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Mental Health Issues on Campus Today


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Title: Mental Health Issues on Campus Today

Mental Health Issues on Campus Today
  • David Mays, MD PhD

If the human brain were so simple that we could
understand it, we would be so simple that we
  • Emerson Pugh

The Current Model
  • Mental Disorders are disorders of brain circuits
    caused by developmental processes shaped through
    a complex interplay of genetics and experience.
  • The onset of mental disorders is almost entirely
    before the age of 25.
  • Medications, cognitive behavioral therapy, and
    other interventions appear to affect different
    parts of the brain circuitry involved in mental

Complex Genetic Risk Plus Experiential Factors
  • The genetics of mental illness are characterized
    by very rare, but potent variations.
  • These rare variations result in changes in brain
    circuitry that, in complex interactions with
    environmental influences, result in many pathways
    to phenotypes of mental illness.

Plan for this morning
  • Substance Use
  • Anxiety disorders
  • Depression
  • Attention Deficit
  • Bipolar Disorder
  • Schizophrenia
  • Borderline Personality Disorder

The Range of Substance Use
  • Use (a cocktail every evening)
  • Misuse (getting high)
  • Risky use (adolescent use, bingeing, use while
  • Problem use (driving while intoxicated)
  • Abuse (heavy use interferes with quality of life)
  • Addiction (loss of control, brain changes)
  • Disability
  • Death

  • From a biological perspective, addiction is
    characterized by
  • 1) uncontrollable, usually compulsive drug
    seeking and drug use, in spite of severe aversive
  • 2) preoccupation with the drug, enhanced cue
  • 3) the experience of craving, often for years or
    decades after abstinence has been obtained.

Variance of Risk
Environmental Factors
  • Availability
  • Social norms (smoking bans)
  • Legal consequences
  • Peer pressure
  • Parents use, attitudes, rules

Gender Issues
  • Men are twice as likely to meet criteria for any
    drug use disorder over a lifetime (13.8 vs.
    7.1.) the 12-month prevalence rates of alcohol
    abuse are 3 times higher in men (6.9 vs. 2.6.)
    By contrast, prescription drug abuse occurs at
    the same rate among men and women. Women are more
    likely to have comorbid anxiety, depression,
    eating disorders, and borderline personality
    disorder. Men are more likely to have antisocial
    personality disorder.

Kinds of Alcohol Dependence
  • Age-limited heavy drinking 30 of people with
    alcohol dependence are symptomatic between the
    ages of 18-25. The problems are usually gone by
    25 to 30 years old. They seldom seek help.
  • Variable onset 40 have an average age of onset
    of about 35, but this is highly variable. The
    symptoms are relatively moderate and it usually
    resolves without intervention.
  • Familial/ Early onset 30 with onset in the mid
    teens have a strong family history, chronicity
    and recurrence. 10-12 of these end up in rehab.

Can We Recover?
  • Several long-term studies have shown that years
    of abstaining can allow brain regions to return
    to their normal size, and some neural connections
    can be repaired.
  • Some reports have found sustained injury to
    certain areas, especially to the hippocampus
    (memory) and white matter lesions.

Brain Susceptibility
  • The teen brain is more susceptible to damage than
    the adult brain for developmental reasons. There
    is more impairment of memory than in adults, more
    cognitive impairment, longer term brain damage.
  • Kids dont drink like adults.
  • They drink exclusively to get drunk.
  • Binge drinking is the norm, not the exception.
  • They experience more bad outcomes accidents,
    drownings, pregnancies, STDs, depression, anxiety

Opioid Analgesics
  • As of 2007, 35 million Americans (14 of the
    population) reported having abused opioid
  • In this same year, prescription opioids surpassed
    marijuana as the most common gateway to illicit
    drug abuse among adolescents, with 9,000
    Americans becoming new opioid users each day.
  • Wisconsin leads most other states in rates of
    non-medical use of pain relievers in persons aged
    12-17. (gt9 of kids 14-15, gt16 kids 16-17)

How Did This Happen?
  • In the 1990s, physicians began to be criticized
    for undertreating pain syndromes. As a result,
    opioid prescriptions increased. Addiction risk
    was underestimated.
  • Multiple providers prescribed opioids without
    coordinating services.
  • Patients were routinely given a 2-week supply.
    Sometimes with multiple refills. Patients used
    them for a few days, then kept the rest in their
    medicine cabinet, where family members had access
    to them.

