The Brain: A Neuroanatomy Guide

A Neuroanatomy Guide

The Central Nervous System and Peripheral Nervous System

Argosy University Online

Kay T. Jewels

Abstract

The human body is controlled by two complex systems called the Central Nervous System and Peripheral Nervous System. In a systematic breakdown of the Central Nervous System and Peripheral Nervous System this is paper will describe the associated features including basic structures, their location, and intended function. 

A Neuroanatomy Guide: The Central Nervous System and Peripheral Nervous System

The human body is controlled by the nervous system including the “central nervous system” (CNS) and the “peripheral nervous system” (PNS) (Carlson, 2009). The central nervous system consists of the brain and spinal cord, which make up the (CNS). The “peripheral nervous system” (PNS) consists of “cranial nerves, spinal nerves, and peripheral ganglia” (Carlson, 2009). These two systems work together to bring sensory and motor information from the body to the CNS and to bring sensory and motor information from the CNS to any location within the body (Carlson, 2009). The CNS interacts with the PNS through the use of the “cranial nerves, spinal nerves, and peripheral ganglia” (Carlson, 2009). Effectively the PNS works as a relay system that communicates all the information collected from the body to the CNS, so the CNS can send signals that regulate function throughout the whole body.  In very simple terms, the PNS can be seen as an interdependent system that connects the brain to the body so they work simultaneously.   

The CNS and the PNS are both well protected; in fact, both the CNS and PNS are in encased in bone and meninges. The brain, consisting of “neurons, glia, and other supporting cells”, is found floating in cerebrospinal fluid, “chemically guarded by the blood–brain barrier”, well protected by meninges and the skull (Carlson, 2009, p. 72). The spinal cord is encased within the vertebral column, which consists of the twenty-four individual vertebrae of the “cervical, thoracic, lumbar, sacral and coccygeal” regions that form the spine (Carlson, 2009, p. 94-95). The spinal nerves, cranial nerves and the peripheral ganglia that compose the PNS are protected by cerebrospinal fluid and two layers of meninges (dura mater and pia mater) (Carlson, 2009, p. 72). Meninges are a tough connective tissue that protects them from damage. Meninges has several layers: the outer tough flexible layer called the dura mater, the middle soft and spongy layer called the arachnoid membrane including a spall gap called the subarachnoid space which is filled with cerebrospinal fluid, and the pia mater which is closely attached to the brain and spinal cord (Carlson, 2009. p 72).

Central Nervous System Breakdown

A series of hollow unified chambers, called ventricles, full of cerebrospinal fluid (CSF) form the brain (Carlson, 2009, p. 74-75).  Located at the midline of the brain, the walls of the third ventricle divide the brain into symmetrical halves (Carlson, 2009). Connected to and located on each side of the third ventricle, are the largest chambers in the brain are called the “lateral ventricles” (Carlson, 2009). The “massa intermedia” a connective piece of neural tissue that crosses through the middle of the third ventricle, while the cerebral aqueduct is a long tube that connects the third ventricle to the fourth ventricle (Carlson, 2009, p. 74-75). Within these four chambers a special tissue called the choroid plexus protrudes and is responsible for the production of CSF (Carlson, 2009, p. 75). The CSF continually produced by the choroid plexus tissue located within the ventricles systematically floods the ventricles and subarachnoid space before passing the arachnoid granulations and reentering the blood stream through the “superior sagittal sinus” (Carlson, 2009, p. 75). Arachnoid granulations are pouch-shaped structures that extend into a blood vessel called the superior sagittal sinus that drains into the veins serving the brain. If there is an interruption in the flow of CSF ventricals may enlarge, a condition called obstructive hydrocephalus may result, causing intracerebral pressure, blood vessels to become occluded, and permanent or possibly fatal brain damage can occur (Carlson, 2009, p. 75).

The brain is divided into two hemispheres called left and right hemispheres. These hemispheres are connected by the corpus callosum, which is “a large band of axons that connects corresponding parts of the cerebral cortex of the left and right hemispheres” (Carlson, 2009, p 87). Typically, but not always, the left hemisphere analyzes and performs functions that include verbal activities, such as talking, understanding the speech of other people, reading, and writing, while the right hemisphere synthesis information, specializes in seeing the global picture and putting things together to make a whole as done in activities like as drawing, read maps, and constructing complex objects out of smaller pieces (Carlson, 2009, p. 87). However, the forebrain, the midbrain, and the hindbrain are the three major subdivisions of the brain.

The front part of the brain, called the forebrain, surrounds the lateral and third ventricles and includes the two subdivision called the telencephalon and diencephalon (Carlson, 2009, p 82).  The midbrain, also called the mesencephalon, is the middle section of the brain, surrounds the cerebral aqueduct and includes the “tectum and the tegmentum”. (Carlson, 2009, p. 91). The hindbrain, located at the rear of the brain, found surrounding the fourth ventricle contains the subdivisions called the metencephalon and myelencephalon (Carlson, 2009, p. 93).

The telencephalon describes the two equal “cerebral hemispheres”, covered by the “cerebral cortex” containing the “limbic system and the basal ganglia”, which form the majority of cerebrum located in the forebrain (Carlson, 2009, p. 83). The cerebral cortex is organized into the frontal lobe, parietal, temporal, and occipital lobes, with the central sulcus dividing the frontal lobe from the other three (Carlson, 2009. p. 95). 

The “central sulcus” deals with movement and the planning of movement, while the other three lobes deal principally with perception and “learning” (Carlson, 2009. p. 95).The limbic system, includes brain structures involved in “emotion, motivation, and learning”, such as the frontal “thalamic nuclei, amygdala, hippocampus, limbic cortex, parts of the hypothalamus” called mammillary bodies, and their interwoven fiber bundles called the fornix (Carlson, 2009, p. 88).

