P - Psychopathology

psychopathology definition

• undesirable state producing severe impairment to a person’s social and personal functioning, often causing anguish

• deviates from the social/statistical norms, causes distress to the individual and others

Definitions of abnormality

• Deviation from social norms

• Failure to function adequately

• Deviation from ideal mental health

• Statistical infrequency

Deviation from social norms

Norms: standards of behaviour that are regarded as acceptable within a given society

• behaviour that doesn’t follow social patterns/rules; varies across cultures/eras

• e.g. clinically abnormal: antisocial personality disorder (may lack conscience and behave aggressively as they experience little to no guilt)

Deviation from social norms - Strengths

strengths:

• can help people as it highlights when its needed

• distinguishes between normal and abnormal

• protects society

Deviation from social norms - limitations

Limitations:

• subjective - dependent on the society

• change over time - often related to moral standards that vary over time as social attitudes change

• human rights abuse - Szasz, mental illness used as a form of control

• situational versus developmental norms

• cultural relativism - must be views in the context of the culture it comes from

Failure to function adequately

• Inability to cope with day-to-day life, caused by psychological discomfort

• Rosenhan and Seligman 1989

  • Suffering → sense of loss

  • Maladaptive → prevents individual from achieving life goals

  • Vividness and unconventionality → way abnormal people behave in situations

  • Unpredictability and loss of control → inappropriate/uncontrolled behaviour

  • Irrationality and incomprehensibility → not always clear why they behave that way

  • Observer discomfort → when we see unspoken rules of social behaviour broken

  • Violation of moral and ideal standards → what happens if out of date?

• global assessment of functioning → DSM-5

Failure to function adequately - Strengths

Strengths:

• matches sufferer’s perspective → most seeking clinical help believe they are suffering

• checklist → allows people to access their level of abnormality

• accesses degree of abnormality → GAF scored on continuous scale

• observable behaviour → allows judgement of others on whether someone is functioning

Failure to function adequately - Limitations

Limitations:

• abnormality does not equal disfunction

• subjective components (e.g. distress)

• awareness → person may not realise abnormality of habits (e.g. hygiene)

Deviation from ideal mental health

• when a person fails to strive for/achieve self-actualisation

• Jahoda 1958

  • self attitudes → sense of identity/high self esteem

  • personal growth → extent of individual growth/development

  • integration → ability to cope with stress

  • autonomy → degree to which someone is independent of social influences

  • perception of reality → clear and not disturbed

  • environmental mastery → extent to which someone is successful and well-adapted

Deviation from ideal mental health - Strengths

Strengths:

• positive approach to mental health

• goal setting → identifies exactly what is needed to achieve normality

• holistic → views individual as whole person rather than individual behaviours

Deviation from ideal mental health - Limitations

Limitations:

• overdemanding criteria → self actualisation only achieved by few

• subjective criteria → not clearly defined and dependent on self-report

• changes overtime → religious visions=schizophrenia

• collectivist societies → would reject autonomy as a criteria

Statistical Infrequency

• Idea that certain behaviours are statistically rare within a population → dependent on normal distribution curve

statistical infrequency - Strengths

Strengths:

• objective → once method of collection and ‘cut off point’ has been decided

• overall view → provides data on what behaviours are infrequent within a population

• no value judgements → not ‘wrong’, just less frequent

• based on real, unbiased data

statistical infrequency - Limitations

Limitations:

• not all infrequent behaviours are abnormal (e.g. high intelligence)

• not all abnormal behaviours are infrequent (10% chronically depressed)

• cultural factors - a behaviour may be normal/abnormal within different cultures

Phobias - definition

• Anxiety disorder characterised by uncontrollable, extreme, irrational, and enduring fears - disproportionate to actual risk

• 10% of population

• 2:1=Female : Male

Phobias → behavioural symptoms

• avoidant/anxiety response → confrontation=high anxiety response, efforts made to avoid

• disruption of functioning → avoidance and anxiety so extreme they interfere with daily functioning

Phobias → emotional symptoms

• persistent and excessive fear → due to presence/anticipation of feared stimulus

• fear from exposure to phobic stimulus → overwhelmed, faint, aware but uncontrolled

Phobias → cognitive symptoms

• irrational nature of thoughts → resistant to rational arguments

• recognition of exaggerated anxiety → generally consciously aware

Types of phobias

• simple phobias

• social phobias

• agoraphobia phobias

Simple phobias

• Fear of specific things and environments

  • animal phobias ^(spiders)

  • injury phobias ^(blood)

  • situational phobias ^(flying)

  • natural environment phobias ^(water)

Social phobias

• involves perception of feeling judged (F2FA and DFMH)

