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CHAPTER 16
SPECIFIC DISORDERS AND TREATMENTS
CHAPTER OUTLINE
Specific Disorders and Treatments
1) Anxiety and Avoidance Disorders
a) Disorders Characterized by Excessive Anxiety: Many psychological disorders are
marked by a combination of fear, anxiety, and avoidance. Anxiety is often not
tied to one specific and present object or event but can be a more nonspecific
apprehensive feeling that something bad is going to happen - evoked whether an
identifiable cause is present or not.
i) Generalized Anxiety Disorder: People with generalized anxiety disorder are
perpetually plagued by worries that seem out of proportion with actual events
or possibilities.
ii) Panic Disorder: Panic disorder is characterized by a constant state of moderate
anxiety, and occasional panic attacks. During panic attacks, people often
hyperventilate in an attempt to control the anxiety. Teaching people to avoid
hyperventilating is one treatment for panic disorders. Often, people with panic
disorder also have a social phobia, a strong desire to avoid other people and an
especially strong fear doing any activity in public.
iii) Agoraphobia is an excessive fear of being in open or public places. Both of
these disorders result in people remaining at home as much as is possible.
iv) Disorders with Exaggerated Avoidance Behaviors: Avoidance Learning and
Its Persistence: Avoidance behaviors are highly resistant to extinction because
once one learns a response to avoid something bad, the response continues
long after it is necessary.
b) Phobias: Phobias are extreme and persistent fears, and lead to avoidance
behaviors. They are so strong that they interfere with normal living. Not all strong
fears qualify as phobias.
i) The Prevalence of Phobias: About 11% of people suffer a phobia at some time
in their life, and these vary in degree. Phobias are more common in younger
people and their incidence declines across the lifespan.
ii) The Learning of Phobias: Some phobias can be traced to a specific event. The
classic case of “Little Albert” is an example of the classical conditioning of a
fear. This case study still leaves many questions about phobias unanswered
though – why people have phobias of things that have not harmed them?
(Some of these may be acquired by observation rather than direct experience.)
Why some phobias are much more common than others? Why are phobias
generally so long lasting?
iii) Why Some Phobias Are More Common Than Others: This may be related to
our relative desensitization to some objects, or general predictability of the
animal, object, or the lack of predictability associated with the same. The most
common phobias are of open spaces, closed spaces, heights, lightning and
thunder, animals, and illness. Some suggest that we are “prepared” to have
certain fears. Both monkey and human research supports this assertion.
iv) The Persistence of Phobias: Well-established phobias can be quite persistent,
because of the difficulty in extinguishing an avoidance response.
v) Behavior Therapy for Phobias: Systematic desensitization is a method of
reducing fear by gradually exposing people to the object of their fear. The
process resembles shaping, requiring people to master one step before going
on to the next. A relaxation response is associated with increasing intensity
exposures to the feared stimulus. Flooding or implosion is a method of
treatment in which the person is exposed to the object that induces the phobia
suddenly rather than gradually.
vi) Drug Therapies for Phobias and Other Anxieties: Tranquilizers are the most
widely prescribed drugs in the U.S. The most commonly prescribed class of
tranquilizer is the benzodiazepines. These drugs relieve anxiety, relax
muscles, induce sleep, and inhibit epileptic seizures. But they can be habitforming, and they suppress symptoms only temporarily. They are really only
appropriate for occasional use (an example would be a person who doesn’t
travel by airplane who MUST take an airplane trip. It may be best that they
take a Valium and get on the plane in a relaxed state of mind).
c) Obsessive-Compulsive Disorder: This disorder is characterized by two problems:
Obsessions are repetitive, unwelcome streams of thought. Compulsions are
repetitive, nearly irresistible actions.
i) The Persistence of Obsessions: People with obsessive-compulsive disorder
feel persistent and frightening impulses. The harder they try to prevent a
thought, the more intrusive it becomes. The disorder occurs most frequently in
people who have perfectionist tendencies and also are of average or aboveaverage intelligence. Nearly all have some insight into their condition.
