Assignment Paper: Describing Etta

This is the video clip referred to in the question.

4-page paper

4 sources required

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Etta can be found in this module. In the video clip the psychiatrist talks you through the video and Etta’s diagnosis. Pay attention to the symptoms and criteria for schizophrenia and be able to list the criteria Etta meets to warrant her diagnosis. What sub-type of schizophrenia does she appear to have? Describe what Positive and Negative symptoms are.

Specifically respond to these 5 questions (each worth 2 points)

1. From the reading and the video clips, describe schizophrenia, the symptoms and criteria as if you are describing them to someone who has never heard of schizophrenia. Do not copy-paste the criteria. (2pts)

2. Describe Etta’s symptoms as seen in the video. (2pts)

3. Which subtype of schizophrenia does she seem to meet criteria for? (2 pts)

4. Describe what Positive and Negative symptoms are as they relate to the diagnosis of schizophrenia. (2pts)

5. Finally, what is your reaction to Etta? (2pts)

11ECh151.pptx

15 Abnormal Psychology: Disorders and Treatment

module 15.1 An Overview of Abnormal Behavior

After studying this module, you should be able to:

Describe and evaluate a definition of mental illness.

Define the biopsychosocial model of mental illness.

Give examples of cultural influences on abnormal behavior.

Describe DSM-5 and give examples of the categories it lists.

Evaluate the assumptions behind DSM and the categorical approach to mental illness.

Defining Abnormal Behavior

The American Psychiatric Association defines mental disorder as a clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior.

It is sometimes difficult to apply that definition, because of disagreements over what constitutes a significant disturbance.

In the past, people have described abnormal behavior in many ways, including spirit possession.

The Biopsychosocial Model

Biopsychosocial model – concept that emphasizes biological, psychological, and sociological aspects of abnormal behavior

Cultural Influences on Abnormality

A culture provides examples not only of how to behave normally but also of how to behave abnormally.

The American Psychiatric Association defined mental disorder as a “clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.” That seems a reasonable definition, but it is not always easy in practice. Who decides whether someone has a clinically significant disturbance? Do we let people themselves decide? Do we always trust a psychiatrist or psychologist to decide? What if therapists disagree with one another?

In previous eras, people have held many views of abnormal behavior and its causes. The idea of demon possession was popular in medieval Europe and is still common in much of the world today.

The ancient Greeks explained behavior in terms of four fluids: An excess of blood caused a sanguine (courageous and loving) personality. An excess of phlegm caused a phlegmatic (calm) personality. Too much yellow bile made one choleric (easily angered). Too much black bile made one melancholic (sad).

In traditional Chinese philosophy, personality cycles through five stages or elements, just as the seasons do. An excessive response could cause too much fear, anger, and so forth.

The standard view today is that abnormal behavior results from a combination of biological, psychological, and social influences.

The biological roots of abnormal behavior include genetic factors, infectious diseases, poor nutrition, inadequate sleep, drugs, and other influences on brain functioning.

The psychological component includes reactions to stressful experiences. For example, people who were physically or sexually abused in childhood are more likely than others to develop psychological problems in adulthood.

Also, behavior must be understood in a social and cultural context. Behavior that is considered acceptable in one society might be labeled abnormal in another. For example, loud wailing at a funeral is expected in some societies, but not in others.

We learn from our culture how to behave normally. We also learn some of the options for behaving abnormally.

DSM and the Categorical Approach to Psychological Disorders (slide 1 of 2)

To standardize their definitions and diagnoses, psychiatrists and psychologists developed the Diagnostic and Statistical Manual of Mental Disorders (DSM).

Diagnostic and Statistical Manual of Mental Disorders (DSM) – a reference book that sets specific criteria for each psychological diagnosis

The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists possible diagnoses and the criteria for identifying each of them.

Table 15.1 Categories of Psychological Disorders According to DSM-5

Neurodevelopmental Disorders	Schizophrenia Spectrum
Bipolar and Related Disorders	Depressive Disorders
Anxiety Disorders	Obsessive-Compulsive Disorders
Trauma-Related Disorders	Dissociative Disorders
Somatic Symptom Disorders	Eating Disorders
Elimination Disorders	Sleep-Wake Disorders
Sexual Dysfunctions	Gender Dysphoria
Impulse Control Disorders	Substance Abuse and Addictions
Neurocognitive Disorders	Personality Disorders
Paraphilias	Others

Table 15.1 shows the categories of disorder, as listed in DSM-5.

DSM and the Categorical Approach to Psychological Disorders (slide 2 of 2)

Criticisms of the categorical approach:

Most troubled people partly fit two or more diagnoses.

The genetic and environmental causes of various disorders overlap.

The treatment designed for one disorder may help with another.

Too many conditions are labeled as “mental illnesses.”

An alternative is to rate each person along several dimensions of distress.

DSM has helped standardize psychiatric diagnoses so that psychologists use terms like depression, schizophrenia, and so forth in more consistent ways than they would otherwise. However, this approach assumes that every disorder fits into one category or another, and that each troubled person can receive a single, unambiguous diagnosis. In fact, many troubled people fit several diagnoses partly and none of them perfectly. If you are suffering from depression, mania, anxiety, substance abuse, conduct disorder, obsessive-compulsive disorder, or schizophrenia, the chances are better than 50/50 that you are suffering from one or more of the others also, at least to a mild degree. You might fit mainly into one diagnosis now but a different one later. Furthermore, different disorders have many overlapping causes. The genes that increase the risk of any one disorder also increase the risk of other disorders. Highly stressful experiences, such as the sudden death of a loved one, can trigger the onset of depression, anxiety, or schizophrenia. Even when therapists agree on a single diagnosis, the diagnosis doesn’t reliably point the way to a treatment. Antidepressant drugs sometimes help people with disorders other than depression, and antipsychotic drugs sometimes help relieve nonpsychotic disorders.

Many psychologists who are dissatisfied with the DSM approach would prefer to rate each client’s problems along several dimensions, instead of trying to give each person a label. For example, instead of a single diagnosis, a therapist might use ratings like the one shown on this slide.

