Psychological Disorders

							        Psychological
Disorders & Treatment
          Chapters 15 & 16




            MFlett 2008
Psychological Disorders
    Defining and diagnosing disorder
    Mood disorders
    Anxiety disorders
    Schizophrenia
    Drug abuse and addiction
    Personality disorders



                      MFlett 2008
    Mental Disorder
   Any behavior or
    emotional state that
    causes an individual
    great suffering or worry,
    is self-defeating or self-
    destructive, or is
    maladaptive and
    disrupts the person’s
    relationships and/or the
    larger community



                                 MFlett 2008
Dilemmas of Definition
    Possible models for defining disorders:
        Mental disorder as a violation of cultural
         standards
        Mental disorder as maladaptive or harmful
         behavior
        Mental disorder as emotional distress




                            MFlett 2008
Diagnostic and Statistical Manual
   Axis I: Primary clinical problem
   Axis II: Personality disorders
   Axis III: General medical conditions
   Axis IV: Social and environmental stressors
   Axis V: Global assessment of overall
    functioning



                       MFlett 2008
Explosion of Mental Disorders

                             Supporters of new
                              categories answer that is
                              important to distinguish
                              disorders precisely
                             Critics point to an
                              economic reason:
                              diagnoses are needed for
                              insurance reasons so
                              therapists will be
                              compensated



                MFlett 2008
Concerns About Diagnostic System

   The danger of over-diagnosis
   The power of diagnostic labels
   Confusion of serious mental disorders with
    normal problems
   The illusion of objectivity and universality



                         MFlett 2008
Advantages of the DSM
   When used correctly and diagnoses are
    made with valid, objective tests, the DSM
    improves the reliability of and agreement
    among clinicians
   The DSM-IV included for the first time a list
    of culture-bound syndromes, disorders
    specific to a particular culture


                        MFlett 2008
Other Means of Diagnosing
   Projective tests
   Objective tests




                       MFlett 2008
Projective Tests
   Projective Tests
       Psychological tests used to infer
        a person’s motives, conflicts,
        and unconscious dynamics on
        the basis of the person’s
        interpretations of ambiguous
        stimuli
   Rorschach Inkblot Test
       A projective personality test that
        asks respondents to interpret
        abstract, symmetrical inkblots            A sample inkblot


                                    MFlett 2008
Objective Tests
   Inventories
       Standardized objective questionnaires requiring
        written responses; they typically include scales on
        which people are asked to rate themselves
       Minnesota Multiphasic Personality Inventory
        (MMPI)
       California Psychological Inventory (CPI)
       Structured Clinical Interview


                            MFlett 2008
Treatment Approaches to
Mental Disorders

   Medications
   Direct intervention (psychosurgery)
   Therapy
   Combined pharmaceuticals and therapy




                     MFlett 2008
Placebo Effect
   The apparent success of a treatment that is due to
    the patient’s expectation of hopes rather than to the
    drug or treatment itself
   Meta-analyses indicates that clinicians considered
    medication helpful yet patient ratings in treatment
    groups were no greater than patient ratings in
    placebo groups
   Can happen with pills or with “talk” therapy



                           MFlett 2008
High Relapse and Dropout Rate
   There may be short term success but many
    patients (50% to 66%) stop taking medication
    due to side effects
   Individuals who take antidepressants alone
    without learning to cope with problems are
    more likely to relapse



                       MFlett 2008
Evaluating Psychotherapy
   Kinds of therapists
   Kinds of therapy
   Benefits of psychotherapy
   When therapy harms
   Self-help




                       MFlett 2008
Kinds of Therapists
Psychiatrist    MD                  Medications &
                                    some therapy
Psychologist    Ph.D., Psy. D.,     Assessment & all
                Ed. D.              types of therapy
LCSW            Masters Degree      Social work and
                in social work      therapy
MFT             Masters Degree      Family, child &
                in counseling       couples work
School          Masters Degree      Assessment of
psychologists                       learning
                      MFlett 2008
Kinds of Psychotherapy
   Psychodynamic (Freudian)
   Cognitive Behavioral
   Humanist & Existential
   Family & Couples
   Mindfulness-based therapies




