Unit 1 Notes: Abnormality, History, Approaches, and Case Formulation

ABNORMALITY: Criteria for Defining Mental Disorder

• Core question: Is there a criteria for abnormality? Common criteria discussed across slides include:
  • Statistical Rarity
  • Social Norm Violation
  • Personal Distress
  • Disability (Impairment in daily functioning)
  • Harmful Dysfunction (Wakefield, 1992)
• Abnormality is often viewed as (i) a deviation from statistical norms, and (ii) something that disrupts functioning or causes harm, but (iii) may be influenced by culture and values. This creates ethical and contextual complexity in labeling behaviors as disorders.

HARMFUL DYSFUNCTION

• Wakefield (1992) proposed mental disorders can be defined as harmful dysfunction, consisting of two parts:
  • A value judgment: harm (the behavior or condition is harmful).
  • An objective, scientific component: dysfunction (an internal mechanism fails to perform its natural function).
• Key points:
  • The harm component relies on a standard that is likely to depend on social norms and values.
  • Dysfunctions occur when an internal mechanism cannot perform its evolved natural function.
  • The concept links philosophical value judgments with empirical questions about brain processes.

DSM-5: Essential Characteristics of a Mental Disorder (Stein et al., 2010)

1) It occurs within the individual.
2) It involves clinically significant difficulties in thinking, feeling, or behaving.
3) It involves dysfunction in processes that support mental functioning.
4) It is not a culturally specific response to a known event.
5) It is not primarily a result of social deviance or conflict with society.

ABNORMALITY: Recap of Key Concepts (Slide Consolidation)

• Abnormality criteria clusters: Statistical Rarity, Social Norm Violation, Personal Distress, Disability, Harmful Dysfunction.
• Each criterion has limitations and cross-cultural considerations; real-world judgments often require integrating multiple criteria.

MENTAL HEALTH PROFESSIONALS: Roles, Training, and Licensure

CLINICAL PSYCHOLOGIST

• Education and training pathways:
  • 2-year MA or MSc in Psychology
  • 4–7 year Ph.D. or Psy.D. program
• Core competencies:
  • Assessment and diagnosis of psychopathology
  • Psychotherapy
  • Specialization in a disorder or therapy form
  • Supervision and intensive internship in hospital/clinic
  • Licensure to practice

CLINICAL PSYCHOLOGIST (IN INDIA)

• Licensure: Licensure is given by the Rehabilitation Council of India (RCI).
• Career paths (current system):
  • Assistant/Associate Clinical Psychologist after 1-year PG Diploma in Clinical Psychology
  • Licensed Clinical Psychologist after 2-year M.Psy in Clinical Psychology
  • Consultant Clinical Psychologist after 4-year Psy.D in Clinical Psychology
• All paths require supervision and postings; Psy.D enables specialization.

PSYCHIATRIST

• Training path:
  • 4-year MBBS
  • 3-year MD or DNB in Psychiatry
  • Residency and supervision in diagnosis and pharmacotherapy
• Roles:
  • Prescribe psychoactive medications
  • Primarily physicians: assess physical parameters, diagnose medical problems
  • Also trained in psychotherapy

COUNSELLOR

• Education: 2-year Masters in Counselling
• Focus:
  • Acute emotional distress
  • Prevention & education
  • General life problems (educational/vocational guidance)
• Work settings: schools, mental health agencies, industry, community health centers, NGOs

PSYCHIATRIC NURSE

• Education: 4-year BSc Nursing; 2-year MSc Nursing
• Focus:
  • Medication management, dosing
  • Handling outbursts and inpatient care

PSYCHIATRIC SOCIAL WORKER

• Education: 3-year B.S.W./BA/BSc; 2-year MSW
• Focus:
  • Psychosocial case management, community intervention, some psychotherapy
• Note: Training in psychological assessment/psychodiagnostics is limited

MARRIAGE / FAMILY THERAPIST

• Education: 2-year MA/MSc in Psychology or Allied Sciences; additional certification in Marriage & Family Therapy
• Focus: treat families or couples; examine how relationships affect mental health; potential for advanced study/specialization

