CHAPTERS 16 & 17ABNORMAL AND THERAPY |
Dorthea Dix |
CHAPTERS 16 & 17ABNORMAL AND THERAPY |
Dorthea Dix |
A. DEFINITION:
1. Statistically unusual 2. Social Norm Violation
3.Personal identity
B. MODELS: 1.
Biomedical 2. Cognitive 3. Psychoanalytic
4. Behavioral 5. Sociological
C. DIAGNOSTIC AND STATISTICAL MANUAL: 1. First 1952 2. Current DSMIV-1994
DISORDERS: ANXIETY;
SOMATOFORM; DISSOCIATIVE (all reaction to trauma)
MOOD: PSYCHO-SEXUAL; SCHIZOPHRENIA;
DEVELOPMENTAL & PERSONALITY DISORDERS.
I. Anxiety Disorders:
Phobia, Panic Disorder, Post Traumatic
Stress Disorder, Obsessive-Compulsive Disorder
II. Somatoform Disorders: Conversion (hysteria) and Hypochondriasis
III. Dissociative Disorders: Dissociative Amnesia & Dissociative Identity
IV. Mood Disorders:
Unipolar (Major Depression & Seasonal) &
Bipolar (Manic-Depression)
V. Psychosexual Disorders:
fetishism, zoophilia, sadism, masochism,
exhibitionism & pedophilia
VI. Schizophrenia: Disorganized, Catatonic, Paranoid, Undifferentiated
VII. Developmental
Disorders: Autism; Academic Skills Disorder; Senile
Dementia & Attention Deficit Disorderw/hyperactivity
VIII. Personality Disorders:
Avoidant, Dependent, Schizoid, Anti-Social
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A. SEEKING THERAPY: 1. Social Stigma 2. Bewilderment--who?where?what?$$$?
B. HISTORICAL: 1. Trephining 2. Greeks 3. Medieval 4. Pinel, Dix and Rush
C. PRESENT: 1. Prevention
Costs 2. Intervention 3. Genetic Predisposition
4. Life Events 5. Multiple Causality 6. Deinstitutionalization
TREATMENT TYPES:
PSYCHOANALYTIC; BEHAVIOR; COGNITIVE; HUMANISTIC
BIOMEDICAL
TREATMENT MODES:
INDIVIDUAL 1:1; GROUP PSYCHOTHERAPY; SELF-HELP
HOSPITALIZATION, CLINICS, PRIVATE COUNSELING
COMMUNITY MENTAL HEALTH CENTERS
I. Psychoanalysis:
Resistance, Free Association, Dreams, Transference,
Insight
attempt to gain insight into the unconscious motivational conflicts and
roots of psychological problem--look for causes more than cure
argue that other treatments deal w/overt problem--symptom substitution
II. Behavior Therapy:
1. Systematic Desensitization 2. Counterconditioning
3. Flooding 4. Implosive 5. Aversion--all 5 types of classical
conditioning
6. Instrumental (operant conditioning) 7. Extinction
III. Cognitive Therapy:
1. Cognitive-Behavior (Bandura-Modeling)
2. Rational Emotive (Ellis) 3.Stress Inoculation 4. Cognitive
(Beck)
IV. Humanistic Therapy:
1. Client-Centered (Rogers) also called PersonCenter
2. Existential (May & Frankl) 3. Gestalt (Perls)
V. Group Psychotherapy: 1. Family 2. Marital 3. Self-Help
VI. Biomedical Therapy:
1. Electro-convulsive
Shock Therapy (ECT)
2. Psychosurgery (lobotomy)
3. Drug Treatment
Antipsychotics: Chlorpromazine, Thorazine, Haldol--block dopamine
receptors--side effects include motor impairment and affect of Zombie
Antianxiety Drugs: Benzodiazepine--Valium, Xanax--inhibit GABA; major
problem is abuse--one is easily addicted to these
Antidepressants: Tricyclic-Elavil; MAO inhibitors-Nordil; new drugs like
Prozac--blocks the reuptake of Serotonin
Lithium-used for Mania
problems include poisoning, swelling, dry mouth, tremors,
decline in sexual performance
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1. What is "normal" anyway?
If reality is based on perception, how can we
label a schizophrenic as "abnormal"?
Good question. We use the terms "normal"
and "abnormal" quite frequently when
discussing mental disorders. Implicit
in this terminology is the idea that we
can somehow define how a "normal"
person functions, thinks, behaves, etc. You
correctly point out that psychological
reality is based to a large extent on
our perceptions. In addition, this
process is influenced by culture and
environment.
(info on a culture in Africa and
their very different way of perceiving the
world)
So, are these people somehow "abnormal"?
Not at all. The concept of normal
must be referenced to the experience
of people in the culture. We can refer
to normal cognitive function in
Western society. If most people do not hear
voices when nobody is communicating
to them, this becomes our standard
against which to judge abnormal
behavior. Note that the concept of "normal"
is really a statistical definition
-- it is referenced to the behavior of
most people. You should also remember
that
"abnormal" behavior must pose a
problem to the individual before we would
consider it a part of a clinical
disorder.
