Psychosocial Nursing
Theories of Development
Freud's Psychosexual Stages of Development
Freud advanced a theory of personality development that centered on the effects of the sexual pleasure drive on the individual psyche. At particular points in the developmental process, he claimed, a single body part is particularly sensitive to sexual, erotic stimulation. These erogenous zones are the mouth, the anus, and the genital region. The child's libido centers on behavior affecting the primary erogenous zone of his age; he cannot focus on the primary erogenous zone of the next stage without resolving the developmental conflict of the immediate one.
A child at a given stage of development has certain needs and demands, such as the need of the infant to nurse. Frustration occurs when these needs are not met; Overindulgence stems from such an ample meeting of these needs that the child is reluctant to progress beyond the stage. Both frustration and overindulgence lock some amount of the child's libido permanently into the stage in which they occur; both result in a fixation. If a child progresses normally through the stages, resolving each conflict and moving on, then little libido remains invested in each stage of development. But if he fixates at a particular stage, the method of obtaining satisfaction which characterized the stage will dominate and affect his adult personality.
The Oral Stage The oral stage begins at birth, when the oral cavity is the primary focus of libidal energy. The child, of course, preoccupies himself with nursing, with the pleasure of sucking and accepting things into the mouth. The oral character who is frustrated at this stage, whose mother refused to nurse him on demand or who truncated nursing sessions early, is characterized by pessimism, envy, suspicion and sarcasm. The overindulged oral character, whose nursing urges were always and often excessively satisfied, is optimistic, gullible, and is full of admiration for others around him. The stage culminates in the primary conflict of weaning, which both deprives the child of the sensory pleasures of nursing and of the psychological pleasure of being cared for, mothered, and held. The stage lasts approximately one and one-half years.
The Anal Stage At one and one-half years, the child enters the anal stage. With the advent of toilet training comes the child's obsession with the erogenous zone of the anus and with the retention or expulsion of the feces. This represents a classic conflict between the id, which derives pleasure from expulsion of bodily wastes, and the ego and superego, which represent the practical and societal pressures to control the bodily functions. The child meets the conflict between the parent's demands and the child's desires and physical capabilities in one of two ways: Either he puts up a fight or he simply refuses to go. The child who wants to fight takes pleasure in excreting maliciously, perhaps just before or just after being placed on the toilet. If the parents are too lenient and the child manages to derive pleasure and success from this expulsion, it will result in the formation of an anal expulsive character. This character is generally messy, disorganized, reckless, careless, and defiant. Conversely, a child may opt to retain feces, thereby spiting his parents while enjoying the pleasurable pressure of the built-up feces on his intestine. If this tactic succeeds and the child is overindulged, he will develop into an anal retentive character. This character is neat, precise, orderly, careful, stingy, withholding, obstinate, meticulous, and passive-aggressive. The resolution of the anal stage, proper toilet training, permanently affects the individual propensities to possession and attitudes towards authority. This stage lasts from one and one-half to two years.
The Phallic Stage The phallic stage is the setting for the greatest, most crucial sexual conflict in Freud's model of development. In this stage, the child's erogenous zone is the genital region. As the child becomes more interested in his genitals, and in the genitals of others, conflict arises. The conflict, labeled the Oedipus complex (The Electra complex in women), involves the child's unconscious desire to possess the opposite-sexed parent and to eliminate the same-sexed one.
In the young male, the Oedipus conflict stems from his natural love for his mother, a love which becomes sexual as his libidal energy transfers from the anal region to his genitals. Unfortunately for the boy, his father stands in the way of this love. The boy therefore feels aggression and envy towards this rival, his father, and also feels fear that the father will strike back at him. As the boy has noticed that women, his mother in particular, have no penises, he is struck by a great fear that his father will remove his penis, too. The anxiety is aggravated by the threats and discipline he incurs when caught masturbating by his parents. This castration anxiety outstrips his desire for his mother, so he represses the desire. Moreover, although the boy sees that though he cannot posses his mother, because his father does, he can posses her vicariously by identifying with his father and becoming as much like him as possible: this identification indoctrinates the boy into his appropriate sexual role in life. A lasting trace of the Oedipal conflict is the superego, the voice of the father within the boy. By thus resolving his incestuous conundrum, the boy passes into the latency period, a period of libidal dormancy.
On the Electra complex, Freud was more vague. The complex has its roots in the little girl's discovery that she, along with her mother and all other women, lack the penis which her father and other men posses. Her love for her father then becomes both erotic and envious, as she yearns for a penis of her own. She comes to blame her mother for her perceived castration, and is struck by penis envy, the apparent counterpart to the boy's castration anxiety. The resolution of the Electra complex is far less clear-cut than the resolution of the Oedipus complex is in males; Freud stated that the resolution comes much later and is never truly complete. Just as the boy learned his sexual role by identifying with his father, so the girl learns her role by identifying with her mother in an attempt to posses her father vicariously. At the eventual resolution of the conflict, the girl passes into the latency period, though Freud implies that she always remains slightly fixated at the phallic stage.
Fixation at the phallic stage develops a phallic character, who is reckless, resolute, self-assured, and narcissistic--excessively vain and proud. The failure to resolve the conflict can also cause a person to be afraid or incapable of close love; As well, Freud postulated that fixation could be a root cause of homosexuality.
