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Understanding Psychopathology
LEARNING OBJECTIVES FOR THIS CHAPTER
- Understand what Introducing Psychopathology is about
- Know the history behind the concept of psychopathology
- Discuss the philosophical underpinnings of psychopathology
- Have insight into the classification of mental disorders
- Realise that cultural and transcultural issues are involved in psychopathology At the heart of counselling, psychotherapy and counselling psychology lies an understanding of mental distress. This is why knowledge of psychopathology is crucial for trainees entering these professions. Without it, they can get lost in a maze of psychobabble. When I was a student, I wished for a book that explained mental disorders in a jargon-free, simple way. During my training, ploughing through the great third edition of the Diagnostic and Statistical Manual for Mental Disorders (APA, 1987) was a daunting task. What I needed was a sim- ple introduction to psychopathology. I write the simply presented and jargon-free book I wish I had in the hope that it helps those who use (or will use) talking as a therapeutic ‘tool’ with their clients or patients. Although having the ability to be a reflective practitioner is key (as I explain later in this chapter), without a breadth and depth of understanding how mental distress manifests in individuals, coupled with a knowledge from theory and research on how to facilitate these people to move in a desired direction, the therapeutic relationship is severely compromised; if indeed, it is present at all. Without such knowledge and understanding, therapists may unwittingly make matters worse. Bearing this in mind, Introducing Psychopathology specifically includes points to reflect on. There are teaching and learning features throughout and these are discussed further on. You do not have to read this book in any particular order. Dip into it at any place. Each chapter can stand in its own right – if you want to find out about being depressed, just go to the chapter that deals with depression. Nevertheless, there is some logic to the order I have written the text. For instance, this chapter is the book’s introduction. The one that follows deals with assessing and referring, because these tasks are normally necessary during a first appointment. Then there is a focus on children before the spotlight shines on adults, and finally I consider possible future avenues. Therefore, you can read Introducing Psychopathology from cover to cover for a more comprehensive picture.
2 Introducing Psychopathology
WHAT IS PSYCHOPATHOLOGY?
Psychopathology derives from two Greek words: ‘psyche’ meaning ‘soul’, and ‘pathos’ meaning ‘suffering’. Currently, ‘psychopathology’ is understood to mean the origin of mental disorders, how they develop and their symptoms. Traditionally, those suffering from mental disorders have usually been treated by the psychiatric profession, which adheres to the DSM-IV-TR (APA, 2002) or ICD-10 (WHO, 1992) for classifying mental disorders. It therefore follows that psychiatrists use the term ‘psychopathology’ more than people in other professions. Psychiatrists are medical doctors who then train in mental health and are able to treat with medication or/ and in whatever psychotherapy model they have trained in. Within psychiatry, the term ‘pathology’ refers to disease. However, viewing mental problems as a disease is a contentious point. Psychotherapists, counselling psychologists and counsellors (who specialise in mind matters and are not medics), view apparent mental dysfunction as men- tal distress, not necessarily related to pathology. So, the term ‘disorder’ is used, rather than ‘disease’. Other words for diagnosing distress within the mind remain: ‘symptoms’ meaning ‘signs’, ‘aetiology’ meaning ‘cause’, and ‘prognosis’ meaning ‘expected outcome’.
