Topic 13: Psychological Disorders

Introduction to Psychological Disorders

Psychological disorders are patterns of behavior or experience that cause distress, impair day-to-day functioning, or increase the risk of harm. The definition and understanding of mental illness have evolved significantly over time, influenced by cultural, social, and scientific developments.

Historical Conceptions of Mental Illness

• Demonic Model (Middle Ages): Mental illnesses were often attributed to evil spirits inhabiting the body, leading to practices such as exorcisms and witch hunts.

• Medical Model (Renaissance): Emergence of the view that mental illness is a physical disorder requiring treatment. Patients were housed in asylums, but these institutions were often overcrowded and treatments were primitive (e.g., bloodletting, "snake pits").

• Moral Treatment (1700s-1800s): Reformers like Phillippe Pinel and Dorothea Dix advocated for treating patients with dignity and kindness, allowing more humane conditions but still lacking effective treatments.

The Modern Era of Mental Health Care

• Pharmacological Advances: The development of chlorpromazine (Thorazine) in the 1950s marked a significant step in treating schizophrenia and related disorders.

• Deinstitutionalization: In the 1960s and 70s, many psychiatric hospitals were closed, and patients were released into the community. However, lack of community support led to mixed outcomes, with some individuals ending up in other institutions such as jails or homeless shelters.

Defining Mental Illness

The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) provides official diagnostic criteria and decision rules for mental disorders. It uses a biopsychosocial approach, considering biological, psychological, and social factors, as well as prevalence and functioning.

• Maladaptive Behavior: Not all maladaptive behaviors are mental illnesses, and not all mental illnesses fit neatly into the criteria of distress or impairment.

• Explosion of Diagnoses: The number of recognized mental disorders has increased dramatically with each DSM revision, raising debates about over-diagnosis and the influence of insurance requirements.

Diagnosis Across Cultures

Certain mental disorders are culture-bound, while others (e.g., schizophrenia, alcoholism) are universal. Culture shapes the expression and interpretation of symptoms.

• Examples:

  • Malocchio (Italy): Headaches, fatigue, and anxiety attributed to the "evil eye" or envy.

  • Calor do corpo/nervos (Portugal/Brazil): Psychological distress expressed as physical symptoms due to bodily imbalance or "nerves."

  • Taijin Kyofusho (Japan): Social anxiety focused on the fear of offending or embarrassing others, reflecting collectivist cultural values.

Major Categories of Psychological Disorders

ADHD (Attention-Deficit/Hyperactivity Disorder)

A developmental disorder characterized by inappropriate levels of hyperactivity, impulsivity, and problems maintaining attention. Diagnosis requires a minimum of six symptoms of inattention or hyperactivity/impulsivity. Treatment includes behavioral therapies and pharmaceuticals. Prevalence is higher in North America compared to Europe, raising questions about over-medication.

Anxiety-Related Disorders

These disorders are marked by distressing, persistent anxiety or maladaptive behaviors that reduce anxiety. While anxiety can be adaptive, it becomes problematic when excessive or inappropriate.

• Generalized Anxiety Disorder (GAD): Chronic worry, tension, and irritability about many areas of life. More common in females and Caucasians.

• Panic Disorder: Repeated, unexpected panic attacks with intense fear and physical symptoms. May lead to avoidance behaviors.

• Phobias: Unrealistic fear of specific situations, activities, or objects. Agoraphobia is the fear of being away from a safe person or place.

• Obsessive-Compulsive Disorder (OCD): Characterized by obsessions (intrusive thoughts) and compulsions (ritualistic behaviors to reduce distress).

• OCD-Related Disorders: Includes hoarding disorder, excoriation disorder (skin picking), trichotillomania (hair pulling), and body dysmorphic disorder.

Mood Disorders

Mood disorders include depression and bipolar disorder, affecting nearly 10% of adults in Canada and the US. Depression is more common in women and those living in poverty, with genetic, environmental, and sociocultural risk factors.

• Major Depression: Periods of sadness, worthlessness, social withdrawal, and cognitive/physical sluggishness. Symptoms include changes in sleep, appetite, and digestion.

• Bipolar Disorder: Extreme shifts in mood, motivation, and energy, with episodes of depression and mania. Manic episodes involve high energy, impulsivity, and risky behaviors.

