PSYC 210 Lecture Notes - Lecture 24: Dopamine Transporter, Stimulant, Comorbidity
30 Apr 2018
School
Department
Course
Professor
Final&Exam
Thursday,&May&3rd
•
Cumulative
•
Same&format&as&other&exams
•
Learning&Catalytics
The&primary difference&between&anorexia&and&bulimia?
Weight
A.
Binging/Purging
B.
Concern&about&weight
C.
low&self-esteem&related&to&appearance
D.
In&the&DSM-5&you&must&show&relevant&symptoms&before&what&age&to&meet&criteria&
for&ADHD?
Any&age
A.
Before&age&7
B.
Before-age-12
C.
Before&age&18
D.
A key neurotransmitter in the pathophysiology of ADHD is:
Serotonin
A.
GABA
B.
Glutamate
C.
Dopamine
D.
Childhood'Disorders
ADHD
Six&or&more&manifestations&of&poor&attentional&control&for&6&months&or&more
In&comparison&to&appropriate&age&group
○
•
Present&in&multiple&settings
More&trait-like&than&state-like
○
Agreement&between&teachers,&parents,&caretakers,&and&assessor
○
•
Impairment&in&social,&academic,&or&occupational&settings•
Not&better&explained&by&other&disorders
A&lot&of&adult&disorders&are¬&formally&recognized&in&childhood
○
Kids&don't&know&how&to&process&or&talk&about&things,&so&they're&more&
likely&to&act&out&when&feeling&other&things&like&depressed&and&can&manifest&
as&things&that&look&like&ADHD
○
•
Must&contain&6&or&more&of&either:
Attention&deficit
Doesn't&pay&attention
○
Cannot&sustain&attention
○
Does¬&listen
○
Doesn't&follow-through
○
Can't&organize&or&plan
○
Avoids&mental&effort
○
Loses&things
○
Easily&distracted
○
Forgetful&in&daily&activities
○
•
Hyperactivity
Fidgety
○
Can't&sit&in&one&place
○
Inappropriately&active
○
Can't&handle&quiet&activities
○
High&energy
○
Excessively&talkative
○
Frequently&interrupts
○
Can't&wait&his/her&turn
○
Intrudes/takes&over
○
•
Subtypes&and&comorbidity
Subtypes
Inattentive&subtype
○
Hyperactive-impulsive&subtype
○
Combined&subtype&(most&common)
○
•
Common&co-morbidities
Internalizing&symptoms&(anxiety/depression)
Difficulty&with&self&control&can&also&lead&to&an&increase&in&anxiety
§
Bidirectional&
§
○
Conduct&disorder
○
•
Prevalence
85%&does¬&have&any&evidence&of&ADHD•
7.5%&diagnosed&with&low&level&ADHD•
4.0%&medium&level•
2.6%&high&level•
Primary&treatment:&
Psychostimulants&(DA&releasing&agents)
Frequently&a&drug&that&will&inhibit&or&reverse&the&role&of&the&dopamine&
transporter
Dopamine&transporter&pulls&dopamine&from&synapse
§
○
Block&DAT&–increase&tonic&DA
A&way&to&control&how&much&dopamine&goes&downstream&to&post-
synaptic&targets
§
Tight&control&–release&just&the&right&amount
§
Block&DAT,&resulting&in&more&dopamine&going&downstream
Also&process&used&by&cocaine
§
§
○
Slow&acting&is&more&effective
○
Drug&like&hetamine&psychostimulant&&reverses&DAT&and&spits&out&
dopamine&to&increase&release
○
Promote&the&idea&of&over-activity&of&dopamine
○
•
DA&signaling
Why&is&increasing&DA&a&good&thing&for&people&with&ADHD?
