Download Chapter 14 - Dr. Saadia McLeod

Chapter 14
Psychological Disorders
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Abnormal Behavior: Concepts and Controversies
LEARNING OBJECTIVES
• Describe and evaluate the medical model of
abnormal behavior.
• Identify the most commonly used criteria of
abnormality.
• Describe the five axes of the DSM-IV and
controversies surrounding the DSM-IV system.
• Summarize data on the prevalence of various
psychological disorders.
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Abnormal Behavior, continued
The medical model applied to abnormal behavior
• The medical model “proposes that it is useful to
think of abnormal behavior as a disease” and has
become the main way of thinking about mental
illness today.
• This view is in stark contrast to how mental
illness used to be perceived (see Figure 14.1).
• Thus, the medical model has brought much
needed improvement in patient care.
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Abnormal Behavior, continued
The medical model, continued
• Diagnosis – “involves distinguishing one illness
from another."
• Etiology – “refers to the apparent causation and
developmental history of an illness."
• Prognosis – “is a forecast about the probable
course of an illness."
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Criteria of Abnormal Behavior
1. Deviance – the behavior must be significantly
different from what society deems acceptable.
2. Maladaptive behavior – the behavior interferes
with the person’s ability to function.
3. Personal distress – the behavior is troubling to
the individual.
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Psychodiagnosis: The Classification of Disorders
The American Psychological Association (A.P.A.) uses
the Diagnostic and Statistical Manual.
• It is now in its fifth revision and referred to as the
DSM-5) to classify disorders.
• It provides detailed information about various
mental illnesses that allows clinicians to make
more consistent diagnoses.
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Classification of Disorders, continued
• Compared to the DSM IV, the DSM-5 no longer has
a multiaxial system.
• One major reason for the change is that individuals
often qualify for the diagnosis of two or more
conditions called “comorbity."
• Rather, the DSM-5 utilizes a dimensional approach,
which describes disorders in terms of how people
score on a limited number of continuous
dimensions (e.g. the degree to which they exhibit
anxiety).
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Prevalence of Psychological Disorders
• Epidemiology is “the study of the distribution of
mental or physical disorders in a population."
• Prevalence “refers to the percentage of the
population that exhibits a disorder during a
specified time period."
• Research suggests that there has been a real
increase in the prevalence in disorder (see Figure
14.3).
• The most common classes are substance use,
anxiety, and mood disorders.
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Anxiety Disorders and Obsessive-Compulsive
Disorder
LEARNING OBJECTIVES
• Describe three types of anxiety disorders, and
discuss obsessive-compulsive disorder.
• Discuss how biology, conditioning, cognition, and
stress contribute to the etiology of these disorders.
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Anxiety Disorders and OCD, continued
• Anxiety disorders “are a class of disorders
marked by feelings of excessive apprehension
and anxiety."
• Generalized anxiety disorder “is marked by a
chronic, high level of anxiety that is not tied to
any specific threat."
• Phobic disorder “is marked by a persistent and
irrational fear of an object of situation that
presents no realistic danger."
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Anxiety Disorders and OCD, continued
Panic Disorder and Agoraphobia
• Panic disorder “is characterized by recurrent attacks
of overwhelming anxiety that usually occur suddenly
and unexpectedly” (see following animation
sequence).
• Agoraphobia “is a fear of going out to public
places."
– Agoraphobia may result from severe panic
disorder, in which people “hide” in their homes
out of fear of the outside world.
– In DSM-5 it is listed as a separate disorder.
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Anxiety Disorders and OCD, continued
Obsessive-compulsive disorder (OCD) “is marked by
persistent, uncontrollable intrusions of unwanted
thoughts (obsessions) and urges to engage in senseless
rituals (compulsions)."
• Common obsessions include fear of contamination,
harming others, suicide, or sexual acts.
• Compulsions are highly ritualistic acts that
temporarily reduce anxiety brought on by obsessions.
• While 17% of people without a disorder report
significant obsession or compulsion,
• True OCD disorders only occur in approximately 2%3% of the population.
