Chapter 15 Psychological Disorders

1. Chapter 15 Psychological Disorders

2. The medical model and mental illness. The medical model �proposes that it is useful to think of abnormal behavior as a disease� and has become the main way of thinking about mental illness today. This view is in stark contrast to how mental illness used to be perceived (see Figure 15.1). Thus, the medical model has brought much needed improvement in patient care.

3. Other key terms. Diagnosis � �involves distinguishing one illness from another�. Etiology � �refers to the apparent causation and developmental history of an illness�. Prognosis � �is a forecast about the probable course of an illness�.

4. Criteria for abnormal behavior. Deviance � the behavior must be significantly different from what society deems acceptable. Maladaptive behavior � the behavior interferes with the person�s ability to function. Personal distress � the behavior is troubling to the individual.

5. Classification of disorders. The American Psychological Association (A.P.A.) uses the Diagnostic and Statistical Manual (now in it�s fourth revision and referred to as the DSM IV) to classify disorders. This provides detailed information about various mental illnesses that allow clinicians to make more consistent diagnoses.

6. Classification of disorders. (cont.) The DSM has five �axes� or components: Axis I: criteria for diagnosing most disorders are listed here. Axis II: specific to personality disorders. Axis III: patient�s general medical condition. Axis IV: psychosocial and environmental problems. Axis V: global assessment of functioning.

7. Prevalence of psychological disorders. Epidemiology is �the study of the distribution of mental or physical disorders in a population�. Prevalence �refers to the percentage of the population that exhibits a disorder during a specified time period�. Research suggests that there has been a real increase in the prevalence in disorder (see Figure 15.4). The most common classes are substance use, anxiety and mood disorders.

8. Figure 15.4. Lifetime prevalence of psychological disorders. The estimated percentage of people who have, at any time in their life, suffered from one of four types of psychological disorders, or from a disorder of any kind, (top bar) is shown here. Prevalence estimates vary somewhat from one study to the next, depending on the exact methods used in sampling and assessment. The estimates shown here are based on pooling data from Wave 1 and 2 of the Epidemiological Catchment Area studies and the National Comorbidity Study, as summarized by Regier and Burke (2000) and Dew, Bromet, and Switzer (2000). These studies, which collectively evaluated over 28,000 subjects, provide the best data to date on the prevalence of mental illness in the United States. Figure 15.4. Lifetime prevalence of psychological disorders. The estimated percentage of people who have, at any time in their life, suffered from one of four types of psychological disorders, or from a disorder of any kind, (top bar) is shown here. Prevalence estimates vary somewhat from one study to the next, depending on the exact methods used in sampling and assessment. The estimates shown here are based on pooling data from Wave 1 and 2 of the Epidemiological Catchment Area studies and the National Comorbidity Study, as summarized by Regier and Burke (2000) and Dew, Bromet, and Switzer (2000). These studies, which collectively evaluated over 28,000 subjects, provide the best data to date on the prevalence of mental illness in the United States.

9. Anxiety disorders �are a class of disorders marked by feelings of excessive apprehension and anxiety�. Generalized anxiety disorder �is marked by a chronic, high level of anxiety that is not tied to any specific threat�. Phobic disorder �is marked by a persistent and irrational fear of an object of situation that presents no realistic danger�.

10. Panic disorder �is characterized by recurrent attacks of overwhelming anxiety that usually occur suddenly and unexpectedly� (see following animation sequence). Agoraphobia �is a fear of going out to public places�. Agoraphobia may result from severe panic disorder, in which people �hide� in their homes out of fear of the outside world.

11. Obsessive Compulsive Disorder (OCD) �is marked by persistent, uncontrollable intrusions of unwanted thoughts (obsessions) and urges to engage in senseless rituals (compulsions)�. Common obsessions include fear of contamination, harming others, suicide, or sexual acts. Compulsions are highly ritualistic acts that temporarily reduce anxiety brought on by obsessions.

12. Obsessive Compulsive Disorder (cont.) OCD disorders occur in approximately 2.5% of the population. Most cases of OCD emerge before the age of 35.

