Download Ch 14 Disorders

Chapter 14: Psychological
Disorders
Abnormal Behavior
• The medical model proposes that it is useful
to think of abnormal behavior as a disease…
– Thomas Szasz and others argue against
this model, contending that psychological
problems are “problems in living,” rather
than medical problems
Abnormal Behavior
• In determining whether a behavior is
abnormal, clinicians rely on the following
criteria:
– Deviant: (does it violate societal norms)
– Maladaptive (does it impair a person’s
everyday behavior)
– Causing personal distress
• Antonyms such as normal vs. abnormal imply
that people can be divided into two distinct
groups, when in reality, it is hard to know
when to draw the line.
Figure 14.2 Normality and abnormality as a continuum
Prevalence, Causes, and Course
• Diagnosis: means of distinguishing one
illness from another
• Etiology: the apparent causation and
developmental history of an illness
• Prognosis: a forecast about the probable
course of an illness
Figure 14.5 Lifetime prevalence of psychological disorders
Stereotypes
• Disorders are Incurable?
– Most psyc. Disorders are treatable and
patients do get “better”
• People with Disorders are Violent or
Dangerous?
– There is only a modest association
• People with Disorders behave in Strange and
Bizarre Ways?
– Only true in a minority of cases, very easy
to fake and even mental health experts can
be fooled
Psychodiagnosis:
The Classification of Disorders
• A taxonomy of mental disorders was first
published in 1952 by the American
Psychiatric Association - the DSM.
– This classification scheme is now in its 5th
revision, which uses a multiaxial system for
classifying mental disorders (there are 5
criteria that must be met for a mental
disorder)
Five Axis
• Diagnostic and Statistical Manual of Mental
Disorders – 4th ed. (DSM - 4)
– Axis I – Clinical Syndromes
– Axis II – Personality Disorders or Mental
Retardation
• diagnoses of disorders are made on Axis I and
II, with most falling on Axis I
Five Axes
• Axis III – General Medical Conditions
– person’s physical disorders are listed
• Axis IV – Psychosocial and Environmental Problems
– the types of stress they have experienced
in the past year
• Axis V – Global Assessment of Functioning
– estimates the individual’s current level of
adaptive functioning
• remaining axes are used to record
supplemental information
• The goal of this multiaxial system is to impart
information beyond a traditional diagnostic
label
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: the percentage of people who
have been diagnosed with a specific disorder at any
time in their lives.
– Current research suggests that about 44% of the
adult population will have some sort of
psychological disorder at some point in their lives
Axis I Clinical Syndromes
• Anywhere from 1/3 to 51% of the population
is said to experience a Psyc. Disorder at one
point in their lives according to DSM-III
– Most Common:
• 1) Substance Abuse
• 2) Anxiety Disorder
• 3) Mood Disorder
Clinical Syndromes: Anxiety Disorders
• anxiety disorders are a class of disorders
marked by feelings of excessive
apprehension and anxiety
• Generalized anxiety disorder
– “marked by a chronic, high level of anxiety
that is not tied to any specific threat…”
free-floating anxiety.
– People worry about yesterday’s mistakes
and tomorrow’s problems
– Usually accompanied by physical
symptoms
Clinical Syndromes: Anxiety Disorders
• Phobic disorder
– Specific focus of fear
– marked by a persistent and irrational fear of an
object or situation that presents no realistic
danger.
– Particularly common are
• acrophobia – fear of heights,
• claustrophobia – fear of small, enclosed places,
• brontophobia – fear of storms,
• hydrophobia – fear of water,
• various animal and insect phobias.
Clinical Syndromes: Anxiety Disorders
• Panic disorder and agoraphobia
– characterized by recurrent attacks of
overwhelming anxiety that usually occur
suddenly and unexpectedly
– After a number of these attacks, victims
may become so concerned about
exhibiting panic in public that they may be
afraid to leave home, developing
agoraphobia or a fear of going out in public
– About 2/3 are women
Clinical Syndromes: Anxiety Disorders
• Obsessive compulsive disorder
– marked by persistent, uncontrollable intrusions of
unwanted thoughts (obsessions) and urges to
engage in senseless rituals (compulsions).
– Obsessions often center on inflicting harm on
others, personal failures, suicide, or sexual acts.
• Common examples of compulsions include
constant handwashing, repetitive cleaning of
things that are already clean, and endless
checking and rechecking of locks, etc.
– 2.5% of the pop.
Clinical Syndromes: Anxiety Disorders
• Posttraumatic Stress Disorder
– involves enduring psychological
disturbance attributed to the experience of
a major traumatic event…seen after war,
rape, major disasters, etc.