A further criticism is that DSM labels too many conditions as “mental illnesses.” If you seek help to increase your enjoyment of sex, you have sexual interest/arousal disorder or hypoactive sexual desire disorder. A woman with premenstrual distress gets a diagnosis of premenstrual dysphoric disorder. If you get at least seven hours of sleep per night but still feel sleepy during the day, and you have trouble feeling fully awake after a sudden awakening, you have hypersomnolence disorder. The list goes on, with hundreds of other possibilities. Surveys have found that almost half of all people in the United States qualify for at least one DSM diagnosis of mental illness at some time in life.

Figure 15.2

◄ Figure 15.2 In this survey, just over one-fourth of U.S. adults suffer a psychological disorder in any given year, and nearly half do at some time in life. (Based on data of Kessler, Berglund, et al., 2005; Kessler, Chiu, et al., 2005)

The most common disorders are anxiety disorders, mood disorders (e.g., depression), impulse control disorders (including attention deficit disorder), and substance abuse, as shown in Figure 15.2.

module 15.2 Anxiety Disorders and Obsessive-Compulsive Disorder

After studying this module, you should be able to:

Describe generalized anxiety disorder and panic disorder.

Explain why learned avoidance responses are so resistant to extinction.

Describe theoretically how classical conditioning could explain the onset of a phobia.

Evaluate the limits of the classical conditioning explanation of phobia, citing observations that it does not easily explain.

Describe obsessive-compulsive disorder.

Explain how therapists treat phobias and obsessive-compulsive disorder.

Disorders with Excessive Anxiety

Generalized Anxiety Disorder (GAD)

Generalized anxiety disorder (GAD) – disorder in which people have frequent and exaggerated worries

Panic Disorder (PD)

Panic disorder (PD) – condition marked by frequent periods of anxiety and occasional attacks of panic—rapid breathing, increased heart rate, chest pains, sweating, faintness, and trembling

Panic disorder is linked to having strong autonomic responses, such as rapid heartbeat and hyperventilation.

Hyperventilation – rapid deep breathing

Many people with panic disorder develop agoraphobia or social phobia.

Agoraphobia – an excessive fear of open or public places

Social phobia – a severe avoidance of other people and a fear of doing anything in public

People with generalized anxiety disorder experience excessive anxiety much of the day, even when actual dangers are low.

Panic disorder is characterized by episodes of disabling anxiety, high heart rate, and rapid breathing. Several studies have shown a genetic contribution, although no single gene has a strong influence. Many people with panic disorder also develop agoraphobia, an excessive fear of open or public places, or social phobia, a severe avoidance of other people and a fear of doing anything in public. The usual treatment focuses on teaching the patient to control breathing and learning to relax. Controlling stress helps also.

Phobia

Avoidance behaviors are highly resistant to extinction.

Phobia – a fear that interferes with normal living

Phobias are learned through observation as well as through experience.

Avoidance behaviors are highly resistant to existence. For example, if you believe that Friday the 13th is dangerous, you are cautious on that day. If nothing goes wrong, you decide that your caution was successful. If a misfortune happens anyway, it confirms your belief that Friday the 13th is dangerous. As long as you continue an avoidance behavior, you never learn whether or not it is useful.

A phobia is a fear that interferes with normal living. Many people develop phobias through traumatic experience. They also learn their phobias by watching others.

Some Phobias Are More Common than Others

Common objects of phobias include:

Public places

Public speaking

Heights

Air travel

Water travel

Being observed by strangers

Snakes or other dangerous animals

Blood

Lightning storms

People develop fears of some objects more readily than other objects.

People may be born with a predisposition to learn fears of objects that have been dangerous throughout our evolutionary history.

We more readily fear objects with which we have few safe experiences and objects that we cannot predict or control.

Common objects of phobias include public places, public speaking, heights, air travel, water travel, being observed by strangers, snakes or other dangerous animals, blood, and lightning storms. Social phobia—avoidance of contact with unfamiliar people—is also common.

People are more likely to develop phobias of certain objects (e.g., snakes) than of others (e.g., cars). The most common objects of phobias have menaced humans throughout evolutionary history. They pose dangers that are difficult to predict or control, and we generally have few safe experiences with them.

Treatment for Phobias

The most successful type of therapy for phobia is exposure therapy, also known as systematic desensitization.

Exposure therapy (or systematic desensitization) – a method of reducing fear by gradually exposing people to the object of their fear

In systematic desensitization, the patient is prevented from fleeing the feared stimulus.

He or she learns the danger is not as great as imagined.

Although exposure therapy is highly effective, at least temporarily, phobias sometimes return.

A common therapy for phobia is exposure therapy, also known as systematic desensitization. The patient relaxes while being gradually exposed to the object of the phobia. For example, someone with a phobia of snakes is exposed to pictures of a snake in the reassuring environment of a therapist’s office. The therapist might start with a cartoon drawing and gradually work up to a black-and-white photograph, a color photograph, and then a real snake. The client is terrified at first, but the autonomic nervous system is not capable of sustaining a permanent panic. Gradually, the person becomes calmer and learns, “It’s not that bad after all. Here I am, not far from that horrid snake, and I’m not having a heart attack.”

Although exposure therapy is highly effective, at least temporarily, phobias sometimes return. Exposure therapy is extinction of the original learning, but extinction is merely a suppression of original learning, not an erasure of it. When time passes after an extinction procedure, spontaneous recovery is likely—that is, a return of the original learned response.

Obsessive-Compulsive Disorder (slide 1 of 2)

Obsessive-compulsive disorder (OCD) – a condition with repetitive thoughts and actions

Obsession – a repetitive, unwelcome stream of thought

Compulsion – a repetitive, almost irresistible action

Common compulsions:

Cleaning

Checking

Counting

Hoarding

People with obsessive-compulsive disorder have distressing thoughts or impulses. Many also perform repetitive behaviors. Obsessions generally lead to compulsions, as an itching sensation leads to scratching. For example, someone obsessed about dirt and disease develops compulsions of continual cleaning and washing.

The most common compulsions are cleaning and checking. Another common one is counting one’s steps, counting objects, or counting almost anything. Hoarding is another common compulsion.