In&SCZ,&DA&is&in&the&striatum
○
Also&plays&a&big&role&in&the&prefrontal&cortex&(PFC)&with&memory&and&
function
○
DA&signaling&has&an&inverted&U&relationship&to&cognitive&function&(esp.&in&
working&memory)&in&the&PFC
○
When&DA&signaling&is&too&low&or&too&high,&working&memory&function&is&
sub-optimal&in&PFC
○
Depending&on&your&individual&biology,&you&may&have&a&PFC&with&too&low&or&
too&high&DA&levels
Linked&to&genetic&variant&in&an&enzyme&that&breaks&down&dopamine
Individuals&with&val-val&allele&are&too&low&in&DA&when&things&
are¬&very&interesting&or&cognitively&demanding
May&get&to&right&level&when&things&get&their&attention&
®
Kids&with&ADHD&are&capable&of&focusing&intensely&when&
something&is&interesting&to&them
®
Problem:&most&things&are¬&interesting&enough&
®
§
Individuals&with&the&met-met&are&naturally&at&a&good&
dopamine&level
If&at&near&optimal&level&and&give&them&a&drug,&it'll&push&
them&too&far&and&won't&perform&as&well
®
§
§
Give&someone&drug&to&increase&DA,&push&them&closer&to&top&of&U&
shaped&curve&even&when&things&aren't&that&demanding
§
Why&psychostimulants&don't&calm&down&kids&without&ADHD
§
○
In&kids&with&ADHD,&psychostimulants&seem&to&calm&them&down
○
•
N-back&task&from&neurocognitive&tasks
Indicates&is&this&the&thing&I&saw&three&images&back
○
Taking&on&working&memory
○
2&back
When&cognitive&demands&are&low,&DA&signals&optimally
§
When&I&give&the&ADHD&kid&the&drug&where&DA&and&cognitive&demand&
is&low,&it&helps&them&concentrate&more&
§
○
3-back
High&cognitive&demand
§
Give&drug&to&someone&at&optimal&level& the&drug,&you&may&push&the&
person&over&to&perform&worse&(as&seen&in&kids&without&ADHD&when&
given&the&drug)
§
○
•
Autism-Spectrum-Disorder
Developmental&delays•
In&some&cases&have&high&verbal&IQ,&but&often&with&deficits&in&other&areas
High&verbal&IQ&is¬&very&common
○
•
Prevalence:&1&in&68
Reasonably&high&prevalence
○
At&birth&it&is&1&in&300
○
Diagnostic&rates&seem&to&be&increasing&over&the&last&50&years
May&have&been&because&we're&modifying&our&diagnostic&criteria&to&
be&more&inclusive&or&something&is&actually&going&on&to&increase&the&
frequency
§
○
•
Collection&of&disorders•
Autism&Spectrum&Disorder&(ASD)
Social&communication
Lack&of&reciprocity&during&social&exchange
○
Poor&nonverbal&communication&skills
○
Unable&to&develop,&maintain,&or&understand&relationships
○
•
Repetitive&behaviors
Repetitive&motor&movements
○
Insistence&on&sameness;&lack&of&flexibility
○
Extremely&narrow&interests&with&abnormal&intensity
○
Hyper&or&hypo-reactivity&to&sensory&input
○
•
Must&be&present&early&in&life•
Must&cause&significant&distress&or&impairment•
Not&better&explained&by&another&disorder•
Specifiers&for&ASD
With/without&accompanying&intellectual& impairment•
With/without&accompanying&language&impairment•
Associated&with&known&medical,&genetic,&or&environmental&factors•
Associated&with&another&disorder
High&comorbidity&with&ADHD
○
•
ASD&starts&early
Can&be&diagnosed&as&early&as&a&few&months&old•
Babies&that&went&to&go&onto&develop&ASD&showed&no&difference&in&fixation&if&
face&was&inverted
Compared&to&typically&developing&children&and&children&with&
developmental&delays&(not&ASD),&there's&a&higher&preference&for&the&up&
face&and¬&the&inverted&face
○
•
Synaptic&pruning&occurs&early&in&the&brain
One&disorder&autism&shares&the&most&genetic&risk&factors&for&is&
schizophrenia
Become&unmasked&by&adolescence&in&SCZ
§
Biologically&differences&were&there&from&an&early&age,&making&it&a&
neurodevelopmental&disorder
§
○
Differences&in&how&the&brain&develops&early&in&life
○
Autism&reveals&itself&much&earlier&than&SCZ
○
•
Treatment&of&ASD
Early&intervention&is&key
Can&have&good&outcomes
○
Is&treatable
System&isn't&learning&from&its&environment&as&if&show&on&its&own
§
Providing&external&scaffolding&can&make&a&difference
§
○
•
Applied&behavioral&analysis/Lovaas&Model
Structured&management&of&interactions&in&therapy&and&via&training&the&
parents
○
Everything&the&child&does&is&either&positively&or&negatively&reinforced
Don't&punish
§
Child&does&a&good&thing,&bring&it&to&attention&and&give&praise
§
Child&does&a&bad&thing,&withhold&praise
§
○
Diligently&track&reinforcement&because&child&isn't&doing&it&on&their&own
○
•
No&pharmacological&treatments,&but&medications&can&be&used&to&treat&comorbid&
conditions
•
The'Third'Wave'of'Behavioral'Therapy:'
Mindfulness'
Mindfulness&based&techniques&to&augment&or&replace&cognitive&behavioral&ones
When&we&feel&bad,&we&often&try&to&push&it&away
Serves&to&inavertedly&magnify&pain
○
Creates&self-blame&for&pain
○
Different&from&how&we&respond&to&pain&of&other&people
For&others,&we&tend&to&be&more&forgiving&and¬&blaming&them&for&
their&pain
§
○
•
In&self&compassion,&help&person&be&okay&that&they&don't&like&something&about&
themselves
Rather&than&trying&to&change&or&criticize& it,&reply&to&it&as&you&would&to&a&
family&member
○
•
Steps&of&self-compassion
Awareness/mindfulness
That&something&is&happening
○
Bring&attention&to&the&negative&self-talk/criticisms/predictions
○
Can&often&fly&under&the&radar&and¬&know&it's&affecting&you
○
•
Common&humanity
Recognition&that&pain&is&something&we&all&have&in&common
○
All&of&us&have&to&make&peace&with&the&harsh&aspects&of&life
One&of&the&hard&things&about&treating&shame&is&that&the&experience&
of&shame&leads&to&shame&of&having&shame
§
Hard&to&get&people&to&admit&they&feel&shame
§
○
We&all&have&things&we're&ashamed&of
See&as&point&of&connection
§
○
•
Self-kindness
Responding&to&things&we&don't&like&about&ourselves&with&kindness,&as&you&
would&with&a&friend
○
•
What&self-compassion&is&NOT
Complacency/resignation
"I&guess&I'm&just&the&way&I&am,&so&screw&it.&I'll&always&be&a&mess."
