Chapter 14

What is Abnormal

n Psychological Disorders

• Mental processes and/or behavior patterns that cause:

n Emotional distress

n Substantial impairment in functioning

n Defining Mental Disorders

• Is the behavior considered strange within the person’s own culture?

n What is normal in some cultures is abnormal in others

• Does the behavior cause personal distress?

n Experiencing considerable emotional distress without any life experience that warrants it

What is Abnormal

n Defining Mental Disorders

• Is the behavior maladaptive?

n Does it lead to healthy or impaired functioning?

• Washing your hands before you eat is healthy.

• Washing your hands 100 times daily is maladaptive.

• Is the person a danger to self or others?

n A priority consideration in committing someone to a mental hospital

• Is the person legally responsible for his or her acts?

n The term “insanity” is not used by mental health professionals

n It is a legal term used by the courts

• Mass murderer Jeffrey Dahmer was ruled legally responsible, but his behaviors were clearly abnormal

Prevalence of Psychological Disorders

n Psychological disorders are more common than many physical ailments

• In the U.S., less than 1% of adults are diagnosed with cancer

n 30% will be diagnosed with cancer at some time in their life

• 22% are diagnosed with a mental disorder of some kind

n 50% will be diagnosed with a disorder at some time in their life

Prevalence of Psychological Disorders

Prevalence of Psychological Disorders

Perspectives on Psychological Disorders

Recognizing and Avoiding 5 Cognitive Traps:

q Setting unrealistic standards for yourself

• “No one must ever see me sad.”

q Negative “what if” thinking

• “What if I lose my job?

q Turning a single negative event into a catastrophe

• Believing that, “I’ll never pass this course,” after a poor grade on one paper

q Judging anything short of perfection to be a failure

q Demanding perfection in yourself and others

n If happiness depends on these conditions, a stage is set for disappointment and depression

Classifying Psychological Disorders

n Diagnostic and Statistical Manual of Mental Disorders (DSM)

• First published in 1952

• DSM IV-TR published in 2000

• 300 specific disorders listed along with criteria to make a diagnosis

• Used by therapists, researchers, mental health workers, and insurance companies

• Common language between professionals

• Multidimensional diagnostic system

n Clinical Disorders

n Personality Disorders and Mental Retardation

n General Medical Conditions

n Psychosocial, Environmental Problems

n Global Assessment of Functioning

The Diagnostic and Statistical Manual of Mental Disorders

Perspectives on Psychological Disorders

n Biological

• Underlying physical disorders cause mental disorders

• Structural, brain biochemical, genetic, or infection

n Biopsychosocial

• Combination of biological, psychological, and social causes

n Psychodynamic

• Stem from early childhood experiences and unresolved, unconscious sexual or aggressive conflicts

n Learning

• Abnormal thoughts, feelings, and behaviors are learned and sustained

• Failure to learn appropriate behaviors

n Cognitive

• Faulty thinking or distorted perceptions

Prevalence of Psychological Disorders

People in the U.S. who suffer from psychological disorders during their lifetimes:

n Any psychological disorder: 46%

n Any anxiety disorder: 29%

n Any mood disorder: 21%

n Any substance abuse / dependence: 15%

n Schizophrenia or other psychosis: 0.4%

n Diagnosis of cancer: 30%

Anxiety Disorders

n Anxiety disorder

• Frequent fearful thoughts about what might happen in the future

n Generalized anxiety disorder

• People who are plagued with chronic worry for 6 months or more

n Finances, health, work, or ability to function socially

• Symptoms include:

n Feeling tense, tired, and irritable

n Trembling, palpitations, sweating, dizziness, nausea, diarrhea

• Affects twice as many women as men

• Antidepressant drugs and cognitive and behavioral therapies may be helpful

Anxiety Disorders

n Panic Attacks

• An episode of overwhelming anxiety, fear, or terror

n About 2% of men and 5% of women in the U.S.

