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Mental Disorders
What is abnormal behavior?
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People who believe psychics/horoscopes?
Superstitions?
Angelina & Billy Bob? J-Lo?
Jeffrey Dahmer?
University professors?
Dog lovers?
Sexual preferences?
Abnormal Behavior
Thoughts/Behaviors/Emotions occur along a
continuum
“ABNORMALITY” can be conceptualized via
4 criteria
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1.
2.
3.
4.
Statistical Infrequency
Disability/Dysfunction
Personal Distress
Violation of norms
My Definition…
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a)
b)
An excess or deficit in any
cognitive/affective/behavioral domain is a
disorder if it:
Is subjectively distressing
Impairs one’s ability to function within their
daily environment
History…
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Mental illness and deviance has been
attributed to evil spirits, occult, etc.
Stone Age – demonic possession – boring
holes in head
Middle Ages – demonic possession –
exorcism
15th Century – people could choose to
collaborate with Devil – Salem Witch Trials
History…
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Establishment of Asylums in Europe circa
16th Century
1792 – Philippe Pinel
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Revamped French asylum by (gasp) insisting on
humane treatment for patients
Some improved to point where could be released
Advanced notion that mental illness was a
disease of the brain, not demonic influence
History…
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Medical model – birth of psychiatry
Psychology – broader explanations for
mental illness
Explanations vary according to theoretical
orientation
Sasz – psychiatric diagnoses serve only to
control those who deviate from social norms,
and to affirm psychiatrists’ place in the
social/medical hierarchy
Perspectives on mental disorders
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Biological (Medical model)
Psychodynamic
Cognitive
Behavioral
Sociocultural – the kinds of psychological
distress people experience, and the way that
it is manifested, vary according to culture
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Cultural factors influence the form, course, and
outcome of mental disorders
Socio-Cultural Perspective
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The content of schizophrenic symptoms tend
to be related to critical problems facing the
culture
Thought insertion & thought broadcasting
appear to be Western phenomenon
Prognosis of schizophrenia appears to be
better in 3rd World countries
Asian countries also better prognosis
Socio-Cultural Perspective
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What about Western society contributes to
more chronic course? Why worse than
industrialized Asia?
Extreme nuclearization of family system
(diminished support)
Rejection/isolation of mentally ill
Internal causal attribution
Assumption of chronic course
Culture-bound disorders
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Disorders related to cultural emphasis on
fertility
Genital Shrinking (Koro in Indonesia, SuoYang in Mandarin Chinese)
Semen Loss (Chat in India, Sukra Pameha in
Sri Lanka, Shenk Uei in China)
Culture-bound disorders
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Disorders related to cultural emphasis on
physical appearance
Anthropophobic reactions among Japanese &
Koreans
Fear that one’s physical appearance is
offensive to others
Anorexia among Western cultures
Classification of mental disorders
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Late 19th and early 20th century – Neuroses &
Psychoses
Neuroses: characterized by anxiety, but
person remains in touch with reality
Psychoses: disturbances of thought or
perception that impairs reality testing
Diagnostic and Statistical Manual of
Mental Disorders (DSM)
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Classification system – under continual
revision
Designed to define mental disorder as
objectively as possible and improve reliabilty
Provides consistency of diagnoses across
individuals and settings
List of disorders with descriptions, categories,
diagnostic criteria, guidelines for differential
diagnosis
Nursing Student’s Disorder
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Characterized by a strong tendency to relate
personally to, and find in oneself, the
symptoms of any disease/disorder one learns
about
Diagnostic and Statistical Manual of
Mental Disorders (DSM)
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Axis I: Clinical Disorders (State disorders)
Axis II: Personality Disorders and Mental
Retardation (Trait disorders)
Axis III: General Medical Condition (physical
problems relevant to etiology/treatment)
Axis IV: Psychosocial & Environmental Probs
(stressors relevant to diagnosis, prognosis,
treatment)
Axis V: Global Assessment of Functioning (GAF)
Primary Categories of Mental Disorders
1.
2.
3.
4.
5.
6.
7.
8.
9.
Anxiety disorders
Mood disorders
Thought disorders
Dissociative disorders
Personality disorders
Substance-related
Somatoform disorders
Factitious disorders
Sexual & Gender
Identity disorders
10.
