Chapter 11: Substance-related disorders

Substance abuse: involves an excessive use of a substance resulting in

-potentially hazardous behavior (driving while intoxicated)
-continued use despite a persistent social, psychological, occupational or health
problem.

Substance dependence: more severe form of substance-use disorders; involves

a marked physiological need for increasing amounts of a substance to achieve
the desired effects.
Dependence means the individual will show a tolerance for a drug and
experience withdrawal symptoms when it is unavailable.

Alcohol dependence: a psychological and physical state resulting from

consuming alcohol. There may be behavioral and other responses that include a
compulsion to take alcohol on a continuous basis to experience its effects or to
avoid the discomfort of its absence.

Detrimental effects of excessive alcohol usage:

1. Increases vulnerability to injury
2. Marital discord
3. Intimate partner violence
4. Lowers performance on cognitive tasks
5. Organic impairment including brain shrinkage
6. Alcohol abuse is associated with:
 -over 40% of deaths in car accidents yearly
 -40-50% of all murders
 -40% assaults
 -50% rapes

Alcohol’s effects on the brain.

• At lower levels it stimulates certain brain cells and activates the brain’s
pleasure areas.
• At higher levels, it depresses brain functioning, inhibiting glutamate (an
excitatory neurotransmitter).
• Lower levels of glutamate associated with impaired ability to learn,
impairs judgement, rational processes and lowers self-control.
• Motor un-coordination develops and perception of cold, pain and other
discomforts become dulled.
• The drinker experiences a sense of well-being; unpleasant realities are
screened out and feelings of self-esteem arise.
Levels of alcohol in the bloodstream.
• At 0.08% the individual is considered intoxicated. The effects of
intoxication are usually more severe than the user feels.
• At 0.5% the individual passes out. This acts as a safety measure because
levels above 0.55% can be lethal (very slowed down brain functioning
and lack of oxygen to the brain).

Physical effects of chronic alcohol use

• Only about 5-10% of alcohol consumed by the body is eliminated
through the breath, perspiration and urine. The rest needs to be
metabolized.
• Alcohol metabolized by liver but large amounts of alcohol lead to the
liver becoming overworked and severely damaged. Liver cirrhosis.
• Alcohol is a high-calorie drug. A pint of whiskey is about 1200 calories.
This means malnutrition results since alcoholic beverages have no
nutritional value.
• Alcohol abuse also impairs body’s ability to absorb nutrients.

Psychosocial effects of alcohol abuse and dependence

• Heavy drinkers suffer from chronic fatigue, oversensitivity and
depression.
• Initially, it helps phase out harsh realities and stressors, enhancing
feelings of adequacy and self-worth (stimulant).
• Eventually, it acts as a depressant. Leads to impaired reasoning, poor
judgment, loss of memory and the drinker assumes less responsibility
over time.
• Leads to rapid deterioration and increased irritability
• Neglect and possible abuse of spouse and family.
• Impaired judgment means loss of employment and marital discord. By
this time, considerable physical damage to the brain and liver may have
occurred.

 Psychoses associated with severe alcohol abuse.

 Acute but short psychotic reactions may cause confusion, excitement and
delirium.

Alcohol withdrawal delirium: occurs after a prolonged drinking

spree when a person enters withdrawal.
  -disorientation for time and place where the individual may confuse a
hospital for a jail, no longer recognize friends or confuse them for
someone else.
 -vivid hallucinations, especially of fast moving insects
 -acute fear where these insects may assume different shapes and sizes.
 -extreme suggestibility (can make them believe something is there when
it isn’t)
 -marked tremors of the hands, tongues and lips
 -perspiration, fever, rapid heartbeat, coated tongue and foul breath.

This delirium may last 3 to 6 days and is usually followed by deep sleep. On
awakening, few symptoms remain.

Alcohol Amnestic Disorder (Korsakoff’s syndrome):

 Most severe of alcohol-related disorders
 Marked primarily by a memory defect (especially related to recent
events) and confabulation of events.
 -they may not recognize pictures of objects or faces they have just seen
even though they may seem familiar to the very least.
 -memory gaps are filled with fanciful tales.
- Memory problems involve inability to make new and easily
retrievable associations

 Involves cognitive impairments like emotionally and intellectual deficits.

 Some memory restoration may occur with prolonged abstinence.
 However, some forms of memory impairment, blunted intellectual
capacity and lowered moral and ethical standards do persist.

Misconceptions about alcohol and alcohol abuse

Fiction Fact
1. Alcohol is a stimulant. 1. Alcohol is both a stimulant and
depressant.

2. Alcohol can help a person sleep more soundly. 2. Alcohol may interfere with sound sleep

3. Impaired judgment does not occur before there 3. Impaired judgment can occur long
are obvious signs of intoxication. before motor signs of intoxication are
present.
 4. Drinking several cups of coffee can counteract the 4. Drinking coffee does not affect level of
effects of alcohol intoxication.\

5. Exercise or cold showers help speed up the 5. Exercise and cold showers are futile
metabolism of alcohol attempts at increasing metabolism

6. People with strong willpower need not be 6. Alcohol can lower resistance of very
concerned about becoming a substance abuser strong-willed people too.

7. Alcohol is not addictive in the way heroin is. 7. Alcohol has strong addictive properties.

8. Alcohol is far less dangerous than marijuana. 8. There are more people who seek help fo
alcohol abuse than for marijuana.

9. Physiological withdrawal reaction from heroin is 9. Alcohol withdrawal involves similar

more dangerous than withdrawal from alcohol. symptoms and is potentially more lethal
than opiate withdrawal.

Biological Causal factors

Why do some substances produce such a powerful dependence in such a short
amount of time?
 The ability of most substances to activate pleasure centers of the brain
and receive immediate rewards.

 -The person’s biological makeup, including genetic influences and

environmental factors.

 Neurobiology of addiction
 The substance consumed activates the pleasure pathway, the
Mesocorticolimbic dopamine pathway (MCLP) in the brain.
 The MCLP is made up of neuronal cells in the middle part of the
brain. The neuronal system is involved in the control of emotions,
memory and gratification.
 Alcohol produces euphoria by stimulating this region of the brain.

Genetic vulnerability.
 Strong genetic vulnerability.
 Rates of alcoholism range from 12% to 30% with one alcoholic parent,
 41.2% with two alcoholic parents.
  Adoption studies on children of alcoholics shows that despite changed
environment, there is an increased predisposition.