Obsessive-Compulsive Disorder (slide 2 of 2)

Distrusting Memory

Compulsive checkers constantly double-check themselves and invent elaborate rituals.

Repeatedly checking something leads to decreased confidence in the memory of having checked it.

Therapies

The most effective treatment is exposure to the source of distress while preventing the ritualized response.

However, this treatment is often ineffective, partly because many patients refuse or quit the treatment.

A valuable supplement is a cognitive intervention to help people reinterpret their thoughts and images.

People with obsessive-compulsive disorder, especially those who are compulsive checkers, distrust their memory. Because they distrust their memory, they check again and again.

The therapy best supported by the evidence is exposure therapy with response prevention: The person is simply prevented from performing the obsessive ritual. For example, someone might be prevented from cleaning the house or checking the doors more than once before going to sleep. Assignment Paper: Describing Etta

However, although exposure therapy is the most successful procedure currently available, it is often ineffective. People with OCD dislike the idea of stopping their rituals, and almost half quit the treatment without achieving any benefits. Many people respond well to a cognitive intervention to help them reinterpret their thoughts and images. In some cases, antidepressant drugs also help.

module 15.3 Substance-Related Disorders

After studying this module, you should be able to:

Define substance dependence or addiction.

Explain why it is difficult to list what substances are or are not addictive.

Discuss possible explanations for addiction.

Describe a procedure to identify young people who may be at increased risk of alcohol abuse.

Describe treatments for alcoholism and opiate abuse.

Substance Dependence (Addiction)

Dependence (or addiction) – inability to quit a self-destructive habit

Addictive substances stimulate dopamine synapses in the nucleus accumbens, a brain area that is associated with attention.

After people develop a compulsive habit of gambling, video game playing, or other activities, those activities also elicit dopamine release in the nucleus accumbens.

It is hard to put limits on what can or cannot be an addictive substance.

What Motivates Addictive Behavior?

People with an addiction continue a habit even though they recognize that it does them more harm than good.

Reasons for continued use include avoiding withdrawal symptoms and coping with distress.

Also, addictive substances alter the brain’s synapses to increase response to substance-related experiences and decrease response to other activities.

People who find it difficult or impossible to stop using a substance are said to be dependent on or addicted to it.

Almost all addictive drugs increase the release of dopamine in a small brain area called the nucleus accumbens, which is apparently critical for attention and reinforcement.

However, beware of assuming that the release of dopamine in the nucleus accumbens causes addiction. For example, compulsive gambling and video game playing have much in common with drug addictions. After they have become addictive, they release dopamine in the nucleus accumbens, but it would be misleading to say they became addictive because they release dopamine.

It is hard to put limits on what can or cannot be an addictive substance. Some people show addictions to gambling or video games, which are not substances at all. Some have managed to abuse water.

The motives for initial use of alcohol or other drugs differ from those of addiction. People drink alcohol for pleasure, to relax, or to suppress social anxieties. An addiction is more insistent. Addicted drug users get much less pleasure than they used to, but they continue to want the drug anyway. Why do addictive behaviors continue with such intensity?

One reason is to escape unpleasant feelings. Abstaining from a drug leads to withdrawal symptoms. Withdrawal symptoms from prolonged alcoholism include sweating, nausea, sleeplessness, and sometimes hallucinations and seizures. With opiate drugs, withdrawal symptoms include anxiety, restlessness, vomiting, diarrhea, and sweating. Consistent cigarette smokers experience unpleasant mood when they abstain.

Also, someone who takes a drug to relieve withdrawal symptoms learns its power to relieve distress, and then begins using it to relieve other kinds of displeasure. People who have quit drugs often relapse during periods of financial or social difficulties. Assignment Paper: Describing Etta

Neuroscientists have demonstrated that when an addictive behavior bombards the nucleus accumbens with massive amounts of dopamine, it stimulates synaptic changes of the same type that occur in learning. For example, after repeated cocaine use, the synapses learn to respond strongly to cocaine and reminders of cocaine, but they decrease their response to other reinforcers. The result is a craving for cocaine and decreased interest in most other activities. Cocaine use then becomes the only efficient way to produce the synaptic activities normally associated with pleasure.

Alcoholism (slide 1 of 2)

Alcoholism – the habitual overuse of alcohol

Genetics and Family Background

A genetic predisposition contributes most strongly to early-onset alcoholism.

Although many genes contribute in small ways, only the gene that affects the liver’s ability to metabolize alcohol produces effects large enough to produce results that are easily replicated.

Alcoholism depends on the environment also.

The prevalence of alcoholism and other kinds of substance abuse varies among cultures and subcultures.

The incidence of alcoholism is greater than average among people who grew up in families marked by conflict, hostility, and inadequate parental supervision.

Alcoholism is the habitual overuse of alcohol. Treating alcoholism is difficult, and the success rate is not impressive.

A genetic predisposition contributes most strongly to early-onset alcoholism. Late-onset alcoholism develops gradually over the years, affects about as many women as men, is generally less severe, and often occurs in people with no family history of alcoholism. Early-onset alcoholism develops rapidly, usually by age 25, occurs more often in men than women, is usually more severe, and shows a stronger genetic basis.

Although many genes contribute in small ways, only one is known to produce effects large enough to produce results that are easily replicated. That gene affects the liver’s ability to metabolize alcohol. The liver converts alcohol into a toxic substance, acetaldehyde, and then uses another enzyme to convert acetaldehyde into harmless acetic acid. However, people vary in the gene for that second enzyme. Those with one form of that gene are slow to convert acetaldehyde into acetic acid. If they drink much at a time, they accumulate acetaldehyde, feel ill, and experience an intense hangover. Assignment Paper: Describing Etta

Alcoholism depends on the environment also. The prevalence of alcoholism and other kinds of substance abuse varies among cultures and subcultures. For example, alcoholism is more prevalent in Irish culture, which tolerates heavy drinking, than among Jews or Italians, who emphasize drinking in moderation. The incidence of alcoholism is greater than average among people who grew up in families marked by conflict, hostility, and inadequate parental supervision.

