JAMAICA THEOLOGICAL SEMINARY

ABNORMAL PSYCHOLOGY – LECTURE NOTES

INTRODUCTION

I. Defining Abnormality (Also referred to as maladaptive

behaviour or deviancy)

a. Consider the following behaviour. Do they seem abnormal?

a. a man wearing a bright red skirtb. a man kissing another manc. a parent slapping a childd. a man driving nails through his hande. a man refusing to eat for several daysf. a woman who works and goes to school for 14-16 hours

a day to build her career, hardly seeing her husbandand children

WHAT IS ABNORMAL BEHAVIOR?

Psychologists tend to agree on certain criteria for a workable definition for psychological disorders. Although there will always be a continuum between normal and abnormal, mental health and mental illness.

I. THREE CRITERIA ARE OFTEN USED TO JUDGE SEVERITY OF PROBLEM BEHAVIORS.

All societies have their standards for acceptable behavior. When one deviates from typical behavior, a given society or culture may label the person different or abnormal. Many of our best-known artists, writers and geniuses have at one time been labeled"abnormal".

1. ATYPICAL BEHAVIOR or unusual behavior that is also disturbing to the values or beliefs of others is likely to be considered deviant.

2. HARMFUL OR MALADAPTIVE. An unusual behavior is more likely to be seen as disordered when it is judged as HARMFUL OR MALADAPTIVE. If one is unable to adjust to society and

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function effectively behavior may be considered abnormal. Often it is a matter of degree. Drinking alcohol becomes a problem when the person is no longer able to function well at home or one the job although the person may deny he has aproblem at all.

3. PERSONAL DISTRESS is the third common criteria. When one feels psychological pain such as in depression or debilitating anxiety as in a phobia the level of distress becomes an important ( pain, anxiety, depression)

II. MALADAPTIVE BEHAVIOUR - POSSIBLE MANIFESTATION OF

ABNORMALITY

The inability to behave in ways acceptable to the society.The following characteristics are often evident:

a. actions physically damaging to self and othersb. causing the individual emotional harm or sufferingc. interfere with the individual’s ability to function in daily

lifed. Indicates that the individual has lost touch with reality

and has difficulty controlling his/her behaviour or thoughts (low GAF score), or has difficulty fit in

e. Suffering “mental and physical”f. Irrationality “absence of reasoning power”g. Unpredictability “loss of self-control”h Unconventionality “bizarre behaviour”i. discomfort “make others uncomfortable”j. Violation of moral standards

III. FACTORS TO CONSIDER IN UNDERSTANDING OR DEFINING ABNORMALITY

a. Cultural Relativism (Social norm violation)

Breaking social "rules". Most of our behavior is shaped by norms

- cultural expectations about the right and wrong way to do

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things. Examples of norms: proper dress, how/what to eat,

behavior on the first date, eye contact with strangers,

student/instructor behavior, in fact, all aspects of our lives.

Someone who frequently violates these unwritten rules is seen as

abnormal.

b. Statistical Deviation (from the mean)The defining characteristic is uncommon behavior - a significant deviation from the average/majority. Many human characteristics are normally distributed. illustrates a normal distribution. Characteristics falling beyond a particular distance from theaverage values are sometimes seen as abnormal. This distance is defined in terms of "standard deviation units" - these are valuesthat tell the scientist how many people fall beyond the average

c. Personal distress: Put simply, if the person is content with his/her life, then s/he is of no concern to the mental health field. If, on the other hand, the person is distressed (depressed,anxious, etc), then those behaviors and thoughts that the person is unhappy about are abnormal behaviors and thoughts.

d. Mental illness Criterion (behaviour which manifest DSM

criteria eg OCD or OCPD).

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IV. DEFINING PERSONALITY

An enduring patter of perceiving, relating to, and thinking aboutthe environment and oneself one’s self, that are exhibited in a wide range of important social and personal context (Carson and Butcher, 1992, p. 265).

1. Defining Normal Personality

a. Behaviour within a society or culture described as acceptable to that society and practiced naturally by its member

b. According to Maslow and Mittlemann, 1951 normalPersonality development results in persons who willreflect:

Adequate feelings of security, reasonable degree of self-evaluative skills,realistic life goals, effective contact with reality, integration and consistencyof personality, ability to learn from experience, adequate spontaneity,appropriate emotional responses, the ability to think individually yet functioncollectively in a group, and adequate body desires with the ability to gratifythem in an approved fashion. (P.6)

c. Trait psychology identified five dimensions of a normalperson. These include:

Emotional; stability; extroversion; openness;agreeableness; and conscientiousness(Santrock, 1993, p. 421) Myer and Deitsch, 1996 (p. 187)

2. Abnormal Personality

Persons who do not manifest sufficiently the above qualities maybe said to abnormal. Abnormality is generally defined asdiscomfort, dysfunction or a statically deviation from theculturally accepted mean or ideal mental health, resulting inclinically significant behavioural or psychological syndromeassociated with present distress, resulting in possibleimpairment, disability, deviant behaviour, significant increasein risk of suffering, death, pain disability, or an importantloss of freedom (DSM, p. xxi).

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V. ABNORMAL PSYCHOLOGY

The aim of abnormal psychology is to objectively study, describe,explain, predict, treat or control abnormal Behaviour

1. Insanity

Legal term referring to mental incompetence

2. PsychopathologyThe science of disease of the mind or the study of mental

illnesses

3. The Bible and Abnormality

VI. MYTHS AND STEREOTYPES ABOUT THE MENTALLY DISTURBED (pages 17

- 18)

i. Mentally disturbed people can always be recognized by the

consistently deviant abnormal behaviour

ii. Mentally disturbed persons inherited their disorders.

