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Chaffee Winter 2013 CHAPTER 14 Psychological Disorders CHAPTER 14: PSYCHOLOGICAL DISORDERS Perspectives Chaffee Winter 2013 on Psychological Disorders Anxiety Disorders Somatoform Disorders Dissociative Disorders Mood Disorders Schizophrenia Personality Disorders Substance-related Disorders (Supplemental) Rates of Psychological Disorders Documentation (Supplemental) INTRODUCTION “To study the abnormal is the best way of understanding the normal” – William James occurs on a spectrum. We will all encounter people with mental health issues in our lives. The World Health Organization (2008) reports that 450 million people worldwide suffer from mental or behavioral disorders Chaffee Winter 2013 Behavior PERSPECTIVES ON PSYCHOLOGICAL DISORDERS How should we define psychological disorders? should we understand disorders? As a sickness that needs to be diagnosed and cured, or as a natural response to a troubling environment? How should we classify psychological disorders? And can we do so in a way that allows us help people without stigmatizing them with labels? Chaffee Winter 2013 How DEFINING PSYCHOLOGICAL DISORDER A psychological disorder is a deviant, distressful, and dysfunctional behavior pattern behavior must cause a person distress to be classified as a psychological disorder Dysfunction is also key to defining a disorder. Examples: Marc, Greta and Stuart on page 593 Chaffee Winter 2013 The THINKING CRITICALLY ABOUT: ADHD Attention-deficit hyperactivity disorder: marked by the appearance by age 7 of one or more of the three key symptoms: Skepticism: Other evidence More boys than girls diagnosed Diagnosis quadrupled since 1987 Better awareness and diagnosis Patterns of brain activity Considerations ADHD symptoms interfere with social, academic, and vocational achievement Treatment with stimulants Chaffee Winter 2013 Extreme inattention Hyperactivity Impulsivity UNDERSTANDING PSYCHOLOGICAL DISORDERS Earlier times: Mental illness explained by strange forces Very brutal treatments were used to “help” people with psychological or behavioral conditions. Reformers (e.g. Philippe Pinel) insisted that sicknesses of the mind were caused by severe stresses and inhumane conditions. He worked to improve the living conditions for people with mental illnesses through activities like his “Lunatic Ball” depicted in this painting by George Bellows UNDERSTANDING PSYCHOLOGICAL DISORDERS CONTINUED Genetic influences, brain structure anomalies, biochemical imbalance can all play a role. Chaffee Winter 2013 The Medical Model: the concept that diseases, in this case psychological disorders, have physical causes that can be diagnosed, treated, and in most cases cured, through treatment. UNDERSTANDING PSYCHOLOGICAL DISORDERS CONTINUED Biology: genetic predispositions and physical states Psychology: inner psychological dynamics Society: social and cultural circumstances Chaffee Winter 2013 The Biopsychosocial Approach: the concept that there are many influences on normal and abnormal behavior CLASSIFYING PSYCHOLOGICAL DISORDERS Current version: DSM-IV-TR, the fourth version, text-revised edition. www.dsm5.org The DSM is a helpful and practical tool. It defines and describes the diagnostic process for 16 clinical syndromes (next slide). Gives ICD-10 (numerical code) for diagnosis, necessary to bill insurance. Chaffee Winter 2013 American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders Chaffee Winter 2013 Chaffee Winter 2013 Chaffee Winter 2013 DSM-IV-TR CONTINUED Other Chaffee Winter 2013 information included for each disorder includes: Episode / Diagnostic Features Associated features and disorders Specific culture, age, and gender features Course Differential diagnosis LABELING PSYCHOLOGICAL DISORDERS Criticism of the DSM: In a classic study, researcher David Rosenhan (1973) and 7 other healthy adults: Went to hospital admissions offices and complained of hearing voices that said: empty, hollow, or thud Apart from this complaint (and giving false names) they answered all other questions truthfully All eight of these individuals were misdiagnosed AND admitted to inpatient mental health care Chaffee Winter 2013 Casting too wide a net and bringing “almost