Abnormal Psychology

Abnormal Psychology

Definition: Scientific study of abnormal behaviour: psychological disorders/mental disorders.

An empirical method to study...

Description

Classification; diagnosis: what is classified as abnormal? How can we tell?

Diagnosis of psychological disorders is very different from physical illness

Causation

Bio-psycho-social factors

The factors all interact with each other; cause is never due to either/or

Treatment

Effectiveness of treatment need to be closely monitored

It is difficult to find out if a treatment is effective since there could also be many factors that affect the patients mental state

...of Psychological/Mental disorders or abnormalityWhat is Abnormal? Deviant (unexpected/rare/unusual)E.g: fetishism (sexual dysfunction)

However: positively valued deviations exist; eccentricity

Impractical to define a characteristic as abnormal just because it is rare

Everyone is different

Distressing (to self or to others)E.g: depression, anxiety

Many symptoms in abnormal behaviour are found in everyday life (healthy people have anxiety too)

Some abnormal behaviour does not involve distress (e.g bipolar disorder)

Dysfunctional (interferes with life goals)E.g: ADHD

What is dysfunctional is defined by society (women wanting to work was dysfunctional as it interfered with societys expectation of them as housewives and child-bearers)

Those with abnormal characteristics can have a fulfilled life (a person with psychopathic tendencies could be born into a wealthy family and thus have a great life

Accepted guideline to what is abnormal: A mental disorder is whatever is included in the DSM, aka Diagnostic and Statistical Manual of Mental DisordersSatisfying one or two of the above three conditions does not mean it is necessary or sufficient to diagnose that behaviour as abnormal.

It is important to note that abnormality is always defined by society and cultural values: different societies may classify different behaviours as abnormal

Psychological abnormality exists on a continuum with normality, and a behaviour is defined as abnormal when it crosses a cut-off point (which can be vague).

Thus, psychological disorders are not as readily definable as physical illness.

Models of Mental Illness

ModelCauseTreatment

SupernaturalSpirits; stars/moon; past livesExorcisms, prayers etc

BiologicalInternal physical problems; biological dysfunction; all disorders are from a biological sourceBleeding, diet, celibacy, exercise, rest, medication

PsychologicalBeliefs, perceptions, values, goals, motivation etc; psychological dysfunction; people see things in a way that causes them to sufferPsychotherapy

SocioculturalPoverty, prejudice, social and cultural systemsFixing social issues

Biological/medicinal model of mental illness

DefinitionCriticisms

Oldest and currently most dominant model of mental illness

Assumes that psychological disorders can be diagnosed similarly to physical illness

Explains mental illness in terms of biological disease process such as

Structural brain abnormalities (schizophrenia)

Neurochemical imbalance (depression)

Best treated with medication, surgery etcExtreme reductionism

Certain complex psychological phenomena (e.g creativity) may be impossible to explain at a purely neural/molecular level

Over-extrapolation from animal research

Animals dont live in the complex society that humans do live in, so animal research overlooks many social and psychological factors that affect us in everyday life

Assuming causation from treatment

May not be applicable to conceptualising and diagnosing mental illnesses

Clear boundary between physical health and illness; however mental health and disorder is a continuum

There are clear boundaries between different physical illnesses; however psychological disorders commonly co-occur

Psychological Models

PsychoanalyticMost dominant during first half of 20th century; usage discontinued by 1970s

Sigmund Freuds id, ego and superego

Three parts of the mind that are always in conflict

Maladjustment (abnormality) arises from unresolved conflicts causing

Anxiety

Defence mechanisms

Protect us from knowing what is causing us suffering

When overly used can also become abnormal symptoms

Is thus both normal and abnormal behaviour

Critiques: lack empirical evidence and also lack falsifiability

HumanisticBelieve that people are born good rather than evil

Happiness is achieved by becoming fully-functioning, self-actualized persons

Maladjustment arises from blockage of ones path to self-actualization

Environments that impose conditions of worth (e.g not being able to pursue a dream career because of familys expectations)

Having ones own experience, emotions and needs suppressed

Treatment: empathy and unconditional positive regard

Critiques: difficult to research

Still used in counselling, though not in critical psychology

Behavioural

Shaping of self purely through environmental influence such as Classical and Operant (Instrumental) conditioning

Maladjustment arises from aversive learning history

Many treatment applications, such as implanting new learning to cover old learning (extinction)

Critiques: does not factor in cognition or emotion, implies that we learn by doing only

Bandura (1974) found that learning is not purely from behaviour with his observational learning theory, which incorporated cognition to behaviourism

Cognitive-Behavioural ModelCurrently dominant model in psychology

Our interpretation of our environment influences our emotions and behaviour

Maladjustment arises from latent core negative beliefs

Negative views of the world formed by past experiences

Could lead to pessimistic/negative interpretation of situations that are consistent with such core negative beliefs, even if situation is ambiguous

Cognitive biases; only picking up information that fits in with our believes

(Over-generalizing, selective attention, catastrophising, personalizing, magnification, mistaking feelings for facts, etc)

Negative automatic thoughts

Models are not necessarily either/or; different models could combine to fit a situation

Classification and Causation (why?)

