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Ask the class how this knowledge
might change their individual therapies of abnormal or pathological behavior.
2. What if someone were to give each member of your class a psychiatric diagnostic label
and offer each of them $100,000 if they would go into a mental hospital ward and live up
to their label for a month without being discharged as either cured or normal? How well
do class members think they would do? What specific acts would they engage in? Have
a student randomly select a diagnostic label from the chapter and then have the class list
the specific actions they would perform to demonstrate the accuracy of the diagnosis.
What does “abnormal” actually mean? Ask the class to give you an operating definition.
Does it mean “crazy”? “Different”? “Nuts”? See how many “definitions” of the term
you can get and be ready for responses you would never have imagined!
4. Because of the deinstitutionalization of the mentally ill that occurred in the 1960s and the
ensuing lack of community health support for that population, we are confronted with
the probability that many of the “homeless” may actually be schizophrenics who are no
longer on medication. Does this seem to be a plausible explanation for the increase in
homeless individuals?
5. Should the mentally ill be forced to take medication if medication exists that will
ameliorate their symptoms? Schizophrenics often consider the voices that they hear gifts
from God. Should we deprive them of this gift? Should they be “locked up” in an
institution where they could receive sound nutrition and protection from the elements?
Are they “better off’ on the streets? What are the ethical issues involved in each of the
above situations?
6. How valid does the class think the “preparedness hypothesis” is as an explanation for
phobic disorders? If we “carry around” an evolutionary tendency to jump when startled
(i.e., “to respond quickly and ‘thoughtlessly’ to once-feared stimuli”), how did that
tendency actually get to us? Think about phobias in terms of the collective unconscious,
as espoused by Carl Jung. What sort of justification might we offer for applying Jung’s
hypothesis to the preparedness hypothesis?
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CHAPTER 15: PSYCHOLOGICAL DISORDERS
SUPPLEMENTAL LECTURE MATERIAL
DSM-IV-TR: What Is It?
DSM-IV-TR is the Diagnostic and Statistical Manual of Mental Disorders, Text Revision Edition. DSMIV-
TR is a diagnostic manual, published by the American Psychiatric Association and is used by />
mental health professionals in an attempt at concordance in evaluation and diagnosis of the
various mental illnesses. If you have medical insurance that covers mental health care, your
carrier probably predicates its decision to pay for your care on the DSM-IV-TR diagnostic criteria,
as reported by your therapist.
DSM-IV-TR proposes five categories, each called an axis (plural = axes), according to which an
assessment of the disturbance is made. Psychological and psychiatric disorders are classified
according to their “fit” on these various axes. This is a multiaxial classification system. In order,
these axes are:
AXIS I: CLINICAL DISORDERS
Clinical syndromes include the major affective disorders, psychoactive substance-induced mental
disorders, eating disorders, organic mental disorders (e.g., senility, Alzheimer’s), the
schizophrenias, adjustment disorders, and depressive disorders. Axis I and Axis II diagnoses are
often indicated at the same time.
AXIS II: PERSONALITY DISORDERS AND MENTAL RETARDATION
Disorders included in this category are mental retardation, pervasive developmental disorders
(e.g., autism), and specific developmental disorders (e.g., academic skills disorders such as
developmental writing disorder, developmental arithmetic disorder, and developmental reading
disorder). Specific personality traits or habitual use of particular defense mechanisms are also
indicated here, e.g., antisocial personality disorder. These disorders all have the common
denominator of having their onset in childhood and/or adolescence. For example, a diagnosis of
antisocial personality disorder in adulthood requires a prior diagnosis of conduct disorder in
childhood. This conduct disorder usually persists in a stable form (without period of remission or
exacerbation) into adult life, at which time it may be “upgraded” to antisocial personality
disorder.
