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Introduction: Understanding Psychological Disorders

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Title: Introduction: Understanding Psychological Disorders


1
Introduction Understanding Psychological
Disorders
  • Pathological
    Eating disorders
  • Psychological disorder
    Personality disorders
  • Anxiety disorder
    Dissociative disorders
  • Generalized anxiety disorder DSM-5
  • Panic attacks
    Schizophrenia types
  • Phobias
    Suicide
  • Behavioral perspective in psychological disorders
  • Post traumatic stress disorder Sexual
    disorders
  • Obsessive-compulsive disorder Paraphilia
  • Mood disorders

2
CASE STUDYMS. JONES
  • Ms. Jones is a 44-year old mother of three
    teenagers. She has recently been hospitalized for
    treatment of major depression. She gives the
    following history
  • One year previously, after an argument that ended
    her relationship with her boyfriend, Ms. Jones
    became acutely psychotic. She became frightened
    that people were going to kill her, and she began
    to hear the voices of friends and strangers
    talking about killing her- sometimes talking to
    each other. She heard her own thoughts broadcast
    aloud and was afraid that others could also hear
    what she was thinking. Over a 3-week period, she
    stayed in her apartment, had new locks put on the
    doors, kept the shades down, and avoided everyone
    but her immediate family. She was unable to sleep
    at night because the voices kept her awake. She
    was unable to eat because of a constant lump in
    her throat. In retrospect, she cannot say whether
    she was depressed. She denies being elevated or
    overactive. She remembers only that she was
    terrified of what would happen to her.
  • Ms. Joness family persuaded her to enter a
    hospital, where, after six weeks of treatment
    with an antipsychotic medication, the voices
    stopped. She remembers feeling back to normal
    for a period of one to two weeks, but then she
    seemed to lose her energy and motivation to do
    anything.
  • She became increasingly depressed, lost her
    appetite, and woke at 400 A.M. or 500 A.M.
    every morning and was unable to get back to
    sleep. She could no longer read a newspaper or
    watch TV because she could not concentrate
    sufficiently.
  • Ms. Joness condition has persisted for nine
    months. She has done very little except sit in
    her apartment, staring at the walls. Her children
    have managed most of the cooking, shopping, bill
    payment, etc. She has continued in outpatient
    treatment and was maintained on the same
    antipsychotic drug until three months before the
    current hospitalization. There has been no
    recurrence of psychotic symptoms since the
    medication was discontinued. However, her
    depression has persisted.
  • In discussing her history, Ms. Jones is rather
    guarded. There is, however, no evidence of a
    diagnosable illness before last year. She
    apparently is a shy, emotionally constricted
    individual who has never broken any rules. She
    has been separated from her husband for ten
    years, but in that time has had two enduring
    relationships with boyfriends. In addition to
    rearing three apparently healthy children full
    time in the four years before her illness, she
    cared for a succession of foster children full
    time. She enjoyed this and was highly valued by
    the agency with whom she worked. She has
    maintained close relationships with a few
    girlfriends and with her extended family.

3
  • Psychopathology is the scientific study of the
    origins, symptoms, and development of
    psychological disorders.
  •  
  • Psychological disorder is a clinically
    significant behavioral or psychological syndrome
    or pattern that occurs in an individual and that
    is associated with present distressor
    disabilityor with a significantly increased risk
    of suffering death, pain, disability, or an
    important loss of freedom (DSM-iV-TR,2000)disab
    ilities include loss of ability to function in an
    important area of functioning, such as home,
    social settings, work or school.
  • Like medical disorders, psychological disorders
    are out of the patients control, they may in
    some cases be treated by drugsmay have both
    biological (nature) as well as environmental
    (nurture) influences. These causal influences are
    reflected in the bio-psycho-social model of
    illness (Engel, 19770).
  • Dispelling Mental Disorder Myths
  •  
  • There are many myths and misconceptions
    surrounding abnormal behavior abnormal behavior
    is always bizarre, normal and abnormal behavior
    are unique to normal and abnormal persons, and
    once someone has a mental disorder, they will
    always have it.
  •  
  • Former mental patients do not have a higher rate
    of violence than the general public.
  •  
  • People with severe mental disorders who are
    experiencing bizarre delusional ideas and
    hallucinated voices have a slightly higher level
    of violent and illegal behavior than do normal
    people.
  •  
  • There is very little risk of violence or harm to
    a stranger from casual contact with an individual
    who has a mental disorder.

4
What Is a Psychological Disorder?
  • A psychological disorder or mental disorder is a
    pattern of behavioral and psychological symptoms
    that causes significant personal distress,
    impairs the ability to function in one or more
    important areas of daily life, or both.
  •  
  • There are five axes of the DSM-5
  •  
  • Axis I- All diagnostic categories except
    personality disorders and mental
    retardationmood, anxiety, or learning disorder
  • Axis II- Personality disorders and specific
    developmental disorders
  • Axis III- General medical conditionsheart
    disease, cancer, diabetes
  • Axis IV-Psychosocial and environmental
    problemshomelessness, divorce, school problems
  • Axis V-Current level functioningin danger of
    hurting oneself or others

5
DSM
  • Diagnostic and Statistical Manual
  • American Psychiatric Association
  • Currently DSM-5
  • Common language and standard criteria for
    classifying mental disorders
  • Controversies include
  • Cultural bias (e.g. sexual disorders)
  • Medical rather than behavioral model
  • Diagnosing, e.g. ADHD, autism.

6
Categories of Disorders include
  • Obsessive Compulsive and Related Disorders
  • Neurodevelopmental Disorders
  • Dissociative disorders
  • Substance Related and Addictive Disorders
  • Depressive Disorders
  • Bipolar and related disorders
  • Schizophrenia spectrum and other psychotic
    disorders
  • Anxiety Disorders
  • Somatic Symptom and Related Disorders
  • Trauma and Stressor-Related Disorders
  • Feeding and Eating Disorders
  • Sexual Dysfunction
  • Personality Disorders
  • Autism Spectrum Disorders
  • Neurocognitive Disorders

7
Diagnosing Disorder The DSM
  • The DSM organizes disorders by category. Within
    a diagnostic category, clinicians may also
    identify specifiers and rate severity.

