1

Clinical Psychology: disorders of the brain or of the mind ?

Professor Michael Joseph

PS 3013. Clinical & Health Psychology

18.10.05

2

Abnormal psychology

Often used as a synonym for clinical psychology. How to define ? - the study of behaviour outside

the normal range. Behaviour includes language, in humans, and by

inference therefore, mental state. Could define “abnormal” statistically. However, a behaviour might be quite common,

and we would still want to define it as abnormal. Concept of extreme rather than uncommon.

3

Social Dimension

Abnormal psychology is constrained from “extreme”; we do not usually include extremely altruistic, truthful, happy.

Need to bring in the context, the social dimension, appropriateness; the behaviour is disturbing to the patient; to their social functioning and relationships.

This leads us to the use of social factors in any definition: (e.g. those from p. 20 in Seligman et al. - see next slide).

4

Seligman et al., criteria

Suffering, Maladaptiveness, Irrationality and incomprehensibility,

Unpredictability and loss of control, Vividness and unconventionality,

Observer discomfort, Violation of moral and ideal standards.

 Clearly borders may be difficult to define.Criteria are culturally dependent.The more criteria that are met, the more

significant the abnormality. 

5

Clinical Psychology

Often used synonymously with Abnormal Psychology.

However, Prof. Wang’s lectures will have indicated how wide the scope of clinical and health psychology is; it is not confined to Abnormal Psychology, and vice versa.

When I did my training, Clinical Psychology was defined with reference to the psychological aspects of disorders treated within the disciplines of Psychiatry and Neurology.

6

Psychiatry and Neurology Psychiatry is by definition the treatment of

disorders of the mind Neurology ought to mean simply the study of the

brain. In fact, medicine has stolen the word Neurology

to mean the study and the treatment of disorders of the brain.

So the distinction, when I was training, was that while both disciplines were studying disorders of behaviour, broadly defined (to include speech for example)…..

Neurology – a clear physical cause in the brain Psychiatry – no clear physical cause in the brain.

7

Psychiatry and Psychology

“Neuropsychology” has a special meaning – the psychology of neurological illness.

However it means “brain-mind-study”, and thus ought to cover all of psychology.

The distinctions between Neurology and Psychiatry are becoming blurred, given that the functions of brain and mind appear to be converging as we learn more about them.

8

Schools of thought in Psychiatry, Neurology and Psychology I

Clinical psychologists also get involved in “mind- treatment” (psychotherapy, cognitive behaviour therapy), which is also a form of “brain-treatment”.

Cartesian dualism (mind/brain); separation of illnesses of the mind from diseases of the brain; psychological and neurological treatments evolved separately.

Physical treatments were developed in neurology, where there was direct physical evidence of brain involvement (lesions, brain injury, etc).

9

Schools of thought in Psychiatry, Neurology and Psychology II

Psychological treatments were developed in psychiatry, which reached an early peak in the work of Freud.

Freud wanted a scientific theory of neurosis, with universal governing principles

He was trying not only to treat the symptoms themselves, but what he saw as their underlying causes.

Also he believed that the applicability of psycho-analysis to the treatment of psychosis (schizophrenia, depression) was necessarily limited.

10

Schools of thought in Psychiatry, Neurology and Psychology III

However illness of the brain, clearly do lead to mental and behavioural changes.

And it is only from changes of behaviour, and inferred changes in mental phenomena that we can infer illnesses of the mind in psychiatry.

Thus it is possible that psychiatric disorders too could have origins in abnormalities in the brain.

When we see behavioural changes reminiscent of those displayed by psychiatric patients arising from physical causes, this possibility is strengthened.

11

Physical causes for psychiatric symptoms

Examples:

syphilis - dementia, grandiose delusions hallucinogenic drugs - hallucinations drug abuse - amphetamine/cocaine

psychosis temporal lobe epilepsy - automatisms,

flight of ideas

12

Biological psychiatry I

Critical impetus to this important next stage in the development of psychiatry was given by the discovery of drugs which were truly effective in treating psychiatric disease.

These of course acted on the brain, and thus indicated that treatment of mind disorders could also involve the brain directly (although, naturally, psychotherapy also works on, and through, the brain).

Thus the dividing line between brain and mind disorders was further blurred.

