Operant Conditioning

• behavior emitted (not elicited)
• reinforcement: primary/$econdary; positive or negative
• punishment

Response Dependent

Reinforcement schedules

• FR: reinforcer follows fixed number of responses
• VR: reinforcer on average follows finxed number of responses (gambling/lottery games)

Response and Time Dependent

• FI: reinforcer follows first desired response after fixed amount of time (course exam)
• VI: reinforcer follows first desired response after specified average amount of time (busy signal)

Conditioning Outcomes

• strengthen CS-CR bond
• extinction
• spontaneous recovery(old habits die hard)
• generalization (behave similarily in different situations
• discrimination (behave differently in different situations)

Behavior Medicine techniques

• biofeedback 
• flooding 
• aversion therapy
• in vivo desensitization (virtual reality)
• hypnosis

Pain

• 80% of all office visits (behind URI)
• chronic pain syndromes cost up to 635billion in medical treatment and lost productivity
• 10-15% of adults have work disability due to back pain 
• low back pain most common cause of job related disability and leading contributor to missed work

US Surgeon General 

Report on Mental Health

(Dr. Satcher)

• Mental health is fundamental to health
• mental illness are real health conditions
• the efficacy of mental health treatment is well documented
• a range of treatments exist for most mental disorders
• mental health and mental illness require the broad focus of a public health approach 
• mental disorders are disabling conditions
• mental health and mental illness are points on a continuum
• mind and body are inseparable
• stimga is a major obstacle preventing people from getting help

Mental Disorders Are Not

• an expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder
• Socially deviant behavior(political, religious or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual as decribed in the previous slide

Current Understanding of 

Psychiatric Disorders

• psychotherapy can change brain function
• modifying behavior can change mind: AA and addiction treatment
• the role of the person in disease outcomes: hope facilitates recovery, personal responsibility facilitates recovery, there is nothing more imp than the clinician/patient relationship in fostering recovery

Personality Disorders

(DSM 5)

• an enduring pattern of inner experience and behavior that deviates markedly from the experiences of the individuals culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment
• Cluster A-Odd Cluster: paranoid, schizoid, schizotypal
• Cluster B-Dramatic Cluster: antisocial, borderline, histrionic and Narcissistic Personality disorder
• Cluster C- Anxious Cluster: Avoidant, dependent, and OCD

DSM 5 Changes

• eliminating multi-axial system
• intellectual disability
• autism spectrum disorder
• schizophrenia: eliminated subtypes and requires positive symptoms
• major depression: eliminated bereavement exclusion

Research Domain Criteria

(RDoC)

• NIMH attempt to develop, for research purposes, new ways of classifying mental disorders based on dimensions of observable behavior and neurobiological measures
• it became immediately clear that we cannot design a system based on biomarks or cognitive performance because of lack of data
• RDoC is a framework for collecting the data needed for a new nosology
• critical we realize we cannot use DSM as the gold standard

Mental Disorders Are Common

• 26.2% of americans 18 and older suffer from a diagnosable mental disorder in a given year
• 6% suffer from a serious mental illness
• leading cause of disability in US for ages 15-44
• 45% of those with any mental disorder meet the criteria for two or more disorders
• US mental disorders are based on DSM-5

Mood disorders

• include major depressive disorder dysthymic disorder and bipolar disorder(and suicide)
• about 20.9 million adults(9.5%) in a given year have a mood disorder
• median age of onset is 30 years
• depressive disorders often co-occur with anxiety disorders and substance abuse

Major Depressive Disorder

• leading cause of disability in US for ages 15-44
• affects 6.7% of adults in a given year
• can develop at any age, median 32 years
• more prevalent in women than in men

Bipolar Disorder

• aprox 2.6% of adults in a given year
• median age of onset is 31

Suicide

• twice as prevalent as homicide
• more than 90% of people who kill themselves have a diagnosable mental disorders, most commonly a depressive disorder or a substance abuse disorder
• highest suicide rate in the US are fond in white men over age 85
• four timeas as many men as women die by suicde but women attempt it two or three times as often

Schizophrenia

• 1.1% in a given year have schizophrenia 
• affects men and women with equal frequency
• often first appears in men in their late teens or early twenties
• generally first affects women in their twenties or early thirties

Anxiety Disorders

• include panic disorder, OCD, PTSD, generalized anxiety and phobias
• 18.1% adults in a  given year have an anxiety disorder
• frequently co-occur with depressive disorders or substance abuse
• usually have first episode by 21