Latency Period The resolution of the phallic stage leads to the latency period, which is not a psychosexual stage of development, but a period in which the sexual drive lies dormant. Freud saw latency as a period of unparalleled repression of sexual desires and erogenous impulses. During the latency period, children pour this repressed libidal energy into asexual pursuits such as school, athletics, and same-sex friendships. But soon puberty strikes, and the genitals once again become a central focus of libidal energy.
The Genital Stage In the genital stage, as the child's energy once again focuses on his genitals, interest turns to heterosexual relationships. The less energy the child has left invested in unresolved psychosexual developments, the greater his capacity will be to develop normal relationships with the opposite sex. If, however, he remains fixated, particularly on the phallic stage, his development will be troubled as he struggles with further repression and defenses.
Psychosocial Theory: Erikson The Epigenetic Psychosexual Stages Erikson believed that childhood is very important in personality development. He accepted many of Freud's theories, including the id, ego, and superego, and Freud's theory of infantile sexuality. But Erikson rejected Freud's attempt to describe personality solely on the basis of sexuality, and, unlike Freud, felt that personality continued to develop beyond five years of age.
All of the stages in Erikson's epigenetic theory are implicitly present at birth (at least in latent form), but unfold according to both an innate scheme and one's up-bringing in a family that expresses the values of a culture. Each stage builds on the preceding stages, and paves the way for subsequent stages. Each stage is characterized by a psychosocial crisis, which is based on physiological development, but also on demands put on the individual by parents and/or society. Ideally, the crisis in each stage should be resolved by the ego in that stage, in order for development to proceed correctly. The outcome of one stage is not permanent, but can be altered by later experiences. Everyone has a mixture of the traits attained at each stage, but personality development is considered successful if the individual has more of the "good" traits than the "bad" traits.
Developmental Stages Personality Stage
Psychosexual Mode
Psychosocial Modality
"Virtue"
Trust vs. Mistrust
incorporative1
incorporative2
getting
taking
Hope
Autonomy vs. Shame, Doubt
retentive
eliminative
holding on
letting go
Willpower
Inititative vs. Guilt
intrusive
making
Purpose
Industry vs. Inferiority
Competence
Identity vs. Role Confusion
Fidelity
Intimacy vs. Isolation
Love
Generativity vs. Stagnation
Care
Integrity vs.Despair
Wisdom
Stage 1 - Basic Trust vs. Mistrust
Developing trust is the first task of the ego, and it is never complete. The child will let mother out of sight without anxiety and rage because she has become an inner certainty as well as an outer predictability. The balance of trust with mistrust depends largely on the quality of maternal relationship.
Stage 2 - Autonomy vs. Shame and Doubt If denied autonomy, the child will turn against him/herself urges to manipulate and discriminate. Shame develops with the child's self-consciousness. Doubt has to do with having a front and back -- a "behind" subject to its own rules. Left over doubt may become paranoia. The sense of autonomy fostered in the child and modified as life progresses serves the preservation in economic and political life of a sense of justice.
Stage 3 - Initiative vs. Guilt Initiative adds to autonomy the quality of undertaking, planning, and attacking a task for the sake of being active and on the move. The child feels guilt over the goals contemplated and the acts initiated in exuberant enjoyment of new locomoter and mental powers. The castration complex occuring in this stage is due to the child's erotic fantasies. A residual conflict over initiative may be expressed as hysterical denial, which may cause the repression of the wish or the abrogation of the child's ego: paralysis and inhibition, or overcompensation and showing off. The Oedipal stage results not only in oppressive establishment of a moral sense restricting the horizon of the permissible, but also sets the direction towards the possible and the tangible which permits dreams of early childhood to be attached to goals of an active adult life.
After Stage 3, one may use the whole repetoire of previous modalities, modes, and zones for industrious, identity-maintaining, intimate, legacy-producing, dispair-countering purposes.
Stage 4 - Industry vs. Inferiority To bring a productive situation to completion is an aim which gradually supersedes the whims and wishes of play. The fundamentals of technology are developed To lose the hope of such "industrious" association may pull the child back to the more isolated, less conscious familial rivalry of the Oedipal time The child can become a conformist and thoughtless slave whom others exploit.
Stage 5 - Identity vs. Role Confusion (or "Diffusion") The adolescent is newly concerned with how they appear to others. Ego identity is the accrued confidence that the inner sameness and continuity prepared in the past are matched by the sameness and continuity of one's meaning for others, as evidenced in the promise of a career. The inability to settle on a school or occupational identity is disturbing.
Stage 6 - Intimacy vs. Isolation Body and ego must be masters of organ modes and of the other nuclear conflicts in order to face the fear of ego loss in situations which call for self-abandon. The avoidance of these experiences leads to isolation and self-absorption. The counterpart of intimacy is distantiation, which is the readiness to isolate and destroy forces and people whose essence seems dangerous to one's own. Now true genitality can fully develop. The danger at this stage is isolation which can lead to sever character problems.
