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Suicide

suicide - intentioned death, a self inflicted death in which one makes an intention, direct, and conscious effort to end ones life 
  • suicide is one of the leading causes of death in the world
  • unsuccessful attempts are called parasuicides
  • many investigators believe that estimates are often low
  • many accidents may be intentional deaths
  • since suicide is frowned upon in our society, relatives and friends often refuse to acknowledge that lobed ones have taken their own lives
  • it is not classified as a mental disorder as of now
  • it is frequently linked to depression
  • around half of all suicides result from other mental disorders or have no clear mental disorder at all
  • (self injury or self mutilation)
Suicide Seekers (shneidman)
1. death seekers: clearly intend to end their lives
2. Death initiators: intend to end their lives because they believe that the process of death is already underway
3. death ignorers: do not believe that their self inflicted death will mean the end of their existence
4. death darers: have ambivalent feelings about death and show this in the act itself 
(5). subintentional death: when individuals play indirect, hidden, partial, or unconcious roles in their own deaths
Suicide Researchers
  • their subjects are no longer alive
  • two strategies to overcome this obstical (with partial success):
  • 1. retrospective analysis - a kind of psychological autopsy
  • 2. Studying people who survive their suicide attempts

Some differences in suicide rates from country to country with religious devoutness

suicide rates of men and women also differ:
  • women 3X men for attempt but men 4X women for completion (due to method)

also related to social environment and marital status
  • many have no close friends
  • dicorced people have a higher rate than married or cohabitating 

U.S. varies according to race
  • white americans twice as high except when it comes to native americans 
Cause/Triggers
  • more stressful events in their lives
  • combat stress is very high
  • both immediate and long term stressors are risk factors
  • mood and thought changes (psychache - feeling of psychological pain that seems intolerable)
  • drugs and alcohol
  • modeling
  • mental disorders

Long term stressors:
  • social isolation
  • serious illness
  • abusive environments
  • occupational stress (helping professions) 

patterns of thinking
  • become preoccupied, lose perspective, and see suicide as the only effective solution
  • develop a sense of hopelessness
  • either/or terms
  • "suicide was the ONLY thing I could do"

those with mood disorders, substance use disorders, and/or schizophrenia are at greatest risk

HOWEVER
  • most people faced with difficult situations never try to kill themselves 
underlying causes of suicide
Psychodynamic
  • results from depression and anger at others that is redirected toward oneself
  • humans have basic death instinct that operates in opposition to the life instinct - while most people learn to direct their death instinct toward others, suicidal people direct it toward themselves
 Sociocultural
  • determined by how attached a persion is to such social groups as the family, religious institutions, and community
  • the more a person belongs the lower the risk of suicide 
  • egotistic suicides - commited by people over whom society has little or no control
  • altruistic suicides - commited by people who are so well integrated into their society that they intentionally sacrifice their lives for its well-being
  • anomic suicides - committed by people whose social environment fails to provide stable structures that support and give meaning to life (also a major change to the individuals immediate surroundings)

Biological view
  • family pedigree and twin studies support 
  • serotonin levels (also contribute to depression, aggressive and impulsive behaviors)
Other Links
Age?
  • increases with age
  • children, adolescents, elderly (most focus)

Children
  • infrequent among children 
  • boys outnumber girls
  • preceded by behavioral patterns such as running away, accident proneness, temper tantrums, self criticism, social withdrawal, dark fantasies, and marked personality changes
  • based on a clear understanding of death and a clear wish to die

Adolescents
  • Suicidal actions more common 
  • tied to clinical depression, low selfesteem, feelings of hopelessness
  • anger impulsiveness, poor problem solving, substance use, and stress
  • far more attempted than succeeded
  • vary by ethnicity

The elderly
  • most likely to commit suicide than any other age group
  • illness, loss of close friends, loss of control over life, loss of social status 
  • more determined than younger persons in their decision to die
Treatments
two categories:

treatment after suicide has been attempted
  • medical care
  • psychotherapy or drug therapy
  • therapy goals: keep them alive, reduce psychological pain, help acheive a non suicidal state of mind and sense of hope, guide them to develop better coping styles
  • cognitive and cognitive behavioral therapies are helpful
suicide prevention
  •  hotlines
  • programs
  • general approach - establish positive relationship, understand and clarify the problem, assess suicide potential, assess and mobilize the callers resources
  • formulate a plan