Alcoholism (slide 2 of 2)

Predisposition to Alcoholism

People who have less than average intoxication from moderate drinking are more likely than average to become heavy drinkers.

Treatments

Only an estimated 10 to 20 percent of people who try to quit alcohol or other drugs on their own manage to succeed.

Alcoholics Anonymous (AA) – a self-help group of people who are trying to abstain from alcohol use and help others do the same

Antabuse – trade name for a drug alcoholics use whereby they become sick if they have a drink

Contingency management involves providing an immediate reinforcement for abstinence from alcohol.

One way to predict which young people will later become heavy drinkers is to measure the amount of body sway after drinking, or ask people to report how many drinks they need to experience various effects. People who report experiencing little effect from a moderate amount of alcohol are more likely than average to become heavy drinkers.

Of all the people who try to quit alcohol or other drugs on their own, an estimated 10 to 20 percent manage to succeed, though many of them quit and relapse repeatedly before eventual success. However, many other people find that they cannot quit a substance abuse problem on their own. Eventually, they “hit bottom,” discovering that they have damaged their health, their ability to hold a job, and their relationships with friends and family. At that point, they might seek help. Options include Alcoholics Anonymous (AA), Antabuse, and contingency management. The self-help group Alcoholics Anonymous provides the most common treatment for alcoholism in North America. Some alcoholics are treated with Antabuse, a prescription drug that makes them ill if they drink alcohol. Rewarding people for abstaining from drugs is sometimes effective.

Opiate Dependence

Opiate dependence generally has a more rapid onset than alcohol or tobacco dependence.

Treatments

Some people who are trying to quit heroin and other opiates turn to self-help groups, contingency management, and other treatments.

For those who cannot quit, researchers have sought to find a less dangerous substitute that would satisfy the craving for opiates.

Methadone – a drug sometimes offered as a substitute for opiates

Opiate dependence generally has a more rapid onset than alcohol or tobacco dependence.

Some people who are trying to quit heroin or other opiates turn to self-help groups, contingency management, and other treatments. Therapists emphasize the importance of identifying the locations and situations in which someone has the greatest cravings, and then trying to minimize exposure to those situations. Assignment Paper: Describing Etta

For those who cannot quit opiates, researchers have sought to find a less dangerous substitute that would satisfy the craving for opiates.

The drug methadone is sometimes offered as a substitute for opiates. Chemically similar to morphine and heroin, methadone can be addictive also, but it is considered a safer addiction.

Table 15.3 Comparison of Methadone and Morphine

	Morphine	Methadone by Injection	Methadone Taken Orally
Addictive?	Yes	Yes	Weakly
Onset	Rapid	Rapid	Slow
“Rush”?	Yes	Yes	No
Relieves craving?	Yes	Yes	Yes
Rapid withdrawal symptoms?	Yes	Yes	No

Table 15.3 compares methadone and morphine. When methadone is taken as a pill, it enters the bloodstream gradually and departs gradually. (If morphine or heroin is taken as a pill, much of it is digested without reaching the brain.) Thus, methadone does not produce the “rush” associated with injected opiates, and therefore does not strongly interfere with important behaviors, such as keeping a job. Methadone satisfies the craving and blocks heroin or morphine from reaching the same receptors. However, methadone does not eliminate the addiction. People who try to reduce their use of methadone generally report that their drug craving returns.

module 15.4 Mood Disorders, Schizophrenia, and Autism

After studying this module, you should be able to:

Describe the symptoms and possible causes of major depression.

Evaluate the advantages and disadvantages of several treatments for major depression.

Distinguish bipolar disorder from major depression.

List the primary symptoms of schizophrenia.

Discuss evidence for a genetic basis of schizophrenia.

State the neurodevelopmental hypothesis of schizophrenia, and cite evidence that supports it.

Describe therapies for schizophrenia.

Describe and discuss autism spectrum disorder.

Depression

Major depression – condition in which someone experiences little interest, pleasure, or motivation for weeks at a time

Nearly all people experiencing depression have sleep abnormalities.

Depression occurs in episodes.

Although the first episode is usually triggered by a stressful event, later episodes occur more easily.

Seasonal affective disorder (SAD) – condition in which a person repeatedly becomes depressed during a particular season of the year

People with depression find little interest or pleasure in life and have trouble sleeping. Sadness is characteristic of depression, but lack of happiness is even more characteristic.

About 20 percent of U.S. adults are depressed at some time in life. Women experience depression more than men, and whites experience major depression more than blacks.

Depression occurs in episodes. Typically, people have an episode of depression that lasts a few months (less commonly, years) and then they recover. However, the depression may return. Later episodes tend to be briefer but more frequent. Typically, an intensely stressful event such as divorce or the death of a close loved one triggers the first episode of depression, but later episodes may occur with less provocation.

In a related condition, seasonal affective disorder (SAD), people repeatedly become depressed during a particular season of the year. The most effective treatment for seasonal affective disorder is exposure to a bright light for a few hours each day.

Environmental and Genetic Influences on Depression

Research has failed to identify a gene with a major effect on depression.

Most people with depression have relatives with depression, and also relatives with other problems, such as substance abuse, attention deficit disorder, and migraine headaches.

Most people recover from depression and then later develop anxiety disorders, substance abuse, or an eating disorder.

The role of genetics with regards to depression is far from clear. Although studies of twins and relatives of patients with depression indicate a moderate degree of heritability, extensive research on the chromosomes of thousands of people failed to identify a gene with a major effect. Perhaps many uncommon genes are capable of leading to depression, or perhaps the explanation lies with epigenetics instead of chromosomal changes. Assignment Paper: Describing Etta

Most people with depression have relatives with depression, and also relatives with other problems, such as substance abuse, antisocial personality disorder, attention deficit disorder, bulimia nervosa, migraine headaches, asthma, arthritis, and others. Many people recover from depression and then later develop anxiety disorders, substance abuse, or an eating disorder. In other words, the genes or other factors that predispose to depression increase vulnerability to many disorders, not just depression.

