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Chapter 14

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Wilfrid Laurier University
Mamdouh Shoukri

Lesson 14 1) Abnormal behavior: myths, realities, and controversies a. The medical model applied to abnormal behaviour i. The medical model proposes that it is useful to think of abnormal behavior as a disease. Refers to abnormal behavior, including 1. Mental illness 2. Psychological disorder 3. Psychopathology (pathology refers to manifestations of disease). ii. The medical model (only analogy) gradually became the dominant way of thinking about abnormal behavior during the 18th and 19th centuries, and its influence remains strong today. iii. Prior to the 18th century, most conceptions of abnormal behavior were based on superstition. iv. Critics of medical model: 1. Thomas Szasz asserts that ―strictly speaking, disease or illness can affect only the body; hence there can be no mental illness. Minds can be ‗sick‘ only in the sense that jokes are ‗sick‘ or economies are ‗sick‘‖ 2. Abnormal behavior usually involves a deviation from social norms rather than an illness. 3. According to Szasz, the medical model‘s disease analogy converts moral and social questions about what is acceptable behavior into medical questions. v. Diagnosis involves distinguishing one illness from another. vi. Etiology refers to the apparent causation and developmental history of an illness. vii. A prognosis is a forecast about the probable course of an illness b. Criteria of abnormal behavior i. Deviance. All cultures have such norms. When people violate these standards and expectations, they may be labeled mentally ill. For example, transvestic fetishism is a sexual disorder in which a man achieves sexual arousal by dressing in women‘s clothing. ii. Maladaptive behavior. Alcohol and drug use is not unusual or deviant. However, when the use of cocaine, for instance, begins to interfere with a person‘s social or occupational functioning, a substance use disorder exists. iii. Personal distress. Depressed people, for instance, may or may not exhibit deviant or maladaptive behavior. Such people are usually labeled as having a disorder when they describe their subjective pain and suffering to friends, relatives, and mental health professionals. iv. Diagnoses of psychological disorders involve value judgments about what represents normal or abnormal behavior. Judgments about mental illness reflect prevailing cultural values, social trends, and political forces, as well as scientific knowledge v. People are judged to have psychological disorder only when their behavior becomes extremely deviant, maladaptive, or distressing. Thus, normality and abnormality exist on a continuum. It‘s a matter of degree, not an either-or proposition c. Stereotypes of psychological disorders (3 stereotypes are largely inaccurate) i. Psychological disorders are incurable. The vast majority of people who are diagnosed as mentally ill eventually improve and lead normal, productive lives. Even the most severe psychological disorders can be treated successfully. ii. People with psychological disorders are often violent and dangerous. This stereotype exists because incidents of violence involving the mentally ill tend to command media attention iii. People with psychological disorders behave in bizarre ways and are very different from normal people. This is true only in a small minority of cases, usually involving relatively severe disorders. d. Psychodiagnosis: The Classification of Disorders i. Guidelines for psychodiagnosis were extremely vague and informal prior to 1952 when the American Psychiatric Association unveiled its Diagnostic and Statistical Manual of Mental Disorders ii. The third edition (DSM-III), published in 1980, represented a major advance, as the diagnostic criteria were made much more explicit, concrete, and detailed to facilitate more consistent diagnoses across clinicians iii. The publication of DSM-III in 1980 introduced a new multiaxial system of classification, which asks for judgments about individuals on five separate dimensions, or ―axes.‖ iv. DSM-IV is the official psychodiagnostic classification sys- tem in the United States. This system asks for information about patients on five axes, or dimensions. v. The diagnoses of disorders are made on Axes I and II. Clinicians record most types of disorders on Axis I: Clinical syndromes. They use Axis II to list long-running personality disorders or mental retardation. A patient‘s physical disorders are listed on Axis III (General Medical Conditions). On Axis IV (Psychosocial and Environmental Problems), the clinician makes notations regarding the types of stress experienced by the individual in the past year. On Axis V (Global Assessment of Functioning), estimates are made of the individual‘s current level of adaptive functioning (in social and occupational behavior, viewed as a whole) and of the individual‘s highest level of functioning in the past year. e. The Prevalence of Psychological Disorders i. Epidemiology—the study of the distribution of mental or physical disorders in a population. ii. Prevalence refers to the percentage of a population that exhibits a disorder during a specified time period. iii. Prior