Classifying Disorders: the DSM (Diagnostic and Statistical Manual of Mental Disorders)

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Adrian Domenic Clark
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1 Psychological Disorders Defining and Diagnosing Disorder Dilemmas of Definition Mental disorder as a violation of cultural standards o Many specific to certain time or group Mental disorder as emotional stress o Based on person s suffering, depression, anxiety, incapacitating fears Mental disorder as behaviour that is self-destructive or harmful to others Mental disorder o Any behaviour or emotional state that causes an individual great suffering, is self destructive, seriously impairs the person s ability to work or get along with others, or endangers others or the community Dilemmas of Diagnosis Classifying Disorders: the DSM (Diagnostic and Statistical Manual of Mental Disorders) Evaluate according to five axes o Primary problem, such as depression o Ingrained aspects of client personality likely to affect person ability to be treated o Medical conditions or medications that might contribute to symptoms o Social and environmental stressors that make the disorder worse o Global assessment of clients overall level of functioning DSM continually updated, important to distinguish disorders precisely to treat them properly Problems with DSM The Danger of Overdiagnosis o Everyone has symptoms of the disorder o ADHD, fastest growing disorder Overused, most people with ADHD symptoms declined over time The power of diagnostic labels o Reassures people seeking an explanation o Once person diagnosed, people see disorder as permanent, official condition, overlook other explanations Confusion of serious mental disorders with normal problems o Implies everyday problems comparable to disorders? Likely to require treatment? Illusion of objectivity and universality o Many decisions based not on empirical evidence but group consensus

2 Prejudice in past notion of mental problems Samuel Cartwright o Drapetomania o Crazy runaway slave Reflect cultural prejudices and lack empirical validation Advantages Help clinicians distinguish among disorders that share certain symptoms Highest risk of suicide Native American men, group at lowest risk African American women Culture bound syndromes Disorders specific to particular cultural contexts Sometimes overlap with DSM categories Japan taijin kyofusho o Disorder in which person feels intensely frightened and irrationally embarrassed that his or her body parts Brain fag o Mental exhaustion of west Africans brains Amok o Violent murderous outburst in Malaysian men Ataque de nervous o Uncontrollable screaming, crying, and agitation Ghost sickness o Preoccupation with death among natives Piblokotoq o Episodes of extreme excitement amongst Inuit s Qi gong psychotic reaction o Chinese have mental symptoms Zar o North Africa belief in possession of spirit causing shouting, laughing Dilemmas of Measurement Projective tests Psychological tests used to infer a persons motives, conflicts, and unconscious dynamics on the basis of the person s interpretations of ambiguous stimuli (pictures, sentences, or stories) Help clinicians establish rapport with clients

3 Tests lack reliability and validity when assessing traits and disorders o Clinicians interpret persons scores differently, projecting own beliefs and assumptions when they decide o Test score affected by sleepiness, hunger, medication, worry, verbal ability, and own personality Rorshach Inkblot Test o Consists of 10 cards of patterns o Test takers interpret what they see on these inkblots, clinicians interpret answers according to symbolic meaning o Does not properly diagnose depression, posttraumatic stress Comprehensive System o Significant reliability and validity problems Use tests for children unable to express feelings verbally Some therapists used it to determine whether a child has been abused o Use a doll to determine if sexual abuse o Did not test belief with non-abused children, both abused and non-abused groups fascinated with doll s genitals Often used inappropriately in child custody assessments, No scientific justification Objective Tests Standardized objective questionnaires requiring written responses; they typically include scales on which people are asked to rate themselves Minnesota Multiphasic Personality Inventory o Organized into validity scales and scales Generally more reliable and valid Limitations o Don t take into account difference in cultural groups o Significant rate of false positives, label a person s responses as evidence of mental disorder when no problem exists Anxiety Disorders Anxiety, general state of apprehension or psychological tensions Chronic anxiety, long lasting feelings of apprehensions Panic attacks, short lived but intense anxiety Phobias, excessive fear of specific things or situations OCD repeated thoughts and rituals to reduce anxiety

