The Brain: An Interactional Perspective To believe that the brain is merely a series of chemical reactions is to remove humans from any effects of their en- vironment and their own actions. In fact, some brain func- tions are “hard-wired” in advance of birth, and some are designed to be shaped by experience. At one time the pre- vailing view held that the brain grew through childhood, took its final shape during adolescence, and then slowly aged. New work shows, however, that each area of the brain de- velops in unique ways throughout life. While some parts of the brain deteriorate, most brain cells continue to form new connections. Three areas of brain research seem especially pertinent to an understanding of both normal and abnormal behavior: 1. Specifying how the brain grows and maintains itself; 2. Identifying the mechanisms by which the brain acquires, stores, and uses information at the cellular and molecular levels, as well as at the level of behavior and social interaction; and 3. Making clear the role that the brain plays in monitoring and regulating internal bodily processes. In the past, people looked for physical causes for all forms of maladaptive behavior. If people behaved in odd ways, it was because there was something physically wrong with them. People could be “born criminals” or have “bad blood.” Then scientists became aware of the psychological and social causes of behavioral problems. As a result, phys- ical explanations came to be seen as inadequate, and even as somewhat simpleminded. Today, however, psychologists are developing a more complete picture of how intertwined the psychological, social, and physical domains of human ior are, _ We learn social skills, interact with others, and acquire attitudes within a framework of physical develop- n functioning ts influenced by organic events intrauterine life before birth, the birth swemtautn cians and of maladaptati ers solely to ohn tional pressures, Unf incorrect. Behavior ences and environm these variables deter think about. There is for each type and de Vulnerability Not only are there m the brain that occurs or disease, but the sa oration can have var degree, these effects ity and abilitiés, and the organic blow. As the psychological ar and tumors do not ¢ the basis of the amou The following 2 vulnerability to brain 1. ge. The age at ' have both long- an instances an infar for an injury than also be more susce} ditions. Many beh justment (0 @ other hand, incre’ normal behavior13-1), In other cases, certain diseases ree A the brain. These changes in the by a ie happen quickly oy for study of the living ical nature—whether they happen quickly oF sloyiy whether they involve large or small ateas—are gpd about the inter- D: forhots F: ce of unusual behavior. Damage 0 the brain can't Despi I characteris; ae variety of behavioral problems, depending og at for the many peaple part ofthe brain i affected and the extent ofthe damga orders, their lives, like those What is known today about brain disorders jg copia rent with what we have said throughout this text abouerfe interactions between personal and environmental fac vulnerability, and stress. It would simplify the lives of clini, | ans and revearchersifthey could assume tha certaineyn ractional of maladaptation were due solely to personal variables, ork, rs solely to physical factors, and still others solely to situa, tional pressures. Unfortunately, such assumptions would be fnerely a series of chemical jncorrect. Behavior is a joint product of individual differ. - ences and environmental variables. The particular mix of these variables determines how people act and what th think about. There is no standard type of psychological effect for each type and degree of brain defect. ‘will never be the same again. Vulnerability to Brain Disorders Not only are there many differences in the actual damage to the brain that occurs in different individuals through injury or disease, but the same amount of brain damage or deteri- oration can have varying effects in different people. To some degree, these effects depend on each jridividual’s PeRSREL. fevandlabilities, and tHe Social Supports available to cushion the organic blow. Asa result, there are many cases in which the psychological and behavioral effects of brain injuries and tumors do not conform to what would be expected on the basis of the amount of brain damage suffered. The following are among the factors that influence vulnerability to brain damage and brain disorders: 1 NAW. The age at which a brain condition develops can have both long- and short-term effects. Although in some instances an infant bi better able to compensate for a injury than i adult