8
Biopsychosocial Model
Key concept is Interaction.
9
What is Abnormal behavior?
  • A psychological disorder, causing distress,
    disability, or dysfunction. Defined
    symptomatically by the DSM
  • 1 in 4 affected each year
  • Each year prevalence 18.1 anxiety disorders
  • 1 schizophrenia 4.4 alcohol use disorder
  • More lower SES
  • Mentally ill stigmatized
  • Many disorders comorbid.
  • Comorbid more than one disorder at a time
  • Most severe disorders in a small group of people
  • 6 of population have 3 or more disorders

10
DSM-5
  • Cluster A (odd or eccentric disorders)
  • Not to be confused with Type A personality.
  • Paranoid personality disorder characterized by
    irrational suspicions and mistrust of others.
  • Schizoid personality disorder lack of interest
    in social relationships, seeing no point in
    sharing time with others, anhedonia,
    introspection.
  • Schizotypal personality disorder characterized
    by odd behavior or thinking.

11
  • Cluster B (dramatic, emotional or erratic
    disorders)
  • Not to be confused with Type B personality.
  • Antisocial personality disorder a pervasive
    disregard for the rights of others, lack of
    empathy, and (generally) a pattern of regular
    criminal activity.
  • Borderline personality disorder extreme "black
    and white" thinking, instability in
    relationships, self-image, identity and behavior
    often leading to self-harm and impulsivity.
  • Histrionic personality disorder pervasive
    attention seeking behavior including
    inappropriately seductive behavior and shallow or
    exaggerated emotions.
  • Narcissistic personality disorder a pervasive
    pattern of grandiosity, need for admiration, and
    a lack of empathy. Characterized by
    self-importance, preoccupations with fantasies,
    belief that they are special, including a sense
    of entitlement and a need for excessive
    admiration, and extreme levels of jealousy and
    arrogance.
  • Cluster C (anxious or fearful disorders)
  • Avoidant personality disorder pervasive feelings
    of social inhibition and social inadequacy,
    extreme sensitivity to negative evaluation and
    avoidance of social interaction.
  • Dependent personality disorder pervasive
    psychological dependence on other people.
  • Obsessive-compulsive personality disorder (not
    the same as obsessive-compulsive disorder)
    characterized by rigid conformity to rules, moral
    codes and excessive orderliness.
  • Appendix B Criteria Sets and Axes Provided for
    Further Study
  • Appendix B contains the following disorders
  • Depressive personality disorder is a pervasive
    pattern of depressive cognitions and behaviors
    beginning by early adulthood.
  • Passive-aggressive (negativistic) personality
    disorder is a pattern of negative attitudes and
    passive resistance in interpersonal situations.

12
Anxiety Disorders Intense Apprehension and Worry
  • Anxiety is an unpleasant emotional state
    characterized by physical arousal and feelings of
    tension, apprehension, and worry. People who
    have anxiety are in a perpetual state of
    fight-or-flight.
  • How do you know if you suffer from an anxiety
    disorder?
  • Three features distinguish normal anxiety from
    pathological anxiety.
  • Pathological anxiety is
  • a. irrationalit is provoked by perceived threats
    that are exaggerated or nonexistent, and the
    anxiety response is out of proportion to the
    actual importance of the situation.
  • b. uncontrollablethe person cant shut off the
    alarm reaction even when he or she knows its
    unrealistic.
  • c. disruptiveit interferes with relationships,
    job or academic performance, or everyday
    activities.
  •  
  • Generalized Anxiety Disorder Worrying About
    Anything and Everything
  • Generalized anxiety disorder (GAD) is
    characterized by excessive, global, and
    persistent symptoms of anxiety it is sometimes
    referred to as free-floating anxiety.

13
Panic Attacks and Panic Disorder Sudden Episodes
of Extreme Anxiety
  • A panic attack is a sudden episode of extreme
    anxiety that rapidly escalates in intensity.
    Panic disorder is an anxiety disorder in which
    the person experiences frequent and unexpected
    panic attacks.
  • People who suffer from panic disorders tend to
    feel safer at home and therefore develop
    agoraphobia, a condition in which the fear is so
    intense, that the person becomes homebound.
  • Explaining panic disorder
  • a. Panic disorder tends to run in families.
  • b. People with panic disorder are unusually
    sensitive to the signs of physical arousal.
  • c. According to the cognitive-behavioral theory
    of panic disorder, people with panic disorder
    tend to misinterpret the physical signs of
    arousal as catastrophic and dangerous.
  • After their first panic attack, they become even
    more attuned to physical changes, increasing the
    likelihood of future panic attacks

