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Chapter 6 Abnormal mental state and maladaptive behavior Section 1 Abnormal mental state : an overview 1.Definition of abnormal mental state Abnormal mental state refers to the abnormality of mental process and personality, such as perception, thought, memory, intellect, attention, emotion, will, behavior etc. Abnormal mental state is a mental condition that causes significant distress or disability, is not merely an expectable response to a particular event, and is a manifestation of mental dysfunction. Maladaptive behavior is behavior that deviates from the norms of the society in which it is enacted. DSM-IV definition of mental disorder:A mental disorder is “conceptualized as a clinically significant behavioural or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.” “The syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one.” “It must currently be considered a manifestation of a behavioural, psychological, or biological dysfunction in the individual.” 2.Criteria of judgment Personal distress (Subjective distress) criterion Statistical criterion (Deviation from statistical norms) Medical criterion Social adaptation criterion (Deviation from social norms) Time criterion (Length of time) Dysfunction 2.1 Personal distress (subjective distress) criterion A person has a mental disorder if they experience personal distress. Mental disorder may be defined as abnormal if it creates subjective distress. (E.g., a hallmark of mood and anxiety disorders is heightened subjective distress.) Problem: Not all distressed individuals are mentally ill & some mentally ill individuals do not show distress (psychopaths). 2.2 Statistical criterion (Deviation from statistical norms) A person has a mental disorder when their behavior, ability, or experience is significantly different from average. Abnormal behavior is often infrequent. Problem: ①We want to use the term disorder to describe some conditions that are statistically infrequent. ②“positive” deviations are not distinguished from “negative” deviations. ③Not all unusual behavior is considered abnormal!! (e.g., superior athletic, musical, or intellectual ability) 2.3 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 The medical criterion thinks of abnormal behavior as a disease,“mental illness” or “psychological disorder”. Rise of medical model brought improvement in treatment. It is viewed with more sympathy, less fear. Problems: ①Labelling ②Encourages passivity 2.4 Social adaptation criterion (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 Problem: ①The violation of norms explicitly makes abnormality a relative concept. ②Societal norms may change which behaviors are deemed abnormal. E.g., Homosexuality was once classified as a mental disorder in the DSM (up till 1973). ③Criminals and prostitutes violate social norms, but would not necessarily fall within the context of abnormal psychology. 2.5 Dysfunction Does the behavior impair an individual’s ability to function in life (work, personal relationships)? (E.g., substance-use disorders) Problem: Some individuals with a DSM diagnosis, live functional lives (e.g., transvestites). 3.Causal factors of mental disorder 3.1Biological factors genetic vulnerabilities Biochemistry (neurotransmitter and hormonal imbalances): dopamine, 5hydroxyltryptamine and norepinephrine. Physical disease: infection , toxicosis , various metabolic block etc. 3.2 Psychological factors Acute mental trauma Enduring mental trauma 3.3 Social factors Politics, economy, religion , culture , ethics morality , customs, habits , family environment and Interpersonal relationship . 4. Classification 4.1 Phenomenology classification: Cognition disorder Emotion disorder Will and behavior disorder Conscious disorder 4.2 Psychiatric classification ICD-10 (International Classification of Disease, the tenth version ) CCMD-Ⅲ ( Chinese Classification of Mental Disorder and Diagnostic Criteria, the third version ) DSM-Ⅳ (Diagnostic and Statistical Manual, the forth version) Section 2 Anxiety disorders 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: ①The first one is signal function. ②The second one is to mobilize body and regulate behavior. ③The third one is learning and accumulating experience. Symptoms of anxiety: ①mood of tension and worry ②mental symptoms ③physical 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. 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. Difference between fear and anxiety: ①Fear is a response to a perceived danger or threat. ②Anxiety is the anticipation of a possible threat. 2. Classification 2.1 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 menacing dog. The most common way of reducing this anxiety is to avoid the threatening object. 2.2 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 2.3 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 experiential, biological, environmental, psychological and cultural factors. 3.1 Biology mechanism Research shows that anxiety disorder tends to run in families, so a genetic link may be involved. Anxiety disorder 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. 3.2 Psychology 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 (anxiolytic) Psychological treatment Relaxation method Meditation method Biofeedback training Cognitive behavioral therapy Section 3 Depressive disorders 1.Definition Depressive disorders or depression are mental illnesses 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) Characteristic symptoms:①feelings of hopelessness, pessimism ②insomnia, early-morning awakening, or oversleeping ③appetite and/or weight loss ④decreased energy, fatigue, being“ slowed down”⑤loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex ⑥feelings of guilt, worthlessness, helplessness ⑦thoughts of death or suicide; suicide attempts ⑧restlessness, irritability ⑨persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain. 2.Causes of depression 2.1 Biological causes Biological causes of clinical depression continue to be studied extensively. Great progress has been made in the understanding of brain function, the influence of neurotransmitters and hormones, and other biological processes, as well as how they may relate to the development of depression. 2.1.1 Genetic factors Scientists believe genetic factors play a role in some depressions. Researchers are hopeful, for instance, that they are closing in on genetic markers for susceptibility to depressive disorder. 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. 2.1.2 Biochemical causes Neurotransmitters are chemicals made by the nerve cells in the brain that send messages back and forth across the space between the cells (synapse). 