11.
12.
13.
14.
15.
16.
Eating disorders
Sleep disorders
Impulse control
Adjustment disorders
Infancy/childhood/earl
y adolescence
Delirium/dementia/am
nesia
MD due to general
medical condition
Prevalence of Mental Disorders
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22% of adults suffer a diagnosable mental
disorder in any given year (1 in 5)
4/10 leading causes of disability are mental
disorders
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Major Depressive Disorder
Bipolar Disorder
Schizophrenia
Obsessive-Compulsive Disorder
Prevalence of Mental Disorders
Males
Anxiety –
19%
Depression 15%
Substance 35%
Schizophrenia - 0.6%
Antisocial PD – 6%
Females
Anxiety Depression Substance SchizophreniaAntisocial PD -
31%
24%
18%
0.8%
1%
Diagnostic Bias
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Males vs. females (APD, histrionic,
borderline)
Genuine differences in manifestation
Sympathy vs. negative reactions
Rosenhan, 1973 – feigned mental illness
study
Multiple Layers of Causation
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A disorder typically arises from (a) a preexisting susceptibility coupled with (b)
triggering circumstances.
Consequences of the disorder may
perpetuate it
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Depression
Paranoid schizophrenia
Social anxiety
Disorders de jour…
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6.
Anxiety Disorders
Mood Disorders
Thought Disorders
Substance-Related Disorders
Somatoform Disorders
Personality Disorders
1. Anxiety Disorders
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Unreasonable, often paralyzing anxiety or
fear
Person feels threatened, unable to cope,
unhappy, and insecure in circumstances of
perceived danger or hostility
The most common category of disorders in
general population
Twice as common in women vs. men
Most amenable to treatment
Generalized Anxiety Disorder
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Characterized by chronic, uncontrollable,
excessive fear and worry lasting at least 6
months, and NOT focused on any particular
object of situation
Afraid of something, but unable to articulate
specific fear
Persistent muscle tension, autonomic fear
reactions, headaches, heart palpitations,
dizziness, insomnia
Generalized Anxiety Disorder
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Comorbid depression is common
Appears to have increased dramatically in
past 50 years (media driven?)
1 in 20 adults (5%)
Panic Disorder
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While GAD is characterized by free-floating
anxiety, panic disorder marked by sudden
(but brief) attacks of intense apprehension
Result in trembling, shaking, dizziness,
shortness of breath, peripheral neuropathy,
tachycardia
Panic Attack – fear/discomfort that arises
abruptly and peaks in 10 minutes or less
Associated with Agoraphobia
Phobias
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Intense, irrational fear and avoidance of
specific objects or situations
i.
Simple Phobias: fear of a specific object or
situation
Generally egodystonic
http://www.phobialist.com/reverse.html
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Phobias
ii.
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Social Phobias: Feel extremely insecure in
social situations – fear of public scrutiny
Irrational fear of embarrassing oneself
Most commonly fear of public speaking or
performing in front of a group
Phobias
iii.
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Agoraphobia – fear of the market place
Often develops following panic attacks
Fear busy, crowded places, or being alone
in wide open places
Fear that something bad will happen and
they won’t be able to escape, or unable to
receive help
Obsessive-Compulsive Disorder
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Persistent, unwanted fearful thoughts
(obsessions) and/or irresistible urges
(compulsions) to engage in ritualistic
behaviors to alleviate the resulting anxiety
Equally common in men and women
Moderate transient forms are common in
childhood
Specific and egodystonic
Compulsions may or may not be rational
Post Traumatic Stress Disorder
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i.
ii.
iii.
