WELCOME TO Abnormal Psychology

1. WELCOME TO Abnormal Psychology Jill Norvilitis

2. Aleksey the Great • Is he mentally ill? • How do you know? • What type of mental illness do you think he has?

3. What do we mean by abnormal behavior? • Incorporates • Psychological distress—neither necessary nor sufficient • Maladaptive—interferes with our well-being, etc. • Statistical abnormality or deviancy • Violation of the standards of society • Social discomfort • Irrationality and unpredictability—dangerous at times

4. Classification of Mental Disorders • Nomenclature—a naming system to structure information allows us to study, assess, and treat • Shorthand—like a diagnostic system—leads to a loss of information • Stigma—people fear what will happen if they reveal a disorder • Stereotyping—automatic beliefs based on knowing one thing about someone • Labeling

5. Diagnostic and Statistical Manual of Mental Disorders • Definition of mental disorders • A clinically significant behavioral or psychological syndrome or pattern • Associated with distress or disability • Not a predictable response to a particular event • Considered to reflect behavioral, psychological, or biological dysfunction

6. How common are mental disorders? • Epidemiology—study of the distribution of diseases, disorders, etc. • Prevalence—point, one-year, lifetime • Any disorder in lifetime—46.6 % • Incidence • Comorbidity

7. Kessler, Berglund et al (2005)Prevalence of disorders 1-year Lifetime MDD 6.7% 16.6% Alcohol abuse 3.1 13.2 Specific phobia 8.7 12.5

8. Eccentricity • Not dysfunctional • Thought processes are not seriously disrupted • Fewer emotional problems than general population • Characteristics: Nonconformity, creativity, strong curiosity, idealism, happy obsession with hobbies, lifelong awareness of being different, high intelligence, outspokenness, noncompetitiveness, unusual eating and living habits, disinterest in others’ opinions or company, nonmarriage, eldest or only child, poor spelling skills

9. Ancient Views • 500,000 yrs ago— trephination • Later ancient societies indicate possession • Babylonians—Idta—spirit who caused insanity • Greek and Roman views and treatments • Hippocrates—460-377 BC—denied influence of demons • Somatogenesis • Plato—Criminally insane shouldn’t be held responsible like others • Galen—130-200 AD believed disorders could have either physical causes (injury to the head) or mental causes (stressors) • After Hippocrates, treatments included pleasant surroundings, giving patients constant activities

10. Europe in the Middle Ages: Demonology Returns: 500-1350 • Increase in power of the clergy, church rejected scientific forms of investigation. • Mass madness: group behavior disorders, apparently hysterical. Peak in 14th-15th centuries. • Tarantism • Lycanthropy • Treatment of mental illness was left to clergy. Return of exorcism. Not generally treated as witches, though this did happen.

11. Renaissance and the Rise of Asylums • Agrippa -1486-1588-began to speak out against possession • Johan Weyer first physician to specialize in mental illness. 16th cent. On—asylums grew in number • Gheel, Belgium—first colony of mental patients • 1547—St. Mary’s of Bethlehem Hospital—bound in chains, popular tourist attractions, mildly mentally ill were forced to beg on the streets

12. Nineteenth Century—Reform and Moral Treatment • La Bicetre—Philippe Pinel • William Tuke—1732-1822—English Quaker—established York Retreat. • Moral management—focused on patient’s social, individual, occupational needs—rehabilitation of character. High degree of effectiveness— • Buffalo Psychiatric Center—originally Buffalo State Hospital for the Insane. Proposed by physician White in 1864, first received patients in 1880. Followed Kirkbride Model of connected buildings. • Mental hygiene movement—focused on physical well being, not treatment • Dorothea Dix—1802-1887—champion of the poor and forgotten in mental institutions and prisons.