brain, the infant brain may more susceptible to a variety of pathological con- ditions. Many behavioral deficits that are caused by dam- age to the brain in infancy are not noticed until 7 ly later, ‘ ee. « presence of caring, accepting Peo toa pag iividual can rely usually eases ad: Aeon 5 # brain condition, Social isolation, on the creases Cognitive deficits and, thus, ab- “Re greater the stress, ¢and the beha : the greater both the coginv pain injuries shat itis hard areas aoe how much, ifany, improvement Figure 13-1 ropes overtime, particularly in the ¢ will oeivaterthe injury has occured. _Y her injury. cht family’s stress is compounded by Source: Jim Berry/Sea common clit « personalityfactors. At al observation that some people react with intense anxiety, feelings of personalization, paranoid thinking, defensiveness, hallucinations to any cond and perceptual functioning. 5. Pigsicalyeondition? The site of the brain rate of onset, and the duration of the disord n, the ind lide | Amindividual’s psychological state and social relationships wid? | Mhetonser of an organic condition can influence the im- irionjonhis or her BeAAVIGHVA person Sarah's external wounds have healed, and she appears unaffected Figure 13-2 Sarah and her teacher rejoice at Sarah’s success in completing 3 computer problem. ‘Source: Jim Berry|Seattle Times. ttle Times. differently (and more adaptively) to treatment than does someone in the throes of marital turmoil or financial: reversal. WHERIpE a condition, both medical and eCESary, In addition to its personal effects, ifipaleiaenege brain function has a profound influence,onsinterpersonal felationships} For example, people with epilepsy suffer from undesirable social consequences as well as from the seizures themselves. "a Because determining the presence and extent of brain damage is complicated by the need to isolate its effects from those caused by personal and social factors, clinicians must avoid overly simple diagnoses. Clearly, a person who is” noticeably disoriented, has trouble solving problems, and displays shallow or very changeable moods and emotions isfrom some sort of behavioral problem. But the aspects of the diagnosis—an estimate of the roles played by organic damage, personality, and life stress 1" ‘causing the disturbance—are not so easily determined. Assessing Brain Damage While the list of rare brain disorders is long, many brain disorders that have major impacts on thought and behavior are fairly common. For example, brain injuries, epilepsy, an ar diseases are more common than schiz, M. Silver et al., 1990). Hi acute cerebrovascul ophrenia and panic disorders (J. This a particular the fact that damage t int is have diverse effects. This poi ch lists symptoms often seen lated to malfunction of the brain's frontal lobes. Some of these symptoms are the following case: task is complicated by area of the brain can illustrated in Table 13-1, whi in patients who have disorders rel evident in Mrs. L., a 58-year-old housewife, was brought t0 the hospital that for the past year her mother by her daughter, who reporte pone mea deneased intrest n caring fr her house and personal reeds The patient lived alone in a real area with few neighbors The daughter, during an infrequent visit, had noticed a change in her mother's behavior; she showed a lack of interest in conversa- tion and had an unkempt appearance, with a lack of concern about family affairs and total neglect of personal and household Cleanliness. Neighbors had noticed that the patient had stopped attending church, did very litle shopping, and no longer made Social visits. On examination at hospital admission, Mrs. L ‘was awake but markedly apathetic. She offered no spontaneous conversation and answered all questions with only single-word Mental Status Ex chological Testing as well as for & tual might make. As we examination provides i behavior and thought. entation to reality, me sions. Table 13-2 gives to detect brain disorde The mental statu by psychological testi Clinicians use the me following information 1. Level of consciousr what is going on? . General appearance Attention span Orientation with r Short-term memo' knowledge) we wnto malfunction of the f these ‘symptoms are evident in wife, was brought to the hospital that for the past year her mother n caring for her house and personal m a rural area with few neighbors. uent visit, had noticed a change in .a lack of interest in conversa- 2 with a lack of concen of personal and household that the patient had stopped e shopping, and no longer made at hospital admission, Mrs. L. etic. She offered no spontaneous questions with only single-word Mental Status Examination ANd Neurs