PSYCH 1101 Psychological Disorder Notes
PSYCH 1101 Psychological Disorder Notes PSYCH 1101
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What differentiates "normal" versus "abnormal" behavior? Moreover, how is abnormal behavior identified and diagnosed? These questions are related to the field ofpsychopathology*, or the study of the origins, development, and symptoms of psychological disorders. Normal or abnormal is most often defined by certain social or cultural norms. Specifically a person's behavior is deemed abnormal if it violates what is considered acceptable behavior by a particular social group or culture. To illustrate the point, consider the following. In the United States giving someone, the "thumbs-up" sign is used to convey approval. Yet, in some Arab countries this gesture would be one of extreme insult and disrespect. Aside from different cultural meanings, it is true that giving a simple hand gesture would not fall under the realm of abnormal behavior by most standards. However, what if an individual felt the need to repeat a certain hand gesture 50 times before ending a conversation? Psychology defines abnormal behavior as behavior that is deviant, maladaptive, and prevents functioning, or a behavior that causes personal distress for a prolonged period of time. Abnormal behaviors also fall on a gradient that range from mild to debilitating. These three criteria help distinguish normal from abnormal behavior. Deviant behavior* is outside of what is acceptable in a culture. Maladaptive behavior* inthat it affects a person's ability to function effectively in society and the world around them. Lastly,personal distress* is when the individual experiences a given behavior as troubling or disruptive. Not all of these criteria need to be met in order for a behavior to be considered abnormal; rather they provide a general framework to use when analyzing behavior. Consider an individual who is a hoarder and how this behavior might fit into these criteria of abnormal behavior. Someone who does not throw away anything could be considered a person with deviant behavior since it would be viewed as unsanitary and unacceptable in most cultures. Hoarding behavior could also be maladaptive since it often becomes impossible for the hoarder to function in his/her living space due to the accumulation of items. Hoarders may or may not meet the third criteria, as they may or may not experience personal distress as a result of their hoarding behavior. More often a hoarder will experience distress when forced to part with items that he/she collected over time. Introductory Essay: Understanding Psychological Disorders A Short History Psychological disorders have been observed since the dawn of humanity and yet to some people, many of the disorders seem to be as mysterious as they were to people who do not have the luxury of psychological treatments and psychological concepts. Early in the course of civilization, the mentally ill were treated with magical spells, hallucinogens, exorcism, incantations, alternative diets and at the worst end of the spectrum—trephining, stoning and beatings. Trephining was chipping into the skull to release the evil spirits that lived within the person's head. Of all the civilization who used some of the earliest treatments, the most advanced peoples were the Egyptians who used concerts, dancing and painting as a suggested relief to patients (Foerschner, 2010). In Christian Europe, madness was viewed as a problem with four bodily fluids (blood, phlegm, bile, and black bile) and so leeching and cupping were popular. Some of the herbal concoctions used with these treatments contained: aloes, colocynth, black hellebore, myrobalans, rhubarb, and senna. But the predominant opinion in Europe was that mental illness was a moral issue. The stigma of having someone in the family who was that disordered eventually led to imprisonment or special hidden rooms to house the afflicted. In Christian Europe, that meant that mental illness was considered a demonic possession or a result of sinful behavior, so penances were often prescribed by priests. Christianity also suggested fasting, prayer, and music and considered grief and overwork a cause. In Islam some also felt the illness was directly associated with the jinn or demons of the desert. But as Islam examined the illness further, they established the first psychiatric hospital in Baghdad and used various treatments including music, baths and drugs (Foerschner, 2010). As the population grew in Europe, many mentally ill people were put into private madhouses or jails. Restraints were used. Families were no longer considered the place to care for these people. Since the network of madhouses, increased physicians finally became involved since caring for 500 inmates could be lucrative. Eventually through all these negative experiences, the 18th century saw improvements. Although most people were still confined to lunatic or insane asylums, the physicians finally understood that there were biological reasons for the illness rather than seeing these people as moral problems. Classification of illnesses and symptoms became established under the term psychiatry and those who treated the mentally ill were often called alienists since they were treating people who were alienated from society. One hero of the movement was the French physician Phillippe Pinel who eventually forbade the beatings and shackling of patients (PBS, 2002). It is only with the advent of the 20th century and the discovery of psychoanalysis that people were finally called patients who had mental illness. Yet even at this late date, Nazi Germany used euthanasia for mental disorders and in the U.S., public institutions were still considered the main treatment centers. It took WWII to finally reveal a broader understanding of the variety of mental disorders and the Diagnostic and Statistical Manual was first published. Eventually, public institutions that used electro- convulsive therapies, surgeries, lobotomies and drugs were closed, and psychiatric treatments began to rely on trained doctors who specifically studied mental disorders who now administered anti-psychotic drugs. In 1963, the Mental Retardation Facilities and Community Mental Health Centers Construction Act created funds for local community mental health facilities and treatments as the large institutions closed (PBS, 2002). Today In contemporary times, the misfortune, the mismanagement and the mystery of mental illness has been dispelled in several ways--we have the advantage of neuropsychology; we have refused to demonize people with disorders in most of the civilized world; we have better treatment options; we understand the complexity of many of the disorders; and most importantly, we understand the underlying genetic causes of some of the disorders. The mentally ill may be understood better but even with these advancements, the individual and his/her family still suffer great distress. So there is much to learn each day about their symptoms, and much to learn about possible and potential therapies. One way of learning about them is to examine how people have coped and managed the disorders, how they are stereotyped, and how they find support. Therefore, it is important to look at the various disorders, see who has experienced the disorder and identify the stumbling blocks. The DSM-IV and the latest diagnostic manual, the DSM-V mention the following categories: (American Psychiatric Association, 2014) Neurodevelopmental disorders Schizophrenia spectrum and other psychotic disorders Bipolar and related disorders Depressive disorders Anxiety disorders Obsessive-compulsive and related disorders