                      MFlett 2008
Which Therapy for Which Problem?
   Depression
       Cognitive therapy’s greatest success has come
        in treatment of mood disorders
   Anxiety Disorders
       Exposure techniques are more effective than
        others; mindfulness-based cognitive therapy
   Anger and Impulsive Violence
       Cognitive therapy is extremely successful


                            MFlett 2008
Which Therapy for Which Problem?
    Health Problems (Chronic pain)
        Cognitive and behavior therapies are effective
         for a wide range of health problems;
         mindfullness
    Childhood and Adolescent Behavior
     Problems (ADHD, Bipolar)
        Behavior therapy is the most effective treatment




                            MFlett 2008
Benefits of Psychotherapy
   Consumer education
   Right fit
   Leaving
   Managed Care vs. Private Pay




                      MFlett 2008
Successful Therapy




   Psychotherapy outcome depends on method of
    therapy AND
   Qualities of client and therapist, and their alliance,
    and the therapists’ experience
                          MFlett 2008
Common Ingredients in
   Successful Therapies
   When there is a bond between therapist and
    client (a.k.a. Therapeutic Alliance)
   When participants want to be helped
   When therapists distinguish normal cultural
    patterns from individual psychological
    problems


                        MFlett 2008
Is More Psychotherapy Better?
   With additional therapy
    sessions, the percentage of
    people improved increased
    up to 26 sessions
   Rate of improvement then
    levels off
       Based on a summary of 15
        studies, 2400 clients
        (Howard, et al., 1996)
   Patients’ sense of
    improvement slower but
    more steady


                               MFlett 2008
When Therapy Harms
   Sexual intimacies, or other unethical behavior on
    the part of the therapist
   Prejudice or cultural ignorance on the part of the
    therapist
   Inappropriate or coercive influence, which can
    create new problems for the client
   The use of empirically unsupported, potentially
    dangerous techniques

                          MFlett 2008
The Scientist-Practitioner Gap
   Some psychotherapists believe that evaluating
    therapy using research methods is futile
   Scientists find that therapists who do not keep up
    with empirical findings are less effective and can do
    harm to clients
   Economic pressures require empirical assessment
    of therapies




                           MFlett 2008
Evaluating Self-Help
   Critical thinking
       Qualified practitioners/authors
       Advice based on evidence
       If the impossible is promised, look elsewhere
       If advice is given, how is it organized?




                            MFlett 2008
Specific Disorders &
Treatment Approaches




             MFlett 2008
Mood Disorders




             MFlett 2008
Depression
   Major Depression
       A mood disorder involving disturbances in
        emotion (excessive sadness), behavior (loss of
        interest in one’s usual activities), cognition
        (thoughts of hopelessness), and body function
        (fatigue and loss of appetite)




                           MFlett 2008
    Symptoms of Depression
   Depressed mood
   Reduced interest in almost all activities
   Significant weight gain or loss, without dieting
   Sleep disturbance (insomnia or too much sleep)
   Change in motor activity (too much or too little)
   Fatigue or loss of energy
   Feelings of worthlessness or guilt
   Reduced ability to think or concentrate
   Recurrent thoughts of death
                                         DSM IV requires 5 of these
                                          within the past 2 weeks

                           MFlett 2008
    Gender, Age, & Depression

   Women are about twice
    as likely as men to be
    diagnosed with
    depression
       True around the world
   After age 65, rates of
    depression drops sharply
    in both sexes




                                MFlett 2008
Biological Theories of Depression
    Studies of adopted children support genetic
     explanations of depression
    5-HTT is a gene that is present in either a long or short
     form
        17% of individuals with the long form become severely
         depressed
        43% of Individuals with 2 copies of the short form become
         depressed
    Genetics may also influence levels of serotonin and
     other neurotransmitters


                                 MFlett 2008
Medications for Depression
   Monoamine oxidase inhibitors (MAOIs)
       Elevate norepinephrine and serotonin in brain by blocking
        an enzyme that deactivates these neurotransmitters
   Tricyclic antidepressants
       Boost norepinephrine and serotonin in brain by preventing
        normal reuptake of these substances
   Selective serotonin reuptake inhibitors (SSRIs)
       work same way as tricyclic antidepressants but target
        serotonin
   Herbal methods such as St-John’s wort and Sam-E
    have also been used
                                MFlett 2008
    Psychotherapy for depression
   Examine the evidence for beliefs
   Consider other explanations for the behavior
    of others
   Identify assumptions and biases
       Rational emotive behavior therapy (RET)
           A form of cognitive therapy devised by Albert Ellis,
            designed to challenge the client’s unrealistic or
            irrational thoughts

