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Psychopathology
Key Terms
biopsychosocial approach obsessive-compulsive disorder
concordance rate personality disorder
diathesis-stress model positive symptoms
expressed emotion psychopathology
maladaptiveness psychotic symptoms
mental illness approach social norm
negative symptoms statistical deviance
Chapter Outline
4.1 INTRODUCTION
4.2 DEFINING ABNORMALITY
4.3 HISTORICAL ROOTS OF PSYCHOPATHOLOGY
4.4 MODERN APPROACHES TO PSYCHOPATHOLOGY
4.4.1 Psychoanalysis and psychodynamic theories
4.4.2 Behaviorism
4.4.3 Cognitive revolution
4.4.4 Biological approaches
4.5 INTEGRATIVE APPROACHES TO PSYCHOPATHOLOGY: THE BIOPSYCHOSOCIAL MODEL
4.6 DIAGNOSIS: CLASSIFYING PSYCHOLOGICAL DISORDERS
4.7 MAJOR PSYCHOLOGICAL DISORDERS
4.7.1 Schizophrenia
4.7.2 Affective disorders
4.7.3 Anxiety disorders and obsessional states
4.7.4 Eating disorders
4.8 CRITICISMS OF THE DIAGNOSTIC APPROACH
4.9 DIMENSIONAL VIEW OF PSYCHOPATHOLOGY AND PERSONALITY DISORDERS
4.10 SUMMARY AND CONCLUSIONS
Psychopathology 49
4.1 INTRODUCTION
This chapter is concerned with psychopathology or the study of abnormal behavior. Before we start, it is important to notice that this is a major area of psy- chology, with links to wider clinical practices such as psy- chiatry, psychiatric nursing, social work, and the medical sciences in general. Thus even a summary of psy- chopathology would exceed the scope of this book. However, the contribution of psychopathology to our under- standing of individual differences cannot be neglected. Differential psychology attempts to explain differences between individuals, and such differences can often be explained in terms of mental illness or psychological disorders. Although this may suggest an overlap between personality and psy- chopathology, there is a distinction between the two. Whereas personality refers to individual differences in general or normal behavior, psychopathology focuses exclusively on abnormality (see Figure 4.1). In the past decade there has been increased inter- est in the relationship between personality and psychopathology as conceptualized in terms of a continuum between normality and abnormality. I present the topic of psychopathology in this chapter by begin- ning with a look at definitions of abnormality and the historical development of this discipline. Then I examine the dominant approaches and systems of classification in psychopathology, which are widely used to define, describe, and categorize specific psychological disorders. Next I look at the salient diagnostic categories for the major psychological disorders, with a particular focus on personality disorders. Applied implications and criticisms, as well as links to other individual differences, are discussed at the end of the chapter.
4.2 DEFINING ABNORMALITY
It would be impossible to understand the meaning and object of study of psychopathology without first defining abnormality.
Unfortunately, this is one of the most contentious issues in psy- chology, which makes for a complicated start! But the difficulties of this task are also a sign of the variety of approaches to the study of abnormal behavior. There are several conventional criteria for defining abnormality, such as statistical deviance, social and moral norms, personal distress, and maladaptiveness associated with behavior, as well as the mainstream clinical approach of mental illness diagnosis (Davison & Neale, 1998). The statistical deviance approach conceptualizes abnormality in terms of behaviors that are extreme, rare or unique, as opposed to typical. Looking back at Figure 4.1, we can think of normal behaviors as those that fall within the central range of the bell curve, whilst abnormal behaviors would be found at the two ends or extremes. One problem, however, is that, even if we had a clear cut-off point to distinguish between frequent and infrequent behaviors (which is not the case anyway), there are many exam- ples of statistical outliers (observations or measurements that are unusually large or small relative to the other values in a dataset) that would rarely be described as “abnormal.” For instance, few people can play the piano like Mozart or football like Diego Maradona, and there are probably even fewer people with Einstein’s ability to discover the hidden laws of physics. We could in fact compile an extensive list of unusual behaviors that would often be considered eccentric, original, or creative, but rarely abnormal. Thus the statistical deviance approach refers to beha- viors that are not merely infrequent, but also undesirable or negative, which suggests an implicit moral code. There is arguably no better way to understand the underlying morals of judging abnormality than by examining the social norm approach, which considers the various cultural factors determin- ing the perceived normality of a wide range of human behaviors (Scheff, 1966). For example, in some countries, burping after a meal is seen as socially acceptable and complimentary to the chef, whereas in others it would
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psychopathology (also called abnormal psychology ) studies the causes, treatment, and conse- quences of psychological disorders or mental illnesses such as depres- sion, anxiety, and psychoses statistical deviance an approach that conceptualizes abnormality in terms of behaviors that are extreme, rare, or unique, as opposed to typical
social norm a rule or guideline, determined by cultural factors, for what kind of behavior is considered appropriate in social contexts, e.g., whether burping after a meal is seen as a compliment or a sign of rudeness
Abnormality (psychopathology)
Abnormality (psychopathology)
Normality (differential psychology)
Figure 4.1 Differential psychology and psychopathology.
Psychopathology 51
is agreement on the taxonomy or system of classification that ought to be used, such as the DSM-IV or ICD-10 (explained in section 4.5), these are simply descriptive and have little scope bey- ond the labeling of symptoms. “Obsessive-compulsive disorder,” for instance, does not refer to a physically based disease but to obsessive and compulsive symptoms. The same can be said about eating disorders and other anxieties: they are self-explanatory but predominantly descriptive. On the other hand, psychological and psychiatric classifications for diagnoses are still influenced by cultural norms and may (fortunately) be subject to change. For example, until 1973, the American Psychological Association (APA) listed homosexuality amongst the most serious psycholo- gical disorders (Spitzer, 1981)!
