Lecture 3-4: Abnormal Behavior and Mental Disorder PDF

Lecture 3-4: Abnormal behavior and mental disorder. How to understand the difference between normal and abnormal behavior? Anna Gabińska, Ph.D.  Lecture overview ⚫ Diagnostic classifications – what for? ⚫ Psychopathology symptoms, syndromes and disorders ⚫ Psychopathology symptom,...

Lecture 3-4: Abnormal behavior and mental disorder. How to understand the difference between normal and abnormal behavior? Anna Gabińska, Ph.D.  Lecture overview ⚫ Diagnostic classifications – what for? ⚫ Psychopathology symptoms, syndromes and disorders ⚫ Psychopathology symptom, its function and psychopathological mechanism ⚫ Normal behavior, typical behavior, moral offence, crime, relativism and social agreement on abnormal behavior, pathology, psychological disorder ⚫ Social and cultural criteria in assessing psychological health Psychiatric disorders and stigma  Classifications of mental disordes ICD-11 (International Classification of Diseases and Related Health Problems, 2019) DSM-5-TR (Diagnostic and Statistical Manual of Mental Disorders, 2020) CCMD-3 (The Chinese Classification of Mental Disorders ( 中国精神疾病分类方案与诊断标准) Some of the wordings of the diagnosis are different: borderline personality disorder in the DSM, emotionally unstable personality disorder (borderline type) in the ICD, impulsive personality disorder in the CCMD.  Goals of classifications Classification provides an essential basis for organizing mental disorders. Nomenclature and information retrieval: developing common language and organization of used terms ◻ Consistency and reliability of psychiatric/ psychological diagnoses ◻ Objectification of the diagnostic process ◻ Raising the level of scientific research Prediction: (of the course of the disorder and what treatment is the best in a given case)  Goals of classifications Sociopolitical: current classification systems are psychiatric ones -> mental disorders as diseases that require biological interventions. Those that may be more psychological/interpersonal in their etiology might be neglected. Treatment providers must indicate the DSM diagnosis in order to get coverage for their clients from insurance companies (which require certain DSM diagnoses for concrete treatment)  Models of classifications Categorical approach -there are separate classes, clusters of disorders of high consistency, different from other classes Dimensional approach - health and disorder differ only in the severity or intensity (highly recommended for the assessment of personality disorders) ◻ Individual problems are best described dimensionally (Markon, Chmielewski & Miller, 2011). ◻ The categorical system is maintained as it is a traditional form of classification in medicine and it is easier for clinicians to understand and use it. ◻ Introducing dimensional approach has been done in different ways, e.g. by broadening some categories of disorders (autism spectrum disorder) and allowing for coding of severity of many problems along with the use of specifiers (major depressive disorder). ◻ Nevertheless DSM has essentially maintained its categorical nature (American Psychiatric Association, 2013).  Transdiagnostic models: ⚫ Focus on shared processes causing and maintaining multiple or comorbid disorders. ⚫ Examples: transdiagnostic biases in cognitive processing; transdiagnostic treatment for emotional disorders ⚫ All are under research. ⚫ A new science of mental disorders: Using personalised, transdiagnostic, dynamical systems to understand, model, diagnose and treat psychopathology (2022): https://www.sciencedirect.com/science/article/pii/S0005796722000675 ⚫ Transdiagnostic Approaches to Mental Health Problems: Current Status and Future Directions (2020): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7027356/  Research Domain Criteria (RDoC) ⚫ project of National Institute of Mental Health (NIMH). ⚫ RDoC is a transdiagnostic research framework to study mental illnesses by shared dimensions. ⚫ Mental disorders as seen as brain disorders, and it is mostly biologically oriented. ⚫ Each domain contains several constructs reflecting negative valence systems (threat, loss, frustration), positive valence systems (reward responsiveness and reward learning), cognitive systems (attention, perception, cognitive control), social processes systems (understanding of others, social communication), arousal and regulatory systems (sleep-wakefulness and arousal), sensorimotor systems (motor actions) ⚫ Deficits in these may be responsible for dysfunctions shared by several mental disorders. The interaction of genes and environment in producing depression (Barlow & Durand, 2015, p.35) Caspi and colleagues (2003) – investigated the gene that produces a chemical transporter that affects the transmission of serotonin. This gene comes in two versions – short (SS) or long allele (LL). Individuals with at least two LL were able to cope better with stress that those with two SS. Having at least 4 stressful life events doubled the risk of MDD in case of SS in comparison with LL.  