Abnormal Psychology

The scientific study of abnormal behavior in order to describe, predicts, explain, and change abnormal patterns of functioning.

Goal of course:

Learn theories of abnormal behavior.

Learn scientific based knowledge about abnormal behavior.

1.1. Definitions

Definition of Abnormal Psychology: Abnormal psychology is the scientific study of abnormal thoughts and behavior in order to understand and change abnormal patterns of functioning. The definition of what constitutes 'abnormal' has varied across time and across cultures, and varies among individuals within cultures.

In general, abnormal psychology can be described as an area of psychology that studies people who are consistently unable to adapt and function effectively in a variety of conditions. An individual's ability to adapt and function can be affected by a number of variables , including one's genetic makeup, physical condition, learning and reasoning, and socialization.

1. The definition of abnormality has gone through many dramatic changes through history:

Demons, gods: According to Homer (800 B.C.) mental illness was caused by God’s taking a mind away. Many early societies attributed abnormal behavior to the influence of evil spirits I , and magic; bodily fluids (a liquid) and wandering uteruses; astral influences; physical illness are various ways people through history have tried to describe abnormality.

Deviant behavior or psychological dysfunction was viewed as created by the conflict between good and evil, God or Satan.

In this lecture we shall discuss abnormality and abnormal behavior from the nature and cause of abnormal behavior. These shall include:

(1) How we conceptualize treatment, the clinician’s role, and the client's role; and

(2) (2) What we see in research and treatment, and perhaps more importantly what we don't see.

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1.2. Problems with the definitions of abnormality

There are exceptions with each stance, or in other words "counter- examples". Identifying counter-examples is a useful exercise.

A. Statistical deviation

This definition would mean a genius should be termed abnormal because if we use average as a standard, we are saying that: "average person" = "ideal person". Is the average the ideal? Are deviations from the average a sign of abnormality?

In many respects, think how boring life would be if we were all "average" - all basically the same - no dramatic differences. Indeed, many of the wonderful advances made in our history (be it in art, science, culture...) resulted from people who took chances and tried new ways of doing things - people who deviated from what was the average way of doing things. Deviations can lead to flexibility.

Measurement of IQ means we can locate individuals according to their IQ:

– Severe intellectual deficiency IQ = 0-30

– Moderate intellectual deficiency IQ = 30-50

– Moderate mental handicap IQ = 50-70

– Low Intelligence IQ = 70-90

– Moderate Intelligence IQ = 90-110

– Higher Intelligence IQ = 110-130

Intelligence tests provide a measurement of intellectual development that is considered to be extremely vague today.

B. Social norm violation

a) Social reformers, protestors, etc. This definition would require that we label all social reformers as abnormal, for example feminist leaders, human right activists etc. These are people who want social rules changed - they reject the norms of society.

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b) Cultural relativism

As natural and absolute the norms of our society seem to us, Sociology and Anthropology have taught us that there is in fact nothing absolute about them. What's abnormal (i.e. "norm violating") in one society may be perfectly normal ("norm consistent") in another. The raw (honest) behavior hasn't changed, but the society has.

Example: Sex and Temperament in New Guinea tribes - research by Margaret Mead (1963): Three tribes, each with very different norms:

1. Arapesh: Both males and females are mild (not severe or strong), parental, and nurturing.

2. Mundugumar: Males and females are fierce (angry and aggressive), oppressive and cannibalistic( a person who eats human flesh).

3. Tchumbuli: Males are catty ( saying unkind things about other people), wear curls ( a small bunch of hair) and pretty clothes, and love to go shopping. Females are energetic, managerial, unadorned (without any decoration).

Each of these cultures is different from the other. By which culture's standards do we judge a behavior to be abnormal?

In addition, even in a single society, there are a myriad of subcultures. Add to this the fact that norms change through the years so that what's normative in one generation, may not be in another. We are left with a single society where there are no clear norms that apply across all individuals. This definitional stance implies that normality is the same as conformity to the mainstream, when in fact there are many streams. The term abnormality thus loses any firm referent.

C. Maladaptive behavior

This position ignores the possibility that there may be abnormal situations. That is, perhaps there are situations in which it would be abnormal to adapt.

Example: Germans who were unable to adapt to Nazi Germany; A woman unable to cope with a husband who abuses her. The risk here is that we will end up "blaming the victim".

Eg: John, a 38 male, drinks every day to the point of losing consciousness. He is argumentative with his family and friends, and has gotten into frequent fights at work. Last week he swore at

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his boss, and as a result has been fired. John does not seem to have any motivation to find further employment. Nevertheless, he spends what little money he has in savings on alcohol and unnecessary items such as candy, video tapes, and whatever else he might want at the moment. John often dwells on how worthless he thinks he is, but also on how others do not treat him properly. When not aggressive, he is frequently depressed.

D. Personal distress

To say that abnormal behavior is behavior that causes a person distress/discomfort is to say that it is normal if there is no discomfort.

Thus, it logically follows that someone like Charles Manson, a mass murderer, is normal: he feels no guilt or discomfort about the killings he is responsible for. Similarly, a psychotic patient who hears voices from his dead mother that makes him happy.

(Psychosis is a general term for a major mental disorder characterized by derangement of personality and loss of contact with reality, often with false beliefs (delusions), disturbances in sensory perception (hallucinations), or thought disorders (illusions). Schizophrenia is both the most common (1% of world population) and the classic psychotic disorder. There are other psychotic syndromes that do not meet the diagnostic criteria for schizophrenia, some of them caused by general medical conditions or induced by a substance (alcohol, hallucinogens,). In the evaluation of any psychotic patient in a primary care setting all of these possibilities need to be considered).

Conversely, distress may not always be a bad thing. Indeed, perhaps people who can easily express their fear, depression, or other forms of distress end up better dealing with their problems. Or some types of distress may actually be very useful: anxiety, for example, can signal you that danger is afoot and that you better prepare for it!

It seems clear that the definition of abnormality must go beyond the limited confines of "distress" and "discomfort", at least in certain situations.

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E. Deviation from an ideal

Who is ideal? Who is ideal for the individual? Who is ideal for the species? Who is ideal for the culture? Who is ideal for God? What if the ideal is unrealistic or unobtainable? Ideals, like social norms, are relative across groups and across time, so all the problems discussed above apply here as well.

F. Medical disorder

a) Historically, some hoped that biological causes would be found for all psychological problems. But as we will see, there is a growing body of evidence that certain abnormal behaviors cannot be fully explained without looking at the psychology of the problem.

Example: Conversion hysteria (symptoms such as paralysis, blindness, deafness, which have no physical causes) results from a person's attempt to unconsciously cope with strong unwanted emotions such as anxiety.

b) Implies "health" is absence of disease. According to the World Health Organization, "health" is "a state of complete physical, mental and social well being and not merely the absence of disease and infirmity”.

Using a definition is unavoidable and it is necessary. But choosing one is inherently unscientific - a value judgment in the final moment. When we choose a definition, we do so in part based on feeling, emotion, convenience, custom, appeal, ethics. There is an inherent nonscientific arbitrariness in this choice. The potential result is that psychologist Y and psychologist X could be talking about very different things when using the word "abnormal" confusion and controversy ensues, especially if the definitions remain implicit.

However, as a science, we ideally make our definitions explicit and then attempt to clarify and modify these definitions through scientific/methodological rigor, with an eye always open to the exception and alternative explanations.

Finally, the definition we use in this course is multifaceted - using aspects of each definitional stance. Their individual shortcomings and mutual incompatibilities will create tensions in our discussions that we can use to explore some of the important issues in the study of

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psychopathology. Or sent to dismal (miserable) institutions called asylums: a hospital where people who were mentally ill could be cared for, often for a long time.

1.3. Classification of Abnormality

Today there are various ways that are used by psychologists and people in general for defining abnormal behavior. These include:

A. Statistical deviation

B. Social norm violation

C. Maladaptive behavior

D. Personal distress

E. Deviation from an ideal

F. Medical disorder

A. Statistical deviation:

The defining characteristic is uncommon behavior - a significant deviation from the average/majority. Many human characteristics are normally distributed.

Basically, we're talking about a nice symmetrical bell-shaped curve along which we can rank people: more people fall around the average; the farther away you get from the average, the fewer the people.

Example: Height is a human characteristic. Most people fall around the average height of 5ft. In this example, height can be said to be normally distributed.

Characteristics falling beyond a particular distance from the average values are sometimes seen as abnormal. This distance is defined in terms of "standard deviation units" - these are values that tell the scientist how many people fall beyond the average.

For example: A convention selected (arbitrarily) by scientists is to see people falling beyond 2 standard deviations as abnormal (95.4% falls within the 2 std boundaries).

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This is perhaps the most straight forward definition: collect data, calculate averages and standard's.

Example: Intelligence - there is a normal distribution of IQ scores. Those whose scores are 2 standard's below the mean of 100 are, by this definition mentally retarded (ie: abnormal).

B. Social norm violation

Breaking social "rules". Most of our behavior is shaped by norms - cultural expectations about the right and wrong way to do things.

Examples of norms: proper dress, how/what to eat, behavior on the first date, eye contact with strangers, attitude to elders, to parents’ student/instructor, behavior, in fact, all aspects of our lives. Someone who frequently violates these unwritten rules is seen as abnormal. It is seemingly common-sense. Norms are so deeply ingrained they seem absolute.