Reasons Young People Choose Prescription
  • Easy to get from parents medicine cabinet 62
  • Are available everywhere 52
  • They are not illegal drugs 51
  • They are cheap 43
  • They are safer than illegal drugs 35
  • Less shame attached to using 33
  • Fewer side effects than other illegal drugs 32
  • Parents dont care as much if you get caught 21

Sources of Painkillers (SAMHSA 2009)

Universal Prevention
  • Increased consumption in a locality is associated
    with increased rates of alcohol related problems
    in that area.
  • Price increases via taxation can reduce
    cirrhosis, mortality, and automobile fatalities.
  • Availability can be controlled by restricting
    time of sales, restricting what kind of stores
    can sell alcohol, and locations of stores.
  • The lower the age for legal drinking, the higher
    rate of consumption and related problems.

Alcohol Screens
  • How much? and How often? are usually not very
    helpful questions. A better focus is on the
    impact that drinking has on the client.
  • CAGE (Cut down, Annoyed, Guilt, Eye-opener)
  • AUDIT (Alcohol Use Disorders Identification Test)
  • Questionnaires are better than laboratory tests,
    but both together are very effective.

Alcohol Use Disorders Identification Test (AUDIT)
  • How often do you have a drink containing alcohol?
  • How many drinks do you have on a typical day you
    are drinking?
  • How often do you have 6 or more drinks on one
  • How often during the last year have you been
    unable to stop once you have started drinking?
  • How often during the last year have you needed a
    drink in the morning to get yourself started
    after a night of heavy drinking?

Alcohol Use Disorders Identification Test (AUDIT)
  • How often in the last year have you experienced
    guilt or remorse after drinking?
  • How often during the last year have you been
    unable to remember what happened the night before
    because of your drinking?
  • Have you or someone else been injured because of
    your drinking?
  • Has anyone been concerned about your drinking and
    urged you to cut down?

  • Most of those who change their problem drinking
    do so without treatment of any kind, including
    self-help groups.
  • A significant percentage maintain their recovery
    with follow-up periods of more than 8 years.
  • Many problem drinkers can maintain a pattern of
    non-problematic moderate use of alcohol without
    becoming re-addicted.
  • Those who seek treatment have more severe alcohol
    and related problems than those who do not.

Alcohol Interventions
  • The Physicians Guide to Helping Patients With
    Alcohol Problems
  • Brief, supportive intervention - 1 or more
    sessions in the clinicians office consisting of
    education, negotiated plan, follow-up. This is
    more efficacious than longer term , more formal
  • Motivational interviewing
  • Pharmacotherapy disulfiram, naltrexone,
    acamprosate, topiramate, baclofen. SSRIs can
    trigger an increase in alcohol use in late onset
  • Self-help groups

Behavioral Therapies
  • Contingency management
  • Cognitive behavioral therapies
  • Relapse prevention
  • Motivational interviewing
  • Empathy
  • Develop discrepancy
  • Avoid arguments
  • Roll with resistance
  • Support self-efficacy
  • Couples/ Family Treatment
  • 12-Step groups

Behavioral Therapies
  • Brief Interventions
  • 10-15 minutes counseling for feedback, education
    and goal setting, follow-up visits
  • Alternative Therapies
  • Exercise
  • Mindfulness training
  • Biofeedback
  • Acupuncture

Cannabis Use
  • Cannabis is the most commonly used illicit drug
    in the US - about 15 million people, 33 of high
    school seniors.
  • Most users do not develop any problems, but a
    subset do - 9 develop dependence. It is now
    known that cannabis abuse can lead to tolerance
    and withdrawal.

Medical Use of Marijuana
  • Unfortunately, most of the research on marijuana
    is based on people who smoke the drug for
    recreational, rather than medical purposes.
  • Consensus exists that marijuana may be helpful in
    treating certain carefully defined medical
  • Modest efficacy for nerve pain
  • Appetite stimulation for AIDS wasting syndrome
  • Control of chemotherapy related nausea and
  • There are FDA approved medications for each of
    these conditions.

Medical Use
  • Drug delivery is a major challenge. The FDA has
    approved two pills containing THC. Most of the
    active ingredient is metabolized during
    digestion, and the drugs work slowly.
  • Inhalation is the fastest way to deliver THC to
    the bloodstream. But smoking cannabis seems to
    have more rapid toxic effects on the respiratory
    system than cigarette smoking.