2. Is it typical to feel "down"
after reading or talking about depression?
(Intern Syndrome)
Yes, this can happen. Remember that
there is a relationship between cognition
and affect. The way we feel can
affect how we think, and the kind of
cognitive processing we are engaged
in can influence our mood. People in a
good mood, for example, are more
efficient at processing information than
those in a bad mood. Similarly,
exposure to comic material will result in
pleasant feelings, while depressing
material makes us feel bad. In fact, one
way to induce a positive or negative
mood in the lab is to have people read
either positive or negative passages.
So you may, in fact, feel down after
reading the section in your textbook
on depression. Please note however, that
it is unlikely such an experience
would result in clinical depression. The
feeling experienced from reading
something is not very intense, and it is
short-lived (perhaps a few minutes).
To be classified as clinically
depressed, you have to experience
intense depression for a period of about
two weeks.
3. What is an "anxiety attack"? Anxiety Disorders
Many people feel anxious about something
from time to time. Will I get to
work on time? What if I say something
wrong while I'm out on a date with ___?
Can I finish the exam on time? It
is perfectly normal to feel anxious in
these situations, but we deal with
this feeling and, hopefully, get on with
things. Anxiety becomes a clinical
problem when you can no longer deal with
it. There are several disabling
clinical disorders referred to as Anxiety
Disorders. These include Generalized
Anxiety Disorder, Panic Disorder, Phobic
Disorder, Obsessive-Compulsive Disorder
and Post-Traumatic Stress Disorder.
Psychologists refer to crippling
anxiety attacks as panic attacks.
Individuals experiencing panic find
themselves in a state of acute terror
with a high level of arousal. They
experience increased heart
rate, dizziness, and shortness of
breath. These symptoms may last for several
minutes. Perhaps most troubling
is that the individual cannot identify what
triggered the attack, so shortly
after it finally ends, they can't help but
worry about when the next one might
begin! The typical treatment involves
tranquilizers such as Valium.
4. Can psychological blindness
correct itself? (Conversion: hysteria and
hypochondriasis)
Definitely. Remember that the problem
in this case is psychological. There is
nothing wrong with the visual system
either at the level of the retina or in
the visual cortex. Everything "works,"
but the patient cannot see. Freud
suggested that this kind of problem
was a conversion reaction to some kind of
trauma. For example, an individual
may have witnessed a horrible accident,
and feeling guilty, they have repressed
the memory by psychologically
refusing to see anything. Some kind
of
talking therapy would be recommended
to help the individual deal with the
trauma and the feeling of guilt.
Once the problem is addressed, the blindness
will vanish.
Dissociative Disorders: Dissociative
Amnesia, Fugue and Dissociative
Identity Disorder
5. With Multiple Personality
Disorder, can one of the personalities be ill
while the other is healthy?
Yes, it is possible. This seems odd,
but the two (or more) personalities can
be completely different from one
another. One might smoke or drink, while the
other abstains. One can be quiet
and shy, while the other is extremely
extroverted. Perhaps more impressive
are cases where the measured IQ of the
two personalities differs by a vast
amount, where one personality is
right-handed and the second is left-handed,
or when one personality is a male
and the other is a female. These
seem to be real differences and not just
very good acting jobs. PET scans
show different patterns in cortical activity
when the individual switches from
one personality to another. Thus, it is
quite possible for the personalities
to differ in their overall level of
health.
Affective Disorders: Unipolar
(depression) Bipolar (Manic Depression)
Seasonal Affective Disorder (SAD),
Dysthymia and Cyclothymia
6. What is bi-polar disease,
and how do you get it? What are some symptoms,
and is there a cure?
Bipolar disorder is a mood disorder
characterized by shifts from extreme
highs to extreme lows. This used
be referred to as manic-depressive syndrome.
In the depressive phase, the individual
feels that he or she is worthless,
that no one wants them, and they
are unable to accomplish almost anything.
They will have problems with sleeping
and eating, and may consider suicide.
You might think that the manic phase
would be great, but it is more that
simply feeling good about yourself.
You feel that you can accomplish anything
(e.g., write the best song/book
the world has ever seen in a day, defy
gravity, and so on). This extreme
high gets in the way of normal day to day
existence. Many researchers
suggest that the cause is biochemical--an
imbalance of certain neurotransmitters
(in particular, norepinephrine and
dopamine). Treatment usually involves
a drug therapy, in conjunction with
some form of "talking" therapy.
Lithium has been shown to be particularly
effective for the treatment of this
disorder.
7. Is it considered abnormal
to sometimes have feelings of depression and
consider suicide?
Depression is something we all experience
from time to time. It is perfectly
normal to feel down or "depressed."
Clinical depression is a different
matter. Technically, clinical depression
would be indicated by severe
feelings of being down for an extended
period of time (at least two weeks).
Thoughts of worthlessness, hopelessness,
etc., would be very prominent. The
individual may consider suicide.
Please note: People do sometimes think about
suicide in a nondepressed state,
but they convince themselves quickly that
this is not an answer. The clinically
depressed person starts to think of
suicide as a logical alternative
to their problems.