13. Early Twentieth Century • Two opposing views: somatogenic and psychogenic • Syphilis • Mental hospitals in the 20th century • Over 500,000 by 1950s • Deinstitutionalization • Thorazine • Today about 55,000 in state hospitals • Criminalization of the mentally ill. By some estimates, 300,000 inmates, 500,000 on probation

14. Gender Shift • 28 % psychologists who were female in 1978 • 52 % female today • 75 % female undergrad psych majors • 66 % female psych grad students

15. Research Methods • Retrospective vs. prospective • Case studies—begin with Hans • Correlational method—can correlations be trusted? • Epidemiological studies • Longitudinal studies • Experimental method • Control groups • Random assignments • Blind designs, placebo treatments • Quasi-experimental designs

16. Ethics • Concerns remain • New drug studies without adequate informed consent • Placebo studies • Symptom-exacerbation studies • Medication-withdrawal studies

17. Causal Factors and Viewpoints • Etiology • Necessary—must exist for a disorder to occur • Sufficient—condition that guarantees the occurrence of a disorder • Contributory—increases the probability of a disorder • Time frame • Distal—in the past • Proximal—immediate

18. Diathesis Stress Models • Diathesis—vulnerability for the disorder • Stress—proximal stressor • Protective factors • Individual • Family • Community • Resilience • Biopsychosocial viewpoint

19. Biological Model • Disease or medical model • Brain anatomy and abnormal behavior— • 100 billion nerve cells called neurons and thousands of billions of support cells called glia. • Bottom of the brain—hindbrain— • Cerebellum—regulates smooth coordinated movement • Pons • Medulla—controls heart rate, breathing, digestion • Midbrain • Forebrain— • Hypothalamus—temperature, hunger, thirst, sex • Thalamus— • Corpus callosum—connects hemispheres

20. Brain Chemistry and Abnormal Behavior • Over 100 neurotransmitters discovered to date • Those most studied with psychopathology • Norepinephrine—emergency reactions in stressful situations • Dopamine—schizophrenia and Parkinson’s • Serotonin—thinking and information processing, anxiety and depression • Gamma aminobutyric acid (GABA)—anxiety and arousal • Neurotransmitter imbalances • Excessive production and release of neurotransmitter • Dysfunction in deactivation process • Problem with receptors—abnormally sensitive or insensitive

21. Sources of Biological Abnormalities • Genetics • Genotype • Phenotype • Behavior genetics—study of individual differences in beh. that are in part attributable to genetic makeup • Family history (pedigree) method—we know what % of genes are shared • Twin method • Adoption • Evolution and abnormal behavior • Viral infections

22. Biological Model Continued • Temperament—reactivity and self-regulation • Behavioral inhibition seems to be innate • Biological treatments • Psychotropic medications • Electroconvulsive therapy • Neurosurgery • Assessing the Biological Model • Lots of valuable new information • Treatments bring great relief • Shortcomings— • 1) some proponents seem to think that everything can be explained by biological terms • 2) lots of evidence is incomplete and inconclusive • 3) biological treatments can produce undesirable side effects

23. Psychodynamic Model • Freud—very deterministic • Structure of the personality: • Id—comprised of instinctual drives of two types • Ego—secondary process thinking—reality principle • Superego—conscience • Defense mechanisms—control unacceptable id impulses or reduce the anxiety they create • Repression • Projection • Rationalization • Reaction formation • Sublimation

24. Psychodynamic Continued • Psychosexual stages of development • Oral—birth to 2 • Anal—2-3 • Phallic—3 to 5 or 6 • Oedipus • Electra • Latency • Genital—After puberty • How to tap the unconscious? • Advantages of Freud’s theory… 1) Helped establish the field 2) Emphasized the importance of childhood for a healthy adulthood • Disadvantages… 1) Hard to Research 2) Largely based on case studies • 19 % of clinical psychologists describe themselves as psychodynamic (Prochaska & Norcross, 2003)

25. Updates to Psychodynamic Theory • Of course, Freud created his theory over 100 years ago. There have been major updates: • Object relations theory: importance of the caregiver is key • Melanie Klein • Healthy relationships as infants result in healthy relationships as adults • Attachment theory: Bowlby, 1969; Ainsworth, 1978 • Secure, ambivalent, avoidant, disorganized (in 4/5 abused kids)

