Abnormal Behavior Lecture Notes PDF

What is abnormal behavior?  Insanity A legal term Concerned with “responsibility” – being able to distinguish right from wrong Should the person be punished? seldom a successful legal strategy e.g., James Holmes 2012 shooting in Colorado movie theatre; killed...

What is abnormal behavior?  Insanity A legal term Concerned with “responsibility” – being able to distinguish right from wrong Should the person be punished? seldom a successful legal strategy e.g., James Holmes 2012 shooting in Colorado movie theatre; killed 12 people and injured 70 others clear evidence that he committed the crime - found guilty despite mental disorder Sentenced in 2015 to life in prison without parole 2 Normal or abnormal? Why?  What is Abnormal Behavior? ◼ “People vs. Behavior” ◼ Behavior might be “abnormal” when it ◼ Does not conform to societal norms – statistical infrequency ◼ Is an experience of subjective distress ◼ Is seen as a disability/dysfunction by the individual and/or society  What is Abnormal Behavior ? ◼ Statistical infrequency definition suggests that rare behaviors are abnormal ◼ Normal curve indicates that some behaviors are common while others are rare ◼ Common behaviors are at middle of normal curve; rare characteristics fall at the tails of the curve  Statistical Infrequency or Violation of Social Norms ◼ Advantages: ◼ Cut-offs or cut-points make decisions to label abnormality easier ◼ Problems: ◼ Choice of cut-off or cut-points: there is no convention for setting them ▪ Cultural relativity: deviance for one group is not deviant for another  What is Abnormal Behavior ? ◼ Subjective/personal distress definition suggests that behaviors that are accompanied by distress are abnormal  Subjective Distress Definition ◼ Advantages ◼ Seems reasonable to expect that people can assess whether or not they are experiencing distress ◼ Problems ◼ Not everyone who we might consider ‘abnormal’ reports subjective distress ◼ How much subjective distress is needed to qualify as abnormal?  What is Abnormal Behavior ? ◼ Disability/dysfunction definition argues that impairment of life function can be a component of abnormal behavior ◼ Social: Interpersonal relationships are affected ◼ Occupational: Job is disrupted, perhaps even lost ◼ Personal: Day-to-day functioning is impaired Disability or Dysfunction Definition ◼ Advantages ◼ Relatively little inference is required ◼ Often prompts people to seek treatment ◼ Problems ◼ Who sets the standards for dysfunction? ◼ In how many domains of functioning must we see problems? (1,2, 3, more?)  What is Abnormal Behavior? ◼ No one definition is sufficient ◼ Abnormal behavior does not necessarily indicate mental illness ◼ When we say someone “has” a mental disorder, it means only s/he meets the diagnostic criteria for a category in the manual, not that we understand what caused the problem  What is Abnormal Behavior? ◼ Clinical psychology has evolved to recognize that human diversity and cultural diversity are too broad to be contained — or constrained — by the descriptor of ‘abnormality.’ ◼ What is deviant for one person (or group) is not necessarily so for another. ◼ Some behaviors that are appropriate at one developmental stage may be inappropriate at another.  Mental Illness and Diagnosis ◼ Diagnosis ◼ The classification of disorders by symptoms and syndromes.  Symptoms and Syndromes ◼ Symptom/Sign: ◼ single behavior (sign) or subjective report of single characteristic (symptom). ◼ By itself, a sign/symptom has multiple possible meanings ◼ Syndrome/Disorder: ◼ A group of signs and symptoms that covary systematically ◼ Specified duration and (possibly) course, prognosis, treatment response, and etiology.  Diagnostic Systems ◼ Diagnostic systems assume that abnormality can be detected and classified by clusters of symptoms (syndromes) ◼ Each cluster is thought to reflect a different disorder ◼ Each cluster may require a different treatment  Goals of a Classification System ◼ Communication: among clinicians, between science and practice ◼ Clinical: facilitate identification, treatment, and prevention of mental disorders ◼ Research: understand etiology and test treatment efficacy ◼ Education: teach about psychopathology  Early Classification Systems ◼ Hippocrates (460 BC) ◼ 4 humors: black bile, yellow bile, phlegm, blood ◼ Classification: Mania, Melancholia, Phrenitis ◼ Kraepelin (1896) ◼ Groups of symptoms occur together often, allowing us to call them diseases or syndromes. ◼ Regarded each mental illness