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full instructions are attached labeled discussion 1 week 4! Lucy Miller has been diagnosed with bipolar disorder. She's been experiencing with illegal drugs. Examine the potential biological basis for lucy's psychological disorder.

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SOC313 Family Document Throughout this class, we will meet two families, the Maldonado’s and the Olson’s. The two families are considered extended family via Sarah and Joe Miller. We will learn about their relationships, work environments, and the psychosocial effects related to health challenges faced by each family. You will use this document for the discussions and written assignments. We begin with the Maldonado family. Manny and Donna Maldonado have been married for 42 years. Manny is age 65 and Donna is 63. Sarah, Mike and Becky are the children of Manny and Donna Maldonado. Sarah is the eldest daughter, followed by her brother, Mike, and her sister, Becky.   Manny is Hispanic American and owns a 20,000-acre produce farm that has been in his family for three generations. Although Manny speaks and understands English, he prefers to speak Spanish. This creates a language barrier between Manny and other family members who do not speak Spanish. Donna is fluent in Spanish, having learned the language from Manny and his family. Donna works on the farm with her husband. She has long suffered from mood swings, which is mostly frustrating to Manny. He says it is “brujeria,” meaning her moods are caused by witchcraft and “mal d ojo” or “evil eye.” He believes someone put a spell on Donna. When this is believed to be the case, the person will visit a Curandero (healer) who will perform a healing ritual. o Sarah works as a nurse, and recently took Family Leave of Medical Absence (FMLA) due to her children’s recent issues. o Joe is the President of Illusion Technologies. Joe’s parents are John and Ella Miller. More details about Joe are shared in the Olson family section below.  Lucy, age 20, has a history of severe substance use disorder, along with having been diagnosed with bipolar disorder. In the past two years, Lucy has had four different jobs. o o o She is unable to hold a job long-term. She now works on her grandparent’s produce farm.  Josh, age 17, has been sneaking away with friends, smoking marijuana and skipping school.  Evan, age 10, was recently diagnosed with leukemia; however, he has not yet started treatments. Evan’s doctors have recommended chemotherapy, radiation, and a bone marrow transplant. Sarah and Joe intend to follow this treatment plan. Mike Maldonado is age 36. He currently works for a state University as a tenured faculty of the College of Agriculture and Life Sciences. Mike was recently diagnosed with HIV. Dan was Mike’s husband. He recently passed away at the age of 38 due to an AIDS-related illness. They were married for 10 years. Mike and Dan did not have any children. Becky is age 33. She is divorced and working on the family produce farm as well as attending a local college at night to complete her bachelor’s degree in Child Psychology. She has one child, Abe.  Abe is age 12. He is a good student, but his behavior has changed recently, showing anger and defiance towards both of his parents and several teachers at school. His mother, Becky, has been treating Abe’s behavioral changes with diet and alternative medicines. Next, we will meet the Olson family. Frederic Olson was married to Mary Olson. Mary passed away 10 years ago at the age of 77. Frederic is age 87. Ella is the only child of Frederic and Mary Olson.   Fredric has pronounced symptoms from Parkinson’s disease. He has tremors and balance problems, along with muscle stiffness and gait (manor of walking) changes. He struggles to begin any movement. However, once he is moving, he cannot stop easily. His gait has changed to smaller steps and shuffling. As he progresses through the stages of the disease, Frederic needs increasing assistance with his activities of daily living (ADLs), which entails bathing, dressing, food preparation, eating, taking medications, et cetera. He recently moved to an Assisted Living community and only leaves the facility for medical appointments. The family visits Grandpa Frederic on an alternating schedule at his new home every week. The Assisted Living community has regularly scheduled social events in which Grandpa Frederic actively participates. o Ella is married to John Miller. Ella and John are both 70 years old. John and Manny Maldonado are best friends. Ella and Manny grew up together on their neighboring farms. Ella and John recently sold their 10,000-acre farm to the Maldonado family since the two farms were adjacent to each other. o Ella has been trying to heal herself from breast cancer using a variety of natural means. She grew up on a farm and was accustomed to using home remedies. Therefore, Ella is not willing to utilize Western medicine practices. o While the alternative health care methods kept Ella in remission for a few years, recently she learned the cancer has returned. In addition, the cancer has metastasized to her lungs and bones. Ella has chosen to forego Western medical treatment options such as chemotherapy, radiation, and pharmacological breast cancer treatment medications. She has requested to live out her last days at home. Ella has agreed to be admitted to Hospice home care, with John as her primary caregiver. Ella and John are seeking quality palliative end of life care. o John, Ella’s husband, is of Native American origin. He is well educated and uses Western medicine, but relies heavily on Native American methods, such as meditation and banishing bad spirits from their home. John speaks fluent Spanish, having learned the language as a child. o John is an attorney for the Maldonado produce farm and his son’s company, Illusion Technologies. o John and Ella’s children are Sam, age 50, Lila, age 45, and Joe, age 43.  Sam is divorced and has no children. He works as a foreman on the Maldonado produce farm. He is an alcoholic and has been diagnosed with severe substance use disorder due to his alcohol addiction. His alcohol use is affecting his position as the foreman. Over the past few months, he has experienced emotional outbursts, missed work, and started arguments with the workers, third-party wholesalers, and Al Goldberg (Olson family).     Sam has been upset that his parents sold the family farm to the Maldonado family instead of passing it down to him. Lila, age 47, is married to Al Goldberg. She is a Social Worker for the state. Her job is very stressful as her caseload includes at-risk children. There is a great deal of documentation required; therefore, she works many 10 to 12 hour days. Lila is overweight and has Type II diabetes. She has not controlled her weight or diabetes well. Recently, her doctor changed her medication. She is now taking daily insulin injections to help manage her diabetes. Al, age 47, Lila’s husband, is the general manager of the Maldonado family produce farm. Al had first option for buying the Olson family farm. He opted out of purchasing the farm and agreed with the sale to the Maldonado family. He has no known health issues; however, due to an early childhood trauma, he is afraid of hospitals and funeral homes.  Alisha is Lila and Al’s only child. She is 20 years old and is currently attending college full time on a nursing scholarship. The college campus is an hour away from her parent’s home. She lives on campus in the dorms, does not work at this time, and has no known health problems. Joe, who is Sarah (from the Maldonado family) Miller’s husband, is the President of Illusion Technologies, a rapidly growing company with 50 employees. He has a patent pending on two security-based software programs that could be worth millions. He and his father are in negotiations to purchase land to build a state-of-the-art office building. Sarah, Joe’s wife, is a nurse and recently took a Family Medical Leave of Absence (FMLA) due to the health and behavioral problems with her children. Details about Joe and Sara’s children are shared in the Maldonado family section. The family members share a long history of friendship and love of farming. They have shared many life events, such as holidays, births, and deaths. Their families have been intertwined for generations through the raising of the children and grandchildren. For the most part, the families get along well. However, even though they share some of the same cultural traditions and backgrounds, they do clash from time to time. For instance, some of the Olson family members are not in full agreement with Ella’s use of home remedies and alternative treatments for her breast cancer. However, the Maldonado family understands and supports her choices. Further, Ella is encouraging Sarah Miller and Mike Maldonado to pursue Complementary and Alternative Medicine (CAM) to treat Evan’s leukemia and Mike’s HIV. The members of both families are dealing with very busy schedules and major health challenges. 7 Mental Health Disorders BSIP/UIG/Getty Images Learning Objectives 1. Understand the evolution of societal perspectives about individuals with mental health disorders 2. Identify the basic physical and environmental elements related to different mental health disorders 3. Describe how mental health disorders affect different individual, familial, and social domains 4. Explain the connections between age groups and the prevalence of different mental health disorders 5. Compare and contrast different treatment approaches and identify which best address the different mental health disorders 6. Describe how stigma and health disparities affect diagnoses and treatments of mental disorders atL80953_07_c07.indd 201 12/5/13 3:30 PM Section 7.2 History CHAPTER 7 7.1 Introduction to Mental Health Disorders W hat is mental health? It isn’t just the absence of mental disorders. The World Health Organization (WHO) defined mental health as follows: A state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. (WHO, 2011b. Copyright © World Health Organization [WHO]. Used by permission.) (For a short video produced by the WHO about the global reach of mental illness, go to http:// www.youtube.com/watch?v=L8iRjEOH41c.) In the following sections, we examine the different common mental disorders in the order that they are likely to appear across the lifespan, from early childhood (neurodevelopmental disorders) to late adulthood (dementia). 