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Chapter 14 Psychological Disorders 5/5/2017 1 5/5/2017 2 I. Dysfunctional Behavior What is “abnormal” behavior? – The 3 clinical criteria • Deviant • Maladaptive • Causing personal distress A continuum of normal/abnormal Mild AVERAGE PERSON Occasional suspicious thoughts Moderate PARANOID PERSONALITY A suspicious cognitive style (no behavioral impairment) Severe PARANOID PERSONALITY DISORDER DELUSIONAL (PARANOID) DISORDER PARANOID SCHIZOPHRENIC A suspicious cognitive style that it impairs effective behavior; no delusions; reality testing is intact A stable and chronic delusional system; reality testing good in all other areas Multiple delusions that are likely to be fragmented, accompanied by marked loosening of associations, obvious hallucinations, disorganization, reality testing markedly distorted. 5/5/2017 “Abnormal” Behavior con’t 3 Six Contemporary Views of Psychological Disorders Psychological disorders are a result of... Biomedical model Cognitive model Physical, biochemical or genetic abnormalities Faulty or unusual ways of thinking Psychoanalytic model Childhood or unconscious conflict Behavioral Sociological Faulty contingencies of reinforcements Variables such as social class, gender and living environment Bio-Psycho-Social bio, psycho and social factors combine to produce disorders 5/5/2017 4 Bio–Psycho–Social Perspective 5/5/2017 Prevalence, Causes, and Course Epidemiology – the study of the distribution of mental or physical disorders in the population Prevalence – the percentage of a population that exhibits a disorder during a specified time period Lifetime prevalence – percentage of people who have been diagnosed with a specific disorder at any time in their lives – Ex: current estimates predict about 44% of the adult population will have some sort of psychological disorder at some point in their lives. Diagnosis Etiology – apparent causation and developmental history of an illness Prognosis – forecast about the probable course of an illness. 5 5/5/2017 6 5/5/2017 Did you know… some ancient treatments involved exorcism, trephining, beating, burning, castration, blood letting, and blood replacement? 7 5/5/2017 Psychodiagnosis: The Classification of Disorders Two Classification Systems – ICD-10 and the DSM-IV – Introduced after WWII – Both systems developed from Emil Kraepelin’s early classification work (1913) ICD -10 – World Health Organization (WHO) – Contains various physical & psychological disorders – Identifies 11 categories of mental disorders 8 5/5/2017 9 The Classification of Disorders con’t DSM–IV TR ( Diagnostic and Statistical Manual of Mental Disorders – 4th ed. Revised text) – American Psychiatric Association (APA) – Multiaxial system • 5 dimensions or Axes – – – – – Axis Axis Axis Axis Axis I – Clinical Syndromes II – Personality Disorders or Mental Retardation III – General Medical Conditions IV – Psychosocial and Environmental Problems V – Global Assessment of Functioning • The first two axes are for diagnosis and the last three provide supplemental information. * Both the DSM-IV and the ICD-10 share terminology and are intentionally written to be similar. 5/5/2017 You SHOULD know… 10 neurosis is no longer used in the DSM (it is in the ICD-10). However, did you know… psychosis is no longer used in the ICD-10, but is in the DSM? Some psychiatric concepts simply outlive their publications. 5/5/2017 An OLD (but valuable) Neurosis Distinction Psychosis – Maintains contact w/ reality, based in anxiety – Breaks from reality – Only part of the personality is affected – The whole personality is affected – Has insight (recognizes problem - neurotic paradox) – Lacks insight – Neurotic behavior is viewed as an exaggeration of normal behavior 11 • Distorted perceptions (i.e. hallucinations) • Irrational ideas/delusions – Psychotic behaviors are seen as discontinuous w/ normal behavior 5/5/2017 II. Axis I Clinical Syndromes Discussed in Text A. Anxiety Disorders B. Somatoform Disorders C. Dissociative Disorders D. Mood Disorders E. Sexual Disorders F. Delusional Disorders G. Schizophrenic Disorders 12 5/5/2017 A. Anxiety–Based Disorders 13 a class of disorders marked by feelings of excessive apprehension and/or maladaptive behaviors that reduce anxiety, prevalence=17% 1. Generalized anxiety disorder (GAD) • chronic, high level of anxiety that is not tied