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PSY2414Notes1 - PSY 2414 Abnormal Psychology Dr. Karen...

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Unformatted text preview: PSY 2414 Abnormal Psychology Dr. Karen Stewart Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener Class of Thursday, August , 2000: I. The Problem of Abnormality A. Judgments, labels and the myth of mental illness 1. Judging abnormality is very subjective and colored by one's culture and experiences--> unusual for lay people to agree about whether its normal or not. Even clinicians disagree about these things. 2. And so, we have adopted a rather medicalized approach to abnormality where we judge it based on whether we can fit it into a disease model. This may not be appropriate in all cases but it has been profitable because useful for some treatments. In the end, it all comes down to a judgment call: a particular behavior is clear cut but other than that its in the eyes of the beholder. B. Sin or Sickness: Metaphors, myths, and models 1. The moral metaphor- most average people see abnormality as a moral weakness or sin, and they have not bought into the medical model. 2. The sickness metaphor- the idea that someone acting strange because they have a disease. C. Definitions 1. More sense to call this a course in psychopathology- pathology refers to disease, or illness or some sort of trauma. In abnormal behavior, often hard to pinpoint where the pathology is, though not impossible. 2. Mental illness= generally used to refer to most serious forms of psychopathology. For example, schizophrenia. We don't use it for more everyday types of things, like a person addicted to cigarettes. American Psychiatric Association (Psychiatrists and not psychologists control this field) uses the term mental disorder instead- any syndrome in which behavior, perceptions, cognition, emotion, or personality is disordered. This involves not only these things but it also has to either cause distress to the individual or to people around him or seriously interfere with his ability to have interpersonal relationships and work. a. DSM- the DSM IV is compendium of every officially recognized mental disorder. You can't get insurance reimbursment unless you use the classification used in the DSM IV. II. How can we have a science of abnormal psychology if its so difficult to judge who is suffering from a disorder? A. Scientific method- overview 1. Observing behavior- if observe lot of people, not just random distribution of abnormal behaviors, but that certain behaviors cluster together. Person who thinks CIA is taping everything he does thru camera in his head does not usually mix with sexual promiscuity. The fact that certain variables do, however, go together shows that there is something fundamental causing both. Losing weight and loss of sleep usually go together with lot of psychological stress like pacing and etc. Things cluster in certain population groups--> suggests that we have manifestations of categories which may be a disease. Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 1 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener 2. Classification- can put different symptoms into clusters. This is really a diagnosis. Can then study the natural history of a disorder. For example, younger people who get schizophrenia usually continue to get worse. But, if get it later, they tend to wax and wane in behavior patterns and they respond to different kinds of medications. 3. Then look for a cause and from this you can hopefully find a treatment. Nevertheless, if take 2 clinicians there is 50% chance that they will disagree about diagnosis. a. Etiology= the cause for a problem. III. Classification and Diagnosis A. Symptoms- any behavioral or physiological deviation from normal. For example, weight gain or loss can be a symptom. But, we never diagnose a mental disorder on the basis of only one symptom. Instead, we look for patterns. B. We also look for signs- behavioral or biological indicator which in itself is not abnormal and is only helpful in the context of everything else. For example, if someone shops an incredible amount, it might be a sign of a disorder rather than a symptom. A symptom, however, is something which is actually abnormal. C. Syndrome- collection of signs and symptoms. Usually use it for when we suspect a disorder but we haven't done enough research yet. D. Scientific and Ethical difficulties 1. People get misdiagnosed and even get incarcerated falsely or hospitalized when not everyone agrees. This leads to a lot of abuses. For example, many believe that ADD is being overdiagnosed and overmedicated. Is he just an undisciplined, energetic child? IV. Causation A. Even if there is such a thing as psychopathology, is it caused by something biological or psychological? Ancient Greeks already debated this and they already recognized many of the same syndromes that we have today. The fact that have been found over broad cultures suggests that they represent some type of entity. B. Physical or psychogenic (disorder that comes about through psychological means) is the big question. Many disorders are behaviorally manifested but have pathology in brain. Until we pinpoint the place in the brain its psychology and when we do so its in the hands of neurologists. The problem with this is that a person does not just have symptoms but also reactions and family is affected and this is why a psychologist is better suited to deal with it. Big debate about who should treat people. C. Difference between psychologist and psychiatrist- psychologists go to graduate school while psychiatrists go to medical school. Until the 1960's, psychologists could not become psychoanalysts (therapy using the Freudian method)--> had to be MD to be accepted. D. Whether a disorder is caused by biology or psychology doesn't matter because many things that are caused by biology can be treated by psychology and vice versa. E. Major Schools of Thought Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 2 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener 1. Psychoanalytic- began in late 1800's with Freud. Says that all disorders are caused by faulty upbringing. Your parents have caused conflict in you from a very young age and what age you were when happened will determine the disease. All symptoms are symbolic about what the inner conflict is. Psychodynamic refers to motives, desires, and concepts that define who we are. And so, your abnormal behavior is caused by some hang-up or some conflict but not necessarily parents. So, psychoanalytic is sort of a subcategory of psychodynamic. 2. Behaviorist- reaction to Freud. Abnormal behavior is learned and no different from any other learning and you learned it through reinforcement or very strange environmental conditions. And so, treat it using learning techniques to unlearn it or substitute it. 3. Cognitive- you are sick because you are thinking wrong. And so, you don't ever leave the house because you think that everyone you meet will dislike you--> have to correct the way that you think. Class of Tuesday, September 5, 2000: Psychodynamic Model I. Historical Background (Psychodynamic model= posits that all behavior normal or not are caused by desires, motives, impulses, wishes, defense mechanisms and that most of these forces are unconscious. And so, to treat it, we need to take the unconscious dynamics and make them conscious so you can have better control over your behavior. Most famous model is the psychoanalytic, though afterwards many came and made slight changes, though all believe that unconscious was the big thing here). A. Hysteria- 1700's had epidemic of hysteria in middle class, European women. Technically, it means loss of physical functioning without any biological basis for it, such as hysterical blindness where can't see but nothing wrong physiologically with them. It might also be just pain without any physiological cause. 1. Physiological symptoms can be cause, apparently, by non physiological diseases. And so, thought that it was something psychological or emotional. But, no proof for this notion yet. B. Mesmer- he believed that there was a physiological cause and that force called animal magnetism and when it was out of balance, it would produce hysterical and other psychological symptoms such as depression, anxiety and etc. 1. Treatment- sat around tub of metals and etc. And would dip their rods into water and he would do it like a show and they would shake and then be cured. This was very popular and accepted for many psychological disorders. Skeptics said that when people seemed to be cured, it was because of suggestion or an early version of the placebo effect. 2. This idea that suggestion could cure psychological or phsical stuff, opens the way to say that something psychological could cause or cure either pysch. Or phys. Diseases. C. Charcot- based on this, he developed hypnosis for hysteria and other psych. Problems. 1. It is quite powerful and effective. Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 3 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener 2. He demonstrated some succeses but many didn't buy that it was something about the trance that did it but rather like suggestion--> he took healthy people and hypnotized them and induced the illness. And, they exhibit that very problem, showing that psychological factors can cause physiological disfunction. This was an important demonstration--> Freud, who seeing a lot of hysteria, went off to study with Charcot. In his early years, he was very interested in hypnosis. In the course of studying with him, came to believe that don't need to really hypnotize people. Could get same kinds of relief using other methods. D. Josef Breuer1. abreaction= get them so emotionally aroused until they have huge emotional scene and then felt better afterwards. 2. Freud adopted this technique from Breuer (whom he was working with). And so, at beginning Freud is borrwing ideas from influential people and trying to find whatever works and has not yet put together his psychosexual theory. II. Freud's Theory of Psychosexual Development (he was always revising his theories-> no one work where gives a coherent, cogent theory. The reading we did was the closest he came to spelling out his psychosexual theory, though he did change some things later on). A. He is very non-judgmental about the people he talks about because for him there is no line separating normal and abnormal. B. Eros and libido1. Eros- name of greek god of love and he used this as name for the life instinct because for him the sex drive is the same as the life instinct and that born with it from infancy. 2. Libido- the word he gave for the sexual drive. This is the drive, like hunger, while eros is the instinct like nutrition. 3. Perversions and all problems result from fixation at an early stage of development. Even newborns have sex drive that can be satisfied. a. His evidence- look at baby who has just finished nursing and has smile like man who just had intercourse. He is projecting a lot of his own feelings onto his observations. In the beginning, no distinction between male and female--> even girls have this after feeding. C. Oral stage1. Major activity of babies is nursing and he said the sucking activity (what he calls organ pleasure) gives infant pleasure. Repetition of this becomes theme in his life and he learns exactly how to get most out of it. Gradually, he brings these activities under his control. A lot of what Freud says is open to interpretation and can't be verified. Many people tried to make it more palatable by calling it sensual rather than sexual, but Freud warned against this because he thought it was really sexual. 2. In a normal family, the mother will start to wean the child and if she does so not too harsh or lenient, the child will leave behind his oral gratification tendencies and move to next stage of development. But, if she is too harsh or lenient, the child can develop a fixation (cathexis). Later in life, types of Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 4 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener pathology will result, such as alcoholism- gratifying needs through way that they were fixated on much earlier on. a. Other manifestationsi. Dependent personality- wants others to take care of him. The "feed me" personality- puts you in same state as baby. ii. Opposite- afraid of the idea of being dependent--> overly independent. If you can be either dependent or independent, which one results from the strict mother and which from the lenient mother? He never clarified this. iii. Sucking thumbs when older. iv. Oral agressive types- express anger by biting or cursing. D. Anal Stage (he says that every person in all places goes through all these phases) 1. At around 1 or 2, baby is being potty trained. (But, this is not true for all cultures!?). Parents very interested in bathroom habits and asks if go to bathroom and etc.--> child puts his attention there and he realizes that he can control it and let it all go or hold it in and make parents nuts--> he has control over parents. 2. Child gets interested in this not just for social reasons but also because they get sexual pleasure out of it. 3. Anus becomes the organ which provides sexual pleasure. If a child wants to rebel against overly strict parent who says did you go yet, did you go yet--> holds it in. If always told to hold it in, then he will rebel by just letting it out. a. Anal expulsive- sloppy people. Rebels against always being told to hold it in. Can't be relied on and don't come throuhg on responsibilities. b. Anal retentive- respond to societal demands by withholding- cold emotionally and they are stingy and etc. c. Male homosexuality is a possible result of anal fixation. E. Phallic Stage 1. Starts around age 3 or 4 till around 6-8. 2. Discovers genitals and begins to masturbate and object of focus switched to genitals. Its pleasure for self and no partner. 