                                 MFlett 2008
Cognitive Habits

                                Cognitive explanations
                                 emphasize particular habits
                                 of thinking and ways of
                                 interpreting events
                                Depressed people believe
                                 their situation is permanent,
                                 and uncontrollable
                                Rumination involves
                                 brooding about negative
                                 aspects of one’s life




                   MFlett 2008
Vulnerability-Stress Model

    “Vulnerability-Stress” is
     more wholistic approach
     to depression
    Not merely a chemical
     imbalance
    Not only a genetic
     predisposition




                                 MFlett 2008
Life Experiences and Circumstances
    Social explanations emphasize the stressful
     circumstances of people’s lives. Examples
     include:
        Loss of or problems with important
         relationships throughout life
        Psychologists investigating sex differences for
         depression have ruled out hormones and
         genetics and are now investigating life
         circumstances
          Women   are less satisfied with work and
           family and more likely to live in poverty
                            MFlett 2008
Psychosurgery
   Electroconvulsive Therapy
    (ECT)
     A procedure used in cases of
       prolonged and severe major
       depression, in which a brief
       brain seizure is induced
   Psychosurgery
     Any surgical procedure that
       destroys selected areas of the
       brain believed to be involved
       in emotional disorders or
       violent, impulsive behavior



                                   MFlett 2008
Transcranial Magnetic Stimulation
   Involves use of pulsing
    magnetic coil held to a
    person’s skull over the
    left prefrontal cortex
   This area is less active
    in those with depression
   Treatment does not
    result in pain or memory
    problems and controlled
    studies have suggested
    positive results
                          MFlett 2008
Specific Issues: Suicide
   Suicide hotline for Sonoma County
             1-800-746-8181
   Take threat seriously
   Know danger signs
   Get involved – ask the hard question – “Do
    you want to hurt yourself?”
   Don’t leave person alone

                       MFlett 2008
Bipolar Disorder
   A mood disorder in which episodes of depression
    and mania (excessive euphoria) occur
   Used to be thought of as an “adult” disorder; now
    being diagnosed at high rates in children
    between birth and 5 years old
   Two types
       rapid cycling
       mixed



                         MFlett 2008
    Bipolar Disorder:
          Depressive Episodes
   Characterized by                    Sadness
    overwhelming feelings of            Excessive crying
    sadness, worthlessness,             Loss of pleasure
                                        Abnormal sleep
    and hopelessness.
                                        Low energy
    Symptoms may include                Restlessness
                                        Difficulty concentrating
                                        Irritability
                                        Loss of appetite or overeating
                                        Feelings of worthlessness and
                                         hopelessness
                                        Thoughts of death or suicide
                           MFlett 2008
    Bipolar Disorder:
         Manic Episodes
   Periods of elated mood,                       Inappropriate sense of euphoria
                                                   (elation)
    which can include racing
    thoughts, extreme irritability                Racing thoughts; talking too much
    or reckless behavior.                         Extreme irritability
    Symptoms may include                          Reckless behavior
                                                  Abnormal sleep
                                                  Excessive energy
                                                  Out of control spending
                                                  Difficulty concentrating
                                                  Abnormally increased activity,
                                                   including sexual activity
                                                  Poor judgment
                                                  Aggressive behavior

                                     MFlett 2008
The Bipolar Brain
   Bipolar disorder can have
    rapid mood swings (within
    minutes or daily) or periods
    of depression followed by
    mania (months)
   These wild changes are
    shown in brain activity
    (right)



                           MFlett 2008
Pharmaco-therapy:
Lithium Carbonate
   Used to treat bipolar disorder
   Moderates levels of norepinephrine or by
    protecting cells from being overstimulated by the
    neurotransmitter, glutamate
   Must be given in right dose and bloodstream
    levels need to be monitored
   Newer drug treatments for bipolar disorder
    include Seroquel, Tegetrol and Depakote


                         MFlett 2008
Psychotherapy
Behavioral Self-Monitoring
   A method of keeping careful data on the
    frequency and consequences of the behavior
    to be changed
   Used to track levels of mood elevation or
    depression