If one family member is sick others will be

iii. The mentally disturbed cannot be cured

iv. People become mentally ill because they are weak willed

v. People who suffer from mental illness can never contribute

to society

vi. Mentally ill persons are unstable and potentially

dangerous

vii. Mentally ill person cannot feel pain

viii. mental disorder is contagious

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13. Models of abnormal behavior

The STATISTICAL APPROACH defines normal behavior by describing what the average person does and abnormality as deviance from this norm. Problems with this definition are that it equates "normality" with conformity. Often deviation from the mean such as a high intelligence quotient may actually be desirable.

The PSYCHODYNAMIC MODEL views abnormal behavior as the result of unresolved psychological conflicts from early childhood and from intra-psychic conflict between instinctual selfish desires of the id and the demands of the society and personal conscience present in thesuperego.

The BEHAVIORAL MODEL proposes that disorders are caused by poor LEARNING ENVIRONMENTS that reinforce problematic behaviors. To a behaviorist there is "no such thing as an abnormal person, only a normal person in an abnormal environment." SOCIAL LEARNING theorists emphasizethat society often provides deviant maladaptive models that children imitate. The key to modifying problem behaviors lies in providing positive learning experiences, healthy models to imitate and in rewarding positive behaviors.

The HUMANISTIC MODEL proposes that we are self-actualizing our potential. If our natural growth toward self-fulfillment is blockedby negative criticism and conditions of worth we may develop a negative self-concept that obstructs our growth and distorts our viewof the world. We may begin to withdraw emotionally and lose touchwith our inner self that longs to self-actualize. Through unconditional positive regard, empathy, acceptance and respect wecan rediscover our inner beauty and seek our self-fulfillment.

The COGNITIVE APPROACH views abnormal behavior as a result of distorted or irrational thinking. The cognitive model asserts the psychological disorder is the result of faulty thinking that leads to inappropriate and self-defeating behavior.

The SOCIOCULTURAL MODEL OF ABNORMALITY argues that abnormal behavior is an attempt to adjust to an unjust mad world. To sociocultural theorists it is society, not the person that is sick. They contend that we who "adjust" to this "insane world" do so at the heavy price

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of "conformity" to the madness around us and a loss of our individuality.

The LEGAL MODEL defines INSANITY as a person who is not responsible for their actions because they cannot understand the difference between right and wrong. To be declared "not guilty by reason of insanity" the person must have a mental illness that causes them to engage in the criminal act.

The PSYCHOPHYSIOLOGICAL APPROACH views abnormal behavior as due to underlying physiological abnormalities in the nervous system and particularly the brain. Recent research with brain-imaging machines gives credence to the approach as the brains for instance of schizophrenics differ from normal brain scans.

The MEDICAL MODEL assumes that the behavior disorder is caused byan underlying illness. Just as when one has a physical illness hegoes to the doctor explains his symptoms, the physician makes a diagnosis and generally prescribes medication. The medical model also uses symptoms, diagnosis and chemotherapy as the main steps in mental illness treatment of mental illness.

The American Psychiatric Association has adopted a DIAGNOSTIC ANDSTATISTICAL MANUAL (4th edition) to assist in the diagnosis of mental illness. It lists the symptoms for each "mental disorder" as well as the statistics of occurrence in a population.

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IV. HISTORICAL PERSPECTIVE ON ABNORMALITY

1. Introduction------EXAMS

Historically there have been three perspectives on deviancy:

a. Mythical/Magical - Abnormality is due to

supernatural or magical force or

possession by spirits.

b. Scientific/medical - Abnormality is due to natural

causes, such as Psychological biological

imbalances, faulty learning processes or

emotional stressors.

c. Humanitarian - Due to cruelty or poor living

conditions

The differing etiological theories as well as advancing knowledge

have had large impact on the treatment of those with

psychological disorder as well as current theories in clinical

psychology.

2. PREHISTORIC AND ANCIENT BELIEFS (10,000 B.C. – 3,000 B.C.)

1. During this period there was little distinction betweenmedicine, belief in supernatural, magic and religion

2. CAUSE: Abnormal Behaviour was due to the influence ofevil spirits, demons revengeful gods

3. CURE: Trephination and exorcism (still practiced in somecultures)

The practice is often performed by a shaman

3. GRECO-ROMAN ERA (800 B.C. – 1000 A.D.)

1. CAUSES:a. Some supernatural views were maintained. E.g. according to Home (800 B.C.) mental illness was due toGod taking the mind away.

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b. More scientific views of mental illness were developed with emphasis on natural causes. This included the study of brain pathology.

c. The foundation of a systemic approach to psychological and physical disorder begun.

d. The work to classify disorders begun [Mania, psychosis,phobias, and paranoia} begun with the work of Hippocrates (460-377 B.C.) His vies dominated the thinking pertaining to disorders for 500 years.

e. His work included theorized that “four humours” or bodily fluids were responsible for both physical and mental health. They wereBlack bile - Melancholic (depressed)Yellow bile - choleric (anxious or irritable)Phlegm - Phlegmatic (indifferent)Blood. - Sanguine (unstable mood shifts

f. The idea that psychological disorders could be as a result of emotional imbalances was first advanced by a Greek physician Asclepiades (129-140 B.C.)|

b. Hippocrates - classification of mental disorders (melancholia, dementia, hysteria, delusions, mania,hallucinations)Plato - family may be responsibleGalen - Brain and nervous system