Trauma- and stressor-related disorders Dissociative disorders Somatic symptom disorders Feeding and eating disorders Elimination disorders Sleep-wake disorders Sexual disorders Gender dysphoria Disruptive, impulse control and conduct disorders Substance use and addictive disorders Neurocognitive disorders Personality disorders Paraphilic disorders Other disorders Besides the categories, the DSM gives a diagnosis of each disorder, the objectives a practitioner must meet to treat someone suffering from the disorder, assessments that can be given, the characteristics of a clinician who treats the person, the emphasis of the treatment, the amount of treatment and medications needed, and possible additional services that are available (American Psychiatric Association, 2014). Here are some examples of some specific well-known mental disorders that fit within these categories. Tourette's syndrome, an inherited disorder, starts in childhood. No gene has been discovered yet that causes the disorder. It manifests within children with various physical and/or vocal tics. Dan Ackroyd experienced the disorder until he was 14-year-old, often grunting and experiencing physical tics. Mozart may have also experienced Tourette syndrome. In some of his correspondence, he would use foul language that was out of character, and other people have spoken of his physical tics. Jim Eisenreich, a baseball player, had to leave baseball for a time due to Tourette's and has a charitable foundation to fight for those who inherit the disease (DeJoseph, 2014). Autism is a complex neurodevelopmental disorder which results from both genetic and environmental conditions. One of the consequences of the disorder is communication problems, repetitive actions, and a preoccupied pattern of interest that seems abnormal in its intensity. Albert Einstein often had trouble communicating in normal everyday life even though he could talk about the most complex topics in physics. He had what could be called high-functioning autism (BBC News, 2003). This was similar with Mozart whose often bizarre behavior in social settings could not be understood even though his musical genius was flourishing and astounding in its complexity. Children with classical autism may not have the gifts associated with Einstein or Mozart and often will need behavioral interventions, medication and educational interventions for their repetitive patterns, their inability to engage others and their restrictive interests (NIH, 2014a). Alzheimer's disease, the most common form of dementia, is a brain disorder that has caused many people who were brilliant and productive in their lives to succumb to the ravages of a progressive decline in memory, attention, language, and problem-solving. For some people, this disease can occur in their 40s and 50s but for most people it happens after age 65. Plaques and tangles in the brain cause the destruction of nerve cells. Some famous people who have suffered from this type of dementia are Ronald Reagan, Sugar Ray Robinson, Pat Summit, Barry Goldwater, Norman Rockwell, Perry Como, and Tommy Dorsey (Anderson, 2012). A very familiar disorder is substance abuse. Craig Ferguson has been sober for 18 years after living the life of an alcoholic. He went to rehabilitation and has had enough success to be able to talk about it as a comedian on his late night show (Huffington Post Media, 2008). Another entertainer, Janis Joplin, was a blues-rock singer and songwriter during the 60s, suffered from addictions to heroin, amphetamines, and alcohol throughout adolescence and young adulthood. She died in 1970 from a drug overdose at the age of 27. Carrie Fisher played Princess Leia in "Star Wars" and wrote a best-selling book, Wishful Thinking. This book detailed her rehabilitation from substance abuse. (NIH, 2014b) (Drug and Alcohol Rehab Solutions for Addiction, 2008). John Nash, the great mathematician, lived with and managed schizophrenia with the help of his wife. The book/movie Beautiful Mind explored the onset of the disorder and its effects in great detail. Nash heard voices that pushed him into isolation, made him fear governmental agencies, and often interfered with his university appointments. But in the end, he worked hard to manage the disease and made significant contributions to his field of work. Another person who experienced the ravages of schizophrenia was Lionel Aldridge, a defensive end for Vince Lombardi's legendary Green Bay Packers. Even though Aldridge played in two Super Bowls, he was homeless for two and a half years due to the disease. His way of combatting the effects was to give talks on his battle and to be interviewed for newspapers (Healthline, 2014). Jane Pauley and Catherine Zeta-Jones have bipolar disorder. They experience extreme highs and lows and are often seen as very creative people. This creativity may be a result of the disease though many scientists are still investigating why this is so. Sinead O'Connor experienced the same disease while she honed her singing career and often had suicidal ideation during her battle with the disorder. Richard Kay Redfield Jamison, a Professor of Psychiatry at Johns Hopkins University School of Medicine, is a leading researcher and author about bipolar disorder. In the book An Unquiet Mind, she detailed her own experiences (Mayo Clinic, 2014a) (Bhatia, 2014). Post-partum depression is a well-known experience of many women when they are having a newborn. Brooke Shields is one person who talked about her experience and sought treatment early. She wrote a book about her suicidal tendencies and acute depression in "Down Came the Rain" (PubMed Health, 2014) (Mann, 2014). Other types of depression have sidelined many people including Emma Thompson. Often she felt like her career saved her from the disorder, working hard and infusing her work with renewed energy. Harrison Ford often slept a lot as a teen because of depression, but eventually his acting class saved him by immersing him in hard work. Billy Joel experienced the disease to the point of suicidal action, and Drew Carey saw the world as his enemy after his father's death. His depression often got him into trouble with both food and alcohol. David Bohm, the great physicist, who had to leave the U.S. during the McCarthy era, suffered from bouts of depression. Mike Wallace used his depression to explore several documentaries on the disorder and talked about it on 60 Minutes. And as the great Winston Churchill aged, he succumbed to depression and suffered greatly (Depression-help-resource.com, 2010). With much experience of depression, Abraham Lincoln wrote to a grieving woman "You cannot now realize that you will ever feel better. Is not this so? And yet it is a mistake. You are sure to be happy again. To know this, which is certainly true, will make you some less miserable now. I have had experience enough to know what I say; and you need only to believe it, to feel better at once. The memory of your dear Father, instead of an agony, will yet be a sad sweet feeling in your heart, of a purer and holier sort than you have known before" (Norton, 1998). Various eating disorders plague many teens and adults around the world. Elton John experienced bulimia for years, eating large amounts of food and vomiting in order to maintain his weight. Another singer of the 60s, Judy Collins, struggled with bulimia during the 1970s and wrote a book entitled, Sanity and Grace: A Journey of Suicide, Survival, and Strength. She expresses her darkest moments in depression after her son committed suicide in 1992 (NIH, 2014c) (Schuman, 2014). OCD-obsessive compulsive disorder was effectively portrayed by Jack Nicholson in the movie As Good