4 Anxiety and Panic Generalized anxiety disorder o Continuous state of anxiety marked by feelings of worry and dread, apprehensions, difficulties in concentration, and signs of motor tensions o Some live through anxiety without a specific producing event (sweaty palms, racing heart, shortness of breath) o Everything perceived as opportunity for disaster Posttraumatic stress disorder o Anxiety disorder in which a person who has experienced a traumatic or life threatening event has symptoms such as psychic numbing, reliving of the trauma, and increased physiological arousal o Brain scans show detachment of PSTD patients was accompanied by increased activity across the lobes of the brain o Most activity in prefrontal cortex around brain o Originally thought trauma shrunk hippocampus Turns out PTSD RESULT of small hippocampus o PTSD may be result of genetic predisposition, or prior history of psychological problems and other traumatic experiences o Also more self-defeating, lack social and psychological resources EXISTS BEFORE TRAUMA TAKES PLACES Panic Disorder Anxiety disorder in which a person experiences recurring panic attacks, periods of intense fear, and feelings of impending doom or death, accompanied by physiological symptoms such as heart rate and dizziness Result of aftermath of stress ESSENTIAL DIFFERENCE Lies in how they interpret bodily reaction o People who panic attack happens think they are dying o People with no disorder will shrug it off Fears and Phobias Phobia o Exaggerated unrealistic fear of a specific situation, activity, or object o Acquired through reflected real dangers, personality differences, or observation of frightening events o Social phobia Anxious in situations where observed by others, eating in a restaurant, speaking in front of a group of people, or performing to others

5 Agrophobia o A set of phobia, often set off by a panic attack, involving the basic fear of being away from a safe place or person o Fear of being trapped in a public place fear of fears Obsessions and Compulsions OCD o Anxiety disorder in which a person feels trapped in repetitive, persistent thoughts (obsessions) and repetitive, ritualized behaviours (compulsions) designed to reduce anxiety o Obsessive thoughts reflect impaired ways of reasoning and processing info o People have no control over compulsions Realize behaviour is senseless, tormented by their rituals If they forgo it, tormented by anxiety, must give in o Prefrontal depleted of serotonin, several brain parts hyperactive in people o Feel in constant danger to due to constant firing of signals o Example is hoarder, less activity in brain parts involved in decision making Mood Disorders Depression Major depression o Mood disorder involving disturbances in emotion (excessive sadness), behaviour (loss of interest in one s activities), cognition (thoughts of hopelessness), and body function o Feel hopeless, think of death and suicide often, exaggerate minor failing, ignore or discount positive events o May overeat, difficulty falling asleep, headaches or inexplicable pain Bipolar Disorder Bipolar disorder o Episode of depression and mania occur Wired, irritable when thwarted Feeling of power, plans based on delusional ideas, thinking they have solved the world s problems Rarer, distinctly different, occurs equally Many people produce best work, but at high cost Diagnosed amongst many children

6 Origins of Depression Vulnerability stress model o Approaches that emphasize how individual vulnerabilities interact with external stresses or circumstances to produce mental disorders Genetic factors o Moderately heritable disorder o Unlikely a single gene directly or inevitably causes severe depression o Long form of one gene apparently helps protect people, short form makes them vulnerable May affect levels of serotonin and other neurotransmitters Affect production of stress hormone cortisol o Depressed patients, the system that regulates reactions to stress in overdrive, overproduces cortisol Life experiences and circumstances o Violence a powerful experience that generates depression o Violent relationship increased rates of depression and anxiety o Higher depression rates among women not due to sexual abuse, more the result of depression o Also condition of people s lives, satisfaction with work and family o Men more likely to have jobs and marriage, become less depressed o Women more likely than men to live in poverty and suffer from discrimination o Childhood maltreatment associated with high risk of adult depressive episodes Prolonged stress puts body s responses to stress in overdrive, overproduces stress hormone cortisol Cognitive Habits Involves specific, negative ways of thinking about one s situation Depressed people believe their situation is permanent and uncontrollable o Do nothing to improve their lives and remain unhappy o Nothing good will ever happen, powerless to change the future Rumination o Brooding about everything wrong in life, sitting alone thinking about how unmotivated you feel, persuading yourself no one loves you Losses of important relationships o Among women, when rumination is combined with stressful experiences, very highly correlated with depression