13. Etiology of anxiety disorders. Biological factors. Inherited temperament may be a risk factor for anxiety disorders. �Anxiety sensitivity� theory posits that some people are more sensitive to internal physiological symptoms of anxiety and overreact with fear when they occur.

14. Etiology of anxiety disorders. (cont.) The brain�s neurotransmitters, or �chemicals that carry signals from one neuron to another�, may underlie anxiety. In particular, drugs that affect the neurotransmitter GABA (e.g., Valium) suggest that these chemical circuits may be involved in anxiety disorders.

15. Etiology of anxiety disorders. (cont.) Conditioning and learning. Classical conditioning may cause one to fear a particular object or scenario. Then, avoiding the fear stimulus is negatively reinforced, through operant conditioning, by making the person feel less anxious. Seligman (1971) adds we are �biologically prepared� to fear some things more than others, however.

16. Etiology of anxiety disorders. (cont.) Cognitive factors. Some people are more likely to experience anxiety disorders because they: Misinterpret harmless situations as threatening. Focus excess attention on perceived threats. Selective recall information that seems threatening.

17. Etiology of anxiety disorders. (cont.) Finally, anxiety disorders may be linked to excessive stress. Specifically, research (Brown, 1998) has found that people with anxiety disorders were more likely to have experienced severe stress one month prior to the onset of their disorder. Thus, stress may precipitate the onset of anxiety disorders.

18. Somatoform disorders �are physical ailments that cannot be fully explained by organic conditions and are largely due to psychological factors�. Somatization disorder �is marked by a history of diverse physical complaints that appear to be psychological in origin�. It occurs mostly in women. Symptoms seem to be linked to stress.

19. Conversion disorder � �is characterized by a significant loss of physical function with no apparent organic basis, usually in a single organ system�. Common symptoms include: Partial or total loss of vision or hearing. Partial paralysis. Laryngitis or �mutism� (inability to speak). Seizures or vomiting. Loss of function in limbs.

20. Hypochondriasis (or hypochondria) �is characterized by excessive preoccupation with health concerns and incessant worry about developing physical illnesses�. People with hypochondria are convinced their symptoms are real and often become frustrated with the medical establishment. Hypochondria often occurs along with anxiety disorders and depression.

21. Etiology of somatoform disorders. Biological factors. People with somatoform disorders may have an inherited sensitivity to the autonomic nervous system. However, there is not much evidence to support a biological basis for this class of disorders.

22. Etiology of somatoform disorders. (cont.) Personality factors. Somatoform disorders are more common in people with �histrionic� personalities (those who thrive on the attention that illness brings). Neuroticism also seems to elevate one�s predisposition to somatoform disorders.

23. Etiology of somatoform disorders. (cont.) Cognitive factors. Some people focus excessive attention on bodily sensations and amplify them into perceived symptoms of distress. They also have unrealistically high standards of �good health�. Thus, any deviation from perfect health is seen as a sign of illness.

24. Etiology of somatoform disorders. (cont.) The sick role. Some people learn to �like� being sick because: It allows one to avoid challenging tasks. Demands aren�t placed on sick people. It provides an excuse for failure. Being sick elicits attention from others.

25. Dissociative disorders �are a class of disorders in which people lose contact with portions of their consciousness or memory, resulting in disruptions in their sense of identity�. Dissociative amnesia �is a sudden loss of memory for important personal information that is too extensive to be due to normal functioning�. It often occurs after a single traumatic event or an extended period of severe trauma or stress.

26. Dissociative fugue is a disorder in which �people lose their memory for their sense of personal identity�. People suffering from this disorder often wander away from home, not know who they are, where they live, or who they know.

27. Dissociative Identity Disorder (DID) �involves the coexistence in one person of two or more largely complete, and usually very different personalities�. Also known as �multiple personality disorder�, in which each personality has their own name, memories, traits and physical mannerisms. Transitions between identities can be sudden and the differences between them can be extreme (e.g., different races or genders).

28. Etiology of dissociative disorders. Psychogenic amnesia and fugue are usually the result of extreme stress. Dissociative identity disorder is a fascinating, and bizarre disorder and its causes are largely unknown. However, many clinicians suspect that DID may result from severe emotional trauma that occurs in childhood.

