Download Chapter 13 Understanding Psychological Disorders

Introduction: Understanding Psychological
Disorders
• Pathological
Eating disorders
• Psychological disorder
Personality disorders
• Anxiety disorder
Dissociative disorders
• Generalized anxiety disorder DSM-5
• Panic attacks
Schizophrenia & types
• Phobias
Suicide
• Behavioral perspective in psychological disorders
• Post traumatic stress disorder
Sexual disorders
• Obsessive-compulsive disorder
Paraphilia
• Mood disorders
CASE STUDY…MS. JONES
• Ms. Jones is a 44-year old mother of three teenagers. She has
recently been hospitalized for treatment of major depression. She
gives the following history:
• She became increasingly depressed, lost her appetite, and
woke at 4:00 A.M. or 5:00 A.M. every morning and was
unable to get back to sleep. She could no longer read a
newspaper or watch TV because she could not concentrate
sufficiently.
• One year previously, after an argument that ended her relationship
with her boyfriend, Ms. Jones became acutely psychotic. She became
frightened that people were going to kill her, and she began to hear
the voices of friends and strangers talking about killing hersometimes talking to each other. She heard her own thoughts
broadcast aloud and was afraid that others could also hear what she
was thinking. Over a 3-week period, she stayed in her apartment,
had new locks put on the doors, kept the shades down, and avoided
everyone but her immediate family. She was unable to sleep at night
because the voices kept her awake. She was unable to eat because of
a constant “lump” in her throat. In retrospect, she cannot say
whether she was depressed. She denies being elevated or overactive.
She remembers only that she was terrified of what would happen to
her.
• Ms. Jones’s condition has persisted for nine months. She has
done very little except sit in her apartment, staring at the
walls. Her children have managed most of the cooking,
shopping, bill payment, etc. She has continued in outpatient
treatment and was maintained on the same antipsychotic
drug until three months before the current hospitalization.
There has been no recurrence of psychotic symptoms since
the medication was discontinued. However, her depression
has persisted.
• Ms. Jones’s family persuaded her to enter a hospital, where, after six
weeks of treatment with an antipsychotic medication, the voices
stopped. She remembers feeling “back to normal” for a period of one
to two weeks, but then she seemed to lose her energy and
motivation to do anything.
• In discussing her history, Ms. Jones is rather guarded. There
is, however, no evidence of a diagnosable illness before last
year. She apparently is a shy, emotionally constricted
individual who has “never broken any rules.” She has been
separated from her husband for ten years, but in that time
has had two enduring relationships with boyfriends. In
addition to rearing three apparently healthy children full time
in the four years before her illness, she cared for a succession
of foster children full time. She enjoyed this and was highly
valued by the agency with whom she worked. She has
maintained close relationships with a few girlfriends and with
her extended family.
• Psychopathology is the scientific study of the origins, symptoms, and development of psychological disorders.
•
• Psychological disorder is “a clinically significant behavioral 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…” (DSM-iV-TR,2000)…disabilities include loss of ability to function in an important area of functioning,
such as home, social settings, work or school.
• Like medical disorders, psychological disorders are out of the patient’s control, they may in some cases be treated by drugs…may
have both biological (nature) as well as environmental (nurture) influences. These causal influences are reflected in the biopsycho-social model of illness (Engel, 19770).
• Dispelling Mental Disorder Myths
•
• There are many myths and misconceptions surrounding abnormal behavior; abnormal behavior is always bizarre, normal and
abnormal behavior are unique to normal and abnormal persons, and once someone has a mental disorder, they will always have it.
•
• Former mental patients do not have a higher rate of violence than the general public.
•
• People with severe mental disorders who are experiencing bizarre delusional ideas and hallucinated voices have a slightly higher
level of violent and illegal behavior than do “normal” people.
•
• There is very little risk of violence or harm to a stranger from casual contact with an individual who has a mental disorder.
What Is a Psychological Disorder?
• A psychological disorder or mental disorder is a pattern of behavioral and
psychological symptoms that causes significant personal distress, impairs
the ability to function in one or more important areas of daily life, or both.
•
• There are five axes of the DSM-5
•
• Axis I- All diagnostic categories except personality disorders and mental
retardation…mood, anxiety, or learning disorder
• Axis II- Personality disorders and specific developmental disorders
• Axis III- General medical conditions…heart disease, cancer, diabetes
• Axis IV-Psychosocial and environmental problems…homelessness, divorce,
school problems
• Axis V-Current level functioning…in danger of hurting oneself or others
DSM *
• Diagnostic and Statistical Manual
• American Psychiatric Association
• Currently DSM-5
• Common language and standard criteria for classifying mental
disorders
• Controversies include:
• Cultural bias (e.g. sexual disorders)
• Medical rather than behavioral model
• Diagnosing, e.g. ADHD, autism.
Categories of Disorders include:
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Obsessive Compulsive and Related Disorders
Neurodevelopmental Disorders
Dissociative disorders
Substance Related and Addictive Disorders
Depressive Disorders
Bipolar and related disorders
Schizophrenia spectrum and other psychotic disorders
Anxiety Disorders
Somatic Symptom and Related Disorders
Trauma and Stressor-Related Disorders
Feeding and Eating Disorders
Sexual Dysfunction
Personality Disorders
Autism Spectrum Disorders
Neurocognitive Disorders
Diagnosing Disorder: The DSM
• The DSM organizes
disorders by category.