C. Maladaptive behavior

Two aspects to this:

1) Maladaptive to one's self - inability to reach goals, to adapt to the demands of life.

2) Maladaptive to society - interferes, disrupts social group functioning.

Example: A 35 years old man, drinks every day to the point of losing consciousness. He is argumentative with his family and friends, and has gotten into frequent fights at work. At one time, he fought his boss, and as a result has been fired. That man does not seem to have any motivation to find further employment.

Nevertheless, he spends what little money he has in savings on alcohol and unnecessary items such as make-ups, video tapes, and whatever else he might want at the moment. That man often dwells on how worthless he thinks he is, but also on how others do not treat him properly. When not aggressive, he is frequently depressed.

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This is a "practical" definition: it identifies those unable to cope. It is also a "flexible" definition: it takes into account an individual's context, recognizing that maladaptive is a relative term - it depends on the person's life circumstances.

C. Personal distress

Put simply, if the person is content with his/her life, then he/she is of no concern to the mental health field. If, on the other hand, the person is distressed (depressed, usually suspicious of persons, anxious, etc), then those behaviors and thoughts that the person is unhappy about are abnormal behaviors and thoughts.

E. Deviation from an ideal

This perspective requires specification of what the "ideal" personality is. Falling short of this specified ideal is an indication of mental illness. Thus a person may be seen as "abnormal" even if they seem to be functioning alright.

Indeed, from this perspective, we are all striving for some ideal (personal or cultural), and many of us will never reach it. We all at some point deviate from or fall short of the ideal. So, in this sense, we are all abnormal to a certain degree, at least until we reach (if ever) the ideal (whatever that may be).

F. Medical disorder

Abnormality exists when there is a physical disease. Abnormal behavior is a symptom of a physical disorder. This is a biogenic definition. The person is qualitatively different from the unafflicted.

For example: Alzheimer's Disease - The major cause is atrophy of certain regions of the brain, typically occurring during the forties or fifties. The individual suffers from difficulties in concentration, leading to absent-mindedness, irritability and even delusions. Memory continues to deteriorate; and death usually occurs 10-12 years after onset of symptoms.

No one definition is the "correct" or the "best" definition. To a certain extent each one captures a different aspect of the meaning of abnormality. When we talk about Abnormality, or when we study it, or treat those suffering from it, we inevitably invoke one or more of these definitions, either explicitly or implicitly -either we're aware of the definition(s) we're using or we're not. But

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we do use some definitions. Various people have some definitions in their heads about what psychological abnormality is, whether or not they could clearly state it.

In any event, it is important, especially as scientists, that we make as explicit as possible the definition(s) we use, and acknowledge any limitations. To operate implicitly hinders our ability to develop as a science - our awareness is limited because as long as our definitions are implicit, they remain unchallengeable, we ignore alternatives, we don't "stretch" ourselves. And each definitional stance can certainly be challenged...

1.4. History of Abnormal Behavior

Since ancient times, people have attempted to understand and treat mental disorders. Many early societies believed that demons caused abnormal behavior. Later, people came to regard the mentally ill as dangerous people with insufficient self-control. Disturbed individuals were imprisoned or sent to dismal institutions called asylums.

During the late 1700's, the idea that abnormal behavior resulted from serious personal problems began to be investigated. People started treating the mentally ill more humanely.

During the 1800's, people believed in possible physical reasons for different kinds of mental disorders. A German psychiatrist named Emil Kraepelin became famous for his Lehrbuch der Psychiatre (A Textbook of Psychiatry, 1883). This classified various illnesses according to their specific types of abnormal behaviors.

In the late 1800's and early 1900's, Sigmund Freud, an Austrian doctor, developed theories about the effects of unconscious drives on behaviour.

Freud and his followers laid the foundations for both the intrapsychic school of psychopathology and psychoanalysis.

The Freudians became especially known for their use of free association to interpret dreams, analyze memories, and make people aware of their unconscious conflicts.

Later in the 1900's, researchers proposed several other theories and treatments of abnormal psychology.

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These proposals centered on the relationship of psychological, physical, and social conditions in the individual and society.

1.5. Theories of Abnormal Psychology

Theories of abnormal psychology describe mental illnesses, suggest possible causes of these illnesses, and propose certain methods of treating them.

These theories can be divided into four main groups or schools: (1) biophysical, (2) intrapsychic, (3) existential, and (4) behavioural.

1.5.1. Biophysical theories

They emphasize the importance of underlying physical causes of psychological disturbances. Such disturbances include two main groups: (1) those related to a medical condition, such as a disease or injury, and

2) those related to the use of a drug or medication. In these disorders, the condition, drug, or medication is believed to cause mental problems by affecting the brain or other parts of the nervous system.

1.5.2. Intrapsychic theories

They focus on the emotional basis of abnormal behavior.

Intrapsychic theorists believe that conflicts in early childhood cause people to worry or have other unpleasant feelings throughout life.

Psychologists use the term neurotic to describe people who sometimes behave abnormally but can usually cope with everyday problems. Individuals who lose track of reality are called psychotic.

Some psychotics believe in very unrealistic ideas called delusions.

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They may also think perceptions such as "hearing voices" or "seeing visions," called hallucinations, are real.

A treatment called psychoanalysis is often used to help neurotics and psychotics understand and resolve their conflicts and anxieties.

During psychoanalysis, the patient talks to the therapist, who is called an analyst.

In one technique, called free association, the patient talks to the analyst about whatever thoughts, images, or feelings come to mind.

Existential theories of abnormal behavior stress the importance of current experiences and the person's view of himself or herself.

Existential therapists try to help patients gain insight into their feelings, accept responsibility for their lives, and fulfill their potential.

Behavioural theories emphasize the effects of learning on behavior.

Behaviourists use a learning process called conditioning to change abnormal behaviour.

In this process, behaviourists treat disturbed people by teaching them acceptable behavior patterns and reinforcing desired behavior by rewards.

1.6. Causes of behavioural problems

Various factors can explain the behavioural problems for children and teenagers.

These factors can be intrinsic or extrinsic.

The intrinsic factors are personal and connected to the student who has difficulties whereas the extrinsic factors deal with family and school environment (educational and social).

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1. Personal factors are among others:

- Student’s personality (unsuitable behaviour prompted by the individual’s character)

- Hyperactivity

- Academic failure (researches indicated a significant relationship between poor school performance and behavioural problems)

- Sex

The majority of students identified as having behavioural problems are boys.

Research in psychology indicates that boys and girls present different behaviors and that this differentiation intervenes throughout the development since the child is always attracted by the activities of people of his/her sex or the models of his/her sex.

Various researchers attempted to comprehend this differentiation. They relied on genetic variables, on cultural models offered to boys and to girls or to the educational environment. The results indicate that the biological variables explain one part of the difference.

For example, concerning aggression, girls would mainly use verbal attacks whereas boys would tend to resort to physical contact. In the school environment, physical attacks disturb more than verbal attacks.

Physical attacks are less tolerated in the learning environment. That is why a great number of boys are found in the category of students identified as having behavioural difficulties.

In addition to biological and genetic variables, researchers tried to understand the phenomenon by using cultural variables. The results indicate that the cultural variables explain a part of the behavioral difference.

There are cultural practices which explain the fact that boys are much more identified as having behavioral problems.

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Cultural models tolerate that the boys should defend their rights while the girls are persuaded not to do so. Parents and teachers encourage boys to react whereas the aggressive gestures of girls are repressed.

2. Family related factors

a.Some family related factors would also constitute the origin of behavioural problems. We can list among others misunderstandings in the family, a very underprivileged socio-economic environment, an extended family.

b.Other researches have indicated that students with behavioral problems often come from families with single-parent or female headed households. This research indicates that the absence of the father is a determining factor for the behavioral problems of boys.

Some data indicate for example that the majority of street children have no father.

c.The way in which children are treated in their family can explain their behavioral problems at school, in the family and in society in general.

Studies in social sciences have proved that ill-treatment or carelessness influences the students’ behaviours at school.

3. School environment

Some school practices can cause behavioral problems in students. Research has shown that the methods of communication, of problem solving, of decision-making at school can have an impact on students’ behaviors.

Within the same context, the students’ social relationships with the administration, their sense of belonging to the school, the mode of preparation and the presence of school regulations constitute the determining school factors for the students’ behaviours.Teaching practices, organisation of the school, physical environment, the collaboration with parents and the community are to be added to these variables.

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To illustrate the influence of these variables, let us take some examples.

Behavioral problems arise when:

1. Discipline rules are not clearly defined and students are not involved in their elaboration.

2. There are too many regulations, punishments given anyhow, anywhere or without apparent reason.

3. There is an overpopulated class which can increase the problems of discipline, aggression, noise

4. The teacher’s behaviour, his/her expectations towards one or several students can influence the students’ answers. In education, this is called « Pygmalion effect» or « self-fulfilling prophecy».

(The main idea concerning The Pygmalion Effect is that if you believe that someone is capable of achieving greatness, then that person will indeed achieve greatness. In other words, believing in potential simply creates potential.)

4. The relationships between a teacher and a student are characterised by mutual aversion:a feeling of intense dislike . As indicated by Brophy (1985), teachers can have positive or neutral relationships with students having behavioural problems. Such teachers would not personally feel affected by these bad behaviours. They can be on good terms with such students. On the contrary, teachers can maintain very negative relationships with some students, including students with behavioural difficulties.

