Fundamentals of Psychological Disorders - 3rd edition Part VI Mental Disorders - Block 5 Module 14 Neurocognitive Disorders

Fundamentals Disorders VI Part VI . Mental Disorders Block edition as of July 2023 Part VI . Mental Disorders Block Disorders Covered 14 . Disorders 15 . Contemporary Issues in Psychopathology Module 14 Disorders edition as of July 2023 Module Overview In Module 14 , we will cover matters related to disorders ( to include their clinical presentation , epidemiology , etiology , and treatment options . Our discussion will include delirium , major disorder , and mild disorder . We also discuss nine to include disease , traumatic brain injury ( vascular disorder , induced , dementia with bodies , frontotemporal , disease , Huntington disease , and HIV infection . Be sure you refer Modules for explanations of key terms ( Module ) an overview of the various models to explain psychopathology ( Module ) and descriptions of the therapies ( Module ) Module Outline . Clinical Presentation . Epidemiology . Etiology . Treatment Module Learning Outcomes Describe how disorders present . Describe the epidemiology of disorders . Describe the etiology of disorders . Describe treatment options for disorders . Clinical Presentation Section Learning Objectives Describe how delirium presents . Describe how major disorder presents . Describe how mild disorder presents . 275

Fundamentals Disorders Unlike many of the disorders we have discussed thus far , disorders often result from disease processes or medical conditions . Therefore , it is important that individuals presenting with these symptoms complete a medical assessment to better determine the etiology behind the disorder . There are three main categories of , major disorder , and mild disorder . Within major and minor disorders are several due to the etiology of the disorder . For this book , we will review diagnostic criteria for both major and minor disorders , followed by a brief description of the various disease in the etiology section . It is important to note as well that the criteria for the various are based on defined cognitive domains . These include the following , with a brief explanation of what it is . Complex attention Sustained , divided , or selective attention and processing speed . Executive function planning , overriding habits , mental , and responding to correction . Learning and memory includes cued recall , immediate or memory , and implicit learning . Language Includes expressive language and receptive language . Includes any abilities related to visual perception , gnosis , praxis , or . Social cognition Includes recognition of emotions and theory of mind . Delirium Delirium is characterized by a notable disturbance in attention along with reduced awareness of the environment . The disturbance develops over a short period of time , representing a change from baseline attention and awareness , and in severity during the day . There is also a disturbance in cognitive performance that is altered from one usual behavior . Disturbances in attention are often manifested as difficulty sustaining , shifting , or focusing attention . Additionally , an individual experiencing an episode of delirium will have a disruption in cognition , including confusion of where they are . Disorganized thinking , incoherent speech , and hallucinations and delusions may also be observed during periods of delirium . Delirium is associated with increased functional decline and risk of being placed in an institution . That said , most people with delirium recover fully with or without treatment , especially if not elderly , but if undetected or the underlying cause is untreated , it may progress to stupor , coma , seizures , or death ( APA , 2022 ) Major Disorder Individuals with major disorder show a decline in both overall cognitive functioning ( see the previously listed six domains ) as well as the ability to independently meet the 276

Fundamentals Disorders demands of daily living such as paying bills , taking medications , or caring for oneself ( APA , 2022 ) While it is not necessary , it is helpful to have documentation of the cognitive decline via neuropsychological testing within a controlled , standardized testing environment . Information from close family members or caregivers is also important in documenting the decline and impairment in areas of functioning . Within the umbrella of major disorder is dementia , a striking decline in cognition and skills due to a disorder . The ( APA , 2022 ) refrained from using this term in diagnostic categories as it is often used to describe the natural decline in degenerative that affect older adults whereas disorder is the preferred term used to describe conditions affecting younger individuals such as impairment due to traumatic brain injuries or other medical conditions . Therefore , while dementia is accurate in describing those experiencing major disorder due to age , it is not of those experiencing issues secondary to an injury or illness . Mild Disorder Individuals with mild disorder demonstrate a modest decline in one of the listed cognitive domains . The decline in functioning is not as extensive as that seen in major disorder , and the individual does not experience difficulty independently engaging in daily activities . However , they may require assistance or extra time to complete these tasks , particularly if the cognitive decline continues to progress . It should be noted that the primary difference between major and mild disorder is the severity of the decline and independent functioning . Some argue that the two are earlier and later stages of the same disease process ( Blaze , 2013 ) Conversely , individuals can go from major to mild disorder following recovery from a stroke or traumatic brain injury ( 2011 ) The describes major and mild as existing on a spectrum of cognitive and functional impairment ( APA , 2022 , 685 ) Key Takeaways You should have learned the following in this section The criteria for the various are based on the cognitive domains of complex attention , executive function , learning and memory , language , and social cognition . Delirium is characterized by a notable disturbance in attention or awareness and cognitive performance that is significantly altered from one usual behavior . Major disorder is characterized by a significant decline in both overall cognitive functioning as well as the ability to independently meet the demands of daily living . Mild disorder is characterized by a modest decline in one of the listed cognitive areas with no interference in one ability to complete daily activities . 277

Fundamentals Disorders Section Review Questions . What are the six cognitive domains the diagnostic criteria for are based on ?