Within a diagnostic
category, clinicians may
also identify specifiers
and rate severity.
Biopsychosocial Model *
Key concept is
Interaction.
biological factors
• come from the body
• e.g., genes;
neurotransmitters
social factors
• come from society
and culture
• e.g.,
socioeconomic
status,
homelessness,
abuse
psychological factors
• come from the
individual
• e.g., patterns of
negative thinking;
stress responses
What is Abnormal behavior?
• A psychological disorder, causing distress, disability, or dysfunction.
Defined symptomatically by the DSM
• 1 in 4 affected each year
• Each year prevalence: 18.1% anxiety disorders;
• 1% schizophrenia; 4.4% alcohol use disorder
• More lower SES
• Mentally ill stigmatized
• Many disorders comorbid.
• Comorbid = more than one disorder at a time
• Most severe disorders in a small group of people
• 6% of population have 3 or more disorders
DSM-5
• Cluster A (odd or eccentric disorders)
• Not to be confused with Type A personality.
• Paranoid personality disorder: characterized by irrational suspicions
and mistrust of others.
• Schizoid personality disorder: lack of interest in social relationships,
seeing no point in sharing time with others, anhedonia, introspection.
• Schizotypal personality disorder: characterized by odd behavior or
thinking.
• Cluster B (dramatic, emotional or erratic
disorders)
• Not to be confused with Type B personality.
• Antisocial personality disorder: a pervasive
disregard for the rights of others, lack of empathy,
and (generally) a pattern of regular criminal
activity.
• Borderline personality disorder: extreme "black
and white" thinking, instability in relationships,
self-image, identity and behavior often leading to
self-harm and impulsivity.
• Histrionic personality disorder: pervasive
attention seeking behavior including
inappropriately seductive behavior and shallow or
exaggerated emotions.
• Narcissistic personality disorder: a pervasive
pattern of grandiosity, need for admiration, and a
lack of empathy. Characterized by selfimportance, preoccupations with fantasies, belief
that they are special, including a sense of
entitlement and a need for excessive admiration,
and extreme levels of jealousy and arrogance.
• Cluster C (anxious or fearful disorders)
• Avoidant personality disorder: pervasive
feelings of social inhibition and social
inadequacy, extreme sensitivity to negative
evaluation and avoidance of social
interaction.
• Dependent personality disorder: pervasive
psychological dependence on other people.
• Obsessive-compulsive personality disorder
(not the same as obsessive-compulsive
disorder): characterized by rigid conformity to
rules, moral codes and excessive orderliness.
• Appendix B: Criteria Sets and Axes Provided
for Further Study
• Appendix B contains the following disorders
• Depressive personality disorder – is a
pervasive pattern of depressive cognitions
and behaviors beginning by early adulthood.
• Passive-aggressive (negativistic) personality
disorder – is a pattern of negative attitudes
and passive resistance in interpersonal
situations.
Anxiety Disorders: Intense Apprehension and
Worry
• Anxiety is an unpleasant emotional state characterized by physical arousal and feelings of tension,
apprehension, and worry. People who have anxiety are in a perpetual state of “fight-or-flight”.
• How do you know if you suffer from an anxiety disorder?
• Three features distinguish normal anxiety from pathological anxiety.
• Pathological anxiety is:
• a. irrational—it is provoked by perceived threats that are exaggerated or nonexistent, and the anxiety
response is out of proportion to the actual importance of the situation.
• b. uncontrollable—the person can’t shut off the alarm reaction even when he or she knows it’s
unrealistic.
• c. disruptive—it interferes with relationships, job or academic performance, or everyday activities.
•
• Generalized Anxiety Disorder: Worrying About Anything and Everything
• Generalized anxiety disorder (GAD) is characterized by excessive, global, and persistent symptoms of
anxiety; it is sometimes referred to as free-floating anxiety.
Panic Attacks and Panic Disorder: Sudden Episodes of
Extreme Anxiety
• A panic attack is a sudden episode of extreme anxiety that rapidly escalates in intensity. Panic
disorder is an anxiety disorder in which the person experiences frequent and unexpected
panic attacks.
• People who suffer from panic disorders tend to feel safer at home and therefore develop
agoraphobia, a condition in which the fear is so intense, that the person becomes
homebound.
• Explaining panic disorder
• a. Panic disorder tends to run in families.
• b. People with panic disorder are unusually sensitive to the signs of physical arousal.
• c. According to the cognitive-behavioral theory of panic disorder, people with panic disorder
tend to misinterpret the physical signs of arousal as catastrophic and dangerous.
• After their first panic attack, they become even more attuned to physical changes,
increasing the likelihood of future panic attacks
The Phobias: Fear and Loathing
Posttraumatic Stress Disorder
• Phobic disorder is an anxiety disorder and is characterized by an
irrational, overwhelming, and intense fear that is directed at a
particular object or situation.
• Natural disasters, catastrophic illnesses, incest, rape, and
assault are a few of the life experiences that can unleash a
wave of intense emotional stress. Distressing, intrusive
recollections of the event are experienced as “flashbacks”.
• Specific phobias are an exaggerated fear of a particular thing,
such as a phobia of spiders, lizards, or a fear of riding in an
elevator.
