Anxiety Disorders

In my post about panic disorder, I described fear as an emotion that elicits the “fight-or-flight” response of the autonomic nervous system. In anxiety, unlike fear, there is no activation of the fight-or-flight response. Anxiety is a long-term response oriented towards future events rather than imminent danger. Short-lived, low levels of anxiety can be good because they help prepare a person for upcoming activities such as an exam or sports event. However, long-term high-intensity anxiety creates a state of chronic over-arousal that can lead to physical troubles such as reduced immune response (i.e. susceptibility to disease) and increased blood pressure, as described in my post about the biological effects of stress.

In generalized anxiety disorder (GAD), anxiety is chronic, excessive, and unreasonable. The excessive worry must be accompanied by at least three of six other symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance. People with GAD live in a constant state of future-oriented apprehension. They are generally hypervigilant for signs of threat and tend to engage in avoidance behaviors such as procrastination and checking. The most common worries are about family, work, finances, and personal illness. They have difficulty making decisions, and then worry endlessly about whether their decision is correct.

My anxiety diagnosis is “anxiety – not otherwise specified (NOS),” which means that my anxiety doesn’t fit into any of the cookie-cutter DSM-5 diagnoses. To me, my symptoms seem to be a combination of those described in panic disorder and those of GAD. Like in panic disorder, my anxiety symptoms seem to have no obvious stimulus, so they become associated with whatever I’m thinking about at the time of the attack. (Though unlike panic disorder my attacks never peak at pure panic – they remain at high-level anxiety.) Like GAD, however, I have difficulty making decisions and can’t stop worrying about whether I’ve made the right choice.

As an example: during my 3-hour anxiety attack described in a previous post, my anxiety took on a very strange form. Instead of worrying about something really troubling, I began obsessing about what book I would read next – probably because that’s what I was thinking about when the anxiety attack hit. While in my physiologically aroused state (heavy breathing, pounding heart, sweating) I had to keep making list after list after list of the books I wanted to read, and reordering them by priority. Every time I made a new list, I’d calm down a little and go back to work. But within 5 minutes my anxiety would peak again, I’d have to make a new list. Rationally, I knew that what I read next was of very little import, and whatever it was I would (hopefully) thoroughly enjoy it. But for some reason my body couldn’t stop panicking, and my unconscious mind associated that anxiety with books. Luckily, I don’t have an anxiety attack every time I think about books. 🙂

Most people with GAD are able to continue with their daily activities despite their impaired ability to function. Therefore, they are less likely to request psychological treatment for their disorder. They do, on the other hand, show up in physician’s offices with medical complaints, probably partly due to unnecessary worry about their health and partly to the negative psychological repercussions of stress.

People with GAD are extremely sensitive to the feeling that they are unable to control their environments. It’s possible that teaching the patients to feel in control (or to let go of things they can’t control) will help them to moderate their own anxiety. Perhaps they should all recite the AA serenity prayer every day. 😉

God grant us the serenity to accept the things we cannot change,

courage to change the things we can,

and wisdom to know the difference.

(Of course, this prayer assumes that the patient believes in God, which makes it annoying to many potential members of AA who are atheists or not of monotheistic origin. But I suppose that’s a gripe for another post.)

This is a series of posts summarizing what I’m learning in my Abnormal Psychology course. Much of the information provided comes from reading my James N. Butcher’s textbook Abnormal Psychology. To read the other posts, follow these links:

The Definition of Abnormal
A History of Abnormal Psychology
Abnormal Psychology in Contemporary Society
Contemporary Viewpoints on Treating Mental Illness – Biology
Contemporary Viewpoints on Treating Mental Illness – Psychology
Frontline: New Asylums
Brave New Films: This is Crazy
Clinical Mental Health Diagnosis: Biological Assessment
Clinical Mental Health Diagnosis: Psychological Assessment
Does the DSM Encourage Overmedication?
Post Traumatic Stress Syndrome – The Basics
Panic Disorder
Obsessive Compulsive Disorder
Hoarding and Body Dysmorphic Disorders
Depression – an Overview
Personality Disorders – Clusters and Dimensions
Personality Disorders – Cluster A
Personality Disorders – Cluster B
Personality Disorders – Cluster C
Biological Effects of Stress on Your Body
Somatic Symptom and Related Disorders
Dissociative Disorders
Borderline Personality Disorder
Dialectical Behavioral Therapy
Paraphilic Disorders
Gender Dysphoria – Homosexuality and Transgender
Anxiety Disorders
Bipolar Disorder – The Basics
Suicide – An Overview

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 6: Panic, Anxiety, Obsessions, and their Disorders. Abnormal Psychology, sixteenth edition (pp. 163-210). Pearson Education Inc.

Somatic Symptom and Related Disorders

Somatic symptoms are medical complaints that arise from mental illness. In my experience, such symptoms are shrugged off by the general public as “oh, that’s not a real symptom, it’s just somatic.” Well, let me tell you: the symptoms feel very real to the suffering individual.(Something I learned in my work at a suicide hotline and my own intensive outpatient therapy is that what you feel is a real feeling, regardless of what others say.) And sometimes (in fact, maybe a lot of the time) symptoms are due to a “real” medical problem caused by the mental illness. Read my post about the physiological effects of anxiety if you don’t believe me.

Yes, sometimes the symptoms are explainable by factitious disorder, in which a person consciously produces physical and/or psychological symptoms. Generally in this disorder, a person is not maliciously lying to try to get out of anything, he simply wants the attention that comes with being sick. This could be due to feelings of being ignored or unloved.

And sometimes the symptoms are malingering. In this case, the person is intentionally producing or exaggerating physical symptoms motivated by a wish to get out of something undesirable (such as work, military service, or criminal prosecution). I imagine it is these two types of symptoms that create the stigma surrounding somatic disorder.

