Chapter 17

1. Chapter 17 The Nature and Causes of Mental Disorders Chapter 17 - Mental Disorders

2. Classifying Mental Disorders • There is a wide variety of psychological disorders. Classifying them is a prerequisite to organized diagnosis and treatment. • The American Psychiatric Association’s Diagnostic and Statistical Manual IV (DSM-IV) is the most commonly used classification scheme. • DSM-IV contains five axes that are described in the textbook. We are going to focus on disorders contained in Axis I and II. Chapter 17 - Mental Disorders

3. A Simpler Classification • A less technical way of classifying mental disorders is in terms : • Neurosis: Excessive irrational emotionality without loss of contact with reality. • Anxiety • Phobia • Obsession • Depression • Psychosis: Severe disturbance of thought and emotion with loss of contact with reality (schizophrenia). • Hallucination • Paranoia • Delusion Chapter 17 - Mental Disorders

4. Anxiety • Anxiety is an emotion, like fear, that is experienced in anticipation of danger. • Whereas fear is experienced in the face of a perceived danger, anxiety is a more diffuse emotional reaction. • There are several forms of anxiety disorders. We will focus on: • Agoraphobia (with panic attacks) • Generalized Anxiety Disorder (GAD) • Hypochondriasis • Obsessive-Compulsive Disorder (OCD) Chapter 17 - Mental Disorders

5. Agoraphobia • Agoraphobia involves fear of being alone in public places. • Agoraphobia is accompanied by panic attacks. • A panic attack involves a period of intense fear and discomfort where some of the following symptoms develop abruptly. • Palpitations, pounding heart, sweating, shaking, feeling of choking, chest pain, nausea, feeling dizzy, feelings of being detached from oneself, fear of going crazy, fear of dying, numbness sensations, chills or hot flashes. • Panic attacks are terrifying, and agoraphobics stay away from public places from fear of having them. Chapter 17 - Mental Disorders

6. Video on Agoraphobia Chapter 17 - Mental Disorders

7. Generalized Anxiety Disorder • GAD is excessive worry that leads to significant distress or impairment in occupational or social functioning BUT that is not focused on panic attacks. • GAD used to be known as free-floating anxiety (being anxious without being aware of the source of the anxiety). • GAD often overlaps with other anxiety disorders (comorbidity is high). Chapter 17 - Mental Disorders

8. Video on Generalized Anxiety Disorder (GAD) Chapter 17 - Mental Disorders

9. Obsessive-Compulsive Disorder • A pervasive pattern of intrusive, unwanted thoughts • accompanied by ritualistic behaviours. • Obsession: Recurrent involuntary thought or image. • Compulsion: Repetitive carrying out of a pointless rituals • checking hundreds of times if the stove is turned off. • washing hands excessively from fear of contamination. • counting to certain numbers before taking an action. Chapter 17 - Mental Disorders

10. Video on OCD Chapter 17 - Mental Disorders

11. Hypochondriasis • Hypochondriasis is a persistent exaggerated fear that one is suffering from a physical illness. • Hypochondriacs tend to interpret their physical symptoms as indicative of a serious illness. They quickly seek medical attention and expect the worst. • When medical tests are negative, they worry that a test was overlooked. • Hypochondriacs may take their blood pressure frequently, and keep lots of medication at hand. Chapter 17 - Mental Disorders

12. Video on Hypochondriasis Chapter 17 - Mental Disorders

13. Causes of Anxiety Disorders • The causes of anxiety disorders are complex, but there is some evidence for each of the following. Some of these causes are more relevant to some anxiety disorders than others: • Stressful life events (having faced danger) • Childhood adversity (parental neglect, worry, abuse) • Attachment style (insecure attachment) • Learning mechanisms (phobia after bad experience) • Cognition (catastrophic misinterpretation) • Biology (high heritability; chemically induced panic) Chapter 17 - Mental Disorders

14. Treatment of Anxiety Disorders • The treatment of anxiety disorders includes one or more of the following: • Medication • Benzodiazepines (Brands: Valium, Xanax) • SRIs (Serotonin reuptake inhibitors used for OCD) • Psychotherapy • Cognitive-behavioral therapy • Exposure with relaxation (systematic desensitization) • Psychoanalysis Chapter 17 - Mental Disorders