Treatments for Major Depression (slide 1 of 3)

Antidepressant Medications

Three common classes of antidepressants:

1. Tricyclic drugs – drugs that interfere with axons’ ability to reabsorb the neurotransmitters dopamine, norepinephrine, and serotonin after releasing them

2. Selective serotonin reuptake inhibitors (SSRIs) – drugs that block reuptake of only serotonin

3. Monoamine oxidase inhibitors (MAOIs) – drugs that block the metabolic breakdown of dopamine, norepinephrine, and serotonin

Although antidepressants affect the synapses within an hour or so, their behavioral effects begin after two or three weeks of treatment.

Perhaps they produce their benefits by enhancing cell growth in the hippocampus.

The common treatments for depression are antidepressant medications and psychotherapy.

Three common classes of antidepressants are tricyclics, serotonin reuptake inhibitors, and monoamine oxidase inhibitors. Tricyclic drugs interfere with the axons’ ability to reabsorb the neurotransmitters dopamine, norepinephrine, and serotonin after releasing them. Thus, tricyclics prolong the effect of these neurotransmitters at the synapses. Selective serotonin reuptake inhibitors (SSRIs) (e.g., fluoxetine, trade name Prozac) have a similar effect, but block reuptake of only serotonin. Monoamine oxidase inhibitors (MAOIs) block the metabolic breakdown of dopamine, norepinephrine, and serotonin by the enzyme monoamine oxidase (MAO). Thus, MAOIs also increase the effects of these neurotransmitters. Psychiatrists seldom prescribe MAOIs except for patients who did not respond to the other drugs.

Antidepressant drugs alter synaptic activity within an hour or so, whereas mood improvement begins two to three weeks later. Prolonged use of antidepressants increases production of a chemical called BDNF (brain-derived neurotrophic factor) that over a period of weeks leads to the birth of new neurons in the hippocampus, expansion of dendrites, and improved learning. (Depression is associated with impaired learning and decreased cell growth in the hippocampus.) Those changes in the hippocampus may be the main reason for how antidepressants help, although researchers are not yet certain. Assignment Paper: Describing Etta

Treatments for Major Depression (slide 2 of 3)

Depressed Cognition and Cognitive Therapy

Cognitive therapy focuses on changing people’s thoughts and encouraging a more active life.

Effectiveness or Ineffectiveness of Treatments

About one-third of patients recover from depression spontaneously within a few months.

Of patients receiving psychotherapy, antidepressant drugs, or both, a little over half recover.

For people with mild to moderate depression, antidepressant drugs apparently produce no more apparent benefit than placebos.

The drugs show a significant benefit for people with severe depression, who do not respond well to placebos.

Cognitive therapy focuses on changing people’s thoughts and encouraging a more active life. According to Aaron Beck, a pioneer in cognitive therapy, depressed people are guided by thoughts that he calls the “negative cognitive triad of depression”:

I am deprived or defeated.

The world is full of obstacles.

The future is devoid of hope.

People who have these “automatic thoughts” interpret ambiguous situations to their own disadvantage. Therapists try to overcome these thoughts and get clients to reinterpret events in a more positive way. A therapist might invite the client to regard the negative thoughts as charges by a prosecuting attorney, and then act as the defense attorney to produce counterarguments.

Cognitive therapists also encourage people to become more active—to take part in more activities that might bring pleasure or a sense of accomplishment.

Because depression occurs in episodes, most people with no treatment at all generally improve, given enough time, and some improve within a short time. Giving a placebo increases the chance of recovery, just by the expectation of improvement. If we look at results a few months after the onset of depression, about a third of patients improve with no treatment or a placebo, and about half improve with either antidepressant drugs or psychotherapy. Assignment Paper: Describing Etta

People with mild to moderate depression respond about as well to placebos as they do to the drugs. The drugs are better than placebos for people with severe depression, mainly because those people don’t respond well to placebos.

Treatments for Major Depression (slide 3 of 3)

Choosing between Psychotherapy and Antidepressant Drugs

Antidepressants are convenient and less expensive than psychotherapy, but psychotherapy’s effects are more likely to produce long-lasting benefits.

Electroconvulsive Shock Therapy

Electroconvulsive therapy (ECT) – a treatment in which a brief electrical shock is administered across a patient’s head to induce a convulsion

Electroconvulsive therapy is administered today only with the patient’s informed consent.

ECT is given in conjunction with muscle relaxants and anesthetics to minimize discomfort.

ECT produces faster benefits than psychotherapy or antidepressant drugs, but its benefits are the least enduring.

Other Treatments

Exercise and seafood help to prevent depression.

Antidepressant drugs usually show benefits a little faster. They are less expensive, and it’s easier to take a pill than to spend an hour with a therapist. However, the drugs produce unpleasant side effects, such as dry mouth, difficulty urinating, or increased blood pressure. Also, many people find that after they stop taking the drugs, their depression returns within a few months. The benefits of psychotherapy usually last longer after the end of therapy.

For the many people who do not respond to drugs or psychotherapy, electroconvulsive therapy (ECT) is another option. ECT, widely used in the 1940s and 1950s, fell out of favor because of its history of abuse. Some patients were subjected to ECT hundreds of times without informed consent, and sometimes, ECT was used more as a punishment than a therapy. ECT is now used only after patients have given their informed consent. The shock is less intense than previously, and the patient is given muscle relaxants to prevent injury and anesthetics to reduce discomfort.

ECT produces faster benefits than psychotherapy or antidepressant drugs, but its benefits are the least enduring. Although it has a high success rate for patients who did not respond to other treatments, only about 10 percent of hospitals in the United States offer it.

Animal research has shown that steady, nonstrenuous exercise increases neuron formation in the hippocampus, known to be an important part of recovery from depression. The best study with humans showed that an increase in physical activity predicts a lower probability of later depression, and depression predicts a decrease in physical activity. Assignment Paper: Describing Etta

Seafood contains omega-3 fatty acids that are important for brain functioning. People who eat at least a pound of seafood per week have a decreased probability of mood disorders. Placebo-controlled studies have confirmed the value of omega-3 fatty acids for relieving depression.