2. CURE

a. Tranquility, moderate exercise, diet, treatment modalities: quiet life, diet, , , bleedings (blood letting), music, massage, baths, warm and supportive

environment, celibacy and abstaining from sex

4. THE MIDDLE (DARK) AGES (300 – 1500 A. D.)

1. CAUSES

a. The church played both important positive and negative roles in the treatment of mental illness

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b. St Augustine helped lay the groundwork for modern psychodynamic theory through the use of introspection to discuss mental processes.

c. The Middle Ages however was primarily marked by a resurgence of superstitions and “spiritual” causes ofmental illness. Demonology returns with the strength of

the church: rise of mass hysteria, rituals, exorcism, folk medicines, EXAM

d. People with psychological disorders were blamed for being morally weak or demon possessed

2. Some of the signs of disorders at the time included:

a. Tarantism: Mass Madness or Mass Hysteria – convulsions, wild raving dumping and dancing (believed to have been caused by spider

bites)

b. Lycanthropy: Victims imagine themselves as wolves

CURESIncarceration, isolation, beatings, repentance, torture, exorcism, sprinkling with holy water, starvation, immersion in hot water (all of the above were to drive out evil spirits); witch hunts

 

5. THE RENAISSANCE - RISE OF HUMANISM (1500 – 1700 A.D.)

1. Demonology declines with flourishing cultural and scientific activity; asylums for lunatics,This period was characterized by an emphasis on well-being.

2. Clinical treatment rather than religious persecution3. Resurgence of rational thinking4. Increased; humane treatment resulted in crowding and

“warehousing” increased; mental institutions became a

popular tourist attraction.

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5. The founder of modern study of psychopathology, and the

first physician to specialize in mental illness was

German physician Johann Weyer (1515-1588)

1. CAUSES

a. Organic factor: mental illnesses due to diseases,

physiological damages

b. Psychological: emotional factors

c. Biological/psychological/social causes

2. CURES

REFORM MOVEMENT OF 1700S:

a. Pinel’s and Tuke’s reform in living conditions of patients began a period of moral treatment, characterized by considerate treatment, rest, fresh air, useful activities, companionship and therapeutic talk.

b. Benjamin Rush , first American psychiatrist in Pennsylvania, reformed American hospital conditions, but still supported barbaric treatments that were commonplace: bloodletting, purging by leeches, cold water submersion, the “well cure”;

c. Dorothea Dix : champion of the cause of humane treatmentof psychiatric patients, helped to establish state hospitalsintended to offer moral treatment.

d. Moral therapy increased the population of patients and custodial programs replaced effective therapy

1800s/1900s:

a. Alternative Models for Abnormal Behavior: introduction of the Medical Model: psychological problems have a physical cause (somatogenic).

b. medical community experimented with new procedures: extraction of teeth, tonsillectomy, hydrotherapy, insulin coma shock, lobotomy.

c. Outpatient therapy begins with the psychoanalytic movement:i. Mesmer, Charcot used hypnotism to cure;ii. Freud heavily influenced by Charcot; offered

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“catharsis” by “talking cure”; iii. Pavlov, Watson, Thorndike, Skinner were leaders in behavioral theory; iv. Iv.

Cognitive therapy introduced by Bandura, and Beck (proponents of psychogenic perspective)

20 th Century :

a. Introduction of psychotropic medications: antidepressants and antianxiety medication;

b. Deinstitutionalization movement to half-way houses and community programs.

c. Rise in HMOs and managed cared. inadequate care and inappropriate treatment, breach of

confidentiality resulted in the need for rules of ethical practices to the rise in in insurance 

Current Trends

a. Negative attitudes towards mental health have not changed dramatically:i. 43% percent of survey respondents believe people bring onmental disorders themselves.ii. 35% see disorders as caused by sinful behaviours, and iii. 19% point to a lack of willpower or self-discipline as a cause!

b. Growing emphasis on prevention (the study and enhancement ofpositive feelings such as optimism and happiness; positive traits like perseverance and wisdom; positive abilities suchas interpersonal skill and other talents; and group-directedvirtues, including altruism and tolerance)

c. Growing influence of managed care programs (HMOs) with mental health

d. Varieties of Models to assess etiology (causes) and treatments

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e. Bio-psychosocial model: an interactionist paradigm for mental illness

f. Eclectic – Biogenic; Psychoanalytic; Humanistic; Existential; Behavioural; Cognitive; Family Systems; Multicultural

12. Contemporary trends in treatment and care of the Mentallyill

i. The drug revolutionii. Prescription and drug administration for psychologistand some nursesiii. Managed Health care facilities (industrialization ofhealth care – public and private)iv. Appreciation of researchv. Greater appreciation of the impact of culture on mentalstatusvi. Social conditioning to accept the mentally ill

 

   

 

V. MENTAL HEALTH PROFESSIONS AND FIELD

1. Psychiatrist - Medical Doctor2. Clinical psychologist—causes, research why-- Ph D Research3. Counseling Psychologist—treatment, what I need to do Ph D Treatment4. Clinical Social Worker MA5. Psychiatric social worker (mental help)6. Psychiatric nurse7. Occupational therapist8. Family therapist9. Behaviour Therapist10. Psychoanalyst

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VI. FILEDS OF PSYCHOLOGY

1. School and educational Psychology2. Clinical and counselling3. Study of personality4. Bio-psychology5. Psychology of gender6. Social Psychology7. Cultural Psychology8. Industrial and engineering Psychology (IP_how it affect the

environment)(EP_9. Forensic Psychology10. Sports and exercise Psychology11. Environmental Psychology12. Animal Psychology13. Pseudo Psychology (astrology and obeah)

VII. RESEARCH IN ABNORMAL PSYCHOLOGY

1. The observation of behaviour is key the research in psychology.

2. For the finding of this observation to be valid the methods must be scientific.

3. Some aspect of the observation is self-observation. It is hence importance for the simplification of the observation process to enable individuals to become meanfully involved in their own therapy.