  • performance phobias ^{(playing at concert/eating)}

  • interaction phobias ^{(dating/interview)}

  • generalised phobias ^{(others present)}

Agoraphobia phobias

• fear of leaving home/safe place

• can be brought on by simple phobias

• e.g. fear of contamination

Explanation for phobias

BEHAVIOURAL APPROACH via two process model

1. Acquisition _(onset) → classical conditioning _{(traumatic experience)}

2. Maintenance → operant conditioning _{(avoidance of fear = negative reinforcement)}

Explanations for phobias - Behavioural approach limitations

Limitations:

• reductionist and deterministic, internal processes ignored, not all trauma = phobias

• tabula rasa → fear of falling

• individual differences

• could be vicarious

Treatments for phobias → systematic desensitisation

• aims to extinguish undesirable behaviour ‘fear; by replacing it with a more desirable one ‘relaxation

• reciprocal inhibition: process of inhibiting anxiety by substituting a competing response

1. identifying phobia/fear

2. learn relaxation techniques (progressive muscle relaxation

3. create hierarchy of fear (least to most)

4. work through hierarchy, learning to use relaxation techniques in presence of feared object

• helps to unlearn maladaptive behaviours and replace them with adaptive → recondition

• in vivo = real object, in vitro = imaginary

Treatment for phobias → flooding

• straight to the top of hierarchy and imagine/have direct contact with most feared scenarios

• cannot make usual avoidance responses peaks at such high levels it cannot be maintained and eventually subsides

Treatment for phobias → systematic desensitisation evaluation

• Denholtz, Hall and Mann 1978 → 60% of clients treated for flying phobias continued to fly in 3.5yr follow up period

• works better for some phobias not others (social and agoraphobia more improvement)

• takes around 6-8 sessions

• gives client control but therapist must first find source of anxiety

• evidence that exposure therapy more effective

Treatment for phobias → flooding evaluation

• Wolpe, girl forced into car and driven for 4hrs until hysteria eradicated

• Rothbaum, used VS for exposure therapy, less harm and embarrassment

Depression → definition

• Affective mood disorder involving lengthy disturbance of emotions (including feelings of despondency and hopelessness)

• 20% of population

• women twice as vulnerable as men (post-natal, hormone fluctuations, more likely to report, societal aspects)

• can occur in cycles, episodes generally lasting 2-6m

• can begin in adolescence→ onwards, avg. age of onset in late 20s, decreased in last 50 yrs as rates increase

Depression → diagnosis

• DSM-5

• at least 5 symptoms apparent everyday for at least two weeks, w impairment to general functioning evident that is not accountable for by other medical conditions/events

Unipolar depression _{or major}

• without mania, only depression, more severe can have delusions and social impairment

• 25%F, 12%M

• don’t respond well to anti-depressants, but combo of anti-depressants and anti-psychotics work

Unipolar depression → behavioural symptoms

• loss of energy → fatigue/lethargy/inactivity

• social impairment → reduced official interactions

• weight changes → significant decreases/increases

• poor personal hygiene → reduced incidence of washing

• sleep pattern disturbance → insomnia/oversleeping

Unipolar depression → Emotional symptoms

• loss of enthusiasm → lessened concern/pleasure

• constant depressed mood → overwhelming sadness

• worthlessness → constant reduced worth/guilt

Unipolar depression → cognitive symptoms

• delusions → generally guilt, punishment, disease

• reduced concentration → attention/indecisive

• thoughts of death → death/suicide

• poor memory → poor retrieval

Bipolar depression _{or manic}

two types: _{OR diathesis stress model → vulnerability+events=dep}

1. endogenous depression → related to internal biochemical and hormonal factors

2. exogenous depression → related to stressful life experiences

less common → 2% equally divided between sexes

onset usually from 20-50

mixed episodes of mania and depression

• mania: intense but inappropriate elation = hyperactivity, distractibility, excessive talking, disruptive thought processes

Bipolar depression → behavioural symptoms

• high energy levels → high social and sexual

• reckless behaviour → risk taking and dangerous

• talkative → fast, endless speech without regard for others

Bipolar depression → emotional symptoms

• elevated mood states → constant and intense euphoria

• irritability → frustrated if they don’t get their way

• lack of guilt → social inhibition and lack of guilt

Bipolar depression → cognitive symptoms

• delusions → and grandiose, can believe others are persecuting them

• irrational thought processes → reckless thinking

Explanations of depression - cognitive

generally in terms of faulty/irrational though processes and perceptions, focus on maladaptive cognitions

Beck 1976 → cognitive triad

• believed people become depressed because world is seen through negative schemas which dominate thinking, triggered when in situation to how learned

• schemas develop in childhood and adolescence, when authority figures place unrealistic demands