any kind of behavior within the compass of psychiatry” (Eysenck et al., 1983). Some find the labels given to disorders to be arbitrary; these labels create preconceptions that guide our perceptions and interpretations. LABELING PSYCHOLOGICAL DISORDERS What Help doctors communicate about cases Comprehend underlying causes Discern effective treatment programs. Drawbacks of labels? Bias perceptions, change reality Self-fulfilling prophecy: a prediction that directly or indirectly causes itself to be true, interaction between belief and behavior. Stigmatization and stereotypes: mental illness does not cause dangerous or violent behavior Chaffee Winter 2013 are the benefits of diagnostic labels? THINKING CRITICALLY ABOUT: INSANITY AND RESPONSIBILITY Legal Created in 1843 Famous examples: Hinkley, Dahmer, Kip Kinkel, Andrea Yates Most people with psychological disorders are NOT violent High instance of psychological illness in the incarcerated population. In order to think critically (rather than intuitively) about this issue, we need to know more about psychological disorders. Chaffee Winter 2013 insanity defense AN OVERVIEW TO PSYCHOPATHOLOGY Disorders Chaffee Winter 2013 are grouped meaningfully by the mechanism of dysfunction: Depression: mood Anxiety: stress Somatoform disorders: mind-body connection Dissociative disorders: reality, assumed roles Schizophrenia: thought Personality disorders: patterns of interacting ANXIETY DISORDERS Anxiety Generalized anxiety disorder Panic disorder Phobias Obsessive-compulsive disorder Post-traumatic stress disorder Chaffee Winter 2013 Disorders are psychological disorders characterized by distressing, persistent anxiety or maladaptive behaviors that reduce anxiety Common anxiety disorders include: ANXIETY DISORDERS CONTINUED Freud: Free-floating anxiety Comorbidity: Depressed Mood Consequences: How does chronic stress affect the body? Panic Disorder An anxiety disorder marked by unpredictable minutes-long episodes of intense dread in which a person experiences terror and accompanying chest pain, choking, or other frightening sensations. Can escalate into a Panic Attack Smokers: risk is doubled Chaffee Winter 2013 Generalized Anxiety Disorder An anxiety disorder in which a person is continually tense, apprehensive, and in a state of autonomic system arousal. PHOBIAS An Chaffee Winter 2013 anxiety disorder marked by a persistent, irrational fear and avoidance of a specific object, activity, or situation. Specific Phobias Social Phobia and agoraphobia OBSESSIVE-COMPULSIVE DISORDER Chaffee Winter 2013 An anxiety disorder characterized by unwanted repetitive thoughts (obsessions) and/or actions (compulsions) Where do we draw the line between normal and disorder? Persistent interference with everyday living, causing distress More common in teens and young adults POST-TRAUMATIC STRESS DISORDER An Biological/Evolutionary wisdom to remembering emotional and traumatic experiences Veterans of war, survivors of accidents, disasters, violent and sexual assault. Highly specific diagnostic criteria. Chaffee Winter 2013 anxiety disorder characterized by haunting memories, nightmares, social withdrawal, jumpy anxiety, and/or insomnia that lingers for four weeks or more after a traumatic experience. DIAGNOSING PTSD Reexperiencing 1. Recurrent thoughts, memories, dreams, nightmares Flashbacks Avoidance 2. Avoid activities that remind them of the event Avoid related thoughts, feelings, conversations Reduced responsiveness 3. People feel detached from others or lose interest in activities Dissociation Increased arousal, anxiety, and guilt 4. Hyper-alert, easy startle, trouble concentrating, sleeping difficulties Survivor guilt PTSD CONTINUED Rates 66% of prostitutes 10% of Vietnam veterans who did not see combat 32% of Vietnam veterans who experienced heavy combat Etiology: Emotional distress during the event Sensitive limbic system Genes may be a factor Post-traumatic growth and survivor resiliency Chaffee Winter 2013 of PTSD: UNDERSTANDING ANXIETY DISORDERS The Stimulus generalization Reinforcement Observational others fears learning: we learn by observing Chaffee Winter 2013 Learning Perspective Fear conditioning: through conditioning, the short list of naturally