• Situational anxiety is usually self-limiting and dissipates as the
stressful event recedes into the past. Ie is an overly anxious
reaction to a situation
• Social phobias are the most common of the phobias, and refer to
an intense anxiety about a social situation. The anxiety is
experienced when the person is in a social or interpersonal
setting such as public speaking, or asking someone out for a date.
Explaining phobias: Learning theories
• Classical conditioning may be involved in the development of a
specific phobia
• Operant conditioning can be involved in the avoidance behavior
that characterizes phobias.
• Observational learning can be involved in the development of
phobias.
• Humans seem biologically prepared to acquire fears of certain
animals and situations that were survival threats in human
evolutionary history.
• How might these perspectives explain Ms. Jones’s situation?
• Very early, severe, recurring child abuse often results in
symptoms of PTSD
• Characteristics of PTSD include:
• a. Frequent, intrusive recall of the event
• b. Avoidance of stimuli or situations that tend to trigger
memories of the experience and a general numbing of
emotional responsiveness
• c. Increased physical arousal associated with anxiety
• Several factors influence the likelihood of a person’s
developing PTSD:
• a. A personal or family history of psychological disorders
• b. The magnitude of the trauma
• c. Experiencing multiple traumas
Obsessive–Compulsive Disorder
• Obsessive-compulsive disorder (OCD) is characterized by obsessional thoughts and/or compulsive behaviors.
Obsessional thoughts are intrusive thoughts that are very distressing to the person thinking them. They evoke a
great deal of anxiety, or fear about oneself or loved ones becoming ill, infected with a deadly virus of dying.
• Obsessions are the thoughts and compulsions are the behaviors
(1) Overt physical behaviors, such as repeatedly washing your hands.
• (2) Covert mental behaviors, such as counting or reciting certain phrases to yourself.
66% -are plagued by obsessions regarding dirtiness, contamination, and germs, with the corresponding
compulsions such as cleaning and hand washing.
• 20%- are worried about safety issues and engage in repetitive checking rituals.
• 15%-are concerned with a sense of incompleteness.
• There are two key reasons for OCD
• Excessive self-doubt
• Intense worry regarding the safety of oneself and others
• Depletion of the neurotransmitter serotonin is thought to be involved in the presentation of OCD.
• Serotonin antidepressants are the most effective treatment used for OCD; they include SSRIs (Prozac, Paxil,
Zoloft, Celexa, and Lexapro).
Mood Disorders
• Jenny is a 12 year old girl. She has been described as moody. Jenny has started to
sleep late, to the point where she is frequently late for school, and she is
becoming sexually curious. She had been a very quiet child, but in the last few
months she has become loud, demanding, and visibly unhappy. Teachers have
noted that she is no longer hanging around her friends, and when questioned,
Jenny has no definitive answer, but responds in a very defensive manner. The
friends who Jenny has started to associate with are also sexually curious and
rebellious.
• Jenny’s attitude has changed at home as well. She has started to yell at her
mother, and she can be heard crying in her room at night. What once was an
uneventful chore, has now become a battle. Jenny has also begun to keep her
door closed and has become very secretive, especially in the bathroom.
• Jenny’s mother has made an appointment with the pediatrician at Jenny’s urging
because of complaints from Jenny of joint pains and frequent injuries as a result
of Jenny’s recent clumsiness, perhaps because of recent weight gain.
• Jenny can also be heard yelling and throwing items around in her room.
• The broad category of mood disorders (aka affective
disorders) includes depressive disorders, bipolar
disorders, mood disorder due to a general medical
condition, and substance-induced mood disorder.
• Depressive disorders are mood disorders in which the
individual suffers depressions without experiencing
mania.
• Mood disorders are psychological disorders
characterized by a disturbance of mood; mood or
emotions cause impaired cognitive, behavioral, and
physical functioning.
• The DSM-5 lists the following depressive disorders:
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Major Depressive Disorder, Single Episode
Major Depressive Disorder, Recurrent
Dysthymic Disorder
Depressive Disorder not otherwise specified
• These symptoms define a major depressive
episode (at least five must be present during
a 2 week period).
• *Appetite disturbance with accompanying
weight loss or weight gain
• *Fatigue
• *Decreased sex drive
• *Restlessness, agitation, or psychomotor
retardation
• *Diurnal variations in mood (usually feeling
worse in the morning) *red flag
• *Impaired concentrations and forgetfulness
• *Pronounced anhedonia (total loss of the
ability to experience pleasure)
• *Sleep disturbance
• Major depression is often triggered by
traumatic and stressful events. Chronic stress
can also produce major depression.
Mood disorders, cont.
• Dysthymic disorder is generally more chronic and has fewer symptoms than major depressive
disorder.
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• Women’s lifetime risk of major depression is one in four; men’s lifetime risk is one in eight. Why?
because women experience a greater degree of chronic stress, have a lesser sense of personal
control, and are more prone to ruminate about their problems.
•
• In seasonal affective disorder (SAD), episodes of depression typically occur during the autumn
and winter and subside during the spring and summer.
•
• Explaining Mood Disorders
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• Family, twin, and adoption studies suggest that some people inherit a genetic predisposition to
mood disorders.
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• Disruption of the neurotransmitters norepinephrine and serotonin has been implicated in the
development of major depression.
Bipolar Disorder
• Bipolar disorder involves periods of incapacitating depression alternating
with periods of extreme euphoria and excitement; formerly called manic
depression.
