Clinical training in NL: master + GZ-course (2 years) + Clinical neuropsychology/specialist (4
years)
Settings: general hospital, school, mental health care organization, nursing homes.
History psychiatry:
before 1800s: Patients in institutions, no doctors/medication involved, sometime exposed
to entertain people, very poorly understood.
1790s: French Revolution (Pinel), moral treatment (psychotherapy), first point in history
where people got treatment for mental illness
1860s: German universities start researching psychiatry (linking brain to behaviour),
researching malfunctioning of the brain
1890s: Classification Kraepelin (course of illness; Kompendium, basis for DSM)
1880s: hypnosis/Catharsis-> release yourself from problems, vent (sofa image, Janet)
1890s: Freud’s psychoanalysis
1900s: Biological psychiatry; ECT, lobotomy (pierce above eyes in frontal lobe)
1940s: Psychopharmacology (first antipsychotic drug chlorpromazine), proof for brain
dysfunction
1950s: Introduction DSM (only provides label, not treatment)
1960s: first neuropsychologists in psychiatry (eg Schizophrenia, difficulty allocating effort
in specific tasks)
Modern psychiatry
Brain x environment, nature x nurture
Recovery beyond symptomatic remission (you can reach functional recovery without
symptomatic recovery), 3 dimensions in recovery:
-Symptomatic recovery: all symptoms gone
-Functional recovery: regain social roles in society, get job/friends/school
-Personal recovery: spiritual, living purposeful life, living life in line with personal values
Psychosocial and pharmacological treatments
2013 last version DSM 5; categorisation/agreement. It is not new information, no new
mental disorders, just a different classification.
Criticism on DSM 5; labelling more and more normal behaviour as impaired.
NIMH RDoC; framework with transdiagnostic way of ordering (biological disorders;
dimensions and focus on domains/units of analysis), you can apply it to patient studies. Way
to remove the ‘labels’.
Goal: understanding the nature of mental health and illness in terms of varying degrees of
dysfunction in fundamental psychological/biological. Not a replacement for DSM, but useful
for research.
Definitions
-Psychiatry: medical specialty concerned with the diagnosis and treatment of mental illness
,-Neurology: medical specialty concerned with the diagnosis and treatment of disorders of
the nervous system (brain, spinal cord and nerves)
-Neuropsychology: psychological specialty concerned with relationship between behaviour,
emotion and cognition on the one hand, and brain function on the other.
Traditional neuropsychology
Assessment traditionally focusses on determining specific
changes in mental processes after discrete brain lesions (in
some situations still part of our job)
Helped neurologists to determine locus of lesion
Knowledge on the role of brain areas in mental processes
Focus on neurological patients
We know now that we have networks, instead of specific brain parts
for specific functions.
How we see ourselves
Generating hypotheses on underlying mechanisms of symptoms
Understanding the role of cognitive processes in the etiology and presentation of
psychiatric disorders (biomedical model)
Understanding the clinical, behavioural and phenomenological correlates of
‘neuropsychological impairments’. Why is a person acting in a certain way?
Doing individual neuropsychological assessments (profile of strengths/weaknesses)
Erik Schrerder learning people about our profession in an accessible way.
How psychiatrists see us (study)
Useful but underutilized resource
Establishing deterioration in cognitive functioning
Making differential diagnosis (this is very hard)
Facilitating improved outcomes
Psychiatrists need to recognise cognitive impairments and to understand common
neuropsychological tests (!)
neuropsychology is much more than taking tests
Assessment questions in psychiatry
What is the DSM-5 label? (Can you make a differential diagnosis; no, need more
information than just tests)
Will this person be able to go back to school/work? (Strict prediction is one of the
hardest things, not really possible)
Are there cognitive limitations that should be taken into account in the treatment of
this person?
Can you evaluate the effect of pharmacological interventions on cognitive
functioning?
Are the cognitive impairments due to ADHD or drug use? Can’t answer, both have
effects on this (and not really important)
please assess cognitive functions!
,Examples of associations between symptoms and cognitive processes:
Traditional interpretation errors:
Neuropsychological tests measure specific functions, and poor performance on a
single test indicates a specific neuropsychological deficit
Abnormal neuropsychological test performance indicates specific regional brain
dysfunction
“Hypoactivity” during functional imaging procedures with cognitive activation tasks
suggests regional brain dysfunction; not motivated/didn’t know how to allocate task
don’t jump to conclusions
Directly linking brain areas and disorders/personality/sexual orientation: neuro-
phrenology
Making a psychiatric diagnosis based on neuroimaging studies
Reductionism: psychological conditions are brain disorders associated with a state of
chemical imbalance
Assuming an association between functional impairments and neuropsychological
impairment is disorder-specific
Assuming neuropsychological dysfunction causes such functional impairments
Therapy
Cognitive remediation
Neuropsychological test data can be used to develop treatment strategies tailored for
an individual’s specific cognitive strengths and deficits (rate limiting factors)
Lecture 2 - Schizophrenia
, There are no symptoms that are specific for Schizophrenia (that are not present in other
cognitive disorders).
Criteria
Two or more of the following symptoms, each present for a significant portion of time during
a 1-month period:
Delusions: holding on to belief that is not shared by other people, despite of contrary
evidence
Hallucinations: can occur in all sensory modalities, most often in auditory
Disorganized speech
Grossly disorganized or catatonic: (frozen like wax statue) behaviour
Negative symptoms: diminished emotional expression or avolition, some emotions
are there internally but not externally
Of the underlined symptoms at least one must be present.
Symptoms must be present for at least 6 months for Schizophrenia.
People can have taste/vision/tactile hallucinations. What people hear or see is not random,
but often has a personal meaning. People can be embarrassed by this because its personal.
Hallucinations and delusions can be connected but can also appear separately.
Schizophrenia spectrum disorder nowadays in DSM 5, because patients don’t like the label
liability for psychoses.
Symptom dimensions
combination of symptom dimensions
Ex. Disorganisation: “The problem is insects. My brother used to collect insects. He's now a
man 5 foot 10 inches. You know, 10 is my favourite number. I also like to dance, draw, and
watch television.”
Every sentence leads to other thought, no top-down structure.
Epidemiology
Lifetime prevalence of Schizophrenia is 1%, appearance in late adolescence or early
adulthood (18-25) 20%, appearance of lifetime general psychoses is 4%.
In men the first psychotic episode is earlier than in women, probably because oestrogen is
protective for this. Around menopause there is a new peak in onset in women (drop in
hormones).
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