to any specific threat • “free-floating anxiety” • a state of autonomic nervous system arousal • Facts: – Prevalence: 3%, Lifetime prevalence: 5% – Onset: anytime (higher btw. childhood & middle-age) – 2X higher in women than men/familial pattern 5/5/2017 14 Anxiety – Based Disorders con’t 2. Panic disorder • recurrent attacks of sudden, unexpected overwhelming anxiety & senseless feeling of terror • Characterized by: – – – – Heart palpitations Sweating Shortness of breath Feeling of helplessness • May lead to development of agoraphobia – 1in 3 may lead to agoraphobia • Facts: – Lifetime prevalence: 2-3% – Onset: late adolescence, early adulthood – Familial pattern (first-degree relatives – 8x higher, if onset before age 20 then may be 20x higher) – 2X higher in women than men – May be linked to depression 5/5/2017 Anxiety – Based Disorders con’t 3. Phobic disorder – Persistent and irrational fear of a specific object or situation that presents no realistic danger – Fear is out of proportion w/ reality – Fears often linked to evolutionary significance • Fear of “modern” objects less common – Today’s phobia categories • 1) simple phobias (7-11% of population) • 2) social phobias (3 - 13%) • 3) agoraphobia (6%) – Facts of a “typical” phobic disorder • • • • • • Prevalence: 4 - 8% Bimodal onset: early childhood, then adulthood 2X higher in women than men (social phobia is equal) Familial pattern, possibly due to learning May vary by age, culture and gender Duration: 24-31 years 15 5/5/2017 16 Common and Uncommon Fears 5/5/2017 17 Phobias may be acquired through classical conditioning, then maintained through operant conditioning. 5/5/2017 18 Just for Kicks! Test your Phobia Knowledge Common phobias – Acrophobia • fear of heights – Claustrophobia • fear of small, enclosed places – Brontophobia • fear of storms – Hydrophobia • fear of water Interesting Phobias 5/5/2017 Anxiety – Based Disorders con’t 4. Obsessive Compulsive disorder (OCD) 19 – Obsessions – unwelcome, involuntary and persistent thoughts/intrusions into the individual’s awareness • often center on inflicting harm on others, personal failures, suicide, or sexual acts – Compulsions - urges to engage in senseless rituals • i.e.: hand washing, repetitive cleaning, endless checking and rechecking of locks • Individual feels a need to resist, but anxiety increases if thought /action is prevented – Facts:Lifetime prevalence: ~3% • Familial patter (twin study support) • Onset: adolescence, early adulthood – Characteristics of OCD individual: • Upper – income. Intelligent • Equally male & female (early onset males) • Tend to stay unmarried 5/5/2017 Anxiety–Based Disorders/OCD con’t Myers, 7th ed. 20 5/5/2017 Anxiety–Based Disorders/OCD con’t Note the high metabolic activity (red) in frontal lobe areas involved with directing attention PET Scan of brain of person with Obsessive/ Compulsive disorder 21 5/5/2017 Don’t trust that Bost-lady… she’s polluting your mind with gooblygook! 22 5/5/2017 23 Anxiety – Based Disorders con’t 5. Post-traumatic Stress Disorder (PTSD) – Anxiety disorder in which a traumatic situation is relived through memory flashbacks or dreams – Common features: • • • • • • • Lifetime prevalence: 8% Evidence of a heritable component Onset: any age 2X higher in women than men Avoidance of activities linked to the trauma Numbed emotions Sleep disturbances 5/5/2017 24 Etiology (causes) of Anxiety Disorders Biological factors • Genetic predisposition (twin studies), anxiety sensitivity • Neurotransmitter disruption (ie - abnormalities in GABA levels in the brain = anxiety) Conditioning and learning • Maintained through operant conditioning • Acquired through classical conditioning or observational learning (parent models) • * Especially pertinent to phobias Cognitive factors • Certain styles of thinking make some vulnerable, such as over interpreting harmless situations as threatening (see next slide) Personality factors • Neuroticism Stress • A precipitating factor 5/5/2017 25 Cognitive Factors In Anxiety Disorders 5/5/2017 B. Somatoform Disorders 26 Somatoform disorders are physical ailments that cannot be explained by organic conditions. 1. Somatization Disorder – a history of diverse physical complaints that appear to be psychological in origin (ex: combo of pain, gastrointestinal and psuedoneurological problems). – Occurs mostly in women/ LP up to 2% – Often coexists with depression and anxiety disorders. 