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XII. Abnormal Behavior (7–9%) Myers book- Chapter 15 In this portion of the course, students examine the nature of common challenges to adaptive functioning. This section emphasizes formal conventions that guide psychologists’ judgments about diagnosis and problem severity. AP students in psychology should be able to do the following: • Describe contemporary and historical conceptions of what constitutes psychological disorders. • Recognize the use of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association as the primary reference for making diagnostic judgments. • Discuss the major diagnostic categories, including anxiety and somatoform disorders, mood disorders, schizophrenia, organic disturbance, personality disorders, and dissociative disorders, and their corresponding symptoms. • Evaluate the strengths and limitations of various approaches to explaining psychological disorders: medical model, psychoanalytic, humanistic, cognitive, biological, and sociocultural. • Identify the positive and negative consequences of diagnostic labels (e.g., the Rosenhan study). • Discuss the intersection between psychology and the legal system (e.g., confidentiality, insanity defense). XIII. Treatment of Abnormal Behavior (5–7%) This section of the course provides students with an understanding of empirically based treatments of psychological disorders. The topic emphasizes descriptions of treatment modalities based on various orientations in psychology. AP students in psychology should be able to do the following: • Describe the central characteristics of psychotherapeutic intervention. • Describe major treatment orientations used in therapy (e.g., behavioral, cognitive, humanistic) and how those orientations influence therapeutic planning. • Compare and contrast different treatment formats (e.g., individual, group). • Summarize effectiveness of specific treatments used to address specific problems. • Discuss how cultural and ethnic context influence choice and success of treatment (e.g., factors that lead to premature termination of treatment). • Describe prevention strategies that build resilience and promote competence. • Identify major figures in psychological treatment (e.g., Aaron Beck, Albert Ellis, Sigmund Freud, Mary Cover Jones, Carl Rogers, B. F. Skinner, Joseph Wolpe). Lesson 1: Psychological Disorders: Historical Perspectives, Classification Systems and Models I. There is no one absolute definition of psychological disorders; moreover, a continuum exists between mental health on the one hand and pathology on the other. Some proposed definitions include: A. A psychological disorder can be defined as a pattern of behavioral or psychological symptoms that causes significant personal distress and impairs the ability to function in one or more important areas of life, or both. (American Psychiatric Association, 1994) B. A psychological disorder may exist when behavior is atypical, disturbing, maladaptive and unjustifiable. (Myers, 1998) C. A psychological abnormality involves the presence of at least two of the following: distress, maladaptiveness, irrationality, unpredictability, unconventional and statistical rarity, and observer discomfort. D. Sanity and insanity are legal rather than psychological terms. In most states the legal definition of insanity relates to the ability of the defendant to distinguish right from wrong. This requires an either/or determination on the part of the court. II. Historical perspectives on abnormal behavior A. The ancient world 1. Greece a) Hippocrates (460-377 BC) believed mental illness was the result of natural, as opposed to supernatural, causes b) Galen (130-200 AD) divided the causes of mental disorders into physical and psychological explanations. 2. In China in 200 AD, Chung Ching stated that both organ pathologies and stressful psychological situations were causes of mental disorders. B. The Middle Ages (500-1500 AD) 1. In Europe, abnormal behavior was most frequently viewed as demonic possession. Treatment performed by the clergy involved prayer, laying on of hands, and exorcism. 2. Islamic countries a) Humane mental hospitals (for example, in Baghdad in 792 AD) were established . b) The Persian physician Ibn Sina (Avicenna, 980-1037) wrote The Canon of Medicine, perhaps the most widely studied medical work ever written. The principles he set-out for testing the effectiveness of new drugs and medications still form the basis of modern clinical drug trials. C. The Renaissance led to the re-emergence of the scientific approach in Europe. 1. The Spanish nun Teresa of Avila (1515-1582) established the conceptual framework that the mind can be sick. 2. Both Johann Weyer (1515-1588) of Germany and Reginald Scot (1538-1599) of England used scientific skepticism to refute the concept of demonic possession. D. Humanitarian reforms of the 18th and 19th century 1. In France, Philippe Pinel (1745-1826) pioneered a compassionate medical model for the treatment of the mentally ill and established a humane hospital in Paris. 2. In England, William Tuke (1732-1822) introduced trained nurses for the mentally ill and helped to change public attitudes regarding their treatment. 3. In the United States, Benjamin Rush (1745-1813), the founder of American psychiatry, encouraged humane treatment of the mentally ill and the establishment of hospitals for their care. E. Scientific advances of the 20th century 1. Developments in technology such as MRI and PET scans have added to our knowledge of the biological bases of psychological disorders. 