To improve communication between researchersTo improve communication between health professionalsMay improve communication and understanding of mental health in the communityMay reduce social stigma against those with mental health issuesClassification Systems

International Classification of Diseases and Health Related Problems (ICD)

Published by World Health Organisation

Mental disorders added for first time in 1948

Currently in 10th edition

DSM

Published by the American Psychiatric Association

1st edition published in 1952

Currently in 5th edition (DSM-5)

Development of DSMDSM-I (1952), DSM-II (1968)

Strongly influenced by psychoanalytic theory

Therefore had problematic reliability

Had no specific conditions to diagnose patients with

How much self depreciation must one exhibit before they can be diagnosed?

How often must patient display conditions?

Can a patient still be suffering from mental health issues if some conditions are not met?

Therefore it was difficult for psychiatrists to agree on diagnosis

Problematic validity

Are the descriptors really accurate?

Freuds theories were often not disprovable/cannot be falsified

DSM-III (1980) and beyond

DSM-III (1980), DSM-III-R (1987), DSM-IV (1994), DSM-IV-TR (2000), DSM-5 (2013)

Major development in classification

Now reflects the medical/biological model (physiological causation)

No theoretical assumptions about causation - all symptoms and causes can be seen or shown through patient report, direct observation and measurement

If causation is not known, then descriptions of symptoms can be used to diagnose

No assumptions about unconscious processes

Clear, explicit criteria and decision rules

Has improved reliability and validity

See lecture 2 slides for comparison between descriptors of depression

Anxiety and Related DisordersDefinition: Systems that are activated in response to perceived threat. The experience of anxiety is the same in normal and abnormal anxiety. Abnormal anxiety is when the occurrence of anxiety is excessive (more intense than objective level of threat) or inappropriate (in absence of objective threat). It is characterised by overestimation of threat, such that the probability and cost of a negative outcome is exaggerated.

There are three interrelated anxiety systems: the Physical, Cognitive and Behavioural systems;

Physical SystemSympathetic nervous system: fight/flight response

Mobilises all resources in the body to deal with threat

Symptoms: sweating, heart rate increase, trembling etc; classic symptoms of autonomic arousal

Cognitive SystemPerception of threat

Hypervigilance: where attention is focused onto the threat alone

Leads to difficulty concentration on other tasks

Behavioural SystemEscape/Avoidance

Aggression

Freezing

Anxiety Disorders according to DSM-IVCategorised according to the focus of anxiety; experience of anxiety is same/similar in each

Separation anxiety disorderAnxiety when away from primary caregiver

Occurs mostly in children

Specific phobiasIrrational fear of things such as animals, blood, specific situations etc

Social phobiaFear of negative social evaluation

Generalized anxiety disorderExcessive and uncontrollable worry about a range of outcomes

No specific focus of anxiety; worried about everything

Obsessive-Compulsive disorderObsessions: intrusive thoughts or impulses

Compulsions: ritualized behaviours to relieve the anxiety caused by obsessions (such as hand-washing)

Often subjects are aware of their compulsive behaviour

Post-traumatic stress disorderAnxiety at thoughts/memories of traumatic experience

Panic disorder (with/without Agoraphobia)Unexpected/spontaneous panic attacks (at least 2), leading to anxiety about having another attack

Agoraphobia: fear and avoidance of places where panic attacks have occurred

Strong avoidance of source of anxiety will maintain the anxiety (because no experience of going to the place and not having an attack)

Those with severe agoraphobia cannot even leave their homes

Selective Mutism (DSM-V)Occurs mostly in children

Will not talk to strangers/will only talk to certain people

Anxiety disorders are highly comorbid (tend to occur with each other. Most people with mental disorders will have several disorders at the same time) with each other as well as Depression.