○
You&can&hold&a&high&standard&for&yourself&and&hold&it&kindly&or&unkindly
Has¬hing&to&do&with&level&of&standard
§
○
•
Self-indulgence
Buying&something,&consuming&something,&eating&something
○
Just&a&distraction&from&something&you&don't&want&to&feel&with&something&
that&is&transiently&pleasurable
○
•
Self-bias
Justifying&your&story&or&viewing&you&narrative&as&the&correct&one
○
•
Self-esteem
Self-esteem&has&an&evaluation&component&in&it&as&a&concept
○
Can&have&low&self-esteem,&but&still&have&self-compassion
○
Self&compassion&is¬&conditional&on&believing&you’re&a&good&or&bad&
person
Trying&to&build&up&someone's&self-esteem&won't&help&always&in&
treatment&because&the&patient&will&argue&about&it
§
○
•
Difference&from&traditional&cognitive&behavioral&approaches
Observational&vs.&challenging
CBT&often&involves&a&lot&of&questioning&and&challenging&of&how&people&see&
the&world,&offering&different&interpretations,&recognize&cognitive&
distortions&or&maladaptive&thinking
○
Self-compassion&is&more&passive
Look&at&how&you&treat&yourself,&and&is&it&how&you&treat&friends&or&a&5&
year&old
§
Observe&pattern&of&self-talk&vs.&challenging&specific&cognitions
§
○
•
Inductive&vs.&deductive
A&lot&of&focus&of&therapy&is&learning&from&observations,&rather&than&
therapist&being&more&prescriptive
○
•
Self-compassion&vs.&self-efficacy•
Not&appropriate&for&all&patients
Not&appropriate&for&someone&suicidally&depressed&or&so&much&anxiety&that&
they&can't&leave&the&house
Too&much&to&handle
§
○
Particularly&for&those&at&severe&levels
○
Better&for&those&at&a&mild/moderate&level&and&preventing&relapse
○
•
Also&in&ACT&(acceptance&and&commitment&therapy)•
Mindfulness&based&cognitive&therapy
For&people&who&have&had&depression,&successful&treated&with&CBT,&and&
trying&to&prevent&relapse
○
•
Childhood'Disorders/Self-Compassion
Thursday,&April&19,&2018
11:27&AM
Final&Exam
Thursday,&May&3rd•
Cumulative•
Same&format&as&other&exams•
Learning&Catalytics
The&primary difference&between&anorexia&and&bulimia?
WeightA.
Binging/PurgingB.
Concern&about&weightC.
low&self-esteem&related&to&appearanceD.
In&the&DSM-5&you&must&show&relevant&symptoms&before&what&age&to&meet&criteria&
for&ADHD?
Any&ageA.
Before&age&7B.
Before-age-12C.
Before&age&18D.
A key neurotransmitter in the pathophysiology of ADHD is:
SerotoninA.
GABAB.
GlutamateC.
DopamineD.
