Modern Abnormal Psychology
Me, You, and Everything in Between
In This Chapter
Living in fear
Helping little ones
A fictional Mr. Smith is a 30-year-old married man with two children who lives in a quiet suburban neighborhood. He works as a shipping manager for a local trucking company. Mr. Smith has been in relatively good health and is considered by most people to be a pretty average guy. About three months ago, Mr. Smith approached his wife with the idea of getting a home security system. She agreed, and they installed an alarm system. Mr. Smith then told her that he wanted to install cameras around the perimeter of their home. She reluctantly agreed and soon after began waking up in the middle of the night to find Mr. Smith peeking out of their bedroom curtains with binoculars. He became very agitated when she questioned him about his behavior.
Mr. Smith’s actions continued for several weeks, and he wouldn’t tell his wife what was going on. Then one day she found a gun as she was cleaning out their closet. She’d never known her husband to own a gun, so she confronted him about it out of concern for their children’s safety. When she approached him, he told her that he bought the gun to protect them from the neighbor next door. Mr. Smith said that he had been watching the neighbor for a few months, and he was convinced that the neighbor was involved in a real-estate scheme to get their home. The plot involved the neighbor hiring some criminals to break into their home and rob them, in order to scare them into moving and selling their home at a really low price. The neighbor could then buy the house for next to nothing, tear it down, and expand his own home onto the property.
Do you think there’s anything strange about Mr. Smith’s behavior? Should his wife be worried, or is he being adequately protective? The answers to these and related questions are part of the field of abnormal psychology — the psychological study of abnormal behavior and mental processes. But what is abnormal about certain behaviors?
In this chapter, I introduce you to the concept of psychopathology and the various disorders that characterize modern abnormal psychology such as schizophrenia, bipolar disorder, depression, and anxiety.
Figuring Out What’s Normal
By abnormal I mean not normal — something beyond the usual and customary. I’ve never taught a psychology course without at least one student raising a protest against the concept of abnormal behavior. “Who gets to decide what’s normal and what’s not?” he tends to ask. This is an excellent question. How is a standard of normalcy determined and who has the final say on this matter?
It’s important to distinguish between abnormal behavior that’s due to a mental illness and abnormal behavior that’s not. A lot of abnormal behaviors are not associated with the presence of a mental illness. Take dancing in a mosh pit, for example. It’s pretty abnormal to find enjoyment in running into people and bouncing around a pit of human pinballs. Yeah, I think that’s abnormal; but do I think that this behavior is a result of mental illness? For the most part, no!
Every society in the world has standards of behavior and conduct that delineate what are acceptable and unacceptable behaviors. Individuals, families, and even groups have norms, or standards. When people act outside those norms, society labels either the behavior or the person himself as “abnormal.” There are at least four different ways, or criteria, to define normal versus abnormal 'margin-top:7.5pt;margin-right:0cm;margin-bottom:3.75pt; margin-left:42.5pt;text-indent:-16.5pt;line-height:normal;text-autospace:none'> Normative criterion: People act abnormally when they do things contrary to what the majority of people do or act very differently than what is expected. Individuals are expected to live up to societal norms; when that doesn’t happen, people suspect something is amiss. Sometimes statistics are used by professionals and researchers to figure out who’s outside the norm. If nine out of ten people act a certain way, then the behavior of the one person who doesn’t conform is statistically abnormal. The non-conforming behavior is considered rare.
Subjective criterion: Sometimes a person senses his feelings may be different from those of most other people or that he may be doing things differently from how most others do it. In this very limited sense, the person is “abnormal.” If I feel like something is wrong with me because of my awareness of my being different, then I may consider myself a suitable subject of abnormal psychology. This is a case of judging one’s own behavior as abnormal.
Maladaptive criterion: Does my behavior help me survive and successfully function in my society? If not, according to this criterion, maladaptive behavior is abnormal. If I have a difficult time adapting and adjusting to life’s demands, my behavior is maladaptive. This may include my engagement in a pattern of risky or otherwise harmful or destructive behavior that would make it more likely I would not survive or function well in society.
Unjustifiable or unexplainable criterion: Sometimes people act in ways and do things that can’t be explained. People often assume that there must always be a reason why someone acts in a certain way. If a reasonable explanation for certain actions doesn’t exist, people may label the behavior as abnormal.
No matter what definition for abnormality is used, it’s pretty hard to argue that everything is normal. I realize that some people think that life for some people is a big free-for-all, but in reality, every society requires a degree of order. Whether it’s a family, a tribe, or a nation, mores and laws enforce and maintain structure. I define abnormal behavior as maladaptive behavior and mental processes that are detrimental to an individual’s physical and psychological well-being.
So, if someone acts abnormally, does that mean he has a mental illness or psychological disorder? No, not necessarily. A person can act abnormally for any number of reasons. In fact, at one point in history, people believed (and some still do) that abnormal behavior was caused by demonic possession or moral weakness. What about committing murder? Isn’t that abnormal? Murder actually meets all four of the criteria established earlier to define abnormal behavior.
The concept of mental illness comes primarily from psychiatry. Psychiatry is a branch of medicine that deals with mental disorders. During the 19th century, people who acted abnormally became the province of physicians. These “crazy” people were seen as sick instead of morally inept or demonically possessed. This way of looking at abnormal behavior was actually a big advance in human healthcare. When physicians began to be responsible for the care of people behaving abnormally, abnormal behavior became a medical problem, an illness, to be diagnosed and treated like other illnesses and diseases. This approach to mental illness is known as the medical model of mental illness.
