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Stability vs. Situation?
• Traits vs. States vs. Types
• 18,000 personality terms to 32 traits to• Big five:
– Extraversion (outgoing, sociable, positive)
– Neuroticism (prone to negative emotions)
– Conscientiousness (organized, efficient, disciplined)
– Openness to experience (non-conventional, curious)
– Agreeableness (trusting & easygoing with others)
40 to 60% heritable
• Low correlations across situations
– Strong vs. weak situations
– But-brain differences and heritability
Introverts more sensitive to external stimuli
More reactive central nervous system
Low pain tolerance
Underactive Nor-epi system
Sensation seeking extraverts
Heritability: Big five correlations
• Identical twins vs. fraternal twins :
• Reared together- .51
• Reared apart.50
Personality Theories
• Psychoanalytic
– Childhood experience, ucs influence, dynamics,
conflict, defenses, development and identification
• Humanistic
– Focus on self & self-actualization, existential
approach, flow & happiness
• Social-Cognitive Theory
– Beliefs, thoughts & personal constructs, often acquired
from social interactions & imitation shape behavior
• Behavioral Theory
– Learning history, self-perception theory, self-control
Who Gets What?
Defining Abnormality
• Medical approach
• Statistical approach
• Functional approach
These reflect two basic views of disorders
--brain based
--behavior/experience/situation based
The “two worlds” of psychiatry
Axis 1: Syndromes (Scz, Depress, etc.)
Axis 2: Retardation & Personality Disorders
Axis 3: General Medical Condition
Axis 4: Social/Environmental Problems
Axis 5: Global Assessment & Coping
Older classification (primarily of Axis 1 & 2)
dichotomized: Neuroses & Psychoses
• Mood (Dep. Bipolar) vs. Thought (Scz) Disrdr
• Now replaced by highly elaborated DSM-V
Three Broad Types/Dimensions
• Personality (Psychopathy…..)
• Mood (Depression, Bipolar)
• Thought (Scz. Delusions, Hallucinations)
SCZ Manifestations/Symptoms
Positive symptoms:
-- Hallucinations
– delusions
– Disorganized or strange behavior & speech
• Negative symptoms:
– Flat affect & other behavior
– Catatonia
– Withdrawel from others
Prevalence of Neurotic Disorders by Age
Hollingshead & Redlech New Haven Study, 1958
Prevalence of Neurosis by Age & Social Class
Prevalence of Psychosis by Age & Gender
& Social
Psychosis: Age
and Social Class
Heritability of Psychosis: Schizophrenia
Scz incidence & poverty/residential area
Some Interim Conclusions
• Psychoses (focus on SCZ) is a disorder of
heredity and/or prenatal environment
• But it’s also a disorder of poverty (and
that may be bidirectional)!
• Another view of prevalence and recent
dramatic changes in prevalence
• Schizophrenia: approx. 1%
• Bipolar Disorder: approx. 1%
• Depression:
approx. M 13% F 21%
Basic Models of Disorder
Stress: Functional Disorder
-Cognitive & Social Origins
Illness: Medical/Biological
– Brain-based (synaptic & neural
Mixed Model: VulnerabilityStress
Szasz: Radical Anti-medical Approach
• Brief History
• Psychological Treatments
• Biomedical Treatments
• Client-Therapist Relationship
• Is Treatment Effective?
• Earliest history
– Mental illness believed to be caused by evil
spirits. Hippocrates began to dismantle
– Treatments were harsh, ineffective
• Drill holes in skulls to create exits for spirits
• Make the body horribly uncomfortable for the
• Purge demons through inducing vomiting
• Middle Ages
– Mental illness viewed more like a
disease, but not treated well!
– Mental institutions were created
• Purpose: confine “madmen”
• Included other social “undesirables”
• Inhumane treatment (shackles and chains)
Beginning of Reform
• Early to Mid 1800s
– Philippe Pinel put in charge of Paris’
hospital system
• Removed shackles and chains
• Patients allowed to exercise, venture outside
Beginning of Reform
• Dorthea Dix
– Fought for humane
treatment of
patients in U.S.
• 19th century
– Freud’s “talking
cure” (Charcot &
Psychological Treatment
• Treatment involves addressing three
major components of the illness:
– Biological
– Psychological
– Social
• Something to keep in mind:
– These three major components are not
necessarily black-and-white/separable
Who provides treatment?
• Clinical psychologists
• Psychologists
• Neurologists
• Psychiatric Nurses
• Marriage and Family Counselors
• Social workers
• School counselors
• Clergy
Who seeks treatment?
• People with mental illness, hoping to relieve
pain and dysfunction
• People looking for assistance in recovering
from grief, anxiety, confusion, relationship
issues and other life challenges…tilted toward
European Americans
Financially well off
People with Health Insurance (which increasingly
controls things)!
