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.
1
Psychopathology
... beyond behavior
1.
Thought:

2.
Emotion:

3.
problems in how and what we think
problems in momentary mood and chronic temperament
Conation:

problems in momentary motives and persistent needs
... the “subject matter” and the “data base”
2
The Definition of “Psychopathology”
Topics: The importance of the historical context
A.
Understanding: scientific description and
explanation
... the history of our curiosity
B.
Intervention: the change technologies
... the history of our compassion
3
History
... of understanding and intervention
3 broad perspectives on both:
4
1.
Sociocultural: natural and supernatural
2.
Biological: body and brain
3.
Psychological: three theories of the mind
... and a narrow-minded tradition
Understanding
Theory
Cause
5
Intervention
Therapy
Cure/Care
Examples:
1.
Biology: from the four humors to the monoamines
2.
Psychology: three “meta-theories”
3.
6
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
Sociocultural factors: natural and supernatural
People and their Problems
... the recurrent millennia of history
Understanding problems, in the past
 the causes of problems
Intervening with people, in the future
 the course of life
7
Some comparisons...
1.
Simple mechanical objects (cars and clocks)
... focus on cause
2.
More complex situations (soups and sauces)
... focus on effect
3.
The complexity of life (you and I)
... focus on resilience
8
Implication
... “problems” as solutions to problems
Factors in the ....
cause (past)
content (present)
course (future)
9
Common confusions
A.
Theory  Therapy
example: “therapeutic nihilism”
B.
Therapy  Theory
example: “post hoc explanations”
10
History of psychopathology
... the myth and the reality
“Those who don’t study history more
carefully are condemned
to repeat it.”
- George Santayana
11
History of psychopathology
... the myth and the reality
1. Ancient writings & archaeological evidence




12
Homer
The Hebrews
Trephining
Asclepius
History of psychopathology
... the myth and the reality
2. Biogenesis: Hippocrates and “the four humors”




Sanguine
Choleric
Phlegmatic
Melancholic
e.g., hysteria
13
History of psychopathology
... the myth and the reality
3. Psychogenesis: Plato and "the tripartite mind“




Affect
Appetite
Reason
Self-management
e.g., catharsis
14
History of psychopathology
... the myth and the reality
3. The Roman Era and The Middle Ages

The Roman Era : Galen and beyond

The Middle Ages : “The Dark Ages” (450 – 1450 A.D)


15
The Arab World :
•
Egypt and Avicenna
The Western World :
•
France
•
Italy
•
Britian
•
Gheel
•
St. Augustine
History of psychopathology
... the myth and the reality
4. The Renaissance
and the Revolutions
A. The Return of
the Supernatural View
Witches
... and the rise
of the asylum
16
History of psychopathology
... the myth and the reality
4. The Renaissance
and the Revolutions
A. The Return of
the Supernatural View
Witches
... and the rise
of the asylum
17
History of psychopathology
... the myth and the reality
Three Threats:
1. Physical:
“The Black Death”
2. Religion:
“The Reformation”
3. Social:
“The Little Ice Age”
18
History of psychopathology
... the myth and the reality
The Solution:
Malleus
Maleficarum:
(and Thesaurus
Exorcismorum)
A witching trial during the Salem Witch Hunt
19
History of psychopathology
... the myth and the reality
The Solution:
Marvin Harris
20
History of psychopathology
... the myth and the reality
The Asylum
London:
St. Mary’s of
Bethlehem
Paris:
LaBicêtre
Salpêtrière
21
St. Mary’s of Bethlehem
History of psychopathology
... the myth and the reality
The Asylum
London:
St. Mary’s of
Bethlehem
Paris:
LaBicêtre
Salpêtrière
22
History of psychopathology
... the myth and the reality
23
History of psychopathology
... the myth and the reality
The Challenge:
–
St. Thomas Aquinas,
from the Middle Ages
–
Johann Weyer
Deception of Demons
24
Johann Weyer
St. Thomas Aquinas
History of psychopathology
... the myth and the reality
The Challenge:
–
Reginald Scot
The Discovery of Witchcraft
25
History of psychopathology
... the myth and the reality
The Challenge:
–
26
Teresa of Avila
History of psychopathology
... the myth and the reality
The Challenge:
–
27
Teresa of Avila
History of psychopathology
... the myth and the reality
The Challenge:
–
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Paracelsus
History of psychopathology
... the myth and the reality
4. The Renaissance and the Revolutions
B. The “Mental Hospital Movement”
Paris:
Philippe Pinel
and Jean Baptiste Pussin
Dorothea Dix
29
History of psychopathology
... the myth and the reality
4. The Renaissance and the Revolutions
B. The “Mental Hospital Movement”
London: William Tuke
... and the York Retreat
Dorothea Dix
30
History of psychopathology
... the myth and the reality
4. The Renaissance and the Revolutions
B. The “Mental Hospital Movement”
The York Retreat
Dorothea Dix
31
History of psychopathology
... the myth and the reality
4. The Renaissance and the
Revolutions
B. The “Mental Hospital Movement”
America: Dorothea Dix
... and “moral management”
Clifford Beers
.
32
Dorothea Dix
.. and “the mental
hygiene movement”
Clifford Beers
History of psychopathology
... the myth and the reality
33
History of psychopathology
... the myth and the reality
34
History of psychopathology
... the myth and the reality
35
History of psychopathology
... the myth and the reality
5. The Psychiatric Revolution: the return of biogenesis
36
History of psychopathology
... the myth and the reality
37
History of psychopathology
... the myth and the reality
38
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History of psychopathology
... the myth and the reality
5.
The Psychiatric
Revolution:
the return of biogenesis
Louis Pasteur
Benjamin Rush
40
History of psychopathology
... the myth and the reality
5. The Psychiatric Revolution: the return of biogenesis
Ignaz Phillip Semmelweis
41
Edward Jenner
Louis Pasteur
History of psychopathology
... the myth and the reality
5. The Psychiatric Revolution: the return of biogenesis
William Farr
Paul Broca
John Snow
42
History of psychopathology
... the myth and the reality
5. The Psychiatric Revolution: the return of biogenesis
Korsakoff
Alzheimer
43
Wernicke
History of psychopathology
... the myth and the reality
44
History of psychopathology
... the myth and the reality
The Story of General Paresis
Diagnosis ...from cases to syndromes
History ...from correlates to causes
Treatment ...from causes to cures
45
History of psychopathology
... the myth and the reality
Ehrlich’s “magic bullet”
46
History of psychopathology
... the myth and the reality
Along the way....