4. Observation of behaviour results in the development of theories of behaviour.

5. Theories help us to draw individual observations into groupsthat helps us to further understand and predict further behaviour.

1. Types of Research:

a. Assessment studies - describe behaviour at any time (not

necessarily to develop

cause/effect)

b. Experimental studies

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a. Longitudinal studies - the observing and recording of

behaviour over long period s of time

b. Follow-up studies – initial assessment and then further

evaluation of same group

c. Case studies

d. Correlational studies - the examination of

relationships between events

e. Assessment studies – objectively account for behaviour

f. Cross-sectional studies – observation of behaviour

across cultures

2. The Clinical Interview

a. Clinical Assessment

Assessment is the process of gathering information and drawing conclusion (p. 74 Sue). The clinical interview is the process ofassessing and diagnosing of a client for the purpose of providingtreatment.

Mental health professionals are concerned with:e. What approach should be taken in assessmentf. what symptoms are presentg. what diagnoses are consistent with these symptomsh. what causes maybe attributed (etiology)i. how can these disorders be effectively treated or

prevented. EXAMS

1. Assess 2.diagnose 3.treat

b. Approaches in a clinical assessment may include:

1. Observation this is the most basic of the approaches and it may be naturalistic or controlled. This involves observation of the client’s overt

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behaviour.

2. Interview this is the approach where the client is questioned either verbally or by use of a structured questionnaire. Both the client’s verbal and non-

verbal responses may be recorded. They may be used to determine the client’s overall clinical state or simply their mental state.

3. Psychological Test and Inventoriesthis involves the use of a standardized instrument to assess

the client’s personality or level of maladaptive behaviour, social development, intellectual ability, vocational interest and cognitive impairment. These test maybe oral or written (see chart on p 75 Sue)

Types of test: i. projective tests - thematic apperceptiontest, sentence completion

ii personality inventories – Myers-Briggs. 16PF,mmpi,

iii intelligence testsiv. Neurological Tests; CAT scan; ECG, MRI

4. Physical/Medical examination

Two sections of the clinical interview are:

a) The diagnostic interview - focus on assessment with a view to diagnoseb) The therapeutic interview - focus on the treatment

During the clinical interview one may often determine whether or not a client has: (Sue P. 120-2

1. Any form of psychopathology (exhibiting any form of abnormal or maladaptive behaviour)

2. Any form of Vulnerability (propensity to be afflicted by a particular abnormality – genetic, social or cognitive)

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3. Any form of Resilience (ability or support resources that may contribute to their rate of recover from any particular abnormality -)

4. Potential Risk factors (factors that may further precipitate the disorders – genetic, social or cognitive) they involve specific factors that may contribute to the development of any

particular disorder.

5. Rate of distribution in a target population during a specific period to manifest a particular disorder (prevalence). This cover new as well a existing cases6. The incident of new cases of a disorder that appears in a particular population during a specific time period. This iscritical to examine and associate specific causes with

specific disorders of specific disorder occurring in specific periods of timeEXAMS7. Co-morbidity - any other conditions or symptoms that is usually present alongside certain condition

8. Differential disorders – other disorders or symptoms that may be confused with the one being experienced by the client1. Panic---Epidemiology in research includes the attempt to examine the prevalence (rate of distribution of a disorder both new and existing cases); incidents (rate of new cases within a specific time ONLY) the risk group (the group most likely to contract the disorder; the risk factors (factors that are likely to predisposeor further precipitate a particular condition.

d. Issues in Research and Diagnosis of Abnormality

i. Reliability (Sue p. 73-74)

Reliability refers to the consistency of scores obtained by the same persons when they are reexamined by the same test on different occasions or with different set of equivalent terms.

(a) If a test is reliable you can often use its scores to predict the outcome of variables changed in the

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administration of the test.

(b) If a test is reliable the score truly represent individual differences in the test subject who with different scores

ii. Validity

Validity of a test is concerned with whether the test measures what it proposes to measure and how well it actually measures it.Amount the factors which affect the validity of a test are:

a. The procedures followed in doing the testb. The wording of the testc. The actual items and whether those items are important in

the process of testing what is being proposed to be tested

d. The number of items in the test

iii. Ethical Issues in Research

There are a number of key phrases that describe the system of ethical protections that the contemporary social and medical research establishment has created to try to protect better the rights of their research participants.

The principle of voluntary participation requires that people not be coerced into participating in research. This is especially relevant where researchers had previously relied on 'captive audiences' for their subjects -- prisons, universities, and places like that.

Requirement of informed consent. Essentially, this means that prospective research participants must be fully informed about the procedures and risks involved in research and must give theirconsent to participate.

Ethical standards also require that researchers not put participants in a situation where they might be at risk of harm as a result of their participation. Harm can be defined as both physical and psychological.

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Confidentiality -- they are assured that identifying information will not be made available to anyone who is not directly involvedin the study.

Anonymity and right to privacy which essentially means that the participant will remain anonymous throughout the study -- even tothe researchers themselves.