 The limbic cortex is located near the middle edge of the cerebral hemispheres, while the “cingulate gyrus” part of the limbic cortex lies just along the sidewalls of a channel “separating the cerebral hemispheres”, just above the corpus callosum (Carlson, 2009, p. 88).  The hippocampus and the parts of the limbic cortex that surround it are associated with learning and memory, while the amygdala and other parts of limbic cortex are specifically involved in “feelings and expressions of emotions, emotional memories, and recognition of the signs of emotions in other people” (Carlson, 2009, p. 88). The basal ganglia is a group of subcortical nuclei including the caudate nucleus, the globus pallidus, and the putamen, that play an important role in the motor system (Carlson, 2009, p. 89). Mammillary bodies refer to a protrusion of the bottom of the brain at the back end of the hypothalamus and contain some hypothalamic nuclei (Carlson, 2009, p. 88).

The diencephalon, located between the telencephalon and the mesencephalon surrounding the third ventrical, includes the thalamus and the hypothalamus (Carlson, 2009, p. 89). The thalamus is located within the dorsal section of the diencephalon, near the middle of the cerebral hemispheres, toward the mid-line and back of the basal ganglia, and above the hypothalamus (Carlson, 2009, p. 89). The thalamus contains nuclei that send information to different regions in the cerebral cortex and receive information from it (Carlson, 2009, p. 89). The hypothalamus is the group of nuclei that lies at the base of the brain under the thalamus, which governs the endocrine system, the regulation of the autonomic nervous system, controls the anterior and posterior pituitary glands, and integration of species-typical behaviors (Carlson, 2009, p. 90).

 The midbrain section, located between the forebrain and hindbrain includes the tectum and the tegmentum. Tectum is the part of the brain concerned with “audition and the control of visual reflexes and reactions to moving stimuli” (Carlson, 2009, p. 96).The tegmentum contains the reticular formation vital to sleep, arousal, and movement; the periaqueductal gray matter that controls various species-typical behaviors; and the red nucleus and the substantia nigra parts of the motor system (Carlson, 2009, p. 96). The hindbrain is located at the back of the brain surrounding the fourth ventricle and containing the cerebellum, the pons, and the medulla (Carlson, 2009, p. 97). The cerebellum contributes to integrating and coordinating movements, while the pons contains various nuclei that are important in sleep and arousal (Carlson, 2009). The medulla oblongata also is involved with the regulation of sleep and arousal, but also plays a significant role in the control of movement and regulating vital functions such as heart rate, breathing, and blood pressure (Carlson, 2009, p. 96).

The spinal cord is a long tapering structure, about as thick as the pinky finger and has various reflexive control circuits (Carlson, 2009, p. 95). The spinal cord extends only to about two-thirds the length of the vertebral column and the rest of the space contains a mass of spinal roots composing the cauda equina (Carlson, 2009, p. 95).The spinal cord contains white matter and gray matter, like the brain but on the spinal cord, unlike in the brain, the white matter is on the outside and gray matter is on the inside (Carlson, 2009, p. 95). White matter consists mostly of ascending and descending bundles of myelinated axons, while the gray matter consists of neural cell bodies and short unmyelinated axons (Carlson, 2009, p. 95). The primary function of the spinal cord is to provide motor fibers to the organs of the body including glands and muscles and collect somatosensory information to share with brain (Carlson, 2009, p. 94).

Peripheral Nervous System Breakdown

All communication from the organs, glands, muscles and extremities is transmitted to the CNS from the PNS nerves called spinal and cranial nerves. First the nerves gather sensory information then convey this information to the central nervous system and then the CNS conveys messages from the central nervous system to the body’s parts (Carlson, 2009, p. 95).  Any cell body that takes information to the CNS (spine or brain) is called an afferent axon, while any cell body that takes information away from the CNS is referred to as efferent (Carlson, 2009, p. 95). The transfer of sensory information is part of the somatic nervous system; this system governs the information from the sensory organs and those organs that control movements of the skeletal muscles (Carlson, 2009, p. 97). The autonomic nervous system (ANS) is also part of the PNS, but is concerned with regulation of smooth muscle, cardiac muscle, and glands which control regulation of “vegetative processes” in the body (Carlson, 2009, p. 97). Autonomic nervous system uses a pathway that contains preganglionic axons from the brain or spinal cord to the sympathetic or parasympathetic ganglia, and postganglionic axons from the ganglia to the target organ (Carlson, 2009, p. 101). The autonomic nervous system is further broken down into two anatomically separate systems: the sympathetic division and the parasympathetic division (Carlson, 2009, p. 97).

With the exception of the retina, all cell bodies of axons that convey sensory information into the brain and spinal cord are located outside the CNS and called afferent axons (Carlson, 2009, p. 97). Dorsal roots and ventral roots are small bundles of fibers that emerge from each side of the spinal cord in two straight lines along its front and back surfaces (Carlson, 2009, p. 95). At the point when the dorsal and ventral roots join together passing through the intervertebral foramens, they become spinal nerves (Carlson, 2009, p. 95). A spinal nerve is a peripheral nerve attached to the spinal cord that branches out along that path it travels to the organ it supplies (Carlson, 2009, p. 97). A cranial nerve is part of the peripheral nervous system that connects with the brain directly (Carlson, 2009). The twelve cranial nerves that are affixed directly to the front bottom surface of the brain provide sensory and motor functions to the head and neck regions (Carlson, 2009, p. 97). For example: The tenth and largest cranial nerve is called the vagus nerve and regulates the functions of organs in the thoracic and abdominal cavities by conveying efferent fibers of the parasympathetic division of the autonomic nervous system (Carlson, 2009, p.97).

