Abnormal Psychology

*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.

*Psychopathology ... beyond behaviorThought: problems in how and what we thinkEmotion: problems in momentary mood and chronic temperamentConation: problems in momentary motives and persistent needs

... the subject matter and the data base

*The Definition of PsychopathologyTopics: The importance of the historical context

Understanding: scientific description and explanation... the history of our curiosityIntervention: the change technologies ... the history of our compassion

*History ... of understanding and intervention

3 broad perspectives on both:Sociocultural: natural and supernaturalBiological: body and brainPsychological: three theories of the mind

*... and a narrow-minded traditionUnderstandingTheory CauseInterventionTherapyCure/Care

*Examples:Biology: from the four humors to the monoaminesPsychology: three meta-theoriesLearning Theories: adaptation to the present and the behavior and cognitive therapiesPhenomenological Theories: growth into the future and the directive and non-directive therapiesPsychodynamic Theories: conflict from the past and the psychoanalytic therapiesSociocultural factors: natural and supernatural

*People and their Problems... the recurrent millennia of historyUnderstanding problems, in the past the causes of problems

Intervening with people, in the future the course of life

*Some comparisons...Simple mechanical objects (cars and clocks)... focus on causeMore complex situations (soups and sauces)... focus on effectThe complexity of life (you and I)... focus on resilience

*Implication... problems as solutions to problems

Factors in the ....cause (past)content (present)course (future)

*Common confusions

Theory Therapyexample: therapeutic nihilism

Therapy Theoryexample: post hoc explanations

*History of psychopathology... the myth and the realityThose who dont study history morecarefully are condemnedto repeat it.

- George Santayana

*History of psychopathology... the myth and the realityAncient writings & archaeological evidence

HomerThe HebrewsTrephiningAsclepius

*History of psychopathology... the myth and the realityBiogenesis: Hippocrates and the four humors

SanguineCholericPhlegmaticMelancholic

e.g., hysteria

*History of psychopathology... the myth and the realityPsychogenesis: Plato and "the tripartite mind

AffectAppetiteReasonSelf-management

e.g., catharsis

*History of psychopathology... the myth and the realityThe Roman Era and The Middle AgesThe Roman Era : Galen and beyond

The Middle Ages : The Dark Ages (450 1450 A.D)The Arab World : Egypt and AvicennaThe Western World : France Italy BritianGheel St. Augustine

*History of psychopathology... the myth and the realityThe Renaissance and the RevolutionsA. The Return of the Supernatural View

Witches ... and the rise of the asylum

*History of psychopathology... the myth and the realityThree Threats:

1. Physical: The Black Death

2. Religion: The Reformation

3. Social: The Little Ice Age

*History of psychopathology... the myth and the realityThe Solution:

Malleus Maleficarum:

(and Thesaurus Exorcismorum)A witching trial during the Salem Witch Hunt

*History of psychopathology... the myth and the realityThe Solution:Marvin Harris

*History of psychopathology... the myth and the realityThe AsylumLondon:St. Marys of Bethlehem

Paris:LaBictre SalptrireSt. Marys of Bethlehem

*History of psychopathology... the myth and the realityThe AsylumLondon:St. Marys of Bethlehem

Paris:LaBictre Salptrire

*History of psychopathology... the myth and the reality

*History of psychopathology... the myth and the realityThe Challenge:St. Thomas Aquinas, from the Middle AgesJohann Weyer Deception of DemonsJohann WeyerSt. Thomas Aquinas

*History of psychopathology... the myth and the realityThe Challenge:Reginald Scot The Discovery of Witchcraft

*History of psychopathology... the myth and the realityThe Challenge:Teresa of Avila

*History of psychopathology... the myth and the realityThe Challenge:Paracelsus

*History of psychopathology... the myth and the realityThe Renaissance and the RevolutionsThe Mental Hospital MovementParis: Philippe Pinel and Jean Baptiste PussinDorothea Dix

*History of psychopathology... the myth and the realityThe Renaissance and the RevolutionsThe Mental Hospital MovementLondon: William Tuke ... and the York RetreatDorothea Dix