chological Testing * ,, which is useful for WAGON as well as for ts the in livid, ual might make. As we noted in Chapter 4, the mental s examination provides information about n ae Its question: ind tasks ions. Table 13-2 gv to detect brain disorders, The mental status examination is often suppleme by psychological testing and a neuro logical examinatiy Clinicians use the mental Status examination to elicit amples of questions and tasks ugh following information: 1. Level of consciousness— what is going on? 2. General appearance (behavior, 3. Attention span 4. Orientation with regan 5 Cheer sae ‘ how aware is the individual dress, cooperation) dtotime and place |Questions and Tasks Used in Mental Status Examinations for the Assessment f Question or Task bane pes ine orientation “What year is th today?” “What city are we in?"; "What state are we in?” "Repeat these words: ball, flag, tree.” "Subtract 7 from 100. Continue subtracting 1s." "Repeat the words [ball, flag, tree] | mentioned earlier” fa ew minut the original presentation). en "What is this?” [Show pencil, t, west, home's best.” over there on the table.” le and then two intert I "Repeat: Eas “Take this pencil and put it "Copy this figure.” (Show triang! data from @ 1. £laharatory tests, vith i ; information about a patient's history, htwith eeinat ee Patients hit a alexamination, and the , : Neuropsychologists use vetlel es lab data from ama and its cause. Neuropsychol, an inch of psychology that deals with ref yior and the condition of the bth logists are particularly interested in, oon on behavior. NeE meat effects of brain impairment in such areas as wart Rigs ate used to siveness t0 Sensory stimulation, ability to ‘ad and respon. communication and to express oneself, mae verbal expression. Neuropsychological testing is sensitive ony functioning of various regions of the brain. Neier study deficits with three major objectives in mind: 1) a insight into the structure and functioning of the normal re — \Caneous nitive system, 2) to explore the localization of various fa an : Re tions in the brain, and 3) to achieve a better understanding of _ allowsres i, Writ ing) any deficits, as a basis for diagnosis and treatment. cent parts ! In working with patients, neuropsychologists seek to de- variousle' scribe changes in psychological functioning (for example, with regard to thought and problem-solving, emotions, x behavior). In doing this they need to be sensitive to nen eo niques toa 'Sa relative tionships Clinical Neur ly new factors that might be pertinent to cognitive dysfunction : rehabilitation (Ferraro, 2002). In addition to detecting level a determine the parts ofthe brain offunctioning, they seek , they seek to logical that are not functionin: roperly- Neuropsyno ee cies not functioning P' = of rehabilitation and cre assessment provides clues about the typ’ i pful, and a0 a Programs that are likely to prove . i Oe (hebben & a Practical guidelines for family an Milberg, 2002). tomer” eructing test ef prain bas Ber , Gin Imaging Progress in const turbances in various TeBiOM> shout ie dis } line by the lack of direct informa’table. [Show triangle and then two intertwined pentagons] goes on in the brain. As we have seen in previous chapters, technology using a variety of brain imaging toMy rapidly changing this situation. This technology helps th the relationship between damage to specific regions of the brain and the effects of the damage on psychological func; tioning. Studies using both brain imaging Ld a Sale neuropsychological tests have often found that conc! pe drawn from them are often comparable (Ritchie S& Richards, 1999). This chapter, which focuses on brain disorders, isa good place to review some of the information about scanning Sad emotional. techniques. Figure 13-3 shows the basic principles involved itivetoimpaired in three of the most widely used scanning techniques— aropsychologists computerized tomography (CT scan), positron emission to- mind: 1) togain ography (PT scan), and magnetic resonance imaging (MRD). the normal cog- The CT scan provides images that show where injury, of various func- deterioration, or enlargement has occurred. The PT scan nderstandingof —_ allows researchers to visualize the chemical activity of differ- : tent parts of the human brain. Much as weather maps show various levels of rainfall, a PT Sean shows thellevels of glucose metabolism in different brain areas as they vary with the per- son’s mental state and behavior. Thus the PT scan enables scientists to study biochemical changes that could never be chatted before. PT scans permit the assessment of metabolic activity, and the measurementof neurotransmitter