Compared to medical doctors, psychologists are relative newcomers to the field of mental illness as defined by psychiatry. As physicians tried to figure out ways to help people from a medical model perspective, psychologists eventually joined in, bringing their knowledge of human behavior and mental processes to the research, diagnosis, and treatment of abnormal behavior that was attributed to a mental illness.
Categorizing Symptoms and Disorders
Over the years, psychiatrists and psychologists have worked to delineate the abnormal behaviors that suggest the presence of a mental illness. This process is called taxonomy — the science of classification. Today, the most widely used classification system for determining the presence of a mental disorder is the Diagnostic and Statistical Manual, 5th Edition (DSM-5) published by the American Psychiatric Association in 2013. The first DSM was published in 1952.
The definition of a mental disorder presented in the DSM-5 is that a mental disorder is essentially a significant behavioral or psychological “syndrome” in associated with “distress,” or “disability” or with a risk of death, pain, or loss of freedom.
A couple of key words in this definition need extra attention:
Symptom: A behavior or mental process that is a sign or signal of a potential disorder. Symptoms are usually found within the following categories:
• Thinking or thought processes
• Mood or affect (referring to how someone feels emotionally, such as depressed, angry, or fearful) and vegetative symptoms (concerning eating, sleeping, and energy level)
• Behavior (such as violence, compulsive gambling, or drug use)
• Physical signs (such as muscle or joint pain, headaches, excessive sweating)
Disorder: A collection of symptoms that indicate the presence of a syndrome (co-occurring groups of symptoms). In developing a taxonomy of abnormal psychological disorders, psychiatrists, psychologists, and other researchers look for specific groups of symptoms that tend to occur together, distinguishing one set of co-occurring symptoms that are distinct from other sets of co-occurring symptoms.
I want to make a couple of final points before getting into the specific mental disorders most commonly observed by mental health professionals today. First, it’s important to realize that psychologists view all behavior on a continuum of normal to abnormal. For example, crying is a normal behavior, but crying all day every day for more than two weeks is abnormal. Second, everyone has experienced a symptom of mental disorder at one time or another. But simply having a symptom does not mean a person has the actual disorder. Remember, disorders consist of specific groupings of symptoms that define a particular syndrome. The rules for determining what symptoms constitute a disorder are complex and include specific time frames and degrees of severity.
So don’t get carried away and start diagnosing everyone you know just because you see a symptom or two. It’s not that simple; a symptom does not a disorder make!
Grasping for Reality
One of the most well-known signs of mental disorder is losing touch with reality. When someone loses touch with objective reality and begins imagining things and acting on those imagined things, he may be suffering from a class of illness known as psychotic disorders.
Psychotic disorders are considered by mental health professionals but also by many a layperson (particularly family members of those who suffer from psychotic disorders) to be the most severe of all mental disorders. In addition to losing touch with reality, people who are suffering from a psychosis often have severe functional deficits related to basic self-care (eating, shelter, and personal hygiene), social and occupational functioning, and thinking.
The most common form of psychosis is schizophrenia. Psychiatrist Eugene Bleuler used the term schizophrenia in 1911 to describe people who exhibited signs of disorganized thought processes, a lack of coherence between thought and emotion, and a state of disconnection from reality. It may be easy to think that “schizophrenia” stands for “split-personality,” but that’s a mistake. In schizophrenia, the different components of personality (thoughts, emotions, behaviors) are inconsistent — for example, a mother laughing when her son breaks his arm because the bone poking through his skin looks funny.
Today, the DSM-5 criteria for schizophrenia include:
Delusions: A delusion is a firmly held belief that a person maintains in spite of evidence to the contrary. One common type of delusion is a paranoid or persecutory delusion, which involves intense fear that you’re being followed, listened to, or otherwise threatened by someone or something. Check out the vignette in the introduction to this chapter. Mr. Smith appears to be experiencing a paranoid delusion. He “knew” that the neighbor was out to get his house!
Another common form of delusion is the grandiose delusion, in which a person experiences an extremely exaggerated sense of worth, power, knowledge, identity, or relationship. Someone who is grandiose may believe he can speak to supernatural beings or that he is a supernatural being himself! Or, he may just think that he’s the smartest, most attractive person alive.
Hallucinations: A hallucination can be defined as a perception that occurs without external stimulation that is experienced as very real. Hallucinations can be auditory (hearing voices or sounds), visual (seeing people who are not there, demons, or dead people), olfactory (smells), gustatory (tastes), or somatic (experiencing physical sensations within the body). Most hallucinations are auditory and often involve someone hearing a voice or voices commenting on his or her behavior.
Command hallucinations are a potentially dangerous form of auditory hallucination because they involve a voice or voices telling the sufferer to do something, often involving violent or suicidal behavior.
Disorganized speech and thought: If you’ve ever had a conversation with someone, and you had no idea what she was talking about, you may have witnessed disorganized speech and thought, which are characterized by extremely tangential (mostly irrelevant), circumstantial (beating around the bush), or loosely associated (jumping from one unrelated thought to another) speech. These abnormal styles of communicating may be evidence of a thought disorder. An extreme form of thought disorder is called word salad — when a person’s speech is so incoherent that it sounds like another language or nonsense. Sometimes people even make up words that don’t exist, called neologisms. For example, “I think the glerbage came by and sluppered the inequitised frames from me.”
