Psychological Disorders
Chapter 13
Introductory Psychology
Steven Isonio, Ph.D
Golden West College
In this unit, we will learn about behavioral and mental deviations that meet the criteria for
consideration as disorders.
We will address the issue of how to define “disorder” and appropriate criteria to use. We will
then cover some of the major psychological disorders, describing symptoms and causes.
Some other terms you might encounter:
Behavioral Disorder
emphasis on overt behavior
Mental Illness
emphasis on mental disturbance
Psychopathology
disease model
Abnormal psychology
emphasis on deviation from norm
Psychological Disorder
disorders of behavior and mental processes
Psychological Disorders
Criteria
Statistical Deviation/ “abnormal”
Abnormality as deviation from the average
Literally abnormal--not the norm
Unusual, rare
Uncommon, atypical
A caution: strictly speaking, this could include behaviors like wearing glasses or writing
with your left hand.
Psychological Disorders-Criteria
The behavior deviates from social norms:
Acting in unexpected ways is indicative of abnormality
Violating social norms-- societal rules for acceptable behavior.
Context, of course, is critical.
Psychological Disorders
Criteria
Causes distress (to self/others)
The behavior is troubling to the person and to people around him/her.
It causes discomfort and often a desire to change/relief the behavior.
Notion of “abnormality as a sense of personal distress”
Psychological Disorders
Criteria
Impairs Functioning
>Interferes with everyday life and the roles we fulfill--significantly impaired as a student,
worker, citizen, parent, friend, etc.
>The behaviors or thoughts “get in our way” and cause problems.
>Because of this, the person might get into some sort of trouble--e.g., lose a job, drop out
of school, or become homeless.
Psychological Disorders
Criteria
Cognitive Disturbance
Our perceptions, thoughts, and feelings are distorted.
This can range from a mildly distorted self-concept, to obsessive thoughts, to very bizarre
delusions and hallucinations.
Psychological Disorders
Criteria
Clinically significant
Part of a pattern that is recurring, is not trivial, and which cannot be explained in some
other way.
The symptoms are not a “fluke”.
Warning Signs
http://www.psych.org/public_info/warnings.cfm
Understanding ABNORMALITY by considering what is NORMAL
What is normality?
Accurate perception of reality
Self-esteem
Achievement
Good relationships
Productivity
Self-directed behavior
Responsible
Being satisfied/happy
Psychological Disorders
Perspectives
Various perspectives . . .
Another view the myth of mental illness
Thomas Szasz, a renowned critic of psychiatry:
“The organic psychiatrist believes that the brain ‘secretes delusions’ just as the kidney
secretes urine”
“The concepts of mental health and mental illness are mythological concepts, used
strategically to advance some social interests and to retard others”
Explaining Psychological Disorders
Explanation is difficult because:
-many causal factors are involved, and
-they interact in complex ways to produce disordered behavior.
Explaining Psychological Disorders--Genetic factors
Biological psychology has established the existence of a genetic contribution to several
disorders, including schizophrenia, mood disorders, as well as others.
Explaining Psychological Disorders--Physiological factors
When our nervous system does not function properly for any of a variety of reasons,
disordered behavior and thought can result.
For example . . .
The striking symptoms of Alzheimer’s Disease are due to its degenerative effects in the
brain
Explaining Psychological Disorders –
Stress as Trigger
Stressors in our life impair our ability to cope effectively.
Often stressors serve as the triggers for onset of disordered symptoms. They have
negative impacts on both physiology and psychology.
Stressors cause symptoms to become manifest and make existing symptoms worse.
Stress and Disorders
Too much stress can distract us from the tasks of life.
Our body’s resources are exhausted by dealing with the stress.
Our nervous system changes in response to stress.
Our behavior and mental processes are affected.
Explaining Psychological Disorders--Cognitive factors
How we think about ourselves and the world can be both a cause and an effect of a
disorder.
Our mental representations of the world are often vital to our well-being--or lack thereof.
Thoughts can affect behavior and biology.
Explaining Psychological Disorders
--Early Experiences and learning
Early experiences play a significant role in shaping our later life.
If the developmental process is thwarted in any way, psychological symptoms may result.