 Asians and native Americans experience ‘alcohol flush reaction’

involving flushing of the skin, a drop in blood pressure, heart
palpitations, nausea. Occurs due to failure of mutant enzyme to break
down alcohol. Lower levels of alcoholism in these groups.

Psychosocial causal factors

• Limited parental guidance
• Especially if parents themselves are abusers.
• Psychological vulnerability
• Children of alcoholics tend to be more predisposed to abuse the substance
as well.

Personality types associated with alcohol abuse:

• Emotional immaturity
• Requirement of excessive praise
• Too many expectations from the world
• Intense reaction to failure with feelings of hurt and inferiority
• Low frustration tolerance
• More impulsive
• More aggressive

 High comorbidity with personality disorders (esp Antisocial personality

disorder) and depression.

• Past trauma and discontent with life; low stress tolerance.

• Expectations of success. According to the reciprocal-influence model,
adolescents may start drinking, expecting it to increase popularity and
acceptance.
• Hostile intimate relationships.
• Cultural differences. Social events incomplete without alcohol in Western
cultures. Muslim, Mormon and orthodox Jews and alcohol
abstinence/prohibition.

Treatment
• Multidisciplinary approaches are more common although relapse rates are
high.
• Meds that reduce desire to drink.
• Antabuse meds cause extreme vomiting if followed by the intake of
alcohol. However, because the drug is self-administered, one may simply
refuse to take it often enough.
 • Opiate antagonists help block the pleasure producing effects of alcohol
usage.

• Medications to reduce side effects of acute withdrawal.

• During withdrawal, medication to block the physical symptoms of
withdrawal are administered. Insomnia, headache, gastrointestinal
distress and tremors. Prevention of seizures and heart arrhythmias.

Psychological treatment approaches.

• Detoxification is followed by psychological treatment.
• Group therapy
• CBT
• Aversive Conditioning therapy -> Involves presentation of a wide range
of noxious stimuli with alcohol in order to suppress drinking behavior.
• Intramuscular injection of an emetic. Before nausea symptoms appear, a
patient is given alcohol so that they associate it with nausea.
• CBT would involve psychoeducation about the effects of alcohol and
modification of cognitions.

Psychoactive drugs most associated with abuse and dependence:

1. Narcotics (includes opium and its derivatives like heroin and morphine)
2. Sedatives such as barbiturates
3. Stimulants such as cocaine and amphetamines
4. Antianxiety drugs like benzodiazepines (valium, Xanax)
5. Hallucinogens such as LSD, cannabis
6. Caffeine and nicotine
7. Opium consumption has a long history.

Greeks and Romans used it as a pain reliever and as a feel-good substance.

Galen: It treats venomous bites, cures headache, vertigo, deafness, epilepsy,

tightness of breath, colic, urinary complaints and melancholy, etc.
Asian countries consumed opium by mixing it with their food. Perhaps this
form of consumption prevented addictions.
The Chinese eventually discovered the Indian method of consuming tobacco
through smoking. They added opium to tobacco and suffered widespread
addictions.
Opium Wars with British India.

Narcotics (depressants: opium and its derivatives)

  Opium is a mixture of 18 chemical substances. One of these was found to
serve as a powerful sedative and pain reliever. It was called morphine.
 Morphine was heavily used to treat American soldiers after the civil war.
However, it proved to be very addictive.
 Later, morphine was treated with another chemical to retain its analgesic
properties whilst eliminating the problem of addictiveness.
 That led to the creation of heroin which replaced morphine for pain relief.
 Heroin proved even more addictive.

Biological effects of morphine and heroin -

 Commonly consumed through smoking/snorting it or injecting it in the
bloodstream (mainlining).
 Instant euphoric rush that lasts 60 seconds.
 Rush is followed by a ‘high’, characterized by lethargy, withdrawn state
where bodily needs for sex and food are reduced. Pleasant feeling s of
relaxation and euphoria continue for 4 to 6 hours.
 After this period, a negative state kicks in that produces a desire for more
of the drug.
 Continued usage over a period of 30 days is usually enough to establish
dependence.
 Not receiving a dose of the drug in roughly 8 hours leads to withdrawal
symptoms.
 Narcotics change neurotransmitter systems that regulate incentives,
motivation and the ability to manage stress.

Withdrawal from heroin:

• Symptoms include runny nose, teary eyes, increased perspiration,
restlessness, increased heartrate and an intense desire for the drug.
• Symptoms become severe with time.
• Body chills, flushing, vomiting, diarrhea, insomnia, weight loss.
• Delirium, hallucinations and manic activity may also occur.
• Opiates actively alter the immune system, rendering people vulnerable to
organ damage.

 Social effects:
• Many people will resort to theft and other crimes like prostitution to fund
their drug dependence. This leads to loss of social position and self-
respect which further perpetuates the addiction.

Causal factors in opiate abuse:

1. Pleasure
2. Curiosity
3. Peer pressure
 4. Personal maladjustment

• Comorbidity: Antisocial personality disorder.

• common traits linked with heroin addiction: antisocial traits, depression,
tension, insecurity, feelings of inadequacy, difficulty in forming warm
and lasting relationships.

Treatment:
1. withdrawal does not remove craving for heroin.
2. Drugs like methadone are used in conjunction with group therapy.
3. These drugs help give the feelings of contentment associated with heroin
without producing actual addiction and psychological effects.

Stimulants (Cocaine and Amphetamines)

1. Cocaine (or crack) is also derived from a plant and has been in
widespread usage throughout history.
• Ingested through sniffing, swallowing or injecting
• Like opiates, they cause a euphoric state that lasts 4 to 6 hours.
• Unlike opiates, cocaine acts like a stimulant, leading to sleeplessness,
excitement and accentuating sexual feelings.
• Continued abuse may lead to frightening hallucinations as in acute
schizophrenia
• Withdrawal period is followed by acute feelings of depressions and
tension.

2. Amphetamines (speed)
• These were introduced as inhalants to relieve stuffy noses but people
quickly became addicted to them in pursuit of the ‘kicks’ they are
associated with.
• Initially, amphetamine and its derivatives were used as ‘wonder pills’ to
help soldiers stay awake and aroused during World War 2.
• Eventually, night workers, truck drivers and students used them too to
ward off fatigue and stay awake.
• These were also used as mild antidepressants.
• However, they were later categorized as controlled substances due to
their addictive power and are unavailable legally.

