Models of Abnormality. A-Level Abnormal AICE Psychology Syllabus Background Content Seth M. Alper, Ph.D.

Transcription

1 Models of Abnormality A-Level Abnormal AICE Psychology Syllabus Background Content Seth M. Alper, Ph.D.

2 AICE Syllabus Content (from 9698) Topic 1: Definitions of Abnormality Definitions: deviations from statistical norms, social norms, ideal mental health, failure to function adequately Problems with defining abnormality Topic 2: Models of Abnormality Medical/biological, behavioral, psychodynamic, and cognitive Assumptions and applications of models Topic 3: Treatments of Abnormality Medical/biological, behavioral, psychodynamic, and cognitive Effectiveness and appropriateness of these treatments

3 Definitions of Abnormality One s definition of abnormality must be objective: It must not depend on anyone s opinion or point of view It should produce the same results whoever applies it It must not be under- or over-inclusive = It must not label as abnormal or normal behaviors or traits that aren t Comer (1998) noted that the 4 Ds were common to most Deviance (difference from the norm) Distress Dysfunctional Dangerous

4 Definitions of Abnormality Four definitions can be asked about for the examination: 1. Statistical infrequency 2. Deviation from social norms 3. Failure to function adequately 4. Deviation from ideal mental health

5 Definitions of Abnormality Statistical Infrequency Under this definition, a person s trait, thinking or behavior is classified as abnormal if it is rare or statistically unusual. With this definition it is necessary to be clear about how rare a trait or behavior needs to be before we classify it as abnormal Some disorders are not statistically rare such as phobias so does that mean they are not abnormal behavior? Just because something is rare doesn t mean it is undesirable a high IQ is abnormal but maybe desirable

6 frequenc y Average IQ in the population is 100pts. The further from 100 you look, the fewer people you find IQ Scores

7 frequenc y A very small subset of the population (<2.2%) have an IQ below 70pts. Such people are statistically rare. We regard them as having abnormally low IQs IQ Scores

8 Deviation from social norms Definitions of Abnormality Under this definition, a person s thinking or behavior is classified as abnormal if it violates the (unwritten) rules about what is expected or acceptable behavior in a particular social group. Their behavior may: Be incomprehensible to others Make others feel threatened or uncomfortable With this definition, it is necessary to consider: The degree to which a norm is violated, the importance of that norm and the value attached by the social group to different sorts of violation. E.g. is the violation rude, eccentric, abnormal or criminal? If we agree that different cultures have different definitions of normal can there be one definition of abnormal?

9 Definitions of Abnormality Failure to Function Adequately Under this definition, a person is considered abnormal if they are unable to cope with the demands of everyday life. They may be unable to perform the behaviors necessary for day-to-day living e.g. self-care, hold down a job, interact meaningfully with others, make themselves understood etc. Rosenhan & Seligman (1989) suggest the following characteristics: a. Suffering b. Maladaptiveness (danger to self) c. Vividness & unconventionality (stands out) d. Unpredictability & loss of control e. Irrationality/incomprehensibility f. Causes observer discomfort g. Violates moral/social standards

10 Definitions of Abnormality Deviation from ideal mental health Under this definition, rather than defining what is abnormal, we define what is normal/ideal and anything that deviates from this is regarded as abnormal This requires us to decide on the characteristics we consider necessary to mental health Jahoda (1958) noted 8 characteristics of ideal behavior: Absence of mental illness Introspection (you know what you are doing and why you are doing it) Show the potential for growth Balance between id, ego and superego The ability to cope with stress Autonomy, the ability to be independent Seeing the world for how it really is Environmental mastery

11 Definitions of Abnormality Accepted Definitions of Abnormality The DSM definition a clinically significant behavior or psychological syndrome that is associated with present distress, disability, a significantly increased risk of suffering death, pain, disability or an important loss of freedom. Additionally, this syndrome or pattern must not be merely an expectable response to a particular event, such as the death of a loved one The ICD-10 definition the existence of a clinically recognizable set of symptoms or behaviors associated in most cases with distress and with interference with personal functions

12 Models of Abnormality The Medical/biomedical Model Notion of normality a person is normal if they have properly functioning physiology and nervous system and no genetic predispositions to inherit mental illness. Notion of abnormality mental illness like physical illness has an underlying physical cause Genetic, organic or chemical disorders cause mental illness which give rise to behavioral and psychological symptoms These can be classified and diagnosed and then treated using medical treatments.

