PSYB32-Final-Exam-Review.docx

Chapter 11: Schizophrenia 

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Schizophrenia: a psychotic disorder characterized by major disturbances in thought, emotion, and behaviour: disorder thinking in which ideas are not logically related, faulty perception and attention, flat or inappropriate affects, and bizarre disturbances in motor activity Withdrawn from other people and reality, and fall into a fantasy life of delusions and hallucinations Significantly higher in males than females Prevalence rates of symptoms such as auditory and visual hallucinations are comparatively higher among people from African nations Key factors that may vary across cultures include the likelihood of experiencing adverse life events, degree of social disadvantage, and family differences across cultures in terms of reactions and interpretations of symptoms of schizophrenia High in Canada due to: immigration rates and high latitude Can begin in childhood, but doesn’t appear until late adolescence or early adulthood (earlier for men than women) Co-morbid substance abuse is a major problem for people who have schizophrenia

Clinical Symptoms of Schizophrenia  Disturbances in several major areas: thought, perception, and attention; motor behaviour; affect or emotion; and life-functioning Positive Symptoms  Positive symptoms: excesses or distortions such as disorganized speech, hallucinations, and delusions  Presence of too much of a behaviour that is not apparent in most people Disorganized Speech  Formal thought disorder/disorganized speech: problems in organizing ideas and in speaking so that a listener can understand (incoherent)  Images and fragments of thought are not connected; difficult to understand exactly what the person is saying  Loose associations/derailment: person may be more successful in communicating with a listener but has difficulty sticking to one topic. They drift off on a train of associations evoked by an idea from the past Delusions  Delusions: beliefs held contrary to reality  The most important delusions: o Person may be the unwilling recipient of bodily sensations or thoughts imposed by external agency o People may believe that their thoughts are broadcast or transmitted, so others know what they’re thinking o People may think their thoughts are being stolen from them, suddenly and unexpectedly, by an external force o Some people believe that their feelings are controlled by an external force o Some people believe that their behaviour is controlled by an external force

o Some people believe that impulses to behave in certain ways are imposed on them by some external force Hallucinations  Hallucinations: sensory experiences in the absence of any stimulation from the environment  They include the following: o Some people report hearing their own thought spoken by another voice o Some people claim that they hear voices arguing o Some people hear voices commenting on their behaviour Negative Symptoms  Negative Symptoms: behavioural deficits; avolition, alogia, anhedonia, flat affect, and asociality.  Attentional deficits contribute to clear reductions and impairments in working memory  Presence of many negative symptoms is a strong predictor of a poor quality of life; some evidence that it is associated with earlier onset brain damage and progressive loss of cognitive skills Avolition  Apathy/Avolition: lack of energy and a seeming absence of interest in or an inability to persist in what are usually routine activities  Inattentive to grooming or personal hygiene, difficulty persisting at work or school, spend time doing nothing Alogia  Alogia can take many forms  In poverty of speech = sheer amount of speech is greatly reduced  Poverty of content of speech = amount of discourse is adequate, but conveys little information and tends to be vague and repetitive Anhedonia  Anhedonia: inability to experience pleasure  A lack of interest in recreational activities, failure to develop close relationships, and lack of interest in sex  Report that normally pleasurable activities are not enjoyable for them Flat Affect  Flat Affect: virtually no stimulus can elicit an emotional response  Client may stare vacantly, muscles of the face flaccid, the eyes lifeless  Client talks in a flat and toneless voice  Refers only to the outward expression of emotion and not to the person’s inner experience, which may not be impoverished at all Asociality  Asociality: severely impaired social relationships  Few friends, poor social skills, and little interest in being with other people  People diagnosed with schizophrenia usually have lower sociability and greater shyness, and report more childhood “social troubles”

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Interpersonal deficits could reflect related deficits in the ability to recognize emotional cues displayed by others

Other Symptoms Catatonia  Catatonia is defined by several motor abnormalities  Some clients gesture repeatedly, using peculiar and sometimes complex sequences of finger, hand, and arm movements that seem to be purposeful  Others manifest an unusual increase in their overall level of activity, which might include excitement, wild flailing of the limbs, and great expenditure of energy, similar to mania  Catatonic Immobility: clients adopt unusual postures and maintain them for very long periods of time  Wavy Flexibility: whereby another person can move the persons’ limbs into strange positions that they maintain for extended periods Inappropriate Affect  Inappropriate Affect: emotional responses of individuals is out of context  Client is likely to shift rapidly from one emotional state to another for no reason History of the Concept of Schizophrenia Early Descriptions  Emil Kraeplin first presented his notion of dementia praecox (Early term for schizophrenia) He differentiated 2 major groups of endogenous, or internally caused, psychoses: manic-depressive illness and dementia praecox  Dementia praecox included several diagnostic concepts – dementia paranoids, catatonia, and hebephrenia  Dementia was referred to severe memory impairments. Kraeplins term refers to a general mental enfeeblement  Bleuer brk with Kraeplin on 2 major points: he believed that the disorder didn’t necessarily have an early onset, and he believed that it didn’t inevitably progress towards dementia  Bleuler proposed his own term “schizophrenia” Greek word schizein (split) ad phren (mind)  The metaphorical concept he adopted was the breaking of associative threads  He viewed blocking (total loss of a train of thought) as a complete disruption of the persons’ associative threads Categories of Schizophrenia in DSM-IV and Elimination in DSM-5  Disorganized Schizophrenia: speech is disorganized and difficult for a listener to follow  Clients may speak incoherently, stringing together similar-sounding words and even inventing new words.  May have flat affect or experience constant shifts of emotions, breaking into inexplicable fits of laughter and crying 

Catatonic Schizophrenia: clients typically alternate between catatonic immobility and wild excitement, but one may predominate

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These clients resist instructions and suggestions and often echo the speech of others

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Paranoid Schizophrenia: key to this diagnosis is the presence of prominent delusions Delusions of persecution are common but clients may experience grandiose delusions (exaggerate sense of their own importance, power, knowledge or identity) Some clients are plagued by delusional jealous (unsubstantiated belief that their partner is unfaithful) Clients with paranoid schizophrenia develop ideas of reference: incorporate unimportant events within a delusion framework and read personal significance into the trivial activities of others

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Additional Ways of Conceptualizing Heterogeneity  Undifferentiated Schizophrenia: applies to people who meet the diagnostic criteria for schizophrenia but not the criteria for any of the 3 subtypes  Residual Schizophrenia: client no longer meets the full criteria for schizophrenia but still shows some signs of the disorder Etiology of Schizophrenia The Genetic Data Family Studies  Relatives of people with schizophrenia are at increased risk, and the risk increases as the genetic relationship between proband and relative becomes closer  Negative symptoms of schizophrenia appear to have a stronger genetic component  A predisposition to schizophrenia may be transmitted genetically  Environment cannot be discounted Twin Studies  Concordance for identical twins 44.3%, much higher than fraternal which is 12.08%  Less than 100% concordance rate is important: if genetic transmission alone accounted for schizophrenia then both should have the disorder  A common “deviant” environment rather than common genetic factors account for the concordance rates Adoption Studies  Children of women with schizophrenia were more likely to be diagnosed as mentally defective, psychopathic and neurotic  Involved more frequently in criminal activity, and had psychiatric issues Molecular Genetics  Not a single gene for schizophrenia, several multi or polygenic models remain viable  5 disorders that have a common genetic vulnerability: schizophrenia, MDD, bipolar, autism, and ADHD  Disorders involve single nucleotide polymorphisms in regions on chromosomes 3p21 and 10q24 and in two calcium subunits CACNA1C and CANB2