Deception. As much as is possible participants must be provided with all relevant information as is related to the research at hand

Assigning of appropriate credits

iv. Mental Health Surveys

A multi-million dollar national survey of over 20,000 persons conducted by the National Institute of Mental Health (1985) found that:

a. over 20% of the adults interviewed had at least one psychiatric disorder during the previous six months.

b. The most common mental illnesses were anxiety disorders (10-12% of the population), alcohol and drug abuse (6-7%), affective disorders (5-6%), schizophrenia, (1%) and antisocial personality (1%).

c. Men and women were found to have an equal chance of developing a mental disorder although women suffered proportionately more from depression and men from antisocialpersonality.d. Multiple studies have indicated that all of us have a one in three chance of developing a mental illness in our lifetime.

e. The most recent comprehensive study was published in 1994, the National Comorbidity Study (NCS) (Kessler and others, 1994). Researchers were surprised that almost one out of two adults, 48%, had experienced symptoms of psychological disorder sometime

in their life, 30% within the previous year. Of those 30%, 80% had not sought treatment for their symptoms during that year.

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f. The NCS study concurs with NIMH study and found that women had higher prevalence of anxiety disorders (30+%) and depression (20+%) while men had a higher incidence of substance abuse (35%) and antisocial personality disorders (5%). Reasons for genetic differences are unknown but social roles and genetics are key suspects.

e. Classification of Abnormality/ maladaptivityOn the basis of research and clinical experience the AmericanPsychiatric Association (APA) has developed as system ofclassification – the Diagnostic and Statistical Manual of MentalDisorder (DSM). The DSM fourth revised edition (DSM–IV-TR) isthe most recent major classification of mental disorders; itcontains eighteen (18) major classifications and describes morethan 200 specific disorders.

1. Understanding the DSM (optional)

DIAGNOSING ABNORMAL BEHAVIOR

Major efforts to classify mental disorders began in 1952 when theAmerican Psychiatric Association published DSM-I, the Diagnostic and Statistical Manual. This systematic classification system provides information on symptoms, likelihood of a disorder occurring statistically and diagnostic criteria. The 1994 revision DSM-IV contains over 250 specific disorders.

Although psychologists are often unhappy with the medical terminology, complexity, reliability and validity of the system it is the best classification system currently available and allows psychologists to construct theories about the onset, progress and treatment of mental disturbances. The greatest problem with the classification system is that once "labeled" with a mental disorder, the patient is often perceived and treated as "mentally ill". Psychiatric labels can dehumanize people causing others to respond with fear, aloofness and suspicion.

DSM IV includes symptoms, the exact criteria that must be met to make a diagnosis and the typical course for the mental disorder.

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DSM gives clinicians a common language to label mental disorders and comprehensive guidelines to diagnose psychological disorders.

2. DSM Multi-axial classification system

Diagnoses now include a MULTIAXIAL SYSTEM, which looks at five different dimensions of behavior.

Axis I Addresses CLINICAL SYNDROMES and contains the major classifications of disorders such as anxiety disorders, schizophrenia and dissociative disorders.

Axis II Addresses PERSONALITY DISORDERS including antisocial, narcissistic, dependent and avoidant disorders that may coexist with the axis I disorders.

Axis III Recognizes the PHYSICAL DISORDERS and conditions such as heart problems, diabetes and asthma that may interact with or precipitate psychological

conditions.

Axis IV Represents the severity of PSYCHOSOCIAL STRESSORS.The clinician uses information from the person’s present and past history to determine the level of

psychological stress that the patient is experiencing.

Axis V Is a GLOBAL ASSESSMENT OF LEVEL OF FUNCTIONING. This code system represents the overall ability of the patient to function effectively in the world. It has a number between 0 – 100

3. General problem with these classification systems

A. Unreliable: Consistent diagnoses were difficult to obtain. In addition, specific characteristics of a disorder as described in the various classification systems were inconsistently associatedwith the disorder they were supposed to be associated with.

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B. Often theory laden: Often the only support for a particular classification system was theoretical - there was no actual evidence/data to support the system (or the theory!). In addition, the theory ladenness of these systems made it virtuallyimpossible for practitioners of different theoretical persuasionsto communicate with each other. As a result, some people argued that the ideal classification system should be theory-free and thereby useful to all.

C. Overlapping categories: It was difficult to distinguish between one category and another - difficult to know where to "place" someone into the diagnostic system.

D. Lack validity: There was little evidence that the nature of psychological disorders was accurately represented by these classification systems.

2. Evaluation of the Classification SystemA. Positives

i. It emphasizes the importance of research and a through evaluation before diagnosing

ii. Promotes a common understanding of disorders among clinicians

iii. There are specific diagnostic criteria

B. Negatives

i. Labeling can at times predispose persons not to explore any other factor

ii. Its focus on the biological model at times rule out other possible cause (demons)

iii. Maybe affected by cultural biases

PSYCHOLOGICAL DISORDERS

Classification of Mental Disorders (See handout)

Objections to Classification of Disorders

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CLASSIFICATION OF MENTAL DISORDERS IN DSM IV

The following reviews major Clinical Syndromes on Axis 1 of DSM IV.

1. DISORDERS USUALLY FIRST DIAGNOSED IN INFANCY, CHILDHOOD OR ADOLESCENCE.

37 diagnoses including mental retardation, eating disorders, conduct disorder, autistic disorder attention deficit/hyperactivity disorder, speech problems, enuresis and highly aggressive behavior.