function. Magnetic resonance imaging (MRI) uses arrays of sensi- tive detectors placed over the head to locate and measure pre- cise sites of neural activity deep within the brain’s furrows and creases. Both the MRI and the CT scan provide visual- izations of brain anatomy and possible structural abnormali- ties. Unlike the CT, which is limited to imaging brain regions ina aor plane, the MRI can image in all planes. a scanning was one of the first imagin; i used in clinical and research work related iS cama RI has largely replaced CT as the most utilitarian and‘way—and, as the text explains, each the form of radio MR ore ed. Under these ‘Magnetic resonance imaging ( the imaging device, a strong magn' gure 13-3 Each of he tee ma] ESPLT pay nave : ‘etic field is creat UI ynance pa’ i iter ust resonate differently. A compu’ (ch) operates ‘through a narro ner. A computer he patient as the measures of the radiation passing through tl e F i phy (PT) scanning proce aaa d and move through th Computerized tomography (C1) patient's body as the patient lies in the scan In order to use positron em! " injected into the patient. As these chemicals ar positively charged electrons, or positrons. create signals by hitting detectors in the app: ‘of chemical activity. cost-effective method of imaging. MRI can better dis- ctiminate the interface between gray and white matter in the brain, and is superior in detecting certain types of Iesions. Like CT, the greatest value of MRI in the evalu- ation of brain disorders is in the diagnoses it can exclude (for example, the presence of a tumor). Although did nostically of . pes aie 6 reat potential, the cost of PT scans is too routine clinical use, and more research is needed to identify with confi a confidence th * . ively carry out. functions it can most clude relativel " ty global cogni ai ‘contusion: In cele Electrons and positrons aratus. These signals are terns to recreate @ mp wly focused X-ray that ‘then builds images of t X-ray source moves fr lures, radioac then collide and then convert Behavior drov ocet spe Mood Am var Thought Thi pel ret Perception Vi haseein ied in 1999 at th ry Quarry, a heavyweight the late 1960s and early 1970s, dis 2 ight with Muhammad sin 1990, In hs ral years, Guary was severely Se TT ‘blows 9. He experienced severe memory loss, hallucinations, and crippled motor res Seog his boxing career. * a “Seance: New York Times January 5, 1999, p. 20, 13-14 Jer of social and occupational functioning, and most ‘ for verbal and visual tasks that require While amnestic disorders have a common core © fons, slurring of speech, tremors of the tongue and lips, poor motor coordination. These symptoms are pro- sesive and eventually lead to a helpless condition, Before than | jpcause and treatment of syphilis were di covered, patients toms, the causes vary depending on the area of the! ‘not | aihgeneral paresis represented between one-tenth and fected. An amnestic disorder is often preceded by "for | gethird of all admissions to mental hospitals. Because of of confusion and disorientation. Most patients with tons | denegative relationship between the degree of possible im- amnestic conditions do not have insight into their deficit, and may actually deny the presence of i | ovement and the extent of irreversible brain damage, even though its presence is obvious to others. The in this jompt diagnosis and medical treatment of syphilitic infec- | iosisclearly the best approach to reducing the incidence The | general paresis. may be amnestic for the time period before, after injary. t & ’ The Diversity of Cognitive Impairment Disorders __varied nature of the events causing brain dysfunction (e.g, an injury to the brain), the location of the injury or the type of illness, and the age of the individual. For this reason, many Patients with cognitive impairment do not fit neatly into standard diagnostic categories. Cerebrovascular accidents and epilepsy illustrate the diversity of dysfunctional brain- behavior relationships. Cerebrovascular Disorders Cerebrovascular accidents (CVAs), or strokes, are block- ages or ruptures of the blood vessels in the cerebrum. When these blood vessels break or are blocked by a clot, a portion of the brain is deprived of its supply of oxygen and blood. Extensive damage to the brain and obvious changes in behavior may result. When the affected blood vessels are small and the interference with blood flow is temporary the symptoms are milder—pethaps only confusion, unsteadiness, and excessivelemotionality. Some of the behavioral effects ‘of a stroke may be similar to those effects in dementia that occur as a result of brain deterioration. HOwever, the symp- toms of stroke