Obsessive-compulsive disorder appears to run in families.
ii) One Type of Compulsion: Cleaning: The most common compulsions are
cleaning and checking. A phobia of dirt is often associated with compulsive
cleaning.
iii) Another Type of Compulsion: Checking: An obsessive-compulsive checker is
constantly checking everything. One reason may be that they do not trust their
memory of what they have done.
iv) Therapies for Obsessive Compulsive Disorder: One treatment for obsessivecompulsive disorder is exposure therapy, in which a person is exposed to
situations that would lead to rituals, and is prevented from doing them, in
hopes of demonstrating to them that the consequences that they dread do not
in fact occur. A relatively new psychopharmacological treatment for OCD is
clomipramine and some drugs that are chemically related to it.
2) Substance-Related Disorders
a) Substance Dependence (Addiction): Dependence or addiction refers to an
inability to quit using a self-destructive substance. Addiction varies in degree, and
different people react in various ways. Any substance can be addictive under
certain circumstances. However, certain substances are much more likely than
others to be addictive.
i) What Makes a Substance Addictive?: Substances tend to be addictive to the
degree that they enter the brain rapidly. Most addictive drugs act to stimulate
the dopamine receptors in the limbic system (in a small structure called the
nucleus accumbens). As mentioned in Chapter 6, substance addiction involves
the need for larger and larger amounts of the substance in order for the user to
experience effects (tolerance) and withdrawal symptoms when less of the
substance is used for some period of time, or when the person abstains from
the substance entirely.
ii) Is Substance Dependence a Disease?: The characterization of alcoholism and
drug abuse as a “disease” is controversial, and certain features of alcoholism
and drug abuse do not fit with this characterization. For one thing, it is quite
hard to answer this question without being extremely clear about what we
mean by “disease.” It is less morally judgmental to refer to substance
addiction as a disease. But it doesn’t fit with the evidence that suggests that
people who are addicted lie along a continuum from mildly to severely
addicted. Also, there isn’t one course of development and deterioration, and
curing addiction does not seem to require medical intervention. (In fact,
research suggests that family therapy is the most effective treatment).
iii) Nicotine Dependence: Despite the perception that people have that nicotine
addiction is mild or “psychological” because smoking is legal, nicotine is one
of the most difficult drugs to quite using and smoking kills more people than
all the other drugs combined (and then some.) People find it almost
impossible to quit smoking without a replacement source of nicotine (patches
or gum, for example.) Low tar cigarettes are ineffective for use in this effort
because smokers find ways to use them that result in the same consumption of
nicotine, tar and the other deadly substances in the cigarette.
iv) Alcoholism: Alcoholism is the chronic overuse of alcohol. Treatment of
alcoholism would likely be more effective if we were able to identify those
who are at risk as early as possible in the lifespan.
(1) Genetics and Family Background: There is good evidence that genetics
plays some role in predisposing people to alcoholism and other addictions.
(2) Type I Alcoholism is milder, develops more gradually during the lifespan,
and appears to be more environmentally influenced.
(3) Genetic influences seem to contribute more to the type of alcoholism that
is early in onset and rapidly developing - Type II Alcoholism.
Development of alcoholism is more common in families in which there is
conflict between parents, or between parents and children.
(4) A history of being sexual abused may contribute to alcoholism in some
females. Alcoholism shows some degree of variation across cultures.
Recent research suggests that men who experience only mild effects from
drinking moderately may continue to drink longer than those who feel
some effects and therefore likely to drink large amounts and become
alcoholics.
(5) Treatments for Alcoholism and Drug Addiction: Only 10-20% of those
who try to quit drinking on their own will succeed. Seeking professional
help increases the chances of long-term abstention although it cannot
guarantee a successful and permanent cure. Some patients undergo a
supervised detoxification period in order to remove the alcohol (or
whatever substance was being used) from their bodies.
(6) Alcoholics Anonymous: The most common treatment for alcoholism in
North America is Alcoholics Anonymous a well-known system of self-help
groups of people who are trying to abstain from alcohol use and to help
others do the same. The group has a strong spiritual focus, but is not
affiliated with any particular religion. Research on the effectiveness of AA
is scarce, in part due to the group’s insistence on member anonymity.
(7) Antabuse: Antabuse is a drug that causes someone to become extremely ill
when mixed with alcohol. The threat of sickness is intended to cause the
person to avoid drinking. In reality, the efficacy of this method depends on
the person’s resolve not to drink. Either they will take the Antabuse pill
and not drink, or they will not take the pill.
