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Ch 15 Disorders
PSYCHOLOGICAL DISORDERS
"To study the abnormal is the best way of understanding the normal"
William James
Background
 1.9 mill inpatient admits to US mental hospitals & psychiatric clinics
 2.4 mill seek help in outpatient clinics
 15% of Americans are judged to need such help
 Disorders appear in every culture
 400 million people worldwide suffer psy disorders
 Top two disorders: schizophrenia & depression
Perspectives on Disorders
Behavior is labeled a psy "disorder" when it:
 Is Atypical - deviates from the norm - that bell curve
- the hermit who completely shuns contact with others
- child molester, incest or rapist
 Is Disturbing - to self and others
- walking around naked in public
- pica - child who eats dirt or feces
 Is Maladaptive - cannot function in daily living
- depression that immobilizes you, can't work, pay bills, raise kids
- anorexic who doesn't eat
- drug use that affects school, homelife, job
 Is Unjustifiable - no logic, reason or purpose to it
- hallucinations or delusions
- phobias
Who gets to decide something is "abnormal"?
 DSM-IV - American Psychiatric Association
 Our general cultural expectations
 Those of us who are sane
 MMPI-2
But be careful
 DSM is constantly being revised
 Cultural expectations can change, what's abnormal now may be normal tomorrow and vice-versa
 "Sane" - that's a legal term, not a psychological term
 Key items are is the behavior
 Harmful?
 Dangerous?
 Does it promote health & growth?
 Does it foster care, love?
 Does it bring us together as a culture?
 Would it be good for young children?
 Does it promote life?
 Does it match our model of a healthy human being?
Understanding Psychological Disorders
 The Medical Perspective
- Philippe Pinel (1745-1826) 1st to treat mental illness as a sickness
- Syphilis - actual disease linked to insanity - milestone in history of
mental health.
Mental illness (psychopathology) needs to be diagnosed on the basis
of its symptoms and cured through therapy, which may include treatment in
a psychiatric hospital.
 The Bio-Psycho-Social Perspective
Biological, Sociocultural & Psychological factors combine and interact to produce psychological disorders.
Examples: Hyperactivity in Japanese culture
Or: Eating disorders in USA
 The Insanity Defense
- very difficult to win in court (less than 5% success rate)
- varies from state to state
- sanity is a legal nor psychiatric term
- M'Naghten rule (1843)
- Usually must show person
 Did not know what he/she was doing was wrong
 Did not have criminal intent
 Was not of "right mind"
 One can be "sick" and have a "disorder" but in reasonable control & be able to appreciate
"wrongfulness" of his actions - Jeffrey Dahlmer
 Some states have "guilty but mentally ill"
 Should we imprison or execute the mentally ill? Retarded?
Classifying Psychological Disorders
 DSM-IV - 230 disorders and conditions into 17 major categories
Remember - DSM only gives symptoms for diagnosis, does not attempt to explain the disorder as to cause nor
give recommended treatment.
 Old time Freudian terms of : Neurosis vs. Psychosis
 Danger in labeling people - David Rosenhan (1973) study
Six Major Categories We'll Study
1. Anxiety Disorders
 Generalized Anxiety Disorder
 Phobias
 Obsessive-Compulsive Disorder (OCD)
 Post-Traumatic Stress Disorder (PTSD)
2. Dissociative Disorders
 Dissociative Amnesia
 Dissociative Fugue
 Dissociative Identity Disorder (DID)
 Depersonalization Disorder
3. Somatoform Disorders
 Hypochondriasis
 Conversion disorders
 Body Dysmorphic disorder
4. Mood Disorders
 Major Depressive Disorder
 Bipolar Disorder
 Dysthemia & Cyclothemia
5. Schizophrenia ( Symptoms &Major types)
 Paranoid
 Disorganized
 Catatonic
 Undifferentiated
6. Personality Disorders
 How they're different from all other categories
 Major types: antisocial, borderline, histrionic, narcissistic
I. Anxiety Disorders
1. Generalized Anxiety Disorder
2. Phobias
3. Post-Traumatic Stress Disorder (PTSD)
4. Obsessive-Compulsive Disorder
Generalized Anxiety Disorder
Anxiety refers to worrying, a tension-filled state and a vague, unspecified fear.
