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Chapter 14

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Psychology 2035A/B
Doug Hazlewood

210 CHAPTER 14 CHAPTER 14 PSYCHOLOGICAL DISORDERS LEARNING OBJECTIVES Abnormal Behavior: Concepts and Controversies (APA Goals 1, 5) • Describe and evaluate the medical model of abnormal behavior. • Identify the most commonly used criteria of abnormality. • Describe the five axes of DSM-IV and controversies surrounding the DSM system. • Summarize data on the prevalence of various psychological disorders. Anxiety Disorders (APA Goals 1, 4) • List and describe four types of anxiety disorders. • Discuss the contribution of biological factors and conditioning to the etiology of anxiety disorders. • Explain the contribution of cognitive factors and stress to the etiology of anxiety disorders. Somatoform Disorders (APA Goals 1, 4) • Distinguish among the three types of somatoform disorders. • Summarize what is known about the causes of somatoform disorders. Dissociative Disorders (APA Goals 1, 4) • Distinguish among the three types of dissociative disorders. • Summarize what is known about the causes of dissociative disorders. Mood Disorders (APA Goals 1, 4) • Describe the two major mood disorders and discuss their prevalence. • Evaluate the degree to which mood disorders elevate the probability of suicide. • Clarify how genetic and neurochemical factors may be related to the development of mood disorders. • Discuss how cognitive processes may contribute to mood disorders. • Outline the role of interpersonal factors and stress in the development of mood disorders. Schizophrenic Disorders (APA Goals 1, 4) • Describe the prevalence and general symptoms of schizophrenia. • Identify the subtypes of schizophrenia and distinguish between positive and negative symptoms. • Outline the course and outcome of schizophrenia. • Summarize how genetic vulnerability and neurochemical factors may contribute to the etiology of schizophrenia. • Discuss evidence relating schizophrenia to structural abnormalities in the brain and neurodevelopmental insults to the brain. • Analyze how expressed emotion and stress may contribute to schizophrenia. APPLICATION: Understanding Eating Disorders (APA Goals 1, 4) • Describe the symptoms of anorexia nervosa, bulimia nervosa, and binge-eating disorder. 211 CHAPTER 14 • Discuss the history, prevalence, and gender distribution of eating disorders. • Explain how genetic factors, personality, and culture may contribute to eating disorders. • Clarify how family dynamics and disturbed thinking may contribute to eating disorders. CHAPTER OUTLINE I. Abnormal Behavior: Concepts and Controversies A. The medical model applied to abnormal behavior 1. Medical model proposes that it is useful to think of abnormal behavior as a disease 2. Basis for many of the terms used to refer to abnormal behavior (e.g., mental illness, psychological disorder, psychopathology) 3. Rise of medical model (in 18th, 19th centuries) brought improvements in treatment 4. Problems with model a. Thomas Szasz suggests that abnormal behavior usually involves a deviation from social norms rather than an illness b. Results in derogatory labels being applied to people with disorders 5. Putting the model in perspective a. Model is useful as an analogy b. Diagnosis involves distinguishing one illness from another c. Etiology refers to the apparent causation and developmental history of an illness d. Prognosis is a forecast about the probable course of an illness B. Criteria of abnormal behavior 1. Three criteria most frequently used a. Deviance (e.g., transvestic fetishism: a sexual disorder in which a man achieves sexual arousal by dressing in women's clothing) b. Maladaptive behavior c. Personal distress 2. Judgments about mental illness reflect prevailing cultural values, social trends, and political forces 3. Normality and abnormality exist on a continuum C. Psychodiagnosis: The classification of disorders 1. First version of Diagnostic and Statistical Manual of Mental Disorders (DSM) published in 1952 by American Psychiatric Association 2. Current version, DSM-IV introduced in 1994, revised 2000 3. The multiaxial system a. Axis I: clinical syndromes b. Axis II: personality disorders c. Axis III: general medical conditions d. Axis IV: psychological and environmental problems e. Axis V: global assessment of functioning 4. Work currently underway for next edition, DSM-V a. Scheduled for 2011 publication b. Decisions whether various syndromes should be added, eliminated, or renamed 5. Controversies surrounding the DSM 212 a. There is enormous overlap among various disorders in symptoms, and people often qualify for more than one diagnosis; the current categorical approach should be replaced by a dimensional approach