• negative schemas fuelled by cognitive biases → misperceive reality

Beck 1976 → types of schemas

• Ineptness schema

• Self-blame schema

• Negative self-evaluation schema

Ineptness schema

depressives expect to fail

Self-blame schema

depressives feel responsible for all misfortune

Negative self-evaluation schema

constant reminder of worthlessness

Beck 1976 → cognitive biases

• Arbitrary inference

• Selective abstraction

• Overgeneralisation

• Magnification and Minimisation

Arbitrary inference

conclusions drawn in absence of sufficient evidence

Selective abstraction

conclusions drawn from just one part of a situation

Over-generalisation

sweeping conclusions based on single event

Magnification and minimisation

exaggeration in evaluations of performance

Ellis’ ABC model

• believed depressives mistakenly blame external events for unhappiness, interpretation of events and distress

Activating event → something happens in environment

Beliefs → what you think about the event

Consequences → emotional/behavioural response

• activating event triggers untrue emotion, consequentially have negative view of themselves and lack of confidence

Evaluation of the cognitive explanation for depression

• McIntosh and Fischer challenge Back as they tested the three elements and found no clear separation

• Boury et al. found depressives misinterpret facts and experiences in a negative way and feel hopelessness about the future

• less success in explaining and treating manic component

• other aspects (e.g. genes) considered → not rlly cog.

• high success when treating depression with cognitive therapies → deny causation as thought and depression are more bidirectional

Explanations of depression - biological

• hereditary

• Plomin gene mapping of other 3000 12yr old twins, genetics for 66% of hereditability of cognitive abilities (key feature of depression)

• Wender, depressed adopted children, generally had depressed biological parent

Explanations of depression - behavioural

• learned

• Lewinsohn → negative life events leads to a decrease in positive reinforcements and learned helplessness

• or social learning theory

Depression → rational thoughts

based on reality → individual seeing things as they really are, allows individual to achieve goals and real full potential, only experience emotions they can handle

Depression → irrational thoughts

distorts idea of reality → blocks/stops you from achieving goals and life purposes

→ extreme emotions which persist and cause distress → harmful to self and others

Treatment of depression → Cognitive behavioural therapy

• main psychological treatment, central idea behind is that beliefs, expectations and cognitive biases affect self perception and approach to problems

• Two main:

  • Rational Emotive Behavioural Therapy (REBT), based on Ellis’ ABC model

  • Treatment of Negative Automatic Thoughts (TNAT), based on cog. triad, schemas, biases

• central idea of both is to challenge and restructure maladaptive ways of thinking into adaptive

  • Kendall and Hammen → clarify, change and challenge both cognitive and behavioural processes (challenge interpretive bias)

Treatment of depression → Beck 1976 CBT

• reality testing, more than just replacement of negative to positive, emphasises homework and hypothesis testing

• predictions=pessimistic, fear=groundless

• ~20 sessions over 16 weeks

• Strategies:

  • behavioural activation (identify fun activities and do them)

  • graded homework (practice new ways of thinking)

  • though catching

  • cognitive reconstruction

  • problem solving (find root and test it)

Treatment of depression → REBT procedure

1. Reframing → challenge through reinterpretation, 1-2 sessions per week over 15 weeks, therapist and client work together

2. Educational → learn relationship between thoughts, emotions and behaviour

3. Behavioural activation and pleasant event scheduling → increase physiological activity and participation

• If improvement in mood and activity = opportunity to challenge thoughts

• given goals between sessions

• hypothesis testing of negative thoughts through behavioural coping skills

Treatment of depression → drug therapy

• Antidepressants have physical affect of increasing serotonin production

  • selective serotonin reuptake inhibitors (common→fluoxetine)

Treatment of depression → evaluation of CBT

• Hollon et al. 40% of moderately to severely depressed patients treated with CBT for 16w relapsed within the following 12m → 45% w drug, 80% for placebo

• Department of Health 2011, reviewed treatments and found CBT to be most effective, but didn’t endorse use alone

• trained therapists essential to effectiveness → ethical concerns as easy to abuse for dependence

• many believe thought process and depression to have a bidirectional relationship

• relatively short time frame for long term benefits (cost effective)

• unsuitable for patients who lack focus, may enhance symptoms instead

OCD → definition

characterised by persistent, recurrent, unpleasant thoughts and/or repetitive, ritualistic behaviours

OCD thought cycle and population

• obsessions and compulsions are very time consuming and therefore interfere with ability to conduct everyday activities

• 2% of population, no real gender differences in rate but present in types

• F: contamination and cleaning

• M: religious and sexual

• M have an earlier onset, with more gradual but severe symptoms

Obsessive-Compulsive and related disorders in the DSM-5

• OCD

• Hoarding disorder: compulsive gathering of possessions and inability to part

• Trichotillomania: compulsive hair pulling

• Excoriation: compulsive skin pulling

Obsession vs Compulsion

O: forbidden/inappropriate ideas and visual images that aren’t based in reality

C: intense, uncontrollable urges to repetitively perform tasks and behaviours to reduce distress