painful and frightening events can multiply into a long list of human fears UNDERSTANDING ANXIETY DISORDERS The Biological Perspective Chaffee Winter 2013 Natural selection – we fear the threats faced by our ancestors Genes: specific genes, including some that regulate neurotransmitters have been identified for their link to anxiety disorders The brain: the anterior cingulate cortex is hyperactive in those with anxiety disorders SOMATOFORM DISORDERS “Medically unexplained illnesses” Regardless of the somatoform disorder, the common response that it is “all in your head” provides little relief as the symptoms are genuinely felt. Conversion disorder and hypochondriasis Also: Pain disorder, somatization disorder, body dysmorphic disorder, somatoform disorder not otherwise specified Chaffee Winter 2013 Somatoform disorders are psychological disorders in which the symptoms take a somatic (bodily) form without apparent physical cause SOMATOFORM DISORDERS CONTINUED Conversion http://www.cbsnews.com/8301-505263_162-57368050/ towns-teen-medical-mystery-solved/ Hypochondriasis is a somatoform disorder in which a person interprets normal physical sensations as symptoms of a disease. Reinforced: sympathy, relief from everyday demands Chaffee Winter 2013 disorder is a rare somatoform disorder in which a person experiences very specific genuine physical symptoms for which no physiological basis can be found. DISSOCIATIVE DISORDERS Dissociation In Perhaps you can recall getting in your car and driving to some unintended location while your mind was preoccupied elsewhere. Dissociation can be protective from overwhelming emotions. E.g. trauma severe cases, dissociation becomes a disorder. Dissociative disorders are disorder in which conscious awareness becomes separated from previous memories, thoughts, and feelings. Chaffee Winter 2013 itself is not rare – now and then, people may have a sense of being unreal, being separated from their body. DISSOCIATIVE DISORDERS Dissociative Chaffee Winter 2013 amnesia Dissociative fugue Dissociative identity disorder Depersonalized disorder Dissociative disorder not otherwise specified DISSOCIATIVE DISORDERS CONTINUED A massive dissociation of self from ordinary consciousness is found in Dissociative Identity Disorder (DID) – this is a rare dissociative disorder in which a person exhibits two or more distinct and alternating personalities. Previously referred to as multiple personality disorder. Exceptionally rare E.g. U.S. of Tara DISSOCIATIVE IDENTITY DISORDER A disorder in which a person develops two or more distinct personalities. Subpersonalities Average number of alters: 15 Differ from the “primary” Interaction between subpersonalities (alters) varies – mutually amnesic relationships versus mutually cognizant patterns, co-conscious subpersonalities Subpersonalities differ in three important ways: Identifying features Abilities and preferences Physiological responses DISSOCIATIVE IDENTITY DISORDER CONTINUED Skeptics of the DID: Since its inclusion in the DSM in 1980s, the diagnosis have increased dramatically. DID is predominantly diagnosed in the U.S. and is thought to be the response of highly imaginative people to hypnosis and fishing by therapists. Evidence suggests DID is related to PTSD – many individuals with DID experienced severe physical, sexual, or emotional abuse as children Chaffee Winter 2013 Extension of our normal capacity for personality shifts. We all engage in different roles – such as at work, when around our friends, or visiting with our older relatives. RECAP What are psychological disorders characterized by distressing, persistent anxiety or maladaptive behaviors that reduce anxiety Somatoform are psychological disorders in which the symptoms take a somatic (bodily) form without apparent physical cause Dissociative Disorders Identity Disorders A disorder in which a person develops two or more distinct personalities. Chaffee Winter 2013 is a psychological disorder? How do we diagnose disorders? Anxiety Disorders: UNDERSTANDING MOOD DISORDERS Mood Disorders: Group of disorders Depressive disorders and Bipolar disorders Severe and enduring disturbances in emotionality ranging from elation to severe depression. MOOD DISORDERS Mood Disorders: psychological disorders characterized by emotional extremes depressive disorder Dysthymic disorder Bipolar I disorder Bipolar II disorder Cyclothymic disorder Bipolar disorder NOS. Mood disorder due to a general medical condition Substance-induced mood disorder Mood disorder NOS. Chaffee Winter 2013 Major MOOD DISORDERS CONTINUED Depression is the common cold of psychological disorders: 13% of adults in the U.S. experience depression in their lifetime (Patten et al., 2006) 44% of college students report that on (at least) one occasion in the last year they have felt “so depressed it was difficult to function” (ACHA, 2006). Depression is the leading cause of disability worldwide (WHO, 2002). Chaffee Winter 2013 Major Depressive Disorder is a mood disorder in which a person experiences two or more weeks of significantly depressed mood, feelings of worthlessness, and diminished interest or pleasure in most activities. MOOD DISORDERS CONTINUED Bipolar Mania: a mood state marked by hyperactivity and wild optimism. Formerly called manic-depressive disorder. Mood swings are normal Bipolar disorder: distress and impaired functioning Chaffee Winter 2013 disorder: a mood disorder in which the person alternates between the hopelessness and lethargy of depression and the overexcited state of mania . MOOD DISORDERS CONTINUED Bipolar is less common than depression but more debilitating. Depressive phase: presents as depressed mood Manic phase: overtalkative, overactive, elated, fewer inhibitions, more energy Mania’s energy fuels creativity. Chaffee Winter 2013 Bipolar claims twice as many lost workdays as depression Individuals with bipolar are significantly more likely to attempt suicide than the general population MOOD DISORDERS CONTINUED Bipolar disorder and artistic aptitude This phenomenon is described briefly in your book, but also by author Kay Redfield Jamison. Kay Redfield Jamison is a professor of psychology at Johns Hopkins University and she has bipolar disorder. Her book An Unquiet Mind documents her experience. She also wrote the book Touched by Fire, which describes the correlation between bipolar and artistic aptitude WATCH THIS INTERVIEW: Kay Chaffee Winter 2013 Redfield Jamison http://www.charlierose.com/view/interview/4024 UNDERSTANDING MOOD DISORDERS Many behavioral and cognitive changes accompany depression. Trapped in depression: inactive, unmotivated Common comorbidities: Anxiety, substance abuse Depression is widespread Women are twice as vulnerable to major depression than men. Gender gap begins in adolescence Internal versus external states Most major depressive episodes self-terminate Stressful events often precede depression Depression occurs earlier and affects more people. Chaffee Winter 2013 UNDERSTANDING MOOD DISORDERS The Biological Perspective: Genetic influences: The heritability of depression is estimated at 35-40% The Depressed Brain: Norepinephrine, a neurotransmitter which increases arousal and boosts mood, is low in depression and overabundant during mania Serotonin, another neurotransmitter associated with mood, is low during depression The Bipolar Brain: UNDERSTANDING MOOD DISORDERS CONT. The Social-Cognitive Perspective: Negative thoughts and negative mood interact Learned helplessness Overthinking and ruminating: “Shoulding” on oneself Explanatory Style Depression’s Vicious Cycle: Chaffee Winter 2013 NEGATIVE THOUGHTS AND NEGATIVE MOODS INTERACT: EXPLANATORY STYLE Chaffee Winter 2013 DEPRESSION AND ANXIETY: COMMON COMORBIDITY A. Five (or more) of the following symptoms have been present during the same 2week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others) Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. Insomnia or hypersomnia nearly every day Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) Fatigue or loss of energy nearly every day Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide 2. 3. 4. 5. 6. 7. 8. 