4.3 HISTORICAL ROOTS OF
PSYCHOPATHOLOGY
The historical roots of psychopathology are relatively well docu- mented. Hippocrates, the Greek philosopher and physician cred- ited with the invention of medicine, believed in the connection between psychological and physical disorders, the former being caused by the latter. As seen in section 2.4, this idea was present in his conceptualization of the major temperament types, though Hippocrates also attempted to explain pathologies such as melan- cholia, mania, and phrenitis, which were common disorders in ancient Greek society. Accordingly, psychological illness was attributed to a physiological dysfunction. Conversely, Plato (428–348 bc) argued that disorders should be understood in terms of intrapsychical conflicts. Rather than looking for physical causes, Plato was convinced that mental dis- orders were, to put it simply, “all in the mind.” Both approaches would be further developed by modern theorists and still coexist in contemporary views of psychopathology. Hippocrates’ idea that psychological symptoms have physiological causes is repre- sented by the somatogenic approaches to psychopathology, whereas Plato’s interpretation of mental disorders in terms of intrapsychical conflicts is deeply embedded in some of the salient psychogenic theories of abnormal psychology. Whilst both approaches focus on different causes, we will see that most psy- chological disorders can be best understood in terms of both psychological and biological determinants. Although psychopathology did not develop as a major area of psychology until the beginnings of the twentieth century, mental disorders have a longstanding history and have been documented in every continent and form of society, from ancient China (as early as 2674 bc!) to ancient Greece, Rome, the Incan empire, and notably Egypt. In most cases, symptoms were regarded as the expression of supernatural forces that controlled the individual’s mind and body, and mental disorders were treated through obscure rituals such as exorcisms and shamanism – a tribal form of medicine based on magical and spiritual intervention. Ancient Egyptians seemed particularly preoccupied with maintaining a healthy balance in the mind or “soul.” They had special temples for the mentally ill and performed rituals that included the use of opium to reduce pain. Archeological discoveries of prehistoric perforated skulls suggest that ancient societies already imple-
mented psychophysical treatments on mentally ill individuals, in many cases successfully. Until modern times, however, behavioral abnormalities were mostly treated with violence and mentally ill individuals were typically marginalized rather than looked after. This was particu- larly common in the Middle Ages, where “loss of reason” was believed to be caused by witches or demons. Thus in 1484 the Pope ordered “possessed” individuals to be burned alive (Nolen- Hoeksema, 2001). An early exception to this reactive and aggressive approach to mental disorders was the small English housing facility of St. Mary of Bethlehem. Known as Bedlam and established in 1243, it is widely regarded as the first formal attempt at psychopathological hospitalization. However, and in spite of remaining open until the early 1800s, treatment was virtually nonexistent at Bedlam, making it more of a tourist attraction than a psychiatric institution. The first attempt to treat and help the mentally ill dates back to the 1700s, when Philippe Pinel (1745–1826), anticipating the spirit of the French Revolution, proposed the moral treatment of those affected by mental disorders. Pinel’s methods introduced friendlier policies for hospitalized patients, such as eliminating chains, preventing physical abuse, improving living conditions, and even offering advice or moral guidance (for a different account, see section 4.8). Another major contribution by Pinel was his attempt to categorize symptoms, which led to the broad differentiation between melancholia, mania, dementia, and idiocy (diagnostic categories are discussed in section 4.7). Inspired by Pinel, William Tuke founded the York Retreat in 1796. Despite the unsurprisingly limited efficacy of moral treatment for the cure of serious mental disorders, this deliberate attempt to help mentally ill individuals inspired the creation of several English and American institutions in order to both understand and treat mental disorders.
4.4 MODERN APPROACHES TO
PSYCHOPATHOLOGY
Modern approaches to psychopathology tend to posit that mental illness has a physical origin and are thus consistent with early somatogenic theories, such as that of Hippocrates/Galen (see sections 2.4 and 4.3). One of the first representative figures of the modern somatogenic paradigm was Wilhelm Griesinger (1817–68), a German psychiatrist who argued that brain patho- logy was the cause of all mental disorders. Around the same time, Emil Kraepelin (1856–1926) and Eugen Bleuler (1898–1927) developed similar theories, no doubt due to the rapid develop- ments in anatomy, physiology, neurology, and chemistry that were then taking place. Kraepelin’s main contribution was the first modern classification of symptoms, labeling and describing different psychological disorders. An important distinction was made between manic depressive disorders and dementia praecox, later referred to as schizophrenia (see section 4.7.1). One particularly clear and famous example of how structural changes in the brain may impair normal psychological function- ing is the Phineas Gage case. Gage was a 25-year-old railworker who suffered a spectacular injury when an iron bar penetrated his
52 Psychopathology
head (see Figure 4.3). Although Gage was lucky enough to survive the accident, he showed radical transformations in behavior after suffering the injury. Having been responsible, agreeable, ambitious, and hardworking all his life, after the injury he became irreverent and capricious, showing no respect towards social norms or other individuals. Surprisingly, and despite his losing every form of emotional and social control over his behaviors, Gage’s intellectual skills remained intact (Damasio et al., 1994). On the other hand, the Austrian physician Franz Anton Mesmer (1734–1815), in the tradition of Plato and the psy- chogenic paradigm (see section 4.3), believed psychological dis- orders to be the expression of psychical rather than physical factors. Mesmer’s initial and no doubt obscure theory assumed mental illness to be caused by “magnetic fluids,” a sort of astro- logical energy force inside people’s bodies. Furthermore, Mesmer believed himself to be in possession of a healing touch that could positively influence ill individuals and cure them! He also devel- oped a hypnotic method called mesmerism (which gave birth to the expression mesmerized ) that he applied on patients, sometimes in sessions lasting for several hours. Jean Martin Charcot (1825–93), a prestigious French neurolo- gist who was initially skeptical of Mesmer’s theory and believed that psychological disorders were caused by a degeneration of the brain, nonetheless experimented with mesmerism and found that patients experienced substantial relief after being able to talk about their symptoms under hypnosis. This process was called catharsis , alluding to the ancient Greek idea of tragic theater as a method of coexperiencing negative emotions with the actors, and would have a major influence on one of Charcot’s students, Sigmund Freud (1856–1939).
