activation in parietotemporal region and
occipitotemporal regions of the brain

MOTOR DISORDERS:
• There are 4 neurodevelopmental motor disorders:
Tourette’s Disorder
Persistent Motor or Vocal Tic Disorder
Stereotypic Movement Disorder
Developmental Coordination Disorder
• Tourette’s Disorder and Persistent Motor or Vocal Tic Disorder: comorbid with other psychological disorders (especially OCD, ADHD, and ASD - all have similar biological and
genetic underpinnings) - tourettes: when complex vocal tics are present, tends to be more debilitating and more comorbid with other disorders in comparison to persistant
motor or vocal tic disorder
Are both tic disorders
Involve motor tics and/or vocal tics
Tics are present for at least 12 months
• Critical difference:
Individuals with Persistent Motor or Vocal Tic Disorder only have motor OR vocal tics, not both
> Prevalence: around 1% for tics and 3-4% for persistent motor or vocal tic
> tics: sudden, recurring, non-rhythmic, motor movements or vocalization
> common vocal tics: throat clearing, grunting and sniffing
> individuals with tics disorder have multiple motor tics and at least 1 vocal
> around 1% of individuals with tourettes have a complex form of vocal tic that involves shouting or uttering socially inappropriate words or phrases
> often feel a tic happening and experience urge to tic before the tic occurs and the urge to tic is temporarily weakened by the tic behaviour
> frequency of tics increases when individuals are in high degree of stress
• Individuals with stereotypic movement disorder often engage in repetitive and apparently purposeless motor behavior such as:
Head shaking
Hair twirling
Body rocking
Head banging
Self-biting
> these behaviours are different than tics since the individual can continue to engage in them for long period
> present among individuals with other disorder (Ex. ASD, intellectual developmental disorder and ADHD)
• Tourette’s Disorder, Persistent Motor or Vocal Tic Disorder and Stereotypic Movement Disorder:
Usually begin in childhood and increase in adolescence and then decline throughout the adulthood year
Highly comorbid with OCD and share underlying causes of OCD as well
> all three, including OCD, tend to co-occur in families and all associated with dysfunction in the dopamine systems in regions of the brain critical for control of motor
behaviour (ex. Basal ganglia, frontal cortex and cerebrum)
• Tourette’s and persistent motor or vocal tic disorder all respond well to drugs that act on dopamine systems (Ex. Atypical antipsychotics)
All can be treated with habit reversal therapy (a form of behavioral therapy)
> triggers for and signs of tics coming on are identified, after they are taught to use competing behaviours (ex. Taught to squeeze hand when vocal tic is coming on or
taught to cross arms if hand flapping is coming on)
>tic awareness training and relaxation training are also used in behavioural therapy
• Developmental coordination disorder:
Fundamental deficits or delays in developing basic motor skills (e.g. sitting, running, writing)
Prevalence: 5-6% of children
More likely to impact boys that girls
> these deficits can’t be explained better by medical condition like muscular dystrophy
> developmental coordination disorder tends to be comorbid with ADHD and causes are not known
> best treatment approach: physical or occupational therapy
 ▫
MAJOR AND MILD NEUROCOGNITIVE DISORDERS: arise later in life and result from medical conditions or substance, or medication use that lead to impairment in cognition
> cognitive issues include memory deficit, perceptual disturbances, language disturbances, etc
• Major neurocognitive disorder (Major NCD):
Commonly known as dementia
Associated with significant difficulties:
• Remembering fundamental life facts
• In expression via language
• In carrying out simple everyday tasks
• major NCD usually occurs late in life, most common type is due to Alzheimers disease with a prevalence of around 5-10% of individuals over the age of 65
• prevalence increases with age (around 30% of individuals 85 or older have a major NCD)
• Mild NCD:
Mild version of neurocognitive disorder
characterized by cognitive declined from previous levels
No significant impairments yet in functioning
SYMPTOMS OF MAJOR NEUROCOGNITIVE DISORDER:
• Symptoms: both cognitive and emotional
Significant cognitive decline:
• Memory lapses
> very common, in early stages it is similar to what we experience (ex. Forgetting name of someone, forgetting why we went to a room) but the difference is that for them,
the memory doesn’t return spontaneously and might not respond to reminders
> individuals with mild neurocognitive disorder tend to repeat questions because they don’t remember asking them or the answer, they also frequently misplace items like their
wallet or keys
> as memory gets worse, might get angry when questions are asked or fabricate answers to hide memory loss
> as memory loss increases, they might become lost in familiar places, and eventually long term memory becomes impaired
> individuals tend to forget the order of events of lives (birth of children, marriage) eventually they are unable to remember life events and may not remember their own
name
• Aphasia: common, deterioration of language
> lot of difficulty with coming up with names of things or people and often come up with vague terms like thing to refer to objects or people to hide their inability to member
terms
> in advance stages, individuals might repeat what they hear (echolalia) or repeat sounds over and over (palilalia
• Apraxia: common, impaired ability to engage in common actions (waving or putting on pants), these aren’t caused by issues in motor functioning, in sensory function or
understanding what action needs to be done, just simply unable to do the actions requested or want to complete
• Agnosia: common, challenges in recognizing people or objects
> not be able to identify common objects (table), at first issues with recognizing friends or family become prominent, but overtime issues recognizing spouse or kids or even
reflection become common
• Loss of executive functions, most individuals with MCD will lose neuro functioning required for planning and for initiating and stopping complex behaviours (ex. Cooking dinner
bc of issues with timing and preparation
> deficits are associated with challenges of abstract thinking that are required in evaluating and responding appropriately in novel situations
Changes in emotional functioning and personality
• Declines in judgement
• Difficulties controlling impulses
> both of these might lead to shop lifting or exhibitionism
> sometimes they don’t recognize or admit to the acts which can lead to dangerous actions like driving when too cognitively impaired, then they experience anger or paranoia
in response to friends and family who try to limit their activities like driving and they view them as trying to inhibit their freedom, and also accuse others of stealing when
they misplaced their own items
> silent outbursts may occur and more common in the moderate to severe stages of MCD
• Depression is common as individuals recognize their declines in cognitive processing