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Schizophrenia seems to reflect relatively rare protein altering gene mutations that have implicated up to 40 genes, including a disruption in DCGR2 (vulnerability for schizophrenia) Cells of people with schizophrenia had fewer synapses

Biochemical Factors Dopamine Activity  Theory that schizophrenia is related to excess activity of dopamine is based principally on the knowledge that drugs effective in treating schizophrenia reduce dopamine activity  D2 receptors – dopamine receptors that are blocked by first-generation or conventional antipsychotics  Amphetamines can produce a state that closely resembles paranoid schizophrenia, and they can exacerbate the symptoms of schizophrenia  Dopamine receptors are greater in number or are hyper-sensitive in people with schizophrenia  Having too many dopamine receptors = having too much dopamine  Amphetamines worsen positive symptoms and lessen negative ones (opposite for antipsychotics)  Mesocortical dopamine pathway begins in the same brain region as the mesolimbic, but projects to the prefrontal cortex which projects onto limbic areas that are innervated by dopamine  Under activity of dopamine in prefrontal cortex may cause negative symptoms of schizophrenia Other Neurotransmitters  Dopamine neurons generally modulate the activity of other neural systems (regulate GABA)  Similairly serotonin neurons regulate dopamine activity in mesolimbic pathway  Glutamate may also play a role  Decrease in glutamate inputs from either prefrontal cortex or hippocampus to the corpus striatum can result in increased dopamine activity Schizophrenia and the Brain: Structure and Function Enlarged Ventricles  Most consistent finding is enlarged ventricles – implies a loss of subcotrical brain cells  Structural problems in subcortical temporal-limbic areas, such as hippocampus and basal ganglia  Reduction in cortical grey matter in both temporal and frontal regions and reduced volume in basal ganglia and limbic structures suggesting deteoriation of brain tissue  Large ventricles are correlated with impaired performance on neuropsychological tests, poor adjustment prior to onset of disorder, and poor response to drug treatment Pre-frontal Cortex  Known to play a role in behaviours such as speech, decision making, and willed action  Lack of illness awareness is related to poor neuropsychological performance

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Reductions of grey matter in prefrontal cortex Low glucose metabolism in prefrontal cortex

Congenital and Developmental Consideration  Consequence of damage during gestation at birth  Presence at birth/infancy craniofacial midline anomaly that commonly occur as symptom of CNS anomaly, were associated with doubling risk for schizophrenia  High rates of delivery complications when babies were born, reduced supply of oxygen, resulting in damage  Virus invades the brain and damages it during fetal development (2nd trimester)  Neurons smaller than normal in prefrontal cortex  3 leading ways of becoming at risk: maternal influenza, toxoplasmosis and genital infections in mother Psychological Stress and Schizophrenia Social Class and Schizophrenia  Highest rates of schizophrenia are found in central city areas inhabited by people in the lowest socio-economic class  Sociogenic Hypothesis: stressors associated with being in a low social class may cause or contribute to the development of schizophrenia  Social-selection theory: reverses the direction of causality between social class and schizophrenia. During the course of developing psychosis, people with schizophrenia may drift into poverty-ridden areas of the city may chose to move to areas where little social pressure will be brought on them  Data supports social selection theory more

Family and Schizophrenia Etiology and the Role of the Family  Schizophrenogenic mother: supposedly cold, and dominant, conflict-inducing parent who was said to produce schizophrenia in her offspring  Mothers were characterized as rejecting, overprotective, self-sacrificing, impervious to others feelings, rigid and moralistic about sex, and fearful of intimacy  Family communication pattern of hostility and poor communication predicted later onset of schizophrenia  Children having a parent with schizophrenia showed a greater increase in psychopathology than did control participants who were reared in a disturbed family environment Relapse and the role of the family  Expressed emotion (EE)  High-EE families = great deal of expressed emotion ; low-EE families = little  Schizophrenia patients returning to low EE families, had greater chances of relapse  High-EE mothers are highly sensitive to excitement and depression in the client and report a high level of burden associated with the child’s illness

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Expression of unusual thoughts by the clients elicited higher levels of critical comments by family members who have previously been characterised as high in EE In high-EE families, critical comments by family member led to increase expression of unusual thoughts

Therapies for Schizophrenia  Many clients lack insight into their impaired condition and refuse treatment  Ultimate goal of treatment is to help the individual to remain in or re-enter and function in the community Biological Treatments Shock and Psychosurgery  Prefrontal Lobotomy: a surgical procedure that destroys the tracts connecting the frontal lobes to the centres of the brain  Used specially for those who behaviour was violent  After surgery, many clients became dull and listless and suffered serious losses in their cognitive capacities Drug Therapies  Antipsychotic drugs or neuroleptic were introduced, produce side effects similar to the symptoms of a neurological disease  First-Generation Antipsychotic Drugs o Antihistames were used to reduce surgical shock. Saw that they made patients sleepy and less fearful about impending operation o Chlorpromazine, calmed people with schizophrenia o Phenothiazines derie their therapeutic properties from their abilities to block dopamine receptors in the brain, thus reducing the influence of dopamine on thought, emotion and behaviour o They reduce positive symptoms but have much less effect on negative o Reported side effects of antipsychotics include dizziness, blurred vision, restlessness, and sexual dysfunction o Extrapyramidal sife effects resemble the symptoms of Parkinson’s disease, develop tremors of the finger, a shuffling gait, and drooling o Other side effects include dystonia, and dyskinesia o Akathisia is an inability to remain still, people pace and constantly fidget o Tardive dyskinesia: mouth muscles involuntarily make sucking, lip-smacking and chin-wagging motions o Neuroleptic malignant syndrome – heart races, blood pressure increase, and client may lapse into a coma  Second-Generation Antipsychotics o Clozapine produced therapeutic gains in individuals with schizophrenia than traditional antipsychotics o Improvements in levels of satisfaction, quality of life, thinking, mood and alertness o Atypical antipsychotics at effective dose levels, less likely to cause side effects Psychological Treatments Social Skills Training  Designed to teach people with schizophrenia behaviours that can help them succeed in a wide variety of interpersonal situations in their daily life

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Focuses on 3 key elements: receiving skills, processing skills, and behavioural responses in social interaction Severely disturbed clients can be taught new social behaviour and independent living skills that may help them function better in their communities