Psychological Disorders
Some (very brief) History
Psychological Disorders-Historical Perspective
Our understanding of psychological disorders has changed greatly over the years.
In the Middle Ages, persons suffering from disorders were thought to be evil, and were
treated in various barbaric ways.
Historical Perspectives
Around the turn of the century, the first mental hospitals (asylums) were opened.
In the US in the mid-1800’s, Dorthea Dix was a strong advocate for the humane treatment
of the mentally ill.
Even today, the struggle to promote recognition of major psychiatric illnesses as brain
diseases continues.
For you to think about. . .
How are the mentally ill viewed today in society? Are we living in a more “enlightened”
age? Interview some of your friends and fellow students to determine their views regarding
the mentally ill.
Psychological Disorders
Prevalence
Prevalence--How common/rare are psychological disorders?
Over one-third of all Americans at some time in their life will suffer from a psychological
disorder. Most common are Anxiety Disorders and Mood Disorders.
Mental illnesses are more common than most of the major medical disorders, such as
cancer and heart disease.
Other Facts about Mental Illness
Of American adults, about 6% have a serious mental illness. Almost half of these persons
are between the ages of 25 and 44.
Four of the leading causes of disability in the US are mental disorders--depression, bipolar
disorder, schizophrenia, and obsessive-compulsive disorder.
Over one-fourth of hospital admissions are for psychiatric purposes.
16% of state prison inmates and 7% of federal inmates have reported mental illnesses.
YET, treatment efficacy rates for schizophrenia and mood disorder range between 70-80%
Worldwide:
From the World Health Organization--THE BARE FACTS:
450 million people worldwide are affected by mental, neurological or behavioral problems
at any time.
About 873,000 people die by suicide every year.
Mental illnesses are common to all countries and cause immense suffering. People with
these disorders are often subjected to social isolation, poor quality of life and increased
mortality. These disorders are the cause of staggering economic and social costs.
One in four patients visiting a health service has at least one mental, neurological or
behavioral disorder but most of these disorders are neither diagnosed nor treated.
For you to think about. . .
How are statistics about prevalence of disorders likely gathered? What are some factors that might
influence the validity of these figures?
Psychological Disorders
Diagnostic & Statistical Manual of the American Psychiatric
Association
The Diagnostic and Statistical Manual of the American Psychiatric Association
The DSM-V contains diagnostic criteria for over 20 major categories of psychological
disorders.
This book is used by clinicians to pinpoint a diagnosis.
It is a “living document”, periodically revised.
Some major diagnostic categories
The DSM-V lists diagnostic criteria for recognized disorders.
It provides details of symptoms associated with the disorders.
Because of this standardization, effective communication is facilitated--we are all “on the
same page”.
Multi-axial System
Axis I: Clinical disorder(s)
Axis II: Mental retardation or personality disorder?
Axis III: General medical condition
Axis IV: Psychosocial/environmental factors
Axis V: Global Assessment of Functioning
Diagnostic Categories
Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
Mental Retardation
Learning Disabilities
Pervasive Developmental Disorders, e.g, Autistic Disorder, childhood disintegration
disorder
Tic Disorders
Elimination Disorders
Attention-Deficit Hyperactivity Disorder
Mental Retardation
Significantly subnormal intelligence (Measured IQ <= 70; descriptors: mild, moderate,
severe, profound)
Causes:
trauma: 5%
heredity: 5%
pregnancy/delivery problems (includes FAS): 40%
social/intellectual deprivation: 50%
Reported in Axis II (general intelligence level)
Autistic Disorder
Early onset; pervasive.
Marked impairment in social interaction (esp. eye contact)
Marked impairment in communication; if speak: echolalia, pronoun reversal (”he” for “I”,
etc.)
Restricted repetitive and stereotyped patterns of behavior, interests, and activities;
preference for “sameness”
Sensory impairments: hypersensitive or oblivious
Explaining Autistic Disorder
Old view: parenting behavior
Today: generally seen as a problem with brain development, e.g., right temporal lobe
dominance (language deficit); increased size of amygdala (temper, head banging);
increased size of basal ganglia (motor disturbances).