2. Conversion Disorder – Psychological conflict is “converted” into a significant loss of physical function – usually involves a single organ system…i.e. loss of vision, partial paralysis, mutism – no apparent organic basis (Ex: glove anesthesia is neurologically impossible) – LP up to 3% 5/5/2017 I’m serious…she is a “person of suspicion”! 27 5/5/2017 28 Somatoform Disorders con’t 3. Hypochondriasis – excessive preoccupation with health concerns and incessant worry about developing physical illnesses. – Characterized by: • • • • Acute awareness of one’s body Detailed accounts of one’s medical history “Doctor-shopping” Poor insight – Facts: • Prevalence: 1-5% 5/5/2017 29 Somatoform Disorders con’t Etiology Biological factors • Reactive autonomic nervous system Conditioning and learning • “the sick role” (learned avoidance strategies, reinforced by attention and sympathy) Cognitive factors • focus excess attention on their physiological processes Personality factors • Highly suggestible, histrionic type Neuroticism Stress • A precipitating factor 5/5/2017 C. Dissociative Disorders 30 a psychological adaptation to stress/trauma that involves a break in which conscious awareness becomes separate from previous memories, thoughts, feelings or identity 1. Dissociative amnesia – sudden loss of memory for personal information too extensive to be due to normal forgetting – loss may be for a single traumatic event or for an extended time period around the event. 2. Dissociative fugue – Loss of memory and sense of personal identity – “amnesia with travel” – Functional memories stay intact • i.e. forget their name, family, where they live, etc., but still know how to do math and drive a car. – Prevalence .2% 5/5/2017 31 Dissociative Disorders con’t 3. Dissociative identity disorder the coexistence of two or more complete, distinct personalities in one person * Formerly multiple personality disorder – Etiology • severe emotional trauma during childhood • child abuse elevates the likelihood of many disorders, especially among females. – Facts: • Prevalence - RARE • Only ¼ of American psychiatrists in the sample indicated that they felt there was solid evidence for the scientific validity of DID • Media creation? 5/5/2017 You don’t need psychology…just jump on a few couches and you’ll feel better. 32 5/5/2017 33 D. Mood/Affect Disorders a class of disorders marked by emotional disturbances/extremes that may spill over to physical, perceptual, social, and thought processes * Evidence suggests prevalence is increasing. 5/5/2017 Mood/Affect Disorders con’t 1. Major depressive disorder (Unipolar Depression) – Profound sadness that appears to have no apparent reason (*may follow a loss or stressful event, but continues long afterward) – Symptoms: • • • • • • • • Loss of interest in usual activities Low self-esteem Feelings of blame, worthlessness, helplessness Change in sleep patterns, change in appetite Suicidal ideation/attempts Health concerns Self-destructive behavior Cognitive changes – Slowed thought process/difficulty concentrating – Unwanted, negative thoughts – Mood congruent memory *Symptoms are present nearly every day for at least two weeks. 34 5/5/2017 Are you still taking these psych notes? Why? She is polluting your mind… you don’t really believe her do you? 35 5/5/2017 Mood/Affect Disorders con’t Note: lower activity (less yellow & white). http://www.mayoclinic.com/health/pet-scan/CA00052 36 Note: it doesn’t say “normal”. 5/5/2017 Mood/Affect Disorders con’t 37 – Facts: • LPrevalence: 10-25% female/ 5-12%male (Onset: any age (median onset age 32) • Women attempt suicide 2-3x as often as men; BUT 4x a many men as women die by suicide • Evidence suggests prevalence is increasing, particularly in certain age cohorts • Often co-occurs with anxiety disorders and substance abuse – Additional Types of Depression • Situational • Seasonal Affect Disorder (SAD) – Dysthymic disorder • chronic depression that is insufficient in severity to justify diagnosis of major depression (symptoms must persist for at least two years in adults to meet the criteria) • Lifetime prevalence: 6% • Onset: any age (median onset age 31) 5/5/2017 Seriously, are you not listening to me??? 38 5/5/2017 Mood/Affect Disorders con’t 2. Bipolar disorder (manic-depressive disorder) – Disorder in which an individual experiences