Ch15: Psychological Disorders & Abnormal Psychology（心理障碍与异常心理学）

Preparatory Mindset

Abnormal psychology = the scientific study of psychological disorders — their definition, classification (DSM-5), causes, and treatment. This chapter consolidates the disorder-specific content (depression, anxiety, PTSD covered in Ch10) into a broad DSM-5 overview: the neurodevelopmental, psychotic, bipolar, personality, and somatic disorders plus suicide risk. The exam asks about the definition of abnormal behavior, DSM-5 classification, and the biopsychosocial model.

Exam mindset: know the 4 D's of abnormal behavior (deviance, dysfunction, distress, danger), the DSM-5 main categories, schizophrenia (positive/negative symptoms), bipolar disorder (mania), and personality disorders (Cluster A/B/C, borderline). This chapter + Ch10 covers the full disorder spectrum.

Core Concepts

1. Definition of abnormal behavior (MUST KNOW)

1. Deviance — behavior deviates from social/cultural norms 2. Dysfunction — interferes with daily functioning (occupational, social, self-care) 3. Distress — causes personal suffering 4. Danger — risk to self or others (not always present)

• The 4 D's:
• Caveat: abnormality is culturally relative — context matters (e.g., grief, religious experience)
• Statistical definition: rare behavior ≠ necessarily abnormal (high IQ is rare but not abnormal)

2. The biopsychosocial model (MUST KNOW)

• Biological: genetics, neurochemistry (dopamine, serotonin), brain structure/function, hormones
• Psychological: cognition, learning, personality, coping
• Social: stress, trauma, family, culture, socioeconomic
• Diathesis-stress model: vulnerability (diathesis) + stress → disorder
• DSM-5: the standard diagnostic manual (dimensional + categorical)

3. DSM-5 main categories (MUST KNOW)

4. Schizophrenia (MUST KNOW)

- Delusions — fixed false beliefs (persecutory, grandiose, reference, thought broadcasting) - Hallucinations — false perceptions (auditory most common; Schneiderian first-rank: voices commenting, arguing) - Disorganized speech (loose associations, neologisms) & behavior (catatonia)

• Core features: psychosis — delusions, hallucinations, disorganized speech/behavior, negative symptoms; ≥6 months (schizophreniform 1-6 months, brief psychotic <1 month)
• Positive symptoms (excess):
• Negative symptoms (deficit): avolition (loss of motivation), alogia (poverty of speech), anhedonia, flat affect, asociality — these predict poor outcome
• Cognitive symptoms: attention, memory, executive dysfunction
• Etiology: dopamine hypothesis (hyperdopaminergic in mesolimbic), genetics (heritability ~80%), neurodevelopmental, stress
• Treatment: antipsychotics (first-gen — haloperidol, chlorpromazine; second-gen — risperidone, olanzapine, clozapine for refractory), psychosocial (CBT for psychosis, family therapy, social skills), long-acting injectables for adherence
• Extrapyramidal side effects: EPS (parkinsonism, akathisia, dystonia), tardive dyskinesia; metabolic syndrome with atypical agents
• Prognosis: positive symptoms respond to medication; negative symptoms are harder to treat

5. Bipolar disorder (MUST KNOW)

- Distractibility, Insomnia (decreased need for sleep), Grandiosity, Flight of ideas, Activity (increased goal-directed), Speech (pressured), Thoughtlessness (poor judgment — spending, risky sex)

• Bipolar I: ≥1 manic episode (with or without depression)
• Bipolar II: hypomania + major depression (never full mania)
• Mania (MUST KNOW — the "DIG FAST" mnemonic):
• Hypomania: same but milder, no psychosis, no marked functional impairment, <4 days
• Treatment: mood stabilizers (lithium — first-line; valproate, lamotrigine), antipsychotics (quetiapine, olanzapine), avoid antidepressants as monotherapy (may trigger mania)
• Lithium monitoring: therapeutic level (0.6-1.2 mmol/L), toxicity (tremor, nausea, ataxia, seizures — monitor renal & thyroid)

6. Personality disorders (MUST KNOW)

• Definition: enduring, inflexible patterns of inner experience & behavior deviating from cultural expectations, causing distress/impairment (onset adolescence/early adulthood, stable)
• Cluster A (odd/eccentric): paranoid, schizoid, schizotypal
• Cluster B (dramatic/emotional): antisocial, borderline, histrionic, narcissistic
• Cluster C (anxious/fearful): avoidant, dependent, obsessive-compulsive (PD — NOT OCD)
• Borderline PD (MUST KNOW): instability of relationships, self-image, and affect; impulsivity; fear of abandonment; splitting; self-harm & suicidal behavior; emptiness; stress-related paranoia — DBT is the evidence-based treatment
• Antisocial PD: disregard for & violation of others' rights; lack of remorse; childhood conduct disorder; psychopathy (PCL-R) overlaps
• Treatment: psychotherapy (DBT for BPD, CBT, mentalization-based, schema); limited medication (symptom-targeted); prognosis guarded

