1 abnormal psychology this is not a course about the problems of someone else. mental illness...

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Abnormal Psychology

This is not a course about the problems of someone else. Mental illness touches all of us at some time during our lives; if we are not the ones afflicted, then it will be a family member, loved one, or close friend.

The problem of abnormal behavior is personally relevant and emotionally charged, but in this course we will explore the problem from an objective and scientific point of view. Although we must be dispassionate in our study of the problem, it is important that we keep in mind the importance and the intense personal ramifications of what we are studying.

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PsychopathologyPsychopathology ... beyond behavior

1. Thought: problems in how and what we think

2. Emotion: problems in momentary mood and chronic temperament

3. Conation: problems in momentary motives and persistent needs

... the “subject matter” and the “data base”

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The Definition of “Psychopathology”The Definition of “Psychopathology”

Topics: The importance of the historical context

A.A. UnderstandingUnderstanding: scientific description and explanation... the history of our curiosity

B.B. InterventionIntervention: the change technologies

... the history of our compassion

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History History ... of understanding and intervention

3 broad perspectives on both:

1. Sociocultural: natural and supernatural

2. Biological: body and brain

3. Psychological: three theories of the mind

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... and a narrow-minded tradition

UnderstandingTheory Cause

Intervention

TherapyCure/Care

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Examples:

1.1. BiologyBiology: from the four humors to the monoamines

2.2. PsychologyPsychology: three “meta-theories”

A. Learning Theories: adaptation to the present and the behavior

and cognitive therapies

B. Phenomenological Theories: growth into the future and the

directive and non-directive therapies

C. Psychodynamic Theories: conflict from the past and the

psychoanalytic therapies

3.3. Sociocultural factorsSociocultural factors: natural and supernatural

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PeoplePeople and their ProblemsProblems... the recurrent millennia of history

Understanding problems, in the past the causes of problems

Intervening with people, in the future the course of life

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Some comparisons...Some comparisons...

1. Simple mechanical objects (cars and clocks)

... focus on causecause

2. More complex situations (soups and sauces)

... focus on effecteffect

3. The complexity of life (you and I)

... focus on resilienceresilience

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Implication... “problems” as solutions to problems

Factors in the ....

cause (past)

content (present)

course (future)

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Common confusions

A. Theory Therapyexample: “therapeutic nihilism”

B. Therapy Theoryexample: “post hoc explanations”

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HistoryHistory of psychopathology... the myth and the reality

“Those who don’t study history more

carefully are condemned

to repeat it.”

- George Santayana

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1. Ancient writings & archaeological evidence

Homer The Hebrews Trephining Asclepius

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2. Biogenesis: Hippocrates and “the four humors”

Sanguine Choleric Phlegmatic Melancholic

e.g., hysteria

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3. Psychogenesis: Plato and "the tripartite mind“

Affect Appetite Reason Self-management

e.g., catharsis

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3. The Roman Era and The Middle Ages The Roman Era : Galen and beyond

The Middle Ages : “The Dark Ages” (450 – 1450 A.D) The Arab World :

• Egypt and Avicenna The Western World :

• France • Italy • Britian• Gheel • St. Augustine

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4. The Renaissance

and the Revolutions

A. The Return of

the Supernatural View

Witches ... and the rise

of the asylum

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4. The Renaissance

and the Revolutions

A. The Return of

the Supernatural View

Witches ... and the rise

of the asylum

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Three Threats:Three Threats:

1. Physical: “The Black Death”

2. Religion: “The Reformation”

3. Social: “The Little Ice Age”

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The Solution:The Solution:

Malleus Maleficarum:

(and Thesaurus

Exorcismorum)

A witching trial during the Salem Witch Hunt

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The Solution:The Solution:

Marvin Harris

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The AsylumThe Asylum

London:

St. Mary’s of Bethlehem

Paris:

LaBicêtre

Salpêtrière


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The AsylumThe Asylum

London:


Paris:

LaBicêtre

Salpêtrière

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The Challenge:– St. Thomas Aquinas,

from the Middle Ages

– Johann Weyer Deception of Demons

Johann Weyer St. Thomas Aquinas

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The Challenge:– Reginald Scot

The Discovery of Witchcraft

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The Challenge:– Teresa of Avila

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The Challenge:– Teresa of Avila

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The Challenge:– Paracelsus

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4. The Renaissance and the RevolutionsB. The “Mental Hospital Movement”Paris:

Philippe Pinel

and Jean Baptiste Pussin

Dorothea Dix

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4. The Renaissance and the RevolutionsB. The “Mental Hospital Movement”

