1. Mental Disorders

2. What is abnormal behavior? • People who believe psychics/horoscopes? • Superstitions? • Angelina & Billy Bob? J-Lo? • Jeffrey Dahmer? • University professors? • Dog lovers? • Sexual preferences?

3. Abnormal Behavior • Thoughts/Behaviors/Emotions occur along a continuum • “ABNORMALITY” can be conceptualized via 4 criteria • Statistical Infrequency • Disability/Dysfunction • Personal Distress • Violation of norms

4. My Definition… • An excess or deficit in any cognitive/affective/behavioral domain is a disorder if it: • Is subjectively distressing • Impairs one’s ability to function within their daily environment

5. History… • Mental illness and deviance has been attributed to evil spirits, occult, etc. • Stone Age – demonic possession – boring holes in head • Middle Ages – demonic possession – exorcism • 15th Century – people could choose to collaborate with Devil – Salem Witch Trials

6. History… • Establishment of Asylums in Europe circa 16th Century • 1792 – Philippe Pinel • Revamped French asylum by (gasp) insisting on humane treatment for patients • Some improved to point where could be released • Advanced notion that mental illness was a disease of the brain, not demonic influence

7. History… • Medical model – birth of psychiatry • Psychology – broader explanations for mental illness • Explanations vary according to theoretical orientation • Sasz – psychiatric diagnoses serve only to control those who deviate from social norms, and to affirm psychiatrists’ place in the social/medical hierarchy

8. Perspectives on mental disorders • Biological (Medical model) • Psychodynamic • Cognitive • Behavioral • Sociocultural – the kinds of psychological distress people experience, and the way that it is manifested, vary according to culture • Cultural factors influence the form, course, and outcome of mental disorders

9. Socio-Cultural Perspective • The content of schizophrenic symptoms tend to be related to critical problems facing the culture • Thought insertion & thought broadcasting appear to be Western phenomenon • Prognosis of schizophrenia appears to be better in 3rd World countries • Asian countries also better prognosis

10. Socio-Cultural Perspective • What about Western society contributes to more chronic course? Why worse than industrialized Asia? • Extreme nuclearization of family system (diminished support) • Rejection/isolation of mentally ill • Internal causal attribution • Assumption of chronic course

11. Culture-bound disorders • Disorders related to cultural emphasis on fertility • Genital Shrinking (Koro in Indonesia, Suo-Yang in Mandarin Chinese) • Semen Loss (Chat in India, Sukra Pameha in Sri Lanka, Shenk Uei in China)

12. Culture-bound disorders • Disorders related to cultural emphasis on physical appearance • Anthropophobic reactions among Japanese & Koreans • Fear that one’s physical appearance is offensive to others • Anorexia among Western cultures

13. Classification of mental disorders • Late 19th and early 20th century – Neuroses & Psychoses • Neuroses: characterized by anxiety, but person remains in touch with reality • Psychoses: disturbances of thought or perception that impairs reality testing

14. Diagnostic and Statistical Manual of Mental Disorders (DSM) • Classification system – under continual revision • Designed to define mental disorder as objectively as possible and improve reliabilty • Provides consistency of diagnoses across individuals and settings • List of disorders with descriptions, categories, diagnostic criteria, guidelines for differential diagnosis

15. Nursing Student’s Disorder • Characterized by a strong tendency to relate personally to, and find in oneself, the symptoms of any disease/disorder one learns about

16. Diagnostic and Statistical Manual of Mental Disorders (DSM) • Axis I: Clinical Disorders (State disorders) • Axis II: Personality Disorders and Mental Retardation (Trait disorders) • Axis III: General Medical Condition (physical problems relevant to etiology/treatment) • Axis IV: Psychosocial & Environmental Probs (stressors relevant to diagnosis, prognosis, treatment) • Axis V: Global Assessment of Functioning (GAF)