The term peripheral ganglia describes a group of cells found in the Peripheral Nervous System outside the spinal cord and brain that are not protected (Carlson, 2009). Peripheral ganglia function is to connect the central nervous system to the different parts of the body, and they are found near the organs in the upper area of the body, specifically the head, abdomen, thorax, stomach, spleen, liver, kidneys, and along the pelvis (Carlson, 2009, p. 95). Dorsal root ganglia is a cell body on the dorsal root that takes somatosensory information to the spinal cord (Carlson, 2009, p. 97). The term sympathetic ganglia refers to nodules containing synapses between preganglionic and postganglionic neurons of the sympathetic nervous system (Carlson, 2009, p. 98)

The sympathetic divisions preganglionic cells are located in the thoracic and first two lumbar segments of the spinal cord, while the parasympathetic division preganglionic neurons are located in the brain stem and in sacral segments of the spinal cord (Henson, 2013). The sympathetic division also controls the adrenal medulla. The Adrenal Medulla a set of cells located in the center of the adrenal gland, just above of the kidney and is similar in nature to the sympathetic ganglion. The adrenal medulla and is controlled by sympathetic nerve fibers and secretes epinephrine and norepinephrine (Carlson, 2009, p. 100).  The secretion of these hormones controls functions like increase blood flow to the muscles, the breakdown of stored nutrients within skeletal muscle cells into glucose and increase energy available to these cells (Carlson, 2009, p. 100)

Parasympathetic Divisions ganglia are located right next to the intended organs (Carlson, 2009, p. 95). The nuclei that give rise to preganglionic axons in the parasympathetic nervous system are located in the nuclei of the “cranial nerves and the intermediate horn of the gray matter in the sacral region of the spinal cord” (Carlson, 2009, p. 100). The Parasympathetic Division works to increase the body’s supply of stored energy including primary functions like salivation, gastric and intestinal motility, secretion of digestive juices, and increased blood flow to the gastrointestinal system (Carlson, 2009, p. 100).

Typically speaking, the Sympathetic Division and the Parasympathetic Division both interact with the organs they affect, just in opposite ways. For example : the  Parasympathetic Division of the autonomic nervous system will constrict the pupil of the eye and slow the heart, while the Sympathetic Division will dilate the eye and speed the heart (Carlson, 2009, p. 97). The sympathetic division of autonomic nervous system controls functions like arousal and expenditure of energy, while the Parasympathetic division of autonomic nervous system controls the functions that occur during a relaxed state (Carlson, 2009, p. 98- 100).

References

Carlson, N. R. (2009). Structure of the Nervous Systems. Physiology of Behavior, 10th Edition. Pearson Learning Solutions. Retrieved from VitalBook file.

CircuitBrain. (2013). Spinal Tap Images. CircuitBrain Blogspot. Retrieved from http://circuitbrain.blogspot.com/2012/08/this-is-real-spinal-tap.html

GenericLook. (2012). Peripheral ganglia. GenericLook Medical Terms. Retrieved from http://medicalterms.info/anatomy/Peripheral-Ganglia/

Henson. O.W. (n.d.). The Autonomic Nervous System. University of North Carolina, Chapel Hill. Retrieved from http://www.csus.edu/indiv/l/lancasterw/bio122/supplementary%20materials/autonomic%20synopsis.htm

HplusMagiazine. (2013). Image of the Brain1. HplusMagiazine. Retrieved from http://hplusmagazine.com/wp-content/uploads/brain1.jpg

Mohsenin, J. (2013). Image of the Brain Lobes. Almost a Doctor. Retrieved from http://almostadoctor.co.uk/content/brain

Modesto Junior College. Image of Chapters 14 and 17: Spinal Cord, Spinal Nerves and Autonomic Nervous System. Modesto Junior College. Retrieved  from http://droualb.faculty.mjc.edu/Lecture%20Notes/Unit%205/adrenal_medulla.jpg

Sci-Therapy. (2013). Image Spinal Nerves. Sci-Therapy. Retrieved from http://www.sci-therapies.info/Overview.htm

ScholarPedia. (2013). Image Autonomic Nervous System. ScholarPedia. Retrieved from http://www.scholarpedia.org/article/Autonomic_nervous_system

Wikispaces. (2013). Image Brain Divisions. Wikispaces. Retrieved from http://phys-mic-vic-ash.wikispaces.com/file/view/brain-divisions.gif/301425706/brain-divisions.gif

Wikispaces. (2013). Image Limbic System. Wikispaces. Retrieved from http://humanmemory2007.wikispaces.com/file/view/limbic.gif/30862176/limbic.gif

Wikispaces. (2013). Image Cranial Nerves. Wikispaces. Retrieved from http://bit.ly/HheXVv

The Brain: Effective Depression Treatment

If I told you within this paper you would find the cure to a common and troubling illness, would you continue to read the whole paper through? According to the National Institute of Mental Health, of the estimated 18.8 million Americans who are affected by some form of depression, 9.5 million have major or clinical depression. Sadly, only 20 percent of these people are currently receiving treatment. Last year, two surveys indicated that 75 percent of depressed patients that seek treatment will receive an anti-depressant. About half of those taking an antidepressant will feel a positive effect from those medications. Less than half of the patients who receive antidepressants will receive psychotherapy treatment for their depression. Possibly, the most effective treatment for depression is treating the source of depression in conjunction with a lifestyle change. Medication should only be used to treat symptoms while receiving psychotherapy with the ultimate goal of being medication free. For more than half my life I suffered from a crippling depression that ruled my every action.  While receiving psychotherapy weekly and medication daily; I also researched mental illness and treatments thoroughly. I now feel cured and no longer receive medications or psychotherapy for depression and anxiety. Only after successfully treating my depression was I able to see clearly the only effective treatment for depression is a targeted and individualized therapy plan.