as it Gets. But in real life, Howard Hughes, a wealthy businessman, experienced the last years of his life in a reclusive bout of OCD. He would not live with other people due to his fear of germs, constantly washed his hands even for the slightest change in his routine. This severely limited his ability to continue his interests in aviation and movie production. Donald Trump also suffers from the disorder in relationship to germ avoidance. Howie Mandel has a similar fear and both men avoid shaking hands with people. Howard Stern used transcendental meditation to combat his OCD (Mayo Clinic, 2014b) (Sound-Mind.org, 2014). At the end of this bibliography are more great examples to read from the authors who wrote them. Theories of Psychopathology As psychologists have examined various types of psychological disorders, they have developed a number of different approaches for explaining and treating abnormal behavior. The are five primary approaches that are used are grounded in psychological perspectives that by now should be quite familiar. These include the psychodynamic approach, the humanistic approach, the behavioral approach, the cognitive approach, and the psychophysiological approach. Please click on each approach in the graphic below to learn more. The Psychodynamic Approach: The psychodynamic approach suggests that abnormal behavior results from intrapsychic conflict. Freud believed that intrapsychic conflict was the motivator of human feelings, thoughts, speech, and actions. For example, a person who has a dominant id will be uninhibited and impulsive. In contrast, a person who has a strong ego is likely to be restrained, rational, and reality oriented. A person who has a strong superego will be paralyzed by moral strictures against any behavior that might be considered morally questionable in any way. The Humanistic Approach: In this school of thought, abnormal behavior emerges when a person is overly sensitive to the judgments of others, or when they cannot accept their own nature. Therefore it highlights the relationship between the individual and society and focuses on personal responsibility. The Cognitive Approach: In this school of thought, abnormal behavior results from distorted thinking. Distortions may occur in the thinking processes or the contents of thinking. For example, depression often occurs in people who minimize the positive and accentuate the negative in their thought processes. Alternatively, a person might have an irrational belief that dogs are dangerous and, therefore, develops a phobia about dogs. Therapy using the cognitive approach would attempt to change the thought processes or the contexts of the person's thoughts. The Psychophysiological Approach: The psychophysiological approach argues that disordered behavior is the result of underlying abnormalities in the nervous system and brain. These abnormalities may relate to neuronal transmission and a shortage/excess of neurotransmitters that cause abnormal behavior. Still other problems may be due to a brain injury or a growth in the brain. Proponents of the psychophysiological approach typically treat psychological problems with drugs and surgery. The Behavioral Approach: The behavioral approach suggests that abnormal behavior results from classical or instrumental conditioning that has gone awry. This approach is based on assessing and diagnosing observable behaviors. A phobia might result from accidentally pairing an object that normally would not stimulate fear with punishment. For example, a person who experiences a plane accident may become abnormally afraid of airplanes. The individual with the phobia acquires a set of responses that is involuntary and nonadaptive. Learning theorists would use principles of learning to counteract the negative effect of the initial conditioning. The Diagnostic and Statistical Manual of Mental Disorders (DSM) What does it mean that someone has a psychological disorder*? What determines whether a given pattern of symptoms qualifies as a psychological disorder? To address these questions, it is first necessary to define various abnormal behavior patterns. It is only after these abnormal patterns of behavior have been identified and clearly outlined by a set of specific criteria, that they can be used as a standard of measurement from which it is possible to make a clinical diagnosis. The Diagnostic and Statistical Manual of Mental Disorders, or DSM for short, was published in 1952 by the American Psychiatric Association created to serve this exact purpose. Purpose of the DSM 1. To provide a common language for defining mental disorders. 2. To provide a comprehensive guideline of diagnostic criteria to be used for diagnosing mental disorders. Source: Adapted from APA (2013) Needless to say, the DSM has proven to be a useful tool, which is used by virtually all mental health professionals concerning diagnosing mental disorders. Evolution of the DSM: DSM 5 The first edition of the DSM contained fewer than 100 distinct disorders. Over the years, the DSM has been revised as new research and information has emerged. With each revision there have been improvements, for example, the first edition listed only general descriptions of mental disorders. As might be expected, this left much open to interpretation when it came to making a diagnosis. The current edition, the DSM 5* (American Psychiatric Association, 2013), describes more than 300 specific psychological disorders. In this edition, each description is quite granular in terms of listing both criteria and symptoms of a given disorder that are grounded in current research. This specificity aids mental health professionals in making accurate assessments and diagnoses. The latest DSM also includes genetic and neurological information that was not able to be present in previous editions because of the advances in those areas. How Is A Diagnosis Made? The graphic below illustrates the steps that a mental health professional use to make a clinical diagnosis of a mental disorder. Click each step to learn more. Clinical interviews- First, mental health professionals utilize a variety of different methods to begin to assess the individual's symptoms. These steps can include clinical interviews, as well as psychological and neurological tests. Psychological tests-Neurological tests Clinical assessment: Identify symptoms -The information obtained through the various assessment tools is then analyzed. Symptoms are outlined and described, and a clinical assessment is made. DSM5: Use symptoms to diagnose mental disorder- The health professional, using the symptoms that are outlined in the clinical assessment, will consult the DSM 5 and match the presented symptoms against the symptom criteria that is listed in the manual to make the final diagnosis of a mental disorder. Criticisms of the DSM: Labels and Social Stigmas While the DSM has proven to be a useful tool as it has created a common language for describing disorders as well as a classification system for their study and diagnosis, it is not without criticism. Two common criticisms of the DSM are related to the negative effects oflabeling and the social and/or political implications of what that label entails (Corrigan, 2005). A person diagnosed with a mental illness can experience fear and judgment rather than support. This type of social rejection is a common factor when it comes to why someone does not seek treatment. Specifically individuals will avoid getting help because of the negative associations society places on the label. Labeling, as the name implies, involves categorizing and naming differences that exist between individuals. As with any label, it can either have