Psychopathology: Understanding Mental Disorders PDF

WE ALL TRY TO understand other people. Determining why another person does or feels something is not easy to do. In fact, we do not always understand our own feelings and behavior. Figuring out why people behave in normal, expected ways is difficult enough; understanding seemingly abnormal behavior,...

WE ALL TRY TO understand other people. Determining why another person does or feels something is not easy to do. In fact, we do not always understand our own feelings and behavior. Figuring out why people behave in normal, expected ways is difficult enough; understanding seemingly abnormal behavior, such as the behavior of Jack and Felicia, can be even more difficult. In this book, we will consider the description, causes, and treatments of a number of different mental disorders. We will also demonstrate the numerous challenges professionals in this field face. As you approach the study of psychopathology, the field concerned with the nature, development, and treatment of mental disorders, keep in mind that the field is continually developing and adding new findings. As we proceed, you will see that the field's interest and importance is ever growing. One challenge we face is to remain objective. Our subject matter, human behavior, is personal and powerfully affecting, making objectivity difficult. The pervasiveness and potentially disturbing effects of psychopathology intrude on our own lives. Who has not experienced irrational thoughts, or feelings? Most of us have known someone, a friend or a relative, whose behavior was upsetting and impossible to fathom, and we realize how frustrating and frightening it can be to try to understand and help a person suffering psychological difficulties. You can see that this personal impact of our subject matter requires us to make a conscious, determined effort to remain objective. The other side of this coin is that our closeness to the subject matter adds to its intrinsic fascination; undergraduate courses in abnormal psychology are among the most popular in the entire college curriculum, not just in psychology departments. Our feeling of familiarity with the subject matter draws us to the study of psychopathology, but it also has a distinct disadvantage: we bring to the study our preconceived notions of what the subject matter is. Each of us has developed certain ways of thinking and talking about mental disorders, certain words and concepts that somehow seem to fit. As you read this book and try to understand the psychological disorders it discusses, we may be asking you to adopt different ways of thinking and talking from those to which you are accustomed. Perhaps most challenging of all, we must not only recognize our own preconceived notions of mental disorders, but we must also confront and work to change the stigma we often associate with these conditions. Stigma refers to the destructive beliefs and attitudes held by a society that are ascribed to groups considered different in some manner, such as people with mental illness. More specifically, stigma has four characteristics (see Figure 1.1) 1. A label is applied to a group of people that distinguishes them from others (e.g., "crazy"). 2. The label is linked to deviant or undesirable attributes by society (e.g., crazy people are dangerous). 3. People with the label are seen as essentially different from those without the label, contributing to an "us" versus "them" mentality (e.g., we are not like those crazy people). 4. People with the label are discriminated against unfairly (e.g., a clinic for crazy people can't be built in our neighborhood). The case of Jack illustrates how stigma can lead to discrimination. Jack was denied an apartment due to his schizophrenia. The landlord believed Jack's schizophrenia meant he would be violent. This belief is based more in fiction than reality, however. A person with mental illness is not necessarily any more likely to be violent than a person without mental illness (Steadman et al., 1998; Swanson et al., 1990). As we will see, the treatment of individuals with mental disorders throughout recorded history has not generally been good, and this has contributed to their stigmatization, to the extent that they have often been brutalized and shunned by society. Torturous treatments have been described to the public as miracle cures, and even today, terms such as crazy, insane, retard, and schizo are tossed about without thought of the people who actually suffer from mental illnesses and for whom these insults and the intensely distressing feelings and behaviors they refer to are a reality of daily life. The cases of Jack and Felicia illustrate how hurtful using such careless and mean-spirited names can be. Mental illness remains one of the most stigmatized of conditions in the twenty-first century, despite advances in the public's knowledge about the origins of mental disorders (Hinshaw, 2007). In 1999, David Satcher, then Surgeon General of the United States, wrote that stigma