Psychiatric Risks
  • There are more psychiatric risks than benefits
    for marijuana
  • Addiction gt10 of regular users show evidence of
    physical dependence. The average THC
    concentration has risen from 1-4 to 7 over the
    last few decades.
  • Anxiety The most commonly reported side effects
    are intense anxiety and panic attacks 20-30.
  • Induction of manic episodes, rapid cycling in
    bipolar clients
  • Psychosis

Categories of Anxiety Disorders
  • Generalized Anxiety Disorder (GAD)
  • 5.1 (women 6.6, men 3.6)
  • Panic Disorder
  • 3.5 (women 5, men 2)
  • Obsessive Compulsive Disorder (OCD)
  • 2 (women 2.5, men 1.5)
  • Phobias
  • Simple phobia 11 (women 15.7, men 6.7)
  • Agoraphobia 5.3 (women 7, men 3.5)
  • Social phobia 13.3 (women 15.5, men 11.1)
  • Post Traumatic Stress Disorder 7.8

  • Anxiety disorders are the most common emotional
    disorders. Lifetime prevalence is 24.9 (women
    30.5, men 19.2), 25 million people.
  • 33 of total mental health bill, average of 37
    medical visits/year (vs. average of 5)
  • Comorbidity with depression 60-80.

Anxiety and Substance Abuse
  • 18 of substance abusers suffer from an
    independent anxiety disorder. 70 of alcoholics
    have anxiety problems, mostly caused by the
    alcoholism. 15 of anxiety disorder clients have
    substance abuse problems. The relationship is
    bidirectional and complex.
  • Alcohol relieves anxiety in the short term, but
    chronic drinking makes agoraphobia and social
    phobia worse.

Generalized Anxiety Disorder
  • GAD is a clinical syndrome characterized by
    excessive worrying, hypervigilance, and anxiety
  • Lifetime prevalence of 5.7 (women 6.6, men
  • Median age of onset is 31 oldest of any anxiety
    disorder. It looks like major depression.
  • It is unique in that sufferers will present to
    their primary care physician, where it is the
    second most frequent mental disorder. The main
    complaints will be insomnia and somatic problems.
    Clients will regard themselves as in poor health
    and will be high utilizers of healthcare
    resources. No other anxiety disorder has such a
    high rate of disability.

Natural History
  • Course of illness is chronic, with waxing and
    waning symptoms.
  • Unlike other anxiety disorders, GAD does not
    decrease with age. Older people tend to worry
    more and for longer periods of time. Fewer than
    33 completely remit. They experience the same
    degree of disability as major depressive disorder
    and coronary artery disease.
  • People with GAD often report problems with memory
    and attention.
  • There is a strong association with suicidal

Treatment of GAD
  • Short term stabilization with benzodiazepines is
    appropriate. Long term treatment should focus on
    lifestyle changes, stress reduction techniques,
    cognitive therapy, appropriate work situation,
    management of personal affairs.
  • Little is known about long term treatment and the
    natural course of the disorder.
  • A poor prognosis is associated with poor family
    relationships, comorbid avoidant, dependent, or
    obsessive compulsive personality, other mental
    illnesses, or female gender.

Panic Attack
  • A panic attack is a discrete episode of
    unexpected terror accompanied by a variety of
    physical symptoms including fear, anxiety,
    catastrophic thinking with a sense of impending
    doom, or the belief that loss of control, death,
    or insanity is imminent.
  • Physical symptoms can be neurological,
    gastrointestinal, cardiac, or pulmonary.

Panic Attack
  • A panic attack lasts from 5 to 30 minutes, with
    symptoms usually peaking at 10 minutes. They may
    occur during sleep.
  • Many psychiatric disorders have panic attacks
    associated with them.
  • Panic attacks can be triggered by certain
    situations - driving in the rain, crossing a
    bridge, being crowded, waiting in line.

Panic Disorder
  • Panic disorder is the presence of recurrent,
    unexpected panic attacks followed by at least a
    month of persistent anxiety or concern.
  • 10 of the population report having a panic
  • 4.7 of the population develop panic disorder.

Five Aspects of Panic Disorder
  • Panic attacks
  • Anticipatory anxiety
  • Panic related phobias (80 will be agoraphobia)
  • Impaired sense of well-being
  • Functional disability

Treatment of Panic Disorder
  • All the newer antidepressant medications have
    efficacy in treating panic disorder. (Two
    medications used for other anxiety disorders do
    not - buspirone and gabapentin.)
  • Clients with panic disorder are extremely
    sensitive to side effects and may need to start
    at lower medication doses than normal.

Social Anxiety Disorder
  • Sufferers experience the triad of worry,
    avoidance, and physical complaints.
  • Few seek help.
  • 70-80 will have a comorbid condition - alcohol
    dependence, depression, another anxiety disorder.
  • 20 are unable to work. 70 will make a below
    average income.
  • 66 are single, divorced or widowed.
  • Risk of suicide is increased.

