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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.
"Psychopathology": beyond behavior, including thought, emotion and motivation
1.
Understanding: scientific description and explanation
2.
Intervention: the change technologies
HISTORY:
Understanding
Theory
Cause

Intervention
Therapy
Cure/Care
The traditional perspectives:
BIOLOGICAL (body and brain)
PSYCHOLOGICAL
SOCIOCULTURAL
(adaptation, growth and conflict)
(natural and supernatural)
People and their problems: the traditional perspectives and the "recurrent millenia" of
history
Understanding problems, in the past
Intervening with people, in the future
Some comparisons:
1.
cars & clocks: simple cause  effect relationships
2.
soups & sauces: interaction of factors
3.
people: coping and resilience
Factors in the cause (past), content (present) and course (future) of psychopathology
Common confusions:
A.
Theory → therapy and "therapeutic nihilism"
B.
Therapy → theory and "post hoc explanations"
"The recurrent millenia"
1.
Ancient writings and archaeological evidence
e.g., Homer, the Hebrews, trephining, Asclepius...
2.
Biogenesis: Hippocrates and "the four humors"
e.g., melancholia and hysteria
3.
Psychogenesis: Plato and mental conflict e.g., catharsis
"The Dark Ages" (450-1450 AD):
Avicenna, St. Augustine and the
town of Gheel
4.
The Renaissance and the Revolutions:
a. Witches and asylums
e.g., St. Thomas Aquinas, Weyer,
Scot, Teresa of Avila, Paracelsus
b.
5.
“The Mental Hospital Movement”
e.g., Pinel, Pussin, Esquirol,
Tuke, Dorothea Dix, Beers
The Psychiatric Revolution: the return
of biogenesis
e.g., Mesmer, Rush, Semmelweiss,
Pasteur, Snow, Korsakoff,
Wernicke, Alzheimer, Broca,
Griesinger, Kraepelin, Charcot
e.g., the case of general paresis: from
Dx (the syndrome) to Hx
(correlates to causes) to Rx
(causes to cures)
6.
Psychodynamics and psychoanalysis: the
return of psychogenesis
e.g., Liebault, Bernheim and Freud
(hysteria and the case of
Anna O.)
7.
The Mental Health Movement
8.
The "New Psychiatry"
The Lesson of History
Limitations to
1.
Understanding (finding causes):
post hoc explanations
correlates and causes
longitudinal and experimental research
the problem of base rates (BR)
2.
Intervention (finding cures):
placebo effects
spontaneous remission (SR)
superstitious behaviour
publication bias
DEFINITIONS
1.
Theoretical/absolute criterion (demons,
diseases and defects)
…. making inferences and pathologizing
the results
2.
Social/cultural criterion (deviance,
difference and disgust)
…. making discriminations and pathologizing
the minority
3.
Personal/subjective criterion (distress,
dysphoria and despair)
…. making introspections and pathologizing
unhappiness
The common-sense criterion:
(disorder,
dysfunction and disability)
e.g. thoughts and perceptions
emotions and feelings
needs and motives
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)
Maladaptation/symptoms
“Other conditions that may be the focus of clinical attentions”, including psychological
factors affecting medical conditions, and the “V” code.
Issues:
1.
reliability & validity
2.
categories, dimensions &
prototypes
3.
comorbidity, artifactual & real
4.
subjectivity & biases
5.
the problem of labeling
Extent of psychopathology: prevalence, incidence and life-time risk
Prevalence
Life-Time Risk
Treatment Ratio
Axis 1
Anxiety disorder
12%
16+%
1 in 7
Affective disorder
5%
17+%
1 in 4
Thought disorder
1%
1+%
1 in 2
7%
7%
unknown
20-30%
30%-40+%
1 in 5
Axis II
Personality disorder
Also
Drugs
MR
6%
2%
15%
2%
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
The nature of causal complexity: the causal pattern
An overall conception: Diathesis-Stress
THEORETICAL PERSPECTIVES
A.
Biological/Physiological: the disease model and modern neuropsychiatry
Genetic, congenital and constitutional factors:
the role of neurobiological inhibition
(Note: passive, evocative, active and interactive
genetic influences)
B.
Mental/Psychological: the three models and modern cognitive perspectives
1.
Psychodynamic theory and psychoanalysis:
conflict and its management
2.
Learning and cognitive theories: adaptation
and its means
3.
a.
classical & operant conditioning and behavior therapy
b.
cognition and cognitive therapies
Phenomenological/humanistic theory and client-centered counselling: growth
and its
directions
Psychological factors in psychopathology: the power of protective factors
C.