EDUCATE
Eating Disorders
western society
  • thinness is beauty
  • morbid fear of weight gain
two main diagnosis
1. anorexia nervosa - a refusal to maintain more than 85% of normal body weight, intense fears of becoming overweight, distorted view of weight and shape, amenorrhea
  • restricting type - lose weight by cutting out sweets and fattening snacks, eliminating all food
  • binge eating/purging - lose weight by forcing themselves to vomit or using laxatives *may engage in eating binges

peak age of onset is 14-18
most patients recover
can become ill and die (medical complications)
may commit suicide 
main goal is to be thin - fear of obesity, giving into desire to eat, losing control of body size and shape 
very preoccupied with food - reading and thinking about it, planning for meals 
medical problems occur - low body temp, low blood pressure, body swelling, reduced bone density, poor circulation, dry skin and brittle nails 
2. bulimia nervosa- bouts of uncontrolled overeating during a limited period of time
innapropriate compensatory behaviors
  • purging type - forced vomiting, misusing laxatives, diuretics, or enemas
  • non purging - fasting, exercising frantically

mostly occurs in femals
15-21 years
may last for several years with periodic let up 
patients generally of normal weight - weight fluctuations
binge eating disorder - binge eating with no compensatory behaviors (such as vomiting) 
many teenagers go on experiments after hearing about it 
between 1 and 30 binge episodes per week 
great tension and/or powerlessness
binge is pleasurable followed by guilt, self-blame, depression, and fears 
vomiting - fails to prevent the absorption of half the calories consumed during a binge, repeated vomiting affects the ability to feel satiated
laxatives - also fails to reduce number of calories consumed 
Similarities/differences

similarities
  • begin after a period of dieting
  • fear of becoming obese
  • drive to become thin
  • preoccupation with food, weight, appearance
  • feelings of anxiety, depression, obsessivenss, perfectionism
  • heightened risk of suicide attempts
  • substance abuse
  • distorted body perception
  • disturbed attitudes toward eating

differences
  • people with bulemia more concerned about pleasing others, being attractive to others, and having intimate relationships
  • people with bulemia tend to be more sexually experienced and active
  • people with bulemia are more likely to have histories of mood swings, low frustration tolerance, and poor coping 
  • personality disorder characteristics in those with bulemia
  • damage due to vomiting and laxatives in those with bulemia
causes
multidimensional risk perspective
  • psychological problems *ego, cognitive, and mood disturbances
  • biological factors
  • sociocultural conditions * societal, family, multicultural 

psychodynamic
  • result of disturbed mother-child interactions that lead to serious ego deficiencies in the child and to severe perceptual disturbances 
  • may respond effectively (accurately attended to biological and emotional needs) or ineffectively (feed when child is anxious, comfort when child is tired)

Cognitive
  • negative self judgement based on body shape and weight 
  • depression/negative thinking

mood disorders
  • set the stage for eating disorders
  • major depressive disorders
Biological
  • are helped by antidepressent meds
  • relatives of people with eating disorders are 6 times more likely to develop it themselves
  • genes
  • serotonin abnormalities
  • dieters can end up in a battle against themselves to lose weight

Societal pressures
  • western standards of attractiveness 
  • models, actors, dancers, gymnasts, athletes
  • higher SES = greater risk

Family environment
  • history of emphasizing thinness
  • mothers of those with eating disorders are likely to be dieters and perfectionistic themselves 
  • abnormal interactions and forms of communication
  • enmeshed family patterns - over involvement, overconcern

racial and ethnic differences
  • white americans and hispanics more than african americans
  • have different ideals about beauty
  • african americans becoming more so because of acculteration 

Gender 
  • mostly women
  • double standard for attractiveness
  • men are more likely to exercise
  • women more likely to diet 
  • men develop eating disorders as linked to requirements - jockeys, wrestlers, distance runners, body builders, swimmers
  • men may have reverse anorexia nervosa or muscle dysmorphobia
treatments for anorexia
two main goals
1. correct dangerous eating patterns
2. address broader psychological and situational factors that have led to and are maintaining the eating problem
  • often requires participatoin of family and friends 

goals
  • regain lost weight
  • recover from malnourishment
  • eat normally again 

setting
  • used to take place in a hospital, now offered in day hospitals or outpatient setting
may use rewards for when patients eat properly or gain weight
may have to force feed in severe cases (distrust and power stuggle here) 

supportive nursing care, nutritional counseling, and high calorie diets
necessary weight gain is often achieved in 8 to 12 weeks 

psychotropic drugs, education, therapy 
behavioral and cognitive intervention
  • monitor feelings, hunger levels, and food intake
  • identify core pathology 
  • recognize need for independence and control
  • correct disturbed cognitions
treatments for bulimia
offered in eating disorder clinics
immediate aims
  • eliminate binge purge patterns
  • establish good eating habits
  • eliminate the underlying cause of bulimic patterns
emphasize education as much as therapy
  •  cognitive behavioral therapy
  • diaries
  • exposure and response prevention is used to break the binge purge cycle
  • cognitive techniques - help them recognize maladaptive attitudes toward food, eating, weight, and shape and teach individuals to identify and challenge negative thoughts

other therapies
  • interpersonal therapy - improve interpersonal functioning  
  • psychodynamic
  • antidepressants

left untreated can last for years
relaps can be a significant problem *triggered by stress
  • more likely of those who had a longer history of symptoms
  • vomited frequently
  • histories of substance use
  • have lingering interpersonal problems 
sexual disorders
two categories:

1. sexual dysfunctions: problems with sexual responses

2. paraphilias: repeated and intense sexual urges and fantasies in response to socially inappropriate objects or situations
sexual dysfunctions
  • disorders in which people cannot respond normally in key areas of sexual functioning
  • very distressing and often lead to sexual frustration, guilt, loss of self esteem, and interpersonal problems
  • many patients with one dysfunction experience another as well

sexual response is described as a cycle with four phases
1. desire
2. excitement
3. orgasm
4. resolution
sexual dysfunctions affect one or more of the first three phases 

sexual dysfunction can be life long
for others, normal sexual functioning preceded the disorder (aquired type)
in some cases the dysfunction is present during all sexual situations (generalized type)
in some cases it is tied to particular situations (situational type)
Disorders of desire
consists of an urge to have sex, sexual fantasies, and sexual attraction to others
two dysfunctions affect this phase
1. hypoactive sexual desire disorder
  • lack of interest in sex and little sexual activity *physical response may be normal
2. sexual aversion disorder
  • characterized by total aversion to and disgust of sex
  • sexual advances may sicken, repulse, and or frighten
  • rare in men and somewhat more common in women 

a persons sex drive is determined by a combination of biological, psychological, and sociocultural factors
most cases of low sexual desire or aversion are caused by sociocultural and psychological factors 
biological causes
  • a number of hormones interact to produce sexual desire and behavior
  • sex drive can be lowered by some medications (birth control, pain meds),psychotropic drugs, illegal drugs, and chronic illness 

psychological causes
  • a general increase in anxiety, depression, or anger
  • fears, attitudes, and memories
  • certain psychological disorders including OCD, depression

sociocultural causes
  • attitudes, fears,a nd psychological disorders that contribute to sexual desire disorders occur within a social context
  • feeling situational pressures *divorce, death, job stress, infertility
  • cultural standards
  • trauma *sexual molestation or assault 
Disorders of excitment
  • marked by changes in pelvic region, general physical arousal, and increases in heart rate, muscle tension, blood pressure, and rate of breathing
  • in men - erection
  • in women - swelling of the clitoris and labia and vaginal lubrication

two dysfunctions affect this phase
1. female sexual arousal disorder
  • characterized by persistent inability to maintain proper lubrication or genital swelling during sexual activity
  • many with this disorder also experience desire or orgasmic disorders
2. male erectile disorder 
  • characterized by persistent inability to attain or maintain an adequate erection during sexual activity
  • according to surveys, half of adult men have erectile difficulty during intercourse at least some of the time
  •  most cases of erectile disorder result from an interaction of biological, psychological, and sociocultural processess

Biological causes
  • hormonal embalances
  • vascular problems
  • damage to nervous system
  • use of medications 

psychological causes
  • performance anxiety and the spectator role (instead of being a participator he becomes a spectator) 

sociocultural causes
  • job and marital stress 
Disorders of Orgasm
  • sexual pleasure peaks and sexual tension is released as the muscles in the pelvic region contract rythmically
  • for men - semen is ejaculated
  • for women - the outer third of the vaginal walls contract

