Chapter 14, Psychological Disorders

What is abnormal: The role of culture

Cultural concepts of distress:

• A pattern of mental illness, distress, and/or symptoms that is unique to a specific ethnic or cultural population

• Does not conform to standard classifications of psychiatric disorders
  

Some behaviours are not culturally specific
Ex. Schizophrenia, bipolar disorder, panic disorder - biological bases
(May have different meanings across cultures)

Koro:

An episode of sudden illness and intense anxiety that the genitals recede into the body and possibly causes death

(Chinese, Malaysian, and Indonesian)

Amok Syndrome:

Period of brooding followed by a sudden outburst of indiscriminate murderous frenzy, sometimes provoked by an insult, jealousy, or a sense of depression
(Brunei, Singapore, Malaysia, Indonesia, Philippines, Timor-Leste)

4 D’s (actually 5 lol)

Deviance

• Departure of what is normal/usual

• Refers to behaviours, thoughts, and feelings that are not in line with generally accepted standards

• Culturally - based
  

Distress

• Behaviors, thoughts, and feelings that are upsetting and cause pain, suffering, or sorrow
  

Dysfunctional

• Behaviors, thoughts, and feelings are disruptive to one’s regular routine or interfere with day-to-day functioning
  

Dangerous

• Behaviors, thoughts, and feelings may head to harm or injury to self or others

Duration

• The interval between the onset of a psychiatric disorder and the administration of the first pharmacological treatment

  (to get a diagnosis, the abnormal behaviours need to persist for a specific amount of time)

Psychological disorder:

Patterns of deviant and dysfunctional behaviors, thoughts, and/or feelings that cause significant dishes, and may even be dangerous, and last for a specific amount of time.

History of Psychiatry: 1840

First attempt in the US to gather info. about mental health (ideas of idiocy and insanity)

History of Psychiatry: 1883

Emil Kraplin
Published a system of psychological disorders centered around a pattern of symptoms

7 categories:

• Mania

• Melancholia

• Monomania
  Paresis
  Dementia
  Dipsomania
  Epilepsy

History of Psychiatry: 1918

America Medico-Psychological Association changed its name to the American Psychological Association (APA)

Issued the statistical manual for use of institutions for the insane

(Beg. of Diagnostic Materials)

First Diagnostic Manuals

1921: Americana Medical Association’s standard Classification Nomenclature of Disease

22 different categories, 21 psychotic conditions

History of Psychiatry: 1946

US army psychiatrists following WW2

• High proportion of soldiers in combat suffered psychiatric breakdowns

• Kinds of breakdowns they had (clearly response to stressful experiences) weren’t encompassed by existing manual (in-patients)

• Model for first DSM

Diagnostic and statistical manual for mental disorders (DSM-I) 1952

Combined 2 major influences:

• Adolf Meyer → emphasized how most mental disorders represented personality reactions to psychological, social, and biological factors

• Sigmund Freud → general underlying processes rather than outward symptoms
  

- Unreliable diagnostic tool, but the first tool to focus on clinical use

- Concepts had not been scientifically tested
- 10 Categories for psychoses and psychoneuroses

- 7 Categories for disorders of character, behavior, and intelligence

Diagnostic and statistical manual for mental disorders (DSM-II): 1968

• 193 personality disturbance

• Based on psychoanalytic theory

• Unreliable diagnostic tool - didn’t pay a lot of attention to symptoms of some conditions, much more general in their outlook
  

• Eliminated the term reaction but kept the term neurosis

• Increased attention to children and adolescents is not seen in the previous version

• Diagnosis of homosexuality renamed “sexual orientation disturbance”

Diagnostic and statistical manual for mental disorders (DSM - III): 1980

Why?