In somatic symptom disorders, the patient must find the symptoms so distressing that they get in the way of the person’s ability to function in daily life. The symptoms must have one of the following three features: disproportionate thoughts about the seriousness of one’s symptoms, persistent high level or anxiety about health or symptoms, or excessive time and energy devoted to these symptoms.

Just because you sometimes exaggerate and worry about symptoms does not mean that you have somatic symptom disorder. As pointed out by Dr. Sapolsky in his first lecture n the Teaching Company Course Stress and Your Body, sometimes when you have a big test or presentation or work-related stressor the next day you can’t sleep. You just lie there in bed stressing about the fact that you’re not sleeping. And eventually you might begin to worry about symptoms you are feeling. Your gut is rumbling – maybe you have Chrohn’s disease. You have a headache or an ophthalmic migraine – maybe you have a brain tumor. This exaggeration is due to normal anxiety, and everybody feels it sometimes. In fact, I’m a big sucker for cyberchondria.

People with somatic symptom disorders tend to be female, nonwhite, and less educated than are people with more medically founded symptoms. People with somatic symptom disorder tend to want test after test after test to find the cause of their disorder. If one test is negative, they want another. If the doctor tells them they’re fine, and they don’t need another test, they find a new doctor. This is because they really believe something is seriously wrong with them. They are disappointed when nothing is found. This is in contrast to “normal” people who would rather avoid more tests are are relieved when nothing is found wrong. Or people with factitious disorder or malingering symptoms who seem completely serene by the test results.

Unlike the DSM-5, the DSM-IV separates hyperchondriasis, pain disorder, and conversion disorder. In hyperchondriasis, an individual is overly sensitive to small changes in his body. He might interpret a cough as lung cancer or varicose veins as blood poisoning. Much of his time and energy is exhausted in monitoring his symptoms and talking to his doctor.

In pain disorder, the patient feels pain in one or more body parts. This pain is not intentionally produced or feigned. This pain is really felt by the patient – just as much as pain caused by a physical condition. This pain often causes the patient significant problems in their ability to function in daily life. The resulting social isolation and feelings of uselessness can result in depression, leading to more somatic pain. Luckily pain disorder is easier to treat than hyperchondriasis. The patient can be taught relaxation techniques which reduce the pain, and they can undergo cognitive behavioral therapy to reduce their cognitive response to the pain. Antidepressants also help with the pain.

I find conversion disorder to be the most interesting of the somatic symptoms and related disorders. In conversion disorder, an individual might suddenly become blind, deaf, partially paralyzed, or have pseudoseizures. These symptoms occur during highly stressful situations like combat. Because the individual becomes too stressed to deal with combat, he suddenly becomes blind or partially paralyzed. These symptoms are not faked. The person really believes that he is blind or deaf. However, upon medical examination, people with conversion disorder unconsciously respond to stimulus. They will turn their head in a direction of a noise. They will be able to avoid obstacles while walking.

Conversion disorder is most common in medically unsophisticated individuals. A particularly effective treatment for conversion disorder is to educate the individual about the psychological causes of his disorder. Also, these symptoms often go away after the stress has been reduced significantly.

As mentioned above, factitious disorder is diagnosed when an individual consciously exaggerates her symptoms in order to get attention. This is distinguished from malingering in that she is not trying to get out of work, win a lawsuit, or get other obvious external gains. In popular culture, a form of factitious disorder called Munchausen’s syndrome by proxy is found frequently in books and movies. (In the DSM-5 it’s called “factitious disorder imposed on another” but that’s a boring name.) In this disorder, a caretaker (generally the mother) will invent symptoms in her child in order to get attention for herself. Often, the mother creates symptoms by slowly poisoning their child. Sometimes a child undergoes numerous surgeries to fix the complaint. It is difficult to diagnose and then prove that a mother is intentionally causing a child’s illness. One hint that such a thing is going on is if the child gets sicker after every time the mother is left alone with the child. But a doctor is hesitant to point fingers at the mother because of lawsuits. One way around this is to put a camera in the child’s room.

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 8: Somatic Symptom and Dissociative Disorders. Abnormal Psychology, sixteenth edition (pp. 264-292). Pearson Education Inc.

Depression – an overview

Depression is a surprisingly common mental health issue, affecting 17% of Americans at some point throughout their lifetimes. Depressions almost always are a result of a stressful life event, though not all of these depressions are severe enough or long enough in duration to be considered a mood disorder.

For instance, grief or bereavement often occurs when an individual has lost a loved one. Grievers tend to experience numbness and disbelief, yearning and searching for the lost person before acceptance that he is gone, disorganization and despair as realization is reached, and finally acceptance and reorganization of life. The DSM-IV had a bereavement exclusion for major depressive disorder (MDD): a person might not receive a diagnosis for MDD if he had experienced a major loss in the last two months. However, in a controversial move, this exclusion principle was left out of the DSM-5, allowing clinicians to diagnosis MDD soon after a major loss.

There are a surprising number of types of depression – many of them are well-known but not generally considered when we think about depression. For instance, postpartum depression is a negative mood response to the birth of a child. Feelings of changeable mood, crying easily, sadness, and irritability occur in 50 to 70 percent of women within 10 days of the birth. These symptoms generally subside on their own.

Another type of DSM-5 diagnosable depression is premenstrual dysphoric disorder. (That’s right. PMS.) In order to get this diagnosis, one of four symptoms must occur a week before onset of menses, and disappear within the first couple of days after onset. Those four symptoms are: mood swings, irritability or anger, depressed mood or self-deprecation, and anxiety or being “on edge.”

MDD is characterized by persistent symptoms that occur most of the day, every day for at least two weeks. The patient must either have a depressed mood or a loss of interest or pleasure (anhedonia). There is also a list of 7 symptoms, of which the patient must have 4: significant weight change, hypersomnia or insomnia, psychomotor agitation or retardation, fatigue, inability to concentrate, and recurrent thoughts of death. Untreated, these symptoms generally last 6 to 9 months.