15. Video on Causes and Treatment of Anxiety Disorders Chapter 17 - Mental Disorders

16. Dissociative Disorders • The loss of the integrated connection of identity, memory and consciousness. Anxiety is often reduced by this disruption. • The most famous case consists of Multiple Personality Disorder, technically known as Dissociative Identity Disorder. • The diagnosis of multiple personality disorder is controversial because the multiple personalities emerge during therapy, usually following strong suggestions by the therapist. • Are multiple personalities real or fabricated? Chapter 17 - Mental Disorders

17. Recovered Memories • Some psychotherapies, such as psychoanalysis, put a lot of emphasis on repressed conflicts and memories. • There has recently been a lot of controversy over the accuracy of memories (such as childhood sexual abuse) that are recovered, during therapy, many years later. • Are recovered memories examples of dissociations, or are they merely examples of the power of suggestion? • This issue is raised in the video. Watch for memory expert Elizabeth Loftus, whose early classic research is discussed on page 268 of your textbook (see figure 8.18 there) . Chapter 17 - Mental Disorders

18. Video on Multiple Personality (Dissociative Identity Disorder) Chapter 17 - Mental Disorders

19. Personality Disorders • A broad class of psychological disorders which reflect long-term characteristics of the person. • Personality disorders tend to be difficult to diagnose and to treat (what is the difference between being eccentric and having a personality disorder? Narcissism is a good example of this ambiguity) • We will look at three examples of personality disorders: • Psychopathy (Antisocial personality disorder - ASPD). • Borderline personality disorder. • Obsessive-Compulsive personality disorder. Chapter 17 - Mental Disorders

20. The Psychopath • Characteristics of the psychopathic personality (ASPD): • Criminality (failure to conform to social norms and laws). • Lack of empathy, anxiety and fear. • Lack of remorse for mistreating others. • Egocentrism and grandiose feelings • Deceit and manipulativeness. • Impulsivity and lack of planning. • Irritability and aggressiveness. • Reckless disregard for the safety of self and others. • Consistent irresponsibility at work and with finances. Chapter 17 - Mental Disorders

21. Video on Psychopathy (Antisocial Personality Disorder) Chapter 17 - Mental Disorders

22. Treatment of Psychopaths • As seen in the video, the news is not good on the success of treatment: • Psychopaths seldom seek treatment. • Few therapists and researchers take on psychopathic subjects. • Behaviour therapy (rewards and punishments) works only while patient is under close supervision. • Psychotherapy that stresses empathy sometimes helps the psychopath develop better ways of manipulating others. Chapter 17 - Mental Disorders

23. Borderline Personality Disorder • What is borderline about this disorder? The label comes from the early belief that the disorder fell at the borderline of neurosis and psychosis. • Today the label is used more broadly to describe people who show instability in their emotions and interpersonal relationships. They often show: • A pattern of chaotic and intense interpersonal relationships. • Unstable self-image and sense of self. • Recurrent suicidal or self-mutilating behaviour. • Instability in the way they feel (unpleasant mood: dysphoria). • Intense anger. Chapter 17 - Mental Disorders

24. Video on Borderline Personality Disorder Chapter 17 - Mental Disorders

25. Mood Disorders • Mood disorders involve discrete periods of time (episodes) during which the person is in a depressed or a manic mood. • Mood disorders are leading causes of disability worldwide: • 1. Major depression • 2. Iron-deficiency anemia • 3. Falls • 4. Alcohol use • 5. Pulmonary disease • 6. Bipolar mood disorder • 7. Congenital anomalies • 8. Osteoarthritis • 9. Schizophrenia • 10. Obsessive-compulsive disorders Chapter 17 - Mental Disorders

26. Depression • Depression is a clinical syndrome that involves a combination of emotional, cognitive and behavioural symptoms relating to overwhelming despair. • Extreme cases of depression are known as major depression, clinical depression or unipolar depression. • Behavioural Symptoms • pacing/fidgeting • inactivity • at extreme: stupor • Physical Symptoms • fatigue • difficulty sleeping • change in appetite • Cognitive Symptoms • guilt • feel worthless • concentration problems • thoughts of suicide Chapter 17 - Mental Disorders

