Psychopathology: the thin line that separates sanity from madness

1. Psychopathology: the thin line that separates sanity from madness “To study the abnormal is the best way of knowing the normal” W. James

2. Fun to hear about uncommon disorders… • Limbic psychotic trigger reactions • Sudden brain seizure triggered by harmless sight or sound causes some men to fly into violent rage • 18 cases (14 murders): quiet, unassuming loners suddenly erupt into violence, only to just as suddenly recoil in horror at their actions, gripped by remorse! • BUT…

3. Historical Roots • Caused by evil spirits… • Need an opening to escape • Witchcraft, demonic possession, full moon, supernatural forces… • Exorcism, torture, primitive surgery, bloodletting, bitter poisons, starvation, noise-making • Today: Medical perspective & Psychological perspective

4. Debate • Biological conditions vs. • Past & present life experiences (natural disasters to abuse, divorce, illness, etc.) • Psychoanalytic • Parental influences, unconscious, defense mechanisms • Behaviorial & CB • Reward, punishment… perceptions, expectations, beliefs • AND… • Diathesis-Stress Model

5. “Pibloktoq” • Intense excitement, seizures, then coma. • Tear off clothing, break furniture, shout obscenities, eat feces… later forget

6. Diagnosis: A Necessary Step • DSM-IV Disorders (we’ll discuss) • Anxiety- GAD, Panic, phobias, OCD, PTSD • Somatoform- Hypochondriasis, conversion • Dissociative- Amnesia, fugue, DID • Mood- Depression, mania, bipolar • Schizophrenic- Paranoid, Disorganized, Catatonic, Undifferentiated, Residual • Personality- borderline, antisocial

7. Who’s crazy here anyway? • However much we may be personally convinced that we can tell the normal from the abnormal, the evidence is simply not compelling

8. Rosenhan, 1973 “On being Sane in Insane Places” • “Hollow, Empty, Thud” • Described true life histories, relationships, etc. • Ceased any symptoms, tried to convince staff of sanity to be discharged (BY THEIR OWN DEVICES) • How many were identified as SANE? • How long did it take…

9. …had a close relationship with his mother but was rather remote from his father during his early childhood. During adolescence and beyond however his father became a close friend while his relationship with his mother cooled. His relationship with his wife was characteristically close and warm. Apart from occasional angry exchanges, friction was minimal, the children had rarely been spanked.

10. “This white 39-year old male manifests a long history of considerable ambivalence in close relationships, which begins in early childhood. A warm relationship with his mother cools during adolescence. A distant relationship to his father is described as becoming very intense. Affective stability is absent. His attempts to control emotionality with his wife and children are punctuated by angry outbursts and in the case of the children, spankings. And while he says that he has several good friends, one senses considerable ambivalence embedded in those relationships also.”

11. Role of Expectations • 7 Schizophrenic diagnoses; 1 bipolar • “I’m fine, no longer experiencing any symptoms” • Pseudopatients’ behavior caused by situation(e.g. boredom, hunger) • Interpreted by staff as reflecting psychopathology

12. Length of stay 7-52 days! • No one detected • EXCEPT… Situation??? • Diagnoses are often not reliable or useful • Sane needlessly stigmatized / feigned insanity excused

13. Line between • Mental health professionals determine (judge) where on the continuum behavior lies • Which criteria to use? • Bizarreness of Behavior • Persistence of Behavior • Social Deviance • Subjective Distress • Psychological Handicap • Effect on Functioning Normal Abnormal

14. Beware! • Medical Students Disorder is prevalent among psych students • Psychological disorders are just exaggerations of tendencies that all of us have • Being sad, anxious, or proud does not mean we are suffering from depression, narcissism, anxiety disorder or schizophrenia

15. Detailed Examples • Anxiety- OCD • Somatoform-Hypochondriasis • Dissociative-DID • Mood-Depression • Schizophrenic-Schizophrenia • Personality- borderline, antisocial