There are several types of MDD. The specifiers are: “with melancholic features,” “with psychotic features,” “with atypical features,” “with catatonic features,” and “with seasonal pattern.”

The melancholic patient awakens early in the morning, has depression that is worse in the morning, exhibits psychomotor agitation or retardation, loss of appetite, and/or excessive guilt.

Psychotic features are delusions or hallucinations that are “mood congruent” (in other words, they tend to be a very depressing psychotic experiences). One example is the belief that one’s internal organs have completely deteriorated, leading to the depression. Patients with psychotic features generally experience extreme guilt and feelings that they deserve depression as punishment.

Atypical features include more mood fluctuations than a person with MDD would usually experience. The patient’s spirits might temporarily lift at a positive event. Other atypical features are increase in appetite, hypersomnia, arms and legs feel as heavy as lead, and being acutely sensitive to interpersonal reaction.

I find the description of atypical features to be interesting because in the times that I have experienced severe depression, I have experienced all of these symptoms. But apparently people with bipolar disorder tend to have atypical features to their depressive episodes. In fact, a person should not be diagnosed with MDD if they have ever experienced a manic or hypomanic episode, as I have. Another interesting difference between MDD and bipolar disorder is that those with bipolar tend to have much deeper depression than those with “unipolar” depression.

Catatonic depressives experience extreme psychomotor retardation often to the point of complete immobility. They often stop talking as well. I have an aunt who experienced these symptoms for weeks at a time during her teenage years. Apparently, she would just sit at the kitchen table all day, every day. Not moving, not talking, just staring. I’ve asked my dad “didn’t she eat or go to the bathroom or to bed?” He just answers “I don’t know. I never saw her doing those things.”

In order to be diagnosed with a seasonal pattern, you must have experienced two or more depressive episodes in the past two years that occurred at the same time of year, usually fall or winter, with a full remission at the same time of year, usually spring or summer. Sometimes the seasons can be switched – these patients tend not to get as much sympathy as those who get depressed in the winter. To get this diagnosis, non-seasonal depression must not have occurred in this 2 year period.

When depression occurs almost every day for most of the day for more than two years, the patient is generally diagnosed with persistent depressive disorder. “Normal” moods may occur, but they generally only last for a few days. This depression contains many of the same characteristics of MDD, though they are not as severe. Persistent depressive disorder generally lasts for 4-5 years, but can last longer than 20 years. It often starts during adolescence. This disorder is quite common, occurring with a lifetime prevalence of 2.5-6% in Americans.

Depression has been attributed to many biological causes. There is a genetic factor – people with family members who have MDD are more likely to develop MDD themselves. The serotonin-transporter gene, which is responsible for the uptake of serotonin in the brain, has a heritable mutation which makes depression much more likely. An imbalance of the neurotransmitters norepinephrine or serotonin is strongly associated with depression, and most anti-depressant medications target these neurotransmitters.

Another biological cause can be a dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis. In response to a perceived threat, norepinephrine signals the hypothalamus to release a signal which eventually leads to release of the stress hormone cortisol from the adrenal gland. Cortisol is not harmful for short periods of time, but long-term it can promote hypertension, heart disease, and obesity. It is hypothesized that during MDD, the signal stimulating cortisol release is continuously present in the system, or the feedback inhibition mechanism, which tells the adrenal gland that it should stop releasing cortisol, is not functional. The HPA axis is related to the stress response, which explains the onset of depression after stressful life events, and also explains the concurrence of depression with anxiety.

There are several theories about psychological causes of depression. In 1967, Aaron Beck proposed the cognitive theory of depression – which led to the development of cognitive behavioral therapy (discussed in my post Contemporary viewpoints on treating mental illness – psychology). Beck proposed that before experiencing depression, a person experienced dysfunctional thinking – these thoughts could be about oneself, about the world, or about one’s future. Dysfunctional thinking may include: 1) all-or-none thinking, for example someone thinks he must get 100% on a test or he is a complete loser; 2) selective abstraction, which includes a tendency to focus on one negative event even if surrounded by positive events; and 3) arbitrary inference in which the individual jumps to a conclusion based on little to no evidence. (Examples of these are given in my previous post.) Although research shows that this dysfunctional thinking occurs during depression, research leaves it unclear whether dysfunctional thinking occurs prior to depression, suggesting that such thinking might not be the cause of depression, as theorized by Beck.

There are also the hopelessness and helplessness theories of the psychological causes of depression. In these, the individual might feel incredibly pessimistic about the future, or incapable of having any impact on himself or his environment. A final theory is the ruminative theory, in which a person’s tendency to roll negative thoughts over-and-over in her head leads to depression. Women tend to ruminate more than men, and they also are more likely to experience depression than men. But when a study controls for rumination, the sex difference disappears, suggesting that rumination has a strong impact on depression.

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 7: Mood Disorders and Suicide. Abnormal Psychology, sixteenth edition (pp. 212-262). Pearson Education Inc.

Hoarding and Body Dysmorphic Disorders

Obsessive compulsive disorder (discussed in a previous post) is grouped in a DSM-5 category called “obsessive compulsive and related disorders.” Other disorders included in this category are hoarding, body dysmorphic, trichotillomania (hair picking), and excoriation (skin picking) disorders.

Upon publication of the DSM-5, there were a lot of ignorant people laughing at the “new” disorder “hoarding,” and giving it as an example of how the DSM-5 encourages over-diagnosis of “normal” individuals. Such people do not understand the dire nature of this disorder. An individual with hoarding disorder finds it extremely distressful to discard objects, regardless of their actual value. These objects fill up their living spaces, leading to impairment of the individual’s ability to live a healthy, functional life.