5. The keystone of these relationships would be a mutual aversion which would be manifested:

- In students through avoidance behaviour

- In the teacher through a lower level of interaction, a higher level of criticism and a tendency to introduce, in class, a student or students as bad students, a persistent refusal to answer their questions, frequent nonverbal communication with negative attitudes.

4. Social environment

Friends can also be causes of behavioral problems. Remember this French expression: “Tell me who your friends are, I will tell you who you are”. Adolescents are often grouped together and

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live in gangs. The problems of delinquency are often connected to the existence of gangs, which are sometimes well-structured and strong. In schools, there can be gangs which violently confront one another.

1.7. Forms of behavioural problems

In the school environment, the forms of behavioral problems can be numerous. We give you just some of the most general ones. We must note, however, that the forms can vary according to the socio-cultural context of the school.

1.7.1 Disruptive behaviours

In a school environment, a student is identified as having behavioral difficulties when he/she manifests inappropriate behaviors that are not in agreement with the current standards of conduct in the school. There are some others, all depending on the normative requirements of the school. Some can be considered to be serious in school “A” while they are more tolerated in school “B”.

1.7.2. Disturbing behaviours

In a school environment, a student identified as facing behavioral difficulties presents inappropriate behaviors, in disagreement with the current norms. It is necessary to note that it is not the disturbing behavior as such which is considered to be serious, but its accumulation and its repetition which disturb the teacher.

For example children who make a noise without an apparent reason; play with objects which are not relevant to the task; do not finish their task; answer the questions at the wrong time, etc.., all this in a repetitive way.

Such behaviors are regarded as disturbing. Studies have proved that children deemed as having behavioral difficulties express themselves verbally three times more than others and that they interact with their teacher four times more than others. These students chat with their peers, play with objects or defy their peers.

As you will remember, the tolerance or the intolerance of these behaviors depends on the teacher, on the type of the learning activity, the nature of class-group and the learning context. Therefore, children can easily move around in some classrooms whereas it is prohibited in others. A behaviour is inappropriate with regard to the established rules. Disturbing behaviours also include inhibition, i.e. the behavior of children who do not communicate, and who do not get involved in the interaction with others.

1.7.3.. Aggressiveness

Every teacher considers aggressiveness as critical. An aggressive student is a student who gets angry, who fights in the classroom or on the playground or who breaks everything in his/her way.

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1.7.4. Hyperactivity

The hyperactive student is characterized by a lower level of concentration and a higher rate of motor activity. The hyperactivity is an excessive activity of motor behavior. These children are isolated by their peers; they are neglected or simply rejected. The other students do not choose them as team-mates in learning activities. These are children who can become unhappy.

A child who has got behavioural problems is not a lost child. There are interventions to help him/her to correct his/her behaviours or to help him/her when his/her learning process is disrupted. Some of them are:

1.8.1. Strong discipline

According to some research, an effective intervention is when schools have good discipline, and the staff members establish practices that lead students to be responsible. These students behave in an appropriate way even if they are not supervised by adults.

To get to such a result, various strategies can be applied:

1. Clearly establish the school regulations

2. Enhance the students’ commitment towards these regulations by involving them and their parents in the discussion and application of these rules. In most cases, students are not involved in the elaboration of school regulations. In fact, they do not really feel comfortable with these regulations. They are imposed on them from outside and are not, in fact, their rules. The involvement of students is then considered to be paramount to avoid cases of indiscipline.

3. Elaborate the school regulations in collaboration with all school stakeholders so as to allow them to have the same interpretation. If the regulations are vague, and their interpretation varies from one stakeholder to another, it will be difficult for students to know which behaviour to adopt. It will be difficult to apply these rules correctly.

1.8.2. To create a quality learning environment

In order to prevent behavioral problems, it is necessary to create a quality learning environment. The fact that the courses should be well-structured, interesting and open solves many problems. A quality environment supposes among others, good planning of learning activities, competence from teachers as well as clear teaching instructions.

1.8.3. Dialogue and confident relationship with students

Very often, it is through behaviour that children send messages to adults as well as to their peers. A student who feels rejected tries to send messages to adults to draw their attention to what he/she is experiencing, to break his/her isolation and loneliness perhaps in a tactless way.

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Before intervening, it is essential to stop and to understand what the child wants to transmit as a message in his/her behaviour.

1.8.4. To work out a personalised intervention plan (PIP) for the student with difficulty

When a child has behavioural difficulties and especially if these difficulties disrupt his/her learning, people responsible for the education of this child must intervene to help him/her. In many countries, educationalists resort to what was agreed to be called a personalised intervention plan. It is so called because it is designed according to the characteristics of the child with difficulty.

It is a genuine action plan. According to Georgette Goupil (1991), “the personalised intervention plan is a planning and consultation tool for meeting the needs of a student with difficulty”. PIP is used to support the setting up of individualized services and interventions and to facilitate the social integration of the student.

In this action plan, we can find various elements:

1. Learning objectives (what are the behaviours to be carried out with regard to the learning activities?).

2. Intervention and learning strategies for each on of the objectives

3. Means and resources necessary for the intervention

4. Schedules of achievement

5. People responsible for the intervention

6. The mechanism of learning assessment (as well as assessment criteria and success conditions).

7. Continuous mechanism of the intervention plan revision

In the elaboration of the intervention plan, there is first of all the evaluation of the strength of the student in difficulty, his/her needs and the nature of his/her difficulties. Thus, the elaboration takes into account the learning assets and potential for the student. It is starting from these assets that the objectives will be written to help the child to develop and to open out. The intervention plan is written in collaboration with the student’s parents, the student if he/she is capable as well as with the various stakeholders (teacher, headmaster or headmistress, etc).

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1.8.5. Resource person

The school can also allocate a resource person to the child with learning difficulties to help him/her adapt in the school environment. This may be a psycho-educator. This is a person trained in dealing with problems related to school and social adaptability. His/her role will be to identify and to set up means of stimulating the individual strengths which are paralyzed by socio-economic, emotional, intellectual or physical deficiency

CHAPTER II: PSYCHOLOGICAL DISORDERS ARISING IN CHILDHOOD AND ADOLESCENCE

2.1. Eating disordersHaving an Eating Disorder is much more than just being on a diet. An Eating Disorder is a condition that permeates all aspects of each sufferer's life, is caused by a variety of emotional factors and influences, and has profound effects on the people suffering and their loved ones.

An eating disorder is a compulsion to eat, or avoid eating, that negatively affects both one's physical and mental health. Eating disorders affect every part of the person's life. Feelings about work, school, relationships, and day-to-day activities are determined by what has or has not been eaten. s

Many kids, particularly teens, are concerned about how they look and can feel self-conscious about their bodies. This can be especially true when they are going through puberty, and undergo dramatic physical changes and face new social pressures.

Unfortunately, for a growing proportion of kids and teens, that concern can grow into an obsession that can become an eating disorder.

Eating disorders such as anorexia nervosa or bulimia nervosa cause dramatic weight fluctuation, interfere with normal daily life, and damage vital body functions.

Generally, eating disorders involve self-critical, negative thoughts and feelings about body weight and food, and eating habits that disrupt normal body function and daily activities.

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2.1.1. Types of Eating Disorders

2.1.1.1. Anorexia nervosaAnorexia nervosa is deliberate and sustained weight loss driven by a fear of distorted body image. In other words, anorexia involves loss of appetite while nervosa implies emotional reasons.

Anorexia Nervosa is not to be confused with anorexia, which is its symptomatic general loss of appetite or disinterest in food. It represents the refusal to maintain normal, healthy body weight. Anorexics don’t really lose their appetite, they actually may really want to eat food, but they refrain.

a.To be anorexic, a person must be 15% of his/her ideal weight. Most anorexics weigh 25-30% below their ideal weight. In girls and women who have begun menstruating, the weight loss causes them to stop having their periods (i.e. they get amenorrhea - missing 3 normal periods in a row). This is an indication that their weight is too low, and they may have anorexia.

Also, b.anorexics have an intense fear of gaining weight. Irrespective of continued weight loss, they have a fear that they are overweight, and will gain weight.

Thirdly, c.anorexics have a distorted sense of their body shape, despite being very thin. They often believe that they are fat and still need to lose more weight. Anorexics typically weigh themselves frequently throughout the day, and look at particular body parts, and spend more time gazing at themselves more critically. They often exercise to the point that it is punishing.

Statistical Manual of Mental Disorders (DSM-IV) characterizes Anorexia Nervosa by suggesting the following criteria:

A patient must be 15% below normal weight (average patient with Anorexia Nervosa is 25-30% below normal weight);

An intense fear gaining weight or becoming fat and a preoccupation with body weight and shape;

Distorted sense of body shape.

DSM-IV Subtypes:

a) Restricting type:

She/he tries to prevent food intake to prevent gaining weight, but eats enough to appease family and friends. They seem to be described as having deep feelings of mistrust of others, and a tendency to cope with their problems through denial.

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b) Binge/purge type

They have small binges that lead to purging behaviors. This type is generally more pathological; they exhibit more personality disorders, have more impulsive behavior, have more drug and alcohol abuse, and have more suicide attempts than the restricting type. Their course is more chronic than is the restricting type’s.