 Amphetamine abuse:
o Can cause hazardous fatigue
o They are psychologically and physically addictive and cause addiction
very fast
 o The body rapidly builds up tolerance, leading to larger amounts
consumed.
o Heightened blood pressure, enlarged pupils, unclear and rapid speech,
sweating, tremors, excitability, weight loss, confusiona nd sleeplessness.
o Can cause death or severe brain damage.

3. Methamphetamine (crystal/ice. The poor man’s cocaine)

• Highly addictive stimulant that can be ‘cooked’ in makeshift labs
• Provides a quick and long-lasting high.
• Injected or sniffed
• Increases dopamine levels n the brain and prolonged use causes structural
changes to the brain.
• Discontinuing the drug can lead to problems with memory, learning and
further cognitive dysfunction.
• Slow to metabolize, leading to highs for a longer period of time.
Followed by periods of weakness, fatigue and depression.
• Addiction seems to be quicker and more severe compared to cocaine and
relapse rates are very high.

Sedatives (Barbiturates)
• Associated with psychological and physiological dependence and lethal
overdoses.
• Once widely used by physicians to calm their patients as they act like
depressants and slow the CNS down.
• Followed by feelings of relaxation in which tensions abate and a tendency
towards drowsiness and sleep takes place.
• Excessive doses cause paralysis of the brain’s respiratory centers,
resulting in death.
• Excessive use leads to brain damage and personality deterioration.

• Addiction most likely to affect middle aged users who use them as
sleeping pills.
• Withdrawal symptoms for habitual users may last for a month and can be
more severe than in opiate withdrawal.

4. Hallucinogens - (LSD and related drugs)

• These are thought to induce hallucinations but actually distort sensory
images.
• LSD, a chemically produced drug, was thought to be useful in the study
of hallucinogenic or psychotic states.
• An amount smaller than a grain of salt is enough to cause intoxication.
 • After consuming LSD, a person undergoes 8 hours of changes in sensory
perception, mood swings, feelings of depersonalization and detachment (a
trip).
• The experience is not always pleasant and can be traumatic.

• Distorted images and sounds can be very frightening and some people
have set themselves alight or jumped off from high places when under the
influence of the drug.
• Flashbacks of the distorted images may occur too; several months after
usage.
• Even if no flashbacks occur, visual disturbances can remain for up to 2
years after using the drug
• LSD is heavily associated with the rave culture or club scene.

4b. Ecstasy/ MDMA

• Was first used as a diet pill but later discontinued.
• Ecstasy is both a stimulant and a hallucinogen and a popular party drug.
• Chemically similar to methamphetamine but its hallucinogenic properties
outweigh its simulating abilities.
• Roughly 20 minutes after consuming the drug, a ‘rush’ kicks in, followed
by feelings of calmness and well-being and an intense experience of
color, sound and mild hallucinations.
• It is addictive but not as much as cocaine.

Personality characteristics associated with Ecstasy and other

drugs:
 Impulsivity and poor judgment
 More likely to engage in binge-drinking
 More likely to smoke
 More likely to have multiple sexual partners.

Use of Ecstasy leads to development of illnesses and psychopathology

even when used in small amounts.
1. -Panic disorder
2. -schizophrenia
3. -memory impairments
4. -sleep apnea

5. Marijuana:
 • Derived from the leaves and flowering tops of the hemp plant, Cannabis
sativa.
• It is smoked in the form of cigarettes and commonly called pot, reefers,
joints, stash and weed.
• It is also linked to a stronger drug called hashish, derived from the resin
exuded by the cannabis plant and made into a powder.
• Marijuana is the most frequently used illicit drug today.
• Most commonly used by people with schizophrenia and is legal in some
US states.

Effects of marijuana
1. These vary widely as per quality and dosage, personality and mood of the
user, past experiences with the drug, the social setting and the user’s
expectations.
Most commonly reported experience
2. -mild euphoria with feelings of well-being, heightened perceptual acuity and
relaxation followed by a sense of floating away.
3. -Sense of time may be stretched so that an event that lasts seconds may feel
like it lasts much longer
4. Rapidly absorbed when smoked; effects appear within seconds and seldom
last 2 or 3 hours.

• Withdrawal symptoms include nervousness, sleep problems and appetite

change.
• Patients do not always show a positive treatment response.
• It is especially dangerous for ‘psychosis-prone’ and anti-social
individuals to consume

Signs of marijuana dependence

• They will begin to need increasingly larger amounts.
• They will spend more time thinking about using.
• Substance use will begin to take a central role in their life.
• They will spend more time and money acquiring more marijuana.
• They will become irritable or agitated if they run out.
• As negative consequences mount, they will continue to use.
• They will deny claims from those close to them that they have changed

5. Spice: this is a marijuana substitute whose effects tend to be

stronger than marijuana’s.
Very little research done on spice so far but it is linked with anxiety,
tachycardia, hypertension, abnormally fast breathing, chest pain, heart
palpitations, hallucinations, racing thoughts and seizures.

6. Nicotine
Nicotine is a poisonous alkaloid and the chief active ingredient in tobacco. It is
also used as an insecticide.
Nicotine linked to respiratory and heart problems; lung cancer, heart attack.
Reduced immunity.
Nicotine use highly prevalent amongst those with anxiety disorders and may
have relaxing properties for anxiety. Enhances performance.
Withdrawal symptoms include craving, irritability, frustration, anger, anxiety,
difficulty concentrating, restlessness, decreased heart rate, increased appetite or
weight gain. Decreased metabolic rate, headaches, insomnia, tremors and
increased coughing.

Chapter 13: Schizophrenia & other psychotic

disorders

Schizophrenia
• Hallmark symptom of schizophrenia: significant loss of contact with
reality or psychosis.

• Extreme oddities in perception, thinking, action, sense of self and manner

of relating to others.

• The clinical representation of schizophrenia differs from person to person

but symptoms generally emerge between 18 and 30 years of age.

• First detailed clinical description of schizophrenia dates back to 1810 in

England. John Haslam noticed several delusions in one of his patients.