9. SCHIZOPHRENIA Schizophrenia is a group of severe disorders characterized by disorganized and delusional thinking, disturbed perceptions, and inappropriate emotions and actions Chaffee Winter 2013 “If depression is the common cold of psychological disorders, chronic schizophrenia is the cancer” (Myers, 2010, p. 621). SYMPTOMS OF SCHIZOPHRENIA Positive symptoms: presence of inappropriate behaviors Negative symptoms: absence of normal behaviors Disorganized and Psychomotor symptoms SYMPTOMS OF SCHIZOPHRENIA CONTINUED Positive Symptoms: “pathological excesses” Presence of abnormal behaviors Delusions: false beliefs Delusions of persecution Delusions of reference Delusions of grandeur Delusions of control Heightened Perceptions and Hallucinations are common Hallucinations: sensory experiences without sensory stimulation. Auditory hallucinations: common, activate auditory areas of the brain Hallucinations and delusions often occur together SYMPTOMS OF SCHIZOPHRENIA CONTINUED Negative symptoms: “pathological deficits” Absence of appropriate behaviors Avolition: apathy, drained of energy and interest Alogia: decrease in speech of speech content, also known as poverty of speech Anhedonia Blunted and Flat Affect Show less emotions than most people Flat affect: marked lack of expressed emotions Social withdrawal DISORGANIZED AND PSYCHOMOTOR SYMPTOMS Ideas are consistently jumbled, causing something called “word salad” One reason for the disorganized thoughts is a breakdown in selective attention: Irrelevant, minute stimuli distract attention. Selective attention: ability to attend to one stimulus when multiple stimuli are present in the environment. Inappropriate emotions and actions Emotions in schizophrenia are sometimes widely inappropriate, such as laughing when discussing the death of a relative People with schizophrenia may lapse into an emotionless state, called flat affect Inappropriate motor behavior. Chaffee Winter 2013 E.g.: “Liberationary movement with a view to the widening of the horizon” SUBTYPES OF SCHIZOPHRENIA Chaffee Winter 2013 UNDERSTANDING SCHIZOPHRENIA Brain Abnormalities: Dopamine overactivity: up to six times more receptors than normal Abnormal brain activity and anatomy: Smaller than normal frontal lobes Smaller than normal cortex in general Larger cerebral ventricles (see images) Increased activity in several areas UNDERSTANDING SCHIZOPHRENIA CONT. Genetic Factors: Predispositions are obvious Details are complicated and unknown Psychological Factors: Early warning signs have been found, but the psychological factors are similar to the genetic – they indicate predispositions and only part of a complicated causal network Zimbardo (1976): “Rational path to madness” ELYN SAKS http://www.ted.com/talks/ elyn_saks_seeing_mental_illness.html Chaffee Winter 2013 PERSONALITY DISORDERS What is personality? Our enduring pattern of inner experience and outer behavior. An individual’s characteristic pattern of thinking, feeling, and acting. Personality trait Warning: medical student syndrome Three clusters of personality disorders Chaffee Winter 2013 Personality disorders are psychological disorders characterized by inflexible and enduring behavior patterns that impair social functioning. CLUSTER A: “ODD” PERSONALITY DISORDERS Paranoid Schizoid Schizotypal Odd or eccentric behaviors that are similar to schizophrenia, but not as extensive. E.g. suspiciousness, social withdrawal, peculiar ways of thinking. Schizophrenia-spectrum disorders CLUSTER A: CHARACTERIZED BY ODD OR ECCENTRIC BEHAVIOR Paranoid PD: Schizoid PD: Pattern of detachment from social relationships and a restricted range of emotional expression. Appear to be loners; aloof, eccentric, cold (no prominent paranoia) Schizotypal PD: Pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior. Magical thinking, paranoid, must precede diagnosis of schizophrenia Chaffee Winter 2013 Pattern of distrust and suspiciousness such that others’ motives are interpreted as malevolent. Concerned that others will harm, exploit, or deceive them. CLUSTER B: “DRAMATIC” PERSONALITY DISORDERS Antisocial Borderline Histrionic Narcissistic Dramatic, emotional, or erratic behavior “Dramatic” PDs are more commonly diagnosed than the other groups. Causes are not well understood. Treatments range from ineffective to moderately effective. CLUSTER B: INDIVIDUALS WITH THESE DISORDERS OFTEN APPEAR DRAMATIC, EMOTIONAL, OR ERRATIC Antisocial PD: Borderline PD: Histrionic PD: Pattern of instability in interpersonal relationships, selfimage, and affects, and marked impulsivity. Frantic