                      MFlett 2008
Psychotherapy:
Skills Training
   An effort to teach a client skills he or she may
    lack as well as new more constructive
    behaviors to replace self-defeating ones
   Also used for treating psychotic disorders and
    addiction




                        MFlett 2008
Anxiety Disorders
   Generalized Anxiety
    Disorder
   Panic Disorder
   Phobias
   OCD
   PTSD




                          MFlett 2008
Generalized Anxiety Disorder
   A continuous state of anxiety marked by feelings of
    worry and dread, apprehension, difficulties in
    concentration, and signs of motor tension
   May accompany another disorder (depression,
    eating disorder, OCD




                          MFlett 2008
    Panic Disorder
   An anxiety disorder in which
    a person experiences
    recurring panic attacks,
    feelings of impending doom
    or death, accompanied by
    physiological symptoms
    such as rapid breathing and
    dizziness.




                                   MFlett 2008
Fears and Phobias
   Phobia
       An exaggerated, unrealistic fear of a specific
        situation, activity, or object




                             MFlett 2008
Agorophobia
   A set of phobias, often set off by a panic
    attack, involving the basic fear of being away
    from a safe place or person
   Difficult to treat because individual is unable
    to come to office due to fears




                        MFlett 2008
Obsessive-Compulsive Disorder (OCD)
      An anxiety disorder in which a person feels
       trapped in repetitive, persistent thoughts
       (obsessions) and repetitive, ritualized
       behaviors (compulsions) designed to
       reduce anxiety
      Person understands that the ritual
       behavior is senseless but guilt mounts if
       not performed
                         MFlett 2008
Posttraumatic Stress Disorder (PTSD)

      An anxiety disorder in which a person who has
       experienced a traumatic or life-threatening event
       has symptoms such as psychic numbing, reliving
       the the trauma, and increased physiological
       arousal
      Diagnosed only if symptoms persist for 6 months or
       longer
      May immediately follow event or occur later


                            MFlett 2008
Anxiety Treatments
   Combination of behavioral therapies and
    pharmacological intervention provides best
    results
       Behavior therapy
       Graduated exposure/Systematic desensitization
       Flooding
   Early anxiety medications were very addictive
    (Valium), but current generation of meds are
    not
                          MFlett 2008
Behavior Therapy
   A form therapy that applies principles and
    techniques of classical and operant
    conditioning to help people change self
    defeating or problematic behaviors
       Reinforcement
       Extinguishing



                        MFlett 2008
Graduated Exposure
   In behavior therapy, a method in which a
    person suffering from an anxiety disorder,
    such as phobia or panic attacks, is gradually
    taken into the feared situation or exposed to
    the traumatic memory until the anxiety
    subsides



                        MFlett 2008
Systematic Desensitization
   A step by step process of desensitizing a
    client to a feared object or experience
   Particularly useful with phobias
   Based on counterconditioning




                       MFlett 2008
Flooding

   A technique whereby a person suffering from
    an anxiety disorder such as a phobia or panic
    attack, is taken directly into the feared
    situation until the anxiety subsides
   Currently being explored using virtual reality
    technology


                        MFlett 2008
Tranquilizers
    Increase the activity of the neurotransmitter
     gamma-aminobutyric acid (GABA)
    Developed for treatment of mild anxiety and often
     inappropriately prescribed by general physicians
     for patients who complain of any mood disorder
      Valium
      Xanax
    Often paired with anti-depressants to maximize
     effect


                           MFlett 2008
Anxiolitics -- Current

   Newer anxiety medications target specific
    neurotransmitters and have fewer side-
    effects




                       MFlett 2008
Psychotic Disorders
   Schizophrenia
   Psychosis




                    MFlett 2008
Symptoms of Schizophrenia
   Bizarre delusions
   Hallucinations and heightened sensory
    awareness
   Disorganized, incoherent speech
   Grossly disorganized and inappropriate
    behavior


                       MFlett 2008
Delusions and Hallucinations
   Delusions
       False beliefs that often accompany schizophrenia
        and other psychotic disorders
   Hallucinations
       Sensory experiences that occur in the absence of
        actual stimulation
       Auditory
       Visual
       Other
                           MFlett 2008
Positive Symptoms
   Cognitive, emotional, and behavioral
    excesses
       Examples of positive symptoms
           Hallucinations
           Bizarre delusions
           Incoherent speech
           Inappropriate/Disorganized behaviors