three disorders of this phase
1. rapid or premature ejaculation
  • persistent reaching of orgasm and ejaculation with littl esexual stimulation
  • psychological and particularly behavioral explanations of this disorder
  • typical of young, sexually inexperienced men
  • may be related to anxiety, hurried masturbation, or poor recognition
  • some men may be born with a genetic pre-disposition, may have greater sensitivity or nerve conduction, and may have faulty serotonin receptors
2. male orgasmic disorder
  • repeated inability to reach orgasm, or very delayed orgasm
  • low testosterone, nuerological disease, and head or spinal cord injury
  • medications can also slow it down
  • performance anxiety and spectator role
  • masturbation habits
3. female orgasmic disorder 
  • persistent delay in or absense of orgasm
  • women who are more sexually assertive and more comfortable with masturbation tend to have orgasms more regularly
  • more common in single women
  •  orgasm is not mandatory for normal sexual function (lack of used to be considered pathological)
  • typically linked to female sexual arousal disorder
  • biological - physiological conditions such as diabetes, medications and illegal substances, postmenopausal changes
  • psychological - depression, memories of childhood trauma, relationship distress
  • sociocultural causes - restrictive cultural messages?, unusually stressful events, traumas, or relationships may produce the fears, memories and attitudes
Disorders of sexual pain
do not fit into a specific phase of the response cycle
1. vaginismus
  • involuntary contractions of the muscles of the outer third of the vagina
  • some clinicians think that it is a learned fear response from anxiety, ignorance, exaggerated stories, trauma from an unskilled partner or trauma from childhood abuse or adult rape
  • some women experience painful intercourse because of infection or disease
  • many often have other sexual disorders
2. dyspareunia
  • severe pain in the genitals during sex
  • both men and women
  • in women usually has a physical cause such as injury sustained in childbirth
  • psychological factors alone are rarely responsible 
Treatments for sexual dysfunctions
early 20th century psychodynamic
  • produced by failure to go through psychosexual stages of development
  • therapy focused on gaining insight and making broad personality changes; often unhelpful 

1950's 60's - behavioral
  • reduce fear by applying relaxation training and systematic desensitization
  • some success 

1970 - human sexual inadequacy
  • techniques from many therapies and sex specific techniques
  • biological interventions more recently being added 

modern sex therapy
  • short term
  • instructive
  • centered on specific sexual problems rather than on broad personality issues
  •  assessment and conceptualization of the problem
  • mutual responsibility
  • education
  • emotion identification
  • attitude change
  • elimination of performance anxiety
  • increasing communication skills
  • changing destructive lifestyles and marital interactions
  • addressing physical and medical factors
Specific techniques to specific dysfunctions
hypoactive sexual desire and sexual aversoin
  • most difficult to treat because many issues that feed them
  • combination of techniques
  • affectual awareness, self instruction training, behavioral techniques, insight oriented expercises and biological interventions 

erectile disorder
  • sensate focus exercises
  • biological (viagra) 

male orgasmic disorder
  • reduce performance anxiety
  • medication 

rapid or premature ejaculation
  • behavioral procedures
  • antidepressents 

female arousal and orgasmic disorders
  • cognitive behavioral techniques, self exploration, enhancement of body awareness, and directed masturbation training
  • biological treatments including hormone therapy 

vaginismus
  • practice tightening and releasing muscles
  • overcome fear of penetration through behavioral exposure treatment 

dyspareunia
  • determine specific cause
  • medical intervention 
Paraphilias
three disorders characterized by intense sexual urges, fantasies, or behaviors that involve: children, nonhumans, nonconsenting adults, and the experience of suffering or humiliation
  • must be occuring at least 6 months
  • must cause distress or interfere with ones functioning
  • performance of sexual contact with children however would need to be fixed/stopped immediately even if it is not distressing or interfering with the individual
  • not that many people recieve a formal diagnosis but patterns may be quite common
  • should only be considered a disorder when it is the sole means of achieving sexual excitement or orgasm
  • psychological and sociocultural treatments have been available the longest but also using biological interventions today
fetishism
  • recurrent intense sexual urges, sexually arousing fantasies, or behaviors that involve the use of a nonliving object, often to the exclusion of all other stimuli
  • far more common in men
  • usually begins in teens
  • almost anything can be a fetish (boots)
  • a defense mechanism?
  • behaviorists sat its learned through classical conditioning - sometimes treated with aversion therapy, orgasmic reorientation (appropriate stimulation)
transvestic fetishism
  • cross dressing
  • fantasies, urges, or behaviors involving dressing in the clothes of the opposite sex in order to achieve sexual arousal
  • usually a hetero male who began cross dressing in childhood or teens
  • follows behavioral patterns of operant conditioning
exhibitionism, voyerism, frotteurism
arousal from the exposure of genitals in public
  • flashing
  • usually no sexual contact is initiated nor desired
  • usually begins before 18
  • mostly males
  • includes aversion therapy and masturbatory satiation
  • social skills training 

voyerism
  • repeated and intense sexual urges to observe and spy on people as they undress or have sex
  • may masturbate while its happening or remember it for later
  • risk of discovery is a plus 
  • may be seeking power (psychodynamic)
  • learned behavior from secret observation (behaviorists)

frotteurism
  • rubbing and touching a nonconsenting person
  • almost always male
  • fantasizing during the event that he is having a caring relationship with the victim
  • usually begins in teens
  • disappear or decrease after 25 
pedophilia
want to have sexual contact with those 13 or younger
  • some satisfied with child porn
  • others like to watch, fondle or engage
  • two thirds of victims are female 
  • develop the disorder in teens
  • some sexually abused as children
  • immature
  • distorted thinking and have an additional psychological disorder
  • brain structure abnormality
  • most are imprisoned or forced into treatment
  • aversion therapy, orgasmic reorientation, antandrogen drugs
  • cognitive and behavioral treatment as well
sexual masochism and sexual sadism
masochism:
wanting to be humiliated, beaten, bound, or made to suffer
begin in childhood and develop through the behavioral processess of classical conditioning

sadism:
find the thought of psychological or physical suffering of a victim sexually exciting
appear in childhood or teens
long term
related to classical conditioning and or modeling
underlying feelings of sexual inadequecy???
brain abnormalities???