Grossly disorganized or catatonic When a person behaves in a disorganized manner, she may act extremely silly or childlike, easily get lost or confused, stop caring for herself and her basic needs, do strange or bizarre things like talk to herself, or be extremely socially inappropriate. Catatonic behavior involves complete immobility, absolute lack of awareness of one’s surroundings, and sometimes being mute.
Negative symptoms: A negative symptom refers to the absence of some usual or expected behavior. The absence of the behavior is what is abnormal. Three negative symptoms are often associated with schizophrenia:
• Flat affect: When a person exhibits no emotionality whatsoever
• Alogia: Indication that a person’s thought processes are dull, blocked, or generally impoverished
• Avolition: When a person has no ability to persist in an activity; looks like an extreme lack of motivation
When a person experiences these symptoms, he may be suffering from schizophrenia. I say may because a person may exhibit these symptoms for different reasons: drug use, sleep deprivation, or a physical disease. Making the diagnosis of schizophrenia is a complex and very serious task. Specific time frames and rule-outs are involved. Rule-outs involve eliminating other possible or plausible explanations.
Schizophrenia is diagnosed in about 4 to 5 of every 1,000 people. Generally the condition is diagnosed in individuals between the ages of 18 to 35. Sometimes, but rarely, it’s diagnosed in childhood. Schizophrenia typically begins in the late teens and early twenties and is fully present by the mid- to late twenties. It can develop rapidly or gradually, and there can be periods of less severe symptoms. Some sufferers are chronically and persistently ill. Periods of illness can be characterized by a marked inability or diminished capacity to function in everyday life, often leading to school failure, job loss, and relationship difficulties.
Don’t be fooled by how easy it is to list the symptoms of schizophrenia and describe them; they are very serious. Individuals with schizophrenia often face enormous challenges in society and sometimes end up in jail, in hospitals or similar institutions, or living on the streets because of their illness.
Revealing schizophrenia’s causes
Determining the causes of psychological disorders constituted part of the old nature-versus-nurture debate. Are the causes of schizophrenia organic (biochemical/physiological) or functional (resulting from experience)? At the moment, perhaps because of the wide array of newly developed brain-scanning techniques, the organic explanations are far more prominent. However, the best answer may lie in a synthesis of the two points of view. This is still a very difficult topic to tackle because numerous theories for the cause of schizophrenia exist, each with varying degrees of scientific support. The main theory in practice today is the diathesis-stress model, which merges two different areas of research.
First, some definitions. A diathesis is a predisposition to a particular disease. Stress can be defined as any number of psychological and social factors. So, the diathesis-stress model holds that schizophrenia is the consequence of a stress-activated diathesis or predisposition.
Proposed biological diathesis for schizophrenia includes problems with brain chemistry and/or development. Researchers have found malformed parts of the brain in people with schizophrenia. These biological abnormalities can lead to problems with thinking, speech, behavior, and staying in contact with reality.
For the stress component, psychological factors address the reality distortion associated with schizophrenia. Why do schizophrenics make a break from reality? Some experts propose that the world experienced by someone with schizophrenia is so harsh, and its conflicts so intense, that the person needs a vacation from it. Research supports that psychic trauma, such as child abuse, can be related to psychotic breakdowns, and it certainly constitutes a harsh reality that inspires an escape. The research, however, does not state that child abuse causes schizophrenia in all or even a majority of cases, but it’s a potentially overwhelming stressor. Trauma is a form of extreme stress, regardless of the source. This stress may interact with the diathesis, the predisposition, and lead to psychotic symptoms.
A social factor related to schizophrenia that has shown promise in recent research is a phenomenon known as expressed emotion. Expressed emotion (EE) refers to negative communication by family members directed at the person suffering from schizophrenia. EE often consists of excessive criticism. Family members may comment on the patient’s behavior, “You’re crazy!” for example. EE also includes emotional over-involvement of family members that can overwhelm the patient. Let me be perfectly clear, though: I am not saying that criticism and over-involvement cause schizophrenia, but only that these factors may contribute to the stress component of the diathesis-stress model, as may many other stressors.
You may think that you’ve developed schizophrenia after reading about its causes. Don’t get too caught up in the detail. The bottom line is that a lot of the research out there about schizophrenia is inconclusive. What’s known is that brain abnormalities in schizophrenics may interact with certain kinds of stress in a way that triggers the disorder. The devastating effects of schizophrenia keep researchers working hard to figure out this disorder. Research has come a long way, but there’s still an awful long way to go.
Schizophrenia is one of the most difficult mental disorders to treat. Its effects are often debilitating for both the individual with the disease and his family. Approaches to treating this illness range from medication to helping individuals develop important functional skills such as money management or social interaction methods.
Antipsychotic medications such as Haldol and Zyprexa are typically the first line of treatment for people suffering from schizophrenia or related psychotic disorders. Although they are extremely beneficial, these medications are known as palliatives because they don’t cure disease; they just lessen the intensity of symptoms.
Psychosocial treatment and rehabilitation have also shown promise in managing schizophrenia. Patients learn social and self-care skills that can help reduce the number of stressors they face.
Although seemingly out of fashion in recent years (too labor-intensive and therefore too expensive), psychotherapy, specifically cognitive therapy, has been used in recent years to teach patients to challenge their delusional belief systems and become better “consumers” of reality.
Most recent research agrees that a combination of medication and talking therapy is the most effective treatment intervention for schizophrenia. Early intervention and solid social support are also factors associated with a favorable prognosis. With medication, psychotherapy, and support from family and friends, many people suffering from schizophrenia can lead productive lives.