13 Models of Abnormality The Medical/biomedical Model Causes of abnormality Neurotransmitter and hormonal imbalances different psychological disorders are associated with various levels of neurotransmitters. Some disorders may be caused by these imbalances other disorders may cause the imbalance Genetic vulnerabilities- Substantial evidence indicates a genetic link for certain disorders. Constitutional liabilities - a term used to describe any detrimental characteristic that is either innate or acquired so early and in such strength that it is functionally similar to a genetic characteristic.

14 Models of Abnormality The Medical/biomedical Model Methods for studying genetic links to mental disorders Pedigree or family history method researchers study all members of the family to look for linkages The Twin method examines concordance rates of a behavior between twins. If it is completely hereditary the concordance rate would be 100% The adoption method = study the biological parents of patients with and without the disorder. If it is genetic you should find higher rates in people who regardless of adoption have parents with the disorder. Best if a combination of all three are used.

15 Models of Abnormality The Psychodynamic Approach Notion of Normality a healthy balance between the id, ego and superego. Sufficient control of the ego over the impulses of the id. Notion of Abnormality emotional disturbances caused by thwarted impulses of the id. Psychological and physical symptoms may be manifestations of unconscious issues. Unconscious conflict is always there so the difference between normal and abnormal is quantitative not qualitative.

16 Models of Abnormality Psychodynamic Approach Dr. Sigmund Freud Unconscious processes underlie both neurotic and normal behavior Different parts of the mind are in constant conflict Personality development occurs in stages, and is shaped by relationships, experience and conflict over time, especially in childhood

17 Models of Abnormality Psychodynamic Approach- The Structures of Personality Conscious Mind = includes those thoughts that we are aware of Preconscious = information that is not in the conscious mind but can be recalled at will Unconscious = According to Freud a reservoir of mostly unacceptable thoughts, wishes, feelings, and memories. We are unaware of these but they may influence our behavior

18 Models of Abnormality Psychodynamic- Structures of the Unconscious Id = Contains a reservoir of unconscious psychic energy that, according to Freud, strives to satisfy basic sexual and aggressive drives Ego = The largely conscious, executive part of personality that according to Freud mediates among the demands of the id, superego, and reality Superego = our moral system The part of personality that, according to Freud represents internalized ideals and provides standards for judgment and for future aspirations It makes ego consider not just reality but morals Built on the morals and values of society

19 Models of Abnormality Psychodynamic Approach- Development of Personality The stages are based on 3 erogenous zones Fixation = according to Freud, a lingering focus of pleasure-seeking energies at an earlier psychosexual stage, where conflicts were unresolved. Psychosexual stages = the childhood stages of development (oral,anal, phallic, latency, genital) during which, according to Freud, the id s pleasure seeking energies focus on distinct erogenous zones

20 Psychodynamic Approach - Stages of Freudian Theory 1. Oral Stage - 1st year of life All psychosexual enjoyment derived orally Fixation may result in overt signs such as smoking or overeating. 2. Anal Stage -18 months to 3 years Occurs during potty-training stage All psychosexual enjoyment derived from eliminating or withholding Fixation may result in overt signs such as Anal retentiveness = excessive neatness and orderliness Anal expulsiveness = excessive messiness.

21 Psychodynamic Approach - Stages of Freudian Theory 3. Phallic Stage - Ages 3 to 5 The penis/vagina (in Freud s eyes this is seen as the lack of a penis) becomes the psychosexual center of pleasure Crisis for males during this stage Oedipal complex = according to Freud, a boy s sexual desires toward his mother and feelings of jealousy and hatred for the rival father. Castration anxiety = the fear that the father will retaliate by cutting of the boy s penis Identification = the process by which, according to Freud, children incorporate their parent s values into their developing superegos and take on the gender roles of their same sex parent iv. Fixation may result in outward signs such as excessive masculinity

22 Psychodynamic Approach - Stages of Freudian Theory 3. Phallic Stage - Ages 3 to 5 Crisis for females during this stage Penis envy/castration complex = the fear that they have had their penis cut off Electra Complex = similar to the Oedipus complex in males Identification with same sex gender roles Fixation may result in relationships with older men relationships where she tries to dominate the male (symbolic castration) to overcome her sense of inferiority

23 Psychodynamic Approach - Stages of Freudian Theory 4. Latency - Ages 5 thorough Puberty a. Identification with same sex parent continues b. No psychosexual issues or development 5. Genital Stage - Ages Puberty - adulthood a. once again psychosexual arousal focuses on the genitals b. however the focus is actually expanded beyond sex and on life and procreation c. Similar to Erikson s term of Generativity is more accurate d. Fixation doesn t really occur in this stage. The danger here is that if the person has expended to much of their libido has been fixated in earlier stages they wont have enough mental energy to focus on adult tasks.