Basic terminology in psychopathology ⚫ Symptom (symptom) – a particular sign of abnormality of one of the mental functions; indicates a clinically significant deviation from the norm; manifest and is a sign of the disease process. ⚫ Syndrome – a couple of abnormal symptoms that occur together yet related to different mental functions (ie. depressive or paranoid syndrome). ⚫ Nosological unit (disease, disorder) - a set of symptoms, with a characteristic beginning, course and descending, conditioned by a certain disease factor (often only implicit).  Psychopathological symptom Disorder of the smallest manifestations of mental life. Examples: anxiety, hallucination, depressed mood, no initiative A sign of abnormality in one of the mental functions: ◻ Cognitive ◻ Emotional ◻ Impulses ◻ Motivational ◻ Volition ◻ Integrating mental activities General Psychopathology within Psychiatry is a field focused on studying psychopathological phenomena and symptoms of abnormal states of mind. Typically attention is on identifying abnormalities and disorders of basic psychological  MOTIVATION COGNITION (Volition) perception, attention, memory, thinking, consciousness BEHAVIOUR EMOTION PHYSIOLOGICAL REACTIONS  Disorders of perception Perception: ⚫ is a complex process of becoming aware of what is presented through the sense organs; ⚫means creating representations of objects based on information coming from sense organs and kept in memory (Cierpiałkowska, 2014) The degree of suitability of perception’s intensity to the size of the stimulus ⚫Decrease / increase in sensitivity ⚫Distortion of perception Accuracy of judgments about classifying objects into categories: ⚫Agnosia - inability to recognize the object, despite the presence of relatively intact functioning of sense organs, memory, and general intellectual function. ⚫Illusions and pseudoillusions Accuracy of realization judgements: ⚫Hallucinations and pseudohallucinations  Disorders of perception Illusions – misinterpretations of real sensory stimuli; perceptual distortions in estimating size, shape and spatial relations. Hallucinations - percepts in the absence of corresponding sensory stimuli; patient believes in their real existence and is unable to distinguish them from reality. Hallucinations may be: ⚫auditory (hearing voice when none are present) ⚫Visual (seeing thing that are not there) ⚫olfactory (smelling smells that do not exist) ⚫gustatory (experiencing taste in the absence of stimuli) ⚫tactile (or deep somatic, feeling touch sensation in the absent of stimuli) Pseudohallucinations - patient can distinguish them from reality.  Disorders of attention Attention: ⚫the ability to manage and maintain the cognitive process on a particular stimulus or activity. ⚫The mechanism of limiting the excess of information at all stages of information processing. attention span (capacity): the number of stimuli recorded during exposure. concentration (focusing attention): ability to focus attention on a particular stimulus or activity. tenacity: describes the range of time in which the person holds their attention on a specific object or activity. vigilance: the ability to passively wait for the appearance of the stimulus or to maintain a consistent behavioral response during continuous and repetitive activity. alternating attention: ability to shift the focus of attention and move between the objects or tasks having different cognitive requirements.  Disorders of attention divided attention: ability to focus on a number of stimuli at the same time or to respond simultaneously to multiple tasks. selective attention: ability to focus attention on only chosen stimuli/tasks and bypassing others, refers to keeping a behavioral or cognitive set in the face of distracting or competing stimuli, thus it incorporates the notion of "freedom from distractibility”. ⚫distractibility: inability to maintain attention, shifting from one area or topic to another with minimal provocation. hypoprosexia (global, selective) - reduced ability to attend or concentrate hyperprosexia - concentration on one thing to the exclusion of everything else. aprosexia - inability to pay attention, characterized by a near-complete indifference to everything. paraprosexia - inability to pay attention to any one thing (a state of constant distraction).  Disorders of memory Memory: ⚫a complex mental process, whose role is to register, retain and recall information. ⚫different types of memory: ◦ sensory modalities – visual memory, auditory memory etc. ◦ storage time – sensory stores, short-term (working) memory and long-term. ◦ content of the memory: semantic memory, episodic, procedural. Quantitaive disorders of memory: hypermnesia - it's excessive memory, the patient quickly memorizes and faithfully recalls even unnecessary details. hypomnesia - poor memory of the past, may include particular or all stages of memory. Its scope is also diverse - from mostly fresh memory limitations or mainly the older memories, to the impairment of both memory forms. amnesia - loss of memory; may be partial or complete.  