c. It medicalizes everyday problems D. The prevalence of psychological disorders 1. Epidemiology is the study of the distribution of mental or physical disorders in a population 2. Prevalence refers to the percentage of a population that exhibits a disorder during a specified time period 3. Estimates suggest that psychological disorders are more common than most people realize (33-51% lifetime prevalence) II. Anxiety Disorders A. Anxiety disorders are a class of disorders marked by feelings of excessive apprehension and anxiety B. Generalized anxiety disorder is marked by a chronic, high level of anxiety that is not tied to any specific threat 1. Worry excessively about minor matters 2. Worry about how much they worry 3. Frequently accompanied by physical symptoms (e.g., trembling, muscle tension, etc.) 4. Tends to have a gradual onset C. Phobic disorders are marked by a persistent and irrational fear of an object or situation that presents no realistic danger 1. Fears seriously interfere with everyday behavior 2. Tends to be accompanied by physical symptoms of anxiety 3. Common phobias include acrophobia (fear of heights), claustrophobia (fear of small, enclosed places), brontophobia (fear of storms), hydrophobia (fear of water), and various animal and insect phobias D. Panic disorder and agoraphobia 1. Panic disorder is characterized by recurrent attacks of overwhelming anxiety that usually occur suddenly and unexpectedly 2. Agoraphobia is a fear of going out to public places E. Obsessive-compulsive disorder (OCD) is marked by persistent, uncontrollable intrusions of unwanted thoughts (obsessions) and urges to engage in senseless rituals (compulsions) 1. Obsessions can center on fear of contamination, inflicting harm on others, suicide, or sexual acts 2. Compulsions usually involve stereotyped rituals that temporarily relieve anxiety 3. Specific types of obsessions tend to be associated with specific types of compulsions 4. Can be a particularly severe disorder, associated with social and occupational impairments F. Etiology of anxiety disorders 1. Biological factors a. May be weak-to-moderate genetic predisposition 213 CHAPTER 14 b. Associated with inhibited temperament in infants c. Anxiety sensitivity may make people vulnerable to anxiety disorders d. Has been linked to neurochemical activity in brain 1) Neurotransmitters are chemicals that carry signals from one neuron to another 2) Disturbances in neural circuits using GABA may play role 2. Conditioning and learning a. Many anxiety responses may be acquired through classical conditioning, maintained through operant conditioning b. Martin Seligman's concept of preparedness helps explain the tendency to develop phobias of certain objects c. Ohman and Mineka propose that the evolved module for fear learning is automatically activated by stimuli related to survival threats in evolutionary history and is resistant to intentional efforts to suppress the resulting fears 3. Cognitive factors a. Certain styles of thinking may make some people vulnerable to anxiety disorders b. Theorists suggest these people tend to 1) Misinterpret harmless situations as threatening 2) Focus excessive attention on perceived threats 3) Selectively recall information that seems threatening 4. Stress: anxiety disorders may be stress related III. Somatoform Disorders A. Somatoform disorders are physical ailments that cannot be fully explained by organic conditions and are largely due to psychological factors 1. Symptoms are more imaginary than real, although people are not simply faking 2. Deliberate feigning of illness, malingering, is another matter altogether 3. Making accurate diagnoses of somatoform disorders can be difficult a) In some cases, a problem is misdiagnosed as a somatoform disorder when a genuine organic cause for a person’s physical symptoms goes undetected b) Diagnostic ambiguities have led some theorists to argue that the category of somatoform disorders should be eliminated in upcoming DSM-V B. Somatization disorder is marked by a history of diverse physical complaints that appear to be psychological in origin 1. Occur mostly in women, often coexisting with depression or anxiety disorders 2. Endless succession of minor physical ailments that correlate with stress in life 3. Diversity of victims' complaints is distinguishing feature (cardiovascular, gastrointestinal, pulmonary, neurological, genitourinary) 4. Resistant to the suggestion that their symptoms might be the result of psychological distress C. Conversion disorder is characterized by a significant loss of physical function, with no apparent organic basis, usually in a single organ system 1. Common symptoms include loss of vision, hearing; paralysis, loss of feeling 2. People with conversion disorders usually troubled by more severe