3. Starts to think about partner and that's when Oedipal complex could happen. a. Little boys fall in love with mothers in a sexual way. He thinks that only thing that stands in his way is his father. And so, hates and resents his father while still ove him--> conflicting feelings. b. Thinks that his father knows about his feelings for his mother--> thinks that his father will punish him by castrating him. Parents tell him not to touch genitals and often said if you don't stop then will cut it off--> this is where the kids get this idea. Wants to even kill father if necessary, but terrified of castration (castration complex). c. Its so tramatic that child resolves the triangle by introjecting the father- in young children, imagining something is same as doing it--> take in image of father in brain which forms new part of mind, later to become the superego- in his fantasy, he is his father and not desire mother in real life or kill father- beginning of sexual identity as a man. Then, you put all of Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 5 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener this material into the unconcious. Beginning of the amnesia that we all have about childhood. d. If fixated in phallic stage, may go out with women who older or look like their mother. Or can date much younger women or everlasting conflict with father. e. Problems with theory is when get to little girls- she wants to have babies with father and fears and hates mother, though also loves her. But, doesn't have to fear castration; instead, thinks that already been castrated (has seen a naked boy by now and realizes that missing something) to keep her from being appealing to her father. For girls, sometimes call this the Electra complex. Class of Thursday, September 7, 2000: Psychodynamic Model II I. Freud's Theory of Psychosexual development (cont.) A. Latency Stage 1. From end of oedipal complex to puberty is latency period 2. Sexual desire is latent or hidden during this time--> no organ assoc. With it. No fixation in either this stage or next one. B. Genital Stage 1. In puberty, physiological changes make kid interested in opp. Sex but now it has an adult spin- attracted to opp. Sex and wants to have relationship and eventually get married. II. The Structure of the Mind (according to Freud) A. He was talking about the mind and not the brain. B. When born, mind is just instinctive desires and impulses. It is selfish and wants it right now and not enough personal resources to make things happen in reality and is at mercy to the world. C. Id1. name he gave to the mind at this stage. Primitive and almost barbaric. Lacking reason and logic. 2. During the oral stage, when id is pre-eminent, cognitive abilities grow in first year and recognizes that sometimes get food right away and sometimes not. When mom not around when hungry, the child fantasizes about his mother's chest and nurses in his imagination and satisfies himself. He thought it was just like real thing becaue child doesn't know the difference between imagination and reality. This is called primary process thinking- doesn't obey logic and not know distinction between real and fantasy. a. Child gets anxiety when mom not around and afraid that ti will die if mom never shows up. (This is a problem because if kid doesn't know difference between real and fantasy, then should never get anxious). b. Distinction between self and non-self and between you and mom is developing at this time. Recognizing that when you are dependent on someone, then you are at their mercy and mommy loves you but may not always run to you--> anxiety and part of mind evolves and forms the ego. D. Ego Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 6 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener 1. Id maintains its desires and primary process thinking but now have new structure, the ego which operates according to the reality principle rather than the pleasure principle. 2. 2ndary process- rational and real. 3. Ego mediates between id and the world. To allow the id to get its way and not get punished by the world. 4. In the course of toilet training, being subjected more and more to parental disapproval which didn't have as much when infant- "don't do that, don't go there."Confrinting the fact that the world doesn't always let him do what he wants. 5. Ego trying to manage anxiety that comes when not getting what wants and when spanked and etc. Ego is to help get what want ad if can't get it, then lessen anxiety. Ego comes up with defense mechanismsa. Defend against inappropriately expressing sexual urges. b. Defends against anxiety. 6. Constant war between ego and id- ego is the rider reigning in the horse so that horse can go without jumping off a cliff or etc. Freud used this horse metaphor. E. Superego 1. Image of father that puts into his mind is the superego. Its like a internal parent. 2. Irrational and illogical just like the id because you have injected a mean father who wants to castrate you. And so, if you have neurotic or irrational guilt, that's coming from the superego. It even punishes you when you do wrong, particularly when you do something wrong concerning sex or agression. If you have a strict parent, then you will have a strict superego. F. Concious and Unconcious 1. Not clear if he is equating these with the three structures of id, ego and superego. 2. Concious- subject to awareness. Ego is largely, though not entirely, concious. 3. Unconcious- everything in the id is unconcious as is the supergo. 4. Preconcious- all the material that not in working memory but which is easily called in from the long term memory. III. Anxiety and Defense A. Child learns that sexual and agressive drives are inacceptable--> develops anxiety not only about punishment and loss of love but also that he will not be able to control himself and the impulses will come out when innappropriate. And so, defense mechanisms let him get through the day. You have to even defend against even awareness that you have these desires. B. They are normal and healthy unless reliying on only one mechanism or if using them innappropriately or if don't work for them. Some are more mature than others-- > adults will use the more mature ones and will have flexibility so can use right one. C. They are not discrete and overlap and its often subject to interpretation. D. Repression1. Major one and involved in almost all other mechanisms. Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 7 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener E. F. G. H. I. J. K. L. M. 2. Pushing thought out of concious into the unconcious. Its done by the ego, even though it is an unconcious process, since you are not even aware that repressing it. Suppresion 1. Its the only defense mechanism that's concious- its when you conciously decide not to think about something. Denial 1. Saying this didn't happen. 2. Common in trauma cases, like a person will believe that wasn't mugged when really was. Rationalization 1. Coming up with excuse after the fact, particularly one that makes you look good and less guilty. Projection 1. Take whatever imulse or thought that unacceptable and anxiety provoking that you attribute it to someone else- he hates me, when really you hate him. 2. Stereotypically, its characteristic of paranoids who think that everyone is out to get him. Also, its classic for homophobics to be projecting this unto others. 3. One of the least mature of defense mechanisms and if you see too much of it, it suggests psychopathology. Isolation/Compartmentalization 1. Take nasty desires and you isolate them from connection with anything else in your life. 2. Its an unconcious mechanism. Reaction formation 1. Less mature mechanism 2. Repress desire and instead you experience the opp. of an emotion- I hate you instead of I love you. 3. Common with daredevils who do risky study- they are often very fearful people who are trying to conquer the fears or show that they are not "woosy." This is what a child does. Displacement 1. Similar to depression. 2. Distorting the object of whatever your unacceptable thoughts are. 3. Example: Terrified of father and fear that will castrate you--> and so, you take that fear and put it on something else--> develop fear of dogs. Regression 1. Revert back to an earlier stage of development. 2. Classic example- a kid who has succesfully been toilet trained and gets new baby sister and starts going all over the place. Identification 1. To see yourself as or like someone else or affiliated with them. You take on some of their characteristics. 2. Example: conclusion of oedipal complex where identify with same sex parent. Or identification with agressor- a person victimized becomes like the people Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 8 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener who victimized them. It allays anxiety because there is less chance that you will be attacked. N. Sublimation 1. Most mature and adaptive one. 2. Take sexual or violent urge and redirect it towards something that is not only adaptive but is growth-oriented and self-adaptive. 3. Example: Has dirty feelings and then goes and paints a picture. And so, anything good that has been done is really a ersault of redirecting their filthy and agressive impulses. O. Mechanisms prevent acting out the impulses and prevents the anxiety that accompanies these impulses IV. The Id will get out A. So powerful that it will get out in different ways 1. Dreams- expression of all of the stuff stuck in there. Dreams are often irrational and its because its an expression of the irrational id. Its safe because its not real. a. Even here, however, there is defense- if you dreamed having sex with parent, you would wake up and have anxiety--> b. Manifest and latent content. Every dream is a conglomeration of meaning and everything is symbolized. 2. Fantasy- even here, we tend to clean up the images and make them more acceptable. 3. The psychopathology of everyday life- things like Freudian slips and accidents- disguised impulses of the id. This allows you to express them and get some satisfaction that minimizes risk. 4. Symptoms a. All of them are expressions of id impulses. Examples: Depression, insomnia. b. They are symbolic of what the issue really is. Class of Tuesday, September 12, 2000: Get stuff that missed. Psychodynamic Model-conclusion I. The id will out A. Dreams- manifest and latent content- and fantasy B. The Psychopathology of everyday life C. Symptoms II. Neuroses and psychoses A. Neuroses- more common and usually less severe. Disorders of anxiety when defense mechanisms mess up (used maladaptively or too rigidly or etc.). Obsessive Compulsive Disorder is a type of neurosis. So are phobias. Resolved oral and anal issues, while fixated in phallic stage. Multiple personality disorder is a neurosis because its about anxiety and defense. They formed a different personality to defend themselves because they usually got abused when younger. B. Psychoses- much more serious. Out of touch with reality. Don't know what happening around you or hallucinating or delusional (believe something that Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 9 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener completely irrational). This begins in already in the oral stage- trouble seeing difference between him and the mother. Freud believed that everyone is either neurotic or psychotic, though neuroses vary in degree so what seems normal to us is really only mildly psychotic. The best you can hope for is to have mild neuroses or to undergo Freudian analysis so the therapist will make you into mild neurotic. That's the next point- psychoanalysis is what Freud told people to use while psychoanalytic therapy is a watered down version. III. Psychoanalysis A. Techniques 1. Lie on a couch and don't face the analyst and the room is somewhat dim and free of distracting stimuli. Relaxed and no prominent stimuli and you are supposed to free associate- say whatever comes to your mind without inhibiting it at all. Over time, you will eventually make Freudian slips and analyst will pounce on them to figure out what's going on inside. Over many years, you say enough for the analyst to get picture. Can't just reveal yourself but have to do transference. B. Transference 1. Respond to therapist as if he was some important person from childhood, usually the parents. Feelings are evoked and this provides data for the analyst. Do this for 4 days a week for couple years and the analyst says almost nothing. And so, you project unto him your issues. 2. In the midst of the transference, you become very emotional and so they may fall in love with analysis (replay of Oedipal complex) or resent them and this is data for the analysis and this is when the therapist starts talking. 3. He points out how innapropriately you are responsding to him and how you are reliving childhood. You realize that you are interacting with all people when its really about relationship with parents. Takes the unconcious and makes it concious. Try to make you gain more control over your defense mechanisms. 4. Effectivity is low in psychoanalysis- hard to be sure because very few randomly assigned control experiments. The few studies that have been done have shown that not really effective. Also, its very time consuming and very expensive. Nowadays, most insurance companies won't pay for it. a. Neo-Freudians- didn't reject it entirely but disagreed usually about primacy of sexual feelings over others and some feminists didn't like what he said about women. Believe in free association and will use easy chair instead of couch and may face you. Neo-Freudian might not be so passive as Freud would have been. IV. Behavioral Model A. Movement that was reaction to Freud in the 20's, and Watson was the first main guy. Can't measure unconcious and mind isn't our focus but rather the behavior. B. Abnormal behavior no different than normal behavior- it was learned and stimuli control behavior just like normal behavior. Only difference is that abnormal behavior is maladaptive. C. Same methods for learning normal and abnormal- classical and operant conditioning, observation and etc. Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 10 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener D. Classical Conditioning 1. Classic case is with phobia. You have an unconditioned stimulus which by itself elicits a reflexive respose (unconditioned response) and then pair unconditioned stimulus with conditioned stimulus then present CS alone and then elicits a CR (conditioned response). CR is not neccesarily exactly the same as UCR- even Pavlov's dog did not put out as much saliva and some of the chemicals in the saliva were different. a. Phobias come about because of some fearful or tramautic event in childhood and there just happened to be a snake lying around. If parent dies with snake around, the parent dying is UCS, the snake is CS, the fear is first UCR and then just fear (CR) without death of parent. Ay, but the death only happened once while dogs conditioned took many times? Some things are so tramautic that there can be one trial learning. Evolution prepares you so can make the connection in just one trial- this connection must have made you survive in the past- you are born biologically that certain things are very dangerous. 2. Operant conditioning a. Reinforcers --pos. or negative--maintain behavior. And so, if child keeps running to you whenever see snake and then you say don't worry I'll take care of you, you are rewarding the phobia and positively reinforcing it. Phobias do tend to run in families- they learn it from their parents, probably and not just biological. b. Secondary gain- acting in abnormal way, though its in some ways maladaptive, in other ways it does get rewarded- for instance, people who know that you are suffering a mental disorder may have sympathy for you. Also, no matter how you got the illness in the first place, it is maintained often by these secondary gains. c. Two process model of phobias- classical conditioning induces the phobia but both classical and operant conditioning maintain it. 3. Behavioral treatment for psychopathology a. Behavioral modification of primary and secondary reinforcersobserve behavior and try to determine what the positive and negative reinforcers are that maintaining it and then change it- example: teach mom not to hug and caress kid when comes running in about a snake. Some times, you may have to use something physical, like giving ice cream for certain behaviors. b. Stimulus satiation1) Used in certain types of addictive behaviors like addictive smokersmany stimuli are initially pleasant but eventually get unpleasent--> and so, make them smoke 1,000 cigarretes until they get sick or naseaus--> it took a reward and made it a punishment. Hard core behaviorists would say that there is no such thing as a disorder (which has many symptoms)- rather, they just try to fix each behavior at a time. They really analyze the behavior to figure out the environmental stimulus. Very into science and data collection and testing their theories, unlike Freudians. Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 11 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener c. Aversive Conditioningi. Class of Thursday, September 14, 2000: Cognitive- Behavioral Models and Treatments I. Behavioral Treatment A. Aversive conditioning -punishment like getting shocked when smoke a cigarrete. This just suppresses the behavior and doesn't work so well for the long run. B. Modeling- used most commonly in treating phobias or social anxiety conditions. 1. E.g.: Therapist may make you wathc a person handling the snake and the person should be similar to you. C. Response Competition- establish some response which is incompatible with the maladaptive trait. Example1. Systematic desensitization (used also for anxiety disorders)a. Have patient make hierarchy of his ten most frightening things. b. Therapist teaches the patient a relaxation technique. c. Once mastered them, actual treatment begins. d. Imagine the least scary situation on the list and gets anxious and therapist tells him to do excercises and since body can't be relaxed and anxious at the same time, he feels less anxious. e. When mastered it, goes to #9 on the list and so on. D. Criticisms 1. Techniques just treat the symptoms and doesn't get at the root. Freudians have warned that if do this, the conflict is still there and will resurface elsewhere- symptom substitution. In the little research about behavioral therapy and its effects later on, there is not much evidence to support this criticism, though it does sometimes happen. II. Cognitive Model A. Started out as backlash to behaviorism. It arose in the 60's. Definitely things going on in your brain and thinking is important. B. Not only thoughts going on in psychopathology, but that its the thoughts or process of thinking that is abnormal. C. Abnormal thinking is the cause of psychopathology. If you think that everything in life is hopeless and bleak, of course you won't be happy. D. Incorporates many behavioral techniques as well as concepts into its theory from the behavioral theory. E. Very effective for things like learning disabilities and etc. F. Modern day behaviorists recognize the biological basis of some diseases but its irrelevant to them. Just try to get rid of the symptoms. Cognitive model would say when remove the symptoms, you still have thoughts on the inside that are very negative. G. All psychopathology results from disordered thought processes or thought contents. And so, you want to change the disordered thoughts to something more normal. H. Cognitions that affect mood and behavior (not an exhaustive list) Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 12 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener 1. Automatic thoughts- In the article, Beck talks about automatic thoughtsthoughts that occur in response to certain environmental stimuli and you feel controlled by them and not even aware that its hapenning. He sees this as evidence that there is some sort of cognitive elements activated in certain situations. a. Example: when student gets a B, might get thought right away that I won't get into grad school now. b. Where do these thoughts come from? This is one of the problems of the model, since they say its learned during childhood which brings us right back to behavioral and psychodynamic models. Also, doesn't explain why it started now and why remit at particular time. But, their treatment is very effective. 2. Beliefs 3. Rules 4. Attributionsa. Seligman is the proposer of the attribution model b. Stems from behavioral model- both learning and cognitions such as attributions (reasons or explanations we come up with for ours and others behavior) which effect psychopathologyi. Example - why got B? Because the teacher is a jerk. 5. Expectations, anticipation 6. Appraisals III. Processes that affect mood and behavior A. Overgeneralization- taking thoughts and etc. From one situation and applying it to others which are innappropriate. 1. Example: if girlfriend dumps you and you think will never get married. B. Catastrophizing- making mountains out of molehills. IV. Cognitive Content A. The actual thoughts seem to fall into different categories depending on disorders1. In depression, feel loss of overwhelming trouble and worthlessness. 2. With anxiety disorders, however, he says that they have thoughts of a threat. With paranoia, have thoughts and feelings of hostility and people out to get you. Mania and hypomania- grandiose and mood more elevated than normal. So manic-depressive is alternation between mania and depression. V. Cognitive Therapy A. Make patient aware of attributions and etc. You have to teach him to listen to his inner thought processes and tell him to keep a journal to write down certain thoughts and what emotion followed the thought. Also, teach them to be aware of their emotions. And then, think back to what happened right before that feeling. Usually, its an attribution. B. Next, works with him to consider alternative cognitions- use hypothesis testing- if girlfriend broke up with you, are there reasons other than you being lousy person. This is difficult because the patient is locked into certain thoughts. C. Later, go out and test the hypotheses like calling that girl and ask why. People see that their anxious feelins were unjustified and then you see a chnage of mood Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 13 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener D. E. F. G. H. I. and then snowballs to better behavior and then better mood. The idea is to get in and break bad cycle. Use behavioral techniques like journals and testing hypotheses. Try to attack many different problems at once- social skills training same time as assertion training. Both cognitive and behavioral therapies big on science and testing efficacy and proving that therapy works. Most have huge literature on efficacy. And so, we can tell which techniques work for what. Generally, short term treatments especially in cognitive therapy. Usually agree at beginning for deadline of therapy and it seems to help the therapy proceed. Since its short term and so much data to show efficacy, insurance companies more willing to pay for this than psychodynamic therapy. Exceptions to the short termness 1. Certain chronic conditions that need constant treatment. 2. Some people have relapses. And so, you can go in and get booster shot of cognitive therapy- repractice the therapy and usually doesn't take that long to get it. Therapy that tries to mold elements of all three models so far- Laborsky- Core Conflictual Relationship Theme. 1. How psychopathology arises is psychodynamic- some sort of conflict, usually unconcious or only dimly aware of. Not necessarily sexual. 2. Most people telling little stories in therapy like I was so mad yesterday and my kid was whining and etc. He realized that these stories are all about conflicts with other people. These relationship episodes tell the whole story about what the pathology is about. You can delineate what wish the person has, then response from the other person and then from the patient. I want respect and other says you don't deserve it and then other responds with anger. You can do content analysis and find out what's the core cinflicting theme and then secondary one and then get picture of what's bugging the patient. Once patient aware of this theme, you make it concious and use cognitive or behavioral techniques to make response more rational or try to change others response to you. Emphasis on science and recording data and trying to prove efficacy. Incredibly effective method. Suggests that there are ways that you can combine the best of every model. Right now, cognitive therapy has been the topic of many efficacy studies. Compared it also to drug treatments as well as combinations of drug treatments and etc. For depression, seems that combination of drugs and cognitive behavioral therapy. Each alone is effective but not as much as together. For schizophrenics, do better with both though kind of therapy that hsa to be is not so clear- may need more social skill therapy. For phobia, used to use cognitive therapy (I think) which was effective and now they found that patients respond even to anti-depressants and so studying now if they do better with combination than alone. Class of Tuesday, September 19, 2000: Biomedical Model Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 14 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener I. Definition of the model- mental illness is exactly the same as any physical illness, except that symptoms are primarily psychological or behavioral rather than medicaldisordered thinking or etc. In stead of a fever. A. Strict version1. Every mental illness is caused by some sort of physical pathogen like germs or genetical defect or etc. B. Loose version1. Some disorders may come about from psychological experience like trauma or how raised. Nevertheless, it is still a form of pathology and need scientific method to uncover causes and give treatment as if it was a physical illness. And so, this model strongly incorporates the scientific method, though so does the cognitive and behavioral model. Decrease now in hard-core biomedical theorists- can't really draw a dividing line between biology and psychology and everything biological is also psychological and etc. We are realizing that in everything there is really both and the scientific method will tease out the truth. 2. Implications- should go to physicians (psychiatrists) rather than psychologists and have more regulations. II. Etiology- examples of how psychological disorders can be caused by physical agents. A. Infectious agent- general paresis1. Viruses and bacteria can cause general paresis (doesn't really exist anymoreit was cured by science). It causes paralysis, dimentia, mood disturbance and paranoaia. 2. Aids dimentia- many people in later stages of HIV experience dimentia. Its not just a response to the realization that dying. 