Stress-Diathesis Model

• genetics and life experiences (social context)
• vulnerability and exposure
• vulnerability versus inevitability
• interactions, synergistic effects, moderation

Moderator Vs Mediator

• Moderator: is a variable that alters the direction of strength of the relationship btw a predictor and an outcome(social support)
• Mediator: a mediator variable explains the relationship btw a predictor and an outcome (control, mastery, efficacy)

Social Cognitive components of Stigma

• stereotype: efficient social belief or knowledge structure
• prejudice: emotion-based endorsement or evaluation of stereotype
• discrimination: behavioral result of prejudice
• dangerousness-> fear-> avoidance
• two types of stimga: public and internalized

Public Stigma as a cause of population

Health Inequalities

• Public stigma increases the likelihood of factors that affect health inequalities
• Material resources are undermined(power, prestige, employment, wages, loans, housing, education)
• social relationships are undermined(increased social isolation and decreased social support
• internalized stigma(self-stigmatization), coping resources such as emotion regulation are strained

Eugen Bleuler

• first used the term schizophrenia in 1911
• splitting of psychic functions
• the four A's: Association, affectivity, ambivalence, Autism

Diagnostic and statistical manual

• I 1952-meyer (reaction) and freud
• II 1968 - Freud
• III 1980 -behavioral descreptions
• IV 1992 - behavioral, updated
• V 2013 (v Research Domain Criteria-RDoC)

Schizophrenia

• need atleast 2
• delusions
• hallucinations
• disorganized speech (frequent derailment or incoherence
• grossly disorganized or catatonic behavior
• negative symptoms 
• common associated features: cognitive deficits(frontal lobe dysfunction), anosognosia(unaware of illness)

Clozapine

• initiating the second generation of antipsychotic medications
• still considered the gold standard fo antipsychotic medicatinos
• thir generation-Aripiprazole(abilify), partial agonist

SAMHSA

Recovery to Practice

2010

• five year project
• grants awarded to psychiatrists, psychologists, nurses, social workers and peer support associations(250k) to become more recovery oriented
• Larry Davidson, Project Director

Fundemental Elements and Guiding

Principals of Recovery

• self-direction
• individualized and person centered
• empowerment
• holistic
• non-linear
• strengths-based
• peer support and respect
• responsibility
• hope 

Syllogism

• a duductive argument consisting of:
• a major premise
• a minor premise
• conclusion

Mood

• type: angry, depressed, anxious, irritable, euphoric, guilty, frightened
• intensity: extreme emotional feeling vs alexithymia
• fluctuations: labile, rapidly shifting 

MMSE

• Mini-mental State Examination
• short, 30 question assessment that can be done quickly and provides a screening tool
• cognitive exam: consciousness, orientation, memory(immediate, recente, remote), attention and concentration(serial 7s and spell backwards), abstract thought(dealing w/ concepts), estimated intelligence, 

Euphoria Producing Drugs

(EPDs)

• opiods
• stimulants
• sedative-hypnotics (beer wine liquor)(barbituates)
• canabinoids(weed)
• other(PCP, Kedamine, LSD)
• all proudce (secondary brain affect) an acute surge of dopamine from mid brain to fore-brain (mediate addictive disease)
• moves from reward to judgement 

Chemical Dependence 

Natural History

• increased dysfunction and disability in the following domains: (from earliest to latest)
• self image
• interpersonal
• social
• financial
• legal 
• work
• physical

Audit/Cage Questionaire

• cut down? 
• Annoyed by comments?
• Guilty?
• Eye openers?
• ask before you ask about how much ect

SOAPE

(brief intervention)

• Support: I want to work with you
• Optimism(you can and will get better)
• Absolution(it is not your fault for having the illness, just your responsibility to manage it)
• Plan(depends on the patient readiness for change)
• Explanatory model(this can be hard to hear, what are your toughts about your substance use)

Cognitive

• realms of mental life
• thinking, memory, visuospatial relations
• neocortex
• preservation of discrete data 
• delirium, dementia, mental retardation 

Affective

(realms of mental life)

• feelings, emotions, moods, drives
• limbic system
• resonant, sustained, fuzzy, background influence
• depression, mania, schizophrenia 

Cognitive Disorders vs Affective Disorders

• Frequently coexist, mixed presentations common
• brain diseases can cause both cognitive and affective symptoms
• major depression can produce poor motivation, psychomotor retardation, social withdrawal, sometimes denial of low mood-but usally with patience the true cognition can be assesed
• often prudent to delay Dx of dementia till depression resolved