Erikson's listed criteria for "genital utopia" illustrate his insistence on the role of many modes and modalities in harmony:
mutuality of orgasm with a loved partner of opposite sex with whom one is willing and able to share a trust, and with whom one is willing and able to regulate the cycles of work, procreation, and recreation so as to secure to the offspring all the stages of satisfactory development
Stage 7 - Generativity vs. Stagnation Generativity is the concern in establishing and guiding the next generation. Simply having or wanting children doesn't achieve generativity. Socially-valued work and disciples are also expressions of generativity.
Stage 8 - Ego Integrity vs. Despair Ego integrity is the ego's accumulated assurance of its capacity for order and meaning. Despair is signified by a fear of one's own death, as well as the loss of self-sufficiency, and of loved partners and friends. Healthy children, Erikson tells us, won't fear life if their elders have integrity enough not to fear death.
Harry Stack Sullivan
(1892-1949)
Postulates
One-genus: "Man [sic] is much more simply human than otherwise." In understanding what I am trying to say you will have to discard the notion that it is something you have known all the time, which just happened to get well formulated by me. We are really up against one of the most difficult of human performances -- organizing thought about oneself and others, not on the basis of the unique individual me that is perhaps one's most valuable possession, but on the basis of one's common humanity. (Sullivan, 1953, p. 4)
Heuristic Stages in Development The Self System: Anxiety All of us are afflicted by the fact that long before we can make brilliant intellectual formulations, we catch on to a good deal which is presented to us, first by the mothering one and then by other people who have to do with keeping us alive through the period of our utter dependence. Before anyone can remember, except under the most extraordinary circumstances, there appears in every human being a capacity to undergo a vary unpleasant experience. This experience is utilized by all cultures, by some a little and by some a great deal, in training the human animal to become a person, more or less according to the prescriptions of the particular culture. The unpleasant experience to which I am referring I call anxiety. (Sullivan, 1953, p. 8)
The tension of anxiety, when present in the mothering one, induces anxiety in the infant. (ibid., p. 41)
Modes of experience
Prototaxic
"All experience occurs in one or more of three 'modes'-the prototaxic, parataxic, and syntaxic. As the Greek roots of this horrendous term indicate, the prototaxic mode refers to the first kind of experience the infant has and the order or arrangement in which it occurs. . . . According to Sullivan's hypothesis all that the infant "knows" are momentary states, the distinction of before and after being a later acquirement. The infant vaguely feels or 'prehends' earlier and later states without realizing any serial connection between them. . . .He has no awareness of himself as an entity separate from the rest of the world. In other words, his felt experience is all of a piece, undifferentiated, without definite limits. It is as if his experiences were 'cosmic'. . . .
Parataxic
"As the infant develops and maturation proceeds, the original undifferentiated wholeness of experience is broken. However, the 'parts,' the diverse aspects, the various kinds of experience are not related or connected in a logical fashion. They 'just happen' together, or they do not, depending on circumstances. In other words, various experiences are felt as concomitant, not recognized as connected in an orderly way. The child cannot yet relate them to one another or make logical distinctions among them. What is experienced is assumed to be the 'natural' way of such occurrences, without reflection and comparison. Since no connections or relations are established, there is no logical movement of 'thought' from one idea to the next. The parataxic mode is not a step by step process. Experience is undergone as momentary, unconnected states of being.
Syntaxic
". . . The child gradually learns the 'consensually validated' meaning of language - in the widest sense of language. These meanings have been acquired from group activities, interpersonal activities, social experience. Consensually validated symbol activity involves an appeal to principles which are accepted as true by the hearer. And when this happens, the youngster has acquired or learned the syntaxic mode of experience." (Mullahy, 1948, pp. 286-291)
Heuristic Stages in Development
Infancy
extends from a few minutes after birth to the appearance of articulate speech, however uncommunicative or meaningless.
Childhood
extends from the ability to utter articulate sounds of or pertaining to speech, to the appearance of the need for playmates -- that is, companions. cooperative beings of approximately one's own status in all sorts of respects. This ushers in the
Juvenile Era
which extends through most of the grammar-school years to the eruption, due to maturation, of a need for an intimate relation with another person of comparable status. This, in turn, ushers in the era that we call
Preadolescence
an exceedingly important but chronologically rather brief period that ordinarily ends with the eruption of genital sexuality and puberty, but psychologically or psychiatrically ends with the movement of strong interest from a person of one's own sex to a person of the other sex. These phenomena mark the beginning of
Adolescence
which in this culture (it varies, however, from culture to culture) continues until one has patterned some type of performance which satisfies one's lust, one's genital drives. Such patterning ushers in
Late Adolescence
which in turn continues as an era of personality until any partially developed aspects of personality fall into their proper relationship to their time partition; and one is able, at
Adulthood
to establish relationships of love for some other person, in which relationship the other person is as significant, or nearly as significant, as one's self. This really highly developed intimacy with another person is not the principal business of life, but is, perhaps, the principal source of satisfaction in life; and one goes on developing in depth of interest or in scope of interest, or in both depth and scope, from that time until unhappy retrogressive changes in the organism lead to old age (Sullivan, 1953, pp. 34).
Beginnings of the Self-System
Successful training of the functional activity of the anal zone of interaction accentuates a new aspect of tenderness -- namely, the additive role of tenderness as a sequel to what the mothering one regards as good behavior. Now this is, in effect -- however it may be prehended by the infant -- a reward, which, once the approved social ritual connected with defecating has worked out well, is added to the satisfaction of the anal zone. Here is tenderness taking on the attribute of a reward for having learned something, or for behaving right.