Family Therapy and Reducing Expressed Emotion  Educate clients and families bout biological vulnerability that predisposes people to schizophrenia  Provide information about antipsychotic medication  Encourage family members not to blame themselves or the client for the disorder  Help improve communication and problem-solving skills in the family  Encourage clients and families to expand social contacts  Instill a degree of hope that things can improve Cognitive –Behavioural Therapy  People with schizophrenia can benefit form techniques designed to address their delusions and hallucinations  CBT can facilitate motivation and engagement in social and vocational activities  People who have been psychotic for some time incorporate their psychotic beliefs into their broader cognitive schemas  Hallucinations and delusions probably result not from perceptual distortion but from cognitive styles that encourage the psychotic person to live in fictional narratives as if they were real  Defeatist beliefs distinguish a group of schizophrenia people with a particularly troubling form of negative symptoms called the deficit syndrome  The presence of defeatist beliefs is associated with greater neurocognitive impairment and the defeatist beliefs also seem to mediate the links that cognitive impairment has with negative symptoms and with poor vocational functioning Treatment Focus on Basic Cognitive functions  People with schizophrenia have deficits in virtually all facets of cognitive functioning and show performance deficits on a range of simple and complex tasks  More molecular approach focuses on trying to normalize such fundamental cognitive functions as attention and memory  Cognitive Enhancement Therapy: a computer-based training in attention, memory and problem-solving, as well as social-cognitive skills  CET proved successful in improving cognition and processing sped and there was evidence to suggest that it also had a positive effect on functional outcomes  Structural MRIs indicated that CET preserved grey matter in areas such as the left hippocampus Chapter 12: Substance-Related Disorders  Substance Dependence: characterized by the primary symptoms of tolerance and withdrawal  Tolerance: indicated by either (1) larger doses of the substance being need to produce the desired effect or (2) the effects of the drug becoming markedly less if the usual amount is taken  Withdrawal: negative physical and psychological symptoms that develop when the person stop taking the substance or reduces the amount

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Substance Abuse: person must experience one of the following as a result of the recurrent use of the drug o Failure to fulfill major obligations o Exposure to physical dangers o Legal problems o Persistent social or interpersonal problems Polydrug (polysubstance abuse): alcohol abuse or dependence combined with other drugs

Alcohol Abuse and Dependence  Patient is often anxious, depressed, weak, restless and unable to sleep. Tremors of the muscles, especially of the small musculatures of the fingers, face, eyelids, lips and tongue, and pulse, blood pressure and temperature are elevated  A person who has been drinking heavily for a number of years may also experience delirium tremens when the level of alcohol in the blood drops suddenly. The person becomes delirious as well as tremulous and has hallucinations that are primarily visual, but may be tactile as well  Increased tolerance is evident following heavy, prolonged drinking  Tolerance results from changes in the number or sensitivity of GABA or glutamate receptors. Withdrawal may be the result of increased activation in some neural pathways to compensate for alcohol’s inhibitory effects in the brain  Some cravings may be so powerful that they are forced to ingest alcohol in a nonbeverage form, such as hair tonic Nature of the Disorder  Disease model: view that problems such as excessive drinking are due to vulnerabilities that reside within a person  Moral Model: the view that excessive drinking reflects personal failings and personal choices of the afflicted individual o Reject moral view and show ambivalence toward disease model Course of the Disorder  The male alcohol abuser passes through 4 stages: beginning with social drinking and progressing to a stage at which he lives only to drink  Difficulties with alcohol usually begin at a later age in women than in men and often after an inordinately stressful experience, such as a serious family crisis  Women with drinking problems tend to be steady drinkers who drink alone and are more unlikely than men to binge Costs of Alcohol Abuse and Dependence  People who abuse alcohol constitute a large proportion of new admission to mental and general hospitals  Problem drinkers use health services four time more often than do non-abusers, and their medical expenses are twice as high as those of non-drinkers  Alcohol may contribute to other injuries as well. Rape, assault, and family violence are alcohol-related crimes, as is homicide. Over half of all murders are committed under the influence of alcohol Short-Term Effects of Alcohol

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Alcohol is metabolized by enzymes after being swallowed and reaching the stomach. Most of it goes into the small intestines where it is absorbed into the blood. It is then broken down, mostly in the liver, which can metabolize about 30 ml of 100 proof whisky per hour. Effects of alcohol vary with the level of concentration of the drug in the bloodstream, which in turn depends on the amount ingested in a particular period of time, the presence of absence of food in the stomach to retain the alcohol and reduce its absorption rate, the size of a person’s body, and the efficiency of the liver This mean that the initial effect of alcohol is stimulating – the drinker experiences an expansive feeling of sociability and well-being as the blood alcohol level rises, but after blood-alcohol level peaks, alcohol acts as a depressant that may lead to negative emotions Large amounts of alcohol interfere with complex thought processes, motor coordinate balance, speech and vision; some people become depressed and withdrawn Stimulates GABA receptors, which may be responsible for reducing tension Alcohol also increases levels of serotonin and dopamine, may be the source of its pleasurable effects Alcohol inhibits glutamate receptors, which may cause the cognitive effects of alcohol intoxication

Long-Term Effects of Prolonged Alcohol Abuse  Almost every tissue and organ of the body is affected adversely by prolonged consumption of alcohol  Malnutrition may be severe. Since alcohol provides calories, heavy drinkers often decrease intake of food  Alcohol also contributes directly to malnutrition by impairing the digestion of food and the absorption of vitamins.  A deficiency of B-complex vitamins can cause amnestic syndrome, a severe loss of memory for both recent and long-past events  Prolonged alcohol use also contributes to the development of cirrhosis to the liver (liver cells become engorged with fat and protein, impeding their function)  Other common physiological changes include damage to endocrine glands and pancreas, heart failure, hypertension, stroke, and capillary hemorrhages (responsible for redness in the face)  Prolonged use of alcohol seems to destroy brain cells. Alcohol also reduced the effectiveness of the immune system and increases susceptibility to infection and cancer  Heavy alcohol consumption during pregnancy is the leading cause of mental retardation  Fetal Alcohol Syndrome: growth of fetus is slowed, and cranial, facial and limb anomalies are produced due to the mother consuming alcohol when pregnant  Light drinking especially of wine, is related to decreased risk for coronary heart disease and stroke Inhalant Use Disorders  Alarming number of young people begin their substance abuse by inhaling such substances such as glue, correction fluid, spray paint, cosmetics, gasoline, household aerosol sprays, and nitrous oxide  Peak age of inhalant use is 14-15 years, with initial onsets in children as young as 6

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Inhalant use disorder can involve behaviours such as sniffing, huffing, and bagging Most inhalants act as depressants and can be seen as similar to alcohol and sedatives. The inhaled substance can result in feelings of euphoria and psychic numbing, but inhalants can cause damage to the central nervous system. Nausea and headaches are experienced eventually in almost all cases.

Nicotine and Cigarette Smoking Nicotine: addicting agent of tobacco. It stimulates receptors, called nicotinic receptors in the brain.  The main receptor mediating nicotine dependence is the nicotinic acetylcholine receptor subtype  Exposure to nicotine influences brain nicotinic cholinergic receptors to facilitate neurotransmitter release thus producing stimulation, pleasure and mood modulation  Addictive effects of smoking start very shortly after one’s first puff  Female smokers have substantially greater changes in cognitive activity after nicotine exposure Health Consequences of Smoking  Single most preventable cause of premature death  Health risks of smoking are significantly less for cigar and pipe smokers because they seldom inhale the smoke into their lungs, but cancers of the mouth are increase  Medical problems caused by smoking: lung cancer, emphysema, cancer of the larynx and esophagus, number of cardiovascular disease  Most probably harmful components in the smoke from tobacco are nicotine, carbon monoxide, and tar (consists of hydrocarbons including know carcinogens)  Smoking contributes to erectile problems in men Consequences of Second-Hand Smoke Second-hand smoke: or environmental tobacco smoke, is smoke coming from the burning end of a cigarette, contains higher concentrations of ammonia, carbon monoxide, nicotine and tar than does the smoke that is inhaled by the smoker  Effects can be found in terms of health outcomes and behavioural tendencies Marijuana Marijuana: dried and crushed leaves and flowering tops of the hemp plan, Cannabis sativa. Can be smoked, chewed, prepared as tea, or eaten in baked goods Hashish: stronger than marijuana, produced by removing and drying the resin exudates of the tops of high-quality cannabis plants Effects of Marijuana Psychological Effects  Depend in part of its potency and size of dose  Smokers find it makes them feel relaxed and sociable, large doses have been reported to bring rapid shifts of emotion, to dull attention, to fragment thoughts, and to impair memory  Increases likelihood of psychotic disorders due to the interactions that relate to the levels of dopamine

