Learning Objectives

1. Describe what we mean by "abnormal" psychology

2. Explain how classification of mental illness influences how we perceive it

3. Understand how research is used to distinguish effective treatments for psychological disorders

4. Explain how beliefs about the causes of mental illness evolved over time and influence our current understanding

5. Discuss how the stigma of mental illness impacts all of us and how to counteract it

6. Understand how our paradigm of mental illness influences how we interpret information and infer the causes of psychological disorders

7. Apply different paradigms to a case study to see how this changes the interpretations

8. Understand the biopsychosocial model of mental illness

9. Understand diathesis-stress models of psychological disorders

10. Determine the primary treatment principles behind each treatment approach discussed.

11. Incorporate your knowledge of the causes of mental illness presumed by each paradigm to identify the corresponding treatment's likely mechanisms of change.

12. Differentiate between the benefits and drawbacks of biological, psychological, and "social" treatment forms.

13. Apply your conceptualization of how each treatment is intended to address mental illness to the Matt case study.

14. Analyze the role stress plays in mental illness

15. Apply the biopsychosocial model to PTSD

16. Identify important commonalities across anxiety disorders (etiology, presentation, and treatment)

17. Understand theories of the development and maintenance of anxiety disorders

18. Examine the principles underlying the efficacy of exposure to treat anxiety disorders

Introduction

• First nations tend to think of mental health and wellness as being a wheel, with human beings at the centre and things that effect them moving outward

• Western European countries tend to value different things including independence, individual rights, logic, productivity, happiness, secularization, and scientific support

• Psychopathology, or abnormal psychology, is the interconnection of four things: behaviours, thoughts, emotions, and physiology. These four components all influence each other and converge to create a psychopathology.

• There is no clear definition of what is abnormal, however there are some clear aspects of abnormality: subjective distress, maladaptiveness, violation of social norms, irrationality or unpredictability, and dangerousness. However, no individual element is sufficient to define and determine abnormality and what is considered deviant changes as society changes.

  • Subjective distress: psychological suffering because of something

  • Maladaptiveness: impairment in important area(s) of life (ex. work, school, or relationships)

  • Violation of social norms: acting outside of cultural standards

  • Irrationality or unpredictability: unexpected responses to stressors (context dependent)

  • Dangerousness: dangerous to self or others

• There are two standardized manuals used to classify abnormality: DSM-5 (USA and Canada) and ICD-10 (everywhere else)

• The DSM-5 defines a psychological disorder as a cycle that starts with some kind of biological, psychological, or developmental dysfunction/impairment. This results in problems in behaviour, emotion regulation, or cognitive function which ultimately leads to distress or disability. This cycle continues as long as the psychological disorder is present.

• Diagnostic classification systems classify disorders, not people

• We classify psychopathologies because it allows us to structure information to communicate in research and clinical settings, organize meaningfully, facilitate research, define what counts as abnormal, and put words to a similar lived experience.

• However, there are many disadvantages with classification including social implications and the development of stigma against people with mental illness. In Canada, stigma against people with mental illness is getting better, but is still a major problem with only 50% of people disclosing their mental illness status and 40% of people agreeing they would try to deal with mental illness themselves and not seek professional help.

• Research estimates that the lifetime prevalence of DSM-5 disorders is at least 46% with many beginning in childhood or adolescence.

  • Prevalence: number of active cases in a population in a given period of time, expressed as percentages

  • Three types of prevalence: point prevalence, one-year prevalence, lifetime prevalence

Research

• We conduct research on psychopathologies to avoid misconceptions and error and to adopt a scientific attitude and approach to the study of abnormal behaviour

• Good research design → good information

• A good research design uses methods that distinguish between what is observable, hypothetical, or inferred. These include cases studies, directed observation, self-report, implicit behaviour, and psychophysiological variables.

  • Observational research designs are a common research method and are used to study things as they are. They determine correlation, NOT causation!

  • Experimental strategies are another common research method that involve manipulating one variable (independent) and seeing the effect it has on another variable (dependent). Experimental research CAN determine causation.

  • When it comes to studying the efficacy of therapy, if the treated groups shows significantly more improvement than the untreated group we can have confidence in the treatment’s efficacy.

  • Single-case experimental designs are used to make causal inferences in individual cases and often follow a ABAB structure.