Although you will not always have an Axis I and Axis II disorder at the same time, you often
will. When you do, you see the diagnoses indicated as follows:
Axis I: Alcohol Dependence
Axis II: Antisocial Personality Disorder (Principal Diagnosis)
When an individual does have both Axis I and II disorders, the “principal diagnosis’ is assumed
to be the Axis I disorder unless the Axis II disorder is followed by the qualifying statement
“Principal Diagnosis” indicated in parentheses.
AXIS III: GENERAL MEDICAL CONDITIONS
This axis permits the clinician to indicate any current physical disorder or condition that is
relevant to the understanding or management of the case. Sometimes these conditions have
clinical significance concerning the mental disorder. For example, a neurological disorder may be
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strongly related to a patient’s manifestations of Senile Dementia.
AXIS IV: PSYCHOSOCIAL AND ENVIRONMENTAL PROBLEMS
This axis provides a scale, the “Severity of Psychosocial Stressors Scale,” that enables the clinician
to code the overall severity of psychosocial stressors that have occurred in the client’s life during
the preceding year and to evaluate their contribution to any of the following:
. development of a new mental disorder
. recurrence of a prior mental disorder
. exacerbation of an already existing mental disorder
Stressors often play a precipitating role in the appearance of a disorder, but they may also be a
consequence of the person’s psychopathology. A common situation is to have the Alcohol
Dependence of one partner in a marriage lead to marital discord and eventually divorce. The sum
of the separation and subsequent divorce (with all its attendant traumas) may progress to the
point of a Major Depressive Episode. Types of psychosocial stressors considered for rating on this
axis include:
. Conjugal (marital and nonmarital): engagement, marriage, discord, separation, divorce,
death of a spouse
. Parenting: becoming a parent, friction with a child, illness of a child
. Other Interpersonal: problems with one’s friends, neighbors, associates, nonconjugal
family members, illness of best friend, discordant relationship with one’s boss
. Occupational: work, school, homemaking, unemployment, retirement
. Living Circumstances: change in residence, threat to personal safety, immigration
. Financial: inadequate finances, change in financial status
. Legal: arrest, imprisonment, lawsuit, trial
. Developmental: phases of the life cycle, puberty, transition to adult status, menopause,
“becoming 30/40/50”
. Physical Illness/Injury: illness, accident, surgery, abortion
NOTE: A physical disorder is listed on Axis III whenever it is related to the development
or management of an Axis I or II disorder. A physical disorder can also be a psychosocial
stressor if its impact is due to its meaning (importance) to the individual. In that case, it
will be listed on both Axis III and IV.
. Other Psychosocial Stressors: natural or manmade disaster, persecution, unwanted
pregnancy, out-of-wedlock birth of a child, rape
. Family Factors (children and adolescents): in addition to the above, for children and
adolescents, the following stressors may be considered: cold, hostile, intrusive, abusive,
conflictual, or confusingly inconsistent relationships between parents or toward child;
physical or mental illness of a family member; lack of parental guidance or excessively
harsh or inconsistent parental control; insufficient, excessive, or confusing social
cognitive stimulation; anomalous family situation, complex or inconsistent parental
custody and visitation arrangements; foster family; institutional rearing; loss of nuclear
family members.
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AXIS V: GLOBAL ASSESSMENT OF FUNCTIONING
This axis allows the clinician to indicate his/her overall judgment of the individual’s
psychological, social, and occupational functioning on a scale (the Global Assessment of
Functioning Scale (GAF) that assesses mental health or illness. Ratings on the GAF are made for
two periods:
· Current: level of functioning at time of evaluation
· Past Year: highest level of functioning for a least at few months during the past year
For children and adolescents, this should include at least one month during the school year. The
ratings of current level of functioning generally reflect the current need for treatment or care.
Ratings of highest level of functioning within the past year are frequently prognostic, because the
individual may be able to return to his or her prior level of functioning, following recovery from
an illness episode.
Eve White and Eve Black
The most extreme form of dissociation is dissociative identity disorder (DID), formerly known as
multiple personality disorder. Until fairly recently, this disorder was thought to be rare.
