Summary Class notes - Neuropsychology & psychiatric disorders

Course
- Neuropsychology & psychiatric disorders
- -
- 2018 - 2019
- Rijksuniversiteit Groningen (Rijksuniversiteit Groningen, Groningen)
- Psychologie
250 Flashcards & Notes
1 Students
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Summary - Class notes - Neuropsychology & psychiatric disorders

  • 1535752800 Lecture 01

  • Neurology definition
    medical speciality concerned with the diagnosis and brain treatment of disorders of the nervous system
  • Psychiattry definition
    medical speciality concerned with the diagnosis and treatment of mental illness
  • Similarities between neurology and psychiatry
    •  application of neurological methodology and diagnostics in psychiatric diseases
    •  interest of neurology in complex mental functions and psychiatric symptoms in neurilogical diseases


    increased recognition
    • profound cognitive concequences of primary psychiatric disorders (schizophrenia)
    • profound affective disorders of primary neurological disorders (Huntington)
  • Huntingtons
    Falls in neurological domain but, 

    • psychiatric symptoms 
    • incorable autosomal dominant inherited disorder
    • associated with cell loss within a specific subset of neurons in the basal ganglia and cortex 
    • characteristics feutures incllude involuntary movements, dementia, and psychiatric symptoms (depression or mania)
  • History
    • neurology and psychiatry were part of a unified branch in western medicine
    • hippocrates > theorised the four humours that were responsible for physical and mental health problems


    began to split in two branches in the 19th century
    • 1940 > journals were split
    • different trainee groups


    neurology and psychiatry came more together in the >1950s 
    • development of psycho-pharmacology supported the hypohesis that psychiatric diseases are diseases of the brain
    • biological psychiatry (dealt with synapses, neurotransmitters and receptors)
    • recent developments (getting better insights into the biologycall basis of psychiatric disorders) question the old division between the two
  • charcot
    • trained neurologist
    • interested in hysteria, a neurolgical problem
    • therapeutic use of hypnosis
  • alzheimer (1864-1915)
    • trained psychiatrist 
    • best known for describing a neurological disorder
  • Freud (1856-1939)
    • trained neurologist 
    • shifted psychiatry from structural neuropathology to psychological modes 
  • Kreaplin (1856-19926)
    • psychiatric diseases are mainly biological disorders
  • Approaches used in neurology and psychiatry
    • neurology used emperism and objectivity
    • psychiatry uses inerviewing skis, psycho-logical therapies and appreciation of individual differences 


    both can learn from each other 
    • neurologists assess psychiatric comorbidities
    • psychiatrist become familiar with neuroscience research tools (neuroimaging)
  • contribution of neuropsychology to psychiatry
    • some brain bases for neuropsychological functions have been established to some degree 
    • our understanding of neural correlates of psychiatric symptoms is more hazy
    • neuropsychological processes may help our understanding of witch brain regions are involved in psychiatric disorders 


    Example
    • wisconsin card sorting test
    • perseverative errors > continues with a wrong sorting strategy 
    • perseverative errors have been associated with frontal lesions
    • same perseverative errors are made in patients with schizophrenia > means that frontal cortex is dysfunctional in schizophrenia

    Higher brain functions cannot be mapped to a specific region  

    most mental processes are regulated by complex neural networks that connect various brain regions 
  • Improving diagnostic classification
    • patients with a specific psychiatric condition form a very heterogenous group
    • different pattern of performance on a neuropsychological test may be used to reduce the heterogeniety within disorders ans may improve diagnostic classifications 
  • improving diagnostic classification comorbidity
    • comotbidity between psychiatric diagnoses is common and similar symptoms are often observed across different disorders
    • examining basic neuropsychological processes in psychiatric disorders may help to explain patterns of comorbidity between diagnostic entities 


    • high comorbidity of adhd and substance use disorders 
    • high levels of impulsivity in patients with adhd and patients with substance use disorders 
  • improving diagnostic classification: identification of people at risk
    • neuropsychological evaluation can reveal changes in cognitive functions that may revael to later onset of psychopathology 
    • verbal memory and attention deficits in children predicted cases of adult schizophrenia 
  • 1535839200 Lecture 02: ADHD in adulthood

  • ADHD
    Core symptoms 
    • inattention
    • impulsivity
    • hyperactivity

    Presentations DSM-5
    • ADHD-I (predominantly inattentive)
    • ADHD-H (predominantly hyperactive/impulsive)
    • ADHD-C (combined presentation)

    prevalence rates 
    • 30-40% of the referrals to mental health clinics 
    • symptoms may still be present in adults 
    • 3-7% of school-aged children have ADHD
    • 4-5% of adults have ADHD 