4.4.1 Psychoanalysis and psychodynamic theories
Freud’s studies of the so-called hysterical disorder, a bizarre ill- ness that caused mostly well-off Victorian women to lose the
functioning of or feeling in specific parts of the body, led him to conclude that there was an unconscious intrapsychical origin to mental illness. Evidence for this claim was derived from the fact that, under hypnosis – when patients are not conscious – hysterical symptoms could be induced. Subsequent clinical observations led Freud to the theoretical development of psychoanalysis, a therapeutic method and theory based on the exploration of the unconscious. Psychoanalytic the- ories are often referred to as psychodynamic, for they deal with the processes underlying dynamic conflicts between unconscious and conscious psychological forces. Although psychodynamic theories developed in the context of abnormal behavior and men- tal disorders, they posit that all behaviors (normal and abnormal) are influenced by unconscious processes. Thus psychoanalysis has been used to understand human behavior in general and applied to a wide range of areas such as philosophy, literature, and sociology, making Freud the most famous psychologist of all times (Haggbloom et al., 2002). Although even a summary of Freud’s theory would exceed the space available for this book (he wrote more than 25 books and there are many more by other authors attempting to explain or reinterpret his theory), it is certainly important to summarize some of the basic ideas of the psychoanalytic approach to psychopathology. Freud understood psychopathological symptoms as a compro- mise between unconscious and conscious forces that represents a symbolic expression of traumatic or repressed events. According to Freud, the sexual and aggressive drives are the two universal forces underlying human behavior. If social and cultural con- straints did not exist, our instinctive reaction would be to release both our sexual and aggressive tensions in order to minimize pain and maximize pleasure. Freud called this “operating by the pleas- ure principle” or “primary process thinking.” However, because every form of society is based on some form of prohibition, we are obliged to trade off immediate pleasures for long-term rewards and conform to the “principle of reality.” Drives not released through actual behavior are directed onto various symbolic formations that allow part of them to be expressed whilst conforming to the principle of reality. Examples of these formations are fantasies, dreams, and, as anticipated, psychological symptoms. In order to untangle the etiology of symptoms and psychological disorders, it is necessary to account for the unique and complex history of every individual. More importantly, there can only be hope of overcoming mental illness if the patient can elaborate on his/her own unconscious wishes – usually repressed childhood fantasies – to overcome the psycho- logical conflict. One possibility is to transfer unconscious desires onto the ther- apist, “pretending,” say, he/she is our father or mother, to allow unconscious desires (of hate or love) to be expressed in behavior rather than symptoms. This, however, is a long and tedious process which would prove ineffective with most serious, biolog- ically based mental illnesses. Some treatments may last for 10 or 20 years, at a rate of more than one meeting per week! Besides, Freud’s theory is based on few case studies and is largely untestable. Most claims are based on circular interpretations and speculative theories rather than robust and representative empirical evidence.
Figure 4.3 Phineas Gage’s brain injury. Source : www.ninds.nih.gov/health_and_medical/pubs/tbi.htm.
54 Psychopathology
In spite of technological advances in brain-measuring equip- ment, most biochemical variables can only be measured indir- ectly in living humans.
4.5 INTEGRATIVE APPROACHES TO
PSYCHOPATHOLOGY: THE
BIOPSYCHOSOCIAL MODEL
Although some (particularly psychiatrists) believe the evolution of psychopathology is largely a function of replacing psychogenic approaches with somatogenic, much of the improvements in psychopathology in recent years have depended on the integration of the different approaches discussed above, though there are also other approaches such as humanis- tic and sociocultural theories of abnormal behavior. This multidisciplinary perspective is often referred to as the biopsychosocial approach to psychopathology, and its major exponent is the diathesis-stress model. According to the diathesis- stress model (Cicchetti & Rogosch, 1996; Monroe & Simmons, 1991; Williams, 1985), psychopathological symptoms and diseases are caused by a combination of biological, psychological, and social factors. In simple terms, this model explains mental illness as a byproduct of inherited vulnerabilities (diatheses) and unbearable life experiences (stress) (see Figure 4.4). An individual’s level of vulnerability or
predisposition is biological and can be explained in terms of pathological brain structures or processes at the level of genes, neurotransmitters, and hormones. The life events or stressors that trigger that disposition, however, are environmental. For example, conflictive relationships with friends or other family members may cause dispositional factors to be manifested in the form of mental illnesses such as schizophrenia (see Meehl, 1962, and section 4.7.1). Thus vulnerability is necessary but not sufficient in itself to cause the mental illness, and so is the stressor. The diathesis-stress model also explains physical illnesses such as hypertension, diabetes, or hyperlipidemia. For example, genetic factors alone may not lead to heart attack if there is sufficient exercise, balanced nutrition, and no smoking or alcohol abuse. Likewise, an unhealthy lifestyle may still lead to serious physical illness even if there is no history of previous illness in the family.