14
  • The Phobias Fear and Loathing
  • Posttraumatic Stress Disorder
  • Natural disasters, catastrophic illnesses,
    incest, rape, and assault are a few of the life
    experiences that can unleash a wave of intense
    emotional stress. Distressing, intrusive
    recollections of the event are experienced as
    flashbacks.
  •  Very early, severe, recurring child abuse often
    results in symptoms of PTSD
  •  Characteristics of PTSD include
  •  a. Frequent, intrusive recall of the event
  • b. Avoidance of stimuli or situations that tend
    to trigger memories of the experience and a
    general numbing of emotional responsiveness
  • c. Increased physical arousal associated with
    anxiety
  •  Several factors influence the likelihood of a
    persons developing PTSD
  • a. A personal or family history of psychological
    disorders
  • b. The magnitude of the trauma
  • c. Experiencing multiple traumas
  • Phobic disorder is an anxiety disorder and is
    characterized by an irrational, overwhelming, and
    intense fear that is directed at a particular
    object or situation.
  • Specific phobias are an exaggerated fear of a
    particular thing, such as a phobia of spiders,
    lizards, or a fear of riding in an elevator.
  • Situational anxiety is usually self-limiting and
    dissipates as the stressful event recedes into
    the past. Ie is an overly anxious reaction to a
    situation
  • Social phobias are the most common of the
    phobias, and refer to an intense anxiety about a
    social situation. The anxiety is experienced
    when the person is in a social or interpersonal
    setting such as public speaking, or asking
    someone out for a date.
  •  Explaining phobias Learning theories
  • Classical conditioning may be involved in the
    development of a specific phobia
  • Operant conditioning can be involved in the
    avoidance behavior that characterizes phobias.
  • Observational learning can be involved in the
    development of phobias.
  • Humans seem biologically prepared to acquire
    fears of certain animals and situations that were
    survival threats in human evolutionary history.
  • How might these perspectives explain Ms. Joness
    situation?

15
ObsessiveCompulsive Disorder
  • Obsessive-compulsive disorder (OCD) is
    characterized by obsessional thoughts and/or
    compulsive behaviors. Obsessional thoughts are
    intrusive thoughts that are very distressing to
    the person thinking them. They evoke a great
    deal of anxiety, or fear about oneself or loved
    ones becoming ill, infected with a deadly virus
    of dying.
  •  
  • Obsessions are the thoughts and compulsions are
    the behaviors
  •   (1) Overt physical behaviors, such as
    repeatedly washing your hands.
  • (2) Covert mental behaviors, such as counting or
    reciting certain phrases to yourself.
  •  66 -are plagued by obsessions regarding
    dirtiness, contamination, and germs, with the
    corresponding compulsions such as cleaning
    and hand washing.
  • 20- are worried about safety issues and engage
    in repetitive checking rituals.
  • 15-are concerned with a sense of incompleteness.
  • There are two key reasons for OCD
  • Excessive self-doubt
  • Intense worry regarding the safety of oneself and
    others
  • Depletion of the neurotransmitter serotonin is
    thought to be involved in the presentation of
    OCD.
  • Serotonin antidepressants are the most effective
    treatment used for OCD they include SSRIs
    (Prozac, Paxil, Zoloft, Celexa, and Lexapro).

16
Mood Disorders
  • Jenny is a 12 year old girl. She has been
    described as moody. Jenny has started to sleep
    late, to the point where she is frequently late
    for school, and she is becoming sexually curious.
    She had been a very quiet child, but in the last
    few months she has become loud, demanding, and
    visibly unhappy. Teachers have noted that she is
    no longer hanging around her friends, and when
    questioned, Jenny has no definitive answer, but
    responds in a very defensive manner. The friends
    who Jenny has started to associate with are also
    sexually curious and rebellious.
  • Jennys attitude has changed at home as well. She
    has started to yell at her mother, and she can be
    heard crying in her room at night. What once was
    an uneventful chore, has now become a battle.
    Jenny has also begun to keep her door closed and
    has become very secretive, especially in the
    bathroom.
  • Jennys mother has made an appointment with the
    pediatrician at Jennys urging because of
    complaints from Jenny of joint pains and frequent
    injuries as a result of Jennys recent
    clumsiness, perhaps because of recent weight
    gain.
  • Jenny can also be heard yelling and throwing
    items around in her room.

17
  • The broad category of mood disorders (aka
    affective disorders) includes depressive
    disorders, bipolar disorders, mood disorder due
    to a general medical condition, and
    substance-induced mood disorder.
  • Depressive disorders are mood disorders in which
    the individual suffers depressions without
    experiencing mania.
  • Mood disorders are psychological disorders
    characterized by a disturbance of mood mood or
    emotions cause impaired cognitive, behavioral,
    and physical functioning.
  • The DSM-5 lists the following depressive
    disorders
  • Major Depressive Disorder, Single Episode
  • Major Depressive Disorder, Recurrent
  • Dysthymic Disorder
  • Depressive Disorder not otherwise specified
  • These symptoms define a major depressive episode
    (at least five must be present during a 2 week
    period).
  •  
  • Appetite disturbance with accompanying weight
    loss or weight gain
  • Fatigue
  • Decreased sex drive
  • Restlessness, agitation, or psychomotor
    retardation
  • Diurnal variations in mood (usually feeling
    worse in the morning) red flag
  • Impaired concentrations and forgetfulness
  • Pronounced anhedonia (total loss of the ability
    to experience pleasure)
  • Sleep disturbance
  • Major depression is often triggered by traumatic
    and stressful events. Chronic stress can also
    produce major depression.

18
Mood disorders, cont.
  • Dysthymic disorder is generally more chronic and
    has fewer symptoms than major depressive
    disorder.
  •  
  • Womens lifetime risk of major depression is one
    in four mens lifetime risk is one in eight.
    Why? because women experience a greater degree of
    chronic stress, have a lesser sense of personal
    control, and are more prone to ruminate about
    their problems.
  •  
  • In seasonal affective disorder (SAD), episodes of
    depression typically occur during the autumn and
    winter and subside during the spring and summer.
  •  
  • Explaining Mood Disorders
  •  
  • Family, twin, and adoption studies suggest that
    some people inherit a genetic predisposition to
    mood disorders.
  •  
  • Disruption of the neurotransmitters
    norepinephrine and serotonin has been implicated
    in the development of major depression.