Most recent studies indicate a strong link between childhood trauma and adult symptoms of mental illness, including depression. The effect of childhood trauma on the developing brain can include increased levels of stress hormones, altered gene regulation, physical changes in hippocampus volume, and cortisol regulation malfunction. Trauma does not need to be life-threating, like physical or sexual abuse for it to be life-altering. Some of the other childhood traumas that result in adult depression can be unobvious ones. For example, emotional abuse, instilling fear in a child, repetitive and unwanted criticism are all examples of unobvious trauma. A child can also be traumatized by the unintentional neglect of two working parents, or rather the events that take place while the two parents are working. Another example of childhood trauma is a prolonged parental separation of any kind. Adoption as a result of abandonment or separation; even if the child grows up in a happier home, they often still feel very abandoned or alone. Violence in the family, neighborhood or TV can cause equal psychological damage, as exposure to constant fighting or yelling within the home. Possibly the most common childhood traumas today that cause adult depression are divorce, family addiction, racism, and poverty, yet this is often not taken into account. Many are aware of the underlying emotional issues that result from these experiences, but how many know these experiences actually shape our brains to be predisposed to depression and mental illness? Experiencing trauma in early life, changes our brain first physically, and then chemically; equally and as a result of our perception of reality and our perspective on life also changes.  With all these chemical changes within the brain, I can understand why so many seek to remedy the problem chemically with medication.

However, I am not convinced that a chemical or drug is an effective long term treatment solution for depression. I have actually tried Paxil, Zoloft, Prozac, Abilify, Celexa, Lexapro, Effexor, Cymbalta, Welbutrin, Lithium, Depakote, Seroquel, and Lamitical, with no success at treating my depression. In fact, living with side effects was often worse than the depression.  While attempting to treat my depression with medication, I gained 80 lbs and was diagnosed with Fibromyalgia. At age 26, I felt as though I was left with a depressed mind and a broken body. After many doctors and therapists, after countless failed attempts to get the “right” combination of medication, after a million tears, I stopped leaving it up to the doctors and started researching on my own. When I started reading the facts about depression medications, I was startled to find out the long list of lasting side effects these medications can leave you with. For example, Tardive Dyskinesia is a facial tic that can be a devastating side effect of some of these medications. Besides the fact, these medications have serious side effects there is also little evidence to support their effectiveness. It made me crazy to read, the pharmaceutical companies sponsored researchers are finding there is little difference between the placebo and the pill. Some studies also indicate no significant advantage to taking higher doses of these medications, as it is suggested by many doctors. Modern research suggests these drugs even target the wrong neurochemicals and the real problem is structural. So many fail to recognize, even effective medications are only treating the symptoms of depression, they do not actually treat the cause of the depression. Ultimately medication is a Band-Aid and underneath the problem is still unchecked. With an average of only 30% of these patients feeling relief from their depression when treated chemically, isn’t it time we tried another method?

The road to recovery from depression is a long, rocky and uncertain climb. Many will never see actual recovery from depression, some will see a remission of their depression symptoms, and most will see a re-occurrence of their symptoms within their lifetime. However, there is hope for those willing to explore the path less traveled, often called psychotherapy. Psychotherapy is less frequently received than medication, yet it yields higher recovery rates and lower relapse rates. Recovery from depression requires treating the underlying relationship causes to depression with psychotherapy, creating a safe environment for the patient to grow in, meeting relationship needs that were not met in childhood, and giving the patient the tools to identify and combat any negative emotional, relationship, cognitive or neuromuscular patterns. Utilizing such tools as, Cognitive Behavioral Therapy (CBT), Repatterning Movements (RPMs), and even hypnosis you can safely address the faulty thought processes that keep the mind depressed. Evidence suggests that psychotherapy can induce positive neuro-biological and structural changes within the brain. Meditation, yoga, art and movement therapies can be quite soothing and help significantly with the many symptoms of depression. In addition to psychotherapy, maintaining a healthy lifestyle is critical to the success of any depressed patient. One important step to depression recovery that is often left out is exercise. Exercise not only helps with the physical body, but it also releases endorphins and affects self-image too. In addition, a patient must change their physical environment and surroundings to reflect their change of mindset. There will be little success for any patient who remains in an unhealthy or re-traumatizing environment. Since the source of one’s depression is individual and unique to them, I do not believe in a universal answer to depression. I see a combination and individualized approach as the solution and possible cure for depression.

During the last few paragraphs we have discussed depression facts; we have mapped the possible sources, exposed startling facts about depression medication and even directed the way to recovery.  With almost 19 million Americans suffering chances are that you know and love someone with depression. I want you to know there is hope for your loved one. Hope for the depressed lies within successfully treating the source of their depression with psychotherapy, not in successfully managing their symptoms with medication. Although treatment of depression symptoms is a critical first step to successfully treating the depression it is not the last, but rather the first of many steps. I can’t stress enough how important psychotherapy is to healing and how fundamentally important processing childhood trauma is to develop a healthy adult mind. I know there is truth in what I say because I did not just write this paper, I have lived it.  Although this paper was supported with detailed research, it was written and inspired by the real experiences of depressed patients and her struggle to find a cure. The answer wasn't always as clear as I wrote it for you today. It took countless hours of reading, over a thousand heartbreaking therapy sessions, ten years of independent research, hard work, and even some trial and error to come to this one conclusion. Only after successfully treating my own depression was I able to see clearly the only effective treatment for depression is a targeted and individualized therapy plan.

The Law is Made to Protect You: The Truth About Mental Illness in Prisons

The Truth About Mental Illness in Prisons 

Abstract

An overview of the Mentally Ill and Prison Population, research into prisoners reveals that many of our current prisoners are suffering from mental illness. Some of these prisoners are mentally ill and/or previously homeless and an alarming percentage of the population is also suffering from substance abuse disorders. This means some of today’s prisons are our leading institutions to house the mentally ill. Unfortunately, prisons are not equipped to deal with mental health issues and many of the correctional officers have only a basic understanding of the mental illness. This leads many mentally patients receiving poor treatment in prison. Recent changes to the court system have been made to accommodate the mentally ill populations that find themselves in the criminal justice department. This essay briefly explains how the mentally ill end up on the streets, in our jails, how the treatment of the mentally ill in prisons is not adequate and what changes in the court system have been made to accommodate the mentally ill. 