is the "most formidable obstacle to future progress in the arena of mental illness and mental health" in his groundbreaking report on mental illness (U.S. Department of Health and Human Services, 1999). Sadly, this remains true more than 10 years later. Throughout this book, we hope to fight this stigma by showing you the latest evidence about the nature, causes, and treatments for these disorders, dispelling myths and other misconceptions as we go. As part of this effort, we will try to put a human face on mental disorders, by including descriptions of actual people with these disorders in the chapters that follow. Additional ways to fight stigma are presented in Focus on Discovery 1.1. But you will have to help in this fight, for the mere acquisition of knowledge does not ensure the end of stigma (Penn, Chamberlin, & Mueser, 2003). As we will see in Chapter 2, we have learned a great deal about neurobiological contributors to mental illness, such as neurotransmitters and genetics, in the last 20 years. Many mental health practitioners and advocates hoped that the more people learned about the neurobiological causes of mental disorders, the less stigmatized these disorders would be. However, results from a recent study show that this may not be true (Pescosolido et al., 2010). People's knowledge has increased, but unfortunately stigma has not decreased. In the study, researchers surveyed people's attitudes and knowledge about mental disorders at two time points: in 1996 and 2006. Compared to 1996, people in 2006 were more likely to believe that mental disorders like schizophrenia, depression, and alcohol addiction had a neurobiological cause, but stigma toward these disorders did not decrease. In fact, in some cases it increased. For example, people in 2006 were less likely to want to have a person with schizophrenia as their neighbor compared to people in 1996. Clearly, there is work to be done to reduce stigma. In this chapter, we first discuss what we mean by the term mental disorder. Then we look briefly at how our views of mental disorders have evolved through history to the more scientific perspectives of today. We conclude with a discussion of the current mental health professions 2. A difficult but fundamental task facing those in the field of psychopathology is to define mental disorder. The best current definition of mental disorder is one that contains several characteristics. The definition of mental disorder presented in the fifth edition of the American diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which was released in May 2013, includes a number of characteristics essential to the concept of mental disorder (Stein et al., 2010), including the following: l The disorder occurs within the individual. l It involves clinically significant difficulties in thinking, feeling, or behaving. l It involves dysfunction in processes that support mental functioning. l It is not a culturally specific reaction to an event (e.g., death of a loved one). l It is not primarily a result of social deviance or conflict with society. In the following sections, we consider four key characteristics that any comprehensive mental disorder definition ought to have including disability, distress, violation of sociain some cultures but not in others it violates a social norm to directly disagree with someone. In Puerto Rico, Josè's behavior would not likely have been interpreted in the same way as it would be in the United States. Throughout this book, we will address this important issue of cultural and ethnic diversity as it applies to the descriptions, causes, and treatments of mental disorders. Dysfunction In an influential and widely discussed paper, Wakefield (1992) proposed that mental disorders could be defined as harmful dysfunction. This definition has two parts: a value judgment ("harmful") and an objective, scientific component---the "dysfunction." A judgment that a behavior is harmful requires some standard, and this standard is likely to depend on social norms and values, the characteristic just described. Dysfunctions are said to occur when an internal mechanism is unable to perform its natural function---that is, the function that it evolved to perform. By grounding this part of the definition of mental disorder in evolutionary theory, Wakefield hoped to give the definition scientific objectivity. Numerous critics have argued that the dysfunction component of Wakefield's definition is not so easily and objectively identifiable in relation to mental disorders (e.g., Houts, 2001; Lilienfeld & Marino, 1999). One difficulty is that the internal mechanisms involved in mental disorders are largely unknown; thus, we cannot say exactly what may not be functioning properly. Wakefield (1999) has tried to meet this objection by, in part, referring to plausible dysfunctions rather than proven ones. In the case of Jack, for example, hallucinations (hearing voices) could be construed as a failure of the mind to "turn off" unwanted sounds. Nevertheless, we have a situation