However, within the past few years, we have reason to believe this disorder to be more pervasive
than originally thought. Ralph Allison, a therapist with extensive experience in treating this DID,
has long believed the actual incidence of this disorder to be much higher, with many cases going
undiagnosed (1977).
DID is frequently confused with schizophrenia. The term, schizophrenia, literally means, “splitting
in the mind” (Reber, 1985). DID is actually a severe form of neurosis; the personality “in
command” at any given moment remains in contact with reality. Schizophrenia is a psychotic
disorder, in which the individual’s functioning is “split off” from external reality. Dissociative
identity disorder is one of the major dissociative disorders in which the individual develops two
or more distinct personalities that alternate in consciousness, each taking over conscious control
of the person for varying periods of time. Both dissociative identity disorder and the
schizophrenias are Axis I clinical syndromes.
Classic cases of dissociative identity disorder manifest at least two fully developed personalities,
and more than two are common. Of cases reported in recent years, about 50% had 10 or fewer
personalities and approximately 50 percent had more than 10. Each personality has its own
unique memories, behavioral patterns, and social relationships. Change from one personality to
another is usually sudden, with the change being accomplished in a matter of seconds to
minutes. The change is usually sudden, often triggered by psychosocial stress.
The original personality, the one from which all the others diverge, is usually unaware of the
existence of the others. However, the first personality to “split” from the original usually knows
about the original, and any additional personalities that may surface subsequently. This first
personality to split from the original is the active controller of which personality is “out,” when it
is out, why it is out, and for how long. This personality is referred to as the dominant personality,
and is often diametrically opposed to the original personality (e.g., Eve White and Eve Black). It
is not unusual for one or more of the “new” personalities to have a different gender than the
original personality, as well as a different sexual orientation.
At any given moment, there is only one personality interacting with the environment.
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Interestingly, the personality that presents for treatment often has little-if any-knowledge of the
multiples-they just are aware that something is a little unusual.
Onset of dissociative identity disorder is usually during childhood, but may not be diagnosed
until adulthood. The disorder is chronic, and the degree of impairment varies from mild to
severe. In nearly all cases, the disorder is preceded by abuse, often sexual in nature, or from some
other form of severe emotional trauma during the childhood years. The disorder is seen three to
nine times more frequently in females than in males.
There is some indication that the incidence in first-degree biological relatives of dissociative
identity disorder is higher than that in the general population. Interestingly, a child is often the
first to notice the presence of multiples (e.g., “I have 2 mommies, but it’s okay because they both
love me.”)
This dramatic form of reaction is well illustrated by the widely publicized case of Eve White. Eve,
25 years old and separated from her husband, had sought therapy because of severe, blinding
headaches, frequently followed by “blackouts.” During one of her early therapy sessions, Eve
was greatly agitated. She reported that she had recently been hearing voices. Suddenly she put
both hands to her temples, then looked up at the doctor with a provocative smile and introduced
herself as “Eve Black.”
It was obvious from the voice, gestures, and mannerisms of this second Eve that she was a
separate personality. She was fully aware of Eve White’s doings, but Eve White was unaware of
Eve Black’s existence. Eve White’s “blackouts” were actually the periods when Eve Black was in
control, and the “voices” marked unsuccessful attempts of Eve Black to “come out.” With
extended therapy, it became evident that Eve Black had existed since Eve White’s early
childhood, when she occasionally took over and indulged in forbidden pleasures, leaving the
other Eve to face the consequences. This habit had persisted, and Eve White frequently suffered
Eve Black’s hangovers. After about eight months of therapy, a third personality appeared. This
one, Jane, was more mature, capable, and forceful than the retiring Eve White. She gradually
came to be in control most of the time.
As the therapist probed the memories of the two Eves, he felt sure that some shocking event must
have hastened the development of these distinct alternate personalities in the disturbed child. In
a dramatic moment, the climax of therapy, the missing incident became known. Jane suddenly
stiffened and in a terrified voice began to scream, “Mother … Don’t make me … I can’t do it!