The Truth about Mental Illness in Prisons

From Institutions to the Streets

Previous to the de-institutionalization policy many of our mentally ill were housed in Mental Institutions. The de-institutionalization policy gave more rights to those suffering from mental illness; including the right to refuse treatment (Martin, 2007). The de-institutionalization policy also relieved the government of the burden of what to do with the Mentally Ill populations. Ultimately the de-institutionalization policy led to the release of the mentally ill patients from institutions all over the country; many of these patients became homeless (Martin, 2007). A 2005 study found that one in six mentally ill individuals was homeless (Martin, 2007). Because of lack of ability, resources, transportation and sometimes desire many of these patients discontinued treatment (Martin, 2007).


From Mentally Ill, Homeless and/or Substance abuser to Prisoner 

Many times those with a mental illness will use substances other than prescribed medications (like illegal drugs or alcohol) to help them cope with the symptoms of an underlying illness. Often time’s mental illness (like depression) will set in during a difficult time (like in adolescence or early twenties); some of these depressed persons may then turn drugs and alcohol to help them cope and possibly become addicts. Those with mental illness and/ or substance abusers disorders often behave so radically and unpredictably that they jeopardize their living situation and become homeless. While not always true, many of today’s prisoners were homeless before their incarceration and imprisoned for desperate acts of survival.(Nieto, 1999). “Approximately 15% of jail inmates had been homeless in the year prior to their incarceration and 54% of homeless individuals report spending time in a correctional facility at some point in their lives, and studies indicate that homelessness increases the risk for incarceration and incarceration increases the risk for homelessness(National Health Care For The Homeless Council, 2011) “Approximately 20 to 30 percent of the homeless population is suffering from a serious mental illness (Martin, 2007; U.S. Mayor’s Survey, 2003;), and if the term “mental illness” also include clinical depression and substance abuse, that percentage jumps to an astounding 50 to 80 percent(Martin, 2007; North, Eyrich, Pollio, & Spitznagel, 2004; Shern et al., 2000). Eventually and sometimes habitually the homeless, mentally ill, and/or substance abuse users end up in our criminal systems.

The Mentally Ill in Prisons

A good majority of prison populations are mentally ill and/or poly-substance abusers; in 1997 a survey concluded that “the range of jail detainees with co-occurring mental health and substance abuse disorders was between 3-11 percent” (Nieto, 1999). In fact, prison populations are flooded with prisoners suffering from mental illness; “There are more than 200,000—perhaps as many as 300,000—men and women in U.S. jails and prisons suffering from mental disorders, including such serious illnesses as schizophrenia, bipolar disorder, and major depression (Fellner, 2006).” In prisons, prisoners are expected to conform to prison rules and maintain functional, non-violent and compliant behaviors. Many of the mentally ill are not able to comply with the demands of prison life, and as a result, they end up incarcerated longer and punished frequently for continuing to commit crimes, and break rules in jail. (Fellner, 2006) Statistics from the Federal Bureau of Justice say that “mentally ill prisoners in state and federal prisons, as well as local jails, are more likely than others to have been involved in a fight or to have been charged with breaking prison rules” and “are more likely to serve maximum sentences” (Fellner, 2006). Prisoners who do not conform to prison rules are punished with solitary confinement and other traumatizing punishments. (Fellner, 2006) Prisoners who break the rules are punished equally despite their mental status at the time. (Fellner, 2006).

Frequently the mentally ill prisoners who are lucky enough to receive psychiatric services in prison are over-medicated and under-treated with mental health services which can also make rule compliance difficult for mentally ill prisoners. (Fellner, 2006) As a result the mentally ill prisoners who are released from prison often find themselves in similar predicaments to before and re-enter the criminal system as a repeat offender. In 1991, a study conducted by the Los Angeles County Board of Supervisor’s Task Force on the Incarcerated Mentally Ill estimated that 90 percent of the mentally ill offenders receiving mental health services in the county jail were repeat offenders (Nieto, 1999).” Many believe that putting the mentally ill in prison is actually detrimental to their mental health because they receive poor mental health management and live in conditions that are not conducive to healthy mental health. 

The Governments Problem with Mental Illness in Prison

The cost of imprisoning mentally ill prisoners is significant! In California, it is estimated that the “annual associated costs to police and sheriff’s departments to handle mentally ill offenders including transfers and escort costs, arrest and booking, and detention are estimated to $605 million in total” (Nieto, 1999). Treating the underlying mental illness and/or substance abuse issues that cause dysfunctional behavior that results in their imprisonment is the preferred method for reducing the cost and burden of the mentally ill on prisons. However many of the mentally ill are medication resistant or become resistant to taking the medications; some refuse to believe they are ill even when presented with overwhelming evidence, and as a result, don’t believe they need medications. A person like this in prison could decompose and withdraw in prison and find themselves in constant trouble for misconduct in jail. ( Nieto, 1999) This presents a challenge for the court and government who would much prefer to rehabilitate the offender so he or she may return to civilized living situations and socialization than pay thousands of dollars for this mentally ill person to be neglected in jail. 

The Current Solution to Mental Illness in Prisons

A recent addition to our public court system is the Mental Health Court. The Mental Health Court is designed to prevent the mentally ill from receiving hard prison time, and when all possible aim to give treatment to the offender. This collaborative effort to keep the mentally ill out of prison and in treatment allows the court a better measure of control when sentencing the mentally ill. “Mental health courts employ incentives and sanctions tailored to the circumstances and needs of each participant to motivate him or her to engage in treatment and comply with the terms of participation.” (Almquist & Dodd, 2009) Incentives including “individual praise and applause, program completion certificates, and fewer court appearances” encourage Mental Health Court participants to engage and stay in treatment often longer than they would have if they had been incarcerated. (Almquist & Dodd, 2009) Allowing the mentally ill to serve time in psychiatric units, community service when applicable, and outpatient treatment programs not only avoid the significant cost of imprisonment, but they can also reduce the rate of repeat offenders, and give the mentally ill a reason to comply with treatment. Some of the services offered by the mental health court are referrals to transportation services, housing, vocational training, group skills training, and substance abuse management. (Almquist & Dodd, 2009) One of the main focuses of the Mental Health Court is to keep the mentally ill out of jail and in treatment, so the services are varied based on need; thus the services provided can depend on the type of case and resources available to the court. (Almquist & Dodd, 2009)