a positive or negative connotation. By design, the DSM 5 serves as a guide to diagnosing (label) the particular disorder that a given individual is experiencing. The associated connotations that accompany these labels are not always positive. This relates to the second criticism -- specifically that labeling a person with a mental disorder, often carries significant social implications. Most often these social implications are detrimental to the individual who has been labeled with a particular diagnosis. The problem with that is society's tendency to categorize mental disorders as something other than an illness. When someone is diagnosed with a terminal disease, the person will generally receive sympathy and support. Often those who are diagnosed with a mental disorder are not afforded the same treatment. Anxiety Disorders Anxiety disorders* occur when an individual is preoccupied with thoughts about what might happen in the future and these thoughts interfere with social or occupational functioning. Additionally, this anxiety is without a clear external cause. The experience of anxiety has both physical and mental effects. The physical effects often evoke a fight or flight pattern of behavior. The mental effects can result in maladaptive moods and thought processes characterized by uncontrollable, irrational thoughts. The individual's anxiety is often provoked by perceived threats that are exaggerated or nonexistent. These cause a response that is out of proportion to the reality of the situation. Often the individual knows the situation is unrealistic but is still unable to abate their anxiety response. There are a number of ways that an individual suffering from an anxiety disorder might display irrational or disordered thinking. 3 Common Examples of Irrational Thinking All-or-nothing thinking*: the individual believes that their performance must be perfect or he/she is a total failure. Magnification*: the predisposition to perceive situations as more dangerous, embarrassing, harmful, embarrassing, important, or threatening, than they really are. Overgeneralization*: interpreting a single event as a pattern that will never end. In the United States, anxiety disorders are the most common category of mental disorders. Some anxiety disorders include: panic attacks, agoraphobia, generalized anxiety disorder, panic disorder, social phobia, specific phobia, and obsessive-compulsive disorder. Panic Disorder A panic attack* is a sudden experience of extreme anxiety; that escalates rapidly. Often times these types of attacks occur when an individual is dealing with a significant amount of stress related to a situation such as moving, changing careers, or losing a loved one. This type of panic attack has recognizable cues and are considered to be the result of learning,not psychological disorder. In contrast, when panic attacks occur frequently and unexpectedly psychologists will often probe to see whether a person's panic attacks point to a deeper problem. Theseuncued panic attacks, are more likely to be associated with a psychological disorder known as panic disorder*. The panic lasts from seconds to hours, and there is not a clear, identifiable stimuli--such as with phobias. Individuals who suffer from these types of panic attacks experience significant and intense worry concerning the possibility of future attacks. This worry often becomes psychologically debilitating. The DSM 5 definition of Panic Disorder A. Recurrent unexpected panic attacks B. At least one of the attacks has been followed by1 month (or more) of one or both of the following: -Persistent concern or worry aboutadditional panic attacks or their consequences -Significant maladaptive change in behavior related to the attacks Source: Adapted from American Psychiatric Association (2013). Panic Attack Symptoms The DSM 5 defines a panic attack as "an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes. During that peak, four or more of the symptoms occur that are listed below. The abrupt surge can happen when in a calm state or an anxious state." Individuals who are experiencing a panic attack often believe that they are having a heart attack given the similarity of the symptoms. Source: MindEdge (2015) Panic Attack Symptoms Rapid heart rate Chest pain Shortness of breath, or feeling like one is choking Body chills Dizziness, lightheadedness Nausea Profuse sweating Trembling Dry mouth Blurred vision Dulled sense of hearing Numbness Sense of being 'out of the body' Fear of losing control Fear of dying Source: Adapted from Medina (2014). Treatment Panic disorders are generally treated with a combination of cognitive-behavior therapy and drug therapy. Psychologists believe that attacks may result from a malfunction in the autonomic nervous system's fight or flight system. Once physical symptoms emerge, a person's higher cognitive functions also are launched. Panicked thoughts further increase the sense of danger. Therefore, one method of treatment is teaching people how to control the cognitive responses to sensations that occur during an attack. Antianxiety drugs called benzodiazepines or certain types of antidepressant drugs called SSRIs are often prescribed. Both types of drugs will be discussed in the next module on treatments. Generalized Anxiety Disorder Generalized anxiety disorder (GAD)* is characterized by chronic, excessive and pervasive worry about almost everything in an individual's life--that occurs for six months or more (American Psychiatric Association, 2013). Individuals who suffer from GAD often report an ever present feeling of "impending doom." While occasional worry is most certainly justified, the type of worry that is experienced by someone suffering from GAD is either out of proportion or without justification. The anxiety that a person experiences as a result of this distorted or irrational thinking does not dissipate with the removal of an identified stressor. Rather, when one source of anxiety is perceived to be removed, another one quickly jumps in and replaces it. As a result, the individual's anxiety interferes with their everyday routine. They will avoid events or postpone obligations if they fear they will have trouble controlling his/her anxiety. Ironically, thinking about this avoidance causes them to feel more anxious, and creates a vicious cycle where the anxiety spins even more out of control, becoming more debilitating. As a result, GAD is often coupled with other anxiety disorders, such as social phobias and depression. Due to this dramatic, overall impact, of GAD on an individual's ability to function in their day-to-day routines, the individual invites more disease. Source: MindEdge (2015) The DSM 5 definition of Generalized Anxiety Disorder A. Excessive anxiety, occurring more days than not for at least six months, abouta number of events or activities (such as work or school performance). B. The person finds it difficult to control the worry. C. The anxiety and worry are associated with three (or more) of the following (with at least some symptoms present for more days than not for the pastsix months). Note: Only one item is required in children. 