*History of psychopathology... the myth and the realityThe Renaissance and the RevolutionsThe Mental Hospital MovementThe York RetreatDorothea Dix

*History of psychopathology... the myth and the realityThe Renaissance and the RevolutionsThe Mental Hospital MovementAmerica: Dorothea Dix ... and moral management Clifford Beers ... and the mental hygiene movementDorothea DixClifford Beers

*History of psychopathology... the myth and the reality5. The Psychiatric Revolution: the return of biogenesis

*History of psychopathology... the myth and the realityThe Psychiatric Revolution:

the return of biogenesisLouis PasteurBenjamin Rush

*History of psychopathology... the myth and the reality5. The Psychiatric Revolution: the return of biogenesisLouis PasteurIgnaz Phillip SemmelweisEdward Jenner

*History of psychopathology... the myth and the reality5. The Psychiatric Revolution: the return of biogenesisJohn SnowWilliam FarrPaul Broca

*History of psychopathology... the myth and the reality5. The Psychiatric Revolution: the return of biogenesisAlzheimerKorsakoffWernicke

*History of psychopathology... the myth and the realityThe Story of General ParesisDiagnosis ...from cases to syndromesHistory ...from correlates to causesTreatment ...from causes to cures

*History of psychopathology... the myth and the realityEhrlichs magic bullet

*History of psychopathology... the myth and the realityAlong the way....

anti-sexualismdegeneracy theoryphrenology

*History of psychopathology... the myth and the realityThe Medical View:

WilhelmGriesingerEmil KraepelinJean-MartinCharcot

*History of psychopathology... the myth and the reality6. Psychodynamic theory and psychoanalysis:The return of psychogenesis

Liebault&Bernheim:

psychoneurosisFreud&Breuer:

The case ofAnna O


The case of Anna O

*History of psychopathology... the myth and the reality7. The Mental Health Movementthe return of sociogenesis, again Sociologists Anti-Psychiatry Clinical Psychology... and then, something happened...

*History of psychopathology... the myth and the reality8. The New Psychiatry The return of biogenesis, again

Drugs and the search for biological causes

The technologies and an integrated approachHeinz Lehmann

*The Lesson of HistoryThe lessons of the pastwere obliterated by the aspirationsof the present.

- Alexander Leighton

*The Lesson of HistoryIt aint what you dont knowthat gets you; its the things youknow that aint so.

- Mark Twain

*The Lesson of HistoryConfusion now hath madehis masterpiece.

- MacBeth

*The Lesson of History...Limitations to Progress1. Understanding (finding causes): post hoc explanations correlates and causes longitudinal and experimental research the problem of base rates (BR)

*The Lesson of History...Limitations to Progress2. Intervention (finding cures): placebo effects spontaneous remission (SR) superstitious behaviour publication bias

*The Lesson of History...Limitations to ProgressSummary:

1. Understanding: it is hard to find out why something happens when it doesnt happen very often

2. Intervention: it is hard to find out if anything makes a difference to the course when that course iserratic and unpredictable

*Definitions1. Theoretical/absolute criterion

demons diseases defects Making inferences and pathologizing the results

*Definitions2. Social/cultural criterion

deviance difference disgustMaking discriminations and pathologizing the minority

*Definitions3. Personal/subjective criterion

distress dysphoria despair

Making introspections and pathologizing unhappiness

*DefinitionsThe common-sense criterion:Maladaptation/symptoms

disorder dysfunction disabilitythoughts & perceptionsemotions & feelingsneeds & motives

*The Modern Diagnostic System(DSM)Why diagnosis?... a present description ...with future implicationsDiagnosis is prognosis

*The Modern Diagnostic System(DSM)

DSM I (1952) and DSM II (1968)DSM III (1980) and DSM IV (1994) ... TR, nowICD 1 (1948) to 10 (1992) ... CM, now

*The Modern Diagnostic System(DSM)What have we gained?