From: genetic factors, prenatal abnormalities
Tic Disorders
Best example: Tourette’s Syndrome:
Multiple motor tics and one or more vocal tics occur many times a day (typically in
bouts) nearly every day for over a year.
Tic = sudden, rapid, recurrent, non-rhythmic (“jerky”), stereotyped motor movement or
vocalization
e.g., coprolalia
Tourette’s Syndrome
Video – either later today, or next time, depending on time . . .
Schizophrenia
Schizophrenia is a psychotic disorder--the patient has to some extent lost contact with
reality.
Major symptoms include:
>disorganized thought
>hallucinations
>delusions
>distortions of affect and movement
Probably many disorders
Disorganized Thought
Loosely associated ideas, disorganized, often incoherent thoughts– a ”flight of
ideas”
Hallucinations
Delusions
Delusions are beliefs that are inconsistent with reality.
They can range from mild to bizarre.
They often relate to paranoid, grandeur themes.
Distortions of Affect and Movement
Affect = emotions/feelings
The distortion can be: flat/absent or inappropriate.
Movement = motor activity
The distortion can be “too much” (hyperkinetic) or “too little” (catatonic)
Imagining what it’s like to have a mental illness--Schizophrenia
Have you gone for 24 hours without sleeping? Longer? How did you feel? How did you
look?
Have you dozed off for a second, awakened with a start and didn’t know where you were?
How did you feel?
Have you ever lost your sunglasses or keys and no matter what you did, you couldn’t find
them? How did it make you feel?
Have you ever suddenly got your directions mixed up? North and south reversed,
confused? How did you feel?
Have you ever had a little tune in your mind for a couple of hours and no matter what you
did it still bothered you? How would you feel if that same tune or a voice or a thought
went through your mind for days, weeks, months?
Major Subtypes of Schizophrenia
Paranoid – paranoid theme to delusions and hallucinations
Catatonic – immobility or excessive motor activity
Disorganized – disorganized speech, bizarre behavior, inappropriate affect
Undifferentiated – mixed symptoms
Residual – primarily negative symptoms
Two Schizophrenias?
Positive Symptoms – hallucinations, delusions, flight of ideas
Negative Symptoms – flat affect and amotivational character, poverty of speech and
thought, asocial
Schizophrenia A and Schizophrenia B
A (Positive Symptoms) - symptoms are “add-ons”; cause is neurochemistry; treatment is
medication; prognosis is fairly positive.
B (Negative Symptoms) - symptoms are “deficits”; cause is brain damage; treatment is
institutionalization / attempt medication; prognosis is poor.
Understanding Schizophrenia
Previously: double-bind (psychosocial)
Modern:
Genetics
Dopamine hypothesis
Ventriculomegaly
Environmental contributions, stressors
= “Neurodevelopmental hypothesis”
One view of the possible causal structure of schizophrenia: The neuro-developmental
model
Flu Virus
Flu during pregnancy linked to schizophrenia in offspring
Study used samples of blood from '59-'66
Boston Globe | August 3, 2004
Children whose mothers have the flu during the first 20 weeks of pregnancy may be more
likely to develop schizophrenia as adults, suggests a study that used four-decades-old
blood samples to examine the suspected link.
Researchers at Columbia University used a collection of blood that had been saved from a
separate study. They used blood samples of women who were pregnant from 1959 to
1966, looked for antibodies to the influenza virus, and tracked down whether their offspring
had developed schizophrenia. They found that the risk of the mental illness was three
times greater for children whose mothers got the flu during the first half of pregnancy.
Video Segment
Schizophrenia -- (approx. 5mins.)
Somatoform Disorders
Physical symptoms without any identifiable physiological cause.
These can range from mere preoccupation with illness to the more dramatic loss of use of
a limb, loss of vision or hearing.
Somatoform Disorders
Hypochondriasis - preoccupation with fear of illness; hyper-vigilant about signs of illness
Conversion disorder - loss of function of part of body (formerly histrionic disorder)
Body dismorphic disorder - preoccupation with an imagined body deficit
Help for Imaginary Suffering
Associated Press -- Wednesday, March 24, 2004
A study has found that six sessions of cognitive behavioral therapy can help
hypochondriacs deal with their fears, but the treatment has its limits: A quarter of the
patients quit after being told the problem is in their heads.
