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.

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.

Panic Disorder

Fear is an emotion that elicits the “fight-or-flight” response of the autonomic nervous system. It is an immediate (uncontrollable) response to a direct danger – such as a rattlesnake, a gun pointed at your head, or a fast car driving right at you. Fear is generally a helpful response that allows you to protect or remove yourself from the imminent peril.

Sometimes the fear response can occur in the absence of any obvious stimulus – this can lead to a panic attack. Panic attacks are terrifying physiological and psychological events in which your autonomic nervous system ramps you up for fight-or-flight. Often, the person becomes terrified that they are dying – usually of a heart attack. Like intense fear, the heart starts pounding, adrenaline flows, breathing races. Sometimes the victim will run from the room – perhaps to a hospital or perhaps with no direction at all – to escape the unseen threat.

A person who experiences frequent panic attacks can be diagnosed with panic disorder. A person with panic disorder is terrified of having another panic attack – and even that fear can elicit another attack. Such a disorder can be crippling. I have a friend with panic disorder that struggled in college because she’d had a panic attack during a particular class, and she was intensely afraid to go back to that class, fearing that she might have another attack. According to the DSM-5, in order to have panic disorder, a person must have 4 of 13 symptoms including: pounding heart, sweating, trembling, shortness of breath, choking, chest pain, nausea, dizziness, chills or heat, numbness or tingling, feelings of unreality, fear of “going crazy,” or fear of dying.

Panic attacks usually last 20-30 minutes with a peak for about 10 minutes, which is good because any longer than that could pose an immediate danger to the person’s metabolism (in case of diabetes) or cardiovascular system (heart attack).

The fear response in a panic attack originates in the amygdala, which is thought to be the central component of the “fear network.” According to the prevailing theory, panic attacks occur when the fear network is activated. Panic disorder develops in people who have a non-adaptive fear network which is overly-sensitive. Although the physiological response to a panic attack originates in the amygdala, there are also cognitive components to panic disorder (e.g. fear of another panic attack in particular situations). The hippocampus, which is involved in learning and emotional responses, is likely involved in this aspect of panic disorder. The cognitive factors in panic disorder (e.g. fears of dying or going insane) are likely controlled by higher cortical centers of the brain.

There are a couple of theories about the development of panic disorder. In the comprehensive learning theory of panic disorder, a person undergoes classical conditioning – such as Ivan Pavlov discovered when his dogs began to salivate reflexively to the sound of a metronome that was always ticking when the dogs ate. In a process called interoceptive conditioning, the person begins to unconsciously associate physiological arousal (e.g. pounding heart, head rush, increased breathing rate) with panic. Thus, when a person is physiologically aroused, such as while running, she will suddenly experience a panic attack. Panic attacks can also be induced by happy events. For instance, when something exciting happens, such as a marriage proposal, the happy person can suddenly rush into panic.

Another theory of panic disorder is the cognitive theory. In this case, the person consciously associates physiological arousal with impending doom. When his heart is pounding, he thinks he could be having a heart attack. When his breathing becomes labored, this could be lung cancer. Such thinking is called “catastrophizing.”

Panic provocation studies support the cognitive theory of panic disorder. In such a study, a subject is given a stimulant that increases heart rate or other physiological symptoms of arousal. One test group is told in advance that the stimulus will increase heart rate, and that it is completely harmless. The other test group will not receive any explanation. It turns out that people who are forewarned of the physiological arousal are less likely to experience a panic attack. This is not in line with the comprehensive learning theory, in which the panic is induced reflexively, and cognition has nothing to do with the attack.

In all likelihood, both theories play some part in the origin of panic attacks.

Many people with panic disorder are prescribed benzodiazapines such as Xanax or Klonopin. These medications are very useful for anxiety relief, but they can be addictive. Upon cessation of the medication, a patient can undergo uncomfortable side effects such as nervousness, sleep disturbance, dizziness, and panic attacks. For those of you who wonder why we are so dependent upon medications for treatment of anxiety, try undergoing a three hour anxiety attack like the one described in My Bipolar Mixed State. You will soon understand that immediate relief is necessary.

Because of the negative side effects of medication, it is good to treat panic disorder with psychological therapy, such as cognitive-behavioral therapy, as described in Contemporary viewpoints on treating mental illness – psychology. In such treatment, a patient can be exposed to internal stimuli of physiological arousal; for instance, running in place, spinning in a chair, or hyperventilating. The patient must continue this activity until he dissociates the physiological symptoms with panic. Such deconditioning therapy can be combined with education about the nature and causes of panic disorder. The patient can be taught to meditate or control their breathing. Patients are also taught about the cognitive errors that they might be making (i.e. my heart is pounding, I must be having a heart attack).