• Eugene Bleuler (1857-139) coined the term schizophrenia where ‘schizo’

means to split.
• Popular misconception to confuse the disorder with DID. The ‘split’
refers to a disconnect between thought processes and emotion and not
within the personality.

High risk people:

People whose fathers were 45 or older at the time of their birth have at last three
times the risk of developing schizophrenia.
People of Afro-Caribbean origin living in the UK and even in the US have
higher than expected rates of schizophrenia.
Children of people who work as dry cleaners (exposure to tetrachloroethylene)

Men are more likely to develop the illness compared to women.

The hormone estrogen seems to serve as a protective factor for women. This
explains why delayed onset can occur during menopause when estrogen levels
fall.

Delusions
These occur in at least 90% of people with schizophrenia.
An erroneous belief that is fixed and firmly held despite obvious contradictory
evidence.
People with delusions believe things that other people from their same social,
religious and cultural backgrounds do not believe.
It is a disturbance in the content of thought.

Prominent delusions:
Thoughts, feelings and actions are being controlled by external agents.
Thought broadcasting; that one’s private thoughts are being broadcast
indiscriminately to others.
Thought insertion; some external agent is transferring thoughts into one’s brain.
Thought withdrawal: an external agency has robbed one of one’s thoughts.
Delusions of reference; a neutral environmental event (TV show) has some sort
of special and personal meaning intended only for the person

Delusions of bodily changes; removal of bowels or other organs

Delusions may not only be isolated beliefs but may form an entire elaborate
system including conspiracy theories, etc.

Hallucinations
• Sensory experience that seems real to the person having it. It occurs in the
absence of the external perceptual stimuli.
• Hallucinations can be auditory, visual, olfactory, tactile or gustatory.
• Auditory hallucinations are the most common.
• Hallucinations have relevance for the patient at some affective,
conceptual or behavioral level.
• Hallucinations can be emotionally incorporated into delusions.
 • People may act on their hallucinations, doing what the voices tell them to
do.

 Majority of people with schizophrenia report that the voices

speak at normal conversation volume.
 -Voices were of people known to the individual although sometimes it
was the voice of God, the devil or other unfamiliar voices can be heard.
 -Most hear more than one voice and hallucinations tend to worse when
alone.
 -Most commonly, hallucinated voices utter rude and vulgar expletives or
were highly critical, bossy or abusive.
 Studies show auditory hallucinations result when the area of the brain
involving speech production is activated. Suggests, patients misinterpret
their own self-talk as coming from an external source.

Disorganized speech and behavior

 Reflects disturbances in thought form
 A person fails to make sense in their speech; this is not attributed to low
intelligence, poor education.
 Neologisms; sometimes new and made-up words appear in speech.
 Disorganized behavior involves complete disruption of goal-directed
activity. Impairment occurs in occupational, relational and hygiene
spheres where the person may no longer feel like themselves anymore to
others.
 Disorganized behavior may involve disregard for personal safety,
stillness and unusual dressing (wearing winter clothing in summer).
 Catatonia; absence of speech or movement and holding an unusual
posture for long periods of time without any seeming discomfort.

Positive and negative symptoms

 Positive symptoms: those that represent an excess or distortion in
normal behavior and experience. Includes:
 -delusions
 -and hallucinations.
 Negative symptoms:
 absence or deficit of behaviors that are normally present in a healthy
individual. Includes
 flat affect
 alogia (very little speech)
  Avolition (inability to initiate or persist in goal-directed activities). A
person may stare into the TV screen all day with little interest in
outside work

Schizoaffective disorder
 Includes features of schizophrenia and a severe mood disorder.
 It is difficult to diagnose.
 Mood symptoms have to meet criteria for a full major mood episode and
must be present for more that 50% of the duration of illness.

Schizophreniform disorder
 Schizophrenia-like psychosis where the disorder lasts at least a month but
not for the 6 months required for a diagnosis of schizophrenia.

Prognosis tends to be better for people with this disorder

Delusional Disorder
 The presence of delusions.
 People with the disorder may otherwise behave normally.
 Relatively little disorganization and performance deficiencies.

Brief Psychotic Disorder

Sudden onset of
 Psychotic symptoms
 Disorganized speech
 Or catatonic behavior

• The episode lasts only a few days and does not warrant a diagnosis of
schizophreniform disorder.
• The person may return to their former level of functioning and may never
have another episode again.
• It is often triggered by stress.

Psychosocial and cultural factors

Cold and Aloof parental style was very heavily associated with being a cause
for schizophrenia.

Double-bind hypothesis.
 • A double bind occurs when the parent presents the child with ideas,
feelings and demands that are mutually incompatible (A parent may
complain about a child’s lack of affection but become angered when the
child tries to then show affection).
• It was believed that such contradictory styles of communication built up
over time and led to the disorder.

Newer research suggest neither of these etiological beliefs are sound

• Instead, communication problems tend to come about as a result of an

individual in the family suffering from schizophrenia.

Families and Relapse

Symptoms, whilst chronic, tend to be especially severe at some times and mild
at other times.
Living situations after leaving the hospital plays a predictive role in outcomes.
Patients tend to be at a higher risk of relapse if they return to parents and/or
their spouse as opposed to living with siblings or alone.

Why?

Expressed Emotion: Researcher George Brown found amongst all

possible dysfunctions in family relationships, EE predicted greater levels of
relapse.
Expressed Emotion is a measure of the family environment that is based on how
a family member speaks about the patient during a private interview with a
researcher. It has three main elements:
1. Criticism (reflects dislike of the patient and is the most important
element)
2. Hostility (more extreme form of criticism)
3. Emotional overinvolvement (excessive feelings of guilt or
overprotectiveness which hampers self-reliance

How does EE trigger relapse?

 Patients with schizophrenia tend to be highly sensitive to stress.

 Environmental stress interacts with their biological vulnerabilities to

increase probability of relapse (diathesis-stress model).
  Stress response activation releases cortisol which triggers dopamine
activity and glutamate release. Both neurotransmitters are implicated in
the incidence of schizophrenia.

 High EE is also linked with well-intentioned attempts to control behavior

of individuals with schizophrenia in order to help them function better.

 Disorganized speech also seems to be linked with critical remarks.

Studies have found that patients were more likely to utter further
senseless remarks followed by criticism from a loved one.

 Neuroimaging techniques show that hearing criticism or EOI comments

leads to different patterns of brain activity in people who are vulnerable
to psychopathology than healthy controls.