3. Bacterial or virul infection can be influential (though not necessarily causal)ADHD and strep throat correlated- can either trigger it or cause it for some. a. Diathesis stress model- everybody has to have some pre-existing inclination, physiological or psychological, and there has to be some stressor to trigger it. B. Toxin1. Substances ingested intentionally or unintentionally which damage the body. Mostly, environmental pollutants or chemicals. a. lead-induced mental retardation. This was one of the major causes of mental retardation until recently. Old paints used to be made with lead and when paint flaked off, the kids would ingest the paint chips and then lead levels build up. The younger the person, the more at risk you are. C. Biochemical or hormonal imbalance1. Parkinson's- a population of *dopamine neurons die, leaving the person with a dopamine deficit. Historically, this has been considered to be a psychological disorder. D. Anatomical1. Some defect in the structure of anatomy a. Hydroencephaly- blockage of ventricular system in brain before born. The head swells a bit and brain gets squished. If not treated immediately Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 15 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener by draining the fluid, ends up with severe retardation or blindness or deafness. E. Trauma1. head injury can cause a change in behavior. Can get rowdy and lose inhibitions and etc. F. Physiological1. Has to do with electrical conducting of the neurons. a. Epilepsy- area of brain undergoes chaotic episode of nerve firings that can result in very odd looking behavior. G. Genetic1. Down syndromea. primary defect is intellectual though there are other abnormalities as well like speech, a type of naivete, and etc. III. Steps of the model- how to employ the scientific method to help out pathology. A. Identify symptoms 1. Not as straightforward as it seems. These are judgment calls, to some extent. On some symptoms, people will just not agree about. Used to think that a women smoking cigarettes was considered mentally ill. 2. Can't be totally free of cultural, moral, and religious background. At least if more aware of biases, maybe you can judge more rationally than before. And so, we never officially diagnose someone on the basis of just one symptom. B. Isolate syndrome 1. Try to see which symptoms co-occur and which don't, in order to isolate a syndromea. people who believe martians have impanted device in them tend to have problematic interpersonal relationships and strange movement disorders and etc. 2. Description of natural course of the disease- does it start suddenly or not and when does it occur. People can have same list of symptoms but may be separate disease depending on the natural history. C. Discover etiology 1. Look for cause (etiology= cause). D. Derive therapy 1. Once found etiology, logic should tell you how to correct for the defect you found. Often, however, we find a treatment that works and don't know the etiology. But, can then find out etiology and then get more effective treatment. IV. Case Study- general paresis (not really exist anymore but used to be number 1 cause of mental disorder in the world in 15 and 1600's). A. Symptoms of paresis- gradual onset of these 1. Dementia- decrease of intellectual abilities across the board. 2. Delusions 3. Paralysis 4. Affect- hyperexcited, grandiose. Get paranoid and always culminated in death. Some think that King George the third had it. Epidemics found among native indians when new world discovered. Disorder was showing up Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 16 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener more in women then in men (which was the usual way of seeing it) because European men were infecting native women with it. Many suspected that it was a sexually transmitted disorder- saw that it and syphollis seemed to go hand in hand. Half of people with paresis denied that ever had syphollis because embarassed or didn't know that originally had syphollis (because goes away so fast). Now, we think that paresis is untreated syphollis. B. Conquest of paresis 1. To prove that people with paresis originally had syphollis, a guy injected syphollis into people with paresis who denied that originally had syphollis. Not one came down with syphollis, showing that they all had syphollis originally (only get it once and then you make antibodies). 2. Could look at the thing under the microscope and found that could find it in neural tissue. Long incubation period until other symptoms. 3. Before knew exactly the cause, the first was to use arsenic which often killed the patient. 4. When penicillin discovered, it treated the syphillis and therefore the paresis as well. Paresis is no longer even in the DSM IV V. Somatic treatments- people think that if have biological cause, need biological treatment. Not necessarily true, because we can treat like high blood pressure with behavioral techniques. Nevertheless, the theorists of this model tend to lean to biological treatments. A. Drugs- first treatment of choice for psychiatrists. B. ECT- electroconvulsive therapy1. You are inducing a seizure. 2. Works very well for severe depression. Back in 30's, 40's and 50's, psychiatrists used to use it indiscriminately to any whom first treatments didn't work. But, now know that doesn't work for everyone. C. Psychosurgery1. Operating on the brain. 2. Unfortunate history- frontal labotomies was pioneered in 40's and 50's- go in and suck out the entire frontal lobes. Then refined the technique so go under eyelid and cuts connections between frontal lobes and rest of the brain. 3. Supposed to be used on violent, anti-social people who had not responded to anything else. They started giving it to anyone they felt like. a. Kids who wanted to inherit from parents and get rid of them would convince a doctor that parent was violent and anti-social. b. Man who pioneered frontal labotomies (Moniz) won nobel prize and then a labotomized patient killed him. And so, don't use it anymore unless have very severe case of epilepsy (or may cut the corpus collosum so that the halves of the brain won't be able to communicate with each other anymore). D. Light treatment 1. Psychologists can administer it, but Dr. Stewart thinks its as much biological treatment as psychological. 2. Used for winter depressiona. Trick body into thinking its summer time. Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 17 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener 3. Used rarely in sleep disorders or PMS or jet leg or shift work related disorders. VI. Articles we read A. Sax 1. He clearly has an axe to grind. 2. Saying that mental illness is just a myth like demons and witches. 3. Arguments a. Its not a physical malady. But, even during his time they discovered relationships between neurological things and behaviors. b. Judging pathology is imbedded in value systems. He's right but its as true for medicine as it is for psychopathology. And so, people are still arguing about whether infertility is a disease or not. c. Points out shortcomings of MD's which are true. B. Ketty 1. Meant to rebut Sax and others simialr to him. 2. Specialized in bilogical psychiatry. 3. If schizphrenia is a myth, its a myth with strong genetic component- saying that once can show this, strongly suggests that genetics can be one factor. 4. Dr. Stewart's opinion- Biomedical model is probably the best method for gathering knowledge even if find that many disorders are caused by psychological things. We seem to make more progress when assume like biomedical model. Class of Thursday, September 21, 2000: I. Some final notes on different models A. There are other models than the ones we discussed. 1. Humanistic a. Carl Rogers was main proponent b. More of a point of view than a model. c. An individual is more than his psychopathology d. Rights of patients and respect them e. Call them clients rather than patients f. Therapist and clients supposed to be equal partners i. Non directive and non judgmental ii. Unconditional positive regard 1) Even if you hold of a different model, its very important to emphasize that this relationship between the therapist and patient is so crucial- patient won't get better if you don't like him and etc. Dr. Stewart always emphasizes this to people no matter what model they believe in. 2. Gestalt Model a. Found its roots in perceptual psychology b. The whole is more than the sum of its parts, just like it is in visual perception. c. And so, you can't really deconstruct the person. d. Doesn't talk about how disorders come about or etiology. Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 18 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener e. Techniques for therapy i. Like take an empty chair and say that's your anger and talk to it. f. Not subjected to much scientific testing. g. Fritz Perls was a main guy. II. Diagnosis and Assessment A. Nosology 1. System for classifying any kind of diseases. We will talk about the nosology of mental disorders. You can theoretically classify based on symptoms or treatments or etc. 2. For a long time, no official efforts to classify disorders. First was done by US government in its 10 years census- in 1840, had two categories of mental disorders (idiots or insane). In 1860, they got a little more fancy- 6 categories. In 1930's, World Health Organization wanted to come up with comprehensive system for medical diseases- ICD- International Classification of Diseases. Everyone depended on this for years B. DSM- Diagnostic Statistic Manual. Used Freudian terminology and not much description. Behaviorists objected to the terminology--> APA revised it when got to DSM III. 1980- DSM III came along. 1. Atheoretical a. Dropped the Freudian point of view b. Trying to make it atheoretical so everyone can use it. Still some categories that have psychoanalytic flavor to them. But, don't talk about what causes the disorder but just describe lists of symptoms. 2. Symptom criteria a. Symptoms as well as minimum duration required in order to be diagnosed. 3. Data-based as well as consensus-based a. Categories that appear are supposedly based on data. b. One criticism- its really based on consensus of a committee who spent a career researching a particular area (biased?) about whether enough information to classify it as a disorder. 4. Emphasis on clinical utility a. Supposed to make it easier for clinicians to agree on a diagnosis. Should equalize the differences in training and etc. 5. Multi-axial system a. Response to people who objected that shouldn't equate a person with his disorder- he has a life also and a context and the clinician needs to take it into count in diagnosing and treating the person. There are five axes. i. Axis I- Name of all of the mental disorders (except 2- see next axis). ii. Axis II- Mental retardation and personality disorders. 1) These are separate because these are considered to be lifetime disorders. It characterizes your whole existence. iii. Axis III- any medical condition that is presumed to play a role in the disorder or interact with it or is excacerbated by the disorder or etc. iv. Axis IV- Psychosocial and environmental stressors Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 19 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener 1) Supposed to rate the psychosocial and environmental problems in his life. Check off any problems going on, such as family conflict and etc. v. Axis V- Global Assesment of functioning 1) Rate on scale of 0-100 with 100 being the best. 2) Many people reject to scale 4 and 5 because so subjective and don't even use it. And so, if leave these off for insurance companies, not a big deal. 3) Any score in the 90's means you are doing well in family and social contexts and etc. 6. Categories of disorders in the DSM IV a. Anxiety 7. Reliability and validity a. How good is the DSM- if different clinicians would use it, would get same diagnosis? Depends on where you are coming from- Rosenhan doesn't think much about this. i. He's a graduate of YC. Did pseudopatient study- rounded up people that are supposedly normal, though he never did a diagnosis of them to determine if they are normal. Dr. Stewart knows some of the patients in this study and they are not diagnosis free. ii. They only reported one symptom, namely of hearing voices- this could be schizophrenia, drug induced state or brain disorder. They go to the admissions office and say the voice is saying "thud" which is not the usual content of voices that people hear. All admitted into the psychiatric unit. These were his friends and colleagues and were not randomly selected, which is not considered good science nowadays. Was trying to prove that classification is worthless and is even detrimental because you end up labelling them for life. And so, he says that instead of giving a label, you should just describe the behaviors (he's a behaviorist). iii. How did they get into the hospital- nowadays, its so difficult because of insurances to get it. Today, they would not have gotten in, but then they were able to do so. iv. Objects to the idea that have to put diagnosis on chart when admit them. Upset that diagnosed on the basis of one system, and for this he has a good point. v. They stop reporting that hearing the voice and spend days taking notes about everything. Accurate criticisms about fact that staff ignore them sometimes and this hasn't changed much. He criticizes the fact that nurse wrote objectively that patient engaged in writing. They get discharged with label of schizophrenic in remission. And so, he says we don't know how to distinguish between sane and insane. Problemno psychologist ever diagnoses anyone as insane- its just a legal term (he was a professor of law and psychology). He says we are way too quick to diagnose things like schizophrenia. Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 20 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener vi. Sptizer organized the DSM III, IIIr and IV- he wrote the bible of diagnosis--> these are 2 famous articles that are opposites. Knowing where Rosenhan is coming from, reread the chapter on reliability and validity of DSM IV (Seligman was a pseudo patient in the study) coefficient of agreement between many clinicians who are diagnosing the same person. He says its not very good. Notice that he never tells you what the numbers were. See what Ketty gives as coeeficient and you'll see that its pretty good in the field. And so, you see its a judgment call. When get low agreement, might mean that clinicians are bad rather than the system. Numerous studies show that when specifically train people in DSM IV, then the agreement is high. Book talks about agreement in one institution and over different institutionshe says its a criticism because talk to each other and revise diagnosis. First, it may actually be a good thing. Also, they are diagnosing from transcript or video which makes it low. He says that sleep disorder agreement coefficient is low. They never had anything in DSM until the 3rd one and in DSM IV there is a totally different system than what most people use--> proactive interference where old learning mixes with new learning--> should also look at people only trained by the new system. And so, keep all this in mind when reading the book. 8. Assessment- how do we go about diagnosing? a. Interviewi. Sit down and talkh with him - can either diagnose or narrow it down to 2-3 and then gather more info. ii. Most common- diagnostic interview- no script, completely unstructured, but try to elicit certain types of info such as why did you come to see me, the history of the problem, their personal history (starting from childhood), their current life situation, and observing how the person interacts with you (eye contact, speech normal or strange, have they bathed today, crying, shaking, etc.