4511. My web site and syllabus:

1. http://myweb.facstaff.wwu.edu/knecht/

2. Topic Questions?3. Readings on website: three with cancer:

1. Read and come up with a question from each to ask Dr. Thompson next week. Turn in your 3 questions to me, either in class on Thursday or by e-mail.

4. For stepping stone project:1. We’ll meet after class to schedule times2. www.steppingStonesWhatcom.org

•Dia - gnosis “to know and to distinguish between”

•Purposes of diagnoses:

•To differentiate those with from those without a condition

•To enhance communication – a short hand

•Ensure treatment specificity so a given illness gets the specific treatment

•This assumes disorders are discrete entities that clearly differ from one another

Most Psychiatric Diagnoses differ from Medical diagnoses:

• More of social process – • Fashionable diagnoses come and go

• Anxiety State decreased, depression and phobia increased

• More social consequences – stigma, discrimination

• More culturally determined Culture Bound syndromes such as

Amuk Pibloktog Anorexia Nervosa Kayak Angst Koro Personality Disorders Taijin kyofu sho Factitious Disorders

• Few definitive or independent tests to confirm dx

Psychiatric diagnoses are mostly syndromes

Signs (observable) and symptoms (reported) that tend to be seen together.

Gr. “Run together”

Used when no clear pathophysiological basis has been defined or identified to explain its occurrence.

Compare Generalized Anxiety Disorder with H1N1

Reliability and validity of Psychiatric Diagnosis

Specificity and sensitivity:

Sensitivity – does it include all “real” cases as well as non-cases (false positives)

Specificity: Does it only include “real” cases and reject all non-cases ( but also some false negatives)

Study: 168 consecutive admissions to mental hospital Schizophrenia

Criteria sets rxx # Sz

NHSI .97 44DSM-III .80 19RDC .90 17Feigner .84 12Taylor-Abrams .65 6

Who is schizophrenic depends on which set of criteria you use?

Which set would you use to study Sz? Why?

Criterion creep makes it fuzzy DSM-VVeteran’s Administration is currently suggesting

changes in PTSD diagnostic criterion A (stressor) for vets to readas follows:

``a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror.'' A claimed stressor must be consistent with the places, types, and circumstances of the veteran's service.“

 If you show up in a war zone, you meet criterion A. What would this change do to Specificity? Sensitivity?

How best to characterize Mental disorderClassical Categorical

E. Kraepelin - 19th C Sz and manic Depression were discrete entities Each with a specific etiology

DimensionalBased on psychological measurement

Sx vary by degree from 0 to …100.. e.g. negative affectivity

Continuum of symptom presence and severity

PrototypicalDescribe a prototypeDetermine essential criteriaAllow polythetic criteriaAccept blurred boundries

. SCHIZOPHRENIA polythetic Diagnosis

A. TWO OR MORE OF:  1. DELUSIONS

2. HALLUCINATIONS3. DISORGANIZED SPEECH (Derailment,

incoherence)4. GROSSLY DISORGANIZED OR

CATATONIC BEHAVIOR5 . NEGATIVE SYMPTOMS

- Flattened affect, alogia, avolitionOnly on of 1 or 2 if bizzare

 B. SOCIAL/OCCUPATIONAL DYSFUNCTION

1. SOCIAL, INTERPERSONAL 2. OCCUPATIONAL 3. SELF-CARE

C, DURATION OF AT LEAST 6 MONTHSD. EXCLUDE SCHIZOAFFECTIVE AND

MOOD DISORDERSE. NOT DUE TO SUBSTANCE ABUSE OR

MEDICAL CONDITION

Where are there boundaries between disordersExample: Sz & Bipolar

Sz ………………………………………….. Bipolar I and II Cyclothymia

Schizoaffective ………………………. Unipolar Depression - dysthymia

Personality DisordersSchizotypy

SchizoidParanoid

Schizophrenia Spectrum disorders …

Proliferation of diagnostic categoriesWhat does this mean?1918 - 59DSM-I –1952 - 106DSM-II 1968 - 182DSM-III 1980 - 265DSM-III R 1987 -292DSM-IV 1994 -357

• Five criteria to evaluate a given Diagnosis – rooted in medicine

1. Describe a set of symptoms for Communication

2. Suggest pathophysiology – • cause or conditions associated with its occurrence

3. Suggest a specific treatment plan to address cause

4. Predict outcome - prognosis5. Predict long term sequelae

• How should we think of Diagnoses? • An entity?• A social construction?• Convenient construct?

• Are they useful?

