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PSY 190: General Psychology Chapters 15: Psychological Disorders & Treatment What Behaviors Are Abnormal? How do we define what is abnormal? The culture’s perspective The generation’s perspective The individual’s perspective The Culture’s Perspective Deviance Here, we are looking at the degree in which an individual’s behavior differs from cultural norms Standards of acceptability vary from culture to culture But to be considered disordered, the atypical behavior must also be disturbing to other people The Generation’s Perspective Standards of acceptability also vary from generation to generation The Individual’s Perspective Distress Does the individual feel psychological pain? Disability Does the behavior interfere with the person’s ability to function personally, socially, or occupationally? Many psychologists believe this is the best criterion for determining the normality of behavior – does it foster individual and group well-being? Traditional Views of Abnormality Demonological Model Some mentally ill individuals were considered witches… Submerged into water – if they drowned it was felt they weren’t really witches Thousands of women were killed in this manner during 13th-16th century A Little History of Mental Illness… Physiological Treatment Bleeding Fear Excessive blood in the brain Put in coffin-like box and submerged in water until bubbles from the patient’s breathing had ceased to come to the surface at which point the person was revived… Drugs The use of alcohol, opium, and marijuana were used to try to cure these individuals A Little History of Mental Illness… Asylums During this time (late 1300’s), places where the mentally ill were cared for began to surface Before this, these people were treated as criminals and put in jails or prisons A medical model where psychological disorders were considered to be sicknesses that could be cured through therapy at a psychiatric hospital became the prevailing viewpoint Bedlam Hospital of St. Mary of Bethlehem (established officially in 1500’s) Bedlam – “lunatics” were treated cruelly…if they became too excited they were chained out of harm’s way and often beaten or doused with water Visitors would pay a small fee to be allowed to go in and ridicule the patients for entertainment purposes The crowds would often become very noisy and disorderly themselves – hence, the name Removing the chains… Medical Model Philippe Pinel institutes a medical model – that psychological disorders were sicknesses That psychopathology needs to be diagnosed on the basis of its symptoms and cured through therapy Biopsychosocial Model Mental disorders are seen as caused by the combination and interaction of: Biological Factors: Includes physical illnesses and disruptions of bodily processes that may in part be due to genetic predispositions Psychological Factors: Includes psychological processes such as our wants, needs, and emotions; our learning experiences; and our way of looking at the world Sociocultural Factors: Includes the social and cultural context that form the background of the abnormal behavior Classifying Psychological Disorders Diagnostic and Statistical Manual Of Mental Disorders (DSM-5) The behavior pattern of all psychological disorders were not clearly described until the publication of the APA’s first diagnostic and statistical manual (DSM-I) in 1952 DSM-5 recently published in 2013; defines 17 major categories of mental disorder Classifying Psychological Disorders Advantages of DSM-5 classification: – No longer the communication problems of the pre1950’s – Allows us to figure out how many people are suffering from these disorders (statistics are now available) – Specific symptoms for each diagnosis are clearly listed – Decision trees: Set of questions leading to correct diagnosis – The distinctive categories in the DSM-5 contribute to the planning of treatment programs and facilities Criticisms & Weaknesses of DSM DSM labels too many conditions are “mental illnesses” The number of disorders listed has been increased Research indicates that almost half (a recent report says 46.4%, see my website) of our population will suffer from a mental disorder at some time during their lives Diagnostic categories are imperfect Differences in clinical judgments Anxiety Disorders Deciding when anxiety is so severe that it is a disorder depends on several variables, and physicians differ in making the diagnosis… If anxiety is very distressing, interferes with functioning, and does not stop spontaneously within a few days, an anxiety disorder is present and merits treatment Anxiety Disorders Generalized Anxiety Disorder Panic Disorder Phobic Disorders Obsessive-Compulsive Disorder Generalized Anxiety Disorder Symptoms and Issues Anxiety that is