the scientific study of behavior and mental processes. Psychological treatment often involves talking therapy or behavior therapy. Behavior is anything you do. Mental processes are your private, internal experiences.
doctorate in philosophy.
doctorate in psychology.
not a clearly delineated group of disorders. Include mood disorders, and generalized and specific anxiety disorders.
include unipolar and bipolar depression, generalized anxiety disorder- and more specific anxiety disorders, phobias, OCD, and PTSD
person must be so deeply sad for at least 2 weeks that they feel despairing and hopeless, see nothing but sorrow in the future, and may not want to live anymore. They see themselves as worthless and unlovable. They have difficulty getting up and going to school or work. One person’s depression can hurt everyone in the entire family.
Physical symptoms occur. These may include difficulty concentrating, difficulty falling asleep, feeling tired all the time, losing weight. Violent behavior or substance abuse occurs more often in depressed men than in women, though depression is more common in women.
When depression is unipolar, the episode will ease with medication. Since the 1950s, tricyclic antidepressant (TCA) drugs have been used for depression, but since 1990 they are being replaced by selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs). Moderate exercise for 3 hours weekly has been shown to reduce the symptoms of depression by 47%. It is believed to alter the serotonin chemistry in the brain. In electroconvulsive therapy (ECT) seizures are electrically induced in anesthetized patients to treat severe depression that has not responded to other treatment.
(used to be called manic-depressive disorder)
mood disorder with alternating periods of depression with mania.
Some medications for bipolar disorder treat only the manic phase, some treat only the depressive phase, some treat both. Cognitive therapy, family education, and group education may be used in conjunction with medication therapy. Electroconvulsive therapy is used only as a last resort.
Both of these terms are related to bipolar disorder; they are opposite phases of the same disorder.
mood disorder with hyperactivity, irritability, and rapid speech. Some people rebound to the opposite extreme of depression called mania, an excessive state of overexcitement and impulsive behavior.
In the manic phase, the person is hyperactive and distractible and may not sleep for days, yet shows no fatigue. Thinking and speech are rapid and disjointed and cannot be interrupted. The person may give away possessions or go on a spending spree. Untreated pure manic episodes usually last 6 weeks. Untreated mixed (manic and depressive) episodes usually last 17 weeks.
(mood disorder) a form of bipolar disorder, combines the frenetic energy of mania with dark thoughts and paranoid delusions. It may be the cause of some mass shootings.
seasonal affective disorder (SAD)
(mood disorder) Depression that occurs at the same time every year. Associated with episodes of depression during the fall and winter months, subsiding during spring and summer. It appears to be related to a lack of sunshine causing increased melatonin production by the pineal gland. It can be helped by phototherapy with bright white fluorescent lights. Antidepressant drugs can also be helpful.
electroconvulsive therapy (ECT)
passage of electric current through the brain to produce convulsions and treat persistent depression mania and other disorders. Seizures are electrically induced in anesthetized patients to treat severe depression that has not responded to other treatment.
tricyclic antidepressants (TCAs)
include Elavil, Tofranil, Anafranil, and Pamelor.
selective serotonin-reuptake inhibitors (SSRIs)
include Paxil, Prozac, Zoloft, and Celexa.
serotonin- and norepinephrine-reuptake inhibitors (SNRIs)
include Effexor, Cymbalta, and Dalcipran.
most common category of mental disorders found in the United States. They are characterized by an unreasonable anxiety or fear that is inappropriate to the circumstances and so intense and chronic that it disrupts the person’s life.
There are five major categories of anxiety disorder:
(1) Generalized anxiety disorder (2) Posttraumatic stress disorder (3) panic disorder (4) phobias (5) OCD
Most patients recognize the senselessness of their behaviors; but if they resist doing them, the fear and anxiety become intolerable. Treatment is with CBT and one of the selective serotonin reuptake inhibitors (SSRIs) listed
Generalized anxiety disorder (GAD)
consists of persistent, excessive worrying and uncontrollable anxiety that is not focused on one particular situation and has lasted for at least 6 months. People with this disorder are frightened of something but are unable to articulate a specific fear; unable to state what they are adraid of. They develop physical fear reactions including palpitations, insomnia, difficulty concentrating, and irritability.