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Major chemical in marijuana is delta-9-tetrahyrdrocannabinol (THC) (2-3x higher than 2 decades ago) Neurocognitive deficits are greater among adults who began cannabis use in early adolescence and adolescents seem much more susceptible than adults to neurocognitive deficits Being high on marijuana impairs the complex psychomotor skills needed for driving

Somatic Effects  CB (cannabinoid) receptors in the brain are located in various regions, and it is believed that receptors in the hippocampus account for the short-term memory loss that sometimes follows smoking  Short-term side effects of marijuana include: bloodshot and itchy eyes, dry mouth and throat, increase appetite, reduced pressure within the eye, and somewhat raised blood pressure  Growing evidence that smoking marijuana is associated with a host of respiratory diseases and related ailements and seriously impairs lung functioning. Symptoms include coughing, wheezing, bronchitis, injury to airway tissue and impaired functioning of immune system components  Most marijuana smokers inhale the smoke more deeply and retain it in their lungs for much longer periods of time  Dependence susceptibility: notion that some people are much more sensitive and prone to becoming addictive than are other people Therapeutic Effects  THC and related drugs can reduce the nausea and loss of appetite that accompany chemotherapy for some cancer patients  Marijuana is also a treatment for the discomfort of AIDS as well as glaucoma, epilepsy, and multiple sclerosis Sedatives and Stimulants Sedatives Sedatives: downers, slow the activities of the body and reduce its responsiveness Opiates Opiates: group of addictive sedatives that relieve pain and induce sleep when taken in moderate doses  Opioids – synthetic or semi-synthetic version of opiates  Oxycontin – opioid with the active ingredient oxycodone that produces a swift and powerful high History  Begin when morphine was created (powerful sedative and pain reliever)  Morphine was use in patient medicines, by being injected directly into veins to relieve pain  Found morphine can be converted into another drug that they called heroin  Heroin was a substituted for morphine in cough syrups and other patent medicines, but proved to be more addictive and more potent that morphine, acting more quickly with greater intensity

Psychological and Physical Effects  Produce euphoria, drowsiness, reverie, and a lack of coordination  Heroin has an additional effect: the rush, a feeling of warm, suffusing ecstasy immediately following an intravenous injection  User sheds worries and fears and has great self-confidence for 4-6 hours, but then experiences letdown, bordering on stupor  Opiates produce their effects by stimulating neural receptors of the body’s own opioid system  The body produces opioids, called endorphins and enkephalins, and opium and its derivatives fit into their receptors and stimulate them  They are clearly addicting, increased tolerance of the drugs and withdrawal symptoms. Reactions to not have a dose may begin within 8 hours after the last injection.  Individual typically has muscle pain, sneezes, sweats, becomes tearful and yawns a lot over the next few hours  Withdrawal symptoms become more severe within 36 hours; may be uncontrollable twitching, cramps, chills alternating with excessive flushing and sweating, and a rise in heart rate and blood pressure  Person is unable to sleep, vomits and has diarrhea Synthetic Sedatives Barbiturates: another major type of sedative, were synthesized as aids for sleeping and relaxation  These drugs were initially considered highly desirable and were frequently prescribed  Sedatives relax the muscles, reduce anxiety, and in small does produce a mildly euphoric state  They are thought to produce these psychological effects by stimulating the GABA system.  With excessive doses, speech becomes slurred and gait unsteady  Judgement, concentration, and ability to work may be severely impaired  The user loses emotional control and may become irritable and combative before falling into a deep sleep  Very large doses can be fatal because the diaphragm muscles relax to such an extent than an individual suffocates Stimulants Stimulants: act on the brain and the sympathetic nervous system to increase alertness and motor activity Amphetamines    

Isolated an alkaloid from the plant belonging to the genus Ephedra, and the result, ephedrine, proved highly successful in treating asthma. But relying on the shrub for the drug wasn’t efficient, so they developed a synthetic substitute -> Amphetamine Amphetamine produces its effects by causing the release of norepinephrine and dopamine and blocking their reuptake They are taken orally or intravenously and cab be addictive Wakefulness is heightened, intestinal functions are inhibited, and appetite is reduced

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Heart rate quickens, and blood vessels in the skin and mucous membranes constrict The individual becomes alert, euphoric, and outgoing and is possessed with seemingly boundless energy and self-confidence. Larger doses can make people nervous and confused, subjecting them to palpitations, headaches, dizziness, and sleeplessness Large doses taken over time can induce a state similar to paranoid schizophrenia, including its delusions As tolerance increases, user stops taking pills and injects methedrine (meth) directly into the veins

Cocaine  Alkaloid cocaine was extracted from the leaves of the coca plant  Cocaine has effects in addition to reducing pain. It acts rapidly on the brain, blocking the reuptake of dopamine in mesolimbic areas that are thought to yield pleasurable states, dopamine is left in synapse and facilitates neural transmission and results in positive feelings  Cocaine increases sexual desire and produces feelings of self-confidence, well-being, and indefatigability  An overdose may bring on chills, nausea and insomnia, as well as a paranoid breakdown and terrifying hallucinations  Chronic use leads to changes in personality, includes heightened irritability, impaired social skills, paranoid thinking, and disturbances in eating or sleeping  Cocaine, a vasoconstrictor, causes the blood vessels to narrow. It increases person’s risk for stroke and causes cognitive impairments  Cocaine poses special dangers in pregnancy, for the blood supply to the fetus may be compromised

LSD and Other Hallucinations History  LSD was first referred to as a psychotomimetic because it was thought to produces effects similar to the symptoms of psychosis  Term in current use for LSD is a hallucinogen  4 other important hallucinogens are mescaline, psilocybin, and synthetic compounds of MDA and MDMA  Mescaline: an alkaloid and an active ingredient of peyote, was isolated from small, disc-like growths on the top of the peyote cactus  Psilocybin: a crystalline power that Hofmann isolated from the mushroom Psilocybe Mexicana  Each of the substances is structurally similar to several neurotransmitters, but effects are thought to be due to the stimulation of serotonin receptors  Ecstasy: refers to 2 closely similar synthetic compounds, MDA and MDMA, is chemically similar to mescaline and the amphetamines and is the psychoactive agent in nutmeg  Drug enhances intimacy and insight, improves interpersonal relationships, elevates mood, and promotes aesthetic awareness

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It can also cause muscle tension, rapid eye movements, increase heart rate and blood pressure, nausea, faintness, chills or sweating, and anxiety, depression, and confusion Lasting side effects include paranoia, confusion and memory complaints

