UNIT IV
CHAPTER 14
Lecture 22: Thursday, November 19, 2009
Text Assignment: Chapter 14 pp. 629-666
What is Abnormal? Axis I Disorders
I. Definition of Abnormal
1. Statistical Definition: Abnormality as deviance from a statistical norm
2. Abnormality as a departure from Cultural Norms
3. Abnormality as a troublesome behavior
4. Bizarre behavior and Abnormality
5. Perception of Reality and Abnormality
6. Personal discomfort and abnormality
7. Theoretical Bias and definition of abnormality
(1) Psychological bias
(2) Medical bias (medical model)
II. Diathesis-Stress Model
1. Diathesis: a predisposition to a state or condition
2. Stress: specific factors which combined with the predisposition, trigger the disorder
3. Diathesis-Stress Model: because of certain biological factors, some people may be more susceptible to developing a particular disorder, but without certain environmental stressors, the disorder is not triggered
III. David Rosenhan’s Classic Study on Psychiatric Hospitalization: On being Sane
in Insane Places Science, 1973, 179, 250-258
1. Rosenhan had eight “pseudo patients” themselves at various mental hospitals with their only complaint being that they heard voices. In all other respects, they behaved normally
2. With one exception, each person was diagnosed as schizophrenic and admitted to the psychiatric ward
3. After their admission, the ceased to claim that they heard voices and behaved as they normally would, but they were not discharged
4. When they finally were discharged, they were still viewed by hospital personnel as schizophrenic although they were judged to be in remission (improved)
5. Rosenhan’s study resulted in two significant findings:
(1) It is very easy to be labeled Schizophrenic
(2) After the diagnosis is made, the label tends to remain – independent of “normal” behavior
6. Rosenhan’s study has been widely criticized by clinicians on several grounds. A
significant criticism is that auditory hallucinations is one of the major symptoms
of psychosis, especially schizophrenia. If it is presented as a prominent symptom,
it almost compels a diagnosis of some form of psychosis – most likely
schizophrenia
7. Rosenhan’s study should not detract from the fact that that psychotic disorders
exist and are recognized as such almost worldwide
8. Perhaps, the most important implication of Rosenhan’s research is the relative
permanency of a label once it is used in a psychiatric diagnosis
IV. Diagnostic practices may well be influenced by economic situations involving third
party payment or lack of payment depending on the nature of the label – is the label a
“billable diagnosis”?
V. The Diagnostic and Statistical Manuel of Mental Disorders (DSM)
1. In 1952, The American Psychiatric Association published the first edition of the DSM. It was heavily influence by psychodynamic theory and was relatively useless from a research standpoint in terms of establishing reliability and validity in a diagnostic system
2. By 1994, the fourth Edition (DSM IV) addressed many of the criticisms regarded clarity of diagnostic procedures and issues regarding reliability and valifdity of diagnostic labels.
3. The DSM IV is referred to as a multi-axial system (five axes)
(1) Axis I: for clinical disorders
(2) Axis II: for personality disorders and mental retardation
(3) Axis III: for any general medical condition that might be relevant to a diagnosis
(4) Axis IV: identifies psychosocial or environmental problems
(5) Axis V: records the patient’s highest level of functioning within the past year
4. In 2000, a revision called DSM-IV-TR (TR = text revision) was published to
include more up-to-date information on incidence rates and cultural factors, but did not change the diagnostic categories nor the criteria
VI. Criticisms/Short Comings of the DSM IV
1. Some of the disorders are not clearly distinct from each other although they are presented as such
2. Problems that are primarily medical in nature have been included as psychological disorders. For example “Breathing-Related Sleep Disorder”
3. There is still lacking a discrete boundary separating abnormality from normality
4. A clinician’s judgment determines whether an impairment is “clinically significant”
VII. Despite criticisms, the DSM IV remains as the predominant means of classifying
psychological disorders in the United States. Most insurance companies require a diagnostic label from this source for third party payment
VIII. See Table 11.1 on page 420 of your text for a summary of:
DSM-IV-TR’s 17 Major Categories of Disorders
1. Major Depressive Disorder (MDD): at least two weeks of depressed mood along with sleep or eating disturbances, loss of interest in almost all activities, loss of energy and feelings of hopelessness
(1) Approximately 30% of persons experiencing clinical depression attempt suicide and roughly half kill themselves
2. Bipolar Disorder: one or more manic episodes, often followed by depression
(1) Manic Episode: a period of at least one week in which there is an abnormally elevated mood
1. Identical twin studies and Major Depression: if one develops the other is four times more likely to develop it than a fraternal twin with a twin who has the disorder
2. In persons with bipolar disorder, there is some evidence of an enlarged amygdala
3. Identical twin studies and Bipolar Disorder: if one develops it there is an 80 % chance that the other will develop Bipolar or some other mood disorder
4. The behavior of depressed individuals sets them up for eventual rejection
II. Anxiety Disorders