47
anti-sexualism
degeneracy theory
phrenology
History of psychopathology
... the myth and the reality
48
History of psychopathology
... the myth and the reality
The Medical View:
Emil Kraepelin
49
Wilhelm
Griesinger
Jean-Martin
Charcot
History of psychopathology
... the myth and the reality
50
History of psychopathology
... the myth and the reality
6. Psychodynamic theory and psychoanalysis:
The return of psychogenesis
51
Liebault
&
Bernheim:
Freud
&
Breuer:
“psychoneurosis”
The case of
Anna O
History of psychopathology
... the myth and the reality
The case of
Anna O
52
History of psychopathology
... the myth and the reality
53
History of psychopathology
... the myth and the reality
7. The “Mental Health Movement”
the return of sociogenesis, again
Sociologists
 Anti-Psychiatry
 Clinical Psychology

... and then, something happened...
54
History of psychopathology
... the myth and the reality
8. The “New Psychiatry”
The return of biogenesis,
again

Drugs and the
search for biological causes

The technologies and
an integrated approach
Heinz Lehmann
55
The Lesson of History
“The lessons of the past
were obliterated by the aspirations
of the present.”
- Alexander Leighton
56
The Lesson of History
“It ain’t what you don’t know
that gets you; it’s the things you
know that ain’t so.”
- Mark Twain
57
The Lesson of History
“Confusion now hath made
his masterpiece.”
- MacBeth
58
The 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)

59
The Lesson of History
...Limitations to Progress
2. Intervention (finding cures):
placebo effects
 spontaneous remission (SR)
 superstitious behaviour
 publication bias

60
The Lesson of History
...Limitations to Progress
Summary:
1. Understanding: it is hard to find out why something
happens when it doesn’t happen very often
2. Intervention: it is hard to find out if anything makes a
difference to the course when that course is
erratic and unpredictable
61
Definitions
1. Theoretical/absolute criterion



demons
diseases
defects
Making inferences and pathologizing the results
62
Definitions
2. Social/cultural criterion



deviance
difference
disgust
Making discriminations and pathologizing the minority
63
Definitions
3. Personal/subjective criterion



distress
dysphoria
despair
Making introspections and pathologizing unhappiness
64
Definitions
The common-sense criterion:
Maladaptation/symptoms



65
disorder
dysfunction
disability
thoughts & perceptions
emotions & feelings
needs & motives
The Modern Diagnostic System
(DSM)
Why diagnosis?
... a present description
...with future implications
“Diagnosis is prognosis”
66
The Modern Diagnostic System
(DSM)
67

DSM I (1952) and DSM II (1968)