Sociocultural factors in the cause, content, and course of psychopathology
Examples of “culture-bound” disorders:
Latah
Koro
Amok
Berserk
Kitsunetsuki
Pibloqtok
Lycanthropy
The Windigo Psychosis
Sociocultural factors in psychopathology
Content: how and how much
Course: cultural “maintaining” causes
Cause: cultural “predisposing” causes:
e.g. the relation between “exit events”
and clinical depression
Note:
The presumption of personal (clinical)
causes for social (cultural) problems
e.g. the relation between suicide and clinical depression
STRESS AND THE
ADJUSTMENT DISORDERS
Stress
The General Adaptation Syndrome:
alarm, resistance & exhaustion.
How stressors are stressful in the diathesis-stress
model.
Measurement
DSM (Axes IV and V)
Self-report procedures (LCUs and beyond)
Results
Frustrations, conflicts and pressures
e.g. the hassle list and stress-induced
analgesia
Coping
Task-oriented/problem-solving and defense-oriented/emotion-focussed methods:
which to
choose?
e.g. mind  body
Personal and interpersonal coping:
the importance of social support
e.g. Alberta study
The Special Case of Extreme Stress: theory and
research
Results: Transient decompensation & residual
fear
e.g. “The Disaster Syndrome”: shock,
suggestibility and survival – the conventional findings
Coping: Positive illusions
e.g. The “Ur” defenses: our immortality, the
omnipotent servant, man’s kindness to man
The “Polyanna Principle” and the “Belief in a
Just World”
Adjustment Disorders
Crucial for Dx: inference of causal importance of
stress
Depressed, anxious, conduct disturbance and
“mixed” types, along with “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:
Social support, exposure and stress-induced
analgesia
The crisis in “Crisis-Counselling”
ANXIETY DISORDERS
Note: Adjustment disorder with anxious mood
Substance-induced anxiety disorder
Anxiety 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+%
12%
16+%
Anxiety
normal vs. abnormal, primary vs. secondary
An aspect of temperament (trait) and mood
(state)….
…with biological components: GABA and the
monoamines in “negative emotionality”
1.
Phobia: specific, social and agoraphobia
BR: irrational fears and phobias
Treatment and SR
Understanding phobias
a.
Learning theory: situational causes
e.g. Little Albert
b.
Psychodynamics: dispositional causes
e.g. Little Hans
Specific phobias: traumas and dispositional
factors
e.g. “the immunization effect,”
“preadaptation” and “the
inflation effect”
Social phobias: experiential and dispositional
factors
e.g. “social sensitivity” and “automatic
thoughts”
Treatments
Exposure: systematic desensitization (vs.
flooding) and chemotherapies
2.
Panic:
with or without agoraphobia
BR: with or without phobia
Understanding panic
a.
Biology: monoamines
Nature and nurture
b.
Psychology: “anxiety sensitivity”
Conditioning and cognition
Treatments
Chemotherapy and PCT
3.
Generalized Anxiety (GAD)
BR: primary and secondary GAD
Understanding GAD
Psychodynamic and Learning theories
Biology of negative emotionality
Treatments
Chemotherapies (benzodiazepines and
antidepressants)
Psychotherapies (exposure and beyond)
4.
Obsessive-Compulsive Disorder (OCD)
BR: OCD and “OCD Spectrum Disorders”
Understanding OCD
Psychodynamic and Learning theories
Modern cognitive psychology: thought
suppression
Modern neurobiology: monoamines
Treatments
Chemotherapy and psychotherapy
The special case
Anxiety disorders and their comorbidities
Among anxiety disorders (e.g., panic,
phobia).
Between anxiety and other Axis 1 disorders (e.g., depression)
Between anxiety and Axis II disorders (e.g., “inhibited” personality disorders)
Affective Disorders:
Clinical depressions and Manic-depressive
disorders
Issues
1.
Emotional states: normal and abnormal
depression
2.
Feelings: the experience and expression of
emotional states
3.
Misattribution: Confusing content and
cause of emotional states
Normal and clinical depression
Primary and secondary affective disorders (e.g.
“dual diagnosis”)
Comorbidity (especially with Anxiety disorders)
Mood disorder due to General Medical Condition
Substance-induced Mood Disorder
Adjustment Disorder with Depressed Mood
Types
Prevalence
Lifetime
risk
A. Unipolar
1. Major
depression
2. Dysthymia
2+% 
2+%
10+% 
6%
15+% 
B. Bipolar
3. Manicdepression
4. Cyclothymia
1%
1+%
1%
1+%
2+%
5+% 
17+% 
Major Depressive Disorder and Dysthymia (and
"double depression")
A.
