by Sandi Mann
a Life Events Theory
b Cognitive Behavioural Theory
c First Contact Theory
d Preparedness Theory
4 Which of the following statements about phobias is not true?
a To be a phobia, it must interfere significantly with the person’s normal routine or social activities
b To be classed as a phobia, the sufferer must recognize that the fear is excessive or unreasonable
c To be classed as a phobia, the sufferer need not recognize that the fear is excessive or unreasonable
d In a phobic response, exposure to the stimulus almost invariably provokes an immediate anxiety response
5 Which of the following is not a category of phobias?
a Animal phobias
b Environmental phobias
c Medical phobias
d Exam phobias
6 Which of these theories might explain how phobias develop?
a Life Events Theory
b Cognitive Behavioural Theory
c First Contact Theory
d Elaboration Likelihood Theory
7 Which of the following statements about OCD is true?
a It is good to reassure OCD sufferers
b OCD sufferers will feel better by acting out their compulsions
c Reassuring OCD sufferers only brings temporary relief
d OCD sufferers usually have depression, too
8 Which one of the following statements about PTSD is true?
a Sufferers show little or no avoidance of stimuli associated with the trauma
b Sufferers rarely experience flashbacks about the traumatic incident
c PTSD can be diagnosed immediately following a traumatic event
d Symptoms must lead to some kind of impairment of normal functioning to be classed as PTSD
9 Which of the following is not an unhelpful pattern of thinking characteristic of depression?
a ‘Should’-ing
b Mindreading
c Ruminating
d Catastrophizing
10 Which of the following statements about eating disorders is true?
a People with eating disorders tend to have low self-esteem
b Individuals with a first-degree relative who has a history of an eating disorder are less likely than individuals without such a relative, to themselves develop an eating disorder
c There are no biological factors associated with eating disorders.
d Mothers who diet or worry excessively about their weight are no more at risk of having their children develop eating disorders than those who do not diet or worry about their weight
15
Psychological disorders
Chapter 14 began to examine some mental health conditions such as anxiety and depressive disorders that often occur in response to events (although sufferers may have an underlying predisposition towards the condition). This chapter concerns itself with psychological disorders that are caused by biological or physiological factors and that develop largely independently of external circumstances. These include mood disorders such as bipolar disorder, psychotic disorders such as schizophrenia, personality disorders such as multiple personality and developmental disorders such as autism and ADHD. Not every psychological disorder can be covered here but this chapter gives an overview of the more common ones.
Bipolar disorder
Bipolar disorder is sometimes referred to as ‘manic depression’ but, unlike clinical depression, discussed in Chapter 14, bipolar disorder is a distinct condition. What makes bipolar disorder different from depression is that it includes not only periods of depression but also periods of elation. It combines episodes of mania with episodes of depression, alternating in cycles.
The depressive symptoms of bipolar disorder are similar to those outlined in Chapter 14 and include:
• depressed mood
• no interest or pleasure in all, or almost all, activities previously enjoyed
• insomnia (inability to sleep) or hypersomnia (sleeping too much)
• fatigue or lack of energy
• feelings of worthlessness or excessive or inappropriate guilt
• diminished ability to think or concentrate
• recurrent thoughts of death (not just fear of dying)
• suicidal ideation.
With bipolar disorder, the depression tends to lift and give way to manic symptoms. After a period of time, this mania also wanes and the sufferer sinks into depression once more. During the manic phase, which lasts for at least a week (for it to be classified as such) and often three to six months, the sufferer may experience three or more of the following symptoms:
• Excessive happiness or energy
• Inflated self-esteem or grandiosity (at its worst, sufferers may even lose touch with reality and become psychotic – e.g. imagining they have been chosen for a special mission)
• Decreased need for sleep (e.g. the sufferer feels rested after only three hours of sleep)
• Very talkative, often speaking excessively fast
• Easily distracted
• Impulsivity, which can lead to taking actions without thoughts of the consequences (e.g. expensive shopping sprees or poor business investments).
Around half of sufferers also experience hallucinations or delusions.
Spotlight: Some statistics
About 3 per cent of people in the United States have bipolar disorder at some point in their life. It usually starts between the ages of 15 to 19; it rarely starts after the age of 40. Rates appear to be similar in males and females.
The causes of bipolar disorder probably vary between individuals and the exact mechanism underlying the disorder remains unclear. Genetic influences are believed to account for 60–80 per cent of the risk of developing the disorder; the risk of bipolar disorder is nearly tenfold higher in first-degree relatives (e.g. a parent or sibling) of those affected with bipolar disorder compared to the general population. Other causes might include abnormalities in the structure and/or function of certain brain circuits; structural MRI studies report an increase in the volume of the lateral ventricles and other parts of the brain. Functional MRI findings suggest that abnormalities within the amygdala are likely to contribute to poor emotional regulation and mood symptoms.
