Some forms of psychopathology, called psychoses, involve losing touch with reality and the disintegra­tion of personality. Two behaviors that occur in these disorders are delusions, which are belief sys­tems not based on reality, and hallucinations, which are distortions in perception.

Although the development of psychotic disorders is rare across adulthood, the number of new cases declines with age (Jeste et al., 1995). The behav­iors present in psychotic disorders are commonly manifested as secondary problems in other disor­ders, especially in dementia (Rabins, 1992). Indeed, psychotic symptoms are an important aspect of the diagnosis of some of these other disorders and can be managed in the same way.

Schizophrenia. Schizophrenia is characterized by the severe impairment of thought processes, including the content and style of thinking, distorted perceptions, loss of touch with reality, a distorted sense of self, and abnormal motor behavior (American Psychiatric

Association, 1994). People with schizophrenia may show these abnormal behaviors in several ways: loose associations (such as saying that they have a secret meeting with the president of the United States in the local bowling alley), hearing voices that tell them what to do, believing that they can read other people’s minds, believing that their body is changing into something else, or sometimes having bizarre delu­sions (e. g., that they are Jesus or that they are being spied on). In addition, schizophrenic people tend to show very little or highly inappropriate emotionality (laughing hysterically at the news of a major tragedy, for instance). They are often confused about their own identity, have difficulty working toward a goal, and tend to withdraw from social contact.

The second hallmark symptom of schizophrenia is delusions, or well-formed beliefs not based in reality. Most often, these delusions involve persecu­tion (“People are out to get me”). The distinction between paranoid disorders and schizophrenia is fuzzy; indeed, one type of schizophrenia is called paranoid-type schizophrenia. In general, hallucina­tions, loose associations, and absent or inappropri­ate emotions do not occur in paranoid disorders (American Psychiatric Association, 1994).

The beliefs underlying delusions can result in anger, resentment, or even violent acts. Because people with psychoses are extremely suspicious and rarely seek help on their own, such people tend to come to the attention of authorities after having repeated run-ins with the police or neighbors, start­ing legal proceedings against others on mysterious grounds, or registering complaints about fictitious or distorted events.

The onset of schizophrenia occurs most often between ages 16 and 30, and much less often after age 40 (Clare & Giblin, 2008). The symptoms of schizophrenia also differ by age; for example, older adults show less thought disorder and less flattening of their emotions than do younger adults (Clare & Giblin, 2008). Some researchers disagree, however, maintaining that there are few differences with age in the numbers of people who experience schizo­phrenic symptoms and no differences in the nature of the symptoms. In any case, there is agreement that new cases of schizophrenia are rare in late life.

Longitudinal research indicates that the natural course of schizophrenia is improvement over the adult life span (Smyer & Qualls, 1999). Studies show that the first 10 years of the disorder are marked by cycles of remission and worsening, but symptoms generally lessen in more than half of people with schizophrenia in later life. This may be caused by a rebalancing of the neurotransmitters dopamine and acetylcholine, which are heavily weighted toward dopamine in younger adults with schizophrenia. Additional rebalancing of other neurotransmitters may also play a role.

Treating Schizophrenia. Traditionally, treatment of schizophrenia has emphasized medication. Drug therapy consists of antipsychotics, medications that are believed to work on the dopamine system (see Chapter 2). Some of the more commonly used antip- sychotics are haloperidol (Haldol), chlorpromazine HCl (Thorazine), and thioridazine HCl (Mellaril). These medications must be used with extreme cau­tion in adults of all ages because of the risk of seri­ous toxic side effects, especially the loss of motor control. Despite these risks, antipsychotics often are used in nursing homes and other institutions as tranquilizing agents to control difficult patients.

In general, people with schizophrenia are diffi­cult to treat with psychotherapy. The severe thought
disturbances characteristic of schizophrenia make it difficult for therapists to work with such clients. Because of their extreme suspiciousness, paranoid people may be reluctant to cooperate in psy­chotherapy. However, there is evidence that a comprehensive and integrated social rehabilita­tion program combined with health care manage­ment intervention can be effective (Pratt, Bartels, Mueser, & Forester, 2008). The goals of therapy for such people tend to be adaptive rather than cura­tive, helping these people adapt to daily living.

Substance Abuse

Although you might think that substance abuse is primarily a problem of adolescents and young adults, it’s not—older adults also have the prob­lem (National Institute on Alcohol Abuse and Alcoholism, 2008). Because of the differences in the types of substances abused by younger and older adults (younger adults are more likely to abuse illegal drugs than are older adults), alcohol provides the best common basis for comparison.

What constitutes alcoholism? Alcoholism, also known as alcohol dependence, is a disease that includes alcohol craving and continued drinking despite repeated alcohol-related problems, such as losing

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Source: NIAAA 2001-2002 National Epidemiological Survey on Alcohol and Related Conditions (NESARC) data (18-60+ years of age) and Substance Abuse and Mental Administration (SAMHSA) 2003 National Survey on Drug Use and Health (NSDUH) (12-17 years of age).

a job or getting into trouble with the law. Alcoholism includes four symptoms: craving, impaired control, physical dependence, and tolerance.

As you can see in Figure 10.4, the prevalence of alcohol dependency drops significantly with age (National Institute on Alcohol Abuse and Alcoholism,

2008) . However, when data are examined more closely, there are gender and ethnic group differences in alco­hol abuse. For example, the percentages of men who abuse alcohol ranges from about 2 times (ages 18-29) to 6 times (ages 65 and over) higher than those for women. Native Americans have the highest rate of abuse, followed by European Americans, Latinos, African Americans, and Asian Americans (Grant et al., 2004). Two patterns of onset are evident with older people with alcohol dependency: early-onset in young adulthood or middle-age lifelong problem drinking, and late-onset problem drinking (Smyer & Qualls, 1999). Left untreated, alcohol dependency does not improve over time.

Taking a life-span view of alcohol dependence pro­vides insights into important differences in drinking patterns and outcomes (National Institute on Alcohol

Abuse and Alcoholism, 2008). For example, young adults are more likely to binge drink, and conse­quently are more likely to experience problems such as alcohol poisoning, drunk-driving offenses, and assaults. The earlier drinking begins, especially if it starts in adolescence, the more likely that brain dam­age occurs and alcohol dependence develops. Young adult drinkers are less likely to feel the effects of alco­hol, such as getting sleepy or losing motor coordina­tion, which may result in their drinking more at one time (“binging”). However, young adults’ cognitive performance is more impaired. Taken together, these effects create a very dangerous situation—they do not feel the effects as easily, so tend to underestimate the degree to which they are impaired, and are worse at performing complex tasks such as driving, providing an explanation of why drunk driving is more preva­lent among young adults.

Middle age is when the effects of continued alcohol dependence that began in young adulthood become evident. Diseases of the liver, pancreas, and various types of cancer and cardiovascular disease may occur. In part due to these health problems,

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