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Chapter 17
The Nature and Causes of Mental Disorders
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Chapter 17 - Mental Disorders
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Classifying Mental Disorders
There is a wide variety of psychological disorders. Classifying
them is a prerequisite to organized diagnosis and treatment.
The American Psychiatric Association’s Diagnostic and
Statistical Manual IV (DSM-IV) is the most commonly used
classification scheme.
DSM-IV contains five axes that are described in the textbook.
We are going to focus on disorders contained in Axis I and II.
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A Simpler Classification
A less technical way of classifying mental disorders is in terms :
• Neurosis: Excessive irrational emotionality without loss of
contact with reality.
– Anxiety
– Phobia
– Obsession
– Depression
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• Psychosis: Severe disturbance of thought and emotion with
loss of contact with reality (schizophrenia).
– Hallucination
– Paranoia
– Delusion
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Anxiety
Anxiety is an emotion, like fear, that is experienced in
anticipation of danger.
Whereas fear is experienced in the face of a perceived danger,
anxiety is a more diffuse emotional reaction.
There are several forms of anxiety disorders. We will focus on:
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Agoraphobia (with panic attacks)
Generalized Anxiety Disorder (GAD)
Hypochondriasis
Obsessive-Compulsive Disorder (OCD)
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Agoraphobia
Agoraphobia involves fear of being alone in public places.
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Agoraphobia is accompanied by panic attacks.
A panic attack involves a period of intense fear and
discomfort where some of the following symptoms develop
abruptly.
– Palpitations, pounding heart, sweating, shaking, feeling of
choking, chest pain, nausea, feeling dizzy, feelings of
being detached from oneself, fear of going crazy, fear of
dying, numbness sensations, chills or hot flashes.
Panic attacks are terrifying, and agoraphobics stay away from
public places from fear of having them.
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Video on Agoraphobia
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Generalized Anxiety Disorder
GAD is excessive worry that leads to significant distress or
impairment in occupational or social functioning BUT that is
not focused on panic attacks.
GAD used to be known as free-floating anxiety (being anxious
without being aware of the source of the anxiety).
GAD often overlaps with other anxiety disorders (comorbidity is
high).
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Video on Generalized Anxiety Disorder (GAD)
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Obsessive-Compulsive Disorder
A pervasive pattern of intrusive, unwanted thoughts
accompanied by ritualistic behaviours.
Obsession: Recurrent involuntary thought or image.
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Compulsion: Repetitive carrying out of a pointless rituals
• checking hundreds of times if the stove is turned off.
• washing hands excessively from fear of contamination.
• counting to certain numbers before taking an action.
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Video on OCD
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Hypochondriasis
Hypochondriasis is a persistent exaggerated fear that one is
suffering from a physical illness.
Hypochondriacs tend to interpret their physical symptoms as
indicative of a serious illness. They quickly seek medical
attention and expect the worst.
When medical tests are negative, they worry that a test was
overlooked.
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Hypochondriacs may take their blood pressure frequently, and
keep lots of medication at hand.
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Video on Hypochondriasis
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Causes of Anxiety Disorders
The causes of anxiety disorders are complex, but there is some
evidence for each of the following. Some of these causes are
more relevant to some anxiety disorders than others:
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Stressful life events (having faced danger)
Childhood adversity (parental neglect, worry, abuse)
Attachment style (insecure attachment)
Learning mechanisms (phobia after bad experience)
Cognition (catastrophic misinterpretation)
Biology (high heritability; chemically induced panic)
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Treatment of Anxiety Disorders
The treatment of anxiety disorders includes one or more of the
following:
• Medication
– Benzodiazepines (Brands: Valium, Xanax)
– SRIs (Serotonin reuptake inhibitors used for OCD)
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• Psychotherapy
– Cognitive-behavioral therapy
– Exposure with relaxation (systematic desensitization)
– Psychoanalysis
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Video on Causes and Treatment
of Anxiety Disorders
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Dissociative Disorders
The loss of the integrated connection of identity, memory and
consciousness. Anxiety is often reduced by this disruption.