characteristically have an abrupt onset, and often include aphasia, the inability to use or comprehend words; partial or total loss of speech; and paralysis of part of the body. . Strokes are the third-ranking cause of death after heart Gifacks and eancer. There are approximately 500,000 new strokes, and 150,000 deaths due to strokes, in the United States each year. More than 80% of these involve people over the age of 65. In addition to age, high blood pressure plays a major role. aPhe singlelmost important way in whieh strokes can be prevented is through the treatment and con- trol of high blood pressure. Many clinicians have observed that strokes occur especially often in people who live pres- sured lives. For reasons that are currently unclear, thes people tend to have their strokes while they are relaxing or vacationing, a period when stress is apparently decreased. Poststroke depression and anxiety typically inhibit phys- ical recovery from stroke (Chemerinski & Robinson, 2000) Successful treatment of these psychological conditions (often using antidepressant medications) improves the likelihood of favorable coping with the stroke's effects. Vascular Dementia Vascular dementia, also called Me caused by a series of minor strokes that occur at different times. The onset of vascular dementia is abrupt, and its course is fluctuating rather than uniformly progressive. The pattern of deficits is “patchy,” depending on which areas of the brain have been damaged. As the condition worsens, the relatively intact areas of intellectual L a functionin, - decrease, and there is increased disturbance i i fictions, including uaheeemianiemmmmmmneces) multi-infarct nn ti helps prevent this type of Kbod of additional mi mentia is already to occur after age 65 thal Korsakoff’s Syn¢ Vitamin and other ag nervous system. Kors: some chronic alcoholic amin BI (thiamine) def versible disorder, desc recent and past memoril able to form new memo} deficits, loss of initial tremens frequently is The longer the vitam| responsive the individ Epilepsy Epilepsy is a transitor develops suddenly, c recut. The form that site in the brain in brain area rgkveted se but instead is episodes of changes i out an accompanyin: An epileptic sei instability of some cel gers an “electrical st the brain. This elec which can take many} only one type of seiz two or more types. petit mal seizures, an« The most sever mal (French for “ lasts from 2 to 5 painful impression of a grand mal sei: toms. The seizure of consciousness, fal These uncontrollab| victim. Among the| severe biting of movements of ag brain dysfunction (e.¢., of the injury or the type For this reason, many Not fit neatly into vascular accidents y of dysfunctional brain- tders is), or strokes, are block- sin the cerebrum. When ocked by a clot, a portion ply of oxygen and blood. and obvious changes in iffected blood vessels are 00d flow is temporary, the y confusion, unsteadiness, of the behavioral effects e effects in dementia that tion. However, the symp- rave an abrupt onset, and ity to use or comprehend ch; and paralysis of part of cause of death after heart proximately 500,000 new to strokes, in the United % of these involve people 2 age, high blood pressure it way in which treatment and con- have observed people who live pres- _ an aura, in which the individual experiences an. including feelings and impulse contr |. Mypertension may be a multi-infaret dementia. Controlling high blo} fetorin Tessie helps prevent this type of dementia, and reduces hood of additional minor strokesiubensmulerig kee mmentia is already present, SimaiimPee MON elMbiins2¢< de. to occur after age 65 than before. re likely Korsakoff’s Syndrome Vitamin and other nutritional deficiencies can affect thy nervous system. Korsakoff’s syndrome, which occur some chronic alcoholics, results from a combination of 2 amin BI (thiamine) deficiency and alcoholism. In this re, versible disorder, described by Sergei Korsakoff in 1887 recent and past memories are lost, and the person seems un. able to form new memories. In addition, there are perceptual deficits, loss of initiative, and confabulation. Delirium tremens frequently is part of the patient’s medical histor. The longer the vitamin deficiency has persisted, the less responsive the individual will be to vitamin therapy Epilepsy Epilepsy is a transitory disturbance of brain function that develops suddenly, ceases spontaneously, and is likely to recur. The form that this disturbance takes depends on the site in the brain in which it originates, the extent of the brain area involved, and other factors. Bpilepsyisinoea dis? ease but instead is a syndrome consisting of recurrent episodes