4.6 DIAGNOSIS: CLASSIFYING
PSYCHOLOGICAL DISORDERS
Aside from the various theoretical approaches discussed above, there are two main frameworks for classifying psychological disorders, namely, idiographic and nomothetic. The idiographic framework, which is widely adopted by psychoanalytic and psy- chodynamic theories (see section 4.4.1), emphasizes the singular- ity of mental illness and assumes psychological disorders to be manifested differently in every individual. Accordingly, it treats each case completely separately and establishes no comparisons with predefined norms or diagnostic classifications. Conversely, the nomothetic framework is based on preestablished categories and compares every case with previously defined, described, and classified psychological disorders. This framework, which will be the focus of the present chapter, represents the mainstream approach in psychopathology and is often referred to as the psychiatric model. As you may note, the distinction between idiographic and nomothetic frameworks in psychopathology is
Genetic predisposition (vulnerability)
Environmental triggers (potentiators)
Impaired social functioning
Impaired occupational functioning
Stress
diathesis
Interaction Symptoms
Figure 4.4 Diathesis-stress model: an integrative approach to psychopathology.
biopsychosocial approach a multi- disciplinary approach to psycho- pathology based on the idea that mental illness results from a combi- nation of biological, psychological, environmental, and social factors
diathesis-stress model this model suggests that some people possess an enduring, inherited vulnerability (diathesis) which is likely to result in psychological disorder (e.g., schizophrenia) when they experience an unbearable life event (stressor)
Psychopathology 55
comparable to the distinction between situational and disposi- tional conceptualizations of personality (see sections 2.2 and 2.5). The two dominant taxonomies for diagnosing mental disor- ders are the International Classification of Diseases, Injuries, and Causes of Death (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM). The ICD, the latest version of which is ICD-10 (World Health Organization, 1992), covers both mental and physical disorders and is more widely used in Europe. The DSM, the latest revision of which is DSM-IV (American Psychiatric Association, 1994), represents the state-of-the-art classification system in the US and refers exclusively to mental disorders, though it is largely based on the ICD. Both systems have converged considerably in the past decades and there is large overlap between them today. Thus I shall focus only on DSM-IV. Diagnostics are based on:
a) some core symptoms that need to be present; b) prespecified periods of time for symptoms to be present; and sometimes c) symptoms that should not be present.
The DSM follows a multi-axial format comprising five different axes, though axes 1 and 2 alone may determine the diagnostic. Axis 1 (shown in Table 4.1) describes the major types of disorders, for example, affective disorders and anxiety disorders. Axis 2 includes lifelong conditions such as mental handicap and per- sonality disorders (e.g., paranoia, schizoid, antisocial behavior, narcissism) (see section 4.9) that lead to enduring maladaptive behavior. Axis 3 refers to the medical or biological causes of mental dysfunctions. Axis 5 focuses on daily adaptive functioning, that is, the extent to which illness interferes with everyday life. Two major aspects to assess the usefulness of the DSM and ICD are reliability and validity. Reliability refers to the extent to which there is agreement about the diagnosis. Just as a reliable scale will signal the same weight for the same object every time
it is weighed, different observers using the same criteria should arrive at the same diagnostic for the same individual, and differ- ent targets exhibiting similar symptoms should be diagnosed with the same illness. Although both DSM-IV and ICD-10 have shown improved reliability with regard to earlier versions, especially for schizophrenia, mood, and anxiety disorders (Sartorius, Ustun, Costa e Silva, Goldberg, & Lecrubier, 1993), the system is far from ideal and inter-agreement correlations are typically modest to moderate, but rarely high. Validity , on the other hand, refers to the question of whether the system of classification can effectively distinguish one diagno- sis from another. Thus two individuals with different symptoms should be diagnosed with different illnesses, just as two indi- viduals who differ in weight should be given different weights. There are different types of validity. Etiological validity is based on the causes of the diseases: the same or similar causes should be identified for the same diagnoses. Concurrent validity refers to the idea that the same disorders should be expressed in terms of the same secondary symptoms. For instance, most schizophrenics suffer from memory impairment, though this is not a central symptom of schizophrenia (Stirling, Hellewell, & Hewitt, 1997). Predictive validity refers to the extent to which we can accurately anticipate the outcome and course of a disorder, as well as indi- viduals’ response to treatment. For instance, people suffering from bipolar disorders will typically respond well to lithium drug treatments. Again, the validity of diagnostic categories is far from perfect and has often been the focus of harsh criticism (see, e.g., section 4.8).
4.7 MAJOR PSYCHOLOGICAL
DISORDERS
Major psychological disorders are at least as likely to occur and be reported as are medical illnesses such as heart diseases and cancer. According to the National Alliance for the Mentally Ill, more than
Table 4.1 DSM-IV, Axis 1 (major types of disorders)
Infancy/childhood/adolescence disorders : e.g., learning and development disorders, attention deficit, hyperactivity, and autism.
Late adulthood disorders : serious and often irreversible impairments of cognition and mental functioning, e.g., delirium, dementia, amnesia.