A core problem is that the symptoms of schizophrenia are often so severe that people with this condition often have a difficult time achieving levels of emotional and behavioral consistency necessary to maintain jobs and effective relationships. In addition, perhaps because of damaged self-esteem, poor self-image, and ambivalent attitudes about relating and succeeding, schizophrenics are notorious for inconsistent medication compliance, which only intensifies unpredictable behavior and well-being.
Struggling with other types of psychoses
In addition to schizophrenia, two other forms of psychosis are delusional disorder and substance-induced psychotic disorder.
Delusional disorder: Characterized by the presence of fixed false beliefs, not particularly bizarre, that are held despite evidence to the contrary. Moreover, these beliefs are not particularly functional or helpful. For example, a husband may be obsessed with the idea that his wife is having an affair but unable to prove it or find any evidence. This belief would be classified as a delusion if it persisted for at least one month. In a different scenario, someone may think that the water in his home is poisoned, contrary to evidence that it is not. The key thing about a delusional disorder is that the delusional person has no other signs of psychosis, such as those found in schizophrenia.
Substance-induced psychotic disorder: Exists when prominent hallucinations or delusions are present as a result of being under the influence of a substance or withdrawing from a substance. People under the influence of LSD or PCP often exhibit psychotic symptoms, and it’s not unusual for people who have used cocaine or amphetamines to experience psychotic-like symptoms when they “come down” — an experience that mimics psychotic symptoms. This problem can be very serious, and anyone considering using drugs, including cannabis or alcohol, should know that they may experience psychotic symptoms as a consequence of this decision.
I wonder if blues music would be around if all those musicians were psychotherapy patients. Those songs don’t seem particularly sad though; they just seem a bit pitiful to me. Nevertheless I sometimes ask new patients if they’ve ever been depressed; some of them reply, “Sure, doesn’t everyone get depressed?” Not exactly.
Sadness is a normal human emotion typically felt during experiences of loss. The loss of one’s job, lover, child, or car keys may trigger sadness. But that’s just it — this is sadness, not depression. Depression is an extreme form of sadness that includes a number of specific symptoms. Being dumped by a boyfriend or a girlfriend at one time or another is a fairly universal experience. How does it feel? Sad. Most people feel fatigued, unmotivated, and sleepless when they get dumped. But all of these feelings eventually go away. People get over it and move on. The same kind of response is normal when a loved one dies. This is called mourning or grief. Again, grieving is not depression. Depression is something different.
In this section, I discuss major depressive disorder, how it manifests, and some of the theories and explanations behind it.
Staying in the rut of major depression
When someone is depressed to the degree of needing professional attention, she experiences a majority of the following symptoms of major depressive disorder over a minimum of a two-week period (because anybody may experience these on occasion or for a day or two, or hours):
Depressed mood for most of the day and for most days
Anhedonia (marked disinterest or lack of pleasure in all or most activities)
Significant weight loss or weight gain, without trying, and decreased or increased appetite
Difficulty sleeping or excessive sleeping
Physical feelings of agitation or sluggishness
Fatigue or lack of energy
Feelings of worthlessness or excessive guilt
Difficulty concentrating and focusing
Repeated thoughts of death or suicide
Hopefully, most people who ask, “Don’t we all get depressed?” won’t have that same response after seeing all of these symptoms. If you are experiencing three or more of these symptoms or if you have any doubts, get thee to a doctor!
Sometimes, depression can become so severe that the sufferer may think about committing suicide. Many dangerous myths about suicide are floating around. One is that people who talk about suicide don’t do it. This is false! In fact, talking about suicide is one of the most serious signals that someone may actually do it. All talk about suicide or self-harm should be taken very seriously. If you’re worried about someone or having suicidal thoughts yourself, contact a mental health professional or call a local crisis or suicide hotline immediately.
Depression is one of the most common forms of mental disorder in the United States, occurring on average in about 15 percent of the population. Major depressive disorder can occur just one time in a person’s life or over and over again, lasting for months, years, or even a lifetime. Most people who suffer from a recurring major depressive disorder have periods of recovery in which they don’t experience symptoms, or they experience the symptoms in a less intense form. Depression can occur at any point in a person’s life and doesn’t discriminate against age, race, or gender.
Revealing depression’s causes
Depending on whom you ask, the search for the causes of depression can be divided into two camps:
Biological: Biological theories of depression place blame on the brain and the malfunctioning of some of the chemicals that comprise it.
Psychological: The psychological theories of depression focus mostly on the experience of loss.
The biogenic amine hypothesis is the most popular theoretical explanation of the biological underpinnings of depression. According to this hypothesis, depression is a function of the dysregulation (impaired ability) of two neurotransmitters in the brain, norepinephrine and serotonin.
Neurotransmitters are chemical substances in the brain that allow one neuron to communicate with another neuron. The brain contains many different neurotransmitters, each with varying functions, in specific regions. Specific neurotransmitters help certain brain regions do the work of particular human activities. The parts of the brain seemingly most affected in depression are those involved with mood, cognition, sleep, sex, and appetite.
Psychological theories of depression come from several sources:
Object Relations Theory: Melanie Klein in the early 20th century proposed that depression was the result of an unsuccessful child developmental process that may result in a difficult time coping with feelings of guilt, shame, and self-worth.
Attachment theory: John Bowlby’s mid-20th-century theory, which argues that all of a person’s relationships with other people originate from the initial attachment bonds he forms with primary caregivers as an infant. A disruption in the attachment relationship may prevent a healthy bond from forming, thus making the child vulnerable to depression when faced with future losses and relationship difficulties.