Bipolar Disorder

Bipolar disorder – a condition previously known as manic-depressive disorder, in which someone alternates between mood extremes

Mania – a condition, the opposite of depression, in which people are constantly active, uninhibited, and often irritable

People with bipolar disorder alternate between periods of depression and periods of mania.

Schizophrenia (slide 1 of 3)

Schizophrenia – a condition marked by a prolonged deterioration of daily activities such as work, social relations, and self-care, and some combination of hallucinations, delusions, disorganized speech and thought, movement disorder, and loss of normal emotional responses and social behaviors

The symptoms must include at least one of the first three (hallucinations, delusions, and disorganized speech and thought) and at least two of the five overall.

Hallucinations – perceptions that do not correspond to anything in the real world

Delusion – belief that is strongly held despite evidence against it

A diagnosis of schizophrenia applies if someone has deteriorated in everyday functioning and shows other symptoms from this list: hallucinations, delusions, disorganized speech and thought, movement disorder, and loss of normal emotional responses and social behaviors. The symptoms must include at least one of the first three (hallucinations, delusions, and disorganized speech) and at least two of the five overall.

Hallucinations are perceptions that do not correspond to anything in the real world, such as hearing voices that no one else hears. The voices may speak nonsense, or they may direct the person to do something. People sometimes think the voices are real, sometimes they know the voices are unreal, and sometimes they are not sure.

A delusion is a belief that someone holds strongly despite evidence against it. For example, a delusion of persecution is a belief that enemies are persecuting you. A delusion of grandeur is a belief that you are unusually important, perhaps a special messenger from God. A delusion of reference is a tendency to take all sorts of messages personally.

Many people with schizophrenia show various problems with communication, including illogical, incoherent, distracted, or tangential speech, as if they start speaking but quickly forget what they are trying to say. Most but not all people with schizophrenia show intellectual impairments of various types, especially with attention and working memory. Assignment Paper: Describing Etta

Another characteristic of schizophrenic thought is difficulty using abstract concepts, such as interpreting proverbs literally instead of seeing the intended meaning.

Schizophrenia (slide 2 of 3)

Prevalence

Schizophrenia is:

Most frequently diagnosed in young adults in their 20s

More common in men than women

More severe in men

More common among people who grew up in big cities than among people who grew up in rural areas or small towns

Causes

Much evidence indicates that it is possible to inherit a predisposition toward schizophrenia.

Neurodevelopmental hypothesis – idea that schizophrenia originates with nervous system impairments that develop before birth or in early childhood because of either genetics or early environment, especially prenatal environment

Worldwide, about one to four people per thousand develop schizophrenia at some point in life.

Schizophrenia is most frequently diagnosed in young adults in their 20s, occasionally in teenagers. It is more common in men than women, by a ratio of about 7 to 5, and on average more severe in men. Schizophrenia is more common among people who grew up in big cities than among people who grew up in rural areas or small towns.

Much evidence indicates that it is possible to inherit a predisposition toward schizophrenia. Research shows the relatives of someone with schizophrenia have an increased probability of developing schizophrenia. A current hypothesis is that schizophrenia can result from changes in any of a large number of genes.

Many researchers believe that schizophrenia originates with abnormal brain development before or around the time of birth because of either genetics or prenatal environment. Early abnormal development leaves a person vulnerable to further deterioration in adulthood. Assignment Paper: Describing Etta

Schizophrenia (slide 3 of 3)

Brain Abnormalities

Many people with schizophrenia show indications of mild brain abnormalities.

Therapies

Antipsychotic drug – a drug that can relieve schizophrenia

Typical antipsychotic drugs block dopamine synapses in the brain.

Antipsychotic drugs produce unwelcome side effects.

Tardive dyskinesia – a condition characterized by tremors and involuntary movements

Atypical antipsychotic drugs – drugs that relieve schizophrenia without causing tardive dyskinesia

Brain scans indicate that people with schizophrenia have, on average, decreased gray matter in several brain areas and slightly enlarged cerebral ventricles, the fluid-filled cavities of the brain. Most people with schizophrenia also have smaller than average neurons and fewer than average synapses, especially in the prefrontal cortex. However, these results must be interpreted cautiously. Many people with schizophrenia abuse alcohol or other drugs that might impair brain functioning, shrink dendrites, and so forth.

Drugs that alleviate schizophrenia block dopamine synapses. However, antipsychotic drugs produce unpleasant side effects, including tardive dyskinesia. Atypical (or second-generation) antipsychotic drugs relieve schizophrenia with less risk of tardive dyskinesia. However, the atypical antipsychotic drugs have side effects of their own. Assignment Paper: Describing Etta

Autistic Spectrum Disorder

Autism spectrum disorder – a lifelong condition characterized by impaired social contact

The main symptoms are:

Impaired social relationships (little eye contact; little social contact)

Impaired communication (repetitive speech; no sustained conversations)

Stereotyped behaviors (repetitive movements such as flapping fingers)

Other symptoms include:

Fluctuations of temperature regulation

Insensitivity to pain

Decreased tendency to become dizzy after spinning with the lights on

A tendency to focus attention narrowly on one item to the exclusion of everything else

The causes apparently relate to genetics and prenatal environment.

Researchers have found many brain abnormalities related to autism but none that occur consistently.

Autism, a condition that begins in early childhood, is characterized by impaired social contact, impaired language, and stereotyped movements.

In addition to the primary symptoms, most individuals with autism show other symptoms, including fluctuations of temperature regulation, insensitivity to pain, and decreased tendency to become dizzy after spinning with the lights on. Another characteristic is a tendency to focus attention narrowly on one item to the exclusion of everything else. Many people with autism perform below average on some intellectual tasks and above average, sometimes way above average, on other tasks.

Twin studies point to a strong genetic basis. One study found 92 percent concordance for autism or related problems in monozygotic twins. That is, if one twin had autism or related problems, the probability was 92 percent that the other did also. For dizygotic twins, the concordance was only 10 percent. To explain this huge discrepancy between monozygotic and dizygotic twins, one possibility is that autism depends on a combination of two or more genes. If autism requires two or three genes, dizygotic twins would have a low probability of getting the same combination.