1. Research: no false positives2. Practice: no false negatives

... communication in principle... but research biases in practice

*Diagnosis of psychopathology(DSM)Axis I - Clinical syndromesAxis II - Personality disorders (and MR)Axis III - Medical conditionsAxis IV - StressAxis V - Coping (GAF)

*Diagnosis of psychopathology(DSM) Other conditions that maybe the focus of clinical attention,including psychological factorsaffecting medical conditions,and the V code.

*Diagnosis of psychopathology(DSM)Issues: 1. reliability & validity2. categories, dimensions & prototypes(polythetic clarification)3. comorbidity, artifactual & real 4. subjectivity & biases5. the problem of labeling

*Extent of psychopathology: ...prevalence, incidence and life-time risk Some ball-park figures: (Canada)

AxisDisorder PrevalenceLife-Time RiskTreatment RatioAxis 1Anxiety disorder18% (12%)30% (20%)1 in 7Affective disorder9% (6+%)17% (12+%)1 in 4Thought disorder1%1+%1 in 2Axis IIPersonality disorder7%9%unknownTotals20 - 30%30% - 40+%1 in 5

*Extent of psychopathology: ...prevalence, incidence and life-time risk

PrevalenceLife-Time RiskDrugs6% (8%)15% (20%)MR2%2%

*Causal Factors and ViewpointsCausation in psychopathology

1.Primary / necessary and sufficient causes2.Predisposing / contributory causes (and the concept of "relative risk")3.Precipitating / proximal and distal causes4.Perpetuating / reinforcing (maintaining) causes

*Causal Factors and ViewpointsThe nature of causal complexity

... not necessarily the number of causes... but the causal pattern

i.e., living systems are self-regulating

*Causal Factors and ViewpointsAn overall conception: Diathesis-Stress... the original additive model... the newer interactive model

i.e., living systems are resilient

*Theoretical PerspectivesWhy do we needthem?

*Theoretical PerspectivesBiological: ...from simplistic to sophisticated

The Psychiatric Revolution circular reasoning

The New Psychiatrytechnologyconceptualizationcausation

*Theoretical PerspectivesA 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

*Theoretical PerspectivesTEMPERAMENT: CHILD ADULT Fearfulness Negative Affect (Neuroticism) Irritability/Frustration Positive Affect Positive Affect (Extroversion) Activity Level Attentional Persistence Conscientiousness Also: Sociability Agreeableness Inhibition. Openness

*Theoretical PerspectivesPsychological: The Three Meta-Theories

Psychodynamic theory Conflict and its management

Psychoanalysis


Learning theory Adaptation and its meansClassical Conditioning & experimental neurosisOperant Conditioning & superstitious behavior

*Theoretical PerspectivesClassical conditioning (aversion)SHOT RSTARTLE (reflex) CSWP - SHOT RSTARTLE CSWP CRSTARTLE

... and extinction

Douglas Wardell 2008

*Theoretical PerspectivesOperant conditioning (escape)SHOT RJUMP - SHOT

SHOT RJUMP

... and extinction

R(reward)


*Theoretical PerspectivesTwo factor conditioning (avoidance)CSWP RJUMP CSWP RJUMP - SFEAR ... and extinction?

R(reward?)


*Theoretical PerspectivesCognition & negative sets

S RS O R

Cognitive and behavior therapiese.g. Rational-emotive and other cognitive therapies



Phenomenological (and humanistic) theory

Growth and its direction

client-centered and directivetherapies

*Theoretical PerspectivesPsychological theories and circular reasoning

A Modern Checklist

Psychological factors in psychopathology

1. Causes and correlates2. The power of protective factors

*Theoretical PerspectivesSociocultural: The Rise and FallExamples of culture bound disorders

Latah Koro Amok Berserk Kitsunetsuki Pibloqtok Lycanthropy The Windigo Psychosis

*Theoretical PerspectivesSociocultural:Sociocultural factors in psychopathology

Content : how & how muchCourse : how longCause : why

*Theoretical PerspectivesSociocultural:Sociocultural theories and circular reasoning

Example:the relation betweenexit eventsand clinical depression

*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 = 509800 not MDD ... 5% with exit events = 490

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

*Theoretical PerspectivesSociocultural:Social problems and the presumption of psychiatric causes

Examples:suicidecrimechild molestation

*Stress and the Adjustment DisordersStress

The General Adaptation Syndrome:

How stressors are stressful in the diathesis-stress model.