Define delirium . How does this differ from mild and major disorders ?

What are the main differences between mild and major disorders ?

Epidemiology Section Learning Objectives Describe the epidemiology of disorders . Delirium The prevalence of delirium in the general community is relatively low at to based on data from the United States and Finland . For older individuals presenting to North American emergency departments , the rate is to 17 . Prevalence rates for those admitted to the hospital range from 18 to 35 . For those in nursing homes or care settings prevalence is 20 to 22 and 88 for individuals with terminal illnesses at the end of life . Prevalence rates are lower for younger African Americans compared to White individuals of similar age . Major and Mild Major and mild disorder prevalence rates vary widely depending on the etiological nature of the disorder and overall prevalence estimates are generally only available for older populations . Internationally , dementia occurs in of individuals at age 65 , and up to 30 of individuals by age 85 . The female gender is associated with higher prevalence of dementia overall . Estimates for mild among older individuals range from to 10 at age 65 and to 25 at age 85 . In the , incidence is highest in African Americans followed by American Natives , Pacific Islanders , Whites , and Asian Americans . Major and Mild disease , the most commonly diagnosed disorder , is observed in nearly million Americans ( Association , with 11 of those aged 65 and older and 32 older 278

Fundamentals Disorders than 85 having dementia due to disease . It should also be noted that somewhere between of are attributable to disease , depending on the setting and diagnostic criteria . In terms of background in the the highest prevalence rates have been found among African Americans and of Caribbean origin ( APA , 2022 ) Over million traumatic brain injuries ( happen each year within the United States , with men being 40 more likely to experience a compared with women . The most common causes of , in order of occurrence , are falls followed by collision with a moving or stationary object , automobile accidents , and assaults . It has also become increasingly recognized that concussion in sport causes mild ( APA , 2022 ) Key Takeaways You should have learned the following in this section As individuals age , the rate of occurrence of delirium and dementia increases dramatically . Estimates for mild among older individuals range from to 10 at age 65 and to 25 at age 85 . As for disease , prevalence rates are 11 of those aged 65 and older and 32 of those older than 85 . Men are more likely to experience a than women . Section Review Questions . What is the rate of occurrence of the disorders ?

Etiology Section Learning Objectives Define degenerative . Describe the symptoms and causes of disease . Describe the symptoms and causes of traumatic brain injury ( Describe the symptoms and causes of vascular disorders . Describe the symptoms and causes of major or mild . Describe the symptoms and causes of dementia with bodies . Describe the symptoms and causes of frontotemporal . 279

Fundamentals Disorders Describe the symptoms and causes of disease . Describe the symptoms and causes of Huntington disease . Describe the symptoms and causes of HIV infection . disorders occur due to a wide variety of medical conditions or injury to the brain . Therefore , this section will focus on a brief description of the nine different of disorders per the ( APA , 2022 ) As you will see , most of these disorders are both degenerative , meaning the symptoms and cognitive deficits become worse over time , as well as related to a medical condition or disease . Per the ( APA , 2022 ) an individual will meet diagnostic criteria for either mild or major disorder as listed above . In order to specify the type of disorder , additional diagnostic criteria specific to one of the following must be met . Disease disease is the most prevalent neurodegenerative disorder . While the primary symptom of disease is the gradual progression of impairment in cognition , it is also important to identify concrete evidence of cognitive decline . This can be done in one of two ways via genetic testing of the individual or a documented family history of the disease , or , through clear evidence of cognitive decline over time by repeated standardized neuropsychological evaluations ( APA , 2022 ) It is crucial to identify these markers in making the diagnosis of disease as some individuals present with memory impairment but eventually show a reversal of symptoms this is not the case for individuals with disease . Causes of disease . Autopsies of individuals diagnosed with disease identify two abnormal brain plaques and both of which are responsible for neuron death , and loss of cellular connections ( Peterson , van , 2010 ) It is believed that plaques , large bundles of plaque that develop between neurons , appear before the development of dementia symptoms . As these plaque bundles increase in size and number , cognitive symptoms and impaired daily functioning become evident to close family members . tangles are believed to appear after the onset of dementia symptoms and are found inside of cells , affecting the protein that helps transport nutrients in healthy cells . Both plaques and tangles impact the health of neurons within the hippocampus , amygdala , and the cerebral cortex , areas associated with memory and cognition ( ones , 2014 ) Researchers have identified additional genetic and environmental in the development of disorder . Genetically , the ( gene that helps to eliminate amyloid from the brain , has been implicated in the development of disorder . One of the three variants of this gene , the allele , appears to reduce the production of , thus increasing the number of plaques within the brain . However , not all individuals with the allele develop disease therefore , this explanation may better explain a vulnerability to disease as opposed to the cause of the disease . 280

