From Last Class

1. Historical Approaches toAbnormal Behavior, Part IJanuary 24, 2014PSYC 2340: Abnormal PsychologyBrett Deacon, Ph.D.

2. From Last Class • Diagnosing mental disorders • Evolution of the DSM • Mental health professions • Getting into graduate school • The supernatural tradition

3. Historical Conceptions of Abnormal Behavior • Mental disorders have existed in all cultures • Treatment based on how they were explained • Three dominant historical traditions: • Supernatural • Biological • Psychological

4. The Supernatural Tradition • Causes of mental illness: • External, supernatural causes (e.g., demons) • Battle of good vs. evil (e.g., sin) • Movement of moon and stars

5. The Supernatural Tradition Today • Schizophrenia and spirit possession • From “The Americanization of Mental Illness:” http://www.nytimes.com/2010/01/10/magazine/10psyche-t.html?th&emc=th • “NOWHERE ARE THE limitations of Western ideas and treatments more evident than in the case of schizophrenia. Researchers have long sought to understand what may be the most perplexing finding in the cross-cultural study of mental illness: people with schizophrenia in developing countries appear to fare better over time than those living in industrialized nations. • This was the startling result of three large international studies carried out by the World Health Organization over the course of 30 years, starting in the early 1970s. The research showed that patients outside the United States and Europe had significantly lower relapse rates — as much as two-thirds lower in one follow-up study. These findings have been widely discussed and debated in part because of their obvious incongruity: the regions of the world with the most resources to devote to the illness — the best technology, the cutting-edge medicines and the best-financed academic and private-research institutions — had the most troubled and socially marginalized patients.”

6. The Supernatural Tradition Today • “Trying to unravel this mystery, the anthropologist Juli McGruder from the University of Puget Sound spent years in Zanzibar studying families of schizophrenics. Though the population is predominantly Muslim, Swahili spirit-possession beliefs are still prevalent in the archipelago and commonly evoked to explain the actions of anyone violating social norms — from a sister lashing out at her brother to someone beset by psychotic delusions.”

7. The Supernatural Tradition Today • “McGruder found that far from being stigmatizing, these beliefs served certain useful functions. The beliefs prescribed a variety of socially accepted interventions and ministrations that kept the ill person bound to the family and kinship group. “Muslim and Swahili spirits are not exorcised in the Christian sense of casting out demons,” McGruder determined. “Rather they are coaxed with food and goods, feted with song and dance. They are placated, settled, reduced in malfeasance.” McGruder saw this approach in many small acts of kindness. She watched family members use saffron paste to write phrases from the Koran on the rims of drinking bowls so the ill person could literally imbibe the holy words. The spirit-possession beliefs had other unexpected benefits. Critically, the story allowed the person with schizophrenia a cleaner bill of health when the illness went into remission. An ill individual enjoying a time of relative mental health could, at least temporarily, retake his or her responsibilities in the kinship group. Since the illness was seen as the work of outside forces, it was understood as an affliction for the sufferer but not as an identity.”

8. The Supernatural Tradition Today • “For McGruder, the point was not that these practices or beliefs were effective in curing schizophrenia. Rather, she said she believed that they indirectly helped control the course of the illness. Besides keeping the sick individual in the social group, the religious beliefs in Zanzibar also allowed for a type of calmness and acquiescence in the face of the illness that she had rarely witnessed in the West.” • Does the supernatural approach necessarily entail mistreatment of the individual? • Does the modern science-based approach necessarily entail benevolent treatment of the individual?

9. Schizophrenia Outcomes • The World Health Organization conducted two long-term follow-up studies involving more than 2,000 people suffering from schizophrenia in different countries. These studies found patients have much better long-term outcomes in developing countries (India, Colombia and Nigeria) than in developed countries (USA, UK, Ireland, Denmark, Czech Republic, Slovakia, Japan, and Russia),despite the fact that antipsychotic drugs are typically not widely available in poorer countries, raising questions about the effectiveness of such drug-based treatments. • In many non-Western societies, schizophrenia may only be treated with more informal, community-led methods. Multiple international surveys by the World Health Organization over several decades have indicated that the outcome for people diagnosed with schizophrenia in non-Western countries is on average better there than for people in the West. Many clinicians and researchers hypothesize that this difference is due to relative levels of social connectedness and acceptance,although further cross-cultural studies are seeking to clarify the findings. • From http://en.wikipedia.org/wiki/Prognosis_of_schizophrenia

10. The Biological Tradition • Cause of mental illness: • Physical disease (like other medical diseases) • Hippocrates: “Men ought to know that from the brain, and from the brain only, arise our pleasures, joys, laughter and jests, as well as our sorrows, pain, grief, and tears … It is the brain which makes us mad or delirious; inspires us with dread and fear, whether by night or day; brings sleeplessness, mistakes, anxieties, absentmindedness, acts that are contrary to our normal habits. These things that we suffer all come from the brain, including madness.”