If you know of anyone who is experiencing
long periods of depression or is
actively considering suicide:
1. Talk to them...assure them that they have friends.
2. Seek guidance from a counselor
or family physician...there are
professionals that you can direct
the individual to.
3. In an emergency, there are help
lines in your community that you can phone
... be familiar with the numbers.
Schizophrenia: More to come
Disorganized Hebephrenic, Paranoid, Catatonic,
Undifferentiated and Residual.
Excess of dopamine, partly genetic, biological
treat w/thorazine and anti-psychotic
drugs.
8. What would happen if someone
with Parkinson's disease took cocaine?
(Parkinsonian patients lack dopamine
and schizophrenics have too much.
Cocaine addiction can cause some
symptoms similar to schizophrenia.
Parkinson's disease is a movement
disorder marked by involuntary shaking,
weakness, and difficulty in initiating
movement. The cause is a depletion of
the neurotransmitter, dopamine (DA),
particularly in a region of the brain
called the substantia nigra . Patients
with Parkinson's are oftentreated with
L-DOPA, the precursor for DA, and
this does result in an improvement of the
symptoms. Cocaine is a stimulant
that blocks the re-uptake of DA. Recall that
synaptic transmission involves the
release of a neurotransmitter into the gap
between an axon and a dendrite.
After the neurotransmitter has diffused
across the gap and locked into the
receptor sites, remaining molecules
are reabsorbed back into the axon
terminal to be used again. Cocaine blocks
this re-uptake process in systems
where the neurotransmitter is DA
(norepinephrine as well). In essence,
the released molecules of DA remain in
the gap and continue to stimulate
the post-synaptic receptor sites. The
psychological experience is a "high."
So will this help a person with
Parkinson's disease? Probably not.
Cocaine merely prevents re-uptake of DA –
it does not create additional molecules.
The Parkinson's patient has very
little DA to begin with, and preventing
re-uptake will have little if any
effect.
9. Is it common to mix treatments
for various disorders, for example,
electroconvulsive therapy (ECT)
and lithium?
Therapy is rarely unidimensional.
For example, in the treatment of a specific
problem, a psychiatrist will often
use a combination of drugs and talking
therapy to control and resolve different
aspects of the disorder.
Occasionally, it may be necessary
to take multiple drugs during treatment, or
two seemingly different approaches.
The treatment of choice for Bipolar
Disorder is lithium. This drug is
prescribed to control the manic phase of
the disorder and is effective in
approximately 80 percent of the cases.
Typically, the control of the mania
results in an associated decrease in
depressive symptoms as well.
But this does not always happen. It may be
necessary to treat the
depression independently. If an
antidepressant drug (for example, Prozac) is
not successful, the psychiatrist
might try another drug (for example, a
tricyclic). ECT is a treatment of
last resort for severe depression and would
be administered only if all other
treatments had failed, the patient was
suicidal, and the patient could
consent to the treatment.
10. I've heard that Prozac has few, if any side-effects. Is this true?
Prozac (the trade name for fluoxetine
hydrochloride) has been presented by
some as the miracle treatment for
depression. It is true that Prozac seems
more effective and has fewer side-effects
than other treatments (for example,
an MAO inhibitor). But all drug
treatments have side-effects, some more
serious than others, and some only
in interaction with other drugs. A few of
the common side-effects of Prozac
include: nervousness, insomnia, headache,
and increased sweating. Patients
may notice a disruption in REM sleep. Less
frequently reported side-effects
include: dizziness, flushing, tremors,
decreased heart rate, ringing in
the ears, nausea, vomiting, dry mouth,
abdominal pain, itching, sore muscles,
and swelling. Prozac works by blocking the
reuptake of serotonin. In essence,
serotonin remains in the synaptic gap for a longer
time interval and this seems to
have a mood-enhancing effect.
11. In treating obsessive-compulsive
disorder, why is Prozac (a seratonin
reuptake inhibitor antidepressant)
given? It would seem that a person
suffering from an anxiety disorder
would want to avoid an antidepressant medication.
You make a good observation here.
Why would we treat obsessive-compulsive
disorder (an anxiety disorder) with
an antidepressant like Prozac? The key
lies in the action of the drug itself.
As you indicate, Prozac inhibits the
re-uptake of serotonin. Thus, for
a person taking Prozac, the action of
serotonin in any synapse is prolonged
since the re-uptake process is
inhibited. Since Prozac is quite
effective for obsessive-compulsive disorder,
this would lead us to believe
that one cause is decreased activity of serotonin
(not enough released, ineffective
binding sites, etc.). Many researchers believe
that the serotonin pathways are
involved in the inhibition of
species-specific behaviors. Thus,
we show the compulsion because we have an
inadequate neurological system to
inhibit such behavior. But why is Prozac
effective for depression? Recall
that a major theory of depression is the
monoamine hypothesis--people with
unipolar depression show decreased activity
of these neurotransmitters. Typically,
we look at dopamine, but serotonin
also is a monoamine.
12. Is electroconvulsive therapy
(ECT) always beneficial?