Hoarding has recently reached the popular eye due to TV shows like A&E’s Hoarders or TLC’s Hoarding: Buried Alive. I haven’t watched either of these shows, so I don’t know if they are a good representative of the dangers of hoarding. But I can give examples of such dangers:

To go along with my Adrian Monk theme in my OCD post, Adrian’s brother Ambrose Monk is an extremely agoraphobic hoarder. In the episode Mr. Monk and the Three Pies, Ambrose’s house is set on fire, and he is unable to exit the house – partly due to the lack of safe pathways through his piles of newspapers.

If you like real-life examples, I have an acquaintance with hoarding disorder. She fell in her home and was unable to get up due to the huge piles of junk surrounding her. She lay there three days before someone found her. Luckily, she was holding a jug of juice when she fell, so she survived surprisingly well during this time.

Obsessive hoarders tend not to respond to the same types of medications or therapies as people with OCD, and their brain activation patterns are different than those recorded in OCD patients. Therefore, it is possible the two disorders might not be as strongly related as categorized in the DSM-5.

People with body dysmorphic disorder (BDD) become obsessed with one or more body parts that they perceive as hideous or deformed. When people with BDD look in the mirror, they often see a defect that is not present, such as the woman above seeing herself as fat when she is actually thin. Such people are often self-conscious about this perceived defect, and believe that everyone around them look down on them for their ugly appearance. People with BDD might spend hours every day looking in a mirror obsessing about their perceived defect, or they might compulsively avoid mirrors altogether. BDD patients often avoid social situations, and sometimes they stop leaving their house altogether. It’s possible, even, that they might have so many plastic surgeries that their nose dies (rumored to have happened to a certain deceased celebrity).

One example you might immediately think of (especially since it is pictured above) is people with anorexia nervosa. However, anorexia is not always a form of BDD. Many anorexics are emaciated and are pleased with their appearance. Some, however, are emaciated and see themselves as fat when they look in the mirror. These are the type with BDD. A long time ago, I remember reading about a study in which a tight-fitting full-body suit was worn by BDD-related anorexics. The tightness of the suit allowed the subjects to change thier proprioceptive perception of their body types. Because they could feel how thin they were, they began to perceive themselves as thin. I’m pretty sure I read about this study in Sandra Blakeslee’s book The Body Has a Mind of Its Own: How Body Maps in Your Brain Help You Do (Almost) Everything Better.

More mainstream treatments for BDD include SSRI’s and a form of cognitive behavioral therapy in which the subject is made to wear clothing or makeup that accentuates the “defect” rather than disguising it. The subject is also told to not look in a mirror, even when they feel compelled to.

This is a series of posts summarizing what I’m learning in my Abnormal Psychology course. Much of the information provided comes from reading my James N. Butcher’s textbook Abnormal Psychology. To read the other posts, follow these links:

The Definition of Abnormal
A History of Abnormal Psychology
Abnormal Psychology in Contemporary Society
Contemporary Viewpoints on Treating Mental Illness – Biology
Contemporary Viewpoints on Treating Mental Illness – Psychology
Frontline: New Asylums
Brave New Films: This is Crazy
Clinical Mental Health Diagnosis: Biological Assessment
Clinical Mental Health Diagnosis: Psychological Assessment
Does the DSM Encourage Overmedication?
Post Traumatic Stress Syndrome – The Basics
Panic Disorder
Obsessive Compulsive Disorder
Hoarding and Body Dysmorphic Disorders
Depression – an Overview
Personality Disorders – Clusters and Dimensions
Personality Disorders – Cluster A
Personality Disorders – Cluster B
Personality Disorders – Cluster C
Biological Effects of Stress on Your Body
Somatic Symptom and Related Disorders
Dissociative Disorders
Borderline Personality Disorder
Dialectical Behavioral Therapy
Paraphilic Disorders
Gender Dysphoria – Homosexuality and Transgender
Anxiety Disorders
Bipolar Disorder – The Basics
Suicide – An Overview

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 6: Panic, Anxiety, Obsessions, and their Disorders. Abnormal Psychology, sixteenth edition (pp. 163-210). Pearson Education Inc.

Obsessive Compulsive Disorder

Most people are familiar with obsessive compulsive disorder as is popularized in many TV shows and movies. My favorite is Monk, a TV show about Adrian Monk, an investigator who works with the San Francisco police department. Due to Monk’s severe OCD (along with other disorders), he was forced into retirement as a detective with the San Francisco PD. The show is unflinching about the negative effects of Monk’s disorder, but of course it introduces humor into his predicament.

According to the DSM-5, obsessions are “recurrent and persistent thoughts, urges, or images” that are intrusive and cause distress. The individual attempts to ignore the obsessions, but is generally unable to. Compulsions are repetitive behaviors – such as hand washing, checking, praying, counting, or word repetition – that the individual feels compelled to perform in order to reduce anxiety and distress.

Often, the compulsion is meant to prevent a terrible event. That event is often excessive or unrealistic. To give a rather trite but recognizable example, someone might try not to step on cracks because they’d “break their mother’s back,” so they must go back to the beginning again and again just to make sure they didn’t step on any of the cracks. Ritualistic hand washing is generally meant to protect the individual from contamination of germs. Adrian Monk, from my example above, had his assistant carry around hand-wipes so that Monk could clean up after he’d shaken hands with anyone.

OCD can be one of the most debilitating mental disorders because it can take up hours of a person’s day. In order to get a diagnosis, the obsessions or compulsions must take up at least 1 hour each day.

Generally the individual is quite aware that his compulsion is excessive and unnecessary. Monk was an intelligent guy – he knew that if he didn’t touch-and-count every car antenna in that traffic jam that nothing bad would happen. But he couldn’t stop himself, even though it slowed down his progress as he walked up to the “crime scene.”