In infancy, many factors — a drug-addicted parent or an unloving foster home are just two examples — can disrupt bonding and attachment. Children with poor attachment relationships are often left feeling helpless. Helplessness is a hallmark of depression.
Learned helplessness theory: Martin Seligman in the 1960s worked with people’s experience of and with failure or an inability to achieve what they desire at some point in their lives. Under normal circumstances, most people can keep on keeping on; they don’t give up or develop any serious sense of pessimism about the likelihood of future successes. But some people, because of adverse circumstances or a general tendency to view their efforts as worthless, may become depressed in the face of disappointing experiences and come to see insurmountable odds in their path.
Cognitive theory: Aaron Beck’s 1960s theory has become extremely popular and is well supported by research. Beck proposed that depression is a type of thinking disorder that produces the emotional outcome of depressed moods and the other related symptoms.
Several cognitive “distortions” may be involved:
• Automatic thoughts: Automatic thoughts are statements people make secretly to themselves that produce depressive experiences. For example, if you get in your car in the morning and it doesn’t start, you may consciously say, “Dang, just my luck.” But unconsciously, you may be having an automatic thought (that you’re not even aware of having), “Nothing ever goes right for me.”
• Mistaken assumptions and self-other schemas: The assumptions and self-other schemas (beliefs about who you are in relationship to others) that you assume to be true — as well as your views of the world, yourself, and the future — greatly influence how you move in the world. Beck introduced the cognitive triad. Each point in the triangle contains a set of beliefs that reflect a negative evaluation of oneself, a hopeless view of the future, and a view of the world as excessively harsh.
• Cyclical thinking: A final component of the cognitive view is the cyclical nature of depressive thinking. For example, if you believe that you can’t do anything, then you won’t exactly be fired up when you approach a task; your motivation is affected by your belief about your abilities. Then, you probably make minimal (if any) effort because of your lack of motivation, and, in turn, “prove” to yourself that you really can’t do anything right. This twisted and self-confirmatory bias in thinking often leads to depression.
Several effective treatment approaches for depression exist. Antidepressant medication, including famous medications as Prozac and Paxil, works for some people. Psychotherapy, specifically cognitive-behavioral therapy and interpersonal psychotherapy, is also helpful for many people. Research also indicates that “activity” — staying physically active and generally busy — makes an effective antidote to depression. Some studies even indicate that regular physical exercise can be as effective as medication in alleviating symptoms of depression according to the self-reports of subjects, but more research needs to be done before this is considered a mainline treatment. The common standard of practice is to utilize both medication and psychotherapy.
Riding the waves of bipolar disorder
Bipolar disorder used to be known as manic-depression can be characterized as a disorder of severe mood swings involving both depression and mania — a state of excessively elevated or irritable mood lasting for approximately one week and co-occurring with the following symptoms:
Inflated self-esteem or grandiosity (coming up with a solution to end starvation and creating peace on Earth, all before tonight’s dinner reservation)
Decreased need for sleep (feeling rested with three to four hours of sleep a night or feeling of not needing sleep at all; there’s just too much to do!)
Extreme need and pressure to talk
Racing and rapid thoughts
Extremely short attention span
Drastically increased activity level (engaging in a lot of projects or mowing the lawn at 2 a.m.)
Excessive engagement in pleasurable activities that have potentially damaging consequences (gambling your house payment, spending sprees, sexual excursions)
An accurate diagnosis of bipolar disorder requires a person to experience at least one episode of mania in his life and currently be experiencing a manic, depressed, or mixed episode (both depression and mania). A person needs to experience both depression and mania — hence the concept of severe mood swings — to earn his bipolar stripes, so to speak.
People suffering from bipolar disorder usually have several recurring episodes over the course of their lifetimes. Manic episodes can be particularly damaging because when someone is in the throes of mania, it’s not uncommon to amass extremely large debts, incur broken relationships, or even engage in illegal or criminal acts.
Bipolar disorder is akin to being on a roller coaster of extreme emotion (sometimes sad, sometimes happy) beyond all proportion, but these mood swings do not occur within a day or even within a week. Bipolar disorder refers to extreme mood swings that occur over a long period of time — such as four mood episodes (either depression, manic, or mixed) within a ten-year period. An episode can last anywhere from one week to multiple years.
Antidepressant medication is one of the most widely prescribed medications in the United States. What’s the story with that? Is everyone in the US depressed? I think it comes down to a great deal of public awareness about depression — and television advertising for these drugs doesn’t hurt either. But it’s important to remember that certain forms of psychotherapy can be just as effective as medication in the short-run and perhaps more beneficial to a person’s long-term well-being than medication. In other words, the best “drug” for depression may not be a drug at all.
Some people have what’s called rapid cycling — they may experience four or more episodes within a one-year period. Rapid-cycling individuals have an especially tough experience because each bipolar episode can be quite disruptive, and there’s no time to get their life back together between episodes.
Revealing bipolar disorder’s causes
The most popular theories on the causes of bipolar disorder — specifically, mania — are biological. Research has implicated neurochemical abnormalities in the specific parts of the brain that involve the neurotransmitters dopamine and serotonin. There is little other conclusive evidence.