Symptoms include excessive worry, uncontrollable anxiety, palpitations, insomnia, irritability, and difficulty concentrating. May be treated with medication and psychotherapy.
posttraumatic stress disorder (PTSD)
occurs when a person who has gone through a significant trauma shows stress symptoms that last for longer than a month and impair the person’s ability to function. The trauma can be a life-threatening accident, a natural disaster, loss of a loved one, torture or abuse, or combat and its related incidents. Characterized by anxiety, fear, preoccupation with memories and dreams of the trauma, and a variety of physical symptoms that occur after a patient has experienced a trauma.
Treatment is multimodal, involving psychopharmacotherapy, psychotherapy, social interventions, and patient and family education. Forms of psychotherapy are cognitive behavioral therapy (CBT), in which the traumatic experiences are relived and worked through, and cognitive processing therapy (CPT), in which the thoughts and beliefs generated by the trauma are explored and reframed. Eye movement desensitization and reprocessing (EMDR) is also used. Social interventions to restore a sense of safety and security are a crucial element in therapy.
characterized by sudden, brief attacks of intense fear that cause physical symptoms. The fear rises abruptly, often for no reason, and peaks in 10 minutes or less. The frequency of the attacks varies widely over many years. The disorder runs in families, but whether it is due to genetics or a shared environment is not clear.
Physical symptoms include SOB, palpitations or tachycardia, sweating, and disorientation.
Treatment may include biofeedback, medication (Table 18.2) and (psychotherapy) cognitive behavioral therapy.
pathological fear or dread. Differ from generalized anxiety and panic attacks in that a specific situation or object brings on the strong fear response. The danger is small, and the person realizes the fear is irrational, but there is still overwhelming anxiety. There are two categories of phobia: (1) situational phobias involve a fear of specific situations (agoraphobia (fear of crowded places, buses, and elevators),) (acrophobia (fear of heights), fear of flying or driving in tunnels,) and (fear of specific animals (snakes, mice).) The basic fear of being trapped in a confined space is called claustrophobia. (2) social phobias involve fear of being embarrassed in social situations. The most common are fear of public speaking (stage fright) and of eating in public. In many, the fear is so strong that it makes normal life impossible.
Numerous treatment options for phobias are available, including psychotherapy and the SSRIs, benzodiazepines, and monoamine oxidase inhibitors (MAOIs).
obsessive-compulsive disorder (OCD)
a majority of patients have both obsessions and compulsions. The obsessions are recurrent thoughts, fears, doubts, images, or impulses. The compulsions are recurrent, irresistible impulses to perform actions such as counting, hand washing, checking, and systematically arranging things. The recurrent actions can be violent or sexual.
persistent, recurrent, uncontrollable thoughts or impulses; recurrent thoughts, fears, doubts, images, or impulses.
uncontrollable impulses to perform an act repetitively; recurrent, irresistible actions that must be performed
to drive out anxiety or obsessions
a feeling of distress that is caused by fear.
inability to fall asleep or stay asleep.
cognitive processing theory (CPT)
psychotherapy to build skills to deal with effects of the trauma in other areas of life
cognitive behavioral theory (CBT)
psychotherapy that emphasises thoughts and attitudes in one’s behavior.
Used for PTSD
using many methods
drug treatment of mental disorders
treatment of mental disorders through communication
person who exaggerates the significance of symptoms. (hypochondriasis) and interprets some minor symptom, such as a bruise or a cough, as a sign of a serious disease and cannot believe normal physical examinations and reassurances.
belief that a minor symptom indicates a severe disease
a physical disorder with, at least in part, a psychological cause, such as tension headache, muscle spasms, TMJ, or IBS. Tension headaches have real pain caused by muscle spasm, but stress and anxiety play a role in causing the symptoms. Biofeedback and relaxation techniques can be helpful in reducing the tension and spasm.
occurs when there is no identifiable physical cause to explain physical symptoms. The symptoms are real to the patient and are not under voluntary control. In conversion disorder, symptoms progress to involve loss of feeling, paralysis, deafness, or blindness.
form of psychosis in which there is a loss of contact with reality. People with schizophrenia do not have a split personality, but their words are separated from the meaning, their perceptions are separated from reality, and their behaviors are separated from their thought processes.