in which we judge a behavior or set of behaviors to be harmful and then decide that the behavior represents a mental disorder because we believe it is caused by a dysfunction of some unknown internal mechanism. Clearly, like the other definitions of mental disorder, Wakefield's concept of harmful dysfunction has its limitations. The DSM definition provides a broader concept of dysfunction, which is supported by our current body of evidence. Specifically, the DSM definition of dysfunction refers to the fact that behavioral, psychological, and biological dysfunctions are all interrelated. That is, the brain impacts behavior, and behavior impacts the brain; thus dysfunction in these is interrelated. This broadening does not entirely avoid the problems that Wakefield's definition suffers from, but it is an attempt that formally recognizes the limits of our current understanding. Indeed, it is crucial to keep in mind that this book presents human problems that are currently considered mental disorders. Over time, because the field is continually evolving, the disorders discussed in books like this will undoubtedly change, and so will the definition of mental disorder. It is also quite possible that we will never be able to arrive at a definition that captures mental disorder in its entirety and for all time. Nevertheless, at the current time, the characteristics that are included in the definition constitute a useful partial definition, but keep in mind that they are not equally or invariably applicable to every diagnosis Many textbooks begin with a chapter on the history of the field. Why? It is important to consider how concepts and approaches have changed (or not) over time, because we can learn not to make the same mistakes made in the past and because we can see that our current concepts and approaches are likely to change in the future. As we consider the history of psychopathology, we will see that many new approaches to the treatment of mental illness throughout time appear to go well at first and are heralded with much excitement and fanfare. But these treatments eventually fall into disrepute. These are lessons that should not be forgotten as we consider more contemporary approaches to treatment and their attendant excitement and fanfare. The search for causes of mental disorders has gone on for a considerable period of time. At different periods in history, explanations for mental disorders have been supernatural, biological, and psychological. As we quickly travel through these different periods, ask yourself what level of explanation was operating at different times. Early Demonology Before the age of scientific inquiry, all good and bad manifestations of power beyond human control---eclipses, earthquakes, storms, fire, diseases, the changing seasons---were regarded as supernatural. Behavior seemingly outside individual control was also ascribed to supernatural causes. Many early philosophers, theologians, and physicians who studied the troubled mind believed that disturbed behavior reflected the displeasure of the gods or possession by demons. The doctrine that an evil being or spirit can dwell within a person and control his or her mind and body is called demonology. Examples of demonological thinking are found in the records of the early Chinese, Egyptians, Babylonians, and Greeks. Among the Hebrews, odd behavior was attributed to possession of the person by bad spirits, after God in his wrath had withdrawn protection. The New Testament includes the story of Christ curing a man with an unclean spirit by casting out the devils from within him and hurling them onto a herd of swine (Mark 5:8--13). The belief that odd behavior was caused by possession led to treating it by exorcism, the ritualistic casting out of evil spirits. Exorcism typically took the form of elaborate rites of prayer, noisemaking, forcing the afflicted to drink terrible-tasting brews, and on occasion more extreme measures, such as flogging and starvation, to render the body uninhabitable to devils. Christ driving the evil spirits out of a possessed man. (© SuperStock/ SuperStock.) 3. Early Biological Explanations In the fifth century b.c., Hippocrates (460?--377? b.c.), often called the father of modern medicine, separated medicine from religion, magic, and superstition. He rejected the prevailing Greek belief that the gods sent mental disturbances as punishment and insisted instead that such illnesses had natural causes and hence should be treated like other, more common maladies, such as colds and constipation. Hippocrates regarded the brain as the organ of consciousness, intellectual life, and emotion; thus, he thought that disordered thinking and behavior were indications of some kind of brain pathology. Hippocrates is often considered one of the earliest proponents of the notion that something wrong with the brain disturbs thought and action. Hippocrates classified mental disorders into three categories: mania, melancholia, and phrenitis, or brain fever. Further, Hippocrates