ailments than people with somatization disorders 3. Symptoms may be inconsistent with medical knowledge about the apparent disease 214 D. Hypochondriasis (hypochondria) is characterized by excessive preoccupation with health concerns and incessant worry about developing physical illnesses 1. People tend to overinterpret every conceivable sign of illness 2. Frequently coexists with other psychological disorders, especially anxiety disorders, depression E. Etiology of somatoform disorders 1. Inherited aspects of physiological functioning may predispose some people to somatoform disorders 2. Personality factors a. Often associated with histrionic personality characteristics b. Neuroticism may also play a role c. Pathological care-seeking behavior may be caused by insecure attachment style 3. Cognitive factors a. Focusing excessive attention on physiological processes and amplifying normal bodily sensations into symptoms of distress b. Drawing catastrophic conclusions about minor bodily complaints c. Unrealistic standard of good health 4. The sick role a. Some people grow fond of role associated with being sick b. Benefits of role include being able to avoid life's challenges, convenient excuse for failure, attention from others IV. 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 A. Dissociative amnesia and fugue 1. Dissociative amnesia is a sudden loss of memory for important personal information that is too extensive to be due to normal forgetting a. Memory loss may occur for single traumatic event or for extended period of time surrounding the event b. Cases have been observed as a result of disasters, accidents, combat stress, physical abuse, etc. 2. In dissociative fugue, people experience extensive amnesia and confusion about their identity and typically wander away from their home area B. Dissociative identity disorder involves the coexistence in one person of two or more largely complete, and usually very different, personalities 1. Former name was multiple personality disorder, still used informally 2. A rare disorder but frequently portrayed in media and mislabeled as schizophrenia 3. Various personalities often unaware of each other, often with great discrepancies 4. Appears that a handful of clinicians were overdiagnosing the disorder C. Etiology of dissociative disorders 1. Dissociative amnesia, fugue usually attributed to excessive stress a. Relatively little is known about why such an extreme reaction occurs in tiny minority of people b. Speculation that certain personality traits may make some people more susceptible (e.g., fantasy proneness) 2. Causes of dissociative identity disorder are obscure 215 CHAPTER 14 a. Some believe that individuals engage in intentional role-playing to use mental illness as a face-saving excuse b. A small minority of therapists help create multiple personalities by subtle encouragement c. Other explanations argue that DID is rooted in severe childhood trauma V. Mood Disorders are a class of disorders marked by emotional disturbances that may spill over to disrupt physical, perceptual, social, and thought processes A. Major depressive disorder is marked by persistent feelings of sadness and despair and a loss of interest in previous sources of pleasure 1. Negative emotions form the heart of the depressive syndrome (hopelessness, dejection, guilt, anxiety, irritability, brooding) 2. Other symptoms may include a. Giving up enjoyable activities b. Lack of energy, moving sluggishly, talking slowly c. Lowered self-esteem, feelings of worthlessness 3. The severity of abnormal depression varies considerably 4. Depression is common (16%) and appears to be increasing 5. Depression is about twice as high in woman as in men B. Bipolar disorder (formerly known as manic-depressive disorders) is marked by the experience of both depressed and manic periods 1. Manic episodes include various symptoms a. Emotional: elation, euphoria, sociable, impatience b. Cognitive: racing thoughts, flight of ideas, desire for action, impulsive behavior, talkative, self-confident, delusions of grandeur, impaired judgment c. Motor: hyperactive, tireless, require less sleep, increased sex drive, fluctuating appetite 2. Milder forms of manic episodes can seem attractive but often escalate into higher levels that are scary and disturbing 3. Affects about 1-2.5% of the population C. Mood disorders and suicide 1. About 90% of the people who complete suicide suffer from some type of psychological disorder 2. Both bipolar disorder and depression are associated with dramatic elevations in suicide rates D. Etiology of mood disorders 1. Genetic vulnerability a. Evidence indicates genetic factors influence likelihood of developing disorder b. A concordance rate is the percentage of twin pairs or other pairs of relatives that exhibit