11. The Biological Tradition • Hippocrates’ Humoral Theory: psychopathology caused by humoral imbalance • Blood, black bile, yellow bile, & phlegm • Example: Too much black bile causes melancholia (depression) • Treatments were generally benign: rest, nutrition, bloodletting, vomiting, emetics

12. The Biological Tradition • General Paresis (Syphilis) – causes delusions and bizarre behavior • Pasteur discovered the cause – a bacterial microorganism • Led to penicillin as a successful treatment • Bolstered the view that mental illness = physical illness • Provided a biological basis for madness • Enthusiasm for biological cures (magic bullets for mental diseases)

13. The Biological Tradition • The 1930’s • Biological treatments were standard practice • Three popular biological treatments: electro-convulsive therapy (ECT), lobotomy, and insulin coma therapy • In depth: insulin coma therapy http://www.youtube.com/watch?v=suFecF3vJW8

14. The Biological Tradition • The 1950’s • Discovery of drugs that reduced: • Psychosis (schizophrenia) • Depression • Mania (bipolar disorder) • Anxiety • Hyperactivity (ADHD) • Two important observations: • Drugs discovered by accident • Older drugs vs. modern drugs

15. The Biological Tradition • Major assumptions of the biological approach • Mental disorders are brain diseases • Mental disorders are caused by biological abnormalities (brain chemistry, brain structure, brain function, genetics) • Biological treatments work by correcting the biological abnormalities that cause mental disorders • Biological research will eventually reveal the biological causes of mental disorders and will lead to “personalized medicine” and even cures

16. The Biological Tradition • Major goals of the biological approach: • Develop biological tests for diagnosis and predicting treatment response • Develop disease-specific “magic bullets” • Develop cures for mental disorders

17. The Biological Tradition • Current status of biological approach • Dominant in psychiatry • Dominant in National Institute of Mental Health and other governmental and grant-funding agencies • Dominant in patient advocacy movement • Dominates the mental health system in the United States • http://1mind4research.org/

18. Biological Tradition in the U.S. • “Mental disorders are brain disorders.” “Many illnesses previously defined as ‘mental’ are now recognized to have a biological cause.” -Thomas Insel, NIMH Director • “Drug addiction is a disease of the human brain.” – Nora Volkow, NIDA Director • “Science has proven that mental disorders are real medical conditions.” – American Psychiatric Association

19. Patient Advocacy Groups “Scientific research has firmly established that major depression is a biological, medical illness.” “A large body of scientific evidence suggests that OCD results from a chemical imbalance in the brain.”

20. Health Websites • WebMD: “Depression is a disease…When you have depression, chemicals in your brain called neurotransmitters are out of balance.” • Mayo Clinic: “If you have depression, you may have a serotonin imbalance.”

21. Public Service Announcements

22. Use of Biomedical Treatments: The Medco Report • Review of prescription drug claims from 2001 to 2010 among over two million insured Americans http://www.medscape.com/viewarticle/753789 • What percentage of insured Americans take one or more psychotropic medications?

23. The Medco Report

24. Use of ADHD Medications

25. Use of Antipsychotic Medications

26. The Biological Tradition • National trends in outpatient mental health services from 1998 to 2007 (Olfson & Marcus, 2010) • “Among individuals receiving outpatient mental health care, use of only psychotherapy (15.9% and 10.5% in 1998 and 2007, respectively; as well as psychotherapy and psychotropic medication together (40.0% and 32.1% declined while use of only psychotropic medication increased (44.1% and 57.4%).”

27. The Biological Tradition • National trends in use of psychotherapy among psychiatrists (Olfson & Marcus, 2010) • “The percentage of visits involving psychotherapy declined from 44.4% in 1996-1997 to 28.9% in 2004-2005. This decline coincided with changes in reimbursement, increases in managed care, and growth in the prescription of medications. At the practice level, the decrease in providing psychotherapy corresponded with a decline in the number of psychiatrists who provided psychotherapy to all of their patients from 19.1% in 1996-1997 to 10.8% in 2004-2005 (P = .001).” • “There has been a recent significant decline in the provision of psychotherapy by psychiatrists in the United States. This trend is attributable to a decrease in the number of psychiatrists specializing in psychotherapy and a corresponding increase in those specializing in pharmacotherapy--changes that were likely motivated by financial incentives and growth in psychopharmacological treatments in recent years.”

28. The Biological Tradition • National trends in psychiatrist prescribing: “polypharmacy” from 1996-1997 to 2005-2006 (Mojtabai & Olfson, 2010) • “Visits with 2 or more medications increased from 42.6% in 1996-1997 to 59.8% in 2005-2006; visits with 3 or more medications increased from 16.9% to 33.2%. The median number of medications prescribed in each visit increased from 1 in 1996-1997 to 2 in 2005-2006 (mean increase: 40.1%). • “There has been a recent significant increase in polypharmacy involving antidepressant and antipsychotic medications. While some of these combinations are supported by clinical trials, many are of unproven efficacy. These trends put patients at increased risk of drug-drug interactions with uncertain gains for quality of care and clinical outcomes.”

29. Anti-Psychotic Medication • From 1993 to 2002, antipsychotic use in people < 21 years increased 600% (now over 1 million prescriptions in US) • Vast majority of prescriptions are “off-label”