constantly present Distractibility, fatigue, muscle tension, sleep disturbances Chronic unrealistic or excessive worry To be diagnosed, the worry must last six months and not be limited to a single life circumstance Always apprehensive even when things seem to be going well Symptoms and Issues Trouble making decisions – agonize over them – then once they finally make the decision… Sex difference: Women 6.6% Men 3.6% Onset: anytime Complications High risk for development of substance abuse or dependence Self-medicating Physiological Explanation: Chemical imbalances Serotonin low levels GABA low levels Norepinephrine high levels Medications Antidepressants and anti-anxiety drugs Valium, Xanax, etc. These fast-acting drugs increase GABA activity Minor Tranquilizers These increase the activity of the inhibitory neurons so that the excitatory neurons will be less active Prognosis Not very good…can be long-standing and difficult to treat Panic Disorder Usually brief periods of intense anxiety Usually unexpected and do not appear to be provoked by the situation the person is responding to Prevalence and Onset Lifetime prevalence: Approximately 1 to 3% of adults Sex difference: Females 4% Males 2% Onset Usually before age 25 Symptoms Rapid deep breathing Hyperventilation Racing heart rate Chest pain Excessive sweating Dizziness and Nausea Chills, shaking, etc. Physiological Explanation It appears that these people have an overly sensitive respiratory control center (RCC) in their brain: RCC detects small increases in carbon dioxide Because of oversensitivity it sends false alarms Higher brain structures think we are suffocating We panic Physiological Explanation Genetics seems to play a role: Biological relatives: 25% Non-Biological relatives: 2-4% MZ twins higher concordance than DZ twins About 5 times more than likely Treatments Medication Anti-anxiety and antidepressants have been successful… Xanax Zoloft Prognosis Bad news This illness can be chronic and difficult to treat One study found 80% of patients were still symptomatic at a 20 year follow-up evaluation Good news Although, disorder may not be cured…nearly all can expect improvement with a drug/psychotherapy combo Phobias Fear that interferes with normal living Fear has no justification in reality Fear is greater than is justified Individual is aware of irrationality of fear Phobias Social phobia Agoraphobia Specific phobias What is Social Phobia? Irrational fear that they will behave in an embarrassing way Is limited to situations in which the scrutiny of others is likely Extreme form of shyness that interferes significantly with an individual’s functioning These individuals avoid all social situations Prevalence/Onset Most studies say its about 4% Sex difference: Slightly more women than men Average onset Early adolescence Symptoms Avoidance of all social situations High anxiety if ever placed in a social situation Rapid heart rate Elevated blood pressure History of phobia What causes social phobia? Basically unknown but… Possible biological reasons: scarcity of serotonin Possible environmental factors… Agoraphobia These people suffer from intense anxiety when in a place where escape would be difficult or embarrassing if they were to experience a panic attack Fear being in a place where they can’t get help In extreme cases, they may not leave their house Prevalence and Onset Prevalence Sex difference Estimated 5% of general population will suffer from agoraphobia Women 7% Men 3.5% Onset Usually occurs in their 20’s Prognosis Very good – 90% improve Specific Phobias DSM-IV classifies all other phobias (besides social phobia and agoraphobia) as “specific phobias” We’re talking about specific objects or situations here Sex difference: Women 16% Men 7% Associated features: depressed mood and dependent personality Exposure to the phobic stimulus may lead to a panic attack As with other phobias, the person recognizes that the fear is excessive and unreasonable Explanations for Phobias Evolutionary Psychodynamic Behavioral Symbolically expressed conflicts and stress Classically conditioned fears Physiological Neurological arousal and genetics Treatment for Phobias Fear-Reduction Methods Systematic Desensitization Breathing and relaxation techniques are sometimes used in conjunction with systematic desensitization Virtual Therapy Flooding Physiological Approach Drug treatment Commonly anti-depressants and anti-anxiety meds are used: Prozac, Paxil, Zoloft, Elavil, etc. Xanax, Klonipin, etc. Prognosis Very good – 90% improve Obsessive-Compulsive Disorder (OCD) To be diagnosed with OCD, a person must have recurrent obsessions and compulsions that are disabling Significantly interfere with a person’s routine, making it difficult to work, or to have a normal social life or relationships Prevalence