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. 2.1.3 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. Of those individuals who are clinically depressed, about one-half will have an excess of a hormone in their blood called cortisol. Other research concerning cortisol has shown that the timing of the release of this hormone may be problematic in those who are depressed. People who are not depressed tend to have secretions of cortisol at certain times of the day. Cortisol levels are highest at approximately 8:00 a.m. and 4:00 p.m., and then lowest during the night. This normal cycling of cortisol levels does not occur in some people who are depressed. For instance, they might have a consistent level of cortisol all the time, or highest amounts in the middle of the night. Cortisol levels can be tested using something called a dexamethasone suppression test (DST). 2.1.4 Medical conditions It is believed that those individuals with chronic and/or very serious medical conditions may be at increased risk of developing depression. Some illnesses that have been known to cause symptoms of depression include: Hypothyroidism Hyperthyroidism Hypoparathyroidism Hyperparathyroidism Epilepsy Diabetes Stroke Brain trauma Parkinson's disease Some cancers 2.1.5 Environmental situations Many environmental factors may be linked to depression, including stress, trauma, childhood events. Research continues to better understand the interaction of genes and environment, and precisely what is inherited. 2.6 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. 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. Thanks to years of fruitful research, there are now medications and psychosocial therapies such as cognitive/behavioral, “talk,” or interpersonal therapies that ease the pain of depression. 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). The SSRIs—and other newer medications that affect neurotransmitters such as dopamine or norepinephrine—generally have fewer side effects than tricyclics. How to help yourself if you are depressed ? Set realistic goals in light of the depression and assume a reasonable amount of responsibility. Break large tasks into small ones, set some priorities, and do what you can as you can. Try to be with other people and to confide in someone; it is usually better than being alone and secretive. Participate in activities that may make you feel better. Mild exercise, going to a movie, a ball game, or participating in religious, social, or other activities may help. Expect your mood to improve gradually, not immediately. Feeling better Take time It is advisable to postpone important decisions until the depression has lifted. Before deciding to make a significant transition—change jobs, get married or divorced—discuss it with others who know you well and have a more objective view of your situation. People rarely "snap out of" a depression. But they can feel a little better day-by-day. Remember, positive thinking will replace the negative thinking that is part of the depression and will disappear as your depression. Let your family and friends help you. 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. Personality disorders are long-term patterns of thoughts and behaviors that cause serious problems with relationships and work. People with personality disorders have difficulty dealing with everyday stresses and problems. They often have stormy relationships with other people. Marked by extreme, inflexible personality traits that cause subjective distress or impaired social/occupational functioning. Long-standing, inflexible ways of behaving Usually emerge childhood/adolescence Some are mild versions of more severe Axis I disorders 2. Classification According to ICD-10 (International Classification of Disease, version ),there are eight personality disorders. 2.1 Paranoid Shows pervasive and unwarranted suspiciousness and mistrust of others Overly sensitive Prone to jealousy. 2.2 Schizoid Defective capacity in forming social relationships Absence of warmth and tender feelings for others 2.3 Schizotypal Social deficits and oddities of thinking tenth Perception and communication that resemble schizophrenia. May see odd superstitious beliefs. 2.4 Histrionic Overly dramatic Tending to exaggerate expressions of emotion Egocentric Attention seeking 2.5 Borderline Unstable self-image Mood, Interpersonal relationships Impulsive Unpredictable 2.6 Narcissistic Grandiosely self-important Preoccupied with success fantasies Expecting special treatment Lacking interpersonal empathy 2.7 Antisocial Chronically violating rights of others Failing to accept social norms or sustain work behavior Exploitive, 2.8 Dependent Excessively lacking in self-reliance and selfesteem Passively allowing others to make all decisions, constantly subordinating own needs to others 2.9 Avoidant Excessively sensitive to personal rejection, humiliation Socially withdrawn in spite of desire for acceptance from others 2.10 Obsessive-Compulsive Preoccupied with organization, rules, schedules, lists Extremely serious, formal Unable to express warm emotions 3.Characteristic of personality disorders Personality disorders emerged in children and adolescent, and is relative stability. Personality disorders has confused indefinite mental feature and tensive relationship, and couldn’t adapt to the social environment. Besides psychopathia, personality disorders doesn’t have morphologic pathological change of nervous system. Those who have personality disorders have clear consciousness, can forecast behavioral consequence, and understand the evaluation criterion of his behavior consequence from society, but have superficial view and motive. 4.Cause of personality disorders A combination of personal history and biology appears to play a role in most personality disorders. Genetics play a significant — but not necessarily singular — role in the development of schizotypal and paranoid personality disorders, which all are more common in families with a history of schizophrenia. Heredity also contributes to the development of obsessive-compulsive personality disorder. A family history of antisocial personality disorder increases your risk of developing the condition, but childhood trauma also has considerable influence. Children with an alcoholic parent, or who have an abusive or chaotic home life, are at increased risk of developing antisocial personality disorder. Sexual abuse is a common risk factor for borderline personality disorder. People with borderline personality disorder who report sexual abuse at a younger age — younger than 13 years old — are also more likely to have post-traumatic stress disorder. Heredity and childhood head injuries also may influence the development of this disorder. The causes of avoidant and dependent personality disorders have been minimally studied and aren't yet well understood. 