• Symptoms include:

n Pounding heart

n Uncontrollable trembling or shaking

n Sensations of choking or smothering

n Feeling as if you are going to die

n Feeling as if you are “going crazy”

• The more catastrophic the belief, the more intense the panic

• Recurring panic attacks may be diagnosed as panic disorder

n Anxiety about the occurrence or consequences of future attacks

• Significant health and social consequences

n Frequently visit doctors’ offices and emergency rooms

n Increased risk for abuse of alcohol and other drugs

• Treatments include medication and psychotherapy

Common Anxiety Disorders

n Agoraphobia

• An intense fear of being in a situation from which escape is not possible or in which help would not be available if one experienced overwhelming anxiety or a panic attack

• Life is planned around avoiding feared situations

• May not leave home unless accompanied by a friend, family member, or, when severe, not even then

• Women are four times more likely than men to be diagnosed

• Typically begins in early adult years with panic attacks

n Leads to avoidance of places or situations where attacks occurred

n Affects physical, psychological, social, occupational, and interpersonal and economic areas of life

Phobias

n A persistent, irrational fear of some specific object, situation, or activity that poses little or no real danger

• Phobics realize their fears are irrational, but feel compelled to avoid the feared situations or objects.

n Social phobia

• An irrational fear and avoidance of any social or performance situation in which one might embarrass or humiliate oneself in front of others

n Shaking, blushing, sweating, or appearing clumsy, foolish, or incompetent

• Most common type of anxiety disorder

• May take the form of performance anxiety

n Barbara Streisand did not perform live for years because of it

• One third only fear speaking in public

• In extremes, can affect performance at work, limit education, or restrict social life

• Many turn to alcohol or tranquilizers to reduce symptom’s affect

n Mickey Mantle used alcohol to calm self before public appearances

Phobias

n Specific phobia

• Marked fear of a specific object or situation

• A general label for any phobia other than agoraphobia or social phobia

• When facing the phobic item or situation, people:

n Experience intense anxiety, even to the point of shaking or screaming

n Will go to great lengths to avoid the feared object or situation

• Phobic items include (ordered by frequency of occurrence):

n Situational phobias (elevators, airplanes, enclosed places, tunnels)

n Fear of natural environment (storms or water)

n Animal phobias (dogs, snakes, insects, or mice)

n Blood injection-injury phobia (fear of seeing blood or receiving an injection)

• Claustrophobia (closed spaces) and acrophobia (heights) are most frequently treated by therapists

Causes of Phobias

Causes vary depending on the type of phobia

n Heredity

• An important factor in the development of phobias

n Direct conditioning, modeling, or the transmission of information

• Traumatic childhood experience with the feared object or situation

n Observational learning

• Children who hear parents talk about a frightening encounter with a dog may develop a fear of dogs

Treatment of Phobias

n Principles of Learning

• Classical conditioning

n Help patients associate pleasant emotions with feared items

• A child who fears dogs is given ice cream when a dog is present

• Behavior modification

n Patients are reinforced for exposing themselves to fearful stimuli

• Modeling

n Observing others who do not fear to the situation or object

• Watch someone handle and play with a dog

n Medication

• Antidepressant drugs have been shown to be helpful, especially when paired with cognitive behavioral therapy

Obsessive-Compulsive Disorder (OCD)

n Anxiety disorder in which a person suffers from recurrent obsession, compulsions, or both

n Obsession

• Persistent, involuntary thought, image, or impulse that invades consciousness and causes great distress

n Contamination by germs

n Whether they performed a specific action

• Turning off the stove or locking the door

n Aggression

n Religion

n Sex

Obsessive-Compulsive Disorder (OCD)

n Compulsion

• A persistent, irresistible, and irrational urge to perform an act or ritual repeatedly

• Individuals know the act is senseless but cannot resist performing it without experiencing intolerable anxiety

n Anxiety is relieved only by doing the action

• Becomes a psychological problem only if:

n The person cannot resist performing it

n It is very time-consuming

n It interferes with normal activities and relationships with others

Obsessive-Compulsive Disorder (OCD)

n Compulsion

• 75% of OCD involves cleaning and checking

• Reflects superstitious thinking of things that must be done to ward off danger

• 2-3% of U.S. population

• Fairly similar rates reported in Canada, Puerto Rico, Germany, Korea, and New Zealand

• Predisposition

n Early autoimmune diseases

n Strep infections,

n Changes in the brain caused by infection

• Twin and family studies indicate genetic factors

n Genes affecting serotonin are suspected of causing OCD

• Antidepressant drugs that increase serotonin levels often helpful

Mood Disorders

n Disorders characterized by extreme and unwarranted disturbances in emotion or mood

n Major Depressive Disorder

• Marked by feelings of great sadness, despair, and hopelessness as well as the loss of the ability to experience pleasure