Childhood'Disorders
ADHD
Six&or&more&manifestations&of&poor&attentional&control&for&6&months&or&more
In&comparison&to&appropriate&age&group
○
•
Present&in&multiple&settings
More&trait-like&than&state-like
○
Agreement&between&teachers,&parents,&caretakers,&and&assessor
○
•
Impairment&in&social,&academic,&or&occupational&settings
•
Not&better&explained&by&other&disorders
A&lot&of&adult&disorders&are¬&formally&recognized&in&childhood
○
Kids&don't&know&how&to&process&or&talk&about&things,&so&they're&more&
likely&to&act&out&when&feeling&other&things&like&depressed&and&can&manifest&
as&things&that&look&like&ADHD
○
•
Must&contain&6&or&more&of&either:
Attention&deficit
Doesn't&pay&attention
○
Cannot&sustain&attention
○
Does¬&listen
○
Doesn't&follow-through
○
Can't&organize&or&plan
○
Avoids&mental&effort
○
Loses&things
○
Easily&distracted
○
Forgetful&in&daily&activities
○
•
Hyperactivity
Fidgety
○
Can't&sit&in&one&place
○
Inappropriately&active
○
Can't&handle&quiet&activities
○
High&energy
○
Excessively&talkative
○
Frequently&interrupts
○
Can't&wait&his/her&turn
○
Intrudes/takes&over
○
•
Subtypes&and&comorbidity
Subtypes
Inattentive&subtype
○
Hyperactive-impulsive&subtype
○
Combined&subtype&(most&common)
○
•
Common&co-morbidities
Internalizing&symptoms&(anxiety/depression)
Difficulty&with&self&control&can&also&lead&to&an&increase&in&anxiety
§
Bidirectional&
§
○
Conduct&disorder
○
•
Prevalence
85%&does¬&have&any&evidence&of&ADHD•
7.5%&diagnosed&with&low&level&ADHD•
4.0%&medium&level•
2.6%&high&level•
Primary&treatment:&
Psychostimulants&(DA&releasing&agents)
Frequently&a&drug&that&will&inhibit&or&reverse&the&role&of&the&dopamine&
transporter
Dopamine&transporter&pulls&dopamine&from&synapse
§
○
Block&DAT&–increase&tonic&DA
A&way&to&control&how&much&dopamine&goes&downstream&to&post-
synaptic&targets
§
Tight&control&–release&just&the&right&amount
§
Block&DAT,&resulting&in&more&dopamine&going&downstream
Also&process&used&by&cocaine
§
§
○
Slow&acting&is&more&effective
○
Drug&like&hetamine&psychostimulant&&reverses&DAT&and&spits&out&
dopamine&to&increase&release
○
Promote&the&idea&of&over-activity&of&dopamine
○
•
DA&signaling
Why&is&increasing&DA&a&good&thing&for&people&with&ADHD?
In&SCZ,&DA&is&in&the&striatum
○
Also&plays&a&big&role&in&the&prefrontal&cortex&(PFC)&with&memory&and&
function
○
DA&signaling&has&an&inverted&U&relationship&to&cognitive&function&(esp.&in&
working&memory)&in&the&PFC
○
When&DA&signaling&is&too&low&or&too&high,&working&memory&function&is&
sub-optimal&in&PFC
○
Depending&on&your&individual&biology,&you&may&have&a&PFC&with&too&low&or&
too&high&DA&levels
Linked&to&genetic&variant&in&an&enzyme&that&breaks&down&dopamine
Individuals&with&val-val&allele&are&too&low&in&DA&when&things&
are¬&very&interesting&or&cognitively&demanding
May&get&to&right&level&when&things&get&their&attention&
®
Kids&with&ADHD&are&capable&of&focusing&intensely&when&
something&is&interesting&to&them
®
Problem:&most&things&are¬&interesting&enough&
®
§
Individuals&with&the&met-met&are&naturally&at&a&good&
dopamine&level
If&at&near&optimal&level&and&give&them&a&drug,&it'll&push&
them&too&far&and&won't&perform&as&well
®
§
§
Give&someone&drug&to&increase&DA,&push&them&closer&to&top&of&U&
shaped&curve&even&when&things&aren't&that&demanding
§
Why&psychostimulants&don't&calm&down&kids&without&ADHD
§
○
In&kids&with&ADHD,&psychostimulants&seem&to&calm&them&down
○
•
N-back&task&from&neurocognitive&tasks
Indicates&is&this&the&thing&I&saw&three&images&back
○
Taking&on&working&memory
○
2&back
When&cognitive&demands&are&low,&DA&signals&optimally
§
When&I&give&the&ADHD&kid&the&drug&where&DA&and&cognitive&demand&
is&low,&it&helps&them&concentrate&more&
§
○
3-back
High&cognitive&demand
§
Give&drug&to&someone&at&optimal&level& the&drug,&you&may&push&the&
person&over&to&perform&worse&(as&seen&in&kids&without&ADHD&when&
given&the&drug)
§
○
•
Autism-Spectrum-Disorder
Developmental&delays•
