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					     To study the abnormal is the best way of
     understanding the normal.
                 William James (1842-1910)


Psychological Disorders
    and Therapies
     Chapter 14 and 15

                                          1
    Rates of Psychological Disorders

                                      1.   There are 450 million
                                           people suffering from
                                           psychological disorders
                                           (WHO, 2004).
                                      2.   Depression and
                                           schizophrenia exist in all
                                           cultures of the world.
                                      3.   Two Major Classifications
                                             Neurotic: Distressing
                                               but one can still
                                               function in society and
                                               act rationally
                                             Psychotic: Person
                                               loses contact with
http://www.learner.org/resources/se            reality, experiences
ries60.html?pop=yes&pid=780                                      2
                                               distorted perceptions
        Common Culture Bound Syndromes
Syndrome    Region/Pop     Description
            Affected
Koro        Southeast      Episode of sudden and intense anxiety that the penis (or in women, the
            Asia and       vulva and nipples) will recede into the body and possibly cause death.
            Africa
Amok        Malaysia       Dissociative episode characterized by a period of withdrawal and
                           brooding followed by an outburst of violent, aggressive or homicidal
                           behavior; often a response to a perceived slight
2-D Love    Japan          Men develop what appear to be amorous relationships with animated
                           female characters; they may carry around pillows or other tangible
                           reminders of these characters wherever they go
Windigo     Native         Morbid state of anxiety with fears of becoming a cannibal
            Americans
Susto       Mexico,        Illness attributed to a frightening event that causes the soul to leave the
            Central        body and results in unhappiness and sickness. Ritual healings are
            America, and   focused on calling the soul back to the body and cleansing the person to
            South          restore bodily and spiritual balance
            America
Taijin      Japan          Intense fear that one’s body, its parts or its functions, displease,
Kyofu Sho                  embarrass, or are offensive to other people in appearance, odor, facial
                           expressions, or movements                                            3
      Defining Psychological Disorders
Mental health workers view psychological disorders as
persistently harmful thoughts, feelings, and actions. Behavior
is judged to be:
1. Atypical – statistically infrequent; uncommon
2. Disturbing – socially disagreeable behaviors (varies with
     time and culture)
3. Maladaptive – cause social or physical harm
     a. To self - Inability to reach goals, to adapt to the
         demands of life
     b. To society – interferes, disrupts social group functioning
4. Personal Distress – behavior causes a person discomfort,
     anxiety, depression.
5. Unjustifiable – no good reason for behavior
                                                             4
DSM IV: Multiaxial Classification
           Is a Clinical Syndrome (cognitive, anxiety,
  Axis I
           mood disorders [16 syndromes]) present?
           Is a Personality Disorder or Mental Retardation
 Axis II
           present?
          Is a General Medical Condition (diabetes,
 Axis III
          hypertension or arthritis etc) also present?
         Are Psychosocial or Environmental Problems
 Axis IV
         (school or housing issues) also present?
        What is the Global Assessment of the person’s
 Axis V functioning?

  The most recent edition, DSM-IV-TR (Text Revision, 2000),
  describes 400 psychological disorders compared to 60 in the
  1950s. DSM-V is supposed to come out in May 2013
            Strengths/Weaknesses of DSM
Strengths                           Weaknesses
1. Describe (400) disorders         1.   Does not explain CAUSES – just
2. Disorders outlined by DSM-IV          describes disorder and lists prevalence
   are reliable. Therefore,         2.   Labels may stigmatize individuals and
   diagnoses by different                increase the risk of creating self-
   professionals are similar.            fulfilling prophecies. Rosenhan Study –
                                         normal people misdiagnosed in mental
3. Determines how prevalent the
                                         hospital
   disorder is
                                         (http://www.psychblog.co.uk/video-
4. Labels may be helpful for             being-sane-in-insane-places-163.html)
   healthcare professionals when    3.   May foster over-diagnosis and confuse
   communicating with one                serious mental disorders with normal
   another and establishing              problems in living
   therapy. Correct labeling of a   4.   Diagnoses can be misused for social and
   disorder may help people              political purposes
   identify the source of their     5.   “Insanity” (legal status indicating that a
                                         person cannot be held responsible for
   unhappiness and lead to a
                                         his or her actions because of mental
   proper treatment                      illness; unable to distinguish right from
                                         wrong) labels raise moral and ethical
                                         questions about how society should  6
                                         treat people who have disorders and
    History of Mental Disorders: Early Theories
• Afflicted people were
  possessed by evil spirits.
   – Music or singing was often
     used to chase away spirits.
   – In some cases trephening
     was used: cutting a hole in
     the head of the afflicted to
     let out the evil spirit.
   – Another theory was to
     make the body extremely
     uncomfortable.
Trephening
History of Mental Disorders: Hospitalization
• In the 1800’s, disturbed people
  were no longer thought of as
  madmen, but as mentally ill.
   – They were first put in hospitals;
      however, they were nothing
      more than barbaric prisons.
   – The patients were chained and
      locked away and some
      hospitals even charged
      admission for the public to see
      the “crazies”, just like a zoo.
• Philippe Panel - French doctor
  who was the first to take the chains
  off and declare that these people are
  sick and “a cure must be found!!!”
  Insisted that madness was not
  due to demonic possession, but
  an ailment of the mind
    Current Perspectives: Medical Model
  When physicians discovered that syphilis led to
mental disorders, they started using medical models
  to review the physical causes of these disorders.
 Psychological disorders are sicknesses and can be
           diagnosed, treated and cured.
1. Etiology: Cause and development of the
   disorder.
2. Diagnosis: Identifying (symptoms) and
   distinguishing one disease from another.
3. Treatment: Treating a disorder in a psychiatric
   hospital.
4. Prognosis: Forecast about the disorder.
                                                10
           Current Perspectives: Biopsychosocial
                        Perspective
Assumes that biological, socio-cultural, and psychological factors combine
              and interact to produce psychological disorders
   (Mental illnesses are socially defined - major disorders, like depression and
schizophrenia appear to be universal, however; other disorders appear to be tied to
                                 specific cultures)

                                                                Used to be
                                                                called
                                                                Diathesis-
                                                                Stress Model:
                                                                diathesis
                                                                meaning
                                                                predisposition
                                                                and stress
                                                                meaning
                                                                environment.
          Models of Abnormality and Therapy:
                 Biological Perspective
  Physiological factors (brain activity, genes, hormones, NTs,
      nervous) determine behavior and mental processes
Causes of Mental Disorders        Treatment of Mental Disorders
 Physical diseases that can be    Drug Therapy
  treated medically                Electroconvulsive Therapy
 Brain abnormalities               (ECT) – effective for certain
 Chemical imbalances               kinds of severe, otherwise-
 Birth difficulties                untreatable depression.
 Heritability                     Psychosurgery/neurosurgery –
                                    surgery to destroy selected
                                    areas of the brain thought to be
                                    responsible for emotional
                                    disorders. Prefrontal lobotomy.
     Brain Abnormalities
 A PET scan of the brain of a person with Obsessive-
Compulsive Disorder (OCD). High metabolic activity
   (red) in the frontal lobe areas are involved with
                   directing attention.


                                           Generalized anxiety, panic
                                           attacks, and even OCD are
                                         linked with brain circuits like
                                           the anterior cingulate cortex.


     PET scans of 41 murderers revealed
  reduced activity in the frontal lobes. In a
 follow-up study repeat offenders had 11%
    less frontal lobe activity compared to
 individuals without antisocial personality
                    disorder
               Brain Abnormalities
  Schizophrenia patients may
exhibit morphological changes          Dopamine
 in the brain like enlargement        Overactivity:
    of fluid-filled ventricles.    Researchers found
                                   that schizophrenic
                                    patients express
                                     higher levels of
                                      dopamine D4
                                     receptors in the
                                  brain (neurons using
                                   dopamine fire too
                                          often).
                     Drug Therapy
   Anti-anxiety drugs: Xanax , Valium,
Klonopin, Ativan depress the central nervous
 system and reduce anxiety and tension by
     elevating the levels of the (GABA)
             neurotransmitter.

                      Atypical antipsychotic drugs: Clozapine (Clozaril)
                         blocks receptors for dopamine and serotonin to
                        remove the negative symptoms (apathy, jumbled
                       thoughts, concentration difficulties, and difficulties
                      in interacting with others) of schizophrenia but does
                               not restore normal thought patterns.