1. Urban living
Being raised in an urban environment seems to increase risk of developing
schizophrenia. (more stress?)

2. Immigration
Immigrants, especially darker colored people are more predisposed to
developing schizophrenia.
Discrimination? Racism?

Cannabis use
 Young men who are heavy users of cannabis by the time they are 18 are 6
times more likely to develop schizophrenia within 27 years.

 Overall, research suggests that cannabis usage during adolescence more

than doubles a person’s risk (safe to say that acausal link has been found).
 This effect is especially pronounced when the user has a particular type of
the gene, COMT.
 THC helps in increasing the synthesis of dopamine is one of the main
components of cannabis.
 Schizophrenia is linked with brain volume loss and when coupled with
the use of cannabis, brain shrinkage is more severe.

 Diathesis-stress model
If stressful environments (given a diathesis) increase the chance of manifesting
symptoms, then a less stressful environment would mean symptoms would not
manifest despite a diathesis.
Treatment and Outcome
 Before the 1950s prognosis for schizophrenia was very bleak.
 Straitjackets
 Electroconvulsive therapy
 Institutionalization for life

 Antipsychotics changed the prognosis for individuals with schizophrenia.

 Studies show that after 15to 25 years of developing the disorder, 38% of
patients can be considered recovered.
 12% required institutionalization.

 Patients with schizophrenia in less industrialized countries tend to do

better than those living in industrialized countries.
 -Might be down to the fact that levels of EE are lower in less developed
countries such as India.

 Spontaneous improvement may take place at any point although usually

later in life.

Mortality rates
 Data from the UK shows that men suffering from schizophrenia die 14.6
years earlier than expected.
 Women die 17.5 years earlier.

Antipsychotic drugs, obesity, smoking, poor diet, use of illicit

drugs and lack of physical activity are significant factors.
About 12% end up taking their own lives.

2nd generation antipsychotics

Seroquel, Risperdal
 These can reduce symptoms of delusions and hallucinations within 24
hours of administering.
 Common side effects: drowsiness, weight gain, diabetes.

 Other side effects include increased depression and fatigue.

 Medication alone tends to not be enough in helping people function well.

Estrogen patches
 Studies have found that Estrogen patches help in reduction of symptoms
in women. Estrogen has antipsychotic effects.
Family Therapy
 Family therapy approaches are aimed at lowering EE by family members.
 This involves:
 Psychoeducation about the disorder
 Improving communication skills

Case management
 Case managers act like brokers, referring the patient to people who can
help them with housing, treatment and employment etc. Community
treatment plans.

Social skills training

 This helps to improve functional outcomes.
 Employment skills, relationship skills, self-care skills, symptom
management.

 Social routines are broken down into components.

 Making eye contact, speaking at a normal volume, taking one’s turn in a
conversation, etc.

Cognitive remediation
 Involves helping patients improve neurocognitive deficits such as
performance-related tasks, attention and improvement in memory

CBT
 This is focused on reducing intensity of positive symptoms and decrease
social disability.
 Exploring content of hallucinations and delusions, establishing evidence
for and against their fears, etc.

Personal therapy
 It is highly individualized modular treatment that helps to equip
individuals with coping techniques.
 Psychoeducation
 Examining link between symptoms and stress levels
 Relaxation strategies
 Social and vocational skills
Chapter 15: Disorders of Childhood and
Adolescence
 Attention towards mental disorders in children is fairly new.

 Mental disorders in children were initially considered similar to adult

disorders.

 Now there is more of a focus on the developmental process looking at

things in context of normal growth processes at a particular age
(developmental psychopathology).

 Most prevalent disorders in children are ADHD and separation anxiety

disorder

Psychological vulnerabilities of children

 Their view of the world is less complex and realistic as that of adults.
 There is a lesser sense of self/self-identity and they simply have not lived
long enough to know what resources they have to deal with problems.
 Immediate perceived threats are interpreted as disproportionately serious.
They are unable to put things in context effectively and tend to react even
more to stressful events.
 Children have limited perspectives and may resort to violence or suicide
without a real understanding of consequences of actions.

 Children are more dependent on other people than are adults. Whilst this
is good for them if the adults around them are protective, it also means
they are more vulnerable to neglect, rejection and dismissal by the same
adults.
 Children’s lack of experience in dealing with adversity can make
manageable problems seem insurmountable.

1. Attention Deficit/Hyperactivity Disorder

 ADHD is marked by difficulties that interfere with effective task-oriented
behavior in children.
 Impulsivity, excessive motor activity such as running, fidgeting and not
being able to sustain attention.
 Highly distractible, fail to follow instructions.
 Tend to be lower in IQ and often have poor academic functioning.
 Talk excessively and can be socially intrusive.
 Leads to difficulty getting along with parents and peers
  Most prevalent amongst preadolescent boys (uptil 10 years of age) and
occurs with greatest frequency till age 8.
 Tends to be comorbid with Oppositional defiant disorder.

Causal Factors
 No concrete opinion on the etiological basis of the disorder.
 Temperament and learning
 Prenatal alcohol exposure
 Different EEG patterns have been observed in children with ADHD
suggesting differences in brain activity patterns.

Treatment and Outcomes

 Medication very heavily used to treat ADHD.
 -Ritalin (an amphetamine) has a quieting effect on children even though it
acts as a stimulant for adults. Has shown many benefits in treating ADHD
symptoms.
 -School nurses administer more daily medication for ADHD than for
other chronic health problems.
 -Side effects of Ritalin: decreased blood-flow to the brain which can lead
to impaired thinking ability and memory loss. Disruption of growth
hormone, insomnia and psychotic symptoms.
 -There are other meds that have lesser side effects.

Psychological interventions
 -selective reinforcement in classroom.
 -positive reinforcement and structure of learning material and tasks in a
way that minimizes error and maximizes immediate feedback and
success.
 These treatments have been quite successful.