16. 1. OCD Recurrent, intrusive, unwanted thoughts and compulsive actions • One boy washed hands so much they became raw & bloodied • One boy ran up and down the stairs 63 times/ day • Woman determined to keep eyebrows symmetric, plucked them all out • Woman spent 8hrs/ day bathing • Man couldn’t leave subway without picking up all litter • Man’s apartment stacked to ceiling with dishes, dirty clothes, collected objects he couldn’t throw away • MENTALLY NEUTRALIZE unacceptable thoughts and behaviors • Treatment: “refocusing” to “unlock” the area stuck in its pattern. Label & refocus to constructive activity

17. Obsessions & Compulsions Dirt, germs, contamination 55% Aggressive impulses 50% Need for symmetry 37% Bodily concerns 35% Forbidden sexual impulses 32% Checking 79% Washing 58% Counting 21%

18. 2. Hypochondriasis Guess who? • Complained of dizzy spells, numbness in fingertips, nausea, indigestion, chest pains, and other assorted ailments… • Chronic, unwarranted preoccupation w/ one’s physical health. Highly sensitive to NORMAL bodily sensations “The whole day was planned out to suit him, to be ready for reading aloud to him, to go on his walks with him, and to be constantly at hand to alleviate his daily discomforts”

19. “Place your foot in this ice water” • Until can’t tolerate it • Heart rate • Temperature • Rate “unpleasantness”

20. Heightened Sensitivity Hypochondriacs: • Removed their foot sooner • Rated cold as moreunpleasant • Showed more physiological reactivity to stimulation

21. 3. Dissociative Identity Disorder • Learn to cope with trauma by mentally divorcing part of self from pain & suffering • Construct alternative identities in which to live • 9X more prevalent in women • 88% victims of sexual abuse • Ea. May have own voice, speech pattern, habits, memories, sexual orientation, clothing, handwriting, brain-wave, BP, eyeglass prescription, rxns…

22. Skeptical? • 1817-1970*: < 200 cases • Faking for personal gain? Undetected • Therapists now more sensitive? • Therapists overdiagnose OR suggest & reinforce • Billy Milligan

23. 4. Depression: “The common cold” • Universal; 2x women; 12-21% will experience • Emotional, Cognitive, Motivational and Somatic symptoms without discernible cause, >2 wks • Profound sadness • Diminished interest in food, sex, social banter • Intense worthlessness, guilt, self-blame • Restlessness, agitation • Depleted energy • Recurring thoughts of suicide & death

24. A cause? • Power & control • Action consequence • Imagine feeling unable to have an effect on life events • If expect bad things to happen over which you have little control • Feel hopeless about making positive changes in your life

25. Learned Helplessness in Humans • More likely to become depressed if attribute failure to: • INTERNAL: “It’s my fault” • STABLE: “It won’t change” • GLOBAL: “It affects my whole life” • Expectation one cannot control important life outcomes pessimism, hopelessness, despair

26. Explanatory Styles and Depression • First-year college • Two years later, p’s w/ negative style (internal, stable, and global) were more likely to experience a major or minor depressive disorder.

27. 5. Schizophrenia • “I wish you a happy, joyful, healthy and fruitful year, and many good wine years to come as well as a healthy and good apple year, and sauerkraut and cabbage and squash and seed year • To E. Bleuler, 1911 • Note “Split mind” = split between thoughts, perceptions, behaviors, emotions and other brain functions (NOT Selves)

28. “I felt like I was the only sane person in a world gone crazy” • Incoherent thinking/ word salad • Delusions- “influence”- thoughts being broadcast in public, stolen, controlled; also reference, persecution, grandeur. • Hallucinations- sensations w/out stimulation (e.g. Son of Sam’s barking dog) • Disturbance of affect- flattened/ inappropriate • Bizarre behavior- withdrawal, exile, self-talk, statue poses, backwards, circles, lack self-insight

29. Next time: treatment

30. Charles Manson

32. Reactions of People with Social Phobias I • Social Phobia • An intense fear of situations that invite public scrutiny • Socially phobic and non-phobic adults prepared a speech. • Both groups showed increased heart rate in anticipation of the speech.

33. Anxiety Disorders Reactions of People with Social Phobias II • However, only those with social phobia reported feeling more anxious.