                         Classical antipsychotics: Chlorpromazine
                          (Thorazine) removes a number of positive
                       symptoms associated with schizophrenia such as
                           agitation, delusions, and hallucinations.
                         Drug Therapy
   Anti-depressants: Monoamine
  Oxidase (MAO) inhibitors elevate
     levels of norepinephrine and                         Pre-synaptic
 serotonin by blocking or inhibiting                        Neuron
  the enzyme that deactivates these    Norepinephrine
                                                                          Serotonin
   NT. Serotonin-norepinephrine
inhibitors (SNRIs) also elevate levels
 of norepinephrine and serotonin by                                Post-synaptic
  blocking the reuptake of these NT.                                 Neuron
                          Anti-depressants: Selective serotonin
                          reuptake inhibitors (SSRIs) – (Prozac,
                           Zoloft, and Paxil) elevate levels of
                           serotonin by preventing its reuptake

                                            Lithium Carbonate, a common
                                             salt, has been used to stabilize
                                           manic episodes in bipolar disorders
                                           reducing levels of norepinephrine
                                                     and glutuamate
   Brain Stimulation
  Electroconvulsive Therapy (ECT)
 ECT is used for severely depressed
   patients who do not respond to
 drugs. The patient is anesthetized
and given a muscle relaxant. Patients
  usually get a 100 volt shock that
     relieves them of depression.




                            Transcranial Magnetic Stimulation (TMS)
                               In TMS, a pulsating magnetic coil is
                              placed over prefrontal regions of the
                             brain to treat depression with minimal
                                            side effects.
          Models of Abnormality and Therapy:
              Psychodynamic Perspective
 Unconscious desires, needs, memories, and conflicts determine
  behavior and mental processes. Struggle to fulfill instinctive
           desires and wishes despite society’s rules
Causes of Mental Disorders        Treatment for Mental Disorders
 Repressed unconscious            Free association – patient reports all
                                    feelings, thoughts, memories, and
  conflicts and drives              images that come to mind in order to
                                    bring repressed feelings into
 Early childhood trauma            conscious awareness where the
                                    patient can deal with them
                                   Dream analysis
                                   When energy devoted to id-ego-
                                    superego conflicts is released, the
                                    patient’s anxiety lessens.
                      Psychoanalysis
  Dissatisfied with hypnosis, Freud developed the method of free
   association to unravel the unconscious mind and its conflicts.
  During free association, the patient    Eventually the patient opens
   lies on a couch and speaks about         up and reveals his or her
  whatever comes to his or her mind.      innermost private thoughts,
     Often, the patient will edit his        developing positive or
thoughts, resisting his or her feelings         negative feelings
 to express emotions. Such resistance      (transference) towards the
becomes important in the analysis of                therapist.
         conflict-driven anxiety.
                                    Interpersonal psychotherapy, a
                                      variation of psychodynamic
                                    therapy, is effective in treating
                                  depression. It focuses on symptom
                                  relief here and now, not an overall
                                          personality change. 19
            Models of Abnormality and Therapy:
                    Cognitive Perspective
The way we process, interpret, and store information determines behavior
 and mental processes. Emphasize cognitions (mental processes such as
     learning, memory, perception, thinking, and decision making)
Causes of Mental Disorders Treatment for Mental Disorders
 Mental disorders are a      Rational Emotive Behavior Therapy (Albert
                               Ellis) – therapist challenges illogical beliefs
  result of learned            directly with rational arguments; aim is to
  maladaptive thought          identify self-defeating thought patterns and
  patterns or irrational       replace them with more constructive thoughts
                              Cognitive Therapy (Aaron Beck) – cognitive
  thoughts (a                  restructuring in which a client sees that his/her
  misinterpretation of what    depression is due in part to erroneous and
  is happening and is not      illogical thought patterns. Therapist helps
                               point out those thoughts that precede anxiety
  supported by the available   and depression and then works with the client
  evidence)                    to test the logic of these thoughts.
  Models of Abnormality and Therapy:
  Humanistic Perspective
 One’s inborn tendency to grow toward his/her unique potential
determines behavior and mental processes. Emphasize free will,
              self-concept, and self-actualization

Causes of Mental Disorders      Treatment
                                 Do not delve into the past; help people to feel
 Distorted sense of self         better about themselves here and now; boost
                                  self-fulfillment by helping people grow in
 Growth-thwarting                self-awareness and self-acceptance.
  environment (real and          Client-centered therapy (Carl Rogers) -
                                  therapist offers unconditional positive regard
  ideal self are                  (non-judgemental) to build self-esteem;
                                  therapist must be warm, genuine, and empathic
  incongruent; did not            so client can adopt these views and become
                                  self-accepting
  receive unconditional          Active listening - echoes, restates, and
  positive regard or              clarifies the patient’s thinking,
                                  acknowledging expressed feelings
  empathy)
            Models of Abnormality and Therapy:
                  Behaviorist Perspective
      Learning through rewards and punishments in our external
      environment (classical conditioning, operant conditioning,
  observational learning) determines behavior and mental processes.
Causes of Mental   Treatment
Disorders           Counterconditioning
                       Flooding or exposure treatments – therapist
 Learned               accompanies client into the feared situation
  maladaptive              Systematic desensitization – a step by step process
                             of desensitizing a client to a feared object or
  patterns of                experience; based on counterconditioning
  behavior cause       Aversive conditioning – substitutes punishment for
  mental disorders      the reinforcement that has perpetuated a bad habit
                         Behavior Modification
                            Skills training – practice in specific acts needed to
                             achieve goals
                            Token economy - in institutional settings therapists
                             may create a token economy in which patients
                             exchange a token of some sort, earned for exhibiting
                             the desired behavior, for various privileges or treats
                              Anxiety Disorders
Anxiety (a sense of apprehension that shares many of the same
 symptoms as fear but builds more slowly and lingers longer)
   that persists to the point that it interferes with one’s life.
  The CNS’s physiological and emotional response to a vague
                 sense of threat or danger.
       http://www.youtube.com/watch?v=_Cr7IomSy8s
1. Generalized anxiety disorders
2. Phobias
     • Copycat Agoraphobia
       http://www.youtube.com/watch?v=u0dpgmwETcg&playnext=1&list=PLD14A589E28BB
       9502

3.       Obsessive-compulsive disorders
     •   As Good as it Gets http://www.youtube.com/watch?v=44DCWslbsNM
     •   Aviator http://www.youtube.com/watch?v=7FapiKgs4y8&feature=related
     •   Grey’s Anatomy http://www.youtube.com/watch?v=ETFQ9fyRP0s&feature=related
     •   Exposure Therapy Aims to Curb OCD http://www.youtube.com/watch?v=B-qtnCiX5b4
     •   Deep Brain Stimulation for OCD http://abcnews.go.com/video/playerIndex?id=3379057

