MENTAL ILLNESS

• • • • ADULT PSYCHOPATHOLOGY Definitions of mental health vs. illness vary: culture: great variability SES (a rich man is eccentric, a poor one is mad) age: more acceptance of ‘odd’ behaviours in the elderly gender: different cultural expectations, less tolerance of deviance in women

• • • ADULT PSYCHOPATHOLOGY (Cont’d) Ideal vs. real mental health (e.g. text) Difference between stress and coping mechanisms, which can sometimes be maladaptive, and full blown mental illness.

Change is always stressful, individual variation in optimal levels of stress.

Summation of stresses as we age: depletion of coping resources vs. development of better coping strategies.

• • • • • • ADULT PSYCHOPATHOLOGY (Cont’d) Important personal variables: past history personality social supports SES locus of control (women, poor and elderly more external) longevity (higher incidence)

ADULT PSYCHOPATHOLOGY (Cont’d) Bottom line criterion for mental illness: • inability to function Importance of label, stigma • Relative influence of nature vs. nurture (heredity/environment): the higher the genetic predisposition, the fewer environmental insults needed to produce mental illness.

• ADULT PSYCHOPATHOLOGY (Cont’d) Most common model of mental illness: • medical model Medical model: a series of culturally unacceptable behaviours is ‘packaged’ into a diagnostic category.

• DSM: no uniform, testable criteria.

• • • • ADULT PSYCHOPATHOLOGY (Cont’d) Each category has: Symptoms (mix of behavioural and physical) • • Underlying cause (etiology) Treatment (can be just palliative or geared to eradicate the cause) Approaches: biological psychological combination of both

ADULT PSYCHOPATHOLOGY (Cont’d) • • Biological approach: organic causes (brain) • treatment: drugs, ECT, surgery Psychological approach: causes: stress, emotions, personality, childhood experiences, poor coping strategies • • • treatment: psychotherapy (rare for the elderly) Combination approach: causes: both organic and environmental treatment: usually drugs and some level of psychotherapy

ADULT PSYCHOPATHOLOGY (Cont’d) • • • • Etiology of mental illness: organic, e.g. Alzheimer's functional or psychic, e.g. phobias organic + environment, e.g. most “problems in living” (Szasz) • • • • Treatments: drugs ECT psychotherapies out vs. inpatient

Brain disorders (

delirium in text – covers only acute disorders

) can be acute or chronic.

Acute: rapid onset, reversible with treatment.

Chronic: slow and gradual onset, degenerative, irreversible.

Acute Brain Disorders: Many possible causes: • • • • • stroke heart attack malnutrition trauma tumors • infections • electrolite imbalance Some symptoms: • confusion • disorganized thinking • • • • • • diabetes thyroid dysfunction liver dysfunction drugs alcohol (Korsakoff syndrome) surgery (anesthesia) • agitation • changes in sensation and perception

Unfortunately, the reversible illnesses are treated as irreversible in the elderly, therefore depriving them of a possible cure.

• • • Chronic Brain Disorders • • Schizophrenia: onset between ages 13 and 30, chronic Delusions: • thought disorders, belief system Hallucinations: • sensory perceptions not based on actual, real stimuli Inappropriate Affect Managed with drugs

• • Depression: Very high incidence all ages. Two types: 1.

Unipolar: depression only, more common in older adults.

2.

Bipolar: alternating depression and mania, also called manic-depression. More common in the young.

Depression can also be: Reactive: acute, short duration, due to events, responds to psychotherapy alone, support.

Chronic: long term, resistant to psychotherapy, often need physical therapies, e.g. drugs, ECT.

• • Drugs: tricyclics, MAO inhibitors, lithium (for bipolar, very toxic to liver and kidneys, increases blood pressure), SSRIs: selective serotonin reuptake inhibitors, e.g. Prozac, Zoloft, Paxil, etc.

Side effects of drugs leads to low compliance. Also danger of drug interactions (potentiate or decrease effect when combined with other drugs) often dangerous.

• • ECT: electroconvulsive therapy, “shock”, memory deficits, brain damage possible. Nobody knows how it works.

• Psychoactive drugs for the elderly: Elderly need lower doses!!

More problematic, as dosages have to be more carefully adjusted, usually downward. Also problem of interaction with other drugs taken for other problems. Polypharmacy.

• • • • • • • • • • • • Some Signs of Depression: dysphoria insomnia fatigue inability to enjoy things that were liked changes in appetite crying jags despair apathy pessimism differences between young and old: young may cover it up better impaired daily functioning negative thoughts, suicidal ideation

• • People with chronic illnesses very vulnerable to depression • • • • • • Some diseases of middle/old age can also cause depression: CV disease brain disorders (Parkinson’s, MS, dementias, etc.) metabolic disturbances (e.g. diabetes, thyroid) cancer post-operatory period many drugs can cause depression and suicide

• • Gender Issues: Gender: women socialized to self-blame, more prone.

Age: depletion syndrome of the elderly, somewhat similar to depression. It increases with age, depression proper decreases.