29. Mood Disorders Mood disorders �are a class of disorders marked by emotional disturbances that may spill over to disrupt physical, perceptual, social and thought processes�. Major depressive disorder is a disorder in which people �show persistent feelings of sadness and despair and a loss of interest in previous sources of pleasure�. Onset can occur at any time, but most cases occur before age 40. The majority of people with depression (75 � 95%) will experience a repeat episode.

30. Major depressive disorder (cont.) Depression is one of the most common mental illnesses (the lifetime prevalence is 16.2%). However, prevalence is tied to gender. Women are twice as likely to be diagnosed with depression. This does not appear to be tied to biological differences between men and women and could result from greater stress and abuse that women experience. Mood Disorders (cont.)

31. Bipolar Disorder (once known as manic-depressive disorder) �is marked by the experience of both depressed and manic periods�. �Manic� periods are characterized by bouts of extreme exuberance and a feeling of invincibility. However, this state of elation alternates (sometimes suddenly) with periods of depression. Mood Disorders (cont.)

32. Bipolar disorder is much less common than depression (a �unipolar� disorder), affecting about 1% to 2.5% of the population. Peak age of vulnerability is between 20 and 29. See following animation sequence. Mood Disorders (cont.)

33. Etiology of mood disorders. Genetic vulnerability. Concordance rates, or �the percentage of twin pairs or other pairs of relatives that exhibit the same disorder�, suggests there is a genetic basis for mood disorders. Concordance rates for identical twins is 65% to 72%, whereas it is only 14% to 19% for fraternal twins who share fewer genes but the same environment. Mood Disorders (cont.)

34. Etiology of mood disorders. (cont.) Neurochemical factors. Mood disorders are correlated with low levels of two neurotransmitters in the brain: Norepinephrine. Seratonin. However, it is unclear whether changes in these chemicals are the cause, or the result, of the onset of mood disorders. Mood Disorders (cont.)

35. Etiology of mood disorders. (cont.) Cognitive factors. Depression may be linked to negative thinking (see Figure 15.13). Specifically, Seligman (1974) proposes that depression is caused by �learned helplessness�, in which people become passive and �give up� in times of difficulty. Learned helplessness is also related to a �pessimistic explanatory style� in which people attribute setbacks to personal flaws. Mood Disorders (cont.)

36. Figure 15.13. Negative thinking and prediction of depression. Alloy and colleagues (1999) measured the explanatory style of first-year college students and characterized them as being high risk or low risk for depression. This graph shows the percentage of these students who experienced major or minor episodes of depression over the next 2.5 years. As you can see, the high risk students, who exhibited a negative thinking style, proved to be much more vulnerable to depression. (Data from Alloy et al., 1999) Figure 15.13. Negative thinking and prediction of depression. Alloy and colleagues (1999) measured the explanatory style of first-year college students and characterized them as being high risk or low risk for depression. This graph shows the percentage of these students who experienced major or minor episodes of depression over the next 2.5 years. As you can see, the high risk students, who exhibited a negative thinking style, proved to be much more vulnerable to depression. (Data from Alloy et al., 1999)

37. Etiology of mood disorders. (cont.) Hopelessness theory, is another cognitive explanation of mood disorders in which other factors, in addition to a pessimistic explanatory style, push people into depression. Such factors include high stress and low self-esteem. Nolen-Hoeksema (1991, 2000) also asserts that those who ruminate about problems put themselves at risk for depression. Mood Disorders (cont.)

38. Etiology of mood disorders. (cont.) Interpersonal roots. Depression has also been correlated with interpersonal factors, such as poor social skills. However, it is unclear what the direction of cause and effect is, with regard to this correlation. Precipitating stress. There is also a link between stress and the onset of mood disorders. Mood Disorders (cont.)

39. Schizophrenic Disorders �Schizophrenia� literally means �split mind�. Schizophrenic disorders �are a class of disorders marked by disturbances in thought that spill over to affect perceptual, social and emotional processes�. Prevalence is quite low, with only about 1% of the population suffering from this class of disorders. Schizophrenia is a severe disorder that usually has an early onset and a poor prognosis.