Common obsessive thoughts include contamination fears, fears of harming oneself or others, and pathological doubt. Another common obsession is the need for symmetry. Mr. Monk had all of these obsessions. Obsessions about sex and aggression are also common. (Well, Monk wouldn’t be as likable if he had those, though he did have a phobia of sex and nudity). OCD is often accompanied by social phobia, panic disorder, generalized anxiety disorder, and PTSD. (Yup. Monk had all of those.)

OCD is thought to be a learned behavior. First, the individual begins to obsess that touching a doorknob will contaminate his hands. As his anxiety increases, he finally breaks down and washes his hands. Washing his hands decreases his anxiety tremendously – he has now learned how to alleviate his distress. So the next time the obsessive thought intrudes, he will wash his hands again. Perhaps this time, he’ll just keep on washing his hands, because that might decrease the anxiety more. Of course, this theory doesn’t explain where the obsessive thoughts come from in the first place.

Top left: basal ganglia; Top right: amygdala;
Bottom: thalamus

In patients with OCD, abnormalities occur primarily in the basal ganglia. The basal ganglia are involved in primitive behaviors such as sex, aggression, and hygiene concerns. In a system known as the cortico-basal-ganglionic-thalamic circuit, urges are passed from the basal ganglia through the caudate nucleus, which filters the urges before sending them to the thalamus, which, in turn, sends the signal to the frontal cortex to create an action-urge. Theories suggest that in OCD, there is something wrong with the filtering aspect of this system, and many inappropriate urges are sent on to the cortex. In addition to connecting to the cortico-basal-ganglionic-thalamic circuit, the basal ganglia is also linked to the limbic system through the amygdala, which is thought to be the source of the “fear network,” as described in my post about panic disorder. This connection explains the panic that the individual feels when the obsessive urges aren’t acted upon.

The most successful treatment for OCD is exposure and response prevention. The individual is asked to rate his disturbing stimuli on a scale of 1 to 100. The individual then exposes himself repeatedly to a stimulus (either by imagination or directly) and is asked not to perform the compulsion. Eventually, the anxiety subsides on its own. Theoretically, each time the individual avoids the compulsion, he becomes a little more sure that the compulsion is not necessary to decrease the anxiety.

For those of you who are interested, Mr. Monk’s greatest fears, in order, are: germs, dentists, sharp or pointed objects, milk, vomiting, death and dead things, snakes, crowds, heights, fear, mushrooms, and small spaces (as listed in the episode “Monk and the Very, Very Old Man). Fortunately for him, his work frequently throws him into situations in which he encounters these things and is unable to fulfill his compulsions. I guess working his its own therapy. 🙂

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 6: Panic, Anxiety, Obsessions, and their Disorders. Abnormal Psychology, sixteenth edition (pp. 163-210). Pearson Education Inc.

Post Traumatic Stress Syndrome – the Basics

I think we all have some idea of what we think PTSD is, but it turns out PTSD isn’t as clear-cut as I thought.

Apparently, when PTSD was first introduced into the DSM, the diagnostic criteria required a traumatic event “outside the range of usual human experience” that would cause “significant symptoms of distress in almost anyone.” That fits pretty well with my own perception of PTSD. Rape, war, torture, violent experiences…these all fit into that description. PTSD is a normal response to an abnormal stressor.

However, in the DSM-IV, the nature of the “traumatic event” broadened drastically, and a requisite response was “intense fear, helplessness, or horror.” So in the DSM-IV, PTSD was a pathological response to a potentially less extreme stressor. Someone could be diagnosed with PTSD if they experienced “intense horror or helplessness” after watching a scary TV show or upon being diagnosed with a terminal illness.

Although I don’t wish to undermine the intense stress that someone with pathological responses may feel, I think this definition undermines the intensely awful experience that someone with PTSD (in my mind) has encountered. The statistics agree with my assessment of these criteria: in a community survey, 89.6% of people reported that they had been exposed to a traumatic event and had responses that could potentially qualify them for a PTSD diagnosis.

Luckily, the DSM-5 tightened the traumatic event criteria again, and broadened the range of response to the traumatic event. Now, the traumatic event must occur directly to the subject, and they can exhibit other pathological responses besides “intense fear, helplessness, or horror.”

To be diagnosed with PTSD by DSM-5 standards, a person must be exposed to “actual or threatened death, serious injury, or sexual violence.” They must exhibit one of the following symptoms: intrusive distressing memories of the event, distressing dreams reliving the event, dissociative reactions, intense psychological distress at cues that remind the person of the event, or marked physiological reactions to cues that remind the person of the event. Additionally, the person must persistently avoid stimuli associated with the traumatic event, have negative alterations in cognitions and moods associated with the event (e.g. distorted cognitions about the cause or consequences of the event), and alterations in arousal and reactivity (e.g. hypervigilance or angry outbursts).

In general, people respond to trauma with decreasing pathological symptoms. In order to be diagnosed with PTSD, the patient must have experienced these negative responses for more than 1 month, otherwise they are experiencing “acute stress disorder.”

Despite the common association of PTSD with war veterans, PTSD is actually more common in women than in men – and the traumatic events are more often domestic violence or rape than war. However, a great deal of money and time has gone into research of PTSD in war veterans.

During WWI, symptoms of PTSD were called “shell shock,” and were thought to be caused by brain hemorrhages. However, this belief slowly subsided as doctors realized that the symptoms presented themselves regardless of injury. By WWII, traumatic reactions were known as “operational fatigue” and “war neuroses,” before the terminology finally settled on “combat fatigue” during the Korean and Vietnam wars. A rigorous longitudinal study of PTSD by Smith et. al. in 2008 found that 4.3% of military personnel deployed to Iraq or Afghanistan had PTSD. Of those, the rate was higher (7.8%) in those that had experienced combat compared to those who hadn’t (1.4%). An issue that is (rightfully!) getting much attention lately is the high rate of soldier suicide. Between 2005 and 2009, more than 1,100 soldiers took their own lives – generally with a gun.