"Most hypochondriac people never will go to a psychiatrist," said study co-author Arthur
Barsky of Harvard Medical School and Brigham and Women's Hospital in Boston. "They'll
say, 'I don't need to talk about this, I need somebody to stick a biopsy needle in my liver, I
need that CAT scan repeated.' "
Body Dismorphic Disorder
Desperate Patients Resort to DIY Plastic Surgery
LONDON - Desperate patients suffering from a body image disorder who are refused,
can't afford or are dissatisfied with plastic surgery sometimes resort to dangerous do-ityourself (DIY) techniques, British doctors said on Wednesday.
Patients with body dysmorphic disorder (BDD), who are preoccupied with an imagined
defect in their appearance, have performed home liposuction for slimmer thighs and
stapled their skin to keep it taut. Others have sawed down teeth to change the appearance
of the jaw and used sandpaper to remove facial scars and to lighten the skin.
Video Segment:
Body Dysmorphic Disorder
Mood Disorders
Disturbances of normal mood/affect
Two major types: Unipolar depression and bipolar affective disorder.
Major Depression
(unipolar)
Mood disturbance is in the depressed direction.
Low energy, sense of hopelessness, sleep disturbance, anhedonia, lack of interest in
living, sense of worthlessness, depressed mood most of the time for many days.
Distorted Thinking (cognitive disturbance) is often a part of Depression
Bipolar affective disorder
-Intermittent periods of
mania (elevated mood, energy, optimism), and depression (sad, hopelessness, low
energy, and possibly, suicidal)
-the CYCLE can take on any of
many possible patterns
Life Events and Bipolar Disorder
Factors related to onset and timing of cycles
Circadian disruptions - daily cycles are interrupted; note: role of sleep disturbance (a
cause or an effect?)
Bio-behavioral Regulation - some persons have more “volatile” nervous systems and
are therefore more prone to variation in moods (as, greater variance)
Kindling - previous experiences with stressors and depressed episodes makes person
more vulnerable to future stressors
Imagining what it’s like to have a mental illness--Depressive illness
Nothing seems enjoyable or fun anymore.
You suddenly find it difficult or impossible to remember anything you read. You can’t
concentrate on what your boss or teacher says.
You live in a black and white and gray world. Someone “pulls the plug” on the energy in
your body.
Simple things you used to do automatically like deciding what to wear or which radio
station to listen to take enormous effort.
You wake up every morning and can’t think of one good reason to get up. You wish you
had died in your sleep.
High risk of suicide
The majority of the approximately 50,000 people who commit suicide each year in the U.S.
suffer from depression.
Dysthymia
(a particular type of mood disorder)
Chronic, low-level depression of more than two years duration, with brief intervals of
normal mood. Effects are more subtle than major depression.
In a sense, dysthymia is long-term, “mild” depression.
Understanding Depression
Causal Factors:
Serotonin levels
Stressors/trauma; virus
Genetics
Hormone changes
Cognitive distortions
Reduced exposure to light;
Seasonal affective disorder
Hemispheric asymmetry (depressed have lower left frontal lobe activity levels)
Sub-syndromal Depression
Recent large scale study:
4% of population meets criteria for depression
11% have significant sub-syndrome level symptoms
Implications -- two views:
“The findings underscore the view that depression is not a singular disease entity, but
instead encompasses a range of symptoms of varying intensity.”
“People are trying to make an illness about what seems like life’s ups and downs.”
To treat or not to treat?
Video Segment
Mood Disorders
Anxiety Disorders
Anxiety (a form of fear) is inappropriate to the situation.
may result from an inappropriate stimulus
may be extreme and uncontrollable
or, the person may not know why s/he is so anxious.
Simple(specific) Phobias
Anxiety concerning a specific stimulus--airplanes, closed spaces, spiders, fire, heights, etc.
This anxiety is clinically significant, causing much distress and avoidance behavior.
Obsessive-Compulsive Disorder
Persistent obsessions (thoughts) and compulsions (behavior tendencies) cause distress
and interfere with normal life.