5. Mental intervention A number of barriers make personality disorders among the most challenging mental health conditions to treat. People with these conditions are likely to have difficulty opening up to or retaining closeness with therapists. Perceived criticism may cause them to react angrily and break off therapy. Those who seek treatment on their own and who are motivated to stick with therapy over many years are the most likely to succeed. Treatment for most personality disorders is with a combination of therapy and medications. 5.1 Psychodynamic psychotherapy This approach entails talking about your condition and related issues with a mental health professional. Psychotherapy can help people with personality disorders recognize how they're responsible for the turmoil in their lives and learn healthier ways of reacting to people and problems. Individual, group and family therapy can all be helpful. 5.2 Cognitive behavior therapy This form of psychological treatment involves actively retraining the way you think about problems, which in turn improves your emotions and behaviors. 5.3 Dialectical behavior therapy This type of cognitive behavior therapy focuses on coping skills — learning how to take better control of behaviors and emotions with techniques such as mindfulness, which helps you observe your feelings without reacting. It is most often used to treat borderline personality disorder. Doctors are studying the effectiveness of this type of therapy with all types of personality disorders. 5.4 Medications People with personality disorders often experience serious mental and emotional strain, causing additional mental health problems, such as depression, phobia and panic. Medications may help alleviate these related conditions, but they can't cure the underlying disorder. Therapy aimed at building new coping mechanisms must be the cornerstone of treatment. Section 5 Abnormal behavior 1.Alcohol dependence 1.1 Concepts 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). This disorder is only diagnosed when these behaviors become persistent and very disabling or distressing. 1.2 Four main features of alcohol dependence Physical dependence, with a characteristic withdrawal syndrome that is relieved by more alcohol (e.g., morning drinking) or other drugs. 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. 1.3 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 alcohol-related absences may occur from school or job. Individuals with this disorder are at increased risk for accidents, violence, and suicide. 1.4 Cause of alcohol dependence Alcohol Dependence often has a familial pattern, and 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. Most studies have found a significantly higher risk for Alcohol Dependence in the monozygotic twin than in the dizygotic twin of a person with Alcohol Dependence. 1.5 Intervention of alcohol dependence Behavior therapy Family therapy 2.Tobacco (Nicotine )addiction 2.1 Concepts 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 2.2 Signs and symptoms You can't stop smoking. You've made one or more serious, but unsuccessful, attempts to stop. You experience strong withdrawal symptoms when you try to stop. Your 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. You keep smoking despite health problems. Even though you've developed problems with your lungs or your heart, you haven't stopped or can't stop. You give up social or recreational activities in order to smoke. You may stop going to certain restaurants or stop socializing with certain family members or friends because you can't smoke in these situations. 2.3 Harmful to health Being addicted to tobacco brings you a host of health problems related to the substances in tobacco smoke. These effects include damage to your 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 10 times the risk of dying from bronchitis and emphysema 2 to 3 times the risk of heart disease 2 times the risk of stroke 2.4 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 you 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 3.1 concepts Drug dependence is used to describe continued use of drugs, even when significant problems related to their use have developed. Signs include an increased tolerance or need for increased amounts of substance to attain the desired effect, withdrawal symptoms with decreased use, unsuccessful efforts to decrease use, increased time spent in activities to obtain substances, withdrawal from social and recreational activities, and continued use of substance even with awareness of physical or psychological problems encountered by extent of substance use. 3.2 Symptoms Psychological addiction Physical addiction Tolerance getting high on drugs or getting intoxicated (drunk) on a regular basis lying, especially about how much they are using avoiding friends and family members giving up activities they used to enjoy such as sports or spending time with non-using friends talking a lot about using drugs believing they need to use in order to have fun pressuring others to use getting in trouble with the law taking risks, such as sexual risks or driving under the influence of a substance missing work due to substance use depressed, hopeless, or suicidal feelings 3.3 Classification Substances frequently abused include, but are not limited to, the following: Alcohol Marijuana Hallucinogens Cocaine Amphetamines Opiates Anabolic steroids Tranquilizer: alcohol, hypnotic 3.4 Intervention Detoxification (if needed, based on the substance abused) and long-term follow-up management are important features of successful treatment. Long-term follow-up management usually includes formalized group meetings and developmentally age-appropriate 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 4.1 concepts 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. 4.2 Theoretical model Young ’s ACE model Davis’ Cognitive-Behavioral Model Grohol’s stage model 4.3 Symptoms of internet addiction Intense desire Tolerance Withdrawal Mood modification Behavior modification Cognition distortions 4.4 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 4.5 Mental intervention of internet addiction Practice The Opposite External Stoppers Setting Goals Abstinence Reminder Cards Personal Inventory Support Groups Family Therapy