4.       Panic disorders
5.       Posttraumatic Stress Disorder
Generalized Anxiety Disorder
Symptoms
1. Feeling unexplainably tense
   and uneasy
2. Anxiety and worry are
   associated with at least 3 of    I wish I could tell you what’s the matter.
   these symptoms: restlessness,    Sometimes I feel like something terrible has
   easily fatigued, difficulty         just happened when actually nothing has
                                    happened at all. Other times, I’m expecting
   concentrating, irritability,     the sky to fall down any minute. Most of the
   muscle tension, sleep               time I can’t point my finger at something
                                        specific. The fact is that I am tense and
   problems                           jumpy almost all the time. Sometimes my
                                        heart beats so fast, I’m sure it’s a heart
3. Difficulty controlling the       attack. Little things can set it off. The other
   worry, which may develop              day I thought a supermarket clerk had
                                    overcharged me a few cents on an item. She
   into “panic attacks”             showed me that I was wrong, but that didn’t
4. Inability to identify or avoid   end it. I worried the rest of the day . I kept
                                     going over the incident in my mind, feeling
   the cause of certain feelings.     terribly embarrassed at having raised the
5. Occurs more days than not for     possibility that the clerk had committed an
                                      error. The tension was so great, I wasn’t
   six months                             sure I’d be able to go to work in the
                                                       afternoon.
                  Panic Disorder
Symptoms:
1. Recurrent, unexpected
   attacks of acute anxiety ,      It happened without any
   peaking within 10 minutes.        warning, a sudden wave
2. Such panic may occur in a         of terror. My heart was
   familiar situation, such as a       pounding like mad, I
   crowded elevator.                couldn’t catch my breath,
3. May include feelings of          and the ground underfoot
   terror, chest pains, nausea,      seemed unstable. I was
   choking, or other frightening    sure it was a heart attack.
   sensations.                            It was the worst
4. Can cause secondary                 experience of my life.
   disorders, such as
   agoraphobia (phobia of open
   places)
                Phobia Disorder
Symptoms:
1. Marked by a persistent
   and irrational fear of an     I can’t tell you why I’m
   object or situation that        afraid of rats. They fill
   disrupts behavior and is        me with terror. Even if
   often accompanied by               I just see the word
   extreme anxiety                  “rat” my heart starts
   symptoms                           pounding. I worry
2. Participate in elaborate              about rats in
   ways to avoid the object         restaurants I go to, in
   or situation; just thinking      my kitchen cupboard,
   about the thing you fear          and anywhere I hear
   causes anxiety                  noise that sounds like a
                                         small animal
                                   scratching or running.
             Types of Phobic Disorder
•   Specific Phobia
     – Most common phobias: specific animals or insects, heights, enclosed spaces,
        thunderstorms, and blood
•   Social Phobia
     – Severe, persistent and unreasonable fears of social or performance situations in
        which embarrassment may occur
•   Agoraphobia
     – Intense fear of being alone in public places from which escape would be difficult
        or help is not readily available




                                                                                   27
Copy Cat: Agoraphobia
 Obsessive-Compulsive Disorder

Persistence of unwanted thoughts, wishes, images,
ideas, doubts (obsessions) and urges to engage in
senseless rituals (compulsions) that cause distress.




                                                       29
      Obsessive-Compulsive Disorder
• 20% of those with OCD have only                   I felt the need to clean
  obsessions or only compulsions; all others
  experiences both                                  my room … spent four
• Obsession: A young woman is continuously          to five hour at it … At
  terrified by the thought that cars might careen
  onto the sidewalk and run over her.               the time I loved it but
  Compulsion: She always walks as far from          then didn't want to do
  the street pavement as possible and wars red
  clothes so that she will be immediately           it any more, but could
  visible to an out-of-control car                  not stop … The clothes
• Obsession: A college student has the urge to        hung … two fingers
  shout obscenities while sitting through
  lectures in classes. Compulsion: Carefully         apart …I touched my
  monitoring his watch, he bites his tongue          bedroom wall before
  every sixty seconds in order to ward off the
  inclination to shout                              leaving the house … I
• Obsession: A young boy worries incessantly         had constant anxiety
  that something terrible might happen to his
  mother while sleeping at night. Compulsion:       … I thought I might be
  ON his way up to bed each night, he climbs                  nuts.
  the stairs according to a fixed sequence of
  three steps up, followed by two steps down in
  order to ward off danger.
         Common Examples of OCD
           Common Obsessions:              Common Compulsions:

Contamination fears of germs, dirt, etc.        Washing
Imagining having harmed self or others          Repeating
Imagining losing control of aggressive
                                                Checking
urges
Intrusive sexual thoughts or urges              Touching
Excessive religious or moral doubt              Counting
Forbidden thoughts                          Ordering/arranging
A need to have things "just so"             Hoarding or saving
A need to tell, ask, confess                     Praying
As Good as it Gets
Grey’s Anatomy: OCD




                      33
Aviator: OCD
              Acute Stress Disorder
• Characteristics of traumatic event:
   – Threatened death or serious injury
   – Person’s response involved intense fear, helplessness, or
     horror
• During/after event person has 3 or more dissociative symptoms:
   – Feel numb, detached, or lack of emotional responsiveness
   – Less aware of surroundings
   – Derealization - an alteration in the perception or experience of
     the external world so that it seems strange or unreal
   – Depersonalization - subjective experience of unreality in one's
     sense of self
   – Dissociative amnesia
• Traumatic event is persistently re-experienced
• Avoidance of stimuli that reminds one of the traumatic event
• Disturbance lasts for a minimum of 2 days and a maximum of 4
  weeks of the traumatic event
      Post-Traumatic Stress Disorder
  Repeated, anxious reliving of a horrifying event
         over an extended period of time.

 1. Haunting memories
 2. Nightmares
 3. Social withdrawal
 4. Jumpy anxiety

 5. Sleep problems




                                                                  Bettmann/ Corbis
http://www.mtv.com/videos/true-life-i-have-post-traumatic-
stress-disorder/1601333/playlist.jhtml                       36
               Etiology of Anxiety Disorders
Biological:                                     Behavioral:
• Genetic; runs in families                     • Through observational learning,
• Inherit overly responsive autonomic              children adopt behaviors of anxiety
   nervous system                                  disorders displayed by their parents.
• Overactivity of norepinephrine,               • As demonstrated in the Little Albert
   (noradrenaline), specifically connected to      experiment, fear can be classically
   the onset of panic attacks                      conditioned and then maintained
• Lack of serotonin function, especially in        through operant conditioning
   OCD and social phobias.                      Cognitive:
• Deficiency in GABA                            • A lack of perceived control (social-
• Too much glutamate in OCD patients,              cognitive)
   which causes the alarm center in the brain   • Inaccurate or irrational interpretation of
   to keep going off                               an event/stimulus.
• Overactive amygdala or an underactive         Psychodynamic:
   prefrontal cortex, which creates an          • Ego defense mechanisms are
   inability to turn off the initial stress        inadequate.
   response by the amygdala                     Sociocultural Perspective
Evolutionary:                                   • Pressures, such as poverty or race, that
• Biological preparedness to acquire some          cause anxiety.
   fears much more easily than others
    Treatment of Anxiety Disorders
Behavioral:
• Counterconditioning
    – Exposure Therapy
         • Systematic desensitization
           (Video 13)
         • Flooding
• Aversion conditioning
Biological:
• Antianxiety drugs (Valium,
   Xanax) – reduce the symptoms of
   anxiety, nervousness, and
   sleeping problems by increasing
   the level of GABA, which
   inhibits nerve impulses in the
   brain.
      Generalized Anxiety Disorder results from…
• Psychodynamic Perspective
   – Ego defense mechanisms are inadequate
       • Severe punishment for expressing id impulses, which causes high
         levels of anxiety
• Cognitive Perspective
   – Unrealistic goals or unreasonable beliefs about the world and ourselves that
     foster worry and fears.
   – Inaccurate or irrational interpretation of an event/stimulus Tendency to
     overgeneralize and magnify the significance of an event.
   – Lack of perceived control.
• Sociocultural Perspective
   – Pressures, such as poverty or race, that cause anxiety.
• Behavioral Perspective
   – Observational learning – parents model the characteristics of anxiety
     disorders for their children; trouble leaving the house or being overly
     concerned about certain events.
• Humanistic Perspective
   – People not looking at themselves honestly and acceptingly
                                                                          39
      Generalized Anxiety Disorder results from…
• Biological Perspective
   – Certain people inherit autonomic nervous system traits that make them
      vulnerable or predisposed to anxiety (such as, overly responsive or
      reactive, strong alarm tendencies,). Minor events trigger anxiety.
        • Heritability of anxiety is 30 to 40%
        • Anxiety disorders run in families
   – Breakdown in the neural circuitry that signals the brain to stop responding.
      May be a result of an overactive amygdala or an underactive prefrontal
      cortex, which creates an inability to turn off the initial stress response by
      the amygdala
   – Anti-anxiety drugs: Xanax , Valium, Klonopin, Ativan depress the central
      nervous system and reduce anxiety and tension by elevating the levels of
      the neurotransmitter GABA. Deficiency in GABA, inhibitory disorder,
      which could account for racing thoughts.
          Panic Disorder results from…