No. Sometimes ECT has little or
no effect and may result in the patient
getting worse. There can be damage
to the cortex as well. Modern ECT attempts
to minimize the danger by giving
the patient a muscle relaxant (so that the
convulsion generated by ECT does
not break bones) and a general anesthetic
(when ECT was first introduced,
the patient remained awake for the
procedure). In addition, the patient
must consent to the procedure. The
number of treatments in a therapy
series ranges between 3 and 12, and the
shock is delivered only to the right
hemisphere to prevent a loss of verbal
memory. We are not completely sure
how ECT works, but many think it achieves
the desired effect by disrupting
REM sleep. Please note: ECT is a treatment
of last resort offered only to
those who can consent and are in
serious danger of suicide. It is used only
in a small fraction of cases.
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The
Lobotomist
By Jack El-Hai
Special to The Washington
Post
Sunday, February 4,
2001 ; Page W16
Frank Freeman remembers
hiking with his father in the woods, going fishing
with him, and setting
off on cross-country driving trips that could last for
weeks. He also recalls
one occasion in 1952 when he helped his father perform
a trans-orbital lobotomy
on a patient.
The procedure, which
his father, Walter J. Freeman, popularized and
perfected, involved
first knocking the patient unconscious with two or three
jolts of electricity
from an electroshock therapy machine. "I was there to
hold the person's
legs down," Frank Freeman says. "We all went for a ride
when he threw the
switch."
After the convulsions
subsided and the patient lay insensate, Walter Freeman
lifted the patient's
eyelid and inserted an ice pick-like instrument called a
leucotome through
a tear duct. A few taps with a surgical hammer breached the
bone. Freeman took
a position behind the patient's head, pushed the leucotome
about an inch and
a half into the frontal lobe of the patient's brain, and
moved the sharp tip
back and forth. Then he repeated the process with the
other eye socket.
"I was kind of impressed,"
Frank Freeman recalls. "He made it look so easy."
For Walter Freeman,
a neurologist and psychiatrist who practiced in
Washington for 28
years, it was easy. He kept record of 3,439 lobotomies he
performed during his
career. His technique of trans-orbital lobotomy was such
a breeze that he could
teach it in a day or two to state-hospital
psychiatrists who,
like himself, had no certification in surgery. Freeman
gave lobotomies to
children, adults, old people, and people with depression,
manic-depression,
schizophrenia, obsessive-compulsive disorder and a variety
of undiagnosed psychiatric
illnesses. He believed in lobotomy, defended it,
promoted it and demonstrated
it during psychosurgical road trips he took to
more than 55 hospitals
in 23 states. He felt certain that lobotomy could
return psychologically
disabled people, many of whom had no other prospect of
effective medical
treatment and who lived in oppressive psychiatric wards, to
useful lives.
"Lobotomy gets them
home" was his motto.
Freeman's enthusiasm
for lobotomy, which developed through his work with his
colleague James Watts
at George Washington University Hospital, began a wave
of psychiatric surgery
that was used on 40,000 to 50,000 Americans between
1936 and the late
1950s. It is difficult to say how many benefited. Few
controlled studies
were ever conducted, and Freeman's own summaries of his
results were difficult
for others to interpret.
By the time Freeman
died in 1972, his theory that mental illness could be
cured by physically
attacking the brain's frontal lobes had been discredited.
While things have
not exactly come full circle since then, there is much in
today's neuropsychiatric
climate that Freeman would recognize.
Many psychiatrists
no longer practice "talk" therapy and instead treat their
patients' brains.
In 1999 Surgeon General David Satcher issued a 450-page
report on mental health
making the case that many psychiatric illnesses are
actually brain disorders,
and that often the most effective treatments affect
the transmission of
messages in the brain's neuro-pathways.
Freeman would fully
agree. He believed that lobotomy succeeded because it
severed neural connections
between the frontal lobes of the brain and the
thalamus, which he
characterized as the seat of human emotion. Mentally ill
people were too self-aware,
he maintained, and their overactive emotions
caused them to obsess
about their problems. Sixty years ago few of Freeman's
colleagues, especially
psychiatrists for whom psychotherapy was the preferred
treatment for psychiatric
disorders, believed that brain disorders caused
mental illness. Now
we live in an era in which a biological and
brain-centered view
of mental illness reigns supreme.
But do today's neuroscientists
celebrate Freeman as a pioneer, far ahead of
his time in his focus
on the brain in treating psychiatric disorders? Far
from it. Researchers
investigating new methods of surgically treating the
brain for mental illnesses
find his legacy a hindrance to the public's
understanding and
acceptance of their research.
Why, 34 years after
his final lobotomy, does Walter Freeman continue to cast
a shadow over psychiatric
surgery? The answer lies in the complex tangle of
Freeman's personality
and motivations, and in the public's fear of past
abuses.
When Freeman arrived
in Washington in 1924 to direct the laboratories at St.
Elizabeths Hospital
-- one of the nation's preeminent institutions for the
insane -- he carried
with him more baggage than medical textbooks and
instruments. He also
shouldered a load of high expectations, courtesy of his
family. Born and reared
in Philadelphia, Freeman belonged to a prominent and
hard-working medical
clan.