In&some&cases&have&high&verbal&IQ,&but&often&with&deficits&in&other&areas
High&verbal&IQ&is¬&very&common
○
•
Prevalence:&1&in&68
Reasonably&high&prevalence
○
At&birth&it&is&1&in&300
○
Diagnostic&rates&seem&to&be&increasing&over&the&last&50&years
May&have&been&because&we're&modifying&our&diagnostic&criteria&to&
be&more&inclusive&or&something&is&actually&going&on&to&increase&the&
frequency
§
○
•
Collection&of&disorders•
Autism&Spectrum&Disorder&(ASD)
Social&communication
Lack&of&reciprocity&during&social&exchange
○
Poor&nonverbal&communication&skills
○
Unable&to&develop,&maintain,&or&understand&relationships
○
•
Repetitive&behaviors
Repetitive&motor&movements
○
Insistence&on&sameness;&lack&of&flexibility
○
Extremely&narrow&interests&with&abnormal&intensity
○
Hyper&or&hypo-reactivity&to&sensory&input
○
•
Must&be&present&early&in&life•
Must&cause&significant&distress&or&impairment•
Not&better&explained&by&another&disorder•
Specifiers&for&ASD
With/without&accompanying&intellectual& impairment•
With/without&accompanying&language&impairment•
Associated&with&known&medical,&genetic,&or&environmental&factors•
Associated&with&another&disorder
High&comorbidity&with&ADHD
○
•
ASD&starts&early
Can&be&diagnosed&as&early&as&a&few&months&old•
Babies&that&went&to&go&onto&develop&ASD&showed&no&difference&in&fixation&if&
face&was&inverted
Compared&to&typically&developing&children&and&children&with&
developmental&delays&(not&ASD),&there's&a&higher&preference&for&the&up&
face&and¬&the&inverted&face
○
•
Synaptic&pruning&occurs&early&in&the&brain
One&disorder&autism&shares&the&most&genetic&risk&factors&for&is&
schizophrenia
Become&unmasked&by&adolescence&in&SCZ
§
Biologically&differences&were&there&from&an&early&age,&making&it&a&
neurodevelopmental&disorder
§
○
Differences&in&how&the&brain&develops&early&in&life
○
Autism&reveals&itself&much&earlier&than&SCZ
○
•
Treatment&of&ASD
Early&intervention&is&key
Can&have&good&outcomes
○
Is&treatable
System&isn't&learning&from&its&environment&as&if&show&on&its&own
§
Providing&external&scaffolding&can&make&a&difference
§
○
•
Applied&behavioral&analysis/Lovaas&Model
Structured&management&of&interactions&in&therapy&and&via&training&the&
parents
○
Everything&the&child&does&is&either&positively&or&negatively&reinforced
Don't&punish
§
Child&does&a&good&thing,&bring&it&to&attention&and&give&praise
§
Child&does&a&bad&thing,&withhold&praise
§
○
Diligently&track&reinforcement&because&child&isn't&doing&it&on&their&own
○
•
No&pharmacological&treatments,&but&medications&can&be&used&to&treat&comorbid&
conditions
•
The'Third'Wave'of'Behavioral'Therapy:'
Mindfulness'
Mindfulness&based&techniques&to&augment&or&replace&cognitive&behavioral&ones
When&we&feel&bad,&we&often&try&to&push&it&away
Serves&to&inavertedly&magnify&pain
○
Creates&self-blame&for&pain
○
Different&from&how&we&respond&to&pain&of&other&people
For&others,&we&tend&to&be&more&forgiving&and¬&blaming&them&for&
their&pain
§
○
•
In&self&compassion,&help&person&be&okay&that&they&don't&like&something&about&
themselves
Rather&than&trying&to&change&or&criticize& it,&reply&to&it&as&you&would&to&a&
family&member
○
•
Steps&of&self-compassion
Awareness/mindfulness
That&something&is&happening
○
Bring&attention&to&the&negative&self-talk/criticisms/predictions
○
Can&often&fly&under&the&radar&and¬&know&it's&affecting&you
○
•
Common&humanity
Recognition&that&pain&is&something&we&all&have&in&common
○
All&of&us&have&to&make&peace&with&the&harsh&aspects&of&life
One&of&the&hard&things&about&treating&shame&is&that&the&experience&
of&shame&leads&to&shame&of&having&shame
§
Hard&to&get&people&to&admit&they&feel&shame
§
○
We&all&have&things&we're&ashamed&of
See&as&point&of&connection
§
○
•
Self-kindness
Responding&to&things&we&don't&like&about&ourselves&with&kindness,&as&you&
would&with&a&friend
○
•
What&self-compassion&is&NOT
Complacency/resignation
"I&guess&I'm&just&the&way&I&am,&so&screw&it.&I'll&always&be&a&mess."
