Psychopathology (Final) Impulse Control Disorders and Schizophrenia Spectrum Disorders

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1

types of Impulse control disorders

  1. Intermittent explosive disorder (IED)
  2. Kleptomania
  3. Pyromania
  4. Pathological gambling
  5. Trichotillomania
  6. Impulse control disorder- NOS (not otherwise specified)
2

Intermittent explosive disorder (IED)

  • impulse control disorder
  • Not the same as conduct disorder
  • Intense angry outbursts that are out of proportion to the stimuli/ context
  • Multiple episodes of failure to resist aggressive impulses; typically result in serious assaultive acts or destruction of property

Example: someone acts out of proportion to a joke/ teasing (might hit someone w a shovel

3

Kleptomania

  • impulse control disorder
  • Irresistible urges to steal even though there is no monetary or personal gain
  • Not shoplifting= this is usually more well plan and done for need/ monetary gain
  • Not accounted for by external motive like hunger
  • Can be consider part of OCD spectrum; there is anticipatory anxiety and thought/ action of stealing reduce this anxiety
  • Not the same as addictive compulsive theft- which is theft is result of anger and is more conscious.
  • Typically feels terrible guilt, remorse, and self loathing after the act
4

Pyromania

  • impulse control disorder
  • Deliberate, purposeful setting of fires on more than one occasion
  • Tension and arousal before the act and relief when fire is set
  • Fascination with fire, how its started, how it burns
  • Not done for gain, for monetary value… just done for thrill
5

Pathological gambling

  • impulse control disorder
  • Persistent and recurrent maladaptive gambling
  • gambling more frequently, or with more money, unsuccessful attempt to cut back, can be an escape for life problems, etc
  • not accounted for by a manic episodes
  • individual may lie to family about it, etc
6

Trichotillomania

  • impulse control disorder
  • Buildup of tension and hair pulling creates relief
  • 1-2% of college students; typically limited to younger children who will outgrow the behavior
7

Impulse control disorder- NOS (not otherwise specified)

  • impulse control disorder
  • Unusual feature of impulse control dx—build up of tension before the behavior, then relief after the behavior and some sort of attempt at control of the behavior
  • People who have impulse control issues but do not fit into the other categories
8

What distinguishes Kleptomania from Addictive Compulsive Theft?

  • Addictive compulsive theft
    • Recurrent failure to resist obsessive, addictive, or compulsive thoughts/ urges to steal objects which are often used even if not needed
    • Already ever0present tension, well before commission of theft
    • Pleasure/ relief at the theft (more conscious of act than kleptomaniac)
    • The stealing is often acting out of anger or a way of “trying to make life right”
    • Most people who steal are good/ caring/ law-abiding citizens
    • DO NOT experience guilt, remorse, self loathing (like in Kleptomania)
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Treatment of IED

  • Counseling/ therapy
    • Psychodynamic psychotherapy
    • CBT
    • Group psychotherapy
    • Marital or family counseling
    • 12-step program
  • Medications
    • SSRIs
    • Mood stabilizers like lithium
    • “major” tranquilizers like clozapine
10

Unproven treatments/medications for IED

  • Beta blockers
  • Decreasing testosterone levels
  • Neurosurgery
11

What are the 4 A's of Schizophrenia (and Schizophrenia Spectrum Disorders)?

  • Association (can’t make appropriate association between items/ things; idea are fragmented)
  • Affect (inappropriate/ blunted in response to stimulation)
  • Autism (general term for a lack of ability to form successful social relationships)
  • Ambivalence (not showing much interaction / motivational engagement with world around them)
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What are the prodromal symptoms of schizophrenia and how are they experienced?

  • These are symptoms that occurred before the actual onset of the dx
  • Termed as attenuated psychosis syndrome
    • Positive symptoms at least once per week in the last month (hallucinations, delusions, disorganize speech, trouble concentrating, movement problems)
    • Onset of symptoms within the past year and worsened within the last year
    • Declining social and role functioning along with sub-threshold psychotic symptoms
    • Motor delays/ abnormalities (often occur in children but then continue on throughout the dx)
13

Evidence-based interventions for Schizophrenia

  • Antipsychotic medications
    • Typical antipsychotic medications
    • atypical antipsychotic medication
  • family therapy
  • social skills training
  • CBT for psychosis (challenge discontinuity between psychotic and normal thinking)
  • Cognitive remediation
14

Antipsychotic medications for Schizophrenia

  • Typical antipsychotic medications= act by clocking activity in the dopamine systems
  • atypical antipsychotic medication= act by blocking dopamine neurotransmission to some extent, and vary in the extend to which they affect serotonin, glutamate, and other NT
15

Cognitive Remediation for Schizophrenia

  • Computerized tasks aimed at enhancing specific cognitive skills (attention, working memory, planning)
  • Basis for this tx: brain is changed by behavior and experience
  • Improved cognitions
  • But mixed findings on if functioning improves
16

What are the three types of behavior that constitute psychosis?