• Reification of psychiatric Diagnoses• Don’t label the person

Mediating MechanismsHow do we get from mental distress (Dx) to

physical systems breaking down or being damaged?

Or from physical disorders or systems malfunctioning to cause specific mental/emotional disorder?

Several Systems:Autonomic Nervous System -sympatho-adrenao-

medullary SAM

Hypothalamic – Pituitary – Adrenocortical Axis : HPANeurotransmitter systems and pathwaysNeuroanatomical structures

Autonomic Nervous System:

Sympathetic division Active defense system– fight or flight – activation

adrenaline/epinepherine, norepinepherine – depletion of energy resources

Parasympathetic division- Conservation, withdrawal, build up of energy

resources and healing – AcetylcholineWhen functioning properly together they

promote Homeostasis among bodily systems when in balance

ANS

Examples of disorders that could involve SNS activation or dysregulation?

Examples of disorders- CHD Hostility

Surges of adrenalin Arterial tears – plaques attachblood clots more readily

GAD .. Chronic Gastric distress

Asthma attacks: SNS activation in strong emotion can trigger

attacks.

SAM and HPA-C axis

CRF/H

Hypothalamic – pituitary – Adrenocortical Axis - HPA

Stress perceived –

Hypothalamus - Corticotropin Releasing factor (CRF/H)

CRF goes to anterior Pituitary – Adreno-corticotropic Hormone (ACTH)

ACTH cortex of the Adrenal gland – CortisolInto blood system to organs Feeds backs to hypothalamus to regulate

productionCortisol had many effects on body

Good in short term, bad in long term activation

Paraventricular Hypothalamus

Anterior pituitary

Adrenal cortexcortisol

Negative Feedback to hypothalamus

Long term CorticosteroidsAffects viability of immune function, reduces itHigh blood pressure Possible atrophy of hippocampus

Memory difficultiesThe HPA axis neurobiology of mood disorders,

anxiety disorder, bipolar disorder, insomnia, post-traumatic stress disorder, borderline personality disorder, ADHD, major depressive disorder, burnout, chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, and alcoholism.[1]

Antidepressants, routinely prescribed for many of these illnesses, serve to regulate HPA axis function.[2]

Hypothisized relationships

normal

depression

Ptsd

Neurotransmitters associated with various diagnosesDopanergic: Schizophrenia, substance

abuse, Bipolar mania

Noradrenergic: Depression, mania

Serotonergic: depression, OCD, schizophrenia

Gabanergic: Anxiety disorders

Neurotransmitter systems regulation and dysregulation - malfunction

Neuroanatomical areas associated with certain diagnoses

Basal ganglia – cognition, emotion, motor activity

Brain Areas mediating OCDThought to be “locked in unison” during disorder

1.Orbito-frontal cortex – error detection2.Caudate Nucleus

1. – regulate “worry” between thalamus and frontal cortex hyperactive

2. -SSRI reduces CN activity3.Cingulate gyrus : “something is deadly wrong” (surgery)4.Releases “Fixed Action Patterns”

1. territoriality (checking). 2. Mating (urges), 3. Washing

Caudate nucleus

Neuroanatomy of OCD ??Straddling the fence between cognition and emotion,

Anterior Caudate has been suggested to be involved in the pathophysiology of :

attention deficit/hyperactivity disorder (Bush et al., 1999),

post-traumatic stress disorder (Shin et al., in press), depression ( Drevets, 2001; Davidson et al., in press), obsessive-compulsive disorder (Jenike et al., 1991), schizophrenia, bipolar disorder, panic disorder, Tourette’s Syndrome (Benes, 1993), and Alzheimer’s

Disease (Vogt et al., 1997).

Neuroanatomical sites of Alzheimer‘s Disease deterioration

Anatomical regions use certain neurotransmittersSerotonin pathwaysNorepinepherine pathwaysDopamine pathways

Genetics

Many disorders have some genetic contributions to etiology

How would that work?

Multiple causation – Diathesis Stress Schizophrenia:

Factors in order of predictive powerCotwin Sz 50Parent Sz 13Sibling Sz 9.6Premorbid pers.EP P50 Continuous prefor.Eye trackingHippocampal volumeObstetric complicationStressful life eventsMaternal influenza

PTSD: Diatheses/correlates

Given a life threatening trauma, what predicts PTSD?

Social support networkNegative affect/neuroticism

Poor coping skillsPrior traumasLower IQNature of the stressorPerceived controllability

Fear Circuitry - J. LeDouxPeripheral NS CNS SNS

Others?