- these observations are just as important as what they say). And you can change the direction of the questioning based on what you find. Also, laying the basis for future therapeutic relatioship- you want to come off as intelligent, trustworthy, non-judgmental so that the person will feel comfortable telling you things that embarassed about or illegal. And so, this interview is like first therapy session. iii. Structured interview 1) Follow a script 2) Spitzer pioneered this 3) Dr. Stewart does not know anyone who used this unless also doing research (so that don't misdiagnose someone and mess up the research). iv. Semi-Structured 1) Script but you can depart from it when its appropriate- if find something Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 21 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener 2) These are very long- takes long time to do and to train--> most clinicians don't use it unless reserach. 3) IF having trouble assessing from interview, go to testing. b. Testing- carried out usually at request of psychiatrist. i. Personality Inventories 1) Most are multiple choice 2) MMPI (Minnesotta Multiphasic Personality Inventory) is most famous a) 550 or so personal statements that you have to write true or false. b) Takes hours to fill out and if person can't read English or etc. Then you can't use it. c) Different scales and everyone ends up with a profile. Never looking at just one scale but a combination of which things are elevated. d) Validation scales- try to catch people who are faking answersone item faked won't make a difference, however. i) Faking good ii) Faking bad e) Some say that there is nothing you can learn from the MMPI that can't learn from talking to the person longer. ii. Projective tests 1) Roscharc Test (inkblot) a) 10 cards b) 7 of them are grey and black and rest have colors. c) All are symmetrical. iii. Intelligence and achievement tests iv. Neuropsychological testing v. Specialized tests vi. Physiological tests Class of Tuesday, September 26, 2000: Assessment (conclusion) I. Projectives A. Test items are deliberately ambiguous and the individual ways that people relate to them is supposed to be indicative of their personality and psychopathology. B. Most famous one- Rorsarch test 1. Ten cards with symettrical inkblots (5 all black, 2 with black and little splot of red and other 3 are colorful). 2. Always presented in same order and then you say tell me what you think. You are supposed to write down verbatim what they say, how long it takes to start speaking, how long speak for, how long look at card afterwards, and any specific behaviors like if the patient turns it around or etc. 3. The person free associates and then therapist should continue the free association. But, in reality, you spend lot of time scoring the responses- it is very complicated. Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 22 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener a. You look at, for instance, are they seeing the card as whole or different parts and ignore the rest of card. If they ignore parts of all cards, it suggests that their personality is to look at only some parts and reject the rest of something. b. If they are looking at details, are they important details or nitpicky ones. c. How unique or common are the responses (in relation to how most people usually respond). d. How is color integrated into what they are seeing. This is important because certain colors reflect let's say violent emotions. e. How closely does he get to what the picture generally seems like. C. TAT (Thematic Apperception Test) 1. Henry Murray designed this. Thought that people have whole catalogues of needs and this test is supposed to test for it. 2. Pick out things that are standard for men and etc. As well as things which you think would be helpful for this particular person. 3. Pictures are a little bit fuzzy so can't really see details. They are supposed to tell a story with beginning, middle, and end based on the picture. You can prompt certain things. 4. Supposed to use complicated scoring system, though most clinicians don't actually do it. 5. Certain themes come up again and again. Not clear in the pictures if they are male or female and if they are hugging or fighting- purposely vague to see how he interprets it. D. The complete a sentence test 1. These are less commonly used 2. Example: "Rainy days always make me feel ___". E. Draw a person test 1. Used for children. II. Intelligence and achievement tests A. The movement towards IQ testing began when France passed a rule that everyone has to go to school- needed way to place all the kids. B. Originally done as mass administrative tests. C. Got refined by American military when had to draft for WWII. D. Today, several well-validated tests 1. 2 Most common- they are very similar- have 11 subscales where each one taps into different ability. Get 3 total scores- verbal scale IQ (comprehension, abstract meaning, understanding relations, verbal memory and etc.), performance scale IQ (manual and other sensory kinds of intelligence like speed of responses), and full scale IQ. a. Stanford-Binet b. WAIS-Ri. = Wechsler Adult intelligence Scale Revised E. Used to have ratio of mental age over chronological age with normal value at 100. If had 110, meant that your mental age was more advanced than your chronological age. Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 23 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener F. Nowadays, the mean score of a population is 100 and standard deviation is 15 points--> if get 85, you are one standard deviation below the mean. The IQ test is part of diagnostic workup- want to know first if the person is retarded. G. An IQ test tells you about relative abilities- is he stronger verbally or etc. Also, look at different subtests within verbal and etc. Also, some things about a person's psychodynamics can be seen from it- a depressed person with average intelligence will be slower and can end up with IQ in normal range but performance scale is much lower than verbal scale. H. Acheivement tests are supposed to test how well you mastered in a particular course. But, even on the intelligence test, its hard to separate intelligence from facts learned. I. To know whether a person has an impairment, its not enough to know his intelligence- need to know if can function- focus on reading, writing, and arithmetic. Also tells you about whether he can be all that can be or whether something else is preventing them from acheiving their potential- and so, if have borderline intelligence and can't read or write on first grade level, you would want to look into this because should be better than this. 1. Advanced Psych GRE- it's an acheivement test but almost never administered in a clinical setting; rather, its used to figure out how much you have learned compared to other applicants. III. Neuropsychological testing A. Extremely specialized form of testing. 1. Its an elective in most psych graduate schools rather than a requirement for all students. B. To detect area of brain damage, how extensive it is, and how affecting the functioning of the individual. C. Usually very complex and take several hours to administer. 1. Most famous ones- take hours to administer--> sometimes have to break it into different sessions. Some subtests are required and some you pick based on what you suspect is problem. Look for sensory function, motor functions, memory, perception and etc. A good neuropsychologist can detect things which a neurologist couldn't (without modern devices). a. Halsted-Reitam b. Luria-Nebraska IV. Specialized tests A. Like career tests B. Also, tests for research purposes. 1. Beck Depression Inventory a. Multiple choice questions- the higher the number, the more depressed you are. 2. Hamilton Depression Scale 3. Tests for sleep disorders V. Physiological tests A. Few psychologists give them. There is no physical test in field of psychopathology to determine whether person have physiological abnormality, like depression. Psychiatrists, however, love to give hormone challenge testsDownloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 24 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener 1. Dexamethasone Suppresion Test- most depressed people have high cortisol levels. By giving a pill, normal people should secrete cortisol. But, in 80% of depressed people, won't happen because have overactive systems. It's only 80%, so Dr. Stewart says why give it. 2. Thyroid Tests to test for depression- sensitivity and efficity are not good enough about this. B. EEG's 1. Look at this for some psychoses, dissociative disorders, and sleep disorders. Class of Thursday, September 28, 2000: Note on last class: Though an interview can be quite helpful to determine things, there are still times when you will have to do testing like when you are consulted for help and the person who called you wants test results. Mood (originally Affective)Disorders I. Diagnostic categories A. Major depression 1. Episodes of depression. 2. We should draw a distinction between disorder and episodes of depression- a disorder can be just once in lifetime or can be chronic. 3. No two depressed people look alike and sometimes he won't even look depressed to outsiders. Sometimes they say that they feel nothing. 4. Symptoms a. so first symptom is sadness or nothingness. b. Also, has to be more than mood- there are physiological symptoms i. Change in appetite and weight in both directions not because of dieting. ii. Sleep- can go in either direction- insomnia or hypersomnia. 1) Even hypersomnia who sleep 14-15 hours a day are still tired. iii. All depressed people are tired or fatigued no matter how much sleep. iv. Psychomotor disturbance1) Psychomotor agitation a) Constantly pacing or shaking 2) Completely lethargic a) Can spend all day literally on the couch. v. Trouble concentrating or getting mental work done. vi. Loss of self-esteem and feelings of worthlessness or misplaced guilt (or out of proportion). vii. Many experience suicidal thoughts, desires, or even attempts. B. Bipolar disorder 1. Episodic illness though here they alternate with episodes of mania. a. Mania- high excitement and mood disturbances, usually grandioseness. Its almost delusional. 2. Symptoms of Mania a. Mood i. Grandiose, optimistic ii. Others are irritable Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 25 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener b. Physiological i. Always insomniac- won't sleep at all or just 1-2 hours a night for a long time and yet they say that they are well rested. ii. They tend not to eat much and lose weight. iii. Extremely high levels of activity 1) Some get a lot accomplished during these periods while others are so excited that don't get much done. iv. Thought processes are very fast--> all complain about racing thoughts (one of the reasons that they can't fall asleep). v. Pressured speech 1) Get feeling that you can't slow them down and they will just keep talking and it makes you anxious. 3. Some have only one manic episode in life while others go back and forth and etc. C. Dysthymic disorder 1. More chronic and usually less severe form of depression. 2. If don't have enough symptoms for major depression, they usually get this. 3. Chronically pessimistic low-grade form of depression. 4. Capable of being happy and have periods when okay. D. Cyclothymic disorder 1. More chronic, less severe form of bipolar. 2. Cycle between up and down but never have true manic episode. a. II. Major depression I. Symptoms A. Anhadonia 1. =Without pleasure- these people don't experience any pleasure. Depressed people say that things that they used to find pleasure with, they no longer find pleasure in it. a. Associated witn melancholia and depression (rather than mania). i. Substance Abuse 1) Big problem for all kinds of depressions ii. Negative self-esteem 1) Trying to medicate themselves so not feel so bad. 2) Even hypersomnic and eating too much are all very anxious even if don't show it. 3) Pessimism B. Time course 1. Seem to go away in 6-9 months if not treated, though not the case for everyone. But, can;t just say not to treat it because we are afraid that may commit suicide. C. Associated features D. Subtypes A. Some Subtypes of Depression (not all of them are still used anymore) 1. Internal vs. External depression Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 26 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener a. if have obvoius identifiable trigger in the environment. They used to think that can divide all types of depression into this. 2. Psychotic versus Neurotic depression a. Some people get so depressed that lost touch with reality and this is psychotic depression. (Rest is neurotic) i. Delusional and believe like they are the devil or etc. ii. Delusions about how sinful they are. 3. Melancholia- disorder which has group of symptoms a. Insomnia i. Specifically, waking up at 4 in the morning b. Weight loss c. Psychomotor agitation d. We still use this classification of melancholia because these people do best on ECT. 4. Typical vs. Atypical a. Typical- eat less, and less sleep b. Atypical- eat more and sleep more 5. Bipolar I (as described above) vs. Bipolar II (never had mania but had something similar where less sleep and more activity). 6. Some say there is a Bipolar III a. Show up with depression and give them drugs and suddenly they are manic i. Say that you were manic all along and now it just came out, but its probably just a way to get out of being sued when overmedicated people. 