of changes in state of consciousness, with or with- out an accompanying motor or sensory involvement. ‘An epileptic seizure is a result of transient electrical instability of some cells in the brain, which sometimes trig- gers an “electrical storm” that spreads through part or all of the brain. This electrical activity culminates in a seizure, which can take many forms. Many people with epilepsy have only one type of seizure, but a sizable minority experience two or more types. The major, types include granid mal and petit mal seizures, and psychomotor epilepsy The most severe form of epileptic disorder is the grand mal (French for “great illness”) seizure, which typically lasts from 2 to 5 minutes. This type of attack leaves @ painful impression on anyone who witnesses it. The vietim of a grand mal seizure displays a set of very striking symP- toms. The seizure often begins with a cry, followed by loss ‘of consciousness, falling to the floor, and extreme spasms: ‘These uncontrollable spasms can cause serious harm to the victim. Among the greatest dangers are head injuries severe biting of the tongue or mouth. The m Movements of a grand mal seizure are usually by alteredee larly comes lee js particularly common in ch, Tench} Rather, there is.a lapse of, el thee ) sicure, fy blank staring and lack of respnee" 0 con. ved Malta minute. The individ y hers to lose consciousness, These a) In wis! ting up, loes nop SPO a oot a 7 Seizures may mes a day y fr many veychomotor epilepsy, a ¢ InP Ype th ciepsy casenanclis rarely seen in cht tts 15% of ep" jscontrol of his or her mot dre 'Y Occur retains © : ‘or functioning baa Patient aalty £0 exercise good judgment in carrying ae loses the During @ psychomotor attack, the individual en setlties, his or her movements may be reper ganized but are in fact semiautomatic, Peon ges may resemble those of petit mal eng f eomOR ist longer (up to 2 minutes), involve muscle yet they ceated to chewing and speech, and show more cha mes fonsciousness. The occasional visual halluciegs eof confused state that characterize psychomotor gurcnt He similar to some symptoms of psychosis, Pilepsy are Aout 2,000,000 Americans have epilepsy proximately 5% to 10% of the population of the Unie} States wll have a seizure of some kind at some time in tha lives (Schwartz & Marsh, 2000). The incidence of epilerm ishighest in the first years of life, remains steady through Sle, and then peaks in elderly persons. ina kind of and highly ances and ap- Changing Views of Epilepsy Throughout history, epilepsy has inspired awe, fear, a sense of mystery, and puz- dlement. The Greek physician Hippocrates argued that epilepsy was a naturally caused disease, but for much of mod- embistory it was seen as a sign of demonic possession. Many famous people—including Julius Caesar, the elder William Pitt, and Fyodor Dostoyevsky—had epilepsy. Dostoyevsky, one of the world’s great novelists, suffered his first epileptic seisure while he was in prison in Siberia. He believed that the agony of living in chains, the stench, and the hard labor bas precipitated his attacks, which persisted for years, even rhe was permitted to leave the prison. The English neurologist Hughlings Jackson (1834-1911) first accounted for epileptic seizures in terms of brain loos Wenow know that epilepsy is caused by intermittent 500 tion of the brain's neurophysiology, and there is moun/0e ¢¥idence that repeated seizures can harm the begin ne Unexplained death occurs ina disproportionate) are 002). bet of people who have epilepsy (Pedley Saute nderstanding epilepsy is important, notonly Pec ,, human problem, but also because it provides # Pa “©vering how the brain works. : avail: Medical treatment Anieplete de ep bing sha teduce the ee 3902). Cli nies for many patients (Levy et 3)" imal dosage pause be ea Soaaet cxublshingor While ‘and identifying possible side effects a ies, especial their illness (5, en ; demoralization would be understandal seizures, underlying brain p higher rates Sepals inepd t the depression experienced by perso Many people with epilepsy with their condition. Because the before adulthood, the emotional reg person's family must also be dealt and the family see epilepsy as a kind it with shame and guilt. Because am: tension and frustration can tic seizures, psychotherapy and recommended both for those who ha their families. Many people still and mysterious. As a result of such epilepsy often feels socially stigmati An Integrative to Brain Disorders‘i izeable ee can help most people with epilepsy: @ fi nt group of those afilicted are resistant (© available cli . A recent study found that 28% of those who are oe Nee sistant have a type of gene