the same disorder 1) Twin studies, which compare identical and fraternal twins, suggest that genetic factors are involved 2) Concordance rates average 65-72% for identical twins, 14-19% for fraternal twins 216 c. Evidence suggests that heredity can create a predisposition to mood disorders, with environmental factors determining whether the predisposition is converted into a disorder 2. Neurochemical and neuroanatomical factors a. Correlations found between mood disorders and levels of two neurotransmitters in brain (norepinephrine, serotonin) b. Drug therapies are fairly effective in treatment c. Correlations exist between mood disorders and a variety of structural abnormalities in the brain, such as depression and reduced hippocampal volume d. Depression appears to occur when major life stress causes neurochemical reactions that suppress neurogenesis, resulting in reduced hippocampal volume 3. Cognitive factors a. Learned helplessness and a pessimistic explanatory style are tied to vulnerability to depression b. Depressed people who ruminate about their depression tend to stay depressed longer c. Difficulty with cognitive theories is their inability to separate cause from effect: does negative thinking cause depression, or vice versa? 4. Interpersonal roots a. Researchers have indeed found correlations between poor social skills and depression b. Depressed people tend to be depressing, resulting in more rejection and less social support 5. Precipitating stress a. Evidence indicates moderately strong link between stress and onset of mood disorders b. Stress may also affect how people with mood disorders respond to treatment c. Stress may trigger mood disorders in people who are vulnerable VI. Schizophrenic Disorders are a class of disorders marked by disturbances in thought that spill over to affect perceptual, social, and emotional processes A. General symptoms 1. Irrational thought a. Delusions are false beliefs that are maintained even though they clearly are out of touch with reality b. Thinking becomes chaotic 2. Deterioration of adaptive behavior 3. Distorted perception a. Hallucinations are sensory perceptions that occur in the absence of a real, external stimulus or that represent gross distortions of perceptual input b. Auditory hallucinations are most common 4. Disturbed emotion a. Some victims show flattening of emotions b. Others show inappropriate emotional responses c. Some become emotionally volatile B. Subtypes 217 CHAPTER 14 1. Paranoid schizophrenia is dominated by delusions of persecution, along with delusions of grandeur 2. Catatonic schizophrenia is marked by striking motor disturbances, ranging from muscular rigidity to random motor activity 3. Disorganized schizophrenia is marked by a particularly severe deterioration of adaptive behavior 4. Undifferentiated schizophrenia is marked by idiosyncratic mixtures of schizophrenic symptoms C. Positive versus negative symptoms 1. Alternative to subtyping in above fashion a. Negative symptoms involve behavior deficits (e.g., flattened emotions, social withdrawal) b. Positive symptoms involve behavioral excesses or peculiarities (e.g., hallucinations, delusions) 2. Most patients exhibit both types of symptoms and vary only in the degree to which positive or negative symptoms dominate D. Course and outcome 1. Disorders usually emerge during adolescence, early adulthood 2. About 75% of cases manifest by age 30 3. Emergence may be sudden, but is more often gradual 4. A patient has a relatively favorable prognosis depending on several factors a) Onset is sudden rather than gradual b) Onset at later age c) Social and work adjustment were relatively good prior to onset d) Proportion of negative symptoms is relatively low e) Cognitive functioning is relatively preserved f) Good adherence to treatment interventions g) Healthy and supportive family situation to return to E. Etiology of schizophrenia 1. Genetic vulnerability a. Much evidence for role of hereditary factors b. People seem to inherit genetically transmitted vulnerability 2. Neurochemical factors a. Associated with changes in neurotransmitter activity in brain b. Current research exploring roles of dopamine, serotonin, and glutamate c. Marijuana use during adolescence may help to precipitate schizophrenia in young people who have a genetic vulnerability 3. Structural abnormalities in brain a. Cognitive deficits suggest that disorders may be caused by neurological defects b. Association with enlarged brain ventricles c. Conclusions are controversial because the structural deterioration in the brain could be a contributing cause or a consequence of schizophrenia. 