believed that normal brain functioning, and therefore mental health, depended on a delicate balance among four humors, or fluids of the body, namely, blood, black bile, yellow bile, and phlegm. An imbalance of these humors produced disorders. If a person was sluggish and dull, for example, the body supposedly contained a preponderance of phlegm. A preponderance of black bile was the explanation for melancholia; too much yellow bile explained irritability and anxiousness; and too much blood, changeable temperament. Through his teachings, the phenomena associated with mental disorders became more clearly the province of physicians rather than priests. The treatments Hippocrates suggested were quite different from exorcism. For melancholia, for example, he prescribed tranquility, sobriety, care in choosing food and drink, and abstinence from sexual activity. Because Hippocrates believed in natural rather than supernatural causes, he depended on his own keen observations and made valuable contributions as a clinician. He also left behind remarkably detailed records clearly describing many of the symptoms now recognized in seizure disorders, alcohol dependence, stroke, and paranoia. Hippocrates' ideas, of course, did not withstand later scientific scrutiny. However, his basic premise---that human behavior is markedly affected by bodily structures or substances and that odd behavior is produced by some kind of physical imbalance or even damage---did foreshadow aspects of contemporary thought. In the next seven centuries, Hippocrates' naturalistic approach to disease and disorder was generally accepted by other Greeks as well as by the Romans, who adopted the medicine of the Greeks after their empire became the major power in the ancient European world. The Dark Ages and Demonology Historians have often pointed to the death of Galen (a.d. 130--200), the second-century Greek who is regarded as the last great physician of the classical era, as the beginning of the so-called Dark Ages in western European medicine and in the treatment and investigation of mental disorders. Over several centuries of decay, Greek and Roman civilization ceased to be. The Church gained in influence, and the papacy was declared independent of the state. Christian monasteries, through their missionary and educational work, replaced physicians as healers and as authorities on mental disorder.1 The monks in the monasteries cared for and nursed the sick, and a few of the monasteries were repositories for the classic Greek medical manuscripts, even though the monks may not have made use of the knowledge in these works. Monks cared for people with mental disorders by praying over them and touching them with relics; they also concocted fantastic potions for them to drink in the waning phase of the moon. Many people with mental illness roamed the countryside, destitute and progressively becoming worse. During this period, there was a return to a belief in supernatural causes of mental disorders. The Persecution of Witches Beginning in the thirteenth century, in response to widespread social unrest and recurrent famines and plagues, people in Europe turned to demonology to explain these disasters. Witchcraft, now viewed as instigated by Satan, was seen as a heresy and 4. a denial of God. Then, as today, when faced with inexplicable and frightening occurrences, people tended to seize on whatever explanation seemed most plausible. The times conspired to heap enormous blame on those regarded as witches, who were persecuted with great zeal. In 1484, Pope Innocent VIII exhorted the clergy of Europe to leave no stone unturned in the search for witches. He sent two Dominican monks to northern Germany as inquisitors. Two years later they issued a comprehensive and explicit manual, Malleus Maleficarum ("the witches' hammer"), to guide the witch hunts. This legal and theological document came to be regarded by Catholics and Protestants alike as a textbook on witchcraft. Those accused of witchcraft should be tortured if they did not confess, those convicted and penitent were to be imprisoned for life, and those convicted and unrepentant were to be handed over to the law for execution. The manual specified that a person's sudden loss of reason was a symptom of demonic possession and that burning was the usual method of driving out the supposed demon. Records of the period are not considered reliable, but it is thought that over the next several centuries hundreds of thousands of people, particularly women and children, were accused, tortured, and put to death. Modern investigators initially believed that many of the people accused of being witches during the later Middle Ages were mentally ill (Zilboorg & Henry, 1941). The basis for this belief was the confessions of the accused that investigators interpreted as delusional beliefs or hallucinations. More detailed research into this historical period, however, indicates that many of the accused were not mentally ill. Careful analyses of the witch hunts reveal that more