DSM III (1980) and DSM IV (1994) ... TR, now

ICD 1 (1948) to 10 (1992) ... CM, now
The Modern Diagnostic System
(DSM)
What have we gained?
1. Research: no false positives
2. Practice: no false negatives
... communication – in principle
... but research biases in practice
68
Diagnosis of psychopathology
(DSM)
Axis I - Clinical syndromes
Axis II - Personality disorders (and MR)
Axis III - Medical conditions
Axis IV - Stress
Axis V - Coping (GAF)
69
Diagnosis of psychopathology
(DSM)
“Other conditions that may
be the focus of clinical attention”,
including psychological factors
affecting medical conditions,
and the “V” code.
70
Diagnosis of psychopathology
(DSM)
Issues:
1. reliability & validity
2. categories, dimensions & prototypes
(“polythetic” classification)
3. comorbidity, artifactual & real
4. subjectivity & biases
5. the problem of labeling
71
Extent of psychopathology:
...prevalence, incidence and life-time risk
Some “ball-park” figures: (Canada)
Axis
Axis 1
Axis II
72
Disorder
BR12
Life-Time
Risk
Treatment
Ratio
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
Personality disorder
7%
9%
unknown
Totals
20 - 30%
30% - 40+%
1 in 5
Extent of psychopathology:
...prevalence, incidence and life-time risk
73
Prevalence
Life-Time Risk
Drugs
6% (8%)
15% (20%)
MR
2%
2%
Causal Factors and Viewpoints
Causation in psychopathology
1.
2.
3.
4.
74
Primary / necessary and sufficient causes
Predisposing / contributory causes (and the
concept of "relative risk")
Precipitating / proximal and distal causes
Perpetuating / reinforcing (maintaining) causes
Causal Factors and Viewpoints
The nature of causal complexity
... not necessarily the number of causes
... but the causal pattern
i.e., living systems are self-regulating
75
Causal Factors and Viewpoints
An overall conception: Diathesis-Stress
... the original additive model
... the newer interactive model
i.e., living systems are resilient
76
Theoretical Perspectives
Why
do we need
them?
77
Theoretical Perspectives
A. Biological:

The Psychiatric Revolution
–

circular reasoning
The New Psychiatry
–
–
–
78
...from simplistic to sophisticated
technology
conceptualization
causation
Theoretical Perspectives
A Modern Checklist:
1. Genes
a. direct influence
b. indirect (passive, evocative, active) influences
c. interactive influence
2. Congenital Factors
3. Constitutional Factors
a. the role of neurobiological inhibition
b. the role of evolution
c. aspects of temperament
79
Theoretical Perspectives
TEMPERAMENT:
CHILD
Fearfulness
Irritability/Frustration
Positive Affect
Activity Level
Attentional Persistence
Also:
Sociability…
Inhibition….
ADULT
Negative Affect (“Neuroticism”)
Positive Affect (“Extroversion”)
“Conscientiousness”
“Agreeableness”
“Openness”
80
Theoretical Perspectives
B.
Psychological:
The Three Meta-Theories
I. Psychodynamic theory
–
Conflict and its management
Psychoanalysis
81
Theoretical Perspectives
B.
Psychological:
The Three Meta-Theories
II. Learning theory Adaptation and its means
a.
b.
82
Classical Conditioning & “experimental neurosis”
Operant Conditioning & “superstitious behavior”
Theoretical Perspectives
1. Classical conditioning (“aversion”)
SHOT
CSWP - SHOT
CSWP
... and extinction
83
RSTARTLE (reflex)
RSTARTLE
CRSTARTLE
Theoretical Perspectives
2. Operant conditioning (“escape”)
SHOT
RJUMP - SHOT (reward)
SHOT
RJUMP
... and extinction
84
R
Theoretical Perspectives
3. “Two factor” conditioning (“avoidance”)
CSWP
RJUMP (reward?)
CSWP
R
RJUMP - SFEAR
... and extinction?
85
Theoretical Perspectives
c. Cognition & “negative sets”
S
S
R
O
R
Cognitive and behavior
therapies
e.g. Rational-emotive and other cognitive therapies
86
Theoretical Perspectives
B.
Psychological:
The Three Meta-Theories
III. Phenomenological (and “humanistic”) theory
Growth and its direction
“client-centered” and directive
therapies
87
Theoretical Perspectives
Psychological theories and circular reasoning
A.
A Modern Checklist
Psychological factors in psychopathology
1. Causes and correlates
2. The power of protective factors
88
Theoretical Perspectives
C.
Sociocultural:
The Rise and Fall
Examples of
“culture bound disorders”
• Latah
• Koro
• Amok
• Berserk
• Kitsunetsuki
• Pibloqtok
• Lycanthropy
• The Windigo Psychosis
89
Theoretical Perspectives
C.
Sociocultural:
Sociocultural factors in psychopathology
1. Content : how & how much
2. Course : how long
3. Cause : why
90
Theoretical Perspectives
C.
Sociocultural:
Sociocultural theories and circular reasoning
Example:
the relation between
“exit events”
and clinical depression
91
Theoretical Perspectives
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 = 50
9800 not MDD ... 5% with exit events = 490
So, we have 540 exit events, with fewer than 10% associated with MDD
92
Theoretical Perspectives
C.
Sociocultural:
Social problems and the presumption of psychiatric causes
Examples:
suicide
crime
child molestation
93
Stress and the
Adjustment Disorders
Stress
The General
Adaptation
Syndrome:
How stressors
are stressful in the
94
diathesis-stress model.
Stress and the
Adjustment Disorders
Measurement