Memory

• physiologic view: encoding, storage, recall
• clinical view: immediate, recent, and remote
• short term(7 items for 20-30 seconds)
• long term(recent vs remote is really testing whether theres been a deterioration in storage)
• explicit memory: semantic(NEOMED is in rootstown) vs episodic (my date with chris); hippocampus
• implicit memory: procedural vs emotional; amygdala
• this is why the nurses fold washcloths with demented patients

The MMSE

• a good screening test for cognitive problems
• only a neurologist would have named it mini-mental state
• scored from 0-30;cutoffs are 23 and 27
• can be used to follow patients serially
• often supplemented as needed
• also the MOCA that is much better for MCI but also 30 points

Level of Consciousness

• evaluated on a continuum of alertness, from fully alert through stupor and coma
• not to be confused with sleepiness or sleep "clouded sensorium"
• can be measured with EEG, perception time
• impairment in the ability to focus the attention, sustain it, and shift it appropriately
• neurology vs psychiatry: encephalopathy, delirium 

DSM IV Criteria: Delirium

• disturbed consciousness with reduced ability to focus, shift, sustain attention
• changed in cognition or perceptual disturbance not better accounted for by something else(dementia, schizophrenia)
• develops over hours to days, fluctuates
• caused bys ome known general medical condition

Pathophysiology of Delirium

• very poorly understood, but:
• reduced activity of the reticular activating system implicated
• reduction in cholinergic activity likely a factor(anticholinergic drugs a prime cause, alzheimer patients very vulnerable)
• increased serotonergic and dopaminergic tone noted, esp in excitatory deliria
• inflammation response(cytokines) appear to mediate Sx in traumatic and infectious cases

Glasgow Coma scale

• Eye Response(4): None, opening to pain, opening to verbal command, opening spontaneously
• Verbal Response(5): none, incomprehendable sounds, inapropriate words, confusion, oriented
• Motor Response(6): none, extension to pain, flexion to pain, withdrawl to pain, localizing pain, obeys commands

Two kinds of delirium

• hyperactive:caused by withdrawl of sedatives or intoxication by stimulants. delirium tremens. autonomic instability, risk of cardiovascular colapse, low voltage, fast EEG
• hypoactive: other drug intoxication, inflamation, metabolic derangements(acute confusional state or metabolic encephalopothy), EEG is slow 

Corticol Dementia

• typical alzheimer pattern
• preservation of social skills early on, normal speech, normal attention and concentration
• good effort, but poor performance on abstractions
• no motor signs
• likely to deny impairments

Subcorticol

• typical parkinsons or huntingtons patient
• abulia(loss of will, speech, movements), apathy, poor effort with suprising cognition for degree of disability, psychomotor retardation, prone to depression
• early motor signs, may exaggerate impairments

Alzheimers Disease

• most common dementing disease, steady variabe deterioration; ECF and then death in less then 10
• some familiarity with basic science required to enderstand emerging treatments
• cognitive deficits: aphasia, apraxia, agnosia, disturbed executive functioning
• significant decline, impaired social/occupation functioning
• gradual onset with decline, not due to other stuff or delirium or schizophrenia/depression ect

Alzheimer's Drugs

• cholinesterase inhibitors: squeeze more out of remaining neurons
• NMDA antagonist: keep glutamate from killing cells
• β-amyloid binders in development: to reduce polymerization
• immunotherapy: get immune system to remove amyloid

Vascular Dementia

• second most common
• group of syndromes, including diffuse small vessel disease, and various stroke patterns
• preventable
• multi-infarct dementia
• stepwise deterioration, focal findings, cardiovascular risk factors
• lacunar infarctions
• first sign is falling down alot and incontinence

Dementia Pugilistica

• primarily in boxers
• due to multiple concussions
• parkinsonian Sx common
• shares some neuroanatomic and molecular pathology with alzheimers

Normal Pressure Hydrocephalus

• classic triad of gait apraxia(magnetic) urinary incontinence and dementia
• subcortical dementia pattern
• enlarged ventricles on CT scan, normal opening pressure on LP
• Caused by abnormal CSF pressure waves and or flow
• patients may improve after LP
• shunting can help but has a  high complication rate

Secret Hints for questions

• Glasgow Coma scale is too insensitive to pick up delirium
• 3X3 table for congitive disorders is important
• sensory deprivation doesnt cause delirium