• Most cases of OCD emerge before the age of 30.
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Anxiety Disorders and OCD, continued
Etiology of anxiety disorders
• Biological factors
– Inherited temperament may be a risk factor for
anxiety disorders.
– “Anxiety sensitivity” theory posits that some people
are more sensitive to internal physiological symptoms
of anxiety and overreact with fear when they occur.
– The brain’s neurotransmitters, or “chemicals that
carry signals from one neuron to another,” may
underlie anxiety.
– In particular, drugs that affect the neurotransmitter
GABA (e.g., Valium) suggest that these chemical
circuits may be involved in anxiety disorders.
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Anxiety Disorders, continued
Etiology of anxiety disorders, continued
• Conditioning and learning
– Classical conditioning may cause one to fear a
particular object or scenario.
– Then, avoiding the fear stimulus is negatively
reinforced, through operant conditioning, by
making the person feel less anxious (See
Figure 14.5).
– Seligman (1971) adds we are “biologically
prepared” to fear some things more than
others, however.
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Anxiety Disorders, continued
Etiology of anxiety disorders, continued
• Cognitive factors
– Some people are more likely to experience
anxiety disorders because they:
o Misinterpret harmless situations as
threatening
o Focus excess attention on perceived threats
o Selectively recall information that seems
threatening
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Somatoform Disorders
LEARNING OBJECTIVES
• Distinguish among the three types of somatoform
disorders.
• Summarize what is known about the causes of
somatoform disorders.
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Somatoform Disorders, continued
• Somatoform disorders “are physical ailments that
cannot be fully explained by organic conditions
and are largely due to psychological factors."
• Somatization disorder “is marked by a history of
diverse physical complaints that appear to be
psychological in origin."
– It occurs mostly in women.
– Symptoms seem to be linked to stress.
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Somatoform Disorders, continued
• Conversion disorder – “is characterized by a
significant loss of physical function with no
apparent organic basis, usually in a single organ
system."
– Common symptoms include:
o Partial or total loss of vision or hearing
o Partial paralysis
o Laryngitis or “mutism” (inability to speak)
o Seizures or vomiting
o Loss of function in limbs
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Somatoform Disorders, continued
• Hypochondriasis (or hypochondria) “is
characterized by excessive preoccupation with
health concerns and incessant worry about
developing physical illnesses."
– People with hypochondria are convinced their
symptoms are real and often become
frustrated with the medical establishment.
– Hypochondria often occurs along with anxiety
disorders and depression.
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Somatoform Disorders, continued
Etiology of somatoform disorders
• Personality factors
– Somatoform disorders are more common in
people with “histrionic” personalities (those
who thrive on the attention that illness
brings).
– Neuroticism also seems to elevate one’s
predisposition to somatoform disorders.
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Somatoform Disorders, continued
• Cognitive factors
– Some people focus excessive attention on bodily
sensations and amplify them into perceived
symptoms of distress.
– They also have unrealistically high standards of
“good health." Thus, any deviation from perfect
health is seen as a sign of illness.
• The sick role
– Some people learn to “like” being sick because:
• It allows one to avoid challenging tasks.
• Demands aren’t placed on sick people.
• It provides an excuse for failure.
• Being sick elicits attention from others.
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Dissociative Disorders
LEARNING OBJECTIVES
• Distinguish between two types of dissociative
disorders.
• Summarize what is known about the causes of
dissociative disorders.
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Dissociative Disorders, continued
Dissociative disorders “are a class of disorders in
which people lose contact with portions of their
consciousness or memory, resulting in disruptions in
their sense of identity."
• Dissociative amnesia “is a sudden loss of memory
for important personal information that is too
extensive to be due to normal forgetting."
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Dissociative Disorders, continued
• Dissociative identity disorder (DID) “involves the
coexistence in one person of two or more largely
complete, and usually very different, personalities."
– Also known as “multiple personality disorder”, in
which each personality has its own name,
memories, traits, and physical mannerisms.