– Symptoms include re-experiencing the
traumatic event in the form of nightmares
and flashbacks, emotional numbing,
alienation, problems in social relations, and
elevated arousal, anxiety, and guilt
Etiology of Anxiety Disorders
• Biological factors
– Genetic predisposition, anxiety sensitivity
• abnormalities in neurotransmitter activity at
GABA synapses have been implicated in some
types of anxiety disorders
• abnormalities in serotonin synapses have been
implicated in panic and obsessive-compulsive
disorders
• Conditioning and learning
• Acquired through classical conditioning or
observational learning (especially phobias)
– Maintained through operant conditioning
• Parents who model anxiety may promote the
development of these disorders through
observational learning.
Etiology of Anxiety Disorders
• Cognitive factors
– Judgments of perceived threat
– overinterpreting harmless situations as
threatening, for example, make some
people more vulnerable to anxiety
disorders
• Personality
– trait of neuroticism has been linked to
anxiety disorders
• Stress—appears to precipitate the onset of
anxiety disorders.
Figure 14.6 Twin studies of anxiety disorders
Figure 14.7 Conditioning as an explanation for phobias
Figure 14.8 Cognitive factors in anxiety disorders
Clinical Syndromes: Somatoform Disorders
• physical ailments that cannot be explained by
organic conditions. (occur mostly in women)
– They are not psychosomatic diseases,
which are real physical ailments caused in
part by psychological factors.
– Individuals with somatoform disorders are
not simply faking an illness, which would
be termed malingering (Recorded on Axis
3 of the DSM)
– Actual Somatoform Disorder are recorded
on Axis 1 of the DSM
Clinical Syndromes: Somatoform Disorders
• Somatization Disorder
– marked by a history of diverse physical
complaints that appear to be psychological
in origin
– often coexist with depression and anxiety
disorders, occur mostly in women
– Come and go with the level of stress
– Marked difference is the huge diversity of
victim complaints
Clinical Syndromes: Somatoform Disorders
• Conversion Disorder
– characterized by a significant loss of
physical function (with no apparent organic
basis)
– usually in a single organ system…
• loss of vision, partial paralysis, mutism,
etc…glove anesthesia, for example, is
neurologically impossible
– Usually more severe ailments than
somatization disorders
Clinical Syndromes: Somatoform Disorders
• Hypochondriasis
– characterized by excessive preoccupation
with health concerns and incessant worry
about developing physical illnesses
– Personality factors: often emerge in people
with highly suggestible histrionic
personalities and in people who focus
excess attention on their physiological
processes (Cognitive factors)
– Over interpretation of every sign of illness
Clinical Syndromes: Somatoform Disorders
• Etiology
– Personality: histrionic personality types,
neurotic personality types, insecure
attachment styles rooted in early
experiences
– Cognitive: the mind amplifies common
process into symptoms of distress
– The Sick Role: reinforcement of “sick
behavior” through the care and nurturing
they receive. (attention, lack of
responsibility, and consolation)
Figure 14.10 Glove anesthesia
Clinical Syndromes: Dissociative Disorders
• Dissociative disorders are a class of
disorders in which people lose contact with
portions of their consciousness or memory,
resulting in disruptions in their sense of
identity.
• Dissociative amnesia: sudden loss of
memory for important personal information
that is too extensive to be due to normal
forgetting.
– Memory loss may be for a single traumatic
event or for an extended time period
around the event
Clinical Syndromes: Dissociative Disorders
• Dissociative fugue: people lose their
memory for their entire lives along with their
sense of personal identity…
– forget their name, family, where they live,
etc., but still know how to do math and
drive a car
Clinical Syndromes: Dissociative Disorders
• Dissociative identity disorder: (formerly
multiple personality disorder) involves the
coexistence in one person of two or more
largely complete, and usually very different,
personalities
– Etiology
• related to severe emotional trauma that
occurred in childhood, although this link
is not unique to DID, as a history of child
abuse elevates the likelihood of many
disorders, especially among females
Controversy
Clinical Syndromes: Dissociative Disorders
• D.I.D. (cont.)
– Media creation? Some theorists believe that
people with DID are engaging in intentional role
playing to use an exotic mental illness as a facesaving excuse for their personal failings and that
therapists may play a role in their development of
this pattern of behavior, others argue to the
contrary.
– In a recent survey, only ¼ of American
psychiatrists in the sample indicated that they felt
there was solid evidence for the scientific validity
of DID
Clinical Syndromes: Mood Disorders
• Mood disorders are a class of disorders marked by
emotional disturbances of varied kinds that may spill
over to physical, perceptual, social, and thought
processes.
• Major depressive disorder
– marked by profound sadness, slowed thought
processes, low self-esteem, and loss of interest in
previous sources of pleasure (also called unipolar
depression)
– lifetime prevalence rate of unipolar depression is
between 7 and 18%.