London: William Tuke ... and the York Retreat

Dorothea Dix

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4. The Renaissance and the RevolutionsB. The “Mental Hospital Movement”

The York Retreat

Dorothea Dix

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4. The Renaissance and the Revolutions

B. The “Mental Hospital Movement”America: Dorothea Dix

... and “moral management”

Clifford Beers . .. and “the mental

hygiene movement”

Dorothea Dix Clifford Beers

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5. The Psychiatric Revolution: the return of biogenesis

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5. The Psychiatric Revolution:

the return of biogenesis

Louis Pasteur

Benjamin Rush

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Louis Pasteur

Ignaz Phillip Semmelweis

Edward Jenner

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John Snow

William Farr

Paul Broca

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Alzheimer

Korsakoff

Wernicke

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The Story of General ParesisGeneral Paresis

Diagnosis ...from cases to syndromes

History ...from correlates to causes

Treatment ...from causes to cures

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Ehrlich’s “magic bullet”“magic bullet”

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Along the way....

anti-sexualism degeneracy theory phrenology

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The Medical View:

Wilhelm

Griesinger

Emil Kraepelin

Jean-Martin

Charcot

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6. Psychodynamic theory and psychoanalysis:

The return of psychogenesis

Liebault&

Bernheim:

““psychoneurosis”psychoneurosis”

Freud&

Breuer:

The case of

Anna OAnna O

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The case of

Anna OAnna O

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7. The “Mental Health MovementMental Health Movement”

the return of sociogenesissociogenesis, again

Sociologists Anti-Psychiatry Clinical Psychology

... and then, something happened...

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8. The “New Psychiatry”

The return of biogenesisbiogenesis,

again

DrugsDrugs and the

search for biologicalbiological causes

The technologiestechnologies and

an integrated approachintegrated approach

Heinz Lehmann

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The Lesson Lesson of History

“The lessons of the past

were obliterated by the aspirations

of the present.”

- Alexander Leighton

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“It ain’t what you don’t know

that gets you; it’s the things you

know that ain’t so.”

- Mark Twain

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“Confusion now hath made

his masterpiece.”

- MacBeth

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The Lesson Lesson of History...Limitations to Progress

1. Understanding (finding causes): post hoc explanations correlates and causes longitudinal and experimental research the problem of base rates (BR)

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2. Intervention (finding cures): placebo effects spontaneous remission (SR) superstitious behaviour publication bias

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Summary:

1. Understanding: it is hard to find out whywhy something

happens when it doesn’t happen very oftendoesn’t happen very often

2. Intervention: it is hard to find out if anything makes a makes a

differencedifference to the course when that course is

erraticerratic and unpredictableunpredictable

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Definitions

1. Theoretical/absolute criterion

demons diseases defects

Making inferencesinferences and pathologizingpathologizing the resultsresults

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Definitions

2. Social/cultural criterion

deviance difference disgust

Making discriminationsdiscriminations and pathologizingpathologizing the minorityminority

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Definitions

3. Personal/subjective criterion

distress dysphoria despair

Making introspectionsintrospections and pathologizing unhappinesspathologizing unhappiness

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Definitions

The common-sense criterion:

Maladaptation/symptoms

disorder dysfunction disability thoughts & perceptions

emotions & feelingsneeds & motives

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The Modern Diagnostic System(DSM)

Why diagnosis?

... a present description

...with future implications

“Diagnosis is prognosis”

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DSM I (1952) and DSM II (1968)

DSM III (1980) and DSM IV (1994) ... TR, now

ICD 1 (1948) to 10 (1992) ... CM, now

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What have we gained?

1. ResearchResearch: no false positives

2. PracticePractice: no false negatives

... communication – in principle

... but research biasesbiases in practice

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Diagnosis of psychopathology(DSM)

Axis I -Axis I - Clinical syndromes

Axis II -Axis II - Personality disorders (and MR)

Axis III -Axis III - Medical conditions

Axis IV -Axis IV - Stress

Axis V -Axis V - Coping (GAF)

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“Other conditions that may

be the focus of clinical attention”,

including psychological factors

affecting medical conditions,

and the “V” code.