Directly tied to specific traumatic events
Involves reliving of traumatic events, and
efforts to avoid associated cues
Intrusive symptoms
Hyperarousal
Avoidance
Psychological Causes of Anxiety
Disorders
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Faulty Cognitions: hypervigilance –
constant scanning of environment for signs of
danger; ignore signs of safety
Magnify ordinary threats
Learning: classical and operant conditioning
Little Albert
Modeling and observational learning (Teddy’s
mom)
Psychological Causes of Anxiety
Disorders
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Biological: evolutionary predisposition
Typical foci are those with survival value
Genetic predispositions, chemical imbalances
Hypersensitive sympathetic nervous system
Stimulants (caffeine, exercise)
Summary – Anxiety Disorders
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Sufferers experience persistent feelings of
fear and dread in everyday circumstances
GAD – free floating anxiety, no specific focus
Simple Phobia – focused, irrational anxiety
Social Phobia – fear of negative appraisal
Agoraphobia – fear of the marketplace
PTSD – fear resulting from traumatic events
that persists and has generalized
Summary – Anxiety Disorders
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Most common disorders among general
population
Highly amenable to psychological treatment
2. Mood Disorders
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1)
2)
Characterized by extreme disturbances in
emotional states
2 main types
Major Depressive Disorder (unipolar
depression)
Bipolar Disorder (manic-depression)
Major Depressive Disorder
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Lasting and continuously depressed mood
without clear trigger or precipitating event
Intense sadness interferes with basic ability
to function
Symptoms include
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Insomnia
Loss of appetite
Tearfulness
fatigue
Major Depressive Disorder
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Symptoms continued
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Hopelessness
Suicidal ideation
Loss of interest in previously enjoyable activities
Irritability
Cognitive and psychomotor slowing
Perceptual disturbance/hallucinations (extreme
cases)
Dysthymia – Depression “Lite”
Bipolar Disorder
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Periods of depression as well as mania
Mania – excessive and unreasonable state of
overexcitement and impulsivity
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Hyperactivity
Easily distracted
Unrealistic self-esteem/grandiosity
Elaborate planning/creativity
Decreased need for sleep
Flight of ideas, loose associations
Examples of Manic Episodes
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Attempt to steal airplane
The problem of multiple Jesus’
Spending sprees
Dar Heatherington
Naked on Younge Street
Bipolar Disorder
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Manic episodes may last days to months
Lifetime risk for bipolar = 0.5 – 1.6 %
Lithium, Depakote
Iatrogenic effects of antidepressants
Hypomania
Cyclothymia
http://groups.msn.com/ABipolarCommunity/fa
mousbipolars.msnw
Causes of Mood Disorders
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Biological: significant role
Imbalances in neurotransmitters related to
sleep cycle, arousal, etc.
50% co-occurrence in identical twins
Causes of Mood Disorders
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ii.
iii.
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Cognitive: Beck’s Depressive Triad
Pessimistic view of…
Self
World
Future
Tendency to attend to and exaggerate bad
experiences and overlook/minimize
positive ones
Causes of Mood Disorders
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Seligman: Hopelessness Theory
Pattern of thinking about negative
experiences that reduces hope that life will
improve
Attribute negative experiences to causes
that are stable (unlikely to change) and
global (widely applicable).
The rules of the game are set, stacked
against me, and apply in many settings
Cycle of Depression (Chicken & Egg)
Negative Thoughts
Depressed Mood
Withdrawal & Inactivity
3. Schizophrenia
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Characterized by
 Disorganized thoughts
 Hallucinations
 Delusions
 Bizarre behavior
Approximate 1% prevalence
Onset between 18 – 30 (slightly later for women)
Similar rates for men and women, but tends to be more
severe/chronic for men
3. Schizophrenia
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Costs of care > 30 Billion per annum
Elevated risk for suicide
NOT multiple personality
Poor prognostic indicators…
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Related disorder among first degree relatives
Early onset
Co-morbid Obsessive-Compulsive Disorder
Negative Symptoms
Positive & Negative Symptoms
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Positive: Usually occur during psychotic
episodes
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Distinctly abnormal behaviors
Include delusions, hallucinations
Negative: generally involves loss of normal
functioning
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Includes reduced speech, low initiative, social
withdrawal, diminished affect, psychomotor
slowing
5 Areas of Disturbance
I.
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Perceptual Symptoms
Either enhanced or blunted sensation
Hallucinations (auditory, visual, tactile,
olfactory)
Command hallucinations
Threat-Command-Override (TCO)
symptoms
5 Areas of Disturbance
II.
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Thought & Language Disturbance
Disorganized thought
Bizarre ideation
Impaired logic and judgment
Loose associations
Circumstantiality
Word salad & neologisms (splisters on my
brain)
5 Areas of Disturbance
Delusions: mistaken beliefs based on
misperceptions/misinterpretations of reality
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Delusions of persecution
Delusions of reference
Delusions of grandeur
Thought insertion
Thought broadcasting
5 Areas of Disturbance
III.