variant that occurs Er Pitas, often in those who are helped by treatment ei Pdaltot 2003). This genetic vatiant is associated with ah ere the protein known as ABCBI, which is baleve! ‘ola bee rier to seizure medication. If drugs are ineffective OF strong side effects, or ifthe seizures are a result of some fe AY tifable structural defect, surgical intervention may 8 ss sidered. However, because brain surgery entails ol vious itis used only when there is clear knowledge of which area Erepetitive and highly brain tissue is causing the seizures. omatic. fralenilesy. bur chey Psychological Factors It has been estimated that Movements 39% to 50% of all those with epilepsy have psychological more clouding of gifficulties, especially depression, sometime in the course of foe andthe their illness (Sadock & Sadock, 2003). While sadness and epilepsy ate demoralization would be understandable rections to having fe seizures, underlying brain pathology may also contribute to Wwe epilepsy, and ap- higher rates of depression in epilepsy relative to comparison flation of the United groups. Antidepressant medications are helpful in treating latsome time in their he depression experienced by persons with epilepsy: incidence of epilepsy Many people with epilepsy need help in order to cope mains steady through with their condition. Because the disorder frequently begins Pr before adulthood, the emotional responses of the affected k person's family must also be dealt with. Often the patient Throughout history, and the family see epilepsy as a kind of disgrace and react to bofmystery, and puz- it with shame and guilt. Because an atmosphere of emotional pocrates argued that tension and frustration can increase the severity of epilep- bur formuch of mod- tic seizures, psychotherapy and counseling are frequently inic possession. Many —_ recommended both for those who have epilepsy and also for a, the elder William their families. Many people still view epilepsy as frightening, pilepsy. Dostoyevsky, and mysterious. As a result of such attitudes, a person with his first epileptic epilepsy often feels socially stigmatized. An Integrative Approach to Brain Disorders Because the conditions discussed in this chapter involve ac- tual organic defects, itis tempting tosee them as purely med. ical problems. Why do we consider brain disorders to be different from other organic problems, such as broken arms or gallstones? A physical defect lies at the root of all of these ae but the ee pas complex effect on our behav- as wel! as on our body. This effect is not as clear and pre- dictable as the effects of damage to other parts of the ba abroken arm has been set and healed, for. example, the to the condition he or she was in before isnot the case with brain injuries, es of @ Brain injury on behav. Person's life history |a and personality as well as environmental and biophysical factors. We need to identify vulnerability factors ne me son's life, and indications of his ot her ability to be resilient. t Purely physical conditions such as broken arms can be ities include treated successfully without such data. However, although intellectual fune brain disorders can be treated medically, the psychodynamic, hyperactivity and shore behavioral, cognitive, and community approaches are also _ tion of pregnancy #s mor important in understanding and treating these conditions. of neurological dystunetig Thus, the most fruitful approach to brain disorders is one feasons, those who focus: that integrates knowledge from these diverse fields phasize the prevention of From a psychodynamic perspective, although certain medical care, especially forms of maladaptive behavior may be organically caused, The stigma attacl the way people respond to their condition involves peycho- _adapesclons steso Eo logical factors such as personality, earlier experience, and situation worse: People characteristic ways of coping. For example, the moreoutgo= ala whvaisxe BET inga person is, the greater the likelihood of improvement in provides one OTN a Bi. Ge Wet condition. Many cates, of brain.disonler have Social meee a Gere tint crindivddualspenonalicy atthe tiene ofthecr: JeutedRGR mea ganic damage has an effect on the degree and form of his or _adapeation Etat Te bohevincl duce ionsion, For exemple, the concenc of lives ir aisica is hallucinations and the ease with which they are expressed al depend on personality characteristics. those who = ve . Behavioral psychologists are less interested in the ef- sometimes lesien| t's fects of personality and experience than are psychologists changes. who emphasize other perspectives. Behaviorists focus instead Cognitive impai tn people's ability to