7. Seasonal affective disorder (winter depression) a. Repeating form of depression when every winter become depressed b. Sleep more and eat a lot and crave carbohydrates and sleeps. Its like a hibernation with animals. c. It starts at the same time every year for the person. d. Many get spring hypomania- positively giddy in the spring and like won't all asleep, though not a full mania. e. Its not separate diagnosis but is major depression with seasonal____. B. More common in women than men- maybe our society victimizes women and puts them in helpless situations. Another theory- maybe our society makes it more acceptable for women to come forward and ask for help, while the men are not admitting it. 1. Women more susceptible to depression after childbirth- Postpartum depression. 2. Women are also more susceptible around menopause. 3. Some give a dexamathosol test to help detect depression. C. Etiological theories and therapies 1. Psychoanalytic a. Freud says that at some point in childhhood, you suffered a real or imagined loss which caused the mood disorder. And so, it can be a rejection or even loss of dog. Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 27 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener b. Even though you think that you are sad, you are really furious at the person who died or left. You do see this a lot of times when a person loses someone. c. The child incorporates the lost person into themselves in order to try to regain them and to hold on. d. Since mad at them as well as love them, you turn anger in on yourself. And so, depression is a form of massochism- punishing yourself because of a loss. When you are adult, something happens to reactivate these old issues and you start paining yourself- that's why attempt to commit suicide and not eating. e. Treatment i. Make the unconcious into concious and try to make them feel the anger and realize where it really came from. ii. Efficacy: psychoanalysis is barely effective for depression. f. For mania, Freud says its a defense against depression. And so, would use same treatment for depressed person as for a manic person. 2. Behavioral a. Many different behavioral theories of depression. i. Change in life circumstances and the positive reinforcers that used to give you pleasure aren't there any more, like if get divorced and etc. And so, analyze your life and figure out where you need to insert positive reinforcers. ii. Because of learning 1) Based on learned helplessness-Seligman found that if take dog or rat nad put into operant temperature where give unpredicatble electric shocks to it. If give it several sessions of this and then put into different chamber where the rat can control it, the rat wouldn't even try to hit the lever. He ran a yoked control- 2 animals hooked up to same generator- one could shut it off while other got same shock but couldn't do anything about it--> only difference is that one has control and one doesn't. Only the one which did not have control got animal type of depression. Lost weight, loss of sleep, wouldn't do anything in competitive situation, same kinds of changes in neurotransmitters that see in human beings, increased cortisol and etc.---> its not the shock that controls the depression but rather the control- rat thinks that nothing I do matter so why even try (this is more cognitive than behavioral). Some have argued that cowering or whimpering in tha situation is adaptive. Used the animal model to test out drugs and other treatments. 3. Cognitive 4. Biomedical a. Drugs b. ECT c. Light Treatment Class of Tuesday, October 3, 2000: Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 28 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener Mood Disorders (conclusion) I. Etiological theories and therapies A. Behavioral Models 1. There are several models that attempt to account for depression. a. Learned helplessness- if unescapable events, they will develop physiological and cognitive deficits. B. Cognitive (2 articles by Beck about this) 1. Certain types of maladaptive thoughts cause it. a. Content- negative, pessimistic view of themselves and the world. b. Process - Characteristic errors in the process of the thought such as generalizations, overinclusions, errors in logic. 2. Seligman changed his original model of learned helplessness, becoming more cognitive-behavioral. a. Inescapable events no longer enough to produce depression, but rather its how you explain these events to yourself. b. Focused on attributionsi. Internal vs. External 1) Internal- I failed the test because I am stupid, for example. 2) External- I failed because the teacher is awful. ii. Global vs. Specific- apply to many situations or only one particular situation1) Global - Ifailed because I'm stupid--> you will fail other tests as well. 2) Specific- I just don't seem to understand this particular area--> you can do well on a different subject. iii. Stable vs. Unstable- it will always be like this vs. It will not always be like this. iv. If make internal, global, and stable attributions, setting up for depression. 1) Problem- hard to believe that rats make attributions. Seems, rather, that can get depressed even without the attribution. a) Also, sometimes people got depressed even after good events and not just bad events. Also, not every rat got depressed when shocked. b) Yet, it does seem that theories derived from this model are incredible affective. 3. Beck's cognitive therapy for depression a. He sets out to change people's deppresogenic cognitions. Gives h.w. Assignments where record their automatic thoughts for 2 weeks. Find moment where feel particularly lousy and think back to what thoughts had right before you felt lousy. And so, makes patient aware of thoughts that not completely concious and shows them relationship between these thoughts and bad mood. b. Then, try to reason the person out of these beliefs by pointing out the flaws like when ignoring contrary information and what hidden assumptions are lying behind it. Trying to get them to generate alternative Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 29 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener hypotheses- if failed midterm, did you do it because you think you are stupid? Can you think of an alternate hypothesis of why you failed? And, have to test the hypothesis- go out and find evidence that goes with the alternative hypothesis against the original one. c. When pushed to the wall, Beck will admit that sometimes you can't just change their thought process, but you have to get them to actually make changes in their life. d. Also, looking at specifics- may need to gain social skills training like mingling, or assertiveness training, and etc. No specific therapy modelled after learned helplessness model, though Seligman emphasizes attribution in his therapy (though its not a formalized therapy). e. Cognitive therapy different than psychodynamic because its usually short in duration, idea of collecting data is important (if go to a center, you'll be in a research center). f. Limitations: People have to be somewhat articulate because its talkcentered. And so, people who can't speak and young children can't have this done on them. Also, if person is psychotic, you can't do cognitive therapy. And so, can't work with most severe patients. Rather, use it for medium range. Also, not very satisfying therapy for the most intelligent people- they find it superficial and not fulfilling. And so, works best for the medium range of people. When have severe depression, you don't want to wait several weeks, because of fear of suicide--> can add drugs, though event these take several weeks--> maybe need hospitalization and then take drugs there and then go to therapy. Often, severely depressed people don't speak because so depressed and so can't do this therapy. C. Biomedical 1. Drugs a. Anti-depressants- all are fairly affective i. Tricyclic antidepressants a) Blocking reuptake of neuroepinephrin back into presynaptic cell. The neuroepinephrin is then hanging around longer so can continue having affects there. They work for 2/3 to of people to give them at least some relief. They take a few weeks to work, however. And, they may not respond and so have to change it and then wait. Also, there are a number of side effects. ii. Monoamnine oxidase inhibitors (MAOI's) 1) Inhibits the enzyme which breaks down neuroepinephrin--> Increases the amount of neuroepinephrin. 2) Usually your second choice, because more serious side effects and huge amounts of drug interaction. iii. SSRI- selective serotonin reuptake inhibitors 2. ECT a. = electroconvlusive therapy. Its misunderstood by the public. Only use it for severe depression- someone who has suicide risk and can't wait the weeks for drugs to kick in, or if tried other things and they didn't work. Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 30 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener Basically, they are causing a seizure and monitoring the person to make sure is okay. Have series of sessions. b. Some people complain of short-term memory problems. Trying to convince some patients to try it is often difficult, especially for psychotic depressed patients, because there are a lot of fears and myths about it. 3. Light treatment a. Only appropriate for winter depression. Not effective for major depression, though some studies suggest that might be okay for Premenstrual depression. b. Trick's the body into thinking that its summer by sitting in front of artificial lights at certain times of day. c. It influences circadian rythms. d. Most people respond to it within 2-3 days, which is a lot faster than medication. Class of Thursday, October 6, 2000: Get notes that missed from beginning of class. Lithium- it makes people feel sick and its dangerous (need blood test every month)--> and so, it is hard to get people to keep taking it. Also, many say that I only get things done when I am in manic state. For bipolar disorder, standard procedure to give them lithium. No other real alternative. Psychoses and Schizophrenia I. Definitions and concepts A. Psychosis 1. A psychotic person suffers from... a. Hallucinations b. Delusions- firmly held bizarre beliefs. c. Or, impaired reality testing 2. Psychoses is different than schizophrenia- in psychoses, person out of touch with reality and it can result from... a. Certain drugs b. Neurological conditions c. Schizophrenia- can't be diagnosed with schizophrenia without psychotic episodes, though you can be psychotic without being schizophrenic. 3. When manic depressive is in manic state, could be psychotic. Same with certain depressive states. B. Hallucinations1. Sensory experience when no real sensory stimulus is there; such as heraing voices when no voices are really there. a. Voices, commands, visual, smell, tactile, etc. b. Their temporal lobes are actually active--> shows that they are really experiencing things. 2. Majority of hallucinations are auditory rather than visual. Hear voices. a. Usually, voices start out being friendly and then get meaner and nastier. And, the voices know exactly which things would make you maddest. Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 31 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener Also, the voices sometimes give nasty running commentary on things that the person is doing. b. A lot of the bizarre behavior that schizophrenics exhibit is in response to the voices. 3. Visual hallucinations a. May involve a whole complex scene or single object or something weird like everything is red. 4. Smells and feelings of touch a. These are more common than visual hallucinations. b. It is almost always unpleasant, such as flesh burning. c. Feel like bugs crawling all over you- this is a very common one. C. Delusions1. Every schizophrenic is delusional. 2. - A belief which is obviously wrong and irrational and clear evidence against it. And yet, they stick to these beliefs with tenacity. For example, might think they are Abraham Lincoln. 3. Types of Delusions a. Persecution i. this is the most common- someone out to get you and spying on youfrequently its the government who they think is spying on them. Its hard, though, sometimes to know for sure if someone is delusionalexample- a patient thought that roommate was drugging them up at night while they slept and it turned out that it was true. b. Reference i. Certain things that are happening in the world, you think are referring to you- many people think that Dan Rather is giving them a personal newsupdate. c. Thought control i. Think that somebody is controlling your thoughts- e.g., the martians made me do it. d. Thought insertion i. Someone is putting ideas in my heads , e. thought broadcast i. Think that everytime they have a thought, its being broadcasted to everybody. f. Thought withdrawal i. Somebody pulling thoughts out of your head- e.g., I had something I wanted to say and the martians withdrew it from my head. g. Somatic i. About your body, such as when think that insides are rotting or think that have steel plates in their head. h. Religious i. D. Reality Testing Class of Tuesday, October 24, 2000: Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 32 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener I. Schizophrenia A. Symptoms 1. Psychotic episodes a. Person either delusional, hallucinatin or shows impaired reality testing. b. In intervening times, person may not be psychotic but will still have schizophrenia. c. When they are not actively psychotic, they know that there is something wrong with them. The myth is that turly crazy people think that they are fine- this is wrong- they know that they are different from everyone else. There is almost constant suffering even if the initial delusions are nice. They get nasty. And so, there is a lot of suffering both of the patient and of the family. 2. Thought disorder- true even when not psychotic. a. Loose associations 1) Will make associations which a non-schiz. person will not usually think of. b. Incoherence1) You understand the actual words, but no meaning coming through. c. Poverty of content 1) A lot of verbiage, but its not get much information across. d. Repetition, stereotypy 1) Saying the same things again and again. Sometimes just like the sound of the word or the ideas behind them. e. Neologisms 1) = a new word that a person coins. f. Perseveration 1) Always obsessed with same things and talking and thinking about them all the time. g. Clanging 1) Responds to the sound of a word rather than the meaning. a) Tend to do a lot of rhyming and alliteration. b) By the way, not all schizophrenics talk alot. h. Motor- not all of them have these possible symptoms. These respond very well to anti-psychotic drugs and so you really don't see them anymore. 