Fundamentals Disorders Various brain regions have also been implicated in the development of disease . More specifically , neurons shrinking or dying within the hypothalamus , thalamus , and the locus have been linked to declining cognition ( 2011 , 1992 ) neurons within the basal forebrain also appear to shrink or die , contributing to disease symptoms ( et , 2015 ) Environmental toxins such as high levels of zinc and lead may also contribute to the development of disease . More precisely , zinc has been linked to the clumping of proteins throughout the brain . Although lead has largely been phased out of environmental toxins due to negative health consequences , current elderly individuals were exposed to these toxic levels of lead in gasoline and paint as young children . There is some speculation that lead and other pollutants may impact cognitive functioning in older adults ( et , 2014 ) Onset of disease . disease is defined by the onset of symptoms . disease occurs before the age of 65 . While only a small percentage of individuals experience early onset of the disease , those that do experience early disease progression appear to have a more genetically condition and a higher rate of family members with the disease . disease occurs after the age of 65 and has less of a familial . This onset appears to occur due to a combination of biological , environmental , and lifestyle factors ( 2015 ) Nearly 30 of individuals within this class of diagnosis have the gene that fails to eliminate the proteins from various brain structures . It is believed that the combination of the presence of this gene along with environmental toxins and lifestyle choices ( more stress ) impact the development of disease . Traumatic Brain Injury ( occur when an individual experiences significant trauma or damage to the head . disorder due to is diagnosed when persistent cognitive impairment is observed immediately following the head injury , along with one or more of the following symptoms loss of consciousness , posttraumatic amnesia , disorientation and confusion , or neurological impairment ( APA , 2022 ) The presentation of symptoms varies among individuals and depends largely on the location of the injury and the intensity of the trauma . Furthermore , the effects of a can be temporary or permanent . Symptoms generally range from headaches , disorientation , confusion , irritability , fatigue , poor concentration , and emotional and behavioral changes . More severe injuries can result in more significant neurological symptoms such as seizures , paralysis , and visual disturbances . Major or mild due to may be with specified or unspecified depressive , anxiety , or personality disorders and . Rates of suicidal ideation are as high as 10 with rates of suicide attempt hovering around to ( APA , 2022 ) The most common type of is a concussion . A concussion occurs when there is a significant blow to the head , followed by changes in brain functioning . It often causes immediate disorientation or loss of consciousness , along with headaches , dizziness , nausea , and sensitivity to light ( Alla , Sullivan , 2012 ) While symptoms of a concussion are usually temporary , there can be more permanent 281

Fundamentals Disorders damage due to repeated concussions , particularly if they are close in time . The media has brought considerable attention to this with the recent discussions of chronic traumatic encephalopathy ( which is a progressive , degenerative condition due to repeated head trauma . are most commonly seen in athletes ( football players ) and military personnel ( et , 2012 ) In addition to the neurological symptoms , psychological symptoms such as depression and poor impulse control have been observed in individuals with . These individuals also appear to be at greater risk for the development of dementia ( et , 2013 ) Vascular Disorders disorders due to vascular disorders can occur from a event such as a stroke or ongoing subtle disruptions of blood within the brain ( APA , 2022 ) The occurrence of these vascular disorders general begins with atherosclerosis , or the clogging of arteries due to a of plaque . The plaque builds up over time , eventually causing the artery to narrow , thus reducing the amount of blood able to pass through to other parts of the body . When these arteries within the brain become entirely obstructed , a stroke occurs . The lack of blood during a stroke results in the death of neurons and loss of brain function . There are two types of hemorrhagic stroke that occurs when a blood vessel bursts within the brain and an ischemic stroke , which is when a blood clot blocks the blood flow in an artery within the brain ( American Stroke Association , 2017 ) While strokes can occur at any age , the majority of strokes occur after age 65 ( Hall , Levant , 2012 ) A wide range of cognitive , behavioral , and emotional changes occur following a stroke . Symptoms are generally dependent on the location of the stroke within the brain as well as the extensiveness of damage to those brain regions ( et , 2012 ) For example , strokes that occur on the left side of the brain tend to cause problems with speech and language , as well as physical movement on the right side of the body whereas strokes that occur on the right side of the brain tend to cause problems with impulsivity and impaired judgement , memory loss , and physical movement on the left side of the body ( et , 2013 ) After disease , vascular disease is the second most common cause of and population prevalence estimates are for those between the ages of years , for individuals aged years , and for those aged 90 years and up . Within three months of a stroke , 20 of people are diagnosed with dementia . Finally , stroke is more common in men up to age 65 and after that , it shifts to women . Vascular disease is frequently with major or mild due to disease and depression . Major or Mild Significant cognitive changes occur due to repetitive drug and alcohol abuse . Delirium can be observed in individuals with extreme substance intoxication , withdrawal , or even when multiple substances have been used within a close period ( APA , 2022 ) While delirium symptoms are often transient during these states , mild impairment due to heavy substance abuse may remain until a significant period of abstinence is observed ( 2013 ) 282

