Introduction to Psychopathology

1. Introduction to Psychopathology Michael Wilson, PhD University of Illinois Department of Psychology and University of Illinois College of Medicine

2. Outline • Defining abnormal behavior • Freud’s view of personality • Modern view of abnormal behavior

3. A clinical vignette A primary care physician notices that many of her patients use statements like “I can’t stop smoking because I’ll gain weight.” Another patient who lost an arm in an accident states “It was good that I lost my arm since it keeps me out of trouble with the law.” Statements like these: • produce conflict in the conscious mind • are conscious mental techniques • increase anxiety • are examples of the use of defense mechanisms • decrease patient’s sense of self-esteem

4. Mental Disorder vs. Abnormal Behavior Mental Disorder Abnormal Behavior Mental Disorder and Abnormal Behavior

5. Mental Disorder vs. Abnormal Behavior Mental Disorder Abnormal Behavior

6. Mental Disorder vs. Abnormal Behavior Abnormal Behavior Mental Disorder

7. Defining Abnormal Behavior • Personal distress • subjective report of problems • Social impairment • violation of moral standards • observer discomfort • Statistical deviance • relative frequency of abnormal behavior • 15-20% of women may experience major depression in lifetime

8. What is abnormal behavior? • Abnormal behavior is a natural, fuzzy concept • but illness is tricky to define • Involves identifying certain symptoms or syndromes that co-occur with mental disorders • plus some sort of assessment of impairment • plus some sort of assessment of distress

9. Public Prejudices About Mental Illness

10. Freud’s view of psychopathology Freud believed that mental life is like an iceberg.

11. Sigmund Freud (1856-1939) • Like an iceberg, most mental life is invisible • Three levels of functioning: • conscious (what we are aware of) • preconscious • not part of our everyday experience, but can be made conscious • unconscious • “powerful primitive drives and forbidden wishes” that constantly pressure conscious mind

12. More Freud… • People struggle with primitive drives and forbidden wishes • some of which are biologically generated • most of which are relegated to unconscious • Unconscious wants uninhibited fulfillment of these wishes • This is psychic reality that motivates human behavior • Victorians did not like idea that they were powered by base drives (e.g., sex). • Reality/socialization construct conscious belief that these behaviors are controllable • In other words, prudish Victorians could pretend behavior not motivated by sex

13. More Freud… • Topographic model • extension of theory • Reality/social forces could not allow gratification of many primitive desires • produces conflict • this leads to psychologically-derived disturbing symptoms

14. More Freud… • Structural model of the mind • refinement of topographic model • Id = source of instinctual drives, functions unconsciously, strives for gratification of desires without taking reality into account • the pleasure principle • Superego = internalized moral standards, values, prohibitions • This is the conscience • uses guilt to prohibit unacceptable behavior • largely unconscious • Ego = aspect of the mind that relates to reality • evolves from id and organizes ways to get what people want in the real world • prevents anxiety or guilt that would arise if became aware of id or violated superego rules • sometimes uses defense mechanisms to prevent this

16. More Freud… • Intrapsychic conflict & anxiety are central features of human psychological functioning • the number, nature, and outcome of these conflicts shape personality • Ego’s mechanisms of defense protect against psychic dissolution or annihilation • As individuals mature & resolve intrapsychic conflict, can learn to use more adaptive and mature defenses • Although abnormalities in development of defense mechanisms may cause various forms of psychopathology, defenses are not of themselves pathological • Often maintain healthy psychological well-being

17. Definitions • Neurosis • Freud: situation where ego fails to resolve conflicts between superego & id • modern use: any unpleasant mental symptom that does not interfere with rational thought • Psychosis • Freud: situation where the “ego gets carried away by the id and detaches from reality” • modern view: a disturbance of rational thought, may involve hallucinations or delusions

18. Primitive Defenses • Range in severity from psychotic to borderline psychological functioning • Denial • Refuse to acknowledge external reality • Example: An alcoholic believes he is only a social drinker • Projection • Attributing personally unacceptable feelings to others • Example: A man with homosexual tendencies begins to believe his boss is homosexual • Splitting • Categorizing people or objects into “good” and “bad” • Example: A patient with a personality disorder tells the doctor that all of the doctors are wonderful, all the RNs are rude

19. Immature Defenses • Passive-Aggressive Behavior • Indirect expression of anger, frustration or aggressive impulses towards others, passive resistance • Example: taking long time to get ready for party that don’t want to attend • Acting Out • Avoiding unacceptable emotions by behaving in an attention-getting manner • A toddler feels abandoned and begins to throw his toys around • Regression • Return to previous stage of development or functioning • Example: a toddler begins to wet the bed when his mom has a baby