Psychological Treatments
• Focused on changing the way the patient thinks and
• Involves discussion, instruction, training,
relationship analysis
• Over 500 different forms of such treatment
Psychodynamic Approaches
Illness result of unconscious
conflicts developed early in
childhood with impact later
Defense mechanisms shield
from the inner conflict
– This can lead to
symptoms of mental
Treatment: Uncovering
unconscious desires and
conflicts, and resolving them
– Integrate thoughts and
memories coherently
Psychodynamic Approaches
• “Working through” the conflict
– Transference
• Used as a therapeutic tool
• In order to be effective, therapist must
remain neutral
Humanistic Approaches
• Based off of Freud’s “talking cure”
• However, less focused on basic drives
• Instead, focus on decisions & creating meaning
• Clients need to take responsibility for their lives
and actions, and live in the “here and now”
• “Tomorrow is the 1st day of the rest of your life”
Humanistic Approaches
• Client-Centered Therapy (Carl Rogers)
– Focuses on achieving self-acceptance
– Does not pass judgment, or provide
– Aim is to create an environment
in which the client feels
understood and valued
-Requires & elicits a capable client
Humanistic Approach
• Creating the therapeutic
– Genuineness- sharing authentic
– Unconditional positive regard
• Non-judgmental, accepting
– Empathic Understanding- putting
oneself in the patients’ shoes
Behavioral Approaches
• Reaction to Freud’s psychoanalysis
• Viewed Freud’s approach as too unscientific
• Treatment directed at reducing or eliminating
problematic behaviors (because behavior is all
there is!)
• Institutional control mechanism (humane?)
• Approach involves replacing old habits with more
effective or adaptive behaviors
– Classical conditioning, operant conditioning, modeling
Behavioral Approaches
Classical Conditioning Techniques
• Treatment of Phobias
– Extinguish the association between the
neutral stimulus and the fearful stimulus
– Exposure Therapy
• Train clients in deep muscle relaxation, pair
relaxation with the fearful stimulus
• Create a hierarchy of progressively more
frightening stimuli
• Systematic desensitization: gradual exposure to
the real phobic stimulus
Systematic Desensitization
Behavioral Approaches
Operant Conditioning Techniques
• Token economies
– Earn tokens for positive behaviors, which can be exchanged for
– Shaping
• Contingency Management
– Strict consequences for certain behaviors
• Successful for shaping communicative behavior in children
with autism (Lovaas)
• Modeling Techniques
– Therapist perceived as role model
Cognitive-Behavioral Approaches
• Rational Emotive Behavioral Therapy
(Albert Ellis)
• People typically think that an event
causes them to behave a certain way
– But…beliefs matter
– Focused therapy on changing beliefs
• Teacher-like
Cognitive Therapy
• Aaron Beck
• Focused on changing dysfunctional
• Cognitive Restructuring
– Challenge a person’s unhealthy
beliefs or interpretations
– Used persuasion and confrontation
– Brief, problem-focused
• Initially treated depression
Cognitive-Behavioral Therapy
• Followers of Ellis and Beck blended the
two therapies to form CBT
• Focus on addressing problems the
patient wishes to solve
• Intimate relationship between behavior
and thought (self perception theory!)
• Often clients are assigned homework
– Practice new ways skills or thought
• Modern therapy tends
to blend aspects from
many of these
• Makes sense, since
there are often many
causes of mental
Client-Therapist Relationship
• Therapeutic Alliance
– Support
• Trust
• Hope
• Understanding
Group Therapies
Often groups are chosen
because they share similar
problems (e.g., Alcoholics
Focus on the shared
problems, less on the
individuals’ emotions
• Advantages
– Social support
– Share advice, information
– Observe other peoples’
– Realize that not alone, others
share similar problems
– Economic advantage
Couple and Family Therapy
• Views the family or relationship as a
complex system
– One person’s negative behavior or
cognitions may reflect a larger issue for the
entire family or relationship
• Can be extended to
• treating children
who have little control
(work with family to change
Biomedical Treatments
The Early Gruesome Years
• Trephination
– Allowed “evil spirits” to escape the skull
• Hot or Cold Baths
• Spinning
Biomedical Treatments
• Prefrontal Lobotomy
– Sever connections between
thalamus and frontal lobes
– Disrupted higher cognitive
• Modern techniques are more
precise and used as a last
resort treatment
Electroconvulsive Therapy (ECT)
Brief electrical current
passed through the brain
causing a convulsive seizure
Originally developed to treat
Very effective for treating
severe depression (70-90%
Memory impairment
Mechanisms are not known
Different Therapies for Different
Conditions (& Sometimes a Mix)
• Medical: Brain targeted drug interventions
--SCZ: Dopamine receptor blockers (the
better the block the more effective it is)
--Other neurotransmitters involved as well
--Depression: ex. Norepinephrine uptake
or release+, Serotonin release+, & a host
of other neurotransmitter controls involved
-- Electro-convulsive shock therapy!
