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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.