• Biological Perspective
  – Heightened startle response –
    hypersensitivity to neurochemicals
    that alert sympathetic nervous
    system.
  – Overactive norepinephrine (NT
    linked with arousal)
• Cognitive Perspective
  – Full panic reactions are experienced
    only be people who misinterpret
    bodily events
               Phobia Disorder results from…
• Behavioral Perspective
   – Learning theorists suggest that fear conditioning leads to anxiety.
     This anxiety then becomes associated with other objects or events
     (stimulus generalization) and is reinforced.
   – Fear is initially learned through classical conditioning
       • Claustrophobia
       • NS (closet)  no response
       • UCS (lack of oxygen)  UCR (gasping for air)
       • UCS (lack of oxygen) + NS (closet)  UCR (gasping for air)
       • CS (closet)  CR (gasping for air)
       • Generalization: closet to enclosed spaces
   – Fear is then maintained through avoidance (operant conditioning)
     because the individual avoids the thing he/she is afraid of, there are
     no opportunities for “reality testing” and new learning.
   – Investigators believe that fear responses are inculcated through
     observational learning. Young monkeys develop fear when they
     watch other monkeys who are afraid of snakes.
                    Phobia Disorder results from…
• Since phobias most likely develop as a result
  of fear conditioning, therapists use learning
  principles to eliminate unwanted behaviors.
• Counterconditioning is a classical
  conditioning procedure that conditions new
  responses to stimuli that trigger unwanted
  behaviors.
   – Exposure Therapy - expose (in real or
       virtual environments) patients to things
       they fear and avoid. Through repeated
       exposures, anxiety lessens because the
       brain habituates to the fear.
         • Systematic Desensitization - A type
           of exposure therapy that associates a
           pleasant, relaxed state with gradually
           increasing anxiety-triggering stimuli
         • Flooding – immediate, direct and
           constant exposure to feared object, no
           chance of escape
   – Aversive Conditioning - associates an
       unpleasant state with an unwanted
       behavior.
44
            Phobia Disorder results from…
• Operant conditioning procedures enable therapists to
  use behavior modification, in which desired behaviors
  are rewarded and undesired behaviors are either
  unrewarded or punished.
   – Token Economy - In institutional settings therapists
     may create a token economy in which patients
     exchange a token of some sort, earned for exhibiting
     the desired behavior, for various privileges or treats.


I
          Phobia Disorder results from…
• Biological Perspective
  – Natural Selection has led our ancestors to
    learn to fear snakes, spiders, and other
    animals. Therefore, fear preserves the
    species. Role of biological preparedness –
    people are biologically prepared by their
    evolutionary history to acquire some fears
    much more easily than others
  – Twin studies suggest that our genes may
    be partly responsible for developing fears
    and anxiety. Twins are more likely to share
    phobias
  – Giving anti-depressants, such as SSRIs
      Obsessive Compulsive Disorder results from…
•   Psychodynamic Perspective
     – Id battles with ego on conscious level
          • Id impulses = obsessive thoughts
          • Ego defenses = counter-thoughts or compulsive actions
•   Behavioral Perspective
     – Compulsions are learned by chance
     – Exposure and response prevention (ERP), in which OCD sufferers don’t
        try to avoid their particular source of anxiety but actually seek it out.
        Eventually, emotional nerve endings grow desensitized to the stimulus.
•   Cognitive Perspective
     – Overreact to unwanted thoughts
     – Try to neutralize these thoughts with actions
     – If neutralizing activity reduces anxiety, it becomes reinforced
•   Biological Perspective
     – Twin studies – genetic component
          • 53% in identical twins                                                High metabolic
          • 23% in fraternal twins                                                activity (red) in
     - Brain abnormalities                                                        frontal lobes
          - Too much glutamate, which causes the alarm centers in the brain to
             keep going off
          - Lack of serotonin functioning (NT involved with regulation of
             sleep and mood
          - High level of activity in frontal lobes, associated with attention
          - In the future, OCD patients may receive deep brain stimulation.
           Causes of Stress Disorders
•   Combat                            • Psychological Debriefing
•   Disasters                            – Normalize responses to
•   Abuse and victimization                the disaster
•   Why doesn’t everyone develop         – Encourage expressions of
    psychological stress disorders?        anxiety, anger, and
     – Biological and genetic factors      frustration
         • Physical changes in body      – Teach self-help skills
         • Abnormal NT and hormonal      – Provide referrals
           activity
     – Personality factors
         • Preexisting high anxiety
         • History of psychological
           problems
         • Negative worldview
     – Negative childhood experiences
     – Weak social support
     – Severity of the trauma                                     48
Additional Anxiety Disorder Videos
 • OCD Videos
    – http://www.metacafe.com/watch/84755/true_life_living
      _with_ocd/
    – http://www.metacafe.com/watch/yt-
      SH0r44qn6pI/my_life_with_ocd_laurens_story_part_i_
      dramatic_health/
    – http://www.metacafe.com/watch/yt-
      T0FMXyp6ZEs/my_life_with_ocd_laurens_story_part_
      ii_dramatic_health/
 • PTSD Videos
    – http://www.mtv.com/videos/true-life-i-have-post-
      traumatic-stress-disorder/1601333/playlist.jhtml

                                                        49
                Mood Disorders
Emotional extremes, which come in two principal forms.
   1.   Unipolar disorders – experience emotional extremes at
        just one end of the mood continuum
          Major depressive disorder
          Dysthymic disorder
          Seasonal Affective disorder
   2.   Bipolar disorders – experience emotional extremes at
        both ends of the mood continuum – depression and
        mania
Major Depressive Disorder
Symptoms
1.  Signs of depression last two weeks or
    more and are not caused by drugs or
    medical conditions
2.  Signs include: Lethargy and fatigue
    (takes tremendous effort to get up and
    get dressed); feelings of worthlessness     I was seized with an unspeakable
                                                physical weariness. There was a
    (tearfulness and weeping; exaggerate       tired feeling in the muscles unlike
    minor failings, discount positive         anything I had ever experienced…
                                                 my nights were sleepless. I lay
    events, interpret things that go wrong      with dry, staring eyes gazing into
    as evidence that nothing will ever go          space. The most trivial duty
    right); loss of interest in family &      became a formidable task. Finally
                                              mental and physical exercises were
    friends; recurrent thoughts of                impossible; the tired muscles
    death/suicide; loss of interest in          refused to respond, my “thinking
                                                   apparatus” refused to work,
    activities; depressed most of the day;       ambition was gone. My general
    significant weight gain/loss;             feeling might be summed up in the
    insomnia; psychomotor                       familiar saying “What’s the use.”
    agitation/retardation; concentration
    difficulties or indecisiveness
              Dysthymic Disorder
Symptoms
1. Mild but chronic; lies between a blue mood and major
   depressive disorder
2. Characterized by daily depression lasting two years or
   more; longer lasting but less disabling
3. When dysthymic disorder leads to major depressive
   disorder, the sequence is called “double depression”


            Blue        Dysthymic     Major Depressive
            Mood         Disorder        Disorder
      Seasonal Affective Disorder
Symptoms
1. Depression on a recurring basis in one season of the year
   when it gets dark early and light late in the day

Treatment
 Light Therapy – exposure to bright light for a specific length
    of time
 The level of light produced must match that of visible light
    outdoors shortly after sunrise or before sunset