19
Bipolar Disorder
  • Bipolar disorder involves periods of
    incapacitating depression alternating with
    periods of extreme euphoria and excitement
    formerly called manic depression.
  •  
  • A manic episode is a sudden, rapidly escalating
    emotional state characterized by extreme
    euphoria, excitement, physical energy, and rapid
    thoughts and speech.
  •  
  • Treatment for the disorder follows a 3 tier
    formula
  •  
  • Rx
  • Psychotherapy
  • Education on the disorder
  •  

20
  • Eating Disorders Anorexia and Bulimia
  •  
  • Eating disorders involve serious and maladaptive
    disturbances in eating behavior and usually
    develop in adolescence.
  •  
  • People with anorexia have an extreme fear of
    gaining weight or becoming fat, have a distorted
    perception about their body size, and are denial
    of how serious their weight loss is. The
    disorder causes changes in their body due to the
    severe loss of weight and malnutrition.
  •  
  • People with bulimia are within a normal weight
    range or may even be slightly overweight
    however, people with bulimia experience extreme
    episodes of binge eating.

21
Sexual disorders and problems
  • Samantha complains of feeling increasingly
    anxious as the time for her husband, Bill, to
    arrive home and as dinner approaches. She has
    trouble being calm through dinner and frets
    during the hour or two of TV in the evening. She
    takes advantage of the opportunity to get out of
    the house for the evening whenever possible. As
    she and Bill climb into bed, she can feel her
    heart race and her muscles tense. Though she
    loves Bill, she feels increasingly anxious about
    his evaluations of her. She is sure he no longer
    finds her attractive despite his constant
    reassurances. Their sex episodes leave her
    feeling painful and sore, even though they do not
    engage in any deviant sexual practices. She
    avoids lovemaking because she feels she does not
    satisfy Bills needs. Lately, she feels a sense
    of relief whenever he leaves for work, finally
    feeling like she can relax. However, as 5 oclock
    approaches, her anxiety begins to increase once
    again.

22
Paraphilias
  • What are paraphilias?
  • Paraphilias are an abnormal way in which people
    achieve sexual gratification. These fantasies,
    urges, or behaviors must occur for a significant
    period of time and must interfere with either
    satisfactory sexual relations or everyday
    functioning if the diagnosis is to be made. There
    is also a sense of distress within these
    individuals. In other words, they typically
    recognize the symptoms as negatively impacting
    their life but feel as if they are unable to
    control them.

23
Common Paraphilias
  • Exhibitionism
  • This disorder is characterized by either intense
    sexually arousing fantasies, urges, or behaviors
    in which the individual exposes his or her
    genitals to an unsuspecting stranger. To be
    considered diagnosable, the fantasies, urges, or
    behaviors must cause significant distress in the
    individual or be disruptive to his or her
    everyday functioning.
  • Treatment
  • Treatment typically involves psychotherapy aimed
    at uncovering and working through the underlying
    cause of the behavior. Medications can at times
    be helpful to assist the client in resisting
    urges, but are typically not utilized in
    treatment.
  • Fetishism
  • Fetishism is characterized by either intense
    sexually arousing fantasies, urges, or behaviors
    in which the individual uses a nonliving object
    (e.g., womans high heeled shoe, stockings) in a
    sexual manner. Typically, the individual requires
    this object to become sexually aroused and is
    therefore unable to be aroused without it. To be
    considered diagnosable, the fantasies, urges, or
    behaviors must cause significant distress in the
    individual or be disruptive to his or her
    everyday functioning.
  • Treatment
  • Treatment typically involves psychotherapy aimed
    at uncovering and working through the underlying
    cause of the behavior.
  • Frotteurism
  • This disorder is characterized by either intense
    sexually arousing fantasies, urges, or behaviors
    in which the individual touches or rubs against
    an non-consenting person in a sexual manner. This
    often occurs in somewhat conspicuous situations
    such as on a crowded bus or subway. To be
    considered diagnosable, the fantasies, urges, or
    behaviors must cause significant distress in the
    individual or be disruptive to his or her
    everyday functioning.
  • Treatment
  • Treatment typically involves psychotherapy aimed
    at uncovering and working through the underlying
    cause of the behavior.

24
  • Pedophilia
  • This disorder is characterized by either intense
    sexually arousing fantasies, urges, or behaviors
    involving sexual activity with a prepubescent
    child (typically age 13 or younger). To be
    considered for this diagnosis, the individual
    must be at least 16 years old and at least 5
    years older than the child.
  • Treatment
  • Treatment typically involves intensive
    psychotherapy to work on deep rooted issues
    concerning sexuality, feelings of self, and often
    childhood abuse. Medical treatments such as
    chemical castration (which is actually a
    hormone medication which reduces testosterone and
    therefore sexual urges) have been investigated
    with very mixed results.
  • Sexual Masochism
  • Sexually masochistic behaviors are typically
    evident by early adulthood, and often start with
    masochistic or sadistic play in childhood. The
    disorder is characterized by either intense
    sexually arousing fantasies, urges, or behaviors
    in which the individual is humiliated, beaten,
    bound, or made to suffer in some way.
  • Treatment
  • Treatment typically involves psychotherapy aimed
    at uncovering and working through the underlying
    cause of the behavior.
  • Sexual Sadism
  • Sexually sadistic behaviors are typically evident
    by early adulthood, and often start with
    masochistic or sadistic play in childhood. The
    disorder is characterized by either intense
    sexually arousing fantasies, urges, or behaviors
    in which the individual is sexually aroused by
    causing humiliation or physical suffering of
    another person.
  • Treatment
  • Treatment typically involves psychotherapy aimed
    at uncovering and working through the underlying
    cause of the behavior.