Substance-related disorders : disorders that involve ingestion of drugs that bring change to mental functioning.
Detachment from reality : disorders that involve hallucinations, delusions, and thinking impairment, either intermittently or indefinitely (e.g., schizophrenia and other psychoses).
Affective disorders : disorders based on severe alterations of mood/affect (e.g., depression, mania, bipolar disorder).
Anxiety disorders : disorders characterized by anxiety and exacerbated worry (e.g., phobias, obsessive-compulsive disorder, post-traumatic disorder).
Somatoform or dissociative disorders : disorders characterized by physical symptoms that do not correspond to physical illness, i.e., have no apparent physical cause.
Sexual/gender disorders : deviations from normative sexual practices (e.g., paraphilias, fetishism, pedophilia, and sadomasochism).
Eating and sleeping disorders : e.g., anorexia nervosa, bulimia nervosa, insomnia, narcolepsy, and apnea.
Factitious disorder : a rare case whereby individuals self-induce physical or psychological symptoms to attract people’s attention.
Adjustment disorder : emotional or behavioral disorders that follow stressful life events and do not fit into any other category.
Impulse control disorder : disorders characterized by impulsive behaviors that are out of control, e.g., kleptomania (compulsive stealing), pyromania (compulsive burning), and gambling (in its pathological form).
Psychopathology 57
cases to be in the region of 2 to 4 per 1,000. This may seem like a low percentage rate, but if you multiply it by the overall popula- tion of a city or a country the number of affected patients will be substantial. There is generally little cross-cultural variability in the number of schizophrenic cases reported, a fact that has often been used to emphasize the biological basis of this disorder. Of those suffering from schizophrenia, 20 percent will typically experience only one acute episode, with about 30 percent experi- encing more than one. In both cases, full or partial recovery will be the most frequent outcome, with only 10 percent of cases being permanently impaired after several incidents. There are many factors that may help recovery, such as being married, having a good educational background, or having a good past employment record (Shepherd, Watt, Falloon, & Smeeton, 1989). In addition, females tend to recover better and more frequently than males. It is also noteworthy that a progres- sive and early start of the illness is more likely to be associated with a slower and more difficult recovery, especially if there are no identifiable external stressors to which the disorder can be attributed. In all cases, symptoms need to be treated as soon as possible. Schizophrenic patients are usually treated with antipsychotic/ neuroleptic drugs, acting mostly on the dopamine and, to a lesser extent, serotonin and histamine neurotransmitters. These chem- ical messengers affect levels of mood and emotionality and are overactive in schizophrenics (Seeman, 1980; Snyder, 1976). How- ever, causal links at the neuropsychological level are yet to be investigated. Cognitive therapy, if combined with antipsychotic drugs, can help to reduce hallucination and delusions, especially in the first stages of illness, and has long-term beneficial effects (Crow, MacMillan, Johnson, & Johnstone, 1986; Kuipers, Fowler, Garety, Dunn, Bebbington, & Hadley, 1998). Little is known about the cause of schizophrenia. Somatogenic approaches focus on the role of brain structure and genes. Although these effects cannot be directly observed, family, adop- tion, and twin studies provide indirect evidence for the biological etiology of schizophrenia_._ It is estimated that there is a 10 percent risk of developing the disorder amongst first-degree relatives, 3 percent amongst second-degree relatives, and 2 percent amongst third-degree relatives (Slater & Cowie, 1971; Kendler & Diehl, 1993). Adoption studies suggest that the risk of developing schizophrenia is virtually the same if individuals have been adopted away than if they were raised by their natural parents (Heston, 1966; Rosenthal, 1971). Most impressively, twin data indicate that the concordance rate for monozygotic (MZ) or identical twins, who have 100 percent of genes in com- mon, is 38 percent higher than for dizygotic (DZ) or non-identical twins, who have 50 percent of genes in common, and first-degree relatives (Gottesman & Shields, 1972). Although this provides convincing evidence for the importance of genetic factors in the etiology of schizophrenia, it does not rule out environmental causes. Other attempts to identify the biological determinants of schizophrenia have included genetic mapping (Sherrington et al.,
1988), searching for deficient chromosomes, computed tomo- graphy (CT), magnetic resonance imaging (MRI), and measuring brain and cerebral ventricles (Raz & Raz, 1990). Cognitive neuro- scientists have found that certain brain areas, such as left frontal lobe, may fail to monitor plans and intentions, leading to unawareness and hallucinations (Frith, 1992; Spence, Brooks, Hirsch, Liddle, Meehan, & Grasby, 1997). On the other hand, psychogenic theories have emphasized the impact of early childhood and family experiences on the development of schizophrenia. Freud (1966/1896) interpreted schizophrenia as the expression of an unconscious conflict between sexual impulses and sociocultural norms. Accordingly, schizophrenic symptoms would be a compromise between these two forces, though mediated by several complex defence mechanisms. As with most psychoanalytical hypotheses, there are not many ways to empirically test this assumption. However, the more general idea that stressful events or environmental demands may trigger schizophrenic symptoms has been accepted more widely (see section 4.5). Other psychoanalysts suggested that schizophrenia could be caused by chaotic family relations or abnormal parenting styles (Fromm-Reichmann, 1948; Laing, 1971). This view is consistent with the expressed emotion perspective, which points out that when families express their negative emotions to the schizophrenic individual, his/ her illness will be likely to aggravate (Vaughn & Leff, 1976; Stirling et al., 1993). Hence the importance of family therapy for the treatment of people with schizophrenia (Hogarty et al., 1991).