Several other possible causes relate to prenatal environment. About 12 percent of mothers of autistic children have certain antibodies that attack the proteins of a developing brain. Also, pregnant women are advised to take folic acid (vitamin B9), which is important for the developing nervous system. Women who get enough folic acid from pills or fresh fruit and vegetables have about half the usual probability of a child with autism. Assignment Paper: Describing Etta

Researchers have found many brain abnormalities related to autism but none that occur consistently. One of the most surprising is that about one-fifth of people with autism have large heads and brains—larger than 97 percent of everyone else. Evidently they have more neurons but abnormal connections among them. Other abnormalities include decreased number of neurons in the cerebellum and alterations of neuron structure in the cerebral cortex.

module 15.5 Treatment of Mental Illness

After studying this module, you should be able to:

Distinguish among forms of psychotherapy.

Describe how researchers evaluate the effectiveness of psychotherapy.

Describe possible ways of providing psychotherapeutic help inexpensively to more people.

List possible methods to prevent psychological disorders.

Discuss the insanity defense and other societal issues related to mental illness.

Table 15.4 Changes in Psychotherapy Between the 1950s and the 21st Century

Aspect of Therapy	1950s	Early 21st Century
Payment	By the patient or family	By health insurance
Types of therapist	Psychiatrists	Psychiatrists, clinical psychologists, others
Types of treatment	Mostly Freudian	Many types; emphasis on evidence-based treatments
Duration of treatment	Usually long, often years	A few sessions if effective; more if necessary
Diagnoses	Usually vague, such as “neurosis” or “psychosis.” Often, no diagnosis.	Many diagnoses. Each carefully defined.
Treatment decisions	By the therapist and patient	By the insurer, unless the patient pays for more

Psychotherapy is a treatment of psychological disorders by methods that include a personal relationship between a trained therapist and a client. Treatment of mental illness has changed greatly since the mid-1900s. Table 15.4 summarizes these changes. Assignment Paper: Describing Etta

In the mid-1900s, people seeking psychotherapy paid for it themselves. Today, most people rely on insurance. In the 1950s, psychiatrists conducted almost all psychotherapy. Today, clinical psychologists and other specialists also provide treatment. Today’s therapists use a variety of empirically supported treatments, with less reliance on Freudian methods. Therapists try to achieve good results in just a few sessions, when possible, instead of proceeding for months or years. Today’s therapists provide diagnoses for more disorders and define their diagnoses more carefully.

Types of Psychotherapy (slide 1 of 3)

Psychodynamic Therapies

Psychodynamic therapies – methods that attempt to understand conflicting impulses, including some that the individual does not consciously recognize

Psychoanalysis – method that tries to bring unconscious thoughts and emotions to consciousness

Techniques used in psychoanalysis:

Free association – procedure in which a client says everything that comes to mind

Dream analysis – method that seeks to understood symbolism in reported dreams

Transference – situation in which clients transfer onto the therapist the behaviors and feelings they originally established toward their father, mother, or other important person

Psychodynamic therapies attempt to understand conflicting impulses, including some that the individual does not consciously recognize. Psychoanalysts try to uncover the unconscious reasons behind self-defeating behaviors. To bring the unconscious to consciousness, they rely on free association, dream analysis, and transference. Assignment Paper: Describing Etta

Types of Psychotherapy (slide 2 of 3)

Behavior Therapy

Behavior therapy – treatment that begins with a clear, well-defined goal, such as eliminating test anxiety, and then attempts to achieve it through learning

Cognitive Therapies

Cognitive therapy – procedure that seeks to improve psychological well-being by changing people’s interpretation of events

Cognitive-behavior therapy – treatment in which therapists set explicit behavioral goals, but also try to change people’s interpretation of situations

Behavior therapists assume that abnormal behavior is learned and can be unlearned. They identify the behavior that needs to be changed, such as a fear or bad habit, and then set about changing it through reinforcement and other principles of learning. Unlike psychoanalysts, they are more interested in changing behaviors than in understanding their hidden meanings. Assignment Paper: Describing Etta

Behavior therapists set specific goals for changing a client’s behavior and use learning techniques to help clients achieve those goals. Setting a clear goal enables a therapist to judge whether the therapy is succeeding. If the client shows no improvement, the therapist changes the procedure.

Cognitive therapists identify distressing thoughts (such as “people don’t like me” or “my enemies are out to get me”) and try to get clients to replace defeatist thinking with more favorable views of themselves and the world.

Many therapists combine features of behavior therapy and cognitive therapy, attempting to change people’s behaviors by altering how they interpret the situation.

Types of Psychotherapy (slide 3 of 3)

Humanistic Therapy

Humanistic therapists assume that people can solve their own problems.

Person-centered therapy (nondirective or client-centered therapy) – procedure in which a therapist listens to the client with total acceptance and unconditional positive regard

Family Systems Therapy

Family systems therapy – treatment based on the assumption that most people’s problems develop in a family setting and that the best way to deal with them is to improve family relationships and communication

Group Therapies

Group therapy – treatment administered to several people at once

Humanistic psychologists believe that people can decide deliberately what kind of person to be. According to humanistic therapists, once people are freed from a feeling of rejection or failure, they can solve their own problems. Assignment Paper: Describing Etta

In Carl Rogers’s version of humanistic therapy, person-centered therapy, also known as nondirective or client-centered therapy, the therapist listens to the client with total acceptance and unconditional positive regard. Most of the time, the therapist paraphrases and clarifies what the client has said, conveying the message, “I’m trying to understand the experience from your point of view.” The therapist strives to be genuine, empathic, and caring, seldom if ever offering interpretation or advice.

In many cases, an individual’s problem is part of an overall disorder of family communications and expectations. What distinguishes family therapists is that they prefer to talk with two or more members of a family together. Solving most problems requires changing the family dynamics as well as any individual’s behavior.

Psychotherapy is sometimes provided to people in groups, often composed of individuals with similar problems. Self-help groups provide sessions similar to group therapy but without a therapist. An example of a self-help group is Alcoholics Anonymous (AA). Assignment Paper: Describing Etta

How Effective is Psychotherapy?/ Comparing Theories

The average person in therapy improves more than at least 80 percent of the equally troubled people not in therapy.