                                                               53
                 Etiology of Mood Disorders
Biological:                                      Psychodynamic:
• Genetic; runs in families                      • Link between depression and grief:
• Low serotonin may “open the door” to a            when a loved one dies, the mourner
   mood disorder and permit norepinephrine          regresses to the oral stage:
   activity to define the particular form the    Cognitive:
   disorder will take:                           • Ruminating response style, self-
     – Low serotonin + Low                          defeating thoughts, external locus of
        norepinephrine = Depression                 control, learned helplessness, and
     – Low serotonin + High                         pessimistic views of: themselves, the
        norepinephrine = Mania.                     world, the future.
• An excessive release of the stress hormone
   cortisol, which could be connected to
   impaired functioning of the hypothalamus
   and pituitary gland of the endocrine system
• Malfunctions in the body’s circadian
   clock, specifically for SAD.
Socio-cultural:
• Dysfunctional family systems, poverty,
   high-crime neighborhoods, domestic
   violence, and other stressful situations
• Women have a higher chance than men of
   developing a mood disorder
                  Treatment of Mood Disorders
Cognitive:                                                        Cognitive-Behavioral Therapy
• Aaron Beck’s Cognitive Therapy – depression is caused           • Combine the reversal of self-defeated
   by errors in thinking - illogical thinking about themselves,      thinking with efforts to modify behavior.
   the world they live in, and the future. In therapy, clients       Aims to alter the way people act
   are taught not only to identify negative, distorted thoughts      (behavior therapy) and alter the way they
   but also to actually go out and test those negative beliefs.      think (cognitive therapy).
   EX: a client who believes that nobody likes him will be
   instructed to engage in conversations with other people        • Lewinsohn’s Behavioral Treatment
   and report back with all of his experiences, which the              – reintroduce clients to pleasurable
   therapist will try to build on successes and explore                   activities and events
   reasons for lack of success.                                        – appropriately reinforce their
• Albert Ellis’ Rational Emotive Behavior Therapy                         depressive and nondepressive
   (RET) –Emotional disorders are caused by irrational                    behaviors
   beliefs - absolute, unrealistic views of the world and
                                                                       – help them improve their social skills
   perfectionistic - that cause us to expect too much of
   ourselves and lead us to feel unnecessarily that we are
   worthless failures. Therapists identify client’s irrational
   beliefs and directly challenge or confront the patient and
   persuade them to adopt more realistic beliefs.
• Stress Inoculation Training - A type of self-instructional
   training focused on altering self-statements an individual
   routinely makes in stress producing situations. EX:
   “Relax, the exam may be hard, but it will be hard for
   everyone else too. I studied harder than most people.
   Besides, I don’t need a perfect score to get a good grade.”
          Treatment of Mood Disorders
Biological:
 Monoamine Oxidase (MAO) inhibitors
 elevate levels of norepinephrine and                       Pre-synaptic
serotonin by blocking or inhibiting the                       Neuron
  enzyme that deactivates these NT. Norepinephrine                          Serotonin

   Serotonin-norepinephrine inhibitors
     (SNRIs) also elevate levels of                                  Post-synaptic
   norepinephrine and serotonin by                                     Neuron
  blocking the reuptake of these NT.


                                     Selective serotonin reuptake inhibitors
                                      (SSRIs) (Prozac, Zoloft, and Paxil)
                                    elevate levels of serotonin by preventing
                                                   its reuptake
       Treatment of Mood Disorders
  Electroconvulsive Therapy (ECT)
 ECT is used for severely depressed
   patients who do not respond to
 drugs. The patient is anesthetized
and given a muscle relaxant. Patients
  usually get a 100 volt shock that
     relieves them of depression.




                            Transcranial Magnetic Stimulation (TMS)
                               In TMS, a pulsating magnetic coil is
                              placed over prefrontal regions of the
                             brain to treat depression with minimal
                                            side effects.
Treatment of Mood Disorders
Psychosurgery was popular even in Neolithic times.
       Although used sparingly today, about
 200 such operations do take place in the US alone.

        Psychosurgery is used as a last resort in
        alleviating psychological disturbances.
    Psychosurgery is irreversible. Removal of brain
    tissue changes the mind. Modern methods use
   stereotactic neurosurgery and radiosurgery that
        refine older methods of psychosurgery.
        Unipolar Disorders results from…
• Biological Perspective
   - Low norepinephrine (a stress hormone which
     affects parts of the brain where attention and
     responding actions are controlled. Underlies
     fight or flight response) and/or low serotonin
     levels
   - Brain scans show reduced frontal lobe activity
   - Mood disorders run in families. The rate of
     depression is higher in identical (50%) than
     fraternal twins (20%).
      - Linkage analysis and association studies link
        possible genes and dispositions for
        depression.
             Unipolar Disorders results from…
• Psychodynamic Perspective
   – Link between depression and grief: when a loved one dies, the
     mourner regresses to the oral stage
       • For most people, grief is temporary
       • If grief is severe and long-lasting, depression results
       • Those with oral stage issues (unmet or excessively met needs)
         are at greater risk for developing depression
• Behavioral Perspective
   – Depression results from changes in rewards and punishments
     people receive in their lives; social rewards are especially important
• Sociocultural Perspective
   – Focus on conditions of people’s lives; may explain gender
     differences in depression rates. Also found links between
     depression and culture, race, and social support
   – Marriage and employment associated with lower rates of
     depression
   – People with depression experience a greater number of stressful life
     events during the month just prior to the onset of their symptoms
                                                                     60
                 Unipolar Disorders results from…
• Cognitive Perspective
   – Conscious thoughts = how a person attends to, interprets, and uses
     information
   – Learned maladaptive thought patterns cause mental disorder (maladaptive
     thinking  maladaptive behavior)
   – Ruminating response style - depressed people hold pessimistic views of:
     themselves, the world, the future and distort their experiences in negative
     ways: exaggerate bad experiences, minimize good experiences.
   – Learned helplessness - people become depressed when their efforts to
     avoid pain or control the environment fail; however, not all depressed
     people have actually experienced failure (social-cognitive)
     Explanatory Style and Depression Cycle
1.   Negative stressful events.
2.   Pessimistic explanatory style.
3.   Learned helplessness/Hopeless
     depressed state.
4.   These hamper the way the
     individual thinks and acts,
     fueling personal rejection.
  Social-Cognitive Perspective
The social-cognitive perspective suggests that
 depression arises partly from self-defeating
   beliefs and negative explanatory styles.




                                                 63
             Rational Emotive Therapy (RET)
•   Albert Ellis
•   Emotional disorders are caused by irrational beliefs - absolute, unrealistic views of the world and
    perfectionistic values (i.e. “Everyone must love me all of the time.” or “I should be thoroughly
    adequate and competent in everything.”) – that cause us to expect too much of ourselves and lead us to
    feel unnecessarily that we are worthless failures
•   Clients are taught that it is not the external events, but the interpretation of such events that leads to
    feeling of despair. 1) Therapists search for a client’s irrational beliefs, especially with respect to the
    irrational “shoulds,” “oughts,” and “musts” that are preventing a more positive sense of self worth and
    a fulfilling life, 2) points out the impossibility of fulfilling them, and 3) uses any and every technique
    to persuade the client to adopt more realistic beliefs, such as directly challenging/confronting the
    client’s beliefs during therapy

ABC Model:
    A = Activating Event (the individual cannot
    find a date for the prom)
    B = Belief, irrational (I guess nobody likes
    me enough to go with me to the prom)
    C = Consequences (Feelings of depression).
    Ellis would challenge irrational beliefs with
    rational arguments and provide other
    reasons why he or she doesn’t have a date
    for the prom, because the thought is causing
    the depression not the event.
Rational Emotive Therapy (RET)
                               Cognitive Therapy
•   Aaron Beck
•   Depression is caused by errors in thinking - illogical thinking about themselves, the world they live in,
    and the future – which lead them to:
      – 1) selectively perceive the world as harmful while ignoring evidence to the contrary
      – 2) overgeneralize on the basis of limited examples – for example, seeing themselves as totally
         worthless because they were laid off at work,
      – 3) magnify the significance of undesirable events – for example, seeing the job loss as the end of the
         world for them,
      – 4) engage in absolutistic thinking – for example, exaggerating the importance of someone’s mildly
         critical comment and perceiving it as proof of their instant descent from goodness to worthlessness
•   Clients are taught not only to identify negative, distorted thoughts but also to actually go out and test
    those negative beliefs.
      – First taught to simply identify their own automatic thoughts (e.g. “This event is a total disaster.”)
         and to keep records of their thought content and their emotional reactions.
      – With the therapist’s help, they then learn about the logical errors in their thinking, and to challenge
         the validity of these automatic thoughts by designing ways in which the client can check out these
         thoughts in the real world. These disconfirmation experiments are planned to give the individual
         successful experiences, thus interrupting the destructive thought sequence. .
      – EX: a client who believes that nobody likes him will be instructed to engage in conversations with
         other people and report back with all of his experiences, which the therapist will try to build on
         successes and explore reasons for lack of success.
Cognitive Therapy
                   Bipolar Disorder
          (formerly called manic-depressive disorder)
An alternation between depression and mania signals bipolar disorder.