Gender identity disorder
  • persistently feel that they have been assigned the wrong biological sex and gender changes would be desirable
  • they experience gender dysphoria and often seek treatment
  •  some argue it is a medical problem that may produce personal unhappiness
  • may reflect alternative, not pathological, ways of experiencing ones gender identity
  • would like to get rid of primary and secondary sex characteristics and acquire those of the other sex
  • men outnumber women
  • often experience anxiety or depression and may have thoughts of suicide
  • sometimes emerges in childhood and dissappears with adolescence
  • may develop into adult gender identity disorder
  • may be biological (abnormalities in brain, genetics)

common patterns
  • female to male
  • male to female - androphilic
  • male to female - autogyneophilic
some change by way of hormones, others opt for surgery, most are in therapy   
Psychosis
a state defined by a loss of contact with reality
  • the ability to perceive and respond to the environment is disturbed
  • symptoms: hallucinations and or delusions *false beliefs
  • may be substance induced
  • may be caused by brain injury
  • most psychoses appear in the form of schizophrenia 
schizophrenia
affects 1 in 100 people
  •  increased risk of suicide
  • increased risk of physical, often fatal, illness
  • appears in all SES groups
  • some say the stress of poverty causes the disorder, while others argue that the disorder causes victims from higher social levels to fall to lower social levels (downward drift theory)
  • equal numbers of men (21 years) and women (27 years)
  • highest among divorced or separated people

clinical outlook on schizophrenia
  • the symptoms, triggers, and course of schizophrenia vary greatly
  • some say schizophrenia is a group of distinct disorders that share common features 
Three Categories
category 1: positive symptoms
pathological excesses are bizarre additions to a persons behavior

delusions: faulty interpretations of reality 
  • being controlled by others, persecution, reference, grandeur
Disordered thinking and speech
  • loose associations, neologisms (made up words), perseverations (repetition), and clang (rhymes) 

Heightened perceptions
  • feel like their senses are being flooded by sights and sounds
Hallucinations: sensory perceptions that occur in the absence of external stimuli
  • most common are auditory
  • can involve any of the senses 

Inappropriate affect
  • emotions that are unsuited to the situation 
Three categories
category 2: negative symptoms
pathological deficits are characteristics that are lacking in an individual

poverty of speech
  • reduction of quantity or content
  • may say a lot but have little meaning 

Blunted and flat affect
  • less emotion
  • avoidance of eye contact
  • immobile or expressionless face
  • monotone, low, difficult to hear voice
  • anhedonia - general lack of pleasure 

Loss of volition
  • feeling drained of energy and interest
  • inability to start or follow through on a course of action
  • ambivalence - conflicted feelings
Social withdrawal
  • may withdraw from social environment and attend only to their ideas and fantasies
  • leads to breakdown of social skills, including the ability to accurately percieve other peoples needs and emotions 
three categories
category 3: psychomotor symptoms
  • awkward movements, repeated grimaces, odd gestures
  • movements seem to have a magical quality
  • may take extreme form *catatonia
Course of schizophrenia
usually first appears between the late teens and mid 30's

experience 3 phases:
1. prodromal - begining of deterioration; mild symptoms
2. active - symptoms become apparent
3. residual - a return to prodromal like levels

1/4 of patients fully recover 
each phase of the disorder may last for days or years

fuller recovery in those:
  • with good premorbid functioning
  • whose disorder was triggered by stress
  • with abrupt onset
  • with later onset
  • who receive early treatment 

diagnosis only given after 6 months or more
people must also show a deterioration in their work, social relations, and the ability to care for themselves 
5 subtypes
Disorganized
  • characterized by confusion, incoherence, and flat or inappropriate affect
Catatonic
  • psychomotor disturbance of some sort
Paranoid
  • characterized by an organized system of delusions and auditory hallucinations
Undifferentiated
  • symptoms which fit no subtype
Residual
  • symptoms which have lessened in strength and number
  • persons may continue to display blunted or inappropriate emotions as well as social withdrawal, eccentric behavior, and some illogical thinking 