and Onset Prevalence Life-time prevalence Afflicts 2%-3% of population some time in their lives Group differences No sex differences Knows no geographic, ethnic, or economic boundaries Onset About two-thirds develop the disorder before they are 25 years old and only 15% after the age of 35 Onset after 40 is very rare Obsessions Constant, intrusive, unwanted thoughts causing distressing emotions such as anxiety or disgust Examples: Thoughts of violence (person feels he/she will hurt someone) Thoughts of contamination (germs) Thoughts of uncertainty (did I lock the door?) They understand yet it doesn’t matter… They know thoughts are irrational Compulsions Compulsions are urges to do something to lessen discomfort Rituals are the behaviors in which these people engage in to accomplish this Physiological Explanations Scarcity of serotonin In certain brain structures there are high levels of brain activity (orbital frontal, etc.) Brain damage Genetics Common Treatments for OCD Cognitive-Behavioral Therapy Antidepressant Medications Cognitive-Behavioral Therapy Response prevention Preventing the person from doing the compulsion or mental act Relaxation techniques Cognitive techniques such as self-talk are often combined with the above techniques Cognitive-Behavioral Therapy Effectiveness: 60-80% of those using the cognitivebehavioral treatments improve (show at least a partial reduction in symptoms) Antidepressant Medications Drugs that influence (increase) serotonin levels have been used effectively Prozac, Zoloft, Paxil, Anafranil, etc. Drawbacks: High doses of these drugs may be required in the treatment of OCD It can take several weeks to feel their beneficial effects Additionally, there are potential side effects to consider Prognosis The disease is chronic for most people even with drug treatment Partial reduction of symptoms is seen in most Most take medication indefinitely, and about 85% of people relapse within one or two months after discontinuing usage Substance Dependence (Addiction) Addiction A chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences Dependence Often used interchangeably with addiction Substance Abuse The use of a drug with serious consequences Substance Misuse Contemporary term The Substance Use and Misuse Journal prefers this term Rationale is that Substances are used or misused; living organisms are and can be abused Alcoholism Refers to one’s dependence on alcohol that seriously interferes with one’s life Most common and costly form of drug abuse in U.S. Aproximately 7% of adults 18 and over (10M people) Traditionally more common (about 2 to 1) among males but recent research suggests that women are closing this gap Detrimental Effects Life span of average alcoholic is 12 years shorter than the norm Alcoholism ranks as the third leading cause of death in U.S. More than one-third suffer at least one coexisting mental disorder Organic impairment such as brain shrinkage occurs in a high proportion of alcoholics About 20% attempt suicide About 10% are successful Symptoms of Alcohol Dependence Use alcohol to boost self-confidence and to relax around others Drink to forget their problems or to relieve stress Often are the ones who want “one more” drink even when their friends have stopped drinking After friends have left they drink with new friends…often close the bar…stay past last call Get drunk without planning to Have blackouts Blackouts Blackouts are much more common among social drinkers than previously assumed and should be viewed as a potential consequence of acute intoxication regardless of age or whether the drinker is clinically dependent on alcohol Blackouts White, Signer, Kraus, & Swartzwelder (2004) Surveyed 772 college undergraduates about their experiences with blackouts and asked, “Have you ever awoken after a night of drinking not able to remember things that you did or places that you went?” Of the students who had ever consumed alcohol, 51 percent reported blacking out at some point in their lives, and 40 percent reported experiencing a blackout in the year before the survey Of those who reported drinking in the 2 weeks before the survey, 9.4 percent said they blacked out during that time The students reported learning later that they had participated in a wide range of potentially dangerous events they could not remember, including vandalism, unprotected sex, and driving Symptoms of Alcohol Dependence Lie about their drinking, try to hide it, sneak drinks at work or school Drink in the morning to cure a hangover May begin to have financial, work, or family problems Complete loss of control Genetic & Family Background Six genes have been linked to addiction Seems to be linked primarily to early-onset alcoholism Treatments Rehab Centers Treatment centers where the addict is supervised 