as distinct from all others with its own origins, symptoms, course, and outcomes. ◼ Classified two major groups: ◼ Dementia praecox (Schizophrenia) ◼ Manic-depressive psychosis (faulty metabolism) International Classification of Diseases ▪ ICD-11 (2022) ▪ World Health Organization Diagnostic and Statistical Manual (DSM) American Psychiatric Association  History of DSMs ◼ DSM (1952) ◼ DSM-II (1968) ◼ DSM-III (1980) ◼ DSM-III-R (1987) ◼ DSM-IV (1997) ◼ DSM-IV-TR (2000) ◼ DSM-5 (2013) ◼ DSM-5-TR (2022)  History of DSMs ◼ First edition of DSM (1952) had vague terms and emphasized psychodynamic (i.e., Freudian) contributions ◼ DSM-II (1968) was less psychodynamically focused ◼ Described 182 mental illnesses ◼ Vague descriptions ◼ Difficult interpretation ◼ Poor interrater reliability  History of DSMs ◼ DSM-III (1980), guided by Robert Spitzer, was atheoretical (revision done in 1987) ◼ 256 disorders; PTSD, ADHD added; homosexuality removed as a disorder from DSM-II ◼ More complete descriptions of diagnostic criteria, multiaxial, increased focus on reliability ◼ personality disorders on Axis II ◼ dropped terms like “neurosis”  History of DSMs ◼ DSM-IV (1997); DSM-IV-TR (Text Revision - 2000) ◼ 297 disorders listed ◼ Person had to experience clinically significant distress in order to meet diagnostic criteria ◼ Further focus on reliability ◼ ‘Working groups’ worked on clusters of disorders ◼ DSM-5 (2013) ◼ Scientific data reviewed for medical treatments ◼ DSM-5-TR (Text Revision - 2022) ◼ current version with 265 disorders  Diagnostic and Statistical Manual of Mental Disorders ▪ DSM-5-TR (2022) by the American Psychiatric Association ▪ Task force chaired by David Kupfer, University of Pittsburgh (Psychiatry) ▪ Produced by 13 workgroups (e.g., depression) and 6 study groups (e.g., lifespan approaches; gender and culture) The DSM Approach to Diagnosis ◼ DSM-5 ◼ Defines a mental disorder as …”a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.” ◼ Associated with distress or disability ◼ A culturally expected response is not a mental disorder  Assumptions of DSM ◼ Mental disorders are discrete entities separated from one another, and from normality, either by: ◼ Recognizably distinct combinations of symptoms and signs, and/or ◼ Demonstrably distinct etiologies ◼ Meaningful syndromes can be identified based on clusters created based on similarity of symptom/sign topography. ◼ Ultimately, each syndrome will be refined until it is homogeneous in terms of etiology, course, treatment response, etc.  DSM-5(-TR) Changes ◼ Multi-axial system of DSM-IV eliminated ◼ Environmental problems checklist ◼ Cross-cutting symptom assessment measures for youth and for adults ◼ Dysfunction measured by scale developed by the World Health Organization  World Health Organization Disability Assessment Schedule In the past 30 days, how much difficulty did you have in: S1 Standing for long periods such as 30 minutes? None Mild Moderate Severe Extreme or cannot do S2 Taking care of your household responsibilities? None Mild Moderate Severe Extreme or cannot do S3 Learning a new task, for example, learning how to get to None Mild Moderate Severe Extreme or a new place? cannot do S4 How much of a problem did you have joining in None Mild Moderate Severe Extreme or community activities (for example, festivities, religious or cannot do other activities) in the same way as anyone else can? S5 How much have you been emotionally affected by your None Mild Moderate Severe Extreme or health problems? cannot do S6 Concentrating on doing something for ten minutes? None Mild Moderate Severe Extreme or cannot do S7 Walking a long distance such as a kilometre [or None Mild Moderate Severe Extreme or equivalent]? cannot do S8 Washing your whole body? None Mild Moderate Severe Extreme or cannot do S9 Getting dressed? None Mild Moderate Severe Extreme or cannot do S10 Dealing with people you do not know? None Mild Moderate Severe Extreme or cannot do S11 Maintaining a friendship? None Mild Moderate Severe Extreme or cannot do S12 Your day-to-day work? None Mild Moderate Severe Extreme or cannot do Main DSM 5 Categories ◼ Neurodevelopmental Disorders ◼ Schizophrenia Spectrum and Other Psychotic Disorders ◼ Bipolar and Related Disorders ◼ Depressive Disorders ◼ Anxiety Disorders ◼ Obsessive-Compulsive and Related Disorders ◼ Trauma and Stressor Related Disorders ◼ Dissociative Disorders ◼ Somatic Symptom Disorders ◼ Feeding and Eating Disorders ◼ Elimination Disorders ◼ Sleep-Wake Disorders ◼ Sexual Dysfunctions ◼ Gender Dysphoria ◼ Disruptive, Impulse Control, and Conduct Disorders ◼ Substance Use and Addictive Disorders ◼ Neurocognitive Disorders ◼ Personality Disorders ◼ Paraphilic Disorders ◼ Other Disorders  DSM-5(-TR): Newly Diagnosed Disorders ◼ Disruptive Mood Dysregulation Disorder ◼ Somatic Symptom Disorder ◼ Illness Anxiety Disorder ◼ Hoarding Disorder ◼ Excoriation (Skin-Picking Disorder) ◼ Disinhibited Social Engagement Disorder ◼ Avoidant/Restrictive Food Intake Disorder ◼ Social (Pragmatic) Communication Disorder ◼ Restless Leg Syndrome ◼ Rapid Eye Movement Sleep Behavior Disorder Example: DSM-5-TR Criteria for Major Depressive Disorder 5 or more of the following symptoms during the same 2-week period: ▪ depressed mood most of the day ▪ diminished interest or pleasure ▪ significant weight loss or gain ▪ insomnia or hypersomnia every day ▪ psychomotor agitation ▪ fatigue or loss of energy ▪ feelings of worthlessness or guilt ▪ diminished ability to think or concentrate ▪ recurrent thoughts of death or suicide  Psychometric Issues ▪ Reliability – refers to consistency ▪ Defined as the consistency of diagnostic judgments across raters ▪ Factors related to reliability: ▪ patients present information inconsistently ▪ institutional or insurance pragmatics that restrict diagnosis possibilities ▪ Structured diagnostic interviews (e.g., SCID) help address reliability concerns  Inter-rater Reliability Extent to which clinicians agree on the diagnosis. Inter-Rater Reliability of Diagnoses from the DSM-5 Field Trials ADULT DIAGNOSES CHILD DIAGNOSES Freedman, R., Lewis, D.A., Michels, R., Pine, D.S., Schultz, S.K., Tamminga, C.A.... & Yager, J. (2013). The initial field trials of DSM-5: New blooms and old thorns. American Journal of Psychiatry, 170, 1-5.  Validity ▪ Validity – refers to whether the category reflects what it is supposed to reflect ▪ Often assessed by examining whether it correlates with what would be expected (convergent versus divergent validity): ▪ Etiology ▪ Course of disorder ▪ Prognosis ▪ Preferred treatment(s) ▪ Treatment outcome  Problems With the DSM Approach ◼ Heterogeneity within syndromes presents a potential problem ◼ Even people who share the same symptoms may differ in important ways: ◼ Example: Variable treatment response ◼ Only about 60% of depressed patients respond to treatments (both biological and psychosocial) ◼ DSM approach responds by dividing syndromes further or narrowing the diagnostic criteria. ◼ But this can lead to an excessively complex taxonomy ◼ DSM-5-TR has 265 disorders Questioning the Categorical Approach ◼ Only a few mental disorders have been shown to have distinct etiologies ◼ With a few exceptions, the genetic and environmental factors underlying syndromes are non-specific. ◼ Examples of specificity for genetics: ◼ Downs Syndrome ◼ Fragile X Syndrome ◼ Phenylketonuria (PKU) ◼ Considerable overlap in genetic factors associated with depression and anxiety  Questioning the Categorical Approach ◼ Argument is that there is little empirical evidence for “natural boundaries” between major syndromes - many mental disorders appear to merge imperceptibly into one another and into normality – issue of comorbidity ◼ Examples: ◼ Major Depressive Disorder ◼ Anxiety Disorders ◼ Schizophrenia ◼ Bipolar Disorder ◼ Researchers have not (yet) identified a ‘neural signature’ for specific disorders ◼ Considerable overlap in findings of structural and functional brain anomalies across different diagnostic categories (e.g., depression, anxiety, bipolar disorder, schizophrenia)  Questioning the Categorical Approach ◼ Similar treatments are effective for a large number of “different” DSM diagnostic categories ◼ Examples: ◼ SSRI medications are comparably effective for depression, anxiety disorders, bulimia, etc. ◼ Cognitive-behavioral therapy is comparably effective for depression, anxiety disorders, bulimia, etc. ◼ CBT for one disorder typically helps with comorbid disorders as well. What About a Dimensional Approach? What About a Dimensional Approach?  