Obsessions: Behavioural symptoms

• Hinder everyday functioning → obsessive ideas of forbidden/inappropriate type creates anxiety

• Social impairment → anxiety levels generated so high, limits ability to conduct meaningful interpersonal relations

Obsessions: Emotional symptoms

• extreme anxiety → persistent inappropriate thoughts or persistent inappropriate/forbidden ideas create excessively high levels of anxiety

Obsessions: Cognitive symptoms

• Recurrent and persistent thoughts → constantly repeated obsessive and intrusive thoughts

• Recognised as self generated → most understand thoughts and images are self-invented

• Realisation of inappropriateness → understand but cannot consciously control

• Attentional bias → perception focused on anxiety generating stimuli

Common obsessions

• contamination

• fear of losing control

• perfectionism

• religion

Compulsions: behavioural symptoms

• Repetitive → feel compelled to repeat behaviours in response to obsessions

• Hinder every day functioning and social impairment

Compulsions: Emotional symptoms

distress → recognition that compulsion behaviours cannot be consciously controlled = strong feeling of distress

Compulsions: Cognitive symptoms

• uncontrollable urges → feel they will reduce anxiety

• realisation of inappropriateness

Common compulsions

• excessive washing and cleaning

• excessive checking

• repetition

• mental compulsions

• hoarding

OCD diagnosis

presence of obsessive and compulsive symptoms on most days for 2 weeks

Explanations of OCD: biological approach

determined by physiological means with treatments based on chemical means

also called the medical model, two explanations:

• hereditary influence of genetics

• damage to neural mechanisms

Explanations of OCD: Genetic

• Lewis 1936 → 37% had parents with OCD, 21% had siblings with OCD hence suggesting genetic vulnerability

• Nestadt et al. 2010 → reviewed twin studies, 68% of MZ twins shared OCD, support genetic influence

• unlikely single gene causes OCD, but combination (polygenic) - Taylor 2013 up to 230 different genes involved

• COMT gene → regulates breakdown of dopamine implicated in OCD, decreased activity of gene=increased levels of dopamine

• SERT gene → affects transport of serotonin, decreased activity=decreased serotonin

Explanations of OCD: Neural

• link to breakdown of immune system functioning

• PET scans show high levels of activity in orbital frontal cortex

• abnormal brain circuits

• abnormal serotonin levels

Neural explanations of OCD: immune system

• (e.g. strep throat) → Lyme disease and influence (often why onset seen in children)

Neural explanations of OCD: orbito-frontal cortex

• associated with higher level thought processes and conversion of sensory information

  • help initiate activity upon receiving impulse to act and stop when lessened

  • difficulty switching off impulses → obsessions

Neural explanations of OCD: abnormal brain circuits

• areas of frontal lobe abnormal

  • caudate nucleus normally supresses signals from OFC (sends signal to thalamus about worry)

  • if caudate nucleus damaged, fails to supress minor worry signals

Neural explanations of OCD: abnormal serotonin levels

• high dopamine and low serotonin, SSRIs reduce OCD symptoms (block reabsorption)

Treatments for OCD → Drug therapy

• antidepressants, e.g. SSRIs, elevate serotonin allowing the OFC to function at normal levels

  • most common → Prozac for adults, Sertaline for 6yr olds, Fluvoxamine for 8yr olds and older

  • Julien 2007, SSRIs show (although symptoms do not fully disappear) between 50-80% of OCD patients improve to live semi-normally

ONLY GIVEN IF SSRIs INEFFECTIVE:

• anxiolytic drugs → anxiety lowering properties (e.g. benzodiazepines, slows CNS)

• antipsychotic drugs → dopamine lowering effect

Treatments for OCD → Psychosurgery

• last resort, involves destroying brain tissue to disrupt cortico-striatal circuit by use of radiofrequency waves, effects OFC, thalamus, and caudate nucleus = decrease in symptoms

  • recent movement towards using deep brain stimulation

• relatively small success rate with serious side effects that can’t be undone, acceptable only for severe forms when no response to other treatments

• 10% of patients with OCD get worse overtime, even with drug treatments

Treatments for OCD → CBT

• focus on changing obsessional thinking to reduce anxiety created (HIT relive → repeated exposure),

  • come to understand thought and action are not the same through realistically accessing risk

  • encouraged to disregard former maladaptive ones

  • most effective with drug treatments

Treatments for OCD → Evaluation

• Pitcher 2004, had 35% decrease of symptoms after surgery; complications → seizures, but were at risk of suicide so relative success

• O’Conner 1999, 3 conditions (drug, CBT, combo), most success with drug and CBT combo