Effects of Hallucinogens  A person’s set is widely held to be an important determinant of his or her reactions to hallucinogens  A bad trip can sometimes develop into a full-blown panic attack and is far more likely to occur if some aspect of taking the drug creates anxiety  Flashbacks: a recurrence of psychedelic experiences after the physiological effects of the drug have worn off Etiology of Substance Abuse and Dependence Social Variables  Various aspects of the social world can affect people’s interest in and access to drugs  Cultural attitudes and patterns of drinking influence the likelihood of drinking heavily and therefore, abusing alcohol  Rates of alcohol are higher among bartenders or liquor store owners - alcohol is readily available  Rates of smoking increase if cigarettes are perceived as being easy to get and affordable  Lack of emotional support from parents is linked with increase use of cigarettes, cannabis and alcohol  A lack of parental monitoring leads to increased association with drug-abusing peers and subsequent use of drugs  The social milieu in which a person operates can also affect substance abuse. Having friends who smoke predicts smoking. Peer influences are also important in promoting alcohol and marijuana use.  Those who have high self-efficacy are influenced less by peers Psychological Variables Mood Alteration, Situations and the role of cognitions Why do people drink?  Drinking occurs if the perceived benefits outweigh the costs  Drinking motives vary along 2 dimensions: the valence of reinforcement and locus, that is, people can drink to obtain pleasurable outcomes or avoid negative outcomes, and they can drink in response to external, social stimulation in response to internal, personal cues  4 combinations involving these two dimensions are possible. Drinking for positive, internal reasons = drinking to enhance positive mood (enhancement scale). Drinking for negative, internal reasons = drinking to reduce or avoid experiencing negative emotions (coping scale). Drinking for positive, external reasons = drinking to obtain social rewards (social scale). Drinking for negative, external reasons = drinking to escape punishment or to avoid being embarrassed by people (conformity scale)  Self-medication theory of addiction: drinking is done with the goal of reducing an aversive state

Cognitive Factors in Drinking  Alcohol may produce its tension-reducing effect by altering cognition and perception  Alcohol impairs cognitive processing and narrows attention to the most immediately available cues (Resulting in alcohol myopia – intoxicated person has less cognitive capacity to distribute between ongoing activity and worry)  Positive alcohol expectation predict higher levels of consumption and alcohol-related problems, while negative expectations tend to inhibit consumption  Explicit cognition: controlled thought processes that can be deliberated upon  Implicit cognition: automatic appraisal of cues that is more uncontrolled and perhaps not subject to conscious awareness  Focus on implicit cognition reflects the reality that behaviour is often not a product of conscious cognitive reflection but is instead due to cognitions spontaneously activated during periods of temptation or periods of stress  Drug-Stroop Task can be used to assess vulnerability to addiction, but it can also be used to evaluate remission and treatment-improvements Personality and Drug Use  Personality variables attempt to explain why certain people are drawn to substance abuse  Personality variables are stable individual differences that can be detected early in childhood and are believed to be relatively stable across the lifespan  Brain systems associated with behavioural activation and behavioural inhibition are associated with 3 genetically inherited dimensions of personality: novelty seeking, harm avoidance, and reward dependence  Substance abuse are likely among people characterized by high levels of neuroticism and psychotism  Maturing out phenomenon: overall tendency for peak drinking levels to occur when people are in their mid-20s and there is a sharp drop in drinking levels when people reach their late 30s Biological Variables  Twin studies revealed greater concordance rate in identical twins for alcohol abuse, caffeine use, heavy use of cannabis, and drug abuse  Genetic component of drinking may be stronger in males than females  Some people may be genetically programmed to be able to quit smoking (heritable component)  Appears that (1) neuroadaptations following continued brain exposure remain even after alcohol exposure stops (2) there is substantial individual variability in neuroadaptations based on genetic factors  Corticotrophin-releasing factor system within the amygdale is central factor in the neuroadaptive changes that accompany problem drinking  Conditioning Theory of tolerance: underscores the need to jointly consider biological processes and environmental stimuli that may be involved in the acquisition and maintenance of addictive behaviours  Feed-forward mechanism: anticipatory regulatory responses made in anticipation of a drug Therapy for Problem Drinking

Admitting the Problem  Substance abuses of all kinds are adept at denying they have a problem and may react angrily to any suggest that they do  Current heavy drinkers were significantly less likely than moderate drinkers to believe that they need treatment  Enabling the drinker to take the first step t betterment can be achieved through questions that get at the issue somewhat directly (page 396) Traditional Hospital Treatment  Detoxification: the withdrawal from alcohol  Can be difficult both physically and psychologically, and usually takes about one month  Tranquilisers are sometimes given to ease the anxiety and general discomfort  To help get through withdrawal, alcohol abusers also need carbohydrate solutions, B vitamins, and sometimes anticonvulsants Biological Treatments  Antabuse: a drug that discourages drinking by causing violent vomiting if the alcohol is ingested  It blocks the metabolism of alcohol so that noxious by products are created  The drinker must already be committed to change. If an alcohol abuser is able or willing to take the drug every morning as prescribed, the chances are good that drinking will lessen because of the negative consequences of inhibiting. Alcoholic Anonymous  Largest and most widely known self-help group in the world  Regular meetings where new-comers rise to announce that they are alcoholics, and older members give testimonials telling stories of their lives and how they are better now  The belief is instilled in each AA member that alcohol abuse is a disease that can never be cured, so continuing vigilance is necessary to resist taking even a single drink lest uncontrollable drinking begin all over again Couples and Family Therapy  Alcohol abusers often abuse their family members  Behaviourally oriented marital or couples therapy has been found to achieve some reductions in problem drinking, as well as some improvements in couples’ distress generally  A focus of this therapy is involving the spouse in helping the drinker take his or her Antabuse on a regular basis  Husbands who drink excessively often have wives who drink to excess Cognitive and Behavioural Treatment Aversion Therapy  Problem drinkers are shocked or made nauseous while looking at, reaching for, or beginning to drink alcohol

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Covert sensitization: problem drinkers are instructed to imagine being made violently and disgustingly ill by their drinking

Contingency-Management Therapy  Involves teaching clients and those close to them to reinforce behaviours inconsistent with drinking  This therapy also includes teaching job-hunting and social skills, as well as assertiveness training for refusing drinks  Behavioural self control emphasizes patient control and includes one or more of the following: o Stimulus control – one narrows situations in which one allows oneself to drink o Modification of the topography of drinking o Reinforcing abstinence Moderation in Drinking  Controlled Drinking: a moderate pattern of alcohol consumption that avoids the extremes of total abstinence and inebriation  Some alcohol abusers can learn to control their drinking and improve other aspects of their life  Guided Self-change: an outpatient approach, emphasizes personal responsibility and control  As stated in the GSCP manual the goals of the program are to (1) help clients help themselves (2) allow clients to make informed choices (3) teach a general problemsolving approach (4) strengthen client motivation and commitment to change (5) encourage self reliance, empowerment and personal competence  Harm reduction therapy: complete abstinence from alcohol Clinical considerations in treating alcohol abuse  A comprehensive clinical assessment considers what place drinking occupies in the person’s life  Depression is often co-morbid with alcohol abuse and that suicide is also a risk  Alcohol researchers recognize that different kinds of drinkers may require different treatment approaches  The challenge is to determine which factors in the drinkers should be aligned with which factors in treatment  Aptitude-treatment interaction is a critical issue in the development of better interventions for problem drinking Therapy for the use of Illicit Drugs  Detoxification is the first way in which therapists try to help an addict or drug abuser, and it may be the easiest part of the rehab process Biological Treatments  2 widely used drug-therapy programs for heroin addiction involve heroin substitutes (drugs chemically similar to heron that replace the body’s craving for it) or heroin antagonists (drugs that prevent the user from experiencing the heroin high)  The first category includes methadone – synthetic narcotics designed to take the place of heroin