– Transitions between identities can be sudden and
the differences between them can be extreme
(e.g., different races or genders).
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Dissociative Disorders, continued
• Etiology of dissociative disorders
– Psychogenic amnesia and fugue are usually the
result of extreme stress.
– Dissociative identity disorder is a fascinating and
bizarre disorder, and its causes are largely
unknown.
• However, many clinicians suspect that DID
may result from severe emotional trauma that
occurs in childhood.
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Mood Disorders
LEARNING OBJECTIVES
• Describe depressive and bipolar disorders, discuss
their prevalence, and explain their relation to
suicide risk.
• Explain how genetic, neurochemical,
neuroanatomical, and hormonal factors
contribute to the development of depressive and
bipolar disorders.
• Discuss how cognitive processes, interpersonal
factors, and stress contribute to the development
of depressive and bipolar disorders.
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Mood Disorders, continued
• Major depressive disorder is one in which people
“show persistent feelings of sadness and despair and
a loss of interest in previous sources of pleasure.“
• - More than just feeling bad:
-Mood/affect/apathy/anhedonia
-Thoughts
-Sleep/Fatigue
– Suicidal ideation/risk high
– Most will experience a repeat episode.
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Mood Disorders, continued
Major depressive disorder, continued
– Depression is one of the most common mental
illnesses (the lifetime prevalence is 13% - 14%).
– Women are twice as likely
o
This does not appear to be tied to biological
differences between men and women and
could result from greater stress and abuse that
women experience.
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Mood Disorders, continued
• Bipolar disorder “experience of both depressed
and manic periods."
– “Manic” periods are characterized by bouts of
extreme exuberance and a feeling of
invincibility.
– However, this state of elation alternates,
sometimes suddenly, with periods of
depression (see Figure 14.8).
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Mood Disorders, continued
• Mood dysfunction and suicide
– Ninety percent of suicide attempts linked to
psychological disorder.
o
o
o
Lifetime risk for those with bipolar disorder is
15-20%; it is 10-15% in those who have had
depression.
Bipolar: highest risk of suicide
Women are three times more likely to
attempt suicide, but men “complete” four
times as many suicides.
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Mood Disorders, continued
Etiology of mood disorders
• Genetic vulnerability
– Concordance rates, or “the percentage of twin
pairs or other pairs of relatives that exhibit the
same disorder”, suggests there is a genetic basis
for mood disorders.
o
Concordance rates for identical twins is 6572%, whereas it is only 14-19% for fraternal
twins who share fewer genes but the same
environment.
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Mood Disorders, continued
Etiology of mood disorders, continued
• Brain: Neurotransmitters (chemical messengers)
1. Norepinephrine
2. Serotonin
3. Antidepressants increase these
neurotransmitters
– Cause and effect problem
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Mood Disorders, continued
Etiology of mood disorders, continued
• Neuroanatomical factors, continued
– Depression is also correlated with
• The hippocampus, is 8-10% smaller in
depressed, than in normal, subjects (see Figure
14.11).
• Development of new neurons stops in
depressed patients (neurogenesis)
• Causes depression or effect of depression?
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Mood Disorders, continued
• Hormonal factors
– Stress Hormones higher in depressed patients : stress
response on over-drive
• Cognitive factors
– Seligman (1974) “learned helplessness”, in which people
become passive and “give up” in times of difficulty.
o
Depressed individuals grew up in a critical and
punishing environment and have been shaped to be
negative and passive.
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Mood Disorders, continued
Etiology of mood disorders, continued
• Social skills/social support
– Depression has also been correlated with
interpersonal factors, such as poor social skills.
– It is unclear what the direction of cause and
effect is, with regard to this correlation.
• Precipitating stress
– There is also a link between stress and the onset
of mood disorders (See Figure 14.14).
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Schizophrenic Disorders, continued
Schizophrenia literally means “split mind."
• Schizophrenic disorders : Thought disorder
• Rare: 1% of the population suffering from this class
of disorders.