26. Behavioral Perspective • Classical conditioning • Pavlov • Important for fears and anxiety • Instrumental conditioning AKA operant conditioning • Thorndike • Law of effect—behavior that is followed by consequences affects repetition • Generalization • Discrimination • Shaping—successive approximations • Observational learning • Behavior therapies—systematic desensitization, assertion training, token economy, role playing

27. Assessing the Behavioral Model • Can be tested in the laboratory • We can show that symptoms can be acquired these ways, but is this the way they are ordinarily acquired? • Improvements in therapists’ offices do not always extend to real life, nor do they always last without continued therapy • Critics argue that it is too simplistic—no cognitions involved; pts. must develop self-efficacy

28. Cognitive and Cognitive-Behavioral Models • Schemas • Observable behavior can be influenced by mental processes • Automatic thoughts • Cognitive distortions • Attributions • Assessing the Cognitive Model • 24 % of psychologists identify approach as cognitive • Appealing because it focuses on a process unique to humans • Lends itself to research • Precise role of cognitions (cause or effect) has yet to be determined • Narrow—deals only with cognitions, not values, meaning, etc.

29. Psychosocial Causal Factors • Family Systems Theory • Identified patient • Homeostasis • Family structures (parents in charge) and alliances (parents united) are often disrupted • Communication is also often disrupted • Can be enmeshed or disengaged

30. Bronfenfrenner’s Ecological Systems Theory • Macrosystem—beliefs and values of the culture • Exosystem—social structures like family, neighborhood, SES • Mesosystem—interconnections between various community systems like peer groups, religious organization, etc. • Microsystem—child’s immediate environment, family, school, work • Ontogenic Development—the child’s own development and adaptation

31. Specific Psychosocial Risk Factors • Neglect and abuse in the home: • Disorganized and disoriented attachment • Problems in all domains • 1/3 will go on to repeat the trauma • Parental Psychopathology • Tiffany Field—transmission of depression, even with those as young as 6 mos.  • Parenting styles: • Authoritative—energetic/friendly • Authoritarian—conflicted/irritable—also moody, eating disorders • Permissive/Indulgent—impulsive/aggressive—demanding, immature • Neglectful/Uninvolved—low s-e, conduct problems, moody, peer and academic problems • Divorce • Ongoing stressor—not just one • Most (3/4) will be fine • But…2x as likely to repeat a grade, report more delinquency, more negative health stuff like smoking, more depression • Poverty!  • Peer Relationships • Deviancy training • Rejected, neglected, controversial, accepted—neglect is particularly negative

32. Sociocultural Factors • Universal vs. culture-specific • Schizophrenia—different presentation, more paranoia in Western cultures, also more negative outcome • Depression—universal, but different presentation—more somatic in China, for instance • Overcontrolled vs. undercontrolled behavior—more under in US, over in Thailand (Weisz et al, 1993) • Culture bound syndromes

33. Clinical Assessment, Diagnosis, and Treatment Approaches • Intake interview— • History of present problem • Thorough personal and family history • Social context • Structured vs. unstructured • Physical assessment • General exam • Neurological exam for neurological disorders. For example, may want an EEG if there are memory deficits, etc.

34. Psychological Assessment • Variety of sources in assessment • Reliability—consistency or agreement among assessment data • Test-retest • Internal consistency • Interrater • Validity—does it measure what it is supposed to measure • Content validity—all domains that is supposed to measure • Predictive validity • Concurrent validity • Diagnostic errors—true positives, true negatives, false positives (Type 1), false negatives (Type 2) • Sensitivity—correctly diagnose someone with any disorder • Specificity—likelihood that people without disorder will be diagnosed that way

35. Types of Tools • Life records—school, police, hospital • Interviews • Observation • Psychological tests • Standardized • Normed • Several subtypes: • Rating Scales (specific vs. broad)

36. Psychological Testing continued • Intelligence Tests • WISC-IV, WAIS-III, Stanford-Binet • Neuropsychological testing—measure deficits in behavior, cognition, or emotion that correlate with brain damage •  Personality Tests • Projective—Ambiguous stimuli that allow for individual responses • Rorschach • TAT/RAT • Draw A Person • Objective • MMPI-2 Revised in 1989, first ed. in 1943 (10 clinical scales, + validity scales and special scales