• Research psychiatrists

  • Consistent diagnostic criteria across different clinicians

• Pharmaceutical industry

  • Products originally marketed for general conditions, not particular diagnoses

  • This changed in the 1970s, when the FDA (US regulatory board) could no longer advertise their products for the “stress of life” (common marketing technique)

  • Needed to prove effectiveness with particular conditions (Concrete, measurable

• Third-party health insurance

  • In the 50’s, most patients paid out of pocket for therapists

Diagnostic and Statistical manual for mental disorders (DSM-III): 1980

Included explicit diagnostic criteria

• Goal: standardized diagnostic reliability (better treatment, randomized clinical trials became easier)

Becoming multiaxial

• Multiaxial: a system/method of evaluation, grounded in the biopsychosocial model of assessment that considers multiple factors in mental health diagnoses

Responsible for the shift to biological psychiatry

Medical model

Diagnostic and statistical manual for mental disorders (DSM - III - R): 1987

DSM-III to DSM-III-TR

Diagnostic and statistical manual for mental disorders (DSM-IV): 1994

Diagnostic and statistical manual for mental disorders (DSM-IV-TR): 2000

Diagnostic and statistical manual for mental disorders (DSM-V): 2013

DSM-IV-TR to DSM-V

Diagnostic and statistical manual for mental disorders (DSM-V-TR): 2022

• Identified out-of-date information in the DSM-V

• Clarified certain diagnostic criteria

• Ensured appropriate attention to risk factor (racism, discrimination)

Other diagnositc manuals

Anxiety Disorders

Fear and anxiety are adaptive reactions to threats

Ex. It is typical to be fearful of a hungry lion or anxious about an upcoming exam

Estimated 30% of Canadians experience one pathological anxiety, although only about 5% of people are ever diagnosed.

DSM-5 recognizes 12 types of anxiety disorders:
Generalized Anxiety Disorder (GAD

An anxiety disorder in which worries are not focused on any specific threat - GAD is used as a case study for examining the different parts of the DSM

In the population, levels of anxiety are constant throughout the lifespan - the content of worries changes

Diagnostic Criteria:

1. Excessive anxiety and worry, occurring more days than not for at least 6 months, about more than one event/stressor

2. The individual finds it difficult to control the worry

3. Three or more of these symptoms:

   a) Restlessness
   b) Fatigue
   c) Concentration deficiency
   d) Irritability
   e) Muscle tension
   f) Sleep disturbance

4. Causes significant distress/affects functioning

5. Cannot be attributed to substance use or other medical condition

6. Cannot be better described by another DSM diagnosis

Onset:

Median age for diagnosis is 30, but many patients report having anxiety symptoms for a long time before reporting them

• In the population, the level of anxiety is constant throughout life spans

• The content of worries changes
  

Prognosis: In individuals, the severity of symptoms waxes and wanes across the lifespan (remission is rare)

Phobic Disorders

A more specific type of anxiety disorder (characterized by marked, persistent, excessive fear of specific objects, activities, or situations)

Usually, the person recognizes the irrationality of their fear but can’t control it

Specific phobias: Have 12% prevalence

• Animals

• Natural environment

• Situations

• Medical events

• Other

Social phobia - maladaptive fear of being publicly humiliated or embarrassed (13% prevalence)

Why are phobic disorders so common? Preparedness Theory

We may be evolutionarily adapted to fear certain types of stimulus

• Evidence for this hypothesis comes from conditioning

• Monkeys can easily be conditioned to fear snakes, but not flowers

• These fears may be overdeveloped in some individuals

Panic Disorder

Sudden occurrence of multiple psychological and physical symptoms typically associated with terror

• Shortness of breath

• Heart palpitations

• Sweating

• Dizziness
  derealisation (feeling that the world is unreal)

• Fear of death/”losing one’s mind?

Panic episodes are common (1/3 Canadian experience a panic attack once or more per year)

Diagnosis:

• Recurrent, unexpected attacks

• Significant fear of another attack

Moods

A sustained emotional state

Emotions

reactions to significant events, involving feelings, physiological changes, and behaviors.

Emotional states:

• Long-lasting

• Non-specific

Mood disorders

Mental disorders that have mood disturbance as their prominent feature

Manic episode

A distinct period of high energy and increased activity

Depressive Episode

A distinct period of sad mood and loss of interest or pleasure

Depressive Disorders

Present in 22% of the female Canadian population and 14% of the male Canadian population

Due to:

• Hormonal differences

• Higher diagnoses

• Difference in coping strategies (sharing and co-rumination)

About 1 in 12 Canadians will experience major depression in their lives

Major Depressive Disorder/Unipolar Disorder (Most well known)

Severely depressed mood and/or inability to experience pleasure that lasts two or more weeks and is accompanied by feelings of worthlessness, lethargy, sleep disturbance, and/or appetite disturbance