HISTORY AND PHILOSOPHY
Historical and philosophical factors of psychopathology can easily take up a whole volume. This section offers a psychopathology foundation, which can be built on by looking up the related resources and references listed at the end of the chapter. Historically, the concept of psychopathology is rooted in the medical tradition. This is where the terms ‘diagnosis’, ‘symptoms’, ‘aetiology’ and ‘prognosis’ come from (Murphy, 2010). Psychiatrists cat- egorise severe mental distress into psychopathological disorders whose symptoms they can treat with prescribed drugs, and use the word ‘patients’. Counselling psychologists, counsellors and psycho- therapists favour the term ‘clients’ over ‘patients’ (because of the medical connotations of the word ‘patients’) and use talking, more than anything else, as a therapeutic ‘tool’.They also prefer the concept of ‘formulation’ instead of ‘diagnosis, symptoms, aetiology and prognosis’. Throughout this book, instead of repeating ‘counselling psychologists, counsellors and psychotherapists’, I use the word ‘therapists’, or ‘talking-cures’ to mean all three of these professions because although they may require different trainings, their overlap is substantial. But what are the historical roots of these professions? Ancient Greece Medical and talking-cure roots are embedded in the soil of ancient Greek philosophy. Indeed, the philosophy of the western world is rooted in ancient Greece, from which the mould of western-world thinking was wrought, influencing the way in which the west is. Therefore it follows that the source of my views grows from this mould, which shapes my world and con- sequently this book, because I was born, raised and live in the west. If I visit a non-western country, the cross-cultural differences may be too great for me to comprehend. I might think that I understand someone whose philosophical ‘template’ is embedded within a non-western philo- sophy, but I may, in my relative ignorance, misunderstand that person. For this reason, the philosophy focused on here relates to the western world. Nevertheless, as therapists in multicultural settings, we need to be aware of a client’s culture and adapt appropriately.
4 Introducing Psychopathology on Rousseau see, for example, Farrel, 2006). Contemporary author Gerhardt expresses a similar idea. She illustrates how it is that the countries with the most inequality also have the most mental distress when compared with those with less inequality; she draws on a substantial amount of research findings that back up her theory (2010). This view adds to the tension between an approach to mental health using a medical model (with its focus on pathology) and one advocating talking-cures (which favour formulations). Hegel As history marched from the eighteenth to the nineteenth century, another great philosopher emerged, Hegel, who was immensely influenced by Rousseau’s ideas. According to Hegel, phi- losophy is the best and absolute form of knowledge, derived dialectically, bringing together knowledge and experience (for more on Hegel see, for example, Stern, 2002). Talking therapies blossom from this stem. He was the forerunner of the existential school of psychotherapy, prizing the individual’s experience and endeavouring to make sense of life; the very idea of psychopa- thology is anathema to this school and its philosophy. Twentieth and twenty-first centuries Existentialism eventually developed into Husserl’s phenomenology (for more on Husserl see, for example, Smith, 2007), central to which is the describing of phenomena as they are experienced, rather than interpreting or theorising. It does not make a comfortable bedfellow with psycho- pathology. What is comfortable for phenomenologists is viewing the relationship between one human life and another.This view continues, flourishing into the current interest shown by many therapists that it is the interpersonal relationship which is of paramount importance for good mental health (Gerhardt, 2008; Rudd, 2008; Gilbert, 2010). Plato’s philosophical thread, then, leads from ancient Greece through the Romantic Movement to modern times and the perspec- tive that what happens to us as children has an effect on us as adults – and that we can do some- thing about it (Dawson and Allenby, 2010). Growing numbers of twenty-first century authors support this perspective (for example, Read, Bentall and Mosher, 2004; Rudd, 2008; Gerhardt, 2010). Furthermore, if mental functioning becomes profoundly disturbed, some authors entwine the perspective of interacting with an important other in a relationship with that of pathology, thereby easing tension between the two philosophical threads (for example, Baldwin et al., 1982; Gerhardt, 2008). By continuing to follow Plato’s thread, we are led to emerging research showing that troubled minds, on the whole, are not diseased, and that talking with clients can be substantially helpful (Read, Bentall and Mosher, 2004; Lipton, 2008; Dawson and Allenby, 2010; McTaggart, 2011). Robust research such as that conducted by doctors Harriet, Macmillan and their team (2001) reveals that even lifelong suffering from psychopathological disorders or mental problems is not due to biological illness or disease, but to abuse in childhood. There is more information on this in Chapter 12. So far, we have followed the thread from Plato in ancient Greece (who declared that the soul is in the pumping heart), to the present day; it therefore seems appropriate to now pick up the thread from Aristotle. The Aristotelian philosophical thread Aristotle disagreed with Plato, believing that the soul is in the head and not in the heart, that it dies in the body, and that only reason and rationality are eternal (for more on Aristotle see, for