His maternal grandfather,
William W. Keen, served as a surgeon during the
Civil War, removed
a tumor from the jaw of President Grover Cleveland,
experimented with
an early form of cardiopulmonary resuscitation, and was a
president of the American
Medical Association. Freeman's father was an
otolaryngologist with
a practice of modest attainments.
Freeman himself attended
Yale and the University of Pennsylvania School of
Medicine before studying
neurology and psychiatry in Europe. Initially, he
regarded mental hospitals
with what he called in his unpublished memoirs "a
rather weird mixture
of fear, disgust, and shame." These feelings soon were
transformed into indignation:
"I looked around me at the hundreds of patients
and thought what a
waste of manpower and womanpower." Freeman thought the
idleness and confinement
of vast numbers of patients a great social tragedy,
and he wanted to do
something about it.
He set about -- ultimately
unsuccessfully -- to discover measurable
differences between
normal brains and those of schizophrenics. While working
at St. Elizabeths,
Freeman opened a private practice and joined the medical
faculty of George
Washington University as a professor of neurology. By the
mid-1930s he had introduced
several new therapies for mental patients at GW
Hospital: insulin
shock therapy, metrazol shock therapy and electroconvulsive
therapy. All of these
treatments were intended to fight psychiatric disease
by subjecting patients
to chemicals or jolts of electricity that might
disrupt unhealthy
neural activity in the brain.
It's easy to imagine
Freeman -- his high forehead, steel-rimmed glasses and
goatee making him
look the part of the consummate 1930s mental doctor --
convincing seriously
ill patients and their desperate families that these
experimental treatments
held the only hope for recovery. For many Americans
with psychiatric diseases,
hospitals could offer little else except the
agonies of cold-water
therapy and long-term storage in facilities that echoed
with the screams and
moans of the hopeless.
In 1935 Freeman caught
his first glimpse of yet another treatment that could
join his arsenal.
At a London conference, he attended a presentation by a
Yale researcher on
the behavioral effects of surgical damage to the frontal
lobes of chimpanzees.
The animals became subdued and inactive. Rather
impulsively, another
conference attendee, a Portuguese neurologist named Egas
Moniz, rushed home
and began performing similar operations on mentally ill
people. Moniz's subsequent
reports on these experiments crossed the Atlantic
and further intrigued
Freeman.
To him, the intoxicating
thing about psychosurgery -- Moniz's coined term for
psychiatric surgery
-- was its potential to sever the links between the
over-excited emotions
of an unhealthy thalamus and the behavioral functions
of the prefrontal
lobes of the brain. If it worked, the destruction of these
nerve fibers would
prevent the thalamus from poisoning patients' thinking.
He absorbed the details
of Moniz's work and, with GW neurosurgeon Watts,
began figuring out
how to adapt the Portuguese physician's techniques.
Freeman and Watts
used brains from the hospital morgue to practice the coring
of sections of the
prefrontal lobes with a leucotome. By the summer of 1936
they were ready for
a live patient: a Mrs. Hammatt from Topeka, Kan.
Sixty-three years
old and suffering from agitated depression, she came to
Washington with her
husband, desperate for an improvement to her sleepless
and hysteria-filled
life. Freeman explained to her that without a lobotomy --
the name he and Watts
gave for their surgery -- she faced an indefinite stay
in a mental hospital.
She decided to take her chances with this new
operation, which was
scheduled for September 14, 1936.
When the day arrived,
Mrs. Hammatt tried to change her mind when she found
out that her head
had to be shaved. Freeman and Watts promised to spare as
much of her hair as
they could, before forcibly anesthetizing her. Later,
Freeman recorded that
her last words before surgery were, "Who is that man?
What does he want
here? What's he going to do to me? Tell him to go away. Oh,
I don't want to see
him," followed by a scream.
Freeman and Watts
then performed America's first lobotomy. They drilled six
holes into the top
of Mrs. Hammatt's skull and inserted a leucotome into
each. The two physicians
shared the task of lesioning the brain, as they did
for all of the approximately
1,000 lobotomies they performed together. They
rinsed the openings
with saline solution and sutured the wounds.
By Freeman's account,
Mrs. Hammatt emerged a transformed woman. She felt a
great relief of her
anxiety. After a hemorrhage scare on the third day of
recovery, she was
discharged from GW Hospital about a week later. "She
survived five years,
according to Mr. Hammatt the happiest years of her
life," Freeman noted
in his autobiography. "As she expressed it, she could go
to the theatre and
really enjoy the play without thinking what her back hair
looked like or whether
her shoes pinched."
Thus encouraged, Freeman
and Watts went on to perform more operations and
further refine their
technique. They replaced Moniz's coring leucotome with
one resembling a butter
knife and moved the entry holes to the sides of the
skull. They developed
a "radical" procedure that made more cuts into the
brain. Some patients
needed multiple lobotomies; others died. They operated
on an alcoholic lawyer
and Rhodes scholar who escaped from the hospital on
Christmas Eve and
was found, drunk, in a downtown Washington bar.