Disorders of memory anterograde amnesia: loss of memory for recent event. retrograde amnesia: loss of memory for remote event. total amnesia: loss of memory for recent and remote event. circumscribed amnesia: loss of memory for limited time. Qualitative disorders of memory: ⚫ déja vu (already seen): a new situation is experienced as the one that had already took place. ⚫ jamais vu (never seen): familiar situation is experienced as novel. ⚫ confabulation: filling the gaps in the memory by innaccurate information (in Korsakov’s syndrome) Korsakoff's syndrome primarily affects the memory system in the brain. It usually results from a deficiency of thiamine (vitamin B1), which may be caused by alcohol abuse, dietary  Disorders of thinking Thinking - a very complex mental process, involving the creation and processing of complex cognitive representations and using them for different purposes (i.e. anticipation, planning effective responses) ⚫Disorders of thinking: ◦ quantitative – flow, form and continuity disturbances (how one thinks) ◦ qualitative – content thought disturbances (what one thinks)  Quantitative disorders of thinking Flow and form disturbances: ⚫slowness of thinking – prolonged, characterized by little initiative or planning, long latency of response. ⚫accelerated rates of thinking – too fast, creating multiple threads ⚫thought blocking – sudden interruption in a train of thought ⚫flight of ideas – flow of thought increases to the point at which train of thought switches direction frequently and rapidly. Complexity of thinking disturbances: ⚫autistic thinking – personally idiosyncratic thought unrelated to reality; preoccupation with inner world; egocentric thought processes. ⚫concrete (literal) thinking – inability to form abstract concepts, expressed in literal mindedness without understanding the implicit meaning behind sentence. Quantitative disorders of thinking Continuity of thought disturbances: ⚫circumstantiality – the flow of thought includes many digressive turns and associations, often including a great deal of unnecessary detail. ⚫tangentiality – thought wanders further and further away from the intended point, without ever returning. ⚫loosening of associations - thinking is random, illogical and confused. Connection of thought is interrupted to this extent that that the flow of ideas are no longer comprehensible to the listener. ⚫word salad – exemplify severe case of loose associations, in which words linked together in speech seem to have no logical associations. ⚫verbigeration – disappearance of understandable speech, replaced by strings of incoherent utterances.  Quantitative disorders of thinking Continuity of thought disturbances: ⚫clang associations – a sequence of thoughts stimulated by the sound of a preceding word; meaningless rhyming of words. ⚫echolalia – repetition of utterance made by the other interlocutor. ⚫perseveration – a sentence or phrase is repeated, sometimes several times over, after it is no longer relevant. ⚫stereotypy – a constant repetition of a phrase or a behavior in many different settings, irrespective of a context. ⚫delusional thought passivity – own thoughts are being experienced as being under the control of other forces (thought insertion, broadcasting) ⚫obsessional thinking – a stereotyped, repetitive, persistent thinking that is recognized as one’s own thoughts. ⚫obsessions - (obsessive thought) are recurrent persistent thoughts, impulses or images entering the mind despite the person's effort to exclude them. Obsessive phenomena in acting (usual as senseless rituals – cleaning, counting, dressing) are called compulsions.  Qualitative disorders of thinking ⚫ overvalued ideas – unreasonable and sustained abnormal beliefs held by a person that are fundamentally true but overly influence their decisions and behavior, clearly distinguishing themselves from the influence of other views ideas of reference – false personalized interpretations of actual events in which individuals believe that occurrences or remarks refer specifically to them when in fact they do not. ⚫ delusions – fixed beliefs firmly held on inadequate grounds, not affected by rational arguments (simple, complex, systematized and complete). Qualitative disorders of thinking Division of delusions according to onset ◦ Primary (delusion mood, perception, ideas) Delusion mood - strange feeling that the world around you is threatening or odd; one feels feel tense and confused because one can’t figure out what about the environment has changed, but one is convinced something is wrong. Perception - about