Contrast between DSM-IV and DSM-V in Anxiety Disorders ChapterDSM-IVDSM-V

Separation Anxiety Disorder

Specific Phobia

Social Phobia

Generalized Anxiety Disorder

Panic Disorder

Post-traumatic Stress Disorder

Acute Stress Disorder

Obsessive-Compulsive DisorderSeparation Anxiety Disorder

Selective Mutism

Specific Phobia

Social Phobia

Generalized Anxiety Disorder

Panic Disorder

Agoraphobia

New Chapters in DSM-V:

Trauma- and Stressor-Related Disorders:

Inc. Post-traumatic stress disorders and Acute stress disorder

Obsessive-Compulsive and Related Disorders:

Inc. Obsessive-Compulsive disorder

Panic AttackAbrupt and intense fear or anxiety

Anxiety peaks within 10 minutes

Has classic symptoms of autonomic arousal and other associated physical symptoms

Produces fear of dying, losing control, going mad, epilepsy and hear attacks

Two types:

Cued panic (situationally bound): occurs in presence or anticipation of feared stimulus and can be associated with any anxiety or related disorder

Uncued panic (unexpected): specifically associated with panic disorder

Average duration is 10 years before receiving psychological treatment

Anxiety and Stress Related Disorders Chart

DisorderDiagnostic (DSM-V)Causes/Associations

Panic disorderAt least 2 uncued panic attacks

Having anxiety/worry about having another attack

Having concerns about heart attacks, going mad, epilepsy etc because of the panic attacks

Significant behavioural changes to try and avoid having another attack (e.g agoraphobia)

Symptoms persisting for 1+ monthsCognitive theory of Panic disorder:

Bodily sensations (heavy breathing, shaking etc) maybe after strenuous activity

Misinterpretation of sensations as cues for heart attack, death etc

Anxiety

Increased bodily sensations (physical system activated)

Increased anxiety

Persist in cycle until panic attack

Specific phobiasExtreme, disabling fear of specific objects or situations that pose little/no objective danger

E.g animals, injections, heights etc

Person knows what they fear and therefore will have great anxiety when encountering the feared object

Anxiety experienced when encountering object is exaggerated to danger level

Can be associated with cued panic attacks

Symptoms persist for 6+ monthsClassical conditioning: previous experience may cause fear of things related to that event

However: conditioning is not sufficient nor necessary to cause phobia

Some stimuli are more likely to become phobic than others (e.g cliffs, snakes)

Associated with evolution: objects that once posed significant threat to survival

Therefore easier to learn to fear/exists as innate fear

Generalized anxiety disorderExcessive and uncontrollable worry

About wide range of outcomes (2+ for diagnosis)

Physical symptoms different from Panic:

Tension, irritability, restlessness, sleep problems, being on edge, inability to relax

3-6(+) needed for diagnosis

Not classic autonomic arousal symptoms (anxiety)

Symptoms persist for 6+ monthsHigh trait anxiety

Trait: tendency to experience anxiety

Intolerance of uncertainty

Need to be 100% certain negative outcome will not occur

Therefore would rather 100% negative outcome than uncertain positive

Reduced ability to tolerate distress (have a need to reduce possibility of distress)

Reduced problem solving confidence/success (since needs to find a perfect solution; thinks of negative outcome with each solution)

Obsessive-Compulsive behaviourObsessions: repeated, intrusive, irrational thoughts or impulses that cause severe anxiety or distress

A minor thought could cause big distress

Compulsions: ritualized behaviours to relieve anxiety caused by obsessions

No longer anxiety disorder because while anxiety is a big part, lots of other negative emotions also occurIntolerance of uncertainty: need to be sure obsessive thought will not occur (leads to repetition of compulsive behaviour)

However trying to not think about something makes thoughts stronger

Inflated responsibility: blames self for possible negative outcome

Thought-action fusion: thinking is as bad as doing

Magical ideation: creating superstitions and rules that the self believes will lead to good outcome

Post-traumatic stress disorderIntrusive symptoms (1+):

Intrusive images, memories, dreams

Re-experiencing: as if events were recurring

Persistent avoidance of stimuli (1+):

Avoidance of reminders of traumatic event

Negative changes in cognition, mood (2+):

Fear, helplessness, self-blame, anger, hopelessness

Changes in arousal, reactivity (2+):

Sleep disturbance, poor concentration, hypervigilance, exaggerated startle, recklessnessExposure to actual or threatened death, serious injury or sexual violence in 1(+) following ways:

Direct experience

Witnessing event that occurred to others

Learning that traumatic event occurred to close family/friends (violent or accidental)

Experiencing repeated or extreme exposure to aversive details of traumatic events