Post Traumatic Stress Disorder
  • PTSD is an illness that occurs in vulnerable
    people exposed to severe trauma.
  • Some people with PTSD do not experience a single
    episode of trauma, but rather repeated physical

Acute Stress vs. PTSD
  • After a traumatic event, most people will
    experience elements of both stress and traumatic
    stress. Perceived threat triggers intense bodily
    reactions that influence memory storage and
    retrieval, as well as cognitive factors and
    symptoms of autonomic arousal.
  • Acute Stress symptoms appear shortly after the
    event, subside in many survivors, but persist in
    others in the form of chronic PTSD. Since at
    least 60 of people with early PTSD symptoms
    recover over the next 6 years, almost all within
    the first year, chronic PTSD might be seen as a
    disorder of recovery.

Psychological First Aid
  • PFA is a form of single-session psychological
    debriefing developed by the National Center for
    PTSD. There is no empirical support as yet. PFA
    consists of 8 core components
  • Contact and engagement
  • Safety and comfort
  • Stabilization
  • Information gathering
  • Practical assistance
  • Connection with social supports
  • Information on coping support
  • Linkage with collaborative service

Symptoms of PTSD
  • The symptoms of re-experiencing and hyperarousal
    are common and reflect normal responses to
  • Avoidance and Numbing are more markers of
    psychopathology and more predictive of developing
    chronic PTSD.

  • 61 of men and 51 of women will experience
    trauma in their lives. Of these, 8 of men and
    20 of women will go on to develop PTSD.
  • Some clinicians believe that PTSD is widely
    under-diagnosed, and healthcare providers need to
    ask clients about a history of trauma and any
    resulting symptoms, especially women with
    substance abuse problems.

Natural History
  • Once PTSD develops, it is often chronic. The
    typical person with PTSD has over 20 years of
    active symptoms. There is a high degree of
    academic failure (40), teenage pregnancy (30),
    marital instability (60), and unemployment.
  • There is significant risk of comorbidity
    including depression, GAD, panic, and suicide
  • Currently there is strong interest in using brain
    scans to better understand and predict pathology.

Treatment of Established PTSD
  • Treatment should start within 5 months of
    exposure, include only those with full-blown
    PTSD, and use trauma-focused CBT.
  • CBT
  • Psychoeducation (teach about the illness, address
    distortions I can never trust anyone again,
  • Exposure (disconnect the memory from its ability
    to trigger the aroused emotional state)
  • Breathing and relaxation training
  • Eye movement desensitization and reprocessing

Treatment of Established PTSD Medication
  • The British National Institute for Clinical
    Excellence no longer recommends antidepressants
    as first line treatment, instead recommending
  • In the US, two SSRIs are approved for PTSD, but
    their efficacy is modest, and they do not appear
    to work for combat-related PTSD.
  • Benzodiazepines may be useful, but should be
    avoided if substance abuse or dependence is also
    a problem.
  • Off-label uses of medication with some clinical
    support include clonidine for hyperarousal,
    prazosin for insomnia, topiramate for flashbacks
    and nightmares, trazodone for insomnia and

  • Depression is a commonly experienced mood and a
    syndrome. A clinical depression is distinguished
    from a depressed mood by the intensity and
    pervasiveness of its symptoms. Depressed people
    are usually not able to relate to others and may
    be able to express only a limited range of
    emotions. They are frequently obsessively focused
    on themselves and how they are feeling moment to
    moment. In a primary care setting the following
    complaints may identify depression sleep
    disturbance, fatigue, somatic complaints.

  • Depression is the fourth leading cause of disease
    burden worldwide, 1st in the United States.
    Lifetime prevalence may be 7-12 of men, 20-25
    of women. High risk groups include Native
    Americans (19.17) and Caucasians (14.58).
    Asians are at lowest risk (8.77).
  • There is high comorbidity with anxiety disorders
    (36) and personality disorder (37).
  • Mortality is high. 46 wish to die. 9 report a
    suicide attempt. Risk of suicide death is 20x
    higher 15 lifetime risk. 30-70 of suicides
    have a depressive disorder.

  • Affective
  • Depressed mood
  • Vegetative
  • Weight loss or gain
  • Insomnia or hypersomnia
  • Decreased sex drive
  • Behavioral
  • Psychomotor retardation or agitation
  • Fatigue
  • Diminished interest or pleasure in most

  • Cognitive
  • Feelings of worthlessness or guilt
  • Diminished ability to think and concentrate
  • Poor frustration tolerance
  • Negative distortions
  • Affective agnosia and apraxia
  • Impulse Control
  • Recurrent thoughts of suicide, homicide, or death
  • Somatic
  • Headaches, stomach aches, muscle tension
  • Chronic Painful Physical Conditions

Natural History
  • Depression is a lifelong illness, likely to
    relapse within a few months after the first
  • Average age of onset is late 20-40 years old.
    Symptoms develop over days or weeks.
  • Prodromal symptoms include anxiety, panic,
    phobias, low grade depression.
  • Episodes last from 6 to 24 months.
  • There is strong evidence that sub-syndromal
    continuation of symptoms represent a continuation
    of the illness, and will lead to relapse.