7. Somatic symptom & related disorders (MUST KNOW)

• Somatic symptom disorder: physical symptoms + excessive thoughts/feelings/behaviors about them (distress out of proportion)
• Illness anxiety disorder (hypochondriasis): preoccupation with having a serious illness despite normal exams
• Conversion disorder (functional neurological): neurological symptoms (paralysis, blindness, seizures) incompatible with medical disease — la belle indifférence (indifference to symptoms)
• Factitious disorder (Munchausen): intentional production of symptoms for the sick role (vs. malingering — external gain)
• Treatment: CBT, reassurance, treat comorbidity (depression/anxiety), avoid unnecessary investigations

8. Eating disorders (MUST KNOW)

• Anorexia nervosa: restriction, low BMI (<18.5), intense fear of gaining weight, body-image distortion, amenorrhea; medical complications (bradycardia, hypothermia, osteopenia, electrolyte disturbance — refeeding syndrome!)
• Bulimia nervosa: binge-purge cycles, normal/low-normal weight, self-induced vomiting, laxative use; complications (dental erosion, esophageal tears, hypokalemia, parotid swelling)
• Binge-eating disorder: binges without purging (obesity association)
• Treatment: multidisciplinary — nutritional rehabilitation, CBT (first-line), family-based (adolescents — Maudsley), SSRIs (bulimia), refeeding cautiously (phosphate monitoring)

9. OCD & related (MUST KNOW)

• OCD: obsessions (intrusive thoughts) + compulsions (rituals to reduce anxiety); insight may be poor
• Treatment: CBT with exposure & response prevention (ERP) — first-line; SSRIs (high dose); severe → augmentation
• Body dysmorphic disorder: preoccupation with imagined defect; mirror checking
• Hoarding disorder: persistent difficulty discarding possessions

10. Substance use disorders (MUST KNOW)

• Criteria: impaired control, social impairment, risky use, pharmacological (tolerance, withdrawal)
• Alcohol: withdrawal (tremor, seizures, delirium tremens), detoxification with benzodiazepines, thiamine (Wernicke-Korsakoff prevention), naltrexone/acamprosate/disulfiram
• Opioids: withdrawal (autonomic storm, mydriasis, diarrhea), naloxone for overdose, methadone/buprenorphine maintenance
• Stimulants (cocaine, amphetamine): cardiac, psychiatric
• Tobacco: nicotine replacement, varenicline, bupropion

11. Neurocognitive disorders (MUST KNOW)

• Delirium: acute, fluctuating, attention impairment, reversible — treat the cause
• Dementia: chronic, progressive, memory + ≥1 domain — Alzheimer's (most common), vascular, Lewy body, frontotemporal
• Mild cognitive impairment (MCI): cognitive decline not meeting dementia criteria

12. Suicide risk assessment (MUST KNOW)

• Risk factors: prior attempt (strongest), male sex, older age, depression/bipolar, substance use, psychosis, hopelessness, chronic pain/illness, social isolation, access to means
• Assessment: ideation, plan, means, intent, timeframe, protective factors (family, faith, reasons for living)
• Management: safety plan, remove means, hospitalization if imminent, treat underlying disorder, follow-up
• In China, suicide is a significant cause of death — one of the leading causes in the young

High-Yield Points

• 4 D's of abnormality: Deviance, Dysfunction, Distress, Danger
• Diathesis-stress model; biopsychosocial model
• Schizophrenia: positive (delusions, hallucinations, disorganized) + negative (avolition, alogia, anhedonia, flat affect); ≥6 months; antipsychotics (2nd gen first-line)
• Mania: DIG FAST (Distractibility, Insomnia, Grandiosity, Flight of ideas, Activity, Speech, Thoughtlessness)
• Bipolar: lithium (0.6-1.2), avoid antidepressant monotherapy
• Personality disorders: Cluster A (odd), B (dramatic), C (anxious); BPD = instability + splitting + self-harm → DBT
• Somatic symptom, illness anxiety, conversion (la belle indifférence), factitious vs malingering
• Anorexia: BMI <18.5, fear of weight gain, refeeding syndrome risk
• OCD: ERP + SSRIs
• Suicide: prior attempt strongest risk factor; safety plan + remove means
• Delirium = acute/fluctuating; dementia = chronic/progressive

Topic Summary

Abnormal psychology defines disorders by the 4 D's (deviance, dysfunction, distress, danger) within the biopsychosocial and diathesis-stress frameworks, classified by DSM-5. Key categories: schizophrenia (positive: delusions/hallucinations/disorganization; negative: avolition/alogia/anhedonia — antipsychotics), bipolar (mania = DIG FAST; lithium first-line), depressive & anxiety (Ch10), personality disorders (Clusters A/B/C; BPD → DBT), somatic symptom & related (conversion with la belle indifférence; factitious vs malingering), eating (anorexia — refeeding risk; bulimia — hypokalemia), OCD (ERP + SSRIs), substance use (alcohol withdrawal/opioid overdose), and neurocognitive (delirium vs dementia). Suicide risk assessment (prior attempt strongest, safety plan, remove means) is a core clinical duty. The exam pairs each disorder with its key features, mnemonics, and first-line treatment.