37. Ethical Issues in Assessment • 1) Potential for cultural bias of the instrument or clinician • 2) Theoretical orientation of clinician • 3) Underemphasis on the external situation • 4) Insufficient validation • 5) Inaccurate data or premature evaluation

38. Diagnosis • Efforts go back thousands of years • Scientific efforts in 19th century • Emil Kraepelin—3 categories—dementia praecox (schizophrenia), manic-depressive psychosis, & organic brain disorders (delirium, dementia, amnestic) • 1917—1st American system, didn’t work • 30s and 40s—military developed system • 1948—Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death—now on ICD 10 • 1952--Diagnostic and Statistical Manual of Mental Disorders • Then DSM-II-in 1968 • DSM-III in 1980, III-R in 1987, IV in 1994, TR in 2000 • DSM I and II lacked consistency, some criteria were based on theories of causation, others on clusters of sx, little effect on tx

39. DSM-III • Multiaxial • Clearly defined diagnostic criteria, • Operationally (not theoretically) defined diagnosis • 5 Axes • I—Major mental disorders • II-Developmental and personality disorders • III-General medical conditions that affect disorders • IV-Psychosocial stressors—topical, labeled acute or chronic • V-Global assessment of functioning • Polythetic approach—must have some # of criteria out of a larger group • Comorbidity

40. Criticisms of the DSM • Labeling produces stereotypes, prejudices, and harm • Rosenhan (1973)—voices saying thud, empty, or hollow; kept 7-52 days • Self-fulfilling prophecies • Gender/ethnic bias— • Antisocial PD more often diagnosed in men, histrionic in women • In a study with randomly assigned gender to APD or HPD criteria, psychologists underdiagnosed women with APD and men with HPD • People are more likely to diagnose others like themselves with less severe diagnoses, those not like them get more severe diagnoses • Disorders are on a continuum, not discrete categories • Why do we use categorical? • Medical model • Easy • No one agrees on personality dimensions  • Not enough attention to validity

41. Treatment of Mental Disorders • From Opinion Research Corporation, 2004 • 67% Am. would not tell their employer that they were seeking mental health treatment • 51% would hesitate to see a psychotherapist if a diagnosis were required • 41% believe they should be able to handle psychological problems on their own • 37% would be reluctant to seek tx because of confidentiality concerns • 33% would not seek counseling for fear of being labeled mentally ill

42. Psychosurgery • 1935 Egaz Moniz—prefrontal leucotomy/lobotomy • Won the 1949 Nobel Prize in medicine • Originally 18 patients, 6 cured, 6 improved, 6 same. Idea took off. • Freeman and Watts—frontal lobotomy—cutting into side of skull and then pivoted • Transorbital lobotomy— • In 20 yrs, 40,000 pts had lobotomies • Side effects—seizures, incontinence, poor judgment, lack of motivation, lethargy, impaired thinking, 5 % died • All surgeries were blind • 2 procedures are done today. • Cingulotomy and stereotaxic subcaudatetractotomy

43. Electroconvulsive Therapy • Convulsions to treat mental illness date back to Paracelsus (1493-1591) • Today, use of electro shock dates to 1938 • Bilateral vs. unilateral • About 100,000 per year • Injuries in 1/1400 tx • Post tx side effects—temporary memory loss, h/a, confusion • Used for severe mood disorders—about 80% are severely depressed

44. Psychopharmacological Treatment • Antipsychotics—aka major tranquilizers, neuroleptics • 60-80% show some improvement • Thorazine-1955, Haldol-1960s—less sedation • Side effects—extrapyramidal symptoms—Parkinsonism—shuffling gate, tremor, muscular weakness, rigidity • Tardive dyskinesia—jerks, tics, twitches of the face and tongue—doesn’t appear for several years and is permanent • Atypical antipsychotic—developed in 1980s and beyond—first Clozaril, now Risperdal, Abilify, Geodon, Zyprexa, Seraquel • Newer meds are better at treating negative symptoms • Side effects—weight gain, drooling, agranulocytosis (drop in white blood cells)