How Does This Help the Mentally Ill Person’s Charged With Crimes

Compared to the previous services offered to prisoners these services are an improvement because once in prison only prisoners with a "serious medical need" have a right to appropriate medical care, this includes persons with serious mental illness as well. (National Alliance on Mental Illness, 1993) Because not all mentally ill patients act out in a manner that would warrant attention to some prisoners who were mentally ill often times could go years in prison without proper treatment. (National Alliance on Mental Illness, 1993) Additionally, their right to treatment does not qualify them for very much, at times it just what is needed to reduce symptomatic behaviors. (National Alliance on Mental Illness, 1993) The number one reason this is helpful to mentally ill persons who have been arrested is that it helps them get help with their mental illness and when possible they avoid jail time and/or confinement in less than tolerable conditions like a prison. Because the Mental Health Court’s focus is treating the illness, when jail time can’t be avoided it is often mandated at facilities that are equipped to treat the mentally ill instead of prisons (Almquist & Dodd, 2009). When jail time can be avoided the mentally ill patients are thus spared a lengthy sentence in exchange for treatment compliance (Almquist & Dodd, 2009). By mandating treatment courts can reduce the cost for imprisonment, reduce prison overpopulation rates, and improve the quality of life for the mentally ill (Almquist & Dodd, 2009).


Does Research Support The Development Of More Mental Health Services To Prisoners?

Because research indicates that these services will reduce re-incarceration of the mentally ill and ultimately improve the quality of life for the mentally ill the findings support the establishment of more mental health programs to the imprisoned mentally ill. (Almquist & Dodd, 2009) However, this program alone is not enough to help mentally ill prisoners who are already in prison and need services desperately. Prisoners already in prisoners should be offered a similar program would be a great first step to making sure all mentally ill prisoners are helped equally. 

How Can We Improve These Services to Better Serve The Mentally Ill Prisoners?

These services could better services could possibly better help the mentally ill population if mental health screenings were offered to persons arrested and before they are bailed. This would help because it would bring attention to mental health concerns before the case is heard in court, possibly even help those who are unaware they have a mental illness or that do not have access to mental health care. This would reveal problems, especially in teen offenders before their problems become so unmanageable that they become homeless and or imprisoned.

Dissociative Identity Disorder: Theoretical Analysis of Case Characteristics, Theory and Treatment Plan

Analysis of Case Characteristics, Theory and Treatment Plan

Angel Littleton is a 19-year-old female, who arrived at the E.R. via ambulance for an attempted suicide. The patient ingested a bottle of prescription drugs and was then found wandering the train tracks near her home. Presenting depressed and clearly suicidal, disoriented about the date and time, the patient reports being sexually assaulted, however, she is unclear when. Hospital medical records reveal the patient came into the hospital two weeks ago. The patient was seen and treated for a severally sprained left ankle, abrasions on the toes. The toenail of the large toe was removed because it had lifted from the toe during the injury and was causing her pain. The patient had some other minor abrasions on her elbows but refused to reveal how she had been injured. The patient left the hospital prematurely against the advice of professionals after hearing from the nurse that the X-ray had come back negative for a break or fracture. Exactly one week before her latest suicide attempt, the patient came into the E.R. and started the admission process and told a nurse she wanted to speak with someone. However, shortly after she started talking she requested to use the bathroom and left the hospital preadmission.

When asked about these incidences the patient remembers coming to the hospital but is unclear about the events surrounding her leaving the hospital. Patient presents at the hospital with alternating periods of extreme discomposure with expressions of sadness and despair, crying at times uncontrollably and muttering incoherently and then suddenly alert, intellectual, ridge, and coherent reporting no symptoms needing treatment and wanting to leave the hospital. The patient has an alternating perception of the staff at times displaying trust and other times suspicion. Patient had poor eye contact during periods of distress she chooses to look down or away, while in periods of composure and coherent conversation about why she is in the hospital and events surrounding her arrival she makes brief eye contact, but then appears to gaze through you as if in a trance. Patient had fragmentary recall about episodic or autobiographical memory and memories recalled were lacking proper effect and emotional congruency.  Patient reports a the lifelong enduring pattern of symptoms including a feeling disconnected from her body, a cloudy mind, tunnel vision, racing heart, periods of insomnia, nightmares, flashbacks, blackouts, auditory hallucinations and dreamlike states- where she questions if the world around her is real or is she dreaming. The patient reports a history of compulsive skin washing since age 6 and compulsive skin picking since age 8, as well as, other mixed compulsive checking and ritualistic behaviors. The patient has self-mutilated in the form of cigarette burns twice on her forearms, claims to have the ability to control pain.

The patient reports she has been staying with friends since the argument with her family that prompted her departure from her home, she is effectively homeless. Patient reports leaving home after an argument with her mother about her brother stealing from her and her sister having intimate relations with her fiancé. While reporting an ambivalent attachment with the mother, the patient reports a strong attachment with the father, and extremely despaired of the recent betrayal of her fiancé. The fiancé is seven years older than the client and she maintains she entered a sexual relationship with him when she 14. The patient has had some meaningful communication with her father whom she intendeds the hospital after discharge. However, she reports he is an active alcoholic, who lives with a new wife almost an hour away. Patient reports no communication with her ex-fiancé or other family members including siblings in six months.  The patient is unable to maintain work due to a high level of interpersonal problems and reports no other viable healthy relationships or attachments. Although the problem is severe and appears to interfere with the person’s family, work, friendships, leisure activities, and relationships it also appears that the level of interpersonal dysfunction in the family and untreated trauma reported would make it hard for anyone to function normally.