Thus the mother, or the parent responsible for acculturation or socialization, now adds tenderness to her increasingly neutral behavior in a way that can be called rewarding. I think that very, very often the parent does this with no thought of rewarding the infant. Very often the rewarding tenderness merely arises from the pleasure of the mothering one in the skill which the infant has learned ... (Sullivan, 1953, p. 158).
Heterosexual Intimacy and Lust
Sullivan notes a problem of timing:
[W]omen undergo the puberty change somewhat in advance of men [and this] leads to a sort of stutter in developmental progress between the boys and the girls in an age community [like the school] so that by the time most of the boys have gotten really around to an interest in girls, most of the girls are already fairly wound up in their problems about boys. (Sullivan, 1953, p. 166)
Piaget's four stages
Sensorimotor period According to Piaget, this child is in the sensorimotor period and primarily explores the world with senses rather than through mental operations. Infants are born with a set of congenital reflexes, according to Piaget, in addition to a drive to explore their world. Their initial schemas are formed through differentiation of the congenital reflexes
The sensorimotor period is the first of the four periods. According to Piaget, this stage marks the development of essential spatial abilities and understanding of the world in six sub-stages:
The first sub-stage, known as the reflex schema stage, occurs from birth to six weeks and is associated primarily with the development of reflexes. The second sub-stage, primary circular reaction phase, occurs from six weeks to four months and is associated primarily with the development of habits. The third sub-stage, the secondary circular reactions phase, occurs from four to nine months and is associated primarily with the development of coordination between vision and prehension. The fourth sub-stage; called the co-ordination of secondary circular reactions stage, which occurs from nine to twelve months, is when Piaget (1954) thought that object permanence developed. The fifth sub-stage; the tertiary circular reactions phase, occurs from twelve to eighteen months and is associated primarily with the discovery of new means to meet goals. The sixth sub-stage, considered "beginnings of symbolic representation", is associated primarily with the beginnings of insight, or true creativity.
Preoperational stage The Preoperational stage is the second of four stages of cognitive development. By observing sequences of play, Piaget was able to demonstrate that towards the end of the second year a qualitatively new kind of psychological functioning occurs.
(Pre)Operatory Thought in Piagetian theory is any procedure for mentally acting on objects. The hallmark of the preoperational stage is sparse and logically inadequate mental operations. During this stage the child learns to use and to represent objects by images and words, in other words they learn to use symbolic thinking. Thinking is still egocentric: The child has difficulty taking the viewpoint of others.
The child can classify objects by a single feature: e.g. groups together all the red blocks regardless of shape or all the square blocks regardless of color. According to Piaget, the Pre-Operational stage of development follows the Sensorimotor stage and occurs between 2–6 years of age. In this stage, children develop their language skills. They begin representing things with words and images. However, they still use intuitive rather than logical reasoning. At the beginning of this stage, they tend to be egocentric, that is, they are not aware that other people do not think, know and perceive the same as them. Children have highly imaginative minds at this time and actually assign emotions to inanimate objects. The theory of mind is also critical to this stage.
The Preoperational Stage can be further broken down into the Preconceptual Stage and the Intuitive Stage. The Preconceptual stage (2-4 years) is marked by egocentric thinking and animistic thought. A child who displays animistic thought tends to assign living attributes to inanimate objects, for example that a glass would feel pain if it were broken.
The Intuitive(4-6 years) stage is when children start employing mental activities to solve problems and obtain goals but they are unaware of how they came to their conclusions. For example a child is shown 7 dogs and 3 cats and asked if there are more dogs than cats. The child would respond positively. However when asked if there are more dogs than animals the child would once again respond positively. Such fundamental errors in logic show the transition between intuitiveness in solving problems and true logical reasoning acquired in later years when the child grows up.
Concrete operational stage The Concrete operational stage is the third of four stages of cognitive development in Piaget's theory. This stage, which follows the Preoperational stage, occurs between the ages of 7 and 11 years and is characterized by the appropriate use of logic. Important processes during this stage are:
Seriation—the ability to sort objects in an order according to size, shape, or any other characteristic. For example, if given different-shaded objects they may make a color gradient.
Classification—the ability to name and identify sets of objects according to appearance, size or other characteristic, including the idea that one set of objects can include another.
Decentering—where the child takes into account multiple aspects of a problem to solve it. For example, the child will no longer perceive an exceptionally wide but short cup to contain less than a normally-wide, taller cup.
Reversibility—where the child understands that numbers or objects can be changed, then returned to their original state. For this reason, a child will be able to rapidly determine that if 4+4 equals 8, 8−4 will equal 4, the original quantity.
Conservation—understanding that quantity, length or number of items is unrelated to the arrangement or appearance of the object or items. For instance, when a child is presented with two equally-sized, full cups they will be able to discern that if water is transferred to a pitcher it will conserve the quantity and be equal to the other filled cup.
Elimination of Egocentrism—the ability to view things from another's perspective (even if they think incorrectly). For instance, show a child a comic in which Jane puts a doll under a box, leaves the room, and then Melissa moves the doll to a drawer, and Jane comes back. A child in the concrete operations stage will say that Jane will still think it's under the box even though the child knows it is in the drawer.