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Emotional Disturbances
Changes in emotion/affect
Exaggerated, blunted, labile
Positive vs. negative symptoms
5 Areas of Disturbance
IV.
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Behavioral Disturbances
Unusual actions that have special meaning
May be driven by hallucinations and/or
delusions (bug tea, the bunker, removal of
fillings)
Waxy flexibility
Catatonic
Social withdrawal
Types of Schizophrenia
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Paranoid: delusions of persecution/grandeur,
persecutory voices
Catatonic: marked by motor disturbances
(immobility or wild activity); echolalia
Disorganized: incoherent speech, flat or
exaggerated emotions, social withdrawal
Undifferentiated: fails to meet criteria for any other
category
Residual: no longer meets criteria but still shows
symptoms
Biological Theories
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Genetics: high heritability
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Monozygotic twins - 50%
Dizygotic twins - 17%
Sibling - 9%
Parent - 6%
Biological Theories
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Structural abnormalities
Dopamine hypothesis
drugs that increase dopamine may also
facilitate schizophrenic-like symptoms
(methamphetamine, cocaine)
drugs that block dopamine have opposite
effect (Parkinsonian symptoms, EPS)
Delusional Disorders
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1 in 3333 people
Onset between 40 – 55 years old
More common in women
Delusions are non-bizarre
Capgras’ Syndrome: believes that a person
known to them has been replaced by a
duplicate/imposter
Delusional Disorders
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Erotomania (de Cleramault’s syndrome):
false belief that someone (usually someone
in higher social strata) is in love with them
Fregoli’s syndrome: someone known to you
has changed identities, and is out to get you
Folie a Deux: shared delusions; one person
with genuine delusional disorder, and a
second person (usually less intelligent) who
has become convinced of the validity of that
delusion
4) Substance-Related Disorders
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Legal or illegal drugs
Abuse: when drug use interferes with
person’s social or occupational functioning
Dependence: when not only interferes, but
also causes physical reactions (tolerance and
withdrawal)
High co-morbidity with other mental
disorders, including mood, personality,
thought and personality disorders
5) Dissociative Disorders
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Splitting apart of significant aspects of experience
from memory or consciousness
Dissociative amnesia: fail to recall/identify past
experience
Dissociative fugue: leaving home, wandering off,
forgetting who one is
Depersonalization disorder: losing sense of reality,
feeling estranged from self
Dissociative Identity Disorder: fragmented
personality
5) Dissociative Disorders
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Day dreaming and driving
Motivated by need to escape from intolerable
anxiety
Environmental factors (i.e., trauma) are
primary cause
Hillside Strangler
MRDP
Somatoform & Related Disorders
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Somatoform Disorder
Means “bodily form”
Person experiences bodily ailments in
absence of identifiable medical cause
Conversion Disorder: loss of specific bodily
function (blindness, deafness, localized
paralysis)
Primary focus of Freud’s early work
Somatoform & Related Disorders
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Decreasing prevalence in Westernized
cultures over past century
Cases most common in non-Western cultures
Somatization Disorder: characterized by
chronic complaints of multiple vague,
unverifiable medical conditions (dizziness,
gastrointestinal, chronic pain, fatigue, chest
pains)
Manifestation of depression? Anxiety?
Personality Disorders
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Axis II
Defined as relatively stable and enduring patterns of
thoughts, feelings, and actions
Inflexible and maladaptive
Antisocial
Avoidant
Depressive
Dependent
Histrionic
Narcissistic
Borderline Personality Disorder
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Characterized by impulsivity, mood
instability/lability, poor sense of self
Insecure/disorganized attachment pattern
Unstable, turbulent relationships that rapidly
alternate between idealization and
devaluation
Efforts to avoid real or imagined
abandonment
Borderline Personality Disorder
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Proclivity for self-harm, attention seeking,
maladaptive coping
Black or White, All or Nothing thinking
Co-morbid substance abuse, depression,
eating disorders
Typically come from chaotic, abusive early
life environments (highly inconsistent
parenting)