Obsessions are the “itch” and compulsions are the “scratch”; anxiety is the root cause.
Counting and checking are common elements of OCD. Common themes relate to germs,
losing control and doing/saying something horrible, order and precision, etc.
Post-traumatic Stress Disorders
Periodic severe delayed reaction to some traumatic event (e.g., being assaulted, losing
one’s home in a disaster, combat, seeing someone murdered).
Nightmares, flashbacks, psychological numbness, persistent thoughts of the traumatic
event(s).
Panic Disorder
Recurrent panic attacks--sudden, unpredictable, overwhelming fear/panic without a
reasonable cause.
Panic attack=Palpitations, sweating, trembling, shortness of breath, chest pain, feeling of
choking, feel dizzy, fear losing control, nausea, de-realization
Although they are often related to life events and thoughts about such events, they can
occur “when least expected”, even in the midst of a night’s sleep.
Agoraphobia
Fear of being in places or situations from which escape might be difficult. Common
difficulties: being out in public, driving, in a crowd, out of one’s home, often due to a fear
of embarrassing themselves.
Agoraphobia can be extremely debilitating.
Video Segment
Anxiety Disorders –
Three anxiety disorders – simple phobias, generalized anxiety disorder, panic disorder
Factitious Disorders
Disorders characterized by physical or psychological symptoms that are intentionally produced or feigned in
order to assume the sick role.
The motivation is not for financial gain.
Munchausen Syndrome by Proxy
Technically, this is not a factitious disorder.
In this case, the false symptoms are created in a second person (usually a young child) by
(usually) the mother.
-e.g., The mother might poison or suffocate the child, prevent wounds from healing,
cause infections, etc.
Dissociative Disorders
Involve some dissociation (separation from, loss of, breakdown of) one’s identity, e.g.,
Dissociation from memories (amnesia)
Dissociation from one’s entire past (fugue)
Dissociation from one’s identity (Dissociative Identity Disorder) . . .
Dissociative Disorders:
Fugue
Dissociative fugue is very rare.
The person suffers complete amnesia, typically leaves home and assumes an entirely new
identity.
Dissociative Disorders:
Dissociative Identity Disorder - the presence of two or more distinct personalities within
one body
Formerly: Multiple personality disorder. Note this is NOT schizophrenia!!
Dissociative Identity Disorder
Is it a “real” disorder??
Views:
-it is actually role-playing, taken to an extreme degree
-the separate personalities are indeed different
Evidence:
dramatic differences--tastes, medical needs, etc.
Case of Kenneth Bianchi (Hillside strangler) -- Martin Orne suggested third “personality”
More about the Bianchi case:
From the Judge’s in the Bianchi case:
“Mr. Bianchi caused confusion and delay in the proceedings. In this, Mr. Bianchi
was unwittingly aided and abetted by most of the psychiatrists, who naively
swallowed Mr.Bianchi’s story, hook, line, and sinker, almost confounding the
criminal justice system.”
Sexual Disorders
Two major types--sexual dysfunction and paraphilias (sexual deviations).
Dysfunction involve problems functioning effectively, e.g., sexually--sexual aversion,
impotence, frigidity.
Deviations involve directing sexuality in inappropriate ways.
Sexual Dysfunctions
Difficulties related to appropriate sexual interest, arousal, performance.
Examples include: hypoactive sexual desire disorder, sexual aversion disorder, male
erectile disorder, female orgasmic disorder, premature ejaculation, etc.
Sexual Dysfunctions, e.g.,
Details of hypoactive sexual desire disorder and male erectile disorder, as examples:
Hypoactive: persisent deficient/absent sexual fantasies and desire for sexual activity.
Erectile: persistent or recurrent inability to attain, or maintain until the completion of the
sexual activity, an adequate erection.
Paraphilias
(Formerly “sexual deviations”)
Include exhibitionism and voyeurism, fetishism, sado-masochism, pedophilia, transvestic
fetishism, among many others.
Gender identity disorder = strong, persistent cross gender identification; discomfort with
own sex; transsexual; not an intersex (hermaphrodite) and not necessarily homosexual.