Formal operational stage The formal operational period is the fourth and final of the periods of cognitive development in Piaget's theory. This stage, which follows the Concrete Operational stage, commences at around 12 years of age (puberty) and continues into adulthood. It is characterized by acquisition of the ability to think abstractly, reason logically and draw conclusions from the information available. During this stage the young adult is able to understand such things as love, "shades of gray", logical proofs, and values. Lucidly, biological factors may be traced to this stage as it occurs during puberty (the time at which another period of neural pruning occurs), marking the entry to adulthood in Physiology, cognition, moral judgement (Kohlberg), Psychosexual development (Freud), and psychosocial development (Erikson). Some two-thirds of people do not develop this form of reasoning fully enough that it becomes their normal mode for cognition, and so they remain, even as adults, concrete operational thinkers.
Psychopathophysiology
MENTAL DISORDERS
Mental disorder or mental illness are terms used to refer to a psychological or physiological pattern that occurs in an individual and is usually associated with distress or disability that is not expected as part of normal development or culture. The recognition and understanding of mental disorders has changed over time. Definitions, assessments, and classifications of mental disorders can vary, but guideline criterion listed in the ICD, DSM and other manuals are widely accepted by mental health professionals. Categories of diagnoses in these schemes may include mood disorders, anxiety disorders, psychotic disorders, eating disorders, developmental disorders, personality disorders, and many other categories. In many cases there is no single accepted or consistent cause of mental disorders, although they are widely understood in terms of a diathesis-stress model and biopsychosocial model. Mental disorders have been found to be common, with over a third of people in most countries reporting sufficient criteria at some point in their life. Mental health services may be based in hospitals or in the community. Mental health professionals diagnose individuals using different methodologies, often relying on case history and interview. Psychotherapy and psychiatric medication are two major treatment options, as well as supportive interventions. Treatment may be involuntary where legislation allows. Several movements campaign for changes to mental health services and attitudes, including the Consumer/Survivor Movement. There are widespread problems with stigma and discrimination.
Classification The definition and classification of mental disorder is a key issue for the mental health professions and for users and providers of mental health services. Most international clinical documents use the term "mental disorder" rather than "mental illness". There is no single definition and the inclusion criteria are said to vary depending on the social, legal and political context. In general, however, a mental disorder has been characterized as a clinically significant behavioral or psychological pattern that occurs in an individual and is usually associated with distress, disability or increased risk of suffering. There is often a criterion that a condition should not be expected to occur as part of a person's usual culture or religion. The term "serious mental illness" (SMI) is sometimes used to refer to more severe and long-lasting disorder. A broad definition can cover mental disorder, mental retardation, personality disorder and substance dependence. The phrase "mental health problems" may be used to refer only to milder or more transient issues.
There are currently two widely established systems that classify mental disorders - Chapter V of the International Classification of Diseases (ICD-10), produced by the World Health Organization (WHO), and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) produced by the American Psychiatric Association (APA). Both list categories of disorder and provide standardized criteria for diagnosis. They have deliberately converged their codes in recent revisions so that the manuals are often broadly comparable, although significant differences remain. Other classification schemes may be in use more locally, for example the Chinese Classification of Mental Disorders. Other manuals may be used by those of alternative theoretical persuasions, for example the Psychodynamic Diagnostic Manual.
Some approaches to classification do not employ distinct categories based on cut-offs separating the abnormal from the normal. They are variously referred to as spectrum, continuum or dimensional systems. There is a significant scientific debate about the relative merits of a categorical or a non-categorical system. There is also significant controversy about the role of science and values in classification schemes, and about the professional, legal and social uses to which they are put.
Disorders There are many different categories of mental disorder, and many different facets of human behavior and personality that can become disordered.
The state of anxiety or fear can become disordered, so that it is unusually intense or generalized over a prolonged period of time. Commonly recognized categories of anxiety disorders include specific phobia, Generalized anxiety disorder, Social Anxiety Disorder, Panic Disorder, Agoraphobia, Obsessive-Compulsive Disorder, Post-traumatic stress disorder. Relatively long lasting affective states can also become disordered. Mood disorder involving unusually intense and sustained sadness, melancholia or despair is know as Clinical depression (or Major depression), and may more generally be described as Emotional dysregulation. Milder but prolonged depression can be diagnosed as dysthymia. Bipolar disorder involves abnormally "high" or pressured mood states, known as mania or hypomania, alternating with normal or depressed mood. Whether unipolar and bipolar mood phenomena represent distinct categories of disorder, or whether they usually mix and merge together along a dimension or spectrum of mood, is under debate in the scientific literature. Patterns of belief, language use and perception can become disordered. Psychotic disorders centrally involving this domain include Schizophrenia and Delusional disorder. Schizoaffective disorder is a category used for individuals showing aspects of both schizophrenia and affective disorders. Schizotypy is a category used for individuals showing some of the traits associated with schizophrenia but without meeting cut-off criteria.