People with schizophrenia have their sensory perceptions jumbled and distorted, have difficulty concentrating, and perceive things without a stimulation—hallucinations. Hallucinations can occur in any of the senses but are most often auditory. These people also suffer from delusions, mistaken beliefs that are contrary to facts. The delusions can be paranoid, with pervasive distrust and suspicion of others. People with schizophrenia can withdraw from society, become homeless, and refuse to communicate.
Their speech is disorganized and can be incoherent. Their behaviors are often totally inappropriate. Their blunted emotions and withdrawal can progress to catatonia, motor immobility that can last for hours. Mutism is the inability or refusal to speak.
Magnetic resonance imaging (MRI) and positron emission tomography (PET) scans show brain abnormalities and changes in function.
Symptoms of schizophrenia typically come on in the late teens and twenties. Although there is no cure, it can be effectively treated with medications and programs of psychological rehabilitation. The goals of therapy are to reduce schizophrenic symptoms, prevent their return, and enable the patient to function in society. Antipsychotic medications such as olanzapine, quetiapine, and risperidone are used, either singly or in combinations if necessary, and mood stabilizers such as lithium are also used.
perception of an object or event when there is no such thing present
fixed, unyielding, false belief or judgement help despite strong evidence to the contrary
agent helpful in the treatment of psychosis. Include medications such as olanzapine, quetiapine, and risperidone
Personality is defined as an individual’s unique and stable patterns of thoughts, feelings, and behaviors. When these patterns become rigid and inflexible in response to different situations, they can cause impairment of the individual’s ability to deal with other people (i.e., to function socially).
Treatment for personality disorders is not successful.
borderline personality disorder (BPD)
a frequent diagnosis in people who are impulsive, unstable in mood, and manipulative. They can be exciting, charming, and friendly one moment and angry, irritable, and sarcastic the next. Their identity is fragile and insecure, their self-worth low. They can be promiscuous and self-destructive, for example, committing self-mutilation (self-injury) or suicide. People with narcissistic personality disorder have an exaggerated sense of self-importance and seek constant attention.
antisocial personality disorder
used interchangeably with the terms sociopath and psychopath, describes people who lie, cheat, steal, make trouble for others, and have no sense of responsibility and no anxiety or guilt about their behavior. The psychopaths have these characteristics but tend to be more violent and anger more easily than sociopaths.
Schizoid and paranoid personality disorders
describe people who are absorbed with themselves, untrusting, and fearful of closeness with others.
(personality disorder) involve a disassociation (splitting apart) of past experiences from present memory or consciousness. Being unable to recall identity is called dissociative amnesia. The development of distinctly separate personalities is called dissociative identity disorder (DID) (formerly called multiple personality disorder (MPD)).
The basic origin of all these disorders is the need to escape, usually from extreme trauma, and most often from sexual, emotional, or physical abuse in childhood.
The most severe of this group of disorders is DID. Two or more distinct personalities, each with their own memories and behaviors, inhabit the same person at the same time. Treatment is with psychotherapy.
impulse control disorders
(personality disorders) an inability to resist an impulse to perform an action that is harmful to the individual or to others. These disorders include
Intermittent explosive disorder, which is characterized by recurrent episodes of unrestrained aggression toward people, furniture, or property, with violent resistance to attempts to restrain. The etiology is thought to be epileptic-like activity in the brain. Medications that generate some improvement include propranolol, lithium, valproate, and phenytoin.
Kleptomania, which is characterized by stealing—not for gain, but to satisfy an irresistible urge to steal. Behavioral therapy can help, and SSRIs appear to be of value.
Trichotillomania (TTM), which is characterized by the repeated urge to pull out scalp, beard, pubic, and other body hair.
Substance abuse and chemical dependence, which involve a person’s continued use of drugs or alcohol despite having had significant problems or distress related to their use. This addiction affects the brain and behavior and develops an increased need for the substance and an inability to stop using it.
Pyromania, which is repeated fire setting with no motive other than a fascination with fire and fire engines. Some pyromaniacs end up as volunteer firefighters. Treatment with behavioral therapy is sometimes successful.