• • Role of marital status: Before age 65: higher incidence for single men and married women.

After age 65: reverse

• • • Gender Issues (Cont’d): Marriage improves men’s mental health. It negatively affects women’s mental health. This is reversed after age 65.

• • • • • Men more likely to show: ‘acting out’ alcoholism drug abuse criminal behaviour reluctance to seek help but, because of social male stereotypes, more tolerance for the above and less likely to be labelled and stigmatized.

• • Gender Issues (Cont’d): • • • • Women more likely to show: anxiety depression self-blaming intense emotional expression Women more likely to acknowledge problems and seek help, and more likely to be labelled, stigmatized and given psychotropic medication. Influence of feminine stereotypes, powerlessness.

• • • • • Psychotherapy for the elderly: Not common. Most therapists not trained to deal with problems of the elderly.

Higher tolerance for deviant behaviour.

Therapists more interested in YAVIS: (young, attractive, verbal, intelligent, successful) Expense (private or public) Many elderly suspicious or reluctant

• • • • • Organic Brain Disorders: Alzheimer’s Multi-infarct dementia Huntington’s chorea Parkinson's Lewy body dementia

• • • • Alzheimer’s Disease: Chronic, irreversible, degenerative disease of brain.

No known cause, some genetic markers – iffy Type of dementia – brain syndrome • • • Parts of brain involved: amygdala (emotions) hippocampus (memory) cerebral cortex (reason, judgment)

Alzheimer’s – Histological Changes 1.

Amyloid plaques: clusters of protein bits that accumulate, causing inflammation and damaging neurons.

2.

Neurofibrillary tangles: dendrites change structure and disintegrate, leading the neuron to wither and die.

Alzheimer’s Affects Amygdala Hippocampus Cortex Personality Appetites Energy Drives ex: Irritable Fussy Memory Works Back wards Reasoning Judgment Decisions Chronic, Irreversible Death Usual Cause: Pneumonia 8 mo. – 20 years

4 Phases: 1.

Early Changes: • • • • Irritability “Something Wrong” Memory Cover-Ups & Compensations • Hard to Assess Retrospective

4 Phases (Cont’d): 2.

• • • • • Memory Worse Paranoia Odd, Inappropriate Social Behavior Needs Help (eg. banking, bills) Personality Change 3.

• • • Unsafe to Leave Alone Poor Concentration Memory Gone 4.

• • • • • Terminal No Coordination Swallowing difficult or impossible Agitation Bed Ridden

Usual Course

Functionality Time

Assessment methods: 1.

Clinical interview (most common) 2.

3.

4.

Self-report (reliability and validity?) e.g. questionnaire Other’s report (relatives, neighbours) Psychophysiological (psychological stimulus, physiological response) e.g. fearful stimulus-situation and EEG or heart rate

Assessment methods: 5.

Direct observation in situ (e.g. nursing home dining room) 6.

Performance test (e.g. remembering list, drawing a picture after looking at it for 10 seconds)

• • • Critical areas: cognitive functioning social cognition personality Must be preceded by medical exam to rule out diseases or medication effects, and assessment of nutritional status.

• • Genetics important only in early onset of Alzheimer’s (age 30-60) • • • • Increased evidence of some prevention factors: exercise folate low cholesterol low blood pressure • • MCI: mild cognitive impairment, different from Alzheimer’s and different from normal age related memory decline.

Drugs may prevent progression to Alzheimer’s

• • • Multi-Infarct or Vascular Dementia: Reduced blood flow to brain areas, due to either an arterial blockage (+85%) or a hemorrhage (+15%) Either ‘regular’ stroke or ‘mini’ stroke. The latter can go undetected, very brief symptoms: transient ischemic attack (episode) TIA E.g. brief fainting, acute brief headache

• • • • • • Huntington’s Chorea: Autosomal disorder, dominant gene. Test available. Expresses between ages 35 and 50. Physical and mental manifestations (see text) involuntary movements of limbs difficulty with voluntary movement hallucinations paranoia mood swings eventually unable to care for self

• • • • • • Parkinson’s disease: Characteristic: involuntary movements, cannot control but also cannot move some voluntary movements, rigidity.

hallucinations paranoia depression mood swings L-dopa (medication) eventually, cognitive decline genetic test available

• • Neurons in the

substantia nigra

in the midbrain do not produce enough dopamine, an important neurotransmitter.

Initially physical symptoms only. Eventually, up to 40% develop dementia, could be due to the illness or to the drugs given. L-dopa, a synthetic dopamine, causes hallucinations and other psychotic symptoms at certain dosages.

• • • • • • Lewy Body Dementia: abnormal brain structures progressive loss of memory, language, reasoning faster progression than Alzheimer’s more ups and downs than Alzheimer’s in early stages psychotic symptoms as illness progresses

• • • • • Substance abuse: In young adults, mostly by choice, though some by prescription medications.

In middle-aged (particularly women) and old adults, by prescribed medications (tranquilizers, pain-killers, etc.) Very widespread in our society Males: alcohol most common Females: sedatives, hypnotics, psychotropic drugs most common