24 Psychodynamic Approach- Defense mechanisms Defined- in psychoanalytic theory, the ego s protective methods of reducing anxiety by unconsciously distorting reality Types of Defense Mechanisms (8 total) 1. Repression = the process that banishes anxiety-arousing thoughts, feelings and memories from consciousness 2. Regression = the process by which an individual faced with anxiety retreats to a more infantile psychosexual stage, where some psychic energy remains fixated

25 Psychodynamic Approach- Defense mechanisms 3. Reaction formation = the process by which the ego unconsciously switches unacceptable impulses into their opposites Such as falling up the stairs and laughing instead of crying 4. Displacement = a process that shifts sexual or aggressive impulses toward a more acceptable or less threatening object or person 5. Sublimation = a process by which people re-channel their unacceptable impulses into socially accepted activities 6. Denial- not being able to admit there is an issue or problem and/or recognizing the truth 7. Rationalization- creating a socially acceptable reason for action 8. Intellectualization- trying to use logic to explain a problem

26 Defense Mechanisms

27 Psychodynamic Approach Over-emphasized sexual causes Euro-centric and male centered The theory is vague and un-testable The theory is good at explaining behavior but not at predicting behavior

28 Models of Abnormality The Behavioral Approach Notion of normality the person has a lifelong history of learning adaptive behaviors Notion of abnormality the person has learned maladaptive behaviors to respond to the environment. The Cognitive Approach Notion of normality rational thought processes that can be used to accurately perceive the world and control behavior. Notion of abnormality Unrealistic, distorted and maladaptive thought patterns interfere with functioning.

29 Models of Abnormality Other models not covered in the syllabus The Humanistic Approach Notions of normality positive self-regard, self actualized healthy interpersonal style. Notions of abnormality doesn t really see abnormality people have been thwarted in their growth by poor interpersonal relationships and by environmental blocks. Social-cultural approach Notions of normality what is the norm for that society. What is expected of that person. Notions of abnormality best understood in the light of the social and cultural factors that influence the individual

30 Diathesis Stress Model Models of Abnormality a psychological theory which tries to explain abnormal behavior in terms of a predisposition that is brought out by environmental stressors. The word diathesis came from the Greek term vulnerability or disposition. These vulnerabilities can take the form of psychological, genetic, situational, and biological factors. Stressors from everyday life cause this pre-existing vulnerability to emerge.

31 Classification of Disorders Models of Abnormality Purpose of classification To identify groups or patterns of mental or behavioral symptoms that reliably occur together (a syndrome) and then group these syndromes into a classification system This allows professionals to identify and discuss groups of people. Allows professionals to make a prognosis (prediction about the future course) for the individual Allows for the investigation into the causes (etiology) of the disorder Allows for the development of common treatments.

32 Classification of Disorders Models of Abnormality Two Main Classification Systems DSM-5- Diagnostic and Statistical Manual of Mental Disorders (5th ed.) created by the American Psychiatric Association (APA) ICD-10 - International Classification of Diseases (ICD-10) created by the World Health Organization. the ICD classifies some of the disorders under different names/headings the ICD is more likely to include causes not just symptoms like the DCM

33 Models of Abnormality Research into Defining Disorders Brown et al (2001) found good to excellent reliability in most DSM-IV categories especially in Anxiety and Mood disorders Stein et al. (2010) Concluded that the explicit DSM-IV position that mental/psychiatric disorders cannot easily be precisely operationally defined seems basically correct At the same time, disorders are more than mere labels, and progress towards a more scientifically valid and more clinically useful nomenclature is possible. Regier et al (2013) Reviewed the field trials of the reliability of the DSM 5 Found that most of the Dx tested had good to very good statistical significance