7.2 History M ental disorders have been recognized from the beginning of human society. In some periods and cultures, people with mental disorders had recognized roles, for example, a shaman or fortune-teller. In other periods and cultures, people with mental disorders were driven from society. Ideas about causation and treatment have also varied. One frequently held idea was that mental disorders were caused by evil spirits. Evidence shows that prehistoric people treated mental disorders by cutting a hole in the skull of the afflicted person, a process called trepanation, to allow evil spirits to escape (Clower & Finger, 2001). Written accounts of mental disorders are found in Egyptian manuscripts from 1550 BCE. Egyptians recognized the brain as the site responsible for mental function and described both depression and mood changes (Nasser, 1987). Among the Greeks, Pythagoras (sixth century BCE) and Hippocrates (fifth century BCE, from whom we get the Hippocratic Oath that physicians should “do no harm”) understood that the brain was the center of thought, intelligence, and emotions (Millon, Grossman, & Meagher, 2004). The Romans built upon Greek approaches to mental disorders, and physicians such as Claudius Galen (second century CE) supported diagnoses based on observation and humane treatment of the mentally disturbed. Most Greco-Roman understanding of mental disorders had been forgotten in Europe by the early Common Era until the 17th century. Instead, European medical understanding of mental disorders was based on faith healing, magic, and superstition (Millon et al., 2004). During a long dark period in western Europe, medical understanding of mental disorders was kept alive in the Islamic world. The first known psychiatric hospital was built in Bagdad, Iraq, in 705 CE (Murad & Gordon, 2002). Also, in Byzantium, the successor to the Roman Empire, special provisions were made for handling the criminally insane differently from other offenders (Tzeferakos, Vlahou, Troianos, & Douzenis, 2011). In Europe, people with mental disorders were generally cared for by relatives. Only those who could not be cared for by relatives might be placed in a public institution. A famous example is Bethlem Royal Hospital (universally known as “Bedlam”), which was granted by Henry VIII to the City of London in 1547 as the first asylum for people with mental disorders. Bedlam became notorious for the poor treatment of patients and the practice of allowing fee-paying spectators, which was atL80953_07_c07.indd 202 12/5/13 3:30 PM Section 7.2 History CHAPTER 7 discontinued in 1770 (Bedlam, 2013). Bedlam became a synonym for mental hospitals and generally for confusion or uproar. Philippe Pinel (1745–1826) played a large part in reforming the treatment of people with severe mental disorders in France. He became head physician of Bicêtre, the public asylum for men near Paris, in 1793 and presented his Memoir on Madness to the Society for Natural Mary Evans Picture Library/Everett Collection History in 1794. In it he explained his theory of “psychologic treatPhillipe Pinel helped reform the treatment of people with ment,” which was also called the mental disorders in France. In this image he is shown ordering “moral treatment.” Pinel believed the manacles removed from patients at Salpêtrière. it possible to cure mental illness, and that to do so, it was necessary to first diagnose the patient by careful observation, gain understanding of the events precipitating the illness, and write an accurate case history. Pinel thought it was possible to “dominate agitated madmen while respecting human rights” (Weiner, 1992, p. 725). His assistant, who succeeded him at Bicêtre, removed the chains from male inmates in 1797, replacing them with more humane strait jackets when needed. Pinel did the same at the public women’s asylum, Salpêtrière, in 1800. Benjamin Rush (1745–1813) played a similar role in psychiatric reform in the United States, where he is known as the father of American psychiatry. Rush believed that mental disorders could be diagnosed, classified, and treated humanely. His Observations and Inquiries Upon the Diseases of the Mind, published in 1812, was the first psychiatric textbook printed in the United States. Rush improved patients’ living conditions and removed their cuffs and chains (Penn Medicine, n.d.-a; n.d.-b). The Industrial Revolution changed family life and made it more difficult for families to care for those with mental disorders at home, giving rise to community asylums (Wright, 1997). For the first time, women began to work outside the home and so were unavailable to care for family members with mental disorders. At the same time, an interest in the geographic or sociologic distribution of disease, or epidemiology, became popular in the United States. As a result, the 1840 federal census was the first one to collect data on mental disorders. However, it counted only those in institutions. A major problem was the lack of a shared language of definitions for mental disorders, so it was impossible to track how many people with what kind of disorder were housed in institutions across the country. In addition, the rate of institutionalization depended heavily on the number of places available in a given community, as well as the willingness of families to allow a stigmatizing diagnosis and the community’s tolerance for deviant behavior (Horwitz & Grob, 2011). As a result, the statistics collected were neither accurate nor scientifically useful. Psychiatrists in the 1800s believed that the rise of industrial civilization increased the prevalence of mental illness. Their conclusion was not based on statistics but rather on their moral and religious beliefs. However, the increasingly sophisticated censuses of the early 1900s proved them wrong; the data collected also showed that immigrants from eastern and southern Europe were atL80953_07_c07.indd 203 12/5/13 3:30 PM Section 7.2 History CHAPTER 7 not particularly prone to insanity, as was generally assumed at the time (Horwitz & Grob, 2011). For a history of the asylum and attitudes toward the mentally ill, as well as the implications for policy change, consider reading Madhouses, Mad-Doctors and Madmen: The Social History of Psychiatry in the Victorian Era, edited by Andrew T. Scull. By 1917, the American Medico-Psychological Association (which became the American Psychiatric Association [APA] a short time later) called for uniform classification of mental diseases. Interest in studying exclusively those with mental illness who were confined to institutions gradually shifted, and by the late 1930s interest in the contribution of social and environmental factors to mental illness in the community was rising. One particularly influential publication was Mental Disorders in Urban Areas (Faris & Dunham, 1939), which made the connection between community conditions and severe mental illness. Although much of what the authors concluded was later proved wrong, the effort to connect where someone lives and mental illness was an important advance. World Wars I and II brought more data. As Horowitz and Grob (2011) concluded, “Psychiatric casualties soared among soldiers who were seemingly normal before entering combat. The policy lesson seemed clear: environmental conditions rather than individual predispositions were the primary causes of mental disorder” (p. 639). The mental disorders that appeared in normal soldiers exposed to combat convinced mental health practitioners that social and environmental factors play a large role in the development of mental disorders. During the period after WWII, the newly formed National Institute of Mental Health (NIMH) was given responsibility for funding research into the connection between social and environmental variables and mental disorders. The movement to establish a uniform classification of mental diseases resulted in the publication of the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952. The first version (DSM-I) used the term reaction to refer to diagnoses, which reflected the theoretical beliefs of Adolf Meyers that mental disorders were reactions of the personality to psychological, social, and biological factors. Later editions of the DSM dropped this terminology along with the mindset that mental disorders result from the interaction of all three spheres of life (APA, 2012). Development of antipsychotic medications for treating severe mental disturbance played a role in this turnabout (see “Prevention and Treatment Approaches to Mental Disorders” later in this chapter). For the first time, people who previously had to be confined to an institution could be treated in a community setting. The release of people with mental disorders from institutions, known as deinstitutionalization, started in the mid-1950s and grew dramatically in the 1960s and 1970s. The idea was that people with mental disorders could be better treated and cared for in their communities. The assumption was that sufficient funding for community mental health centers to deal with those who needed guidance and treatment would be available. However, funding for community centers and treatment specialists has fallen short of needs ever since, leaving many vulnerable people to depend on their families or the social service system, or worse, the prison system. Concepts of causality made an about-face during the late 1960s and early 1970s, when the Nixon administration together with Congress decided NIMH should not fund research on social problems such as poverty, racism, and violence (Horwitz & Grob, 2011). Focus instead turned to how disturbance within the individual affected society. As of 2013, the debate about how best to treat and ensure compliance by the mentally ill is as sharp as ever. A series of violent shooting rampages on innocent victims (e.g., the Newtown, Connecticut, massacre) have brought to light the anguish of families of mentally ill and potentially violent or suicidal people. How to protect the public while ensuring the civil rights of mentally ill people is a difficult balancing act. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 made it much more difficult to institutionalize those in danger of harming themselves or others, because it requires the affected person’s permission for anyone else to talk to mental atL80953_07_c07.indd 204 12/5/13 3:30 PM Section 7.3 Definitions and Familial and Biological Basis CHAPTER 7 health providers about him or her. A social worker who has had to hospitalize his mother and sister a number of times remarked that someone who is paranoid is not likely to give anyone, even family, permission to talk. The pendulum of patients’ rights has indeed swung to the other side, and HIPAA has made the family’s attempt to help much more difficult. In January 2013, in response to the shootings in Newtown, Connecticut, and Aurora, Colorado, the U.S. Department of Health and Human Services (HHS) issued a letter to the nation’s health care providers, making it clear that reporting someone they believe to be a danger to either themselves or others is not a violation of HIPAA rules (Rodriguez, 2013). Unfortunately, to date, very few health care providers appear to be aware of this. We can see how through the ages responsibility and blame for mental disorders has shifted from “evil spirits” to social conditions and experience and to the individual. Now let’s look at definitions for many of the major mental disorders. 7.3 Definitions and Familial and Biological Basis O ne of the difficulties in studying mental health and treatment of mental disorders is finding a common language. Without a common language, it is impossible to answer questions about how disorders arise, how they are related, and how they are best treated. This section discusses current definitions of some of the major mental disorders and lists short descriptions for some of the others. It also discusses the role that family environment, genetic makeup, resilience, environment, and supportive social interactions, particularly within the family, play in various mental disorders. Only recently have researchers begun to examine what accounts for people growing up in particularly difficult circumstances who nonetheless do very well in life—those who are particularly resilient. For instance, some scientists have looked at children who experienced extreme neglect or abuse and yet appeared to function well (Cicchetti, 2010). Others examined structural and functional brain differences between people with bipolar disorder, their relatives, and healthy controls (Frangou, 2011). Case Study: The Diagnostic and Statistical Manual of Mental Disorders Our understanding is constantly changing, and the DSM reflects changes in society. For instance, homosexuality was considered a mental disorder until 1973. Another cultural shift can be seen when the 2013 fifth edition (DSM-5) replaced the term gender identity disorder with gender dysphoria, suggesting that the problem is not one of gender mismatch but rather the resulting emotional distress. Exactly how disorders are defined may depend upon the particular work environment, as well as the norms and values of society, which are always changing. So treat the definitions in this chapter as a general guide, rather than a dictionary. The DSM, published by the APA, provides criteria for mental disorders that are used by clinicians, insurance companies, policy makers, and researchers in the United States and around the world. The DSM-5 was approved in December 2012 and formally adopted on May 18, 2013, at the 166th annual meeting of the APA with much fanfare and controversy. The DSM-5 is the first major update since publication of DSM-IV in 1994, and much was expected of it. (continued) atL80953_07_c07.indd 205 12/5/13 3:30 PM Section 7.3 Definitions and Familial and Biological Basis CHAPTER 7 Case Study: The Diagnostic and Statistical Manual of Mental Disorders (continued) According to Dr. Thomas Insel, director of the NIMH, the problem with the