What About a Dimensional Approach? ◼ 2013: NIMH Director Thomas Insel: ◼ “While DSM has been described as a ‘Bible’ for the field, it is, at best, a dictionary” ◼ “Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, DSM diagnoses are based on a consensus about clusters of clinical symptoms, not on any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever.” What About a Dimensional Approach? ◼ The DSM’s “weakness is its lack of validity” ◼ “NIMH will be re-orienting its research away from DSM categories” http://www.newyorker.com/tech/elements/the-new-criteria-for-mental-disorders  Research Domain Criteria (RDoC) Research Domain Criteria (RDoC): an initiative of the National Institute of Mental Health (NIMH) ◼ Promotes research integrating genetics, neuroscience, and behavioral science ◼ Leads to objective diagnostic system of “biotypes” aligning with biologically based treatments ◼ RDoC includes six domains with sets of constructs ◼ Problems understood in terms of neurobiological processes to determine treatment Research Domain Criteria (RDoC) Summary of the RDoC Structure Domain Name Description (and Constructs) Negative valence systems Brain systems that control responses to adverse situations such as fear (acute threat), anxiety (vague threat), prolonged exposure to threat (sustained threat), grief and sad events ( loss ), and losing out on a potential reward (frustrative nonreward) Positive valence systems How the brain responds to receiving rewards (reward responsiveness), learns to adapt to reward contingencies (reward learning), and places values on rewards (reward valuation) Cognitive systems Brain processes that control awareness (attention), representations of the environment (perception), memory for facts (declarative memory), how we represent the world through verbal communication (language), decision-making processes (cognitive control), and short-term memory storage (working memory) Social processes The brain’s regulation of how we relate to others, including developing social connections (affiliation and attachment), production and reception of verbal and nonverbal communication (social communication), self-awareness (perception and understanding of oneself), and awareness/understanding of others (perception and understanding of others) Arousal and regulatory systems The body’s regulation of hunger, thirst, sleep, and sex (arousal); energy; physical/mental health (circadian rhythms); and sleep (sleep/wakefulness) Sensorimotor systems Processes responsible for learning to control and execute motor behaviors (motor actions) NIMH Alternative – Research Domain Criteria (RDoC)  How Does RDoC differ from DSM-5-TR? ◼ RDoC is dimensional; DSM-5-TR is categorical  Categorical vs. Dimensional Systems ◼ Categorical ◼ Presence/absence of a disorder ◼ Either you are anxious or you are not anxious. ◼ Dimensional ◼ Rank on a continuous quantitative dimension ◼ Degree to which a symptom is present ◼ How anxious are you on a scale of 1 to 10? ◼ Dimensional systems may better capture an individual’s functioning  How Does RDoC differ from DSM-5-TR? ◼ RDoC is dimensional; DSM-5-TR is categorical ◼ RDoC approach starts with brain–behavior relations and links these to clinical signs and symptoms; DSM-5-TR starts with categories and determines what fits into those categories ◼ RDoC is grounded in biological theory; DSM (-5-TR) is a descriptive diagnostic system  Is the Structure of Psychopathology Categorical or Dimensional? ◼ Are psychopathological problems continuous with the broader range of individual differences? ◼ Do the same factors that contribute to variation in the typical range of individuals also account for the extremes? ◼ Or are such problems qualitatively distinct? ◼ Do they have different etiology than individual differences in the broader population distribution? How Do We Find Out If a Syndrome is Dimensional or Categorical? ◼ Naïve assumption: ◼ Look for bimodality in distributions of the characteristic(s) in question.  Categorical vs. Dimensional Conditions 60 60 Frequency Frequency 40 40 20 20 0 0 1 3 5 7 9 11 13 15 17 19 1 3 5 7 9 11 13 15 17 19 Scores Scores (A) Dichotomy (B)Dimensional There are only two Considerable levels, and all people are variability across the at one of those two population levels How Do We Find Out If a Syndrome is Dimensional or Categorical? ◼ Naïve assumption: ◼ Look for bimodality in distributions of the characteristic(s) in question. ◼ But it’s not that simple: ◼ Few characteristics correlate so strongly with category membership that they would produce non-overlapping or clearly bimodal distributions. ◼ Bimodality is neither necessary nor sufficient to conclude that a construct is categorical.  