to the advent of DSM-III, studies suggested that about one-fifth of the population exhibited clear signs of mental illness at some point in their lives iv. Studies published in the 1980s and early 1990s, using the explicit criteria for substance use disorders in DSM-III, found psychological disorders in roughly one-third of the population v. All these figures are estimates that depend to some extent on the sampling methods and assessment techniques used vi. Critics of the recent high estimates argue that they include many people whose problems have little clinical significance; vii. Those who defend the recent research argue that it makes sense to count people with mild disorders because such disorders often progress into more severe disorders and this progression might be prevented by early diagnosis and intervention viii. The most common types of psychological disorders are (1) substance (alcohol and drugs) use disorders, (2) anxiety disorders, and (3) mood disorders. ix. The data that yielded the 44% estimate of total lifetime prevalence 2) Anxiety disorders: five principle Anxiety disorders are a class of disorders marked by feelings of excessive apprehension and anxiety. a. Generalized anxiety disorder i. The generalized anxiety disorder is marked by a chronic, high level of anxiety that is not tied to any specific threat. ii. People with this disorder worry constantly about yesterday‘s mistakes and tomorrow‘s problems. iii. Their anxiety is commonly accompanied by physical symptoms, such as trembling, muscle tension, diarrhea, dizziness, faintness, sweating, and heart palpitations. iv. Generalized anxiety disorder tends to have a gradual onset and is seen more frequently in females than males. v. The lifetime prevalence of generalized anxiety disorder appears to be around 5% b. Phobic disorder i. A phobic disorder is marked by a persistent and irrational fear of an object or situation that presents no realistic danger. ii. People are said to have a phobic disorder only when their fears seriously interfere with their everyday behavior. iii. Phobic reactions tend to be accompanied by physical symptoms of anxiety, such as trembling and palpitations iv. People can develop phobic responses to virtually anything. v. Particularly common are acrophobia (fear of heights), claustrophobia (fear of small, enclosed places), brontophobia (fear of storms), hydrophobia (fear of water), and various animal and insect phobias vi. Even imagining a phobic object or situation can trigger great anxiety c. Panic disorder and agoraphobia i. A panic disorder is characterized by recurrent attacks of overwhelming anxiety that usually occur suddenly and unexpectedly. ii. These paralyzing panic attacks are accompanied by physical symptoms of anxiety. iii. Agoraphobia is a fear of going out to public places (its literal meaning is ―fear of the marketplace or open places‖). iv. About two-thirds of people who suffer from panic disorder are female v. The onset of panic disorder typically occurs during late adolescence or early adulthood d. Obsessive-compulsive disorder i. An obsessive-compulsive disorder (OCD) is marked by persistent, uncontrollable intrusions of unwanted thoughts (obsessions) and urges to engage in senseless rituals (compulsions). ii. People troubled by obsessions may feel that they have lost control of their mind. Compulsions usually involve stereotyped rituals that temporarily relieve anxiety. iii. Full-fledged obsessive-compulsive disorders occur in roughly 2.5% of the population iv. The typical age of onset for OCD is late adolescence, with most cases (75%) emerging before the age of 30 e. Posttraumatic stress disorder i. Posttraumatic stress disorder (PTSD) involves enduring psychological disturbance attributed to the experience of a major traumatic event. ii. PTSD is often seen after a rape or assault, a severe automobile accident, a harrowing war experience, a natural disaster, or the witnessing of someone‘s death iii. In some instances, PTSD does not surface until many months or years after a person‘s exposure to severe stress iv. Common symptoms include re-experiencing the traumatic event in the form of nightmares and flashbacks, emotional numbing, alienation, problems in social relations, an increased sense of vulnerability, and elevated arousal, anxiety, anger, and guilt. v. Increased vulnerability is associated with greater personal injuries and losses, greater intensity of exposure to the traumatic event, and more exposure to the grotesque aftermath of the event. One key predictor of vulnerability that emerged in a recent review of the relevant research is the intensity of one‘s reaction at the time of the traumatic event. f. Etiology of anxiety disorders i. Biological factors 1. A concordance rate indicates the percentage of twin pairs or other pairs of relatives who exhibit the same disorder. 2. Anxiety sensitivity may make people vulnerable to anxiety disorders 3. The results of both twin studies and family studies suggest that there is a moderate genetic predisposition to anxiety disorder. 4. If relatives who share more genetic similarity show higher concordance rates than relatives who share less genetic overlap, this finding supports the genetic hypothesis 5. Anxiety sensitivity may fuel an inflationary spiral in which anxiety breeds more anxiety, which eventually spins out of control in the form of an anxiety disorder. 