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.

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.

Contemporary viewpoints on treating mental illness – psychology

This post will discuss the psychological causes and treatments of mental illness, as described in Butcher’s Abnormal Psychology.

Psychological viewpoints consider humans not only as biological entities but as products of our personalities and experiences. There are three major psychosocial views on behavior: psychodaynamic, behavioral, and cognitive-behavioral.

They psychoanalytical school was founded by Sigmund Freud, as described in my summary of Chapter 2. Freud structured personality into three elements: id, ego, and superego.

The id is the individual’s instinctive drives, and is the first element to develop in infancy. It is separated into life instincts (such as libido) and death instincts (such as aggression). The id can generate wish-fulfilling fantasies but cannot undertake any actions to meet these desires. The superego develops later in childhood, and basically comprises the conscience.

After a few months of life, the ego develops. The ego mediates between the demands of the id, the urging of the superego, and the realistic constraints of the world. For instance, during toilet training, the id tells the child that he needs to go poo, the superego urges the child not to go poo in his mother’s bed because she is annoying, and the ego takes these two drives and determines the right place and time to go poo. Sometimes these three drives can come into conflict because they are striving for different goals. These intrapsychic conflicts can cause mental illness.

Freud also described a set of psychosexual stages, which you can read about on Wikipedia. I do not put much credence in the psychosexual stages, so I will skip them in my summary.

Later, a few psychoanalysts branched off from Freud with the interpersonal perspective. Alfred Adler focused on social and cultural forces instead of instincts. In Adler’s view, humans are social beings, and we are driven to interact effectively with other members of our group. Erich Fromm focused on the dispositions of people, and how that affected their interactions with other members of society.

Despite the current unpopularity of Freud’s psychosexual stages and gender prejudices, Freud is considered the father of psychoanalysis. He developed the groundwork for further psychotherapy. He showed that certain maladaptive behaviors develop as a result of an attempt to cope with difficult problems. He also laid the foundation for the study of unconscious motives of maladaptive behaviors.

Another psychological approach to treatment of mental illness is the behavioral perspective. It is described in my summary of Chapter 2. In addition to Pavlov’s classical conditioning and Skinner’s operant conditioning, we can also learn by observation. For instance, my sister apparently developed a fear of insects only after seeing a friend respond very negatively to an insect that my sister had collected in a jar.

Behavior theory was not well-received by psychoanalysts, but it provided several important views of the causes of mental illness. It suggested that maladaptive behaviors develop when a person fails to learn the adaptive behaviors, or when he learns maladaptive solutions.

The third psychological viewpoint is my favorite – the cognitive-behavioral perspective. Albert Bandura developed an early form of cognitive-behavioral theory when he suggested that people learn by internal reinforcement rather than external reinforcement – we choose to perform a difficult task because we can visualize the negative outcomes of not performing that task. For instance, I’m writing this blog post despite the fact that I’m so tired my eyes are blurring over and I’m not sure my sentences make sense because I can envision the negative consequence of doing poorly on my upcoming exam.

Today, cognitive behavioral therapy focuses on how distorted perspectives can influence maladaptive behaviors. For instance, if I’m walking down the street, and I see a friend getting on a bus…I wave at that friend, and he doesn’t wave back. I might have the distorted perspective that the friend hates me, and I might consequently be rude or abusive to that friend. The maladaptive cognitive process is called assimilation, where I gather new information (the friend didn’t wave at me) and distort it to fit my existing self-schema (nobody likes me).

The adaptive cognitive process that our therapists attempt to elicit is accommodation, in which we change our existing frameworks to incorporate new information that doesn’t fit. In this case, my self-schema might be “nobody likes me,” but for some reason I’ve been asked out to prom. Instead of distorting the friendly behavior (he’s only asking me to prom so that he can dump pig’s blood on me in a highly public setting), the therapist encourages me to accommodate the information (he might actually like me).

Chapter 3 finished its description of the psychological causes of mental illness by describing some of the events that can lead to a predisposition to mental illness. It discussed early deprivation or trauma, inadequate parenting styles, marital discord and divorce, and maladaptive peer relationships. I found this section interesting since I’ve just finished reviewing The Blank Slate, by Stephen Pinker, which discussed Pinker’s views of the relative influences of parenting styles verses peer relationships on a child’s behavior. Pinker claimed that parenting style had much less to do with the child’s ability to adapt than peer influences did. He implied that the reason we don’t accept that peers have a greater impact than parents is because parents don’t want to think that all the love they’re pouring into their child doesn’t matter. (He also points out that such a worry is silly, since we’d never say that all the love we’re pouring into our spouses doesn’t matter.)