40. General symptoms of schizophrenia: Irrational thought. Delusions �are false beliefs that are maintained even though they clearly are out of touch with reality�. A common delusion is the belief that one�s mind is being controlled by an external source. Delusions of grandeur are irrational beliefs that one is �extremely important or famous�. Schizophrenic Disorders (cont.)

41. General symptoms of schizophrenia: (cont.) Deterioration of adaptive behavior. (e.g., inability to function at work or home.) Distorted perceptions. Auditory hallucinations � �sensory perceptions that occur in the absence of a real external stimulus or that represent gross distortions of perceptual input� are common symptoms. Disturbed emotions (either �flat� affect or inappropriate emotions for a situation). Schizophrenic Disorders (cont.)

42. Subtypes of schizophrenia: Paranoid type. Paranoid schizophrenia �is dominated by delusions of persecution along with delusions of grandeur�. People with this type often believe others are watching and plotting against them. Catatonic type. Catatonic schizophrenia �is marked by striking motor disturbances, ranging from muscular rigidity to random motor activity�. Schizophrenic Disorders (cont.)

43. Subtypes of schizophrenia: (cont.) Disorganized type. In disorganized schizophrenia, �a particularly severe deterioration of adaptive behavior is seen�. Major symptoms include: Emotional indifference. Incoherence. Severe social withdrawal. Aimless giggling and babbling. Delusions centered on bodily functions. Schizophrenic Disorders (cont.)

44. Subtypes of schizophrenia: (cont.) Undifferentiated type. Undifferentiated schizophrenia �is marked by idiosyncratic mixtures of schizophrenic symptoms�. Essentially, symptoms do not fit neatly into one of the subtypes. Schizophrenic Disorders (cont.)

45. Subtypes of schizophrenia (cont.) Positive versus Negative Symptoms An alternative to dividing schizophrenia into four subtypes has been proposed by Andreasen (1990) and others. There are only two subtypes with this approach: Schizophrenias with negative symptoms (behavioral deficits, such as flat affect). Schizophrenias with positive symptoms (hallucinations, delusions & bizarre behavior). Schizophrenic Disorders (cont.)

46. Course and outcome. Schizophrenia usually emerges during adolescence or early adulthood. Its course is variable, with three likely outcomes: Patients with milder versions who experience a full recovery. Patients who experience a partial recovery and who are in and out of treatment facilities. Patients whose symptoms are persistent and severe, and who require permanent hospitalization. Schizophrenic Disorders (cont.)

47. Course and outcome. (cont.) Patients with a favorable prognosis: Have a sudden onset of the disorder. Experience onset at a later age. Were well adjusted before the onset. Have a low proportion of negative symptoms. Do not have a loss of cognitive function. Show good adherence to treatment. Have a relatively healthy, supportive family environment to return to. Schizophrenic Disorders (cont.)

48. Etiology of schizophrenia. Genetic vulnerability. Concordance in identical twins is 48%, versus 17% in fraternal twins, suggesting a genetic basis for the disease (see Figure 15.16). Neurochemical factors. Schizophrenia is also linked with excess activity in the transmitter, Dopamine. Schizophrenic Disorders (cont.)

49. Figure 15.16. Genetic vulnerability to schizophrenic disorders. Relatives of schizophrenic patients have an elevated risk for schizophrenia. This risk is greater among closer relatives. Although environment also plays a role in the etiology of schizophrenia, the concordance rates shown here suggest that there must be a genetic vulnerability to the disorder. These concordance estimates are based on pooled data from 40 studies conducted between 1920 and 1987. Adapted from Gottesman, I.I. (1991). Schizophrenia genesis: The origins of madness. New York: W.H. Freeman. Copyright � 1991 by @.H. Freeman, Reprinted by permission. Figure 15.16. Genetic vulnerability to schizophrenic disorders. Relatives of schizophrenic patients have an elevated risk for schizophrenia. This risk is greater among closer relatives. Although environment also plays a role in the etiology of schizophrenia, the concordance rates shown here suggest that there must be a genetic vulnerability to the disorder. These concordance estimates are based on pooled data from 40 studies conducted between 1920 and 1987. Adapted from Gottesman, I.I. (1991). Schizophrenia genesis: The origins of madness. New York: W.H. Freeman. Copyright � 1991 by @.H. Freeman, Reprinted by permission.