25
  • Transvestic Fetishism
  • This diagnosis is used for heterosexual males who
    have sexually arousing fantasies, urges, or
    behaviors involving cross-dressing (wearing
    female clothing). To be considered diagnosable,
    the fantasies, urges, or behaviors must cause
    significant distress in the individual or be
    disruptive to his or her everyday functioning.
  • Treatment
  • Treatment typically involves psychotherapy aimed
    at uncovering and working through the underlying
    cause of the behavior.
  • Voyeurism
  • This disorder is characterized by either intense
    sexually arousing fantasies, urges, or behaviors
    in which the individual observes an unsuspecting
    stranger who is naked, disrobing, or engaging in
    sexual activity. To be considered diagnosable,
    the fantasies, urges, or behaviors must cause
    significant distress in the individual or be
    disruptive to his or her everyday functioning.
  • Treatment
  • Treatment typically involves psychotherapy aimed
    at uncovering and working through the underlying
    cause of the behavior.

26
Sexual Disorders
  • Dyspareunia
  • Recurrent or persistent genital pain associated
    with sexual intercourse. Can be diagnosed in
    males or females, is not better accounted for by
    another diagnosis (psychiatric or physical) and
    is not the direct effect of substance use.
  • Treatment
  • Resolving underlying sexual and relationship
    issues can be helpful in many cases.
  • Female Orgasmic Disorder
  • Delay of orgasm following normal excitement and
    sexual activity. Due to the widely varied sexual
    response in women, it must be judged by a
    clinician to be significant taking into account
    the persons age and situation. The condition is
    persistent or occurs frequently and causes
    significant distress. Is not a direct effect of
    substance use.
  • Treatment
  • Typical treatment would involve discovering and
    resolving underlying conflict or life
    difficulties.
  • Female Sexual Arousal Disorder
  • Inability to attain or maintain until completion
    of sexual activity adequate lubrication in
    response to sexual excitement. Must result in
    significant distress and not better accounted for
    by another disorder or the use of a substance.
  • Treatment
  • Typical treatment would involve discovering and
    resolving underlying conflict or life
    difficulties.

27
  • Gender Identity Disorder
  • A strong and persistent identification with the
    opposite gender. There is a sense of discomfort
    in their own gender and may feel they were born
    the wrong sex. This has been confused with
    cross-dressing or Transvestic Fetishism, but all
    are distinct diagnoses.
  • Treatment
  • Other disorders may be present with this one,
    including depression, anxiety, relationship
    difficulties, and personality disorders, and
    homosexuality is present in a majority of the
    cases. Treatment is likely to be long-term with
    small gains made on underlying issues as
    treatment progresses.

28
  • Hypoactive Sexual Desire Disorder
  • Deficient or absent sexual fantasies and desire
    for sexual activity. This judgment must be made
    by a clinician taking into account the
    individuals age and life circumstances. The lack
    of desire must result in significant distress for
    the individual and is not better accounted for by
    another disorder or physical diagnosis.
  • Treatment
  • Typical treatment would involve discovering and
    resolving underlying conflict or life
    difficulties.
  • Male Erectile Disorder
  • Recurring inability to achieve or maintain an
    erection until completion of the sexual activity.
    Must result in significant distress for the
    individual and is not better accounted for by
    another disorder (e.g. drug abuse) or physical
    diagnosis.
  • Treatment
  • The most commonly applied treatment for
    non-medical related impotence is Sensate Focus,
    which involves a progression of sexual intimacy,
    typically over the course of several weeks, and
    eventually leading to penetration and orgasm.
  • Male Orgasmic Disorder
  • Delay or absence of orgasm following normal
    excitement and sexual activity. Due to the widely
    varied sexual response in men, it must be judged
    by a clinician to be significant, taking into
    account the persons age and situation. The
    condition is persistent or occurs frequently and
    causes significant distress. Is not a direct
    effect of substance use.
  • Treatment
  • Typically once a medical cause is ruled out,
    working through the underlying issues is very
    helpful. Some therapists also use behavioral
    techniques such as sensate focus which is a more
    direct approach if underlying issues are not
    significant.

29
  • Premature Ejaculation
  • Ejaculation with minimal sexual stimulation
    before or shortly after penetration and before
    the person wishes it. The condition is persistent
    or occurs frequently and causes significant
    distress. Is not a direct effect of substance
    use.
  • Treatment
  • Relaxation training, education, and working
    through underlying issues are treatment options.
    If the relationship is new, often the
    difficulties will resolve as the relationship
    matures.
  • Sexual Aversion Disorder
  • Persistent or recurring aversion to or avoidance
    of sexual activity. The aversion must result in
    significant distress for the individual and is
    not better accounted for by another disorder or
    physical diagnosis. When presented with a sexual
    opportunity, the individual may experience panic
    attacks or extreme anxiety.
  • Treatment
  • Typical treatment would involve discovering and
    resolving underlying conflict or life
    difficulties.
  • Vagismus
  • Recurrent or persistent involuntary spasm of the
    vaginal muscles that interferes with sexual
    intercourse. It must cause significant distress
    and not due to a medical condition or another
    disorder.
  • Treatment
  • Psychological treatment involves working through
    underlying issues, while other treatments can
    involve progressively larger dilators and therapy
    to help relax muscles which prevent intercourse