                                MFlett 2008
Negative Symptoms

   Cognitive, emotional, and behavioral deficits
   Examples of negative symptoms
       Loss of motivation
       Emotional flatness
       Social withdrawal
       Slowed speech or no speech



                          MFlett 2008
Genetic Vulnerability to Schizophrenia
    The risk of developing schizophrenia (i.e.,
     prevalence) in one’s lifetime increases as the genetic
     relatedness with a diagnosed schizophrenic increases




                            MFlett 2008
What causes schizophrenia?
   Genetic issues
   Biological issues
   Socio-cultural issues




                        MFlett 2008
Structural Brain Abnormalities
    Several abnormalities exist, especially when
     schizophrenia is characterized by primarily
     negative symptoms:
        Decreased brain weight
        Decreased volume in temporal lobe or hippocampus
        Enlargement of ventricles
    About 25% do not have these observable brain
     deficiencies


                             MFlett 2008
Neurotransmitter Abnormalities

   Include serotonin, glutamate, and dopamine
   Many schizophrenics have high levels of brain
    activity in brain areas served by dopamine as well
    as greater numbers of particular dopamine receptors
   Similar neurotransmitter abnormalities are also
    found in depression and alcoholism




                          MFlett 2008
Prenatal or Birth Complications
   Damage to the fetal brain increases chances
    of schizophrenia and other mental disorders
       May occur as a function of maternal malnutrition,
        maternal illness
       May also occur if brain injury or oxygen
        deprivation occurs at birth
       Exposure to virus in utero


                            MFlett 2008
Adolescent Abnormalities in
     Brain Development

   Normal pruning of excessive synapses in the
    brain occurs during adolescence
   In schizophrenics, a greater number of
    synapses are pruned away
       Many explain why first episode occurs in
        adolescence or early adulthood


                             MFlett 2008
Pharmaceutical Interventions
Antipsychotic Medications
    Many block or reduce sensitivity of brain
     receptors that respond to dopamine
    Some increase levels of serotonin, a
     neurotransmitter that inhibits dopamine activity
    Can relieve positive symptoms of schizophrenia
     but are ineffective for or even worsen negative
     symptoms


                          MFlett 2008
Dosage Problems
    Finding the therapeutic window or the amount of
     medication that is enough but not too much
    Drugs may be metabolized differently in:
        men and women, old and young, and in different
         ethnic groups
        Groups may differ in dosages due to variations in
         metabolic rates, amount of body fat, number or type of
         drug receptors in the brain, smoking and eating habits




                               MFlett 2008
Long-term risks
   Antipsychotic meds can be dangerous, even
    fatal, if taken for many years
       Tardive dyskinesia (TD)
       Extra-pyramidal symptoms (EPS)
       May cause excessive weight gain
       May cause diabetes



                          MFlett 2008
Psychotherapeutic Interventions
Social Skills Training
   An effort to teach a client skills he or she may
    lack as well as new more constructive
    behaviors to replace self-defeating ones
   Particularly effective in treatment of
    schizophrenia as onset may have occurred
    before acquiring adult social skills



                        MFlett 2008
Psycho-social interventions
   Supported housing
   Medication management
   Case management




                    MFlett 2008
Personality Disorders




               MFlett 2008
Problem Personalities
   Personality Disorder Defined
       Rigid, maladaptive patterns that cause personal
        distress or an inability to get along with others
   Types
       Cluster A (odd or eccentric)
       Cluster B (dramatic/erratic)
       Cluster C (anxious/fearful)



                              MFlett 2008
Problem Personalities
Borderline personality disorder (Cluster B)
     Intense, unstable relationships; unrealistic self-
      image; self-destructive & impulsive (cutters)
     Females more likely to be diagnosed than
      males




                          MFlett 2008
Antisocial Personality Disorder (APD)
(Cluster C)
      A disorder characterized by antisocial
       behavior such as lying, stealing, manipulating
       others, and sometimes violence; and a lack of
       guilt, shame and empathy
        Sometimes called psychopathy or
         sociopathy
      Occurs in 3% of all males and 1% of all
       females