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Issues: 1. reliability & validity

2. categories, dimensions & prototypes

(“polythetic” clarification)

3. comorbidity, artifactual & real

4. subjectivity & biases

5. the problem of labeling

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Extent of psychopathology: ...prevalence, incidence

and life-time risk

Axis Disorder PrevalenceLife-Time

RiskTreatment

Ratio

Axis 1

Anxiety disorder 18% (12%) 30% (20%) 1 in 7

Affective disorder 9% (6+%) 17% (12+%) 1 in 4

Thought disorder 1% 1+% 1 in 2

Axis II Personality disorder 7% 9% unknown

Totals 20 - 30% 30% - 40+% 1 in 5

Some “ball-park” figures: (Canada)

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Extent of psychopathology: ...prevalence, incidence

and life-time risk

Prevalence Life-Time Risk

Drugs 6% (8%) 15% (20%)

MR 2% 2%

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Causal Factors and Viewpoints

Causation in psychopathology

1. Primary / necessary and sufficient causes

2. Predisposing / contributory causes (and the concept of "relative risk")

3. Precipitating / proximal and distal causes

4. Perpetuating / reinforcing (maintaining) causes

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The nature of causal complexity

... not necessarily the numbernumber of causes

... but the causal patterncausal pattern

i.e., living systems are self-regulatingself-regulating

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An overall conception: Diathesis-Stress

... the original additive additive model

... the newer interactiveinteractive model

i.e., living systems are resilientresilient

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Theoretical Perspectives

Why do we need

them?

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A. Biological: ...from simplistic to sophisticated

The Psychiatric Revolution – circular reasoning

The New Psychiatry– technology– conceptualization– causation

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A Modern Checklist:

1. Genesa. direct influenceb. indirect (passive, evocative, active) influencesc. interactive influence

2. Congenital Factors

3. Constitutional Factorsa. the role of neurobiological inhibitionb. the role of evolutionc. aspects of temperament

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TEMPERAMENT:

CHILD ADULT

Fearfulness Negative Affect (“Neuroticism”)

Irritability/Frustration

Positive Affect Positive Affect (“Extroversion”)

Activity Level

Attentional Persistence “Conscientiousness”

Also: Sociability… “Agreeableness”

Inhibition….

“Openness”

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B. Psychological: The Three Meta-Theories

I. Psychodynamic theory – Conflict and its management

Psychoanalysis

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II. Learning theory Adaptation and its means

a. Classical Conditioning & “experimental neurosis”

b. Operant Conditioning & “superstitious behavior”

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1. Classical conditioning (“aversion”)

SHOT RSTARTLE (reflex)

CSWP - SHOT RSTARTLE

CSWP CRSTARTLE

... and extinction

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2. Operant conditioning (“escape”)

SHOT RJUMP - SHOT

SHOT RJUMP

... and extinction

R(reward)

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3. “Two factor” conditioning (“avoidance”)

CSWP RJUMP

CSWP RJUMP - SFEAR

... and extinction?

R

(reward?)

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c. Cognition & “negative sets”

S R

S O R

Cognitive and behavior therapies

e.g. Rational-emotive and other cognitive therapies

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III. Phenomenological (and “humanistic”) theory

Growth and its direction

“client-centered” and directivetherapies

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Psychological theories and circular reasoning

A. A Modern Checklist

Psychological factors in psychopathology

1. Causes and correlates

2. The power of protective factors

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C. Sociocultural: The Rise and Fall

Examples of “culture bound disordersculture bound disorders”

• Latah • Koro• Amok• Berserk • Kitsunetsuki• Pibloqtok• Lycanthropy• The Windigo Psychosis

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C. Sociocultural:Sociocultural factors in psychopathology

1.1. ContentContent : how & how much

2.2. Course Course : how long

3.3. CauseCause : why

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C. Sociocultural:Sociocultural theories and circular reasoning

Example:Example:the relation between

“exit events”and clinical depression

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EXAMPLE: “25% of people experiencing Major Depressive Disorder (MDD) had an exit event.” “Only 5% of the control group without MDD had an exit event.” (“Exit Event”=physical departure of a significant person in the last six months”) Do exit events cause MDD? Base rate for MDD (point prevalence): 2%

Take a population of 10,000 adults...200 MDD ... 25% with exit events = 509800 not MDD ... 5% with exit events = 490

So, we have 540 exit events, with fewer than 10% associated with MDD

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C. Sociocultural:Social problems and the presumption of psychiatric causes

Examples:Examples:suicidecrime

child molestation

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Stress and the Adjustment Disorders

Stress

The General The General Adaptation Adaptation Syndrome:Syndrome:

How stressors

are stressful in the

diathesis-stress modeldiathesis-stress model.

