Psychological Abnormal Disorders

Cases• Andrea Yates• Ted Kaczynski: the unibomber• “Nancy”• Mark David Chapman (shot John Lennon)• John Hinckley (shot Pres. Reagan)• Jeffrey Dahmer, Ted Bundy• John Nash “A Beautiful Mind”

“Abnormal” is Difficult to Define• Symptomology exists on a continuum• Often quantitative rather than qualitative

differences• Point of view of the individual

– Distress– Dysfunction

• Point of view of the culture– Deviance from cultural norms– Threatening or troublesome for society

Defining Abnormal Behavior

I prefer the 4 D’s Dysfunctional behavior (maladaptiveness of

ineffectiveness) Deviance (Bizarreness, social deviance) Distress (discomfort)Dangerousness

Characteristics & Criteria for Defining Abnormal Behavior 1

1. Distress: Personal discomfort, or subjective distress Is the person anxious, depressed? Does the person have nightmares, feel guilty, feel dead and so forth? Exception: manics, antisocial PD

2. Deviance: Extreme Social Deviance Is the behavior bizarre, threatening, troublesome, dangerous, unpredictable? Are rules of conduct being broken? Does the person misperceive reality? (e.g.,hearing voices, pulling out one’s hair, starving)

Characteristics & Criteria for Defining Abnormal Behavior 2

3. Dysfunction: Maladaptive behavior, psychological handicap. Does the person have an impaired ability to function adequately in everyday social and occupational roles. (e.g., if agoraphobia keeps a person from working, or depression keeps the person from going to school, the behavior has become dysfunctional or maladaptive for that person)

Characteristics & Criteria for Defining Abnormal Behavior3

4. Dangerousness: Is the person a danger to himself, others, or society?

Most people who have psychological problems are not dangerous to others. If the person has a history of violence, he or she could be more dangerous than the average person--otherwise, they are usually not dangerous. Those who commit crimes receive a great deal of publicity which leads us to overestimate the threat (vividness).

• Distress, disability, deviance, and dangerousness all play a role in defining abnormal behavior but no one factor is sufficient to account for all abnormal behavior.

Level of Disturbance (how severe)

1. Bizarreness--How extreme is the behavior?2. Duration--How long have the symptoms

persisted? 1 month(?) 6 months(?) Years(?)

3. Social Functioning--The extent of the effect on social functioning. (Can the person leave the house, hold a job, etc.?)

Eccentrics• Do not have a psychological disorder• Behavior may violate social norms

(deviant)• No distress, the behavior provides

pleasure• Weeks studied & concluded they were

happy & well-adjusted (2 in 10,000)

Terms for Abnormal Behavior Abnormal BehaviorPsychological Disorder-a preferred termPsychological ProblemsPsychiatric Disorder-a preferred termPsychopathology-medical termDeviant BehaviorMental Illness-medical term.Disorder is probably a better term.Deviance-used by sociologistsMental Disease

Mental ProblemsMental DifficultiesNervous DisorderEmotional DisorderEmotional ProblemsEmotionally DisturbedMaladaptive BehaviorPsychologically HandicappedSociopathySociopathPsychopathAdjustment Disorders

Terms for Abnormal Behavior 2

Organic Brain Disease/Psychogenic diseaseDevelopmental DisordersPoor Mental HealthInsanity-legal term which has no meaning in DSM

IV"Neuroses"-no longer used”Nervous Breakdown"- a layperson’s termPsychosesPersonality Problems/DisordersProblems in Living--preferred by those opposed to

diagnosis

Incidence/Prevalence• Epidemiology: Public Health• Incidence: How many new cases per

population unit in time period (e.g., one year)

• Prevalence: Relative proportion of active cases at a given point in time or during a given period of time. Lifetime prevalence vs. point prevalence vs. one-month prevalence

Frequency/Prevalence of Serious Mental Disturbances 1

Estimates depend on a variety of factors, but one credible estimate is that in any given year, as many as 30 percent of the adults and 20% of the children and adolescents in the United States are believed to display serious mental disturbances and to be in need of clinical treatment. 

Frequency/Prevalence of Serious Mental Disturbances 2

Of every 100 people in the U.S.