Symptoms - kind of a "free-floating" anxiety that is persistent and long-term
 Worry
 Feeling edgy
 Avoiding social contacts
 Physiological arousal: racing heart, jittery, jumpy, clammy hands, stomach butterflies
 Sleeplessness
 The person cannot identify (and therefore cannot avoid) these persistent, unpleasant symptoms
 May have "panic attacks" - a minutes-long episode of intense fear that something horrible is about to
happen to them
 Panic attacks usually display: shortness of breath, choking sensations, trembling, or dizziness. They are
unpredictable and not associated with any one stimulus.
Agoraphobia - fear that if one goes out into open spaces (outside, the mall, etc.) they will have panic attacks and
there will be no help available.
Phobias
Phobias are irrational fears that focus on some specific object, activity or situation.
 There or hundreds of phobias
 Insects
 Closed spaces
 Blood
 Heights
 Tunnels
 Social phobia - intense fear of being scrutinized by others, so they avoid embarrassing social situations
Obsessive-Compulsive Disorder
Obsession - a thought that you can't get out of your mind
Compulsion - the behavior you do to get rid of the thought
Creates a vicious feedback-loop. One feeds on the other.
Common Obsessions and Compulsions
Thought or Behavior % Reporting Symptom
Obsessions (repetitive thoughts)
Concern with dirt, germs, or toxins 40%
Something terrible happening (fire, death) 24%
Symmetry, order, or exactness 17%
Compulsions (repetitive behaviors)
Excessive hand washing, bathing, tooth brushing, 85%
Or grooming
Repeating rituals (in/out of a door) 51%
Checking doors, locks, appliances, etc. 46%
Post-Traumatic Stress Disorder (PTSD)
Common among victims of sexual assault (rape) and combat veterans.
Symptoms
 Haunting memories
 Nightmares,
 Social withdrawal
 Hallucinations of event
 Fearful, anxious
 Trouble sleeping
 Sense of hopelessness about the future
 Suicidal thoughts
Explaining Anxiety Disorders
 Learning Perspective
- fear conditioning
- stimulus generalization
- reinforcement
- observational learning - monkeys & snakes
 Biological Perspective
- fears serves evolutionary purpose
- consider what we tend not to learn to fear
- genes - there is a hereditary component to phobias & OCD
- physiology - some of us are "wired" more high strung than others, PET scans show folks with OCD have
unusually high activity in frontal lobes and other areas in the brain - that's why antidepressants can help dampen
the anxious thoughts.
II. Dissociative Disorders
1. Dissociative Amnesia
2. Dissociative Fugue
3. Dissociative Identity Disorder (MPD)
4. Depersonalization Disorder
Dissociative Amnesia
Characterized by "forgetting" - failure to recall events
 Common in head injuries
 Common in alcohol poisoning (blackouts, Korsakoff's Syndrome)
 Or as a response to some intolerable psychological trauma
 Usually, it's a "selective" forgetting - we forget the trauma but we remember everything else (our name,
how to drive, etc.)
Dissociative Fugue
I call it "travelling amnesia" - has to involve a flight
 involves presumed forgetting
 and an actual flight (fleeing) to somewhere
 sometimes another personality takes over
 or sometimes it's a severe amnesia
Dissociative Identity Disorder
Commonly known as Multiple Personality Disorder (DID)
or "split personality"
DO NOT CONFUSE THIS WITH SCHIZOPHRENIA!
 presence of two or more distinct personalities
 mostly women who have suffered abuse in childhood
 tend to have parents who are harsh, authoritarian, bigoted or ultra religious & narrow minded
 kind of a "defense mechanism" - a way to handle the repressed traumas of childhood
 each personality has their own memories, traits and expressive style
 usually has something traumatic in background
 there's even distinct brain wave patterns!
 made popular by Sybil & Three Faces of Eve
 lots of controversy over this
Depersonalization Disorder - feelings of being unreal or detached - sometimes even from one's own body.
 Out-of-body experience
 Self is out there watching your own body
 Feel numb, disconnected from your body
III. Somatoform Disorders
1. Hypochondriasis
2. Conversion disorders
3. Body Dysmorphic disorder
Hypochondriasis - involves severe anxiety over the belief that one has a disease without any evident physical
cause.