the person who’s affected rather than about the outside world. What the person believes is real, but they put an unreal amount of importance on it. This intense focus goes beyond what makes sense rationally or emotionally and can feel urgent and personal. Ideas: This sort of delusion involves complicated, fully formed thoughts that come out of nowhere. ◦ Secondary Systematized - an organized cluster of delusions arising as a consequence of a single basic delusion in order to preserve a coherent or logical belief system. - Shared (folie a deux) Qualitative disorders of thinking Division of delusions according to theme - paranoid (persecutory) - d. of persecution, d. of influence, d. of reference, d. of jealousy, d. of infidelity, d. of control, d. concerning possession of thought - megalomanic (grandiose, expansive) – d. of power, worth, noble origin, supernatural skills and strength, amorous d., d. of erotic attachment - depressive (micromanic, melancholic) – d. of guilt and worthlessness, having sinned, nihilistic d. - hypochondriacal delusions – somatic d.  Psychopathological syndrome A pattern of symptoms indicative of some disease Several symptoms coming from different psychological functions occurring together A set of symptoms and signs that are usually due to a single cause (or set of related causes) and together indicate a particular physical or mental disease or disorder. Also called symptom complex. Example: manic syndrome ➤ Mood changes ➤ Sudden changes in energy and activity ➤ Speech disruptions ➤ Impaired judgment ➤ Changes in thought patterns  Mental disorder A pattern of symptoms with characteristic beginning, course and final, conditioned with specific disease factor A set of symptoms which follow a characteristic pattern and develop in a specific way. It’s process it goes through different phases. Example: bipolar disorder DSM-5-TR: “… syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in psychological, biological, or developmental processes underlying mental functioning.  Mental disorder DSM-5-TR cont.: “…Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g. political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above” (American Psychiatric Association, 2022, p. 13-14)  The function of symptoms They manifest and indicate the disease process Description approach: interest in determining comorbid symptoms ◻ subjective and social context are omitted ◻ the sick person seen as „a symptoms` bearer”  Specificity of psychological norm ⚫ Norm – ideal or real pattern of characteristics (i.e. behavior, personality or development) ⚫ Primacy of negativity – norm as a lack of pathology ⚫ Terms “psychological norm” and „health” used interchangeably  Statistical model ⚫ Normal or healthy = mediocre, average, or present in most people ⚫ Refers to the normal distribution of certain features - normal is what is in the area of central tendency (the area defined by the acceptable standard deviations) ⚫ Pathological phenomena due to the prevalence may be considered as norm ⚫ And people deviating positively? ⚫ How many people procrastinate?  Socio-cultural model ⚫ Normal is something that is recognized as common, typical for a particular culture – behavior consistent with commons and conventions ⚫ Normal individual – typical for a particular group or culture. ⚫ Related to the cultural heritage, values and social roles ⚫ An indicator of optimal functioning - the ability to meet own important needs in a manner consistent with social norms  Socio-cultural model ⚫ Abnormal individual – a person who doesn’t meet the common social-cultural, ethical and legal norms of a society in culture (abnormal in a sense that he/she violates the social order and jeopardizes the functioning of society and personal development) ⚫ Disorder (social maladjustment) is a violation of socio-cultural norms (also ethical, legal etc.) ◦ entails social sanctions ⚫ The most relativized model, charged with evaluation ⚫ In periods of social change, breakthroughs and sudden shifts in the systems of values the phenomena considered abnormal intensify  Theoretical model ⚫ Norm is determined by reference to theoretical models ⚫ Norm comes from scientific claims, reasonable concepts or empirically proven relationship ⚫ Models within the paradigms: psychoanalytic, cognitive-behavioral, humanistic, systemic ⚫ Theoretical norm became a standard, to which the individual data are referred  How to define abnormality? ⚫ Qualitative criteria: ◦ Abnormal functioning is of different quality than healthy ⚫ Quantitative criteria: ◦ Abnormal is something that significantly differs from the average, defined for a given feature ⚫ Criteria of coexisting combinations of traits: ◦ Abnormality when few symptoms exist together,  The DSM-5-TR based definition of mental disorder (APA, 2022): ⚫ A behavioral or psychological syndrome or pattern that occurs in an individual ⚫ That reflects an