Anorexics are commonly perfectionists, driven to succeed; yet they set unattainable standards of performance for themselves. When they fail to meet these standards, they look for a part of their lives they can control; food and weight become that “control” for them. Low self-esteem and constant self-criticism cause anorexics to constantly fear losing control, and even consuming a small amount of food could be considered a loss of control.

Epidemiology of Anorexia Nervosa

90-95% of diagnosed with Anorexia Nervosa are female.

Onset begins in the early to middle teenage years. The onset usually follows after a period of dieting and the co-occurrence of a life stressor (usually an interpersonal life event like parental divorce or separation).

50% recover in 4 years – 30% still have Anorexia Nervosa after 4 years and beyond, and are still 30% under weight.

The death rate is 15%.

Medical consequences:

Cardiovascular Complications:

- Slowness of heart rate

- Irregular heart beat

- Fluid in the sac enclosing the heart

- Heart Failure

Metabolic Complications:

- Yellowing of the skin

Impaired taste:

- Hypoglycemia

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Fluid and Electrolyte Complications:

- Dehydration

- Weakness

- Tetanus

Hematological Complications:

- Susceptibility to bleeding

- Anemia

Dental Problems:

- Decalcification

- Tooth decay

Endocrine complications:

- Amenorrhea (missing 3 normal periods in a row).

- Lack of sexual interest

- Impotence

Gastrointestinal Complications:

- Salivary gland swelling

- Acute expansion of the stomach

- Constipation

General Complications:

- Weakness

- Hypothermia

The most serious medical complications of anorexia nervosa are:

- Heart failure

- Acute expansion of the stomach to the point of rupturing

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- Kidney damage

2.1.1.2. Bulimia NervosaBulimia nervosa is a cyclical and recurring pattern of binge eating (uncontrolled bursts of overeating) followed by guilt, self-recrimination and over compensatory behavior such as crash dieting, over exercising and purging to compensate for the excessive caloric intake.

Bulimia usually means “ox hunger”. It includes rapid binging. Eating is seen (by the patient) to be out of control. The patient is engaging in purging techniques.

Bulimics often have "binge food," which is the food they typically consume during binges. The binge episode leads the individual to feel guilt, shame, embarrassment, and complete failure. Bulimics try to regain control of themselves and the situation by purging the food–making up for their mistake. This leads to feeling famished and empty again, and therefore, another uncontrollable binge, followed by feeling powerless, and the vicious binge/purge cycle continues.

Bulimics have extreme eating and exercising habits, instead of demonstrating moderation. This compulsive behavior is often echoed in similar destructive behavior such as sexual promiscuity, pathological lying, and shoplifting. Some bulimics not only struggle with the eating disorder, but they have other harmful behaviors as well.

Subtypes of Bulimia Nervosa

a) Purging type:

There is evidence that purging type bulimics are more psychopathological than non-purging bulimics. They have more frequent binging, more co-morbid anxiety and depression than the non-purgers, more entrenched negative attitudes towards eating, and are distinguishable from binge-purge anorexia because the anorexics must be 15% below their normal body weight, where the bulimics don’t have to be 15% below their normal body weight.

b) Non-purging type:

They fast or exercise excessively after binging. Non-purging type involves rapid consumption of enormous amounts of food, often upwards of 2000-4000 calories (twice that required for the normal person in one day). Some people consume 15000 to 20000 calories in one episode.

1.2.2.3. Bulimia Nervosa and DSM-IV

The DSM says that binging has a.to be eating an excessive amount of food within 2 hours. The binging is usually concealed by the person.b. The binging usually continues until the person is uncomfortably full. C.After the binge is over, there are feelings of disgust and discomfort and there is a fear of weight gain. These feelings and fears together lead to purging behaviors. The purging techniques include self-induced vomiting, or using laxatives.

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Alternatively, the people exercise excessively (57% of bulimics).

About 57% of college students have binges.

Bulimics must have at least 2 binges per week for 3 months to meet the DSM-IV criteria.

Bulimia nervosa patients are afraid of gaining weight, and their self-esteem is dependent on regulating their weight. They also have a distorted view of their body image – they see themselves as fat, even when their weight is normal.

Epidemiology of Bulimia Nervosa

For women the prevalence rate is 1% while it is <1% for men.

Among women, 30% of 2000 reported binging at least once per month, but only 3% felt that the binges were out of control, and only 1% actually purged.

The full syndrome for bulimia is fairly uncommon.

The onset begins during adolescence.

Many patients with Bulimia Nervosa are overweight.

Medical complications

Renal complications:

- Dehydration

- Kidney disease

Gastrointestinal Complications

Electrolyte Abnormalities

Dental Problems

Laxative Abuse complications

Other Abnormalities

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2.1.2. Etiology of Eating Disorders2.1.2.1. Biological factors

Genetics – Both anorexia and bulimia run in families. Female relatives of women with an eating disorder are 5 times more likely to develop an eating disorder themselves. Concordance rates among monozygotic twins were 20% and 10% in dizygotic twins.

Hypothalamus – this is the key brain center in regulating hunger and eating. Lesions of the hypothalamus lead to weight loss and loss of appetite. The anorexics are still hungry, they just don’t eat. Their hypothalamus model fails to help us understand why people are still hungry, why they have a distorted body image, and why the fear becoming fat.

Endogenous Opiods – these are substances produced by the body that reduce pain sensations, and are released during periods of binging. Binging in anorexia is accompanied by release of opiods, which condition starving behavior. Bulimia may also cause the release of opiods.

Serotonin – the serotonin system is currently being researched extensively. This may relate to greater impulsivity which could lead to binge eating.

2.1.2.2. Family Factors

Family conflict – high levels of conflict within the family with parental denial. Families are socially isolated and have very little social support. There is guilt, frustration, fear and hurt, and the person with the disorder becomes part of the family dynamic. The expression of emotion becomes discouraged in these families.

2.1.2.3. Psychological Factors Low self-esteem (at least in terms of their physical appearance);

low perceived control;

Pre-occupation with how others feel about them;

Early social anxiety may be related to later eating disorder incidence. Purging behaviors in these cases may be used to relieve social anxiety.

2.1.3. TreatmentsTreatment focuses on helping kids cope with their disordered eating behaviors and establish new patterns of thinking about and approaching food. This can involve medical supervision, nutritional counseling, and therapy. The professionals will address a child's perception about his or her body size,

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shape, eating, and food. Kids who are severely malnourished may require hospitalization and ongoing care after their medical condition stabilizes. Generally, the earlier the intervention (ideally, before malnutrition or a continual binge-purge cycle starts), the shorter the treatment required.

2.1.3.1. Medications

Drug treatments have not been found to be effective in treating anorexia.

When medication is prescribed, it is usually an SSRI (antidepressants). Co-morbid depression may be helped by the SSRI’s. There have been some reports of SSRI’s (antidepressants) being helpful in treating bulimia. Prozac (an SSRI) leads to a 60% reduction in binging. As soon as the patient is off of the SSRI, the patient returns to binging.

- Tricyclics reduced binging 47%

- Prozac reduces binging 65%

2.1.3.2. Cognitive Behavioral Therapy

Therapist focuses on what binging does to the person’s body. Looks at the benefits of continuing to purge and use laxatives (doesn’t actually help reduce weight). Therapist schedules 5-6 meal times throughout the day, and tries to schedule small meals through the day to prevent cravings. He/she helps people develop coping strategies. This method results in 75% having a significant reduction in purging, and 57% had elimination in purging altogether.

Cognitive Behavioral Therapy remains the preferred treatment for bulimia.

Parents can help prevent kids from developing an eating disorder by nurturing their self-esteem, and encouraging healthy attitudes about nutrition and appearance. Also, if you are worried that your child may be developing an eating disorder, it's important to intervene and seek proper medical care.

It's important to remember that eating disorders can easily get out of hand and are difficult habits to break. Eating disorders are serious clinical problems that require professional treatment by doctors, therapists, and nutritionists.

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2.2. Attention deficit hyperactivity disorder (ADHD)Everybody probably knows at least one child considered to be hyperactive (Whalen, 1983) - a child who is overly impulsive, has trouble attending to the task at hand, and in general is exceedingly overactive: a child in perpetual motion, a child who flits around and blurts out but doesn't finish assignments or chores, a child with a short and highly flammable fuse, a child of the present who neither benefits from the past nor plans for the future (Loney, 1980).

Background

Attention Deficit Hyperactivity Disorder (ADHD) has also been called Childhood Hyperactivity, Hyperkinetic Syndrome, Attention Deficit Disorder, and Minimal Brain Dysfunction to name but a few of the more common terms.

Minimal Brain Dysfunction

Modern, scientific interest in what we now know as ADHD began in the 1940's with the work by Alfred Strauss and his colleagues (Schwartz & Johnson, 1985) (although reports about hyperactivity can be found as early as the 1800's [Barkley, 1981]). In a series of studies, Strauss isolated a number of characteristics which he believed could discriminate between groups of mentally retarded children with and without brain damage.

Associated with brain damage were aggressiveness, impulsivity, distractibility and hyperactivity. Hyperactivity was seen as the most valid indicator of brain damage (Schwartz & Johnson, 1985). And so, it became widely accepted for many years that children with hyperactive behavior patterns were also brain damaged; the term Minimal Brain Dysfunction (MBD) was widely used to identify these children.

Problem: Strauss's reasoning was circular! In effect, he was arguing that hyperactive children were brain damaged because they were hyperactive (Schwartz & Johnson, 1985).