2. Developments in psychopharmacology have provided effective treatments for many psychological disorders. III. Models (or perspectives) of psychological disorders Models of Psychological Disorders Biopsychological Model Psychoanalytic Model Behavioral Model Cognitive Model Definition Type of T Biopsychosocial Model IV. The Diagnostic and Statistical Manual of Mental Disorders, 4th edition A. Published by the American Psychiatric Association, the DSM-IV, as it is known, is a widely used diagnostic classification system. It provides a set of criteria which allows diagnosticians to make assessments. B. The diagnostic system is based on five axes that are used by clinicians to provide a complete diagnosis. 1. 2. An example of how a therapist might make a complete DSM multiaxial diagnosis is: a) Axis 1: alcohol dependence b) Axis 2: dependent personality disorder c) d) Axis 3: diabetes Axis 4: death of spouse; unemployment e) GAF = 60 (moderate symptoms, e.g., occasional panic attacks or moderate difficulty in social, occupational, or school functioning) C. Criticisms of classification 1. The system relies heavily on the medical perspective. 2. Reliability in diagnosis remains a problem; psychological disorders have "fuzzy borders." Different disorders share certain characteristics, for example, and a person might exhibit some, but not all, characteristics of a particular disorder. 3. Controversy exists regarding the existence of some disorders, such as dissociative identity disorder and premenstrual syndrome. Lesson 3: Dissociative and Personality Disorders I. Dissociative disorders are A. Specific dissociative disorders 1. Dissociative amnesia involves partial or total loss 2. Dissociative fugue occurs when the individual suffers 3. Depersonalization disorder is the most common dissociative disorder and is characterized by 4. Dissociative identity disorder (formerly called multiple personality disorder) is a rare, dramatic, and controversial disorder characterized by B. Explaining dissociative disorders. Amnesia and fugue are usually attributed to 1. Dissociation is a relatively common response to traumatic experience. People report feeling detached from their surroundings and their own bodies. Most are rooted in severe emotional trauma that occurred during childhood like because of a disturbed home, sexual abuse and beatings). 2. In those persons with dissociative disorders the dissociative experiences are more extreme and frequent, and the symptoms severely disrupt everyday functioning. 3. The learning perspective views dissociation as rewarding and thus highly reinforcing. 4. Some psychologists suggest that dissociative identity disorder is a diagnostic fad. Some think that DID is the result of modern North American culture (Sybil affected the # of personality disorder people) II. Personality disorders (these make up a separate axis of the DSM-IV) A. In general, personality disorders are 1. Characterized by long-standing chronic, inflexible, maladaptive patterns of 2. Usually recognizable by the time the person reaches adolescence. 3. As a group, among the least reliably judged and are questioned as to their existence independent of the social and cultural factors in which they develop. B. Examples of specific personality disorders 1. Narcissistic personality disorder is marked by a grandiose 2. Antisocial personality disorder is marked by a long-standing pattern of irresponsible behavior that hurts others without causing feelings of guilt for oneself. The individual often does not C. Explaining antisocial personality disorders 1. The biological perspective suggests that a genetic vulnerability (related to little or low level autonomic system arousal) may contribute to the antisocial personality disorder. This is correlated with a fearless approach to life. 2. The biopsychosocial perspective suggests that, in the case of antisocial personality disorder, if fearlessness is channeled in productive directions, heroism or adventurism may result. Lacking a sense of social responsibility, the same disposition produces, for example, a con artist or killer. 3. Some studies have detected early signs of antisocial behavior in children as young as 3 to 6 years old. Lesson 4: Mood (Affective) Disorders I. Mood disorders in general A. This category of mental disorders has significant and chronic disruption in mood as the predominant symptom. This causes impaired cognitive, behavioral, and physical functioning. B. Mood disorders are differentiated from normal moods on the basis of C. Prevalence of mood disorders 1. Mood disorders are among the most common of all psychological disorders, affecting about 12 million Americans in any given year. 2. Mood disorders are more common in women than in men. 3. The greatest risk of developing major depression occurs between the ages of 15- 24 and 35-44. 4. Episodes recur in one half of all cases and last at least two weeks. II. Major depression aka Major Depressive Disorder- persistent feelings of III. Other depressed mood disorders A. Dysthymic disorder involves chronic, low-grade feelings of B. IV. Seasonal affective disorder (SAD) involves Bipolar disorder is characterized by alternating episodes of A. B. V. Cyclothymic disorder, a milder, but chronic form of bipolar disorder, Explaining affective disorders A. The biopsychological perspective 1. Family, twin, and adoption studies indicate that some people inherit a genetic predisposition for mood disorders. Concordance rate in identical twins higher (65%-68%) compare to 15% for fraternal twins. Recent studies show that this genetic role may be higher in females. 