3. Restlessness or feeling keyed up or on edge 4. Being easily fatigued 5. Difficulty concentrating or mind going blank 6. Irritability 7. Muscle tension 8. Sleep disturbance Source: Adapted from American Psychiatric Association (2013). Treatment GAD is most often treated with a mixture of psychotherapy and drug therapy. There is growing evidence that GAD is linked to imbalances of several neurotransmitters. Individuals with GAD have lower levels of both GABA and serotonin, two neurotransmitters that calm the stress response (Pollack, 2005). Therefore, drug therapies focus on correcting these imbalances. Psychotherapeutic approaches to treating GAD vary, depending on the psychological school of thought and the perspective for the anxiety. A behaviorist would attribute anxiety responses to learned behaviors, so treatment would focus on disassociating the learnedstress response with external stimuli. A cognitive approach would attribute the source of anxiety to irrational thought processes. Therefore, this type of treatment would explore ways to change the mental interpretations and perceptions of events. A psychodynamic approach would believe that the source of anxiety resides in the unconscious as repressed urges, and would work with the client to uncover them. Everyday Psychology: Anxiety disorders linked with heart problems A recent (Oct. 2014) article posted on MedicalResearch.com discusses a finding that anxiety disorders are common in patients with coronary heart disease. Read more here. Obsessive-Compulsive Disorder Obsessive-compulsive disorder (OCD)* describes an anxiety disorder that is characterized by recurrent obsessions, compulsions, or both. Obsessions: Obsessions* are persistent and involuntary impulses that dominate a person's consciousness. Common obsessions are: contamination (a fear of germs or dirt),persistent violent or sexual thoughts (fear of harming others),pathological doubt (uncertainty of accomplishing a simple task) Compulsions: Compulsions*, in contrast, are the persistent and irrational urge to perform an act over and over again. Common compulsions are:washing (often coupled with contamination obsessions), checking, counting, and precision/symmetry (a need for objects or actions to be symmetrical or in exact positions or order) Although a person may realize that the act is senseless, they experience great anxiety if they do not perform the act. Compulsions are only considered psychological problems if the person cannot stop doing the act, if it is time-consuming, or if it interferes with the person's normal activities and relationships. Examples of compulsions include the need to wash one's hands repeatedly or excessive organizing. Studies indicate that early autoimmune system diseases, early strep infections, and changes in the brain caused by infection, can predispose an individual to OCD (Swedo et al., 1998). The DSM 5 definition of Obsessive-Compulsive Disorder (OCD) According to the DSM 5, in order to receive an OCD diagnosis, an individual must meet the following general criteria. A. Must have obsessions and compulsions B. Obsessions and compulsions must significantly impact daily life C. May or may not realize that obsessions and compulsions are excessive or unreasonable Obsessions must meet specific criteria: The obsessions are intrusive, repetitive and persistent thoughts, urges, or images that cause distress The thoughts do not just excessively focus on real life problems The person experiences a lack of success in suppressing or ignoring the disturbing thoughts, urges, or images Compulsions must meet specific criteria: They are marked by excessive and repetitive ritualistic behavior coupled with a strong feeling that these behaviors must be performed, or something bad will happen. Examples include hand washing, counting, silent mental rituals, checking door locks, etc. The ritualistic compulsions take up at least one hour per day Physical rituals or mental acts are performed to reduce the severe anxiety caused by the obsessive thoughts Source: Adapted from American Psychiatric Association (2013). Treatment Antidepressant drugs are often used in the treatment of OCD as they have been found to help control the obsessions and compulsions (Abramowitz, 1997). Additionally, a specific type of therapy called exposure therapy* has proven to be an effective method of treatment. This therapy involves the gradual exposure of the individual to the feared object or obsession and having the individual learn healthy ways to cope with their anxiety. This type of therapy may take place in individual, family or group sessions. Regardless of the setting, it is challenging and takes effort and practice on the part of the sufferer. However, those that are able to stay with this course of treatment report a better quality of life upon successful completion. Phobias Phobia* is the term used to describe a persistent and irrational fear of an object, situation, or activity that poses little to no danger. In the DSM 5 phobias are divided into two categories, specific phobias, and social phobia(American Psychiatric Association, 2013). Specific Phobias: A specific phobia is a fear of a specific object or situation. When a person confronts the object or situation that he/she is afraid of, they experience strong anxiety. The DSM 5 lists the diagnostic criteria for specific phobias as (American Psychiatric Association, 2013): The DSM 5 definition of Specific Phobia Specific Phobia: DSM 5 Diagnostic Criteria An intense fear or anxiety triggered by an object or situation An immediate anxiety response when the person confronts the source of your fear Fear or anxiety that is irrational or out of proportion to the risk posed by the object or situation Avoidance of the object or situation the person fears, or endurance of it with extreme distress Significant distress or problems with social activities, work or other areas of a person's life due to the fear, anxiety and avoidance Persistent phobia and avoidance, usually lasting six months or longer Source: Adapted from American Psychiatric Association (2013). Common Specific Phobias There are literally hundreds of specific phobias, most of which fall into one of four broad categories. The Four Broad Categories of Specific Phobias Situational phobias: involves fear of situations like riding in an elevator or airplane, being in an enclosed place like a tunnel, or fear of heights. Natural environmentphobias: such as fear of storms or water Animal phobias: such as fear of dogs, snakes, or insects. Blood-injection-injury phobias: which relate to the fear of seeing blood or an injury, or fear of receiving an injection. Source: Adapted from Smith, Segal, & Segal (2014). Some of the more common specific phobias are listed in the table below. If you would like to view a more extensive list you can find one atwww.phobialist.com. Scientific Names of Common Specific Phobias Acrophobia Fear of heights Arachnophobia Fear of spiders Aviatophobia Fear of flying Claustrophobia Fear of enclosed spaces Hemophobia Fear of blood Mysophobia Fear of dirt, germs Zoophobia Fear of animals Social Phobias: Individuals with social phobia, which is also called social anxiety disorder, are afraid of social or performance situations where they might embarrass themselves in front of others. This is what differentiates social phobia from specific phobias in the DSM 5 (American Psychiatric Association, 2013). One example of this type of type phobia is stage fright or glossophobia*. While a social phobia is considered to be less debilitating than agoraphobia, it can still seriously affect the quality of a person's life. Sometimes people with social phobias will drink alcohol or take tranquilizers to reduce their anxiety. The DSM 5 definition of Social Phobia Social Phobia: DSM 5 Diagnostic Criteria In addition to the diagnostic criteria listed for specific phobias, the individual must exhibit: An intense fear or anxiety in one or more social situations where there is the possibility of scrutiny by others Source: Adapted from American Psychiatric Association (2013). Treatment There are a variety of ways that phobias may be treated. A psychologist may ask a person to associate pleasant emotions with the feared