In these notes I discuss the psychological disorders: their classification and reclassification, behavioral “symptoms,” and, in selected cases where something is known about it, heritability and underlying physiological changes.
Classification of the Psychological Disorders
In medicine, classification of the various medical disorders typically is based on the particular combinations of symptoms that patients present to the physician; the physician then renders a diagnosis based on those symptoms. Thus, if a patient comes into the doctor’s office complaining about chills and fever, muscular aches and pains, nausia, and so, the physician might conclude from these symptoms that the patient has the flu. The idea here is that patients who present the same symptoms are probably suffering from the same underlying disorder, a common cause for which there will be a specific treatment. Psychiatrists, clinical psychologists, and other mental health workers confonted with a variety of behavioral, cognitive, and emotional “symptoms” of their clients likewise began to identify combinations of these symptoms that seemed to hang together, forming a particular “syndrome” that differentiated these particular cases from others. Category lables were developed for the different syndromes and it was hoped that those falling into the same category might turn out to be suffering from the same set of underlying causes of their condition. Thus was born labels such as “schizophrenia,” “hysteria,” and “manic-depressive psychosis.
Such labels can be very helpful to practitioners. They make it relatively easy to communicate the major features of a person’s disorder to other practioners, as everyone in the field knows what sorts of abnormalities a person diagnosed, for example, as “schizophrenic” is likely to display. And once a person has been identified as having a particular disorder, this immediately suggests which treatments are likely to be the most beneficial to the client.
On the negative side, however, it is too easy to label someone as “a schizoprenic” and forget that one is dealing with an individual human being and not merely a collection of symptoms. Furthermore, nonspecialists soon learned that to be labeled a schizophrenic, manic-depressive, or psychpathic personality was not exactly an honor, and as the general public became more familiar with the typical symptoms of the various disorders, they tended to use them as stereotypes, as if everyone with the label “schizophrenic” exhibited the entire set of symptoms in their most extreme forms. Developing category labels for these disorders may have been necessary, but it did not always have positive consequences for those who were being pinned with the label.
The initial system of categories developed slowly over decades and in some ways proved unsatisfactory in practice. Eventually the American Psychiatric Association conviened a committe to develop a new classification system that would reorganize some of the major categories and provide additional ones based on the latest information. The result of the committee’s deliberations was a publication called the Diagnostic and Statistical Manual or DSM. Over the years this has been revised several times, the current revision is the DSM IV.
The old classification system included two main types of psychological disorder which differ in severity and characteristic problem: Neurosis and Psychosis. Although these are no longer considered current, I’ll start with these two types, as I believe that they still offer a way to differentiate certain of the classes of disorder now included in the new scheme as presented in the DSM:
- characterized by anxiety, often as a result of inner conflict. The outward signs of anxiety may be hidden, however, as the person uses ego defenses to keep the anxiety under control.
- person remains in good contact with reality (no irrational thought, dilusions, or hallucinations).
- characterized by a loss of contact with reality. The person may be delusional, have irrational beliefs that conflict with common sense, or suffer hallucinations.
- although anxiety may be present (or not), it is not a characteristic of the disorder.
The major category of neurosis has been replaced by several more specific categories in the current scheme of classification. I’ll take up those milder disorders that would have fallen under “neurosis” first, beginning with the “anxiety disorders.”
The Anxiety Disorders
- Specific Phobia — The term “phobia” means “fear.” A specific phobia is an irrational fear of some specific thing or situation. The fear is “irrational” in the sense that it is all out of proportion to the actual danger presented. For example, some people are terrified when they see a spider, even though it is on a wall 20 feet away and could not possibly do the person any harm from that distance. A common phobia is agoraphobia (literally, “fear of the marketplace”), in which a person develops a fear of being amongst crowds of people.
- Panic Disorder — This is a disorder characterized by unforewarned attacks of extreme dread, as if some terrible thing is about to befall the person, generally lasting only a couple of minutes and leaving the person physically exhausted because of the extreme activation of the physiological mechanisms aroused by terror. These attacks do not appear to be caused by any particular situation or thing, but if they occur several times within a given context, the person may develop agoraphobia as a secondary effect.
- Post-traumatic Stress Disorder — In World War I, soldiers who came down with this were said to be “shell shocked,” the idea being that the symptoms must have resulted from being exposed to too many concussions from exploting artillary shells. Actually, the disorder arises when people are exposed to servely stressful, life-threatening situations in which they perceive that they have no control over the outcome. Those affected have flashbacks about the situation in which they were helpless, nightmares, difficulty sleeping, and and find it impossible to put the situation behind them and get on with their lives. Situations inducing the disorder include military combat, natural disasters (e.g., being caught in an earthquake), accidents (e.g., a plane crash or train wreck) and being taken hostage, among others.
- Obsessive-Compulsive Disorder — The name comes from two related symptoms: obsessions and compulsions. Obsessions are thoughts, usually of a distressing nature, that constantly intrude into awareness, over and over again. Compulsions are ritualistic behaviors the person feels to perform over and over again, because not to perform them means experiencing rapidly increasing levels of anxiety. Certain drugs and behavior modification techniques have been used to treat the disorder.
- Generalized Anxiety Disorder — This gets its name from the theoretical notion that what started as specific phobias has spread though generalization to almost all situations. The person suffering from this disorder experiences continuous, high levels of “free-floating” anxiety that does not seem to have been triggered by any specific thing or situation. The symptoms of anxiety are often treated by prescribing minor tranquilizers as an initial step; this is followed by psychological therapy aimed and uncovering and eliminating the source of the anxiety.