Long before biological studies, however, psychoanalysts offered their explanation: Mania is a defensive reaction to depression. Rather than feeling overwhelmed with depression, a person’s mind makes a switch of sorts, turning that extreme sadness into extreme happiness. The symbolic equivalent to this idea is laughing when someone you love dies. It’s a severe form of denial. When a manic patient is seen in psychoanalytic-oriented psychotherapy, the main focus is this defensive hypothesis.
Stress, too, is thought to play a role in intensifying the mood episodes within bipolar disorder. Stress doesn’t necessarily cause mania or depression, but it can make matters worse or speed up the arrival of an approaching mood episode.
Treating bipolar disorder
Currently, the first line in treating bipolar disorder is medication. A class of drugs known as mood stabilizers is used to stabilize a person’s mood and reduce the likelihood of future episodes. Common mood stabilizers are Lithium and Depakote.
Supportive psychotherapy can also be part of treatment, mainly to help people deal with the negative consequences of manic behavior and come to terms with the seriousness of this illness. Cognitive-Behavioral Therapy (CBT) is being used increasingly to help people with bipolar disorder manage their behavior and identify early warning signs of an upcoming mood episode.
For more information on bipolar disorder, read Bipolar Disorder For Dummies by Candida Fink and Joe Kraynak (Wiley, 2012).
Euphemisms abound when it comes to the most common class of mental disorders, the anxiety disorders. “Stress,” “worry,” “nerves,” “nervousness,” and “fear” are all everyday terms for this condition. Anxiety is a sense of generalized fear and apprehension. When someone is anxious, he is generally fearful. Fearful of what? That depends. Identifying what scares a person helps psychologists determine what kind of anxiety disorder he may have.
Normal worrying aside, anxiety disorders are probably the most common type of mental disorder. But is worrying actually a mental disorder? Remember, all behavior and mental processes exist on a continuum of normalcy. Worry can be so intense or bothersome to the worrier that it reaches the level of a disorder in need of professional attention. Worried about being a pathological worrier yet? Relax, take a deep breath, and read on. There’s more to cover before you start jumping to conclusions and running for help.
People can fear or worry about all kinds of things. When someone is extremely afraid of a particular thing or situation, even if she knows it poses no real danger, it’s called a phobia. There are different types of phobias. Social phobia is the fear of people. Agoraphobia is the fear of being outdoors, away from home, or in crowded places. Angoraphobia is fear of sweaters and heavy winter coats. Just kidding about the last one, but hundreds of phobias are out there. Here are a few notables:
Acrophobia: Fear of heights
Claustrophobia: Fear of closed spaces
Nyctophobia: Fear of the dark
Mysophobia: Fear of germ contamination
Zoophobia: Fear of animals or a specific animal
Some of the most common anxiety disorders include:
Generalized anxiety disorder: Excessive and persistent worry about many different things
Posttraumatic Stress Disorder (PTSD): Reexperiencing traumatic events that were life threatening, hyper or excessive physiological arousal and avoidance of trauma-related places and people
Obsessive-compulsive disorder: Obsessions (recurring thoughts) and compulsive behavior (driven to repeat an activity like hand-washing)
In this section, I focus on one of the most common anxiety disorders; it’s known as panic disorder.
If you live in a bad neighborhood and you’re afraid to leave your home at night, that’s not a phobia; that’s realistic (or rational) anxiety! On the other hand, some people are afraid to leave their homes, and it’s not because they live in a bad neighborhood. The people I’m referring to suffer from a phobia of large, open, or crowded places called agoraphobia. Agoraphobia is typically associated with a major anxiety disorder known as panic disorder — a condition in which a person experiences recurring panic or anxiety attacks and a fear of future attacks.
The DSM-5 definition for a panic attack is “a discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes”:
Palpitations, pounding heart, or accelerated heart rate
Sweating, trembling, or shaking
Shortness of breath, feeling of choking, or chest pain
Nausea, dizziness, or lightheadedness
Feelings of unreality or being detached from oneself
Fear of losing control or going crazy or dying
Numbness, tingling, chills, or hot flashes
A person who has recurrent panic attacks may be suffering from panic disorder if he worries incessantly about having more attacks, has unrealistic fears of the implications of the attack, or has significantly changed his behavior as a result of the attacks. A hallmark of panic disorder is fear that the panic attacks are a signal of some major illness, such as a heart attack, losing one’s mind, or dying. This symptom can be very serious because it can lead to excessive stress. Worrying about dying can be pretty stressful and may well be a factor in triggering the very illnesses a person is actively dreading.
The most common change in a person’s behavior is the development of agoraphobia. This state involves an intense fear of being in places or situations in which it may be difficult to get away or to get help if needed. Common examples of situations associated with agoraphobia are riding in elevators, standing in a large crowd, traveling on a crowded subway car, or even driving in thick traffic.
This is only the first half of agoraphobia, though. The other part involves the person avoiding these potentially trapping situations and, often, confining himself to his home. This symptom can be extremely stressful for the person suffering from panic disorder and for his family members as well. What kind of life can you have if your spouse or parent won’t leave the house? Severe marital strain is not uncommon for people with panic disorder.
Revealing panic disorder’s causes
At least two excellent explanations of panic disorder exist; there’s David Barlow’s biopsychosocial approach as well as the cognitive model.
Barlow’s main idea is that panic attacks are the result of a hyperactive fear response within the brain under stress. Certain individuals possess a physiological vulnerability in which their nervous systems overreact in some situations. This biological vulnerability is paired with the psychological vulnerability that’s caused by exaggerated beliefs about the dangerousness of certain bodily sensations and the world in general.