The most famous case consists of Multiple Personality Disorder,
technically known as Dissociative Identity Disorder.
The diagnosis of multiple personality disorder is controversial
because the multiple personalities emerge during therapy,
usually following strong suggestions by the therapist.
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Are multiple personalities real or fabricated?
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Recovered Memories
Some psychotherapies, such as psychoanalysis, put a lot of
emphasis on repressed conflicts and memories.
There has recently been a lot of controversy over the accuracy of
memories (such as childhood sexual abuse) that are recovered,
during therapy, many years later.
Are recovered memories examples of dissociations, or are they
merely examples of the power of suggestion?
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This issue is raised in the video. Watch for memory expert
Elizabeth Loftus, whose early classic research is discussed on
page 268 of your textbook (see figure 8.18 there) .
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Video on Multiple Personality
(Dissociative Identity Disorder)
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Personality Disorders
A broad class of psychological disorders which reflect long-term
characteristics of the person.
Personality disorders tend to be difficult to diagnose and to treat
(what is the difference between being eccentric and having a
personality disorder? Narcissism is a good example of this
ambiguity)
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We will look at three examples of personality disorders:
• Psychopathy (Antisocial personality disorder - ASPD).
• Borderline personality disorder.
• Obsessive-Compulsive personality disorder.
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The Psychopath
Characteristics of the psychopathic personality (ASPD):
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Criminality (failure to conform to social norms and laws).
Lack of empathy, anxiety and fear.
Lack of remorse for mistreating others.
Egocentrism and grandiose feelings
Deceit and manipulativeness.
Impulsivity and lack of planning.
Irritability and aggressiveness.
Reckless disregard for the safety of self and others.
Consistent irresponsibility at work and with finances.
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Video on Psychopathy
(Antisocial Personality Disorder)
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Treatment of Psychopaths
As seen in the video, the news is not good on the success of
treatment:
• Psychopaths seldom seek treatment.
• Few therapists and researchers take on psychopathic subjects.
• Behaviour therapy (rewards and punishments) works only
while patient is under close supervision.
• Psychotherapy that stresses empathy sometimes helps the
psychopath develop better ways of manipulating others.
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Borderline Personality Disorder
What is borderline about this disorder? The label comes from
the early belief that the disorder fell at the borderline of
neurosis and psychosis.
Today the label is used more broadly to describe people who
show instability in their emotions and interpersonal
relationships. They often show:
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A pattern of chaotic and intense interpersonal relationships.
Unstable self-image and sense of self.
Recurrent suicidal or self-mutilating behaviour.
Instability in the way they feel (unpleasant mood: dysphoria).
Intense anger.
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Video on Borderline Personality Disorder
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Mood Disorders
Mood disorders involve discrete periods of time (episodes)
during which the person is in a depressed or a manic mood.
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Mood disorders are leading causes of disability worldwide:
1. Major depression
2. Iron-deficiency anemia
3. Falls
4. Alcohol use
5. Pulmonary disease
6. Bipolar mood disorder
7. Congenital anomalies
8. Osteoarthritis
9. Schizophrenia
10. Obsessive-compulsive disorders
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Depression
Depression is a clinical syndrome that involves a combination of
emotional, cognitive and behavioural symptoms relating to
overwhelming despair.
Extreme cases of depression are known as major depression,
clinical depression or unipolar depression.
Physical Symptoms
•fatigue
•difficulty sleeping
•change in appetite
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Behavioural Symptoms
•pacing/fidgeting
•inactivity
•at extreme: stupor
Cognitive Symptoms
•guilt
•feel worthless
•concentration problems
•thoughts of suicide
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Video on Major Depression
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Causes of Depression
Severe Life Events
• Loss of important people (death, separation)
• Loss of important roles (job, promotion)
Psychological Factors
• Cognitive responses (negative self view)
• Learned helplessness
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Biological Factors
• Abnormal neural transmission in the brain; hormonal levels
• Twin studies show high heritability
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Mania
Mania involves a euphoric mood that varies from mild
(hypomania) to extreme (psychotic manic episodes).