      Depressive Symptoms               Manic Symptoms

              Gloomy                          Elation
            Withdrawn                        Euphoria
    Inability to make decisions          Desire for action
                Tired                     Hyperactive
       Slowness of thought                Multiple ideas




                                                               68
              Types of Bipolar Disorder
• Manic Episode                                           When experiencing manic
   – Three or more symptoms of mania lasting          symptoms, a 38 year old woman,
     one week or more                               periodically hospitalized because of
• Hypomanic Episode                                  her extreme moods, would become
   – a less severe version of a manic episode      “overactive and exuberant in spirits
     that does not cause marked impairment in      and visited her friends, to whom she
     social or occupational functioning            outlined her plans for reestablishing
• Bipolar I Disorder                               different forms of lucrative business.
   – Full manic and major depressive episodes      She purchased many clothes, bought
   – Most sufferers experience an alternation of   furniture, pawned rings, and wrote
     episodes                                        checks without funds. She played
   – Some experience mixed episodes                    her radio until late in the night,
                                                         smoked excessively, took out
• Bipolar II Disorder
                                                    insurance on a car that she had not
   – Hypomanic episodes and major                    yet bought. Contrary to her usual
     depressive episodes                              habits, she swore frequently and
• Cyclothymic Disorder                             loudly and created a disturbance in
   – a chronic pattern of less-severe mood          a club to which she did not belong.
     swings                                             On the day prior to her second
       • hypomania                                      admission to the hospital, she
       • mild depression                                      purchased 57 hats.
       • may blossom into bipolar I or II
          disorder
                             Bipolar Disorder
 Many great writers, poets, and composers
suffered from bipolar disorder. During their
manic phase creativity surged, but not during
           their depressed phase.



                                       George C. Beresford/ Hulton Getty Pictures Library




                                                                                                                                           Earl Theissen/ Hulton Getty Pictures Library
                                                                                                      The Granger Collection
          Bettmann/ Corbis




Whitman                        Wolfe                                                        Clemens                            Hemingway
             Bipolar Disorder results from…
• Biological Perspective
   - Low serotonin may “open the door” to a mood disorder and permit
      norepinephrine activity to define the particular form the disorder will
      take:
        - Low serotonin + Low norepinephrine = Depression
        - Low serotonin + High norepinephrine = Mania. Excessive
          production of norepinephrine.
   - Ions, which are needed to send incoming messages to nerve endings,
      may be improperly transported through the cells of individuals with
      bipolar disorder this improper transport may cause neurons to fire
      too easily (mania) or to resist firing (depression)
   - PET scans show that brain energy consumption rises and falls with
      manic and depressive episodes.

Lithium Carbonate, a common salt, has
  been used to stabilize manic episodes in
bipolar disorders. It moderates the levels of
      norepinephrine and glutamate
            neurotransmitters.
   Schizophrenia
Symptoms: The literal translation is
“split mind.” A group of severe
disorders characterized by the
following:
1. Disorganized thinking               This morning when I was at
    (neologisms, clang/loose           Hillside [Hospital], I was
    associations, word salad)          making a movie. I was
2. Delusions and hallucinations.       surrounded by movie stars
3. Inappropriate emotions and          … I’m Marry Poppins. Is
    actions.                           this room painted blue to get
    http://www.youtube.com/watch?v=t   me upset? My grandmother
    vkj1qlQ9vM&feature=related         died four weeks after my
                                       eighteenth birthday.”
                                           This monologue illustrates
                                       fragmented, bizarre thinking with
                                        distorted beliefs called delusions
                                             (“I’m Mary Poppins”).
   Subtypes of Schizophrenia
Schizophrenia is a cluster of disorders. These
 subtypes share some features, but there are
   other symptoms that differentiate these
                  subtypes.




                                                 73
          Schizophrenia Symptoms
  Inappropriate symptoms     Appropriate symptoms absent
present (positive symptoms –    (negative symptoms –
    behavioral excesses)         behavioral deficitis)
Hallucinations, disorganized    Apathy, (avolition – no
 thinking, deluded ways.     emotion), expressionless faces,
                              rigid bodies blunted or flat
                               affect, social withdrawal,
                              poverty of speech (alogia) .
   When schizophrenia rapidly develops (acute/reactive)
   recovery is better. Such schizophrenics usually show
                    positive symptoms.
 When schizophrenia is slow to develop (chronic/process)
 recovery is doubtful. Such schizophrenics usually display
                   negative symptoms.
       Positive Symptoms (Behavioral Excesses)
 Schizophrenics have inappropriate symptoms (hallucinations, disorganized
       thinking, deluded ways) that are not present in normal individuals
 Delusions: false beliefs about reality
    a. delusions of grandeur – GOD complex/meglomania – people maintain
       that they are famous or important
    b. delusions of persecution – they’re out to get me/ paranoia
    c. delusions of being controlled – the CIA is controlling my brain with a
       radio signal
 Disordered thought & speech - Many psychologists believe disorganized
   thoughts occur because of selective attention failure (fragmented and
   bizarre thoughts).
    a. loose associations/derailment – people shift topics in disjointed ways.
    b. neologisms – meaningless, made up words
    c. Perseveration – repetition of speech
    d. thought insertion
    e. thought broadcasting
 Heightened perception
 Hallucinations - A schizophrenic person may perceive things that are not
   there. Frequently such hallucinations are auditory and lesser visual,
   somatosensory, olfactory, or gustatory. Sensory perceptions that occur in
   the absence of sensory stimulus
 Inappropriate affect - A schizophrenic person may laugh at the news of
   someone dying                                                               75
      Psychomotor Symptoms
1. Awkward movements, repeated
   grimaces, odd gestures
2. Movements seem to have a magical
   quality
3. Catatonia: extreme form
   includes stupor, rigidity, posturing, and
    excitement - patients with schizophrenia
    may continually rub an arm, rock a chair,
    or remain motionless for hours

                                                76
              Schizophrenia
Nearly 1 in a 100 suffer from schizophrenia, and
 throughout the world over 24 million people
    suffer from this disease (WHO, 2002).
  Schizophrenia strikes young people as they
 mature into adults. It affects men and women
 equally, but men suffer from it more severely
      and it appears earlier than women.

    More common among the poor. Stress of
      poverty might cause the disorder or
schizophrenia causes victims from higher social
 levels to fall to lower social levels (downward
                     drift theory)               77
                     Etiology of Schizophrenia
Biological:                                            Behavioral:
• Genetic; runs in families.                           • Some people are not reinforced for their
• Increased size in the ventricles (negative              attention to social cues and, as a result, they
    symptoms)                                             stop attending to those cues and focus instead
                                                          on irrelevant cues (e.g., room lighting) and
• Dopamine Hypothesis: Excessive dopamine or              their responses become increasingly bizarre
    excessive receptor sites for dopamine is           Cognitive:
    connected to the positive symptoms..               • Faulty interpretation and a misunderstanding
• Prenatal viruses, such as influenza, or physical        of biological events (EX: a man experiences
    trauma during fetal development.                      auditory hallucinations and approaches his
Socio-cultural:                                           friends for help; they deny the reality of his
• Dysfunctional family systems: display conflict,         sensations; he concludes that they are trying
    verbal exchanges are often confused, vague or         to hide the truth from him; he begins to reject
    incomplete, critical and overly involved parents      all feedback and starts feeling persecuted)
• Substance abusers are more likely to develop
    disorder, such as cocaine users.
• Disadvantaged communities report more
    incidences of disorder than better-off areas..
• Vulnerability theory of schizophrenia
    (diathesis-stress model): schizophrenia is the
    result of a biological predisposition and the
    amount of stress one encounters.
          Treatment of Schizophrenia
   Biological:
Classical antipsychotics: Chlorpromazine (Thorazine) blocks all
receptor sites for dopamine; thereby lessening the effects of dopamine
and removing a number of positive symptoms associated with
schizophrenia such as agitation, delusions, and hallucinations. Also
known as neuroleptic drugs because they often produce undesired movement
effects similar to symptoms of neurological diseases, such Tardive Dyskinesia
(involuntary movements, usually of the mouth, lips, tongue, legs, or body)