– Evidence suggests that the prevalence of
depression is increasing, particularly in more
recent age cohorts, and that it is 2X as high in
women as in men
Clinical Syndromes: Mood Disorders
– Dysthymic disorder: consists of chronic
depression that is insufficient in severity to justify
diagnosis of major depression
• Bipolar disorder
– formerly known as manic-depressive disorder) is
characterized by the experience of one or more
manic episodes usually accompanied by periods
of depression.
– In a manic episode, a person’s mood becomes
elevated to the point of euphoria
– Cyclothymic disorder: People are given the
diagnosis of cyclothymic disorder when they
exhibit chronic but relatively mild symptoms of
Clinical Syndromes: Mood Disorders
• Etiology
– Evidence suggests genetic vulnerability
– Neurochemical factors: disorders are
accompanied by changes in neurochemical
activity in the brain, particularly at
norepinephrine and serotonin synapses
– Interpersonal inadequacies and poor social
skills may lead to a paucity of life’s
reinforcers and frequent rejection
• Depressed people are depressing
Clinical Syndromes: Mood Disorders
• Etiology
– Stress has also been implicated in the
development of depressive disorders
– Reduced hippocampal volume: plays a
major role in memory consolidation and
tends to be 8-10% smaller
Clinical Syndromes: Mood Disorders
– Cognitive factors: suggest that negative thinking
contributes to depression
• Learned helplessness and a pessimistic
explanatory style have been proposed by
Martin Seligman as predisposing individuals to
depression
• Hopelessness theory, the most recent
descendant of the learned helplessness model
of depression, proposes a sense of
hopelessness as the “final pathway” leading to
depression
• high stress, low self-esteem, and other factors
combine in the development of depression
Figure 14.11 Episodic patterns in mood disorders
Figure 14.13 Twin studies of mood disorders
Figure 14.15 Negative thinking and prediction of depression
Figure 14.16 Interpersonal factors in depression
Clinical Syndromes: Schizophrenia
• Schizophrenic disorders are a class of disorders
marked by delusions, hallucinations, disorganized
speech, and disorganized behavior.
• Disturbed thought lies at the core of schizophrenia,
whereas disturbed emotion lies at the core of mood
disorders.
• General symptoms
– Delusions: false beliefs that are maintained even
though they clearly are out of touch with
reality…belief that you are a tiger, that private
thoughts are being broadcasted to others
• Delusions of grandeur occur when people think
they are famous or important
Clinical Syndromes: Schizophrenia
• General symptoms (cont.)
– Irrational thought: chaotic thinking, or loose
associations, where a person shifts topics in
disjointed ways
– Deterioration of adaptive behavior: noticeable
deficits in the quality of a person’s routine
functioning in work, social relations, and personal
care
– Hallucinations: sensory perceptions that occur in
the absence of a real, external stimulus or are
gross distortions of perceptual input…hearing
voices
Clinical Syndromes: Schizophrenia
• General symptoms (cont.)
– Disturbed emotions: may manifest as little
emotional responsiveness (blunted or flat
affect) or inappropriate emotional
responses (laughing at a story of a child’s
death).
Subtyping of Schizophrenia
• 4 subtypes in the DSM-IV
– Paranoid type: dominated by delusions of
persecution, along with delusions of grandeur
– Catatonic type: striking motor disturbances,
ranging from muscular rigidity to random motor
activity
– Disorganized type: particularly severe
deterioration of adaptive behavior is seen
• incoherence, complete social withdrawal,
delusions centering on bodily functions
– Undifferentiated type: People who clearly have
schizophrenia, but cannot be placed in any of the
above subtypes
Subtyping of Schizophrenia
• There are many critics of the current
subtyping system for schizophrenia
• New model for classification
– Positive: behavioral excesses or
peculiarities, such as hallucinations,
delusions, bizarre behavior, and wild flights
of ideas
– Negative symptoms: behavioral deficits,
such as flattened emotions, social
withdrawal, apathy, impaired attention, and
poverty of speech
Schizophrenia Prognosis
• Prognostic factors (more favorable prognosis
exists when):
– the onset of the disorder is sudden and at
a later age
– the individual’s social and work adjustment
was good prior to onset
– the proportion of negative symptoms is
low,
– the patient has a good social support
system
– 15- 20% make full recovery
Etiology of Schizophrenia
• Genetic vulnerability: positive correlation (46%
parents- 1% parents do not)
• Neurochemical factors: neurotransmitter activity at
dopamine, and perhaps serotonin, receptors
• Structural abnormalities of the brain: such as
enlarged ventricles, are associated with
schizophrenia, as are metabolic abnormalities in the
prefrontal and temporal lobes
– Theories are that positive symptoms are related to
prefrontal abnormalities and negative symptoms to
temporal abnormalities.