27. Video on Major Depression Chapter 17 - Mental Disorders

28. Causes of Depression • Severe Life Events • Loss of important people (death, separation) • Loss of important roles (job, promotion) • Psychological Factors • Cognitive responses (negative self view) • Learned helplessness • Biological Factors • Abnormal neural transmission in the brain; hormonal levels • Twin studies show high heritability Chapter 17 - Mental Disorders

29. Mania • Mania involves a euphoric mood that varies from mild (hypomania) to extreme (psychotic manic episodes). • Symptoms • inflated self-esteem (delusional at extreme) • decreased need for sleep • distractibility • talkativeness • thoughts race through head Only a small proportion of patients have manic episodes and no depressive episodes. In most cases, patients who have manic episodes also have depressive episodes. This is known as bipolar mood disorder, or manic-depressive disorder. Chapter 17 - Mental Disorders

30. Video on Bipolar Disorder Chapter 17 - Mental Disorders

31. Causes of Bipolar Disorder • We know less about the causes of mania than depression. • These are a few findings: • Manic episodes tend to be preceded, weeks earlier, by stressful life events. • Patients who live in families that are hostile towards the disorder are more likely to relapse. • Some of the biological factors seem to be the same for unipolar and bipolar mood disorders. Chapter 17 - Mental Disorders

32. Video on Treatment of Depression Chapter 17 - Mental Disorders

33. Treatment of Mood Disorders • Medication: • Depression: • Tricyclics such as Trofanil (in use since 1950’s) • SSRI’s such as Prozac (present medications of choice) • Bipolar: • Lithium Carbonate • Electroconvulsive Therapy (ECT) • We do not know why ECT works but it helps in cases of deep depression. Invasive with memory loss side effect. • Psychotherapy • Psychotherapy applies particularly well to mood disorders. • We will look at relevant psychotherapies in Chapter 18. Chapter 17 - Mental Disorders

34. Sexual Disorders • Some sexual disorders involve dysfunctions with sexual desire and physiological response leading to orgasm. • Our focus is on paraphilias, which involve sexual arousal to unusual things and situations such as inanimate objects, children, exhibiting genitals to strangers, inflicting pain to others. We will look at: • Exhibitionism (indecent exposure) • Rape (though not defined as paraphilia in DSM-IV) • We will also look at Gender Identity “disorder” (or is it a mental disorder?) Chapter 17 - Mental Disorders

35. Exhibitionism (Indecent Exposure) • Recurrent, intense sexually arousing fantasies, urges and behaviours involving exposure of genitals to a stranger. • Almost exclusively a male disorder. • About half the time the male has an erection while exposing. • Some masturbate while exposing, while others do afterwards. • Exhibitionists are often married and have satisfactory sexual relations with adult women. Chapter 17 - Mental Disorders

36. Video on Exhibitionism Chapter 17 - Mental Disorders

37. Rape and Sexual Assault • Legal definition of rape: Acts involving nonconsensual sexual penetration obtained by physical force or threat of bodily harm, or when the victim is incapable of giving consent by virtue of mental illness, retardation or intoxication. • Rape and sexual assault are disturbingly common: • 28% of university students across Canada report having been sexually assaulted in the past year. • 6% of women living in Winnipeg report having been raped. • Efforts are currently made to distinguish between sex offenders for whom sexual arousal motivates the act, and those motivated primarily by anger, control, and violent impulses. Chapter 17 - Mental Disorders

38. Video on Rape Chapter 17 - Mental Disorders

39. Gender Identity Discomfort (?) • Some people are firmly convinced that they are living in the wrong body. In females this means that they feel that they are a man trapped in a woman’s body. • DSM-IV classifies this discomfort as gender identity disorder (also known as transsexualism and gender dysphoria). • Gender identity “disorder” is estimated to be relatively rare: • Male-to-female transsexuals: 1 in 12,000. • Female-to-male transsexuals: 1 in 30,000. • Many LGBTQ people assert that transsexuals are mentally healthy. So why does the DSM-IV consider this a disorder? Chapter 17 - Mental Disorders