Eating Disorders

DSM-IVDSM-V

Anorexia Nervosa

Bulimia Nervosa

EDNOS

Subclinical AN or BN

Binge Eating Disorder

Purging Disorder

Night Eating Syndrome

GrazingAnorexia Nervosa

Bulimia Nervosa

Pica

Rumination Disorder

Avoidant/Restrictive Food Intake Disoder

Binge-Eating Disorder

Other Specified Feeding or Eating Disorder

Unspecified Feeding or Eating Disorder

Eating Disorders Chart (DSM-IV)

Anorexia NervosaBulimia Nervosa

DescriptionRefusal to maintain body weight at a minimally normal weight for age and height

Weight is less than 85% of that expected

Intense fear of gaining weight or becoming fat even though already underweight

Two types:

Restricting: successful in restricting intake of foods; usually eat same foods every day

Binging/Purging: sometimes break restriction; then feel like have to compensate for extra calorie intake

Objective binging: eating larger than normal human amount

Subjective binging: larger than normal restricted amount

Body image disturbance

Denial/unable to realize extent of underweight

Undue influence of body weight/shape on self evaluation: believe they will only be happy/good person if they are skinny

Amenorrhoea (periods stop)Binge eating + compensatory behaviours

Recurrent episodes of binge eating

Objective binging

Lack of control over eating during episode

Eating because cannot stop eating

Tend to be ashamed of binging episodes

Recurrent inappropriate compensatory behaviour to prevent weight gain

Purging: self-induced vomiting, laxative abuse

Non-purging: fasting, excessive exercise

Tend to be normal/slightly over weight

Because compensatory methods do not work

Body image disturbance

Associated FeaturesPsychological problems:

Depressed mood, irritability, anger, social withdrawal, preoccupation with food, poor concentration

Often associated with starvation syndrome: become obsessed with food as result of starvation;

Unable to maintain social relationship; complete daily tasks

Comorbid with: mood disorder, anxiety disorders (esp. Social phobia), substance abuse (amphetamines to suppress appetite); personality disorders (OCPD [obsessive])

Physical problems:

Low body temperature, brittle hair/nails, hair growth

Low estrogen -> osteoporosis (brittle bones)

Malnutrition, anaemia, immune system suppression

Mortality rate of 5-10% over 10 year period

Anorexic thinking remains (e.g obsessing over calories) even after patient symptoms no longer meet criteria for DSM-VPsychological problems:

Comorbid mood disorders, anxiety disorders, substance abuse, personality disorders (BPD [impulsive])

Physical problems:

Associated with binges (e.g stomach rupture)

Associated with compensatory behaviours e.g:

Loss of dental enamel, scarring/ulceration of oesophagus, salivary glad enlargement,

Loss of normal bowel function,

Dehydration,

Electrolyte disturbances (irregular heartbeat, heart failure)

EpidemiologyPrevalence

Affects 0.5-1.0% of females

90% of individuals with AN are female

Age of onset

Mid-late adolescence (though getting earlier)

Course

Slow recovery (up to 10 years for most)

20% remain chronically ill

50% then develops BNPrevalence

Affects 1.0-3.0% of females

90% of individuals with BN are female

Age of onset

Late adolescence-early adulthood

Course

Long term outcome better than for AN

10% still affected after 10 years

Proposed Causes of Eating Disorders

BiologicalPsychological

Genetic factors

Family and twin studies suggest moderate heritability component for AN and BN

Chances of depression, personality disorders, substance abuse are also higher in families of persons with ED

No adoption studies have been conducted because of difficulty separating genetics and environment

Neurotransmitter disturbances

Serotonin involved in appetite regulation

There are mixed findings regarding direction of causation

As in serotonin could cause ED, or ED could cause disturbance in serotonin levels

NOTE: ED is becoming more recognised in males (who display the same symptoms), except they want to be overly buff rather than skinny

AN and BN have many features in common

Tendency to base self-worth on weight/shape

Desire to attain unrealistic levels of thinness

Intense fear of gaining weight

High degree of overlap in proposed causes

Cognitive-Behavioural theory (refer to Lecture 5 ppt)

Proposed Psycho-Social Causes

Family factors

Higher parental criticism, control and conflict

Lower parental empathy and support

Comments regarding childs eating/body

Parental modeling of eating/body concerns

Peer factors: social approval

Social-cultural valuesEmphasis on thinness as key basis for attractiveness for females