DSM is that it classifies mental disorders by clinical symptoms, which he thinks are not sufficient for diagnosing disease: While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment. (Insel, 2013) Dr. Insel pointed out the difference between having a shared definition so that various people are talking about the same thing, which is reliability, and being logically or factually correct (evidence based), which is validity. The NIMH is the major funding source for research in mental health and mental illness for the entire United States and much of the world. An important goal of the NIMH is to transform diagnosis of mental illness so that it is based on biology, not on symptoms or subjective criteria. This goal can be achieved by incorporating cognitive science, genetics, imaging, and other information into the Research Domain Criteria, which is envisioned as a 10-year project (Insel & Lieberman, 2013). In other words, DSM-5 may be flawed when it comes to applying it to research, but it is still the best tool available for diagnosing mental disorders. Some changes in DSM-5 include classifying attention deficit hyperactivity disorder (ADHD) as a neurodevelopmental disorder instead of a disruptive disorder. Also, several criteria within posttraumatic stress disorder (PTSD), trauma, and stress-related disorders, are now more explicit about what constitutes a traumatic event and specifically include sexual assault and a new preschool PTSD subtype. Changing the classification of ADHD has social implications: It removes the negative implication from this disorder and places it in a more neutral, developmental context. Similarly, by recognizing that sexual assault is by definition a traumatic event, the DSM-5 validates the impact of such events on people’s lives. Neurodevelopmental Disorders Neurodevelopmental disorders are changes in the normal growth and development of the nervous system, resulting in slowed maturity in behavior, communication, or ability to focus. This section concentrates on two neurodevelopmental disorders: autism spectrum disorders (ASD) and ADHD. Autism Spectrum Disorders Children with ASD have an unusual way of communicating with people and their environment. They may have trouble with social interactions and communication and may be unusually interested in a particular subject; they also may show restricted, repetitive patterns of behavior. These atL80953_07_c07.indd 206 12/5/13 3:30 PM Section 7.3 Definitions and Familial and Biological Basis CHAPTER 7 problems are believed to be caused by differences in the way the brains of children with ASD process information. When symptoms begin, when they are first noticed, and how much they affect a child’s functioning vary widely. There is also wide variation in how the families and social systems surrounding these children accept them, which has profound effects on the child’s functioning. The Centers for Disease Control and Prevention (CDC) has sponsored the Autism and Developmental Disabilities Monitoring (ADDM) Network to estimate the number of U.S. children who have shown ASD symptoms any time between birth and the end of the child’s eighth year: the prevalence of ASD. The most recent information, published in 2012 about the survey done in 2008, suggests that one child in every 88 in the United States has been identified with ASD. The trend appears to increase across time: The 2006 survey found one child in every 110 had an ASD, and the 2002 survey found one child in every 150 had an ASD. In all surveys approximately 5 times as many boys as girls were identified with ASD. The majority of children identified with ASD (62%) did not have an intellectual disability. According to a report on the prevalence of ASDs, children are identified at an earlier age, many by age 3 years, but most were not identified until they were at least 4 years old (ADDM Network, 2012). Some signs that a child might have ASD: • • • • • • does not respond to his or her name by 12 months; avoids eye contact; is not interested in social interaction; gets upset by minor changes in routine; does not engage in make-believe or pretend games by 18 months; and shows repetitive body movements (e.g., spinning, rocking, flapping hands). Early identification is important, because evidence shows that it can improve outcomes for both children and their families. However, ASD goes undetected in many children until later because of limited social demands and inadequate support from parents and caregivers in early life. The resulting lack of early intervention can affect the child’s functioning throughout life. Of late, ASD has undergone several “lumping and splitting” reorganizations. In DSM-IV, four separate disorders were recognized: autistic disorder, Asperger disorder (the highest functioning form of ASD), childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. The DSM-5 does away with this splitting and lumps all of the above into the ASD category. This change has been roundly criticized, because parents are concerned that some children, particularly higher functioning children who had been formerly labeled with Asperger disorder, may no longer qualify for special services to help them learn to function well. For an overview of ASD and its symptoms (using the DSM-IV criteria), watch a video from the National Center on Birth Defects and Developmental Disabilities: http://www.cdc.gov/ncbddd/video/autism/what isautism/index.html. Attention Deficit Hyperactivity Disorder ADHD is characterized by age-inappropriate levels of inattention, hyperactivity, impulsivity, or a combination of these. These behaviors impair functioning in multiple settings and cause problems in school, in relationships with other children, and in the family. Although the disorder frequently begins in childhood, it often continues into adulthood. There is no cure for ADHD, but it can often be successfully managed. atL80953_07_c07.indd 207 12/5/13 3:30 PM CHAPTER 7 Section 7.3 Definitions and Familial and Biological Basis A recent survey reported that ADHD is the most common childhood mental disorder, found in 6.8% of those aged 3 to 17 in the United States between 2005 and 2011. The survey described childhood mental disorders as “serious deviations from expected cognitive, social and emotional development” (Perou et al., 2013, p. 1). It emphasized that these disorders are “an important public health issue because of their prevalence, early onset, and impact on the child, the family, and the community, with an estimated total annual cost of $247 billion” (Perou et al., 2013, p. 1). (Onset is the first appearance, or beginning, of a trait, symptom, or other sign of a disorder.) The prevalence of ADHD appears to have increased between 1997–1999 and 2008–2010, and it is higher among children whose household income is low. Non-Hispanic White children are most likely to be diagnosed with ADHD; Hispanic children are much less likely to be diagnosed with ADHD, and there was no effect of household income in that group (Figure 7.1). Boys are twice as likely to be diagnosed with ADHD as girls (CDC, 2013c), and the incidence of ADHD appears to increase with age through adolescence. Visit the CDC website for a personal account of one child helped through ADHD by her family: http://www.cdc.gov/ncbddd/adhd/stories.html. Figure 7.1: Attention deficit hyperactivity disorder among children 5–17 years old in the United States, 2009–2010 Non-Hispanic White children are most likely to be diagnosed with ADHD. Below 100% 100%–199% 13 11 All children 200%–399% 400% or more 8 8 6 5 Hispanic 4 6 18 15 White only, not Hispanic 10 9 17 10 Black only, not Hispanic 8 7 0 10 20 30 Percent Source: National Center for Health Statistics. (2012). Health, United States, 2011: With special feature on socioeconomic status and health (Library of Congress No. 76-641496). Hyattsville, MD: Author. Retrieved from www.cdc.gov/nchs/data/hus/hus11.pdf Mood Disorders One in five adults experience a mood disorder (also termed affective disorder) sometime during his or her life. Major mood disorders include depression and bipolar disorder (also known as manic atL80953_07_c07.indd 208 12/5/13 3:30 PM CHAPTER 7 Section 7.3 Definitions and Familial and Biological Basis depression). As shown in Figure 7.2, each year 9.5% of adults experience a mood disorder, and in almost half (4.3%), the experience is termed severe (NIMH, n.d.-a). Severe mental illness is a loose definition that can vary according to the agency defining it. It often includes people who have psychosis (usually those diagnosed with bipolar disorder or schizophrenia) with a period of dysfunction lasting for 12 months or longer. Generally those with schizophrenia, bipolar disorder, and major depression are included. Mental health disorders always occur within a social context, and how dysfunctional an individual is may be determined by the support received and the responses of family and friends in the environment. Figure 7.2: Prevalence of mood disorders in the U.S. adult population Definitions of severe mental illness vary according to the agency defining it, but each year 9.5% of adults experience a mood disorder. Percent of U.S. adult population 35 30 25 20.8 20 15 9.5 10 5 0 4.3 Lifetime Prevalence 12-month Prevalencea 12-month Prevalence Classified as Severeb a. 9.5% of U.S. adult population b. 45.0% of these cases (e.g., 4.3% U.S. adult population) are classified as “severe” Source: National Institute of Mental Health. (n.d.-a). Any mood disorder among adults. Retrieved from http://www.nimh.nih.gov/statistics/1ANYMOODDIS _ADULT.shtml Mood disorders affect how people feel for long periods of time. Most people have days in which they feel particularly sad or happy, but mood disorders are more persistent and affect how people function in everyday life. Although we don’t yet understand why, people with mood disorders are also at increased risk for comorbidities, such as heart disease and diabetes (Wahlqvist et al., 2012). More generally, people with different mental disorders, including mood disorders, anxiety disorders, and PTSD, have a higher prevalence of cardiovascular disease and higher mortality compared with people without mental disorders (Fiedorowicz, He, & Merikangas, 2011; Weiner, Warren, & Fiedorowicz, 2011; Xue et al., 2012). atL80953_07_c07.indd 209 12/5/13 3:30 PM CHAPTER 7 Section 7.3 Definitions and Familial and Biological Basis Web Field Trip View the Synthesis Project’s online report, “Mental Disorders and Medical Comorbidity” (http://www .rwjf.org/content/dam/farm/reports/issue_briefs/2011/rwjf69438; (Goodell, Druss, & Walker, 2011). After looking at the graphic on page 1 and reading the commentary, consider why the overlap between mental disorders and physical illnesses is so great. Critical Thinking Questions 1. How could care be coordinated for these patients to achieve better health outcomes? 2. What are some of the pressing unmet needs in this area of public health? Depression According to the WHO (2008), depression is the most important cause for loss of healthy life years due to disabling disease, or burden of disease, in middle- and high-income countries. In the United States during 2007–2010, depression had a nearly 8% prevalence among people 12 years and older (See Figure 7.3). Significantly more women (10%) than men (6%) reported experiencing depression (CDC, 2012d), and because it is influenced by social factors such as overcrowding, family turmoil, and violence, depression was more prevalent among people with lower income (National Center for Health Statistics, 2012). Figure 7.3: Prevalence of current depression among persons 12 years and older For all age groups, more women than men report depression. Percentage 15 Overall Males Females 10 * 5 0 ≥12 12–17 18–39 40–59 ≥60 Age group (years) * 95% confidence interval Source: Centers for Disease Control and Prevention. (2012d). QuickStats: Prevalence of current depression among persons aged ≥ 12 years, by age group and sex—United States, National Health and Nutrition Examination Survey, 2007–2010. (2012). Morbidity and Mortality Weekly Report, 60(51–52), 1747. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6051a7.htm Depression is also seen in children as young as 3 years old, although the prevalence appears to be lower (Table 7.1). In young children, there does not appear to be a difference in prevalence between girls and boys (Perou et al., 2013). atL80953_07_c07.indd 210 12/5/13 3:30 PM Section 7.3 Definitions and Familial and Biological Basis CHAPTER 7 Table 7.1: Prevalence of mental disorders in childhood (ages 3–17 years) Mental Disorder Prevalence (%) Attention deficit hyperactivity disorder 6.8 Behavioral or conduct problems 3.5 Anxiety 3.0 Depression 2.1 Autism spectrum disorders 1.1 Tourette syndrome 0.2 (children aged 6–17) Source: Perou, R., et al. (2013). Mental health surveillance among children—United States, 2005-2011. Morbidity and Mortality Weekly Report. Surveillance Summaries, 62(2), 1–35. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/su6202a1.htm When people are depressed, they have less interest in activities that they used to enjoy, have difficulty concentrating, may either lose or gain weight, and may have trouble sleeping (or sleep too much). Interpersonal relationships at home and at work are likely to suffer. In addition, people who are depressed are more likely to smoke, overuse alcohol, and neglect their health. Although people usually experience episodes of depression, if the first signs of depression are not treated, they are more likely to recur and to become chronic. Untreated depression can lead to serious problems in functioning and even suicide. Case Study: Suicide and Suicide Prevention Melissa was 13 when she made her first suicide attempt. She had always had trouble committing to and completing things. A major family gathering was coming up, but she had decided to skip it and go on a class trip instead. Then she changed her mind. But her parents sent her on the class trip; they felt she had to learn to deal with the consequences of her decisions. Just before going she said, “If I have to go on this trip, I’m going to kill myself!” She managed to stick it out during the trip, but when she returned, the first thing she said was, “I’m going to kill myself!” After attempting to hang herself (unsuccessfully), she was committed to a psychiatric hospital for a week, diagnosed with major depressive disorder, placed in individual psychotherapy, and put on an antidepressant medication. Melissa hated the hospitalization. Melissa’s mom, Janice, recounts that her father was bipolar and acknowledges that mental disorders like this tend to run in families. Although her 22-year-old daughter and her 20-year-old nephew appear to be fine, her 24-year-old nephew has been diagnosed with ADHD. Melissa’s parents, Janice and Craig, found the National Alliance on Mental Illness (NAMI) particularly helpful in dealing with their depressed teenage daughter. They participated in a support group and were part of the 12-week Family-to-Family Program. Melissa participated in a peer support group for a while but, paradoxically, found it depressing. Melissa made two more suicide attempts: four years after the first attempt, and again just recently, when she went off medication with the permission of her psychiatrist. She found that the medication interfered with her ability to think clearly, and because she was starting college, she wanted to apply herself to her courses. However, two months after stopping medication, she was no longer attending classes. (continued) atL80953_07_c07.indd 211 12/5/13 3:30 PM Section 7.3 Definitions and Familial and Biological Basis CHAPTER 7 Case Study: Suicide and Suicide Prevention (continued) After cutting her wrists, she called her friends and her sister, bypassing her parents, who were visiting just a few miles away. After Melissa’s sister called their parents, they came home immediately. Melissa was adamant about not wanting to return to the hospital, so her parents consulted a local suicide prevention center. A trained volunteer agreed that because she already had an appointment with her psychiatrist for the next day, Melissa could safely be kept at home with her parents. Melissa’s psychiatrist changed her antidepressant. She seems to be doing well on this one and has fewer complaints about side effects. In addition to the antidepressant, Melissa takes anti-anxiety medication as needed and she receives psychotherapy. It has been three months since her last suicide attempt. Family support, psychotherapy, medication, and other tools that Melissa and her family have learned through NAMI have all contributed to Melissa’s improvement. Recently Melissa and Janice participated in a NAMI walk to raise funds and awareness of mental health. Melissa said, “Mom, I’m so glad that you’re doing this with me. Because you’re here, no one will think that it’s me who has the problem!” For more information on suicide and suicide prevention, visit the NAMI website (http://www.nami .org/). Melissa’s background is typical of people with depressive illness. In a large clinical trial report of those with major depression, more than half of the participants reported a family history of depression. Also, family history of depression was associated with an earlier age of onset of the disorder, more comorbid anxiety, and more suicide attempts. This same group had a somewhat faster onset of remission with medication but a greater incidence of side effects (Husain et al., 2009). These data point to a difference in biology between those with and without a family history of major depression, although they do not point to a particular mechanism or pathway. Although a family history of depression may produce an environment that contributes to the development of this disorder, it is also possible that the family is more attuned to depression and therefore quicker to recognize it and make sure the affected person gets help. Bipolar Disorder Bipolar disorder (also known as manic-depressive illness) is characterized by dramatic shifts in mood, energy, and activity level. The last large U.S. study, published in 2005, estimated that 5.7 million adults 18 years old and older, or 2.6% of the population, were affected by bipolar disorder each year (Kessler, Chiu, Demler, Merikangas, & Walters, 2005). Bipolar disorder is assessed along a spectrum, classified by severity of the manic component from bipolar I (most severe, with episodes of full-fledged mania), to bipolar II (episodes of mania that are not severe enough to qualify as full mania, but affect function), to subthreshold bipolar. A recent worldwide study of bipolar disorder found a 1.5% 12-month prevalence of bipolar spectrum disorder. Although both mania and depression increased from subthreshold bipolar through bipolar I, difficulties in patterns of behavior in social or work situations (role impairment) was similar across subtypes (Merikangas et al., 2011). Bipolar disorder is associated with serious difficulties in social interaction and high economic costs. Despite its severity, bipolar disorder has received less research attention than depression or schizophrenia. Bipolar disorder that starts in childhood or early adolescence is termed early-onset bipolar disorder. It is associated with more severe disease. The prevalence of early-onset bipolar disorder has been a subject of controversy, because the definitions are not yet clear. atL80953_07_c07.indd 212 12/5/13 3:30 PM Section 7.3 Definitions and Familial and Biological Basis CHAPTER 7 During a manic phase, someone might: • • • • be overly silly or joyful, have a very short temper, not sleep much but not be tired, and engage in risky behavior. During a depressive phase, a person with bipolar disorder might resemble someone who is depressed but also might have symptoms of mania. People with bipolar disorder are sometimes misdiagnosed as having depression, which can be a problem, because treatments for the two disorders differ. Before sophisticated genetic analysis was available to examine disorders, it became clear from family, twin, and adoption studies that the risk of developing certain disorders had a strong genetic component—especially more so in monozygotic (or so-called identical) twins, who share genetic identity, than in dizygotic (or fraternal) twins, who are no more closely related than any two siblings. Studies of adopted monozygotic twins separated at birth have teased apart genetic and environmental triggers of a particular mental disorder. One review of family, twin, and adoption studies of bipolar disorder made it clear that the disorder is partly due to genetic risk factors and partly due to other risk factors (Smoller & Finn, 2003). Another study on twins estimated that heritability accounted for more than 80% of the risk of developing bipolar disorder (McGuffin et al., 2003). However, inheritance accounted for only part of the risk (McGuffin et al., 2003; Smoller & Finn, 2003). Recently, scientists have been looking for variation in genetic markers between people with a particular disorder compared with people without the disorder. These so-called genome-wide association studies are a powerful way to uncover the genetic components of disorders. Studies of White people with and without bipolar disorder uncovered several different markers of bipolar disorder located within known genes. In addition to identifying most cases of bipolar disorder as involving the interplay between several different genes and the environment, the researchers found some marker overlap in people identified as having schizophrenia; surprisingly, they found less overlap with people identified as having depression (Craddock & Sklar, 2013). In addition to genetic components, changes in brain pathways and circuits are likely implicated in bipolar disorder. For example, researchers have identified structural and functional differences in specific neural networks involving the emotional and motivation portions of the brain in people with bipolar disorder compared with unaffected controls (Wessa, Kanske, & Linke, 2013). These differences (observed though imaging studies), combined with genetic studies and measurements of blood levels of several components, might be useful for identifying people at risk. Eventually, this combination of factors may prove to be a good biomarker, denoting the risk of developing the disorder. What sorts of environmental and social triggers may be involved in risk for bipolar and other disorders? A recent study has identified at least one environmental trigger: the mother’s exposure to the flu during pregnancy. Children whose mothers had had the flu during their pregnancy developed bipolar disorder at 4 times the rate of those whose mothers had not had the flu (NIMH, 2013a). Exposure to flu during pregnancy is also associated with increased risk of schizophrenia, and a viral disease or immune response to the flu during pregnancy is associated with an increased risk of autism in mouse offspring (Malkova, Yu, Hsiao, Moore, & Patterson, 2012), suggesting that these different mental disorders may be connected. Note, however, that these environmental triggers are still highly speculative. atL80953_07_c07.indd 213 12/5/13 3:30 PM Section 7.3 Definitions and Familial and Biological Basis CHAPTER 7 Case Study: Bipolar II Disorder When Abby was growing up, her parents considered her an emotional child, but because they attributed her character to an artistic temperament (she was interested in the theater and the arts), her personality type made sense to them. During her college and graduate education, she was subject to bouts of depression and phases when she felt she could do anything. While in law school, she became dependent on alcohol and went to see a counselor, who treated her for depression. After she graduated from law school, Abby moved to another city and went into a severe depression, barely leaving her apartment for a year except for grocery shopping and other essential errands. During her next job, as a stockbroker, Abby went into a manic state that affected all her activities except for cold-calling clients, which she hated. She quit that job after about a year, went into mild depression, decided she wanted to be an architect, and spent three really happy years, pretty much on a continuous high, in architecture school. Only when she turned 35 did she hit bottom and move back in with her parents. Her parents said that she could stay with them but that she