TYPES OF MAJOR AND MILD NEUROCOGNITIVE DISORDER:

• DSM: recommends that the type of NCD is specified based upon the specific cause (medical or substance/medication-induced)
• The most common NCD worldwide: Alzheimer’s Disease and this accounts for about 2/3 of all cases of neurocognitive disorders
> prevalence of alzheimers diseases is increasing because of higher life expectancy around the world
> NCD can be caused by vascular disease (ex. Stroke, traumatic brain injury, progressive diseases like Parkinson’s or HIV) and also from chronic substance abuse

NEUROCOGNITIVE DISORDER DUE TO ALZHEIMER’S DISEASE:

• Individuals with NCD due to AD:
Can meet the criteria for major or mild NCD
Show significant declines in memory and learning
> individuals with AD have cognitive declines that start with difficulty forming recent memories and eventually impacts all domains of intellectual functioning
> around 2/3 of AD patients show agitation, apathy, dysphoria and irritability (difficult for caregivers to contend with)
> as AD progresses, individuals will sometimes violent and experience delusions and hallucinations
> early on-set progresses faster than late on-set and overall
AD is chronic and incurable
Typically begins after the age of 65
Typically individuals with AD die within 8-10 years of diagnosis typically as a result of physical decline or other independent diseases popular in older age
 ▫
Neurocognitive disorder due to Alzheimer’s disease cont’d:
• Brain abnormalities in AD:
Neurofibrillary tangles
> common in brain of individuals with AD, but rare in normal brains
> made of a protein called tau (these tangles prevent nutrients and critical supplies from moving through cells to the point that cells die
Beta-amyloid plaques
> neuro toxic and accumulate in spaces between cells within neural areas that are required for memory and cognition (ex. Hippocampus and amygdala)
• Brain abnormalities in AD:
Shrinking cortex
Enlargement of ventricles
*among individuals with Alzheimers disease, significant degree of cell death in cortex, this results in the shrinking cortex and significant increase in size of the ventricles

CAUSES OF AD (Alzheimer’s disease):