In the second quarter of the 20th century, neuropharmacol-ogy made rapid strides, establishing the reality of chemical transmission between neurones in the nervous system.

13

Biological psychiatry II

Neuropharmacology also generated the tools which permitted the pharmacological analysis of many new compounds these could be synthesised using the chemical knowledge

developed in the 19th and early 20th centuries. In this early period, many new drugs became available for

medical use, but none of these were directed at psychiatric disorders.

Beyond the use of non-specific sedatives, no-one had any idea where to start, since the neurobiology of psychiatric disorders was at best unknown.

Many still thought their neurobiology to be non-existent, that they were of purely psychological origin

At the worst the theories were plain wrong, e.g. epilepsy, schizophrenia and ECT, the use of insulin coma therapy, and the use of psychosurgery in schizophrenia (abuse).

14

Psychoses I

Chlorpromazine (CPZ), revolutionised the treatment of schizophrenia, and also the atmosphere in psychiatric hospitals.

Minor manipulation of the molecular structure of CPZ produced imipramine, an effective treatment for endogenous depression, the other common psychosis. This was the first of the tricyclic drugs.

Another treatment for depression, the MAOIs, of which the first was iproniazid, came from the observation of an anti-depressant action of certain anti-tubercular drugs.

15

Psychoses II

The “monoamine theory” of depression was consolidated when it was found that depression could be precipitated by reserpine, since this reduced the activity of the neuronal systems potentiated by tricyclics and MAOIs

Cade, in Australia discovered variations in the excretion of uric acid in manic-depressive psychosis. He used the lithium salt of uric acid, as the most soluble one available to treat them with uric acid.

The treatment was remarkably effective; indeed it was also prophylactic, as Schou’s later work showed, but it was the Lithium doing the work, not the uric acid part.

16

Anxiety; Drugs in psychiatry

Benzodiazepines were developed from the observation that a series of synthetic compounds exerted a taming effects in animals.

A number of these, including valium and librium, proved to be remarkably effective in treating human anxiety.

In all three clinical areas, drug treatments rapidly multiplied.

Thus from a situation in 1950 when we had no drugs for specifically treating any of the major psychiatric disorders, within 10-20 years we were able to treat all of the major psychiatric disorders, in most cases with a choice of different agents.

17

Drug administration and Psychosis

This new evidence was added to that from symptoms produced by drug administration.

We have already mentioned hallucinogenic drugs, which produced symptoms analogous to schizophrenic hallucinations.

This led to the idea that in schizophrenics, endogenous hallucinogens might be produced via abnormal metabolism

Even better models of psychiatric disorders were produced by amphetamine (paranoid schizophrenia) and more recently PCP (angel dust) - (psychosis).

Also, as mentioned reserpine results in symptoms of endogenous depression in a proportion of those to whom it was given for heart disorder.

18

Actions of drugs

Knowledge that these drugs, and the therapeutic ones mentioned earlier, acted on particular (chemical) neuronal subsystems in the brain led to the idea that overactivity or underactivity of particular systems might underlie psychiatric disorders.

An important model was provided by a neurological condition, Parkinson’s disease, which turned out to be due to a loss of certain nerones in the mid-brain.

These neurones used dopamine (chemical messenger), and their deficit was treated effectively with the dopamine precursor L-dopa.

19

Anti-psychiatry movement. Meanwhile, during these dramatic developments in

biological psychiatry, developments were taking place in the psychological field.

Some unorthodox psychiatrists were taking the extraordinary step of listening to their patients.

They were saying that what other psychiatrists regarded as nonsense could have meaning, and that this meaning could throw light on the situation that these patients found themselves in. [R.D. Laing]

 While their corollary, that schizophrenia was only appropriately treated by family therapy, was wrong, the important breakthrough, which is still relevant today, is that what patients say is not meaningless.

20

Behaviour therapy

Treatment developed using behaviourist principles.

Psychiatric symptoms are simply behavioural problems, which can be eradicated using behavioural training techniques.

The main “disorders” to which these were applied were anxiety, especially phobias, and sexual deviation (or as we now call it diversity).

This of course was exactly the opposite approach to that of the Freudians, who believed that if the symptoms rather than the causes were treated, other symptoms would simply re-emerge.