2. DELIRIUM, DEMENTIA, AMNESTIC AND OTHER COGNITIVE DISORDERS of the brain caused by drugs, toxins, aging or diseases. Examples include Delirium (extreme mental confusion), dementia (marked deterioration of intellect) and Alzheimer's disease as well as damage caused by ingestion of toxic substances (lead, drugs). Psychological symptoms are directly related to injury to the brain or its biochemical environment.

3. PSYCHOACTIVE SUBSTANCE USE DISORDERS include excessive use anddependence on psychoactive drugs including cocaine, amphetamines,barbiturates, alcohol, heroin and other drugs that alter perception, emotions and/or behavior. Although controversial, tobacco and marijuana are also included.

4. SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS

Schizophrenia is characterized by three common symptoms.

1. Disorders of Thought - include disturbed content including delusions and disorganization including word salad and looseassociations.

2. Disorders of Perception – include hallucinations or false or distorted perceptions

3. Disorders of Emotion - inappropriate or odd emotional responses, flat affect or inappropriate tears, laughter or anger and sometimes bizarre motor behavior (waxy flexibility)

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"Schizo", Latin for "split" and "phrenic", "mind" describes the split from reality experienced by the schizophrenic mind. The personality loses it unity and wholeness as a result of unorganized, incoherent thinking, shifting emotional moods and strange perceptions. Main types of schizophrenia are described below. Persons suffering from DISORGANIZED SCHIZOPHRENIA have HALLUCINATIONS, sensory experiences such as auditory hallucinations, hearing voices or feeling bugs crawling on them that are not there. They often have DELUSIONS, false beliefs suchas delusions of persecution, believing someone is trying to hurt or kill them or other deluded thoughts. With such unorganized andincoherent thoughts, disorganized schizophrenics have difficulty communicating and are confused. They often withdraw and regress to silly, childlike behavior.

A less common form of schizophrenia is CATATONIC SCHIZOPHRENIA. The catatonic person may become completely immobile, maintaining the same position for long periods of time. In this condition known as a CATATONIC STUPOR the person is robot-like but completely conscious of what is happening. They may also exhibit other bizarre motor behavior such as WAXY FLEXIBILITY taking a bizarre posture or waving the hands in front of the face in a repetitive series of odd circles.

The PARANOID SCHIZOPHRENIC has elaborate systematized delusions about the world. Three main types of delusions are delusions of grandeur in which one is a famous person such as Christ, delusions of reference in which chance events such as thunderstorms carry important messages and delusions of persecution that cause the schizophrenic to feel others are plotting against him.

UNDIFFERENTIATED SCHIZOPHRENIA includes schizophrenic symptoms that do not fit any of the other subtypes. Often after a schizophrenic disorder, the person returns to a more normal functioning state. They often exhibit minor symptoms of schizophrenia and are then classified as RESIDUAL SCHIZOPHRENICS.

5. ANXIETY DISORDERS

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Anxiety disorders encompass the individual’s feelings of anxiety – tension, distress, nervousness or uncomfortable arousal by a strong and persistent unpleasant feeling of apprehension and fear. Although most of us feel anxiety and tension at times, persons suffering from anxiety disorders are constantly apprehensive and nervous. Their anxiety is intense, long-standingand disruptive.

Common symptoms are:

MOTOR TENSION (unable to relax, jittery, muscle tension),

APPREHENSION (fear, worry, overconcern),

AUTONOMIC HYPERACTIVITY (pounding heart, faintness, nausea or fast breathing), and

HYPERVIGILANCE (hyper-attentive focus on anxiety-provoking stimuli).

GENERALIZED ANXIETY DISORDER

Excessive persistent anxiety lasting over a month that is not focused on a particular situation or object characterizes GENERALIZED ANXIETY DISORDER. Since the person generally does notknow the real cause of the anxiety the tension becomes FREE-FLOATING ANXIETY. The person is generally anxious, tense and irritable. Unable to sleep the person becomes fatigued and unableto concentrate and function well.

PANIC DISORDER The main feature of a PANIC DISORDER is terrifying PANIC ATTACKS that are spontaneous and recurrent. Victims are overcome with feelings of panic and helplessness. Anxiety attacks may include chest pains, trembling, heart palpitations and intense terror. Women are twice as likely as men to suffer from these episodic attacks of acute anxiety.

PHOBIC DISORDER PHOBIC DISORDER is overwhelming fear of an object or situation not likely to be dangerous. People with phobias recognize their irrationality but cannot keep fear from interfering with daily

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life. SIMPLE PHOBIAS are excessive irrational fears of specific situations or things. Common fears are acrophobia (heights), claustrophobia (enclosed spaces,) and acrophobia (fear of flying). Phobias usually caused by a specific traumatic experience are fear of snakes, darkness, insects, dogs or blood.

SOCIAL PHOBIAS are described in DSM as "fear of, and compelling desire to avoid a situation in which the individual is exposed topossible scrutiny by others and fears he or she may act in a way that will be humiliating or embarrassing". Social phobias often develop in adolescence and include a fear of criticism, fear of making mistakes and fear of public speaking. AGORAPHOBIA is an extreme fear of being alone in a public place away from the security of home. Once the fear generalizes the person experiences an intense, irrational fear of leaving the house.

OBSESSIVE-COMPULSIVE DISORDERS Another common type of anxiety disorder is the OBSESSIVE-COMPULSIVE DISORDER. OBSESSIONS are anxiety-provoking thoughts that are repetitive and will not go away. COMPULSIONS are repetitive actions that are carried out ritualistically to avoid some feared situation. Common compulsions include excessive cleansing of hands, counting things, checking locks and straightening things up around the house. People feel compelled to indulge in meaningless rituals (compulsions) to control their irrational and persistent thoughts (obsessions).