13 Anxiety Disorder10 Alcohol and Drug abuse problems 6 Profound Depression 5 Personality Disorder 1 Schizophrenia 1 Alzheimer’s36  Friedman et al, 1996, Kessler et al, 1994, 1996

Sex Differences (One-Month Prevalence Rate)

Men WomenSubstance Abuse 6.3 1.6Antisocial PD .8 .2Mood Disorders 3.5 6.6Anxiety Disorders 4.7 9.7Eating Disorders mostlySomatization neg. .2

Reasons for Diagnoses

1. diagnosis is a communication shorthand

2. it may suggest something about treatment

3. it may suggest etiology

4. it aids scientific communication

5. it allows payment by third parties

Taxonomies: Imply Levels of Knowledge

• Symptom• Syndrome• Disorder: a cluster of symptoms not

accounted for by another problem• Disease: underlying etiology is known

DSM-IV• Axis I: Clinical Disorders

– (Anxiety Disorders, Mood Disorders)• Axis II: Personality Disorders & Mental

Retardation (long- standing problems)• Axis III: General Medical Conditions

(Diabetes, CHD)• Axis IV: Psychosocial & Environmental

problems (Divorce, lose job) • Axis V: Assessment of functioning

Some Axis I Clinical Disorders• Anxiety Disorders• Mood Disorders• Schizophrenia & other Psychoses• Somatoform Disorders• Sexual Dysfunctions• Dissociative Disorders• Substance-related Disorders

Stress; Adjustment Disorders; PTSD 1

Except as listed below, reactions to stress are not listed in DSM IV.  

Adjustment disorders:  Disorders characterized by the development of clinically significant emotional and behavioral symptoms within 3 months following the onset of an identifiable common stressor, i.e., divorce, losing a job, etc. Worse than average response. Symptoms must be maladaptive and can last up to six months.  After that, diagnosis must change.       

     

Stress; Adjustment Disorders; PTSD

•  Adjustment disorder with anxiety       •  Adjustment disorder with depressed mood •  Adjustment disorder with conduct

disturbance 

Stress; Adjustment Disorders; PTSD 3

Reactions to Catastrophic or Traumatic (Life- threatening) Events 

 •  Acute Stress Disorder.  Occurs within four weeks of the traumatic event, lasts a minimum of two days and a maximum of four weeks.  If symptoms last longer than one month, it becomes PTSD  

•  Post-traumatic stress disorder.  If symptoms last

longer, and are more severe.  

Anxiety Disorders

Panic Disorder w/o agoraphobia- (palpitations of the heart, shortness of breath, dizziness, trembling, chest pains, etc.)

Panic Disorder with agoraphobia (avoid public places)Specific phobia- (e.g.,snakes, heights)

Social phobia- severe, persistent and irrational fears of social or performance situations in which embarrassment may occur.

Anxiety Disorders cont.Obsessive-compulsive Disorder- (persistent

thoughts, images, that invade a person’s consciousness); repetitive and rigid behaviors or mental acts that a person feels compelled to perform to avoid anxiety).

Post-traumatic Stress DisorderAcute Stress DisorderGeneralized anxiety disorder (pervasive anxiety)

Criteria for Diagnosing Anxiety Disorders 1

 Panic Disorder:  recurrent, unexpected panic attacks followed by a period of 1 month or more in which there is persistent concern about having additional attacks, or significant behavior change 

Agoraphobia:  anxiety about being in situations from which escape might be either difficult or embarrassing. Avoidance & distress are elements. 

Specific phobia:  a marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation.  Must interfere with normal activities or relationships. 

Criteria for Diagnosing Anxiety Disorders

 Social phobia:  like above but includes “performance”. A person avoids or is afraid of  social situations (performance anxiety or interpersonal interactions).  Fear of being humiliated 

GAD: excessive anxiety and worry.  The worry must occur more days than not for a period of at least 6 months.  Must include a number of different activities and events. 

OCD: Has either obsessions or compulsions which he or she must recognize as unreasonable and attempt to suppress.

Depression 1

Unipolar:            •  Dysthymia  (depressed mood, 2 yrs)•  Major depressive disorder (twice as many women

as men) Bipolar:•  Cyclothymia•  Bipolar I  (at least 1 manic attack)•  Bipolar II  (one or more hypomanic episodes)

Depression 2---------------------------------------------------

Model Diatheses + Personality + Life Events --->Depression Biological Diathesis, e.g., genes, neurotransmitters Psychological Diatheses, e.g., early loss of parent Personality traits:  oral dependent personality, internal

attributional style, learned helplessness Negative life events: e.g., divorce, failure, health

Psychotherapy

Psychotherapy Questions• What is psychotherapy?• How does psychotherapy differ from talking

with a friend about your troubles?• Does psychotherapy work? How do we know

it works?• What percentage of people will get better

without psychotherapy? Spontaneous remission, placebo effects

Psychotherapy cont.• How does psychotherapy compare to

medications?• Are some types of psychotherapy better

than other types?• What factors predict success? Therapist

variables vs client variables• Is psychotherapy good for everyone?

Psychotherapy cont.• How important is the therapeutic

relationship?• Outcome studies vs process studies• Common vs specific factors

Def. Butler & Strupp• Psychotherapy is the “systematic use of

a human relationship for therapeutic purposes”.

Techniques cannot be separated from the human relationship; techniques are interpersonal events inevitably linked to expectations and beliefs.

One person trying to help “heal” another.

Psychotherapy• How does it differ from what a friend

does? In many ways it doesn’t. • What ingredients are common to all

types of therapy and what are specific to particular types of therapy?