• There can be inherent errors in research design though. For example, many research is only done or men or only on male and female ‘normal’ subjects, meaning most psychological research doesn’t include most people.

• Within a research study, it’s important that the research include lots of people with similar behaviours, who are similar to the greater population, and who are randomly selected.

• To test hypotheses, researchers use a comparison group of people who do not exhibit the disorder and who are comparable in other major ways to the criterion (experimental) group. These restrictions are used to identify which behaviour(s) are related only to the disorder.

Historical Views of Abnormal Behaviour

• Throughout history, psychologists have used many strange and unethical treatments to treat mental illness and abnormal behaviour including: drilling a hole in the skill, starvation, vegetarianism, dunking the body into hot water, sensory deprivation, marriage, and sterilization.

• Looking at the history of mental illness helps us understand the history or treatments and prevents for mental illness as well as it’s historical foundations.

• However, while good observation is timeless the interpretation of causes of behaviour is subject to bias and always interpreted within the dominant paradigm. (ex. someone not from that culture might be seen as having abnormal behaviour, even if it’s normal from their native culture)

• Historically demonology, renaissance, and asylums were all present.

  • demonology is the idea that bad spirits swell within a person and control their mind a body, causing them to exhibit abnormal behaviour. Ostracism (social exclusion), exorcisms, and trepanning (drilling a hole in the skull) were all popular treatments.

• In the 20th century, three critical areas of abnormal behaviour emerged: somatogenic, psychogenic, and psychological research.

  • Somatogenic theorists believe that physical problems are the root of all thought and behaviours problems. These problems were the four humors: blood, black bile, yellow bile, and phlegm (ex. excess black bile → melancholia). Treatments for somatic problems included a quiet lifestyle, vegetarian diet, exercise, celibacy, and bleeding.

  • Psychogenic theorists believed that mental illness is due to psychological malfunctions. For example, inadequate moral development would be treated with moral treatment, getting stuck in a psychosexual developmental phase would be treated with psychodynamic psychotherapy, and reinforced problem behaviour would be treated by creating a token economy.

• It’s important to remember that doctors throughout history did believe that they were curing people.

Paradigms

• A paradigm is a viewpoint / set of assumptions about how to understand, study, and treat psychological disorders. In short, it is the way we look at things.

• Many indigenous groups in Canada use the mental wellness circles as the major way in which they understand, study, and treat psychological disorders.

  • The inner most layer of the circles is a human being and focuses on self-responsibility.

  • The second layer can be labeled balance and represents an individuals balance between emotion, mental, physical, and spiritual wellbeing.

  • The third layer is respect, wisdom, responsibility, and relationships.

  • The fourth layer is land, community, family, and nations which represents the strong connection that indigenous people have with the land and it’s importance to their wellbeing.

  • The fifth layer is social, environmental, cultural, and economic well-being.

  • The sixth and final layer represents the people of the community.

• First nations approach mental wellness as a continuum and the foundations of treatment are often cultural and traditional healing. They emphasize providing services that are appropriate to the persons needs and integrating traditional and western treatment approaches.

  • Wellness across the continuum (circles) is used to enhance conditions that support wellness and address the root causes of illness so that they are being prioritized over treating the symptoms.

  • Using both traditional and western treatments (two-eyed seeing) is important and provides the best results for most indigenous people.

  • Most treatment is person- and family-centered, trauma-informed, and humble, with all of it being appropriate to the individuals needs.

  • Integrated services are used to address the person’s whole needs and is usually considered a more holistic approach to treatment.

  • Finally, by using local nation-based approaches to treatment a psychologist can increase an individual’s sense of cultural identity.

• There are 5 major western paradigms that are used to treat psychological disorders: biological, psychoanalytic, learning/behavioural, cognitive, and humanistic/existential.

• According to the biological paradigm, mental illness results from dysfunctional biological processes including biochemistry, behavioural genetics, and biological insults.

  • Temperament is an aspect of personality that is strongly influenced by genes and includes 5 dimensions: openness, conscientiousness, extraversion, agreeableness, and neuroticism.

  • Neurotransmitters also play a major role in the biological factors that influence personality.

    • Norepinephrine (NE) is an excitatory neurotransmitter that causes arousal and prepares the body for action.

    • Gamma aminobutyric acid (GABA) is an inhibitory neurotransmitter that regulates behaviour and emotion.

    • Dopamine (DA) has effects that are both excitatory and inhibitory and controls motivation and reward systems.