                               Atypical antipsychotic drugs: Clozapine
                               (Clozaril) also blocks receptors for
                               dopamine, but selectively blocks some of
                               them and not all of them; thereby,
                               eliminating some of the negative side
                               effects of classic antipsychotics (i.e. has less
                               of an effect on the D-2 receptors which control
                               body movements, so it does not cause
                               symptoms like Parkinson's disease). Also
                               blocks serotonin receptors
               Treatment of Schizophrenia
• Socio-Cultural Perspective
   – Family Therapy attempts to address the issues of living with a
     schizophrenic, creating more realistic expectations, and providing
     psychoeducation about the disorder
   – Social Therapy focuses on techniques that address social and
     personal difficulties in the clients’ lives (e.g., practical advice,
     problem solving, decision making, social skills training,
     medication management, employment counseling, financial
     assistance, and housing
                 Schizophrenia results from…
• Psychodynamic Perspective
   – Freud believed that schizophrenia developed from two processes:
       1. regression to a pre-ego stage
       2. efforts to re-establish ego control
• Behavioral Perspective
   – Cites principles of reinforcement as the cause; some people are
     not reinforced for their attention to social cues and, as a result,
     they stop attending to those cues and focus instead on irrelevant
     cues (e.g., room lighting) and their responses become increasingly
     bizarre
• Cognitive Perspective
   – Schizophrenic symptoms develop because of faulty interpretation
     and a misunderstanding of biological events (EX: a man
     experiences auditory hallucinations and approaches his friends
     for help; they deny the reality of his sensations; he concludes that
     they are trying to hide the truth from him; he begins to reject all
     feedback and starts feeling persecuted)
                   Schizophrenia results from…
 • Biological Perspective
    – Twin studies – genetic component
       • Risk of schiz for general population is 1-2 percent
       • The likelihood of an individual suffering from
         schizophrenia is 50% if their identical twin has the
         disease
       • No specific genes for schiz have been identified
                   0 10 20 30 40 50
       Identical
   Both parents
      Fraternal
     One parent
        Sibling
Nephew or niece
      Unrelated
                    Schizophrenia results from…
•   Biological Perspective
     – Schizophrenia may develop through 2 kinds of biological abnormalities:
     – Dopamine Overactivity Hypothesis
          • neurons using dopamine fire too often, producing symptoms of schizophrenia
          • there are an unusually large number of dopamine receptors in people with
            schizophrenia
          • take antipsychotic meds, which block dopamine and help with positive
            symptoms
          • may have low levels of serotonin, which may lead to high levels of dopamine
            activity.
     – Brain abnormalities
          • decreased brain weight
          • reduced volume in specific brain areas, or reduced number of neurons in
            certain brain areas
          • enlarged ventricles
          • Abnormal activity in frontal lobe, thalamus, and amygdala. Adolescent
            schizophrenic patients also have brain lesions.
                 Schizophrenia results from…
• Biological Perspective
   – Schizophrenia has also been observed in individuals who
     contracted a viral infection (flu) during the middle of their fetal
     development.
       • large # of people with schizophrenia born in winter months
       • women with schizophrenic children were more often
           exposed to the influenza virus during pregnancy
       • link between schizophrenia and a particular group of
           viruses found in animals


 Diathesis-Stress Model: People with a biological predisposition
    will develop schizophrenia only if certain kinds of stressors or
      events are also present. Psychological and environmental
   factors can trigger schizophrenia if the individual is genetically
                              predisposed
                 Schizophrenia results from…
• Socio-Cultural Perspective
   – Family dysfunction: parents of people with schizophrenia often:
   – display more conflict – negative emotional climate
   – have greater difficulty communicating; erbal exchanges are often
     confused, vague, or incomplete.
   – are more critical of and overinvolved with their children
   – “expressed emotion:” family members frequently express criticism
     and hostility and intrude on each other’s privacy
   – Family Therapy attempts to address the issues of living with a
     schizophrenic, creating more realistic expectations, and providing
     psychoeducation about the disorder
   – Social Therapy focuses on techniques that address social and
     personal difficulties in the clients’ lives (e.g., practical advice,
     problem solving, decision making, social skills training,
     medication management, employment counseling, financial
     assistance, and housing
    Dr. Phil Schizophrenia




http://www.youtube.com/watch?v=uJOT45wXErk&
feature=related
http://www.youtube.com/watch?v=CoaZgvXQjik
  20/20 Schizophrenia: Part 1




http://www.youtube.com/watch?v=moP_e-gx5hk   87
        20/20 Schizophrenia: Part 2




                                                       88
http://www.youtube.com/watch?v=QPXkwYM9G-s&feature=related
        Childhood Schizophrenia




                                                        89
http://www.hulu.com/watch/134660/abc-2020-fri-mar-12-2010
 Young Schizophrenic at Her Mind's Mercy




http://www.youtube.com/watch?v=UTUMt05_nCI&feature=fvwrel
                                                      90
        Dissociative Disorders
Conscious awareness becomes separated (dissociated)
  from previous memories, thoughts, and feelings.

1. Dissociative Identity Disorder
   (Multiple Personality Disorder)
2. Dissociative Amnesia
3. Dissociative Fugue
           Dissociative Disorders
   Conscious awareness becomes separated (dissociated)
     from previous memories, thoughts, and feelings.

Symptoms:                      Common Dissociative Experiences
                               in Everyday Life
1. Having a sense of being
                               • Daydreaming
   unreal.                     • Missing parts of conversations
2. Being separated from the    • Forgetting part of drive home
   body - depersonalization.   • Reading an entire page and not
   Watching yourself as in a      knowing what you read
   movie                       • Not sure whether you’ve done
                                  something or only thought
3. Feature major losses or        about doing it
   changes in memory,          • Seeing oneself as if looking at
   consciousness, and             another person
   identity, but do not have   • Not sure if an event happened
   physical causes.               or was just a dream
      Dissociative Identity Disorder (DID)
                   (formally called Multiple Personality Disorder)
   Symptoms:                                             Norma has frequent gaps and
   1. Person exhibits two or more distinct and           cannot account for her
      alternating personalities,                         whereabouts during certain
                                                         periods of time. While being
   2. Each personality has his or her own                interviewed by a clinical
      name, memories, traits and physical                psychologist, she began
      mannerisms. The original personality               speaking in a childlike voice.
                                                         She claimed that her name was
      often is unaware of the alternate                  Donna and that she was only
      personalities. The alternate personalities         six years old. Moments later,
                                                         she seemed to revert to her
      usually are aware of the original one and          adult voice and had no
      have varying amounts of awareness of               recollection of speaking in a
      each other. Alternate personalities                childlike voice or claiming that
                                                         her name was Donna.
      display traits that are quite foreign to the
      original’s personality
Criticisms:
• The diagnosis of DID increased in the late 20th century.
   DID has not been found in other countries.
• Role-playing by people open to a therapist’s
   suggestion.
• Learned response that reinforces reductions in anxiety.
                Dissociative Fugue
                                          Jay, a high school physics
Symptoms:                                 teacher in NY City,
1. Forget their personal identities of    disappeared three days
   their past (name, family, where        after his wife unexpectedly
   they live, and where they work)        left him for another man.
   and also flee to an entirely different Six months later, he was
   location                               discovered tending bar in
2. For some, the fugue is brief: they     Miami Beach. Calling
   may travel a short distance but do     himself Marin, he claimed
   not take on a new identity             to have no recollection of
3. For others, the fugue is more          his past life and insisted
   severe: they may travel thousands that he had never been
   of miles, take on a new identity,      married.
   build new relationships, and
   display new personality
   characteristics
                                                                94
            Dissociative Amnesia
 Unable to recall important information, usually of
an upsetting nature, about their lives. Memory loss
  is the only symptom and does NOT result from
  other medical trauma, such as blow to the head
     Marian and her brother were recently victims of
    robbery. Marian was not injured, but her brother
     was killed when he resisted. Marian is unable to
   recall any details from the time of the accident until
                      four days later.
                     Sybil – Part 1




http://www.youtube.com/watch?v=m1_Z6-v4uT0&feature=related
                                                         96
                 Sybil – Part 2




                                                  97
http://www.youtube.com/watch?v=1vANyDFgjZU&NR=1
      60 Minutes: A Fractured Mind




Robert Oxnam discovered he had multiple personality disorder in
1990. Oxnam, or in this case his personality 'Bobby,' performing a
balancing act with bottles in New York's Central Park.
http://www.cbsnews.com/video/watch/?id=890396n&tag=related;photovideo
http://www.cbsnews.com/stories/2005/09/30/60minutes/main892181.shtml
                                                                        98
     Etiology & Treatment of Dissociative Disorders
• Psychodynamic Perspective
   – Dissociative disorders are caused by repression, the most basic ego
     defense mechanism
   – People fight off anxiety by unconsciously preventing painful
     memories, thoughts, or impulses from reaching awareness
   – Repeated, severe sexual or physical abuse with biological
     predisposition toward dissociation, such as fantasy prone
     personality.
• Behavioral Perspective
   – Dissociation grows from normal memory processes and is a
     response learned through operant conditioning
   – Momentary forgetting of trauma decreases anxiety, which increases
     the likelihood of future forgetting

 In Eye Movement Desensitization and Reprocessing (EMDR) therapy, the
therapist attempts to unlock and reprocess previous frozen traumatic memories by
                 waving a finger in front of the eyes of the client.