Butcher’s text, on the other hand, spent a lot of space discussing the different parenting approaches (authoritative, authoritarian, permissive/indulgent, and neglectful/uninvolved) and their effects on child development. Despite Pinker’s strong arguments, I’m still convinced that parents have just as much impact on a child’s development as his peers.

Contemporary viewpoints on treating mental illness – biology

Chapter 3 of Butcher’s Abnormal Psychology has too much information for me to adequately summarize in one post. Therefore, I will break it into a few posts. So please bear with me. Of the chapters so far, this chapter was the longest and the least interesting to me. Which is unfortunate, because it’s also the chapter that has the highest distribution of points in the upcoming exam.

The main purpose of this chapter is to review the three contemporary viewpoints on treating mental illness – biological, psychological, and social. This post will review the biological causes of mental illness.

From the biological viewpoint, there are four commonly accepted causal factors of mental illness: neurotransmitter and hormonal abnormalities, genetic vulnerabilities, temperament, and brain dysfunction and neural plasticity.

The reason scientists believe that neurotransmitter imbalances lead to mental illness is the success of serotonin reuptake inhibitors (SSRIs) and similar drugs on alleviating symptoms. Serotonin is a molecule which is released by neurons to send signals to other neurons. The other neurons have serotonin receptors, which stimulate the neuronal response. They also have serotonin reuptake molecules, which bind to the serotonin and remove it from the system. An SSRI inhibits the reuptake of serotonin, thus increasing the length of time serotonin is present and able to bind the serotonin receptor.

According to the book, sometimes psychological stress can lead to neurotransmitter imbalances. There could be excessive production and release of the neurotransmitter, dysfunction in the reuptake or enzymatic breakdown of the neurotransmitter, or problems in the neurotransmitter receptors which may be overly- or under-sensitive.

My professor suggested during last week’s lecture that he doesn’t think the theory of “chemical imbalance” is necessarily plausible. Just because an SSRI decreases symptoms, doesn’t mean that the symptoms were caused by abnormally low levels of serotonin; anymore than the fact that Aspirin decreases certain symptoms means that those symptoms were caused by abnormally low levels of Aspirin. My professor even said that the “chemical imbalance” theory is just as well-founded as the ancient Greek humor imbalance theory (discussed in my summary of Chapter 2). I admit that I’m not familiar with the neurotransmitter research, so I can’t say whether my professor’s reservations are well-founded. But he certainly made me think critically about the subject.

Hormonal imbalances can cause mental illness; an example is hypothyroidism leading to depression because it causes fatigue and slows the body down. My textbook focuses on the hypothalamic-pituitary-adrenal (HPA) axis. This focus seems to be because the HPA axis can release the stress hormone cortisol.

The genetic effect on mental illness seems fairly straight-forward at first glance. Some mental illnesses can be heritable. This heritability is because of genes that can, when activated by the right stressors, cause mental illness. If someone has such a gene, she has a preinclination for the mental illness but doesn’t necessarily develop symptoms.

What makes genetic effects complicated is that genes can interact with the environment. For instance, a person with a gene for depression might also have depressive parents who create an environment that is less nurturing and functional, thus providing stressors which may lead to depression in the child. This is considered a passive effect. On the other hand, the child’s genotype may actively affect her environment. For example, a sulky child may have trouble making friends, thus changing her environment to be one that increases likelihood of depression. There is also an evocative effect, in which parents may react negatively to sulky babies, leading to a less healthy relationship and more likelihood of depression. (I admit I’m having difficulty distinguishing between an active effect and an evocative effect – unless it is simply whether the child’s temperament affects the parent’s behavior or not.)

Psychologists study the genetic factor in mental illness using three models: pedigree analysis, twin studies, and adoption studies. In pedigree analysis, a psychologist can determine the strength of heritability within a family by comparing incidence within a family versus incidence within the community at large. The problem with this method is that families not only share genes, but also environments.

Thus, the other two methods are used to tease out the environmental factors from the genetic factors. Looking at the concordance rate in identical twins (the percentage of twins who share the disorder), compared to the concordance rate in siblings or fraternal twins could indicate how big of a role genetics plays.

Another method to tease out environmental factors from genetic factors is studying siblings (or better yet, identical twins) who are adopted into different families – and thus different environments. If identical twins who are adopted into different families have a high concordance rate for a mental illness, then it is likely that the genetic effect is strong.

An environment that is often forgotten is the womb during pregnancy. The child of a mother who was undergoing intense stress during pregnancy may have an inclination to respond strongly to stressful situations. The stress during pregnancy could be the cause of epigenetic changes – in which the genes themselves don’t change, but there are changes in the chromosomes, such as the binding of certain molecules which change the expression of a particular gene (or set of genes).

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.