Freeman and Watts
headquartered their increasingly lucrative private practice
in a house at 2014
R St. SW. Watts occupied an office at ground level, their
assistant manned the
first floor, and Freeman worked upstairs. Lobotomy
Patient No. 157 once
returned to threaten their lives and two others pulled
guns on Freeman when
he recommended psychosurgery.
As much as some of
Freeman's colleagues lamented the practice of damaging
healthy brain tissue
in order to treat mental illness and the absence of
scientific evidence
that lobotomy actually worked, doctors were even more
critical of Freeman's
hunger for public recognition. More than once, AMA
members tried to censure
him for advertising his services, which was then
considered an unethical
practice for physicians. The suspect advertising
appeared, his accusers
said, in the colorful lobotomy exhibits Freeman set up
every year from 1939
through the early '40s at the annual AMA convention.
Freeman targeted his
displays not at other doctors, but at the press.
"I found the technique
of getting noticed in the papers," he later
acknowledged. "It
was to arrive a day or two ahead of the opening [of the
convention] and install
the exhibit in the most graphic manner and then be
alert for prowling
newsmen." Playing the role of barker, entertainer and
scientist, Freeman
used hand-held clackers to draw reporters and frequently
displayed a lobotomized
animal.
The results were immediate.
Freeman described what happened after journalists
viewed the exhibit
in 1939: "That night our monkey died but Watts and I made
the headlines even
though we did not get an award." A photo of Freeman and
Watts in the operating
room appeared in Time magazine in November 1942, and
many other magazines
and newspapers published laudatory accounts of the
Freeman-Watts operation.
By his own reckoning,
52 percent of their first 623 surgeries yielded "good"
results, 32 percent
"fair," and 13 percent "poor." Three percent died during
or after surgery.
At first glance, those results seemed miraculous, given
that few other treatments
held much promise for hard-core cases of
depression, agitation
and obsessive behavior. But Freeman and Watts often did
not define what they
considered improvement to be. Relapses frequently
occurred. In addition,
a certain number of these cases were bound to get
better on their own.
And the aftereffects of lobotomy, separate from the
symptoms of mental
illness, often crippled the emotions, inhibitions and
personalities of patients.
Nurses who cared for
Freeman-Watts patients immediately after the operations
grew accustomed to
dealing with people who needed to be retaught how to eat
and use the bathroom.
The patients often made clumsy passes at their
caregivers, urinated
on their shoes, sat unmoving for hours, stubbornly
refused to follow
instructions and behaved childishly. Nurses learned that
spanking and tickling
could reliably distract patients from delusions and
perceived threats.
The most famous failure of Freeman and Watts from this
period is Rosemary
Kennedy (JFK's sister), who was probably the first
mentally retarded
person to receive a lobotomy and who has needed full-time
care for the past
60 years.
Freeman believed that
many of these changes were not only acceptable, but
also therapeutic.
He saw laziness, indifference and dullness as signs that
the overcharged emotional
impulses of the thalamus had successfully been
derailed. The less
that patients paid attention to their own troubles, the
better.
Officials at state
mental hospitals and veterans hospitals across the country
also found the trade-offs
acceptable. (An exception was William Alanson
White, superintendent
of Freeman's own St. Elizabeths, who never allowed
lobotomies in the
hospital during his tenure.) Lobotomy arrived on the scene
at a time when these
institutions overflowed with patients, many of them
servicemen who developed
mental illnesses during World War II, with no re
liable courses of
treatment ahead of them. Mental health practitioners
desperately needed
new therapies.
By 1945, however,
Freeman was starting to doubt the effectiveness of his
standard lobotomy
procedure. The damage it caused was undeniable. Its cost
and requirement of
a skilled neurosurgeon limited its application. Freeman
was also rethinking
the standard wisdom that lobotomy should be the therapy
of last resort. He
suspected that people who had been seriously disordered
for more than five
years were usually too far gone to be helped, and that
lobotomy might work
best for patients in the early stages of psychiatric
illness.
His research led him
to the work of Amarro Fiamberti, an Italian
psychosurgeon who
eliminated the need for boring holes into the skull by
breaking through the
easily accessible bone at the rear of the eye socket and
injecting alcohol
or formalin into the brain. Again practicing on cadavers,
Freeman altered this
technique by replacing the injection with the cuts of a
sharp instrument --
first an ice pick from his kitchen whose handle bore the
name of the Uline
Ice Company and later a type of leucotome that he designed
and always carried
with him in a felt-lined case.
Freeman kept his new
trans-orbital technique a secret from Watts. In January
1946, he performed
the first such operation in his R Street office on a
patient named Ellen
Ionesco. Eight more followed in quick succession. He
often sent patients
home in a taxi an hour after the operation. Freeman later
wrote that during
his 10th trans-orbital surgery, he called Watts to his
office to assess the
operation. Watts later claimed, however, that he entered
Freeman's office unsummoned
and found Freeman pushing an ice pick in the eye
socket of an unconscious
patient.