Risk of Recurrence of Depression (DSM-IV-TR)
(No Transcript)
Behavioral Activation for Depression
  • Encourage people not to wait until they feel like
    doing something, but just go ahead and do it. It
    is usually the case that people who are depressed
    are unable to do things, its just that they
    cant start things.
  • People often underestimate what they are capable
    of doing. Helping them break tasks down to size
    and act on them is a good therapeutic activity.
  • In a recent study, depressed individuals who were
    able to question their negative beliefs and
    practice behavioral activation were least likely
    to relapse

Treatment Response
  • 33 of patients with depression will achieve
    remission on their first antidepressant. Up to
    65 will achieve remission on the second
    medication. Expect a relapse to depression in 50
    of those who achieve remission within 12 months.
  • Women and men are equally likely to respond to

Choosing an Antidepressant
  • There is no evidence that any antidepressant is
    any more efficacious than any other. Therefore,
    the choice of the first antidepressant should be
    based on patient preference of what side effects
    are tolerable.

Complementary and Alternative Treatments
  • Omega-3 fatty acids epidemiologic evidence,
    modest efficacy data as adjunctive treatment, low
  • St Johns wort greater consensus for mild to
    moderate depression than severe, significant
    drug-drug interactions
  • SAMe studies support that more rigorous research
    is needed so far we have small samples,
    different delivery systems, few comparison
    studies, unstable preparations
  • Folate which forms cross the blood-brain
    barrier? Low risk as an augmenter

Client Adherence
  • Clients need a lot of education during the
    beginning of treatment. 10 never fill their
    prescription, 16 stop the first week, 41 within
    two weeks, 59 in three weeks, 68 in four weeks.
    The number of educational messages given to
    clients by their physician was the single
    greatest predictor of adherence. Best messages
  • Take pills daily
  • They wont work for 2-4 weeks
  • Continue even when you feel better
  • Dont stop without calling your doctor
  • Feel free to call

ADHD Incidence and Prevalence
  • More frequently diagnosed in boys, but it is
    being recognized more in girls, who may have more
    of the inattention subtype.
  • 50-60 will have another condition, such as
    learning disorder, restless-legs syndrome,
    depression, anxiety, conduct disorder,
    obsessive-compulsive behavior
  • It is not clear how much is carried over into
    adulthood. NCR estimates persistence into
    adolescence in 40-60, into adulthood in
    40.Hyperactive symptoms may decrease with age
    because of increased self-control. Attention
    problems may continue. Many youths seem to get

Executive Functions and ADHD
  • There are six dimensions of cognitive executive
    functions that are problematic for people with
  • 1) Self-awareness probably the chief executive
    function is the ability to see yourself and
    monitor your actions. ADHD patients do not
    monitor their actions and are less aware of their
    failures. They also tend to have a positive
    illusory bias.
  • 2) Non-verbal working memory hindsight the
    ability to remember the past and predict the
    future. People with ADHD are terrible at time
    management and making predictions.
  • 3) Verbal working memory self-speech, using
    internal language to reason with and guide

Executive Functions and ADHD
  • 4) Inhibition People with ADHD cant inhibit
    their initial reactions and responses to
    situations and things.
  • 5) Emotional regulation ADHD patients cannot
    inhibit their initial emotional reactions and
    dont have the tools to regulate their feelings
    when they occur. They come across as very
    emotional, quick to anger, silliness, overly
    affectionate. People forgive the silliness, but
    not the hostility. 50-70 of ADHD children have
    no friends by the 3rd grade.
  • 6) Self-motivation the ability to activate
    yourself when their are no immediate rewards.
    People with ADHD are very dependent on immediate
    feedback, If there are no consequences, they fall
    apart. They can pay attention to video games, but
    cant sit still to do homework.

  • Complicated diagnosis inattention and
    impulsivity are seen with bipolar, depression,
    anxiety, oppositional defiant disorder, conduct
    disorder, learning disabilities
  • Heavy pharmaceutical marketing
  • Those with diagnosis get special considerations
  • Primary care MDs have difficult time with
    diagnosis - requires time and testing
  • Diagnosis is unusually dependent on social and
    educational circumstances

  • Stimulant medication has become the mainstay of
    treatment. All of the medications seem to be
    equally effective. Studies of efficacy beyond 2
    years are rare. Core symptoms seem to benefit,
    but associated domains (social skills,
    achievement, family function) do not.
  • The question of medication effect on the
    development of substance use disorders remains
    unclear. Studies have shown conflicting results.
    Controlling for conduct disorder is difficult.
  • Also required are psychoeducation, behavioral
    interventions, parent training, and school