•
• A manic episode is a sudden, rapidly escalating emotional state
characterized by extreme euphoria, excitement, physical energy, and rapid
thoughts and speech.
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• Treatment for the disorder follows a 3 tier formula:
•
• *Rx
• *Psychotherapy
• *Education on the disorder
•
• Eating Disorders: Anorexia and Bulimia
•
• Eating disorders involve serious and maladaptive disturbances in eating
behavior and usually develop in adolescence.
•
• People with anorexia have an extreme fear of gaining weight or becoming
fat, have a distorted perception about their body size, and are denial of
how serious their weight loss is. The disorder causes changes in their body
due to the severe loss of weight and malnutrition.
•
• People with bulimia are within a normal weight range or may even be
slightly overweight; however, people with bulimia experience extreme
episodes of binge eating.
Sexual disorders and problems
• Samantha complains of feeling increasingly anxious as the time for
her husband, Bill, to arrive home and as dinner approaches. She has
trouble being calm through dinner and frets during the hour or two of
TV in the evening. She takes advantage of the opportunity to get out
of the house for the evening whenever possible. As she and Bill climb
into bed, she can feel her heart race and her muscles tense. Though
she loves Bill, she feels increasingly anxious about his evaluations of
her. She is sure he no longer finds her attractive despite his constant
reassurances. Their sex episodes leave her feeling painful and sore,
even though they do not engage in any deviant sexual practices. She
avoids lovemaking because she feels she does not satisfy Bill’s needs.
Lately, she feels a sense of relief whenever he leaves for work, finally
feeling like she can relax. However, as 5 o’clock approaches, her
anxiety begins to increase once again….
Paraphilias
• What are paraphilias?
• Paraphilias are an “abnormal” way in which people achieve sexual
gratification. These fantasies, urges, or behaviors must occur for a
significant period of time and must interfere with either satisfactory
sexual relations or everyday functioning if the diagnosis is to be made.
There is also a sense of distress within these individuals. In other words,
they typically recognize the symptoms as negatively impacting their life
but feel as if they are unable to control them.
Common Paraphilias
• Exhibitionism
• This disorder is characterized by either intense sexually arousing fantasies, urges, or behaviors in which the individual exposes his or her
genitals to an unsuspecting stranger. To be considered diagnosable, the fantasies, urges, or behaviors must cause significant distress in
the individual or be disruptive to his or her everyday functioning.
• Treatment
• Treatment typically involves psychotherapy aimed at uncovering and working through the underlying cause of the behavior. Medications
can at times be helpful to assist the client in resisting urges, but are typically not utilized in treatment.
• Fetishism
• Fetishism is characterized by either intense sexually arousing fantasies, urges, or behaviors in which the individual uses a nonliving
object (e.g., woman’s high heeled shoe, stockings) in a sexual manner. Typically, the individual requires this object to become sexually
aroused and is therefore unable to be aroused without it. To be considered diagnosable, the fantasies, urges, or behaviors must cause
significant distress in the individual or be disruptive to his or her everyday functioning.
• Treatment
• Treatment typically involves psychotherapy aimed at uncovering and working through the underlying cause of the behavior.
• Frotteurism
• This disorder is characterized by either intense sexually arousing fantasies, urges, or behaviors in which the individual touches or rubs
against an non-consenting person in a sexual manner. This often occurs in somewhat conspicuous situations such as on a crowded bus or
subway. To be considered diagnosable, the fantasies, urges, or behaviors must cause significant distress in the individual or be disruptive
to his or her everyday functioning.
• Treatment
• Treatment typically involves psychotherapy aimed at uncovering and working through the underlying cause of the behavior.
• Pedophilia
• This disorder is characterized by either intense sexually arousing fantasies, urges, or behaviors involving sexual activity with a
prepubescent child (typically age 13 or younger). To be considered for this diagnosis, the individual must be at least 16 years old and at
least 5 years older than the child.
• Treatment
• Treatment typically involves intensive psychotherapy to work on deep rooted issues concerning sexuality, feelings of self, and often
childhood abuse. Medical treatments such as ‘chemical castration’ (which is actually a hormone medication which reduces testosterone
and therefore sexual urges) have been investigated with very mixed results.
• Sexual Masochism
• Sexually masochistic behaviors are typically evident by early adulthood, and often start with masochistic or sadistic play in childhood.
The disorder is characterized by either intense sexually arousing fantasies, urges, or behaviors in which the individual is humiliated,
beaten, bound, or made to suffer in some way.
• Treatment
• Treatment typically involves psychotherapy aimed at uncovering and working through the underlying cause of the behavior.
• Sexual Sadism
• Sexually sadistic behaviors are typically evident by early adulthood, and often start with masochistic or sadistic play in childhood. The
disorder is characterized by either intense sexually arousing fantasies, urges, or behaviors in which the individual is sexually aroused by
causing humiliation or physical suffering of another person.
• Treatment
• Treatment typically involves psychotherapy aimed at uncovering and working through the underlying cause of the behavior.
• Transvestic Fetishism
• This diagnosis is used for heterosexual males who have sexually arousing fantasies,
urges, or behaviors involving cross-dressing (wearing female clothing). To be
considered diagnosable, the fantasies, urges, or behaviors must cause significant
distress in the individual or be disruptive to his or her everyday functioning.