• Genetic factors play a significant role:
AD is highly heritable
> family history studies suggest around 24-49% of first degree relatives of individuals with AD will eventually develop AD
> twin studies support the role of genetic factors in the development of neurocognitive disorders
> concordance rates for all neurocognitive disorders in monozygotic is around 44% for men and 58% for women
> concordance rates for dizygotic twins is 25% for men and 45% for women
e4 version of the ApoE gene
> on chromosome 19 and regulates ApoE protein which is important for passing cholesterol through the blood and binds to beta amyloid protein
> ApoE gene has three versions
1 E2
2.. E3
3. E4
> individuals with an E4 allele from 1 parent have a 2-4x greater risk in developing AD
> individuals with E4 alleles from both parents, have 8-12x greater risk
> individuals with the E4 version, have reduced cortex and hippocampus volume even as children, as adults they tend to show more significant deficts and earlier onset of AD
Gene on chromosome 21
> individuals with down syndrome tend to be more likely to develop AD later on in comparison to others
> close to gene responsible for making the precursor of the amyloid protein and deficits in this gene might lead to an abnormal production of amyloid protein
• Neurotransmitters are impacted:
Individuals with AD show deficits in:
• Acetylcholine
>places strong role in memory
>deficits are significantly associated with degree of cognitive decline
> drugs that enhance acetylcholine can slow down progression of AD among some individuals
• Norepinephrine
• Serotonin
• Somatostatin
• Peptide Y

VASCULAR NEUROCOGNITIVE DISORDER:

• Vascular Neurocognitive Disorder:
Common type of NCD
Most prominent symptoms include significant declines in:
• Processing speed
• Executive functioning
• Attention
* individuals with NCD can meet the criteria for major or mild neurocognitive disorder, contingent upon symptom severity
For diagnosis, there must be evidence of cerebrovascular disease or a recent vascular event
• individuals at high risk of NCD are those who are over age 80, less educated and have diabetes
> this disease happens when the blood supply to regions of the brain are locked, can lead to tissue damage within the brain
> PET Scan or MRI can confirm disease
• In terms of a stroke (sudden damage to a neural region because of blockage of blood or hemorrhaging, NCD can occur after just 1 stroke or after accumluation of many
small strokes
> causes of strokes: high blood pressure, accumulation of fatty deposits in arteries, complications of diseases which inflame the brain or traumatic brain injuries
> around 25% of people with strokes will develop cognitive deficits that will be severe enough to be classified as NCD

NEUROCOGNITIVE DISORDERS ASSOCIATED WITH OTHER MEDICAL CONDITION:

• minor and major NCD can be caused by cruz felt jakob disease, brain tumours, endocrine conditions (like hypothyroidism), nutritional conditions (like vitamin b12 defiency),
infections like syphilis), and other neurological diseases like MS, also chronic and heavy use of alcohol, inhalants and sedatives can also cause brain damage which lead to
NCD
• Many medical conditions can lead to NCDs:
Lewy body disease
> progressive cognitive impairments, motor dysfunction, sleep dysfunction and suppressive symptoms, vision hallucinations and delusions
> overlap with cognitive symptoms with lewy body dementia and parkinsons , this includes progressive issues in terms of executive functioning, visual spacial abnormalities and
memory deficits

CONTINUE TO NEXT PAGE

 ▫
Parkinson’s disease
> degenerative brain disorder
> prevalence around 0.3% of individuals in the general population , and 2% individuals over 65
> mohammad ali and michael j fox well-known examples
> primary symptoms: tremors, muscle rigidity, inability to initiate movements (symptoms are caused by death of brain cells responsible for producing dopamine)
> around 75% of individuals with Parkinson’s disease will go on to develop NCD
Human Immunodeficiency Virus (HIV)
> causes AIDS, can cause mild or major NC
> around 50% of HIV patients show neurocognitive dysfunction (recent of chronic low level inflammation due to HIV)
> symptoms: impairment in terms of memory and concentration, lowing of processing speed, difficulty with emotion (manifests as depression and apathy), motor deficits
(include weakness in hands and legs, lose of balance and lack of coordination)
> as mental processing slows down, hard time following convos and take long time completing simple tasks, as a result, often withdrawal socially
> As NCD progresses, speech becomes significantly impaired, individuals are eventually confined to bed and indifferent in environment
> as antiretroviral therapy becomes widely used, new onset of HIV related NCD have declined
Huntington’s disease
> rare genetic disorder, effects individuals around the ages of 25 and 55
> will eventually develop major NCD and chorea (consists of irregular jerks, twitches, and grimaces)
> transmitted by 1 single dominant gene on chromosome 4 (if a parent has the gene, children have a 50% chance of inheriting this disorder)
> impacts numerous nerotransmitters
> the specific changes associated with NCD and chorea remain unclear
Traumatic Brain Injury
> associated with development of NCD, the TBI that lead to NCDare falls, motor vehicle accidents, being struck with an object, violence and bike accidents
> individuals with NCD resulting from TBI often experience cognitive declines and impairments in social cognition, moral judgement and memory
> disruption in emotional function is common: personality changes and irritability
> sometimes experience neurological symptoms like gate and speech abnormalities (depression is also very commonly comorbid)