underlying psychobiological dysfunction ⚫ The consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) ⚫ Must not be merely an expectable response to common stressors and losses (for example, the loss of a loved one) or a culturally sanctioned response to a particular event (for example, trance states in religious rituals) ⚫ That is not primarily a result of social deviance or conflicts with society  The four D’s: Comer (2014) states that most current definitions of abnormality: ⚫Deviance ⚫Distress ⚫Dysfunction ⚫Dangerousness Impairment: extent to which a behavior or set of behaviors gets in the way of successful functioning in an important domain of the individual’s life (including the psychological, interpersonal and achievement/performance domains)  Concepts of normality and abnormality Rosenhan and Seligman (1995) suggested that there are seven criteria that could be used to decide whether a person or a behavior is normal or not. 1.Suffering – does the person experience distress or discomfort? 2. Maladaptation – does the person engage in behaviors that make life difficult for him or her rather than being helpful? 3. Violation of moral or ideal standards – does the person habitually break the accepted ethical and moral standards of the culture?  Concepts of normality and abnormality 4. Irrationality – is the person incomprehensible or unable to communicate in a reasonable manner? 5. Unpredictability – does the person act in ways that are unexpected by himself, herself or other people? 6. Vividness and Unconventionality – does the person experience things that are different from most people? 7. Observer discomfort – is this person acting in a way that is difficult to watch or that makes other people embarrassed? Criteria of normality, by Jahoda (1958) Defined what is abnormal by pointing to six fecatures of people who are normal/healthy 1. Efficient self-perception. Awareness of characteristics that constitute one's knowledge. 2. Realistic self-esteem and acceptance. Realistic expectations make it easy to experience success and feel personally valuable. 3. Voluntary control of behavior. The management of acts or behaviors by intentional action. 4. True (positive) perception of the world. 5. Sustaining relationships and giving affection. 6. Self-direction and productivity. Feeling responsible  A Case Study ⚫ Anne is a 16-year-old girl living in a medium-sized city in the Midwest. Her family includes a mother, father, 14-year-old brother, and a great-aunt, who has lived with the family since Anne was 4. Anne is a junior at City High School and is taking a college-preparatory program. Her appearance is strikingly different from the appearance of the other girls in her class. She wears blouses which she has made out of various scraps of material. The blouses are accompanied by the same pair of overalls every day, two mismatched shoes, and a hat with a blue feather. She is a talented artist, producing sketches of her fellow classmates that are remarkably accurate. She draws constantly, even when told that to do so will lower her grade in classes where she is expected to take lecture notes.  A Case Study ⚫ She has no friends at school, but seems undisturbed by the fact that she eats lunch by herself and walks alone around the campus. Her grades are erratic; if she likes a class she often receives an 5 or 4, but will do no work at all in those she dislikes. Anne can occasionally be heard talking to herself; she is interested in poetry and says she is “composing” if asked about her poetry. She refuses to watch television, calling it a “wasteland”. This belief is carried into the classroom, where she refuses to watch videos on youtube, saying they are poor excuses for teaching. Her parents say they don’t understand her; she isn’t like anyone in their family. She and her brother have very little in common. He is embarrassed by Anne’s behavior and doesn’t understand her either. Anne seems blithely unaware of her apparent isolation, except for occasional outbursts about the meaninglessness of most people’s activities.  Different levels of disorders` analysis Qualitative and quantitative behavior`s analysis - descriptive approach Analysis of conditions/causes of the disorders – etiopathogenetic approach Analysis of the mechanisms causing the disorder - explanatory approach  Levels of mental disorders` analysis First level: DESCRIPTION ◻ qualitative or quantitative analysis of disturbed behavior or process ◻ precise description of the symptoms (often helps to determine the type of the disease) Second level: MECHANISMS` EXPLANATION ◻ analysis of the internal mechanism`s causing the disorder ◻ referring to the psychological theories (psychodynamic, behavioral, cognitive, systemic, humanistic) Third level: CAUSES/CONDITIONS` EXPLANATION ◻ the most advanced level: etiopathology ◻ Reference to situational, environmental, biological, developmental factors