50. Etiology of schizophrenia. (cont.) Structural abnormalities in the brain. CT and MRI (brain imaging) scans have shown that patients with schizophrenia have enlarged brain ventricles (fluid-filled holes in the brain). It is unclear, however, whether this abnormality is the cause, or the result, of the disorder. Schizophrenic Disorders (cont.)

51. Etiology of schizophrenia. (cont.) The neurodevelopmental hypothesis �posits that schizophrenia is caused in part by various disruptions in the normal maturational processes of the brain before or at birth� (Brown, 1999). Potential disruptions could include: Prenatal exposure to a flu virus. Severe famine. Birth trauma. Schizophrenic Disorders (cont.)

52. Etiology of schizophrenia. (cont.) Expressed emotion (EE) is �the degree to which a relative of a schizophrenic patient displays highly critical or emotionally overinvolved attitudes toward the patient�. A family�s EE is a good predictor of the course of a schizophrenic�s illness. Patients who return to family�s high in EE are three to four times more likely to relapse because they add stress. Precipitating stress itself may trigger the onset of schizophrenia in someone who is already vulnerable to the disease. Schizophrenic Disorders (cont.)

53. Insanity �is a legal status indicating that a person cannot be held responsible for his or her actions because of mental illness�. However, most people with mental illnesses do NOT meet the legal definition of �insanity� because it requires that the person cannot distinguish right from wrong. Additionally, it is a myth that the �insanity defense� is used successfully as a criminal defense. Schizophrenic Disorders (cont.)

54. Involuntary commitment involves hospitalizing people against their will. Although laws vary from state to state, generally a person may be committed when: They are dangerous to themselves (usually suicidal). They are dangerous to others (potentially violent). They are in dire need of treatment. The first two scenarios are the most common grounds for involuntary commitment. Schizophrenic Disorders (cont.)

55. Eating disorders �are severe disturbances in eating behavior characterized by preoccupation with weight and unhealthy efforts to control weight�. Anorexia nervosa �involves intense fear of gaining weight, disturbed body image, refusal to maintain normal weight, and dangerous measure to lose weight�. This is usually achieved by severely limiting caloric intake or by using laxatives and excessive exercise to eliminate food and/or burn calories. Application: Understanding Eating Disorders

56. Anorexia nervosa (cont.) Medical complications from anorexia are serious can can include: Amenorrhea (ceasing of menstrual cycles). Gastrointestinal problems. Dental problems. Osteoporosis (loss of bone density). Low blood pressure. Metabolic disturbances that can trigger cardiac arrest. Application: Understanding Eating Disorders (cont.)

57. Bulimia nervosa �involves habitually engaging in out-of-control overeating followed by unhealthy compensatory efforts, such as self-induced vomiting, fasting, abuse of laxatives and diuretics, and excessive exercise�. Unlike with anorexia, patients with bulimia usually maintain a normal weight. However, they do risk medical problems such as cardiac arrythmias, dental problems, metabolic, and gastrointestinal problems. Application: Understanding Eating Disorders (cont.)

58. History and Prevalence Anorexia has existed throughout history, but became more common in the middle of the 20th century. Bulimia, in contrast, appears to be a new disorder. Young women are much more likely to develop eating disorders and the gender gap is likely due to the unrealistic cultural standards for weight in Western societies. Still, these are rare conditions, with about 1% developing anorexia and 2% - 3% developing bulimia. Application: Understanding Eating Disorders (cont.)

59. Etiology of eating disorders (see Figure 15.20 for an overview). Genetic vulnerability. Twin studies show higher concordance rates for identical twins than fraternal twins, suggesting a genetic predisposition for the disease. However, many other factors influence the development of eating disorders. Application: Understanding Eating Disorders (cont.)