There are several risk factors that increase the likelihood of PTSD – being female, lower social support, neuroticism, preexisting depression or anxiety, family history of depression, substance abuse, lower socioeconomic status, and race/ethnicity. (Apparently, compared to whites, African Americans and Hispanics who were evacuated from the World Trade Center in 2001 were more likely to get PTSD.) There is also a genetic factor that increases susceptibility to PTSD. Preliminary studies suggest that people with a particular form of the serotonin transporter gene may be more susceptible to PTSD than those with the “normal” form of this gene.

On the other hand, there is at least one factor that promotes resilience to traumatic events: intelligence. It’s possible that people with higher intelligence are better able to make “sense” of the event by viewing it as a larger whole. Or an intelligent person may be better able to recognize and buffer cognitive distortions such as “I deserved that,” “why should I have lived when they died?” and “If I had only done _______, this wouldn’t have happened.”

Researchers have come up with several ways to decrease likelihood of succumbing to PTSD after a traumatic event.

Stress-inoculation training has proved successful with members of the Armed Forces. Soldiers can be exposed, through virtual reality, to the types of stressors that might occur during deployment. Thus they are better able to deal with the trauma when exposed to the events in real life.

Debriefing after a traumatic event can also be helpful. This allows the victim to process the event in a safe environment, before the details become internalized.

Interestingly, one study showed that subjects who were exposed to a highly disturbing film were less likely to report flashbacks if they played Tetris for 10 minutes after the film than if they sat quietly for those 10 minutes. This team of researchers also showed that simply being distracted after the disturbing video was not enough to decrease flashbacks, and that doing a verbal task actually increased the number of flashbacks. So, apparently, visio-spacial tasks decrease the likelihood of intrusive flashbacks if performed immediately after the traumatic event. I’m not sure this information is particularly useful, but it’s interesting.

As of yet, there isn’t a highly successful way to “cure” people with PTSD. Cognitive behavioral therapy, which helps the victims recognize cognitive distortions (e.g. “I deserved that,” “why should I have lived when they died?” and “If I had only done _______, this wouldn’t have happened.”), can be helpful in reducing anxiety. Antidepressant medications can alleviate some of the depression and anxiety experienced by victims.

One up-and-coming treatment has shown promising results. Someone with PTSD can undergo prolonged exposure to the traumatic events. They can do this through repeatedly reliving the events out loud, or even by re-experiencing them through virtual reality. Unfortunately, many PTSD vitimcs drop out of such treatments because reliving the events is too difficult. However, this treatment method has proven very helpful to people who complete the process, and I hope that work in this area continues.

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 5: Stress and Physical and Mental Health. Abnormal Psychology, sixteenth edition (pp. 129-161). Pearson Education Inc.

Does the DSM-5 encourage overmedication?

Oh, the irony of life – I clicked on a link to read an article by Dr. Allen Frances (chair of the DSM-IV task-force and author of Saving Normal: An Insider’s Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life) – and I was forced to wait through a 15 second advertisement on a psychiatric medication. This is exactly the type of thing Dr. Frances complains about. People have “too much” access to information that they are not trained to understand. Dr. Frances urges the public to beware self-overdiagnosis. (This could also be referred to as cyberchondria.)

Before the publication of DSM-5 Dr. Frances strongly argued against many of the changes proposed…he even admitted that there were some mistakes made in the DSM-IV. One of his main arguments is that the DSM-5 added many new diagnoses that could push people formerly considered “normal” into the disordered range. For instance, disruptive mood dysregulation disorder is a new diagnosis for children who have too many temper tantrums; internet gaming disorder is a diagnosis for hard-core gamers. The DSM-5 also rejected the bereavement exclusion, which had previously discouraged clinicians from diagnosing major depressive disorder in people who had undergone a major loss in the past two months.

At the time that DSM-5 was being written, media pounced on the omission of the bereavement exclusion, claiming that people who were going through a natural process of grief would be stigmatized by a “mental illness” diagnosis. But is this really what happens?

The 2012 study The bereavement exclusion and DSM-5 concludes that the symptoms of bereavement aren’t fundamentally different from those of major depressive disorder. If the grieving individual’s symptoms and impairments are as severe as a person with major depressive disorder, they may benefit from treatment – and treatment requires a diagnosis. The purpose is not to throw drugs at every bereaved soul that walks through the doctor’s door. In fact, most people who are bereaved will not go into their doctors because they think their symptoms are “normal.” Those that go into their doctors are most likely suffering from more severe symptoms which might need to be treated.

In his 2013 PsychCentral post How the DSM-5 Got Grief, Bereavement Right, Ronald Pies argued that clinicians will not have to diagnose major depressive disorder in grieving patients, but they will be able to if such a diagnosis would be beneficial.

On the other hand, Allen Frances argues in his 2013 Psychology Today post Last Plea to DSM 5: Save Grief From the Drug Companies that the “medicalization of grief” will provide more “normal” patients at which to fire Big Pharma’s semi-automatic pill-dispensing guns (that’s not a direct quote). It will be a huge profit to the drug companies, but will the over-medicated grievers really be helped? Frances insists that we should focus our attention on the more severely mentally ill, who are in more need of treatment, but who are being lost in the bonanza of over-diagnosis.

Frances argues (understandably, since he was chair of the DSM-IV task-force) that there was no problem in the DSM-IV bereavement exclusion, why fix what isn’t broken? We should let the bereaved grieve with respect and dignity. If they were severely impaired, they were still diagnosable for major depressive disorder, so there was no need for change.

Here’s my conundrum: Who’s right? Ronald Pie or Allen Frances? With the DSM-IV were doctors just as capable of diagnosing a bereaved individual with major depressive disorder if necessary, as Dr Frances claims? If that truly is the case, then I’d say he’s right. Allowing too much freedom in the diagnosis might encourage general practitioners – who, despite their relative ignorance of mental illness compared to psychiatrists, are the go-to doctors for anti-depressants and anxiety meds – to over-diagnose and over-medicate. Generally, allowing the natural grieving process to progress is the best way to heal.

