Mental Health Issues on Campus Today

David Mays, MD PhDdvmays@wisc.edu

“If the human brain were so simple that we could understand it, we would

be so simple that we couldn’t.”

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 disorders.

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

pregnant)• Problem use (driving while intoxicated)• Abuse (heavy use interferes with quality of life)• Addiction (loss of control, brain changes)• Disability• Death

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.

Variance of Risk

Environmental Factors

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

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 don’t 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, STD’s, depression, anxiety

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. (>9% of kids 14-15, >16% kids 16-17)

How Did This Happen?• In the 1990’s, 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 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 don’t care as much if you get caught 21%

Sources of Painkillers (SAMHSA 2009)

LOCK UP YOUR MEDS!

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)• AUDIT-C• Questionnaires are better than laboratory tests,

but both together are very effective.– GGT, AST, ALT, MCV, CDT

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?

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?

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.

Alcohol Interventions• The Physicians’ Guide to Helping Patients With Alcohol

Problems: www.niaaa.nih.gov• Brief, supportive intervention - 1 or more sessions in

the clinician’s 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. SSRI’s can trigger an increase in alcohol use in late onset alcoholism.

• 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 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.

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: >10% 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%

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%.

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 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.

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.

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 attack.

• 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 assaults.

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 trauma.

• Avoidance and Numbing are more markers of psychopathology and more predictive of developing chronic PTSD.

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.

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.

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)

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 SSRI’s 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

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.

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.

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

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

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.

Risk of Recurrence of Depression (DSM-IV-TR)

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, it’s just that they can’t 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 antidepressants.

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 risk

• St John’s 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 were:– Take pills daily– They won’t work for 2-4 weeks– Continue even when you feel better– Don’t 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 better.

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

Executive Functions and ADHD• 4) Inhibition: People with ADHD can’t inhibit their initial

reactions and responses to situations and things.• 5) Emotional regulation: ADHD patients cannot inhibit their

initial emotional reactions and don’t 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 can’t sit still to do homework.

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 MD’s have difficult time with diagnosis -

requires time and testing• Diagnosis is unusually dependent on social and

educational circumstances

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.

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 ECG’s for all children before starting stimulants. All psychiatry groups disagree. (Rate of cardiac death with stimulants 2:million, rate of sudden death in non-treated children 8-62:million)

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.

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.

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.

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 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?

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

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

eating– Keep negative expressed emotion in the family at a

minimum, improve communication– Don’t make important decisions while symptomatic

Improving Stress Management

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

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.

Three Aspects of Schizophrenia

Deficit Symptoms

Psychotic Symptoms

Cognitive Symptoms

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.

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

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, 2009)

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 medication.

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 > 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 abuse• 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 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

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 person’s 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 20’s, 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 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.

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 borderline’s idealizing transference.

Individual Psychotherapy

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

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.

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