7 Personality Disorders Problem Personalities Unchanging, maladaptive traits that cause great distress or an inability to get along with others Paranoid personality disorder o Disorder characterized by unreasonable, excessive suspiciousness and mistrust, irrational feelings of being persecuted by others Narcissistic Personality Disorder o Disorder characterized by an exaggerated sense of self important and selfabsorption o Fantasies of their own importance, power, and brilliance Borderline Personality Disorder o Disorder characterized by intense but unstable relationships, a fear of abandonment by others, an unrealistic self-image, and emotional volatility o Abuse drugs, cut themselves, threaten suicide Cultures differ in how they draw the line, depends on the group Criminals and Psychopaths Psychopathy o Personality disorder characterized by a lack of remorse, empathy, anxiety, and other social emotions; the use of deceit and manipulation; and impulsive thrill seeking o Use charm to manipulate others, some very sadistic, others direct energies into con games o Common in western societies o Yupik in Canada describe them as kunlangeta o DEFINING ESSENCE IS HEARTLESSNESS AND CHARM Antisocial personality disorder o Disorder characterized by lifelong pattern of irresponsible, antisocial behaviour such as lawbreaking, violence, and other reckless impulsive acts o Revision of psychopathy o Repeatedly break the law, seek quick thrills, reckless o History of problems since childhood o People with APD not necessarily psychopaths Most psychopaths meet criteria of APD, those with APD not necessarily psychopaths Gary Ridgeway o Killed 48 women in clusters around US Chris Rocancourt

8 o Adopted false identities Several Factors involved in the disorder Abnormalities in the central nervous system o Have low physiological arousal o Electrical conductance in skin doesn t shift when exposed to danger, pain, or punishment, like it normally would in a regular individual Impaired frontal lobe functioning o Both psychopaths and APD have impulsivity, inability to control responses to frustration and provocation o Leads to breaking rules o Abnormalities in prefrontal cortex, responsible for planning and impulse control o Murderers have less brain activity and less grey matter o May be result of physical neglect or accidents/abuse as child Genetic Influences o Genes account for 40-50% of variation in antisocial behaviour o Those with deficiency in gene and had been physically abused grew up to be violent, those who had gene but weren t physically abused didn t Environmental events o Poor nutrition in first three years of life o Can disrupt pathway and alter ways that genes express themselves Overall APD and psychopathy reflect genetic vulnerabilities and also experience Drug Abuse and Addiction substance abuse o pattern of substance use leading to significant impairment or distress o impairment means failure to hold job, use drug in hazardous situations, conflicts over drugs Biology and Addiction strongest evidence to date is not that genes are involved with alcoholism but with protection against alcoholism genetic factor that causes low activity of an enzyme important in metabolizing alcohol, very common amongst Asians genes MIGHT contribute to trait that predispose a person to become alcoholic heritable component in the kind of alcoholism that begins in adulthood, unrelated to other disorders genes affect sensitivity to alcohol, how much needed to drink, tolerate some inherit vulnerability to specific drugs, such as nicotine

9 o produce variation in nicotine receptors, one reason people vulnerable can become addicted to cigarettes, while others can easily quit usual way to look at relationship is biological factors cause the addiction, also evidence of the reverse order Learning, Culture, and Addiction addiction patterns vary according to cultural practices and the social environment o some accept drunkenness in adults, while others condemn drunkenness o in cultures with low alcoholism rates, adults demonstrate correct drinking habits to children o alcoholism more likely in societies that forbid children to drink, but condone adult drinking o cultural environment especially crucial for the development of alcoholism youths of native America developed drinking problems when encouraged by parents, those who stuck to religious traditions less likely o in colonial period in US, average American drank two-three times amount of liquor consumed today with family, yet alcoholism was not serious problem o when frontier expanded, drinking symbolized masculine and toughness, people stopped drinking with families alcoholism rates shot up disease model assumes consequences of drug use are automatic, if children are given any taste of a drink or drug more likely to become addicted (however results in increased likelihood substance abuse) learning model assumes cultural context is crucial in determining whether people will become addicted or use drugs moderately (this method result is less likely to have substance abuse) Policies of total abstinence tend to increase rates of addiction rather than reduce o Prohibition reduced overall drinking, but increased rates among those who did drink o When substance is forbidden it becomes more attractive Not all addicts have withdrawal symptoms when they stop taking a drug o Expectations and setting have a powerful influence on drugs physiological effects Addiction does not depend on properties of the drug alone but also on reasons for taking it o Depends more on the motives and norms of the peer group, than on chemical properties of the drug o Those looking to escape world more likely to abuse drug then those who use it for social purposes