HISTORY OF PSYCHOPATHOLOGY: Timeline Overview

• Early Demonology
  • Belief: evil spirits or supernatural forces cause abnormal behavior
  • Lack of scientific brain understanding; supernatural explanations common
  • Common practices: trephination, exorcism, prayer and fasting
• Early Biological Explanations (pre-19th century emphasis)
  • Hippocrates distinguished medicine from magic/superstition; illnesses have natural causes
  • Brain considered the organ of consciousness, intellect, and emotion
• Dark Ages & Lunacy Trials; Development of Asylums; Humanitarian Movement; Moral Treatment (19th century)
  • Lunacy trials sought to judge insanity by assessing orientation, memory, intellect, daily life, and habits (13th-12th centuries context)
  • Bethlehem Royal Hospital (Bedlam) as a notable historic asylum; social perceptions of mental illness shaped treatment approaches
  • Emergence of humanitarian and moral treatment approaches in some settings; movement toward more humane care
• 19th Century U.S. and Europe: Moral Treatment and Asylum Reform
  • Dorothea Dix and advocacy for better mental health care
  • Introduction of moral treatment concepts and organized asylums with improved living conditions
• Terminology and Cultural Legacy
  • Terms like “bedlam” entered common language to denote chaos or uproar; hospital and asylum history influenced contemporary stigma and language

DETAILED HISTORICAL SLIDES: Key Figures and Concepts

• Lunacy Trials (13th century onward): Crown’s right to protect; judgement of insanity; evaluation of orientation, memory, intellect, daily life, and habits
• The Royal Hospital of Bethlehem (Bedlam): historic emblem of mental institutions; later perceptions and public tours
• 1784 Lunatics Tower: exemplary of early institutional responses
• Exemplar asylums and advocates: Benjamin Rush (MD), Bicetre, etc. (as listed in slides)
• Shift toward humanitarian approaches and reform movements in the 18th–19th centuries

APPROACHES TO PSYCHOPATHOLOGY

BIOLOGICAL APPROACHES

• Notable concepts and treatments:
  • General Paresis (neurosyphilis) and other biological underpinnings of mental illness
  • Eugenics Movement (historical context and ethical concerns)
  • Biological treatments: insulin coma therapy, electroconvulsive therapy (ECT), prefrontal lobotomy
• Key figures highlighted:
  • Lucio Bini; Ugo Cerletti (pioneers associated with ECT)
• Ethical/Practical implications:
  • Eugenics and its misuse; the importance of distinguishing scientific inquiry from coercive social policies
  • The evolution of medical treatments and the need for evidence-based practice

PSYCHOLOGICAL APPROACHES

• Early influences:
  • Mesmer and the era of magnetism; Charcot and hypnosis; Breuer & Cathartic Method
• Studies on Hysteria: Breuer & Freud
• Neo-Freudians: Jung, Adler
• Adler: Individual Psychology
  • Core ideas: Inferiority feelings drive striving; compensation; style of life; birth order effects
  • Birth order theory details: oldest, middle, youngest, twin; characteristics and dynamics in families
• Jung: Analytical Psychology
  • Personal unconscious vs collective unconscious; archetypes and universal symbols
  • Archetypes include: The SAGE, CREATOR, HERO, EXPLORER, MAGICIAN, LOVER, RULER, CAREGIVER, INNOCENT, JESTER, OUTLAW, ORDINARY GUY/GIRL, etc.
  • Anima/Animus, Shadow, Persona, Self concepts; individuation as a growth process
• MBTI (Myers-Briggs Type Indicator) framework:
  • Four dichotomies: Extraversion vs Introversion (E/I); Sensing vs Intuition (S/N); Thinking vs Feeling (T/F); Judging vs Perceiving (J/P)
  • Resulting 16 personality types (e.g., ENTJ, INFP, ISTJ, etc.)
  • Examples from slides mapping Bridgerton characters to typologies (illustrative, not diagnostic):
  • ENTJ: Daphne? (note: mapping shown in slides with various characters)
  • ISFP: Eloise Bridgerton? (illustrative)
  • ISTP: Colin? (illustrative)
  • ESFP: Simon Basset? (illustrative)
  • Important caveat: MBTI is a popular culture tool; not a definitive measure of psychopathology or personality.

COGNITIVE AND BEHAVIOURAL APPROACHES (CBT and Related)

• Cognitive Perspective (Beck, Ellis, Neisser, Seligman)
  • Core idea: Thoughts, feelings, and behaviors influence each other
  • Negative schemas and cognitive biases contribute to depressive and anxiety processes
• Cognitive Schemas, Biases, and Triad (Beck, 1960s–1990s)
  • Cognitive schemas: persistent, dysfunctional attitudes formed by early experiences
  • Cognitive biases: systematic errors in judgment (e.g., overgeneralization, jumping to conclusions)
  • Cognitive Triad: negative views about self, world, and future
• Types of Maladaptive Schemas (examples shown):
  • Abandonment, Vulnerability to Harm/Illness, Defectiveness/Shame, Social Isolation, Entitlement, Self-Sacrifice, Grudges, etc.
• Irrational Beliefs (Ellis; 4 main types):
  • Demandingness (e.g., I must get that job)
  • Frustration Tolerance (it would be awful if I didn’t get it)
  • Self/Other/Life evaluation (I will be a total loser if I don’t get promoted)
  • Global rating of self/others/life (universal judgments about worth)
• ABCDE Model (Beck/Ellis/Seligman):
  • A = Adversity/Activating event
  • B = Beliefs about the event
  • C = Consequences (emotional/behavioral)
  • D = Disputation (challenge irrational beliefs)
  • E = Effective new beliefs (new adaptive beliefs)
  • Example from slides: choir selection as adversity; self-doubt as belief; sadness as consequence; disputation leads to healthier beliefs
• CBT Core Formula: Thoughts, Feelings, Behaviors interact and influence each other; goal is to modify maladaptive thoughts to change feelings and behaviors