2. Indirect evidence indicates that two neurotransmitters, seratonin and norepinephrine, are implicated in major depression. 3. Symptoms of major depression are alleviated in about 80% of people for whom antidepressant medication is prescribed. These medications increase the availability of seratonin and norepinephrine in the brain. 4. B. Continued use of antidepressants can prevent recurrences of major depression. The behavioral perspective stresses the role of reinforcement. 1. Depressed people may lack the social skills needed to gain normal social reinforcement from others. 2. Thus, a vicious cycle develops in which reduced social reinforcement leads to depression, and depressed behavior further reduces social reinforcement. C. The cognitive perspective stresses that the way people think can result in depression. 1. Perfectionists set themselves up for depression through irrational self-demands they may not be able to meet. 2. Paying attention to negative information, being highly self-critical, being pessimistic about the future, and focusing on the cause of the negative mood all contribute to depression. 3. Making attributions that are internal ("it's all my fault"), stable ("nothing can change to improve the situation") and global ("it is a major, all-encompassing problem") may cause depression. 4. Martin Seligman’s learned helplessness- depression is based on passive giving up. D. The biopsychosocial perspective recognizes the roles played by an individual's biochemistry, behavior and mood (along with environmental stress factors), thus acknowledging that depression is an ailing mind in an ailing body. It also acknowledges that altering any one of the components of the chemistry-cognition-mood circuit can affect the others. Lesson 5: Schizophrenia and the Impact of Psychological Disorders I. Description and symptoms of schizophrenia A. Schizophrenia is a group of severe disorders characterized by the breakdown of personality functioning, withdrawal from reality, distorted emotions, and disturbed thought B. Originally, the vague, general description of the disorder led to its over diagnosis. Bipolar disorder, for example, was mistaken for schizophrenia. C. The Diagnostic and Statistical Manual, 4th Edition (DSM-IV), tightens the standards to be used for positive diagnosis. Organic and affective disorders are ruled out as possible causes. DSM-IV indicates that the following symptoms must be manifested: 1. Delusions that 2. Auditory hallucinations 3. Marked disturbance 4. Deterioration from former 5. Symptoms that last at least six months and D. The symptoms of schizophrenia 1. Positive symptoms (meaning an excess or distortion of normal functioning) 2. Negative symptoms (meaning restriction or reduction of normal functioning) II. Types of schizophrenia A. Paranoid schizophrenia involves 1. The onset of symptoms tends to occur later in life (in the 30s) than in other types of schizophrenia. 2. The individual rarely displays obviously disorganized behavior, but may act upon the delusions. This may result in behavior which seems reasonable to the individual, but not to others. B. Disorganized schizophrenia involves inappropriate behavior and C. Catatonic schizophrenia involves frozen, rigid or excitable motor behavior. For example, patients can maintain postures D. Undifferentiated schizophrenia has a mixed (undifferentiated) set of symptoms. It involves thought disorders and features from other types of schizophrenia. III. The course of schizophrenia A. Onset 1. The disorder typically occurs in men younger than 25 and in women between 25 and 45 years of age. a. Men and women are equally affected but males have earlier onset and are more likely to have hospitalizations and a higher rate of relapse. b. Schizophrenia occurs in approximately one percent of the world's populations and is seen in all cultures. 2. Gradual onset a. Some changes in previous behavior may be noted by others, especially social withdrawal. b. The promodal phase (preceding the active phase) involves increased withdrawal with peculiar actions or talk. c. During the active phase, full-blown symptoms are present. d. Residual phase (1) The symptoms are no longer prominent. (2) There is some remaining impairment in functioning e. Generally, one third of patients recover, one third are helped with medication (they are likely to be in and out of treatment their whole lives, but retain some symptoms, and one third are not helped by drug therapy. Individuals with chronic symptoms may be hospitalized permanently. This is sometimes referred to as the "Rule of Thirds." 3. Sudden onset in a previously symptom-free individual usually occurs early in life (in the 20s) and presents a better prognosis for recovery with no recurrance. This is not true for gradual onset schizophrenia. IV. Long-term outcome studies regarding schizophrenia indicate that recovery may be more rapid in developing countries than in the U.S., Europe, or Russia. This may be due to greater acceptance or work opportunities available in third world communities. This has important implications for social policy. V. Explaining schizophrenia: a biopsychological perspective A. Studies of families, twins, and adopted individuals have firmly established that genetic factors play a role in many cases. B. Abnormal brain chemistry (there is a lot of doubt about this theory) 1. One theory implicates an excess of the neurotransmitter 2. Dopamine blocking drugs often reduce symptoms of schizophrenia, particularly positive ones. C. In some patients there is evidence of a prenatal viral infection-based cause. D. Abnormalities in brain structures and functioning are present in some patients with schizophrenia. 