Future research failed to find the link between hyperactivity and brain damage. Most children suffering from brain damage do not develop hyperactivity, and it's been estimated that fewer than 5% of hyperactive children suffer from brain damage (Rutter, 1977).

There was no clear understanding of just what was meant by MBD; some clinicians insisted that restlessness, distractibility, impulsivity, and short attention spans were the key, others insisted it was

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perceptual/conceptual/learning deficits, and still others saw aggressiveness as the key ((Schwartz & Johnson, 1985).

2.2.1. Attention Deficits and Psychosocial Variables

During the late 60's and early 70's, the focus shifted to the attentional qualities of the disorder. Virginia Douglas and her colleagues at McGill University demonstrated the marked attention deficits seen in these children. Douglas argued that the major deficit was the inability to "stop, look, and listen" (Douglas, 1972) – i.e: to sustain attention and inhibit impulsive responding (Barkley, 1981).

In the late 70's, the focus broadened: research was indicating that the problems went beyond mere attention deficits. People like Susan Campbell and Charles Cunningham conducted a number of studies on parent-child interaction. It was found that the hyperactive children were noncompliant, attention-seeking and aggressive, and in need of ongoing supervision; and the mothers were overly directive, negative, and less responsive to the child in general (Barkley, 1981).

Thus, researchers included social variables into the increasingly complex picture. Compliance and aggressiveness gained diagnostic importance.

1. Inattention

Inattentiveness is a key symptom of ADHD. Difficulties in attention can take various forms (Barkley, 1981; Levine, 1987):

• trouble orienting to stimuli;

• failure to even detect stimuli;

• respond to the wrong aspects of a stimulus or to an entirely inappropriate stimulus;

• failure to sustain attention to task-relevant stimuli, while inhibiting responding to nonrelevant stimuli - they are easily distracted / short attention span;

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• In the home: failure to complete chores, homework, etc, to listen to directions, to play for prolonged periods without supervision or attention form others;

• At school: problems with attending to the teacher and completing in-class assignments. The child is often distracted by other events (what other kids are doing, what's happening outside the window...). However, they may attend at length to these nonrelevant stimuli - so the problem is more than just a short attention span; it often seems to be a problem of allocating the right amount of time and focus to the appropriate information (Levine, 1987).

Note: Many children who exhibit deficits in attention alone do not have ADHD (Garfinkel, 1986). Problems with attention may be time limited, due to environmental factors (stressors, significant distractions), physiological variables (fatigue, illness), and mood (irritability, anger). Attention deficits are also seen in other disorders such as depression and mental retardation. So, by itself, attention deficits are not usually sufficient to make the diagnosis of ADHD (Garfinkel, 1986). They must be part of a larger clinical picture.

2. Impulsiveness

Impulsivity or the failure to inhibit responding, has also been identified as a primary characteristic. This can take various forms (Barkley, 1981):

o quick responding, with numerous errors;

o do not stop to think about consequences of their actions place themselves in dangerous and risky situations;

o fail to fully appreciate all aspect of instructions given to them;

o more likely to respond aggressively (verbally and physically) when frustrated or emotionally hurt by others;

o do not consider the impact of their actions or statements on others.

Such actions can lead others to see such children as immature and to their being shunned by others. The impulsive child will also experience more punishment than normal children.

3. Hyperactivity

Over activity has also been identified as a key feature of ADHD. The typically picture of such a child is "long on motility and short on restraint" (Loney, 1980); in other words, always on the move, with no apparent regard to rules, directions, or the like. It is thus not surprising that ADHD is often first identified

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upon the child's entrance to school. It is here that hyperactivity (as well inattentiveness and impulsivity) is directly incompatible with the structure and goals of the classroom.

There is some debate, however, over the significance of excesses in motor behavior. Studies that have actually measured rates of motor activity have found that ADHD children are not necessarily more active than other children, certainly not in all situations. Hyperactivity seems to be most often a problem when the child is in a restrictive environment where concentration is required (eg: a classroom!). Novel or unfamiliar situations seem to elicit the hyperactive behaviors as well (Barkley, 1981).

2.2.1.1. Biological factors

Much research has been conducted to find specific organic or neurological factors that could account for ADHD. The "jury is still out", although a number of factors have been hypothesized:

1. Prefrontal cortex abnormalities:

This part of the brain plays an important role in inhibiting, modulating, planning, and regulating complex behavior, such as planning for the future and following instructions. People with damage to this part of the brain often exhibit ADHD-like symptoms (inattentive, easily distracted, impulsive, restless, etc). It has thus been hypothesized that ADHD may be caused by abnormalities in this part of the brain (Barkley, 1981). Nevertheless, there is presently no clear direct evidence to support this hypothesis.

2. Neurotransmitter abnormalities:

It is known that many (60-90%) [Schwartz & Johnson, 1985]) ADHD children respond to stimulants with reduced ADHD symptoms, a seemingly paradoxical effect. The behavior most improved: attention. For a number of years it was thought that this effect indicated abnormal biochemical processes, especially deficiencies of the neurotransmitters norepinephrine and dopamine (Barkley, 1981).

More recent research, however, has shown that ADHD children do not respond differently to stimulant drugs than "normal" children: Stimulants increase attention and concentration for both groups (Schwartz & Johnson, 1985, Yellin, 1986)). There is nothing "paradoxical" about the effects of these drugs: they have the same effects on non ADHD children. This does not necessarily mean neurotransmitters are not etiologically important, only that their importance must be more complex than a simple deficiency model.

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3. Neurological Immaturity:

An alternative hypothesis is that maturation of central nervous system structures is delayed, rather than actually damaged (Barkley, 1981). Observations of ADHD children make this hypothesis appealing - the children do seem to be acting in immature ways. Some studies of brain activity (especially CNS structures underlying attention and response inhibition) also suggest immature processes. For example, as many as 50% of ADHD children show under aroused EEG (a recording of brain waves) patterns suggestive of cortical immaturity (Barkley, 1981). Nevertheless, the support for this hypothesis is still very far from conclusion.

4. Genetics

Studies have found a higher incidence of ADHD in the biological relatives of hyperactive children than in the population at large. This seems to be true even with ADHD children who are adopted. Similarly, there is a high concordance rate for twins (when one twin has ADHD, the other has a higher than average chance of also having ADHD) (Barkley, 1981; Schwartz & Johnson, 1985). These studies all suggest a genetic component to the disorder, although how general and how significant the genetic contribution remains to be determined.

5. Other signs:

Abnormalities have been found in EEG patterns, Event-related potentials, particularly the P300, and skin conductance (Yellin, 1986). In addition, drugs that reduce ADHD symptoms (Ritalin) also normalize the abnormal P300 patterns. These findings all point to deficits in arousal and orienting, in processing information from the environment, or in other words: deficits in "arousal" and "attention". Because ADHD children appear to have a lower than normal state of arousal, some researchers have hypothesized that the children are therefore engaging in extra activity in order to increase their level of stimulation (Schwartz & Johnson, 1985). This could also be why stimulant drugs are effective - they provide the needed stimulation.

2.2.1.2. Environmental Factors

Various toxins and allergy-producing substances in the environment have been identified as possibly relevant to the etiology of ADHD.

1. Lead Poisoning:

Lead is found in many substances: paint, automobile fumes (although this is decreasing as unleaded fuel becomes more the standard). A number of studies during the 70's noted an elevated level of lead in the blood of ADHD children. 30 -35% of children with elevated blood lead levels were also hyperactive. So,

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there does seem to be a connection between lead and at least one symptom of ADHD: hyperactivity (Barkley, 1981: Schwartz & Johnson, 1985).

2. Food Additives and Refined Sugars:

For a while there was a lot of talk about food additives (eg: artificial food colorings and flavorings) and refined sugars as being a cause of ADHD. The interest in this hypothesis was spurred on by the publication of the popular book Why Your Child is Hyperactive, by Feingold, in 1975. While still quite popular as an explanation of the disorder, there is actually very little scientific evidence to support this hypothesis (Barkley, 1981).

2.2.1.3. Psychosocial Factors

Some researchers have claimed that hyperactivity is the result of poor parenting skills: inconsistent rules, over-reliance on punishment, excessive and ill-timed commands.

Indeed, treatment programs which teach parents more effective parenting skills have had significant success.

Nevertheless, it is not at all clear that these psychosocial factors are the cause of ADHD. For example: such a model fails to explain why ADHD symptoms often occur at a very early age; or why the symptoms are consistent across situations (home, school, play) and thus different forms of child management.

In addition, inconsistent or chaotic rules, excessive punishment, and the like are possibly a result of ADHD. There is a concern that parents are being blamed for something that is not their fault (Barkley, 1981).

Nevertheless, it is safe to say that for some of these children, parenting styles can have an important influence on maintaining or even aggravating the ADHD symptoms (Wicks-Nelson & Israel, 1984).

2.2.1.4. Other Factors:

Various other environmental factors have been suggested, including low-level X-rays emitted by fluorescent lights, maternal smoking during pregnancy, and maternal alcohol consumption during pregnancy. These factors have failed to gain any clear cut support, however (Barkley, 1981).

2.3. Adolescent outcome

Most studies indicate the core features persist; however, they are frequently no longer the most obvious complaint. Instead, the following become salient:

poor school performance;

social deviancy;

relationship difficulties with peers and adults;

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delinquency;

low self-esteem;

significant under-achievement;

nervousness, restlessness;

aggressive/easily angered;

Alcohol/drug use or abuse.