    Comorbidity 
    • high frequencies of comorbidities 
    • most have at least one other psychiatric disorder 
    • 3/4 adults have one or more comorbid disorders 

    Etiology 
    • significant heredity factor in ADHD 
    • patients with ADHD display global moorphometric alterations of the brain (prefrontal cortex and basal ganglia)
    • Biochemical abnormalities of neurotransmitter functions (dopaminergic or noradrenergic hypotheses of ADHD)
  • Adult presentation of ADHD
    • symptoms diminish in severity and frequency 
    • higher impact if symptoms due to increased demands of adult environment 
  • Adult presentation of ADHD: core symptom shift
    • reduction of motor symptoms 
    • reduction of impulsivity 
    • inattention more prominent 
  • Adult presentation of ADHD: associated features
    • affective instability, emotional over-reaching resulting in poor tolerance of stress 
    • cognitive disturbances 
    • disorganisation 
    • marital problems 
    • occupational problems 
    • financial problems 
    • substance abuse 
    • increased risk behaviour 
    • delinquency 
  • Adult presentation of ADHD: diagnosis
    • ADHD in adults is often misdiagnosed or overlooked 


    • either diagnosed in children (easy to recognise) or never diagnosed before (difficult to recognise)
    • 91-98% self-referral
    • diagnosis in childhood, family members trigger self-recognition of symptoms, learning about condition through media
  • adult presentation of ADHD: Clinical assessment
    • diagnosis in childhood -> presence of core symptoms -> compromised functioning in at least two settings -> persistence of condition -> symptoms cannot be better accounted for 


    • Step I
      - assess current symptoms in the last six months 
    • Step II 
      - assess impact of symptoms on current functioning (interview, corroboration with spouse i.e., neuropsychological testing, records)
    • Step III 
      - establishing childhood history of ADHD (interview, corroboration with parents i.e., retrospective symptom rating scales, records)
      - Many adults were not diagnosed as a child, less sources and diminished symptoms
      - self-awareness impaired due to frontal lobe damage -> self report may underestimate levels of childhood symptoms
    • Step IV 
      - obtain complete histories

  • adult presentation of ADHD: pharmocalogical treatment
    • Stimulants
      - first choice 
      - releases norepinephrine and dopamine
      - methylphenidate (ritalin, concerta, equasym), amphetamine (Adderall)
      - 30% does not respond or are able to tolerate the stimulants 
    • non-stimulants
      - antidepressants 
      - antihypertensive agents 
      - etc. 
    • compliance better in adults than in children, but discontinuation due to:
      - disorginazation
      - difficulty with persistence 
      - negative and uninformed media
      - fears over dependency 
      - mistaking the treatment as the cause of stigma or disorder
      - lack of knowledge on long-term effects
  • adult presentation of ADHD: non-pharmocalogical treatment
    • counseling 
    • education
    • psychotherapy
    • skills training programs 
    • cognitive training programs 
    • coaching 


    But, are time consuming and have small effects 
  • adult presentation of ADHD: Attention
    • is not a unitary entity 
    • refers to a broad range of cognitive and behavioural processes 
    • is a fundamental function of other cognitive abilities such as speaking, memory, orientation, problem solving
    • is crucial for internal planning 
    • is crucial for external control of behaviour 
  • adult presentation of ADHD: multi-dimensional models of attention
    • alertness
    • vigilance/sustained attention
    • selective attention
    • divided attention 
    • strategy/flexibility 


    sustained attention deficit is the most prominent distubance of attention in ADHD 
    it enables the subject to direct attention for a long and unbroken period of time 
  • adult presentation of ADHD: continious performance test (CPT)
    • adults and children are impaired in:
      - commission errors
      - omission errors 
      - reaction time
      - variability of reaction time 
    • reaction time decreases with time in healthy individuals, but there is a greater decrease in individuals with ADHD 
    • A SUSTAINED ATTENTION DEFICIT IN ADHD CANNOT BE CONCLUDED IN STUDIES 
  • adult presentation of ADHD: vigilance
    • ability to maintain attention over a prolonged period during which infrequent response-demanding events occur
    • individuals with ADHD have an impairment of vigilance compared to healthy individuals, but the slope is the same. 
    • no evidence of a sustained attention deficit in children and adults with ADHD
    • on methylphenidate improves omission errors in CPT compared to not using methylphenidate 
  • adult presentation of ADHD: Alertness
    • tonic alertness:
      - refers to a relatively stable level of attention which changes slowly according to diurnal (during the day) physiological variations of the organism 
    • phasic alertness 
      - the ability to enhance the activation level following a stimilus of high priority