40. Video on Transexualism Chapter 17 - Mental Disorders

41. Aversion Therapy for Paraphelias? • Aversion therapy is based on classical conditioning. The idea is to associate the stimulus that elicits inappropriate sexual arousal, with aversive stimuli: • Electric shock. • Chemically induced nausea. • The approach is of questionable effectiveness. • Aversion therapy was illustrated nicely in A Clockwork Orange(a wonderful 1971 movie by Stanley Kubrick, based on the novel by Anthony Burgess. Rated R for sexual violence). • Let’s see how Stanley Kubrick represents aversion therapy. Chapter 17 - Mental Disorders

42. Video on Aversion Therapy Chapter 17 - Mental Disorders

43. Schizophrenia • A set of disorders that encompass a variety of symptoms, including disturbances of: + Perception: Hallucinations (perception of things not there). + Cognition: Delusions (belief that have no objective basis). + Behaviour: Bizarre behaviour such as taking a shower fully dressed. - Emotion: Flat affect and social withdrawal. • Note distinction between positive and negative symptoms. • Schizophrenia usually involves a series of acute episodes with periods of remission. Following a severe episode, the patient is rarely completely rid of the disorder. Chapter 17 - Mental Disorders

44. Types of Schizophrenia • Disorganized Schizophrenia: Includes hallucinations and delusions. Speech is often incoherent. • Catatonic Schizophrenia: Mostly absence of reactivity (negative symptoms), including stupor and immobility for long periods of time. May stare into space. • Paranoid Schizophrenia: Experience delusions of persecution, hearing critical or threatening voices. • Undifferentiated Schizophrenia: A catchall category for symptoms that do not quite fit, or fit more than one of above. • Residual Schizophrenia: Cases where there was at least one schizophrenic episode, but currently only mild symptoms. Chapter 17 - Mental Disorders

45. Video on Schizophrenia Chapter 17 - Mental Disorders

46. Biological Factors in Schizophrenia • There is a strong genetic component to schizophrenia. Having an identical twin, or both parents, diagnosed with the disease puts one’s chances of having the disease over one’s lifetime at close to 50% • Neuroimaging studies (e.g. MRI) show that the brains of schizophrenics tend to have less brain tissue (larger ventricles and fissures). Also, the neural network connecting limbic areas with the frontal cortex appears disordered. • Levels of neurotransmitters (like dopamine and serotonin) appear not to be regulated properly in some cases of schizophrenia. Chapter 17 - Mental Disorders

47. Other Factors in Schizophrenia • How about the other 50%? • Biological factors are clearly important in schizophrenia, but it appears that biologically vulnerable individuals only have full-blown episodes when other factors are also present: • Low socio-economic status: • Poor nutrition, less education, low income. • Family interaction: • Poor communication confuses the child. • Negative expressed emotion: • Patients are more likely to relapse if those around them express hostility, or are overly protective of them. Chapter 17 - Mental Disorders

48. Medication for Schizophrenia • Canadian Guidelines: “antipsychotic medications are currently the most effective treatment available for schizophrenia, especially when combined with psychosocial treatment.” • Phenothiazines: e.g.,Chlorpromazine (Thorazine) • Very effective in about half the patients. • 25% of patients do not improve. • Nasty side effect: Tardive dyskinesia (TD) • Atypical Antipsychotics: e.g., Clozapine, Risperidone • Newer medications with fewer side effects. • Work with more than 30% of patients who are unresponsive to Phenothiazines. Chapter 17 - Mental Disorders

49. Video on Antipsychotic Drugs Chapter 17 - Mental Disorders

50. Bridge to Chapter 18 • We will soon turn our attention to psychotherapies for the treatment of mental disorders. • Let’s first look at self-abusive behaviour and the application of behaviour therapy to control it. • Self-abusive behaviour usually stems from severe forms of autism and mental retardation. • Self-abuse in some cases can take extreme forms that can result in self mutilation and even death. Chapter 17 - Mental Disorders