    • Serotonin (5-HT) is an inhibitory neurotransmitter that regulates bodily functions including mood, appetite, sleep, and impulse control.

    • Glutamate (GLU) is an excitatory neurotransmitter that affects learning and memory.

• The psychoanalytic paradigm (Freud) stipulates that our mind is composed of three primary structures.

  • The Id is the most basic structure and controls basic urges for food, warmth, and sex. It is also known as the pleasure principle.

  • The Ego is the reality principle and is tasked to deal with how we can meet our basic needs in the real world.

  • The Superego is our conscious and helps us decide what is right and what is wrong.

• Freud also stipulated that every person has defence mechanisms, which are unconscious strategies used to protect the ego from distress.

  • Repression is the act of burying an event so deep that you believe it never occured.

  • Denial is denying that a traumatic event ever occured.

  • Projection is projecting your emotions onto another person

  • Displacement is being upset at one thing/person and taking it out on a different thing/person.

  • Rationalization is the act of attempting to explain why you behaved in a certain way to yourself and others.

  • Reaction formation is the tendency of emotions to be expressed in a contradictory form (ex. I’m mad at my mom so I’m going to go give her a hug)

  • Regression is exhibiting behaviours from when you were younger, often to soothe.

  • Sublimation is putting your emotions into a creative output.

• According the the learning/behavioural paradigm all behaviour is learned, meaning that psychological disorders come from learning. Two common learning processes are classical and operant conditioning.

  • Classical conditioning is the association of unrelated elements due to repeated pairing.

  • Operation condition is the idea that behaviour followed by pleasant consequences will increase while behaviour followed by unpleasant consequences will decrease.

    • Positive reinforcement is when a stimulus is added to reinforce behaviour.

    • Negative reinforcement is when a stimulus is taken away to reinforce behaviour.

    • Positive punishment is when a stimulus is added to decrease behaviour.

    • Negative punishment is when a stimulus is taken away to decrease behaviour.

  • Mowrer’s two factor theory says the first step in developing psychological disorders is classical conditioning through the form of an emotional response to a neutral stimulus. The second step is operant conditioning which is learned avoidance of the conditioned stimulus.

• The cognitive paradigm states that psychological disorders come from cognitive (thinking) errors. Cognitive psychologists have found that we actively intepret situations, imposing meaning though perception, interpretation, judgement, memory, and reason.

  • We create schemas which are organized networks of accumulated knowledge that guides our interpretation of events.

  • Cognitive psychologists believe that depression is a set of self-fulfilling pessimistic prophecies and social anxiety is caused by the act of jumping to conclusions.

• The humanistic/existential paradigm posits that inner, subjective experiences are the core of human functioning.

  • It emphasizes positive growth, searching for meaning in like, using agency and taking responsibility for your choices and attitude, and living life according to your values.

• There are also many social factors that play a large role in the development of psychological disorders, even though they are not part of a major paradigm.

  • Poverty, especially in development, can result in poor housing, unsafe conditions, and disrupted social ties which will all influence mental health.

  • Parental stress can cause parental depression, family conflict, and harsh parenting which will also influence mental health.

  • Minoritized status has also been linked as an indicator for psychological distress, often due to discrimination.

  • Other cultural factors such as immigration, accessibility of services in native languages, community knowledge, and the cultures approaches to mental health will all have an influence.

The Biopsychosocial Model

• The biopsychosocial model is a unified model of psychopathology that includes biological factors, psychological factors, and social factors when understanding mental health and illness.

  • It is often visualized as three circles, with biological factors being the innermost circles, then psychological factors, and finally social factors.

  • It can be used to study psychopathologies in the form of a grid with the y-labels being biological, psychological, and social and the x-labels being etiology (cause), presentation, and treatment.

    	Etiology	Presentation	Treatment
    Bio
    Psycho
    Social

Gene-Environment Interactions

• The diathesis stress models are the idea that predisposing causes or underlying vulnerability paired with precipitating causes or triggering circumstances leads to psychological disorders.

  • In the interactive model the level of stress and the probability of developing a mental disorder are plotted on the x and y axis respectively. In this model, if someone has no diathesis (predisposition) they will not develop mental illness such as anxiety and depression whereas someone who has high diathesis has a high likelihood of developing them even at low levels of stress.