TOP
2. Which
of the following is a somatoform disorder?
fugue state
phobia
hypochondriasis
post-traumatic stress disorder
3. What disorder
was illustrated in a wave of cases in the 1970s, during
the Cambodian reign of terror in which many women who were tortured
or saw their own children tortured and murdered, became
psychologically blind?
conversion disorder
dissociative identity disorder
amnesia
hypochondriasis
4. Major
depression is a type of
dissociative disorder.
somatoform disorder.
personality disorder.
mood disorder.
5. What
is the single best predictor of suicide potential?
problems with grades
problems with lovers or parents
problems with money
a sense of hopelessness
6. What
used to be called "manic depression?"
generalized anxiety disorder
bipolar disorder
schizophrenia
depression
7. For
individuals with schizophrenic disorders, the most common
hallucinations are
tactile.
auditory.
gustatory.
visual.
8. Jake
believes that his thoughts are broadcast to the public due to evil
forces. What symptom of schizophrenia is he exhibiting?
delusions
hallucinations
disturbance of affect
incoherent thinking
9. Which
of the following is a negative symptom of schizophrenia?
thought disorders
flattened affect
delusions
hallucinations
10.
Which of the following symptoms of schizophrenia is affected by
antipsychotic drugs that block the activity of dopamine in the brain?
lack of speech
attention problems
flat affect
hallucinations
11. Jane
went from doctor to doctor complaining of stomach troubles and
diagnosing herself with cancer, even though every test came up
negative. Jackie may suffer from
generalized anxiety disorder.
fugue state.
hypochondriasis.
conversion disorder.
12. Glove
anesthesia is an example of a(n)
generalized anxiety disorder.
phobia.
conversion disorder.
obsessive-compulsive disorder.
13.
Alex feels compelled to wash his hands nine times before he eats and
nine times after he eats because he is afraid of swallowing germs. Alex
displays
conversion disorder.
hypochondriasis.
obsessive-compulsive disorder.
generalized anxiety disorder.
14. Your
text describes a study conducted by Rosenhan (1973) in which he
and his colleagues were admitted to mental hospitals after complaining
of certain symptoms. What was the main point of this classic study?
Once a diagnostic label is applied to someone, all behavior comes
to be seen in terms of that label.
Most people in psychiatric hospitals are not mentally ill.
The DSM cannot be used reliably to diagnose schizophrenia.
It is hard to tell the difference between normal and abnormal
behavior.
15. Kess
goes through each day feeling uneasy and tense. She is very
sensitive to criticism and has difficulty making decisions, even about
little things. She constantly worries about her job, her financial situation,
and family matters. Her symptoms fit the diagnostic category of
generalized anxiety disorder.
phobic disorder.
major depression.
somatoform disorder.
16.
Patricia seldom leaves her home. She works out of a home office, has
friends visit her at home, and has most things delivered to her. The
idea of being in a movie theater, going to a public park, or eating in
a
restaurant scares her. Such symptoms are typical of
panic disorder.
agoraphobia.
obsessive-compulsive disorder.
fugue states.
17. Chuck
complains of numbness and tingling in his fingertips, nausea,
chest pains, and indigestion. He is intensely aware of his own bodily
sensations, often becoming extremely alarmed the moment that he
sneezes or coughs. Certain that he suffers from extremely poor health,
Chuck has seen over a dozen doctors in the past two years. Chuck
may have
paranoid schizophrenia.
bipolar disorder.
a social phobia.
hypochondriasis.
18. During
a soccer game at the local park, Sheila is hit on the head by the
ball. For a short time afterward she cannot remember the name of the
park and the name and mascot of her soccer team. However, she
remembers who she is and where she lives. Later, her memory clears
up. This condition is called
a fugue state.
dissociative amnesia.
organic amnesia.
dissociative identity disorder.
19. The
"vicious cycle of depression" refers to the fact that depressed
people
are prone to become aggressive and vicious toward others.
dislike social support and refuse to interact with their friends and
partners.
have learned to become helpless in the face of adversity.
need social support, but behave in ways that almost always result in
social rejection.
20.
Michelle has difficulty maintaining friendships and romantic
relationships. She is uncertain about her own identity and about her
goals in life. She experiences extreme mood fluctuations and is prone
to inappropriate outbursts of anger. When Michelle meets a potential
new friend, partner, or colleague, she clings to that person so fiercely
that he or she becomes alienated and leaves the relationship. Michelle
may have
mania.
antisocial personality disorder.
borderline personality disorder.
disorganized schizophrenia.
21. A
physician who views anxiety as the result of a neurotransmitter
imbalance and who treats this disorder with drugs is following the
__________ model.
sociocultural
demonology
psychological
medical
22. A
doctor who views anxiety as a learned response to situations is
following the __________ model of abnormality.
demonology
sociocultural
psychological
medical
23. One
day during his lunch hour, Geraldo suddenly couldn't breathe. He
felt his heart racing, he began to hyperventilate, and he became
worried that he was dying. He wanted to get help from his coworkers,
but he was worried about embarrassing himself in front of them. If these
episodes continue, Geraldo might be diagnosed with __________.
simple phobia
panic disorder
generalized anxiety disorder
bipolar disorder
24. All
during the day, Don has repetitive thoughts about dirt and germs. To
deal with these unpleasant images, he carefully washes and disinfects
his hands precisely three times each hour. Don's thoughts reflect
__________ and his washing behavior reflects __________.
an obsession; a compulsion
a compulsion; an obsession
a simple phobia; a social phobia
generalized anxiety; panic disorder
25.