Descriptive features: symptoms, severity,
single and recurrent episodes
B.
Treatment: chemotherapy, SR and
controversy
C.
Distinctions:
a. exogenous/endogenous (distal causes?)
b. major/minor (severity)?
c. psychotic/neurotic (severity → cause)?
d. melancholic/non-melancholic
(proximal causes)
ca
Explanations: Biogenesis
1. Genetics-Concordance Rates and
prospective research
Adoptions: retrospective &
2. Theory - The Biology of Mood: The
Monoamine Hypothesis and
Monoamine Hypothesis and beyond
3. Therapy - Antidepressants and
their
action:
their action:
First generation drugs: Tricyclics
MAOIs (and “the cheese effect”)
Second generation drugs: Prozac
and beyond
(a
New developments:
neurobiology of positive & negative
emotionality
biology of stress and sleep
Explanations: Psychogenesis
"anaclitic
1. Psychodynamic Theory:
depression", Bowlby's
depression”, Bowlby’s
attachment theory and
Klerman's interpersonal
therapy (IPT)
2. Learning Theories:
conditioning and cognitive theories...
a. Rewards: “Response contingent
positive reinforcement”
(Lewinsohn)
b. Punishments: “Learned
helplessness/hopelessness”
(Seligman's “pessimistic
attributional style”)
c.
Negative cognitive sets(Beck's
“dysfunctional beliefs”) and
Freud's
F
cognitive therapy (CT)
3. Humanistic and Existential
perspectives ... and “logotherapy”
Explanations: Sociocultural aspects
Content: autonomous and sociotropic people
Course: interpersonal factors
Summary
Major Depressive Disorders
melancholic and non-melancholic:
personality factors & disorders?
Dysthymia
primary and secondary:
melancholic and non-melancholic?
Treatment
drugs and the alternatives:
specific patient-symptom and nonspecific factor approaches
Notes:
ECT
SAD (“depression with a seasonal pattern”)
PDD (“premenstrual dysphoric disorder”)
Post-Partum Syndromes: (“maternity blues”,
post-partum depression & puerperal
psychosis)
Sex: Why the difference? Predisposing and
reinforcing causes
Bipolar Disorder and Cyclothymia
A. Descriptive Features
B. Theory and Therapy:
Genetics (concordance rates
and adoptions)
Theory: monoamines and/or
acetylcholine
Lithium and its alternatives
A Note on Schizoaffective Disorder
Suicide
Rates and trends in Canada
Theory: “Escape from self” and egoistic,
altruistic & anomic
suicide
Issues: 1.
Ambivalence: "to be, not to
be & maybe"
2. Prevention: imitation &
contagion (“The Werther
Effect”)
3.
Prediction: availability of
lethal means & social support
Somatoform Disorders
1.
2.
3.
4.
5.
Conversion: sensory/motor symptoms,
purpose?
Somatization: chronic conversion?
Hypochondriasis: medical preoccupations,
purpose?
Somatoform pain: pain preoccupation,
purpose?
“Body dysmorphic disorder”: physical
preoccupations, purpose?
Note: group forms
Malingering: Deceit with a purpose
Factitious disorder: Munchausen syndromes
Note: self-induced and “proxy” forms
Dissociative Disorders
1.
2.
3.
Dissociative Amnesia: preattentive
processing
Fugue: ….. with travelling
Dissociative Identity (MPD): …. with
fragmentation
4.
Note: Post-traumatic theory and
sociocognitive view
Depersonalization: … with partial
fragmentation
Note: “Possession/trance disorder”
EATING DISORDERS
Anorexia and bulimia
Diagnostic criteria
BR
1.
Family context: “expressed emotionality”
2.
Personal context: “cluster B and C”
3.
Cultural context: social expectations
The Biological context:
Monoamines and the hypothalamus
Comorbidities: MDD, OCD, et al.
“Binge-eating Disorder”
Biological, psychological and
sociocultural context
PSYCHOLOGICAL FACTORS AND PHYSICAL ILLNESS (AXIS III)
History
Psychosomatic (“psychological”) and psychophysiological (“biological”) viewpoints
and the problem of circularity.
Modern Health Psychology and Behavioral Medicine: cause, course, cure, and
care.
Examples:
1.
Peptic ulcers: Dispositional and situational factors in duodenal ulcers.
2.
Immunocompetence: Stress, the hypothalamus, hormones, and the nervous
system
3.