Environmental factors are also likely to play a part for those susceptible to the disorder. Thus, for example, traumatic events or stressful experiences might lead to onset of a bipolar episode for those at risk. There may also be neuro-endocrinological factors; for example, dopamine, a known neurotransmitter responsible for mood, has been shown to increase during the manic phase.
A number of medications are used to treat bipolar disorder. The medication with the best evidence is lithium, which is effective in treating acute manic episodes and preventing relapses. There are also other medications that can be used to help; it is possible that sodium valproate, an anti-convulsant, works just as well as lithium. Carbamazepine and lamotrigine are also effective for some people.
Schizophrenia
Schizophrenia is probably the best-known disorder that comes under the category of ‘psychoses’; these are mental health conditions where the sufferer is, at times, unable to distinguish between what is real and what is not. For example, people with schizophrenia may see or hear things that don’t exist, speak in strange or confusing ways, believe that others are trying to harm them, or feel as if they’re being constantly watched. Most cases of schizophrenia appear in the late teens or early adulthood. However, schizophrenia can appear for the first time in middle age or even later. Around 1 per cent of the population suffers from schizophrenia (and this is similar for most countries). About 25 per cent of people who suffer an episode of schizophrenia will go on to recover completely without any further problems in the future.
The symptoms of schizophrenia include those described as ‘positive’ and those described as ‘negative’. Positive symptoms are those that are more ‘active’ as opposed to
the more inactive negative symptoms (which tend to imply an absence of ‘normal’ thought processes or emotions). Positive symptoms include:
• Delusions: this is where you believe something totally even there is clear evidence that you are wrong. Delusions occur in more than 90 per cent of those who have the disorder. Often, these delusions involve illogical or bizarre ideas or fantasies. Common schizophrenic delusions include:
– Delusions of persecution: belief that others, often a vague ‘they’, are out to get him or her
– Delusions of control: belief that one’s thoughts or actions are being controlled by other people (e.g. the police)
– Delusions of reference: a particular object is believed to have a special and personal meaning. For example, a person with schizophrenia might believe a certain colour car or a person on TV is sending a message meant specifically for them
– Delusions of grandeur: belief that one is a famous or important figure, such as Jesus Christ or Elvis Presley. Alternately, delusions of grandeur may involve the belief that one has unusual powers that no one else has (e.g. the ability to make oneself invisible).
• Hallucinations: these are sounds or sights that seem real to the sufferer but do not in fact exist outside their own mind. The most common hallucination is hearing voices; these voices may provide a commentary on the patient’s activities, carry on a conversation with them, warn of impending dangers, or even issue orders. The voices are very real to the sufferer and during calmer periods they might be able to control or manage them – or simply learn to ignore them. But during severe or ‘acute’ phases, these voices can take over, becoming very controlling and sometimes menacing.
• Disorganized speech: people with schizophrenia often have trouble concentrating and maintaining a train of thought; this can lead them to start sentences on one topic and then veer completely into an unrelated area, or to say illogical or incoherent things that make little sense to anyone else. Their speech is often punctuated by loose associations (where thoughts or sentences have only loose connections with previous ones), neologisms (made-up words or phrases) and perseveration (repetition of words and statements).
• Chaotic behaviour: people with schizophrenia can quickly lose the ability to behave within the range of acceptable parameters. Their behaviour might become unpredictable or bizarre, with inappropriate reactions. They might lose their inhibitions and be unable to control their impulses. They might experience sudden and extreme mood swings and stop taking care of their personal hygiene. They are likely to become socially withdrawn as they struggle to cope with social interactions.
Often, the negative symptoms of schizophrenia contribute more to poor functional outcomes and quality of life for individuals with schizophrenia than do positive symptoms. Negative symptoms often persist longer than positive ones and may be more difficult to treat. Negative symptoms, which are to do with the absence of normal functioning, include:
• Lack of emotional expression: the patient may not display any emotions, either facially or with their voice. For example, they may not smile or make eye contact and may speak in a flat monotone.
• Lack of interest or enthusiasm: they may display little interest in the world, in hobbies or even in day-to-day activities like eating or personal hygiene.
• Social withdrawal: they tend to stop interacting with the world around them.
The causes of schizophrenia are not fully known. However, it appears that schizophrenia usually results from a complex interaction between genetic, physiological and environmental factors. Schizophrenia has a strong hereditary component; people with a first-degree relative (parent or sibling) who has schizophrenia have a 10-per-cent chance of developing the disorder, compared with 1-per-cent chance within the general population. But genetics are not the only explanation for the onset of the condition; about 60 per cent of schizophrenics have no family members with the disorder.