Side Effects of Stimulants
  • Side effects of all the stimulants are the same
    decreased appetite, initial sleep difficulty,
    headaches, stomachaches, tics, and irritability.
  • The most common sustained side effect is appetite
  • Cardiovascular effects include a slight increase
    in blood pressure and heart rate. Because of
    reports of sudden death, the Am Heart Assoc
    recommends ECGs for all children before starting
    stimulants. All psychiatry groups disagree. (Rate
    of cardiac death with stimulants 2million, rate
    of sudden death in non-treated children

Adult ADHD
  • One study suggests that 4 of adults meet the
    criteria for ADHD.
  • ADHD probably does not arise spontaneously as an
    adult. There should be a history of the disorder.
  • Symptoms of ADHD evolve. In adults, we are most
    likely to see difficulty with memory and
  • Two studies of adults with ADHD found extensive
    comorbidity anxiety, major depression, substance
  • Treatment is with stimulants and psychotherapy to
    help with compensating for the symptoms.
    Cardiovascular side effects of stimulants are of

Bipolar Disorder
  • A medical condition in which people have mood
    swings out of proportion, or totally unrelated to
    things going on in their lives.
  • These swings affect thoughts, feelings, physical
    health, behavior, and functioning.
  • The present view is that the mood swings are
    secondary to an illness that creates a wide range
    of vulnerabilities, not just of mood, but also of
    arousal, motivation, impulsivity, and behavioral

Sleep Disruption
  • Decreased need for sleep is one of the criteria
    for bipolar mania and the ability to maintain
    energy without sufficient sleep is seen in few
    other disorders.
  • Sleep disturbance escalates just before an
    episode and continues to worsen during an
    episode. It is the most common prodrome before
  • Induced sleep disruption is associated with the
    onset of hypomania and mania. An increase in bed
    rest or sleep is associated with an onset of

The Manic Phase
  • Hypomania
  • Energetic, extroverted, assertive, hypersexual,
    self-confident, rapid speech
  • Mania
  • Poor judgment, euphoric, grandiose, paranoid,
    irritable, hyperactive, manipulative, demanding,
    pressured speech
  • Psychosis
  • Delusional, labile, distractible, confused,
    combative. Hallucinations are relatively rare.
    May mimic schizophrenia.

Rates of Violence (Fazel S et al, Arch Gen Psych
Sept 2010)
Bipolar Depression
  • Very difficult to treat and prevent
  • Usually the first and most frequent episode,
    causing the most impairment.
  • Patients with depression onset have a more
    unstable course, more mixed states, and more
    suicidal behavior. This may in part be due to
    early treatment with antidepressants.

Natural History
  • Onset can occur at any time, from childhood to
    old age, but it is usually in adolescence. Early
    onset of depression, anxiety, substance abuse,
    and behavioral disorders are all linked to
    eventual bipolar disorder.
  • Depression is the most frequent episode.
  • Depressive episodes last longer (25.4 weeks) than
    manic episodes (5.5 weeks).
  • The time between episodes is usually 12-14 months.

Evaluation Questions
  • Has there ever been a time when you were not your
    usual self and
  • You felt so good or so hyper that you got into
  • You were very irritable?
  • You were more self-confident than usual?
  • You needed less sleep than usual?
  • You were more talkative than usual?
  • Your thoughts raced in your head?
  • You had more energy than usual?
  • Spending money got you into trouble?

  • In evaluating the effectiveness of treatment in
    bipolar disorder, you must consider three
    different phases
  • Treatment of mania
  • Treatment of depression
  • Prevention of relapse

Rhythms in Bipolar Disorder
  • Disrupted social and circadian rhythms, life
    events, and medication non-adherence can all
    precipitate a manic episode. The final common
    pathway may be sleep disruption.
  • Psychoeducation, family-focused treatment,
    interpersonal and social rhythm therapy, and CBT
    have all proven to be useful, reducing relapse
    rates by 30-40.

Early Warning Signs of Mania
  • Sleep disruption
  • Sudden drop in anxiety (devil-may-care attitude),
    or sudden lifting of depression
  • Overly optimistic in absence of problem solving
  • Overly social, poor listening
  • Loss of concentration
  • Increased sexuality
  • Increased activity hyper focus or no focus

Psychotherapeutic Interventions
  • Principles of treatment are
  • Identify signs of relapse and make plans for an
    early response
  • Use education to increase the likelihood of
    adherence use mood charting
  • Practice stress management and problem solving,
    improve capacity to manage stressors
  • Maintain regular rhythms for exercise, sleep, and
  • Keep negative expressed emotion in the family at
    a minimum, improve communication
  • Dont make important decisions while symptomatic

