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Chapter 6 Mental Disorder Cao Fenglin Section 1 Mental Disorder : An Introduction 1. Definition of mental disorder ◆Mental disorder refers to the abnormality of mental process and personality, such as perception , thought , memory , intellect , attention , emotion , will , behavior etc. Mental health 2. Criteria of judgment ◆ Experience criterion (Subjective distress) ◆ Statistical criterion (Deviation from statistical norms) ◆ Medical criterion ◆ Social adaptation criterion (Deviation from social norms) ◆ Time criterion (Length of time) ◆ Dysfunction Experience criterion ◆ A person has a mental disorder if they experience personal distress. Mental disorder may be defined as abnormal if it creates subjective distress. (For example, a hallmark of mood and anxiety disorders is heightened subjective distress.) ◆Observer’S experience Problem (Cont) • Not all distressed individuals are mentally ill . • Some mentally ill individuals do not show distress (psychopaths). Statistical deviance • A person has a mental disorder when their behaviour, ability, or experience is significantly different from average. • Abnormal behavior is often infrequent. Mental disorder as statistical deviance (Cont) Problem (Cont) • We want to use the term disorder to describe some conditions that are statistically infrequent. • “positive” deviations are not distinguished from “negative” deviations • Not all unusual behavior is considered abnormal. (e.g., superior athletic, musical, or intellectual ability) Medical criterion The medical criterion proposes that mental disorders have a biological basis, can be classified into discrete categories, and are analogous to physical disease. • Symptoms: Signs of a disorder • Diagnosis: To distinguish one from another • Etiology: Cause • Prognosis: The likely course of the disorder Medical criterion (Cont) • To think of abnormal behavior as a disease, such as “mental illness” “psychological disorder” • Rise of medical model brought improvement in treatment • Viewed with more sympathy, less fear Problems: • Labelling Mental disorder as deviation from social norms • A person has a mental disorder if they have experiences and exhibit behaviours that are inconsistent with the norms and values of society of a given culture. • Examples: – Behaviour that is harmful to oneself or others – Poor reality contact – Inappropriate emotional reactions – Erratic behaviour Homosexuality was defined as a disorder in previous DSM Manuals Problem (Cont) • The violation of norms explicitly makes abnormality a relative concept. • Social norms may change which behaviors are deemed abnormal. E.g., Homosexuality was once classified as a mental disorder in the DSM (up till 1973). • Criminals and prostitutes violate social norms, but would not necessarily fall within the context of abnormal psychology. Dysfunction • Does the behavior impair an individual’s ability to function in life (work, personal relationships)? (E.g., internet addiction) Problem (Cont) • Some individuals with a DSM diagnosis, live functional lives (e.g., transvestites). 3. Causal factors of mental disorder (1) Biological factors ◆Genetic vulnerabilities ◆Biochemistry (neurotransmitter and hormonal imbalances) : dopamine, 5-hydroxyl tryptamine and norepinephrine. ◆Physical disease: Infection, toxicosis, various metabolic block etc. (2) Psychological factors • Acute mental trauma • Enduring mental trauma (3)Social factors ◆politics, economy, religion , culture , ethics morality , customs, habits , family environment and interpersonal relationship. 4. Classification ◆Phenomenology classification (1) cognition disorder (2) emotion disorder (3) will and behavior disorder (4) conscious disorder ◆Psychiatric classification (1)ICD-10 (International Classification of Disease, the tenth version ) (2)CCMD-Ⅲ ( Chinese Classification of Mental Disorder and Diagnostic Criteria, the third version ) (3)DSM-Ⅳ (Diagnostic and Statistical Manual, the forth version) Section 2 Anxiety Disorder 1.Definition of anxiety ◆Anxiety is an uncomfortable feeling that occurs in response to the fear of being hurt or losing something valued. ◆Anxiety is a common human emotion. The morbidity of anxiety disorder is about 15%. The female overtakes the male. Adaptation functions of anxiety ◆The first one is signal function. ◆The second one is to mobilize body and regulate behavior. ◆The third one is learning and accumulating experience. Normal Anxiety “Disordered” or “Maladaptive” Experience of Anxiety or Fear “Normal” or “Adaptive” Experience of Anxiety or Fear Symptoms of anxiety (1) Mood of tension and worry (2) Mental symptoms (3) Physical symptoms • Worry constantly about yesterday's mistakes, tomorrow’s problems. • Worry about family, finances, work, personal illness more than others. • May see muscle tension, poor concentration, irritability, sleep disturbance, feeling on edge. video A case: ◆Hazel was walking down a street near her home one day when she suddenly felt flooded with intense and frightening physical symptoms. Her whole body tightened up, she began sweating and her heart was racing, she felt dizzy and disoriented. ◆She thought, “I must be having a heart attack! I can’t stand this! Something terrible is happening! I’m going to die.” Hazel just stood frozen in the middle of the street until an onlooker stopped to help her. ◆Physiological/somatic symptoms Heart racing Sweating Tense muscles ◆ Cognitive Symptoms Often exaggerated beliefs ◆ Behavioral Symptoms Freezing ◆ Emotional Symptoms Sense of dread and terror 2. Classification (1) Reality anxiety (objectivity anxiety) ◆Reality anxiety is fear of real-world events. ◆The cause of this anxiety is usually easily identified. For example, a person might fear receiving a dog bite when they are near a dog. ◆The most common way of reducing this anxiety is to avoid the threatening object. (2 ) Id anxiety (neurotic anxiety) Neurotic anxiety is the unconscious worry that we will lose control of the id's urges, resulting in punishment for inappropriate behavior. ◆" free-floating anxiety" ◆phobia ◆panic response (3) Moral anxiety ◆Moral anxiety involves a fear of violating our own moral principles. ◆In order to deal with this anxiety, Freud believed that defense mechanisms helped shield the ego from the conflicts created by the id, superego, and reality. 3. Causal factors and psychology theory ◆A precise cause of anxiety disorder is not known, but researches have identified a variety of biological, psychological, social,and cultural factors. (1) Biology mechanism ◆Research shows that anxiety disorder tends to run in families, so a genetic link may be involved. ◆AD is associated with irregular levels of neurotransmitters in the brain , such as norepinephrine and serotonin. ◆Specific medical conditions, such as an overactive thyroid gland, also can produce anxiety and its symptoms. Anxiety disorder also occurs more frequently in people with chronic conditions such as diabetes or high blood pressure. ◆Anxiety is coordinated partly by a small organ deep inside the brain called the amygdala. The amygdala is involved in stress, fear, anxiety. The Limbic System (2) Psychosocial mechanism ◆Traumatic events in early life can make a person vulnerable to anxiety disorders. ◆Parenting style, family environment and culture may also influence whether a person is susceptible to developing AD. 4. Mental intervention of anxiety disorder • Precaution • Drug treatment • Psychological treatment Relaxation method Biofeedback training Cognitive behavioral therapy Section 3 Depressive disorder 1. Definition ◆ Depressive disorder is mental illness characterized by a profound and persistent feeling of sadness or despair ..., accompanied with anxiety, body malaise and sleep disorder. There are four main types of symptoms • • • • Mood Cognitive Motivational Somatic (Bodily) video Characteristic symptoms(in detail) ◆feelings of hopelessness, pessimism ◆insomnia, early-morning awakening, or oversleeping ◆appetite and/or weight loss ◆decreased energy, fatigue, being“ slowed down” ◆loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex ◆feelings of guilt, worthlessness, helplessness ◆thoughts of death or suicide; suicide attempts ◆restlessness, irritability ◆persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain 2. Causes of depression ◆Biological causes Genetic factors ●Scientists believe genetic factors play a role in some depressions. ● Recent genetic research also supports earlier studies reporting family links in depression. ◆For example, if one identical twin suffers from depression, the other twin has a 70 percent chance of also having the illness. ◆Other studies that looked at the rate of depression among adopted children supported this finding. Depressive illnesses among adoptive family members had little effect on a child's risk of depression; however, the disorder was three times more common among adopted children whose biological