Mental Health Issues on Campus Today

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Mental Health Issues on Campus Today

• David Mays, MD PhD
• dvmays_at_wisc.edu

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If the human brain were so simple that we could
understand it, we would be so simple that we
couldnt.

• Emerson Pugh

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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
  disorders.

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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.

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Plan for this morning

• Substance Use
• Anxiety disorders
• Depression
• Attention Deficit
• Bipolar Disorder
• Schizophrenia
• Borderline Personality Disorder

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The Range of Substance Use

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

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Addiction

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

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Variance of Risk
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Environmental Factors

• Availability
• Social norms (smoking bans)
• Legal consequences
• Peer pressure
• Parents use, attitudes, rules
• SIBLINGS!

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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.

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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.

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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.

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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

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Opioid Analgesics

• As of 2007, 35 million Americans (14 of the
  population) reported having abused opioid
  analgesics.
• 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)

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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.

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Reasons Young People Choose Prescription
Medications

• 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

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Sources of Painkillers (SAMHSA 2009)
18

• LOCK UP YOUR MEDS!

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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.

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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)
• AUDIT-C
• Questionnaires are better than laboratory tests,
  but both together are very effective.
• GGT, AST, ALT, MCV, CDT

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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
  occasion?
• 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?

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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?

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Treatment

• 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.

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Alcohol Interventions

• The Physicians Guide to Helping Patients With
  Alcohol Problems www.niaaa.nih.gov
• 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
  therapy.
• Motivational interviewing
• Pharmacotherapy disulfiram, naltrexone,
  acamprosate, topiramate, baclofen. SSRIs can
  trigger an increase in alcohol use in late onset
  alcoholism.
• Self-help groups

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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

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Behavioral Therapies

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

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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.

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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
  conditions
• Modest efficacy for nerve pain
• Appetite stimulation for AIDS wasting syndrome
• Control of chemotherapy related nausea and
  vomiting
• There are FDA approved medications for each of
  these conditions.

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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.

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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

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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

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Demographics

• 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.

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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.

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Generalized Anxiety Disorder

• GAD is a clinical syndrome characterized by
  excessive worrying, hypervigilance, and anxiety
• Lifetime prevalence of 5.7 (women 6.6, men
  3.6)
• 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.

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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
  behavior.

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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.

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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.

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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.

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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
  attack.
• 4.7 of the population develop panic disorder.

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Five Aspects of Panic Disorder

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

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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.

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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.

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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
  assaults.

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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.

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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

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Symptoms of PTSD

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

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Demographics

• 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.

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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
  (19).
• Currently there is strong interest in using brain
  scans to better understand and predict pathology.

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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,
  etc.)
• Exposure (disconnect the memory from its ability
  to trigger the aroused emotional state)
• Breathing and relaxation training
• Eye movement desensitization and reprocessing
  (EMDR)

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Treatment of Established PTSD Medication

• The British National Institute for Clinical
  Excellence no longer recommends antidepressants
  as first line treatment, instead recommending
  CBT.
• 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
  nightmares

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Depression

• 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.

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Demographics

• 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.

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Symptoms

• 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
  activities

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Symptoms

• 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

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Natural History

• Depression is a lifelong illness, likely to
  relapse within a few months after the first
  episode.
• 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.

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Risk of Recurrence of Depression (DSM-IV-TR)
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(No Transcript)
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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

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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
  antidepressants.

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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.

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Complementary and Alternative Treatments

• Omega-3 fatty acids epidemiologic evidence,
  modest efficacy data as adjunctive treatment, low
  risk
• 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

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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
  were
• 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

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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
  better.

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Executive Functions and ADHD

• There are six dimensions of cognitive executive
  functions that are problematic for people with
  ADHD
• 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
  yourself

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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.

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Problems

• 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

67
Treatment

• 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
  support.

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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
  loss.
• 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
  8-62million)

69
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
  attention.
• Two studies of adults with ADHD found extensive
  comorbidity anxiety, major depression, substance
  abuse.
• Treatment is with stimulants and psychotherapy to
  help with compensating for the symptoms.
  Cardiovascular side effects of stimulants are of
  concern.

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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
  sensitization.

71
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
  mania.
• 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
  depression.

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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.

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Rates of Violence (Fazel S et al, Arch Gen Psych
Sept 2010)
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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.

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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.

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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
  trouble?
• 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?

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Treatment

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

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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.

79
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

80
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
  eating
• Keep negative expressed emotion in the family at
  a minimum, improve communication
• Dont make important decisions while symptomatic

81
Improving Stress Management

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

82
Schizophrenia

• 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
  symptoms.

83
Three Aspects of Schizophrenia
Cognitive Symptoms
Deficit Symptoms
Psychotic Symptoms
84
Deficit Symptoms

• Restricted emotional expression, reduced
  initiative, poor rapport, poor hygiene
• These may be the most distinctive feature of
  schizophrenia
• They appear earlier, are harder to treat, and
  worsen over time, unlike positive symptoms
• Antipsychotics cause these symptoms in healthy
  volunteers.

85
Psychotic Symptoms

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

86
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

87
Rates of Violence (Fazel S, et al. JAMA May 20,
2009)
88
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.

89
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
  medication.

90
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.

91
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.

92
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

93
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

94
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
  abuse
• Learning how to interact with supervisors/peers
• Learning how to socialize successfully
• Learning how to recruit social support

95
Description of Borderline PD

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

96
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.

97
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.

98
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.

99
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.

100
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

101
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?

102
Borderline Personality Disorder

• Most predictors of suicide death (previous
  attempts, depression, SIB, substance abuse) are
  not helpful because they are so common in the
  disorder.
• 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.

103
Boundaries

• 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
  transference.

104
Individual Psychotherapy

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

105
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
  treatment.

106
Common Ingredients of Successful Therapies (Paris
2008)

• 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
  reacting
• Manage bad interpersonal relationships get
  patients to broaden their sources of satisfaction
  and support