 The belief is real, despite contrary evidence
 The person is preoccupied with and misinterprets bodily symptoms as indicative of an illness or disease
 Any reassurance from doctors that they aren't sick is short-lived, they'll show up again in the doctor's
office
 1% - 14% of medical patients
 Ask about koro (Chinese culture) & dhat (India)
Conversion Disorders - physical malfunctioning (or loss of a physical ability), such as blindness or paralysis,
suggesting neurological impairment, but with no organic pathology to account for it.
The "conversion" was popularized by Freud who believed that anxiety resulted from unconscious conflicts and
were somehow converted into physical symptoms. It's a kind of displacement in which the individual got rid of
some of the anxiety without actually experiencing it. The anxiety is displaced onto part of one's body.
Examples:
 Blindness
 Mutism
 Deaf
 Partial paralysis
 Some patients are blasT toward the loss and some are upset by it
 Conversion symptoms are almost always precipitated by some marked stress or trauma
 They can usually function normally, but they seem truly and honestly unaware of this ability or the
sensory input they are receiving.
Body Dysmorphic Disorder - features a disruptive preoccupation with some imagined defect in one's physical
appearance (imagined ugliness)
 Weight
 Size of your nose, ears, head, lips, butt, etc.
 Preoccupation with imagined defect who otherwise looks reasonably normal
 They become fixated on mirrors - constant checking, or almost phobic about mirrors
 Believe everything in their world somehow revolves around this imagined defect
 Might become housebound or avoid others because of it
 How about the anorexic who looks at a skinny image in a mirror and says "I'm fat"?
 They may go to extreme lengths to "correct" these defects - plastic surgery, liposuction, implants, special
skin treatments
 . . . . . . . now that you mentioned it, what's with Michael Jackson?
IV. Mood Disorders - disorders of "affect" or one's emotions.
 Major Depressive Disorder
 Mania
 Bipolar Disorder
 Dysthemia & Cyclothemia
Major Depressive Disorder - characterized by prolonged hopelessness and lethargy.
 "Common Cold" of psychological disorders
 Number 1 reason people seek psychological help
 Suicide risk is high! So, take subtle hints or threats seriously.
 Sort of a psychic hibernation - slows us down and elicits support
 Becomes maladaptive when it interferes with our life, responsibilities and goals
 Lose interest in family, friends, interests
 Rate is increasing with each generation - including teen depression
Causes of Depression
 Ask about Freud's definition of depression . . .
 Biochemical imbalance - serotonin
 Genetic influences - what do we mean by "concordance rate"? Remember linkage analysis?
 Seligman's "learned helplessness"
 Cognitive approach - negative thoughts/negative mood feedback cycle
 What explains woman's double risk for depression? (Women think/men act)
Listen to how depressives explain bad events:
1. Stable - it's going to last forever
2. Global - everything sucks
3. Internal - it's all my fault
 Negative, self-blaming, pessimistic attributions
 Ruminating on them makes them worse
 Losing a sense of perspective
 Too much individualism, not enough collectivism?
 Depression's vicious cycle (p. 474)
 Be careful, aloneness breeds lonliness (p. 475)
Mania - a mood disorder marked by extreme hyperactivity and a wildly optimistic state
 Overexcited
 Talkative
 Overactive, elated
 Easily irritated if crossed
 Little need for sleep
 Shows few sexual inhibitions
 Speech is loud, flighty, and hard to interrupt
Bipolar Disorder - person alternates between the low of depression and the overexcited state of mania (formerly
known as manic-depressive disorder).
Dysthemia & Cyclothemia - long term but more mild fluctuations of depression and/or bipolar mood swings
 Chart Depression/Dysthemia/Cyclothemia using colored pens
V. Schizophrenia - a psychotic disorder in which a person loses contact with reality, experiencing grossly irrational
ideas or distorted perceptions
Warning: Do not confuse this with split-personality (DID/MPD)
 If depression is the common cold of mental disorders, schizophrenia is the cancer.
 1% of population
 Billions in health care costs
 Cruelest and most devastating illness
 Strikes ages 17 - 26 (mostly) some late onset in 30s - 40s
 1898 German psychiatrist Emil Kraepelin 1st defined it as "dementia praecox". Dementia meaning "loss
of mind or cognitive functioning" and praecox meaning "early". He wanted to distinguish this kind of dementia from
that studied by his friend Alois Alzheimer who did so much work in studying dementia in the elderly. Kraepelin
originally identified it as a discrete mental illness and helped define the major symptoms.