one or more manic episodes accompanied by periods of depression – Divided into two categories: Bipolar I (LP 0.4-1.6%) and Bipolar II (LP .5%) • Bipolar I is marked by a higher level of mania – Individuals alternate btw. depression and mania • Symptoms of Mania: – – – – – Elevated mood/euphoria Hyperactivity/irritability Increased sociability Bizarre behavior Cognitive changes » Incoherent speech, play on words (often loud) » Grandiose, unrealistic self-evaluation 39 5/5/2017 Comparing Symptoms Mania vs. Depression 40 5/5/2017 http://www.nimh.nih.gov/publicat/bipolar.cfm#bp1 41 5/5/2017 42 5/5/2017 43 Bipolar disorder con’t – Facts: • • • • • Prevalence: Bipolar I (LP 0.4-1.6%) and Bipolar II (LP .5%) Equally common in males & females Onset: first manic episode - early twenties (median age 25) Manic episodes tend to be shorter in duration, end abruptly “rapid cyclers” - four or more episodes occur w/in a 12 mo. period (about 15% of cases)* * Develops later in illness, more women than men – Cyclothymic disorder • chronic but relatively mild symptoms of bipolar disturbance. • LP 0.4- 1% http://www.nimh.nih.gov/publicat/numbers.cfm#MajorDepressive – Prevalence rates 5/5/2017 44 Bipolar Disorder PET Scan at Various States Depressed state Manic state High activity Depressed state Low activity Note: Brain energy consumption rises and falls with emotional switches 5/5/2017 Mood/Affect Disorders con’t Etiology: Major Depression – Genetic vulnerability – Neurochemical factors • Disrupted chemical levels at the norepinephrine and serotonin synapses • Serotonin = low levels – Disrupted circadian rhythm – Cognitive factors • Learned helplessness • Pessimistic explanatory style (Martin Seligman) – Interpersonal roots – Precipitating stress 45 Etiology: Bipolar Disorder – Genetic vulnerability – Vulnerability + personal or environment triggers – Neurochemical factors • acetylcholine sensitivity (?) • hypothyroidism 5/5/2017 Why won’t anyone believe me… “There is no such thing as a chemical imbalance.” 46 5/5/2017 47 5/5/2017 Over one hundred years of research is wrong. I am right because I have “read a book”. 48 5/5/2017 49 E. Sexual Disorders (only some) Paraphilias – Arousal to objects or activities involving either • (1) nonhuman objects (i.e. fetishism) • (2) the suffering or humiliation (not merely simulated) of oneself or one's partner (i.e. sadism/masochism) • (3) children or other nonconsenting persons (i.e. pedophilia, voyeurism, exhibitionism) • The diagnosis is made only if the person has acted on these urges, or is markedly distressed by them. • Prevalence: difficult to determine 5/5/2017 50 Ever have the sensation that someone is watching you? 5/5/2017 F. Delusional Disorders 51 class of disorders characterized by a wellorganized system of false beliefs, yet lacking schizophrenic symptoms Facts: – – – – Reality testing is good in other areas Prevalence - .03% Onset: 40-50 years old Anti-psychotics may be used as treatment Some types: – – – – Paranoid Jealous Erotomatic Granduer 5/5/2017 52 G. Schizophrenia psychological disorder characterized by faulty reality testing and gross cognitive disturbances General symptoms – Faulty reality testing • Delusions (false beliefs) and irrational thought • Hallucinations - sensory perceptions that occur in the absence of a real, external stimulus or are gross distortions of perceptual input – Deterioration of adaptive behavior • deficits in routine functioning (work, social, hygiene) 5/5/2017 Schizophrenia General symptoms con’t – Disturbed (flat or inappropriate) emotions – Cognitive Processing Disturbances • Incoherent or chaotic thinking – Loose associations or word salad – Memory deficits • Incoherent or chaotic speech – Odd motor behavior – Altered sense of self (possible loss of identity, may be part of delusional system) 53 5/5/2017 54 Subtyping of Schizophrenia *Note: general symptoms are present to warrant a schizophrenic diagnosis, however, distinct patterns of behavior may warrant diagnosis of a specific subtype 4 subtypes (DSM-IV) – Paranoid type • dominated by delusions of persecution, along with delusions of grandeur – Catatonic type • marked by striking motor disturbances, ranging from muscular rigidity (catatonic stupor) to random motor activity. – Disorganized type (hebephrenic) • severe deterioration of adaptive behavior , childlike/silly behavior, incoherence, complete