Hospitals records reveal two other suicide attempts, at ages 14 and 16, both with prescription drugs also requiring a gastric lavage with charcoal. The patient reports adamantly and convincingly no memory of intent to attempt suicide, rather reporting she had a migraine both times and could not remember clearly what had happened. In all suicide attempts, after 24 hours patient became coherent, lacking symptoms of depression, insistent she was not trying to harm herself and was later released to a parent. Early childhood onset of mixed symptoms key areas is attention, memory, impulsivity, with mixed obsessive-compulsive symptoms as early as age 6. The patient has a history of migraines, no other serious organic illness, yet the patients report a history of somatic symptoms including gastrointestinal symptoms, pelvic pain, fatigue, migraines, and various areas of generalized pain. Somatic and psychiatric symptoms appear to wax and wane in severity and duration-however, no clear indication to her as of yet to what triggers them. After both suicide attempts, the patient reports her mother bringing her to seeing psychiatrist no more than once and no prescription drugs were ever prescribed to manage symptoms. Other than the suicide attempts the patient medical history reveals only one significant other hospitalization for wisdom teeth removal.

Prenatal development was normal, mother was 40 at delivery, nothing noted as abnormal about the child at birth. The patient's parents were separated at age 6, after the divorce at 9 some typical behavioral issues arose when the house became increasingly chaotic and childcare became sporadic. Some behavioral issues in school: Memory attention, focus, impulsivity, and withdrawal from most peer social relationships. She is the youngest of five, has one older brother that is a half brother from the mother's previous relationship. She now has one new step sister through the father’s remarriage. The mother never remarried and has no new children from other partners. Mother has cancer and has recently sold her house and moved to New Hampshire to live with her eldest son. The mother has a major in psychology the father is in the science field.  The patient reports one brother, age 24, has learning disabilities, bipolar, and substance abuse history, a father is an active alcoholic and sister uses drugs recreationally.

The patient reports being molested as a child by an uncle yet is unclear of all the details. The patient reports low libido and some level of sexual dysfunction. She was sexually active before the sexual assault beginning at age 14 but has not had relations since the

recent assault. The patient admits a history of being a victim of domestic violence, both in the childhood home and in her personal relationship. She has never been married, though she once was engaged her engagement was recently and traumatically called off. The patient identifies her sexual orientation as a bi-sexual. The patient reports good grades despite skipping school and falling asleep in class often. Ultimately, leaving after high school after an angry outburst at a teacher who touched her shoulder and then obtaining her GED at 16. The patient has no career, however, reports many different service position, starting at age 10, which ultimately ended because of personal reasons i.e broken hand, lack of care, homelessness, etc. Patient reports never been arrested or serving time in prison.

Discussion: Analysis of Case Characteristics, Theory and Treatment Plan 

Despite enmeshment in abusive attachments to the mother, the fiancé, and siblings, the patients unhealthy the family dynamic that have to lead her to flee from her home and attachments and come to therapy in search of help. Her level of commitment to a healthy way of life is demonstrated by her weekly prompt arrival in therapy since discharge and is a positive sign of her desire to stay free of abuse and distressing symptoms. The patient is smart and able to understand intellectually the benefits of treatment and at least partially able to maintain composure through the use of dissociation.

The patient was sexually assaulted as a child and neglected then later subject to stress and abuse during the divorce at an early developmentally sensitive age- these are the early contributing childhood traumas that lead to her current state. The patient started to display early behavioral adaptations of distress that were ignored in childhood and adolescence. During adolescence (age 14) she became sexually active and developed an attachment to an abusive older man, whom she was engaged to marry. Within the last year, this important yet clearly unhealthy attachment was severed by betrayal with her sister, which was further exasperated by her mother ignoring this and the brothers theft of her possessions. Eventually, she left home to live on the streets, where she was sexually assaulted (age 19), which lead to the current to state of discomposure.

Patient show symptoms and reports a history of depersonalizing and derealization, as well as, dissociation. The patient appears to be displayed to at least two levels of awareness and differing attitudes about the events that have surrounded her arrival in therapy. The alternating patterns of behavior fit the description of apparently normal personality and emotional personality, i.e. switching back and forth from identifying herself as Angelica and then Angel with alternating patterns of behaviors and thoughts. Her perceptions of blackouts during these alternate periods are congruent with interruptions in cognition and memory that are found in Dissociative Identity Disorder. Currently, the patient seems unaware of the switching only disturbed by the other symptoms associated with trauma and the dissociation i.e. blackouts, time-lapse, post-traumatic memories. At some point, the patient should receive a comprehensive clinician-administered structured interview such as the structured clinician interview for dissociative disorders (SCI-DD) to determine the validity of a DID diagnosis.

  

Based on the Post Traumatic Theory of Dissociative Identity Disorder, that presumes an origin manifesting from a child’s attempt to cope with an overwhelming sense of hopelessness and powerlessness in the face of repeated traumatic abuse (Butcher, 2009, p. 29) we will consider the symptoms seen as behavioral adaptations that help the patient cope with trauma, and label poor social and economic environments, as well as, harmful family dynamics as contributing stressors. Given the current traumatic experiences and the traumatic history, we will presume that many of the current symptoms have developed as results of the memories of previous traumatic experiences being repressed coupled with the patient’s lack of ability to cope with the overwhelming anxiety, she feels when confronted with the memories of the repressed traumatic experiences. Thus we will try to counter this process by giving the patient coping skills and therapy aimed at helping her integrate disassociated memories and identities into consciousness. The long-term the objective is to work on dissociated mental processes throughout treatment to help the patient work towards better integrative functioning as well as gain an increased degree of communication and coordination among the identities and resolution (International Society for the Study of Trauma and Dissociation, 2011, p.133).

During treatment, we will use a phase-oriented treatment plan starting with phase one establishing safety, stabilization, and symptom reduction (International Society for the Study of Trauma and Dissociation, 2011, p.135). Helping the patient understand, accept, and access the alternate identities that play an active role in their current lives will help the patient develop internal cooperation and increase co-consciousness-which is a focus of early treatment (International Society for the Study of Trauma and Dissociation, 2011, p.139). In phase two we will work on confronting, working through, and integrating traumatic memories (International Society for the Study of Trauma and Dissociation, 2011, p.135). We will use hypnosis trauma therapy to help the patient confront the memories of trauma, cope with the anxiety, manage symptoms and work to improve the emotional awareness and regulation through cogitative behavioral therapy.  Lastly, we will begin working on identity integration and rehabilitation (International Society for the Study of Trauma and Dissociation, 2011, p.135).