• Treatment
• Treatment typically involves psychotherapy aimed at uncovering and working
through the underlying cause of the behavior.
• Voyeurism
• This disorder is characterized by either intense sexually arousing fantasies, urges, or
behaviors in which the individual observes an unsuspecting stranger who is naked,
disrobing, or engaging in sexual activity. To be considered diagnosable, the fantasies,
urges, or behaviors must cause significant distress in the individual or be disruptive to
his or her everyday functioning.
• Treatment
• Treatment typically involves psychotherapy aimed at uncovering and working
through the underlying cause of the behavior.
Sexual Disorders
• Dyspareunia
• Recurrent or persistent genital pain associated with sexual intercourse. Can be diagnosed in males or females, is not better
accounted for by another diagnosis (psychiatric or physical) and is not the direct effect of substance use.
• Treatment
• Resolving underlying sexual and relationship issues can be helpful in many cases.
• Female Orgasmic Disorder
• Delay of orgasm following normal excitement and sexual activity. Due to the widely varied sexual response in women, it must be
judged by a clinician to be significant taking into account the person’s age and situation. The condition is persistent or occurs
frequently and causes significant distress. Is not a direct effect of substance use.
• Treatment
• Typical treatment would involve discovering and resolving underlying conflict or life difficulties.
• Female Sexual Arousal Disorder
• Inability to attain or maintain until completion of sexual activity adequate lubrication in response to sexual excitement. Must
result in significant distress and not better accounted for by another disorder or the use of a substance.
• Treatment
• Typical treatment would involve discovering and resolving underlying conflict or life difficulties.
• Gender Identity Disorder
• A strong and persistent identification with the opposite gender. There is
a sense of discomfort in their own gender and may feel they were ‘born
the wrong sex.’ This has been confused with cross-dressing or Transvestic
Fetishism, but all are distinct diagnoses.
• Treatment
• Other disorders may be present with this one, including depression,
anxiety, relationship difficulties, and personality disorders, and
homosexuality is present in a majority of the cases. Treatment is likely to
be long-term with small gains made on underlying issues as treatment
progresses.
• Hypoactive Sexual Desire Disorder
• Deficient or absent sexual fantasies and desire for sexual activity. This judgment must be made by a clinician taking into account
the individual’s age and life circumstances. The lack of desire must result in significant distress for the individual and is not
better accounted for by another disorder or physical diagnosis.
• Treatment
• Typical treatment would involve discovering and resolving underlying conflict or life difficulties.
• Male Erectile Disorder
• Recurring inability to achieve or maintain an erection until completion of the sexual activity. Must result in significant distress for
the individual and is not better accounted for by another disorder (e.g. drug abuse) or physical diagnosis.
• Treatment
• The most commonly applied treatment for non-medical related impotence is ‘Sensate Focus,’ which involves a progression of
sexual intimacy, typically over the course of several weeks, and eventually leading to penetration and orgasm.
• Male Orgasmic Disorder
• Delay or absence of orgasm following normal excitement and sexual activity. Due to the widely varied sexual response in men, it
must be judged by a clinician to be significant, taking into account the person’s age and situation. The condition is persistent or
occurs frequently and causes significant distress. Is not a direct effect of substance use.
• Treatment
• Typically once a medical cause is ruled out, working through the underlying issues is very helpful. Some therapists also use
behavioral techniques such as sensate focus which is a more direct approach if underlying issues are not significant.
• Premature Ejaculation
• Ejaculation with minimal sexual stimulation before or shortly after penetration and before the person
wishes it. The condition is persistent or occurs frequently and causes significant distress. Is not a direct
effect of substance use.
• Treatment
• Relaxation training, education, and working through underlying issues are treatment options. If the
relationship is new, often the difficulties will resolve as the relationship matures.
• Sexual Aversion Disorder
• Persistent or recurring aversion to or avoidance of sexual activity. The aversion must result in
significant distress for the individual and is not better accounted for by another disorder or physical
diagnosis. When presented with a sexual opportunity, the individual may experience panic attacks or
extreme anxiety.
• Treatment
• Typical treatment would involve discovering and resolving underlying conflict or life difficulties.
• Vagismus
• Recurrent or persistent involuntary spasm of the vaginal muscles that interferes with sexual
intercourse. It must cause significant distress and not due to a medical condition or another disorder.
• Treatment
• Psychological treatment involves working through underlying issues, while other treatments can
involve progressively larger dilators and therapy to help relax muscles which prevent intercourse
Clinical Vignette
• Mr. Rodriguez, a 52-year old, Cuban born president of a successful family business in Miami, was brought to a hospital by his wife after
he told her that he had suddenly remembered setting several major fires when he was a child and murdering a man 30 years ago.
• Mr. Rodríguez tells the following story. He has been “on edge” recently because of a lot of financial problems in his business. A few
weeks ago he became enraged with a long-time employee of whom he had been very fond. He yelled at him for misspending a
considerable amount of the firm’s money and almost threw an ashtray at him. He was stunned by the violence of his impulses and
began to realize how angry and hateful he has always been, particularly in relation to his wife and children.
• Later, at home, when thinking about the events of the day, “the curtains were opened and I was flooded with memories of acts that
had previously been cut off from my conscious mind.” He recalled having set fire to a woman’s house while she was inside. This
occurred when he was 5 years old, at his father’s urging. He also recalled having set fires in doctor’s offices and libraries. In addition,
he was convinced that, at age 19, he had shot a man for having assaulted his wife. There were many other similar “memories” of
violent acts, which he had never had before.