• Schizophrenia is a severe disorder that usually has an
early onset and a poor prognosis. (adolescence or
early 20s)
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Schizophrenic Disorders, continued
Symptoms
1. Irrational thought
– Delusions : false beliefs disconnected from
reality
– Example: mind is being controlled by an external
source.
– Delusions of grandeur are irrational beliefs that
one is “extremely important or famous.“
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Schizophrenic Disorders, continued
2. Deterioration of adaptive behavior
– Feed self, care for self, hygiene, etc.
3. Distorted perception
– Hallucinations – Hearing voices or seeing things
that are not there (auditory and visual
hallucinations).
4. Disturbed emotion (“flat” affect or inappropriate
emotions for a situation).
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Schizophrenic Disorders, continued
• Schizophrenia was divided into four subtypes:
1. Paranoid type
2. Catatonic type
3. Disorganized type
4. Undifferentiated type
• (DSM-5 has discarded this distinction.)
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Schizophrenic Disorders, continued
Positive versus negative symptoms
• Another way to classify:
1. Schizophrenias with negative symptoms
(behavioral deficits, such as flat affect).
2. Schizophrenias with positive symptoms
(hallucinations, delusions, & bizarre behavior).
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Schizophrenic Disorders, continued
Course and outcome
• Schizophrenia usually emerges during adolescence or
early adulthood.
• Its course is variable, with three likely outcomes:
1. Patients with milder versions who experience a
full recovery.
2. Patients who experience a partial recovery and
who are in and out of treatment facilities.
3. Patients whose symptoms are persistent and
severe, and who require permanent
hospitalization.
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Schizophrenic Disorders, continued
• Patients with a favorable prognosis:
1. Have a sudden onset of the disorder
2. Experience onset at a later age
3. Were well adjusted before the onset
4. Have a low proportion of negative symptoms
5. Have well preserved cognitive function
6. Show good adherence to treatment
7. Have a relatively healthy, supportive family
environment to return to
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Schizophrenic Disorders, continued
Etiology of schizophrenia
• Genetic vulnerability
– Concordance in identical twins is 48%, versus
17% in fraternal twins, suggesting a genetic basis
for the disease (see Figure 14.15)
• Brain:
– Excess Dopamine link
– Some studies have linked marijuana use in
adolescence with the onset of schizophrenia.
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Schizophrenic Disorders, continued
Etiology of schizophrenia, continued
– The neurodevelopmental hypothesis :disruptions
in the normal maturational processes of the brain
before or at birth."
– may include:
• Prenatal exposure to a viral infections
• Malnutrition during prenatal development
• Obstetrical complications during birth
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Schizophrenic Disorders, continued
– Expressed emotion (EE) is “the degree to which a
relative of a schizophrenic patient displays highly
critical or emotionally overinvolved attitudes
toward the patient."
• A family’s EE is a good predictor of the course of
a schizophrenic’s illness.
• Patients who return to families high in EE are
three to four times more likely to relapse
because they add stress.
– Precipitating stress itself may trigger the onset of
schizophrenia in someone who is already
vulnerable to the disease.
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Autism Spectrum Disorder, continued
Autism, or autism spectrum disorder,
– Social Deficits: Reciprocity
– Verbal and Pragmatic Language
– Restricted Interests
– Self-Stimulation
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Autism Spectrum Disorder, continued
Symptoms and prevalence
• Symptoms may include:
– Lack of interest in other people
– Tendency to avoid eye contact
– Failure to bond
– Delayed, or inability to develop speech
– Echolalia – rote repetition of others’ words
– Inflexibility with changes in routine
• Prevalence
– About 1% of children are presently diagnosed with autism or an
autism spectrum disorder. (some stats show higher prevalence –
1/100)
– This is a fourfold increase since the mid-1990s
– Early Tx: 15% - 20% of autistic individuals can live
independently.
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Autism Spectrum Disorder, continued
Etiology
• Given its appearance so early in life, most theorists
believe autism has biological origins.