34 Biological Treatments Treatments of Abnormality Electro convulsive therapy (ECT) used to treat severe depression Acts as control-alt-delete for your brain Psychotropic medications drugs that impact our behavior such as antidepressants, anti-psychotics, and anti-anxiety drugs. Psychosurgery such a lobotomy, height in 50s/60s, but seldom used now

35 Biological Treatments Treatments of Abnormality Ethical considerations On the positive side, it means the illness is at fault, not the individual Therefore, it can be seen as being more humane than other models. Negative implications Since someone is mentally ill, they can lose their rights of self-control and self-determination Assumes that directive therapy (controlled by therapist or psychiatrist) is needed which limits the rights and power of the client. Can lead to prejudice against people (remember eugenics?) Evaluation Has been considered to be too reductionist (treating effects, not cause) Many drugs have significant side effects.

36 Treatments of Abnormality Psychodynamic treatments The use of free association Therapist gets client to rapidly say the first thing that comes to mind which is a way of delving into the unconscious Dream analysis The therapist makes interpretation of the dreams reported by the client, tying them to unconscious drives and motivations Analysis of the use of defense mechanisms In almost all cases, disorders are the result of overuse or faulty use of defense mechanisms (little Hans) Ethical Implications Directive therapy in that the patient must allow the therapist to make interpretations about the unconscious and accept those interpretations Can be anxiety provoking as the patient uncovers repressed unconscious desires and motives. However, it is seen as humane because it does not blame the person for the desires of his unconscious.

37 Treatments of Abnormality Psychodynamic treatments Practical implications Expensive and time consuming with PERCEIVED low success rates Long-term (may require several sessions a week over a year or more) No institutionalization Psychodynamic concepts are vague and un-testable Freud disputed this, saying the scientific proof is in the success of the therapy Has lost popularity in the US because it lacks empirical research, and insurance companies won t pay for the lengthy treatment Evaluation Smith, Glass, & Miller (1980 )- meta-analysis of 475 studies yielded an overall effect size for psychotherapy (all types)of.85 (compare to.26 for Prozac)

38 Behavioral Treatments Treatments of Abnormality Systematic desensitization a technique used with phobias where clients learn to react calmly to anxiety provoking stimuli Taught how to relax Create a hierarchy of fears starting with the least anxiety provoking and moving to the most severe. Confronted with the stimuli from the fear hierarchy and taught to relax until all stimuli can be faced Token economies based on operant conditioning by earning rewards for completing desired behaviors (like washing regularly for schizophrenics) Exposure and response prevention a technique associated with treating OCD whereby the patient is exposed to an emotion provoking stimuli such as exposure to germs then prevented from acting on compulsions. This is then followed by a reward

39 Behavioral Treatments Treatments of Abnormality Ethical Implications Directive the therapist reprograms the client with more adaptive behaviors. Stressful behavioral therapies like flooding and aversion therapy can be disturbing. Humane as the behavior is the problem not the person. Practical implications Relatively cheap as it is normally very brief sessions High success rates with many disorders Institutionalization may be needed to control environment while achieving change (such as for drugs or anorexia)

40 Behavioral Treatments Evaluation Treatments of Abnormality Behaviorist say that disorders are acquired through conditioning (CC or OC). For example Lil Hans. Even though phobias have been recreated in the lab (Lil Albert) no evidence exists to suggest this is how disorders result in the real world. Some claim that the behaviorist model is too simplistic (reductionist) in that it tries to boil all behavior down to simple conditioning principles. This has been addressed somewhat by the advent of CBT Paul & Lentz (1977) found token economies to be effective in reducing bizarre behavior in schizophrenics Wolpe (1958) found that systematic desensitization was effective in treating phobias

41 Cognitive Therapies Treatments of Abnormality CBT (cognitive behavioral therapy) created by Beck aims at trying to change or modify people s thoughts and beliefs and the behaviors that are a result of these thoughts Covert sensitization person imagining an aversive stimulus with an impulsive behavior. Used by treat kleptomania (Kohn & Antonuccio, 2002) Imaginal desensitization involves teaching progressive muscle relaxation then pairing it with imagined thoughts of situations that trigger an impulsive behavior. has shown to be effective for gamblers (Blaszcznski & Nower, 2003)

42 Cognitive Therapies Treatments of Abnormality Ethical implications Semi-directive depending on the type of cognitive therapy, this can be done yourself after training or therapist may intervene to help stop maladaptive thoughts Stressful breaking negative thought patterns and cognitive distortions can be painful. Practical implications Relatively cheap as it is normally very brief. Fairly-high success rates with many disorders especially when combined with behavioral therapy (CBT) Institutionalization is not normally necessary.