ADHD in adults may involve:

 Anxiety
 Chronic boredom
 Chronic lateness and forgetfulness
 Depression
 Trouble concentrating when reading
 Trouble controlling anger
 Problems at work
 Low self-esteem
 Mood swings
 Poor organization skills
 Procrastination
 Relationship problems
 Substance abuse or addiction
 Low motivation
 Impulsiveness
 Low tolerance for frustration

2. Oppositional Defiant Disorder

 Aggressive or anti-social behavior are prevalent in this disorder.
 Usually becomes apparent by age 8 and may then lead to conduct
disorder which becomes apparent around age 9.
 Must distinguish between persistent antisocial acts that involve harm or
injury to others and less serious pranks carried out by adolescents on
other people.
 Involves 3 sub-types: angry/irritable mood, argumentative/defiant
behavior, vindictiveness.
 We’re looking for a recurrent pattern of negativistic, defiant, disobedient,
and hostile behavior toward authority figures that persists for at least 6
months.

 Lifetime prevalence of ODD: 11.2% of boys, 9.2% of girls.

 Virtually all cases of conduct disorder are preceded by ODD but not all
children with ODD develop conduct disorder.

3. Conduct Disorder
 CD and ODD both involve persistent, repetitive violation of rules and a
disregard for the rights of others.
 Children with CD show a deficit in social behavior
 Overt and covert hostility, disobedience, physical and verbal
aggressiveness, vengefulness and destructiveness.
 Lying, stealing, temper tantrums.
 Sexually uninhibited and inclined towards sexual aggression
 Cruelty to animals and bullying.
 Vandalism
 Frequently comorbid with substance abuse, depressive disorders and
highly associated with later anti-social personality disorder.
Causal Factors
 A self-perpetuating cycle
 Genetic predisposition linked with low verbal intelligence, difficult
temperament.
 A difficult temperament may lead to an insecure attachment because
parents find it hard to deal with the child without getting exasperated.
 A preschooler may have a delayed readiness for school and doesn’t
receive the attention he needs from teachers. He then goes on to have a
series of class failures and eventually may be grouped with other children
with behavioral disorders in a remedial program. The child may pick
delinquent behaviors from his new friends.

 25-40% of children with CD go on to develop antisocial personality

disorder.
 Even if they don’t develop ASP disorder, they may experience social
dysfunction.
 Most children belong to a lower socio-economic class.
 Family setting of children with CD is generally characterized by
ineffective parenting, rejection, criticism, harsh and inconsistent
discipline.
 Parents usually themselves have unstable marital relationships, are
emotionally disturbed.
 Rejection by peers due to socially inept behaviors can also lead to a
spiralling effect.

Treatment
Remember: Punishment only intensifies anti-social behavior.

a. Cohesive-Family Model
 The initial focus is on modifying the child’s environment.
 In the family-oriented approach, the parents are viewed as being
ineffective at reinforcing only appropriate behavior. Children escape
parental guidance by escalating negative behaviors. Responding, though
harshly, to misbehavior leads to its reinforcement.
 -Problematic if parents simply do not agree to correcting their behavior or
don’t have the time for therapy.

Anxiety and Depression in Children and Adolescents

 Traumatic events can predispose children to developing anxiety
disorders.
  Children with anxiety disorders tend to be more extreme in their
behaviors.
 Marked by oversensitivity, unrealistic fears, shyness, timidity, pervasive
feelings of inadequacies, sleep disturbances and fear of school.
 Children suffering from an anxiety disorder typically tend to become
overly dependent on others.
 Anxiety disorders are often comorbid with depressive disorders.

4. Separation Anxiety Disorder

 Most common anxiety disorder among children.
 They exhibit unrealistic fears, oversensitivity, self-consciousness,
nightmares and chronic anxiety.
 Lack self-confidence, are anxious in new situations and tend to be
immature for their age.
 They are overly dependent especially on their parents.
 Hallmark symptom is excessive anxiety about separation from major
attachment figures.
 When separated from the attachment figure, they have morbid fears such
as a fear of the attachment figure dying or becoming ill.

At 15, Lisa started becoming very anxious following her parent’s divorce. Her
and her younger brother lived with their mother and saw their father weekly.
The arrangements were amicable. Shortly after the divorce her father had a 
stroke and was in hospital for several weeks. Within weeks, Lisa starting getting
nervous when her mother went out – even for short periods (under an hour) to
the shops. She texted and rang her mother every 3-4 mins to ask if she was
alright, and when was she coming back to the house. Her mother was worried
about her and, uncertain as to what to do, reduced her trips out and when she did
need to shop always took Lisa with her. Things didn’t improve and Lisa became
more anxious, not wanting to let her  mother out of sight around the house even
though, by now, her father had made a good recovery from his stroke and was
out of hospital. Both parents had an amicable relationship and were jointly
supportive to the children.

Causal Factors
 Genetic factors
 Temperament: easy to get upset by aversive stimuli or small
disappointments
 Harder time to calm down fear reaction
 Early illnesses, accidents
 Hospitalization in childhood
  Moving away from friends.
 Overanxious and protective parents.

 Indifferent or detached parents

 Repeated experience of academic failure.
 Cultural differences?

Treatment

5. Childhood Depression and Bipolar Disorder

 Childhood depression includes behavior like withdrawal, crying,
avoidance of eye contact, physical complaints, poor appetites and even
aggressive behavior.
 In children, irritability is often found as a major symptom and can be
substituted for depressed mood.

Causal Factors
 Biological factors
 Learning maladaptive behaviors
 Cultural factors in the expression of depression.
 Mother-child interaction where the mother is clinically depressed.
 Thinking patterns- internal, global and stable causes.
 -fatalistic thinking, feelings of helplessness.

Treatment
 Very small children benefit from a more favorable environment where
they can learn emotional expression and better coping strategies.

 Older children can benefit from a positive therapeutic relationship.

 Play therapy helps children express emotions and fears in an uncensored

manner. The clinician carefully observes behavior. This is found to be as
effective as behavior therapy.

Neurodevelopmental disorders
 These are severely disabling conditions and are very difficult to treat.

 Arise due to structural differences in the brain. These are evident at birth
or can be seen as the child develops.

 Includes Autism spectrum disorder.

 1. Autism Spectrum Disorder
A developmental disorder including a wide range of problematic behaviors:
 deficits in language
 deficits in motor and perceptual development
 defective reality testing
 inability to function in social situations

Matthew is 5 years old. When spoken to, he turns his head away. Sometimes, he
mumbles unintelligibly. He is neither toilet-trained nor able to feed himself. He
actively resists being touched. He dislikes sounds and is uncommunicative. He
cannot relate to others and avoids looking at people in the eye. He often engages
in routine manipulative activities such as dropping an object, picking it up, and
dropping it again. He shows a pathological need for sameness. While seated, he
often rocks back and forth in a rhythmic motion for hours. Any change in
routine is highly upsetting to him.