24/7 Supervised detoxification period to eliminate drugs from our bodies system Alcoholics Anonymous Self-help group Little research because of members anonymity but indications are most don’t stick to it Need to go to regular meetings for it to work 90 meetings in first 90 days and then at least once per week after that Antabuse A type of aversion therapy where usually a pill is taken that will cause the patient to become sick whenever they drink alcohol Contingency Management Monitor alcohol use by Breathalyzer; reinforcement is given Dissociative Disorders Dissociative Amnesia Dissociative Fugue Dissociative Identity Disorder Dissociative Amnesia Prevalence Very rare (less than 1%) Symptoms The sudden inability to remember important personal information or events Usually begins as a response to intolerable psychological stress Dissociative Fugue Formerly termed Psychogenic Fugue Name of illness also changed in DSM IV An episode during which an individual leaves his usual surroundings unexpectedly and forgets essential details about himself and his lives It is very rare, with a prevalence rate of about 0.2% in the general population Etiology Is usually triggered by traumatic and stressful events, such as wartime battle, abuse, rape, accidents, natural disasters, and extreme violence, etc. Usually a delay as fugue states may not occur immediately after the above Dissociative Amnesia and Dissociative Fugue Treatment Therapy can be useful to help with residual aspects of the disorder Family therapy Prognosis is very good Dissociative Identity Disorder Symptoms The individual may change from one personality to another in a matter of a few minutes to several years (shorter time frames are more common) A person alternates between two or more distinct personality systems The personalities are often dramatically different Usually there is a main or basic personality Click on picture for video Probably the #1 “Hollywood Disorder” Prevalence No reliable figures Nevertheless, appears to be increasing cases Why? Etiology Unknown Possibility: Severe physical and sexual abuse Dissociative Identity Disorder Treatment Psychoanalysis -- try to give therapy to the main personality who "knows" the others Prognosis Poor Somatoform Disorders Physical symptoms with an absence of physical reasons for the symptoms No physical damage results from the disorder These individuals believe that their illnesses are real Psychosomatic Disorders Tension headaches, cardiovascular problems, etc. which cause physical damage State of mind appears to be causing the illness Somatoform Disorders Somatization Disorder Hypochondriasis Body Dysmorphic Disorder Conversion Disorder Somatization Disorder Diagnostic Criteria To be diagnosed a person must have reported at least the following: Gastrointestinal symptoms (2) Sexual symptoms (1) Neurological symptoms (1) Pain (4 locations) These symptoms cannot be explained by a physical disorder Somatization Disorder Sex difference Onset F>M Primarily a female disorder with about 1% suffering from this disorder Usually by age 30 but its seen from childhood on up Familial tendencies 5 to 10 times more common in female first-degree relatives Genetic links to antisocial personality and alcoholism A typical scenario… Typically, patients are dramatic and emotional when recounting their symptoms They are often described as exhibitionistic and seductive and self-centered In an attempt to manipulate others, they may threaten or attempt suicide These patients “doctor-shop”… Often dissatisfied with their medical care, they go from one physician to another… They usually don’t go and further than their General Practitioner… Psychologists and psychiatrists rarely manage the majority of patients with somatoform disorders -this difficult undertaking falls predominantly on general practitioners Learning Explanation A child with an injury quickly learns the benefits of playing the sick role Reinforced by increased parental attention and avoidance of unpleasant responsibilities Physiological Explanation Genes Cognitive Explanation They do not accept psychologists advice Therefore treatment is difficult More research is needed for this one Treatments Not successful Etiology We know it tends to run in families but the cause is unknown at this time Prognosis Poor Its usually a lifelong disorder Hypochondrasis Unrealistic belief that a minor symptom reflects a serious disease Excessive anxiety about one or two symptoms Examination and reassurance by a physician does not relieve the concerns of the patient They believe the doctor has missed the real reason Hypochondrasis Gender difference More common in women than men Onset Usually in 30’s But seen in all age groups Treatments Much research suggests a cognitive-behavioral combo is best with therapist