6. Recent evidence suggests that a link may exist between anxiety disorders and neurochemical activity in the brain. 7. Therapeutic drugs (such as Valium) that reduce excessive anxiety appear to alter neurotransmitter activity at GABA synapses. 8. Abnormalities in neural circuits using serotonin have recently been implicated in panic and obsessive-compulsive disorders ii. Conditioning and learning 1. Many anxiety responses may be acquired through classical conditioning and maintained through operant conditioning. 2. An originally neutral stimulus may be paired with a frightening event so that it becomes a conditioned stimulus eliciting anxiety. 3. Once a fear is acquired through classical conditioning, the person may start avoiding the anxiety- producing stimulus. The avoidance response is negatively reinforced because it is followed by a reduction in anxiety. This process involves operant conditioning. Thus, separate conditioning processes may create and then sustain specific anxiety responses 4. The tendency to develop phobias of certain types of objects and situations may be explained by Martin Seligman‘s concept of preparedness. Like many theorists, Seligman believes that classical conditioning creates most phobic responses. However, he suggests that people are biologically prepared by their evolutionary history to acquire some fears much more easily than others. Evidence is inconsistent. 5. Critics: many people with phobias cannot recall or identify a traumatic conditioning experience that led to their phobia. Conversely, many people endure extremely traumatic experiences that should create a phobia but do not. 6. Observational learning occurs when a new response is acquired through watching the behavior of another iii. Cognitive factors 1. According to these theorists, some people are more likely to suffer from problems with anxiety because they tend to a. (a) Misinterpret harmless situations as threatening b. (b) Focus excessive attention on perceived threats c. (c) Selectively recall information that seems threatening 2. Consistent with our theme that human experience is highly subjective iv. Stress 1. Faravelli and Pallanti (1989) found that patients with panic disorder had experienced a dramatic increase in stress in the month prior to the onset of their disorder 2. Brown et al. (1998) found an association between stress and the development of social phobia. Thus, there is reason to believe that high stress often helps to precipitate the onset of anxiety disorders. 3) Somatoform disorders a. Psychosomatic diseases involve genuine physical ailments caused in part by psychological factors, especially reactions to stress. These diseases, which include maladies such as ulcers, asthma, and high blood pressure, are not imagined ailments. They are recorded on the DSM axis for physical problems (Axis III) When physical illness appears largely psychological in origin, we are dealing with somatoform disorders, which are recorded on Axis I. Somatoform disorders are physical ailments that cannot be fully explained by organic conditions and are largely due to psychological factors. Malingering: Deliberate feigning of illness for personal gain. People with somatoform disorders typically seek treatment from physicians practicing neurology, internal medicine, or family medicine, instead of from psychologists or psychiatrists. b. Somatization disorder i. A somatization disorder is marked by a history of diverse physical complaints that appear to be psychological in origin. ii. Somatization disorder occurs mostly in women and often coexists with depression and anxiety disorders iii. The distinguishing feature of this disorder is the diversity of the victims‘ physical complaints. c. Conversion disorder i. Conversion disorder is characterized by a significant loss of physical function (with no apparent organic basis), usually in a single organ system. ii. People with conversion disorder are usually troubled by more severe ailments than people with somatization disorder. iii. Telltale clues reveal the psychological origins of the illness because the patient‘s symptoms are not consistent with medical knowledge about their apparent disease. d. Hypochondriasis i. Hypochondriasis (more widely known as hypochondria) is characterized by excessive preoccupation with health concerns and incessant worry about developing physical illnesses. ii. When hypochondriacs are assured by their physician that they do not have any real illness, they often are skeptical and disbelieving iii. Hypochondriacs don‘t subjectively suffer from physical distress as much as they overinterpret every conceivable sign of illness. Hypochondria frequently appears alongside other psychological disorders, especially anxiety disorders and depression e. Etiology of somatoform disorders i. Personality factors 1. The prime candidates appear to be people with histrionic personality characteristics 2. The histrionic personality tends to be self-centered, suggestible, excitable, highly emotional, and overly dramatic. 