Pharmacological Treatments
• Psychotropic drugs
– Not only helped treat patients, but also
further understanding of the illness
Pharmacological Treatments
• Antipsychotics
– Treat positive symptoms of schizophrenia
– Not effective for treating the negative symptoms
– Most common are Thorazine, Haldol and Stelazine
• Block dopamine receptors in particular brain pathways
• Atypical Antipsychotics
– Treat negative symptoms of schizophrenia, too
– Risperdal, Clozaril, Seroquel
Antipsychotics and Deinstitutionalization
• Movement in the 1950s shortly after
development of the first antipsychotics
– Aimed to provide less expensive mental health care at
local community centers instead of institutions
• Pros
– Fewer people spending their lives in institutions
– Shorter stays
– Thomas Szasz argument
• Downside
– Lack of appropriate care in community settings
– Lack of integration into the community (support
services, employment)
– Many mentally ill are now homeless, or in jail
The next slides
• The next six slides are for informational
purposes to show the variety and nature of
particular psycho-pharmacological approaches
but should not be memorized!
• Monoamine Oxidase Inhibitors (MAOIs)
– Nardil
• Tricyclic antidepressants
– Tofranil
• Increase serotonin and norephinephrine for
synaptic transmission
• Both very effective (significant improvement in
65% of patients)
– Many negative side effects
• Selective Serotonin Reuptake Inhibitors (SSRIs)
– Prozac, Zoloft, Paxil, Celexa, Lexapro
– Minimally effect dopamine and norepinephrine, and
maximally effect serotonin
• Reduced side effects
– Most commonly prescribed
• Atypical Antidepressants
– Effect serotonin, norepinephrine and dopamine in
various ways
• Wellbutrin (fewer side effects)
• Downside
– Takes a while before effective (a month)
– Trial-and-error
– Side effects
• Weight gain, nausea, diarrhea, insomnia,
reduced sexual desire or response
Mood Stabilizers
• Treat symptoms of bipolar disorder
• Lithium carbonate
– Treats manic episodes as well as depressive episodes
– Side Effects
• Weight gain, sedation, dry mouth, tremors
– Adherence to medication
• Often patients do not wish to treat mania, only depression
– Lethal at high doses
– Effective for 60 – 70% of patients
Anxiolytic Medications
• Treat anxiety disorders
• Increase neurotransmission of GABA
• Beta Blockers
• Benzodiazepines
• Tricyclic Antidepressants and SSRIs
Anxiolytic Medications
• Beta Blockers
– Controls autonomic arousal
• Benzodiazepines
– Valium, Xanax, Klonopin
– Short term treatments
– Highly addictive
– Interact dangerously with alcohol
– New drugs are being developed to reduce these negative side
– Rebound effect
Medication: Costs and Benefits
• Can be highly effective
• Only treats and controls the
– Relapse
• Requires trial-and-error for
correct drug and correct dosage
• Side effects
– Reduce adherence to medication
• Overprescription
with Drugs vs.
Emerging Biomedical Treatments
• Repetitive TMS
– Areas of the brain stimulated
with magnetic coil for 20-30
minutes over several weeks
– Effective for medicationresistant depression
– No cognitive side effects
• Deep Brain Stimulation
– Electrodes implanted in brain
- Future: increased ability to
interface with brain sub-areas
via many pathways.
Combined Treatments
• Most therapists use a combination of
– Drug treatments for short-term effects
– Therapy for long-term effects
Evaluating the Efficacy of Treatments
• Randomized Clinical Trial (RCT)
– Treatment group
– Placebo group
– Random assignment
– Symptoms and severity similar across
– Follow participants over several months
Is therapy effective?
• A meta-analysis found that 80% of
patients who received treatment
fared better than those without
Are all Therapies Equally Effective?
Who provides the most effective psychological
• Number of years of practice?
– Not necessarily
• Professional credentials?
– No
• The rapport between therapist and
client seems to be strongest predictor
– Respect, trust, comfort
Who is most likely to benefit from
• Strong alliance with therapist
• Motivated
• Optimistic
• More effective with more therapy
Are All Treatments Equally Effective?
• A depression meta-analysis shows…
– Drug treatment alone 55% effective
– Therapy alone 52% effective
– Drug AND therapy 85% effective!
(New England Journal of Medicine, 2000)
Are all Treatments Equally Effective?
• Treatment more effective than no
• Combining treatments appears most
• Some therapies seem particularly
effective for specific disorders
– Exposure therapy phobias
Moral of the Story
• Treatment is effective!
• Modern treatments are much more
effective and humane than past
• The relationship between therapist
and client really matters!
Recent Reconceptualization
• Some people are able to cognitively
overcome even serious levels of
– Available to psychotherapy
– Find meaning in some symptoms
– Able to live normally or quasi-normally
– Example in Nash film and in today’s reading
If you feel you need help…
• Seek it! Ask for advice, or set up an appointment
with a counselor. It’s not a weakness.
• Make sure the therapist is a good match for you!
• Remember it can take time and you may face
some setbacks, but also…
• Remember treatment is effective! Most people
• The “Two Worlds” of psychiatry approach is
• The brain is the source of behavior and thus a
possible route of change via medical
intervention, but….
• Behavior and experience can modify the brain,
thus psychotherapy, while targeting behavior,
also “tunes the engine” by acting on the brain.