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Measurement

DSM – (Axes IV and V)

Self-report procedures – (LCUs and beyond)

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Results

– Frustrations– Conflicts– Pressures

e.g. the hassle list and stress-induced analgesiastress-induced analgesia

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Coping:1. Task-oriented, problem solving method2. Defense-oriented, emotion focused method

“God grant me the serenityto accept the things I cannot change,

the courage to change the thingsI can, and the wisdom to

know the difference”

- Reinhold Niebuhr

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Coping:The big factor in choosingchoosing: “self –perceived competence”

... and its ramifications

The big factor in copingcoping: social support

... e.g. the Alberta Study

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The Special Case of Extreme Stress

Results:1. “transient decompensation”2. “residual fear”

e.g. The Disaster Syndrome : shock, suggestibility and survival

The conventional findings ... and the caveat

e.g the “allostatic load”

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The Special Case of Extreme Stress

Coping:The “Ur” defenses (“Positive illusions”)

1. Our immortality2. The omnipotent servant3. Our kindness to one another

Also: The Polyanna PrincipleThe Belief in a Just World

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Adjustment Disorders

Dx: inference of the causal importance of stress

Types: – depressed– anxious– conduct disturbance ...– ... “mixed” types– “N.O.S”

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Anxiety Disorders Related to Extreme Stress

Acute Stress Disorder and Post-Traumatic Stress Disorder (PTSD)

Crucial for Dx: re-experiencing of an extremely traumatic event

The demographics of PTSD: BR and SR

Why do some people develop PTSD?– The nature of the trauma– The nature of the person– The nature of subsequent experience

Implications for treatment:– Social support, “debriefing”, exposure & stress-induced analgesia– The crisis in “Crisis-Counseling”

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Anxiety Disorders

Note: Adjustment disorder with anxious moodSubstance-induced anxiety disorderAnxiety disorder due to general medical condition

Prevalence Life-Time Risk

Phobia 1-2% 6+%Panic 1-2% 3+%Generalized anxiety 3-4% 5+%Obsessive-compulsive 1-2% 2+%Acute stress and PTSD 1-5% 7+%

10 - 12% 15 - 20%

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Anxiety Disorders

Anxiety

Normal vs. abnormal, Primary vs. secondary diagnoses An aspect of temperament (trait) and mood (state)…. …with biological components: GABA and the

monoamines in “negative emotionality”

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Anxiety Disorders

1. Phobia: specific, social and agoraphobia

BR: irrational fears and phobias

Treatment and SR

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Anxiety Disorders

Understanding phobiasa. Learning theory: situational causes e.g. Little Albert

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Anxiety Disorders

Understanding phobias

b. Psychodynamics:

dispositional causese.g. Little Hans

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Anxiety Disorders

Specific phobias:

Traumas and dispositional factorse.g. “the immunization effect”

Note: “preadaptation” and “the inflation effect”

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Anxiety Disorders

Social phobias:

Experiential and dispositional factorse.g. “social sensitivity” & “automatic thoughts”

Treatments

Exposure: systematic desensitization (vs.flooding) and chemotherapies

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Anxiety Disorders

2. Panic: with or without agoraphobia

BR: with or without phobia

Understanding panica. Biology: monoamines in “the fear network”

Nature and nurture

b. Psychology: “anxiety sensitivity”Conditioning: “Fear of Fear

Model”Cognition: “Cognitive Model”

Treatments Chemotherapy and PCT

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Anxiety Disorders

3. Generalized Anxiety (GAD)

BR: primary and secondary GAD

Understanding GAD Psychodynamic theory: personality

Learning theories: conditioning and cognitiveBiology of negative emotionality

TreatmentsChemotherapies (from the beta-blockers to the

benzodiazepines, Buspar & antidepressants)Psychotherapies (exposure and beyond)

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Anxiety Disorders

4. Obsessive-Compulsive Disorder (OCD)

Descriptive featuresBR: OCD and “OCD Spectrum Disorders”

Understanding OCD Psychodynamic and Learning theories

Modern cognitive psychology: though suppression and its vicissitudes

Modern neurobiology: monoamines and the caudate nucleus

TreatmentsChemotherapy and psychotherapyThe special case

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Anxiety Disorders

Anxiety disorders and their comorbidities

1. Among anxiety disorders (e.g., panic and phobia).

2. Between anxiety and other Axis 1

disorders(e.g., depression)

3. Between anxiety and Axis II disorders

(e.g., “inhibited” personality disorders)

1 abnormal psychology this is not a course about the problems of someone else. mental illness...

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supernatural slide

resilience slide

mind slide

hysteria slide

asclepius slide

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problems factors