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Synthetic narcotics are cross-dependent, by acting on the same CNS receptors, they become a substitute for the original dependency Clonidine – an antihypertensive medication, may ease withdrawal from a variety of addicting drugs Bromocriptine also shows some promise in reducing craving, perhaps by reversing the depletion of dopamine that is believe to underlie cocaine’s addicting properties

Psychological Treatments  Patients receiving cognitive treatment learned how to avoid high-risk situations, recognize the lure of the rug for them, and develop alternatives to using cocaine  Cocaine abusers in this study also learned strategies for coping with the craving and for resisting the tendency to regard a slip as a catastrophe  Motivational interviewing: combines CBT principles with the humanistic principles by Rogers. The central premise is that people must be motivated and ready to change in order for psychological interventions to work and motivation needs to be enhance among ambivalent clients  3 key motivational concepts that are related to whether someone with a drinking problem can overcome it are readiness to change, ambivalence, and resistance Treatment of Cigarette Smoking Biological Treatments  Attention to nicotine dependence is clearly important because the more cigarettes a person smokes daily, the less successful attempts to quit will be  Gum containing nicotine may help in quitting, the nicotine in the gum is absorbed much more slowly and steadily than in tobacco  Nicotine patches are applied to the skin that slowly and steadily release the drug into the bloodstream and thence to the brain  Vareicline is a nicotine receptor partial agonist that seems effective in reducing smoking when used over a period of 3 months. It not only reduces withdrawal symptoms, it tends to reduce the urges to smoke among those who have quit smoking Psychological Treatments  Variations in smoking may help. Such as rapid puffing, focused smoking, and smoke holding  Use various coping skills such as relaxation and positive self-talk, when confronted with a tempting situation  Combined approach with counselling and pharmacotherapy is the best Relapse Prevention  People who smoked the most and more addicted to nicotine, relapse more often and more quickly  So called booster or maintenance sessions help, and represent a continuation of treatment, but when they stop, relapse happens  Self-efficacy is a smokers’ most difficult challenge

Chapter 16: Aging and Psychological Disorders Subjective Age Bias: presence of negative aging stereotypes may account for the fact that most people report that they feel younger than they actually are  Younger subjective age is linked with greater life satisfaction and a host of other positive outcomes  Positive health experiences and greater health satisfaction are linked with lower subjective age  Physical realities of aging are complicated by ageism Ageism: discrimination against any person, young or old, based on chronological agee  The old are usually defined as those who are over the age of 65. This was set largely by social policies. Diversity in Older Adults  The word diversity is well suited to the older population  Old people are more different from one another than are individuals in any other age group Age, Cohort, and Time of Measurement Effects  Must be cautious when we attribute differences in age groups solely to aging – 3 kinds of effects: o Age effects: consequences of being a given chronological age o Cohort effects: consequences of having been born in a given year and having grown up during a particular time period with its own unique pressures, problems, challenges and opportunities o Time-of-measurement effects: confounds that arise because events at an exact point in time can have a specific effect on a variable being studied over time  Two major research designs are cross-sectional and longitudinal studies  Cross-Sectional studies: investigator compares different age groups at the same moment in time on the variable of interest  They allow us to make statements about age effects in a particular study or experiment, not about age changes over time.

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Longitudinal Studies: researcher selects one cohort and periodically retests it using the same measure over a number of years Allows researchers to trace individual patterns of consistency or change over time and to analyze how behaviour in early life relates to behaviours in old age Selective mortality: least-able people drop out, leaving a non-representative group of people who are usually healthier than the general population

Diagnosing and Assessing Psychopathology in Later Life  Measures of cognitive functioning is often included as standard practice in research to determine whether the elderly respondent has experienced declines in cognitive ability  One goal is to develop short but reliable measures suitable for screening purposes (elderly have diminished attention spans)  Another goal is to create measures whose item content is tailored directly to the concerns and symptoms reported by elderly people, not to those of younger respondents Range of Problems  Old age individual have all problems: physical decline and disabilities, sensory and neurological deficits, loss of loved ones, the cumulative effects of a life of many unfortunate experiences, and social stresses  Elderly people with a mental disorder may suffer from a double jeopardy – suffer stigma from being old and from being mentally ill Old Age and Brain Disorders Dementia Dementia: a general descriptive term for gradual deteoriation of intellectual abilities to the point that social and occupational functions are impaired  Difficulty remembering things or events in the most prominent symptoms and memory problems in people who objectively have normal cognition predict subsequent dementia  May leave tasks unfinished; poor hygiene and appearance because they forget to bathe or how to dress  Get lost, even in familiar settings; judgement may be fault and difficulty comprehending situations  They relinquish their standards and lose control of their impulses; may use coarse language, tell inappropriate jokes, or shoplift  Trouble recognizing familiar surroundings or naming familiar objects  Episodes of delirium – a state of great confusion – may also occur  Course of dementia may be progressive, static or remitting, depending on the cause, many people with progressive dementia become withdrawn and apathetic Causes of Dementia Alzheimer’s Disease  Alzheimer’s Disease accounts for 50% of the cases of dementia  The brain tissue deteoriates irreversibly, and death usually occurs 10-12 years after the onset of symptoms

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Women with Alzheimer’s Disease live longer than men, but more women than men die as a result of the disease  The person may at first have difficulties only in concentration and in memory, and may appear absent minded and irritable  Well before the onset of clinical symptom, subtle deficits in learning and memory are revealed by neuropsychological tests  As the disease develops, the person often blames others for personal failings and may have delusions of being prosecuted. Memory continues to deteoriate and the person becomes increasingly disoriented and agitated  The main physiological change in the brain, evident at autopsy, is an atrophy of the cerebral cortex, first the entorhinal cortex and the hippocampus and later the frontal, temporal, and parietal lobes  As neurons and synapses are lost, the fissures widen and the ridges become narrower and flatter and ventricles also become enlarged  Plaques: small, round areas making up the remnants of the lost neurons and bamyloid, a waxy protein deposit – are scattered throughout the cortex  Tangled abnormal protein filaments Neurofibrillary Tangles accumulate within the cell bodies of neurons.  These plaques and tangles are present throughout the cerebral cortex and hippocampus  Volume loss in the medial temporal lobes was the most sensitive measure when identify patients with Alzheimer’s disease  Alzheimer’s disease has a structural effect on the entorhinal and hippocampal regions, and functionally, it impacted the inferior parietal lobules and precuneus  Strong evidence for a genetic basis for Alzheimer’s disease Gene appears to be related to the development of both plaques and tangles, and it seems to increase the likelihood that the brain will incur damage from free radicals Environment is also likely to play a role in most cases Remaining active at the cognitive level may buffer or protect an individual in terms of the degree of cognitive decline experienced Cognitive Reserve Hypothesis: notion that high education level delays the clinical expression of dementia because the brain develops backup or reserves neural structures as a form of neuroplasticity A related protective factor is being bilingual; they engage in more stimulating mental activities and more extensive cognitive practice that contribute to a cognitive reserve that becomes ultimately reflected in brain plasticity Frontal-Lobe Dementias Accounts for 10-15% of dementia cases Typically begins in a person’s late fifties Frontal-temporal dementias are marked by extreme behavioural and personality changes Sometimes people are very apathetic and unresponsive to their environment; other times, they show an opposite pattern of euphoria, over-activity and impulsivity Serotonin neurons are most affected, and there is widespread loss of neurons in the frontal and temporal lobes Pick’s disease is one cause of frontal-lobe dementia; it is a degenerative disease in which neurons are lost. It is also characterized by the presence of Pick bodies,