The Somatoform Disorders
“Soma” means “body,” so these are disorders with some obvious connection to the state of the body. Included are the following two diagnoses:
- Hypochondriasis — You are probably more familiar with the label for the person: “hypochondriac.” This is someone who is perpetually convinced that he or she has some dread disease which, if not treated promptly, is going to lead to their demise. If their own diagnosis is not confirmed by the doctor, hypochontriacs are likely to ask for a second opinion or to decide that, well, if it’s not THIS, then surely it must be THAT. The disorder may be maintained by a strong fear of death, although being the center of attention and concern of physicians, friends, and others can provide its own source of motivation.
- Conversion Disorder (old name: Hysteria) — The old name comes from the Greek for “womb,” suggesting that it is a disorder restricted to females. For reasons unknown it is much more common in women, but men have occasionally been known to develop it. The person with this diagnosis has suffered a loss of sensory experience (sight, hearing, feelings in some part of the body) or a paralysis of some part (e.g., arms, legs), but medical examination reveals no abnormalities. Another symptom is that the person appears to be surprisingly unconcerned about developing the problem and does not wish to seek help to get it cured (indifference toward the disorder). Sigmund Freud suggested that the symptoms appear because they allow the person unconsciously to resolve a “damned if you do, damned if you don’t” conflict.
The Dissociative Disorders
This category includes those psychological disorders that involve a “walling off” of some part of the mind from consciousness. (The walled off parts are said to become “dissociated.” At one time conversion disorder was included here, but evidently it was needed above so that somatoform disorders would include more than just hypochondriasis!
- Dissociative Amnesia — Loss of memory due to psychological factors as opposed to physical trauma to the brain.
- Dissociative Fugue — The person disappears, forgets their true identity and past, replaceing them with an imaginary identity and past, and begins a new life in some other place, but is not conscious of having done these things.
- Dissociative Identity Disorder (old name: “Multiple Personality) — the person develops several alternate personalities, each of which seems like a normal person. The currently “active” personality may or may not have any awareness of what was happening when other personalities were active.
This completes my review of disorders that fell under the older category of “neurosis.” Next I cover two more severe disorders, involving a loss of contact with reality and other extreme symptoms, that fall under the old category of “psychosis.”
Although the term “schizophrenia means “split mind,” it does not refer to the splitting of the personality into several functioning personality subtypes as in dissociative identity disorder. Rather, the term was intended to convey a splitting of the normally integrated cognitive/behavioral/emotional functioning of the brain. For example, a person may suddenly become emotionally agitated even though there is no apparent objective reason for this change.
Symptoms of Schizophrenia
Schizophrenia includes a variety of symptoms, not all of which will necessarily be present at any one time.
- Hallucinations — a hallmark of Schizophrenia. Usually, these take the form of hearing voices. These voices may be critical of the person, and in some cases may tell the person to do certain things. Visual Hallucinations are less common, but do occur in some cases.
- Disordered Thought — Thinking is irrational and disorganized.
- Attentional Difficulties — The person is easily distracted and has a difficult time focusing attention on one line of thought for long.
- “Word Salad” — In severe cases, the individual may exhibit such disordered thinking that sentences are almost completely disconnected, except perhaps by a chain of loose associations. Occasionally the person uses stange words (“neologisms”) which seem to have a private meaning for the person and yet the person seems to believe that others know their meaning.
- Delusions — false beliefs that are firmly held regardless of evidence to the contrary. Paranoid delusions involve (a) delusions of grandeur — an irrational belief that one is someone of elevated position or abilities, e.g., Christ; and (b) delusions of persecution — an irrational belief that “they” are out to get you.
- Catatonia — the person “freezes” into a position of “waxy flexibility”: you can reposition their arms etc. as if the person were a doll, and they will hold the new position (even a very uncomfortable one) for long periods of time. The person seems to be in a trance-like state, but upon emerging from the catatonia can report what had been happening.
Classification of Schizophrenia
Schizophrenia may be broken into two classes according to the rapidity of its development:
- Reactive Schizophrenia
- Symptoms develop over a period of days or weeks, usually in adulthood.
- Good prognosis: the person is likely to recover from the disorder.
- Process Schizophrenia
- Symptoms develop gradually, over a period of months and years, usually beginning in the teens or early twenties.
- Poor prognosis: the person is unlikely to recover from the disorder.
Causes of Schizophrenia
The causes of schizophrenia are unknown. Genetic factors may somewhat dispose one to develop the disorder, but even among identical twins, if one develops schizophrenia, the other has only about a 50-50 chance of developing it also, so there must be other precipitating factors. It is now known that there is some degree of brain deterioration associated with the disorder, at least in those diagnosed with “process” schizophrenia. A biochemical imbalance involving the neurotransmitter dopamine is implicated in the disorder, as drugs the have proven effective in reducing the symptoms of schizophrenia tend to be those that reduce activity in the brain’s dopamine systems.
Bipolar Disorder (Manic-Depressive Disorder)
Bipolar Disorder gets its name from the fact that the person alternates between two “poles” along a continuoum of emotion running from mania at one extreme to severe depression at the other. In most cases, the person cycles between these two extremes over a period of days, weeks, or months, with periods of apparent normality in between. During the manic phase the person exhibits agitation, an emotional high where everything seems possible, high energy with little apparent need for sleep, a flood of ideas coming one right after the other, and irrationalty. During the depressive phase the opposite is evident: little energy, difficulty in initiating activity, slowed thought processes, serious depression. Irrationality is again present — the person may believe that he or she has done some horrible thing for which they are being punished, for example.
As with schizophrenia, there is some evidence that genetics is a factor in that relatives of someone with the disorder are somewhat more likley than nonrelatives also to develop it, but the actual causes remain unknown. The disorder appears to relate to a problem in the regulation of synaptic sensitivities in a certain class of neurotransmitters; one of the effective drug treatments, lithium chloride, may act to stabilize this sensitivity and thereby stop the cycling.