Understanding Psychopathology 5 example, Halper, 2005). Due to this, the initial sturdy thread of ancient Greek philosophy split into two fine ones, which is where the tension between them starts. Following the thread from Aristotle, we again weave our way to the seventeenth century. Locke and CBT Seventeenth-century philosopher Locke said that mental distress results when we link our emotions to ‘wrong’ ideas (for more on Locke, see Grayling, 2005). This way of thinking can be seen in the modern approach of cognitive behaviour therapy (CBT) where certain thoughts of those who seek therapy are viewed as unreasonable and the therapist endeavours to teach the client to change these to reasonable ones, thereby influencing emotions. In other words: to change irrational ideas to rational thoughts and therefore impact on emotion. Within this model, the concept of psychopathology can nestle comfortably. Indeed, there is much litera- ture linking CBT with psychopathological labels (for example, Butler, Melanie and Hackman, 2008; van Niekerk, 2009; Christensen and Griffiths, 2011; Kingdom and Turkington, 2005). What are these labels and how might they be grouped? This is deliberated further on. No more demons To continue following the Aristotelian thread from Locke, we reach the eighteenth century, where the idea of psychopathology took hold due to the notion that madness was a result of illness, rather than being possessed by the devil, and therefore not under the individual’s control. So torturing, which went on previously to remove so-called demons, was stopped and the medical model, with its belief in pharmacology, was adopted, quickly becoming widespread even though much literature supports the perspective that psychological inter- vention has a powerful effect on individuals (for example, see Rudd, 2003; Gerhardt, 2008; Gilbert, 2010). Nineteenth, twentieth and twenty-first centuries The Aristotelian philosophical thread can be followed from the eighteenth, into the nine- teenth century where, due to developments in medicine, theories of mental illness were expanded and bathed in medical descriptive language such as ‘aetiology’ and ‘pathology’. There was then a sea-change in the twentieth century with the closing down of mental asy- lums (in the UK) as a result of a move away from the disease model. This created space for an interpersonal approach to share the mental-health arena with the medical model. Consequently, tension between the two philosophical threads eased. Today, the mental-health arena con- tinues to be shared, mainly by those who use formulation to look at psychological issues, with those using psychopathology.
HOW MENTAL PROBLEMS ARE ORGANISED
In terms of psychopathology, mental problems are labelled according to symptoms (for exam- ple, ‘depression’), and theoretically organised by being chunked. Chunking forms categories, for ease of reference, as in the DSM-IV-TR (APA, 2002); an important book which can be, for therapists, what Gray’s Anatomy is for medics (Gray, 1974). It is worth noting here that, at the time of writing, the DSM-V is soon due to be published (this is addressed later in the book).
Understanding Psychopathology 7 Global assessment of functioning or children’s global assessment scale Classified under Axis V in DSM-IV-TR is a category for global assessment of functioning or children’s global assessment scale (APA, 2002). Therapists must know about assessment. If, for example, a therapist is referred a client and the referral letter states that the client is suffering from obsessive compulsive disorder (OCD), the therapist should know about this condition and have the ability to assess for themselves, in order to ascertain whether they agree with the referrer or not. Knowing what to do about referrals, whether relating to a child or adult, is part of practising professionally.
A BIRD’S-EYE-VIEW OF INTRODUCING PSYCHOPATHOLOGY
Our journey through this book takes us via twelve stages. Every stage involves travelling through a different chapter. Thus, each chapter can be focused on either per week or month, depending on the course programme a student is on. Chapter 1 The portal into our journey. Here we perceive the essence of the whole book. This stage puts psychopathology into perspective. Chapter 2 Our route takes us into assessments and referrals. We see how mental distress is identified. We also perceive the limits of therapists’ capabilities. Chapter 3 Developmental mental problems is the next stage.Young people are highlighted here. In this way, we see issues that may arise at any time from pre-birth to late teens. Chapter 4 We are a third of the way along our journey, travelling through the anxiety disorders. OCD, panic attacks and negative stress are included in this stage. Chapter 5 Here, our journey takes us through diagnostic criteria for cognitive disorders. We also voyage through Alzheimer’s and vascular disorders. For a more comprehensive view, we take a literary vantage point.