relatives suffered depression. Biochemical causes ◆The neurotransmitters believed to play a role in mental functioning are serotonin (5-HT), noradrenaline (NA), dopamine (DA) . ◆ When the normal balance of these neurotransmitters is upset, depression may develop. Hormones and the endocrine system ◆Abnormal functioning of the endocrine system may cause abnormal levels of hormones to be present in the body, potentially playing a role in the development of depression. ◆Dysfunction of hypothalamic-pituitary-adrenal axis ◆Dysfunction of hypothalamic-pituitary-thyroid axis. Brain structure and function • MRI • fMRI • PET Medical conditions ◆It is believed that those individuals with chronic and/or very serious medical conditions may be at increased risk of developing depression. • • • • • • Epilepsy Diabetes Stroke Brain trauma Parkinson's disease Some cancers Environmental situations ◆Many environmental factors may be linked to depression, including stress, trauma, childhood events. Psychological/Cognitive factors – Attributions are inferences we draw about causes of events, others’ behavior, own behavior. – Hopelessness theory of depression: ◆People who are depressed tend to make internal, stable, global attributions for negative experiences and external, unstable, and specific attributions for positive experiences. Maladaptive thoughts in depression 3.Mental intervention of depressive disorders ◆Most people with a depressive illness do not seek treatment, — even those whose depression is extremely severe— can be helped. ◆ There are now medications and psychosocial therapies such as cognitive/behavioral, “talk,” or interpersonal that ease the pain of depression. Medications • There are several types of antidepressant medications used to treat depressive disorders. • These include newer medications—chiefly the selective serotonin reuptake inhibitors (SSRIs)—the tricyclics, and the monoamine oxidase inhibitors (MAOIs). • Hospitalization • Supportive psychotherapy • Cognitive therapy Section 4 Personality Disorder 1. Definition • An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. 2. Classification • ICD-10 (International Classification of Disease, tenth version ) There are eight personality disorders. ◆ Paranoid PD – Suspicious, believes that other people will treat you wrongly, insists on own rights. ◆ Schizoid PD – Defective capacity in forming social relationships; absence of warmth and tender feelings for others. ◆ Dissocial PD – Chronically violating rights of others; failing to accept social norms or sustain work behavior. ◆ Emotionally Unstable PD (Explosive type,Borderline type,Aggressive type) – Characterized by instability, impulsivity, recklessness, explosiveness. ◆ Histrionic PD – People who show exaggerated emotional expressions and have an extremely strong longing for attention. ◆ Obsessive-Compulsive PD – Preoccupied with organization, rules, schedules, lists; extremely serious, formal; unable to express warm emotions. ◆ Anxious, Avoidant PD – Excessively sensitive to personal rejection, humiliation; socially withdrawn in spite of desire for acceptance from others. ◆ Dependent PD –Not able to make day-to-day decisions. They are afraid of being rejected or abandoned, and they put aside their own wishes and needs, while doing what others want. 3.Cause of personality disorders ◆A combination of personal history and biology appears to play a role in most personality disorders. 4. Mental Intervention ◆psychotherapy and medications. -Psychodynamic psychotherapy, Cognitive behavior therapy -Medications may help alleviate these related conditions, but they can't cure the underlying disorder. Section 5 Maladaptive Behavior 1.Alcohol dependence ★Concept Alcohol dependence is a condition characterized by the harmful consequences of repeated alcohol use, a pattern of compulsive alcohol use, and (sometimes) physiological dependence on alcohol (i.e., tolerance and/or symptoms of withdrawal). Four main features of alcohol dependence • Physical dependence, with a characteristic withdrawal syndrome that is relieved by more alcohol (e.g., morning drinking); • Physiological tolerance, so that more and more alcohol is needed to produce the desired effects; • Difficulty in controlling how much alcohol is consumed once drinking has begun; • A craving for alcohol that can lead to relapse if one tries to abstain. Harmful to health • School and job performance may suffer either from hangovers or from actual intoxication on the job or