• Familial studies suggest genetic factors may
contribute.
• The popular “mercury vaccine” hypothesis has been
discredited.
– The 1998 study that reported the link between the
vaccinations and autism has been found to be
fraudulent.
– Recent attempts to replicate it have failed.
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Application: Understanding Eating Disorders
LEARNING OBJECTIVES
• Describe the subtypes, history, prevalence, and
gender distribution of eating disorders.
• Explain how genetic factors, personality, culture,
family dynamics, and disturbed thinking contribute
to the development of eating disorders.
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Application: Eating Disorders, continued
Types of eating disorders
• Eating disorders “are severe disturbances in eating
behavior characterized by preoccupation with weight
and unhealthy efforts to control weight."
• There are three main types:
– Anorexia nervosa
– Bulimia nervosa
– Binge-eating disorder
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Application: Eating Disorders, continued
Types of eating disorders, continued
Anorexia nervosa “involves intense fear of gaining
weight, disturbed body image, refusal to maintain
normal weight, and dangerous measure to lose weight."
• Two subtypes include
1. Restricting type anorexia nervosa
2. Binge-eating/purging type anorexia nervosa
• Both entail distortions in body image.
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Application: Eating Disorders, continued
Anorexia nervosa, continued
• Medical complications from anorexia are serious and
can include:
– Amenorrhea (ceasing of menstrual cycles)
– Gastrointestinal problems
– Dental problems
– Osteoporosis (loss of bone density)
– Low blood pressure
– Metabolic disturbances that can trigger cardiac
arrest
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Application: Eating Disorders, continued
Types of eating disorders, continued
Bulimia nervosa “involves habitually engaging in out-ofcontrol overeating followed by unhealthy compensatory
efforts, such as self-induced vomiting, fasting, abuse of
laxatives and diuretics, and excessive exercise."
• Unlike with anorexia, patients with bulimia usually
maintain a normal weight.
• However, they do risk medical problems such as
cardiac arrhythmias, dental problems, metabolic
deficiencies, and gastrointestinal problems.
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Application: Eating Disorders, continued
Types of eating disorders, continued
Binge-eating disorder “involves distress-inducing eating
binges that are not accompanied by the purging, fasting,
and excessive exercise seen in bulimia."
• Patients with this disorder are often overweight and
disgusted with their bodies.
• Excessive overeating is often triggered by stress.
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Application: Eating Disorders, continued
History and prevalence
• Anorexia - more common in the middle of the 20th
century.
• Bulimia appears to be a more recent disorder (it did
not become common until the 1970s).
• Young women are much more likely to develop
eating disorders (90% - 95% of cases)
• Age of onset is early, and late adolescence for
anorexia, and bulimia nervosa, respectively.
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Application: Eating Disorders, continued
Etiology of eating disorders
• Genetic vulnerability
– Twin studies show higher concordance rates for
identical twins than fraternal twins, suggesting a
genetic predisposition for the disease.
– However, many other factors influence the
development of eating disorders.
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Application: Eating Disorders, continued
Etiology of eating disorders, continued
• Personality factors
– Victims of anorexia tend to be perfectionistic,
rigid, and anxious
– In contrast, bulimia is associated with
impulsiveness and low self-esteem.
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Application: Eating Disorders, continued
Etiology of eating disorders, continued
• Cultural values
– In Western society, young women are socialized
to believe they must be very thin in order to be
attractive
– “Desirable” weight, as seen in models and
actresses, has decreased in recent decades.
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Application: Eating Disorders, continued
Etiology of eating disorders, continued
• The role of the family
– Control over body as coping in chaotic family or
over-involved family.
– Some mothers even contribute to eating
disorders by endorsing society’s obsession with
being thin.
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Application: Eating Disorders, continued
Etiology of eating disorders, continued
• Cognitive factors
– Beliefs:
• “I must be thin to be accepted.”
• “If I am not in complete control, I will lose all
control.”
• “If I gain one pound, I will become obese.”
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