healthy than ill people were tried. Confessions were typically obtained during brutal torture, having been suggested to the accused witches both by their accusers and by the prevailing beliefs of the times. Indeed, in England, where torture was not allowed, the confessions did not usually contain descriptions resembling delusions or hallucinations (Schoeneman, 1977). Lunacy Trials Evaluations of other sources of information also indicate that mental illness was not primarily ascribed to witchcraft. From the thirteenth century on, as the cities of Europe grew larger, hospitals began to come under secular jurisdiction. Municipal authorities, gaining in power, tended to supplement or take over some of the activities of the Church, one of these being the care of people who were mentally ill. The foundation deed for the Holy Trinity Hospital in Salisbury, England, dating from the mid-fourteenth century, specified the purposes of the hospital, among them that the "mad are kept safe until they are restored of reason." English laws during this period allowed people with mental illness to be hospitalized. Notably, the people who were hospitalized were not described as being possessed (Allderidge, 1979). Beginning in the thirteenth century, lunacy trials to determine a person's mental health were held in England. As explained by Neugebauer (1979), the trials were conducted under the Crown's right to protect the people with mental illness, and a judgment of insanity allowed the Crown to become guardian of the lunatic's estate. The defendant's orientation, memory, intellect, daily life, and habits were at issue in the trial. Usually, strange behavior was attributed to physical illness or injury or to some emotional shock. In all the cases that Neugebauer examined, only one referred to demonic possession. Interestingly, the term lunacy comes from a theory espoused by the Swiss physician Paracelsus (1493--1541), who attributed odd behavior to a misalignment of the moon and stars (the Latin word for "moon" is luna). This lunar explanation, even if unsubstantiated, was a welcome alternative to explanations involving demons or witches. Even today, many people believe that a full moon is linked to odd behavior; however, there is no scientific evidence to support this belief. 5. Development of Asylums Until the fifteenth century, there were very few hospitals for people with mental illness in Europe. However, there were many hospitals for people with leprosy---for example, in the twelfth century, England and Scotland had 220 leprosy hospitals serving a total population of a million and a half. Leprosy gradually disappeared from Europe, probably because with the end of wars came a break with the Eastern sources of the infection. With hospitals now underused, attention seems to have turned to people with mental illness. Leprosariums were converted to asylums, refuges for the confinement and care of people with mental illness. Bethlehem and Other Early Asylums The Priory of St. Mary of Bethlehem was founded in 1243. Records indicate that in 1403 it housed six men with mental illness. In 1547, Henry VIII handed it over to the city of London, thereafter to be a hospital devoted solely to the confinement of people with mental illness. The conditions in Bethlehem were deplorable. Over the years the word bedlam, the popular name for this hospital, came to mean a place or scene of wild uproar and confusion. Bethlehem eventually became one of London's great tourist attractions, by the eighteenth century rivaling both Westminster Abbey and the Tower of London. Even as late as the nineteenth century, viewing the patients was considered entertainment, and people bought tickets to see them. Similarly, in the Lunatics Tower, which was constructed in Vienna in 1784, patients were confined in the spaces between inner square rooms and the outer walls, where they could be viewed by passersby. Obviously, confining people with mental illness in hospitals and placing their care in the domain of medicine did not necessarily lead to more humane and effective treatment. Medical treatments were often crude and painful. Benjamin Rush (1745-- 1813), for example, began practicing medicine in Philadelphia in 1769 and is considered the father of American psychiatry. Yet he believed that mental disorder was caused by an excess of blood in the brain, for which his favored treatment was to draw great quantities of blood from disordered individuals (Farina, 1976). Rush also believed that many people with mental illness could be cured by being frightened. Thus, one of his recommended procedures was for the physician to convince the patient that death was near! Pinel's Reforms Philippe Pinel (1745--1826) has often been considered a primary figure in the movement for humanitarian treatment of people with mental illness in asylums. In 1793, while the French Revolution raged, he was put in charge of a large asylum in Paris known as La Bicêtre. A historian described the conditions at this particular hospital: \[The patients