What concerns me about the bereavement exclusion, though, is that grieving patients who have some severe symptoms of major depressive disorder (persistent insomnia, weight loss, profoundly impaired concentration), but who do not admit to suicidal ideation would not be treated for depression. It is too likely that such patients are not entirely honest about their suicidal ideations, and the doctor may therefore miss this crucial criterium for diagnosis. Are we “better safe than sorry” – providing treatment to people who might not need it? Should we risk overmedicating and supporting the “evil” Big Pharma?

Honestly, I don’t know.

References:

Frances, Allen. (2010, July 08). Normality Is an Endangered Species: Psychiatric Fads and Overdiagnosis. Retrieved from: http://www.psychiatrictimes.com/blogs/dsm-5/normality-endangered-species-psychiatric-fads-and-overdiagnosis.

Zisook S, Corruble E, Duan N, Iglewicz A, Karam EG, Lanouette N, Lebowitz B, Pies R, Reynolds C, Seay K, Katherine Shear M, Simon N, Young IT. (2012).The bereavement exclusion and DSM-5. Depress Anxiety. (29):5, 425-43.

Clinical Mental Health Diagnosis – Psychological Assessment

In my post about the biological assessment of mental health diagnosis, I mentioned that there are three ways a clinician can focus a mental health assessment: biological, psychodynamic, and behavioral. In this post I will discuss the psychodynamic and behavioral assessments of patients.

I’m not sure what a psychological assessment feels like to the clinician, but I have been through several assessments as a patient. Some of them have been very grueling and embarrassing – my 2 hour long assessment for dialectical behavioral therapy comes to mind. Generally, the mental health worker will ask a series of questions to determine personality (am I maladaptive?), social context (am I from an abusive family? caring for an sick family member? a bullied teen?), and culture (I’m a WASC) .

Such an assessment can be either a structured or unstructured interview. In the structured interview, the patient is asked a set of pre-determined questions, even if some of the questions seem inapplicable. In the unstructured interview, the clinician decides which questions to ask. The unstructured interview is much less grueling than the structured one, but it is more likely to produce bias due to the direction of questions that the clinician chooses.

Generally while the clinician is giving the interview, she also assesses the general appearance and behavior of the individual. Is he well-dressed, have good hygiene, look the clinician in the eye? Does he seem to be lying? Observation can also be done through role-playing and self-monitoring. Self-monitoring is a fantastic way to get information that the clinician might miss in a one-hour interview, but it tends to be biased towards what the patient is willing and able to record.

There are also a lot of tests to determine personal characteristics. A famous one of these is the Rorschach Inkblot Test. It’s a series of 10 inkblot pictures to which the patient tells the clinician what she sees and thinks while looking at the picture. The Rorschach test takes a lot of time both to administer and to evaluate, though it can be very enlightening to a clinician who is well-trained in the system.

Another well-known personality-trait test is the Thematic Apperception Test (TAT). The TAT uses a series of simple pictures of people in various contexts. The patient tells a story about what the character is doing and why. Like the Rorschach test, the TAT takes a long time to administer and interpret. The TAT has become a bit obsolete since the pictures were designed in 1935, making them harder for the modern patient to relate to.

The Rorschach and TAT are considered subjective assessments, because they are subject to the clinician’s interpretation. There are also objective tests like the Minnesota Multiphasic Personality Inventory (MMPI), which was introduced in 1943, and revised to the MMPI-2 in 1989. The MMPI-2 is a computerized test consisting of 550 true-false questions on topics ranging from physical condition and psychological states to moral and social attitudes. From these 550 questions, several “clinical scales” are determined. Such scales quantify hypochondria, depression, hysteria, pscyhopathic deviance, masculinity-femininity, paranoia, psychasthenia, schizophrenia, hypomania, and social introversion. It also quantifies the likelihood of lying (inconsistent answers), addiction proneness, marital distress, hostility, and posttraumatic stress.

Such computerized objective tests are helpful because they (for the most part) lack clinician bias, and they are inexpensive. However, they depend upon the patient’s ability to honestly and accurately describe themselves, which many patients are unable or unwilling to do. These tests also tend to be impersonal, and might alienate the patient.

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 4: Clinical Assessment and Diagnosis. Abnormal Psychology, sixteenth edition (pp. 101-127). Pearson Education Inc.

Clinical Mental Health Diagnosis – Biological Assessment

One of the most difficult tasks for mental health workers is to clinically assess and diagnose mental illnesses – especially when comorbidity (having more than one mental illness) is so common. It usually begins with a psychological assessment through tests, observation, and interviews so the clinician can catalog the symptoms. Then the DSM-5 is consulted to give the diagnosis.

A clinician may focus the assessment in three ways – biological, psychodynamic, and behaviorally.

Biological approach

For the sake of appropriate treatment, it is very important to make sure that the symptoms are not due to a physical rather than a mental illness. In my experience, many doctors shrug off certain types of symptoms as those of a mentally ill patient. For instance, when I fainted at work a while back I was told it was “anxiety.” (And because it was diagnosed as a mental problem, my insurance didn’t pay – but that’s a problem to discuss on another day.) Granted, my fainting spell could have been anxiety-induced, but it could have been many things.

A more extreme example that I heard of from a doctor at a large university hospital was that a foreign patient (I can’t remember his origin) kept coming in complaining that there was a worm in his head. The doctors kept shunting him off to mental health. Eventually, the man came back and said “There’s a worm in my eye!” They looked, and sure enough there was a worm in his eye. (Possibly something like this?) Yeah. Sometimes the patient knows what he’s talking about.