1) Catatonia a) Two forms i) Some are wildly excited, flaling about and almost in a panic state. If you try to intervene, they'll fight you off. ii) Others are immobile. Will maintain a position for hours or even days at a time. 2) Posturing a) Adopt strange, or uncomfortable postures for hours or days at time. 3) Stupor 4) Excitement i. Affective 1) All schizophrenics describe some emotional problems. Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 33 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener j. k. l. m. n. o. p. q. 2) Many are very anxious and cry alot--> don't sleep well. a) Not sure if this is part of this disorder or consequence of being schiz. in an unfriendly world. 3) Most schiz.'s feel some depression. a) Not sure if they have 4) High's and low's similar to bipolar disorder. 5) Emotional Ambivalence- feel conflicting emotions about many different issues. Can't resolve it and like paralyzed and helpless. Interpersonal 1) Don't feel very comfortable around others. 2) Feel that their reality is different from everyone else and that no one else can know what they are experiencing. 3) People are uncomfortable around them because there is often hygiene issues and accuse others of spying on them and etc. a) Course Great debate about whether its a chronic disease. Many say that you'll be shciz. For life when get it. Usually get first psychotic episode in late teens to early 20's. Then, you see decrease in level of functioning and most don't ever get back to that level again. Others say that some little signs show up before that, but you have to know how to recognize it- prodromal sequence of events before first psychotic episode. First psychotic episode can be a couple of days to a year at a time. But, nowadays, they are often taken to hospital pretty soon after. Debate about whether schiz. is lifetime disorder or not has not been resolved. Those who seem to have gotten over it, are probably in the minority. A guy last year had seemed to have gotten over his disease and went to Yale and then got great job and wrote a book about his experience, saying "look I got better." Then, he went psychotic and killed his girlfriend 2 years later. Episodes seem to get worse over time and get more frequent. 1) Types of schizophrenia Paranoid 1) Believe that they are being followed and etc. 2) Less likely to actively hallucinate; their big problem is delusionsdon't actually see the spy following them, but they really believe it. 3) Tend to be higher functioning 4) Very hostile and angry- may be consequence of believing that followed and etc. But may have been there before. 5) Don't show a lot of joy and etc. 6) Very cold and calculating when not angry. 7) Don't show many of the other symptoms except for interpersonal and delusional experiences. Disorganized (hebephrenic) 1) Act silly or out of control. A lot of homeless people who have schiz. Are hebephrenics. Page 34 of 61 Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener 2) Speech signs of the disorder are common. 3) Not angry or suspicious necess. r. Catatonic 1) Motor symptoms are most prominent. 2) Delusional and hallucinating but mostly exhibit this thru strange stupor or adopt waxy flexibility (they don't move but you can go and move them). 3) Negativism a) Anything you tell them to do, they do the opposite. And, this is considered a motor disfunction and tend to see this only in catatonic disorder. Trying to cancel out the effects of the world. (Alot of schiz.'s are good "B.S." Detectives, though on a one-onone interaction, they are almost clueless." s. Undifferentiated 1) Don't meet the criteria of any other categories, so this is like a "garbage can" categories. t. Residual 1) Acute psychotic episode has ended, but person has not completely recovered. Instead, have persisting interpersonal problems and emotional problems (depression, anxiety, or ambivalence). Class of Thursday, October 26, 2000: Schizophrenia and Psychoses I. Etiological Theories A. Psychodynamic Theories 1. Freud's view- schizophrenia as primary process thinking. a. He didn't spend a lot of time working with or writing about schiz.'s. b. He thought was result of primary process- can't get some desire in reality-> excessive form of fantasizing, sort of. They either got fixated in oral stage and whenever things went wrong they would resort to one tool that got them what they wanted, namely fantasizing. c. He thought that you can't do psychoanalysis with schizophrenics because disordered--> can't do transference. d. Neo-Freudians, however, had a great deal to say about schizophrenia. At the beginning, almost everyone blamed the mother, and there was even a name for it. 2. The schizophrenogenic mother- cold, hostile towards the child and very domineering. Child grows up in fear that mother will get angry. And yet, they depend on her for survival--> intolerable situation--> the child turns inward and gratifies his emotional needs by creating fantasies. They seem to use it as defense mechanisms- originally, the fantasizing was a response to stress. a. Splitting as a defense i. Made anxious by incongruent cognitions or attitudes toward someone else, like towards his mother. And so, split mommy into 2 images and forgets one of the mommy's whenever one is present. And so, their Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 35 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener attitudes about mom are unstable and unpredictable. Child grows up with skewed view of reality and difficulty dealing with ambivalence. b. Fantasy as a defense c. Abnormal relationships 3. The double-bind (not blind) a. Gregory Dateson (or Bateson, I'm not sure) i. Many children get mixed messages when not equipped to resolve the conflict. And so, can't trust reality; never really knows what mom wants and what doesn't want. He never really learns to trust his own feelings-doesn't know if he loves mom or hates her. To escape, he retreats to fantasy world. ii. There have been a handful of studies very poorly done, like without proper control groups. Studies have tried to find out if schizophrenics had cold, hostile mother. But, the percentages are same for a person who doesn't become a schiz. Other data have looked at communication in families of a schiz. Seem to have some strange communication- messages not so clear and tend not to be understood. Tend to use strange grammar and etc. But, the argument is made that you don't know which is the chicken and which is the egg. Also, its very subtle and hard to see that this leads to such a harsh disorder. Some research done about interpersonal relationships- family systems theory says that psychopathology is caused by strange interaction in the family. Many people relapse right after getting back to their families. Have looked at way that family members express emotionsfamilies of schiz.'s tend to express emotions very highly and if the emotions are negative, not surprising that will relapse. Still have the question of chicken and egg. B. Behavioral theories 1. Disordered social learning a. This theory says that schiz. Is because of maladaptive learning. Identify specific behaviors and figure out how to change them. For example, might focus on the patient's speech or interpersonal difficulties. 2. Labelling a. This theory says that first, the person might exhibit a couple of odd or eccentric behaviors. Then, the people around him say that's crazy and they pin the schiz. label on him and he begins to act like that. And so, its a societal thing. The consequences of labelling and stigmatizing is enormous. Many people have this myth that schiz.'s are violent or dangerous. The likelihood that a schiz. Will engage in violent behavior is only a teeny bit higher than everyone else. 3. Disordered environmental conditions a. So many schiz.'s seem to be concentrated in lower socioeconomic levels, particularly in cities. And so, maybe the environment of poverty, discrimination, pollution and etc. cause schiz. b. Here, also, you have the chicken and the egg problem- some say that because of schiz. problems, makes it hard to keep down job and etc. Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 36 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener People in lower socioeconomic levels also have more frequent and more intense bouts. c. It's also important to mention that in a lower socioeconomic levels, there is less medical care, poorer nutrition and etc.-which aspect, specifically, is the one that causes schiz.? C. Cognitive theories- she doesn't know any therapists who say that disordered thinking is the cause of the disease, but they think that its the core of the disordered, the most important symptom. 1. Disordered attention and filtering a. At any given moment, everyone is bombarded with thousands of stimuli. But, we normally are able to concentrate on specific things. A schiz., however, has a lot of trouble with this. And so, they get hung up on internal stimuli and then shut out everything else. 2. Disordered content and processes a. Actual content is abnormal like the belief that being followed. b. Also, the form of thought is abnormal- incoherence, loosness of associations and etc. Class of Tuesday, October 31, 2000: Schizophrenia and Psychoses (conclusion) I. Biomedical theories- we'll cover just the ones that have held up to research. A. Genetic studies 1. In Ketty's article, he summarizes the research studies and there is evidence for a genetic contribution- it is fairly high. If have family member is schiz., your risk increases dramatically. However, also clear that its not solely a genetic disorder, since otherwise there would be perfect concordance rates between twins. And so, genes don't tell the whole story and we are not even close in determining which genes are involved or what the mechanism is. B. Pregnancy and birth complications 1. Some suggest that these may be the reason, based on epidemiological evidence. 2. Schiz.'s seem to have higher rates of having suffered from birth complications like low birth weight and etc. C. Viral infection 1. Schiz.'s are more likely than non-schiz.'s to have been born during the winter months. This is interesting because believe that schiz. May have viral origin. Babies in winter births tend to be more likely to catch bugs and colds and etc. But, this is certainly not the whole story. Yet, this is a very popular theory. D. Neuropathology- some focus on anatomical diff.'s between schiz.'s and nonschiz.'s 1. Ventricular enlargement a. Have cerebral ventricles that are enlarged and may have some etiological role. But, this research does not distinguish between before and after. 2. Hypofrontality Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 37 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener a. Frontal lobes in schiz.'s seem to have less volume and not as elaborated. Frontal lobes are seen as seat of executive functions- make complex plans and carry out complex sequences and monitoring results and correcting mistakes. And so, suggests that given the symptoms of schiz.'s have, have some consistency. But, whihc is the chicken and which is the egg. 3. The dopamine hypothesis a. Strongest hypothesis b. Around since the 60's. c. Observed that people who took large doses of amphetamines and other stimulants dev. Psychosis and look similar to schiz.'s. We didn't know a lot about pharmacology and thought that caused sudden release of all the dopamine in cells. d. People with Parkinson's disease seemed to have depletion of dopamines-> link to schiz. e. Theory is that schiz. results from too much dopamine- originally dev. "Major tranguilizers" for anxiety disorders and it knocked `em out too much but it did work for schiz.- not only calms him down but also stops the hallucinations and ends the delusions or at least makes them less distressing and weakens the person's belief in them. Also, they are not so bothered by it anymore. f. The dev. Of these drugs revolutionized the treatment of schiz.'s. They used to be institutionalized and not treated very well. Now, could send a lot of people home to the hospital. The number of such anti-psychotic drugs have increased dramatically- called neuroleptics, major tranquilizers, or phenothrazines, or also known as dopamine receptor blockers- prevent dopamine from activating postsynaptic neurons by occupying the receptors so dopamine can't bind with them. g. Seem to also eliminate the motor symptoms. Also, reduce the general feeling of being separate and not apart of world. Does not get rid of all symtpoms- still have interpersonal problems and ambivalence and mood problems. Some of the idiosyncrasies are not fully treated by the drugs. Anywhere from to 1/3 of schiz.'s who try the drugs do not respond to it. Also, they have some incredibly bad side effects. First, there are a number of motor problems that show up such as akathesia- uncontrollable movements of face, tongue, etc.. Also, there is akinesthesis (tend not to move like make a masklike expression), and tardive diskinesia (when on them for long time like 10-15 years- motor problems- worse spasms and weird arm movements. It is permanent and irreversible-only gets worse even if stop taking the neuroleptic). And so, now you don't give more of the drug than you absolutely need and give frequent drug holidays to ensure if really need the drug. And, if have some time each year where not on the drug, seems to push off the onset of the problems. Each of the different drugs (Thorazine and etc.) have slightly different chemistries--> can try a bunch of them if doesn't work. h. In last few years, new drug has come out- clozapine- many kinds of dopamine receptors and this works on a different type of receptors. Seems Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 38 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener to be more effective and seems to work on many who do not respond to others and reduces the risk for tardive diskenisia. Yet, not many have switched over because its incredibly expensive and if in lower socioeconomic classes--> don't have the money. Also, not so available in this country. II. Treatment A. Psychodynamic 1. Freud said that psychoanalysis not appropriate for schiz.