8 Introducing Psychopathology Chapter 6 Here, we travel through mood disorders. Self-harm and suicide are also visited. The difference between just feeling low and depression is spotlighted too. Chapter 7 Next, our journey takes us to eating and sleeping disorders. For this stage, anorexia and bulimia nervosas are identified. Additionally, problems with over and under-sleeping are floodlit. Chapter 8 Substance issues are addressed in this section. Substance dependency, commonly called ‘addiction’, is visited. Further, the concepts of compulsively using a substance or using it for social reasons are unpacked. Chapter 9 We journey through psychotic disorders of schizophrenia, psychosis and psychotic problems. Factors associated with good and bad outcomes are looked at.We also look at signs and causes of such disorders. Chapter 10 Somatic disorders are deliberated on at the tenth stage of our route. Body dysmorphia and hypo- chondriasis are covered. We ‘discover’ that a somatic disorder can also include pain. Chapter 11 We voyage through the personality disorders. Here, we consider borderline, narcissistic, dependent, avoidant, paranoid, schizoid, schizotypal, antisocial, obsessive compulsive and histrionic disorders. Plus, relevant literature is perused. Chapter 12 An overview of Introducing Psychopathology is our final stage, in which holistic approaches to mental health are also viewed. These include emotional literacy and the transpersonal concept. We exit our route via a tantalising glimpse of an amazing yet possible future direction.
ASPECTS OF LEARNING
Students have various ways of learning. For this reason, features I offer include all sorts of ways to learn. These are:
10 Introducing Psychopathology most and is seeing what most are blind or deaf to. In some cultures, for example, Shamanic and Asian cultures (Lukoff, 2007), such a person might be seen as a visionary or spiritual leader. I am being contentious here in the hope of facilitating reflection and debate, as part of the learning experience. Throughout, I do this in various places.
CULTURAL AND TRANSCULTURAL ISSUES
Different disorders, as well as their prevalence in different countries and ethnicities, are involved in cross-cultural issues. It has been vehemently argued that both psychopathology itself and the DSM-IV-TR categories of mental disorders are 90 per cent culture-bound within the USA and the western world (Kleinman, 1997). Intriguingly, a good-enough research project was con- ducted in Ontario, Canada, where 142 adults aged between 22 and 26 years self-reported being born with very low birth-weight. Findings showed that a statistically significant number suf- fered as adults either from depression, anxiety or avoidant personality problems (Boyle et al., 2011). It could be useful to have further research conducted internationally to see whether such a correlation exists in other countries between low birth-weight and similar psychological problems in young adults. Societal and cultural factors are very important when it comes to mental health. There is a gradual move away from disease models relating to mental distress (at least in the UK) and a movement towards explaining meanings, using the concept of formulation rather than diagnosing, while endeavouring to appreciate social and cultural aspects (Bentall, Boyle and Chadwisk, 2000). Consequently, there is a re-emerging of the tension between the psychiatric and psychological approaches, coming from the more contemporary comments on the notions of psychopathology from psychologists such as Bentall and his team who bring societal and cultural factors into relief (2000). An awareness of cross-cultural issues and ethnic diversity can help trainees realise that every town and social group has a different culture. For instance, those living in rural areas may cope differently to mental stresses than inner-city people. With this in mind, it is very important that the universality of psychopathology is not assumed, however tempting it might be when perusing findings from research.
PSYCHOPATHOLOGY RELATED TO THE HEALTH SERVICE AND INDEPENDENT
PRACTICE
Within the UK, psychopathology is related to health services, either with those who work inde- pendently, for a charity, a private organisation or the National Health Service. Not just health service professionals, but anyone can have access to the NICE (2011) guidelines. Although seem- ingly prescriptive, they can be useful, particularly for trainees in placements when faced with clients, especially for the first time. However, it is important not to forget practice-based evidence. Medication Under the health services umbrella, clients seeing a therapist may also be prescribed medicine for a mental health disorder (see Chapters 8 and 9 for more on this). The case vignette below illustrates this point.