There is also a type 1 and type 2
type 1: dominated by positive symptoms
  • seem to have better adjustment prior to the disorder, later onset of symptoms, and a greater liklihood of improvement
  • may be linked more closely to biochemical abnormalities
type 2: dominated by negative symptoms
  • may be tied to structural abnormalities in the brain 
Theorists and schizophrenia
Biological has recieved most research
  • predisposition coupled with certain stressors or events 
  • genetics - more common in those with relatives who have the disorder
  • gene defects
  • biochemical abnormalities - certain neurons using dopamine fire too often; antipsychotics are antagonists that bind to receptors preventing dopamine binding and neuron firing
  • abnormal brain structure: enlarged ventricles; smaller temperol and frontal lobes; viral problems

psychodynamic
  •  regression to pre-ego stage
  • efforts to re establish ego control
  • the regression leads to the loose associations, delusions of grandeur, and neologisms
  • schizophrenic mothers

Behavioral
  • operant conditioning and reinforcement as cause
  • not reinforced for their attention to social cues and as a result stop attending to those social cues and start to focus on irrelevent cues 

cognitive view
  • agree that biological factors produce the symptoms
  • further features come from the faulty interpretation and misunderstanding of the symptoms 

sociocultural
  • multicultural factors
  • social labeling (self fulfilling prophecy)
  • family dysfunction (contradictory messages "double bind situations" where the parent is saying one thing but nonverbally saying another ) - can progress toward paranoid schizophrenia
  • RD laing: constructive process in which people try to cure themselves of the confusion and unhappiness caused by their social environment; left alone to complete the process they will achieve a healthy outcome
Institutional care in the past
  • overcrowding
  • understaffing
  • poor patient outcome - backward human warehouses filled with hopelessness
  • social breakdown syndrome: extreme withdrawal, anger, physical aggressiveness, loss of interest in personal appearance and functioning
1950's and antipsychotics
  • two new approaches
  • milieu therapy (humanistic): creating a social climate that promotes productive activity, self respect, and individual responsibility
  • token economy (behavioral): rewarded when they behave in socially acceptable ways and not rewarded when behave unacceptably

both helped improve self-image and personal care of patients


antipsychotics also came around in the 1950's 
those developed in 60's, 70's, and 80's are considered conventional antipsychotic drugs
  • also known as neuroleptic because produce undesired movement effects
drugs developed in more recent years are refered to as atypical or second generation antipsychotics

drugs produce the max level of improvement within the first 6 months of treatment 
reduce positive symptoms more quickly and completely then the negative ones 

extrapyramidal effects
  • medication induced movement disorders
  • tremors, rigidity, bizzare movements of face, neck, tongue, and back, restlessness, agitation, and discomfort in the limbs (parkinsons symptoms) 
  • sometimes the dosage just needs to be decreased, sometimes it must be stopped
  • antiparkinsons drugs can be taken with it

neurological malignant syndrome
  • muscle rigidity, fever, altered consciousness, improper functioning of the ans
  • drug needs to be stopped!
tardive dyskinesia
  • writhing and tic-like movements
  • difficult, sometimes impossible to eliminate 

atypical are better then the conventional but can cause a fatal drop in white blood cells and can cause weight gain, dizziness, and elevations of blood sugar
psychotherapy for schizophrenia
most too far removed from reality for it to help (before meds were around)
most helpful forms are cognitive behavioral, family therapy, and social therapy 

cognitive behavioral
  • change their view and reactions to their hallucinatory experiences
  • provide education and evidence of biological causes
  • help them learn about the comings and goings of the delusions and hallucinations
  • challenges the clients inaccurate ideas about the power of their hallucinations
  • teach clients to more accurately interpret their hallucinations
  • teach coping techniques
  •  accept streams of problematic thoughts
  • gain a greater sense of control and become more functional

family therapy
  • over half live with family members
  • creates stress
  • at greater risk for relapse when living with a family who displays high levels of expressed emotions 
  • address the issues, create realistic expectations, provide education

social therapy
  • practical advice, problem solving, decision making, social skills training, medication management, employment counceling, financial assistance, and housing
  • reduces re-hospitalization 

the community approach
  • broad
  • patients should be able to recieve care within their own communities rather than an institution
  • however, community care is inadequate
  • result: revolving door syndrome 
effective community care
coordinated services - community mental health centers that provide therapy, medication, and inpatient emergency care
short term hospitalization - after being treated for a few weeks in hospital patients released to an aftercare program for follow up in the community 
partial hospitalization - day center programs; daily supervised activities and programs to improve social skills 
supervised residences - halfway houses (staff are usually paraprofessionals, run with milieu therapy) help those to adjust to community life and avoid rehospitalization 
occupational training and support - in a sheltered workshop, a supervised workplace for employees who are not ready for competitive or complicated jobs
community treatment has failed
poor coordination of services
to combat this community therapists are becoming case managers for people suffering from schizophrenia
  • offer therapy and advice, teach problem solving and social skills, and ensure compliance with meds
  • try to coordinate available community services and guide them through the system and protect their legal rights 