The cognitive model (Beck, Emery, & Greenberg, 1985) is similar to Barlow’s model, but it puts more emphasis on the person’s beliefs. The basic idea of the cognitive model is that panic attacks are the result of a misattribution of normal bodily sensations that leads to increased fear, which in turn exacerbates the sensations, which leads to more misattribution. It’s a vicious cycle. A person interprets something that he feels is life threatening or dangerous, and this makes him worry, which intensifies both the feeling and his fear of it.
Treating panic disorder
Panic disorder is treated by mental health professionals with both medications and various forms of psychotherapy. Antidepressant medications known as tricyclics can reduce the occurrence of panic. Benzodiazapines, a class of “relaxing” drugs, are also used for some people to reduce the likelihood of anxiety symptoms getting “out of control” and blossoming into full-blown panic.
Behavior therapy is usually an important part of treatment for panic patients. It sounds kind of cruel, but behavior therapy basically involves teaching relaxation techniques and then, in small-step increments, exposing patients to situations that formerly triggered panic. The exercise teaches participants how to endure a panic attack until it subsides. More importantly, it works. Patients become calm in situations that initially triggered strong anxiety.
Cognitive therapy can teach sufferers to change their thinking in ways that reduce their tendency to misperceive or misinterpret bodily sensations and blow them out of proportion. The intent of cognitive therapy is to change “what if thinking” to “so what thinking” through education about physiological processes and available sources of help.
Understanding Young People’s Problems
Mental disorders affect children and adolescents at rates similar to adults, which is about 1 in 5, or 20 percent, according to the United States Surgeon General. Kids are not exempt from mental problems; they experience many of the same disorders that adults do, in slightly different numbers. For example, rates of depression in people under the age of 18 years old are similar to adults, but the occurrences of schizophrenia in the under-18 set are much lower than for adults. Schizophrenia is considered fairly rare in children. Anxiety disorders, on the other hand, may be the most common disorder of childhood; incidences among kids are similar to occurrence rates for adults.
Although children and adults can experience the same mental disorders, there are some disorders that are more likely to show or “turn up” during childhood; they’re typically recognized in a person before she reaches adulthood:
Intellectual disability: Characterized by abnormally low intellectual and adaptive skills such as self-care and communication abilities
Learning disorders: Problems related to acquiring, manipulating, and using information, including dyslexia and mathematics disorder
Motor skills disorders: Insufficient development of coordinated physical activity
Communication disorders: Difficulties with expressive and receptive speech
Oppositional defiant and conduct disorder: Characterized by behavior that violates the rights of others such as aggression, criminal behavior, and bullying
Feeding and eating disorder of infancy and early childhood: Abnormal eating in terms of amount, intake method, or some other feature such as ingesting nonnutritive substances, known as the disorder pica
Tic disorders: Involves the presence of involuntary vocal or motor movements and includes Tourette’s disorder
Elimination disorders: Includes encopresis (the soiling of clothing with feces) and enuresis (same problem only with urine)
Attention deficit/hyperactivity disorder: Characterized by abnormal levels of activity and deficits in concentrating, attending, and impulse control
Pervasive developmental disorders: Involves disorders of severe deficits in communication, social functioning, and behavior, including autism
Dealing with ADHD
Are you always on the go, unable to sit still, constantly messing with things, struggling to think before acting or doing something foolish, spacing out frequently, and having a hard time finishing things? These are common examples of behaviors and symptoms of Attention Deficit/Hyperactivity Disorder or ADHD.
ADHD used to be called ADD or Attention Deficit Disorder, but it’s been officially recognized as ADHD for at least 20 years. The actual diagnostic symptoms of ADHD are divided into two categories: symptoms of hyperactivity and impulsivity and symptoms of inattention. Individuals can display predominant symptoms in one of the two categories and meet criteria for the diagnosis. Or, they can have symptoms in both and be considered a “combined type.”
Here’s rundown of the symptoms associated in each of the two categories:
Hyperactivity and impulsivity: Fidgety, squirmy, can’t stay seated, runs and climbs excessively, can’t play quietly, always on the go, talkative, can’t wait, interrupts, and is intrusive
Inattention: Difficulties with paying close attention to details, making careless mistakes, difficulty sustaining attention, not appearing to listen, poor follow-through and finishing things, loses things, is distractible, and forgetful
ADHD can range in severity from very mild to severe and is not typically diagnosed before the age of 4 years old. Boys are more likely to have ADHD, but it shows up in girls, too. The most common treatment is medication, typically in the class of psychostimulants (such as Ritalin or Straterra), but behavior modification and psychosocial interventions are also important parts of treatment. Specifically, the approach popularized by Russell Barkley and in the work of Dr. Arthur D Anastopoulos uses psychosocial interventions that include behavior modification components, parent education, child education, and counseling, if necessary.
Wait a minute, did that say “psychostimulants”? That’s right, the medication used to treat ADHD functions as a brain stimulant. It’s the concept of adults using coffee to stay up and work or study. People tend to concentrate a little better when they’re a little wired.
Although it seems counterintuitive, the underlying neuropsychological deficits of ADHD are consistent with the use of a stimulant medication. Essentially, the symptoms of ADHD are the result of the less-than-optimal functioning of the frontal lobe of the brain, deficits in its functions known as executive functions, such as planning and organizing. The frontal lobe and its executive functions play a critical role in inhibition and impulse control, organization, attention, concentration, and goal-directed behavior, which is knowing how to stay on target to meet a goal, even if that goal is simply picking up your socks.