17. Anxiety disorders Mood disorders Thought disorders Dissociative disorders Personality disorders Substance-related Somatoform disorders Factitious disorders Sexual & Gender Identity disorders Eating disorders Sleep disorders Impulse control Adjustment disorders Infancy/childhood/early adolescence Delirium/dementia/amnesia MD due to general medical condition Primary Categories of Mental Disorders

18. Prevalence of Mental Disorders • 22% of adults suffer a diagnosable mental disorder in any given year (1 in 5) • 4/10 leading causes of disability are mental disorders • Major Depressive Disorder • Bipolar Disorder • Schizophrenia • Obsessive-Compulsive Disorder

19. Males Anxiety – 19% Depression - 15% Substance - 35% Schizophrenia - 0.6% Antisocial PD – 6% Females Anxiety - 31% Depression - 24% Substance - 18% Schizophrenia- 0.8% Antisocial PD - 1% Prevalence of Mental Disorders

20. Diagnostic Bias • Males vs. females (APD, histrionic, borderline) • Genuine differences in manifestation • Sympathy vs. negative reactions • Rosenhan, 1973 – feigned mental illness study

21. Multiple Layers of Causation • A disorder typically arises from (a) a pre-existing susceptibility coupled with (b) triggering circumstances. • Consequences of the disorder may perpetuate it • Depression • Paranoid schizophrenia • Social anxiety

22. Disorders de jour… • Anxiety Disorders • Mood Disorders • Thought Disorders • Substance-Related Disorders • Somatoform Disorders • Personality Disorders

23. Anxiety Disorders • Unreasonable, often paralyzing anxiety or fear • Person feels threatened, unable to cope, unhappy, and insecure in circumstances of perceived danger or hostility • The most common category of disorders in general population • Twice as common in women vs. men • Most amenable to treatment

24. Generalized Anxiety Disorder • Characterized by chronic, uncontrollable, excessive fear and worry lasting at least 6 months, and NOT focused on any particular object of situation • Afraid of something, but unable to articulate specific fear • Persistent muscle tension, autonomic fear reactions, headaches, heart palpitations, dizziness, insomnia

25. Generalized Anxiety Disorder • Comorbid depression is common • Appears to have increased dramatically in past 50 years (media driven?) • 1 in 20 adults (5%)

26. Panic Disorder • While GAD is characterized by free-floating anxiety, panic disorder marked by sudden (but brief) attacks of intense apprehension • Result in trembling, shaking, dizziness, shortness of breath, peripheral neuropathy, tachycardia • Panic Attack – fear/discomfort that arises abruptly and peaks in 10 minutes or less • Associated with Agoraphobia

27. Phobias • Intense, irrational fear and avoidance of specific objects or situations • Simple Phobias: fear of a specific object or situation • Generally egodystonic • http://www.phobialist.com/reverse.html

28. Phobias • Social Phobias: Feel extremely insecure in social situations – fear of public scrutiny • Irrational fear of embarrassing oneself • Most commonly fear of public speaking or performing in front of a group

29. Phobias • Agoraphobia – fear of the market place • Often develops following panic attacks • Fear busy, crowded places, or being alone in wide open places • Fear that something bad will happen and they won’t be able to escape, or unable to receive help

30. Obsessive-Compulsive Disorder • Persistent, unwanted fearful thoughts (obsessions) and/or irresistible urges (compulsions) to engage in ritualistic behaviors to alleviate the resulting anxiety • Equally common in men and women • Moderate transient forms are common in childhood • Specific and egodystonic • Compulsions may or may not be rational

31. Post Traumatic Stress Disorder • Directly tied to specific traumatic events • Involves reliving of traumatic events, and efforts to avoid associated cues • Intrusive symptoms • Hyperarousal • Avoidance

32. Psychological Causes of Anxiety Disorders • Faulty Cognitions: hypervigilance – constant scanning of environment for signs of danger; ignore signs of safety • Magnify ordinary threats • Learning: classical and operant conditioning • Little Albert • Modeling and observational learning (Teddy’s mom)

33. Psychological Causes of Anxiety Disorders • Biological: evolutionary predisposition • Typical foci are those with survival value • Genetic predispositions, chemical imbalances • Hypersensitive sympathetic nervous system • Stimulants (caffeine, exercise)