3. Such people thrive on the attention that they get when they become ill. The personality trait of neuroticism also seems to elevate individuals‘ susceptibility to somatoform disorders 4. In addition, research suggests that the pathological care-seeking behavior seen in these disorders may be caused by insecure attachment styles that are rooted in early experiences with caregivers ii. Cognitive factors 1. Recent evidence suggests that people with somatoform disorders tend to draw catastrophic conclusions about minor bodily complaints 2. They also seem to apply a faulty standard of good health, equating health with a complete absence of symptoms and discomfort, which is unrealistic 3. Some people focus excessive attention on their internal physiological processes and amplify normal bodily sensations into symptoms of distress, which lead them to pursue unnecessary medical treatment. iii. The sick role 1. Their complaints of physical symptoms may be reinforced by indirect benefits derived from their illness 2. One payoff is that becoming ill is a superb way to avoid having to confront life‘s challenges. 3. Attention from others is another payoff that may reinforce complaints of physical illness. 4) Dissociative disorders a. 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. b. Dissociative amnesia and fugue i. Dissociative amnesia is a sudden loss of memory for important personal information that is too extensive to be due to normal forgetting. Memory losses may occur for a single traumatic event or for an extended period of time surrounding the event. ii. Dissociative fugue, people lose their memory for their entire lives along with their sense of personal identity. iii. Despite this whole-sale forgetting, they remember matters unrelated to their identity, such as how to drive a car and how to do math. c. Dissociative identity disorder i. Dissociative identity disorder (DID) multiple personality disorder involves the co-existence in one person of two or more largely complete, and usually very different, personalities. ii. Dissociative identity disorder rarely occurs in isolation. Most DID patients also have a history of anxiety, mood, or personality disorders d. Etiology of dissociative disorders i. Some theorists speculate that certain personality traits— fantasy proneness and a tendency to become intensely absorbed in personal experiences—may make some people more susceptible to dissociative disorders, but adequate evidence is lacking on this line of thought. ii. Nicholas Spanos (1994, 1996) and others believe that people with multiple personalities are engaging in intentional role-playing to use mental illness as a face-saving excuse for their personal failings. iii. Spanos also argues that a small minority of therapists helps create multiple personalities in their patients by subtly encouraging the emergence of alternate personalities. iv. Some clinicians are convinced that DID is an authentic disorder. They argue that there is no incentive for either patients or therapists to manufacture cases of multiple personalities, which are often greeted with skepticism and outright hostility. They maintain that most cases of dissociative identity disorder are rooted in severe emotional trauma that occurred during childhood v. A substantial majority of people with dissociative identity disorder reports a childhood history of rejection from parents and physical and sexual abuse. However, this abuse typically has not been independently verified 5) Mood disorders a. Mood disorders are a class of disorders marked by emotional disturbances of varied kinds that may spill over to disrupt physical, perceptual, social, and thought processes. b. Major (unipolar) depressive disorder i. Crucial considerations in this judgment include the duration of the depression and its disruptive effects. ii. In major depressive disorder people show persistent feelings of sadness and despair and a loss of interest in previous sources of pleasure iii. Depressed people often give up activities that they used to find enjoyable. iv. Alterations in appetite and sleep patterns are common. People with depression often lack energy. They tend to move sluggishly and talk slowly. Anxiety, irritability, and brooding are commonly observed. Self-esteem tends to sink as the depressed person begins to feel worthless. Depression plunges people into feelings of hopelessness, dejection, and boundless guilt. v. The onset of depression can occur at any point in the life span, but a substantial majority of cases emerge before age 40 vi. The median duration of depressive episodes is 5 months vii. The vast majority (75%–95%) of people who suffer from depression experience more than one episode over the course of their lifetime viii. In one longitudinal study, after recovery from a first episode of depression, the cumulative probability of recurrence was 25% after 1 year, 42% after two years, and 60% after 5 years ix. Dysthymic disorder, which consists of chronic depression that is insufficient in severity to justify diagnosis of a major depressive episode. x. In particular, age cohorts born since World War II appear to have an elevated risk for depression xi. Researchers also find that the prevalence of depression is about twice as high in women as it is in men xii. Susan Nolen-Hoeksema (2001) argues