30
Clinical Vignette
  • Mr. Rodriguez, a 52-year old, Cuban born
    president of a successful family business in
    Miami, was brought to a hospital by his wife
    after he told her that he had suddenly remembered
    setting several major fires when he was a child
    and murdering a man 30 years ago.
  • Mr. Rodríguez tells the following story. He has
    been on edge recently because of a lot of
    financial problems in his business. A few weeks
    ago he became enraged with a long-time employee
    of whom he had been very fond. He yelled at him
    for misspending a considerable amount of the
    firms money and almost threw an ashtray at him.
    He was stunned by the violence of his impulses
    and began to realize how angry and hateful he has
    always been, particularly in relation to his wife
    and children.
  • Later, at home, when thinking about the events of
    the day, the curtains were opened and I was
    flooded with memories of acts that had previously
    been cut off from my conscious mind. He
    recalled having set fire to a womans house while
    she was inside. This occurred when he was 5
    years old, at his fathers urging. He also
    recalled having set fires in doctors offices and
    libraries. In addition, he was convinced that,
    at age 19, he had shot a man for having assaulted
    his wife. There were many other similar
    memories of violent acts, which he had never
    had before.
  • For two weeks, Mr. Rodriguez stayed home from
    work. He sat, inactive, sometimes tearful about
    the damage he thought he had done, ruminating
    about what a terrible father he had been.
    Although his thoughts were painful, he actually
    enjoyed the pleasure of knowing and discovering
    and denied being persistently depressed. He also
    denied having experienced any change in weight,
    appetite, sleep, or psychomotor activity. He
    admitted to poor concentration, beginning about
    one month previously, when financial pressures to
    work had begun to escalate. Sometimes he thought
    of killing himself.
  • The day before, he had had another revelation.
    He remembered for the first time that his
    father had beaten and sodomized him. He now
    understood that his destructiveness was caused by
    his fathers abuse. With this realization, he no
    longer felt guilty about the terrible things that
    he had done. Nevertheless, he had agreed today
    to his wifes request that he come to the
    hospital.
  • Mr. Rodriguez is a tall, slender, neatly dressed
    man with a piercing gaze, poised demeanor, and
    polished manners. He smokes constantly throughout
    the session. He is quick witted and playful,
    even when talking about the serious crimes he
    claims to have committed. He does well on tests
    of cognitive functioning. When told that his
    wife and others maintain that his memories cannot
    be accurate, he remarks, Their facts do
    contradict my recollections. I cant explain the
    discrepancy. All I know is I set those fires.
    When asked to explain how he could have no police
    record, he replies that this is because he was so
    quick and wily that no one could catch him. He
    accounts for his wifes refusal to believe his
    stories by asserting that she must have blocked
    the memories of the events because they are so
    upsetting to her.
  • On admission, physical examination of Mr.
    Rodriguez, including a neurological evaluation
    revealed no abnormality. All laboratory tests
    were also negative.

31
Schizophrenia
  • Paranoid-the presence of prominent delusions
    including persecution and grandiosity
  •   The jumbled ideas form a word salad, jumbled up
    sentences
  • Undifferentiated- when an individual displays
    some combination of positive and negative
    symptoms that does not clearly fit the criteria
    for the paranoid, catatonic, or disorganized
    types.
  • Residual-withdrawal, after hallucinations and
    delusion have disappeared
  • Disturbed perceptions
  • A person diagnosed with schizophrenia may also
    have hallucinationssensory experiences without
    sensory stimulation, hearing, seeing, feeling,
    tasting, or smelling things that are not there
  • The emotions of a person diagnosed with
    schizophrenia are inappropriate, split off from
    reality
  • Some persons may laugh when others cry or vice
    versa, still others exhibit no emotions...flat
    affectmake it hard to have a normal life
  •  Biological Factors in Schizophrenia-Ventricles
    in the brain tend to be larger and widened
    cortical sulci which means that in some types of
    schizophrenia, there has been abnormal brain
    development.
  •  Individuals with schizophrenia produce higher
    than normal levels of the neurotransmitter
    dopamine and that the excess dopamine causes
    schizophrenia.
  •  The onset of schizophrenia typically occurs
    during young adulthood.
  • Nearly 1 in every 100 people will develop
    schizophrenia almost 24 million people suffer
    from schizophrenia
  • Schizophrenia is a serious debilitating disorder
    in which the mind seems split. Drug therapy is
    the main source of treatment for persons
    suffering from schizophrenia.
  • Schizophrenia is the chief example of a psychotic
    disorder, a disorder marked by irrationality and
    lost contact with reality symptoms excesses or
    distortions of normal functioning include
    delusions, hallucinations, and severely
    disorganized thought processes, speech, and
    behavior.
  •  Negative symptoms reflect defects or deficits in
    normal functioning including flat affect, alogia
    (greatly reduced production of speech), and
    avolition (the inability to initiate or persist
    in goal-directed behaviors, catatonic state).
    )the absence of appropriate behaviors
  •  Types of schizophrenia
  •  Disorganized schizophrenia-the individual has
    delusions and hallucinations and the person tends
    to withdraw, disorganized speech and flat affect
    a general disruption of behavior
  • Disorganized thoughts may result from a breakdown
    in selective attention, a break down in the
    filter such that minute details may distract
    attention from bigger, more significant details
  • Catatonic-prolonged states of motor immobility so
    much so that the individual can be manipulated
    physically, that alternate with periods of
    excitability
  • Persons with schizophrenia think in fragmented,
    bizarre, and often distorted beliefs called
    delusions

32
Onset and development of Schizophrenia
  • Schizophrenia manifests in emerging adulthood
  • Schizophrenia may strike suddenly as a response
    to stress, or a stressor
  • Schizophrenia may be gradual, for those who have
    experienced a gradual onset of schizophrenia they
    may be homeless and may be in the lower
    socioeconomic bracket
  • Schizophrenia affects both males and females, men
    tend to be struck earlier
  • Schizophrenia is a cluster of disorders and as
    such, there exists a variety of symptoms

33
  • The causes of schizophrenia seem to be extremely
    complex.
  •  Evidence from family, twin, and adoption studies
    has firmly established the role of genetic
    factors in many cases of schizophrenia.
  •  Biological Factors in Schizophrenia-Ventricles
    in the brain tend to be larger and widened
    cortical sulci which means that in some types of
    schizophrenia, there has been abnormal brain
    development.
  • Midpregnancy viral infections may impair fetal
    brain development and are an additional
    consideration in the cause of schizophrenia and
    increase the probability that a child will
    develop schizophrenia (flu)but only 2 of women
    who contract the flu during their second
    trimester develop trimester
  • For identical twins who share a placenta, if one
    twin develops schizophrenia, there is a 6 in 10
    chances that the other twin will also develop
    schizophrenia
  • Children adopted by someone who develops
    schizophrenia seldom develop schizophrenia the
    disorder
  • Approximately 10 of people with schizophrenia
    commit suicide
  •  
  • Women outnumber men by three to one in the number
    of suicide attempts. Men outnumber women by
    better than four to one in suicide deaths.
  •  
  •  
  •  
  •  
  •  
  •  