4.7.2 Affective disorders
Another major type of mental illness is represented by the so- called affective disorders, which are characterized by the exag- gerated intensity of mood experiences throughout long periods of time. Crucially, such experiences seem either unrelated or disproportionate reactions to external real-life events. Depression, as the everyday connotation of the word suggests, is characterized by a persistent low mood or anhedonia. It causes speech reduction, lack of joy, and pessimistic, often suicidal, feel- ings of guilt. Perceptual abnormalities and reductions in appetite and sex drive are also frequent_._ In addition, depression is often associated with lack of concentration and attention, and increased anxiety. Depressive symptoms are classified as reactive if they develop as a response, albeit disproportionate, to real-life stres- sors, or endogenous if they have no external cause at all. They are also classified on the basis of their gravity, namely, as neurotic if minor or psychotic if severe, though no clear-cut distinction exists (Paykel, Hollyman, Freeling, & Sedgwick, 1988). Depression is one of the most common and disabling mental disorders, with approximately 20 percent of reported cases glob- ally, including 6 percent with lifetime risks. It is more frequent in women, poor, and lonely people (Brown & Harris, 1978),
concordance rate the extent to which people show the same disorders
expressed emotion refers to the specific set of feelings and behaviors directed at people with schizophrenia by their family members
58 Psychopathology
suggesting cultural and social determinants. Depression can last from a mere few weeks up to several years (Angst, 1978), but most treated patients will tend to recover. The most widely used and effective treatment for depression is antidepressant medication, though in urgent cases quicker methods such as electroconvulsive therapy (ECT) are often applied. ECT is a speedy but controversial technique by which electric activity is induced on the brain. Specifically, it involves the introduction of a tonic seizure where the patient loses con- sciousness for at least one minute. Contrary to popular belief, long-term negative effects of ECT are rare (Zervas & Fink, 1992), especially when administered under anesthesia and muscle relax- ants, as it normally is. Another alternative to psychopharmaco- logical treatment is cognitive therapy (CT), which requires patients to systematically collect information about distorted self- beliefs and restructure them in an adaptive fashion (Beck, Rush, Shaw, & Emery, 1979). It has recently been argued that CT is superior to psychopharmacological treatment because it prevents future relapses (Hollon, Stewart, & Strunk, 2006). The authors claimed that “prior CT has an enduring effect that is at least as large in magnitude as keeping patients on medications” (p. 11.6). However, it is not clear why such an effect would take place. One plausible explanation is that the newly introduced cognitions would persist over the original self-defeating beliefs, thus making the individual less vulnerable to future stressors (Hollon, Shelton, & Loosen, 1991). Psychoanalytic theories explain depression in terms of lack of maternal affection and symbolic loss (Freud, 1957/1917; Klein, 1935), whilst psychosocial approaches similarly emphasize the etiological aspects of stressful life events (Brown & Harris, 1978), for instance the loss of a partner or family member. According to Seligman (1974), repeated exposure to negative and unpleasant events will lead to a state of learned helplessness/hopelessness , which predisposes individuals to negative expectations and feel- ings. Along these lines, cognitive psychologists have argued that depression may be caused by low self-esteem and negative attribu- tional style (Lewinsohn, Roberts, Seeley, Rohde, Gotlib, & Hops, 1994), particularly in adolescence. These biased and self-defeating beliefs can often be changed through CT (Beck, 1983). The second major type of mood disorder is mania and is rep- resented by the opposite extreme of affect than depression. Thus manic individuals experience exacerbated elevated mood and an inappropriate sense of well-being (e.g., optimism, overconfidence, and overexpression of positive emotions). These states can last for several weeks, though usually in alternation with normal mood states. Other symptoms may include abnormal thought and speech (e.g., rapid, uninterrupted, incoherent, inconsistent) as well as psychotic symptoms , notably delusions of grandeur. Manic behavior is charac- terized by overactivity and increased sexual and aggres- sive impulses. About 1 percent of the population is estimated to suffer from mania, though manic symptoms are more frequent in the context of bipolar mood disorders, where manic and depressive symptoms
alternate. Manic patients are treated with lithium and anti- psychotics and require hospitalization, often against their will, no doubt because of their subjective feeling of well-being. If adequately treated, the most common prognosis for manic patients is recovery within six weeks. Biological explanations point at genetic factors underlying affec- tive disorders. Twin studies indicate that the concordance rate for MZ is very high (68 percent if reared together, 67 percent if reared apart), and much larger than in DZ (23 percent) (Shahuria, 2003). It is possible that genetic factors determine biochemical differences in neurotransmitters, particularly in the so-called monoamine group, involved in mood regulation (Sachar & Baron, 1979). In addition, endocrinal factors (hormones) seem particu- larly relevant with regard to depression, notably the underactiv- ity of the thyroid gland. However, causal links are difficult to demonstrate and it is likely that psychological processes affect physiological states as much as physiological processes affect psychological states.
