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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