For people with ADHD, the frontal lobe is “underpowered” and not up to its tasks, thus leaving the rest of the brain disorganized, impulsive, overly active, and prone to a bit of wandering. Stimulant medications address the power shortage, give the frontal lobe a boost, and slow down Joe ADHD to focus him and increase his impulse control.
The cause of this frontal lobe power deficit has yet to be fully identified but research shows a strong genetic component and the role of some sort of negative developmental event or exposure that results in underdevelopment of the frontal lobe and executive functions.
Living in a world of her own
I am much less autistic now, compared to when I was young. I remember some behaviors like picking carpet fuzz and watching spinning plates for hours. I didn’t want to be touched. I couldn’t shut out background noise. I didn’t talk until I was about 4 years old. I screamed. I hummed. But as I grew up, I improved.
— Temple Grandin
Temple Grandin is a relatively famous adult woman who has autism, a neurodevelopmental disorder characterized by deficits or abnormal language development, abnormal social skills and development, and repetitive and restricted behavior. Actress Claire Danes starred in a TV movie about Temple Grandin made in 2010 that featured her life, her struggles, and her success. Ms. Grandin, who holds a PhD in animal science, is considered by many as a spokesperson and advocate for those with autism and engages in numerous speaking engagements every year to increase awareness of this condition.
Autism, usually recognized by the age of 3 to 4 (although signs and symptoms can manifest and show up earlier) consists of symptoms and deficits the following three areas:
Impairment in social interaction: Deficits in nonverbal social behavior such as eye contact and gestures; failure to develop peer relationships appropriate to age level; a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people; and lack of social or emotional reciprocity
Impairments in communication: Delay in, or total lack of, the development of spoken language or, in individuals with adequate speech, impairment in the ability to initiate or sustain a conversation with others; stereotyped and repetitive use of language or idiosyncratic language such as repeating incessantly or odd intonation or word usage; and deficits in varied, spontaneous make-believe play or social imitative play
Repetitive and stereotyped patterns of behavior, interests, and activities: Intense preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus; inflexible adherence to specific, nonfunctional routines or ritual; stereotyped (persistent repetition of a behavior with no obvious purpose) and repeated motor mannerisms (such as hand or finger flapping or twisting, or complex whole-body movements); and persistent preoccupation with parts of objects
Autism is a complex neurodevelopmental disorder that can range from mild (often called high-functioning autism) to severe. A cause for the disorder has yet to be identified, but research findings are promising. For example, genetic research is progressing. No “autism gene” has been identified, but much has been learned about the underlying cognitive and neuropsychological aspects of autism. Two areas in particular stand out: neural connectivity models and theory of mind models.
It is thought that the brain in individuals with autism develops and is organized differently from the brain in children with typical development (see Chapter 3 for content on how the brain is organized and works). Research findings are complicated, showing that autistic people have some underdeveloped areas as well as some overdevelopment — and even larger brain volume. Taken as a whole, researchers propose that the brain in autism interacts and communicates with itself in unique and disordered ways that differ from activity in typical individuals. From this perspective, autism can be considered a disorder of neural organization and integration.
Thinking that someone you’re looking at or talking to has a “mind of his own” is known as “theory of mind” (abbreviated TOM). Most people believe that other people have a mind just like their own, which helps them understand the world from another person’s point of view. Consistently, research and clinical work show that individuals with autism have deficits in TOM. In other words, people with autism do not assume the existence of an “other’s mind” and, as a result, display social and communication deficits. Their difficulties with understanding facial expressions and gestures, anticipating the actions and of others, engaging in conversation, and showing social and emotional reciprocity may be a consequence of TOM deficits. But, as with genetics, TOM deficits have yet to come through as the “silver bullet” of underlying deficits that account for or produce the entire syndrome of autism.
One thing is for certain; in many respects, autism is a lifelong disorder. Yet there’s significant hope for those who get early and intensive intervention. As a neurodevelopmental disorder, the course of autism can likely be altered in a significant and positive direction. A comprehensive interventions approach that broadly addresses a child’s neurodevelopment and development have been developed, researched, and show encouraging results. These approaches use a “teaching” approach of sorts to facilitate the normal development of children and address developmental delays. Here are four of the most well-researched and exciting intervention approaches for autism:
Applied behavior analysis — Discrete trial teaching (DTT): DTT is a specific teaching technique in which the principles of operant and classical conditioning are used to present children with massed learning trials that are very intensive (find details on ABA in Chapter 16 and information on operant and classical conditioning in Chapter 8). DTT is most associated with the work of Dr. Ivar Lovaas (1927—2010)).
Pivotal response treatments (PRT): PRT is considered an ABA intervention, but it differs from DTT in that it tends to be more play-based, uses naturalistic reinforcement within the operant conditioning paradigm, and focuses on increasing the motivation of the participant to optimal levels. PRT is associated with the work of husband-and-wife psychologist team, Drs. Robert and Lynn Koegel of University of California, Santa Barbara, who first developed their work in the 1970s.
Early start Denver model: Developed by psychologists Sally Rogers and Geraldine Dawson in the early 2000s, the early start Denver model combines the PRT approach and a “developmental model” in which experiences identified as critical in child development are used to guide the intervention and its curriculum.
Verbal behavior approach: Dr. Mark Sundberg developed the VB approach in the early 2000s to help children with autism learn how to communicate and speak. Although not considered a comprehensive intervention approach for all developmental areas, the verbal behavior approach is widely respected as a sophisticated and well-designed intervention for communication and language development.