4.7.3 Anxiety disorders and obsessional states
Another main psychopathological category comprises anxiety disorders and obsessional states, both of which are characterized by the experience of high levels of anxiety. As noted elsewhere (chapters 2, 3, and 9), anxiety is a fundamental human emotion and is therefore not exclusive of abnormal disorders. Further, it has long been observed that anxiety has several positive adapta- tional functions, preparing the individual for action by signaling danger in threatening situations. When chronic, however, it is unrealistic (disproportionate to any threat) and unbearable for the individual. Anxiety can be experienced both psychologically and somatically (physically). The most common psychological symp- toms are unpleasant and dreadful feelings, though in severe cases they may include panic attacks and fear of death. Somatic symptoms include increased heart rate, accelerated breathing rate, muscular tension (e.g., scalp, back, shoulder), and, in gen- eral, increased arousal (e.g., inability to relax/settle, fall asleep, concentrate). One of the most common anxiety disorders is phobias, i.e., the experience of irrational or disproportionate fear of an object or phobic stimulus that leads the individual to avoid contact with that object. The object of phobias can be anything from spiders to darkness and social interaction, though usually it is represented by a group of related stimuli (e.g., insects, heights, people). Even when phobic individuals are aware of the irrationality of their fear, they are still unable to establish contact with the phobic event or object, which impairs normal functioning. Women are more commonly affected by phobias than are men, except during childhood when there are no significant gender differences in phobias. Thus, adult phobias are often regarded as a continuation of normative childhood fears. A common treatment for phobias is systematic desensitization , which consists of progressive expos- ure to the phobic object. In recent years this technique has also been combined with computer technology, notably applying
psychotic symptoms symptoms such as hallucinations, incoherent speech, and delusions that indicate a distorted perception of reality
60 Psychopathology
psychotherapy and psychopharmacological drugs constitutes the best treatment for eating disorders (Agras et al., 1992). There has been much speculation about the etiology of eating disorders, particularly in recent years. Unlike other disorders, there is little evidence for the vulnerability hypothesis, though there is some proof of genetic influence as the concordance rate for relatives is 10 percent, compared to 2 percent in the general population (Theander, 1970). Twin studies have found higher concordance rates for MZ than DZ twins (Sullivan, Bulik, & Kendler, 1998). On the other hand, from a feminist perspective (Bemis, 1978), eating disorders have been explained as an attempt to conform to certain stereotypes (usually portrayed by the media), whilst the family interaction hypothesis focuses on the role of dysfunctional families (Minuchin, Rosman, & Baker, 1978), notably intrusive or overinvolved parents.
4.8 CRITICISMS OF THE
DIAGNOSTIC APPROACH
Whereas the classification of syndromes into predefined diagnos- tic categories represents the dominant approach to mental illness in both psychiatry and psychopathology, there have been several opposing views, most notably criticisms by the anti-psychiatry movement (Szasz, 1960). In his famous book Madness and Civilization , French philoso- pher Michel Foucault (1926–84) presented a comprehensive his- torical analysis highlighting the subjectivity underlying the idea of mental illness and the fact that madness has always been asso- ciated with punishment. In the Middle Ages, lepers, the homeless, and “lunatics” were locked up or shipped away; in the seven- teenth century, they were imprisoned alongside criminals. Even with the introduction of treatment by the likes of Pinel and Tuke (see section 4.3), says Foucault, the aim was to control rather than help those suffering from mental illness. Tuke’s method was largely based on punishment and intimidation of the mad until they were able to behave like most people, whereas Pinel’s treatment included freezing showers and straitjackets. Likewise, preestablished definitions of mental illness may merely reflect a political maneuver to punish individuals who do not “fit” into desirable social models, and diagnostic manuals such as the ICD or DSM would be designed to justify medical and social action against individuals who, albeit not responsible for any crimes, deviate from the norm. Critics of the diagnostic approach also include experimental psychologists, such as Bentall (1990), who questioned the sci- entific soundness of the notion of schizophrenia (see also Boyle, 1990). Evidence for the occurrence of hallucinations and other psychotic symptoms in normal populations has long suggested that there may be a “continuum” between mental illness and normality (Bentall, 1990; Galton, 1880; Laroi, DeFruyt, Van Os, Aleman, & Van der Linden, 2005). Indeed, Sarbin and Juhasz (1967, p. 353) argued that “Since the 1920s textbooks of general psychology have differentiated hallucinations from errors of perception by the simple expedient of locating them in separate chapters.” Even when hallucinations are indicative of mental illness, they are not exclusive of schizophrenia but can often be
found in affective psychoses such as mania (Taylor & Abrams, 1975).
4.9 DIMENSIONAL VIEW OF
PSYCHOPATHOLOGY AND
PERSONALITY DISORDERS
In recent years, there has been an increasing shift towards a dimensional view of psychopathology, that is, the idea that mental illnesses merely represent quantitative (as opposed to qualitative) departures from normal behavior. This approach is epitomized by the notion of personality disorders , defined as an “enduring pattern of inner experience and behavior that deviates from the expectations of the individual’s culture, is perva- sive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” (APA, 1994, p. 629). Less severe than major psychoses and famously conceptualized by Freud as “character neuroses,” personality disorders affect an estimated 10–15 percent of the population (Zimmerman & Coryell, 1989). Although personality disorders may cause individuals to “feel at home in their own disordered condition” (O’Connor & Dyce, 2001, p. 1119), their disruptive nature is substantial and affects educational, occupational, and interpersonal functioning. Whilst personality disorders represent “either extreme or significant deviations from the way the average individual in a given culture perceives, thinks, and feels” (WHO, 1993), they have been traditionally classified in categorical terms. Thus Axis 2 of the DSM (in its current as well as previous 1980 edition) lists the following clusters:
- Cluster A:^ antisocial^ (the most widely researched and oldest personality disorder, previously known as “psychopathic”), borderline , narcissistic , and histrionic , which are characterized by odd and eccentric behaviors as well as disregard for others.