34
  • How can you help prevent suicide?
  •  
  • 1. Actively listen as the person talks and vents
    her feelings.
  • 2. Dont deny or minimize the persons suicidal
    intentions.
  • 3. Identify other potential solutions.
  • 4. Ask the person to delay his decision.
  • 5. Encourage the person to seek professional
    help.
  •  

35
Somatoform Disorders
  • Somatoform disorders are now referred to as
    somatic disorders
  • Individuals with somatic symptoms plus abnormal
    thoughts, feelings, and behaviors may or may not
    have a diagnosed medical condition. The
    relationship between somatic symptoms and
    psychopathology exists along a spectrum.
  • Somatic symptom disorder (SSD) is characterized
    by somatic symptoms that are either very
    distressing or result in significant disruption
    of functioning, as well as excessive and
    disproportionate thoughts, feelings and behaviors
    regarding those symptoms. To be diagnosed with
    SSD, the individual must be persistently
    symptomatic (typically at least for 6 months).
  • TheDSM-5 does not require that the sufferer have
    a medically unexplained condition.
  • The diagnosis of somatization disorder was
    essentially based on a long and complex symptom
    count of medically unexplained symptoms.
    Individuals previously diagnosed with
    somatization disorder will usually meet DSM-5
    criteria for somatic symptom disorder, but only
    if they have the maladaptive thoughts, feelings,
    and behaviors that define the disorder, in
    addition to their somatic symptoms.

36
The Dissociative Disorders
  • Dissociative disorders are psychological
    disorders that involve a sudden loss of memory or
    change in identity.
  •  
  • People with dissociative disorders escape their
    reality in involuntary and unhealthy ways.
  • Dissociative disorders most often form in
    children who have been subjected to chronic
    physical, sexual, and/or emotional abuse.
  •  
  • Dissociative disorders come in many forms the
    most famous is Dissociative Identity Disorder
    (DID).
  •  
  • Dissociative amnesia is characterized by blocking
    out of critical personal information, usually of
    a traumatic or stressful nature. Memory loss is
    more extensive than normal forgetfulness and
    cannot be explained by a physical or neurological
    condition, such as a head injury.
  •  

37
DID, cont.
  • Dissociative fuge is a very rare disorder. An
    individual with dissociative fuge suddenly and
    unexpectedly takes physical leave of his or her
    surrounding and sets off on a journey of sorts.
    An individual in a fugue state is unaware of or
    is confused about his identity, and in some cases
    will assume a new identity. Dissociative fugue
    typically ends as abruptly as it begins.
  •  
  • Psychotherapy with a combination of medication
    treatment is the primary treatment for
    dissociative disorders. The therapist works with
    the patient to help the individual understand the
    cause of the condition and to form new ways of
    coping with stressful circumstance.
  •  
  • DID represents an extreme form of dissociative
    coping brought on by suffering trauma in
    childhood often extreme physical or sexual
    abuse.

38
Clinical Vignette
  • Mr. Nehru is a 32-year-old, single, unemployed
    man who migrated from India to the United States
    when he was 13 years old. Mr. Nehru recently
    ended a three year relationship with a woman he
    met in the United States. According to his
    brother, Mr. Nehru was emotionally heavily
    involved with the woman, often fantasizing about
    her, writing her name on objects, and often
    calling her several times without speaking when
    she answers. His brother claims that the
    relationship ended because the woman was not
    accepting of his religious beliefs. His brother
    brought him to the emergency room of an Atlanta
    hospital after neighbors complained that he was
    standing in the street harassing people about his
    religious beliefs. To the examining psychiatrist,
    he keeps repeating, I am Vishnu. I am Krishna.
  •   Mr. Nehru has been living with his brother and
    sister-in-law for the past seven months and has
    been attending an outpatient clinic. During the
    last four weeks, his behavior has become
    increasingly disruptive. He awakens his brother
    at all hours of the night to discuss religious
    matters. He often seems to be responding to
    voices that only he hears. He neither bathes nor
    changes his clothes.
  •   Mr. Nehrus first episode of emotional
    disturbance was five years ago. Medical records
    are not available, but from the brothers
    account, it seems to have been similar to the
    present episode. There have been two other
    similar episodes, each requiring hospitalization
    for a few months. Mr. Nehru admits that, starting
    about five years ago and virtually continuously
    since then, he hasnt been troubled by voices
    that he hears throughout the day. There are
    several voices, which comment on his behavior and
    discuss him in the third person. They usually are
    either benign (Look at him now he is about to
    eat) or insulting in content (What a fool he
    is he doesnt understand anything).
  •  
  •  Between episodes, according to both his
    outpatient psychiatrist and his brother, Mr.
    Nehru is a quiet, somewhat withdrawn person, but
    popular in his neighborhood because he helps some
    of his elderly neighbors with shopping and yard
    work. At these times his mood is unremarkable.
    However, he claims that, because of the
    (voices,) he cannot concentrate sufficiently to
    hold a job. He sometimes reads books, but watches
    little TV, because he hears the voices coming out
    of the TV and is upset that the TV shows often
    refer to him. Mr. Nehru has also become
    sensitive to bright lights, complaining that the
    lights are searing into his flesh, preferring
    to remain in darkness when inside, constantly
    closing curtains and shades. Mr. Nehru is slowly
    becoming intolerant to bright lights both inside
    the home and outside.
  •   For the past six weeks, with increasing
    insistence, the voices have been telling Mr.
    Nehru that he is the Messiah, Jesus, Moses,
    Vishnu, and Krishna, and should begin a new
    religious epoch in human history. He has begun to
    experience surges of increased energy, (so I
    could spread my gospel,) and needs very little
    sleep. According to his brother, he has become
    more preoccupied with the voices and disorganized
    in his daily activities.