It could be that genetics give a person susceptibility to the illness, and that environmental circumstances then trigger it in some people. Stress is one such environmental factor that could trigger schizophrenia in susceptible people, perhaps due to the high levels of cortisol that stress produces. Examples of stressful events include prenatal exposure to a viral infection, low oxygen levels during birth, exposure to a virus during infancy, early parental loss or separation, bereavement or other trauma.
Abnormalities in the brain might also play a role in the development of the illness. Schizophrenic patients have sometimes been shown to have enlarged ventricles (fluid-filled cavities), which might suggest some lack in density of brain tissue in these areas. There may also be low activity in the frontal lobe, while some studies also suggest that abnormalities in the temporal lobes, hippocampus and amygdala correlate with some of schizophrenia’s positive symptoms.
Research also suggests that schizophrenia may be caused by a change in the level of two neurotransmitters (see Chapter 17 for more on neurotransmitters): dopamine and serotonin. Indeed, drugs that alter the levels of neurotransmitters in the brain can relieve some of the symptoms of schizophrenia. Certain drugs, particularly cannabis, cocaine, LSD and amphetamines, may trigger symptoms of schizophrenia in people who are susceptible.
Spotlight: Cannabis and schizophrenia
Studies have shown that teenagers under 15 who use cannabis regularly, especially ‘skunk’ and other more potent forms of the drug, are up to four times more likely to develop schizophrenia by the age of 26.
The most common treatment options for schizophrenia involve medication, although psychological therapies can be used, too.
Personality disorders
Personality develops throughout childhood and everyone has some aspect of their personality that may cause them difficulties at times. However, people with personality disorders (PDs) have more severe problems such that their personality traits cause them significant difficulties in a range of ways; for example, they may find it hard to maintain close relationships, to get on with people, to control their feelings, to keep out of trouble and so on. There are thought to be ten main types of personality disorder that can be grouped into three categories, as shown in the following table.
Suspicious Emotional/impulsive Anxious
Paranoid: suspicious, finds it hard to trust others, always looking for signs of betrayal, feels easily rejected, tends to hold grudges, etc. Borderline: very impulsive, hard to control emotions, makes friends easily but hard to maintain those friendships, suffers mood swings, may self-harm, clings to damaging relationships due to fear of being alone. Avoidant: worries a lot, very anxious and tense, very sensitive, insecure, avoids close relationships because of fear of rejection, reluctant to try new activities.
Schizoid: emotionally ‘cold’, prefers not to have close relationships with others, has little interest in intimacy. Histrionic: self-centred, over-dramatizes events, strong emotions that change quickly, craves excitement, easily influenced, tries to be centre of attention. Dependent: passive, relies on others to make decisions, feels helpless, needy, low in confidence.
Antisocial: uninterested in how others feel, likely to commit crimes, acts impulsively, feels no guilt, acts in ways that hurt others, aggressive, doesn’t learn from experience. Narcissistic: strong sense of own importance, believes they will achieve great things, craves admiration from others, uses other people for own ends, fragile self-esteem. Obsessive-compulsive: has unrealistically high standards, likes everything to be just so, worries about making mistakes, wants everything to be perfect, may hang on to items with no obvious value, likes routines, preoccupied with detail.
Schizotypal: eccentric behaviour sometimes related to schizophrenia, odd ideas, may think they have special powers like reading peoples’ minds.
It should be noted that the diagnosis of PD remains controversial as there is no definitive test for any particular type of PD. Like many mental health conditions, the causes of PD are unclear and there are likely to be a variety of factors, such as environm
ental influences and genetics, contributing to the development of the condition. For example, the role of the family and upbringing may have an impact in the development of some personality traits associated with PD; a family environment where a child’s understanding and experience of their own mind and feelings are constantly undermined might, for example, harm the development of social skills that are key to the process of ‘mentalization’. Mentalization is akin to empathy and is the ability to make sense of other people’s actions by thinking through what is going on in their minds. Parents who constantly belittle a child’s opinions and thoughts may thus hinder the development of this trait – and this could be a factor leading to a PD. Even verbal abuse can have an impact on the development of PD. In a study of 793 mothers and children, researchers asked the mothers whether they had told their children that they didn’t love them or threatened to send them away. Children who had experienced such verbal abuse were three times as likely as other children to have borderline, narcissistic, obsessive–compulsive or paranoid personality disorders in adulthood.
Other studies have shown a link between the number and type of childhood traumas and the development of personality disorders. People with borderline personality disorder (BPD), for example, had especially high rates of childhood sexual trauma (although this does not mean that all BPD patients have experienced sexual abuse or that all victims of sexual abuse will develop BPD).
Some researchers suggest that abnormalities with the neurotransmitters (the chemicals that act as messengers between different parts of the brain) may cause the development of some PDs – particularly serotonin, norepinephrine and dopamine.
Treatment of PDs usually involves psychological therapies rather than medication, although drugs can be used for conditions that may occur alongside the PD (such as depression).
Spotlight: Some statistics