Dependence on drugs can be both psychological and physical.
chemicals that change consciousness, awareness, or perception (Table 18.5). The most commonly used drugs are caffeine, tobacco, and alcohol.
naturally-occurring chemicals in the body that produce the same effect as opium.
intensify sensory perceptions.
have the ability to alter mood, behavior, and cognition.
state of exaggerated well-being.
refers to a drug’s ability to diminish central nervous system activity.
refers to a drug’s ability to increase central nervous system activity.
study of the social, mental, and physical aspects of aging. Professionals from diverse fields call themselves gerontologists. The medical field that involves the study, care, and treatment of the elderly is called geriatrics, and a medical specialist in geriatrics is called a geriatrician.
According to the statistics published by the Administration on Aging of the United States Department of Health and Human Services in 2011:
The older population (65+) numbered 40.4 million in 2010; this is 13.1% (more than 1 in 8) of the total population of the United States.
Older women (23.0 million) outnumber older men (17.4 million). Forty percent of older women are widows.
Women reaching age 65 in 2010 had an average life expectancy of an additional 20.0 years; males 17.3 years.
The older population is expected to increase to 55 million in 2020.
The 85+ population is projected to increase from 5.5 million in 2010 to 6.6 million in 2020.
Most older people have at least one chronic medical condition, and many have multiple conditions. The most frequently occurring chronic conditions among the elderly are diagnosed arthritis (50%), hypertension (38%), all types of heart disease (32%), any cancer (22%), and diabetes (18%). Alzheimer disease occurs in 13% of older people and accounts for 70% of all dementias.
the age to which individual humans aspire to live and the process of getting there.
Life expectancy is the average length of life for any given population.
Longevity is living beyond the normal life expectancy.
Aging is the gradual, spontaneous change resulting in maturation through childhood, adolescence, and young adulthood. Changes then cause decline in function rather than maturation, through late adulthood and old age.
Senescence is the loss over time of the ability of cells to divide, grow, and function, a process that terminates in death. It is sometimes used interchangeably with the term aging.
(senescence of organ systems) begin to show signs of senescence at very different ages and do not degenerate at the same speed. Most physiologic studies show general peak physical performance occurs during a person’s twenties, but surprisingly, autopsies (postmortem) in children will often reveal atherosclerosis in the arteries supplying the heart. Autopsies are usually performed by a pathologist or a medical examiner.
(senescence of organ systems) changes begin in a person’s forties. Melanocytes die, and hair becomes gray and thinner. The skin becomes paper thin, loses elasticity, and hangs loose, and wrinkles appear. Flat brown-black spots called senile lentigines (age spots) appear on the back of the hands and areas exposed to sunlight.
(senescence of organ systems) start to decline in the twenties. Visual acuity declines at that time. In the forties, presbyopia begins, and many people develop cataracts later, in old age. Hearing loss occurs as the ossicles become stiffer and the number of cochlear hair cells declines. Taste and smell are also blunted late in life, as taste cells and olfactory buds decline in number.
(senescence of organ systems) changes appear during a person’s thirties, as osteoblasts become less active than osteoclasts. The result is osteopenia, which later develops into osteoporosis—particularly in postmenopausal women. The joints of people in their later years have less synovial fluid and thinner articular cartilage, and often, osteoarthritis results.
(senescence of organ systems) changes begin around age 30, when the brain weighs twice as much as it does at age 75. Motor coordination, intellectual function, and short-term memory decline more quickly than long-term memory and language skills.
(senescence of organ systems) always have coronary artery atherosclerosis, even at a very early age. As a result, when aging myocardial cells die, the heart wall gets thinner and weaker, and cardiac output declines. This causes the decline in physical capabilities with aging. Atherosclerotic plaques narrow arteries and trigger thrombosis, leading to strokes and heart attacks. In veins, valves become weaker, and blood flows back and pools in the legs, leading to poor venous return to the heart and heart failure.
(senescence of organ systems) changes are noticeable in the thirties, as pulmonary ventilation declines. This decline is a factor in the gradual loss of stamina that occurs as people age. The rib cage becomes less flexible, and the lungs become less elastic and have fewer alveoli. Respiratory function declines. As respiratory health declines, hypoxic degenerative changes occur in all the other organ systems.