In general, all mainstream therapies appear about equally effective, although cognitive or cognitive-behavioral therapy is somewhat better for reducing anxiety or other primary symptoms.

To evaluate psychotherapy, we cannot simply compare people who did or did not choose to enter therapy. Those who sought help might differ from the others in the severity of their problems or their motivation for improvement. In the best studies, people who contact a clinic are randomly assigned to receive therapy at once or wait for therapy later. A few months later, the investigators evaluate people’s improvement, often by their answers to a standardized questionnaire.

Most experiments have included only a moderate number of people. To draw a conclusion, researchers use a method called meta-analysis, taking the results of many experiments, weighting each one in proportion to the number of participants, and determining the overall average effect. According to a meta-analysis that pooled the results of 475 experiments, the average person in therapy showed greater improvement than 80 percent of similar people who did not receive therapy. Assignment Paper: Describing Etta

For a variety of disorders relating to anxiety or depression, all the mainstream types of therapy appeared nearly equal in effectiveness. Later research qualified this statement somewhat: For several types of disorder, cognitive therapy or cognitive-behavioral therapy produces a slightly greater reduction of the target symptoms (such as anxiety), but all the common types of treatment are roughly equal for less specific goals, such as overall quality of life.

Table 15.5 Similarities and Differences among Four Types of Psychotherapy

Procedure	Psychoanalysis	Behavior Therapy	Cognitive Therapy	Person-Centered Therapy
Therapeutic alliance				
Discuss problems openly				
Expect improvement				
Commit to make changes				
Probe unconscious	
Specific goals			
Emphasize new learning		
Reinterpret situation			
Unconditional positive regard				
Change thinking			

Table 15.5 highlights similarities and differences among four types of therapy.

Nearly all forms of psychotherapy include a close relationship between client and therapist, an effort to discuss personal difficulties openly, an expectation of improvement, and a commitment to make changes in one’s life.

The Future of Psychotherapy and Prospects for Prevention

Community psychologists – those who try to help people change their environment, both to prevent disorders and to promote a positive sense of mental well-being

Prevention – avoiding a disorder from the start

We need careful research to identify effective methods of prevention and treatment.

Effective prevention programs:

Give participants active practice at specific behaviors

Build up step by step from simpler skills to more complex ones

Work with people at appropriate times in their lives

Examples of effective prevention programs:

Educate pregnant women about prenatal care.

Outlaw smoking in public places and educate people about the risks of smoking.

Help people get jobs.

Psychologists, especially community psychologists, seek to help people change their environment to promote mental health.

Prevention is avoiding a disorder from the start. Prevention takes several forms. A universal program targets everyone, such as an antismoking campaign, or abolition of lead-based paints and leaded gasoline. A selective program includes only people at risk, such as people with a family history of some disorder. An indicated program identifies people in the early stages of a disorder and tries to stop it. Assignment Paper: Describing Etta

Effective prevention programs need careful testing. Many interventions that sound reasonable don’t work. For example, prolonged discussions of a stressful experience shortly after the event are more likely to cause than prevent post-traumatic stress disorder. “Scared straight” interventions tend to increase, not decrease, criminal behavior.

The best programs give participants active practice at specific behaviors, such as resisting peer pressure to risky behaviors. They build up step by step from simpler skills to more complex ones. And they work with people at appropriate times in their lives. For example, AIDS prevention or pregnancy prevention should start at an age when students might begin to be sexually active, not many years earlier or many years later. Assignment Paper: Describing Etta

Examples of effective prevention programs include the following:

Ban toxins. The sale of lead-based paint has been banned because children who eat flakes of it sustain brain damage.

Educate pregnant women about prenatal care. The use of alcohol or other drugs during pregnancy damages the brain of a fetus, and bacterial and viral infections during pregnancy can impair fetal brain development.

Outlaw smoking in public places and educate people about the risks of smoking. Improvements in physical health improve psychological well-being, too.

Help people get jobs. People who lose their jobs lose self-esteem and increase their risk of depression and substance abuse. Summer jobs for low-income teenagers decrease their probability of violent crime, not only during the summer but also long after.

Neighborhood improvement. Low-income people who move from a crime-ridden neighborhood to a less distressed neighborhood experience long-term benefits in mental health.

Prevent bullying in school. Children who are frequently bullied have an increased risk of anxiety, depression, and other distress throughout life.

Social Issues Related to Mental Illness

Deinstitutionalization – the removal of patients from mental hospitals

Deinstitutionalization was and is a good idea in principle but only if implemented well, and too often it has not been, as many patients released from mental hospitals do not receive adequate alternative care.

The Duty to Protect

Tarasoff case – court ruling that a therapist who has reason to believe that a client is dangerous to someone must warn the endangered person or take other steps to prevent harm

The Insanity Defense

Some defendants accused of a crime are acquitted for reasons of insanity, which is a legal rather than a medical or psychological concept. Assignment Paper: Describing Etta

M’Naghten rule – statement that someone is legally insane if he or she was so mentally disordered at the time of an act as not to understand what he or she was doing

Until the 1950s, huge numbers of troubled people were confined in understaffed, overcrowded state mental hospitals supported by the government. In the 1950s, hospitals moved toward deinstitutionalization, the removal of patients from mental hospitals, to give them the least restrictive care possible. The hope was that patients would go home, free to live as normal a life as possible, while receiving outpatient care at community mental health centers, which are usually cheaper and more effective than large mental hospitals. However, implementing good alternative care isn’t easy, and the effectiveness has been undependable.

The courts have ruled that a therapist who is convinced that a client is dangerous should warn the endangered person.

Insanity is a legal term, not a psychological or medical term. The most famous definition of insanity is the M’Naghten rule. To be regarded as insane under the M’Naghten rule, people must be so disordered that they do not understand what they are doing. Anyone who tries to prevent the police from detecting a murder or other crime presumably did understand what he or she was doing. Assignment Paper: Describing Etta

In the United States, fewer than 1 percent of accused felons plead insanity, and of those, fewer than 25 percent are found not guilty. So, no more than 0.25 percent of all defendants are found not guilty by reason of insanity.