Eating Disorders
Bulimia - episodes of binge eating; compensatory behavior (e.g., vomit, laxatives,
exercise); preoccupation with body shape.
Anorexia - weight < 85% normal; intense fear of gaining weight; persistent body image
distortion.
Sleep Disorders
Sleep disorders fall into two categories:
Dyssomnias - difficulty with sleeping, per se (too much, too little, etc.)
Parasomnias - difficulties related to sleeping, but not involving sleep, per se.
Dyssomnias
Including:
Insomnia; hypersomnia
Narcolepsy
Sleep apnea
Periodic Leg Movements
REM sleep behavior disorder
Parasomnias
Including:
Nightmares
Sleep terror
Sleepwalking (somnambulism)
Impulse Control Disorders
For example:
Intermittent explosive disorder
Kleptomania
Pyromania
Pathological Gambling
Trichotillomania
Personality Disorders
Personality Disorders
Personality disorders are characterized by pervasive, inflexible, maladaptive ways of
thinking and behaving.
The person’s entire personality is colored by this pervasive orientation.
Personality Disorders—not rare
Personality Disorders Common in U.S.
Personality disorders are much more common in the United States than researchers had
thought, affecting nearly one in seven adult Americans, a new survey finds. Researchers
say that 31 million people, or 15 percent of the adult population, suffer from at least one
type of personality disorder.
Roughly half of these people had obsessive-compulsive personality disorder, and a sizable
minority were paranoid and harbored an unusual distrust of others, according to the
review. "This is the first national survey ever conducted on the prevalence of seven of the
10 personality disorders," said Bridget Grant, lead author of the study, which appears in
the July issue of the Journal of Clinical Psychiatry.
Personality Disorders:
Three Clusters
Cluster A: ODD OR ECCENTRIC
Cluster B: ERRATIC OR EMOTIONAL
Cluster C: ANXIOUS OR FEARFUL
Personality Disorders
(Cluster A: Odd/Eccentric, e.g., Paranoid PD)
A pervasive distrust and suspiciousness of others such that their motives are
interpreted as malevolent, beginning by early adulthood and present in a variety of
contexts, as indicated by four (or more) of the following:
suspects, without sufficient basis, that others are exploiting, harming, or
deceiving him or her
is preoccupied with unjustified doubts about the loyalty or trustworthiness of
friends or associates
is reluctant to confide in others because of unwarranted fear that the information
will be used maliciously against him or her
reads hidden demeaning or threatening meanings into benign remarks or events
persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights
perceives attacks on his or her character or reputation that are not apparent to
others and is quick to react angrily or to counterattack
has recurrent suspicions, without justification, regarding fidelity of spouse or
sexual partner
Personality Disorders
(Cluster B: Erratic/Emotional, examples)
Borderline = instability in interpersonal relationships, mood (depressed, angry), identity
(complains of being “empty”), and behavior (impulsive, self-mutilating)
Histrionic = wants to be center of attention, acts in dramatic ways, is suggestible, shifting
and shallow emotions, believes relationships are more intimate than they actually are
Narcissistic = preoccupied with success, power, beauty; lacks empathy; arrogant; exploits
others; believes self to be “special”; exaggerated sense of self-importance
Personality Disorders
(Cluster C: Anxious/Fearful, examples)
Avoidant = avoids interpersonal contact due to fear of criticism or rejection, views self as
inept or inferior, reluctant to take personal risks
Dependent = difficulty making decisions without help, does not assume responsibility,
seeks relationships to get nurturance or support, difficulty disagreeing or taking initiative
Obsessive-compulsive = preoccupied with details, rules, lists, schedules; shows
perfectionism; overly consciousness and inflexible; rigid and stubborn; cannot discard
worthless projects; reluctant to delegate responsibility.
Looking Ahead
Beyond DSM-V
The DSM is truly an evolving document.
Certainly more changes in how we view specific disorders will take place.
For example, schizophrenia will probably be viewed as at least two distinct disorders.
Abnormal Psychology after the Decade of the Brain
Our understanding of the biological basis for many disorders has revolutionized our view of
the cause and treatment of them.