21

Brain disorder or mind disorder ?

Thus by about 1970, debate had polarised as to whether the origin of psychiatric disorders was psychological or physiological, e.g. Schizophrenia as a brain disorder, or a mental disorder.

This polarisation as to the origins led to two exclusive schools as to treatment:

1) an abnormality of the mind, of mental processes - hence treat by altering the mind – psychotherapy, or cognitive, or behavioural therapy. 

2) an abnormality of the brain - hence treat by drugs; the function of psychiatrists and psychologists is to provide a context where this can take place.

22

Brain and mind order

Nowadays few would subscribe to the theory that the mind is not firmly anchored in the brain, or that phenomena such as speech, memory and learning do not have physical counterparts in the brain

From this position, since events influence brainstates, directly and indirectly, and brainstates produce behaviours, the polarised debate seems pointless.

It must be that a synthesis of these approaches is feasible and appropriate.

23

Subsequent Events 1970-2000 Biological basis for schizophrenia firmly

established. (CRC) – enlarged ventricles; flupenthixol trial

and dopamine block; neuropathological changes Development of alternative and equally effective

drugs led to wider understanding of their mode of action, and hence discovery of a still wider range of drugs.

Use of animal models which could be validated on this wider range led to the discovery of new classes of drugs with different modes of action, and often fewer side effects.

24

Nature of Biological theories

Most simple theories of deficiencies/excesses on a regional or neurochemical basis were ruled out as research progressed.

Any physical lesions or changes in psychiatric disorders will be subtle, and by no means evenly distributed.

They could have developmental origins. It also became apparent that the finding that

doing X improved condition Y did not mean that Y, untreated, was characterised by the opposite of X (e.g. dopamine and schizophrenia)

25

Cognitive behaviour therapies

Have been developed and become established for the treatment of depression, and to some extent even for the treatment of schizophrenia.

Thus such symptoms are amenable to cognitive control, and meaningful - the legacy of Laing.

The other outcome of the Laingian experience is that psychologists now look at symptoms from the point of view of obtaining information on which cognitive systems have gone awry in each disorder.

26

Psychology, and interactions

This has implications for treatment, and also for understanding normal functions, including attention, beliefs and the regulation of consciousness (Frith)

 We now see pathological behaviour as arising from the interaction of social factors with vulnerable individuals.

Thus it is appropriate both (a) to treat at the brain activity level, using drugs,

which can often reverse distressing symptoms, and (b) to treat at the mental level, using treatments which can help to understand and deal with the background social factors. These might include counselling and psychotherapy, and social work.

27

Drugs and psychological treatments

Many trials now suggest that a combination of drug and psychological treatments do better than either one alone, especially in depression.

 The fundamental vulnerability may not be alterable, at present, e.g. if developmental.

Drugs can help to deal with the symptoms. They may also have a prophylactic action. We then need to consider what can be done

to improve the social context and environment.

28

Other approaches

On the other hand, many degenerative disorders are due to an ongoing toxic process. If this were true for some psychiatric disorders, it might be possible to arrest it.

We are gaining knowledge of how to re-construct the nervous system, although re-developing it promises to be a much harder problem. Doing proper controlled trials will be ethically difficult.

Beware example of psychosurgery – reversing any physical intervention in the brain (e.g. transplants, genetic manipulation) will be harder than simply taking patients off drug treatments.

29

Bottom line I

Clinical disorders are not EITHER psychological OR neurochemical/ neurophysiological disorders.

Experience and behaviour ARE determined by activity within the brain, whether normal or abnormal

Clinical disorders are almost certainly NOT simple in brain terms: not simply a missing enzyme, or a missing transmitter or receptor.

Drugs used to treat disorders, while often having one predominant or critical action, are complex in their actions in detail. Developing more pharmacologically specific drugs has rarely improved them

30

Bottom line II

 In principle, all clinical disorders can be helped by psychological treatments. Drugs may facilitate a reduction in symptoms, needed before psychological treatment can become effective.

 In some conditions or individuals, continued drug treatment may be useful, or even essential, in protecting against relapse.

 Psychological treatments are also likely to be useful, both in moderating specific experiences in the illness, and in having a prophylactic effect, protecting against precipitating factors in the environment.