There is also some indication that a significant percentage of ADHD adolescents (about 25%) have a history of antisocial behavior. It has been suggested that adults with Antisocial Personality Disorder may have been hyperactive as children.

2.4. Adult outcome

As many as 1/3 to 1/2 of hyperactive children continue to be troubled by symptoms of ADHD in adulthood. Continued problems seem particularly likely if antisocial behavior and drug use/abuse was present in their childhood/adolescence. Adulthood problems include:

20% or more have Antisocial Personality Disorder;

low self-esteem;

impaired social skills;

Inferior work status (held jobs for a shorter duration, laid off/quit more frequently, inferior work performance).

2.5. Treatment

Effective treatments for ADHD are available, and include psychotherapy and medications.

2.5.1. Medication

The most common type of medication used for treating ADHD is called a "stimulant." Although it may seem unusual to treat ADHD with a medication considered a stimulant, it actually has a calming effect on children with ADHD. Many types of stimulant medications are available. A few other ADHD medications are non-stimulants and work differently than stimulants. For many children, ADHD medications reduce hyperactivity and impulsivity and improve their ability to focus, work, and learn. Medication also may improve physical coordination.

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2.5.2. Psychotherapy

Different types of psychotherapy are used for ADHD. Behavioral therapy aims to help a child change his or her behavior. It might involve practical assistance, such as help organizing tasks or completing schoolwork, or working through emotionally difficult events. Behavioral therapy also teaches a child how to monitor his or her own behavior. Learning to give oneself praise or rewards for acting in a desired way, such as controlling anger or thinking before acting, is another goal of behavioral therapy.

Parents and teachers also can give positive or negative feedback for certain behaviors. In addition, clear rules, chore lists, and other structured routines can help a child control his or her behavior.

Therapists may teach children social skills, such as how to wait their turn, share toys, ask for help, or respond to teasing. Learning to read facial expressions and the tone of voice in others, and how to respond appropriately can also be part of social skills training.

CHAPTER III: SUBSTANCE ABUSE DISORDERS3.1. Definitions

Substance disorders, as the term suggests, are disorders related to the misuse of certain substances, usually drugs. These disorders are the result of the actions of the toxins in the substances on the individual’s mental activities. Common terms vis-à-vis substance disorders include substance/drug abuse, addiction, alcoholism, etc.

Substance abuse is the overindulgence in and dependence of a drug or other chemical leading to effects that are detrimental to the individual's physical and mental health, or the welfare of others.

The disorder is characterized by a pattern of continued pathological use of a medication, non-medically indicated drug or toxin, that results in repeated adverse social consequences related to drug use, such as failure to meet work, family, or school obligations, interpersonal conflicts, or legal problems. Sometimes drugs are good for you.

Substance abuse may lead to addiction or substance dependence. Medically, physiological dependence requires the development of tolerance leading to withdrawal symptoms. Abuse is distinct from dependence and addiction, which involves a compulsion to continue using the substance despite the negative consequences, and may or may not involve chemical dependency.

Dependence almost always implies abuse, but abuse frequently occurs without dependence, particularly when an individual first begins to abuse a substance. Dependence involves physiological processes while substance abuse reflects a complex interaction between the individual, the abused substance and society.

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Drug abuse is sometimes used synonymously with drug addiction, and chemical dependency, but it actually refers to the use of substances in a manner outside sociocultural conventions. All use of illicit drugs and all use of licit drugs in a manner not dictated by convention (e.g. according to physician's orders or societal norms) is abuse according to this definition, however there is no universally accepted definition of substance abuse.

3.2. Difference between abuse and dependence

The diagnosis of substance abuse is given when the person’s recurrent use of a substance results in significant harmful consequences. There are four categories of harmful consequences that suggest substance abuse:

A person fails to fulfill important obligations at work, school, and home.

He/she repeatedly uses the substance in situations in which it is physically hazardous to do so.

He/she repeatedly has legal problems as a result of substance use.

He/she continues to use the substance even tough he/she repeatedly had social or legal problems as a result of the use.

A person has to show repeated problems in at least one of these categories within a 12-month period. The diagnosis of substance dependence preempts the diagnosis of substance abuse, since dependence is considered a more advanced condition than abuse. This is what we are talking about when we colloquially talk about an addiction.

A person is physiologically dependent on a substance when he/she shows either tolerance or withdrawal from the substance. Here, tolerance refers to the tendency to require greater and greater amounts of the drug to experience the same effect whereas withdrawal refers to the negative physical symptoms which occur when the substance is no longer ingested.

Physiological dependence, however, is not required for a diagnosis of substance dependence. The diagnosis can be given when a person compulsively uses a substance. With dependence, the person is often in a constant state of craving for the substance, and will often do anything to get it.

Symptoms of Substance Dependence:

- Tolerance to the substance, indicated by a need fort increased amounts of the substance to achieve intoxication and or by a diminished effect of the same amount of substance with continued use, is experienced.

- Symptoms of withdrawal from the substance and the use of the substance to relieve or avoid withdrawal symptoms are experiences.

- The substance is used over a longer period of time or in larger amounts than was intended.

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- The person has a persistent desire to cut down on substance use or stop using it altogether.

- The person spends a great deal of time acquiring or using the substance or recovering from its effects.

- The person gives up or reduces important social or job-related activities as a result of substance use.

- The person continues to use the substance despite recurrent physical or psychological problems that result from substance use.

3.3. Alcohol Use and Dependence

Alcohol abuse is the diagnosis given to someone who uses alcohol in dangerous situations, fails to meet obligations at work or at home due to alcohol use, and has recurrent legal or social problems.

Alcohol dependence is the diagnosis given to someone who has a physiological tolerance to alcohol, spends a lot of time intoxicated or in withdrawal, or continues to drink despite significant legal, social, medical, or occupational problems that result from the alcohol.

3.3.1. Three distinct patterns of alcohol abuse:

- One is that the alcoholic drinks large amounts of alcohol every single day.

- The second type of drinking pattern of alcoholics is the showing of abstinence for a certain period of time, but then goes on binges for days of weeks.

- The third drinking pattern of alcoholics is that they are sober during the week days, but drink heavily during the evenings or weekends.

People who begin drinking early in life develop their alcoholic withdrawal symptoms during their early 30s and 40s. There are three stages of withdrawal symptoms:

Stage 1: Usually begins a few hours after drinking has stopped. Symptoms may include tremors, weakness, and heavy perspiration. At moderate levels of dependence the person may experience these symptoms for a few days and then they disappear all together.

Stage 2: The person experiences convulsive seizures that usually occur between the second and third day.

Stage 3: The person has auditory, visual, and tactile hallucinations, and the person often experiences delusions. The person often experiences agitation, disorientation, and is stuck in a fever. In 10% of cases, this level of withdrawal will lead to death. Fortunately, only 11% of individuals with alcoholism will experience stage 3 or stage 2 symptoms.

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3.3.2. Dementia resulting from Alcoholism

Dementia may occur as a result of neurotoxicity of the brain by excessive amounts of alcohol – resulting in a loss of intellectual abilities including memory, abstract thinking, judgment, and problem-solving, often accompanied by personality changes. Dementia occurs in about 9% of those diagnosed with substance dependence (alcoholism) and is the second greatest cause of adult dementia.

The effect of alcohol use extends beyond the well-being of the drinker. The effects of alcohol can extend to the children born to mothers who are alcoholics. This effect is termed Fetal Alcohol Syndrome. The child may be born with fetal growth retardation, cognitive deficits, behavioural problems, and learning difficulties. The development of fetal alcohol syndrome is dependent on high alcohol use and a genetic risk factor.

3.4. Cocaine Use Disorders

Cocaine became popular in the 1970s. In small amounts, cocaine leads to feelings of euphoria, alertness, feelings of self confidence, and creativity. This comes as cocaine activated the areas of the brain associated with reward and pleasure. These effects are often short lived (around 1 hour), and so the user must take frequent doses. Tolerance can develop very easily with cocaine. At high doses, or even when taken chronically, cocaine can lead to hyper sexuality, agitation, and increased anxiety and paranoia. In fact, 2/3 of cocaine users report paranoia.

Many cocaine users started with chronic alcohol or marijuana use, and then moved on to cocaine. Cocaine makes the heart beat more rapidly and more irregularly, potentially leading to heart failure. Babies may also be affected by mothers using cocaine. These babies are known as Crack babies, are more irritable, and have a high pitched squealing cry. The effects may be due to the cocaine, or to other substances (such as alcohol or nicotine).

3.5. Theories of Substance Use Abuse and Dependence: Etiology

3.5.1. Biological Models

Family history, adoption, and twin studies all suggest that genetics may play a substantial role. The sons of alcoholic fathers are 4 –5 times more likely to develop alcoholism than are sons of non-alcoholic sons. Mucuge found that the concordance rate for alcoholism was 0.76 for monozygotic twins, and 0.53 for dizygotic male twins. For female twins, it was 0.38 for monozygotic twins, and 0.42 for dizygotic twins (NS).