 About 1 in 50 children suffer from Autism with socioeconomic condition

having no bearing.
 It is usually identified before a child is 30 months of age and may be
suspected in the very first few weeks of life.
 Diagnostic stability over the course of childhood is quite high.
 Lack of empathy, inattention to others, inability to imitate becomes
apparent by the first 20 months.
 A hallmark sign of autism is that a child seems apart or aloof from others,
even in early stages of life.

Behaviors most evident in Autism.

 A social deficit
 -Little to no show of need for affection or contact with others.
 -Tend to not know or care who their parents are.
 -Many researchers disagree that children with Autism are emotionally
flat. Instead, there is simply a lack of social ability to respond to others.
 -Inability to take the attitude of others or to see things from the point of
view of other people. Includes limited ability to understand where exactly
someone else is pointing.
 -Deficits of attention and in locating and orienting to sounds in their
environment.
 Tend not to socially engage with other children and tend not to play
either.
 Encopresis is common.
  Absence of speech
 -Autistic children do not effectively learn through imitation and so their
use of speech is severely limited.
 -Speech that is present is rarely used to communicate. They may respond
‘yes’ to a question or repeat words in a parrot-like manner (echolalia).

Self-stimulation
 -Repetitive movements like head-banging, spinning and rocking.
 -Actively arrange the environment on their own terms in an effort limit
variety and intervention from others. They prefer to be solitary in their
routine.
 -Tend to be very aversive to sounds, even parents’ voices at times. At
other times, they may not react to even loud noises.

Intellectual Ability
 -Marked cognitive impairment especially with memory-related tasks.
 -They may be highly skilled at fitting objects together but seem to have
deficits in terms of meaning.
 They will show a marked deficiency in arranging pictures in an order to
tell a story.

Maintaining Sameness
 Children with autism become preoccupied with maintaining sameness
and develop strong attachments to unusual objects.
 -Any attempts at substituting the object or retrieving it or a change in the
environment can be met with a temper tantrum until the same order is
restored.

 High functioning autistic children

 Autistic children with unusually high IQs

Causal Factors
 An inborn defect that impairs an infant’s perceptual-cognitive
functioning- the ability to process incoming stimuli and to relate to the
world.
 Defective genes or damage from radiation in prenatal stage.
 Genetic factors.
 Increased glutamate activity also implicate in autism.
Treatment and Outcome
 Prognosis is generally poor and so many times, children with autism
remain insufficiently treated.
 Medical Treatment
 Antipsychotics and antidepressants may help check uncontrollable
behavior at most.
 For violence and aggression, separate medication may be given.
 No current medication promises reduction of symptoms to the extent of
sanctioning its regular use.

Behavioral Treatment
 Has been used effectively to eliminate self-injurious behavior, improve
social behavior, help develop some language skills.

 Several treatment programs are very rigorous and conducted in children’s

homes. Based on discrimination training and aversive training techniques,
parents are enlisted in the process and children are made to learn how to
interact with others from their normal peers. There is usually a teacher
who guides in one-to-one learning. This arrangement may last years.

 However, children have trouble generalizing behavior outside the

treatment context.

2. Specific Learning Disorders

 Refers to delayed development manifested in language, speech,
mathematical and motor skills.
 More to do with academic skills.
 Most common condition is dyslexia.

a. Dyslexia
Impairment in:
 -Word recognition
 -Reading comprehension
 -spelling and memory

 On assessments of reading skills, people with dyslexia omit, add and

distort words. Their reading is painfully slow too.

 Diagnosis is restricted to cases where a clear impairment in school

performance occurs or in daily activities.
  Children with specific learning disorders tend to have regular IQs.
 There are no obvious emotional problems or lack of motivation.
 However, their continued academic disability can lead to psychological
problems.
 These problems can be overcome with professional help.

b. Intellectual Disability/Intellectual Developmental

disorder
 Characterized by deficits in general mental abilities.
 Includes reasoning, problem-solving, planning, abstract-thinking,
judgment, academic learning and learning from experience.

 Problems must begin before the age of 18 otherwise it may be

characterized as dementia.

Mild intellectual disability

 -Form majority of those diagnosed with intellectual disability.
 -Intellectual level as adults is comparable to 8-11 year olds.
 -They have far more experience in living so they are not literally
comparable to 11 year olds.
 -They may not show signs of brain pathology or other physical
abnormalities.
 -With adequate support, they can adjust socially.

Moderate intellectual disability

 -They are presumed able to master certain routine skills such as cooking
or minor janitorial work with specialized instructions.
 -Can attain intellectual levels similar to 4-7 year olds as adults.
 -Can learn to read or write a little but their learning is very slow.
 -Appear clumsy, suffer from body deformities and poor motor
coordination
 -May be hostile and aggressive but are mostly nonthreatening.
 -Can achieve partial independence in daily self-care and economic
sustenance.

Severe Intellectual Disability

 -Motor and speech development are severely retarded.
 -Very limited self-help skills.
 -Are usually always dependent on others for care.
  -May be able to perform some very simple tasks under supervision.

Profound Intellectual disability

 -Severely deficient and unable to master most tasks.
 -Speech is rudimentary.
 -Severe physical deformities.
 -Mutism, deafness.

 -Poor health and low life expectancy and low resistance to disease.
 -Can be diagnosed in infancy because of obvious signs.
 -Need life-long care.

Causal Factors
 Genetic-chromosomal factors
 Infections and toxic agents such as carbon monoxide during fetal
development. If the pregnant mother develops German measles or
syphilis. Drug overdose.
 Physical injury at birth can result in intellectual disability.
 Ionizing radiations. X rays, nuclear weapons testing, leakage at nuclear
plants.

Organic retardation syndromes

Intellectual disability caused by very obvious biological deficits.

a. Down’s syndrome
 -Moderate and severe intellectual disability
 -Facial features: almond shaped eyes, abnormally thick skin on eyelids.
Face and nose are often flat and broad. Back of the head is flat and broad
too. Tongue may be too large. Neck is short and broad.
 -Life expectance used to be 9 years but can now live into adulthood.
 -Can learn self-help skills and acceptable social behavior.