1. Anxiety Disorder: a state involving intense fear, usually triggered by an external stimulus
2. Generalized Anxiety Disorder: excessive anxiety that is not consistently related to any particular external event
III. Four Major types of Anxiety Disorders
1. Panic Disorder:
(1) Panic attacks involving chest pains, breathing problems, nausea, sweating and dizziness – often leads to a visit to the emergency room because the person believes they are having a heart attack
(2) Agoraphobia (fear of the marketplace): panic attacks may lead the person to avoid any situation which they may have an attack
2. Phobias:
(1) Social Phobias: also called Social Anxiety Disorder
(2) Specific Phobias
3. Obsessive Compulsive Disorder:
(1) Obsessions: recurrent and persistent thoughts, impulses, or images that feel intrusive and inappropriate
(2) Compulsions: repetitive behaviors or mental acts that some people feel compelled to perform in response to an obsession
4. Post Traumatic Stress Disorder: three conditions must be met for a diagnosis:
(1) A person witnesses an even that involves actual or threatened serious injury or death
(2) The traumatized person responds with fear and helplessness
(3) The traumatized individual experiences three sets of symptoms: persisting re-experiencing of the traumatic event, a persistent avoidance of anything to do with the traumatic event, and heightened arousal often associated with a startle response
III. Schizophrenia: a psychotic disorder that profoundly alters affect, behavior, and
cognition particularly the pattern or form of thought
1. Positive Symptoms: Delusions, Hallucinations, disordered behavior, disorganized speech
2. Negative Symptoms: flat affect, slow empty replies to questions (alogia), avolition – inability to initiate goal directed behavior
3. Four Subtypes
(1) Paranoid: delusions of persecution, auditory hallucinations
(2) Disorganized: disorganized speech, flat or inappropriate affect
(3) Catatonic: bizarre or immobile motor behaviors
(4) Undifferentiated: not clearly the symptoms of any of the above
4. Dopamine Hypothesis: the hypothesis that schizophrenia caused by excessive
levels of the neurotransmitter Dopamine
5. Cultural factors – persons afflicted often have lower socioeconomic status
(1) Social Selection of Social Drift: persons who are afflicted drift downward because of difficulties in functioning in society
(2) Social Causation: the stress of social conditions is causally related to the origin
6. Diathesis-Stress Model: persons are biologically vulnerable and stress triggers the
manifestation of the symptoms
IV. Eating Disorders
1. Anorexia Nervosa: potentially fatal disorder bin which there is refusal to maintain even a low normal weight. Of those hospitalized for the disorder, approximately 10% will die – usually from cardiovascular disorders caused by severe malnutrition
2. Bulimia Nervosa: recurrent episodes of binge eating usually followed by efforts to rid the body of food by vomiting or laxatives
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THANKSGIVING BREAK: MONDAY, NOVEMBER 23 THRU FRIDAY, NOVEMBER 27, 2009
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UNIT IV
CHAPTER 14
Lecture 23: Tuesday, December 1, 2009
Text Assignment: Chapter 14 pp. 667-680
Other Axix I Disorders and Axis II Disorders
I. Dissociative Disorders
II. Eating Disorders
III. Personality Disorders (Axis II Disorder)
1. Personality Disorder: a set of relatively stable personality traits that are inflexible and maladaptive, causing distress or difficulty in daily functioning
2. Theoretical differences: some question whether personality disorders are simply variations of a normal range of personality differences (for example, Dependent Personality Disorder). Or, if a personality disorder such as an “Avoidant Personality Disorder” really should be viewed as an Axis I disorder such as Social Phobia
IV. Two Frequently Described Personality Disorders
1. Borderline Personality Disorder: a pattern of instability in relationships, self-image, and feelings, and pronounced impulsivity such as in spending, substance abuse, reckless driving, or binge eating. In general, relationships tend to be chaotic. Often, clinicians describe persons with this diagnosis as extremely difficult, often exasperating patients that show minimal progress in therapy. There is some overlap in characteristics with the Antisocial Personality Disorder
2. Antisocial Personality Disorder: a pattern of disregard or violation of the rights of others, an apparent inability to develop empathy for others and a notable lack of conscience. There appears to be no remorse following mistreatment of others or legal difficulties. Typically the person is very manipulative, inspires fruitless rescue fantasies in inexperienced clinicians, and shows no progress in any of the traditional therapies.
(1) Approximately 1 to 2% of Americans are diagnosed with an Antisocial Personality Disorder
(2) 60% of male prisoners are estimated to have Antisocial Personalities
(3) Antisocial Disorders are three times more likely to occur in men than women
(4) A major physiological characteristic (probably influenced by genetics) is a relatively under-responsive central and autonomic nervous system – a chronic state of under-arousal that leads persons to seek out high levels of stimulation
(5) Usually, the symptoms of an Antisocial Personality begin in early childhood and often are associated with peer conflicts, aggressive behavior, cruelty to animals, and a lack of responsiveness to rules set by parents or school personnel