• Symptoms

n Changes in appetite, weight, or sleep patterns

n Loss of energy

n Difficulty in thinking or concentrating

n Psychomotor disturbances

• Slowed body movements, reaction time, and speech

• Constant movement, fidgeting, wringing of hands, and pacing

n Psychotic depression

• Delusions or hallucinations

Mood Disorders

Major Depressive Disorder

n 1 year after initial diagnosis:

• 40% of patients are without symptoms

• 40% are still suffering from the disorder

• 20% are still depressed, though not enough to warrant hospitalization

• Less than half of hospitalized patients are fully recovered

n Many receive antidepressant drugs

n Studies reflect psychotherapy can be equally effective

n Recurrence of disorder:

• 50-60% of patients will have a recurrence

• Recurrence greatest for females and when initial onset is before 15

• May be frequent or infrequent

• 20-35% of patients recurrence is chronic–lasting more than 2 years

• Medication, psychotherapy, social support, and exercise preventative

Depression in 10 Countries

n Rate of depression for females twice that for males

n Largely due to conflicting roles of wife, mother, lover, friend, etc.

n Boys twice as likely before puberty; after, females twice as likely

n Women more likely to face negative consequences from depression

Bipolar Disorder

n Bipolar disorder

• A mood disorder in which manic episodes alternate with periods of depression

• Usually with relatively normal periods in between

• Manic episode

n Excessive euphoria

n Inflated self-esteem

n Wild optimism

n Hyperactivity

n Temporarily lose touch with reality

n Frequently have delusions of grandeur along with euphoric highs

n May waste large sums of money on get-rich schemes

n Likely become irritable, hostile, enraged, or dangerous if stopped

n May be hospitalized to protect themselves from disastrous consequences

Bipolar Disorder

n Bipolar disorder

• Van Gogh suffered from bipolar disorder

n During manic episode, created 60 paintings in 2 month period

n Between frantic periods Van Gogh experienced deep despair

n Committed suicide at age 37

• Afflicts 1.2% of the U.S. population

• Prevalence equal between male and female

• Onset during late adolescence or early adulthood

• 90% have recurrences, about 50% within a year of recovery

• 70-80% return to a state of emotional stability

• Mild cognitive deficits persist following manic episode

• Many manage their disorder and lead normal lives with the aid of medication

• Psychotherapy helps cope with stress of chronic mental illness

Explaining Mood Disorders

n Neurological & Hereditary Correlates

• Heredity and abnormal brain structure and chemistry

n Abnormal levels of serotonin linked to depression and suicide

n Production, transport, and reuptake patterns of dopamine, GABA, and norepinephrine different than “normal” people

n Neurotransmitter abnormalities may reflect genetic variations

n Heritability of depressive disorder is 70%, environment 30%

• Twins of those diagnosed with bipolar disorder:

n 50% of identical twins also diagnosed

n 7% of fraternal twins also diagnosed

• Biological relatives of bipolar disorder sufferers are at increased risk for a number of other mental disorders

n Cognitive Factors

• Depressed individual view themselves, the world, and the future in a negative way

• Interactions are seen as a series of burdens and obstacles that end in failure

Causes of Mood Disorders

n Life Stressors

• Vast majority of first depression episodes occur after major life stress

• Negative life events and family history significant in development

• Women are more likely to experience a severe negative life event just prior to the onset of depression

• Recurrence of depression in people with biological predisposition often occurs without major life stressor

Suicide and Race, Gender, and Age

n Mood disorders, schizophrenia, and substance abuse are major risk factors for suicide in all age groups

n Suicide risk increases when exposed to troubling life stressor

n Suicidal behavior runs in families

n 30,000-31,000 suicides are reported annually in the U.S.

n Suicide rates far lower for white and African American women than for men

n Older Americans are at far greater risk than young people

n 90% of individuals who commit suicide leave clues

• Verbally: “You won’t be seeing me again”

• Behavioral: giving away most valued possessions

• Taking unnecessary risks

• Showing personality changes

• Losing interest in favorite activities

n Warning signs should be taken seriously

n Encourage them to get professional help or call 24-hour hotline

Suicide by Race, Gender, and Age

Schizophrenia

Schizophrenia

Types of Schizophrenia

n Paranoid schizophrenia

• Characterized by delusions of grandeur or persecution

• Convinced they have an identity other than their own or that they possess great ability or talent