 -greatest deficits are in verbal and language related skills.

Cranial anomalies
 Many intellectual disabilities are associated with conditions that involve
alterations in head size and shape without known causal factors.

Microcephaly: small headedness.

 Considerable difference in appearance from others.
  Fall in moderate to profound categories.
 Most show little language development and are limited in mental
capacity.
 Many cases emerged after Hiroshima and Nagasaki. Intrauterine infection
in pregnant women.

Macrocephaly and hydrocephaly

Chapter 17: Contemporary & Legal Issues

in Abnormal Psychology
Preventing Mental Disorders
Universal interventions (for the general population)

Selective interventions (at-risk subgroups like adolescents and ethnic

minorities)

Indicated interventions (high-risk individuals with mild symptoms of mental

disorders; natural disasters etc)

Universal interventions
These aim at:
Reducing risk-factors by altering conditions that cause MI
Establishing conditions that foster positive mental health

Biological strategies
Promoting more adaptive lifestyles (health psychology)
Improving diet, physical exercise, good health habits, maintaining good
physical health

Psychosocial strategies
Goal is to create an environment where people can be high functioning as
opposed to simply free of mental illness (health psychology).
-developing skills for effective problem-solving, emotional regulation and
expression, engaging in satisfying relationships with others.

-acquiring an accurate frame of reference on which to build one’s identity.

Inaccurate assumptions about oneself or the world is likely to lead to
maladaptive behavior.
-preparedness for the types of problems likely to be faced during given life
stages. Marriage, parenting, retirement.

Sociocultural strategies
Community-based interventions to make the community a safe and supportive
place.
Public education and social security measures.

Selective interventions
These are usually more effective than universal interventions.
Aimed heavily at reducing substance usage amongst adolescents.
-intercepting/reducing supply of drugs available (but still cant stop access to
readily available tobacco and alcohol).
-encouraging prevention. Most effective strategy.

School-based interventions.
These are focused on behavioral principles and target the risk factors (peer
pressure, mass media) and protective factors (alcohol-free fun activities).
Includes developmentally-appropriate information about alcohol and other
drugs.

Intervention programs for high-risk teens

Early intervention program can help identify high-risk teens.

Indicated interventions

Emphasizes early detection and prompt treatment of maladaptive behavior in a

person’s family and community setting.
Crisis intervention after traumatic events.

Deinstitutionalization, a good thing?

Legal status of mentally ill people

Rights of patients and the right of members of societies to be safe from mentally
disturbed individuals.

Individuals judged to be potentially dangerous because of their mental health

condition must be confined in a mental institution after civil commitment
procedures.
Conditions for formal involuntary commitment:
-individual is a danger to themselves or others
-incapable of providing for their basic physical needs
-unable to make responsible decisions about hospitalization
- In need of treatment in a hospital

Petition for commitment signed by a relative or concerned individual

Judge appoints two examiners to evaluate the patient
Patient is asked to appear for psychiatric examination before hearing.
Decision is made
Upon confinement, the hospital must report to the court within 60 days on
whether the person needs to be confined for longer.

Once committed, patients have the right to refuse treatment.

Assessment of dangerousness
Most individuals with mental illness deemed not dangerous
Disorders with increased risk of violent behavior:
-schizophrenia
-mania
-personality disorders
-substance abuse

Accurate appraisal of dangerousness is incredibly difficult to do.

Violent acts particularly difficult to predict because they are heavily determined
by situational factors (influence of alcohol, hostile environment) and not just by
personality traits.

You may look at past history of violence to make a prediction.

Typically, mental health professionals overpredict violence.

What should a therapist do on learning that a patient is planning to harm

someone?

Tarasoff decision- duty to warn?

What if the threat to harm is global, with no specific person mentioned?

What if they threaten suicide?

NGRI-Not guilty by reason of insanity

The attempt is to prove that acts of crime lack moral blameworthiness because
they are not intentional since defendants did not possess their full mental
faculties at the time of the crime and did not know what they were doing.
General public tends to be outraged whenever his plea is successfully proven in
court.
-Hinckley’s assassination attempt on Reagan in 1981.

Typically, lawyers for the defendant will try to portray their client as someone
who has suffered considerable past traumas in order to gain public sympathy.

Faking insanity
Michael McDermott testified that Michael the Archangel had sent him on a
mission to prevent the Holocaust when he gunned down seven coworkers on
December 26, 2000. McDermott stated that he believed that he was soulless and
that by killing, he would earn a soul. McDermott claimed to have been raped by
a neighbour when he had been a young boy and had a history of paranoia and
suicide attempts. Despite this claim of insanity, a jury found McDermott guilty
in the shooting deaths of his seven coworkers. The prosecution argued that
McDermott was motivated to kill because his employer was about to deduct
from his wages back taxes owed to IRS. Evidence seized from his computer
showed that McDermott had researched how to fake being mentally ill.
McDermott is currently serving seven consecutive life sentences for his crimes.

Knowing right from wrong. It must be proven that at the time of the criminal
act, the individual did not know the nature and quality of the act they were
committing and did not know it was wrong.
Irresistible impulse. They could not avoid doing the act in question because they
were compelled beyond their will to commit the act.
The accused is not criminally responsible if their unlawful act was the product
of mental disease or mental defect (broadens the insanity defense).
Combines the first two. At the time of the act, the individual couldn’t tell right
from wrong and also had an irresistible urge to commit the act.
Mental disorder involved must be a severe one and the defence must establish
insanity as opposed to the prosecution trying to establish sanity

Guilty but mentally ill, GBMI.

Defendant may be sentenced but placed in a treatment facility until the entire
sentence period has been served.

To some, this is a more realistic approach.

Competence to stand trial.

If unable to understand trial proceedings due to intellectual deficit or mental
health issues, defendants may be given time before the start of a trial where they
are hospitalized and given treatment.
Efforts at the workplace
Americans with Disabilities Act. It is against the law to discriminate against
people with disabilities in the US.

Employers are encouraged to hire psychiatric services for their employees.

However, it is argued that this proves too costly.

Efforts needed in:

Work load, pace
Work schedule (timings)
Role ambiguity (need to clearly demarcate responsibilities)
Job security and career progression
Interpersonal relations with colleagues
Job content (allow for more creativity and less monotony)