(8) The Controlled Drinking Controversy: Some psychologists contend that
total abstinence is not the best approach for all alcoholics. Programs have
been established to try and teach alcoholics “controlled drinking.” This
strategy has at least occasional success. Similar to this method, the harm
reduction strategy focuses on decreasing frequency of use (instead of
insisting on strict abstinence) in order to minimize the harmful
consequences of the substance.
v) Opiate Dependence: To help opiate addicts who cannot quit “cold turkey”,
researchers have tried for decades to develop a non-addictive substitute that
would satisfy craving for opiates without producing the harmful effects. The
drug methadone “is commonly offered as a less dangerous substitute for
opiates.” While methadone is successful in reducing the craving without
serious disruption of behavior, it does not eliminate the addiction.
3) Mood Disorders
a) Depression: Major depression refers to a very persistent condition in which the
person experiences little interest in his or her life, little enjoyment, and little
reason for any productive activity. Other symptoms may include thoughts of
suicide, sleep abnormalities, feelings of worthlessness, fear, guilt, and
powerlessness. It is common from adolescence to old age, but sufferers are most
commonly first diagnosed in one’s 30's. Very few people remain depressed for
their entire lives, and later episodes tend to be of shorter duration than earlier
ones.
i) There are some special varieties of depression. Seasonal Affective Disorder
(SAD) is depression that coincides with a certain season of the year – usually
winter.
ii) Bipolar disorder (previously termed manic-depressive disorder) is a condition
in which “a person alternates between periods of depression and periods of
mania, which is the opposite extreme.”
iii) Genetic Predisposition to Depression: Evidence indicates a genetic
predisposition to depression. The most likely scenario is that different families
have genes that express themselves in a variety of ways.
iv) The Sex Difference in Depression: Women are about twice as likely to
experience major depression, and around four times as likely to experience
severe depression. One possible reason is the hormonal changes associated
with menstrual cycles, or as a result of pregnancy and childbirth, after which
some women enter into a postpartum depression. Evidence tends not to
support the hormonal explanation of the gender difference in the prevalence of
depression. Another hypothesis is that men try to distract themselves from
depression, while women tend to ruminate, making the depression worse.
v) Events That Precipitate Depression: People generally become depressed when
bad things happen to them. The severity of an event does not seem to be
related to the severity of the subsequent depression. Differences in
vulnerability to depression may relate to when losses are experienced in life;
early losses may make people more vulnerable to depression later on. Also,
vulnerability is higher in those with poor social support.
vi) Cognitive Aspects of Depression
(1) Explanatory Styles: Learned helplessness in its simple form is not a viable
explanation for depression. It is not failure itself that leads to depression,
but the reasons people think they have failed. Depression is related to
explanatory style, which is a tendency to accept one kind of explanation
for success or failure more often than others. This is related to our
discussion of attributions, a topic first discussed in Chapter 14. People
tend to be more consistent in their explanatory style regarding failures
than in their attributions related to success. People who usually take the
blame for their own failures (using mostly internal attributions) have a
pessimistic style. This style is associated with giving up, indecisiveness,
inactiveness, and depression.
vii) Therapies for Depression:
(1) Cognitive Therapy: Beck characterizes the “negative cognitive triad of
depression”, which includes “I am defeated”, “The world is full of
obstacles”, “The future is devoid of hope.” These “automatic thoughts”
lead people to interpret situations to their own disadvantage. The goal of a
cognitive therapist is to help clients substitute more favorable beliefs.
(2) Biological Therapies for Depression: Tricyclic drugs work to block the reabsorption of several neurotransmitters–dopamine, norepinephrine, and
serotonin–after they are released by at the synapse. Monoamine oxidase
inhibitors block the metabolic breakdown of released dopamine,
norepinephrine, and serotonin. Second-generation antidepressants, or
serotonin reuptake blockers block the reuptake of released
neurotransmitters, but their effect is limited to the neurotransmitter
serotonin. These drugs produce fewer side effects than earlier generation
of antidepressants. The effects build up gradually, due to a slow series of
changes in the presynaptic and postsynaptic neurons. Atypical
antidepressants (such as Wellbutrin) are prescribed to help patients whose
depressions do not respond to any of the other commonly used classes of
antidepressant drugs. Atypical antidepressants tend to only produce very
mild side effects. St. John’s Wort is an herb that appears to have some
antidepressant effects. The evidence for these benefits is mixed and the
production of this herb for consumption is not well regulated. It can
interfere with the working of other medications a patient might be taking.