(senescence of organ systems) changes begin in a person’s twenties, when the number of nephrons starts to decline. Later in life, many of the remaining glomeruli become atherosclerotic. The body’s glomerular filtration rate (GFR) decreases, and the kidneys become less efficient. For example, drug doses in the elderly are generally lower than those for younger people because drugs cannot be cleared from the elderly’s blood as rapidly.
(senescence of organ systems) function declines in the elderly, as the amounts of lymphatic tissue and red bone marrow in their bodies decrease with age. This leads to a reduction in both cellular and humoral (antibody) immunity. As a result, the elderly have lower levels of protection against infectious diseases and cancer.
Keynotes senescence of organ systems
Visual acuity starts to decline very early in life. Eye exercises can help prevent this normal occurrence.
Exercise and good nutrition help prevent osteopenia.
Exercise and good nutrition help prevent muscle degeneration.
Exercising your brain enhances your quality of life in old age.
Exercise and good nutrition extend longevity and enhance the quality of life.
Bronchitis and emphysema, the chronic obstructive pulmonary diseases (COPDs), are the cumulative effects of cigarette smoking and are a leading cause of death in old age.
The kidneys of an 80-year-old receive only half as much blood as those of a 30-year-old because of atherosclerosis.
Because they have lowered immunity, the elderly are advised to receive vaccinations against influenza and other infections.
Free radicals can damage cells and can be neutralized by antioxidants.
It is highly likely that senescence has more than one etiology.
Both PVS and MCS differ from coma, in which the individual is unresponsive and keeps his eyes closed.
transmission of characteristics from parents to offstpring through genes
Theories of senescence
The causes of senescence are unknown. Heredity plays a role because longevity or early death tends to run in families. Theories of senescence include: (1) protein abnormalities (2) free radicals (3) autoimmune-altered molecules.
One-quarter of the body’s protein is collagen. With age, collagen and other proteins show abnormal structures in their cells and tissues and become less soluble and more rigid. The cells accumulate more of these dysfunctional proteins as they age, and their functions are impaired, leading to senescent changes.
These molecules may be recognized as foreign antigens, and an immune response may be generated against the body’s own tissues. This theory is helped by the fact that autoimmune diseases such as rheumatoid arthritis are more common in old age.
short-lived product of oxidation in a cell that can be damaging to the cell. These are chemical particles with an extra electron. For example, the stable oxygen molecule (O2) has two atoms with many electrons. If it picks up an extra electron through some metabolic reaction, by radiation, or by chemical action, it becomes a free radical. The free radical’s life is short because it combines quickly with other molecules that, in turn, become free radicals with the addition of the extra electron. A chain reaction occurs as more and more molecules become free radicals. Among the damage they cause are cancer, myocardial infarction, and perhaps senescence. They can be neutralized by antioxidants.
substance that can prevent cell damage by neutralizing free radicals
diminishing of normal function
Complex Effects of Aging
The appearance of symptoms of aging depends on the remaining healthy reserves of organs as they decline with age. For example, renal impairment can be part of aging, but renal failure is not. This decline in physiological reserve can produce complications from mild problems. For example, dehydration in mild gastroenteritis can cause confusion in the elderly, which, in turn, can lead to a fall and to a fractured femur.
Many diseases in elderly persons may present with very vague and nonspecific symptoms. For example, pneumonia can present with low-grade fever, confusion, or falls rather than with the high fever and cough seen in younger adults. Delirium in the elderly can be caused by something as simple as constipation. Some elderly people may have difficulty describing their symptoms, particularly if they have cognitive impairment. Therefore, time and care have to be taken to discover the root cause.
Many elderly patients take multiple medications, sometimes prescribed by different specialists without reference to other medications prescribed by other specialists. This polypharmacy can result in adverse drug interactions. In addition, most drugs are excreted by the liver or kidneys, either of which can be impaired in the elderly. As a result, the dosage of medications may need to be adjusted to avoid excessive levels in the blood and undesirable side effects.
Benefits and Advantages of Aging
Increased knowledge of life (wisdom) (2) freedom from many of the day-to-day responsibilities that working adults face (3) Freedom to be gentle and grow with oneself (4) Time to enjoy family. (5) Freedom to choose to participate in childrearing for grandchildren or other relatives. (6) Increased participation in volunteer organizations.