Understanding Psychopathology 11 Lucy, aged fifty-five, went to see a psychotherapist because she felt anxious. Her doctor had prescribed drugs, which she took diligently. The therapist noticed that Lucy’s hands were shaking. During their initial meeting, Lucy said she did not know whether her hands shook because she felt anxious or because of her medication. The therapist looked up the medicine in a reference book and showed Lucy that a side effect is trembling hands. With her permission, he wrote to the doctor stating Lucy’s concern about her hands shaking. Lucy’s GP responded by changing the medication and gradually reducing it while she was supported by the therapist. Within a month, her hands stopped trembling and she was able to use psychological techniques for managing anxiety. In this case, the client’s wish to explore medication was achieved within the boundaries of knowledge and experience of the therapist who liaised appropriately interprofessionally.
CASE VIGNETTE
Points to ponder
- If much relevant research shows that the relationship is key in a therapeutic encounter, is it ethi- cal to favour one theoretical model above all others?
- What are the implications of stating that specific symptoms point to a disorder, while we live in a twenty-first century postmodernist or poststructuralist society characterised by the idea that there is more than one truth?
- Is it important or not for therapists to belong to a professional organisation such as the UKCP, BPS, BACP or HCPC?
- If the study of psychopathology identifies mental disorder, how can we identify mental normality? Exercise (Answers are embedded in this chapter.) 1 What does ‘psychopathology’ mean? 2 Is body dysmorphia classified as a personality or somatoform disorder? 3 Is schizophrenia classified as a substance or psychotic disorder? 4 Is bulimia nervosa classified as a sleeping or eating disorder? 5 Is depression classified as a mood or cognitive disorder? 6 Is social phobia classified as an anxiety or developmental disorder? 7 Historically and philosophically, what are the roots of psychopathology embedded in?
Understanding Psychopathology 13 (Continued) Appignanesi, L. (2010) Mad, Bad and Sad (London, Virago Press). Baldwin, A.L., Cole, R.E., Baldwin, C.P., Fisher, L., Harder, D.W. and Kokes, R.F. (1982) ‘The role of family interaction in mediating the effect of parental pathology upon the school function- ing of the child’, Monographs of the Society for Research in Child Development, 47, 5, p. 72. Bentall, R. P., Boyle, M. H. and Chadwisk, P.D.J. (2000) BPS Psychosis Report, www. authorstream.com/Presentation/FunnyGuy-9087-abpsy-ppt-powerpoint/, accessed 19 September 2011. Boyle, M.H., Miskovic, V., van Liesshout, R., Duncan, L., Schmidt, L.A., Hoult, L., Paneth, N. and Saigel, S. (2011) ‘Psychopathology in young adults born at extremely low birth weight’, Psychopathology and Medicine, 41, 8, pp. 1763–74. Bloom, W. (2011) Personal communication, 9 November. Butler, G., Melanie, F. and Hackman, A. (2008) A Cognitive-Behavioural Therapy for Anxiety Disorders: Mastering Clinical Challenges (Guides to Individualized Evidence- based Treatment) (New York, The Guilford Press). Christensen, H. and Griffiths, K. (2011) The Mood Gym: Overcoming Depression with CBT and Other Effective Therapies (London, Vermilion). Danielson, N. (2007) Our Shell-shocked Soldiers, www.ninadanielson.com/docs/ptsf.pdf, accessed 1 August 2011. Davis, W. (2011) Instroke, Empathy and the Therapeutic Relationship, www.functionalanalysis. de/e107_files/downloads/Instroke,Empathy%20and%20theTherapeutic%20Relationship.pdf, accessed 