心理学与生活-第79章

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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　munity　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　mon　
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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PSYCHOLOGY　AND　LIFE　

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　mon　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：　being　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；　
“being　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；　plex　or　inconsistent　parental　
custody　and　visitation　arrangements；　foster　family；　institutional　rearing；　loss　of　nuclear　
family　members。　

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CHAPTER　15：　PSYCHOLOGICAL　DISORDERS　

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　
mand”　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　mon。　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　acplished　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　environm