10 Debating the Causes of Addiction Total abstinence groups not as effective as dropout programs that teach people to drink moderately Heavy drinkers who are more likely to become moderate drinkers have less dependence on the drug Those at greater risk of abuse o Have physiological vulnerability to the drug that it changed the brain o Believe in no control o Live in a peer group that promotes binge drinking o Come to rely on the drug as avoiding problems Dissociative Identity Disorder/MPD controversial disorder marked by the apparent appearance within one person of two or more distinct personalities, each with its own name and traits; formerly known as MPD THE MPD CONTROVERSY o One side believes MPD is common but often unrecognized or misdiagnosed Believe disorder originates in childhood as means of coping with trauma Personality emerges to produce mental splitting One to cope with everyday experiences and the other with bad ones o One side believes MPD generated by clinicians themselves, during interaction with clients who have psychological problems More likely clinicians actively creating personalities and sometimes outright intimidation The Sociocognitive Explanation o Provides culturally acceptable way for trouble people to make sense of their problems o Allows them to account for sexual/criminal behaviour they find embarrassing Schizophrenia Schizophrenia o Psychotic disorder marked by delusions, hallucinations, disorganized and incoherent speech, inappropriate behaviour, and cognitive impairment Example of psychosis o Extreme mental disturbance involving distorted perceptions and irrational behaviour; may have psychological or organic causes

11 Symptoms of Schizophrenia Bizarre delusions o Report thoughts have been inserted into their heads by someone controlling them o Delusional identities, believe they are moses, jesus, or another famous person Hallucinations, false sensory experiences that feel intensely real o Most common is hearing voices in head Disorganized, incoherent speech o Word salads, meaningless rhyming words by remote association Grossly disorganized and inappropriate behaviour Impaired cognitive ability o Speech is impoverished Catanic stupor o Sitting for hours without moving, completely withdraw into private world First full blown episode occurs in late adolescence or early adulthood Breakdown occurs suddenly in some, while others it is more gradual The more breakdowns, the less chance of recovery Possible for people to go on and lead healthy lifestyle Some schizophrenic people completely impaired, while others do well in certain areas Origins of Schizophrenia Genetic Predispositions o At greater risk if have identical twin or child of schizophrenic parent o DISC1 Chromosomal aberrations on this gene involved in schizophrenia and bipolar disorder, share severe disturbances of emotion and cognition Structural brain abnormalities o Smaller temporal lobe or hippocampus o Enlarged ventricles o Abnormalities in the thalamus and auditory cortex Neurotransmitter abnormalities o Serotonin, glutamate, and dopamine Prenatal problems or birth complications o Fetal brain damage due to malnutrition of mother, flu virus, deprived oxygen, or prenatal stress Adolescent abnormalities in brain development o Pruning away to many synapses, explains schizophrenic episodes o Show extensive and rapid tissue loss, primarily in the sensory and motor regions

12 Mental Disorder and Personal Responsibility cause emotional distress to the individual or his friends/family some psychologists agree activities are comparable to drug addiction or to any other behaviour others believe finding way to avoid common problems (students use internet to avoid homework) Andrea Yates, killed five young children in state of despair

16 Overview! 16 Mental disorder! Psychological disorders! Dilemmas of definition! Your turn!

16 Overview! 16 Mental disorder! Psychological disorders! Dilemmas of definition! Your turn! Psychological disorders! Overview! Defining and diagnosing disorder Anxiety disorders Mood disorders Personality disorders Drug abuse and addiction Dissociative identity disorder Schizophrenia Dilemmas