• For two weeks, Mr. Rodriguez stayed home from work. He sat, inactive, sometimes tearful about the damage he thought he had done,
ruminating about what a terrible father he had been. Although his thoughts were painful, he actually “enjoyed the pleasure of
knowing and discovering” and denied being persistently depressed. He also denied having experienced any change in weight,
appetite, sleep, or psychomotor activity. He admitted to poor concentration, beginning about one month previously, when financial
pressures to work had begun to escalate. Sometimes he thought of killing himself.
• The day before, he had had another “revelation.” He “remembered” for the first time that his father had beaten and sodomized him.
He now understood that his destructiveness was caused by his father’s abuse. With this realization, he no longer felt guilty about the
terrible things that he had done. Nevertheless, he had agreed today to his wife’s request that he come to the hospital.
• Mr. Rodriguez is a tall, slender, neatly dressed man with a piercing gaze, poised demeanor, and polished manners. He smokes
constantly throughout the session. He is quick witted and playful, even when talking about the serious crimes he claims to have
committed. He does well on tests of cognitive functioning. When told that his wife and others maintain that his memories cannot be
accurate, he remarks, “Their facts do contradict my recollections. I can’t explain the discrepancy. All I know is I set those fires.” When
asked to explain how he could have no police record, he replies that this is because he was so “quick and wily” that no one could catch
him. He accounts for his wife’s refusal to believe his stories by asserting that “she must have blocked the memories of the events
because they are so upsetting to her.”
• On admission, physical examination of Mr. Rodriguez, including a neurological evaluation revealed no abnormality. All laboratory tests
were also negative.
Schizophrenia
• Paranoid-the presence of prominent delusions including persecution and
grandiosity
•
Nearly 1 in every 100 people will develop schizophrenia; almost 24 million people
suffer from schizophrenia
•
•
Schizophrenia is a serious debilitating disorder in which the mind seems “split’.
Drug therapy is the main source of treatment for persons suffering from
schizophrenia.
• Undifferentiated- when an individual displays some combination of
positive and negative symptoms that does not clearly fit the criteria for the
paranoid, catatonic, or disorganized types.
•
Schizophrenia is the chief example of a psychotic disorder, a disorder marked by
irrationality and lost contact with reality symptoms excesses or distortions of
normal functioning include delusions, hallucinations, and severely disorganized
thought processes, speech, and behavior.
•
Negative symptoms reflect defects or deficits in normal functioning including flat
affect, alogia (greatly reduced production of speech), and avolition (the inability to
initiate or persist in goal-directed behaviors, catatonic state). )…the absence of
appropriate behaviors
The jumbled ideas form a word salad, jumbled up sentences
• Residual-withdrawal, after hallucinations and delusion have disappeared
• Disturbed perceptions
• A person diagnosed with schizophrenia may also have
hallucinations…sensory experiences without sensory stimulation, hearing,
seeing, feeling, tasting, or smelling things that are not there
• The emotions of a person diagnosed with schizophrenia are inappropriate,
split off from reality
•
Types of schizophrenia
•
Disorganized schizophrenia-the individual has delusions and hallucinations and the •
person tends to withdraw, disorganized speech and flat affect; a general disruption
of behavior
•
Disorganized thoughts may result from a breakdown in selective attention, a break
down in the filter such that minute details may distract attention from bigger, more
significant details
•
Catatonic-prolonged states of motor immobility so much so that the individual can
be manipulated physically, that alternate with periods of excitability
•
Persons with schizophrenia think in fragmented, bizarre, and often distorted beliefs
called delusions
Some persons may laugh when others cry or vice versa, still others exhibit
no emotions...flat affect…make it hard to have a normal life
•
Biological Factors in Schizophrenia-Ventricles in the brain tend to be larger
and widened cortical sulci which means that in some types of
schizophrenia, there has been abnormal brain development.
•
Individuals with schizophrenia produce higher than normal levels of the
neurotransmitter dopamine and that the excess dopamine causes
schizophrenia.
•
The onset of schizophrenia typically occurs during young adulthood.
Onset and development of Schizophrenia
• Schizophrenia manifests in emerging adulthood
• Schizophrenia may strike suddenly as a response to stress, or a
stressor
• Schizophrenia may be gradual, for those who have experienced a
gradual onset of schizophrenia they may be homeless and may be in
the lower socioeconomic bracket
• Schizophrenia affects both males and females, men tend to be struck
earlier
• Schizophrenia is a cluster of disorders and as such, there exists a
variety of symptoms
• The causes of schizophrenia seem to be extremely complex.
• Evidence from family, twin, and adoption studies has firmly established the role of genetic factors in many
cases of schizophrenia.
• Biological Factors in Schizophrenia-Ventricles in the brain tend to be larger and widened cortical sulci
which means that in some types of schizophrenia, there has been abnormal brain development.
• Midpregnancy viral infections may impair fetal brain development and are an additional consideration in
the cause of schizophrenia and increase the probability that a child will develop schizophrenia (flu)…but
only 2% of women who contract the flu during their second trimester develop trimester
• For identical twins who share a placenta, if one twin develops schizophrenia, there is a 6 in 10 chances that
the other twin will also develop schizophrenia
• Children adopted by someone who develops schizophrenia seldom develop schizophrenia the disorder
• Approximately 10% of people with schizophrenia commit suicide
•
• Women outnumber men by three to one in the number of suicide attempts. Men outnumber women by
better than four to one in suicide deaths.