were\] shackled to the walls of their cells, by iron collars which held them flat against the wall and permitted little movement. They could not lie down at night, as a rule. Oftentimes there was a hoop of iron around the waist of the patient and in addition chains on both the hands and the feet. These chains \[were\] sufficiently long so that the patient could feed himself out of a bowl, the food usually being a mushy gruel---bread soaked in a weak soup. Since little was known about dietetics, \[no attention\] was paid to the type of diet given the patients. They were presumed to be animals and not to care whether the food was good or bad. (Selling, 1940, p. 54) Many texts assert that Pinel removed the chains of the people imprisoned in La Bicêtre, an event that was memorialized in well-known paintings. Pinel is said to have begun to treat the patients 6. as sick human beings rather than as beasts. Light and airy rooms replaced dungeons. Many who had been completely unmanageable became calm. Patients formerly considered dangerous now strolled through the hospital and grounds without creating disturbances or harming anyone. Some patients who had been incarcerated for years were apparently restored to health and eventually discharged from the hospital. Historical research, however, indicates that it was not Pinel who released the patients from their chains. Rather, it was a former patient, Jean-Baptiste Pussin, who had become an orderly at the hospital. In fact, Pinel was not even present when the patients were released (Weiner, 1994). Several years later, though, Pinel did praise Pussin's efforts and began to follow the same practices. Consistent with the egalitarianism of the new French Republic, Pinel came to believe that patients in his care were first and foremost human beings, and thus these people should be approached with compassion and understanding and treated with dignity. He surmised that if their reason had left them because of severe personal and social problems, it might be restored to them through comforting counsel and purposeful activity. Pinel did much good for people with mental illness, but he was no paragon of enlightenment and egalitarianism. He reserved the more humanitarian treatment for the upper classes; patients of the lower classes were still subjected to terror and coercion as a means of control, with straitjackets replacing chains. Moral Treatment For a time, mental hospitals established in Europe and the United States were relatively small, privately supported, and operated along the lines of the humanitarian changes at La Bicêtre. In the United States, the Friends' Asylum, founded in 1817 in Pennsylvania, and the Hartford Retreat, established in 1824 in Connecticut, were established to provide humane treatment. In accordance with this approach, which became known as moral treatment, patients had close contact with attendants, who talked and read to them and encouraged them to engage in purposeful activity; residents led lives as close to normal as possible and in general took responsibility for themselves within the constraints of their disorders. Further, there were to be no more than 250 patients in a given hospital (Whitaker, 2002). Moral treatment was largely abandoned in the latter part of the nineteenth century. Ironically, the efforts of Dorothea Dix (1802--1887), a crusader for improved conditions for people with mental illness who fought to have hospitals created for their care, helped effect this change. Dix, a Boston schoolteacher, taught a Sunday school class at the local prison and was shocked at the deplorable conditions in which the inmates lived. Her interest spread to the conditions at mental hospitals and to people with mental illness who had nowhere to go for treatment. She campaigned vigorously to improve the lives of people with mental illness and personally helped see that 32 state hospitals were built. These large public hospitals took in many of the patients whom the private hospitals could not accommodate. Unfortunately, the small staffs of these new hospitals were unable to provide the individual attention that was a hallmark of moral treatment (Bockhoven, 1963). Moreover, the hospitals came to be administered by physicians, most of whom were interested in the biological aspects of illness and in the physical, rather than the psychological well-being of patients with mental illness. The money that had once paid the salaries of personal attendants now paid for equipment and laboratories. (See Focus on Discovery 1.2 for an examination of whether the conditions in today's mental hospitals have improved.) In the nineteenth century, Dorothea Dix played a major role in establishing more mental hospitals in the United States. (Corbis Images.) The freeing of the patients at La Bicêtre (supposedly by Pinel, as pictured here) is often considered to mark the beginning of more humanitarian treatment of people with mental illness. (Archives Charmet/The Bridgeman Art Library International.) History of Psychopathology 1 7.