Schizophrenia

Schizophrenia involves significant breaks from reality, disorganized thinking, and problems with attention and memory. Symptoms are classified as positive (hallucinations, delusions, thought disorder, movement disorder) and negative (absence of adaptive behaviors, social withdrawal).

• Brain Structure: Larger ventricles, loss of brain tissue, and differences in the hippocampus and amygdala.

• Brain Activity: Reduced activity in the frontal lobes and emotion/memory regions.

• Neurotransmitters: Dopamine overactivity is linked to positive symptoms; glutamate underactivity may also play a role.

• Environmental Factors: Extreme stress, low socioeconomic status, minority status, prenatal environment, and cannabis use increase risk.

Personality Disorders

Personality disorders are enduring patterns of behavior that are maladaptive, distressing, and resistant to change. They are grouped into three clusters:

• Cluster A: Odd or eccentric behavior (e.g., paranoid, schizoid personality).

• Cluster B: Dramatic, emotional, or erratic behavior (e.g., antisocial, borderline, narcissistic personality disorders).

• Cluster C: Anxious, fearful, or inhibited behavior (e.g., avoidant personality disorder).

Borderline Personality Disorder: Marked by intense emotional swings, unstable sense of self, impulsivity, and difficult relationships. Often rooted in early trauma and maladaptive coping strategies.

Antisocial Personality Disorder (APD): Characterized by lack of empathy, disregard for others' rights, and impulsive or violent behavior. Linked to frontal lobe dysfunction and early conduct disorder.

Psychopathy: Extreme form of APD with interpersonal/emotional deficits (e.g., lack of remorse, glibness) and social deviance (e.g., impulsivity). Associated with amygdala and frontal lobe abnormalities.

Uncommon Psychiatric Syndromes

• Capgras’s Syndrome: Belief that a loved one has been replaced by an exact double.

• Ekbom’s Syndrome: Delusions of infestation.

• Munchausen Syndrome: Persistent fabrication of medical symptoms, leading to unnecessary treatment.

Mental Illness and the Justice System

Mental Health and Legal Responsibility

Mental illness can impact legal responsibility, particularly through the "insanity defense" (NCRMD: Not Criminally Responsible by Reason of Mental Disorder). Insanity is a legal, not psychological, definition. Criminal guilt requires both actus reus (guilty action) and mens rea (guilty mind). Mental illness can negate mens rea.

NCRMD in Canadian Law

• Section 16 of the Canadian Criminal Code: No person is criminally responsible for an act committed while suffering from a mental disorder that rendered them incapable of appreciating the nature and quality of the act or knowing it was wrong.

• Possible Outcomes:

  • Absolute discharge (no threat to society)

  • Conditional discharge (community living with conditions)

  • Detention in a hospital (high risk)

• Decisions are made by a Review Board, not a judge, and are based on risk to public safety and treatment needs.

Myths and Realities of NCRMD

• Myth: NCRMD is frequently used and successful. Reality: Used in only 1% of felony cases and fails 75% of the time.

• Myth: NCRMD is a loophole for the guilty. Reality: Most defendants spend time in jail or hospital; only 2-10% are successful.

• Myth: Mentally ill people are highly dangerous. Reality: Most NCRMD cases are non-violent, with low recidivism rates.

• Myth: Quick release for NCRMD. Reality: Most spend longer in institutions than if found guilty.

Mental Illness in the Correctional System

• High prevalence of mental illness among incarcerated individuals (up to 70% in federal prisons).

• Jails and prisons are often ill-equipped to provide adequate mental health care.

• Segregation and solitary confinement are common, with profound psychological and neurological effects (e.g., hallucinations, cognitive disabilities, self-harm, and increased suicide risk).

• Disproportionate impact on marginalized groups (e.g., Black and Indigenous prisoners).

Effects of Solitary Confinement

• Psychological effects: hallucinations, insomnia, paranoia, self-harm, suicidal tendencies.

• Neurological effects: changes in brain structure, neuron shrinkage.

• Case examples: Kalief Browder, Edward Snowshoe, and Ashley Smith illustrate the severe consequences of solitary confinement for individuals with mental illness.

Community and Advocacy

• Organizations such as the John Howard Society, Fred Victor, Elizabeth Fry Society, Addictions and Mental Health Ontario (AMHO), CMHA, and CAMH work to support individuals with mental illness and advocate for systemic change.