DIATHESIS-STRESS MODEL

• Central idea: Psychological disorders arise from an interaction between a predispositional factor (diathesis) and environmental stressors
• Diagrammatic expression:
  • ext{Diathesis} + ext{Stress}
    ightarrow ext{Psychological Disorder}
• Diathesis encompasses:
  • Biological factors: genetics, brain chemistry, biological vulnerabilities
  • Psychological factors: coping style, temperament, early attachment
  • Social factors: isolation, lack of social support, discrimination
• Stressors include:
  • Childhood abuse (physical/sexual), neglect, family conflict, life changes, economic hardship, health issues, etc.
• Protective factors can buffer the impact of diathesis and stress, improving prognosis
• The model emphasizes that higher diathesis requires less stress to trigger a disorder, and vice versa

BIOPSYCHOSOCIAL MODEL (4P Factor Model)

• Four-factor framework across three domains:
  • Biological: genetic vulnerability, prenatal exposures, birth complications, traumatic brain injury; iatrogenic factors; drug effects; sleep/health status
  • Psychological: attachment style, personality traits, coping strategies, beliefs about self/others/world; insights and cognitive strategies
  • Social: family dynamics, poverty, stability of home, support networks, school context, community resources, cultural norms
• The 4P model components:
  • Predisposing factors
  • Precipitating factors
  • Perpetuating factors
  • Protective factors
• Case example structure (Biopsychosocial Formulation):
  • Predisposing: genetic vulnerabilities, early abuse, insecure attachment, etc.
  • Precipitating: recent stressors or triggers (e.g., relationship breakup, health issues)
  • Perpetuating: ongoing stressors, cognitive patterns, avoidance, poor coping
  • Protective: supportive relationships, coping skills, routines, safety plans

CASE FORMULATION: 5 P’s Framework (Macneil et al., 2012)

• Presenting Problem: main current issues/symptoms the client experiences
• Predisposing Factors: background factors making the person vulnerable (early experiences, temperament, family history)
• Precipitating Factors: events or triggers that immediately preceded onset
• Perpetuating Factors: factors that maintain or worsen the problem over time
• Protective Factors: strengths and resources that buffer against the problem and support recovery

CASE STUDY EXEMPLARS (Slides 119–125)

Cinderella Case (Depression Presentation)

• Profile: 20-year-old female referred for depression; presents with repeated crying spells, persistent sadness, anhedonia (no interest in eating or singing)
• Perceived trigger: breakup with Prince; emotional cue tied to glass slippers (symbolic)
• Background:
  • Lives with her Evil stepmother and two Evil stepsiblings; domestic servant in her own home; homeschooled
  • Childhood bullying by stepsisters; punitive treatment by stepmother; few childhood friends
  • No reported chronic physical illness; self-reported good physical health and quick recovery when ill
• Relationships:
  • Father: loving until father’s death; after his death, the father’s second marriage affected his mood and drinking
  • Biological mother: pleasant memories, died early; distant relationship
  • Aunt: highly supportive; provides clothing and transport to events; important protective factor
• Daily functioning (pre-depression):
  • Engaged in chores, hobbies (knitting, singing, visiting fairy aunt)
  • Maintained house duties (dusting, mopping) before sadness and crying disrupted routine
• Biopsychosocial Formulation (Cinderella):
  • Biological: intact physical health; no chronic illnesses reported
  • Psychological: depressive cognitive patterns emerging from loss, breakup, and stress; potential negative schemas about self-worth
  • Social: abusive/neglectful home environment earlier; supportive aunt as protective factor; social isolation from peers during youth
• 4P Factor Model application (Biological, Psychological, Social):
  • Predisposing: early bullying, punitive family environment, loss of father, homeschooling social isolation
  • Precipitating: breakup triggering emotional distress
  • Perpetuating: ongoing grief, withdrawal from activities, possible rumination
  • Protective: supportive aunt, hobbies, coping strategies, safety plan (if applicable)

Case Formulation (General): Cinderella’s Core Beliefs (Examples from slides)