The fundamental characteristics of a person that influence his or her cognitions, motivations, and behaviors across situations and time - can be seen as disordered due to being abnormally rigid and maladaptive. Categorical schemes list a number of different personality disorders, such as those classed as eccentric (e.g. Paranoid personality disorder, Schizoid personality disorder, Schizotypal personality disorder), those described as dramatic or emotional (Antisocial personality disorder, Borderline personality disorder, Histrionic personality disorder, Narcissistic personality disorder) or those seen as fear-related (Avoidant personality disorder, Dependent personality disorder, Obsessive-compulsive personality disorder).
There may be an emerging consensus that personality disorders, like personality traits in the normal range, incorporate a mixture of more acute dysfunctional behaviors that resolve in relatively short periods, and maladaptive temperamental traits that are relatively more stable. Non-categorical schemes may rate individuals via a profile across different dimensions of personality that are not seen as cut off from normal personality variation, commonly through schemes based on the Big Five personality traits.
Other disorders may involve other attributes of human functioning. Eating practices can be disordered, at least in relatively rich industrialized areas, with either compulsive over-eating or under-eating or binging. Categories of disorder in this area include Anorexia nervosa and Bulimia nervosa or Binge eating disorder. Sleep disorders such as Insomnia also exist and can disrupt normal sleep patterns. Sexual and gender identity disorders, such as Dyspareunia or Gender identity disorder or ego-dystonic homosexuality. People who are abnormally unable to resist urges, or impulses, to perform acts that could be harmful to themselves or others, may be classed as having an impulse control disorder, including various kinds of Tic disorders such as Tourette's Syndrome, and disorders such as Kleptomania (stealing) or Pyromania (fire-setting). Substance-use disorders include Substance abuse disorder. Addictive gambling may be classed as a disorder. Inability to sufficiently adjust to life circumstances may be classed as an Adjustment disorder. The category of adjustment disorder is usually reserved for problems beginning within three months of the event or situation and ending within six months after the stressor stops or is eliminated. People who suffer severe disturbances of their self-identity, memory and general awareness of themselves and their surroundings may be classed as having a Dissociative identity disorder, such as Depersonalization disorder or Dissociative Identify Disorder itself (which has also been called multiple personality disorder, or "split personality".). Factitious disorders, such as Munchausen syndrome, also exist where symptoms are experienced and/or reported for personal gain.
Disorders appearing to originate in the body, but thought to be mental, are known as somatoform disorders, including Somatization disorder. There are also disorders of the perception of the body, including Body dysmorphic disorder. Neurasthenia is a category involving somatic complaints as well as fatigue and low spirits/depression, which is officially recognized by the ICD-10 but not by the DSM-IV. Memory or cognitive disorders, such as amnesia or Alzheimer's disease exist.
Some disorders are thought to usually first occur in the context of early childhood development, although they may continue into adulthood. The category of Specific developmental disorder may be used to refer to circumscribed patterns of disorder in particular learning skills, motor skills, or communication skills. Disorder which appears more generalized may be classed as pervasive developmental disorders (PDD) also known as autism spectrum disorders (ASD); these include autism, Asperger's, Rett syndrome, childhood disintegrative disorder and other types of PDD whose exact diagnosis may not be specified. Other disorders mainly or first occurring in childhood include Reactive attachment disorder; Separation Anxiety Disorder; Oppositional Defiant Disorder; Attention Deficit Hyperactivity Disorder.
Causes Numerous factors have been linked to the development of mental disorders. In many cases there is no single accepted or consistent cause currently established. A common view held is that disorders often result from genetic vulnerabilities combining with environmental stressors (Diathesis-stress model). An eclectic or pluralistic mix of models may be used to explain particular disorders. The primary paradigm of contemporary mainstream Western psychiatry is said to be the biopsychosocial (BPS) model - incorporating biological, psychological and social factors - although this may not be applied in practice. Biopsychiatry has tended to follow a biomedical model, focusing on "organic" or "hardware" pathology of the brain. Psychoanalytic theories have been popular but are now less so. Evolutionary psychology may be used as an overall explanatory theory. Attachment theory is another kind of evolutionary-psychological approach sometimes applied in the context for mental disorders. A distinction is sometimes made between a "medical model" or a "social model" of disorder and related disability.
Genetic studies have indicated that genes often play an important role in the development of mental disorders, via developmental pathways interacting with environmental factors. The reliable identification of connections between specific genes and specific categories of disorder has proven more difficult.
Environmental events surrounding pregnancy and birth have also been implicated. Traumatic brain injury may increase the risk of developing certain mental disorders. There have been some tentative inconsistent links found to certain viral infections, to substance misuse, and to general physical health.
Abnormal functioning of neurotransmitter systems has been implicated, including serotonin, norepinephrine, dopamine and glutamate systems. Differences have also been found in the size or activity of certain brains regions in some cases. Psychological mechanisms have also been implicated, such as cognitive and emotional processes, personality, temperament and coping style.
Social influences have been found to be important, including abuse, bullying and other negative or stressful life experiences. The specific risks and pathways to particular disorders are less clear, however. Aspects of the wider community have also been implicated, including employment problems, socioeconomicinequality, lack of social cohesion, problems linked to migration, and features of particular societies and cultures.