43 Treatments of Abnormality Cognitive Therapies Evaluation Has had great success with many disorders and lends itself to empirical evaluation. Research on CBT Hofmann et al. (2012) Examined 269 meta-analyses of CBT for various disorders Small positive effect of CBT for cannabis abuse but lower than others such as Motivational approaches Good effect at reducing positive symptoms of schizophrenia CBT vs no Tx showed good results for depression however results of relative efficacy were mixed when compared to other treatments like psyd.

44 Issues, Debates, & Evaluations Gender Bias This can change the definition of abnormality. Behaviors such as dependency which is normal for females in many cultures would seem abnormal in males. Likewise assertiveness is seen as normal for males whereas abnormal for females Some disorders like depression are more common in women while others such as Anti-Social Personality Disorder are more common in men. Does this fact indicate a possible bias in diagnosis? Cultural Bias Is it possible for those defining abnormality to understand normal and abnormal in all cultures? When people immigrate from one society to another they may be more likely to be diagnosed with particular disorders. This may indicate another cultural bias.

45 Issues, Debates, & Evaluations Reliability of classification Beck et al (1962) 153 patients were assessed by 2 psychiatrists yielding only a 54% agreement rate. Cooper et al (1972) when looking at the same video of clinical interviews: NY psychiatrists were 2x likely to diagnose schizophrenia London psychiatrists who were 2x likely to diagnose mania or depression Rosenhan (1973) refer to AS content Di Nardo et al (1993) Using the DSM III, 2 clinicians examined 267 clients seeking treatment for anxiety separately. Found that diagnoses ranged from OCD to Major Depression to GAD *this diagnosis problem was corrected with the publication of the DSM-IV

46 Issues, Debates, & Evaluations Ethical Concerns of diagnosis Can negatively impact the individual s life as previously discussed Can create labels that are hard for a person to lose Institutionalizing patients can cause them to lose responsibility for their own behavior (some say this situation makes them more abnormal too) Labeling can create self-fulfilling prophecies. Goffman (1971) found that patients may internalize the role of a mental patient and may actually worsen the disorder Doherty (1975) found that those patients that reject the mental health Dx actually recover more quickly than those that accept the Dx May take away their legal rights to make decisions for themselves. Should someone with a past Dx of mental illness be prohibited from owning a gun in violation of their 2 nd Amendment rights?

47 Issues, Debates, & Evaluations Freewill vs Determinism Debate If a person has a Dx of a mental disorder are they allowed to exercise their freewill? We say things like substance abusers have a disease that they cannot kick, or people with OCD can t stop doing behavior X. Are people with disorders responsible for crimes that they commit? Reductionism vs Holism Most researchers and therapist today take an eclectic view for both treatment and etiology However, some models that we will examine are more reductionist than others such as the biological/medical. Other models, such as the humanistic one, take a much more holistic view. Nature vs. Nurture Are we born predisposed to particular disorders? Genetic link? Are we a product of our environment like those of the sociocultural model would claim? Or what about the diathesis stress model?

48 Issues, Debates, & Evaluations Evaluating Methodology Meta-analysis (a study of studies) How do you choose the studies for your meta-analysis? Could this lead to experimenter bias in the selection process? Are statistical measures adequate for comparing outcome measures between studies? How do you assure adherence to model? How do you know it isn t due to common factors?

49 Issues, Debates, & Evaluations Evaluating Methodology Using Kappa levels to assess interrater reliability Many medical diagnoses have Kappa levels of below.5 and these are based on observable phenomenon (not self-report) Is it fair then to expect higher levels of interrater reliability when so much of the data comes from self-report? Accuracy vs Precision Is hitting the bullseye 1 out of 10 times while the other 9 are scattered all over the board better than never hitting the bullseye but being consistently clustered outside but near to the bullseye < 0 Less than chance agreement Slight agreement Fair agreement Moderate agreement Substantial agreement Almost perfect agreement