It should be used with great caution. All antidepressants may work in part
by producing some level of placebo effect in users.
(3) Choosing Between Psychotherapy and Antidepressant Drugs: Cognitive
therapy is slightly more effective than drug therapy, and the benefits
generally persist longer, and of course, there are no side effects. However,
the use of antidepressants is widespread, primarily for the reasons of
convenience and cost.
(4) Electroconvulsive Shock Therapy: Electroconvulsive shock therapy (ECT)
is a controversial treatment for depression In ECT a brief electrical shock
is administered across the patient’s head in order to induce a convulsion
similar to the kind experienced in epilepsy. ECT is used as a last resort for
severely depressed individuals who fail to respond to drugs, whose
thinking is strongly disordered, and who have strong suicidal tendencies.
The reasons behind ECT’s effectiveness are not well understood, and its
use continues to be controversial.
viii) Bipolar Disorder: People with bipolar disorder alternate between the
extremes of mania and depression. About 1% of adults in the United States have
been diagnosed with some form of bipolar disorder. Mania is the opposite of
depression; in the manic phase, people are constantly active and uninhibited. In
the depressed phase, they feel helpless and sad.
(5) Bipolar Cycles: Periods of depression lasting months alternate with shorter
periods of mania (extreme episodes of mood featuring lack of inhibition,
constant activity and great happiness or irritability). There are two
varieties of bipolar disorder – Type I involves at least one episode of
mania, and Type II involves episodes of major depression interspersed
with episodes of hypomania, which is a milder form of mania. A recent
case study of creativity in those diagnosed with bipolar disorder
demonstrated no difference between the quality of works produced during
manic and depressive phases.
(6) Drug Therapies for Bipolar Disorder: Lithium is a common and effective
treatment for bipolar disorder. It reduces mania and prevents a patient
from lapsing into depression or mania. The reasons for lithium’s success
are unclear. It seems to work in pathways within the neuron rather than at
the synapses. Other mood stabilizers and anticonvulsants have also been
used to treat bipolar disorders with some success.
viii) Mood Disorders and Suicide: Depression and suicide are not inextricably
linked. Suicides occur for other reasons – mass cult suicides, feelings of
individual or family disgrace, or for relief from the intractable pain that might
be associated with terminal illness. Accurate epidemiological is hard to obtain
because often suicides are “disguised” as accidents or accidental drug
overdoses. Women make more suicide attempts than men, but more men die
by suicide, because men use more violent means. Suicide and suicide attempts
follow no reliable pattern; some involve warning signals, and some do not.
There are some factors besides depression that are associated with a greater
likelihood of attempting suicide: isolation, recent loss and previous history or
family history rank highly among these.
4) Schizophrenia
a) Schizophrenia: The term schizophrenia refers not to dissociative identity disorder,
as many believe, but to a condition in which there is a “split” between the
emotional and intellectual aspects of personality. An official diagnosis of
schizophrenia would likely be given to a person on the basis of an observed
dramatic deterioration of daily activities, including work, social relations, and self
care. He or she must also exhibit at least two of the following: hallucinations,
delusions, incoherent speech, grossly disorganized behavior; certain thought
disorders, or a loss of normal emotional responses and social behavior.
i) Positive and Negative Symptoms: Positive symptoms of schizophrenia refer
behaviors that are “present” or happening – such as hallucinations and
delusions. Negative symptoms are things that should happen and do not; they
are absent. Examples would be a lack of appropriate affect or speech.
ii) Hallucinations: Hallucinations are false sensory experiences. Hallucinations
in and of themselves are not a sign of mental illness, but they are usually
present with all the other symptoms of schizophrenia. Auditory hallucinations
are the most common; visual hallucinations are relatively rare.
iii) Delusions: Delusions are unfounded beliefs. A delusion of persecution is a
belief that others are out to harm a person; a delusion of grandeur is a belief
that one is unusually special or important; a delusion of reference is the
tendency to interpret all sorts of messages as if they were meant for especially
for oneself.