adapt to even the most drastic situa and amnesia, s 2 Pt ae eR aching new responses to compensate for those that but several other fac pene een lost is seen as more important for adjustment than logical and social var simply helping people accept their new lot in life. Moreover, __ in determining the| the way people respond to such training can provide more variety of vulnerabi relevant information about their present psychological state eral health, the ava than an examination of their personality before the illness characteristics, cop occurred. Because of their emphasis on revising people’s the impact of brain maladaptive responses as quickly as possible, behavioral psychologists have a major contribution to make in the treatment of organic brain disorders. Cognitively oriented psychologists have contributed a Our Take-Ay variety of techniques to help people in the early stages of For many years, a dementia deal with the deterioration in their abilities. “organic” and “fu Memory-aiding techniques (such as making lists) can help was identifiable brd Alzheimer’s disease victims, for example. Cognitive tech- discernible organi niques are also useful in counteracting the depression that _as outdated, and n| often accompanies the development of physical problems agree with the bat} and declining intellectual competence made clear in pre Damage to the brain and central nervous system would ously regarded as not seem to be a condition that is influenced by community of some organic al variables, Yet, from all indications, central nervous system and schizophrenia dysfunction is not randomly distributed. Cases of brain only parkog the st damage are highly concentrated in the segments of the pop- We have sees ulation lowest in socioeconomic status. Within this group, such problems seem to be most prevalent among African American children. This is true for sociological, not reasons. Poor African American it ote ae amlnorable Snare, Bi eth te ee td a sat eaecases of brain disorder have sonality at the time of the or- ‘the degree and form of his or ‘example, the content of foes expressed eristics. fnadequate nutrition and prenatal care Bee ot pregnancy, which take hte ollin high of premature births and congenital defects. These abnormah, ities include neurological damage that results in impain, inellectual functioning, and in behavioral difficulties suchas hyperactivity and short artention span. No single complica: tion of pregnancy is more clearly associated with a wide ra of neurological dysfunctions than premature birth. For thes reasons, those who focus on the community perspective ems phasize the prevention of brain disorders through preventive medical care, especially good prenatal care The stigma attached to many of the behavioral mal- adaptations stemming from brain damage often makes the situation worse. People tend to avoid and isolate individu. als who are markedly deviant. The behavior of old people provides one of the clearest illustrations of the effects of this social rejection. Mild brain deterioration in a socially re. jected older person may lead to greater behavioral mal- adaptation than moderate deterioration in a person who lives in a friendlier, more accepting environment. From the community perspective, changing people's attitudes toward those who behave differently because of brain disorders can sometimes lessen the behavioral effects of these biological changes. Cognitive impairment, as seen in delirium, dementia, and amnesia, is a product of events occurring in the brain, but several other factors also play important roles. Psycho- logical and social variables interact with physical condition in determining the individual's level of functioning. A variety of vulnerability and resilience factors (such as gen- eral health, the availability of social support, personality characteristics, coping skills, and interests) can influence the impact of brain dysfunction. Our Take-Away Message For many years, a distinction was routinely made between “organic” and “functional” disorders. In the former, there was identifiable brain pathology; in the latter, there was no discernible organic basis. This distinction is now recogni as outdated, and neither term appears in DSM-IV-TR. We agree with the banishment of this distinction. As we have made clear in previous chapters, several conditions previr ously regarded as functional now show growing indications of some organic abnormalities (for example, mood disorders and schizophrenia). However, the organic abnormalities are only part of the story, but by no means all of it. We have seen in the present chapter that, while thet _ are tissue abnormalities in a number of condones eee