had to see a psychiatrist. Finally, Abby was diagnosed with bipolar II disorder. The psychiatrist diagnosed her in about two minutes and put her on medication. Abby was able to work in a bookstore for about eight months while her dosage was adjusted, and it was through that job that she met her present supervisor. Abby now works 30 flexible hours a week. Even with medication, some days she can’t get herself moving until 10:00 a.m., and other days she is happy to start her commute at 6:30 a.m. Abby confesses, “It would be almost impossible for me to succeed at a job requiring a 9-to-5 schedule.” Abby’s supervisor knew about her diagnosis and yet was sure that she would be a good fit for the needs of the U.S. government agency position he hired her for. About two years ago Abby had to undergo an additional security clearance, which required an interview with a government psychiatrist. Although she was somewhat apprehensive about it, the interview went fine and Abby gained her additional clearance. Last year Abby earned agency-wide recognition for her ability to translate convoluted government regulations into an easily understandable format. Although Abby sometimes missed the highs of her manic phases, whenever she went off medication she found herself deeply depressed and went back on it immediately. She has been at her present job for more than 10 years now and is doing very well. She needs to be monitored at regular intervals to ensure that her medication does not cause any side effects and is at a safe and effective level. Anxiety Disorders Anxiety disorders comprise panic disorder, obsessive-compulsive disorder (OCD), PTSD, phobias, generalized anxiety disorder (GAD), and social anxiety disorder (or social phobia). Although PTSD is often classified as an anxiety disorder, we look at it separately here, because it shares a common causal agent (etiology) with other trauma- and stress-related disorders. Anxiety disorders are the most common mental disorders in the U.S. population, with a 12-month prevalence of 18% (Kessler, Chiu et al., 2005). However, compared with mood disorders, a smaller percentage of anxiety disorders are considered “serious mental illness.” There appear to be some sex differences, with more women than men experiencing anxiety and women finding it more disabling than men (McLean, Asnaani, Litz, & Hofmann, 2011). Anxiety disorders cause people to “feel excessively frightened, distressed, or uneasy during situations in which most other people would not experience these same feelings” (NAMI, 2012a). atL80953_07_c07.indd 214 12/5/13 3:30 PM Section 7.3 Definitions and Familial and Biological Basis CHAPTER 7 People with anxiety disorders are likely to use alcohol, tobacco, and other drugs in an attempt to relieve their symptoms. This self-medication can be self-defeating or even dangerous, because when the effect of the drug wears off, the person is likely to feel even more anxious. Furthermore, self-medicating interferes with learning how to cope with anxiety-producing situations. Despite the prevalence of anxiety disorders, much less attention has been paid to them, even though anxiety can result in as much impairment as, and is often found together (is comorbid) with, depression (CDC, 2011c). Panic Disorder People with panic disorder experience sudden attacks of terror, usually with physical symptoms such as a pounding heart, sweatiness, and weakness or dizziness. Panic attacks can happen repeatedly and without warning, often producing a sense of unreality and a fear of dying. Twice as many women as men experience panic disorder, which can become very disabling, because people might avoid leaving their home (and develop agoraphobia) for fear they will have a panic attack (NIMH, 2009a). Obsessive-Compulsive Disorders People experiencing OCD have persistent, upsetting, and unwanted thoughts (obsessions) and react with a set of repetitive activities or rituals (compulsions) to control the anxiety produced by these thoughts. For example, those with OCD might have to check that the stove is turned off several times before leaving the house or wash their hands 25 times each day to make sure they are “free from germs.” Although checking that the stove is turned off is a normal routine, for people with OCD, the obsessions and compulsions interfere with their normal activities and start to control their lives. Research suggests that approximately one third of adults with OCD experienced symptoms as children and that the disorder may run in families (NIMH, 2009a). Children whose parents have OCD face challenges and burdens in dealing with the parent’s mental health problems (Griffiths, Norris, Stallard, & Matthews, 2012). Family reactions and responses to children with OCD do not make the rituals go away, but can actually strengthen them (Bond & Guastello, 2013). In contrast, an accepting and autonomy-granting parental style protects children with OCD from comorbid anxiety and depression (Cohen, Sade, Benarroch, Pollak, & Gross-Tsur, 2008). Phobias Phobias are intense, irrational fears of something that actually poses little or no threat. Common phobias are the fear of heights, spiders, public speaking, highway driving, and tunnels (as in claustrophobia, fear of enclosed spaces). People with phobias often acknowledge that their fear is irrational, but it doesn’t stop the fear from causing terror or panic. Phobias are twice as common in women as in men and often begin in childhood or adolescence (NIMH, 2009a). Generalized Anxiety Disorder GAD is characterized by worrying excessively about everyday problems and events. Symptoms last for at least six months and make it difficult to concentrate and carry out everyday activities. Like people with phobias, people with GAD are often aware that their concerns are excessive, but that “head knowledge” does not stop them from experiencing disturbing thoughts and reacting to them. GAD is often accompanied by other anxiety disorders, depression, or substance abuse (NIMH, 2009a). atL80953_07_c07.indd 215 12/5/13 3:30 PM Section 7.3 Definitions and Familial and Biological Basis CHAPTER 7 Social Anxiety Disorder People with social anxiety disorder or social phobia are excessively anxious and self-conscious in everyday social situations, leading to difficulties in work and personal relationships (NAMI, 2012a). Social anxiety usually begins in childhood or early adolescence and unlike many other anxiety disorders is found at the same rate in women and men (NIMH, 2009a). Trauma- and Stress-Related Disorders When people are exposed to traumatic or stressful events, many respond with an acute stress reaction. Some, but not all, who experience an acute stress reaction may go on to develop a more chronic reaction, such as PTSD. Approximately 18% to 36% of those experiencing trauma develop PTSD (Heinzelmann & Gill, 2013). Posttraumatic Stress Disorder Trauma consists of different things for different people. Initiating events for PTSD can be abuse or assault, combat experience, natural disasters, serious accidents, sudden and major emotional losses, or terrorist attacks (NIMH, 2010). A child experiencing neglect or abuse, a woman who has been raped, and a veteran who has been injured in combat are all likely candidates for PTSD. The severity of the traumatic event and length of exposure are critical risk factors for developing PTSD but don’t tell the whole story. Depending on their genetic makeup and early experiences, people can be more or less resilient—able to bounce back from traumatic events (Heinzelmann & Gill, 2013). PTSD is associated with changes in parts of the brain involved with fear and stress. Symptoms include strong memories of the event, nightmares and difficulty sleeping, emotional numbness, edginess or hyperarousal (or hypervigilance) during ordinary events, and an aversion to thoughts and situations that might remind the person of the event. Approximately 7.7 million people in the United States age 18 or older, or 3.5%, experience PTSD in a 12-month period (Kessler, Chiu et al., 2005). Web Field Trip Visit the National Center for PTSD’s website AboutFace, and view video excerpts of veterans who have suffered from PTSD after serving in the military (http://www.ptsd.va.gov/apps/AboutFace/). Critical Thinking Questions 1. How were the veterans helped by medication and other forms of therapy? 2. In what ways to you see therapy being tailored to individual cases? atL80953_07_c07.indd 216 12/5/13 3:30 PM Section 7.3 Definitions and Familial and Biological Basis CHAPTER 7 We are beginning to understand some of the biology of PTSD. Studies of military personnel both before and after deployment have yielded clues to what makes one person more vulnerable to PTSD than another. Long-term studies of people following natural disasters have been able to look at those who do and do not develop PTSD. In addition, there is a large body of literature on the short- and long-term effects of stress on animals. Stress and trauma may have direct effects on brain structures, including those involved in fear, emotional reactivity, and cognition (Sherin & Nemeroff, 2011). Children may be particularly vulnerable to these effects. One study compared 62 children who had witnessed a violent act committed on someone they knew; 27 developed PTSD, and 35 did not (Samuelson, Krueger, Burnett, & Wilson, 2009). Children who developed PTSD showed slower and less effective learning, although both groups were below average in executive function, attention, and intellectual ability. PTSD appears to affect the neuroendocrine, the autonomic nervous (which controls automatic functions such as the heart and digestion), and the immune systems, producing changes that have both short- and long-term effects (Sherin & Nemeroff, 2011; Tucker, Tiller, & Dalthorp, 2013). One particularly sensitive component appears to be the glucocorticoid system, which is responsible for the immediate response to stress. A prospective study of 448 male soldiers looked at several measures of the glucocorticoid pathway in white blood cells before and after deployment to a military zone (van Zuiden, Kavelaars, Geuze, Olff, & Heijnen, 2013). Soldiers rated themselves for PTSD symptoms after deployment. Several predeployment characteristics, including glucocorticoid receptor number and target gene activity, were independently associated with high risk for PTSD. Experiencing childhood trauma was also an independent risk factor for developing PTSD. Survivors of Hurricane Katrina who relocated to Oklahoma had higher rates of PTSD and depression than controls from the same Oklahoma community (Tucker, Jeon-Slaughter, Pfefferbaum, Khan, & Davis, 2010). They also exhibited greater heart rate and blood pressure responses to an interview about the trauma and had higher levels of inflammatory cytokines, all of which put them at greater risk for cardiovascular events. Previous data suggested that people with PTSD have a higher risk of comorbid heart disease, most likely resulting from biological changes induced by PTSD (Kubzansky & Koenen, 2009). Traumatic Brain Injury Traumatic brain injury (TBI) is caused by a blow or bump to the head or penetrating head injury that disrupts normal brain function. TBI can be mild, for instance a brief change in consciousness, to severe, for instance an extended period of unconsciousness or memory loss (amnesia). Most TBIs are concussions or other mild forms, but each year, some TBIs result in severe injury and death (CDC, 2010b). Athletes who play contact sports, such as boxing and football, are prone to these injuries, as are military personnel deployed in combat situations. See Figure 7.4 for a graph showing the prevalence of TBI among military personnel. atL80953_07_c07.indd 217 12/5/13 3:30 PM CHAPTER 7 Section 7.3 Definitions and Familial and Biological Basis Figure 7.4: Total worldwide traumatic brain injury diagnosis among service personnel by year Traumatic brain injuries disrupt normal brain function. Military personnel, especially those in combat situations, are prone to such injuries. 