• Often show exaggerated anger and suspiciousness

• Feel they are being harassed or threatened

• May become violent to defend themselves against imagined persecutors

• Behavior is not as disturbed as other types

• The chance for recovery is better

Types of Schizophrenia

n Disorganized Schizophrenia

• Most serious type

• Extreme social withdrawal

• Hallucinations

• Delusions

• Silliness

• Inappropriate laughter

• Grotesque mannerisms

• Flat or inappropriate affect

• Frequently incoherent

• May exhibit obscene behavior

• May swallow almost any kind of object or material

• Results in the most severe disintegration of personality

• Poorest chance of recovery

Types of Schizophrenia

n Catatonic schizophrenia

• Complete stillness or stupor

• Great excitement or agitation

• Frequently alternate rapidly between the two

• May assume an unusual posture

n Remain in the pose for long periods of time

n Undifferentiated schizophrenia

• Catchall term used when schizophrenic symptoms either:

n Do not conform to the criteria of any one type of schizophrenia or

n Conform to more than one type

Explaining Schizophrenia

Constitutional vulnerability

n An individual’s congenital risk of developing schizophrenia

• Gender

n Males are more likely to develop schizophrenia

• Heredity

n Genes may affect fetal brain structure and may influence neurotransmitters like dopamine through out life

• Prenatal and postnatal experiences

n Exposure to maternal stress hormones

n Exposure to alcohol or drugs ingested by the mother

n Nutrients, bacteria, or viruses that cross placenta

n Birth trauma or other threats to infant’s health

• Stress

n Plays a role in development of schizophrenia only among those with relevant constitutional vulnerability

n Neurological sensitivity to biochemical changes that go along with being under stress

• Stress hormones ‘flip switches’ in the brains of the vulnerable

• Neuromaturational processes

Neuromaturational Processes

n Brains of schizophrenic individuals differ both structurally and functionally

• Low levels of neural activity in the frontal lobes

• Defects in neural circuitry of cerebral cortex and limbic system

• Slower communication between left and right hemispheres

• Linked to neuromaturational process in late teens early 20’s

• Neurological deterioration

n Deterioration of cerebral cortex and hippocampus

n Decrease in gray matter

n Decrease in overall brain size

n Damage to neurons impairs:

• Communications between emotional and intellectual parts

• Coordination of brain’s sub-systems

• Neurotransmitters

n Abnormal dopamine activity is common

n Many neurotransmitters, notably glutamate and GABA, underlie the symptoms of schizophrenia

Genetic Similarity and Probability of Developing Schizophrenia

Somatoform Disorders

n Physical symptoms present due to psychological causes rather than any known medical condition

n People with somatoform disorders are not faking illness to avoid work or other activities

n Hypochondriasis

• Persons preoccupied with their health; fear their physical symptoms are the sign of some serious disease

• Despite reassurance from doctors to the contrary

• Not convinced when medical examination reveals no problem

• Symptoms are not consistent with known physical disorders

• May “doctor shop,” seeking confirmation of their worst fears

• Not easily treated

• Poor chance of recovery

Somatoform Disorders

n Conversion Disorder

• A person suffers a loss of motor or sensory functioning in some part of the body

• Loss has no physical cause but solves some psychological problem

• May become blind, deaf, unable to speak, or paralysis in some part of the body

• Freud believed it is an unconscious process to help solve an unconscious sexual or aggressive conflict

Dissociative Disorders

n Disorders in which, under unbearable stress, consciousness becomes dissociated from a person’s identity, her/his memories of important personal events, or both

n Dissociative amnesia

• Complete or partial loss of the ability to recall personal information or identify past experiences

• Cannot be attributed to forgetfulness or substance abuse

• Often caused by traumatic experience

• Can be caused by a situation creating unbearable anxiety, causing the person to escape by “forgetting”

n Victims of 9/11 tragedy were discovered in mental hospitals months later with dissociative amnesia

n Brought to hospitals with no identification and couldn’t recall

• Forget name, age, address, and may not recognize parents, family, or friends

• Do not forget how to carry out routine tasks

• Basic personality remains intact

Dissociative Disorders

n Dissociative fugue

• Complete loss of memory of one’s entire identity

• Travel away from home

• May assume a new identity that is more outgoing and uninhibited than the former identity

• May last hours, days, or months

• Usually a reaction to a severe psychological stress

n Natural disaster

n Serious family quarrel

n Deep personal rejection

n Military service in wartime

• Recovery is usually rapid

n May have no memory of initiating stressor

• May have no memory of events during the episode

Dissociative Disorders

n Dissociative Identity Disorder (DID)

• Two or more distinct, unique personalities occur in the same person

• Severe memory disruption concerning personal information about the other personalities