Diagnosis Many mental health professionals, particularly psychiatrists, seek to diagnose individuals by ascertaining their particular mental disorder. Some professionals, for example some clinical psychologists, may avoid diagnosis in favor of other assessment methods such as formulation of a client's difficulties and circumstances. The majority of mental health problems are actually assessed and treated by family physicians during consultations, who may refer on for more specialist diagnosis in acute or chronic cases. Routine diagnostic practice in mental health services typically involves an interview (which may be referred to as a mental status examination), where judgements are made of the interviewee's appearance and behavior, self-reported symptoms, mental health history, and current life circumstances. The views of relatives or other third parties may be taken into account. A physical examination to check for ill health or the effects of medications or other drugs may be conducted. Psychological testing is sometimes used via paper-and-pen or computerized questionnaires, which may include algorithms based on ticking off standardized diagnostic criteria, and in relatively rare specialist cases neuroimaging tests may be requested, but these methods are more commonly found in research studies than routine clinical practice. Time and budgetary constraints often limit practicing psychiatrists from conducting more thorough diagnostic evaluations. It has been found that most clinicians evaluate patients using an unstructured, open-ended approach, with limited training in evidence-based assessment methods, and that inaccurate diagnosis may be common in routine practice.
Comorbidity is very usual with mental disorders, i.e. same person can suffer one or more disorder. The work for fifth version of Diagnostic and Statistical Manual of Mental Disorders (DSM-V has raised some questions about dimensional diagnostic criteria compared to categorical diagnostic criteria. Journal of Abnormal Psychology (Vol 114, Issue 4) devoted a whole issue to discuss about categorical and dimensional diagnostic criteria. In short it the argument is that diagnosis of mental disorder can be based on several overlapping dimensions and not categorical and/or two-dimensional classes. One possibility in diagnosis is to have several (>2) dimensions overlapping and that it is harder to describe. In the following picture idea is that multiple dimension lines are crossed with one diagnostic line and the combination of crossing points is basis for a diagnosis.
Treatment Mental health services may be based in hospitals, clinics or the community. Often an individual may engage in different treatment modalities. They may be under case management (sometimes referred to as "service coordination"), use inpatient or day treatment, utilize a psychosocial rehabilitation program, and/or take part in an Assertive Community Treatment program. Individuals may be treated against their will in some cases, especially if assessed to be at high risk to themselves or others. Services in some countries are increasingly based on a Recovery model that supports an individual's journey to regain a meaningful life.
Psychotherapy A major option for many mental disorders is psychotherapy. There are several main types. Cognitive behavioral therapy (CBT) is widely used and is based on modifying the patterns of thought and behavior associated with a particular disorder. Psychoanalysis, addressing underlying psychic conflicts and defenses, has been a dominant school of psychotherapy and is still in use. Systemic therapy or family therapy is sometimes used, addressing a network of signicant others as well as an individual. Some psychotherapies are based on a humanistic approach. There are a number of specific therapies used for particular disorders, which may be offshoots or hybrids of the above types. Mental health professionals often employ an eclectic or integrative approach. Much may depend on the therapeutic relationship, and there may be problems with trust, confidentiality and engagement.
Medication A major option for many mental disorders is psychiatric medication. There are several main groups. Antidepressants are used for the treatment of clinical depression as well as often for anxiety and other disorders. There are a number of antidepressants beginning with the tricylics, moving through a wide variety of drugs that modify various facets of the brain chemistry dealing with intercellular communication. Beta-blockers, developed as a heart medication, are also used as an antidepressant. Anxiolytics are used for anxiety disorders and related problems such as insomnia. Mood stabilizers are used primarily in bipolar disorder. Lithium A (a metal) and Lamictal (an epileptic drug) are notable for treating both mania and depression. The others, mainly targeting mania rather than depression, are a wide variety of epilepsy medications and antipsychotic. Antipsychotic are used for psychotic disorders, notably for positive symptoms in schizophrenia. Stimulants are commonly used, notably for ADHD. Despite the different conventional names of the drug groups, there can be considerable overlap in the kinds of disorders for which they are actually indicated. There may also be off-label use. There can be problems with adverse effects and adherence.
Classification of Mental Disorders
Diagnostic and Statistical Manual of Mental Disorder (DSM-IV).
Categorical description of symptoms - person meets all or some of symptoms for a period of time (almost 400 disorders
5 axes – primary problem, personality, medical condition, social and environmental stressors, global assessment
Problems – over diagnosis, problems with labels, distinction between serious mental disorders and normal problems
Anxiety Disorders
Anxiety - apprehension, dread, worry,muscle tension, sweating, increased breathing and heart rate.
Phobia - Excessive, irrational fear
Simple phobia - Fear of a specific object
Social phobia - Fear of social settings involving evaluation, embarrassment, looking foolish
Agoraphobia - Fear of being in public places. Often associated with panic disorder.
Panic Disorder - Sudden, overwhelming, intense anxiety, fear, terror.
Lasts for a short time period.
May include shortness of breath, dizziness, fear of dying or going crazy.
Simple phobias
Bugs, mice, snakes, bats; heights; water; storms; closed places
Obsessive-Compulsive Disorder
Obsession - Intrusive, irrational, recurrent, unwanted thoughts, images, or impulses
Compulsion - Repetitive, ritualistic behavior, feel compelled to perform, irresistible urge. Anxiety builds up from obsession and compulsion helps relieve anxiety
Most common: Cleaning (hand washing) and Checking. (everything unplugged, locked) Also counting and touching
Mood Disorders
Major Depressive Disorder
Several possible symptoms (does not need to have ALL symptoms to be diagnosed):
Chronic, extreme sadness, unhappiness.