that women experience more depression than men be cause they are far more likely to be victims of sexual abuse and somewhat more likely to endure poverty, harassment, and role constraints. xiii. Nolen-Hoeksema also believes that women have a greater tendency than men to ruminate about setbacks and problems. Manic Episode Characteristics Depressive Episode Elated, euphoric, very sociable, Emotional Gloomy, hopeless, socially withdrawn, irritable impatient at any hindrance Characterized by racing thoughts, flight Characterized by slowness of thought processes, obsessive of ideas, desire for action, and impulsive Cognitive behavior; talkative, self-confident; Worrying, inability to make decisions, negative experiencing delusions of grandeur Self-image, self-blame and delusions of guilt and disease Hyperactive, tireless, requiring less Less active, tired, experiencing difficulty in sleeping, Motor sleep than usual, showing increased sex drive and fluctuating appetite Showing decreased sex drive and decreased appetite c. Bipolar disorder i. Bipolar disorder (formerly known as manic-depressive disorder) is characterized by the experience of one or more manic episodes as well as periods of depression. ii. Cyclothymic disorder when they exhibit chronic but relatively mild symptoms of bipolar disturbance. iii. Unlike depressive disorder, bipolar disorder is seen equally often in males and females iv. The onset of bipolar disorder is age related, with the peak of vulnerability occurring between the ages of 20 and 29 v. About 20% of bipolar patients exhibit a rapid-cycling pattern, which means they go through four or more manic or depressive episodes within a year. d. Etiology of mood disorder i. Genetic vulnerability 1. Twin studies have found a sizable disparity between identical and fraternal twins in concordance rates for mood disorders 2. This evidence suggests that heredity can create a predisposition to mood disorders. Environmental factors probably determine whether this predisposition is converted into an actual disorder. 3. Research suggests that genetic vulnerability may play a larger role in women‘s depression than in men‘s 4. The influence of genetic factors also appears to be stronger for bipolar disorders than for unipolar disorders ii. Neurochemical and neuroanatomical factors 1. Correlations have been found between mood disorders and abnormal levels of two neurotransmitters in the brain: norepinephrine and serotonin 2. Low levels of serotonin appear to be a crucial factor underlying most forms of depression 3. The best documented correlation is the association between depression and reduced hippocampal volume 4. The hippocampus, which is known to play a major role in memory consolidation, tends to be about 8%–10% smaller in depressed subjects than in normal subjects 5. Jacobs (2004) has theorized that depression occurs when major life stress causes neurochemical reactions that suppress neurogenesis, resulting in reduced hippocampal volume. 6. According to this view, the suppression of neurogenesis is the central cause of depression. Consistent with this view, Jacobs maintains that antidepressant drugs that elevate serotonin levels relieve depression because serotonin promotes neurogenesis. iii. Cognitive factors 1. Martin Seligman‘s learned helplessness model of depression. 2. Based largely on animal research, Seligman (1974) proposed that depression is caused by learned helplessness—passive ―giving up‖ behavior produced by exposure to unavoidable aversive events 3. He originally considered learned helplessness to be a product of conditioning but eventually revised his theory, giving it a cognitive slant. The reformulated theory of learned helplessness postulates that the roots of depression lie in how people explain the setbacks and other negative events that they experience 4. According to Seligman (1990), people who exhibit a pessimistic explanatory style are especially vulnerable to depression. These people tend to attribute their setbacks to their personal flaws instead of situational factors, and they tend to draw global, far-reaching conclusions about their personal inadequacies based on these setbacks. 5. In accord with this line of thinking, Susan Nolen Hoeksema (1991, 2000) has found that depressed people who ruminate about their depression remain depressed longer than those who try to distract themselves. People who respond to depression with rumination repetitively focus their attention on their depressing feelings, thinking constantly about how sad, lethargic, and unmotivated they are. According to Nolen Hoeksema (1995), excessive rumination tends to extend and amplify individuals‘ episodes of depression. As we noted earlier, she believes that women are more likely to ruminate than men and that this disparity may be one of the primary reasons why depression is more prevalent in women. 6. In sum, cognitive models of depression maintain that negative thinking is what leads to depression in many people. 7. The principal problem with cognitive theories is their difficulty in separating cause from effect 8. Retrospective designs, which look backward in time from known outcomes. Retrospective designs can yiel
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