Empirical Relation Between Categorical and Continuous Constructs  Research Domain Criteria (RDoC) Drawbacks of RDoC ◼ RDoC conceptualizes psychological signs, symptoms primarily as dysfunctions in brain systems ◼ The RDoC initiative privileges biological methodology, assuming their reliability and validity ◼ RDoC assumes identified domains, constructs are exclusively markers of psychological distress and dysfunction. Case Formulation  Case Formulation ◼ Case formulation: a hypothesis about particular psychological mechanisms leading to and maintaining psychological distress/dysfunction ◼ It is principle-driven, grounded in psychological theories ◼ Four elements of case formulation: ◼ Problem list outlines the presenting problem ◼ Hypotheses about mechanisms for treatment problems ◼ Predisposing factors leading to psychological problems ◼ Precipitants: events that trigger/worsen client’s problem Components of Case Formulation Component Definition Shane Kiara Problem list Psychological signs and Aggressive behavior Obsessional fears of harm, symptoms, and difficulties with Self-injury mistakes, and contamination various areas of life (e.g., Attention difficulties Washing and checking social, academic) compulsions Depressed mood, sleep and appetite disturbance, tiredness and trouble concentrating at work Mechanisms Empirically supported factors Behavioral reinforcement Dysfunctional cognitions about that maintain the problem (i.e., attention) follows intrusive thoughts, need for (e.g., cognitive distortions, each act of aggression certainty, and responsibility classical conditioning) Poor emotional lead to obsessional fear understanding and Compulsions are maintained by inconsistent emotional negative reinforcement expression Depressive symptoms result Family disruption from negative cognitions about self and future Trouble at work results from compulsive behaviors, fatigue Predisposing factors Factors that predispose the Social withdrawal Perfectionist and worry client to developing problems Poor verbal skills tendencies (e.g., traumatic brain injury, New job sexual abuse) Family history of depression Precipitants Factors that trigger or worsen Aggressive behavior Working with clients the client’s problems (e.g., occurs when lonely or Recording information in charts being turned down for a date) isolated Thoughts/reminders of germs and mistakes  Multicultural Considerations ◼ Case formulation reflects sociocultural variables during the clinical interview ◼ Psychologists assess degree of client’s assimilation or acculturation ◼ Context of behavior within a broad context also assessed ◼ Behaviors atypical in one community may be considered adaptive in another  An Iterative Approach ◼ Psychologist gathers assessment data when case formulation is complete ◼ Suggested intervention is based on client’s self- monitoring ◼ Case formulation and treatment are revised if other precipitating factors are identified ◼ Process is iterative; testing and revising formulation are repeated throughout treatment ◼ Several iterations may be required to achieve desired results Evaluation of the Case Formulation Approach Strengths ◼ Rooted in cognitive, behavioral theory; researched ◼ Tailored to suit individual clients (but not all clients) ◼ Considers sociocultural factors ◼ Typical and atypical behaviors exist on continua ◼ Iterative approach allows revision of hypotheses Drawbacks ◼ Little research available evaluating the usefulness of case formulation or its outcomes ◼ Unknown reliability ◼ Clinicians must keep up to date with relevant research, theories Developing and Communicating the Treatment Plan  Planning Treatment Treatment Planning ◼ Selection of intervention guided by case formulation ◼ Allows psychologist to devise a treatment course ◼ Addresses hypothesized mechanisms identified in case formulation Communicating the Treatment Plan ◼ Clinician provides rationale for treatment plan ◼ Explains risks and benefits to client ◼ Discusses interventions and alternate plans ◼ Referral to psychiatrist if medications are required  Monitoring Progress ◼ Client and therapist collect data to monitor process and outcome of therapy ◼ Formal and informal methods used ◼ Allows client and therapist to monitor improvement, or to modify treatment plan ◼ An iterative process ◼ Monitoring progress strengthens client-therapist relationship and confidence Ethnic and Cultural Considerations ◼ Culture can influence: ◼ Risk factors ◼ Types of symptoms experienced ◼ Willingness to seek help ◼ Availability of treatments ◼ DSM includes: ◼ Enhanced cultural sensitivity ◼ Appendix of culture-bound syndromes ◼ Amok - dissociative aggressive outbursts ◼ Zar – possession by spirits ◼ Hikikomori - Japan, a combination of agoraphobia, hoarding, and social anxiety - https://www.youtube.com/watch?v=50Y7R5zP0wc