spherical inclusions within neurons

Frontal-Subcortical Dementias Types include: o Huntington’s Disease: caused by a single dominant gene located on chromose 4 and is diagnosed principally by neurologists on the basis of genetic testing. Its major behavioural feature is the presence of writhing movements o Parkinson’s Disease: muscle tremors, muscular rigidity, and akinesia (an inability to initiate movement) and can lead to dementia o Vascular Dementia: now referred to as major or mild neurocognitive disorder. Diagnosed when a patient with dementia has neurological signs, such as weakness in arm or abnormal reflexes, or when brain scans show evidence of cerebrovascular disease Other Causes of Dementia Number of infectious diseases can produce irreversible dementia Encephalitis is caused by viruses that enter the brain from other parts of the body or from the bites of mosquitoes or ticks Meningitis caused by bacterial infections Organism that produces the venereal disease syphilis can invade the brain and cause dementia Head traumas, brain tumours, kidney or liver failure, nutritional deficient and endocrine-gland problems can result in dementia Treatment of Dementia Biological Treatments of Alzheimer’s disease  Various studies have attempted to increase the levels of acetylcholine  Tetrahydroaminoacridine (Tacrine) inhibits the enzyme that breaks down acetylcholine, which produces mild improvement or slows the progression of cognitive decline  Tacrine cannot be used in high doses because it has severe side effects  5 drugs have been approved thus far: tacrine, donepezil, rivastigmine, galantamine, and memantine  These drugs have not stopped progression of Alzheimer’s disease though they may slow down the progression of symptoms Psychosocial Treatments for the individual and Family  Overall goal is to minimize the disruption caused by the person’s behavioural changes. Achieved this by allowing the person and the family the opportunity to discuss the illness and its consequences, providing accurate information about it, helping family members care for the person in the home, and encouraging a realistic attitude in dealing with disease’s specific challenges  Psychotherapy provides little long-term benefit for those with severe deteoriation  Depression is twice as evident among caregivers  Depression and feelings of being burdened are highly correlated among caregivers

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4 significant burden areas were identified: emotional burden, physical burden, financial burden, and employment burden Resilience promotes well-being among caregivers experiencing significant burden 3 best predictors of making the difficult decision to institutionalize a loved one are the elderly person’s level of aggression, incontinence, and the presence of psychiatric disturbance

Delirium Delirium: implies being off track or deviating from the usual state; a clouded state of consciousness  Great trouble concentrating and focusing attention and cannot maintain a coherent and directed stream of thought  Early stage: Frequently restless, sleep-waking cycle is disturbed, vivid nightmares and dreams are common  May be impossible to engage in conversation because of their wandering attention and fragmented thinking  Speech is rambling and incoherent; lose sense of time and place  In the course of a 24 hour period, delirious people have lucid intervals and become alert and coherent. This distinguishes delirium from other syndromes  Fever, flushed face, dilated pupils, tremors, rapid heartbeat, elevated blood pressure, and incontinence are common Causes of Delirium  Drug intoxications and drug-withdrawal reactions, metabolic and nutritional imbalances, infections or fevers, neurological disorders, and the stress of a change in the persons’ surroundings  Delirium may also occur following major surgery (most commonly hip surgery), during withdrawal from psychoactive substances, and following head traumas or seizures  Common physical illnesses that can cause delirium are congestive heart failure, pneumonia, urinary tract infection, cancer, kidney, or live failure Treatment of Delirium  Generally takes one to four weeks for the condition to clear  If the underlying cause is not treated, permanent brain damage and death can ensue  Primary prevention strategies appear to reduce the high rates of delirium, as well as the duration of delirium episodes in hospitalized older adults  The intervention addresses such risk factors for delirium such as sleep deprivation, immobility, dehydration, visual and hearing impairment, and cognitive impairment Old Age and Psychological Disorders Depression  Major depression is less prevalent among adults age 65 and older, relative to younger people  Depression and other disorders are still quite evident in the elderly  Greater prevalence of depression was associated with female gender, the presence of dementia, and the presence of physical health problems  At least half of depressed older adults are experiencing depression for the first time (late-onset depression)

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Those with early-onset depression are more likely to have a family history o depression and personality dysfunction that renders them vulnerable Early-onset depression have comparatively greater depression and less social support, and have more severe cognitive and neurological changes Older adults are less likely to demonstrate impaired social and occupational functioning because they are less likely to be working Depletion syndrome – depression without sadness; loss of pleasure, vitality and appetite; hopelessness and somatic symptom; self-blame, guilty, and dysphoric mood a

Causes of Depression in Older Adults  Decreases involvement in daily activities and maintained by self-critical thoughts  Elderly with health problems and depression don’t know whether if depression or the health problem came first  As we age, experience a lot of life events that could cause depression  Bereavement after the loss of a loved one has been hypothesized to be the most important risk factor  Women with ill husbands anticipate the loss and may become depressed prior to their spouse’s death  People who were optimistic and found meaning in their lives had better psychological adjustment  Importance of social support as a stress buffer for elderly people facing life challenges Treatment of Depression  Quality of the alliance between elderly and his/her therapist is a key factor in determining whether there is a positive treatment response  Depressed elders with negative self-views had less positive responses to the cognitive interventions  CBT was effective in reducing levels of depression as assessed by Beck-Depression Inventory  Interpersonal psychotherapy (IPT) is a short-tem psychotherapy that addresses themes such as role loss, role transition, and interpersonal disputes, which are problem areas prominent in the lives of many older adults  A form of treatment known as reminiscence therapy can also be effective for treating depression the elderly. It is also known as life review therapy. It is as cognitive therapy that requires individuals to reflect on previous negative events and address any remaining conflicts. It also requires that they strive to find life’s meaning while examining the present situation and the past  Helps the person address the conflict between ego integrity and despair. Ego integrity refers to a process of finding meaning in the way one had led one’s life, and despair reflects the discouragement that can come from unreached goals and unmet desires.  Electroconvulsive therapy is also back in favour among many geriatric psychiatrists  ECT has many risks, and should only be considered when other treatments have not been effective, or when a rapid response is needed Anxiety Disorders  Can be a continuation or re-emergence of problems experienced early in life, or they can develop for the first time in senior years

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Risk factors for anxiety in older people are: being female, several chronic medical conditions, not being married, having lower levels of education, adverse childhood experiences, and elevated neuroticism Anxiety among people with dementia is linked with poorer quality of life, behavioural disturbances, and poor outcomes Elderly report more worries about health and fewer worries about work Differences exist in the structure of affect, with elderly people placing less emphasis on feelings of guilt and self-blame Elderly people emphasize the somatic aspects of anxiety rather than the cognitive Symptoms of anxiety may be more closely intertwined with symptoms reflecting sleep difficulties and decline in cognitive capabilities PTSD and acute stress disorder may be especially relevant in the lives of older adults CBT consisting of relaxation training, cognitive therapy, and exposure-based procedures; is useful for older adults because it is time-limited, symptom-focused, and collaborative