1. MRI studies have found abnormalities in the frontal lobes, temporal lobes, and basal ganglia. 2. The fluid-filled ventricles are enlarged in some brains of schizophrenic patients (an effect, not a cause according to many). E. Schizophrenia may be viewed as a complex, chronic medical illness, similar to diabetes or cancer, affecting different people in different ways. F. Researchers have been unable to find a single psychological factor which emerges consistently as causing schizophrenia. Rather, it seems that those who are genetically predisposed to developing schizophrenia may be more vulnerable to such factors as disturbed family environments and stress. VI. The impact of psychological disorders A. Frequency of psychological disorders 1. The World Health Organization estimates that 400 million people worldwide suffer from psychological disorders. Though not all disorders are seen in all cultures, no known culture anywhere in the world is free of depression or schizophrenia. 2. A U.S. government survey estimates that 15% of the population are in need of psychological therapy. a. 1.9 million people per year are admitted to mental hospitals and psychiatric units in the U.S. b. 2.4 million Americans seek out-patient help each year. c. In any given year, about 5 million adults and 3 million children in the U.S. suffer from an acute episode of one of five serious disorders: schizophrenia, bipolar disorder, major depression, obsessive-compulsive disorder and panic disorder. B. Stigma associated with mental illness 1. Misconceptions about people with psychological disorders often lead to misunderstandings and discrimination. 2. Examples of misconceptions a. "People with mental illnesses will never recover." The reality is: (1) The current success rate for treating schizophrenia is 60%; for bipolar disorder it is 65%; and for major depression it is 80%. (2) Mental illnesses can now be diagnosed and treated as precisely and as effectively as other medical disorders. b. "All people with mental illnesses are dangerous to society." The reality is: (1) People with mental illness pose no more of a crime threat than do other members of the general population. (2) They are often victims of crime. c. "Individuals treated for psychological disorders will make poor employees." The reality is: (1) People who have been treated for these disorders have been shown to be about equal to their co-workers in the areas of motivation, quality of work, and length of time on the job. (2) Many employers report them to be more punctual and to have better attendance records than their co-workers. C. Efforts to combat stigma and misconceptions 1. Some of the organizations that are making efforts to combat the misconceptions and stigma attached to psychological disorders are a. The American Psychological Association b. The National Mental Health Association c. NAMI, the Family Organization for People with Brain Disorder d. Anxiety Disorders Association of America 2. Some of the goals of these organizations are a. to educate the public about mental illness. b. to confront discrimination in insurance coverage, housing, education, employment and access to services. c. to challenge negative stereotypes such as those portrayed in the media d. to emphasize that treatment works. e. to ultimately achieve the understanding that serious mental illnesses are no- fault, biologically based brain diseases which should receive the same attention, concern, research and care dollars as do other physical diseases. Treatment of Disorders I. Introduction and Overview A. Definition of psychological treatment— 1. Psychotherapy— 2. Biological— 3. Combined treatments— B. History of treatment—Historically, treatment of people with psychological disorders ranged from lack of care to extreme and often violent mistreatment of individuals with serious psychological disorders. 1. Early treatment approaches (circa 1300–1900)—Early psychological treatment consisted primarily of imprisonment, rather than specific techniques to help people with mental illness. Bethlam (or the more common name of Bedlam) is located in London and is considered the oldest hospital caring for people with mental illness. The term bedlam aptly describes the conditions that were present in hospitals at that time. Treatment facilities, called asylums or mental hospitals, were built to house people with mental illness in the mid-1500s. Patients often were chained and mistreated in the early attempts to treat psychological illness. a. Phillipe Pinel (1745–1826) was the first physician to remove chains from seriously mentally ill patients, which resulted in calmer patients. In the 1840s, in the United States, Dorothea Dix (1802–1887) also initiated freeing the mentally ill from mistreatment in jails and other locations. She was instrumental in helping to establish state-funded mental hospitals (Weiten, 1994). b. The precursor to modern psychotherapy began with a physician, Josef Breuer (1845–1925), who used hypnosis to get his patients to talk about their problems or what became known as cathartic therapy. 