*Stress and the Adjustment DisordersMeasurement

DSM (Axes IV and V)

Self-report procedures (LCUs and beyond)

*Stress and the Adjustment DisordersResults

FrustrationsConflictsPressurese.g. the hassle list and stress-induced analgesia

*Stress and the Adjustment DisordersCoping:

Task-oriented, problem solving methodDefense-oriented, emotion focused methodGod grant me the serenityto accept the things I cannot change,the courage to change the thingsI can, and the wisdom toknow the difference - Reinhold Niebuhr

*Stress and the Adjustment DisordersCoping:

The big factor in choosing: self perceived competence... and its ramifications

The big factor in coping: social support... e.g. the Alberta Study

*The Special Case of Extreme StressResults:

transient decompensationresidual fear

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

The conventional findings ... and the caveat

e.g the allostatic load

*The Special Case of Extreme StressCoping:

The Ur defenses (Positive illusions)

Our immortalityThe omnipotent servantOur kindness to one another

Also: The Polyanna PrincipleThe Belief in a Just World

*Adjustment DisordersDx: inference of the causal importance of stress

Types: depressedanxiousconduct disturbance ...... mixed typesN.O.S

*Anxiety Disorders Related to Extreme StressAcute 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 traumaThe nature of the personThe nature of subsequent experience

Implications for treatment:Social support, debriefing, exposure & stress-induced analgesiaThe crisis in Crisis-Counseling

*Anxiety DisordersNote: Adjustment disorder with anxious moodSubstance-induced anxiety disorderAnxiety disorder due to general medical condition

Sheet1

PrevalenceLife-Time Risk

Phobia1-2%6+%

Panic1-2%3+%

Generalized anxiety3-4%5+%

Obsessive-compulsive1-2%2+%

Acute stress and PTSD1-5%7+%

10 - 12%15 - 20%

Sheet2

Sheet3

*Anxiety DisordersAnxiety

Normal vs. abnormal, Primary vs. secondary diagnosesAn aspect of temperament (trait) and mood (state).with biological components: GABA and the monoamines in negative emotionality

*Anxiety DisordersPhobia: specific, social and agoraphobiaBR: irrational fears and phobias Treatment and SR

*Anxiety DisordersUnderstanding phobiasa. Learning theory: situational causes e.g. Little Albert

*Anxiety DisordersUnderstanding phobiasb. Psychodynamics:

dispositional causese.g. Little Hans

*Anxiety DisordersSpecific phobias: Traumas and dispositional factorse.g. the immunization effect Note: preadaptation and the inflation effect

*Anxiety DisordersSocial phobias: Experiential and dispositional factorse.g. social sensitivity & automatic thoughtsTreatmentsExposure: systematic desensitization (vs.flooding) and chemotherapies

*Anxiety DisordersPanic: with or without agoraphobiaBR: with or without phobia

Understanding panica. Biology: monoamines in the fear networkNature and nurtureb. Psychology: anxiety sensitivityConditioning: Fear of Fear ModelCognition: Cognitive Model

TreatmentsChemotherapy and PCT

*Anxiety DisordersGeneralized Anxiety (GAD)BR: primary and secondary GADUnderstanding GADPsychodynamic theory: personalityLearning theories: conditioning and cognitiveBiology of negative emotionalityTreatmentsChemotherapies (from the beta-blockers to the benzodiazepines, Buspar & antidepressants)Psychotherapies (exposure and beyond)

*Anxiety DisordersObsessive-Compulsive Disorder (OCD)Descriptive featuresBR: OCD and OCD Spectrum DisordersUnderstanding OCDPsychodynamic and Learning theoriesModern cognitive psychology: though suppression and its vicissitudesModern neurobiology: monoamines and the caudate nucleusTreatmentsChemotherapy and psychotherapyThe special case

*Anxiety DisordersAnxiety disorders and their comorbidities1. 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)

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Abnormal Psychology

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