• Can we determine what is responsible for change? For success?

Best known types of therapy• Psychodynamic

– IPT • Humanistic (client-centered), Rogers

– Existential (Rollo May) Counselors.• Behavior therapies• Cognitive therapies, Beck, Ellis (REBT)• Family Systems• Group

Some additional types--less well-studied and less well-regarded

• Gestalt: Fritz Perls• Janov (1924): Primal Therapy• Eric Berne: TA-Games Analysis• Reich: Bioenergic therapy• Jungian analysis

Common vs. Specific Factors• How are all types of psychotherapy

alike?

Some common factors(Non-specific ingredients)

• Characteristics of a “good clinician”. Warm, sympathetic person, unconditional positive regard, supportive, empathetic, good role model, responsible, non-judgmental, opportunity for catharsis, provides social-emotional support,good rapport, good advice/coaching, hope, encouragement

Some specific factors• Transference• Interpretation• Free association• Desensitization• Empty chair• Challenging assumptions• Homework exercises• Role play

Insight vs Action• Focus on past or present• How important is the therapeutic

alliance?, what is the role of the therapist

• Is the goal to have insight or to change thinking and behavior?

• Is the focus on emotion, cognitions, behavior, unconscious conflicts, symptoms? What is most imp.?

Client variables• Intelligence/education• Ability to introspect• Motivated to change (prob. most imp.)• Confidence and trust in the therapist• Maybe middle class, young, attractive,

share the values of the therapist.(Client variables are more important to

success than therapist variables)

Research on Psychotherapy• How do you define success?• Placebo controls (wait-list)

– Medications only• Sloan study, Temple study, Vanderbilt

study. • NIMH

General Information about Treatment

1. People with the most serious disorders probably need medication and/or ECT. (Schizophrenia, Bipolar, Unipolar with psychotic features, OCD)

2. People with mild disorders seem to improve significantly by seeing a professional. Type of training and type of therapy do not matter much. Why? Client variables more important than therapist variables for this group.

3. Type of therapy matters for moderate to severe problems.

Treatment cont.4. Cognitive behavior therapy appears to work best for

moderate to severe depression. Interpersonal therapy OK. IPT

5. Behavior therapy and cognitive behavior therapy work best for most anxiety disorders.

6. Somatoform disorders- hard to treat. Combinations of therapy.

General Information about Treatment

7. Dissociative disorders. Hypnosis plus psychodynamic-based therapies.

8. Meaning of life issues: Humanists/existential therapies helpful

9. Eating Disorders: Combinations including Family Therapy

Treatment cont.10. Personality Disorders: in general therapy doesn’t

work--neither does anything else. Recent progress with borderlines

11. Schizophrenia: in general, therapy does not help. Medications plus controlled environment. Teaching family how to live with patient helps.

Advice: Don’t just accept the statement from a therapist who tells you he or she is "eclectic". Most therapists identify with an orientation and are trained in a particular orientation. Many do use various techniques but most have a primary identification that matters a great deal.

Insanity Defense 1

Mens Rea (Guilty Mind or Evil Intent)

1843: M’Nagten Rule (Right from Wrong)late 1800’s:   Irresistible Impulse1954: Durham Test: Product of Defect (too

broad)1955: ALI:  American Law Institute 

“A person is not responsible for criminal conduct if at the time of such conduct as a result of mental disease or defect he lacks substantial capacity either to appreciate the criminality (wrongfulness) of his conduct or to conform his conduct to the requirements of the law.”

Insanity Defense 2

• ALI was widely used until after Hinckley (1981) Then “Unable to Conform” removed

1983: APA “...as a result of mental disease or mental retardation, he was unable to appreciate the wrongfulness of his conduct at the time of his conduct”

---Used in all Federal Courts and about 1/2 of all State Courts.

The rest use ALI of have abolished insanity plea altogether (Idaho, Montana, Utah).

Insanity Defense 3

2/3 of those acquitted are diagnosed with schizophrenia with a history of hospitalization.

Less than 1% of the defendants plead insanity; less than 1/4 are successful.

Alternatives:  • Guilty but mentally ill (Georgia)• Guilty with diminished capacity

California Twinkie Defense.  In San Francisco, Dan White killed Mayor Moscone and

City Supervisor Harvey Milk. Convicted of manslaughter.

Insanity Defense 4

Civil Commitment  

•  Danger to themselves or others •  Need treatment •  Clear and convincing evidence of

dangerousness (75% sure)                          

Insanity Defense5

Burden of proof      Preponderance of the evidence (51% sure)     Clear and convincing evidence (75% sure)    Beyond a reasonable doubt (90-99% sure) 

•  2 PCs--Physician Certificates  Professionals are not good at predicting violence long-term. 

Overestimate the likelihood. The purpose of civil commitment is to help the person,

not to punish.