  1. Perceptual disturbances (hallucinations)
  2. Disorganized thinking (expressed thru speech)
  3. Bizarre beliefs (delusions)
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Perceptual disturbances in schizophrenia

  • symptoms of psychosis
  • Impaired reality testing
  • Affecting the senses
  • hallucinations
18

Disorganized thinking in schizophrenia

  • Thought dx- deficiencies in organization and communication
  • Loose associations- shifting from topic to topic
  • Idiosyncratic associations- subjective connections
  • Fragmentation- word salad (literally just doesn’t make sense)
  • Hyperabstraction- really broad and weirdly abstract
19

Bizarre beliefs in schizophrenia

  • Delusions
  • Can have story-like interpretations about the individual that are not based in reality
  • Grandeur- you are a god are married to god
  • Persecution- they are out to get me
  • Reference- being controlled/ influenced by outside forces
20

Argue the necessity/or not of psychosis as a symptom for a schizophrenia diagnosis

  • Psychosis is NOT specific to any particular disorder
    • schizophrenia, schizoaffective disorder, delusional disorder
    • Can be seen in mood disorder (mania and depression) and dissociative disorders
    • Drugs/alcohol, neurological conditions (epilepsy), and medical conditions (kidney disease) can cause psychotic symptoms
  • Necessity of psychosis to schizophrenia
    • Studies have shown that psychotic symptoms don’t really add anything to the diagnosis of schizophrenia (since it can be seen in many dx)
    • Psychosis can be compared to a fever-- a fever is a non-specific indicator of any number of underlying medical conditions. And psychosis is a serious, but non-specific marker, of severe mental illness
    • There may be a separate continuum of psychosis based on genetic liability- those with this liability ay be come psychotic, but this is somewhat independent of disease entities like schizophrenia
21

Psychosis compared to a fever

  • a fever is a non-specific indicator of any number of underlying medical conditions. And psychosis is a serious, but non-specific marker, of severe mental illness
    • indicates that maybe psychosis is not necessary for a diagnosis of schizophrenia... bc psychosis could be indicative of MULTIPLE disorders
22

Genetic causes of schizophrenia

  • Genetic predisposition to schizophrenia
  • Stressors may spark schizophrenia
  • More likely amongst relatives
  • Higher chance of developing it if both parents have it
  • Identical twins have high chance of developing it
23

Biological causes of schizophrenia

  • Viral infection (pregnancy- trimester 2)
    • Causes Lack of acetylcholine in hippocampus; fetal brain has disorganized neurons that lead to disorganized thought processes
  • Genetic theory (chromosome 22 and 6)
  • Ventricular enlargement (poor neuro-transmission resulting in negative symptoms)
  • Dopamine hypothesis (excess dopamine in nigrostriatal pathway)
24

social causes of schizophrenia

  • Double-bind theory – proposed that families and individual are placed in double-bind; they received mutually contradictory messages. What we say and what is implied (nonverbal) are contradicted… this results in confusion of kids and they are placed in this double bind
  • High expressed emotion (HEE) family members express hostility, criticism, and over-involvement in each other’s affairs
25

psychodynamic causes of schizophrenia

  • Schizophrenia form of regression to an earlier (childlike) egocentric existence
  • Schizophrenia as re-establishing ego control
  • May be caused by cold and uncaring relationships
  • Schizophrenogenic (schizophrenia-causing) parenting= very little evidence supports this
  • Child may withdrawal from reality and may develop primary narcissism (egocentric self love)
  • à contemporary= reject Freudian schizophrenogenic in favor of biological explanations
26

Type 1 of Schizophrenia

  • Positive symptoms which include: delusions, hallucinations, incongruent affect, disorganized thoughts (thru speech)
  • Dopamine hypothesis as explanation
27

Type 2 of Schizophrenia

  • Negative symptoms which include: social withdrawal, blunted affect, and apathy
  • Abnormal brain structure as explanation
28

PORT recommendations for schizophrenia treatment

Patient Outcomes Research Tams (PORT) tx recommendations

General conclusions from looking at a large group of cases related to schizophrenia outcomes and conditions that lead to successful outcomes for patients

  1. Antipsychotic medications as first line of treatment; reduces positive psychotic symptoms
  2. Individual and group therapies with combo of support, edu, and behavioral/ cognitive skills training are helpful--> improves functioning and enhance other targeted problems, like medication non-compliance
  3. People with schizophrenia who have contact w family should use a family psychosocial intervention--> lasts at least 3 months, w/ psychoedu, crisis intervention, emotional support, and coping skills training
  4. People w schizophrenia offered supported employment (especially with integrated mental health services)
29

Schizoaffective disorder

  • Disorder with schizophrenia- aspects/ psychosis aspects but with mood disorder aspects
  • Interventions strategies are similar to those of schizophrenia
  • Medication is challenging
    • Anti psychotics
    • Lithium (bipolar type)
    • Anti-depressants (depressive type)
  • Hospitalization sometimes required
  • Prognosis is more positive for those with bipolar type
  • Factors that lead to positive prognosis--> tx compliance, high premorbid functioning, abrupt onset, less severe psychotic symptoms, no family history of schizophrenia