object or situation. Behavior modification is also sometimes used ‐ this is when a person is exposed to fearful stimuli and receives reinforcement. Agoraphobia Agoraphobia* is the specific fear of being in a public place or situation where escape is perceived to be difficult or impossible should something go wrong (American Psychiatric Association, 2013). While this may sound similar to social phobia, the two types of phobias are in fact a quite distinct from each other. The source of social phobia is limited to social situations, and these types of situations can often be avoided without too much trouble. For example, individuals who suffer from social phobia may simply avoid jobs and other types of social situations that require them to meet other people face to face. Agoraphobics on the other hand cannot avoid the source of their anxiety as easily since it relates to just simply being out in the real world. For example situations like being in a crowd, elevator, or airplane all might trigger panic attacks in an agoraphobic person. In order to live with this disorder, individuals must confront situations in which panic attacks are likely to occur. This is extremely difficult for agoraphobics. In extreme cases, agoraphobics have been known to become housebound as a result of their anxiety. Panic disorder with agoraphobia is considered to be one of the most debilitating psychological disorders (American Psychiatric Association, 2013). A big change in the DSM-5 is that panic disorder and agoraphobia are no longer linked together. Previously agoraphobia fell under the umbrella of panic disorder; however it is now recognized as a separate disorder. The reason behind this is the finding that a significant number of people with agoraphobia do not experience panic symptoms(American Psychiatric Association, 2013). The DSM 5 definition of Agoraphobia According to the DSM 5, an individual with agoraphobia will meet the same general diagnostic criteria for other types of phobias (persistent phobia and avoidance, usually lasting six months or longer, fear or anxiety that is out of proportion). However, the DSM 5 outlines additional and specific diagnostic criteria for agoraphobia, which point out the differences between agoraphobia and social phobia. Diagnostic Criteria of Agoraphobia Individual must have a severe fear or anxiety about two or more of the following situations: Using public transportation, such as a bus, plane or car Being in an open space, such as a parking lot, bridge or large mall Being in an enclosed space, such as a movie theater, meeting room or small store Waiting in line or being in a crowd Being outside of the person's home alone Source: Adapted from American Psychiatric Association (2013). Post-Traumatic Stress Disorder (PTSD) Post-traumatic stress disorder (PTSD)* is an anxiety disorder that is a response to an extreme psychological or physical trauma (American Psychiatric Association 2013). These types of traumas cause intense feelings of terror or helplessness, such as experiences in time of war, during natural disasters, from physical or sexual assaults, or from terrorist attacks. PTSD is often associated with military veterans; however the trauma does not always have to be lived firsthand. PTSD it is also prevalent among rescue personnel and emergency first-responders as a witness to a death or a traumatic event. Family members have also been known to develop PTSD when a serious threat or injury has been the experience of a loved one (McNally, 2003). Interestingly, research has shown that women are more than twice as likely to develop PTSD than men (Olff et al., 2007). It's worth noting that not all people will develop PTSD after experiencing the same traumatic event, no matter how stressful. While it is not exactly known why some people develop PTSD and others do not, some of the factors believed to influence the why some people develop PTSD are family history of psychological disorders, exposure to multiple traumas, and the severity of the trauma. The DSM 5 definition of PTSD A diagnosis of PTSD must meet two criteria. The first criterion is a history of exposure to a traumatic event that meets specific stipulations. Specifically the individual was exposed to one of the following stressors (American Psychiatric Association 2013): DSM 5 PTSD Diagnostic Stressors Death or threatened death Actual or threatened serious injury Actual or threatened sexual violence Source: Adapted from American Psychiatric Association (2013). The second criteria is that the individual must experience symptoms from each of the following four symptom clusters (American Psychiatric Association 2013). Diagnostic Symptom Clusters of PTSD 9. Intrusion: Defined as recurrent, involuntary, and intrusive memories, flashbacks, traumatic nightmares 10. Avoidance:Definedasavoidanceofdistressingtrauma-relatedstimuliaftertheevent(i.e.people, places, activities, situations) 11. Negative alterationsin cognitions andmood: These caneitherhave began orworsened afterthe traumatic event. Examples are persistent and distorted negative beliefs about oneself, blame of selforothers, inability to experience positive emotions, diminished interest inpreviously enjoyed activities. 12. Alterations in arousal and reactivity: This can include self-destructive or reckless behavior, problems in concentration,anexaggeratedstartle response,anddisturbances in sleeppatterns Source: Adapted from American Psychiatric Association (2013). Dissociative Disorders Have you ever been caught daydreaming, or being so self-absorbed in your own thoughts that you momentarily lose touch with your surroundings? For example, did you ever have a professor call on you to answer a question in class only to realize that you have no idea what is being discussed because you have been thinking about what you are going to do when you get out of class? Most of us, at one time or another, have had this experience. This is commonly known as a dissociative experience and is an example of a normal break from reality. This is quite different from dissociative disorder*, which happens when individuals lose the ability to consciously integrate the elements of the self into a coherent representation of his/her identity (American Psychiatric Association, 2013). This experience is so extreme that it results in a split or breakdown of the self. In some cases, dissociation may have physical causes, but it often has psychological causes rooted in the experience of extreme stress. This disorder is extremely rare. Below three of the five more common dissociative disorders listed in the DSM 5 are discussed. Select a list item tab, press enter, then search down for text. When you hear End of tab content, go back to the next list item to access the next list item tab. Dissociative amnesia Dissociative fugue Dissociative identity disorder (DID) One form of dissociative disorder is called dissociative amnesia*. This is a complete or partial loss of the ability to recall personal information or identify past experiences (American Psychiatric Association 2013). Dissociative amnesia is usually the result of psychological trauma that motivates a person to escape through "forgetting." Although an individual with dissociative amnesia has no recollection of their personal information or family members, he/she can still recall how to live day to day and his/her basic personality remains intact. Dissociative amnesia has several subtypes: Subtypes of Dissociative Amnesia Localized amnesia Loss of memory that is localized Example: A survivor of an to a specific window of time. assault that has no memory of the event until a few days later Selective amnesia Ability to recall limited