• In 50% of cases, there are more than 10 different personalities

• Change usually occurs suddenly and during stress

• Host personality is in charge of body most of the time

• Alter personalities may differ radically in:

n Intelligence, speech, accent, vocabulary, posture, body language, hairstyle, taste in clothes, manners, handwriting, and sexual orientation

• In 80% of cases, host personality doesn’t know alter personalities

n Alter personalities have varying levels of awareness of each other

• Lost time – periods with no memory while in alter personality

• Usually begins in childhood; rarely in adolescence

• 90% women

• 95% have history of severe physical and/or sexual abuse

Personality Disorders

n A long-standing, inflexible, maladaptive pattern of behaving and relating to others, which usually begins in early childhood or adolescence

Personality Disorders

n A long-standing, inflexible, maladaptive pattern of behaving and relating to others, which usually begins in early childhood or adolescence

Cluster A: Odd Behavior

n Paranoid

• Highly suspicious

• Untrusting, guarded

• Hypersensitive, easily slighted

• Lacking emotion, holds grudges

n Schizoid

• Isolates self from others

• Appears unable to form emotional attachments

• Behavior may resemble that of autistic children

n Schizotypal

• Dresses in extremely unusual way

• Lacks social skills

• May have odd ideas resembling schizophrenic delusions

Personality Disorders

Cluster B: Erratic, Overly Dramatic Behavior

n Narcissistic

• Exaggerate sense of self importance and entitlement

• Self-centered, arrogant, demanding, exploitive, envious

• Craves admiration and attention; lacks empathy

n Histrionic

• Seeks attention and approval, craves excitement

• Overly dramatic, self-centered, shallow, demanding, easily bored, manipulative, suggestible

• Often attractive and sexually seductive

n Borderline

• Unstable mood, behavior, self-image, and social relationships

• Intense fear of abandonment

• Exhibits impulsive, reckless behaviors and inappropriate anger

• Makes suicidal gestures and self-mutilating acts

n Antisocial

• Disregards rights, feelings; manipulates, etc. without remorse

• Aggressive, irresponsible, reckless, willing to break the law

• Breaks the law, lies, cheats, exploits, and fails to hold jobs

Personality Disorders

Cluster C: Anxious, Fearful Behavior

n Obsessive-Compulsive

• Perfectionistic, things must be done the “right” way

• Relationsihps are emotionally shallow

n Avoidant

• Fears criticism and rejection

• Avoids social situations to prevent being judged by others

n Dependent

• Overly dependent on others for advice and approval

• Clings to lovers and friends

• Fears abandonment

Childhood Diagnosed Disorders

Pervasive Developmental Disorders

n Group of disorders in which children exhibit severe disturbances in social relationships derived from:

• Poor communication skills

• Inability to understand reciprocal give-and-take aspect of social relationships

• Exhibit odd, repetitive behaviors

• Develop attachments to odd objects

• Become extremely anxious when separated

• Self injurious behaviors

n 1% of all children have some form of PDD

Childhood Diagnosed Disorders

Pervasive Developmental Disorders

n Autistic disorder

• Limited or nonexistent language skills for age

• Inability to engage in reciprocal social relationships

• Severely limited range of interests

• Most are mentally retarded, easily distracted, highly impulsive, and slow to respond to external stimuli

n Asperger’s disorder

• Possess same characteristics as autistic disorder, but have intact, age-appropriate language and cognitive skills

• Do not develop capacity to understand others’ thoughts, feelings, and motivations

• May engage in obsessive behaviors

Childhood Diagnosed Disorders

Attention Deficit Hyperactivity Disorder

n Significant problems with:

• Focusing attention

• Physical hyperactivity

• Easily distraction

n 3-7% of children worldwide suffer from ADHD

n Many with ADHD also have learning disabilities

n May show aggressive behaviors or conduct disorder

n Largest difficulty is attention to boring or repetitive tasks

n Function well when they have freedom to move freely from one activity to another

n Diagnosis most common during school years

n Neurological and hereditary basis

n Amplified by risk factors or balanced by protective factors

Childhood Diagnosed Disorders

Attention Deficit Hyperactivity Disorder

n Treatment

• Medication

n Amphetamines (methylphenidate)

n Selective Norepinephrine Reuptake Inhibitors (Strattera)

• Parent training

n Use non-authoritarion strategies

• 4.4% of adults in the U.S. have the disorder

n Medication treatment results are mixed