Improving Stress Management
  • Activity scheduling
  • Distraction techniques
  • Relaxation exercises
  • Problem-solving
  • Insomnia activities
  • Stimulus control
  • Cognitive restructuring
  • Coping cards

  • The most current view is that schizophrenia is a
    syndrome rather than a disease, i.e. individuals
    diagnosed with schizophrenia may have substantial
    differences in psychopathology, in the same way
    that individuals with congestive heart failure
    will have different causes for their condition.
  • Schizophrenia is associated with marked social
    and occupational dysfunction and a course of
    chronic remissions and exacerbations. The three
    major dimensions of schizophrenia are psychotic
    symptoms, deficit symptoms, and cognitive

Three Aspects of Schizophrenia
Cognitive Symptoms
Deficit Symptoms
Psychotic Symptoms
Deficit Symptoms
  • Restricted emotional expression, reduced
    initiative, poor rapport, poor hygiene
  • These may be the most distinctive feature of
  • They appear earlier, are harder to treat, and
    worsen over time, unlike positive symptoms
  • Antipsychotics cause these symptoms in healthy

Psychotic Symptoms
  • Reality distortion (hallucinations, bizarre
    delusions - most frequently of prosecution, or of
    being controlled by outside forces, x-rays, outer
  • Disorganized thought (autistic language, mutism,
    echolalia, word salad, autistic logic, thought
  • Less a cause of disability than negative symptoms
  • 5 of people without schizophrenia experience
    auditory hallucinations

Cognitive Symptoms
  • Disorganized and dissociative thinking
  • Loss of attention, memory, executive function,
    verbal skills, motor skills
  • Generalizations are incorrect
  • Trouble with abstraction
  • Difficulty with understanding the main idea
  • May be the most disabling aspect of the illness

Rates of Violence (Fazel S, et al. JAMA May 20,
Natural History of Schizophrenia
  • The illness begins with genetic vulnerability,
    and lies dormant until the premorbid phase
    neurological soft signs, minor physical
    anomalies, mild cognitive, sensory, and motor
    deficits. These are too non-specific to be of
    diagnostic value.
  • The prodromal phase begins in puberty anxiety,
    blunted affect, depression, irritability, poor
    sleep, social withdrawal, cognitive decline.
    30-50 progress to schizophrenia within a year.

Natural History
  • With the onset of the illness, the disease enters
    the progressive phase. If treated 86 will
    recover, but the vast majority will relapse
    within 3 years.
  • In the chronic/residual phase, people with
    schizophrenia experience repeated episodes and
    relapses. The illness often becomes resistant to

Natural History and Relapse
  • Prediction of poor outcome
  • Poor premorbid adjustment
  • Early and gradual onset
  • Absence of affective features
  • Male gender
  • Duration of psychosis before treatment
  • More psychotic episodes
  • Discontinuing medication increases the relapse
    rate by 5x.
  • Noncompliance after the first episode is 75.

Biological Treatment
  • Antipsychotic drugs treat psychosis but not
    schizophrenia. Efficacy for negative symptoms and
    cognitive problems is modest, at best. The
    primary benefit of the drugs is to prevent
    relapse of psychosis.
  • Some provocative recent studies suggest that
    antipsychotics may exert a neuroprotective effect
    if given early enough in the illness.
  • Nonetheless, medications seem to be most
    effective early in the illness. Psychosocial
    interventions can be added to medication to
    improve relapse prevention.

Psychosocial Treatments
  • Assertive community treatment (ACT) reduces
    frequency of hospitalization, increases housing
    stability, shows high satisfaction from clients
    and families.
  • Integrated dual disorders treatment
  • Supported employment - individual placement and
    support (IPS) is effective
  • Family psychoeducation reduces relapse, improves
    symptomatic recovery, enhances family outcomes.
    Programs must gt 9 months.
  • Social skills training improves social skills in
    group but not necessarily in the community.
  • Personal/Cognitive therapy may help with
    delusions, hallucinations, social functioning

Vocational Needs
  • Interpreting the behaviors of co-workers
  • Understanding how personal work relationships
    should be
  • Recognizing how their behavior effects others
  • Problems with substance abuse
  • Transportation and clothing
  • Performance of job tasks
  • Dependability

Training Modules
  • Identifying how work changes your life
  • Learning what the job expectations are
  • Identifying personal strengths and preferences
  • Learning to cope with stress
  • Learning to manage symptoms and medications
  • Learning to manage health concerns and substance
  • Learning how to interact with supervisors/peers
  • Learning how to socialize successfully
  • Learning how to recruit social support