- Cluster B:^ schizotypal ,^ schizoid , and^ paranoid , which are characterized by dramatic, erratic, and emotional behaviors.
- Cluster C:^ avoidant ,^ obsessive-compulsive ,^ dependent , and passive-aggressive , which are characterized by anxious and fearful behaviors.
Despite widespread agreement on the above list, which is purely descriptive, mainstream personality researchers are hoping that the next revision of the DSM shifts to a dimensional model of per- sonality disorders (McCrae, Loeckenhoff, & Costa, 2005). Indeed, a recent issue of the European Journal of Personality (2005) was entirely devoted to the cause of a model that integrates normal and abnormal classifications of personality along a continuum, with a focus on psychometric inventories (both self- and other- reports) rather than the currently dominant unstructured
personality disorder a persistent pattern of thinking, feeling, and behaving that deviates from cul- tural expectations and impairs a person’s educational, occupational, and interpersonal functioning. Such disorders begin at a relatively early age, are stable over time, and are pervasive and inflexible
Psychopathology 61
interviews (Westen, 1997). Thus Widiger and Samuel (2005, p. 279) argued that “few clinicians would attempt to diagnose mental retardation in the absence of a structured test, yet this is the norm for most other diagnoses.” Trull and Durrett (2005) proposed a dimensional model that conceptualizes abnormal and normal personality in terms of four common factors, namely, Neuroticism/negative affect/emotional dysregulation , Extraversion/positive affect , dissocial/antagonistic behavior , and Conscientiousness/constraint/compulsivity. This taxo- nomy is consistent with several previous studies (e.g., Austin & Deary, 2000; Livesley, Jang, & Vernon, 1998; O’Connor & Dyce,
- and suggests that, except for Openness to Experience, the same latent factors cause responses to both clinical and non- clinical personality inventories, which implies that they can be simultaneously used to describe normal and abnormal patterns of behavior. Accordingly, it should be possible to use specific levels and combinations of the Big Five personality traits to describe and predict personality disorders, but which ones? In a recent meta-analysis of more than 15 studies (1967–2001), Saulsman and Page (2004) looked at the particular combination of the Big Five associated with each personality disorder, as well as the recurrent pattern of Big Five correlates of personality disorders. Table 4.2 summarizes these findings. As can be seen, most personality disorders were positively correlated with Neuroticism (N), and negatively correlated with Agreeableness (A) and Conscientiousness (C). The Extraversion (E) and Openness (O) correlates of personality disorders are more variable in both direction and strength. For instance, people with histrionic personality disorder tend to be substantially higher on E, whilst those with avoidant personality disorder tend to be substantially lower on E. O, on the other hand, was negatively associated with schizoid but positively associated with histrionic personality disorders. The mean effects suggest that N (positively) is the most significant correlate of personality disorders, followed by A (negatively). A clear advantage of incorporating a dimensional model in psychopathology would be the capacity to explain the stability of
personality disorders as these are extreme variations of genetically influenced traits (Cloninger, 1987; Zuckerman, 1991). Normal traits, such as the Big Five, are fairly stable throughout the life- span, with typical reliabilities in the region of .50 over a 10-year period. Drastic changes are particularly odd for Neuroticism and Extraversion (the two classic dimensions of temperament) and after the age of 30 years. Although the notion of stability seems incompatible with the idea of treatment – the success of psychotherapy, for instance, is largely based on the possibility of introducing change – this conflict is mainly apparent. Thus Costa and McCrae (1994, p. 35) explained that “behaviors, attitudes, skills, interests, roles, and relationships change over time, but in ways that are consistent with the individual’s underlying personality.” Whereas personality traits are largely the product of genetic influences, “the personality pathology is found in the character- istic adaptations, not the basic tendencies” (McCrae et al., 2005, p. 273). In Figure 4.5 (adapted from McCrae & Costa, 1999), we can see how biologically based personality dimensions may affect an individual’s adaptation and self-concept, which would in turn be affected by external influences (e.g., cultural and social norms, life events). Psychotherapy and other forms of treatment may be regarded as external influences, too.
4.10 SUMMARY AND CONCLUSIONS
In this chapter I have examined theories of psychopathology, an important area of psychology with historical roots dating back more than two thousand years. As seen:
- Throughout its history, the ongoing leitmotiv of psy- chopathology has been the study of abnormal behavior. Modern conceptualizations of normality are based primarily on the four conventional criteria of statistical frequency, per- sonal distress, social norms, and maladaptiveness, as well as the mental illness or diagnostic approach from mainstream
Table 4.2 The Big Five and personality disorders
DSM-IV personality disorders Five Factor model personality dimensions
N E O A C
Paranoid .28**** −.12**** −.04** −.34**** −.07**** Schizoid .13**** .23**** −.12**** −.17**** −.03* Schizotypal .36**** .28**** −.01 −.21**** −.13**** Antisocial .09**** .04 .05** −.35**** −.26**** Borderline .49**** −.09**** .02 −.23**** −.23**** Histrionic .02 .42**** .15**** −.06** −.09*** Narcissistic .04 .20**** .11**** −.27**** −.05* Avoidant .48**** −.44**** −.09**** −.11**** −.10**** Dependent .41**** −.13**** −.11**** .05** −.14**** Obsessive-compulsive .08*** −.12**** −.07**** −.04 .23**** Mean .24 −.07 −.01 −.17 −. Median .20 −.12 −.02 −.19 −.
Source : Saulsman & Page (2004), Table 5, p. 1068. Reproduced with permission from Elsevier.