STRESS DISORDERS A Stress Disorder is an extreme reaction to a highly stressful even or situation. ACUTE STRESS DISORDER is an acute, intense, brief reaction to stress which directly follow a traumatic event and last less than 4 months. POSTTRAUMATIC STRESS DISORDER is theintense psychological reenactment of a traumatic event that may include nightmares, flashbacks and recurrent and painful memories. These may be so strong that a person may believe they are reliving the event.

6. MOOD DISORDERS

When a person experiences a severe disturbance of mood or emotional imbalance, we call the problem a MOOD OR AFFECTIVE

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DISORDER. There are two major types, DEPRESSION (Unipolar Disorder) and MANIC DEPRESSION (Bipolar Disorder).

MAJOR DEPRESSION

When emotions are low and the individual is sad, hopeless, despondent and discouraged, often overcome with feelings of guiltor worthlessness, we call this MAJOR DEPRESSION. Other symptoms are becoming withdrawn, apathetic and unresponsive while losing physical stamina, weight and motivation. Many experience a diminished ability to think, concentrate or make decisions.

DEPRESSION is the COMMON COLD OF MENTAL DISORDERS. More than a quarter million people are hospitalized every year with depression. The despondent mood, loss of interest and pleasure inactivities and/or feelings of emptiness and worthlessness often lead to thoughts of suicide.

Although SUICIDE is not a disorder, it can result from depression. Most people who commit suicide were depressed. Over 30,000 people commit suicide every year. For every successful suicide there are 10 or more attempts. Women are four times as likely to attempt suicide while men are four times as likely to commit suicide.

MANIC DEPRESSION

DEPRESSION can occur alone as a UNIPOLAR DISORDER, or it can alternate with episodes of mania becoming MANIC-DEPRESSION, a BIPOLAR DISORDER. In MANIA the person's mood is elated and exuberant. Seemingly tireless the manic person can become restless and irritable in his overdrive state. Mania seldom occurs by itself. The exciter moods of mania generally swing to the listless moods of depression.

Manic-depressive persons in manic phase are euphoric, excited, and full of energy and may believe there is no limit to their possible accomplishments and act accordingly. Often manic-depressives are very successful in life but suffer extreme depressive mood swings that may lead to suicidal thoughts.

7. SOMATOFORM DISORDERS 27

SOMATOFORM DISORDERS are mental disturbances in which psychological problems take a physical (somatic) form, even though no physical cause may be found. Although the symptoms are not caused physically the pain or distress is real, not faked. These differ from Psychosomatic Diseases, genuine physical ailments caused in part by psychological factors such as ulcers and asthmathat have a genuine organic basis.

CONVERSION DISORDER

The classic example, which Freud called HYSTERIA, is CONVERSION DISORDER in which the anxiety is "converted" into a physical lossor impairment of sensory or motor function. The person appears tobe blind, deaf, paralyzed or unable to speak or feel pain. Although the physical problems have no underlying organic basis people suffering form conversion disorders are not MALINGERING (faking) their physical symptoms. Apparently energy of an unresolved psychological conflict is "converted" to a physical symptom.

HYPOCHONDRIASIS HYPOCHONDRIASIS is a pervasive fear of disease or illness. Hypochondriacs are always checking for symptoms of various diseases and searching for doctors that will agree with their self-diagnosis. Preoccupied with their bodies, hypochondriacs areobsessed with fear of a serious medical disease. Tiny alterationsfrom normal make them believe they have contracted a disease.

SOMATIZATION DISORDER A Somatization Disorder is marked by a long-standing history of diverse physical complaints that appear to be psychological in origin. While hypochondriacs fear illness persons suffering from SOMATIZATION DISORDER complain of specific physical symptoms. Common complaints are headaches, backaches, pain, dizziness, allergies, cramps, diarrhea, psycho-sexual problems, fatigue, painful menstruation, chest pain and missed heart beats. No organic cause can be found.

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8. DISSOCIATIVE DISORDERS

In DISSOCIATIVE DISORDERS the afflicted person dissociates from or alters his consciousness or identity. Dissociative disorders are usually attempts to escape from excessive anxiety through memory loss such as AMNESIA, through a change of identity (FUGUE)or a dissociation of one part of the mind from another (MULTIPLE-PERSONALITY).

DISSOCIATIVE AMNESIA

In PSYCHOGENIC (produced by the mind) AMNESIA individuals literally forget who they are along with the conflicts they are escaping. It is a selective amnesia. While they lose their sense of identify they do not forget their language or other intellectual skills.

DISSOCIATIVE FUGUE FUGUE, "flight", is a special form of psychogenic amnesia in which the dissociated person not only loses his identity but actually flees to another location, beginning life anew with another identity.

MULTIPLE-PERSONALITY DISORDER MULTIPLE PERSONALITY is a rare but striking dissociative disorderin which two or more distinct personalities exist within one individual. Each personality has its own characteristics, memories, desires and relationships. Each identity speaks, writesand acts in a very different way. Personalities within the individual may be aware of the existence of the others. Generallyshifts among personalities are stress-related, sudden and dramatic. When anxiety overwhelms or threatens one personality the multiple personality switches to another opposite personalitythat can handle the particular stress.All DISSOCIATIVE DISORDERS provide a means of escape from anxietyand personal responsibility. Amnesia and fugue are usually precipitated by excessive stress and are a form of fantasy escapedefense against stress. By losing one's memory one is no longer faced with obligations, severe conflicts, anxiety or guilt. A

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substantial number of people with multiple-personality disorder have a history of child abuse and rejection from parents.