4. The neurodevelopmental hypothesis a. This hypothesis proposes that schizophrenia is produced by a series of disruptions in the normal development of the brain b. The suspected causes of these disruptions are exposure to viruses during prenatal development, malnutrition, and obstetrical complications 218 5. Expressed emotion a. Expressed emotion is degree to which relatives are highly critical, emotionally overinvolved b. Relapse rates are much greater for patients returning to families high in expressed emotion 6. Precipitating stress may trigger a schizophrenic disorder in someone who is vulnerable VII. Eating Disorders are severe disturbances in eating behavior characterized by preoccupation with weight and unhealthy efforts to control weight A. Anorexia nervosa involves intense fear of gaining weight, disturbed body image, refusal to maintain normal weight, and dangerous measures to lose weight 1. Two subtypes a. Restricting type characterized by tendency to drastically reduce intake of food, sometimes to point of starvation b. Binge-eating/purging type involves attempts to lose weight by deliberately vomiting after meals, misusing laxatives and diuretics, and engaging in excessive exercise 2. Both types entail a disturbed body image, which results in relentless decline in body weight 3. Leads to variety of medical problems, including amenorrhea (loss of menstrual cycles in women), gastrointestinal problems, low blood pressure, etc. 4. Leads to death in 5-10% of patients B. 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 1. Eating binges usually carried out in secret, followed by intense guilt a. Feelings motivate ill-advised strategies to undo the effects of overeating b. People suffering from bulimia nervosa typically maintain reasonably normal body weight 2. Medical problems include cardiac arrhythmias, dental problems, metabolic Deficiencies, and gastrointestinal problems 3. Often coexists with other psychological disturbances, including depression, anxiety disorders, and substance abuse 4. Shares many features with anorexia nervosa (e.g., morbid fear of becoming obese) 5. Different than anorexia nervosa in crucial ways a. Bulimia is less life-threatening b. Bulimics are more likely to recognize that eating behavior is pathological, cooperate with treatment C. Binge-eating disorder involves distress-inducing eating binges that are not accompanied by the purging, fasting, and excessive exercise seen in bulimia 1. Resembles bulimia, but is a less severe disorder 2. Individuals tend to be disgusted by their bodies and distraught about their overeating 3. Excessive eating is often triggered by stress D. History and prevalence 219 CHAPTER 14 1. Although disorder is not new, it did not become a common affliction until middle part of 20th century 2. Anorexia, bulimia are products of modern, affluent Western culture 3. Technology and communications have exported Western culture, with eating disorders appearing in many non-Western societies, especially affluent Asian 4. About 90-95% of sufferers are female a. Appears to be result of cultural pressures b. Prevalence of disorders also elevated in groups that place undue emphasis on thinness (e.g., fashion models, dancers, actresses, athletes) E. Etiology of eating disorders 1. Genetic vulnerability a. Evidence not as strong as it is for other types of psychopathology b. But genetic predisposition may exist 2. Personality factors a. Most victims of anorexia tend to be obsessive, rigid, neurotic, emotionally restrained b. Victims of bulimia tend to be impulsive, overly sensitive, low in self-esteem c. Most of these personality traits are influenced by genetics 3. Cultural values a. Contribution can hardly be overestimated b. Western society’s emphasis on thinness, attractiveness in women plays a role 4. The role of the family a. Some theorists suggest overly involved parents may have an influence b. Other theorists argue that parents of adolescents with eating disorders tend to define their children’s needs for them 5. Cognitive factors a. Cognitive theorists emphasize role of disturbed thinking b. Additional research is needed to determine whether disturbed thinking is a cause or merely a symptom of eating disorders DISCUSSION QUESTIONS 1. What do you think of Thomas Szasz’s criticisms of the medical model of psychological disorders? Do you think it makes sense to treat psychological disorders the same way we treat diseases? Why or why not? 2. What do you think of the process of "labeling" people with psychological disorders? Do you think pinning a potentially derogatory label on a person may do more harm than good? Why do you think psychiatrists and psychologists generally support the use of some classification system for psychological disorders? 3. Recent editions of the DSM include everyday problems that are not traditionally thought of as mental illnesses (e.g., developmental coordi
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