social withdrawal, delusions centering on bodily functions. – Undifferentiated type • clearly schizophrenic, but cannot be placed in any of the above subtypes 5/5/2017 I think I can beat up Matt Laurer! Wait until I see him again on the today show. 55 5/5/2017 56 Schizophrenia con’t Critics push for new model of classification – Positive vs. negative symptoms • positive symptoms – behavioral excesses or peculiarities (hallucinations, delusions, bizarre behavior) • negative symptoms – behavioral deficits (flattened emotions, social withdrawal, apathy, impaired attention, poverty of speech) Facts: – Prevalence: 1% population – First classified by Emil Kraepelin as “dementia praecox” (premature madness) – Eugen Bleuler coined term “schizophrenia” 1911 – Affects men and women equally – Onset: men – late teens, early twenties women – twenties, early thirties – Favorable prognostic factors • • • • Acute onset @ later age Adaptive behavior prior to onset Low negative symptoms Support system 5/5/2017 57 Etiology of Schizophrenia 1. Biological and/or Genetic vulnerability • Family history, twin studies • Defect on chromosome 5 5/5/2017 58 Etiology of Schizophrenia con’t 2. Neurochemical factors • Dopamine Hypothesis = elevated levels of dopamine Dopamine, dopamine & MORE dopamine!!!!!! 5/5/2017 Etiology of Schizophrenia con’t 59 3. Structural abnormalities of the brain • Enlarged ventricles (correlation w/ lower alpha waves) • Metabolic abnormalities in prefrontal (positive symptoms) and temporal lobes (negative symptoms) • Left hemisphere activity even when not engaged in problem solving 5/5/2017 Etiology of Schizophrenia con’t 4. Neurodevelopmental hypothesis • Maturational disruptions (prenatal or early life) 5. Diathesis-stress hypothesis • Environmental stressors trigger onset – Stressor examples: Double binds, low SES, highly critical or emotionally over involved families 60 5/5/2017 61 H. Developmental Disorders class of varied disorders that first become evident between infancy & adolescence Autism – Prevalence: recent increase – Marked by severe impairment in… – Communication – Social relationships – Activity Clip: "In My Language" with Amanda Baggs (Utube video – I can’t connect to it in school, so if you want to see it go to Utube. It’s a good one – you have to watch it all the way to the end to “get it”.) ADHD – Prevalence 3%, more boys than girls – Marked by • Inattentive • Hyperactivity • Impulsiveness Academic Skills Disorders Enuresis (past age 5 - @ night) Encopresis (past age 3) 5/5/2017 Axis II Disorders I. Personality Disorders a class of disorders marked by enduring, inflexible and maladaptive behavior patterns that impair social functioning (usually without anxiety, depression, or delusions) * May resemble personality characteristics that are seen in people functioning adaptively Anxious-fearful cluster – Avoidant, dependent, obsessive-compulsive Dramatic-impulsive cluster – Histrionic, narcissistic, borderline, antisocial Odd-eccentric cluster – Schizoid, schizotypal, paranoid Etiology – Genetic predispositions – Inadequate socialization in dysfunctional families See class handout for details! 62 5/5/2017 Did you know… boys who were later convicted of a crime showed relatively low arousal? Myers, 8th ed. 63 5/5/2017 Good details – if you want to, put on right hand side. 64 5/5/2017 Inside a Criminal Mind Normal Murderer PET scans show reduced activation in a murderer’s frontal cortex 65 5/5/2017 Are you diagnosing me? Don’t do it or you too will be a person of suspicion!!!! 66 5/5/2017 67 Psychological Disorders and the Law Insanity (legal term) – M’naghten rule - insanity exists when a mental disorder makes a person unable to distinguish right from wrong at the time of the crime Involuntary commitment (temporary: 24-72 hours) – danger to self – danger to others – in need of treatment 5/5/2017 68 Remember, the availability heuristic influences our perception of how often the insanity defense is used. 5/5/2017 69 IV. Culture and Pathology * Note: Culture-bound disorders illustrate the diversity of abnormal behavior around the world, as well as cultural influence. Examples of culture bound disorders – Anorexia nervosa – Windigo – Koro 5/5/2017 THE END! Keep Working on your note cards. The test will be after we talk about treatments. Don’t let that Bost-lady win. I am the supreme voice on psychology…don’t trust her! 70