○
You&can&hold&a&high&standard&for&yourself&and&hold&it&kindly&or&unkindly
Has¬hing&to&do&with&level&of&standard
§
○
•
Self-indulgence
Buying&something,&consuming&something,&eating&something
○
Just&a&distraction&from&something&you&don't&want&to&feel&with&something&
that&is&transiently&pleasurable
○
•
Self-bias
Justifying&your&story&or&viewing&you&narrative&as&the&correct&one
○
•
Self-esteem
Self-esteem&has&an&evaluation&component&in&it&as&a&concept
○
Can&have&low&self-esteem,&but&still&have&self-compassion
○
Self&compassion&is¬&conditional&on&believing&you’re&a&good&or&bad&
person
Trying&to&build&up&someone's&self-esteem&won't&help&always&in&
treatment&because&the&patient&will&argue&about&it
§
○
•
Difference&from&traditional&cognitive&behavioral&approaches
Observational&vs.&challenging
CBT&often&involves&a&lot&of&questioning&and&challenging&of&how&people&see&
the&world,&offering&different&interpretations,&recognize&cognitive&
distortions&or&maladaptive&thinking
○
Self-compassion&is&more&passive
Look&at&how&you&treat&yourself,&and&is&it&how&you&treat&friends&or&a&5&
year&old
§
Observe&pattern&of&self-talk&vs.&challenging&specific&cognitions
§
○
•
Inductive&vs.&deductive
A&lot&of&focus&of&therapy&is&learning&from&observations,&rather&than&
therapist&being&more&prescriptive
○
•
Self-compassion&vs.&self-efficacy•
Not&appropriate&for&all&patients
Not&appropriate&for&someone&suicidally&depressed&or&so&much&anxiety&that&
they&can't&leave&the&house
Too&much&to&handle
§
○
Particularly&for&those&at&severe&levels
○
Better&for&those&at&a&mild/moderate&level&and&preventing&relapse
○
•
Also&in&ACT&(acceptance&and&commitment&therapy)•
Mindfulness&based&cognitive&therapy
For&people&who&have&had&depression,&successful&treated&with&CBT,&and&
trying&to&prevent&relapse
○
•
Childhood'Disorders/Self-Compassion
Thursday,&April&19,&2018 11:27&AM
Final&Exam
Thursday,&May&3rd•
Cumulative•
Same&format&as&other&exams•
Learning&Catalytics
The&primary difference&between&anorexia&and&bulimia?
WeightA.
Binging/PurgingB.
Concern&about&weightC.
low&self-esteem&related&to&appearanceD.
In&the&DSM-5&you&must&show&relevant&symptoms&before&what&age&to&meet&criteria&
for&ADHD?
Any&ageA.
Before&age&7B.
Before-age-12C.
Before&age&18D.
A key neurotransmitter in the pathophysiology of ADHD is:
SerotoninA.
GABAB.
GlutamateC.
DopamineD.
Childhood'Disorders
ADHD
Six&or&more&manifestations&of&poor&attentional&control&for&6&months&or&more
In&comparison&to&appropriate&age&group
○
•
Present&in&multiple&settings
More&trait-like&than&state-like
○
Agreement&between&teachers,&parents,&caretakers,&and&assessor
○
•
Impairment&in&social,&academic,&or&occupational&settings•
Not&better&explained&by&other&disorders
A&lot&of&adult&disorders&are¬&formally&recognized&in&childhood
○
Kids&don't&know&how&to&process&or&talk&about&things,&so&they're&more&
likely&to&act&out&when&feeling&other&things&like&depressed&and&can&manifest&
as&things&that&look&like&ADHD
○
•
Must&contain&6&or&more&of&either:
Attention&deficit
Doesn't&pay&attention
○
Cannot&sustain&attention
○
Does¬&listen
○
Doesn't&follow-through
○
Can't&organize&or&plan
○
Avoids&mental&effort
○
Loses&things
○
Easily&distracted
○
Forgetful&in&daily&activities
○
•
Hyperactivity
Fidgety
○
Can't&sit&in&one&place
○
Inappropriately&active
○
Can't&handle&quiet&activities
○
High&energy
○
Excessively&talkative
○
Frequently&interrupts
○
Can't&wait&his/her&turn
○
Intrudes/takes&over
○
•
Subtypes&and&comorbidity
Subtypes
Inattentive&subtype
○
Hyperactive-impulsive&subtype
○
Combined&subtype&(most&common)
○
•
Common&co-morbidities
Internalizing&symptoms&(anxiety/depression)
Difficulty&with&self&control&can&also&lead&to&an&increase&in&anxiety
§
Bidirectional&
§
○
Conduct&disorder
○
•
Prevalence
85%&does¬&have&any&evidence&of&ADHD
•
7.5%&diagnosed&with&low&level&ADHD
•
4.0%&medium&level
•
2.6%&high&level
•
Primary&treatment:&
Psychostimulants&(DA&releasing&agents)
Frequently&a&drug&that&will&inhibit&or&reverse&the&role&of&the&dopamine&
transporter
Dopamine&transporter&pulls&dopamine&from&synapse
§
○
Block&DAT&–increase&tonic&DA
A&way&to&control&how&much&dopamine&goes&downstream&to&post-
synaptic&targets
§
Tight&control&–release&just&the&right&amount
§
Block&DAT,&resulting&in&more&dopamine&going&downstream
Also&process&used&by&cocaine
§
§
○
Slow&acting&is&more&effective
○
Drug&like&hetamine&psychostimulant&&reverses&DAT&and&spits&out&
dopamine&to&increase&release
○
Promote&the&idea&of&over-activity&of&dopamine
○
•
DA&signaling
Why&is&increasing&DA&a&good&thing&for&people&with&ADHD?