• Core beliefs about self: feeling defective, unworthy, and needing protection; fear of harm or rejection
• Core beliefs about others: distrust or expectation of abandonment or harm
• Core beliefs about the world: dangerous or unsafe environment
• These beliefs feed emotional responses (sadness, crying) and future behaviors (withdrawal, reduced functioning)

SUMMARY: Practical Implications and Connections

• Abnormality criteria must be used cautiously; culture, context, and ethics influence judgments about what constitutes a disorder.
• The Harmful Dysfunction model provides a bridge between philosophical value judgments and empirical science, highlighting that harm and dysfunction are not purely objective in practice.
• DSM-5 criteria emphasize the internal (within the person) and functional dysfunction, while cautioning against pathologizing culturally appropriate responses.
• A variety of mental health professionals contribute to assessment, diagnosis, and treatment, each with distinct training, scopes, and licensure requirements; local licensing bodies determine paths and scope (e.g., RCI in India).
• Historical perspectives—from demonology and moral treatments to biological and cognitive-behavioral approaches— illustrate how explanations of mental illness change with science, culture, and ethics.
• Biological approaches remind us of the importance of medical and pharmacological models, but also of ethical concerns (e.g., eugenics history).
• Psychological approaches emphasize the role of learning, unconscious processes, cognition, and personality dynamics in explaining and treating psychopathology; they provide tools for understanding change (e.g., CBT, psychodynamic concepts, and personality theories).
• CBT integrates cognitive, behavioral, and emotional dimensions; key tools include ABC/ABCDE models, cognitive restructuring, exposure, and skills training.
• The Diathesis-Stress model and the Biopsychosocial framework offer comprehensive lenses for understanding risk, resilience, and treatment planning by integrating biology, psychology, and social context.
• Case formulation tools (5 P’s; 4P Factor Model) help clinicians organize information to design targeted interventions and to identify protective factors and social supports.
• Real-world applications include case studies like Cinderella, illustrating how life events, family dynamics, and personal beliefs interact to shape mental health outcomes and treatment needs.
• Ethical and practical implications include respecting cultural variation in what is considered normative behavior, avoiding stigma, and balancing medical/psychological explanations with social justice considerations.

Key Formulas and Models (LaTeX)

• Diathesis-Stress Model:
  ext{Diathesis} + ext{Stress}
  ightarrow ext{Psychological Disorder}
• Cognitive-Behavioral ABC Model:
  $A= ext{Activating event (Adversity)},<br />\newline B= ext{Beliefs},<br />\newline C= ext{Consequences (Feelings/Behaviors)}$
• ABCDE Model (CBT for change):
  A
  ightarrow B
  ightarrow C
  ightarrow D
  ightarrow E
  where
  $D= ext{Disputation (challenge irrational beliefs)},$
  $E= ext{Effective new beliefs}$
• 5P Framework (Case Formulation): Presenting Problem, Predisposing, Precipitating, Perpetuating, Protective factors
• 4P Factor Model (Biopsychosocial):
  ext{Biological}, ext{Psychological}, ext{Social}
  ightarrow ext{Predisposing, Precipitating, Perpetuating, Protective}

Notes for Exam Practice

• Be prepared to delineate how each abnormality criterion could apply to a hypothetical case and discuss potential cultural considerations.
• Be able to explain Wakefield’s harmful dysfunction concept and critique its applicability to various disorders.
• Recall the DSM-5 criteria for a mental disorder and discuss potential cultural or contextual caveats.
• Compare and contrast roles of different mental health professionals and their typical training pathways, with attention to licensure in your jurisdiction.
• Outline the historical progression from demonology to modern understandings of psychopathology and the ethical lessons learned (e.g., eugenics caution).
• Summarize the major Biological and Psychological approaches and give one example of a treatment or concept from each (e.g., ECT or exposure therapy).
• Explain Jung’s archetypes and Adler’s inferiority theory, including how birth order is used in Adlerian theory.
• Understand MBTI typology as described in the slides and its educational use, including its limitations.
• Master the CBT framework (ABC/ABCDE), cognitive biases, and common irrational beliefs; be able to generate example vignettes.
• Practice constructing a 4P Biopsychosocial formulation for a case, identifying Predisposing, Precipitating, Perpetuating, and Protective factors across Biological, Psychological, and Social domains.
• Apply the 5P framework to case vignettes, ensuring you identify all components and link them to potential intervention targets.

End of Unit 1: Final Reflection

• Unit emphasizes that understanding psychopathology requires an integrated lens across historical, theoretical, clinical, and ethical dimensions.
• The goal of coursework is to develop a nuanced, compassionate, and evidence-informed approach to assessment and intervention.
• The meme at the end signals a shift from uncertainty to consolidation of knowledge and application in clinical thinking.