Little interest or pleasure in usual activities.
Sleeps more or less than usual.
Eats more or less than usual.
Little energy or enthusiasm.
Feelings of worthlessness; self-blame and despair.
Difficulty concentrating, making decisions.
Thoughts of dying or suicide.
Bipolar Disorder: - Periods of mania and depression
Mania characterized by:
Euphoric or irritable mood
Restlessness, pacing.
Distractibility
Little need for sleep .
Emotional behavior – MANIA - elation, euphoria, extreme sociability, expansiveness, impatience, DEPRESSIVE – gloominess, hopelessness, social withdrawal, irritability, indecisiveness
Cognitive characteristics – MANIA - distractibility, desire for action, impulsiveness, talkativeness, grandiosity, inflated self esteem, DEPRESSION – slowness of thought, obsessive worrying about death, negative self image, delusions of guilt, difficulty concentrating
Motor characteristics – MANIA – hyperactivity, decreased need for sleep, sexual indiscretion, fluctuating appetite, DEPRESSIVE – decreased motor activity, fatigue, difficulty sleeping, decreased sex drive, decreased appetite
Seasonal Affective disorder - winter
Crave carbohydrates, overeat, oversleep
Light
Somatoform Disorders
Physical symptoms in the absence of any physical cause.
Hypochondriasis - Excessive, unwarranted concern/preoccupation for personal health. Minor pains and other symptoms are overblown, convinced have serious disorder
Not done to get attention - not "faking" or Munchausen syndrome
Conversion Disorder - Serious physical symptoms (motor or sensory function) without physical cause but may solve psychological problem (Paralysis, blindness)
La belle indifference - Nonchalance , lack of concern
Body Dysmorphic disorder - imagined ugliness to the point of obsession (not the same as anorexia or bulimia)
Dissociative Disorders
Dissociation - loss of ability to integrate all components of self into coherent representation of one’s identity
Dissociative Amnesia - Sudden inability to recall personal info (name, parents, profession, address). - Also known as repressed memory.
Usually occurs after severe stress or trauma.
Dissociative Fugue (to flee) - Memory loss and wander or move to a new place (New identity, job, home, family, and personality). Often resolve spontaneously with no memory of what happened
Dissociative Identity Disorder (multiple personality) - 2 or more personalities, each with distinct traits, names, memories, speech patterns, hair style, sex. Traumatic incident usually precedes split
Dissociative disorders (repression, multiple personality disorder) are on the rise, large amount of controversy
Schizophrenia
Severe, debilitating, often chronic. Loss of contact with reality, inappropriate affect, disturbances in thought and/or other behavior
Many kinds of symptoms
Agitation
Hallucinations
Delusions
Disruptions in cognition/speech
Social withdrawal
Problems in emotional expression
Descriptions of Symptoms
Positive – abnormal behavior is present
Hallucinations - Sensory experiences without sensory stimulus - Usually auditory
Delusions - False belief, Can’t be convinced it’s not true.
Grandeur – one is famous or has power
Persecution – someone is out to get them
Reference – materials refer to them personally
Influence – something influencing their behavior
Types of Schizophrenia
Paranoid type - Elaborate delusions (grandeur, persecution), suspicious, argumentative
Disorganized type - Bizarre, inappropriate speech & behavior, flat or inappropriate affect, silliness, grotesque mannerisms, bizarre behavior.
Catatonic type
Catatonic Excitement - Restlessness, pacing & purposeless, repetitive movements
Catatonic Stupor - Almost never talks, barely moves, Waxy flexibility(assume posture and remain in same position for long periods of time)
Childhood Disorders
Autism - oblivious to others, unresponsive, preference for nonsocial object (social isolation)
Abnormal response to stimuli or change
mute or talk in parrot-like fashion
Self stimulating behavior (hand wringing, rocking, etc.)
Attention Deficit Disorder - hyperactivity
inability to attend, focus attention in sustained way
impulsive, distractible, aggressive
Ritalin (stimulant) or new one - ephinephrine
Eating Disorders
Fear of getting fat
Anorexia Nervosa - abnormal concern with weight and body image, extreme measures to lose weight, excessively thin
Bulimia Nervosa - binge eating followed by purging - remain normal in weight
.Sexual Disorders
Problems having sex - no interest, problems with arousal, pain
Paraphilias - fetish, transvestite, sadism, masochism, exhibitionist, pedophile, voyeurism
Transexual
The Notion of Insanity - legal
Insanity as incompetence to stand trial.
Not able to participate in own defense. May be placed in a mental hospital or forced treatment
Insanity as a criminal defense
Varies from state to state
Model Penal code: Not responsible for crime if as result of mental disorder cannot appreciate wrongfulness of conduct or conform to law
Alternative: Guilty but Mentally Ill
Only used in 1% of cases, 2 in 1000 acquitted, 3 in 10,000 set free
The Notion of Insanity - legal
Insanity as a condition of involuntary commitment
A danger to self or others or inability to care for self.
Emergency vs. formal commitment