In&SCZ,&DA&is&in&the&striatum
○
Also&plays&a&big&role&in&the&prefrontal&cortex&(PFC)&with&memory&and&
function
○
DA&signaling&has&an&inverted&U&relationship&to&cognitive&function&(esp.&in&
working&memory)&in&the&PFC
○
When&DA&signaling&is&too&low&or&too&high,&working&memory&function&is&
sub-optimal&in&PFC
○
Depending&on&your&individual&biology,&you&may&have&a&PFC&with&too&low&or&
too&high&DA&levels
Linked&to&genetic&variant&in&an&enzyme&that&breaks&down&dopamine
Individuals&with&val-val&allele&are&too&low&in&DA&when&things&
are¬&very&interesting&or&cognitively&demanding
May&get&to&right&level&when&things&get&their&attention&
®
Kids&with&ADHD&are&capable&of&focusing&intensely&when&
something&is&interesting&to&them
®
Problem:&most&things&are¬&interesting&enough&
®
§
Individuals&with&the&met-met&are&naturally&at&a&good&
dopamine&level
If&at&near&optimal&level&and&give&them&a&drug,&it'll&push&
them&too&far&and&won't&perform&as&well
®
§
§
Give&someone&drug&to&increase&DA,&push&them&closer&to&top&of&U&
shaped&curve&even&when&things&aren't&that&demanding
§
Why&psychostimulants&don't&calm&down&kids&without&ADHD
§
○
In&kids&with&ADHD,&psychostimulants&seem&to&calm&them&down
○
•
N-back&task&from&neurocognitive&tasks
Indicates&is&this&the&thing&I&saw&three&images&back
○
Taking&on&working&memory
○
2&back
When&cognitive&demands&are&low,&DA&signals&optimally
§
When&I&give&the&ADHD&kid&the&drug&where&DA&and&cognitive&demand&
is&low,&it&helps&them&concentrate&more&
§
○
3-back
High&cognitive&demand
§
Give&drug&to&someone&at&optimal&level& the&drug,&you&may&push&the&
person&over&to&perform&worse&(as&seen&in&kids&without&ADHD&when&
given&the&drug)
§
○
•
Autism-Spectrum-Disorder
Developmental&delays•
In&some&cases&have&high&verbal&IQ,&but&often&with&deficits&in&other&areas
High&verbal&IQ&is¬&very&common
○
•
Prevalence:&1&in&68
Reasonably&high&prevalence
○
At&birth&it&is&1&in&300
○
Diagnostic&rates&seem&to&be&increasing&over&the&last&50&years
May&have&been&because&we're&modifying&our&diagnostic&criteria&to&
be&more&inclusive&or&something&is&actually&going&on&to&increase&the&
frequency
§
○
•
Collection&of&disorders•
Autism&Spectrum&Disorder&(ASD)
Social&communication
Lack&of&reciprocity&during&social&exchange
○
Poor&nonverbal&communication&skills
○
Unable&to&develop,&maintain,&or&understand&relationships
○
•
Repetitive&behaviors
Repetitive&motor&movements
○
Insistence&on&sameness;&lack&of&flexibility
○
Extremely&narrow&interests&with&abnormal&intensity
○
Hyper&or&hypo-reactivity&to&sensory&input
○
•
Must&be&present&early&in&life•
Must&cause&significant&distress&or&impairment•
Not&better&explained&by&another&disorder•
Specifiers&for&ASD
With/without&accompanying&intellectual& impairment•
With/without&accompanying&language&impairment•
Associated&with&known&medical,&genetic,&or&environmental&factors•
Associated&with&another&disorder
High&comorbidity&with&ADHD
○
•
ASD&starts&early
Can&be&diagnosed&as&early&as&a&few&months&old•
Babies&that&went&to&go&onto&develop&ASD&showed&no&difference&in&fixation&if&
face&was&inverted
Compared&to&typically&developing&children&and&children&with&
developmental&delays&(not&ASD),&there's&a&higher&preference&for&the&up&
face&and¬&the&inverted&face
○
•
Synaptic&pruning&occurs&early&in&the&brain
One&disorder&autism&shares&the&most&genetic&risk&factors&for&is&
schizophrenia
Become&unmasked&by&adolescence&in&SCZ
§
Biologically&differences&were&there&from&an&early&age,&making&it&a&
neurodevelopmental&disorder
§
○
Differences&in&how&the&brain&develops&early&in&life
○
Autism&reveals&itself&much&earlier&than&SCZ
○
•
Treatment&of&ASD
Early&intervention&is&key
Can&have&good&outcomes
○
Is&treatable
System&isn't&learning&from&its&environment&as&if&show&on&its&own
§
Providing&external&scaffolding&can&make&a&difference
§
○
•
Applied&behavioral&analysis/Lovaas&Model
Structured&management&of&interactions&in&therapy&and&via&training&the&
parents
○
Everything&the&child&does&is&either&positively&or&negatively&reinforced
Don't&punish
§
Child&does&a&good&thing,&bring&it&to&attention&and&give&praise
§
Child&does&a&bad&thing,&withhold&praise
§
○
Diligently&track&reinforcement&because&child&isn't&doing&it&on&their&own
○
•