2. Contemporary treatment approaches (1900–2000)—Early twentieth century treatments also included harsh medical interventions (e.g. ECT, prefrontal lobotomy), which were performed in mental hospitals. Although these hospitals remained operational, they failed to reach their full potential, and in the 1950s, efforts were undertaken to close many large mental hospitals. Deinstitutionalization of patients resulted in release of many patients. Treatment of psychological disorders now includes hospital inpatient treatments and community mental health or outpatient treatments. Several specific treatments modalities were introduced in the second half of the twentieth century. Freud’s approach to therapy, or psychoanalysis, is perhaps the most well-known contemporary approach to therapy. Freud emphasized understanding the unconscious mind as a central tenet of treating psychological disorders. Freud’s patients would lie on a couch and talk about heir problems through free association or reporting dreams. Humanistic therapy, which consists of more egalitarian behavioral treatments that emphasize change in actions; cognitive therapy, designed to change a person’s thought processes; and biomedical treatments are among the specific techniques that will be outlined. . C. Those who provide treatment—Professionals who treat people with psychological problems have training as medical doctors (psychiatrists), psychologists, or other professions with specialized mental health training (e.g., social workers, nurses, counselors). 1. Psychiatrist—A psychiatrist is a medical doctor who specializes in treating psychological disorders. A psychiatrist can diagnose a mental illness, prescribe medication, or administer other biomedical treatments. 2. Psychologist—A clinical or counseling psychologist has a doctoral degree (PhD or PsyD) that includes training in diagnosis and treatment of psychological illnesses. 3. Psychiatric social worker or psychiatric nurse—This social worker or nurse works as part of a team of people in a hospital setting. Services include monitoring treatments that are prescribed by a psychiatrist or psychologist. 4. Counselor—A counselor provides limited psychotherapy for individuals who do not have a serious mental illness. D. Ethical issues in treatment—Professionals should adhere to a set of ethical standards issued by their respective organizations. For example, psychologists should adhere to the ethical principles of the American Psychological Association. In addition to ethical standards, professionals must adhere to legal stipulations governing the practice of psychology. One example of the nexus of law and ethical code relates to the right to privacy, which is granted by the U.S. Constitution. Although this right to privacy is a legal mandate, specific application of this right to privacy is specified in the ethics code (Koocher & Keith-Speigel, 1998). Essentially, practitioners should be sure that they keep all information confidential. Information about a client should be released only under very specific circumstances, and the client has a right to know, in advance, about the conditions under which information will be released. For example, if a client tells a psychologist that (s)he plans to hurt someone, the psychologist must break confidentiality. II. Psychoanalytic Treatment Approaches A. Introduction and overview—Psychoanalytic, humanistic, and cognitive approaches to therapy are often called insight therapies. Insight therapy helps B. Psychoanalytic approaches—Sigmund Freud (1856–1939) pioneered work in psychodynamic therapies. His particular type of therapy has been labeled psychoanalysis. 1. Psychoanalysis emphasizes the importance of the unconscious mind. Freud attempted to help people understand, or develop insight, into their unconscious conflicts as a way to relieve neurotic anxiety. 2. Techniques—Psychoanalysis is an intensive and long-term therapy that may include several sessions per week over a period of several years. A psychoanalyst helps the patient to discover unconscious conflicts, yet the therapist remains neutral, does not reveal personal information, and does not give advice. a. Free association—During a therapy session, psychoanalysts encourage patients to verbalize any thoughts or feelings that come into their consciousness. Resistance occurs when patients unconsciously b. Dream analysis—According to Freud, dreams reflect symbolic or unconscious desires. A psychoanalyst asks a patient to describe a dream in as much detail as possible. Then, the psychoanalyst interprets the underlying meaning of the dream. Freud believed that unfulfilled desires that are not expressed consciously during waking hours may be represented in latent content of dreams. 3. Other psychoanalytic therapies—Carl Jung, Erik Erikson, and Karen Horney are neoFreudians who believed that therapy should include conscious and unconscious aspects of the patient. A neo-Freudian psychoanalyst seeks to understand the patient’s past and helps to understand the patient’s future. This type of therapy is usually shorter in duration compared to traditional psychoanalysis. Ego analysis, interpersonal therapy, and individual analysis are among some of the neo-Freudian therapies that include both conscious and unconscious aspects. According to the newest neo-Freudian approach, object relations theory, children should form a secure relationship with a caregiver in order to feel secure as adults. In this case, the object is the “relationship with the parent.” If a secure bond is not formed, the child may not be able to form strong social relationships as an adult. An object relations therapist treats a patient with the underlying perspective that object relations are influential in the development of the patient.