Diagnostic Criteria:

1. Five or more of the following symptoms in the same 2-week period

• Depressed mood

• Diminished interest

• Significant weight loss/gain

• Insomnia or hypersomnia

• Psychomotor agitation, retardation (anxiety/restlessness or intellectual disability)

• Fatigue

• Feelings of worthlessness/guilt

• Diminished concentration/decisiveness

• Recurrent thoughts of death/suicidal ideation
  

2. No evidence of a manic episode

3. Symptoms cause clinically significant distress/impairment

4. Not better described by another DSM disorder

5. Not attributable to another medical condition or physiological effects of substance use
   

Onset:
It may appear at any age, but is most likely to appear in the 20s

Prognosis:
2/5 of individuals recover within 3 months
4/5 of individuals recover within 1 year
1/5 of individuals do not experience remission

Bipolar Disorders

Mood disorders are not unipolar

Bipolar Disorders are characterized by cycles of abnormal, persistent high mood (mania) and low mood (depression)

→ Bipolar I Disorder - At least one manic episode, possibly with hypomanic and depressive episodes as well

→ Bipolar II Disorder - Presence of both hypomanic and depressive episodes; no manic episodes

Criteria:
1. Distinct period of abnormal, persistently elevated mood; increased activity or energy; lasting at least 1 week (manic episode)

2. 3 or more of the following:
- Inflated self-esteem
- Decreased need for sleep
- Talkative
- Racing thoughts
- Distractibility
- Increase in Goal-Directed Activity or Psychometer Agitation
- Excessive Involvement in Activities with a high potential for painful consequences

3. Symptoms cause clinically significant distress/impairment

4. Not better described by another DSM disorder

5. Not attributable to another medical condition or physiological effects of substance use

Prevalence:

• 1 in 40 individuals

• No differences between women and men (1:1)

Onset:

• Mean age of first episode = 18 years

• Onset can occur for the first time in the 60s or 70s
  

Prognosis:

90% of individuals who experience a manic episode will experience more of them throughout life

• Full remission is very rare
  

Risk Factors

• Temperamental (particularly neuroticism, or negative affect)

• Environmental (childhood experiences, stressful life events)

• Biological (neurotransmitter imbalance)

• Genetic (family members of individuals with MDD are 2-4 times more likely to be diagnosed with MDD; 40% heritability)

The Helplessness Theory

It argues that the way a person thinks about failure makes them more or less likely to be depressed

• Attribute failures to internal characteristics

• Believes that failures are permanent (stable)

• Believes that failures are global (apply to many areas of life)

Dysthymia or Dysthymic Disorder

Moderate depressive symptoms that last for more than 2 years

When dysthymia is punctuated by an episode of major depression, it is called Double Depression

Obsessions

Recurrent, unwanted, and intrusive thoughts, fears, urges, or images

Ex. Fear of germs

Compulsions

Behaviors in response to obsession

Ex. Repetitive handwashing

Hoarding Disorder

Difficulty getting rid of useless possessions

• results in excessive accumulation of items

• areas in living space become unusable and hazardous

Trauma

An emotional response to something shocking or dangerous

Stress

A reaction to life demands

Post-traumatic stress disorder (PTSD)

Experiencing or witnessing a traumatic event
Ex. war, natural disasters, and /or violent crime

Addiction

Repeated and compulsive engagement in rewarding activities

• disregard for negative, long-term outcomes

• addictions can be substance-related or behavioral

Substance use disorder/ Substance induced disorders

Substance-related disorders lead to physiological dependence and tolerence

Gambling Disorder

Repeatedly placing bets to risk some money to gain even more (chasing a feeling of euphoria)
- this is a behavioral addiction

General Neurocognitive Disorders

Neurocognitive disorders are acquired (cognitive deficit was not present at birth)

Attributed to:

• Brain injury

• Disease
  substance/Medication use

General Personality Disorder

Drastically different characteristics, beliefs, and behaviors

3 Categories of behavior:

1. Cluster A: odd and eccentric

2. Cluster B: dramatic, emotional, and erratic

3. Cluster C: anxious and fearful

Borderline Personality Disorder

• Instability in interpersonal relationships, self-image, and emotion

• Intense emotions that quickly change

• Thinking in absolutes of all good or bad