parts of Example: A victim of abuse may events that took place. recall only certain parts of the abuse Systematized amnesia Memory loss of a specific Example: An individual who is category of information missing all memories about a specific time in their life such as childhood Generalized amnesia Amnesia encompasses an Example: An individual who has individual's entire life no memory of who he/she was before entering treatment Dissociative fugue* is when an individual forgets their identity (American Psychiatric Association 2013). A person who is experiencing a dissociative fugue experiences intense confusion as a result of forgetting their identity. Often these individuals tend to travel away from home as a result of the confusion they are experiencing. Some people in a dissociative fugue will assume a new identity. The fugue state may last for hours, days, or months. Dissociative fugues are often a reaction to major psychological stress, such as a natural disaster, war experience, or deep personal rejection. Recovery from this condition is usually fast. However, most people do not remember what triggered the dissociative fugue, and they usually do not remember the fugue itself (American Psychiatric Association 2013). Dissociative identity disorder (DID)* is a condition in which two or more distinct and unique personalities exist in the same person (American Psychiatric Association 2013). The disorder is expressed as distinct identities or personality states that surface in the individual on a recurring basis. Previously this disorder was called multiple personality disorder and is perhaps the most well known dissociative disorder despite its rarity. With DID, there is also a major disruption in memory. This disruption is related to the individual's constant shift from one personality to the other. These shifts usually occur suddenly and during stressful times. Stress Stress* is a person's physiological and emotional response to perceived threats and challenges, (environmental or otherwise), the factors that cause the response, and the process by which a person evaluates and copes with those threats. A person's response to stress is innate and automatic, controlled by the sympathetic nervous system. When a threat is perceived, the body prepares the fight-or-flight response* by increasing the heart rate, sweating, releasing stored energy sources, and restricting vision, among other physiological changes; in essence, focusing all energies and systems on making the person faster and stronger. This is done, in part, by releasing cortisol, which suppresses the immune system, slows metabolism, and changes cellular pH (Randall, 2011). In contrast, the parasympathetic nervous system helps the body to recover from sympathetic reactions to a stressful situation. For example, it can slow the heart rate down and change breathing (Merck Manuals, 2015b). Approaches to Stress Select a list item tab, press enter, then search down for text. When you hear End of tab content, go back to the next list item to access the next list item tab. Stress: A Unified Mind-Body System Stress: A General Response Stress: A Unified Mind-Body System In the 1920s Walter Cannon suggested that the human stress response is part of a unified system between the mind and the body (Hugdahl, 1995). Conditions like extreme cold, lack of oxygen, and events that arouse emotions all trigger the output of the stress hormones epinephrine and norepinephrine. In response, the sympathetic nervous system increases heart rate and respiration and dulls pain. These responses prepare the body for fight-or-flight (Cannon, 1932). End of tab content. Chronic Stress When the stress response is prolonged — meaning, when a person lives in a state of constant stress — the effects of sustained cortisol release can be detrimental. Constantly suppressed immune systems have a harder time healing from injury and staving off illness. Metabolic changes may lead to weight gain, high blood pressure, and heart disease (Randall, 2011). Further, the body loses the "umph" that it experiences each time a highly stressful event occurs; it is less able to respond quickly and appropriately. Stress: A General Response Canadian scientist Hans Selye researched the effect of stress on humans and animals. He suggested that the body's adaptive response to stress is general—that is, the reaction to stress is the same regardless of the type of stressor. He termed this response the general adaptation syndrome (GAS)*. GAS has three phases: the alarm reaction, resistance, and exhaustion (Selye, 1956). Three Phases of GAS Alarm reaction: The sympathetic nervous system is suddenly activated. An individual's heart rate increases and other physiological responses occur. Resistance: A person's temperature, blood pressure, and respiration remain high. Hormones flood the body. Exhaustion: The final phase occurs if the stress is persistent. During exhaustion, a person is more likely to succumb to illness, or in extreme cases, death. Types of Stress While physical harm and violence is still a real stressor for people living in high areas of crime, non- violent threats cause stress on a daily basis for many people as well. Researchers have classified stressors into three categories: catastrophes, significant life changes, and daily hassles (Wheaton & Montazer, 2010). Catastrophes are unpredictable and large-scale events that the vast majority of people view as threatening. Significant life changes include leaving home, the death of a family member, loss of a job, or divorce. Source: Adapted from Wheaton & Montazer, 2010 Daily hassles are run of the mill, daily events. Small, but everyday annoyances can be a significant source of stress. The cumulative effect of daily hassles can result in negative health effects, such as high blood pressure. Framing the Issue: The Cognitive Component of Stress Stress can arise more from the way that a person evaluates an event than from the event itself. The type of stress that is most familiar is the negative type of stress, known asdistress*. However, it important to note that stressors do not always have to be negative. Stressors can also be positive in that they can arouse and motivate an individual to conquer a problem. The technical term for this type of stress is eustress*. The Scream by Edvard Munch, (PD). For example, some people like deadlines. The threat of an impending deadline motivates them to organize their thoughts, prioritize their tasks, and use their time effectively. For these people, the deadline is eustress. In another example, some people may feel pressure to meet the expectations of their peers and superiors. Similar to deadlines, this may motivate them to prepare, perform, and meet challenges. However, whether an event qualifies as distress or eustress varies from person to person. Some may see the expectations of others as a frightening, restrictive stressor that causes them to panic. In this case, the expectations of others is distress. For this reason, framing stress as either a threat or a challenge is immensely important to how a person deals with it. When stress is seen as a challenge, the person is less likely to feel the negative physiological and cognitive effects of stress, and the opposite is true when a person sees the stressor as a threat or a danger. Further, a person's mental framework can aid them in managing stress after the initial physiological response. Often people who deal with stress functionally will evaluate the tools (both tangible and intangible) at their disposal, fortify themselves mentally, generate a plan, and set themselves in motion. The Cultural Components of Stress Culture plays a role in shaping