•
•
•
•
• How can you help prevent suicide?
•
• 1. Actively listen as the person talks and vents her feelings.
• 2. Don’t deny or minimize the person’s suicidal intentions.
• 3. Identify other potential solutions.
• 4. Ask the person to delay his decision.
• 5. Encourage the person to seek professional help.
•
Somatoform Disorders
• Somatoform disorders are now referred to as somatic disorders
• Individuals with somatic symptoms plus abnormal thoughts, feelings, and behaviors
may or may not have a diagnosed medical condition. The relationship between
somatic symptoms and psychopathology exists along a spectrum.
• Somatic symptom disorder (SSD) is characterized by somatic symptoms that are
either very distressing or result in significant disruption of functioning, as well as
excessive and disproportionate thoughts, feelings and behaviors regarding those
symptoms. To be diagnosed with SSD, the individual must be persistently
symptomatic (typically at least for 6 months).
• TheDSM-5 does not require that the sufferer have a medically unexplained
condition.
• The diagnosis of somatization disorder was essentially based on a long and complex
symptom count of medically unexplained symptoms. Individuals previously
diagnosed with somatization disorder will usually meet DSM-5 criteria for somatic
symptom disorder, but only if they have the maladaptive thoughts, feelings, and
behaviors that define the disorder, in addition to their somatic symptoms.”
The Dissociative Disorders
• Dissociative disorders are psychological disorders that involve a sudden loss of
memory or change in identity.
•
• People with dissociative disorders escape their reality in involuntary and unhealthy
ways.
• Dissociative disorders most often form in children who have been subjected to
chronic physical, sexual, and/or emotional abuse.
•
• Dissociative disorders come in many forms; the most famous is Dissociative Identity
Disorder (DID).
•
• Dissociative amnesia is characterized by blocking out of critical personal information,
usually of a traumatic or stressful nature. Memory loss is more extensive than normal
forgetfulness and cannot be explained by a physical or neurological condition, such as
a head injury.
•
DID, cont.
• Dissociative fuge is a very rare disorder. An individual with dissociative fuge
suddenly and unexpectedly takes physical leave of his or her surrounding and sets
off on a journey of sorts. An individual in a fugue state is unaware of or is
confused about his identity, and in some cases will assume a new identity.
Dissociative fugue typically ends as abruptly as it begins.
•
• Psychotherapy with a combination of medication treatment is the primary
treatment for dissociative disorders. The therapist works with the patient to help
the individual understand the cause of the condition and to form new ways of
coping with stressful circumstance.
•
• DID represents an extreme form of dissociative coping brought on by suffering
trauma in childhood— often extreme physical or sexual abuse.
Clinical Vignette
• Mr. Nehru is a 32-year-old, single, unemployed man who migrated from India to the United States when he was 13 years old. Mr. Nehru recently ended a
three year relationship with a woman he met in the United States. According to his brother, Mr. Nehru was emotionally heavily involved with the woman,
often fantasizing about her, writing her name on objects, and often calling her several times without speaking when she answers. His brother claims that
the relationship ended because the woman was not accepting of his religious beliefs. His brother brought him to the emergency room of an Atlanta
hospital after neighbors complained that he was standing in the street harassing people about his religious beliefs. To the examining psychiatrist, he keeps
repeating, “I am Vishnu. I am Krishna.”
•
Mr. Nehru has been living with his brother and sister-in-law for the past seven months and has been attending an outpatient clinic. During the last four
weeks, his behavior has become increasingly disruptive. He awakens his brother at all hours of the night to discuss religious matters. He often seems to be
responding to voices that only he hears. He neither bathes nor changes his clothes.
•
Mr. Nehru’s first episode of emotional disturbance was five years ago. Medical records are not available, but from the brother’s account, it seems to have
been similar to the present episode. There have been two other similar episodes, each requiring hospitalization for a few months. Mr. Nehru admits that,
starting about five years ago and virtually continuously since then, he hasn’t been troubled by “voices” that he hears throughout the day. There are
several voices, which comment on his behavior and discuss him in the third person. They usually are either benign (“Look at him now; he is about to eat”)
or insulting in content (“What a fool he is; he doesn’t understand anything”).
•
•
Between episodes, according to both his outpatient psychiatrist and his brother, Mr. Nehru is a quiet, somewhat withdrawn person, but popular in his
neighborhood because he helps some of his elderly neighbors with shopping and yard work. At these times his mood is unremarkable. However, he claims
that, because of the (“voices,”) he cannot concentrate sufficiently to hold a job. He sometimes reads books, but watches little TV, because he hears the
voices coming out of the TV and is upset that the TV shows often refer to him. Mr. Nehru has also become sensitive to bright lights, complaining that the
“lights are searing into his flesh”, preferring to remain in darkness when inside, constantly closing curtains and shades. Mr. Nehru is slowly becoming
intolerant to bright lights both inside the home and outside.