Of course generally there aren’t really worms in people’s heads – but symptoms that seem mental could be due to head injuries, strokes, seizures, etc. There are a number of brain scans that can be performed to check for such problems.

One is computerized axial tomography (CAT) scan, which moves X-ray beam around the head to create a 2D image of the brain. CAT scans have become more rare because of the availability of magnetic resonance imaging (MRI). MRI quantifies magnetic fields affecting varying amounts of water content in tissue, thus giving a sharp image of different structures (or lesions / tumors) in the brain.

Another brain imaging technique is the positron emission tomography (PET) scan. PET scans measure the metabolic activity in the brain, thus allowing more clear-cut diagnoses to be made. PET can reveal problems that are not anatomically obvious. However, the images in PET images are low-fidelity and the scans are prohibitively expensive.

Functional MRI (fMRI) measures blood flow of specific areas of tissues, thus providing information about which areas of the brain are active. fMRI is the scan that helps researchers discover which parts of the brain are important for certain types of thoughts or activities. At the moment, it is more important in the research than in the clinical world, but there is some optimism that fMRI might eventually be used to map cognitive processes in mental disorders.

Sometimes, a lesion hasn’t developed enough to be recognizable by brain scans. In this case, neuropsychological tests can be performed to quantify a person’s cognitive, perceptual, and motor performance to determine what parts of the brain might be affected. The neuropsychological assessment usually involves a battery of tests such as the Halstead-Reitan assessment for adults. This assessment is composed of 5 tests.

1. Halstead Category Test: Measures learning, memory, judgement, and impulsivity. Patient hears a prompt and selects a number 1-4. A right choice gets a pleasent bell sound and a wrong choice gets a buzzer. Patient must determine the underlying pattern in prompt-number combinations.

2. Tactual Performance Test: Measures motor speed, response to the unfamiliar, and the ability to use tactile / kinesthetic cues. A blindfolded patient is asked to place blocks in the correct spaces on a board. Then she draws the board from memory, without ever seeing the board.

3. Rhythm Test: Measures attention and concentration. The patient listens to 30 pairs of rhythmic beats and must determine whether the pairs are the same or different.

4. Speech Sounds Perception Test: Determines whether patient can identify spoken words, and measures concentration, attention, and comprehension. Nonsense words are spoken, and the patient must choose the word from a list of four printed words.

5. Finger Oscillation Task: Measures the speed at which the patient can press a lever.

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 4: Clinical Assessment and Diagnosis. Abnormal Psychology, sixteenth edition (pp. 101-127). Pearson Education Inc.

The Definition of Abnormal

Well, my first week of Abnormal Psychology is through. We’ve read chapters 1-2 of our textbook, Abnormal Psychology by James N Butcher.

Chapter 1 was mainly about defining “abnormal” in the sense of “abnormal psychology.” This is a lot more difficult than you might imagine.

You could try a statistical approach, for instance. If someone’s behavior is statistically rare, then that behavior is abnormal. But lots of people have behavior that is statistically rare. For instance, I went to the Minnesota Renaissance Festival just yesterday, and enjoyed some good people-watching. The Ren Fest has a variety of people – some are just pop-culture “nerds.” Some are people who love cosplay (where you dress up as a character – either made up by you or pre-created in popular culture – and act as if you are that person). And some people honestly believe they are wizards. Should we consider any of these statistically rare behaviors due to mental illness? Well, perhaps people who really believe they are wizards, but some of those people are pagans – and should we consider people of a rare religion to be mentally ill per se?

You could also try a societal norm approach. If someone behaves outside the behavioral norm, then they are abnormal. But this, in itself does not imply mental illness. Societal norms can change from culture to culture. As an example, in some tribal cultures, the men cut themselves over and over again to “beautify” themselves with scars; but in America teens who cut are generally diagnosed with depression. Norms can also change within one culture over time. For instance, a couple decades ago homosexuality was considered a mental illness, but now it is, for the most part, accepted as “normal” behavior for certain individuals.

There is also the maladaptive approach. If someone’s behavior is injurious to himself or to society, then he is abnormal. A person with OCD who washes her hands so much that they are cracked and bleeding is maladaptive. But this approach is not full-proof either. Not everyone who commits a crime is mentally ill. Likewise, should we consider someone who donates bone marrow, blood, or a kidney mentally ill?

Many people who are mentally ill suffer. But not all. The mania state of bipolar disorder is often pleasant to the patient, but he is considered mentally ill. Also, where do we draw the line of diagnosing mental illness for those who are suffering? If someone has just lost her home or a loved one, she is suffering from grief. But isn’t grief a natural and healthy response, within limits?

Another approach is irrationality and unpredictability, but teenagers and young adults often do irrational and unpredictable things for attention or just because they’re trying to impress a girl. Mental illness? Nah.

The last approach I will discuss is dangerous behavior. But yet again, that is not always indicative of mental illness. Many people jump out of planes, bungee jump, or fight in a war. These people are not considered “abnormal.”

The DSM-5 defines mental disorder as:

“a syndrome characterized by 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. Mental disorders are usually associated with significant distress in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.”

What the heck does that mean?

In the end, mental illness diagnoses are subjective to the clinician. For instance, I was diagnosed with bipolar disorder II. This means that I experience abnormal highs and lows (as well as other traits). I totally agree with this diagnosis. But another psychiatrist diagnosed me with borderline personality disorder. “What?!” I said. I don’t have an intense fear of abandonment, a pattern of intense interpersonal relationships characterized by alternating states of idealization and devaluation, paranoid ideation, or disassociative symptoms. Granted, I have more than 5 other traits, which makes me diagnosable with borderline. But all of those symptoms are traits that can be explained by bipolar disorder. So why the boderline personality disorder diagnosis?

What do you think? How would you define “abnormal”?

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 1: Abnormal Psychology: An Overview. Abnormal Psychology, sixteenth edition (pp. 2-27). Pearson Education Inc.