The strongest genetic factor was found to be for early onset alcoholism. What is inherited in this risk is that people with this genetic risk factor report less intoxication with small doses of alcohol than do people without this genetic risk factor. There seems to be lower reactivity to moderate doses of alcohol in this genetic predisposition, leading to the requirement for more alcohol to achieve intoxication, and faster build up of tolerance. Long term studies of men with lower reactivity to moderate doses of alcohol show that they are significantly more likely to become alcoholics than are men with out this low reactivity.

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3.5.2. Neurobiological Models

All of the studies we have talked about so far have effects on the brain. The mesolimbic dopamine system in particular seems to be widely implicated. It is activated by natural rewards of many kinds (e.g. good food, sexual pleasure). The mesolimbic dopamine system is more intensely activated by drugs than by natural pleasure. One hit of cocaine feels so good that you want to come back to it. When the mesolimbic system is activated the brain may try to counter the effects by releasing factors that have the opposite effects of the drugs. This is known as the opponent processes.

The opponent processes may remain active after the substance use has been stopped, and it may be that it is these opponent processes that produce withdrawal symptoms.

Chronic use may permanently affect the mesolimbic dopamine system causing craving for the abused substances even after the drug use has stopped. There is increased sensitivity in the mesolimbic dopamine system after drug use, leading to a strong craving for the used substance.

3.5.3. Psychological Models

1. Reinforcement Models

All of the psychoactive drugs are pleasurable in some way. From a psychological perspective, these reinforcing effects may be particularly attractive to people under great stress. Higher rates of abuse and dependence among people facing severe chronic stress. This includes people living in impoverishment, amongst women in abusive relationships, and amongst adolescents living in families experiencing conflicts. About 20% of Vietnamese people used Heroin during the war, and 50% continued using even after the war. Drugs also help people escape from pain. Opiods help people escape pain, alcohol helps people escape stress.

2. Cognitive Factors

Cognitive theories have focused on people’s expectations about the use of the drug. People expectation will determine weather or not people will go on to use the drug, and the beliefs about the appropriateness of using the drug might also predict those who go on to abuse or dependence. People who expect alcohol to reduce their stress and who don’t have other means of coping are more likely to resort to alcoholism.

3.6. Treatments

The first step in treatment is getting the person to Detox. They have to get off the drug, and the drug must be allowed to exit the body. Once the drug is out of the body, a variety of treatments are available

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to prevent relapse. Symptoms of withdrawal may be so severe that other drugs may be prescribed to reduce symptoms.

In alcohol dependence, a benzodiazopine may be prescribed to reduce dependence (the dose is really low to prevent addiction).

Gradual withdrawal from heroin can be used through the use of a substitute drug known as methodone. Methodone is an opiod itself, but it is less potent, and longer lasting than heroin. Heroin dependents are given drugs that reduce the effects of heroin.

Neltraxone and melaxone block the effects of opiods, preventing the effects of heroin.

Neltraxone also removes the effects of alcohol.

Antabuse makes people vomit if they consume alcohol.

Psychosocial treatment is usually done through AA. In this treatment, people completely abstain from drinking. This is done in 12 steps. The people have to accept that they are powerless, and that there is a need for a higher power. These features don’t appeal to everyone. Drop out rates in an AA program tend to be 75%. Yet, AA remains the most common source of treatment with alcoholism.

CHAPTER IV: SCHIZOPHRENIC DISORDERS 4.1. Characteristics of schizophrenia

Schizophrenia, a class of psychological disorders, is perhaps the ultimate in psychological breakdown (Carson, et al., 1988). The individual typically has marked breaks with and distortions of reality.

Schizophrenia "strikes at the very heart of what we consider the essence of the person" (Carpenter, 1987, p.3). Such a disturbance is often termed psychotic to distinguish it from the milder "neurotic" disorders (Anxiety and Mood disorders). Schizophrenia affects all areas of functioning: thought, perception, emotion, behavior. A Schizophrenic individual suffers from impairment in multiple areas of functioning.

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The following is a list of those symptoms:

1. Content of Thoughts: delusions (false beliefs). Example: Others are able to read my thoughts (thought broadcasting), thoughts are being placed in my head (thought insertion), and other people/beings are controlling me.

2. Form of Thoughts: Example: loose associations (one thought has little to do with the previous or forthcoming thoughts), poverty of content (talks a lot, but says very little), unique/made-up words (neologisms), clanging (speech follows meaningless rhymes). The specificity of thought disturbances is not altogether clear (disturbances of thought occur to varying degrees in many psychological disorders (Rattenbury Silverstein, De Wolfe, et al., 1983).

3. Perception: hallucinations, especially auditory. Example: hearing voices.

4. Affect: flat and/or inappropriate emotional responses. Example: extreme silliness or an utter lack of emotion.

5. Sense of Self: no sense of self, of being an individual. No sense of meaning.

6. Volition: inadequate self-initiated behavior. Example: inability to meet goals or complete tasks.

7. Interpersonal Relations: withdrawn, detached (sometimes called "autism") or excessive clinging, dependency, and intrusiveness.

8. Psycho-Motor Behavior: unresponsive or bizarre responses to the environment. Example: Catatonia (such as extreme rigidity or stupor), overexcited activity, strange faces.

The final, overarching diagnostic criterion is that the person's functioning has declined markedly below the highest level of functioning achieved prior to the disorder. This criterion is included to discriminate between people with Schizophrenia and those with more isolated problems (such as someone who, although experiencing some form of delusion, shows no reduction in social or work functioning). Schizophrenia typically involves impairment in multiple areas of functioning. Because of the impairment is often so pervasive, schizophrenic individuals often require prolonged or repeated hospitalization.

Case Study: (Susan, a young woman, placed by her school in a class for the emotion disturbed)

She talked at length about her interests and occupations. She said she made a robot in the basement that ran amok and was about to cause a great deal of damage, but she was able to stop it by remote control.

She claims to have built the robot from spare computer parts, which she acquired from the local museum. When pressed on details of how this worked, she became increasingly vague, and when asked to draw a picture of one of her inventions, drew a picture of an overhead railway and went into what

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appeared to be complex mathematical calculations to substantiate the structural details, but which in fact consisted of meaningless repetitions of symbols (plus, minus, divide, multiply).

When the interviewer expressed some gentle incredulity, she blandly replied that many people did not believe that she was a supergenius. She also talked about her unusual ability to hear things other people cannot hear, and said she was in communication with some sort of creature. She thought she might be haunted, or perhaps the creature was a being from another planet. She could hear his voice talking to her and asking her questions (Spitzer, Skodol, Gibbon & Williams, 1981, p.221-222).

The DSM-III-R has suggested a narrow conception of Schizophrenia, as illustrated by its diagnostic criteria.

1. Duration Criterion

To be diagnosed as Schizophrenic, the individual must have had the symptoms for at least 6 months. This criterion eliminates brief psychotic episodes and Mood Disorders such as Major Depression from the diagnostic category of Schizophrenia.

2. Characteristic Symptoms

Only those symptoms that are reliably identifiable are included. Problem: even with a highly reliable symptom, if it occurs infrequently it may not be useful as a criterion symptom. The symptoms should be common enough to be present in enough patients so that the diagnosis can be made accurately. In addition, the symptoms ideally discriminate between Schizophrenia and other disorders (i.e.: symptoms shouldn't also typically occur in other disorders).

3. Age Criterion

DSM-III required onset prior to age 45. This criterion has been broadened a bit in the DSM-III-R: onset can occur after 45, but you must specify it as "late onset". The idea is that, after 45, we may be dealing with a different disorder, perhaps symptoms due to natural aging processes.

4. Organic Exclusion Criterion

If there is evidence that the symptoms are due to an organic (biological) disorder (example: mental retardation, drug intoxication) then the diagnosis of Schizophrenia is not made. This is a confusing criterion, especially with all the evidence that various organic factors may be the cause of Schizophrenia.

4.2. Types of schizophrenia

In recognition that there do seem to be distinct types of Schizophrenia, a number of subtypes have been defined in the DSM-III-R.

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1. Catatonic Type

The essential feature is serious motor behavior disturbance. Such disturbance can take various forms: Stupor (marked decrease in responsiveness to environment, reduction in spontaneous movements, mutism); Negativism (resistance to all instructions or attempts to be moved); Rigidity (maintaining a rigid posture against all efforts to be moved); Excitement (purposeless and excited activity and movements); Posturing (voluntary assumption of inappropriate or bizarre postures, often for extended periods of time).

2. Disorganized Type (previously known as hebephrenia)

A particularly severe (although also less common) type of Schizophrenia, characterized by incoherent behaviors, thoughts, and affect. There is extreme loosening of associations. The individual seems to become increasingly indifferent and infantile. Giggling, silliness, weeping, anger and other reactions inexplicable and inappropriate to the situation are common. In some cases the incoherence progresses to the point where the person "makes no sense at all".

3. Paranoid Type

Characterized by delusions that have themes of suspiciousness, persecution, or grandeur. For example, the individual may become extremely suspicious that everyone at work is trying to kill him, or that he possesses some profound or even divine powers. Hallucinations will often accompany these delusions, often reinforcing the false beliefs.

4. Undifferentiated Type

A "waste basket" category, for those individuals who do not fit neatly into the other categories, but who do show prominent psychotic symptoms (delusions, hallucinations, incoherence, grossly disorganized behavior).

5. Residual Type

A category reserved for those individuals who have had at least one episode of Schizophrenia, but where there are no prominent psychotic symptoms. Nevertheless, the individual still exhibits signs of disorder (eg: marked social isolation or withdrawal, peculiar behavior, inappropriate affect, illogical thinking, mild loosening of associations).