efforts to avoid real or imagined abandonment. Pattern of excessive emotionality and attention seeking. Lively and dramatic – feel unappreciated when not the center of attention. Narcissistic PD: Pattern of grandiosity, need for admiration, and lack of empathy. Self-importance – overestimate abilities and inflate their accomplishments Chaffee Winter 2013 Pattern of disregard for, and violation of, the rights of others; low baseline arousal Sometimes confused with psychopathy, sociopathy ANTISOCIAL PERSONALITY DISORDER Antisocial Lack of conscience for wrongdoing, even toward friends and family members May be aggressive and ruthless or a clever con artist Symptoms emerge in childhood or adolescence Low baseline arousal: Personality Disorder: Lower levels of stress hormones Unemotional and fearless tendencies Frontal lobe: Reduced activity Deficits in frontal lobe cognitive functions Respond less to facial displays of others’ distress VIDEO CLIPS Ted Talk: http://www.ted.com/talks/ jim_fallon_exploring_the_mind_of_a_killer.html Ted Talk: http://www.ted.com/talks/lang/en/ philip_zimbardo_on_the_psychology_of_evil.html CLUSTER C: “ANXIOUS” PERSONALITY DISORDERS Avoidant PD Dependent PD Obsessive-Compulsive PD Display anxious or fearful behavior Limited research support for the explanation of this disorder. Treatments can be moderately successful (better than other PDs CLUSTER C: INDIVIDUALS WITH THESE DISORDERS OFTEN APPEAR ANXIOUS OR FEARFUL Avoidant Dependent PD: Pattern of submissive and clinging behavior related to an excessive need to be taken care of. Difficulty making everyday decisions without excessive advice and reassurance for others. Obsessive-Compulsive PD: Pattern of preoccupation with orderliness, perfectionism, and control. Lacks presence of true obsessions and compulsions in OCD. Chaffee Winter 2013 PD: Pattern of social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation. SUBSTANCE-RELATED DISORDERS Three classes of psychoactive drugs: depressants, stimulants, hallucinogens. Influences on drug use: biological and sociocultural influences DSM categories of substance abuse: Substance Dependence Substance Abuse Substance Intoxication Substance Withdrawal Chaffee Winter 2013 There is a little monster inside your head that says “you know you’ll feel better” ~ Kurt Cobain, describing addiction, April 1992 RATES OF PSYCHOLOGICAL DISORDERS Correlates Poverty – cause or effect? Varies with the disorder and the individual When do disorders strike? In early adulthood: by age 24, 75% of those will experience first symptoms (Robins & Regier, 1991) Diathesis stress model: mental illness occurs based upon a combination of genetic vulnerability and environmental factors (stress) Chaffee Winter 2013 of mental illness: RATES OF PSYCHOLOGICAL DISORDERS Many successful people pursued and succeeded in brilliant careers while enduring psychological difficulties, including Leonardo da Vinci, Isaac Newton, Leo Tolstoy, and 18 U.S. presidents. CHAPTER 14 LEARNING OBJECTIVES Perspectives on Psychological Disorders: Define psychological disorders. What are the key aspects of this definition? Describe the Medical Model and the Biopsychosocial approach. What is the DSM-IV-TR? What are the benefits and drawbacks of the DSM and labeling disorders? For each disorder: Anxiety disorders Define and give a specific example. Explanations for anxiety disorders: Learning perspective, biological perspective. Somatoform disorders: Define. Dissociative disorders Define dissociative identity disorder. Relationship to PTSD How do skeptics interpret DID? Define Mood Disorders Define major depressive disorder Define bipolar disorder and mania Biological perspective of depression Social-cognitive perspective of depression. Define thought disorders. Schizophrenia, disorganized thought, delusions, hallucinations, inappropriate emotions/actions What are some explanations for the development of schizophrenia? Define personality disorders. Choose one cluster of personality disorders to define. What is antisocial personality disorder? What is the diathesis stress model? Chaffee Winter 2013 Understand the main features: definition and symptoms Cause of the disorder Theoretical explanation of the disorder (if provided)