As she has been abused she is suspicious and untrusting, so it is especially important to develop a trusting relationship with the client from the start for treatment to be successful. In addition to developing a therapeutic alliance, educating her about the diagnosis and symptoms, explaining the process of treatment, helping the patient cope and manage symptoms of depression, begin modulating affect, awareness and emotional regulation, decreasing affect phobia, building distress tolerance, reduction of behaviors like self-mutilation, and learning to optimize effectiveness in relationships, the clinician must also advise the patient of alternative methods to relieve stress and teach her symptom management strategies such as grounding techniques, crisis planning, self hypnosis to help her cope (International Society for the Study of Trauma and Dissociation, 2011). The key phase one objectives are to teach the client to establish control over posttraumatic and dissociative symptomatology and learn to modulate psychophysiological arousal levels, rather than invest further into intrusive traumatic material (International Society for the Study of Trauma and Dissociation, 2011).

Helping the patient find harmonious ways to take into account the wishes and needs of all identities in making decisions and pursuing life activities, to enhance internal support between identities is an important focus of phase one and two (International Society for the Study of Trauma and Dissociation, 2011, p. 142). During phase two, the focus is on remembering, tolerating, processing, integrating and overall abreaction (International Society for the Study of Trauma and Dissociation, 2011, p. 142). Abreaction is the process of letting strong emotions in connection with experience or perception go and overall has been shown to have great overall benefits for the client (International Society for the Study of Trauma and Dissociation, 2011, p. 142). Integrating the memories mean working to restore memories including the sequence of the events, the associated affects, and the physiological and somatic representations of the experience (International Society for the Study of Trauma and Dissociation, 2011, p. 142). Helping the patient come to terms with these memories should only be done after safety, stabilization, and symptom reduction has laid the the way for this process and during the process of integration the patient may need intermittent help with stabilization and symptom reduction. As the process of integration and abreaction can exasperate symptoms causing discomposure it is vital the patient be prepared for phase two adequately.

During phase two, the providers work will involve working with alternate identities that experience themselves as holding the traumatic memories (International Society for the Study of Trauma and Dissociation, 2011, p. 143). As the various elements of a traumatic memory emerge the provider can explore them with the patient to help them broaden the emotional depth and understanding, as well as slowly become accustomed to the feelings associated with the memories. Eventually the material in these memories become altered from “traumatic memory” and subjective memory into “narrative memory” which will help the patient make sense of her past in relation to identity (International Society for the Study of Trauma and Dissociation, 2011, p. 143). It is thought that part of the reasons these patients lack a coherent sense of self is because of the dissociated memories that have not integrated into consciousness (Spring, 2011). Therefore, it is believed by giving them the tools to cope with the feelings instead of dissociate in the face of them (phase one) and then helping the patient “reassociate” these dissociated memories (phase two) that patients will begin to formulate a more cohesive sense of self (phase three).

Accordingly, by phase three the client should show marked improvements and have begun to formulate a stable sense of self and sense of how they relate to others and to the outside world and the clinician should continue to foster ideas of unification (International Society for the Study of Trauma and Dissociation, 2011, p. 145). During this the phase of treatment it is important to advise the patient on how to deal with everyday problems in a nondissociative manner to promote future healthy functioning (International Society for the Study of Trauma and Dissociation, 2011, p. 145 ). Depending on how far the patent makes it’s into integration and fusion there may be a need to show the patient the new pain threshold is, or how to integrate all the dissociated ages into one chronological age (International Society for the Study of Trauma and Dissociation, 2011, p. 145). Integration is a broad, longitudinal process referring to all work on dissociated mental processes throughout treatment, while fusion is when two or more alternate identities are no longer defined as separate and the two (or more) experience themselves as united and one (International Society for the Study of Trauma and Dissociation, 2011, p.134). Lastly, final fusion is the point in time that the client stops seeing themselves as someone with subjective separate identity and views themselves as one (International Society for the Study of Trauma and Dissociation, 2011, p.134)

Often patients are highly traumatized thus their treatment takes a long time, which is why provider commitment to treatment is as important as client commitment. Sometimes there are complications in the patient’s life that interfere with treatment and the provider may spend the majority of treatment trying to meet phase one goals consequently, the goals of phase one and phase two can take so long that phase three and final fusion may never occur (International Society for the Study of Trauma and Dissociation, 2011, p.134). It is cautioned “chronic and serious situational stress; avoidance of unresolved extremely painful life issues and traumatic memories, lack of resources for treatment, comorbid medical disorders; advanced age; significant unremitting DSM Axis I and/or Axis II comorbidities; or significant narcissistic investment in the alternate and/or DID itself” often are contributing factors to patients being unable to achieve final fusion (International Society for the Study of Trauma and Dissociation, 2011, p.134). Therefore, the focus of treatment overall is to help the patient the gain in internal cooperation, coordinated functioning, with hopes of integration and later fusion of alter identities (International Society for the Study of Trauma and Dissociation, 2011, p.134).

References

Butcher. (2009). Dissociative Disorders. Abnormal Psychology, 14th Edition. Pearson Learning Solutions. Retrieved from VitalBook file.

International Society for the Study of Trauma and Dissociation (2011): Guidelines

for Treating Dissociative Identity Disorder in Adults. Journal of Trauma & Dissociation, Third Revision, 12:2, 115-187. Retrieved from http://dx.doi.org/10.1080/15299732.2011.537247

Spring, C. (2011). A Guide to Working with Dissociative Identity Disorder. Healthcare Counseling & Psychotherapy Journal. Retrieved from. http://www.tasc-online.org.uk/pods-online/briefguidetoworkingwithDissociative Identity Disorder.pdf