Note that many non-western cultures had low levels of ED before west invaded

Mood Disorders

Mood Disorders Chapter in DSM-IV:Depressive DisordersBipolar Disorders

Unipolar: negative end of mood spectrum only [Depressive]

Depressive: abnormally low mood

Such as:

Major Depressive Disorder

Dysthymic Disorder

DD-NOSBipolar: extremes in both ends of mood spectrum:

Both Depressive and Manic

Manic: abnormally elevated mood

Manic episodes are extreme highs in normal mood, as opposed to a normally energetic person

Such as:

Bipolar I Disorder

Bipolar II Disorder [mild version of I]

Cyclothymic Disorder

NOS

NOTE: DSM-V both are given own chapters rather than under Mood Disorders

Depressive Disorders:

Major Depressive Disorder

SymptomsDiagnosis

One or more major depressive episodes with symptoms:

Depressed mood for most of the day, nearly every day

Markedly diminished pleasure/interest in activities

Significant weight loss/gain

Recurrent thoughts of death/suicide attempts

Nearly every day:

Insomnia/hypersomnia

Psychomotor agitation or retardation

Fatigue/loss of energy

Feeling worthlessness, excessive guilt

Diminished ability to concentrate

IndecisivenessMajor Depressive EPISODE:

5 or more symptoms including 2. or 3.

Over 2 week period

NOTE: bereavement waives time condition as many symptoms can be also caused by grief

NOTE 2: bereavement condition deleted in DSM-V

Now anyone can be diagnosed with depression after 2 weeks of symptoms

Major Depressive DISORDER:

Single or recurrent episodes, not accounted for by other disorders

One episode will increase risk of recurrent episodes

Risk will build up

Dysthymic Disorder

Renamed persistent depressive disorder in DSM-V

SymptomsDiagnosis

Milder depressed mood compared to MDD e.g

Does not enjoy life; no mood fluctuations

Risk of Double Depression: both MDD and Dysthymia occur where:

Patient sinks into MDD, recovers back into DysthymiaPersistent: continues for at least 2 years

Symptoms may remain unchanged over long periods (20+ years)

Cause

Biological Theories

Genetic VulnerabilityHeritability: 35-60%

Some genes associated with vulnerability to mood disorders in general

More vulnerable to mood disorders when situation triggers it

No specific gene associated with mood disorder/depression

NeurochemistryLow levels of Noradrenalin and/or Serotonin

Only correlation: causal direction is uncertain

Neuroendocrine SystemAlso uncertain if legit cause:

Excess cortisol in response to stress

Cortisol interacts with neurochemicals

Mood disorder = unable to turn stress off (?)

Increased stress strongly related to mood disorders

Biological vulnerability + stress = depression (?)

Psychological Theories

Schema TheoryPre-existing negative schemas based on previous experience

Have distorted view of self, others and environment

Negative schemas activated in bad/stressful situations:

Result in biased [negative] information processing

In turn strengthens schema

Learned Helplessness TheoryNegative events are interpreted based on 3 kinds of factors:

Internal (self is cause of bad outcome)

Stable (situation will always be bad)

General (because world and I are bad)

Positive events are associated to luck

Positive events are diminished and negative are exaggerated

Ruminative Response StylesUnable to disengage from negative outcomes in a situation

Cannot move on from bad event

Interpersonal FactorsThe way patients interact with others

Poor social skills =

Less positive reinforcers in life e.g good job, friends

Rejected by others because of negativity

Gravitate to those who confirm negative self-views

Cognitive vulnerability + stress = depression

Treatments

MethodExplanation/Limitations

BiologicalDrugs

SSRIs

Effective in 70-80%

Electroconvulsive Therapy (ECT)

Used as last resort for severe depression

Effective in 80%SSRIs only inhibit serotonin re-uptake

Fewer side effects compared to older drugs

ECT causes seizure to cure depression

Uncertain why it works

Limitation:

Relapse common when treatment stopped

Suggests treatment only suppresses symptoms rather than targeting cause

PsychologicalCognitive-Behavioural Therapy

Addresses cognitive errors in thinking

Include behavioural components:

Behavioural Activation

Behavioural Experiments

Compared to drug therapy there is lower rate of relapse

29% vs 60%Aims to lead patient into developing more realistic and complex view of world/event

Compared to unrealistically negative viewpoint

NOT encouraging blind positive thinking

Behavioural Activation:

Encourage patient to start doing previously enjoyable things again

Helps to see positively on a cognitive level

Behavioural Experiments:

Testing beliefs - is there really no one who loves you?

Tests to deconstruct negative beliefs

Develops skill to recognise relapse and refrain from it