THE IMPACT OF GENDER, CULTURE, AND EDUCATION ON NEUROCOGNITIVE DISORDER:

Women tend to be more likely to develop AD and experience more cognitive impairment in comparison to men (reason is unclear
> these sex differences tend to increase as individuals age,might be due to the fact that women tend to live longer than men and live long enough to develop age-related
neurocognitive disorders
• Individuals with NCD who have less education show more neural deterioration
> may be that because of lower education they have lower SES which might impact nutrition and overall health
>might be that education and cognitive activity throughout life span seem to increase neuralresources that can delay the development of neurocognitive disorders
>cultural differences : probability a person will be institutionalized instead of being cared for at home is different across cultures (tends to be higher across white north
americans in comparison to native or latin X groups
> European Americans might have more financial resources for the prevision of care and asian and latin X cultures tend to put on high premium among caring for family
members

TREATMENT FOR AND PREVENTION OF NEUROCOGNITIVE DISORDER:

• Drugs that are used to treat the cognitive symptoms of NCD:
Drugs that prevent the breakdown of acetylcholine
Drugs that regulate the activity of glutamate
> in addition, anti-depressants and anti-anxiety drugs can help treat emotional symptoms of NCD and anti-psychotic drugs can help treat agitation, hallucinations and delusions
• Behavioral therapies are useful
> can help control angry outbursts and emotional instability
> family members who are given training in these techniques can help them in terms of taking care of patients at home
> can also reduce stress and emotional distress among family caregivers and tend to be associated with fewer behavioural issues among the family member affected
>Aerobic exercises and physical activity tends to be protective against declines in terms of cognition
> study was done of many hundred elderly nuns at schools sisters, found that nuns who enter old age with more intellectual strengths were less likely to have severe NCD
even when their brains had many neurofibrillary tangles and plaques
> linguistic skills revealed journal writings in their 20s tended to be a significant predictor of the risk of developing NCD later in life
DELIRIUM:
• Delirium is associated with:
Disorientation
Recent memory loss
Difficulty with attention
Disrupted sleep-wake cycles
Incoherent speech
Delusions
Hallucinations
> a person with delirium has a hard time focusing, sustaining or shifting attention
> signs usually happen within a few hours or days
> Sundowning: individuals tend to fluctuate their symptoms within the course of the day and often become worse at night
> duration: rarely longer than a month
> individuals who are in a state of delirium tend to be agitated and frightened
> likelihood increases with age around 11-42% of patients who are 65 or older in hospitals have delirium
CAUSES OF DELIRIUM:
• Neurocognitive disorder is a strong predictor of delirium
> individuals with a NCD are 5x more likely to develop delirium
• Many medical disorders are associated with a high risk of delirium
> stroke, congestive heart failure, infectious diseases, HIV, high fever
• Delirium can be caused when the level of acetylcholine in the brain is disrupted by a medical condition, toxic substance, or drug

TREATMENT FOR DELIRIUM:

• If a medical condition is the cause for the delirium, the medical condition must be treated
• Antipsychotic medications:
can be used to treat confusion and agitation
•Nursing Care:
can be necessary to monitor an individual’s state (helpful to prevent patients from ripping out IV tubes, tripping, or wandering off
> restraints for these patients are sometimes necessary
> providing a reinsuring atmosphere with providing personal belongings (pictures) can help patients feel more in control
>psychosocial treatments that improve sleep and encourage mobility can also be useful
> delirium is a common problem in older adult hospital patients

