Transcript 19 Psychopathology I -- Wilson 2006 -

Introduction to
Psychopathology
Michael Wilson, PhD
University of Illinois Department of Psychology
and
University of Illinois College of Medicine
Outline
• Defining abnormal behavior
• Freud’s view of personality
• Modern view of abnormal behavior
A clinical vignette
A primary care physician notices that many of her
patients use statements like “I can’t stop smoking
because I’ll gain weight.” Another patient who lost
an arm in an accident states “It was good that I lost
my arm since it keeps me out of trouble with the
law.” Statements like these:
A.
B.
C.
D.
E.
produce conflict in the conscious mind
are conscious mental techniques
increase anxiety
are examples of the use of defense mechanisms
decrease patient’s sense of self-esteem
Mental Disorder vs.
Abnormal Behavior
Mental Disorder
Abnormal Behavior
Mental Disorder
and
Abnormal Behavior
Mental Disorder vs.
Abnormal Behavior
Mental Disorder
Abnormal Behavior
Mental Disorder vs.
Abnormal Behavior
Mental Disorder
Abnormal Behavior
Defining Abnormal Behavior
• Personal distress
– subjective report of problems
• Social impairment
– violation of moral standards
– observer discomfort
• Statistical deviance
– relative frequency of abnormal behavior
– 15-20% of women may experience major depression
in lifetime
What is abnormal behavior?
• Abnormal behavior is a natural, fuzzy concept
– but illness is tricky to define
• Involves identifying certain symptoms or
syndromes that co-occur with mental
disorders
– plus some sort of assessment of
impairment
– plus some sort of assessment of distress
Public Prejudices About Mental
Illness
Freud’s view of psychopathology
Freud believed that mental life is like an iceberg.
Sigmund Freud (1856-1939)
• Like an iceberg, most mental life is invisible
• Three levels of functioning:
– conscious (what we are aware of)
– preconscious
• not part of our everyday experience, but can be made
conscious
– unconscious
• “powerful primitive drives and forbidden wishes” that
constantly pressure conscious mind
More Freud…
• People struggle with primitive drives and forbidden wishes
– some of which are biologically generated
– most of which are relegated to unconscious
• Unconscious wants uninhibited fulfillment of these wishes
– This is psychic reality that motivates human behavior
– Victorians did not like idea that they were powered by base drives
(e.g., sex).
• Reality/socialization construct conscious belief that these
behaviors are controllable
– In other words, prudish Victorians could pretend behavior not
motivated by sex
More Freud…
• Topographic model
– extension of theory
– Reality/social forces could not allow gratification of
many primitive desires
– produces conflict
– this leads to psychologically-derived disturbing
symptoms
More Freud…
• Structural model of the mind
– refinement of topographic model
– Id = source of instinctual drives, functions unconsciously, strives for
gratification of desires without taking reality into account
• the pleasure principle
– Superego = internalized moral standards, values, prohibitions
• This is the conscience
• uses guilt to prohibit unacceptable behavior
• largely unconscious
– Ego = aspect of the mind that relates to reality
• evolves from id and organizes ways to get what people want in the real
world
• prevents anxiety or guilt that would arise if became aware of id or
violated superego rules
• sometimes uses defense mechanisms to prevent this
More Freud…
• Intrapsychic conflict & anxiety are central features of
human psychological functioning
– the number, nature, and outcome of these conflicts shape
personality
– Ego’s mechanisms of defense protect against psychic dissolution or
annihilation
– As individuals mature & resolve intrapsychic conflict, can learn to
use more adaptive and mature defenses
– Although abnormalities in development of defense mechanisms
may cause various forms of psychopathology, defenses are not of
themselves pathological
• Often maintain healthy psychological well-being
Definitions
• Neurosis
– Freud: situation where ego fails to resolve conflicts between
superego & id
– modern use: any unpleasant mental symptom that does not
interfere with rational thought
• Psychosis
– Freud: situation where the “ego gets carried away by the id
and detaches from reality”
– modern view: a disturbance of rational thought, may involve
hallucinations or delusions
Primitive Defenses
• Range in severity from psychotic to borderline
psychological functioning
– Denial
• Refuse to acknowledge external reality
• Example: An alcoholic believes he is only a social drinker
– Projection
• Attributing personally unacceptable feelings to others
• Example: A man with homosexual tendencies begins to believe
his boss is homosexual
– Splitting
• Categorizing people or objects into “good” and “bad”
• Example: A patient with a personality disorder tells the doctor
that all of the doctors are wonderful, all the RNs are rude
Immature Defenses
• Passive-Aggressive Behavior
– Indirect expression of anger, frustration or aggressive impulses
towards others, passive resistance
– Example: taking long time to get ready for party that don’t want
to attend
• Acting Out
– Avoiding unacceptable emotions by behaving in an attentiongetting manner
– A toddler feels abandoned and begins to throw his toys around
• Regression
– Return to previous stage of development or functioning
– Example: a toddler begins to wet the bed when his mom has a
baby
Neurotic Defenses
•
Displacement
–
–
•
Dissociation
–
–
•
Control of feelings and impulses by thinking about them instead experiencing them
Example: Med student who has cancer calmly explains the pathophysiology of the diease
Rationalization
–
–
•
Temporary but drastic modification of personal identity/character to avoid emotional distress
Example: A teenager has no memory of the car accident in which he was driving & his girlfriend
was killed
Intellectualization
–
–
•
Express emotion to a different object than the one causing conflict
Example: Man who gets angry kicks the dog.