34. Summary – Anxiety Disorders • Sufferers experience persistent feelings of fear and dread in everyday circumstances • GAD – free floating anxiety, no specific focus • Simple Phobia – focused, irrational anxiety • Social Phobia – fear of negative appraisal • Agoraphobia – fear of the marketplace • PTSD – fear resulting from traumatic events that persists and has generalized

35. Summary – Anxiety Disorders • Most common disorders among general population • Highly amenable to psychological treatment

36. Mood Disorders • Characterized by extreme disturbances in emotional states • 2 main types • Major Depressive Disorder (unipolar depression) • Bipolar Disorder (manic-depression)

37. Major Depressive Disorder • Lasting and continuously depressed mood without clear trigger or precipitating event • Intense sadness interferes with basic ability to function • Symptoms include • Insomnia • Loss of appetite • Tearfulness • fatigue

38. Major Depressive Disorder • Symptoms continued • Hopelessness • Suicidal ideation • Loss of interest in previously enjoyable activities • Irritability • Cognitive and psychomotor slowing • Perceptual disturbance/hallucinations (extreme cases) • Dysthymia – Depression “Lite”

39. Bipolar Disorder • Periods of depression as well as mania • Mania – excessive and unreasonable state of overexcitement and impulsivity • Hyperactivity • Easily distracted • Unrealistic self-esteem/grandiosity • Elaborate planning/creativity • Decreased need for sleep • Flight of ideas, loose associations

40. Examples of Manic Episodes • Attempt to steal airplane • The problem of multiple Jesus’ • Spending sprees • Dar Heatherington • Naked on Younge Street

41. Bipolar Disorder • Manic episodes may last days to months • Lifetime risk for bipolar = 0.5 – 1.6 % • Lithium, Depakote • Iatrogenic effects of antidepressants • Hypomania • Cyclothymia • http://groups.msn.com/ABipolarCommunity/famousbipolars.msnw

42. Causes of Mood Disorders • Biological: significant role • Imbalances in neurotransmitters related to sleep cycle, arousal, etc. • 50% co-occurrence in identical twins

43. Causes of Mood Disorders • Cognitive: Beck’s Depressive Triad • Pessimistic view of… • Self • World • Future • Tendency to attend to and exaggerate bad experiences and overlook/minimize positive ones

44. Causes of Mood Disorders • Seligman: Hopelessness Theory • Pattern of thinking about negative experiences that reduces hope that life will improve • Attribute negative experiences to causes that are stable (unlikely to change) and global (widely applicable). • The rules of the game are set, stacked against me, and apply in many settings

45. Cycle of Depression (Chicken & Egg)

46. Schizophrenia • Characterized by • Disorganized thoughts • Hallucinations • Delusions • Bizarre behavior • Approximate 1% prevalence • Onset between 18 – 30 (slightly later for women) • Similar rates for men and women, but tends to be more severe/chronic for men

47. Schizophrenia • Costs of care > 30 Billion per annum • Elevated risk for suicide • NOT multiple personality • Poor prognostic indicators… • Related disorder among first degree relatives • Early onset • Co-morbid Obsessive-Compulsive Disorder • Negative Symptoms

48. Positive & Negative Symptoms • Positive: Usually occur during psychotic episodes • Distinctly abnormal behaviors • Include delusions, hallucinations • Negative: generally involves loss of normal functioning • Includes reduced speech, low initiative, social withdrawal, diminished affect, psychomotor slowing

49. 5 Areas of Disturbance • Perceptual Symptoms • Either enhanced or blunted sensation • Hallucinations (auditory, visual, tactile, olfactory) • Command hallucinations • Threat-Command-Override (TCO) symptoms

50. 5 Areas of Disturbance • Thought & Language Disturbance • Disorganized thought • Bizarre ideation • Impaired logic and judgment • Loose associations • Circumstantiality • Word salad & neologisms (splisters on my brain)