Symptoms
•inflated self-esteem (delusional at extreme)
•decreased need for sleep
•distractibility
•talkativeness
•thoughts race through head
Only a small proportion of patients have manic episodes and
no depressive episodes.
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In most cases, patients who have manic episodes also have
depressive episodes. This is known as bipolar mood disorder,
or manic-depressive disorder.
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Video on Bipolar Disorder
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Causes of Bipolar Disorder
We know less about the causes of mania than depression.
These are a few findings:
– Manic episodes tend to be preceded, weeks earlier, by
stressful life events.
– Patients who live in families that are hostile towards the
disorder are more likely to relapse.
– Some of the biological factors seem to be the same for
unipolar and bipolar mood disorders.
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Video on Treatment of Depression
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Treatment of Mood Disorders
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Medication:
• Depression:
– Tricyclics such as Trofanil (in use since 1950’s)
– SSRI’s such as Prozac (present medications of choice)
• Bipolar:
– Lithium Carbonate
Electroconvulsive Therapy (ECT)
• We do not know why ECT works but it helps in cases of deep
depression. Invasive with memory loss side effect.
Psychotherapy
• Psychotherapy applies particularly well to mood disorders.
• We will look at relevant psychotherapies in Chapter 18.
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Sexual Disorders
Some sexual disorders involve dysfunctions with sexual desire
and physiological response leading to orgasm.
Our focus is on paraphilias, which involve sexual arousal to
unusual things and situations such as inanimate objects,
children, exhibiting genitals to strangers, inflicting pain to
others. We will look at:
– Exhibitionism (indecent exposure)
– Rape (though not defined as paraphilia in DSM-IV)
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We will also look at Gender Identity “disorder” (or is it a mental
disorder?)
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Exhibitionism (Indecent Exposure)
Recurrent, intense sexually arousing fantasies, urges and
behaviours involving exposure of genitals to a stranger.
• Almost exclusively a male disorder.
• About half the time the male has an erection while exposing.
• Some masturbate while exposing, while others do afterwards.
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• Exhibitionists are often married and have satisfactory sexual
relations with adult women.
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Video on Exhibitionism
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Rape and Sexual Assault
Legal definition of rape: Acts involving nonconsensual sexual
penetration obtained by physical force or threat of bodily
harm, or when the victim is incapable of giving consent by
virtue of mental illness, retardation or intoxication.
Rape and sexual assault are disturbingly common:
• 28% of university students across Canada report having been
sexually assaulted in the past year.
• 6% of women living in Winnipeg report having been raped.
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Efforts are currently made to distinguish between sex offenders
for whom sexual arousal motivates the act, and those
motivated primarily by anger, control, and violent impulses.
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Video on Rape
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Gender Identity Discomfort (?)
Some people are firmly convinced that they are living in the
wrong body. In females this means that they feel that they are
a man trapped in a woman’s body.
DSM-IV classifies this discomfort as gender identity disorder
(also known as transsexualism and gender dysphoria).
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Gender identity “disorder” is estimated to be relatively rare:
– Male-to-female transsexuals: 1 in 12,000.
– Female-to-male transsexuals: 1 in 30,000.
Many LGBTQ people assert that transsexuals are mentally
healthy. So why does the DSM-IV consider this a disorder?
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Video on Transexualism
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Aversion Therapy for Paraphelias?
Aversion therapy is based on classical conditioning. The idea is
to associate the stimulus that elicits inappropriate sexual
arousal, with aversive stimuli:
– Electric shock.
– Chemically induced nausea.
The approach is of questionable effectiveness.
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Aversion therapy was illustrated nicely in A Clockwork Orange
(a wonderful 1971 movie by Stanley Kubrick, based on the
novel by Anthony Burgess. Rated R for sexual violence).