                           MFlett 2008
Emotions and
Antisocial Personality Disorder

   People with APD were
    slow to develop
    classically conditioned
    responses to anger,
    pain, or shock
   Such responses indicate
    normal anxiety



                         MFlett 2008
DSM-IV Criteria for APD
   Must have three of these criteria and a history of
    behaviors
       Repeatedly break the law
       They are deceitful, using aliases and lies to con others
       They are impulsive and unable to plan ahead
       They repeatedly get into physical fights or assaults
       They show reckless disregard for own safety or that of
        others
       They are irresponsible, failing to meet obligations to
        others
       They lack remorse for actions that harm others
                                 MFlett 2008
Causes of APD
   Abnormalities in the Central Nervous System
       Inability to feel emotional arousal
       Emotional flatness
   Impaired frontal-lobe functioning
       Abnormalities in pre-frontal cortex
       Less brain activity in frontal lobe
       Less gray matter in frontal lobe
       Injury and head trauma
   Genetic influences

                              MFlett 2008
Drug Abuse & Addiction
   Biological models
   Learning, Culture & Addiction
   Causes of Addiction




                       MFlett 2008
The Addicted Brain




              MFlett 2008
Biology of Addiction
   The biological model holds that addiction,
    whether to alcohol or other drugs is due
    primarily to:
       a person’s biochemistry
       metabolism
       genetic predisposition
   Most evidence comes from twin studies

                           MFlett 2008
Learning, Culture, and Addiction
     Addiction patterns vary according to cultural
      practices and the social environment
     Policies of total abstinence tend to increase
      addiction rates rather than reduce them
     Not all addicts have withdrawal symptoms when
      they stop taking a drug
     Addiction does not depend on the properties of
      the drug alone, but also on the reason for taking
      it
                          MFlett 2008
Problems with drugs are more
likely when a person:
   Has a physiological vulnerability to a drug
   Believes she or he has no control over the drug
   Is encouraged to take the drug in binges, and
    moderate use is neither tolerated nor taught
   comes to rely on a drug as a method of coping
    with problems, suppressing anger or fear, or
    relieving pain
   Has a peer group using drugs or drinking heavily


                          MFlett 2008
Treatment Approaches
Peer-Led Groups
   AA, NA, OA are based on belief that individuals can
    help each other without needing specially trained
    intervention
   Rates of effectiveness vary, but are generally low
   Benefits are finding you are not alone and support
    from group of individuals who have experienced use




                          MFlett 2008
Harm Reduction &
  Motivational Interviewing

   If abstinence doesn’t work, approach problem
    through harm reduction; meet client where s/he is at
   Changing behaviors to lessen exposure to risk
     Needle exchange programs
     Outreach

   Motivational Interviewing
       Engaging individual in choosing heathier
        behaviors by creating cognitive dissonance

                           MFlett 2008
Family-Systems Perspective
   Therapy with individuals or families that focuses
    on how each member forms part of a larger
    interacting system




                             MFlett 2008
Family and Couples Therapy

   Problems develop in the context of family, are
    sustained by the dynamics of the family and that
    any changes made will affect all members of the
    family
   Can look for patterns of behavior across
    generations and create a family tree of
    psychologically significant events




                           MFlett 2008
Pharmaceutical Approaches
   Alcohol dependence
       disulfiram, the opioid antagonists naltrexone and
        nalmefene, acamprosate, various serotonergic
        agents (including selective serotonergic reuptake
        inhibitors), and lithium
       Hallucinogenics




                            MFlett 2008
Pharmaceutical Approaches
   Heroin (opiates)
       Methadone
       Norco
   Cocaine, Amphetamine
       None . . .
   Nicotine
       Antihypertensives


                            MFlett 2008
Mental Disorder &
Personal Responsibility
   Mental illness as an excuse for illegal
    behavior
       Diminished capacity
           Drunk driving
           Dan White killing of Moscone/Milk
       Competence
           Age/cognitive capacity



                                MFlett 2008
Mental Disorder &
Personal Responsibility
   Mental illness as a defense for illegal
    behavior
       Not guilty by reason of insanity (NGRI)
           Andrea Yates
       M’Naughton Rule -- as a result of his/her mental
        disease or defect, the individual (i) did not know
        that his/her act would be wrong; or (ii) did not
        understand the nature and quality of his/her
        actions
                             MFlett 2008