Fundamentals Disorders . Dementia with Bodies Symptoms associated with disorder due to bodies include significant in attention and alertness recurrent visual hallucinations impaired mobility and sleep disturbances such as rapid eye movement sleep behavior disorder ( APA , 2022 ) While the trajectory of the illness develops more rapidly than disease , the survival period is similar in that most individuals do not survive longer than eight years ( Body Dementia Association , 2017 ) bodies are irregular brain cells that result from the buildup of abnormal proteins in the nuclei of neurons . These brain cells deplete the cortex of acetylcholine , which causes the behavioral and cognitive symptoms observed in both dementia with bodies and disease . The motor symptoms seen in both these disorders occur from the depletion of dopamine by the body nerve cells that accumulate in the brain stem . Major or Mild Frontotemporal Frontotemporal causes progressive development of behavioral and personality change language impairment ( APA , 2022 , 696 ) For the behavioral variant , individuals display at least three of the following behavioral , apathy or inertia , loss of sympathy or empathy , preservative or compulsive behavior , or and dietary changes . For the language variant , they show prominent decline in language ability ( speech production , word finding , object naming , grammar , or word comprehension ) There is relative sparing of learning and memory and motor functioning . Individuals with frontotemporal commonly present in their though the age of onset has a range of age 20 to 80 years . The median survival is years after symptom onset and years after diagnosis ( APA , 2022 ) Disease The awareness of disease has increased in recent years due in large part to Michael . early diagnosis in 1991 . It affects approximately individuals ( Storm , 2013 ) While many are aware of the tremors of hands , arms , legs , and face , the other three main symptoms of disease are rigidity of the limbs and trunk slowness in initiating movement and drooping posture or impaired balance and coordination ( National Institute of Neurological Disorders and Stroke , 2017 ) These motor symptoms are generally present at least one year prior to the beginning of cognitive decline , although severity and progression of symptoms vary from person to person . Onset of disease is typically from age 50 to 89 years . Mild develops early in the course of disease while Major does not occur until individuals are much older . The prevalence of disease in the increases with age and is more common in men than women . The disease is with disease and cerebrovascular disease . Depression , psychosis , REM sleep behavior disorder , apathy , and motor symptoms can make functional impairment worse ( APA , 2022 ) 283

Fundamentals Disorders . Huntington Disease Huntington disease is a rare genetic disorder that involves involuntary movement , progressive dementia , and emotional instability . Due to the degenerative nature of the disorder , there is a shortened as death typically occurs years of symptoms ( 2013 ) Although symptoms can present at any time , the average age of symptom presentation is during middle adulthood ( between ages 35 and 45 years APA , 2022 ) Symptoms generally begin with decline , particularly in executive function , along with changes in mood and personality . As symptoms progress , more physical symptoms present , such as facial grimaces , difficulty speaking , and repetitive movements . Because there is no treatment for Huntington disease , the severity of the cognitive and physical ultimately leads to complete dependency and the need for care . Suicide is among the leading causes of death in Huntington disease ( APA , 2022 ) HIV Infection Not many people are aware that cognitive impairment is sometimes the first symptom of untreated HIV . While symptoms vary among individuals , slower mental processing , impaired executive function , problems with more demanding attentional tasks , and difficulty learning new information are among the most common early signs ( APA , 2022 ) When HIV becomes active in the brain , significant alterations of mental processes occur , thus leading to a diagnosis of disorder due to HIV infection . Significant impairment can also occur due to related throughout the central nervous system . Fortunately , therapies used in treating HIV have been effective in reducing and preventing the onset of severe cognitive however , brain changes still occur in nearly half of all patients on medication . There is hope that once therapies can cross the barrier in the central nervous system , there will be a significant improvement in the prevalence of disorder ( et , 2014 ) Key Takeaways You should have learned the following in this section Most disorders are degenerative meaning they become worse over time . disease is characterized by the gradual progression of impairment in cognition as well as the presence of plaques and tangles . occur when an individual experiences significant trauma or damage to the head with the most common type being a concussion . Vascular disorders generally begin with atherosclerosis which leads to a stroke . Significant cognitive changes occur due to repetitive drug and alcohol abuse such as delirium . Dementia with bodies is characterized by significant in attention and alertness recurrent visual hallucinations impaired mobility and sleep disturbance . Frontotemporal causes progressive declines in language or behavior due to the degeneration in the frontal and temporal lobes of the brain . 284