    Is unimpaired in individuals with ADHD
  • adult presentation of ADHD: selective attention
    • the ability to focus attention in the face of a distraction 
    • selective attention matches with the term concentration 
  • adult presentation of ADHD: divided attention 
    • divided attention is required to respond simultaneously to multiple tasks or multiple task demands
  • adult presentation of ADHD: flexibility
    the ability to shift the focus of attention in order to control which information from competing sources will be selectively processed
  • adult presentation of ADHD: Methylphenidate 
    improvement on:
    • vigilance
    • selective attention
    • divided attention (unimpaired)
    • flexibility 
  • adult presentation of ADHD: executive functions 
    consists of:
    • problem solving 
    • planning 
    • flexibility
    • abstract thinking
    • concept formation 
    • etc.  
  • adult presentation of ADHD: problem solving
    • process to attain a goal
    • no immediate apparent approach to solve the problem
    • to attain goal, obstacles have to be surmounted
    • distinction between open en closed problems
  • adult presentation of ADHD: Closed problems
    • both initial state and goal state clearly defined.
    • goal state can only be achieved by a certain solution
    • actions and rules are known
    • requires inimpaired convergent thinking 
    • transformation tasks (Tower of hanoi/london)


    Improvement on MPH
  • adult presentation of ADHD: open problems
    • initial state or goal state not defined 
    • requires divergent thinking (fluent and original thinking process)
    • verbal and figural fluency tasks


    No effect MPH (most real world problems are open problems)

    adults with ADHD suffer from
    • impaired social and sexual relationships 
    • occupational problems
    • impaired leisure functioning 
    • problem in financial matters
  • adult presentation of ADHD: Memory
    • prospective memory 

    remembering to remember. To perform actions in the feature 

    planning (executive functions) -> retention (retrospective memory) -> self-initiation (prospective remembering) -> execution (executive functions)

    Planning deficit in adults with ADHD 
  • adult presentation of ADHD: Neuropsychological markers
    • evidence for impairment in numerous functions
    • no significant or conclusive results


    regularily found impairments
    • vigilance
    • inhibition
    • working memory
  • adult presentation of ADHD: Conclusion
    • convincing evidence of cognitive dysfunction 
    • no reliable test profile 
    • unique profiles in neuropsychological functioning in individuals 
    • patients differ from healthy individuals, but there is no distinctive marker
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Suicide: facilitation of acts in emotional contexts
Example
  • suicidal patients displayed impairment in hayling tests (Part A half finished sentence, patients has to finish with a logical answer. Part B, finish with a nonsensical answer), part B 
  • impaired cognitive inhibition in patients with suicidal behaviour 
Suicide: reduced regulation of emotional and cognitive responses
Example
  • suicidal patients had significantly lower scores in tests assessing verbal and design fluency 
  • decreased ability of suicidal patients to generate new ideas, when no alternatives are provided  
Suicide: altered modulation of value attribution
Example 
  • significant differences in neural response to angry faces between suicide attempters and ontrol subjects
  • increased sensitivity to others disapproval, higher propensity to act on negative emotions  
Suicide: a neurocognitive model
  1. triggering of automated negative emotions 
  2. intense and prolonged negative emotional state & suicidal ideas
  3. suicidal act 


Processes 
- altered modulation of value attribution
- impaired regulation of emotional and cognitive responsess 
- facilitation of acts in emotional context  
Suicide: Neuroimaging

  1. regions associated with suicidal behaviour venrolateral prefrontal cortex
  2. anterior cingulate gyrus 
  3. dorsomedial prefrontal cortex
  4. dorsolateral prefrontal cortex
  5. amugdala and medial temporal cortex 
Suicide: neurotransmitters
  • low activity of serotonin in people who commit suicide (especially in violent or impulsive suicide)
Suicide: vulnerability
  • trait dependent factors
    - genetics
  • state dependent factors 
    - stressors 
  • threshold factors 
Suicide: suicidal crisis
  • negative feeling (guilt, shame, pain) -> emergence of hopelessness and suicidal ideas -> committing suicide 
  • triggering of suicidal crisis often has external causes but reasons (job, relationship) are common, and external causes are not sufficient to explain the occurrence of a suicidal crisis 
Suicide: Prevalence
  • 1 in 20 attempts results in death
  • 10-20% of people report suicidal ideation in their life 
  • 3-5% of people have made at least one suicide attempt 
  • suicidal behaviour or thinking is the most common reason for admission to a mental hospital
  • 50% of psychiatrists and 20% of all psychologists lose a patient to suicide at some point in their career 
schizophrenia: a cognitive regulatory control explanation
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