35,000 Number of cases 30,000 25,000 20,000 15,000 10,000 5,000 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Calendar year Source: DoD Worldwide Numbers for TBI. Retrieved from http://www.dvbic.org/dod-worldwide-numbers-tbi. Schizophrenia Schizophrenia is a serious and complex chronic mental disorder that “interferes with a person’s ability to think clearly, manage emotions, make decisions and relate to others” (NAMI, 2012b). An estimated 1.1% of the U.S. population 18 and older is diagnosed with schizophrenia in a 12-month period (NIMH, n.d.-b). Although some studies have found that men and women are equally affected by schizophrenia (NIMH, n.d.), others have found more men than women affected, with a 1.4:1 ratio (McGrath, Saha, Chant, & Welham, 2008). Symptoms The diagnosis of schizophrenia is currently based on clinical criteria that include positive (psychotic) symptoms, negative symptoms (reductions in normal emotions and behaviors), and cognitive (thought-related) symptoms (NAMI, 2012b; NIMH, 2009b). See Table 7.2 for a breakdown. atL80953_07_c07.indd 218 12/5/13 3:30 PM Section 7.3 Definitions and Familial and Biological Basis CHAPTER 7 Table 7.2: Variety of symptoms in schizophrenia Positive Symptoms Negative Symptoms Cognitive Symptoms Delusions (belief in things that are not real, or outside the person’s culture) Flat affect (lack of facial or vocal expressiveness) Poor executive function (inability to organize and prioritize tasks or information) Hallucinations (hearing, seeing, smelling, or feeling things others cannot sense) Anhedonia (lack of pleasure or interest in everyday life) Trouble focusing and paying attention Disorganized thought; incoherent speech (not making sense when talking) Inability to start or follow through on activities Problems with working memory (inability to use information immediately after learning it) Agitated or repetitive body movements, movement disorders Withdrawal (speaking little, even when forced to interact) Sources: National Alliance on Mental Illness. (2012b). Schizophrenia fact sheet. Retrieved from http://www.nami.org/factsheets /schizophrenia_factsheet.pdf. National Institute of Mental Health. (2009b). Schizophrenia (NIH Publication No. 09-3517). Bethesda, MD: Author. Retrieved from http://www.nimh.nih.gov/health/publications/schizophrenia/schizophrenia-booket-2009.pdf Schizophrenia is considered a chronic disease, but symptoms may cycle through the negative and positive phases, becoming more or less severe with time. People with schizophrenia often have difficulty taking care of themselves and so must rely on family or institutions for help. However, as they age, many people with schizophrenia manage their lives better, particularly if they have access to social support systems, and a surprising number are able to hold jobs and have regular family contact. Biological Basis Schizophrenia, like so many disorders, is thought to result from a combination of genetic and environmental influences. Many theories and much evidence have been presented about the biological basis of schizophrenia, but as yet there is little consensus as to the mechanisms involved. Because schizophrenia onset is usually seen between late adolescence and early adulthood, which coincides with a major brain rearrangement, one suggestion posits that something about this process goes amiss in people with schizophrenia. The density of nerve cell connections, or synapses (the space in which the nervous impulse passes between neurons), in the cerebral cortex reaches a maximum when children are between 2 and 4 years old and then declines to adult levels during adolescence. The process of eliminating excess connections is termed synaptic pruning. Though the data suggest that problems in synaptic pruning are a possible trigger of schizophrenia, however, the process is far from proven responsible (Boksa, 2012). atL80953_07_c07.indd 219 12/5/13 3:30 PM Section 7.3 Definitions and Familial and Biological Basis CHAPTER 7 Another long-held hypothesis about schizophrenia is that disruptions during early brain development increase risk for the disorder. Again, some data have correlated maternal infection, nutritional stresses, and obstetric complications with heightened risk for schizophrenia, but the findings are not definitive. As in other mental disorders, schizophrenia is more common in some families, which suggests that risk for schizophrenia is at least partly genetic, likely involving contributions from a large number of genes involved in the nerve signaling pathways. One gene linked to schizophrenia risk was discovered in a large Scottish family with a number of members diagnosed with schizophrenia and major depressive disorder. Affected family members carried a chromosomal rearrangement that was later linked to a specific gene termed Disrupted in Schizophrenia 1 (DISC1; Thomson et al., 2013). DISC1 appears to play an important role in the formation of neurons during development and the production of neurons in the adult brain. In addition, DISC1 appears to be involved in neuronal signaling, and its activity is modulated by environmental stress, suggesting direct mechanisms for gene–environment interactions (Thomson et al., 2013). However, how much influence DISC1 exerts in risk for schizophrenia or other mental disorders in the wider population is unknown. Comorbidities More than one disease or disorder occurring together in one person or population is termed comorbidity. Comorbidity can make it more difficult to determine which disease or disorder is responsible for a particular sign or symptom. Using Swedish national health care records, a recent study examined what might have caused the increase in cardiovascular mortality among people with schizophrenia (Crump, Winkleby, Sundquist, & Sundquist, 2013). Sweden has universal health care and collects extensive data on diseases and treatments. Crump et al. followed a cohort of more than six million adults from 2003 to 2009 to detect mortality and illness. Among the 8,277 people with schizophrenia, men died 15 years earlier and women died 12 years earlier than the rest of the population. Contrary to expectations, these deaths were not from suicide but mostly from cardiovascular disease and cancer, which were underdiagnosed in this population despite their having twice as many contacts with the health system as people without schizophrenia. Lack of antipsychotic treatment was associated with an increased mortality risk. These findings underscore the importance of integrating medical care with mental health care tailored to the needs of people with mental disorders. Dementia Dementia is not a specific disease; rather, it is a cluster of symptoms affecting thinking and social interactions that are severe enough to interfere with social or occupational functioning (Table 7.3 compares the different forms). Dementia is usually caused by a number of different brain disorders, including Alzheimer’s disease, Lewy body dementia, vascular dementia, frontotemporal dementia, and Huntington’s disease. Dementia is more prevalent among people older than 60 years, although there are some young-onset forms (e.g., frontotemporal, Parkinson’s disease related). atL80953_07_c07.indd 220 12/5/13 3:30 PM CHAPTER 7 Section 7.3 Definitions and Familial and Biological Basis Table 7.3 Forms and Symptoms of Cognitive Impairment Symptoms Mild Alzheimer’s Cognitive Disease Impairment Lewy Body Dementia Vascular Dementia Frontotemporal Other Forms Dementia Slowed thinking and mild memory problems Fluctuations in alertness and attention Depression and anxiety more severe than in Alzheimer’s Difficulties with language and changes in personality and behavior Apathy, memory loss, depression, poor judgment, and confusion Depression and apathy Decline in cognition Frequent visual hallucinations Late stage: personality changes, emotional dysregulation --- Memory is preserved compared with Alzheimer’s disease Parkinsonian motor symptoms, e.g., rigidity and shuffling gait Etiology Clinical course Age-related Does not always lead to dementia Neuro­degenerative disease (neurofibrillary tangles form in the brain) Mid-to-late stage: emotional outbursts, behavioral changes Buildup of Lewy bodies (bits of alpha-synuclein protein) inside neurons in brain areas that control memory and movement Progressive; course is variable Brain damage following a stroke or other obstruction to brain’s blood supply The common form, multiinfarct dementia, results from many small strokes (transient ischemic attacks) --- This less common form of dementia results from degeneration of nerve cells in the frontal and temporal lobes of the brain Mixed, e.g., Alzheimer’s disease and Lewy body disease or Alzheimer’s disease and vascular dementia Parkinson’s or Huntington’s disease Onset is early, 50s and 60s --- Patients may lose language early in the disease Late stage: trouble walking, speaking, and swallowing; severe memory loss Risk factors --- Genetic/familial component (APOE4 gene implicated) Advanced age, cardiovascular risk factors, and head injury atL80953_07_c07.indd 221 --- High blood pressure, diabetes, previous stroke or heart attack, late-life depression --- --- 12/5/13 3:30 PM Section 7.3 Definitions and Familial and Biological Basis CHAPTER 7 As people age, they may experience slightly slowed thinking and mild memory problems; this mild cognitive impairment is part of the normal aging process and does not always lead to dementia. Dementia goes beyond the consequences of aging and usually results from brain nerve cells (neurons) stopping their function, losing connections to other cells, or dying. Although it may be possible to slow the rate of decline, the progress of these diseases cannot be halted or reversed. However, other types of dementia, caused by metabolic problems, brain tumors, or reactions to medications, may be reversible with appropriate treatment (National Institute of Neurological Disorders and Stroke [NINDS], 2013a). Possible symptoms of dementia include memory problems, difficulty communicating, difficulty problem solving, difficulty planning and organizing, and difficulty with orientation in space (getting lost). They also include difficulty controlling emotions, agitation, the belief that people are threatening (or paranoia), and hallucinations. Alzheimer’s Disease The most common form of dementia is Alzheimer’s disease, which is also considered a neurodegenerative disease (in which neurofibrillary tangles form in the brain). The Alzheimer’s Association (2012) estimated that in 2012, 5.4 million people in the United States had Alzheimer’s disease, including 200,000 who were less than 65 years old. The burden of disease in U.S. society is expected to grow rapidly, as the aging of the baby boomer population (those born between 1946 and 1964) is projected to increase the prevalence of Alzheimer’s disease to between 11 and 16 million by 2050. Alzheimer’s disease places a tremendous financial and emotional burden on the family and society because of the increased need for care between diagnosis and death, a period that is usually four to eight years but may be as long as 20 years (Alzheimer’s Association, 2012). Not surprisingly, more than 50% of caregivers of patients with Alzheimer’s disease had high anxiety and depression scores that increased along with the duration and severity of dementia in the people they cared for (Garcia-Alberca, Lara, & Berthier, 2011). Alzheimer’s disease has a subtle onset. It may begin with trouble remembering names and recent events (short-term memory). People also may become apathetic or depressed and lose interest in their normal activities. As the disease progresses, problems with judgment and confusion may become apparent. A person with Alzheimer’s has trouble remembering and asks the same question or repeats the same story over and over, much to the dismay of family members and friends. Emotional outbursts and other behavioral changes may become a problem as the disease progresses. The person with Alzheimer’s may need assistance with activities of daily living, including eating, personal hygiene, and toileting. In the late stage, people with Alzheimer’s disease have trouble walking, speaking, and swallowing. They often no longer recognize family members, which can be very upsetting to those closest to them. Unfortunately, during the disease course, it is common for people to spend the most time in the late stages, when they are