Cardiovascular disorders: Coronary heart disease and Essential hypertension
(Type A and beyond)
Personality Disorders (Axis II)
Diagnostic criteria that don’t work:
1.
2.
3.
Theoretical criterion: personality isn’t
pathology
Personal criterion: ego syntonic vs. ego
dystonic disorders
Social criterion: eccentricity isn’t
pathology
Comorbidity within and beyond Axis II
BR & SR
A.
“Eccentric”
Schizoid (solitary)
Schizotypal (idiosyncratic)
Paranoid (vigilant)
B.
Erratic
Borderderline (mercurial)
Narcissistic (self-confident)
Histrionic (dramatic)
Antisocial (adventurous)
C.
“Anxious”
Avoidant (sensitive)
Obsessive-compulsive (conscientious)
Dependent (devoted)
D.
In the Appendix . . .
Passive-aggressive
“Depressive”
Note, also: “Sadistic” and “Self-defeating”
personalities
ANTISOCIAL PERSONALITY DISORDER
History:
moral insanity, psychopathy, and the DSM
Descriptive features:
The psychopathic personality type (Cleckley’s criteria)
The diagnosis of ASPD (DSM III and IV)
BR and SR
Research
A.
Biology, then (Lombroso, Lange) and now
Concordances, then and now
Adoption research
Retrospective (e.g., Mednick)
Prospective (e.g., Crowe)
Cross-fostering cases
Longitudinal research
“Deviant children grown up” (Robins)
B.
Psychological and Sociocultural factors, then (Gluecks, McCords) and now
Cause, course, and content
Attachment (Bowlby)
Adaptation to life (Vaillant)
Cross-cultural observations
Theory
“Types” of “psychopathy”
1.
Pure, primary, true, classic, Cleckley or constitutional, defect type
2.
Symptomatic, secondary, “non-psychopathic”, “neurotic” or “strategic”,
familial, developmental types
The nature of the psychopath, then and now
Passive avoidance conditioning
1.
Biology: Autonomic nervous system under-arousal
Central nervous system immaturity and beyond:
Behavioral Inhibition and Activation systems
2.
Psychology
Parents and their children
3.
Sociocultural factors
Two views of human nature
“The Psychopathic society”
“The psychopath within us”
BEYOND PSYCHOPATHY
Human nature, the nature of evil, and the concept of insanity
IMPULSE CONTROL DISORDERS
1. Intermittent explosion
2.
Kleptomania
3.
Pyromania
4.
Pathological gambling
5.
Trichotillomania
(Lykken)
Drug and substance abuse on the DSM
Diagnosis: “Substance-induced organic mental
disorders” and “Substance-related
disorders”
Why drugs?
“Life as we find it, is too hard for us; it brings
too many pains, disappointments and
impossible tasks. In order to bear it, we cannot
dispense with palliative measures…there are
perhaps three such measures: powerful
deflection, which causes to make light our
misery; substantive satisfaction, which diminish
it; and intoxication, which makes us insensitive to it.”
Freud
Forms of intoxication:
1.
Sedation: alcohol, barbituates,
benzodiazepines...
2.
Stimulation: caffeine, nicotine,
amphetamine...
3.
Fantasy: psychedelics, hallucinogenics
cannabis...
4.
Narcotics: opium, morphine, heroin...
Example:
Alcohol:
BR and adoption studies
Type I (binge) and II (persistent)
Treatment: AA, relapse prevention and
comorbidities
Associated organic states:
Alcohol amnestic disorder (WernickeKorsakoff
Alcohol withdrawal delirium (Delirium
tremens)
Fetal alcohol syndrome (FAS/FAE)
SEX and the DSM IV
I.
Sexual dysfunctions: desire, arousal, orgasm (and pain)
II.
Variants and deviations: paraphilias, gender identity disorders (and sexual
orientation)
History
Kinsey, Masters and Johnson
The old “Barbie Doll” (psychological) and new
evolutionary (biological) perspectives
Back to basics: Why sex?
The (human) sexual response: releasers (cues and rituals) and boundary conditions
(e.g., androgen)
a.
b.
c.
d.
I.
partner location $ elicit desire
pretactile sexual interaction $ maintain arousal
tactile sexual interaction $ “acception”
intercourse $ “conception”
Sexual Dysfunctions
1.
Desire: hypoactive sexual desire and sexual aversion
2.
Arousal: SADF and SADM
3.
Orgasm: Orgasmic dysfunction, male and female, and Premature ejaculation
4.
Pain: dyspareunia and vaginismus
Therapies: Masters and Johnson and beyond
II.
Variants and Deviations
A.
Paraphilias and their relation to “sexual” offenses
B.