extremely gentle in his/her questioning the patient’s incorrect beliefs Prognosis is poor Major Differences between Somatization Disorder and Hypochondrasis Focus of Complaint Style of Complaint Interaction with Clinician Physical Appearance Conversion Disorder Sensory/motor dysfunction in the absence of a physical basis… Symptoms develop unconsciously and are limited to those that suggest a neurological disorder Examples: numbness of limbs, paralysis, speech problems, blindness and hearing loss, difficulty swallowing, sensation of a lump in your throat, difficulty speaking, difficulty walking, etc. Symptoms are not feigned (as in factitious disorder or malingering) Individual is often highly dramatic Conversion Disorder History Was first studied by the Nancy School of Hypnosis (Nancy, France) and Freud in examinations of hysteria (1880’s) Onset Tends to be adolescence to adulthood but may occur at any age Sex Difference Appears to be "somewhat" more common in women No stats Prevalence 1% - 3% of general population Tends to occur in less educated, lower socioeconomic groups Conversion Disorder: Important Characteristics Glove anesthesia Conversion Disorder: Important Characteristics Doctor Shop They visit many physicians hoping to find one who will propose a physical treatment for their non-physical problems La Belle Indifference The tendency of these people to be relatively unconcerned about their physical problem More research is needed for this one, too Explanations Pure speculation at this point Prognosis Poor No treatment is considered very effective Body Dysmorphic Disorder Preoccupation with an imagined or minor defect in one's physical appearance It is distinguished from normal concerns about appearance because it is time-consuming, causes significant distress, and impairs functioning Depression, phobias, and OCD may accompany this disorder Sex difference: Females > Males Females: breasts, legs Males: genitals, height, and body hair Symptoms Major concerns involving especially the face or head but may involve any body part and often shifts from one to another Examples: hair thinning, acne, wrinkles, scars, eyes, mouth, breasts, buttocks, etc. Case Study: Cindy Jackson Why would someone want to undergo over 50 operations to try to obtain the “perfect” figure and face? What would drive a woman to spend a fortune to look like a “Barbie”? Cindy Jackson, the small town Ohio woman did just that… Cindy: Before… Cindy: After… A total transformation 1979 1990 1994 2003 Once had lunch with Michael Jackson: What do you think they talked about? Cindy Jackson: Today She’s 60 years old Click on picture for video Treatments Cognitive-Behavioral Exposure is used to treat phobia-like symptoms Therapy will focus on improving the distorted body image that these people possess Again, not much known… Treatment Preliminary evidence that selective serotonin reuptake inhibitors may be helpful but data on drug treatment is limited Prognosis Poor Schizophrenia A disease of the brain Changes in neurophysiological function that characterize schizophrenia have been identified Exact cause: Unknown High levels of dopamine and low levels of serotonin have been found in these patients Prevalence Less than 1% of the general population Onset Young adulthood (although late onset is possible) Risk Factors Equal numbers of men are women are diagnosed In men, symptoms begin earlier and are more severe Rates of diagnosis differ by marital status 3% of divorced or separated people 2% of single people 1% of married people It is unclear whether marital problems are a cause or a result Symptoms of Schizophrenia Cognitive symptoms Hallucinations Perceptions that do not correspond to anything in the real world Auditory is most common type Symptoms of Schizophrenia Cognitive symptoms Delusions Beliefs that are strongly held despite a lack of evidence for them Delusions of persecution Delusions of grandeur A belief that enemies are out to get you A belief that you are unusually important Delusions of reference A tendency to take all types of messages personally Newspapers have coded messages of what he or she should do Symptoms of Schizophrenia Cognitive symptoms Disturbed speech and thought processes Word salad Mood symptoms Depression Inappropriate emotional responses Professor portrayed in media: “He saw the world in a way no one could have imagined” John Nash Strong genetic link Genain Quadruplets: 1 in 100,000,000 History of Treatment of Schizophrenia Psychosurgery Prefrontal Lobotomy (introduced in 1935) Transorbital Lobotomy (introduced in 1948) Referred to as “the icepick lobotomy” Before During After Today’s Treatment Neuroleptics Low-potency Neuroleptics Mellaril Thorazine High-potency Neuroleptics Haldol Navane Atypical Neuroleptics Clozaril Risperidal Zyprexa