People older than 65 make up 13% of the population and use about 30% of all prescriptions written.
A study of 27,600 Medicare patients documented more than 1,500 adverse drug effects (ADEs) in a single year.
When a physician or nurse practitioner or a pharmacist oversees an elderly patient’s medication regimen, drug-related problems are less likely to occur.
The elderly patient should bring all of his/her medications to every hospital or office visit, including prescription, over-the-counter (OTC) drugs, and all supplements.
adverse drug effect (ADE)
GERIATRIC GIANTS of impairment
The major categories of impairment in elderly people as they begin to fail include: immobility (2) instability (3) incontinence (4) impaired intellect/memory
(GERIATRIC GIANTS) a common pathway produced by many diseases and problems, particularly those that involve prolonged bed rest, immobilization, or inactivity. It can also occur when it is self-imposed, when elderly patients do not exercise to keep limbs flexible, promote circulation, and improve well-being. Many factors influencing the elderly’s state of immobility are iatrogenic, or arising from medical regimens, institutional policies, and resident and staff characteristics in nursing homes. The negative consequences of immobility can often be avoided with careful and vigilant medical and nursing management.
(GERIATRIC GIANTS) abnormal tendency of a joint to partially or fully dislocate. Or difficulty in balance, is often the first problem that the elderly person encounters. The instability and associated falls can result from a single disease process or the accumulated effects of multiple diseases. It is essential to take a careful, detailed history and examination to define all the factors contributing to the instability and to develop the appropriate interventions to prevent future falls. Instability and falling are not inevitable in aging but are problems that arise from identifiable disabilities that are often treatable.
(GERIATRIC GIANTS) (if present for at least six months is called dementia). The cognitive functions that are affected include decision making, judgment, memory, thinking, reasoning, and verbal communication. Dementia is not a normal part of aging, but advancing age is the greatest risk factor. More than 5 million people aged 65 and older have dementia and more than 500,000 people under 65 have early-onset dementia.
Alzheimer disease accounts for 70% of all dementias; it is progressive and there is no cure. Other types of dementia are vascular dementia, frontotemporal dementia, and dementia with Lewy bodies.
Delirium is a set of symptoms including an inability to focus attention; mental confusion; impairments in awareness, time, and space; and perhaps hallucinations. It often has a fluctuating course, and it can follow head trauma, stroke, drug withdrawal, hypoxia, hypoglycemia, physical illness of almost every type, and the use of opiates and benzodiazepines. Delirium is probably the single most common disorder affecting adults in hospitals and occurs in 30-40% of elderly hospitalized patients and in up to 80% of intensive care unit (ICU) patients. Treatment is to the underlying disease causing the delirium.
defined as the chronic, irreversible and progressive loss, over at least six months, of cognitive and intellectual functions without impairment of consciousness or perception. Characterized by disorientation, impaired memory, impaired judgement, and impaired intellect.
inability to prevent discharge of urine or feces. It is a common, but never normal, part of aging. In the nursing home population, some 50% of residents have urinary incontinence. There are five main types of urinary incontinence:
Urge incontinence, the loss of urine before one can get to the toilet, is the most common form in the elderly. It can be caused by strokes, multiple sclerosis, dementia, and pelvic floor atrophy in women or prostate enlargement in men.
Stress incontinence is caused by weak bladder muscles. It occurs when the abdominal pressure when you cough, sneeze, laugh, or climb stairs overcomes the closing pressure of the bladder.
Overflow incontinence is rare. It occurs when the bladder never completely empties and leaks small amounts of urine.
Functional incontinence is an inability to reach the toilet in time, for example, due to arthritis, stroke, or dementia.
Mixed incontinence is usually a combination of stress and urge incontinence.
Fecal incontinence occurs in about one-third of the elderly in institutional care, and is the second most common reason for committing the elderly to a nursing home. It can be produced by local causes such as chronic laxative abuse or muscle damage to the sphincter muscles in surgery or childbirth. It is also seen in dementia, multiple sclerosis, and diabetes.
minimally conscious state (MCS)
Physician’s Orders for Life-Sustaining Treatment (POLST)
persistent vegetative state (PVS)
Flat Line on Electroencephalogram Shows Brain Death.