Justification of attitudes, beliefs, or behavior that may be otherwise unacceptable
Example: A man who loses an arm in an accident says that the loss was good because it keeps
him from getting in trouble with the law
Reaction Formation
–
–
Unacceptable impulses are expressed in antithetical form as the opposite
Example: Man who feels guilty about pornography goes on anti-smut crusade
Mature Defenses
• Altruism
– Service to others
– Example: donating to charity
• Humor
– Jokes focus attention away & distracts from the feeling
– Example: A man uncomfortable about ED jokes about viagra
• Sublimation
– Acknowledgement & subsequent channeling of thoughts, feelings
and behaviors in a socially valued way
– Example: A teenager who fights a lot becomes a boxer
• Suppression
– Conscious or semiconscious decision to postpone attention to an
impulse or conflict
– An M1 mentally changes the subject when her mind wanders to
the anatomy practical during lecture
Psychosexual development
• Postulated inborn developmental sequence
– individuals, starting in infancy, experience linear
progression from each phase to next
– psychic conflict leads to fixation or regression to
earlier stage
Stage
age
oral
1
Oedipus/Electra complex
anal
2
phallic
3-5
…latency period…
genital
teens-death
Later theorists
• Later researchers have argued that internal
traits cannot accurately predict behavior
– Must take into account motivations and
development, individual differences, & life
narrative
• = internalized & evolving story of one’s life
Changing behavior externally
TERM
DEFINITION
OUTCOME
Positive Reinforcement
a reinforcer that gives
something desirable after a
behavior
increases behavior
Negative Reinforcement
a reinforcer that takes away
something aversive (avoidance
behavior the result)
increases behavior
Positive Punishment
a punishment that gives
something undesirable after a
behavior
decreases behavior
Negative Punishment
a punishment that removes a
positive reinforcer after a
behavior
decreases behavior
Extinction
discontinuing a reinforcer that
maintained a behavior
decreases behavior
Developmental Cognitive
Neuroscience
• “Human behavior emerges from embedded
and interacting complex systems that include
the genome and its expression in epigenesis
and development, the brain, interacting
psychological functions, and the individual in
his or her social and cultural contexts.”
– Pennington, B (2002). The Development of
Psychopathology. Guilford Press
Classifying abnormal behavior
• If behavior = interacting & complex
systems
– how may it be described?
– what is abnormal?
How then do we classify
abnormal behavior?
• DSM-IV lists criteria for mental illness
– Depends on observations and
descriptions
• rather than internal traits or causes
– Categorical
– Multi-Axial
Why use a standard classification
system for mental illness?
• Benefit: a shared scientific language
– All illnesses have some sort of agreed-upon
classification
– Facilitates description
– Aids treatment decisions, prognosis
– Facilitates research on etiology, treatment outcome
– Facilitates 3rd-party reimbursement
• Concerns about classifying mental illness
– Unlike other illness, many diagnoses stigmatized
– may lead to discrimination
– Unrelated problems may be misattributed to Dx
Description of DSM-IV System
• Axis I -- Clinical disorders
 Mostly characterized by episodic
periods of psychological turmoil
• Axis II -- Personality disorders and
mental retardation
 Mostly concerned with stable,
longstanding problems
Description of DSM-IV System
• Axis III -- General Medical Conditions
 Conditions relevant to etiology of patient’s
behavior or treatment program
– Example: Diabetes
• Axis IV -- Psychosocial & Environmental
Problems
 Factors that may affect the treatment and
prognosis of mental disorder
– Example: Poverty
Description of DSM-IV System
• Axis V -- Global Assessment of
Functioning
 Rating of 1 to 100 of individual’s overall
level of functioning
 Usually assessed at several points
a. highest in last year
b. at intake
c. current
Axis V: Global assessment of
functioning (GAF) scale
90 -100: Superior functioning in a wide range of activities,
life’s problems never seem to get out of hand, is sought
out by others because of his or her many positive
qualities. No symptoms.
51-60: Moderate symptoms (e.g., flat affect and
circumstantial speech, occasional panic attacks) OR
moderate difficulty in social, occupational, or school
functioning (e.g., few friends, conflicts with peers or coworkers).
1-10: Persistent danger of severely hurting self or others
(e.g., recurrent violence) OR persistent inability to
maintain minimal personal hygiene or serious suicidal
act with clear expectation of death.
Limitations of the DSM-IV
• Arbitrary boundary between normal and
abnormal
 Cutoff points not always empirically
justified
 Reliance on clinicians’ subjective judgment
 Time periods in definitions of diagnoses
Limitations of the DSM-IV
• Problem of comorbidity
 Simultaneous appearance of two or more
disorders in the same person
 56% of those who meet criteria for one
disorder also meet criteria for at least one
other disorder
 Comorbidity affects validity of the system
and the reliability of diagnosis
Last word (for now) on
classification:
• Beware of “Intern's syndrome”
– Tendency to diagnose one's self while studying
any particular disorder
– look at frequency and severity of
symptoms
• as well as number of symptoms
A clinical vignette
A primary care physician notices that many of her
patients use statements like “I can’t stop smoking
because I’ll gain weight.” Another patient who lost
an arm in an accident states “It was good that I lost
my arm since it keeps me out of trouble with the
law.” Statements like these:
A.
B.
C.
D.
E.
produce conflict in the conscious mind
are conscious mental techniques
increase anxiety
are examples of the use of defense mechanisms
decrease patient’s sense of self-esteem
Readings
• Fadem (4th edition), chapter 6