No&pharmacological&treatments,&but&medications&can&be&used&to&treat&comorbid&
conditions
•
The'Third'Wave'of'Behavioral'Therapy:'
Mindfulness'
Mindfulness&based&techniques&to&augment&or&replace&cognitive&behavioral&ones
When&we&feel&bad,&we&often&try&to&push&it&away
Serves&to&inavertedly&magnify&pain
○
Creates&self-blame&for&pain
○
Different&from&how&we&respond&to&pain&of&other&people
For&others,&we&tend&to&be&more&forgiving&and¬&blaming&them&for&
their&pain
§
○
•
In&self&compassion,&help&person&be&okay&that&they&don't&like&something&about&
themselves
Rather&than&trying&to&change&or&criticize& it,&reply&to&it&as&you&would&to&a&
family&member
○
•
Steps&of&self-compassion
Awareness/mindfulness
That&something&is&happening
○
Bring&attention&to&the&negative&self-talk/criticisms/predictions
○
Can&often&fly&under&the&radar&and¬&know&it's&affecting&you
○
•
Common&humanity
Recognition&that&pain&is&something&we&all&have&in&common
○
All&of&us&have&to&make&peace&with&the&harsh&aspects&of&life
One&of&the&hard&things&about&treating&shame&is&that&the&experience&
of&shame&leads&to&shame&of&having&shame
§
Hard&to&get&people&to&admit&they&feel&shame
§
○
We&all&have&things&we're&ashamed&of
See&as&point&of&connection
§
○
•
Self-kindness
Responding&to&things&we&don't&like&about&ourselves&with&kindness,&as&you&
would&with&a&friend
○
•
What&self-compassion&is&NOT
Complacency/resignation
"I&guess&I'm&just&the&way&I&am,&so&screw&it.&I'll&always&be&a&mess."
○
You&can&hold&a&high&standard&for&yourself&and&hold&it&kindly&or&unkindly
Has¬hing&to&do&with&level&of&standard
§
○
•
Self-indulgence
Buying&something,&consuming&something,&eating&something
○
Just&a&distraction&from&something&you&don't&want&to&feel&with&something&
that&is&transiently&pleasurable
○
•
Self-bias
Justifying&your&story&or&viewing&you&narrative&as&the&correct&one
○
•
Self-esteem
Self-esteem&has&an&evaluation&component&in&it&as&a&concept
○
Can&have&low&self-esteem,&but&still&have&self-compassion
○
Self&compassion&is¬&conditional&on&believing&you’re&a&good&or&bad&
person
Trying&to&build&up&someone's&self-esteem&won't&help&always&in&
treatment&because&the&patient&will&argue&about&it
§
○
•
Difference&from&traditional&cognitive&behavioral&approaches
Observational&vs.&challenging
CBT&often&involves&a&lot&of&questioning&and&challenging&of&how&people&see&
the&world,&offering&different&interpretations,&recognize&cognitive&
distortions&or&maladaptive&thinking
○
Self-compassion&is&more&passive
Look&at&how&you&treat&yourself,&and&is&it&how&you&treat&friends&or&a&5&
year&old
§
Observe&pattern&of&self-talk&vs.&challenging&specific&cognitions
§
○
•
Inductive&vs.&deductive
A&lot&of&focus&of&therapy&is&learning&from&observations,&rather&than&
therapist&being&more&prescriptive
○
•
Self-compassion&vs.&self-efficacy•
Not&appropriate&for&all&patients
Not&appropriate&for&someone&suicidally&depressed&or&so&much&anxiety&that&
they&can't&leave&the&house
Too&much&to&handle
§
○
Particularly&for&those&at&severe&levels
○
Better&for&those&at&a&mild/moderate&level&and&preventing&relapse
○
•
Also&in&ACT&(acceptance&and&commitment&therapy)•
Mindfulness&based&cognitive&therapy
For&people&who&have&had&depression,&successful&treated&with&CBT,&and&
trying&to&prevent&relapse
○
•
Childhood'Disorders/Self-Compassion
Thursday,&April&19,&2018 11:27&AM
Document Summary
Concern about weight low self-esteem related to appearance. A key neurotransmitter in the pathophysiology of adhd is: Six or more manifestations of poor attentional control for 6 months or more. A lot of adult disorders are not formally recognized in childhood. Kids don"t know how to process or talk about things, so they"re more likely to act out when feeling other things like depressed and can manifest as things that look like adhd. Difficulty with self control can also lead to an increase in anxiety. 85% does not have any evidence of adhd. Frequently a drug that will inhibit or reverse the role of the dopamine transporter. A way to control how much dopamine goes downstream to post- synaptic targets. Tight control release just the right amount. Block dat, resulting in more dopamine going downstream. Drug like amphetamine psychostimulant reverses dat and spits out dopamine to increase release.