How biological, environmental and psychosocial factors impact

neurodevelopmental and neurocognitive disorders
 changes in cognitive processes with age:
• Some cognitive processes show decline with age, while word knowledge
increases with age
• as brains age into middle and older adult, tend to show decreases in size
and eficiency
• most people show reductions in terms of speed of processing
information and in working memory
• most people can use accumulated expertise in order to compensate
for the declines
• for some people, deterioration in the brain is more severe which can lead
to sigificant challenges in processing information and functioning in daily
lives
• Brain dysfunction has to be understood in the context of what is
functional for the people in those stages of life?
• Developmental psychopathologists focus on functional and dysfunctional
development in children
• geroplychologists focus on functional and dysfunctional changes in older age
• All future disorders and associated with dysfunction in the brain and are
classified in the DSM and neurodevelopment disorders (arise in childhood,
ex. ADHD, Austism, intellectual disabilities and learning communication and
motor disorders) and neurocognitive disorder(arise in older age, ex. Major
and minor neurocogntive disorders and delirium_

Wrote book of her life with autism and how she thinks

Sean case study:

• most elementary school kids his age can sit for a logn duration of
time and play games that take patience and time that can help inhibit
their impulses

DSM-5 Criteria for Attention-deficit/hyperactivity disorder

DSM-5-TR criteria for delirium
• delirium is often a sign of a very serious medical condition
• When the underlying medical condition is treated, delirium is
reversible and temporary
• The longer the delirium continues, the more likely it is that the
individual will suffer permanent brain damage
Case study Robyn
• robyn shows communication difficulties which is common among kids with
ASD
• Instead of generating her own words, she echoes what she already heard
which is called echolalia

DSM-5 for diagnostic criteria for autism spectrum disorder

Scans such as these help researchers to understand the brain activity of

autism spectrum disorder
• when children with ASD perform tasks that require perception, facial
expressions, empathy or joined attention, it is found that they show
abnormal functioning in the neural areas that are usually recruited for
these taks
> ex. When they are shown pictures of faces, show less activation of
the brain that is typically recruited for facial perception known as the
fusiform gyrus
• adults with ASD tend to show atypical patterns of neural activation when
they hear their own name
• Challenges in terms of understanding and perceiving facial expressions
and verbal communciation seems to signifcantly contribute to the deficits
in social interactions

DSM-5-TR. criteria for intellectual developmental disorder (intellectual disorder)

• significant deficits are present in a persons life functioning and intellectual
abilities
• DSM requires that the deficits are confirmed using formal and clinical
assessments like IQ tests
• The deficits and functioning of daily living make it so the personal cannot
live alone without support
• Overall, this disorder, 3 main domains are impacted
• 1. Conceptual domain: deficits in language, reasoning, memory,
problem-solving
• 2. Social domain: difficulty with interpersonal communication, the
ability to make and keep friends, and challenges regulating reactions
• 3. Practical domain: deficits in terms of managing personal care like
hygiene, cooking, cleaning, issues with transportation and holding jobs
 Abel doris case study

DSM-5-TR criteria for specific learning disorder

Diagnostic features of communication disorders

Criteria for motor disorders

DSM-5-TR criteria for major neurocognitive disorder

Neurofibrillary tangles and beta-amyloid plaques in Alzheimer’s disease
• protein deposits up and cause neurofibrillary tangles and beta-amyloid
plaques in neurons in the brain of people with Alzheimer’s disease

First discovered by alois alzheimer in 1906 in a 51 year old patient

• noticed she had severe memory loss and disorientation and after her death
at 55, the autopsy revealed that the filaments of nerve cells within her
brain were tangled and twisted

Cortical regions in Alzheimers disease, Cell death causes shrinkage of cortical

regions in the brains of people with advanced disease (left; compare to
healthy brain on right)

Among individuals with alzheimers disease, the cells start loosing dendrites
(branches that connect 1 cell to others)
• all the brain abnormalities including neurofibrillary tangles, beta amyloid
plaques, shrinking of the cortex, enlargement of the ventricles and the loss
of dendrites are associated with traumatic memory loss and inability in
engaging in daily activities and inability to care for self

Case study 41 year old factory worker LeLand

• showed changes in both cognitive and emotional function
• Although his symptoms seems to subside after numerous
months, many individuals with moderate to severe brain
injuries will never fully recover