Al complains about how the other patients are spying on him and trying
to poison him. He is highly suspicious of other people and he also
believes that the government is monitoring his activities through the
television set. These features are characteristic of __________
schizophrenia.
catatonic
paranoid
disorganized
undifferentiated
TOP
1. middle childhood
2. hypochondriasis 3. conversion 4. mood disorder 5. hopelessnes
6. bipolar 7. auditory
8. delusions 9. flat affect 10. hallucinations 11. hypochondriasis
12. conversion 13. OCD 14.
ALL SYMPTOMS 15. GENERALIZED ANXIETY DISORDER
16. AGORAPHOBIA 17. HYPOCHONDIASIS
18. ORGANIC AMNESIA 19. NEED SOCIAL SUPPORT 20 BORDERLINE
21. MEDICAL 22. PSYCHOLOGICAL 23. PANIC DISORDER
24. OCD
25. PARANOID
2. One
psychoanalytic form of group therapy is
the sensitivity-training group.
transactional analysis.
the self-help group.
the encounter group.
3. Benzodiazepines
are most effective in treating
depression.
schizophrenia.
generalized anxiety disorder.
bipolar disorder.
4. What
is the most widely used antidepressant in the world today?
Trofranil
Lithium
Xanax
Prozac
5. Antipsychotic
drugs are used to treat
bipolar disorder.
schizophrenia.
generalized anxiety disorder.
depression.
6.
Ugo Cerletti introduced
chlorpromazine.
ECT.
Prozac.
the lobotomy.
7.
In order to deal with his recurrent bouts of anxiety, Charley is seeing
a
psychoanalyst. During each session, Dr. Farias encourages Charley to
lie back, relax, and say whatever comes to his mind. This part of
psychoanalysis is called
free association.
transference.
resistance.
catharsis.
8. After
about six months of therapy, Charley finds himself becoming more
and more angry with Dr. Jones. Jones believes that Charley is really
angry with his father and that the feelings he has for his therapist reflect
catharsis.
resistance.
insight.
transference.
9. Andrea
is extremely afraid of snakes. To eliminate her phobia, the
therapist locks her in a room with a caged snake. Although she
experiences an initial panic reaction, her fear subsides after 45
minutes. This procedure is repeated several times until the phobia is
completely gone. The therapist has used the classical conditioning
technique of
anxiety hierarchies
systematic desensitization
flooding
relaxation training
10. Lee
is also extremely afraid of snakes and has sought treatment for his
phobia. During his therapy, he is trained in relaxation techniques, he
and his therapist construct an anxiety hierarchy, and he is gradually
exposed over several sessions to the items on the anxiety hierarchy.
Lee has experienced
systematic desensitization.
flooding.
aversion therapy .
modeling.
11.Ryan was
diagnosed with generalized anxiety disorder a few years
ago. In order to help Ryan learn how to more effectively interact with
people, his therapist demonstrates appropriate forms of eye contact,
social distance, and conversational style. Ryan then imitates and
rehearses the same behaviors while his therapist provides praise and
constructive feedback. Ryan is receiving
interpersonal perception training.
social-skills training.
biofeedback.
systematic sensitization.
12. In
Mary Cover Jones classic study of three-year-old Peter who was
afraid of rabbits (1924), she began putting Peter in situations that
required closer and closer contact with the rabbit, until the rabbit was
on his lap. This technique became known as
flooding.
aversive conditioning.
systematic desensitization.
covert sensitization.
13. Encounter
groups are used by psychologists who take the
psychoanalytic approach.
cognitive approach.
humanistic approach.
behavioral approach.
14. Which
of the following types of therapists has received medical
training?
clinical psychologist
counseling psychologist
psychiatric social worker
psychiatrist
15. Albert
Ellis believes that psychopathology is caused by
people's rational beliefs.
learning pathological behaviors.
dysfunctional family interactions.
people's irrational beliefs.
16.
Which of the following problems is most suited for systematic
desensitization?
a person's alcoholic behavior
a person's fear of dogs
a person's attempt to quit smoking cigarettes
a person's violent behaviors
17. In
Patty's session with her psychoanalyst, she is to say whatever comes
to mind, even if it is unpleasant or seems irrelevant. This is the
technique of
resistance.
free association.
analysis of transference.
dream analysis.
18. Brad
is a psychologist who believes that his clients know themselves
better than he does. He listens and restates the client's feelings in more
direct and emotional terms. Brad adheres to the
behavioral approach.
psychoanalytic approach.
humanistic approach.
cognitive approach.
19. In
classical conditioning therapy, Jane's therapist constructs a
graduated list of situations that Jane finds threatening. This is called
an
anxiety
hierarchy.
pyramid.
ladder.
stairstep.
20. A
group of inmates are able to earn poker chips for completing daily
chores. These chips can be exchanged then for books. What is this
approach of rewarding called?
modeling
shaping
covert sensitization
token economy