      In order to treat DID, the therapist has to help recover memories (often
      through hypnosis); merge the subpersonalities into one; further therapy
                           is needed to maintain fusion
              Somatoform Disorders
  Involve physical symptoms that have no organic (biological)
          cause (ulcers, asthma, high blood pressure).

1. Conversion Disorder
  –   Band of Brothers http://www.youtube.com/watch?v=_2NbEV8cFzs

2. Somatization Disorder (Briquet’s syndrome)
3. Pain Disorder Associated w/ Psychological
   Factors
4. Hypochondriasis
5. Body Dysmorphic Disorder
  –   Too Ugly for Love http://www.youtube.com/watch?v=MUKlLpMg-eM&feature=related
  –   Mirror Mirror http://www.youtube.com/watch?v=iAuc2xAM7-8&feature=related
  –   Dr. Phil http://www.youtube.com/watch?v=QMxL1uv9Vh0&feature=related;
      http://www.youtube.com/watch?v=hYJRlPk0ShI&feature=related;
      http://www.youtube.com/watch?v=NvAPYutZUUU&feature=related;
                 Somatoform Disorders
    Involve physical symptoms that have no organic (biological)
            cause (ulcers, asthma, high blood pressure).
Hysterical Somatoform Disorders: suffer actual changes in their physical functioning.
Hard to distinguish from genuine medical problems.
1. Conversion Disorder
    – A psychological conflict or need is converted into dramatic physical symptoms that
       affect voluntary or sensory functioning. Person temporarily loses some bodily
       function. No physical damage to cause problems
    – Symptoms often seem neurological, such as paralysis, blindness, or loss of feeling
    – Most conversion disorders begin between late childhood and young adulthood
    – They usually appear suddenly and are thought to be rare
2. Somatization Disorder (Briquet’s syndrome)
    – Have numerous long-lasting physical ailments that have little or no organic basis.
       Complaints usually vague, undifferentiated (heart palpitations, dizziness, nausea)
    – To receive a diagnosis, a patient must have multiple ailments that include several
       pain symptoms, gastrointestinal symptoms, a sexual symptom, and a neurological
       symptom
    – Patients usually go from doctor to doctor seeking relief.
3. Pain Disorder Associated w/ Psychological Factors
    – Diagnosed when psychosocial factors play a central role in the onset, severity, or
       continuation of pain
    – The disorder often develops after an accident or illness that has caused genuine
       pain. The disorder may begin at any age, and more women than men seem to
       experience it
                Somatoform Disorders
Faking Medical Disorders
1. Malingering
    – Intentionally faking illness to achieve external gain (e.g., financial
      compensation, military deferment)
2. Factitious disorders
    – Intentionally producing or feigning symptoms simply from a wish to be a
      patient
    – Factitious Disorder is Common Among:
        • received extensive medical treatment for a true physical disorder as a
           child
        • family problems or physical/emotional abuse in childhood
        • grudge against medical profession
        • worked in medical field
        • have an underlying personality problem
    - Most Common Factitious Disorders
        • Münchausen syndrome - fake being ill or make oneself ill
        • Münchausen syndrome by proxy – parents make up or produce physical
           illnesses in their children
             Somatoform Disorders
Preoccupation Somatoform Disorders
1. Hypochondriasis
   – Unrealistically interpret bodily symptoms as signs of serious
     illness. Excessive preoccupation with health concerns.
     Assume physician must be incompetent
   – Often their symptoms are merely normal bodily changes, such
     as occasional coughing, sores, or sweating
   – Although some patients recognize that their concerns are
     excessive, many do not
2. Body Dysmorphic Disorder
   – Preoccupation with an imagined or exaggerated defect in one’s
     appearance
        Etiology of Somatoform Disorders
• Psychodynamic Perspective
   – two mechanisms are at work in the hysterical disorders:
       • Primary gain: hysterical symptoms keep internal conflicts out of
         conscious awareness
       • Secondary gain: hysterical symptoms further enable people to avoid
         unpleasant activities or to receive kindness or sympathy from others
• Behavioral Perspective: classical conditioning or modeling
   – physical symptoms of hysterical disorders bring rewards to sufferers
       • may remove individual from an unpleasant situation
       • may bring attention to the individual – sick role
• Cognitive Perspective: oversensitivity to bodily cues
   – Hysterical disorders are a form of communication, providing a means for
     people to express difficult emotions
   – Some people focus excessive attention on their internal physiological
     processes and amplify normal bodily sensations into symptoms of distress,
     which lead them to pursue medical treatment. Tend to have a faulty
     standard of good health, equating health with a complete absence of
     symptoms.
                                                                        104
            Personality Disorders
Enduring or continuous inflexible patterns of thinking, feeling, and
 acting. Start in childhood and continue through adolescence and
adulthood. Personality disorders tend to be lifelong, pervasive, and
  inflexible (which makes them different from clinical disorders in
   Axis I). Tend to be more resistant to treatment than those with
                         clinical disorders.


      3 Clusters of Personality Disorders
          A. eccentric/odd behavior
          B. dramatic/erratic behavior
          C. anxious/fearful behavior

                                                             105
   Cluster A Personality Disorders
Type          Characteristics
Paranoid      Distrust of others, believe people
              out to harm them; could react with
              violence to defend themselves

Schizoid      No social relationships; the
              “hermit”
Schizotypal   Problems with either starting or
              maintaining relationships; odd
              perceptions, emotions, thoughts,
              and behavior
    Cluster B Personality Disorders
Type           Characteristics

Histrionic     Obsessed with being center of attention; very
               dramatic; emotionally shallow person
Narcissistic   Exaggerated belief that he or she is very
               important and has achieved much success;
               arrogant
Borderline     Instability of emotions, impulse control,
               obsessive fear of being alone, difficulty
               maintaining relationships and routines
Antisocial     No feelings of regard for others or their welfare;
               lack of conscience or remorse; most heavily
               studied personality disorder; sociopath and
               psychopath have been used to describe this
               disorder.
       Cluster B Personality Disorders
Psychopathy vs. ASPD
• Psychopathy - focuses primarily on underlying
   personality traits (e.g., being self-centered or       “Social predators who
   manipulative)
• ASPD - focuses primarily on observable
                                                         charm, manipulate, and
   behavior (e.g., impulsivity, repeatedly changes     ruthlessly plow their way
   jobs)                                                  through life, leaving a
ASPD vs. Criminality
• “criminal” is a legal term denoting conviction
                                                           broad trail of broken
   for breaking a law:                                       hearts, shattered
     – not all people with ASPD are criminals (or       expectations, and empty
        in jails)
     – not all people in jail or considered criminal
                                                           wallets. Completely
        have ASPD                                      lacking in conscience and
     – not all people with ASPD are psychopaths          empathy, they selfishly
ASPD Influences & Treatment                             take what they want and
• deficient emotional arousal and conditioning is
   associated with a lack of empathy, thrill-seeking        do as they please,
• punishment of offenders not likely to be very        violating social norms and
   effective for rehabilitation                         expectations without the
• programs like “Scared Straight” and boot camps
   make kids with ASPD potential worse rather           slightest sense of guilt or
   than better                                                   regret.”
• “getting tough” with this population not likely
   to work
                                                          Robert Hare (1993)
                                                                          108
                 Etiology of Antisocial PD
Biological::
• Reduced activity in the frontal lobe,
   which is responsible for planning and
   organization.
Socio-cultural:
• Dysfunctional family, lack of positive
   parenting, attachment problems that
   appeared in early childhood, and
   childhood trauma.
• Living in a high crime neighborhood
   Cluster C Personality Disorders
Type         Characteristics
Dependent    An enormous need to be taken
             care of; cannot make
             decisions; very needy
Obsessive    Obsession with order and
Compulsive   control; perfectionist
Avoidant     Oversensitive to criticism;
             does not partake in social
             situations.
What about Bob? Dependent Personality Disorder




     http://www.youtube.com/watch?v=GCfq7yistd4
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