shortage of services
Personality
a unique, long term pattern of inner experience and outward behavior
it is usually consistent and often is described in terms of "traits"
traits can be inherited, learned, or both
personality is flexible, allowing us to learn and adapt to new environments
**those who have a personality disorder, the flexibility is usually missing 

The disorder is...
  • inflexible pattern of inner experience and outward behavior
  • the rigid traits of people with these disorders often lead to psychological pain for the individual and social or occupational difficulties
  • may also bring pain to others 
  • usually becomes recognizable in adolescence or early adulthood
  • among the most difficult to treat
  • many sufferers are not even aware of their personality disorder
  • patterns not marked by changes in intensity or periods of clear improvement
  • usually also marked with another disorder - called comorbidity
  • the presence of a personality disorder complicates and reduces a persons chances for successful recovery
3 categories
Category 1: odd or eccentric behavior
display behaviors similar to but not as extensive as schizophrenia
  • extreme suspiciousness, social withdrawal, and peculiar ways of thinking and perceiving things
  • such behaviors leave the person isolated
  • some clinicians believe that these disorders are related to schizophrenia and call them "schizophrenia spectrum disorders" 
  • people with these disorders rarely seek treatment

PARANOID PERSONALITY DISORDER
  • deep distrust and suspicion of others
  • although inaccurate, the suspicion is usually not delusional
  • the individual is not removed from reality
  • often remain cold and distant as a result of the mistrust 
  • critical of weakness and fault in others, particularly at work
  • unable to recognize their own mistakes and extremely sensitive to criticism
  • blame others for the things that go wrong in their lives and bear grudges
  • Psychodynamic - back ro early interactions with parents; Cognitive - maladaptive assumptions such as people are evil; Biological - genetic causes
  • not really any treatment because people rarely come and if they do they distrust their therapists
  • behavioral try to help clients control anxiety and improve interpersonal skills, drug therapy is limited, and object relations therapists try to see past anger and work on the underlying wish for a satisfying relationship

SCHIZOID PERSONALITY DISORDER
  • persistent avoidence of social relationships and limited emotional expression
  • withdrawn, reclusive, no close ties, genuinely prefer to be alone
  • focus mainly on themselves and are often seen as flat, cold, humorless, and dull 
  • linked to an unsatisfied need for human contact (abusive or unaccepting parents); deficiencies in their thinking (vague empty thoughts)
  • unless some other disorder brings them to therapy they probably wont end up there
  • cognitive therapy focuses on thinking about emotions, behavioral on teaching social skills, group therapy is useful as a safe environment for social contact, and drug therapy is of little benefit

SCHIZOTYPAL PERSONALITY DISORDER
  • range of interpersonal problems, marked by extreme discomfort in close relationships, odd or even bizzare ways of thinking, and behavioral eccentricities
  • may have ideas of reference or bodily illusions
  • have great difficulty keeping their attention focused
  • conversation is digressive and vague and has loose associations 
  • tend to drift aimlessly and lead an idle unproductive life
  • believe this has similar factors that are at work with schizophrenia - linked to family conflict and psychological disorders in parents and some of the same biological factors (high dopamine activity)
  • also linked to depression and mood disorders
  • therapy: evaluate thoughts and perceptions, provide social skills training, need to help them reconnect and recognize the limits of their thinking and powers
  • drugs are somewhat helping in certain thought problems
3 categories
category 2: dramatic
so dramatic and emotional or erratic that it is almost impossible for them to have relationships that are truely giving or satisfying
more commonly diagnosed than the others
causes are not well understood 

ANTI SOCIAL PERSONALITY DISORDER
  • psychopaths or sociopaths
  • disregard and violate others rights
  • most linked to criminal behavior (aside from substance related disorders)
  • the person must be at least 18 yrs old to recieve this diagnosis
  • likely to lie, be reckless, and impulsive
  • sadistic, aggressive, cruel, and violent 
  • high amount in prison populations
  • higher rates of alcoholism and other substance related disorders among this group
  • children with ADHD and conduct disorder have a heightened risk
  • psychodynamic - absence of love and basic trust
  • behaviorists - learned through modeling or unintentional reinforcement
  • cognitive - hold attitudes that trivialize the importance of other peoples needs
  • biological - low serotonin impacting impulsivity and aggression, lower levels of anxiety and arousal
  • ineffective treatments - most forced into treatment
  • attempted to create theraputic communities in prisons and hospitals