– The question remains to be answered re: do these
abnormalities cause or are the consequence of
Etiology of Schizophrenia
• The neurodevelopmental hypothesis: asserts that it is
attributable to disruptions in maturational processes
of the brain before or at the time of birth that are
caused by prenatal viral infections or malnutrition,
obstetrical complications, and other brain insults
• Expressed emotion: the degree to which a relative of
a person with schizophrenia displays highly critical or
emotionally overinvolved attitudes toward the patient
– expressed emotion is a good predictor of the
course of schizophrenic illness, negatively
impacting prognosis.
• Precipitating stress and unhealthy family dynamics
have also been shown to be related to schizophrenia
Figure 14.18 The dopamine hypothesis as an explanation for schizophrenia
Figure 14.20 The neurodevelopmental hypothesis of schizophrenia
Personality Disorders
• Personality disorders are a class of disorders
marked by extreme, inflexible personality
traits that cause subjective distress or
impaired social and occupational functioning.
• Anxious-fearful cluster
– Avoidant: excessively sensitive to potential
rejection, humiliation or shame,
– Dependent: excessively lacking in selfreliance and self-esteem
– Obsessive-compulsive: preoccupied with
organization, rules, schedules, lists, and
trivial details
Personality Disorders
• Dramatic-impulsive cluster
– Histrionic: overly dramatic, tending to
exaggerate expressions of emotion
– Narcissistic: grandiosely self-important,
lacking interpersonal empathy
– Borderline: unstable in self-image, mood,
and interpersonal relationships
– Antisocial: chronically violating the rights of
others, non-accepting of social norms,
inability to form attachments.
Personality Disorders
• Odd-eccentric cluster
– Schizoid: defective in capacity for forming
social relationships
– Schizotypal: social deficits and oddities in
thinking, perception, and communication
– Paranoid: pervasive and unwarranted
suspiciousness and mistrust
Personality Disorders
• Specific personality disorders are poorly defined, and
there is much overlap among them…some theorists
propose replacing the current categorical approach
with a dimensional one
• Research on the etiology of personality disorders has
been conducted primarily on antisocial personality
disorder
– Etiology
• Genetic predispositions , along with autonomic
reactivity
• Inadequate socialization in dysfunctional
families and observational learning
Table 14.2 Personality Disorders
Psychological Disorders and the Law
• Insanity
– Insanity is not a diagnosis, it is a legal
concept.
– Insanity is a legal status indicating that a
person cannot be held responsible for his
or her actions because of mental illness
– M’naghten rule: holds that insanity exists
when a mental disorder makes a person
unable to distinguish right from wrong.
Psychological Disorders and the Law
• Involuntary commitment
– occurs when people are hospitalized in
psychiatric facilities against their will.
– Rules vary from state to state
– Generally, people are subject to
involuntary commitment when:
• danger to self
• danger to others
• in need of treatment
Psychological Disorders and the Law
• In emergency situations, psychiatrists and
psychologists can authorize temporary
commitment only for a period of 24-72 hours.
• Long-term commitments must go through the
courts and are usually set up for renewable
six-month periods
Figure 14.22 The insanity defense: public perceptions and actual realities
Culture and Pathology
• The principal categories of psychological
disturbance are identifiable in all cultures, but
milder disorders may go unrecognized in
some societies
Culture and Pathology
• Culture bound disorders: illustrate the diversity of
abnormal behavior around the world, as well as
cultural influence
– Koro: an obsessive fear that one’s penis will
withdraw into one’s abdomen, seen only in Malaya
and other regions of southern Asia
– Windigo: intense craving for human flesh and fear
that one will turn into a cannibal, seen only among
Algonquin Indian cultures
– Anorexia nervosa: eating disorder characterized
by intentional self-starvation, until recently seen
only in affluent Western cultures
Eating Disorders
• Anorexia Nervosa
– Intense fear of gaining weight, disturbed
body image, refusal to maintain normal
body weight, and dangerous measures to
lose weight
• Restricting Type: people reduce their
intake of food (literally starve
themselves)
• Binge-eating/ Purging: vomiting,
laxatives, diuretics, excessive exercise
Eating Disorders
• Bulimia Nervosa
– Out-of-control overeating followed by
unhealthy compensatory efforts (vomiting,
fasting, etc)
– They usually maintain a normal body
weight
– Med. Problems include: cardiac
arrhythmias, dental problems, metabolic
deficiencies, gastrointestinal problems
Eating Disorders
• Similarities:
– Morbid fear of obesity, preoccupation with
food and maladaptive processes to control
weight (if you have one it is easy to cross
over from one to another)
• Differences:
– Bulimia is much less life threatening and
people’s appearances are more normal
looking, people with bulimia are much
more likely to cooperate with treatment