most impaired and need the most assistance (Alzheimer’s Association, 2012). However, the particular course of disease and rate of decline vary greatly from person to person. As in Huntington’s disease (see Chapter 3), some forms of early Alzheimer’s occur in those who carry a single gene that ensures that person will develop dementia. Early-onset Alzheimer’s disease appears in the 30s, 40s, or 50s and is caused by a mutation in one of three different genes (Alzheimer’s Association, 2012). Fortunately, less than 1% of people who develop Alzheimer’s disease carry one of these mutations. For older-onset Alzheimer’s disease (≥ 65 years), the greatest risk factor is advancing age itself. More women than men have Alzheimer’s disease, but this is a atL80953_07_c07.indd 222 12/5/13 3:30 PM Section 7.3 Definitions and Familial and Biological Basis CHAPTER 7 result of women living longer than men; at any given age, women are no more likely than men to develop the disease (Alzheimer’s Association, 2012). People who have a first-degree relative (a parent or sibling) with Alzheimer’s are at somewhat increased risk for developing the disease. Some data suggest that people who have cardiovascular risk factors (smoking, obesity, diabetes, physical inactivity) or who have had head trauma are at increased risk of developing Alzheimer’s disease (Alzheimer’s Association, 2012). Those carrying a common variant of the apolipoprotein E gene (APOE4) are at a higher risk of developing it and at a somewhat younger age than usual, but it is only an increased risk, not a guarantee of disease. APOE4 is involved in cholesterol metabolism, but how it is implicated in Alzheimer’s disease remains a mystery. Most genetic studies have been carried out in White people. A recent study of Black people in the United States found two gene variants associated with increased risk for late-onset Alzheimer’s disease: APOE4 and ABCA7 (Reitz et al., 2013). The risk for Alzheimer’s with APOE4 was similar to that seen in Whites, but the risk conferred by ABCA7 was much higher in Blacks compared with Whites. Like APOE4, ABCA7 is involved in lipid metabolism. Studies such as this one are useful because they may uncover new biological targets for treatment. Lewy Body Dementia Lewy body dementia (also known as dementia with Lewy bodies) is a prevalent, progressive form of dementia. Lewy bodies (found in the brains of people with Lewy body dementia and several less common dementias) are clumps of misfolded alpha-synuclein protein. Their accumulation appears to be toxic to nerve cells. Researchers are attempting to prevent these proteins from misfolding or to increase removal of misfolded proteins before they destroy the cells. Lewy body dementia is characterized by a decline in the ability to think (cognition) combined with the following symptoms: noticeable fluctuations in alertness and attention (drowsiness, lethargy, long periods of time spent staring into space, disorganized speech); frequent visual hallucinations; and parkinsonian motor symptoms, such as rigidity and shuffling gait. Symptoms appear to be caused by the buildup of Lewy bodies inside neurons in brain areas that control memory and movement (NINDS, 2013b). Lewy body dementia shares many features with Parkinson’s disease dementia (see Chapter 3), and many people believe that the two are part of the same disease spectrum. To distinguish between them, clinicians have decided that if signs of dementia are apparent before or within a year after the appearance of motor symptoms, then the formal diagnosis is Lewy body dementia; if the signs of dementia appear more than a year after motor symptoms, the diagnosis is Parkinson’s disease dementia (Dodel et al., 2008). Survival rates are similar to those seen in Alzheimer’s disease, averaging eight years after diagnosis. During this time, patients become more disabled and eventually need care for all activities of daily living. Vascular Dementia Vascular dementia is another common form of dementia, resulting from brain damage following a stroke or other blockage of the brain’s blood supply. A common form of vascular dementia is multi-infarct dementia, the result of many small strokes. Symptoms vary depending on which brain structures are involved, but, unlike Alzheimer’s disease, personality and regulation of emotional states are usually not affected until later stages of the disease (NINDS, 2013a). Symptoms usually start suddenly, and the disorder is more common in people with high blood pressure and those who have had strokes or heart attacks. atL80953_07_c07.indd 223 12/5/13 3:30 PM Section 7.4 Using Bronfenbrenner’s Model to Better Understand Mental Health CHAPTER 7 Frontotemporal Dementia Frontotemporal dementia, a less common form of dementia, results from the degeneration of nerve cells in the front and sides (or frontal and temporal) lobes of the brain. Typical symptoms include difficulties with language and changes in personality and behavior that begin when a person is 50 or 60 years old, rarely later in life (Alzheimer’s Association, 2012). Mixed Forms Often, someone with dementia has symptoms that suggest more than one type of dementia. Although in the past clinicians attempted to diagnose a single type of dementia, now they are more willing to acknowledge that the hallmarks of several different dementias can coexist—this is called mixed dementia. An autopsy may reveal the presence of both neurofibrillary tangles and Lewy bodies, suggesting that the patient had a mixture of Alzheimer’s and Lewy body dementias. 7.4 U  sing Bronfenbrenner’s Model to Better Understand Mental Health and Mental Disorders B ronfenbrenner’s bioecological model places the individual within several concentric circles of the larger environment: the micro perspective of the family; the meso perspective of the immediate community (including school or work); and the macro perspective of the larger world, including race, ethnicity, socioeconomic status, national origin, and political systems. Micro Perspectives In Bronfenbrenner’s model, interaction is a two-way phenomenon. For example, because a child with ASD requires so much attention as a toddler, one parent probably spends a lot of time tending to and interacting with the child and is less able to hold a demanding, full-time job. In turn, the extent to which the parents understand and are willing to cope with the child’s demands plays a role in helping the child learn to interact with the environment. Case Study: ASD Diagnosis Many parents assume they will have an essentially problem-free child, and it comes as a shock to the entire family system when they realize that isn’t true for them. Steve had special needs from birth. He had an underactive suck reflex and a gag reflex, so he couldn’t feed properly; he didn’t sleep more than four hours a night; and he needed to be engaged constantly, which was hard on his mother Andrea. Steve’s pediatrician suggested using educational videos, which mesmerized him and allowed Andrea to take a break once in a while. As Steve approached his first birthday, Andrea was concerned that he was not doing what other babies his age were doing, but Steve’s father Will had been a late talker and Steve’s pediatrician reassured Andrea that Steve was fine. (continued) atL80953_07_c07.indd 224 12/5/13 3:30 PM Section 7.4 Using Bronfenbrenner’s Model to Better Understand Mental Health CHAPTER 7 Case Study: ASD Diagnosis (continued) A new pediatrician, who saw Steve when he was 18 months old, said, “This kid needs to be evaluated immediately.” Although the pediatrician didn’t know much about ASD, she knew that a child should reach certain developmental milestones. For instance, by 18 months a child most often: • • • • • • • is afraid of strangers; shows affection to familiar people; says several single words; says and shakes his or her head “no”; knows a number of ordinary things, for example, telephone, spoon, and brush; points to get the attention of others; and drinks from a cup (CDC, 2008). Steve was sent to a specialist who diagnosed him with ASD and helped Andrea connect to public intervention services immediately. Steve started therapy at home twice a week with a speech therapist and twice a week with an occupational therapist. The therapists helped the family learn how to interact with Steve in a way he could respond to. Andrea was also encouraged to learn as much as possible about ASD so that she could become part of the therapeutic environment. Andrea found the training she got when Steve received early intervention services continued to help her even when Steve was almost 10 years old. For example, Steve listens to Andrea more attentively in a busy situation when she tells him something and signs it at the same time—a technique she learned from an occupational therapist when Steve was very young. Some parents resist having their children evaluated, even when they suspect serious developmental delays. They may be afraid that having their child “labeled” will be a problem in the future. But in doing so, they pass up services that can help their children develop and that are available for free in every state. They also are not learning how to interact with their child in ways that might benefit both the child and the family. Other factors that may prevent children or adults from getting services for autism or other mental health problems include language barriers, lack of trust in providers, competing family demands, problems with transportation to a service provider, lack of integrated services, and the need for the parent to earn an income. Meso Perspectives Mental disorders affect how a person functions in school, at work, or in their immediate community. Sometimes people with mental disorders are lucky and are able to receive accommodations in their various environments. For example, Abby, the woman we met earlier who has bipolar II disorder, has been functioning well for 10 years in her position as a technical writer for a government agency. But it was mainly the understanding of her supervisor and the flexible policies of her employer that made it possible. A mental disorder in a child, such as autism, affects how family members interact with the larger community. For example, children with autism are abnormally sensitive to sensory input and can become overwhelmed when they are in a grocery store, for example, with its array of colors, patterns, and smells. When overstimulated, these children are likely to exhibit what is often termed a “temper tantrum.” How well the outside community (e.g., daycare facilities, schools) understands the problems of such children and makes allowances for them determines how the meso-level environment influences that child’s development, for good or ill. atL80953_07_c07.indd 225 12/5/13 3:30 PM Section 7.5 Mental Disorders Through the Life Span CHAPTER 7 Case Study: Interactions With the Community Andrea, Steve’s mother, related how difficult it can be to have normal interactions in her community. Just going to the grocery store with an autistic child can become an adventure. Andrea wishes she could tell the other shoppers who eye her with disapproval when he’s upset, “No, my child is not a spoiled brat because he’s screaming; that’s just how he communicates. His nervous system becomes overwhelmed by sensory input and goes into a meltdown.” Macro Perspectives The macro perspective looks at how the disorder affects the person within the culture and the larger society, and conversely, how the larger society affects the person with the disorder. For example, the flexible schedule worked out by Abby’s government employer allowed her to have a fulfilling job and allowed the government agency to have the services of one of their top performers. This is an example in which representatives of the larger society, U.S. government officials, were able to resist the stigma of a mental disorder and look instead at the functioning of the individual with the disorder. Possibly more significantly, as a matter of public policy, the Americans with Disabilities Act (ADA) requires such employers to make reasonable accommodations for a person’s disability, if doing so will allow them to function well in their job. (For more discussion of the ADA, see Chapter 2.) 