39
Is this a disorder or not?
  • Andy is a 54-year-old auto mechanic who was
    accompanied by his wife to the mental health
    clinic. He was so tense and anxious that his wife
    had to do most of the talking. It turns our that
    during the past six months Andy has turned into a
    bundle of nerves. Hes never been this way
    before, but now hes nervous all the time suffers
    from insomnia, and sleep when it does come is
    fitful and restless. Andy is distressed and is
    desperate for help. As the therapist was
    gathering information from Andy and his wife, she
    noticed that Andy was using a nasal spray. After
    the third time, in which he pulled it out of his
    pocket and sprayed each nostril, the therapist
    inquired what it was for. Andy said he had begun
    to use it six months ago during the hay fever
    season and had just kept using it.

40
Additional disorders as listed in the DSM-5
  • Motor Disorders
  • The following motor disorders are included in the
    DSM-5 neurodevelopmental disorders chapter
    developmental coordination disorder, stereotypic
    movement disorder, Tourettes disorder,
    persistent (chronic) motor or vocal tic disorder,
    provisional tic disorder, other specified tic
    disorder, and unspecified tic disorder. The tic
    criteria have been standardized across all of
    these disorders in this chapter. Stereotypic
    movement disorder has been more clearly
    differentiated from body-focused repetitive
    behavior disorders that are in the DSM-5
    obsessive-compulsive disorder chapter.

41
  • Communication Disorders
  • The DSM-5 communication disorders include
    language disorder (which combines DSM-IV
    expressive and mixed receptive-expressive
    language disorders), speech sound disorder (a new
    name for phonological disorder), and
    childhood-onset fluency disorder (a new name for
    stuttering). Also included is social (pragmatic)
    communication disorder, a new condition for
    persistent difficulties in the social uses of
    verbal and nonverbal communication. Because
    social communication deficits are one component
    of autism spectrum disorder (ASD), it is
    important to note that social (pragmatic)
    communication disorder cannot be diagnosed in the
    presence of restricted repetitive behaviors,
    interests, and activities (the other component of
    ASD). The symptoms of some patients diagnosed
    with DSM-IV pervasive developmental disorder not
    otherwise specified may meet the DSM-5 criteria
    for social communication disorder.

42
  • Body Dysmorphic Disorder
  • For DSM-5 body dysmorphic disorder, a diagnostic
    criterion describing repetitive behaviors or
    mental 8 Highlights of Changes from DSM-IV-TR
    to DSM-5
  • acts in response to preoccupations with perceived
    defects or flaws in physical appearance has been
    added, consistent with data indicating the
    prevalence and importance of this symptom. A
    with muscle dysmorphia specifier has been added
    to reflect a growing literature on the diagnostic
    validity and clinical utility of making this
    distinction in individuals with body dysmorphic
    disorder. The delusional variant of body
    dysmorphic disorder (which identifies individuals
    who are completely convinced that their perceived
    defects or flaws are truly abnormal appearing) is
    no longer coded as both delusional disorder,
    somatic type, and body dysmorphic disorder in
    DSM-5 this presentation is designated only as
    body dysmorphic disorder with the absent
    insight/delusional beliefs specifier.

43
  • Hoarding Disorder
  • Hoarding disorder is a new diagnosis in DSM-5.
    DSM-IV lists hoarding as one of the possible
    symptoms of obsessive-compulsive personality
    disorder and notes that extreme hoarding may
    occur in obsessive-compulsive disorder. However,
    available data do not indicate that hoarding is a
    variant of obsessive-compulsive disorder or
    another mental disorder. Instead, there is
    evidence for the diagnostic validity and clinical
    utility of a separate diagnosis of hoarding
    disorder, which reflects persistent difficulty
    discarding or parting with possessions due to a
    perceived need to save the items and distress
    associated with discarding them. Hoarding
    disorder may have unique neurobiological
    correlates, is associated with significant
    impairment, and may respond to clinical
    intervention.

44
  • Trichotillomania (Hair-Pulling Disorder)
  • Trichotillomania was included in DSM-IV, although
    hair-pulling disorder has been added
    parenthetically to the disorders name in DSM-5.
  • Excoriation (Skin-Picking) Disorder
  • Excoriation (skin-picking) disorder is newly
    added to DSM-5, with strong evidence for its
    diagnostic validity and clinical utility.
  • Adjustment Disorders
  • In DSM-5, adjustment disorders are
    reconceptualized as a heterogeneous array of
    stress-response syndromes that occur after
    exposure to a distressing (traumatic or
    nontraumatic) event, rather than as a residual
    category for individuals who exhibit clinically
    significant distress without meeting criteria for
    a more discrete disorder (as in DSM-IV ). DSM-IV
    subtypes marked by depressed mood, anxious
    symptoms, or disturbances in conduct have been
    retained, unchanged.

45
  • Pain Disorder
  • DSM-5 takes a different approach to the important
    clinical realm of individuals with pain. In
    DSM-IV, the pain disorder diagnoses assume that
    some pains are associated solely with
    psychological factors, some with medical diseases
    or injuries, and some with both. There is a lack
    of evidence that such distinctions can be made
    with reliability and validity, and a large body
    of research has demonstrated that psychological
    factors influence all forms of pain. Most
    individuals with chronic pain attribute their
    pain to a combination of factors, including
    somatic, psychological, and environmental
    influences. In DSM-5, some individuals with
    chronic pain would be appropriately diagnosed as
    having somatic symptom disorder, with predominant
    pain. For others, psychological factors affecting
    other medical conditions or an adjustment
    disorder would be more appropriate.
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