Substance-Related Disorders Alcohol Abuse and Dependence  Heavy drinking was linked with depression, anxiety, and health problems  Binge drinking among men was linked with being separated, divorced or widowed  Problem drinking in older adults may be a continuation of a pattern established earlier in life; but many drinkers begin having alcohol-related problems after the age of 60 (late-onset alcoholism)  Tolerance for alcohol diminishes with age (ratio of body water to body mass decreases; results in higher blood alcohol concentration per unit of alcohol inhibited)  Older people metabolize alcohol more slowly. Drug may cause greater changes in brain chemistry and more readily bring on toxic effects (such as delirium)  Cognitive deficits associated with alcohol abuse, such as memory problems, are more likely to be more pronounced in the aged alcoholic than in younger individuals  Residual cognitive effects may remain long after the older person has stopped drinking Medication Misuse  Elderly people have a higher overall rate of legal drug intake than any other group  Abuse of prescription or legal drugs is often inadvertent but can be deliberate  Older adults may abuse tranquilizers, antidepressants, or sleep aids, to deal with postoperative pain or the grief and anxiety of losing a loved one  These drugs often create physical as well as psychological dependency  Slurred speech and memory problems caused by drugs may be attributed by others to old age and dementia Sleep Disorders  Insomnia is a frequent complaint among older adults  1 in 5 of people over 65 experience insomnia  The prevalence of insomnia goes up steadily as age increases  Insomnia in the elderly Is both more frequent and severe that in younger people and is associated with more complications

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Need for help is indicated by insomnia being linked with lower self-reported levels of physical health and psychological health The most common sleep problems experienced by older adults are waking often at night, frequent early-morning awakenings, difficulty falling asleep, and daytime fatigue Older adults spend less time in REM sleep, and stage 4 sleep (deepest stage) is virtually absent Older men experience it more than women

Causes of Sleep Disorders  Various illnesses, medications, caffeine, stress, anxiety, depression lack of anxiety, and poor sleep habits may make insomniacs of older adults  Depressed mood has been shown to be related to sleep disturbances in older adults too  It is worsened by self-defeating actions such as ruminating over it and counting the number of hours slept and those spent waiting to fall asleep  Sleep apnea: respiratory disorder in which breathing ceases repeatedly for a period of a few seconds to as long as 2 minutes as the person sleeps. It disrupts normal sleep and can lead to fatigue, muscle aches, and elevation in blood pressure over a period of time  Disruption is due to markedly reduced airflow caused by relaxation produced obstruction from excessive tissue at the back of the throat Treatment of Sleep Disorders  Pharmacotherapy is most common form of treatment for sleep disorders for elderly, receive one-third of the sedatives and hypnotics that are used  Sleep drugs rapidly lose their effectiveness with continuous use, and may make sleep light and fragmented  Medications can even bring about a drug-dependent insomnia – gives people drug hangovers and increase respiratory difficulties  CBT is an effective long-term treatment for insomnia  Tranquilizers are not appropriate for elderly to treat insomnia  Melatonin, a hormone secreted by the pineal gland plays an important role in regulating sleep and is known to decrease with aging; therefore it has been used to treat sleep disorders Suicide  Several factors put people in general at especially high risk for suicide: serious physical illness, feelings of hopelessness, social isolation, loss of a loved one, dire financial circumstances, and depression  Suicide rates for people over 65 are high, approximately 3x higher than younger individuals  Older white men are more likely to commit suicide, peak ages are 80-84  Elderly men more than elderly women, were more likely to use lethal methods as a means of committing suicide (Ex using a gun)  Older people are less likely to communicate their intentions to commit suicide and make fewer attempts as the most often kill themselves with lethal methods  Elderly people are often more socially isolated and less likely to be rescued prior to death

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Suicide acts themselves are more planned and determined in older people and are less impulsive As more people survive longer, the number of suicides as people age is almost certain to increase Individual differences in loneliness and feelings of isolation predicted suicide ideation in elderly Poor cognitive functioning, depression, general hopelessness, and interpersonal hopelessness were predictors of suicide ideation Feeling like a burden tends to have a negative impact in protective factors such as the meaning of life Link between physical illness and suicide Elderly suicides were more violent and alcohol was more likely to be involved

Treatment and Care of Older Adults Treatment of Older Adults  Clinicians tend to expect less success in treating older people than in younger people  The views of psychotherapists are paralleled by equally negative views of the elderly endorsed by people in the general population  If older clients were viewed has having limited possibilities for improvement, they may not be treated  Admissions of older adults to hospitals and psychiatric units have decreased substantially in recent years due to changes in mental health policy Nursing and Home care  Most older people needing mental health treatment now live in nursing homes or receive community-based care  Significant and ongoing concerns about the quality of care in nursing homes and this has been exacerbated by some horrific stores of abuse and neglect towards elderly Alternative Living Settings  Dramatic rise in assisted-living or retirement homes, a viable alternative to placement in a nursing home for many older adults who require assistance  Assisted-living facilities resemble hotels with separate rooms and suites for the residents, as well as dining rooms and on-site amenities  Philosophy of assisted living stresses autonomy, independence, dignity and privacy  Many residences are quit luxurious with attentive staff, nursing and medical assistance readily available, daily activities such as bingo and movies, and other services all designed to provide assisted care for older adults too infirm to live on their own

Issues Specific to Therapy with Older Adults  Guidelines for Psychological Practice with Older adults agreed on six areas: (1) attitudes (2) general knowledge about adult development, aging, and older adults (3) clinical issues (4) assessment (5) intervention, consultation, and other service provision (6) education

Content of Therapy  Incidence of brain disorders increases with age but other mental health problems of older adults are not that different from those experienced early in life  Medical illnesses can create irreversible difficulties in walking, seeing and hearing. Finances may be a problem.  Therapy with older adults must take into account the social contexts in which they live, something that cannot be accomplished merely by reading the professional literature  Mental health care workers need to know and understand the social environments in which their older patients live in. many neglect to consider this in older adults  The social needs of older people often different from those of younger people. There is no link between level of social activity and psychological well-being among old people  As we age, our interests shift away from seeking new social interactions to cultivating those few social relationships that really matter to us Process of Therapy  Traditional individual, group, family and marital therapies are effective with older adults  Therapists hold that therapy with older people needs to be more active and directive, and thus they provide information and take the initiative in seeking out agencies for necessary services  Certain kinds of thinking in therapy simply take longer for many older people. Older people also tend to experience some diminution in the number of things that can be held in mind at any one time  Therapists may find that it helps to move with greater deliberation when seeing an older adult  Older adults often receive must more social reinforcement for dependent behaviours  The growing specialization of behavioural gerontology emphasizes helping older people to enhance their self-esteem by focusing on specific, deceptively motor behaviours, such as controlling toileting better, increasing self-care and mobility, and improving telephone skills in order to enhance social contacts  One development though hardly a formal therapy, involves teaching older adults computer skills so that they can access the internet and expand their social contacts  Therapists must be able to interpret the facial expressions of these adults and understand the meaning of their words and reactions