  • In the additive model the level of stress and the probability of developing a mental disorder are also plotted on the x and y axis respectively. However, if someone has no diathesis they will still develop certain disorders however they require more stress to develop them then someone with a high level of diathesis.

  • There are also protective factors that can influence a person’s response to stress and make it less likely that a person will have a bad reaction. The strongest protective factor is resilience, which is an individual’s ability to successfully adapt to very difficult circumstances.

• A good example of the diathesis stress model is the interaction between genes and the environment. Genes are inherited tendencies (diathesis) and the environment is where those tendencies are activated (stress).

  • For example, low levels of 5-HT (serotonin) genetically when paired with chronic stressors can lead to eating disorders, depression, substance use, or aggression.

• Most disorders, psychological and physical, are polygenic, meaning they are influenced by multiple genes. These genes create a vulnerability for the disorder. The environment can override genetic influence and turn on/off specific genes.

• The rats adoption experiment is a good example of gene-environment interactions.

  • Two female rats, one aggressive and one calm, had babies and the babies were swapped.

  • The nurturing mother, even when raising the aggressive mothers babies, ended up raising gentle rats which was dictated by their maternal environment

• The Gene-environment correlation is the correlation between how an individuals genotype can shape their environment. Things like genetic activity, neural activity, behaviour, and environment all play a large, bidirectional role.

Treatment

• The underlying premise of western treatment is the belief that people can change how they interact with the world.

• There are two major divisions of treatment: biological and psychological.

  • Biological treatments consists of things like psychopharmacology (medication), ECT, and TMS.

  • Psychological treatments most often take the form of psychotherapy, which some types being evidence-based and others being not evidence-based.

    • Evidence-based treatments are treatments that efficacy studies have found to be efficacious, meaning that the treatment works to decrease symptoms and the treatment group performs better than the comparison group (placebo or other treatment type)

    • Not-evidence-based treatments are treatments that aren’t backed by scientific data (yet) and usually rely on personal experiences of success rather than statistical analyses. This does not mean they don’t work.

• Psychopharmacology is the prescription of various medications to treat psychological disorders.

  • Psychosis is treated with antipsychotics which primarily influences DA (dopamine)

  • Bipolar mood disorders are treated with lithium which primarily influences GABA

  • Anxiety is treated with benzodiazepines which primarily influence GABA

  • Depression is treated with SSRIs which primarily influence 5-HT (serotonin)

• Psychotherapy is a very common form of treatment for various psychological disorders and influences multiples types: psychodynamic, behavioural, cognitive, cognitive-behavioural, humanistic, and interpersonal.

  • There are two types of psychodynamic therapies: classical psychoanalysis and psychoanalytically oriented psychotherapy.

    • Classical psychoanalysis includes practices like free association, dream analysis, transference, and resistance.

    • Psychoanalytically oriented psychotherapy focuses on object-relations and attachment styles.

  • Behavioural therapy is founded on the premise that if you modify behaviour, a modification in feelings will follow. Types of behavioural therapy include exposure therapy, modeling, reinforcement, and behavioural activation. Behavioural therapy is commonly used to treat anxiety disorders and sometimes depression.

  • Cognitive therapy is founded on the premise that thoughts cause feelings and moods, and those feelings and moods influence behaviour. It examines distorted patterns of thinking and focuses on changing a person’s behaviour by changing their thoughts (ex. modifying self-statements or changing interpretations of events)

  • Cognitive-behavioural therapy incorporates thoughts and behaviours and contributes them both to the maintaining of a disorder. It is the most widely practiced form of therapy and works well to treat anxiety, mild-moderate depression, conduct disorders, and bulimia.

    • CBT follows a three component model: affect (feelings) → behaviours (actions) → cognitions (thoughts) → … It argues that a change in one component will influence the two others.

  • Humanistic therapy is client-centered and often uses one of two techniques: motivational interviewing or gestalt therapy.

    • Motivational interviewing is good for building commitment to treatment and it useful to treat behaviours that are often difficult to target with other treatments (ex. substance use or domestic violence)

  • Interpersonal therapy is a premise that uses multiple paradigms to address the ways the client relates to others. It uses the therapist-client relationship to work towards clients changing their thoughts and behaviours. It has been successfully used to treat borderline personality disorder and depression.

• People in minoritized groups tend to be less studied, use fewer mental health services, and have less clinitiants who are part of the minoritized group. In-turn, people in minoritized groups often have less access to empirically-supported treatment options.