 1908 Swiss Psychiatrist Eugen Bleuler - didn't like the term "dementia" because dementia usually refers
to progressive loss of cognitive functions whereas many of these people did get better over time. So, he introduced
the term "schizophrenia" meaning "splitting or fragmenting of the mind". He chose this term because the essential
feature is an inability to think clearly and to ling together "associative threads" during the process of thought and
speech.
Symptoms:
First you need to know the difference between positive vs. negative symptoms
Positive - typically those that call attention to the illness, they are the exaggeration of normal functions (the
presence of something that should be absent). Too much of something.
Negative - those that are often the first signs of the illness to appear (the loss of something that should be present).
Too little of something. These are harder to treat, persist longer and do more damage to the person.
People lose ability to
 Work
 Return to school
 Have friends
 Socialize
 Enjoy hobbies and sports
 have girlfriend/boyfriend
 feel close to family
 of pleasure and enjoyment of life
 one's personality and identity (they're just not the same anymore)
Symptoms of Schizophrenia
SYMPTOMS MENTAL FUNCTIONS
Positive
Hallucinations Perception
Delusions Inferential thinking
Disorganized speech Organization of language/ideas
Disorganized behavior Monitoring and planning of behavior
Inappropriate emotions Emotional appraisal and response
Negative
Alogia Amount and content of speech
Affective blunting Expression of emotions and
Anhedonia Ability to experience pleasure
Avolition Ability to start things and follow through
Attentional impairment Ability to focus attention
Causes & Contributing Factors
 Genetics - 10% if one parent has it, 40% if both
 Neurochemical imbalances - especially Dopamine "Dopamine Hypothesis". Serotonin and glutemate
also implicated.
 1960s Arvid Carlsson Swedish neuropharmacologist and Nobel laureat gets credit for dopamine
hypothesis.
 Neurodevelopmental disorder - something (or several things) have gone wrong in the normal
development of the brain from conception on into young adult life. Remember that the brain doesn't complete its
growth until late teens or early 20s.
 Teenage onset - remember brain begins to "prune" itself of unnecessary neurons - but in schizophrenics
there is a decline in total brain volume.
 Some research shows cerebellum may be malfunctioning as a "metronome" or timekeeper, causing
signaling to lose its syncrony and coordination.
 Faulty thalamus - supposed to act as a filter to screen information out keeping the mind from becoming
overwhelmed with too much data - so the person becomes confused or sluggish
 Enlarged ventricles - fluid filled chambers (thus less brain tissue)
 Misconnections in the brain - sort of like when your computer locks up or malfunctions in trying to
process: hardrive info, various applications, incoming modem information, printer info, screen info, and the
hundreds of systems trying to keep everything in focus and in touch. Perhaps there is a confusion of neural circuits
rather than single cells or single regions of the brain. The brain just can't integrate all the functions the way it
should.
 Viruses - acting on fetal neural development
 Seasonal data - winter & spring babies more at risk- after fall flu season (reversed in Southern
Hemisphere)
 Birth injury or perinatal complications - could cause hidden brain injury that sets the stage for later
development of schizophrenia
 Strong environmental factors - trauma and stress may trigger latent genetic/neurobiochemical
predispositions
 "Double bind" theories - putting kids in untenable situations and confusing them.
Early Warning Signs
 mother who's schizophrenia was severe and lasting
 birth complications and low birth weight
 separation from parents
 short attention span and poor muscle coordination
 disruptive or withdraw behavior
 emotional unpredictability
 poor peer relations
Subtypes of Schizophrenia
Paranoid type - symptoms primarily involve delusions and hallucinations but their cognitive skills, speech, motor
skills and emotions are relatively intact.
Disorganized type - disrupted speech and behavior, disjointed delusions and hallucinations, and flat or silly affect.
Catatonic type - motor disturbances (rigidity, agitation, odd mannerisms) predominate.
Undifferentiated type - meet the general criteria but not for any one of the defined subtypes.
Residual type - for people who have had at least one episode of the illness and who no longer display its major
symptoms but still show some bizarre thoughts or social withdrawal.