6. Alternative Subtyping Schemes Most investigators would agree that Schizophrenia is probably made up of a heterogeneous group of disorders. However, not all would agree with the way the DSM-III-R has

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cut up the pie. The DSM- III-R is just one of many proposed subtyping systems (Andreasen, 1985; Andreasen, 1987; Carson, et al., 1988; Neale Oltmanns, 1980):

a) Process vis-à-vis Reactive

Some cases of Schizophrenia develop slowly and gradually over a period of time, not in response to any obvious stressors, and tend to be long-lasting. Other cases seem to arise quite suddenly, marked by intense emotional turmoil and confusion. These cases are often associated with identifiable stressors; the symptoms usually fade. These two subtypes have been termed Process Schizophrenia and Reactive Schizophrenia, respectively. Alternative terms that are approximately equivalent have been Poor Premorbid or Chronic Schizophrenia for the Process type, and Good Premorbid or Acute Schizophrenia for Reactive Schizophrenia.

b) Paranoid vis-à-vis Nonparanoid

Schizophrenia has also been subdivided and based on the presence or absence of paranoid symptoms (delusions and hallucinations of grandeur, persecution, suspiciousness, etc). Paranoid type: paranoid symptoms are a dominant feature. Nonparanoid type: paranoid symptoms, if present at all, tend to be fleeting, rare, and inconsistent. Paranoid Schizophrenia tends to be more "reactive" than "process" in type, to have a more benign course and outcome, and has a less clear genetic link. There may be, however, a subgroup of paranoid schizophrenics whose disorders are quite chronic.

c) Positive vis-à-vis Negative

Currently, there is much interest in the possible subtyping of Schizophrenia into positive and negative types. [To some extent, this approach overlaps the "process" vis-à-vis "reactive" approach].

Positive Schizophrenia: prominent positive symptoms (delusions, hallucinations, emotional turmoil, motor agitation, bizarre behavior, and perhaps catatonic features). In addition, there tends to have been good premorbid adjustment, a relatively acute onset, and a good prognosis.

Negative Schizophrenia: negative symptoms (dulled emotions, little movement, impaired or absent reactivity to the environment). In other words, there is a deficit or absence of behaviors normally present in a person's repertoire. In addition, there tends to be poor premorbid adjustment, suggesting an underlying process beginning early in life (perhaps biological); onset is slow and subtle, making it difficult to date the precise time of onset; and there is a poor prognosis.

4.3. Causes and prognosis of Schizophrenia

4.3.1. Psychosocial Factors

Most researchers today see psychosocial factors as part of an overarching diathesis-stress model - that is, there is an interaction between genetic/biological predispositions and environmental stresses.

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Vulnerability

To identify psychosocial vulnerability factors (i.e.: personal attributes of the person and social/environmental conditions which predispose the person to schizophrenia), it is necessary to examine the person and his/her environment prior to the development of the disorder. Typically, identification of such "high-risk" people is accomplished by finding children with one or more schizophrenic blood relatives (usually a parent). It is hypothesized that such individuals are at higher risk than those without disturbed relatives (Goldstein, 1987).

2. Developmental Dysfunction

A number of cognitive and behavioral abnormalities have been identified in children who later develop schizophrenia (Goldstein, 1987, for a review). These include:

- periods of disorganized or delayed motor, visual, physical development

- impaired balance, motor coordination, perception, attention

- passive, unenergetic, short attention span

- cognitive impairment on complex tasks.

These abnormalities, however, are not consistently found across studies. Results are often contradictory. Currently, these findings are suggestive at best.

4.3.2. Social Factors

Perhaps one of the most consistent social factors associated with later onset of schizophrenia is marked social withdrawal and generally poor interpersonal relationships (Goldstein, 1987, Parnas, Schulsinger, et al., 1982). These social difficulties become particularly noticeable during later childhood and adolescence.

Problem: Such social problems are seen with children who develop other psychological disorders as well.

4.3.3. Psychosocial Stress Factors

The family environment as a source of chronic stress has been hypothesized to be a critical provoking factor in schizophrenic disorders.

4.3.3.1. Communication

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During the 1950's there was a growing interest in the role disturbed family interactions might play in the development of schizophrenia in a family member. Of particular interest were disturbed patterns of communication.

1. Double binds

Bateson and his colleagues (example: Bateson, Jackson, Haley & Weakland, 1956) identified a particularly insidious communication pattern that they hypothesized could play a causal role in schizophrenia. They first noted that communication occurs on multiple levels: verbal, facial, voice tone, posture. In the double bind situation, a parent gives the child simultaneous messages on more than one level which contradict each other: he/she says one thing but acts differently.

For example: A schizophrenic patient, glad to see his mother "impulsively put his arm around her shoulders, whereupon she stiffened. He withdrew his arm and she asked, "Don't you love me anymore?" He blushed, and she said, "Dear, you must not be so easily embarrassed and afraid of your feelings." (Bateson, et al., 1956, p.251).

No matter what the child does, he/she loses. This "crazy" type of communication, Bateson hypothesized, leads to "crazy" behavior and thought processes.

Once a very popular theory of schizophrenia, there has not been a lot of empirical support for the double bind hypothesis. In addition, it has been difficult to explicitly define double bind communication. Thus, even if it does occur, it is difficult for researchers to agree on when it has occurred (Ringuette & Kennedy, 1966).

2. General Communication Patterns

Other lines of research have looked at general patterns of communication within the family as a whole. Families of schizophrenics tend to have deviant communication patterns. For example, parents are unable to establish a focus of attention and instead communicate with each other and other family members in an incoherent manner (Wynne, Singer, Bartko & Toohey, 1975).

Verbal exchanges are often confused, vague, or incomplete. For example (Wynne & Singer, 1963, quoted in Neale & Oltmanns, 1980, p.315):

• Daughter (presenting patient), complainingly: Nobody will listen to me. Everybody is trying to still me.

• Mother: Nobody wants to kill you.

• Father: If you're going to associate with intellectual people, you're going to have to remember that still is a noun and not a verb.

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One hypothesis is that such communication patterns teach the child the disturbed thinking associated with schizophrenia. In addition, these communication disturbances are often occurring in the context of marital conflicts, thus making the home environment even more stressful for the child. The child is caught between his parents (Neale & Oltmanns, 1980), in a situation that makes very little sense.

It seems clear that deviant communication occurs in these families, but such deviance may not be causally related to schizophrenia. For instance, both the schizophrenia disorder and the deviant communication patterns may be due to some third variable, such as a family genetic defect (Reis, 1974, Goldstein, 1987).

Alternatively, we may just have our causal arrows pointing the wrong way: the presence of a schizophrenic person in the family may give rise to the disturbed communication. Perhaps such communication is how the family learned to cope with the schizophrenic child. For example, in one study (Liem, 1974), 11 families with schizophrenic sons were compared with 11 families with normal sons.

Results:

- Disorder was not observed in the communications of parents of schizophrenic sons - there was no significant difference between the two sets of parents;

- Normal and schizophrenic sons were not differentially affected by the communications of normal and schizophrenic parents;

- Both sets of parents were adversely affected by the communications of schizophrenic sons.

In any event, the communication variables that are hypothesized to be stressful and thus provoke a schizophrenic episode also appear to contribute to its exacerbation. Interventions that teach family members more adaptive communication methods have lead to substantial reductions in relapse rates. Indeed, family based communication skills training appears more effective than individual psychotherapy or drug treatment in reducing relapse rates over a 1 year period (Goldstein, 1987).

3. Expressed Emotion

Another family variable associated with schizophrenia is a negative emotional climate, or more generally, a high degree of expressed emotion (EE). Of particular interest are things like critical comments, hostility and emotional overinvolvement (high levels of tension and emotion).

It has been claimed by some that families with high EE seem more likely to have a member who develops a schizophrenic disorder (Goldstein, 1987). Nevertheless, the problems with interpreting communication deviance discussed above, apply here as well.

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The most consistent evidence is that EE modulates relapse (Falloon, 1988): A patient returned to a family with high EE is much more likely (e.g.: 76%) to relapse, than a patient whose family is low in EE (e.g.: 28%) (Brown, Monck, Carstairs & Wing, 1962; see also Brown, Birley & Wing, 1972). What seems to then happen is that the negative emotional climate (eg: hostility and criticism) in these families raises the patient's arousal and stress beyond his or her already impaired coping mechanisms.

An alternative explanation: patients in high EE families are initially more disturbed than patients in low EE families - i.e.: severe pathology is the key variable for both the negative emotional climate and the increased relapse rate. The data do not support this, however, neither relapse rate nor level of EE is related to the degree of disturbance.

Indeed, relapse rates have been found to be related to the extent to which the patient is actually exposed to the EE climate: In one study (see Neale & Oltmanns, 1980), relapse rates were examined not only for low EE and high EE groups, but also within the high EE groups based on the amount of time the patient spent in face-to-face contact with family members.

Family based therapies, already shown to be particularly effective in reducing relapse rates, also typically decrease (Doane, Goldstein, Miklowitz & Falloon, 1986). In fact, whatever the therapy method (family based, individual...), when family members shift to low EE patterns, relapse rates are as low as 0%; if EE stays high, relapse rates stay high (Hogarty, Anderson, Reiss, et al., 1986).

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