at school; child care or household responsibilities may be neglected; and alcoholrelated absences may occur from school or job. • Individuals with this disorder are at increased risk for accidents, violence, and suicide. Cause of alcohol dependence • It is estimated that 40%-60% of the variance of risk is explained by genetic influences. • The risk for alcohol dependence is 3 to 4 times higher in close relatives of people with alcohol dependence. Intervention of alcohol dependence • Behavior therapy • Family therapy VIDEO 2.Tobacco (Nicotine )addiction ★Concept • Nicotine addiction is classified as nicotine use disorder according to the DSM-IV-TR. The criteria for this diagnosis include any 3 of the following within a 1-year time span: – Tolerance to nicotine with decreased effect and increasing dose to obtain same effect – Withdrawal symptoms after cessation – Smoking more than usual – Persistent desire to smoke despite efforts to decrease intake – Extensive time spent smoking or purchasing tobacco – Postponing work, social, or recreational events in order to smoke – Continuing to smoke despite health hazards Signs and symptoms ◆Individuals can't stop smoking. They have made one or more serious, but unsuccessful attempts to stop. ◆They experience strong withdrawal symptoms when they try to stop. Their attempts at stopping have caused physical signs and symptoms of addiction, such as craving for tobacco, anxiety, irritability, restlessness, difficulty concentrating, headache, drowsiness, stomach upset, even constipation or diarrhea. ◆They keep smoking despite health problems. Even though they have developed problems with their lungs or their heart, they haven't stopped or can't stop. ◆They give up social or recreational activities in order to smoke. They may stop going to certain restaurants or stop socializing with certain family members or friends because they can't smoke in these situations. Harmful to health • Being addicted to tobacco brings smokers a host of health problems. These effects include damage to their lungs, heart and blood vessels. Smokers have significantly higher rates of heart disease, stroke and cancer. If you are a smoker, you have: • 22 times the risk of dying from lung cancer if male • 12 times the risk of dying from lung cancer if female Intervention • Health education • Behavior training • Cognitive-Behavioral therapy • There are many ways to quit smoking, including using medications and getting some sort of counseling or support. • The approved effective medications to help smokers stop smoking fall into two categories — nicotine replacement therapy and non-nicotine medications. Any of these effective medications combined with behavioral changes can double your chances of quitting. 3.Drug dependence ★Concept ◆Drug dependence is used to describe continued use of drugs, even when significant problems related to their use have developed. VIDEO Symptoms • Psychological addiction • Physical addiction • Tolerance Classification • • • • • • • Substances frequently abused include, but are not limited to, the following: alcohol marijuana hallucinogens cocaine amphetamines opiates Tranquilizer Intervention ◆Detoxification and long-term follow-up management are important features of successful treatment. ◆Long-term follow-up management usually includes formalized group meetings and developmentally ageappropriate psychosocial support systems, as well as continued medical supervision. ◆Individual and family psychotherapy are often recommended to address the developmental, psychosocial, and family issues that may have contributed to and resulted from the development of a substance abuse disorder. 4. Internet Addiction ◆Concept Internet Addiction, also described as pathological internet use, is defined by an individual’s inability to control his or her use of the internet, which eventually causes psychological, social, school, and/or work difficulties in a person’s life. Symptoms of internet addiction Intense desire Tolerance Withdrawal Behavior modification Cognition distortions Diagnosing internet addiction • Young (1998) developed an eight-item Internet Addiction Diagnostic Questionnaire (YDQ) • Davis developed the Online Cognition Scale (OCS) that measures problematic Internet use. • Chou’S Questionnaire • Chen’S Questionnaire Mental intervention of internet addiction • • • • • • • • Practice The Opposite External Stoppers Setting Goals Abstinence Reminder Cards Personal Inventory Support Groups Family Therapy