45. Antidepressants • Monamine oxidase inhibitors—Parnate, Marplan—dev. as tx for TB, but people became less depressed • -slow activity of serotonin and norepinphine • -work well, but decreases REM sleep, can’t eat foods with tyramine • Tricyclics—Tofranil, Elavil, Anafranil, Pamelor • Fewer serious side effects but—fatal in overdose • SSRIs—1988-Prozac—most widely prescribed antidepressant in the world, others include Zoloft, Paxil, Celexa, fluvoxamine, Lexapro • Less deadly in overdose • Better tolerated but nervousness, insomnia, sexual dysfunction, long time to effectiveness • 60-70% on antidepressants improve • More effective for major depression, less effective for dysthymia • Elderly are less able to metabolize

46. Other Medications • Mood stabilizers—lithium--some pts miss the highs  • Anxiolytics—most prescribed class of psychoactive drugs • At times, on top of all drugs prescribed • Benzodiazepines—minor tranquilizers—prescribed by length of action or time to onset • Long acting—valium, Librium • Intermediate—ativan, klonopin • Short acting—xanax, halcyon • Side effects—rebound, addiction, drowsiness, fatigue, clouded thinking • But they work—after 8 wks, 50-60% are free of panic • Psychostimulants—ritalin, dexadrine, etc. • Why might you not want to prescribe meds? • Reliance on drugs • Decreased self-efficacy

47. Psychotherapy • Why does it work? • Common factors are not inert or trivial • Hawthorne effect • Placebo effect—phone call improvement • Insight-oriented therapy—assumes beh, emo, and thoughts become disordered because people don’t understand what motivates them, esp. when needs and drives conflict • Psychoanalytic therapy—remove repressions that have prevented the ego from helping the individual grow into a healthy adult.—unresolved, buried conflicts • Focus of therapy is not on presenting problems such as anxiety, but conflicts in the psyche from childhood • Techniques—free association • Resistance—blocks to free association—come late, change subject, miss appointments.  • Is it effective? Time consuming, expensive, no rigorous, controlled outcome studies of traditional analysis. Appears to have some utility. Newer forms of short-term psychoanalytic have had some outcome studies, look good.

48. Humanistic and Experiential Therapies • Greater emphasis on freedom of choice • Free will-most important characteristic—offers pleasure but also pain •  Carl Rogers’ client centered therapy • Techniques— • Genuineness-spontaneity, openness, authenticity • Unconditional Positive Regard—get rid of conditions of worth • Accurate empathic understanding—accept, recognize, and clarify feelings • Reflect back statements • Inconsistent results • Gestalt Therapy—Fritz Perls—originally an analyst; we react to people in the context of our needs. Clients are made aware of what is going on now in session. • Techniques—I language; Empty chair; Reversal (beh. opposite) • Evaluating Humanistic-Experiential therapies— • Many of the ideas have had an impact on psychotherapy • However, lack of agreed upon procedures, a bit vague • More research these days—looks ok

49. Behavioral Approaches • Exposure therapy • Systematic desensitization • Aversion therapy—pair negative stimuli with stimuli that are inappropriately appealing • Token economy • Premack principle • Modeling • Evaluating Behavior Therapy • Achieves results in a short period of time—less distress, lower cost • Methods are clearly delineated; results easily measured • Works better with some problems than others—rarely used for complex personality disorders (except dialectical behavior tx for borderline)

50. Cognitive and Cognitive-Behavioral Approaches • Ellis—Rational Emotive Therapy • Sustained emotional reactions are caused by internal sentences that people repeat to themselves—irrational beliefs • Eliminate self-defeatingness by rational examination  • Beck—Cognitive therapy • Negative beliefs that people have about self, world and future cause disorders. • Both behavioral and cognitive.  • Ellis is more harsh and direct • Beck—inductive—seek negative beliefs • Social problem solving; skills training, assertion training • Efficacy • Less research on Ellis’ model—what is there says that it does not work as well as Beck’s approach. • Combined use of cog and beh is routine these days.