•
For the past six weeks, with increasing insistence, the voices have been telling Mr. Nehru that he is the Messiah, Jesus, Moses, Vishnu, and Krishna, and
should begin a new religious epoch in human history. He has begun to experience surges of increased energy, (“so I could spread my gospel,”) and needs
very little sleep. According to his brother, he has become more preoccupied with the voices and disorganized in his daily activities.
Is this a disorder or not?
• Andy is a 54-year-old auto mechanic who was accompanied by his
wife to the mental health clinic. He was so tense and anxious that his
wife had to do most of the talking. It turns our that during the past six
months Andy has turned into a “bundle of nerves”. He’s never been
this way before, but now he’s nervous all the time suffers from
insomnia, and sleep when it does come is fitful and restless. Andy is
distressed and is desperate for help. As the therapist was gathering
information from Andy and his wife, she noticed that Andy was using
a nasal spray. After the third time, in which he pulled it out of his
pocket and sprayed each nostril, the therapist inquired what it was
for. Andy said he had begun to use it six months ago during the hay
fever season and had just kept using it.
Additional disorders as listed in the DSM-5
• Motor Disorders
• The following motor disorders are included in the DSM-5
neurodevelopmental disorders chapter: developmental coordination
disorder, stereotypic movement disorder, Tourette’s disorder,
persistent (chronic) motor or vocal tic disorder, provisional tic
disorder, other specified tic disorder, and unspecified tic disorder. The
tic criteria have been standardized across all of these disorders in this
chapter. Stereotypic movement disorder has been more clearly
differentiated from body-focused repetitive behavior disorders that
are in the DSM-5 obsessive-compulsive disorder chapter.
• Communication Disorders
• The DSM-5 communication disorders include language disorder (which
combines DSM-IV expressive and mixed receptive-expressive language
disorders), speech sound disorder (a new name for phonological disorder),
and childhood-onset fluency disorder (a new name for stuttering). Also
included is social (pragmatic) communication disorder, a new condition for
persistent difficulties in the social uses of verbal and nonverbal
communication. Because social communication deficits are one component
of autism spectrum disorder (ASD), it is important to note that social
(pragmatic) communication disorder cannot be diagnosed in the presence
of restricted repetitive behaviors, interests, and activities (the other
component of ASD). The symptoms of some patients diagnosed with DSMIV pervasive developmental disorder not otherwise specified may meet the
DSM-5 criteria for social communication disorder.
• Body Dysmorphic Disorder
• For DSM-5 body dysmorphic disorder, a diagnostic criterion describing
repetitive behaviors or mental 8 • Highlights of Changes from DSM-IV-TR
to DSM-5
• acts in response to preoccupations with perceived defects or flaws in
physical appearance has been added, consistent with data indicating the
prevalence and importance of this symptom. A “with muscle dysmorphia”
specifier has been added to reflect a growing literature on the diagnostic
validity and clinical utility of making this distinction in individuals with body
dysmorphic disorder. The delusional variant of body dysmorphic disorder
(which identifies individuals who are completely convinced that their
perceived defects or flaws are truly abnormal appearing) is no longer
coded as both delusional disorder, somatic type, and body dysmorphic
disorder; in DSM-5 this presentation is designated only as body dysmorphic
disorder with the absent insight/delusional beliefs specifier.
• Hoarding Disorder
• Hoarding disorder is a new diagnosis in DSM-5. DSM-IV lists hoarding
as one of the possible symptoms of obsessive-compulsive personality
disorder and notes that extreme hoarding may occur in obsessivecompulsive disorder. However, available data do not indicate that
hoarding is a variant of obsessive-compulsive disorder or another
mental disorder. Instead, there is evidence for the diagnostic validity
and clinical utility of a separate diagnosis of hoarding disorder, which
reflects persistent difficulty discarding or parting with possessions
due to a perceived need to save the items and distress associated
with discarding them. Hoarding disorder may have unique
neurobiological correlates, is associated with significant impairment,
and may respond to clinical intervention.
• Trichotillomania (Hair-Pulling Disorder)
• Trichotillomania was included in DSM-IV, although “hair-pulling disorder”
has been added parenthetically to the disorder’s name in DSM-5.
• Excoriation (Skin-Picking) Disorder
• Excoriation (skin-picking) disorder is newly added to DSM-5, with strong
evidence for its diagnostic validity and clinical utility.
• Adjustment Disorders
• In DSM-5, adjustment disorders are reconceptualized as a heterogeneous
array of stress-response syndromes that occur after exposure to a
distressing (traumatic or nontraumatic) event, rather than as a residual
category for individuals who exhibit clinically significant distress without
meeting criteria for a more discrete disorder (as in DSM-IV ). DSM-IV
subtypes marked by depressed mood, anxious symptoms, or disturbances
in conduct have been retained, unchanged.
• Pain Disorder
• DSM-5 takes a different approach to the important clinical realm of
individuals with pain. In DSM-IV, the pain disorder diagnoses assume
that some pains are associated solely with psychological factors, some
with medical diseases or injuries, and some with both. There is a lack
of evidence that such distinctions can be made with reliability and
validity, and a large body of research has demonstrated that
psychological factors influence all forms of pain. Most individuals with
chronic pain attribute their pain to a combination of factors, including
somatic, psychological, and environmental influences. In DSM-5,
some individuals with chronic pain would be appropriately diagnosed
as having somatic symptom disorder, with predominant pain. For
others, psychological factors affecting other medical conditions or an
adjustment disorder would be more appropriate.