9. SEXUAL AND GENDER IDENTITY DISORDERS

The Diagnostic and Statistical Manual includes a range of atypical sexual behaviors or problems of adjustment. Three major types are SEXUAL DESIRE DISORDERS, inhibited ability or desire tohave satisfying sexual experience, GENDER IDENTITY DISORDERS involving our sense of maleness or femaleness and PARAPHILIAS, unusual and bizarre forms of sexual arousal.

SEXUAL DESIRE DISORDERS

Psychological factors such as fear or anxiety are considered to be the cause for most forms of SEXUAL DESIRE DISORDERS such as impotence and frigidity. Problems reaching orgasm are often linked to problems in the relationship, depression or self-consciousness. Sexual dysfunctions are common and often related to emotions but may be caused by physical factors such as fatigue, diabetes or resulting from medication or excessive use of alcohol.

GENDER IDENTITY DISORDERS GENDER IDENTITY DISORDERS develop in childhood or adolescence andinvolve our comfort with our maleness or femaleness. Persons who are TRANSSEXUALS want to be the opposite sex and feel trapped in the wrong body. They may undergo a sex-change operation to fulfill their desires. A homosexual prefers sexual relations withpersons of his or her own sex. Formerly considered a psychosexualdisorder in DSM-II, homosexuality was eliminated in the third edition as it was not found to be inherently harmful of self or others. However if one is distressed and anxious about his or herhomosexuality, this is included in DSM-IV as EGO-DYSTRONIC HOMOSEXUALITY.

PARAPHILIAS PARAPHILIAS are abnormal patterns of sexual arousal from unusual sources or objects including fetishism, exhibitionism, voyeurism,sadism, masochism, transvestism, rape and pedophilia.

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AXIS II - PERSONALITY DISORDERS

PERSONALITY DISORDERS are maladaptive personality styles that aredeveloped early in life and are very resistant to change. They become styles of life including extreme and rigid personality traits that involve odd or eccentric behaviors, dramatic and impulsive behavior or fearful or anxious behavior. Generally people with personality disorders do not think they have a problem but often create problems for others!

ANXIOUS-FEARFUL CLUSTER

The ANXIOUS-FEARFUL cluster includes efforts to control anxiety about social rejection.

An AVOIDANT-PERSONALITY is sensitive to potential social rejection and socially withdraws in spite of real desire for acceptance from others.

The DEPENDENT PERSONALITY reduces the possibility of rejection bypassively allowing others to make decisions while subordinating one's needs to those of others.

The PASSIVE-AGGRESSIVE PERSONALITY does not risk direct confrontation but indirectly resists through procrastinating, forgetting, lying or indirect methods.

The OBSESSIVE-COMPULSIVE PERSONALITY copes with anxiety by imposing rigid rules and order to their lives and relationships to reduce anxiety.

ODD-ECCENTRIC CLUSTER

People suffering from the ODD-ECCENTRIC cluster of personality disorders remain aloof, distrustful and shield themselves from the anxieties of interpersonal intimacy.

The SCHIZOID PERSONALITY socially withdraws, has no close friendships and is indifferent to the feelings of others.

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The SCHIZOTYPAL PERSONALITY has bizarre beliefs, oddities in perception, speech and behaviors similar to the schizophrenic butnot as severe.

The PARANOID PERSONALITY shows pervasive and unwarranted mistrustof people, is oversensitive and suspicious, prone to jealousy.

DRAMATIC-IMPULSIVE CLUSTER

The DRAMATIC-IMPULSIVE cluster is divided. Histrionics and Narcissistics share a flare for over-dramatizing everything whileborderline and antisocial personalities are marked by impulsiveness.

The HISTRIONIC PERSONALITY is egocentric and seeks attention withoverly dramatic expressions of emotion. Their emotions are exaggerated and may border on the hysterical.

People with a NARCISSISTIC PERSONALITY also thrive on attention. Feeling grandiosely self-important they demand special treatment and constant admiration while lacking empathy.

The BORDERLINE PERSONALITY is unstable in their self-image, mood and interpersonal relationships and is therefore impulsive and unpredictable.

The ANTISOCIAL PERSONALITY fails to agree to social norms and violates the rights of others. They are often exploitative, usingtheir intellect and social savvy to charm people to get their wayor to use people for personal gain.

THE ANTISOCIAL PERSONALITY – A CLOSER LOOK

Perhaps the most troubling of the PERSONALITY DISORDERS is the ANTISOCIAL PERSONALITY as it is marked by chronic violation of the rights of others. Over 4% of the male population suffer from this disorder and are responsible for a large amount of violent crime as well as white-collar crime.

ANTISOCIAL PERSONALITIES are irresponsible, impulsive and often unscrupulous, callous, aggressive and often criminal. Antisocial people rarely feel guilt and lack an adequate conscience. They may

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seem to be quite appealing and charming when we first meet them as they are skilled at faking interest and affection so they can exploit people. Their lack of conscience allows them to seem carefree, socially at ease and stress-free.

While many end up in prison because of their amoral, callous and aggressive behavior, many antisocial personalities successfully channel their exploitative behavior within boundaries of the law becoming unprincipled, scheming, self-serving politicians, con artists, business executives, lawyers or even evangelists. Their selfish, impulsive, irresponsible, manipulative behaviors make them unreliable, unfaithful, undependable and disloyal employees,mates, friends and parents. DSM-IV reports that this is a moderately common disorder affecting 1-3% of the population, mostly males.

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