7.5 Mental Disorders Through the Life Span T he onset of mental disorders occurs at different times in the life span and, depending upon age and stage in life, has different effects on those with the disorder and their families. Mental disorders are often first diagnosed during childhood and adolescence. Fully half of all lifetime cases of mental disorders start by age 14, and three quarters by age 24 (Kessler, Berglund et al., 2005). However, age at onset appears to differ among the various mental disorders. Childhood ASDs are probably among the first mental illnesses to be diagnosed. More severe forms of the disorder are likely to be diagnosed earlier. For instance, children with autistic disorder are usually diagnosed by age 4, but children with Asperger’s disorder (now part of ASD in DSM-5) are not diagnosed until an average age of 6 years, 3 months (CDC, 2012d). The CDC has an active campaign to urge early diagnosis of ASD: “Learn the Signs. Act Early” (CDC, 2008). Although age at diagnosis is getting younger, many children are missing out on early intervention programs that could address specific developmental concerns and help them catch up with their peers. These programs are effective for young children, and all school systems across the country are mandated to provide appropriate education for all children, no matter what their disability. atL80953_07_c07.indd 226 12/5/13 3:30 PM CHAPTER 7 Section 7.5 Mental Disorders Through the Life Span Sometimes the symptoms exhibited by a child with a mental disorder are different from those seen in an adult with the same disorder. For instance, unlike adults, children with bipolar disorder sometimes have an extremely short temper and show unusual irritability when they are in a manic state, and they complain about pain when they are in a depressed state (NIMH, 2012a). Adolescence Tony Gutierrez/Associated Press As in schizophrenia, the peak period of onset for bipolar disorder occurs Early detection of ASD allows children to be placed in during adolescence (Merikangas et programs that address their specific developmental concerns. al., 2012). One recent study looked at mania and depression in a large community sample of 10,123 adolescents aged 13 to 18 years. To their surprise, the investigators found that 1.7% of adolescents met criteria for lifetime mania only, without depression (Merikangas et al., 2012). A larger group, 2.5%, met criteria for lifetime bipolar I or bipolar II disorder, and the prevalence of mania increased twofold between ages 13–14 and 17–18. What happens to children with ASD as they get older? Once graduated from high school, those with ASD have limited opportunities. One study of 1,900 youths found that fewer people with ASD than other disabilities are either employed or undergoing further education two years after graduating from high school. It also found that youths from low-income families were much more likely to become disengaged, regardless of the severity of their disability. More impaired youths were also at greater risk of disengagement (NIMH, 2012b). Case Study: Mainstreaming Children Diagnosed With ASD Marie has a large family, starting with a husband and five children. When the family gets together, as they like to do, there are at least 15 people and often more. One of Marie’s grandsons, Charlie, is 14 and has the physique of a grown man. He was diagnosed in childhood with ASD. Marie confides that it is getting more difficult to deal with Charlie at family gatherings as he gets older. Family members prefer to have Charlie’s younger sister Betsy, who is “neurotypical” (not having ASD) visit without Charlie. The children’s mother, Theresa, is offended that people don’t want to have Charlie around. Charlie is now being “mainstreamed” at his local school, which means he is part of the regular classes. However, Marie thinks this is the wrong idea. She protests, “He needs to learn to eat with a fork, not learn algebra!” atL80953_07_c07.indd 227 12/5/13 3:30 PM Section 7.5 Mental Disorders Through the Life Span CHAPTER 7 Mainstreaming has many proponents and many detractors. Some people think that children with ASD, particularly those who are higher functioning, can learn communication skills by interacting with more typical children in a mixed classroom. Others think that children with ASD, particularly those who are not so high functioning, learn social skills best from specially trained teachers. Most parents of children with ASD think it is most important to match the individual child with the school situation that best fits his or her needs, whether a special needs school, a special needs class within a regular elementary school, some mix of special needs classes and mainstreaming, or all mainstreaming. For a more extensive discussion of mainstreaming, see “School Inclusion for Children with Autism Spectrum Disorders” (http://www.aboutourkids.org/articles /school_inclusion_children_autism_spectrum_disorders). Adulthood ADHD is thought of as a childhood disorder; it is usually diagnosed in preschool or during early elementary years (Kessler, Chiu et al., 2005). Although many people diagnosed with ADHD as children seem to grow out of it, a significant percentage continues to have symptoms as adults, and some people are not diagnosed with ADHD until they are adults. In all, prevalence of ADHD among adults aged 18 to 44 years was found to be 4.4% of the population. These adults were more likely to be unemployed and have other comorbid disorders than those without ADHD (Kessler et al., 2006). Adults with ADHD were also more likely to perform poorly in the workplace, with an excess of 35 lost work days compared with those without ADHD (Kessler, Adler et al., 2005). It is not known whether treatment improves the incidence and severity of this disorder and its effects. A recent study compared adults (mean age, 27 years) diagnosed with ADHD as children with those from the same birth cohort who had not been diagnosed with ADHD. Researchers found that childhood ADHD persisted in 29.3% of the adults and that, tragically, those adults who had been diagnosed with ADHD as children were significantly more likely to have one or more mental disorders and to die from suicide (Barbaresi et al., 2013). The Elderly The most common mental disorders seen among the elderly living in long-term care facilities are dementia, depression, and anxiety (Seitz, Purandare, & Conn, 2010). Depression is quite prevalent among people in the United States aged 65 and older. Although many experience depression for most of their lives, others experience its onset late in life—even as late as their 80s and 90s. Although elderly women are more likely to experience depression, it is a greater risk factor for suicide among elderly men (NAMI, 2009a). Social factors that may contribute to late-onset depression include loneliness, loss of a spouse, perceived lack of support, and feelings of isolation. The effects of GAD do not appear to diminish with age. Instead, compared with older adults with no mental disorders, older adults with GAD were found to be more disabled and exhibited worse health-related quality of life (Porensky et al., 2009). Although we think of PTSD as occurring in children, young adults, and those who have served in the military, it can also be found in older adults. A meta-analysis of cognitive functioning in older adults found that those with PTSD had worse cognitive performance compared with those of the same age without PTSD (Schuitevoerder et al., 2013). In some cases, PTSD emerges late in life, years after exposure to trauma. This observation is termed late-onset stress symptomatology, and it has been observed in aging combat veterans after years of functioning well (King, King, Vickers, Davison, & Spiro, 2007). atL80953_07_c07.indd 228 12/5/13 3:30 PM CHAPTER 7 Section 7.6 Prevention and Treatment Approaches to Mental Disorders Psychosis is another aspect of mental illness that affects the elderly; it may be caused by schizophrenia, a mood disorder, or some form of dementia (most likely Alzheimer’s disease, vascular dementia, Parkinson’s disease, or Lewy body dementia). Although their functional status is generally poorer than that of people without schizophrenia, many elderly adults with early-onset schizophrenia (during adolescence or early adulthood) function surprisingly well—better than young adults with the disorder. They may live independently, drive, have been employed, and have a surprising amount of social interaction with family and friends (Iglewicz, Meeks, & Jeste, 2011). Psychosocial functioning in adults with schizophrenia appears to improve over time and features better self-management, fewer psychotic symptoms, and fewer psychiatric hospitalizations (Jeste, Wolkowitz, & Palmer, 2011). For those who experience schizophrenia onset between ages 40 and 60 years, or even after age 60, the response to medication is equivalent to that of younger patients (Iglewicz et al., 2011). And, unlike dementia, late-onset schizophrenia is not associated with cognitive decline. The greatest risk factor for dementia is age, so one might expect that almost all people who reach 100 years exhibit signs of dementia. However, it seems that dementia is not an inevitable consequence of aging. At least one study of 244 centenarians found that 25% showed no signs of memory deficits, 25% showed signs of transient confusion, and half did show signs of classic dementia (Poon et al., 2012). 7.6 P  revention and Treatment Approaches to Mental Disorders T hree basic approaches are taken to treat the major mental disorders discussed here: medication; psychotherapy, cognitive or behavioral therapy, and counseling of various types (in both inpatient and outpatient settings); and a group of instrumental interventions, such as biofeedback, nerve stimulation, and electroconvulsive therapy (ECT). For most mental disorders, the combination of two or more treatment types yields the best results. Tables 7.4 and 7.5 outline the major forms and providers of therapy for mental illness. Table 7.4: Providers of treatment for mental disorders atL80953_07_c07.indd 229 Provider Academic Training Function Setting Psychiatrist MD Only one who can prescribe medication; may also provide therapy Various (inpatient and outpatient) Clinical psychologist PhD Provides therapy Various Psychiatric nurse MSN, NP Provides therapy Various Licensed clinical social worker MS, PhD Provides therapy Various Licensed social work associate AA Provides counseling Various Mental health counselor MS, PhD Provides counseling Various Psychosocial rehabilitation counselor AA Teaches skills to reintegrate into society Community-based mental health programs 12/5/13 3:30 PM Section 7.6 Prevention and Treatment Approaches to Mental Disorders CHAPTER 7 Table 7.5: Therapies for mental disorders Treatment Modality Brief Description Psychodynamic or insight oriented Focuses on unconscious processes that contribute to present behavior; goals are self-awareness and understanding how the past influences present behavior. Family centered Views the individual in the context of the family and the family’s history; may involve more than one person in the room with the therapist. Cognitive-behavioral therapy Views that feelings are based on maladaptive thinking and that changing those thought patterns can change the patient’s subjective feelings. Behavioral therapy Theorizes that rewarding desirable behavior increases that behavior and that not rewarding unwanted behavior eliminates it; teaches parents of children with ADHD or ASD techniques to accomplish this. Psychosocial therapy for bipolar disorder Umbrella term; may include family therapy, cognitivebehavioral therapy, and other modalities. Goal is to enhance quality of life and decrease the frequency of affective episodes by teaching techniques for medication ad...
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Biology of Bipolar Disorder
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Mental health is a state of well-being in which an individual realizes their personal
potential and has the ability to cope with the normal stresses of life, is productive and contributes
to the community’s we...

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