Gender identity and its disorders
C.
Sexual orientation and the controversy over diagnosis
The concept of the lovemap
A.
Paraphilia
Definition: “. . . reiteratively responsive to and dependent on atypical or
forbidden stimulus imagery, in fantasy or practice, for the initiation and
maintenance of erotosexual arousal and achievement or facilitation of
orgasm.”
Examples
voyeurism, exhibitionism, fetishes, fetishistic transvestism, pedophilia,
zoophilia, sexual sadism and masochism, and others . . .
Theories
Psychodynamic: management of impulses
Learning: classical & operant conditioning,
and cognition
Problems with these theories: the “vandalized
lovemap”
Therapies
behavior therapies, antiandrogens and the problem of relapse
Beyond the paraphilias:
“sexual” offenses in society
1.
2.
3.
B.
Rape: convicted cases…and the rest (power,
anger, pain…and “narcissistic
reactance”)
Child molestation and incest
Sadism and masochism
Gender identity disorders (GID)
Development of Gender Identity
“The relay race”: Genes, prenatal hormones,
physical appearance and learning in the
“gendermap”
Biasing the brain”: Studies of intersexual syndromes and prenatal hormonal
variations
(e.g. adrenogenital & androgen insensitivity
syndromes)
Definition
Masculinity, femininity, and the discordance of body and mind
Child GID
the diagnosis and its prognosis
Adult GID
the diagnosis and its treatment
FTM and “masculine women”
MTF, “feminine men”, and “autogynephilic”
transsexuals
C.
Sexual orientation and the DSM
Definition: Erotosexual attraction to others and
the discordance of behavior and mind
Prevalence of same-sex sexual behaviour
and homosexuality
Development of Sexual orientation:
psychodynamic, learning and biological
perspectives
What is wrong with sexual orientation?
1.
2.
Theoretical criterion (disease, defect) and
DSM I
Social criterion (difference, deviance) and
DSM II
3.
Personal criterion (distress, dysphoria) and
DSM III
4.
Maladaptation (dysfunction, disorder) and
DSM IV
Treatment: “conversion” or “reparative” therapy
and the controversy
Sleeping disorders
Dyssomnias: insomnia, hypersomnia,
narcolepsy breathing (e.g. apnea)
and circadian
Parasomnias:
nightmares, sleep terrors and
sleepwalking
Schizophrenia
History: Kraepelin, Bleuler and the DSM
Descriptive features and differential diagnoses:
Brief psychotic disorder,
Schizophreniform disorder, et al.
Positive and negative symptoms
BR and SR
Research
A. Biology
Concordances, then and now
Adoption research, then and now
Prospective (Heston and beyond)
Retrospective (Kety and beyond)
Longitudinal research
Mednick “high risk” study
Israel “kibbutz” study
Finland “adoption” study
Cross-fostering studies
The Genains
Theory: The dopamine hypotheses
Factors: genes, age and prenatal
complications
Results: “high mesolimbic activity” and
“denervation supersensitivity”
Theory, revised: Glutamate and other
monoamines
Some neurophysiological findings
Therapy: Antipsychotics
Phenothiazines and their “side” effects:
pseudoParkinsonism, extrapyramidal
effects, tardive dyskinesia
Newer antipsychotics (e.g. Clozapine)
B. Psychological and Sociocultural factors
Cause, course and content
Theory:
then and now
Therapy:
from analysis, milieu therapy, the token
economy to modern social and family therapy
and community intervention (sociotherapy)
Types: paranoid, “disorganized”, catatonic,
undifferentiated & “residual”.
Summary:
the biology and psychology the schizophrenia
THE DELUSIONAL DISORDERS
Some types:
persecutory, erotomania, grandiose, jealous, somatic, etc.
Some theory:
psychogenesis (interpersonal conflict, chaos
& confusion
Some therapy?
Legal Issues
1.
Criminal Commitment
A.
Competence
B.
Insanity / “Not Criminally Responsible”
The knowledge test and “the elbow rule”
The “product” test and the “substantial
capacity” test
The results in Canada and the U.S.
2. Civil Commitment (The Mental Health Act)
3.
A.
Hospitalization / “Certification”
B.
Rights in hospital
The Public’s Right to Protection
A.
Dangerousness
B.
Duty to protect
Hospitalization, Community Care and Prevention
From traditional mental hospitals to modern
deinstitutionalization and community care
Costs and prevention:
Primary: universal and selective interventions
Secondary: “indicated” interventions
Tertiary: relapse prevention
Organized efforts for mental health
Public awareness and mutual concern