20. Neurotic Defenses • Displacement • Express emotion to a different object than the one causing conflict • Example: Man who gets angry kicks the dog. • Dissociation • Temporary but drastic modification of personal identity/character to avoid emotional distress • Example: A teenager has no memory of the car accident in which he was driving & his girlfriend was killed • Intellectualization • Control of feelings and impulses by thinking about them instead experiencing them • Example: Med student who has cancer calmly explains the pathophysiology of the diease • Rationalization • Justification of attitudes, beliefs, or behavior that may be otherwise unacceptable • Example: A man who loses an arm in an accident says that the loss was good because it keeps him from getting in trouble with the law • Reaction Formation • Unacceptable impulses are expressed in antithetical form as the opposite • Example: Man who feels guilty about pornography goes on anti-smut crusade

21. Mature Defenses • Altruism • Service to others • Example: donating to charity • Humor • Jokes focus attention away & distracts from the feeling • Example: A man uncomfortable about ED jokes about viagra • Sublimation • Acknowledgement & subsequent channeling of thoughts, feelings and behaviors in a socially valued way • Example: A teenager who fights a lot becomes a boxer • Suppression • Conscious or semiconscious decision to postpone attention to an impulse or conflict • An M1 mentally changes the subject when her mind wanders to the anatomy practical during lecture

22. Psychosexual development • Postulated inborn developmental sequence • individuals, starting in infancy, experience linear progression from each phase to next • psychic conflict leads to fixation or regression to earlier stage Stage age oral 1 anal 2 phallic 3-5 …latency period… genital teens-death Oedipus/Electra complex

23. Later theorists • Later researchers have argued that internal traits cannot accurately predict behavior • Must take into account motivations and development, individual differences, & life narrative • = internalized & evolving story of one’s life

24. Changing behavior externally

25. Developmental Cognitive Neuroscience • “Human behavior emerges from embedded and interacting complex systems that include the genome and its expression in epigenesis and development, the brain, interacting psychological functions, and the individual in his or her social and cultural contexts.” • Pennington, B (2002). The Development of Psychopathology. Guilford Press

26. Classifying abnormal behavior • If behavior = interacting & complex systems • how may it be described? • what is abnormal?

27. How then do we classify abnormal behavior? • DSM-IV lists criteria for mental illness • Depends on observations and descriptions • rather than internal traits or causes • Categorical • Multi-Axial

28. Why use a standard classification system for mental illness? • Benefit: a shared scientific language • All illnesses have some sort of agreed-upon classification • Facilitates description • Aids treatment decisions, prognosis • Facilitates research on etiology, treatment outcome • Facilitates 3rd-party reimbursement • Concerns about classifying mental illness • Unlike other illness, many diagnoses stigmatized • may lead to discrimination • Unrelated problems may be misattributed to Dx

29. Description of DSM-IV System • Axis I -- Clinical disorders • Mostly characterized by episodic periods of psychological turmoil • Axis II -- Personality disorders and mental retardation • Mostly concerned with stable, longstanding problems

30. Description of DSM-IV System • Axis III -- General Medical Conditions • Conditions relevant to etiology of patient’s behavior or treatment program • Example: Diabetes • Axis IV -- Psychosocial & Environmental Problems • Factors that may affect the treatment and prognosis of mental disorder • Example: Poverty

31. Description of DSM-IV System • Axis V -- Global Assessment of Functioning • Rating of 1 to 100 of individual’s overall level of functioning • Usually assessed at several points    a.  highest in last year   b.  at intake   c.  current

32. Axis V: Global assessment of functioning (GAF) scale 90 -100: Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms. 51-60: Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). 1-10: Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death.

33. Limitations of the DSM-IV • Arbitrary boundary between normal and abnormal • Cutoff points not always empirically justified • Reliance on clinicians’ subjective judgment • Time periods in definitions of diagnoses

34. Limitations of the DSM-IV • Problem of comorbidity • Simultaneous appearance of two or more disorders in the same person • 56% of those who meet criteria for one disorder also meet criteria for at least one other disorder • Comorbidity affects validity of the system and the reliability of diagnosis

35. Last word (for now) on classification: • Beware of “Intern's syndrome” • Tendency to diagnose one's self while studying any particular disorder • look at frequency and severity of symptoms • as well as number of symptoms

37. A clinical vignette A primary care physician notices that many of her patients use statements like “I can’t stop smoking because I’ll gain weight.” Another patient who lost an arm in an accident states “It was good that I lost my arm since it keeps me out of trouble with the law.” Statements like these: • produce conflict in the conscious mind • are conscious mental techniques • increase anxiety • are examples of the use of defense mechanisms • decrease patient’s sense of self-esteem

38. Readings • Fadem (4th edition), chapter 6