19 December 2012. Dawson, K. and Allenby, S. (2010) Matrix Reimprinting Using EFT: Re-write Your Past, Transform Your Future (London, Hay House). Ellis-Christensen, T. (2011) What is Talk Therapy?, www.wisegeek.com/what-is-talk-therapy. htm, accessed 16 September 2011. Farrel, J. (2006) Paranoia and Modernity: Cervantes to Rousseau (New York, Cornell University Press). Gerhardt, S. (2008) Why Love Matters (Hove, Brunner-Routledge). Gerhardt, S. (2010) The Selfish Society (London, Simon and Schuster). Gilbert, P. (2010) The Compassionate Mind (London, Constable). Gray, H. (1974) Gray’s Anatomy (Philadelphia, Running Press Book Publishers) Grayling, A.C. (2005) Descartes: The Life and Times of a Genius (New York, Walker). Halper, E.C. (2005) One and Many in Aristotle’s Metaphysics, Volume 2, The Central Books (Las Vegas, Parmenides). Harriet, L., MacMillan, M.D., Fleming, J.E., Streiner, D.L., Lin, L., Boyle, M.H., Jamieson, E., Duku, E.K., Walsh, C.A., Maria, M.S.W., Wong, Y. and Beardslee, W.R. (2001) ‘Childhood abuse and lifetime psychopathology in a community sample’, American Journal of Psychiatry, 158, pp. 1878–83. Hunter, R.A. and Macapline, I. (1963) Three Hundred Years of Psychiatry 1535– (Oxford, Oxford University Press). Kingdom, D.G. and Turkington, D. (2005) Cognitive Therapy for Schizophrenia (New York, The Guildford Press).
14 Introducing Psychopathology Kleinman, A. (1997) ‘Triumph or pyrrhic victory? The inclusion of culture in DSM-IV’, Harvard Review of Psychiatry, 4, 6, pp. 342–4. Krupnick, J.L., Stotsky, S.M., Elkin, I., Simmens, S., Moyer, J., Watkins, J. and Pilkonis, P.A. (2011) ‘The role of the therapeutic alliance in psychotherapy and pharmacotherapy out- come: findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program’, Focus, 4, pp. 269–77. LeBuffe, M. (2010) Spinoza and Human Freedom (New York, Routledge). Lipton, B. (2008) The Biology of Belief (London, Hay House). Lukoff, D. (2007) ‘Visionary spiritual experiences’, Southern Medical Journal, 100, 6, pp. 635–41. McTaggart, L. (2011) The Bond (London, Hay House). Murphy, D. (2010) Philosophy of Psychiatry, www.plato-stanford.edu/entries/psychiatry/, accessed 24 September 2011. Nails, D. (2006) The Life of Plato of Athens (Oxford, Blackwell). NICE (2011) National Institute for Health and Clinical Excellence, www.nice.org.uk/ action=by.Type&type=2&status=3, accessed 16 September 2011. Read, J., Bentall, R. and Mosher, L. (eds) (2004) Models of Madness: Psychological Approaches to Schizophrenia and Other Psychoses (Hove, Brunner-Routledge). Rogers, C. (1961) On Becoming a Person: A Therapist’s View of Psychotherapy (London, Constable). Rogers, C. (1980) A Way of Being (Boston, Houghton-Mifflin). Rudd, B. (2003) Body Mind Update, Resource for New Health Findings (Haywards Heath, Hygeia Health). Rudd, B. (2008) Talking is for All: How Children and Teenagers Develop Emotional Literacy (London, Sage). Seligman, M. (2011) Flourish: A New Understanding of Happiness and Well-Being – and How to Achieve Them (Belgium, Hein Zegers). Smith, D.W. (2007) Husserl (London, Routledge). Stern, R. (2002) Hegel and the Phenomenology of Spirit (New York, Routledge). van Niekerk, J. (2009) Coping with Obsessive-Compulsive Disorder: A Step-by-Step Guide Using the Latest CBT Techniques (Oxford, One World Publications). WHO (1992) ICD-10: The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines (Copenhagen, World Health Organization). Williamson, M. (2008) The Age of Miracles (London, Hay House). (Continued)