BORDERLINE PERSONALITY DISORDER
  • great instability including shifts in mood, unstable self image, and impulsivity
  • interpersonal relationships are unstable
  • prone to bouts of anger which can result in physical aggression and violence
  • can direct this anger and harm at themselves
  •  alcohol and substance abuse, reckless behavior, self injury, suicidal actions and threats
  • form intense conflict ridden relationships while struggling with fear of abandonment
  • reach peak of instability and suicide at young adulthood
  • psychodynamic - early relationships with parents
  • biological - overly reactive amygdala, lower brain serotonin activity
  • a mix of internal and external forces
  • psychotherapy can help a little - dbt
  • meds

HISTRIONIC PERSONALITY DISORDER
  • attention getting behavior, act like they are always on stage
  • approval and praise are the lifeblood
  • often described as vain, self centered and demanding
  • some attempt suicide often to manipulate others
  • psychodynamic - cold parents 
  • cognitive - lack of substance and extreme suggestibility; helpless to care for themelves so they seek others that can meet their needs
  • sociocultural - caused by norms and expectations
  • more likely to see treatment on their own - however will be demanding, seductive, and have tantrums
  • cognitive - change beliefs that they are helpless
  • drug therapy is less successful

NARCISSISTIC PERSONALITY DISORDER
  • generally grandiose, need admiration, and feel no empathy
  • exaggerate their achievements and talents and often appear arrogant
  •  not interested in the feelings of others and take advantage of others to achieve their own goals
  • psychodynamic - cold, rejecting parents
  • cognitive - may result when people are treated too positively in early life, taught to over value their self worth
  • usually do not go to therapy unless for a related disorder
  • may try to manipulate therapist
3 categories
category 3: anxious
people with these disorders display anxious and fearful behavior
no direct links to this and anxiety or depressive disorders
treatments are modeslty and moderately helpful 

AVOIDANT PERSONALITY DISORDER
  • very uncomfortable and inhibited in social situations, overwhelmed by feelings of inadequacy, and extremely sensitive to negative evaluation
  • unappealing or inferior and have few close friends
  •  similar to social phobia, and many with one experience the other
  • similarities include fear of humiliation and low self confidence
  • difference - social phobias mainly fear social circumstances where as those with avoidant personality disorder fear close social relationships
  • theorists assume - early trauma, conditioned fears, upsetting beliefs, and biochemical abnormalities
  • come to therapy seeking acceptance and affection - later avoid sessions, important to gain trust and then treat it like a social phobia or anxiety disorder
  • meds sometimes help

DEPENDENT PERSONALITY DISORDER
  • pervasive, excessive need to be taken care of
  • clingy, obedient, fear seperation
  • rely on others, they cannot make decisions by themselves
  • feel distressed, lonely, sad, dislike themselves
  • at risk for depression, anxiety, suicide, eating disorders 
  • psychodynamic - early parental loss or rejection
  • other theorists argue overprotective or overinvolved parents
  • behaviorists - parents unintentionally reward clingy behavior and punish acts if independence; also may have modeled the behaviors
  • two maladaptive attitudes: I am inadequate and helpless, and I must find a person to provide protection
  • in therapy they rely soley on the therapist, they need to instead accept responsibility for themselves
  • group therapy, cognitive behavioral therapy, some meds

OBSESSIVE COMPULSIVE PERSONALITY DISORDER
  • preoccupied with order, perfection and control - no openness or flexibility
  • unreasonably high standards for themselves and others
  • fear making decisions because of fear of making a mistake
  • rigid and stubborn
  • trouble expressing affection and their relationships are often stiff and superficial 
  • no link found between this and OCD
  • freud - anal regressive (harsh toilet training, angry and fixaated on this stage)
  • do not usually believe that there is anything wrong with them
  • unlikely to seek treatment unless suffering from another disorder
  • success with SSRI's and psychodynamic or cognitive therapy
problems
some of the diagnositc criteria cannot be observed directly, relying heavily on the impressions of the individual clinician
clinicians differ widely in their judgements about when a normal personality style crosses the line and deserves to be called a disorder
 usually people with disorders of personality meet criteria for multiple personality disorders
they must meet a certain number of criteria but no single feature is necissary 
uses categories rather than dimensions
 suggests that its like an on off switch, its either there or its not, no in between
now it is believed that they vary more in degree than in type 

BIG 5
 supertraits - neuroticism, extroversion, openness to experience, agreeableness, and conscientiousness
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