Fundamentals Disorders disease is characterized by tremors of hands , arms , legs , or face rigidity of the limbs and trunk slowness in initiating movement and drooping posture or impaired balance and coordination . Huntington disease involves involuntary movement , progressive dementia , and emotional instability . HIV infection begins with slower mental processing , impaired executive function , problems with more demanding attentional tasks , and difficulty learning new information . Section Review Questions Define degenerative . What disorders discussed in this module are considered degenerative ?

Identify the biological causes of disease . What is a ?

How do vascular disorders occur ?

What are bodies ?

How does dementia with bodies differ from disease ?

What are the main symptoms of disease ?

Huntington disease ?

Treatment Section Learning Objectives Describe treatment options for disorders . Treatment options for those with disorders are minimal at best , with most attempting to treat secondary symptoms as opposed to the disorder itself . Furthermore , the degenerative nature of these disorders also makes it difficult to treat , as many diseases will progress regardless of the treatment options . Pharmacological Pharmacological interventions , and more medications designed to target acetylcholine and glutamate , have been the most effective treatment options in alleviating symptoms and reducing the speed of cognitive decline within individuals diagnosed with disease . Specific medications such as ( and ( 285

Fundamentals Disorders are among the most commonly prescribed ( Association , Due to possible negative side effects of the medications , these drugs are prescribed to individuals in the early or middle stages of as opposed to those with advanced disease . Researchers have also explored treatment options aimed at preventing the of and tangles however , this research is still in its infancy ( Association , disease has also found success in pharmacological treatment options . The medication increases dopamine availability , which provides relief of both physical and cognitive symptoms . Unfortunately , there are also significant side effects such as hallucinations and psychotic symptoms therefore , the medication is often only used when the benefits outweigh the negatives of the potential risks ( 2013 ) Psychological Among the most effective psychological treatment options for individuals with disorders are the use of cognitive and behavioral strategies . More specifically , engaging in various cognitive activities such as cognitive stimulation programs , reading books , and following the news , have been identified as effective strategies in preventing or delaying the onset of disease ( 2013 Wilson , Boyle , Bennett , 2012 ) Engaging in social skills and training are additional behavioral strategies used to help improve functioning in individuals with deficits . For example , by breaking down complex tasks into smaller , more attainable goals , as well as simplifying the environment ( labeling location of items , removing clutter ) individuals can successfully engage in more independent living activities . Support for Caregivers Supporting caregivers is an important treatment option to include as the emotional and physical toll on caring for an individual with a disorder is often underestimated . According to the Association ( nearly 90 of all individuals with disease are cared for by a relative . The emotional and physical demands on caring for a family member who continues to decline cognitively and physically can lead to increased anger and depression in a caregiver ( Kang et al . 2014 ) It is important that medical providers routinely assess caregivers psychosocial functioning , and encourage caregivers to participate in caregiver support groups , or individual psychotherapy to address their own emotional needs . Key Takeaways You should have learned the following in this section Pharmacological interventions for disease target the neurotransmitters acetylcholine and glutamate and newer research is focused on the of and 286

Fundamentals Disorders tangles . Psychological treatments include cognitive and behavioral strategies such as playing board games , reading books , or social skills training . Caregivers need to join support groups to help them manage their own anger and depression , especially since 90 of such caregivers are relatives of the . Section Review Questions Review the listed treatment options for disorders . What are the main goals of these treatments ?

Module Recap Our discussion in Module 14 turned to disorders to include the categories of delirium , major disorder , and Mild disorder . We also discussed the of disease , traumatic brain injury ( vascular disorder , induced , dementia with bodies , frontotemporal , disease , Huntington disease , and HIV infection . The clinical description , epidemiology , etiology , and treatment options for disorders were discussed . edition 287