iv) Disordered Thought: People with schizophrenia usually have average or
above average IQ scores, but they tend to have problems thinking. They have
trouble with tasks requiring selective attention. They exhibit loose
associations between ideas, have trouble using abstract concepts, and tend to
misunderstand simple statements.
v) Types of Schizophrenia: Psychologists distinguish between four different
types of schizophrenia. Undifferentiated schizophrenia is characterized by
basic symptoms–deterioration of daily functioning plus some combination of
hallucinations, delusions, inappropriate emotions, thought disorders, and
others. Catatonic schizophrenia is characterized by basic symptoms plus
prominent movement disorders such as rigid inactivity or excessive motor
activity. This is a rare disorder. Disorganized schizophrenia involves
incoherent speech, lack of social relationships, and strange or bizarre
behavior. Paranoid schizophrenia involves basic symptoms plus persistent
hallucinations and delusions, especially delusions of persecution and
delusions of grandeur. Some persons with schizophrenia exhibit a
combination of types, or switch between the types.
vi) Prevalence: About 1% of Americans are diagnosed with schizophrenia during
their lifetimes. It occurs in all ethnic groups but somewhat less frequently in
developing nations. It is usually first diagnosed late in adolescence or early in
adulthood. Males tend to be diagnosed earlier in life than females. The onset
tends to be sudden, but there are exceptions.
b) Causes of Schizophrenia:
i) Genetics: Family studies indicate that genetic factors contribute to
schizophrenia, although its influence is probably overestimated by
underestimating the importance of the prenatal environment. A current
research focus is to find those with the genes for schizophrenia, but who do
not exhibit the symptoms. “Markers” that may indicate a later onset of
schizophrenia include failure to habituate normally to a repeated sound and an
impairment of pursuit eye movements.
ii) Brain Damage: People suffering from schizophrenia show minor but
widespread brain damage. The hippocampus and some areas of the cerebrum
are smaller than is typical in a normally developed brain. The causes of these
brain abnormalities, and their connection to schizophrenia are not well
understood. They usually develop early in life.
iii) The Neurodevelopmental Hypothesis: Many researchers now accept the
neurodevelopmental hypothesis. This hypothesis states that schizophrenia is
caused by impaired development of the nervous system before or around the
time of birth, possibly but not necessarily for genetic reasons. A difficult labor
and delivery, poor prenatal care, small size at birth and Rh factor differences
between mother and neonate have all been related to this hypothesis.
iv) Research has also revealed a season-of-birth effect, in northern climates, being
born in the winter months carries slightly increased risk of developing
schizophrenia compared to being born at other times of the year. There may
be a link between season-of-birth and the increased occurrence of influenza
during the fall, resulting in mother’s infection with the sickness while
pregnant, especially during the second trimester when critical brain regions
are forming.
c) Therapies for Schizophrenia: By far the most common treatments for
schizophrenia are psychopharmacological.
i) Drug Therapies: Drugs that help relieve schizophrenia are known as
antipsychotic drugs or neuroleptic drugs. The drugs do not cure the disorder
but do help to control it. All of the drugs block dopamine in the brain. The
dopamine hypothesis of schizophrenia states that the underlying cause of
schizophrenia is excessive stimulation of some of the dopamine synapses. An
alternative view, the glutamate hypothesis of schizophrenia proposes that the
underlying problem in schizophrenia is deficient stimulation of certain
glutamate synapses in the brain.
ii) Side Effects of Drug Therapies for Schizophrenia: Antipsychotic drugs have
some unpleasant side effects including tardive dyskinesia, which results in
tremors and involuntary movements. This normally only develops after years
of taking the drugs. Newer drugs that do not produce this side effect include
clozapine and respiradone. These drugs also relieve the negative symptoms of
schizophrenia, unlike other antipsychotic drugs.
iii) Family Therapy for Schizophrenia: Family therapy can be a valuable adjunct
to drug therapies. The (understandable) emotional upset and stress
experienced by a family in which a member has been diagnosed with
schizophrenia can contribute to relapses in the identified patient. Research
suggests that when family members make hostile comments (expressed
emotion) this expression can increase the likelihood of a relapse. Data
gathered in cultures where there is typically a large, supportive extended
family available to the person with schizophrenia suggests that fewer and less
severe relapses tend to occur. This is probably due to the fact that there is
more care available for the patient and less strain on the individual members
of the family.