  • Having a clinician with a different cultural background than you can influence your comfortability and feelings of being understood during treatment.

  • By having less access to empirically-supported treatment options, minoritized groups are likely to see an impact on individual and communal mental health, from being less likely to seek treatment, to an increase in stigma and chronic stress within the community.

Posttraumatic Stress Disorder (PTSD)

• When you are under stress it activates your HPA axis which triggers the release or cortisol.

• Extreme or prolonged stress can cause extensive physical and psychological problems.

  • It increases reactivity in the sympathetic nervous system which results in more stress in response to stressful situations.

  • It decreases the efficacy of the bodies immune system.

  • It decreases psychological self-efficacy making it harder to resist other stressors.

  • It causes personality deterioration.

  • In severe cases it can cause death.

• There are many psychosocial factors that contribute to stress:

  	Stressor	Crisis	Resources
  External	Nature of the stressor (chronic? who? accidental?)	Life changes due to crisis (injury? job? relationships?	Social support (family/friends? $ for treatment?)
  Internal	Perception of stressor (predictable? controllable?)	Experience of crisis (make meaning?)	Stress tolerance (biological, psychological)

• PTSD occurs when an individual is exposed to an event threatening death, serious injury, or sexual violence through direct experience, witnessing others’ experience, learning it happened to close family/friends (must be violent or accidental) or repeated/extreme exposure to aversive details of an event.

  • The most common triggering events are combat, assault, natural disasters, and torture.

• While men are exposed to more traumatic events throughout their lifetimes, women are 2x more likely to develop PSTD and when they do they exhibit more severe symptoms.

  • The reason for this is human intent. Men tend to be exposed to more accidents and traumatic events where they don’t know the perpetrator while women are much more likely to know and have a close relationship with their assaulter.

  • Sexual assault is the most common cause of PTSD in women and 39% of Canadian women report being sexually assaulted since the age of 16.

    • The seriousness of the psychological problems resulting from sexual assault depends on past coming skills and current psychological functioning (e.g. how much stress you’re under).

    • Current research has also shown that disclosing assault soon after the incident decreases negative reactions and increases positive reactions (post-traumatic growth), making an individual less likely to develop PTSD

• Transgeneration trauma, also known as intergenerational trauma, is another contributing factor to the development of PTSD.

  • Some examples of groups who may have high transgenerational trauma include indigenous survivors of residential schools, those affected by the Rwandan genocide, or those affected by the Holocaust.

  • The likely mechanism underlying transgenerational trauma is epigenetics.

• In some cases stress-inoculation training is used to prevent the development of PTSD. This is commonly used before combat (ex. having people yell at you a lot so you’re more used to it) and is now being attempted with people facing stressful events.

Anxiety Disorders

• There are multiple types of anxiety disorders including specific phobias, social anxiety disorder, panic disorder, agoraphobia, and generalized disorder.

• Most anxiety disorders have some common characteristics:

  • Most disorders have biological and psychological causes including genes, neuroticism, conditioning, and lack of perceived control. The influence of social factors in the etiology of the disease depends a lot on the dominant culture.

  • They all present as unrealistic, irrational fears or anxieties with disabling intensity.

  • The most effective treatments are similar and is usually exposure therapy

• Basic research on anxiety has shown that perceived controllability and predictability of situations decrease the likelihood of developing anxiety disorders and result in low anxiety in general.

• Research has also shown that an interpretive bias towards a threat (you look for them more) increases the likelihood of seeing the perceived threat which increases the fear/anxiety, in-turn increasing the interpretive bias.

Specific Phobia

• Specific phobias are strong fears or avoidance of specific objects or situations that are out of proportion to the actual danger, disrupt everyday life by avoiding the object/situation, and are recognized as unreasonable.

• Some examples of specific phobias include animals, natural environment, blood-injection-injury, situational, and more (ex. choking, vomiting, etc.).

• Research has shown that 75% of people who have a phobia have 2 or more specific phobias while 25% of people who have a phobia only have one.

  • Blood-injection-injury phobia affects roughly 3-4% of the population and is highly genetic.

• Some important treatment terms include:

  • Extinction - the fear is gone.

  • Habituation - slowly getting used to the fear.

  • Systematic desensitization - the process by which habituation occurs.

  • Flooding - lots of fear exposure at once.