Let’s see how Stanley Kubrick represents aversion therapy.
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Video on Aversion Therapy
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Schizophrenia
A set of disorders that encompass a variety of symptoms,
including disturbances of:
+ Perception: Hallucinations (perception of things not there).
+ Cognition: Delusions (belief that have no objective basis).
+ Behaviour: Bizarre behaviour such as taking a shower
fully dressed.
- Emotion: Flat affect and social withdrawal.
Note distinction between positive and negative symptoms.
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Schizophrenia usually involves a series of acute episodes with
periods of remission. Following a severe episode, the patient
is rarely completely rid of the disorder.
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Types of Schizophrenia
Disorganized Schizophrenia: Includes hallucinations and
delusions. Speech is often incoherent.
Catatonic Schizophrenia: Mostly absence of reactivity
(negative symptoms), including stupor and immobility for long
periods of time. May stare into space.
Paranoid Schizophrenia: Experience delusions of persecution,
hearing critical or threatening voices.
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Undifferentiated Schizophrenia: A catchall category for
symptoms that do not quite fit, or fit more than one of above.
Residual Schizophrenia: Cases where there was at least one
schizophrenic episode, but currently only mild symptoms.
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Video on Schizophrenia
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Biological Factors in Schizophrenia
There is a strong genetic component to schizophrenia. Having
an identical twin, or both parents, diagnosed with the disease
puts one’s chances of having the disease over one’s lifetime at
close to 50%
Neuroimaging studies (e.g. MRI) show that the brains of
schizophrenics tend to have less brain tissue (larger ventricles
and fissures). Also, the neural network connecting limbic
areas with the frontal cortex appears disordered.
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Levels of neurotransmitters (like dopamine and serotonin)
appear not to be regulated properly in some cases of
schizophrenia.
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Other Factors in Schizophrenia
How about the other 50%?
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Biological factors are clearly important in schizophrenia, but it
appears that biologically vulnerable individuals only have
full-blown episodes when other factors are also present:
– Low socio-economic status:
• Poor nutrition, less education, low income.
– Family interaction:
• Poor communication confuses the child.
– Negative expressed emotion:
• Patients are more likely to relapse if those around them
express hostility, or are overly protective of them.
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Medication for Schizophrenia
Canadian Guidelines: “antipsychotic medications are currently
the most effective treatment available for schizophrenia,
especially when combined with psychosocial treatment.”
Phenothiazines: e.g., Chlorpromazine (Thorazine)
– Very effective in about half the patients.
– 25% of patients do not improve.
– Nasty side effect: Tardive dyskinesia (TD)
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Atypical Antipsychotics: e.g., Clozapine, Risperidone
– Newer medications with fewer side effects.
– Work with more than 30% of patients who are
unresponsive to Phenothiazines.
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Video on Antipsychotic Drugs
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Bridge to Chapter 18
We will soon turn our attention to psychotherapies for the
treatment of mental disorders.
Let’s first look at self-abusive behaviour and the application of
behaviour therapy to control it.
Self-abusive behaviour usually stems from severe forms of
autism and mental retardation.
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Self-abuse in some cases can take extreme forms that can result
in self mutilation and even death.
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Treatment of Self-Abusive Behaviour
The first course of action in controlling self-abusive behaviour is
the use of restraints.
Behaviour therapy with the use of rewards and punishments can
also be used to change the abusive behaviour.
Let’s look at Harry, a patient who was treated with behaviour
therapy, which succeeded without the use of direct punishment
(such as the administration of electric shock).
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Video on Behaviour Therapy
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Aversive Therapy
Some self-abusive patients are so uncommunicative, that
punishment in the form of electric shock is used to stop the
self-abusive behaviour.
Note that here, as with Harry, the therapy is based on principles
of operant (not classical) conditioning. The principle is that
behaviours that are reinforced increase, and those that are
punished diminish.
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Video on Aversive Therapy
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