Description of Borderline PD
  • Interpersonal problems
  • Turbulence, fear of abandonment, self-esteem
    dependent on important others
  • Affective instability
  • Reactivity, intense negative emotions, pervasive
  • Behavioral difficulties
  • Impulsive, self-destructive, addictions,
  • Cognitive problems
  • Lack of stable sense of self, psychosis and
  • Comorbidity
  • Substance abuse, impulse control disorders, mood
    disorders, eating disorders, anxiety disorders,

The Fundamental Pathology
  • Gunderson primarily a disorder of attachment,
    with excessive fear of aloneness and abandonment,
    and mentalization failure
  • Linehan a disorder of emotional dysregulation
  • Zanarini
  • hyperbolic temperament (overly sensitive)
    traumatic experience results in chronic, intense
    inner pain.
  • The person is insistent and persistent that this
    anguish be recognized and acknowledged by others
    (I am in the worst pain in the history of the
    world.) This contributes to their sense of
    isolation and alienation.

Zanarini Description Two Key Features
  • Intense inner pain
  • Dysphoric affect
  • I feel grief stricken. I feel panicky.
  • Distorted cognition
  • I am damaged beyond repair.
  • Behavioral responses (partly communicative)
  • Self-injury, manipulative suicidal behavior
  • Substance abuse, eating disorders, promiscuity
  • Interpersonal patterns devaluation,
    manipulation, entitlement, rage. They may overact
    to criticism and negatively personalize
    disinterest. Basic trust is not achieved.

Demographics and Natural History
  • 2.7 of the population, seen worldwide
  • Most prevalent personality disorder in clinical
    settings 10 of psychiatric outpatients, 20 of
    psychiatric inpatients.
  • 75 female in clinical settings, 50 in general
  • Onset is in adolescence with chronic instability
    and high use of mental health resources
  • Diagnosis is unstable, improvement over time is
    the norm, hospitalization is uncommon after the
    first few years of illness.

Interpersonal Agenda of the Borderline Personality
  • The persons primary concern is to find someone
    who can understand them perfectly enough so that
    their sense of isolation will abate and their
    misery will stop. It is a kind of Golden
    Fantasy by finding the one person who can help
    them, all of their needs will be met.
  • A strong fear of abandonment arises when
    something seems to disrupt the developing
    relationship. Abandonment fear is expressed with
    rage as a kind of hostile dependence.

Caveat About Self-Injury
  • There are many reasons why people do things to
    their bodies that may seem deviant to mainstream
    observers. Not everyone is manifesting
    psychiatric pathology.
  • Causes for concern
  • Injury to face or genitals
  • Carving words or messages on the body
  • Indifference or odd affect
  • Severe injury

Borderline Personality Disorder
  • BPD is the only disorder that includes recurrent
    suicidal behavior as part of the disorder.
  • 70 will attempt suicide with an average of 3
    attempts per person. 3-10 will die of suicide,
    40 men.
  • Most attempts occur early in the 20s, but most
    deaths will happen later in the illness (mean age
    of 37), so during the most alarming stage of the
    illness, there is less chance of death.
  • How is a clinician to manage this?

Borderline Personality Disorder
  • Most predictors of suicide death (previous
    attempts, depression, SIB, substance abuse) are
    not helpful because they are so common in the
  • Two recent studies suggest that risk increases
    with the cumulative consequences of chronic
    illness, including impaired functioning and
    progression of suicidal behavior. In addition,
    PTSD and cognitive-perceptual symptoms, like
    dissociation may increase risk.

  • Clients will consciously and unconsciously
    manipulate to get what they think they need. The
    sense of entitlement can lead therapists to grant
    favors and cross boundaries that they normally
    would not.
  • Impulsivity may precipitate therapists having to
    act immediately with phone calls, extended
    sessions, etc.
  • The traumatic history may bring out rescue
    fantasies fed by the borderlines idealizing

Individual Psychotherapy
  • The best way to avoid transference and
    countertransference disasters with a BPD is to
    keep very firm boundaries, both physical and

Pharmacological Treatment
  • No medication has been approved by the FDA for
    BPD or BPD traits, although MSAD showed 40 of
    clients on 3 medications, 20 taking 4
    medications, 10 taking 5 or more medications.
  • Medication is hard to use with these clients
    because of their extreme reactivity, transference
    problems, suicidality, comorbidity, and variety
    of symptoms among clients.
  • Clients with impulse disorders often exhibit a
    strong initial transient response to placebo

Common Ingredients of Successful Therapies (Paris
  • Emphasize getting a life in the present a job,
    going to school, having a relationship, etc
  • Managing emotional dysregulation learning and
    labeling feelings, then modifying them through
    mindfulness, distress tolerance, problem solving
  • Dealing with impulsivity using behavioral
    analysis, teaching patients to slow down before
  • Manage bad interpersonal relationships get
    patients to broaden their sources of satisfaction
    and support
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