Abnormal

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Abnormal

• Psychology 101 Section 002

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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

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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

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Defining Abnormal Behavior

• I prefer the 4 Ds
• Dysfunctional behavior (maladaptiveness of
  ineffectiveness)
• Deviance (Bizarreness, social deviance)
• Distress (discomfort)
• Dangerousness

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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 ones
  hair, starving)

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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)

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Characteristics Criteria for Defining Abnormal
Behavior3

• 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).

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• 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.

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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.?)

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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)

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Terms for Abnormal Behavior

• Abnormal Behavior
• Psychological Disorder-a preferred term
• Psychological Problems
• Psychiatric Disorder-a preferred term
• Psychopathology-medical term
• Deviant Behavior
• Mental Illness-medical term.
• Disorder is probably a better term.
• Deviance-used by sociologists
• Mental Disease

• Mental Problems
• Mental Difficulties
• Nervous Disorder
• Emotional Disorder
• Emotional Problems
• Emotionally Disturbed
• Maladaptive Behavior
• Psychologically Handicapped
• Sociopathy
• Sociopath
• Psychopath
• Adjustment Disorders

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Terms for Abnormal Behavior 2

• Organic Brain Disease/Psychogenic disease
• Developmental Disorders
• Poor Mental Health
• Insanity-legal term which has no meaning in DSM
  IV
• "Neuroses"-no longer used
• Nervous Breakdown"- a laypersons term
• Psychoses
• Personality Problems/Disorders
• Problems in Living--preferred by those opposed to
  diagnosis

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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

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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. 

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Frequency/Prevalence of Serious Mental
Disturbances 2

• Of every 100 people in the U.S.
• 13 Anxiety Disorder
• 10 Alcohol and Drug abuse problems
• 6 Profound Depression
• 5 Personality Disorder
• 1 Schizophrenia
• 1 Alzheimers
• 36  
• Friedman et al, 1996, Kessler et al, 1994, 1996

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Sex Differences (One-Month Prevalence Rate)

• Men Women
• Substance Abuse 6.3 1.6
• Antisocial PD .8 .2
• Mood Disorders 3.5 6.6
• Anxiety Disorders 4.7 9.7
• Eating Disorders mostly
• Somatization neg. .2

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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

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Taxonomies Imply Levels of Knowledge

• Symptom
• Syndrome
• Disorder a cluster of symptoms not accounted
  for by another problem
• Disease underlying etiology is known

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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

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Some Axis I Clinical Disorders

• Anxiety Disorders
• Mood Disorders
• Schizophrenia other Psychoses
• Somatoform Disorders
• Sexual Dysfunctions
• Dissociative Disorders
• Substance-related Disorders

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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.       
•      

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Stress Adjustment Disorders PTSD

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

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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.
•  

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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.

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Anxiety Disorders cont.

• Obsessive-compulsive Disorder- (persistent
  thoughts, images, that invade a persons
  consciousness) repetitive and rigid behaviors or
  mental acts that a person feels compelled to
  perform to avoid anxiety).
• Post-traumatic Stress Disorder
• Acute Stress Disorder
• Generalized anxiety disorder (pervasive anxiety)

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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. 

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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.

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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)

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Depression 2

• --------------------------------------------------
  -
• Model 
• Diatheses Personality Life Events
  ---gtDepression 
• 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

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Psychotherapy
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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

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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?

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Psychotherapy cont.

• How important is the therapeutic relationship?
• Outcome studies vs process studies
• Common vs specific factors

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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.

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Psychotherapy

• How does it differ from what a friend does? In
  many ways it doesnt.
• 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?

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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

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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

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Common vs. Specific Factors

• How are all types of psychotherapy alike?

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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

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Some specific factors

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

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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.?

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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)

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Research on Psychotherapy

• How do you define success?
• Placebo controls (wait-list)
• Medications only
• Sloan study, Temple study, Vanderbilt study.
• NIMH

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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.

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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.

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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

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Treatment cont.

• 10. Personality Disorders in general therapy
  doesnt 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 Dont 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.

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Insanity Defense 1

• Mens Rea (Guilty Mind or Evil Intent)
• 1843 MNagten Rule (Right from Wrong)
• late 1800s   Irresistible Impulse
• 1954 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.

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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).

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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.

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Insanity Defense 4

• Civil Commitment 
•  
•   Danger to themselves or others 
•   Need treatment 
•   Clear and convincing evidence of dangerousness
  (75 sure)                          

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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.