a person's perception of, and response to, stress. Different cultures naturally have different stressors. For example, people living in parts of Africa deal with threats to their safety brought on by social and political wars, whereas the people of Canada enjoy relative peace. Similarly, stress can come from the cultural emphasis of some values over others. The very same dilemma - whether to take a job far away from family or to stay close by - would probably cause more stress for someone raised in a culture that places a high value on family ties and time together than someone in an individualistic society that urges children to "spread their wings and fly." The cultural coping resources available to each person will also differ. Some countries make mental health professionals very available for their citizens. Other countries place emphasis on leading a lifestyle that avoids stress altogether. Finally, some cultures have strong social support systems for people feeling stressed. Coping with Stress There are many ways that a person can deal with stress, ranging from exercise to biofeedback, relaxation, social support, and spirituality. The following list is adapted from the Centers for Disease Control and Prevention (2014). Aerobic Exercise: Research shows that aerobic exercise can reduce stress, depression, and anxiety (Salmon, 2001). In fact, exercise is considered to be a useful adjunct to antidepressant drugs and psychotherapy. Exercise increases the levels of mood-boosting chemicals like norepinephrine, serotonin, and endorphins. Biofeedback: a system of recording, amplifying, and feeding back information about subtle psychological responses. For example, a person with headaches could learn to control the tension in forehead muscles by receiving feedback about tension in those muscles. Then as the individual relaxes those muscles, he/she sees a reduction of tension on a screen. Biofeedback, while complex, has shown in studies to produce a relaxation response (Achmon, Granek, Golomb, & Hart., 1989). Social Support: Social support has been proven to promote both happiness and health. Studies show that close relationships predict health (Thoits, 1995). Environments that support one's need to belong generate stronger immune functioning. Close relationships also offer the opportunity to confide painful feelings. Confiding calms people. Religious Involvement: research shows, is a predictor of health and longevity (George, Ellison, & Larson, 2002). Religiously active people tend to have healthier lifestyles than others. In addition, individuals who are religiously active benefit from social support. Researchers also believe that those who have a religious faith have a sense of hope for the future, enjoy feelings of acceptance, and benefit from the relaxed meditation of prayer. Optimistic Outlook: Optimism, or having a positive outlook, also influences one's vulnerability to stress. Optimists tend to perceive more control, cope better with stressful events, and enjoy better health (Brissette, Scheier, & Carver, 2002). When people feel that they have control over their life and environment, they are less likely to experience stress. Conversely, a perceived loss of control results in stress hormones flooding the body and can also contribute to high blood pressure. Thus people who have a pessimistic outlook and believe that they are losing control (or that they never had control) tend to experience more stress. Health Psychology Health psychologists are concerned with how a person's psychological state affects their overall health, and vice versa. Given the link between stress and poor health, professionals in this field are integral to mitigating the risks of stress. Often they work in places where illness and stress may coincide, such as hospitals, or places where stress is particularly high, such as universities. Foremost among a health psychologist's activities is teaching ways to manage the causes and effects of stress. They may teach patients to reframe distress into eustress when applicable. They encourage healthy lifestyles that will prevent the onset of chronic stress, both because they relegate time to leisure, and because sleep, adequate nutrition, and relaxation prepare a person to handle stress. They teach appropriate coping mechanisms for when negative stressors do occur. They strengthen an individual's support system. Finally, they work with patients that may be experiencing severely stressful events, such as fatal illness or trauma. Eating Disorders Eating disorders are characterized by maladaptive eating behavior, such as binge eating, purging, restriction of food intake, or obsessive concerns about weight and body shape (NIMH, 2012). While the symptoms of these disorders are the same for both men and women, eating disorders are overwhelmingly more present in women. The unhealthy body images that women who suffer from these disorders share has been linked to how women's bodies are portrayed today in the media and popular culture (NEDA, 2014). There are a number of eating disorders that are described in the DSM 5. Below we will focus on two of these, specifically anorexia nervosa and bulimia nervosa. Anorexia nervosa Distorted body image Anorexia nervosa*, or as it is commonly calledanorexia, is characterized by self-induced starvation and excessive weight loss, to the point that the individual weighs more than 15% below his/her expected healthy body weight (American Psychiatric Association, 2013). This disorder has the potential to become life-threatening as the resulting malnutrition poses a number of serious health risks. Symptoms The physical symptoms associated with this disorder range from dull, dry hair, skin and nails, increased sensitivity to cold, abnormal hormone levels, low blood glucose, a decrease in bone density, and weakening of the heart muscle. As the heart weakens, heart rhythms may become irregular and serious heart problems can develop. In the most severe cases, anorexics are at a high risk of cardiac arrest. Women who are anorexic also run the risk of becoming amenorrheic due to the disruption of normal hormone levels in the body. (NEDA, 2014) Additional behaviors that are associated with the disorder may include: abuse of laxatives or diet pills, excessive and compulsive exercise, reported feelings of guilt or shame after eating, low self-esteem, mood swings, withdrawal, and depression. The DSM 5 Definition of Anorexia Nervosa The DSM 5 outlines the following three diagnostic criteria for anorexia nervosa. a. Restriction of food intake relative to a significantly low body weight b. Distorted body image; denial of the seriousness of weight loss c. Intense fear of gaining weight or becoming fat Bulimia nervosa: Bulimia nervosa*, or bulimia, is defined as a disordered pattern of eating where an individual repeats a pattern of binging (excessive overeating) and then purging what has been ingested by inappropriate methods (American Psychiatric Association, 2013). These methods can include the misuse of laxatives, as well as deliberately forcing oneself to vomit. During a binge, most individuals who suffer from bulimia experience a feeling of being out of control, and a sense that they are unable to regulate their consumption. Symptoms Unlike anorexics, bulimics will eat. However, the disorder is not without serious health implications. Bulimics often have severe tooth decay and erosion of their esophagus as a result of constant vomiting and therefore exposure to the acids in the digestive system. Additionally purging behavior can cause severe imbalances of sodium, calcium, and potassium that can also be qu
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