DSM
–

Self-report procedures
–
95
(Axes IV and V)
(LCUs and beyond)
96
97
Stress and the
Adjustment Disorders
Results
– Frustrations
– Conflicts
– Pressures
e.g. the hassle list and stress-induced analgesia
98
Stress and the
Adjustment Disorders
Coping:
1.
2.
Task-oriented, problem solving method
Defense-oriented, emotion focused method
“God grant me the serenity
to accept the things I cannot change,
the courage to change the things
I can, and the wisdom to
know the difference”
- Reinhold Niebuhr
99
Stress and the
Adjustment Disorders
Coping:
The big factor in choosing: “self –perceived competence”
... and its ramifications
The big factor in coping: social support
... e.g. the Alberta Study
100
The Special Case of
Extreme Stress
Results:
1.
2.
“transient decompensation”
“residual fear”
e.g. The Disaster Syndrome :
shock, suggestibility and survival
The conventional findings ... and the caveat
e.g the “allostatic load”
101
The Special Case of
Extreme Stress
Coping:
The “Ur” defenses (“Positive illusions”)
1.
2.
3.
Our immortality
The omnipotent servant
Our kindness to one another
Also: The Polyanna Principle
The Belief in a Just World
102
Adjustment Disorders
Dx: inference of the causal importance of stress
Types:
–
–
–
–
–
103
depressed
anxious
conduct disturbance ...
... “mixed” types
“N.O.S”
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:
–
–
104
Social support, “debriefing”, exposure & stress-induced analgesia
The crisis in “Crisis-Counseling”
Anxiety Disorders
Note: Adjustment disorder with anxious mood
Substance-induced anxiety disorder
Anxiety disorder due to general medical condition
Phobia
Panic
Generalized anxiety
Obsessive-compulsive
Acute stress and PTSD
105
Prevalence
Life-Time Risk
1-2%
1-2%
3-4%
1-2%
1-5%
10 - 12%
6+%
3+%
5+%
2+%
7+%
15 - 20%
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”
106
Anxiety Disorders
1.
Phobia: specific, social and agoraphobia
BR: irrational fears and phobias
Treatment and SR
107
Anxiety Disorders
Understanding phobias
a. Learning theory: situational causes
e.g. Little Albert
108
Anxiety Disorders
Understanding phobias
b. Psychodynamics:
dispositional causes
e.g. Little Hans
109
Anxiety Disorders
Specific phobias:
Traumas and dispositional factors
e.g. “the immunization effect”
Note: “preadaptation” and “the inflation effect”
110
Anxiety Disorders
Social phobias:
Experiential and dispositional factors
e.g. “social sensitivity” & “automatic thoughts”
Treatments
Exposure: systematic desensitization
(vs.flooding) and chemotherapies
111
Anxiety Disorders
2.
Panic: with or without agoraphobia
BR: with or without phobia
Understanding panic
a. 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
112
Anxiety Disorders
3.
Generalized Anxiety (GAD)
BR: primary and secondary GAD
Understanding GAD
Psychodynamic theory: personality
Learning theories: conditioning and cognitive
Biology of negative emotionality
Treatments
Chemotherapies (from the beta-blockers to the
benzodiazepines, Buspar & antidepressants)
Psychotherapies (exposure and beyond)
113
Anxiety Disorders
4.
Obsessive-Compulsive Disorder (OCD)
Descriptive features
BR: OCD and “OCD Spectrum Disorders”
Understanding OCD
Psychodynamic and Learning theories
Modern cognitive psychology: thought suppression and its vicissitudes
Modern neurobiology: monoamines and the caudate nucleus
Treatments
Chemotherapy and psychotherapy
The special case
114
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)
115