60. Figure 15.20. The etiology of eating disorders. The causes of eating disorders are complex and multifaceted. Psychological, biological, and social factors often lead people into �normal� dieting, which sometimes spins out of control. Maladaptive weight control efforts temporarily relieve individuals� pathological fear of gaining weight, but this reduced anxiety has a tremendous cost, as anorexia nervosa and bulimia nervosa are very dangerous illnesses. Graphic adapted from Barlow, D.H., & Durand, V.M. (1999). Abnormal psychology: An integrative approach. Belmont, CA: Wadsworth. Copyright � 1999 Wadsworth Publishing. Reprinted by permission. Figure 15.20. The etiology of eating disorders. The causes of eating disorders are complex and multifaceted. Psychological, biological, and social factors often lead people into �normal� dieting, which sometimes spins out of control. Maladaptive weight control efforts temporarily relieve individuals� pathological fear of gaining weight, but this reduced anxiety has a tremendous cost, as anorexia nervosa and bulimia nervosa are very dangerous illnesses. Graphic adapted from Barlow, D.H., & Durand, V.M. (1999). Abnormal psychology: An integrative approach. Belmont, CA: Wadsworth. Copyright � 1999 Wadsworth Publishing. Reprinted by permission.

61. Etiology of eating disorders. (cont.) Personality factors. Victims of anorexia tend to be rigid, neurotic, emotionally restrained and obsessive. Perfectionism is a risk factor for anorexia. In contrast, bulimia is associated with impulsiveness, being overly sensitive and low self-esteem. Application: Understanding Eating Disorders (cont.)

62. Etiology of eating disorders. (cont.) Cultural factors. Cultural factors are especially influential. In Western society, young women are socialized to believe they must be very thin in order to be attractive and the �desirable� weight, as seen in models and Miss America contestants, has decreased over recent decades (see Figure 15.21). Application: Understanding Eating Disorders (cont.)

63. Figure 15.21. Weight trends among Playboy centerfolds and Miss America contestants. This graph charts how the average weight of Playboy centerfolds and Miss America contestants changed over the course of 30 years (from 1959 to 1989). To control for age and height, each woman�s weight was compared to the average weight for a woman of that age and height and expressed as a percentage of the expected weight. Given the small samples, the figures are a little erratic, but overall, the data show a clear downward trend. (Data from Garner, et al., 1980; Wiseman, et al., 1992) Graphic adapted from Barlow, D.H., & Durand, V.M. (1999). Abnormal psychology: An integrative approach. Belmont, CA: Wadsworth. Copyright � 1999 Wadsworth Publishing. Reprinted by permission. Figure 15.21. Weight trends among Playboy centerfolds and Miss America contestants. This graph charts how the average weight of Playboy centerfolds and Miss America contestants changed over the course of 30 years (from 1959 to 1989). To control for age and height, each woman�s weight was compared to the average weight for a woman of that age and height and expressed as a percentage of the expected weight. Given the small samples, the figures are a little erratic, but overall, the data show a clear downward trend. (Data from Garner, et al., 1980; Wiseman, et al., 1992) Graphic adapted from Barlow, D.H., & Durand, V.M. (1999). Abnormal psychology: An integrative approach. Belmont, CA: Wadsworth. Copyright � 1999 Wadsworth Publishing. Reprinted by permission.

64. Etiology of eating disorders. (cont.) The role of the family. Anorexia is often an attempt to exert control. In families in which parents are overly involved in their children�s lives, adolescents may use anorexia as a way to control the one aspect of their life they feel they can exert control over � their body. In addition, some mothers even contribute to eating disorders by endorsing society�s obsession with being thin. Application: Understanding Eating Disorders (cont.)

65. Etiology of eating disorders. (cont.) Cognitive factors. Individuals with eating disorders often display all-or-none, irrational thinking and hold beliefs such as: �I must be thin to be accepted.� �If I am not in complete control, I will lose all control.� �If I gain one pound, I will become obese.� Application: Understanding Eating Disorders (cont.)

66. Etiology of eating disorders. (cont.) Course and outcome. Approximately half (40% to 50%) of patients with eating disorders experience a full recovery. Unfortunately, for 20% to 25%, treatment fails completely. However, recovery is more likely for bulimia, with about 70% of patients recovering. Application: Understanding Eating Disorders (cont.)