Treatment
 Combination of psychotherapy & medications
 Control symptoms, not a cure
 Some get better in time with no intervention
 Newer drugs have less side effects and target more specific receptor sites in specific areas (SSRI) neuroleptics
 Clozapine (Clozaril)
 Haldoperidol (Haldol)
 But, be careful of
Tardive dyskinesia (20-30%)
 Irreversible movement (motor) disorder
 Disfiguring tendency to grimace, twitch and pace
Akinesia
 Expressionless face
 Slow motor activity (walking, shuffling)
 Monotonous speech
Also
 Weight gain
 Slurred speech
 Feeling groggy, sleepy
 Problems with salivation
 Blurred vision
 Decreased libido
VI. Personality Disorders - they are enduring maladaptive patterns for relating to the environment and oneself,
exhibited in a wide range of contexts that cause significant functional impairment or subjective distress.
Or, "personality traits" (characteristics, etc.) that are out of control and cause drastic problems in a person's life.
 These are really different from all other major kinds of disorders
 No problem with reality, no real anxiety, no mood swings, no hallucinations just traits blown out of
proportion that can do real damage to a person and everyone he/she comes into contact with.
 The person may or may not see that they have a "problem"
 They are usually present from early childhood
 Fairly common, 10%-13% of population
 They differ according to gender: antisocial & paranoid PD is mostly male, borderline & dependent PD is
mostly female
 These traits pervade almost every aspect of a person's life: job, home, goals, relationships, etc.
Let's look closely at a few:
 Paranoid PD (Hitler?)
 Pervasive distrust and suspiciousness of others
 Interpret other people's motives as malevolent
 People are out to deceive me
 Fearful
 Distrustful without justification
 Schizoid PD
 Pervasive pattern of detachment from social relationships
 Restricted range of emotions
 Classic "hermit" who doesn't even feel need to relate
 "Extreme loner"
 Appear cold and detached from others
 Consider themselves to be "observers" rather than participants in the world
 Ted Kazinski
 Antisocial PD
 A.K.A. "psychopath" "sociopath"
 Pervasive disregard for the rights of others
 Violates the rights of others: steals, kills, con-man
 No "conscience" , no sense of "guilt", no "superego"
 No "remorse" for what they have done
 It is their "behavior" (what they do- overt acts) that stand out more than any particular "trait"
 Charles Manson, Ted Bundy, Joseph Stalin, Hannibal Lecter
 Read Truman Capote's In Cold Blood
 These people are scary, some would argue evil
 They can be cruel, lie through their teeth and they are very manipulative and cunning.
 They are very smart in using people.
 This label can only go on someone who is at least 18 years old, prior to that, we have another disorder
(for kids) called "Conduct Disorder". Kids with this almost always turn into Anti-Soc PD
Checklist - know anyone who . . . .
1. Glibness/superficial charm
2. Grandiose sense of self-worth
3. Proneness to boredom/need for stimulation
4. Pathological lying
5. Conning/manipulative
6. Lack of remorse
7. Shallow affect
8. Lack of empathy
9. Parasitic life-style
10. Poor behavioral controls
11. Promiscuous sexual behavior
12. Early behavior problems
13. Lack of realistic long-term plans
14. Impulsively
15. Irresponsibility
16. Failure to accept responsibility for actions
17. Many marital relationships
18. Juvenile delinquency
19. Poor risk for conditional release
20. Criminal versatility
 Borderline PD
 More females than males
 Most common PD - 15% of people in psychiatric settings and 50% of all PDs are these
 Very intense but turbulent relationships with others
 Lack control over their emotions
 Fear abandonment yet at other times sarcastic
 The boyfriend who abuses his girlfriend - can't live without her yet lives to beat her
 Self-destructive behaviors - cutting, burning, carving initials in body (how about excessive body
piercing?)
 Quiet impulsive
 25% of bulimics have this
 Substance abuse is common
 Suicidal
 History of trauma and/or sexual abuse
 Read cases in Piper's Reviving Ophelia
 Narcissistic PD
 Pervasive need for admiration & attention from others
 Stuck on him/herself
 Pattern of grandiosity
 See themselves as "special" and deserving of special treatment
 Exaggerated sense of self-importance
 Lack of empathy for others
 Emphasis on short-term hedonism, individualism, competitiveness and success
 Classic "me generation" - quite egocentric
 Obsessive-compulsive PD
 Preoccupation with orderliness
 Perfectionism
 Control, control, control at the expense of flexibility
 Rigid, super focused on their needs
 How is this different from OCD disorder?
 Fears that underlie the need for orderliness?
 Procrastinate and excessively ruminate about the important and the not-so-important things in their lives
 Ever seen the movie "The Odd Couple'? Check out Felix Unger.