--> didn;t dev. Techniques for them. 2. Neo-Freudians, however, have tried to dev. Techniques- and so, beleivers of schizophregwnic mother were big on institutionalizing the person to get him away from mother. Problem is that they say the problems start in infancy while it doesn't show up until teens--> not until brought in by families were they institutionalized. Observed that there was a relationship between what going on with patient and with family- for instance, when released for a weekend, would get hallucinations and etc. Didn't develop specific techniques and just remove from home. 3. Those who looked at patterns of communication believed that need to treat the whole family. And so, many psychodynamically oriented people try to do family therapy. Can work on specific communication problems. Also, family can talk about the pressures involved in caring for a schiz. and it supports the support system. Also, its a bonus if can identify specific behaviros which disturb the schiz. and vice versa. This has turned out to be very helpful in improving the bonds between the family members and improving communication in general so will help his interpersonal life. B. Behavioral 1. Concentrate on changing specific maladaptive behaviors. Might include changing the person's grooming habits so look more normal and etc.. 2. Might have 30-40 targert behaviors and are concrete and specific. 3. Also, education about their illness is very important. One of the problems is that don't realize that getting psychotic episodes. You don't want to wait until very accutely psychotic. And so, you want to train them to monitor themselves and bring themselves to the doctor when feel an episode coming on. Make them understand the need for medication- many schiz.'s don't like the medication because of side effects and cost. Suicide attempts are very high, second only to depressive people. Many schiz.'s die because like have an illusion that can fly off a building. 4. 2 years ago, a large end study suggested that schiz.'s more likely to engage in violent behavior, though it's only slightly higher than anyone else. C. Social/interpersonal 1. Group therapy is extremely useful in helping the individual by giving him more supportive people and people are more willing to accept interpretations when coming from others rather than the doctor. Also, they can try out social skills and etc. with members of the group. Also, the group can be very encouraging because they know what its like to be schiz. D. Biomedical Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 39 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener 1. Basically, its neuroleptics. (I never promised you a rose garden- its a book which gives you a good picture of what a schiz. was like before neuroleptics.) Midterm Up Until Here!!! Class of Thursday, November 2, 2000: Anxiety Disorders I. Phobias and panics- get notes that missed from today. The most serious types of phobias are those that set in at late teens or early twenties. You can have two people who have the same fear yet only one can have a phobia because to classify as a phobia, it needs to be distressing or cause functional problems (and someone who has a fear of planes but never has to fly doesn't cause him real problems). A. Simple phobias 1. Animal phobias a. These are the vast majority- lots of dog phobias, snakes, cats, horses, and etc.. 2. Natural phenomena phobias a. Like fear of dark, lightning, thunder, earthquakes. 3. Situational phobias a. Phobia of heights, elevators, clostrophobia, and etc.. 4. Illness-injury phobias a. Phobia of blood, hospitals, needles, surgery and nosophobias (= fear of diseases). With nosophobia, the fear is whatever the bid disease is at the time- now, for instance, there is a fear of AIDS. B. Social phobias 1. Fear of what other people will think about you, such as fear of public speaking. 2. Also, fear of writing in public because afraid that their hand will shake and then people will call them crazy--> can't take notes in class. 3. Fear of urinating in public or using a public restroom (almost entirely in men). C. Agoraphobia and panic attacks 1. Main thing of agoraphobia- fear of the "marketplace"- fear going out in public. a. Some afraid that will have heart attack or etc. and everyone will be around them and no one will help or will stare at them. 2. Panic attack- can last a couple of minutes or continue for an hour or so. When get frightened, they get even worse--> it's a cycle. The attacks range in frequency- some have just a handful and some have a couple a day. a. Physiological symptoms i. Increased heart rate ii. Short of breath and gsaping iii. Lightheaded, faint b. Psychological Symptoms i. Confusion Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 40 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener ii. Fear and anxiety iii. Afraid that will die 3. Agoraphobia (cont.) a. Have fear of going out because of fear of heart attack or having a panic attack. And so, these 2 disorders are related. There is a disorder of agoraphobia with panic attcks, without, and also panic disorder with agoraphobia. b. Unlike schiz, people with anxiety disorders do have a certain amount of recognition of their disorder and appreciation that its irrational. Except for agoraphobia, its circumscribed and doesn't affect whole life. Childhood phobias tend to resolve themselves pretty often. II. Obsessive-compulsive disorder A. Either obsessions and/or compulsions 1. Obsessions a. Mental events- repetititve, unwanted disturbing thoughts or images or impulses or desires. Tend to be violent, sexual, bizarre or etc. i. General Themes of Obsessive Thoughts 1) Germs, contamination, infection 2) Locking doors or shut off the stove ii. Content relates to the content of compulsions 1) Compulsive hand washing for Theme #1. 2) Go back and shut the door thousands of times for #2. 2. Compulsion a. Behavior- the thoughts make them very anxious--> the behavior is what they feel that they have to do. If you prevent them from doing it, they will like blow up until they just have to go and do it. That's why it's called "compulsions." OCD usually starts in early adulthood. i. Ritual- it's a subcategory of compulsion- get strange thought and do ritual to either undo the thought or protect them from the thought. Many people have this fear that will hurt someone else and develop a ritual to undo it. III. Post-Tramatic Stress Disorder A. Symptoms 1. The definition of this disorder has changed over the years. Originally, only used for severe trauma that so severe that otuside of the realm of normal human experience like being in a concentration camp or terrorist attack. 2. In the 80's, therapists claimed that had slightly less extreme distressors but were desribed as having PTSD, such as people who were raped. Big dispute about whether this is outside realm of normal experience. 3. Then, therapists kept extending the boundaries--> some cases have been written when kid gets a B on the test and therapist calls it PTSD. 4. Symptoms include some sort of re-experiencing of the original trauma, usually nightmares. Otherwise, they have flashbacks and feel like back in the situation- this happened often with people in Vietnam. Also, could take the form of extremely strong day dreams. Its involuntary and you are helplessly reliving the situation. Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 41 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener 5. Also, emotional consequences; tend to get depressed, get anxious, and also a numbing over time so that no longer feel happy when something good happens or bad when something bad happens. Class of Tuesday, November 14, 2000: Anxiety Disorders I. Phobias- Etiological theories and therapy A. Psychoanalytic theory and therapy 1. Theory a. The Little Hans Article i. It was the mother who threatened to castrate the boy and not the father (-the father is the one that Freud, in his theory, blames). ii. Also, a lot was interpretation- so many levels before the data even gets to Freud--> we don't know how accurate the data is. They are not just reporting but also interpreting--> not sure how accurate. iii. You have to remember, however, that Hans lived almost 100 years ago when times were different and little boys were not expected to behave like today. iv. Also, talking a lot about what the father calls his "widdler" and sleeping with playmates is not pathological according to any cliniciantake for instance, their they are being toilet trained--> of course they will be interested in their widdler and etc. Animal phobias are very common in children and usually spontaneously remit. v. Also, sleeping with girlfriends is very common with little childrenlittle boys often want to sleep in mom's bed, sister's bed, etc. Also, in their European upper class, it was very common to sleep with mom or governess until they were even 4 years old. vi. When the mother threatened to cut off his widdler, we should not be shocked- there are many parents even today that say things like this. And so, if even a disciple of Freud, who studied with him and etc., could not help herself from saying it, all the more so for regular people. Freud only met him once or so. Years later, he meets this pleasant, handsome man and its little Hans- he has no memory whatsoever of anything about this. vii. So Hans has interest in sleeping with little girls- has puppy love and its very common. Freud sees this as building up of Oedipal complex. Freud writes about how Hans gets obssessed with sleeping with mother and keep Dad out of way- and so, Freud did an excellent job of formulating the case in accordance of his theory, though there are some big problems with the whole thing. viii. Freud says the horse symbolizes his father- says the horse is big and has big widdler like his father. Hair on chin of horse looks like father's beard and etc. He is afraid really of his father, But, he really loves his father--> ambivolence. He is afraid of the horses but also fascinated by it. It's his father in certain situations that really afraid of like when horse falls down and loses control--> afraid of father losing Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 42 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener control and being violent and will castrate him. (Hans, at times, changed the story according to what his father wanted to hear). b. According to Freud, a phobic object is really a symbol of the real fear. It expresses the real fear as well as the real wish- horse is his desire to be like Dad but also is fear of his father that will castrate him. c. Distortion of the underlying desire- real wish is displaced onto something less scary. But, that object is not truly neutral; it is something that symbolizes the wish and the fear. d. At same time, repression sets in and prevents you from realizing what the true wish is. e. Hans was going through Oedipal conflict in the phallic stage. He eventually resolves the Oedipal complex and the phobia. When he realizes the symbolism of his father, this resolves the Oedipal conflict and he can enter the latency stage and then repress all energy of the conflict--> not surprised that Hans has any recollection. f. The phobic object symbolizes the conflict--> commonality of certain types of phobic objects, Many are afraid of snakes, he says, because its a phallic symbol. g. The therapy they did on little Hans was not really like what Freud would have done with an adult patient. 2. Therapya. not different than any other neurotic disorder- lie down on couch with dim light- as few stimuli as possible so imagination free. Would ask them to free associate and say anything that comes to mind and not feel uptight about anything. It takes some practice to do so correctly. b. Wants to hear the train of associations so that can interpret the structure of the mind. c. Analyst picks up on certain kinds of connections, like the fact that whenever talks about the brother, she starts to get angry. And so, tries to gather data to explain your case. But, analyst is quiet and not reacting--> causes the patient to get angry or etc.. We are used to humans responding to us, especially when you are spilling their guts. Analyst is blank slate and not displaying his personality--> patient fills in the gaps with his own experience--> this is the transference. People begin to imagine that its a particular person with a particular relationship- "you are just like the father that walked out on me when I was a baby." Indicate things about how their early relationships were. Transference happens in all therapy situations, even in behavioral ones. d. Therapist starts making interpretations- I wonder why you are so angry at me. The idea is to make the patient realize that you are not his father and etc. And that the patient has been unrealistic and interpreting and once aware that doing so, can adopt a healthier way of dealing with relationships. Aware of underlying, unacceptable desire and then substitute more adaptive types of behavior. Class of Thursday, November 16, 2000: Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 43 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener Anxiety Disorders (cont.) I. Phobias- Etiological theories and therapies A. Behavioral theories- posits that they are a combination of both classical and operant conditioning- two process model. 1. Classical conditioning- initial acquisition of the phobia-->there has to be some tramautic event which initializes the phobia. a. There is an unconditioned stimulus and unconditioned response, and conditioned stimulus became associated with the unconditioned one. 2. Operant conditioning- this maintains the phobia. With pavlov's dogs, once regularly salivating to tone, if just make tone without meat, the response goes away. And so, we see that if you confront the conditioned stimulus and no unconditioned response, then the conditioned response will go away (I may have mixed this up). Also, when you run away from snake, you are rewarded with feeling better--> negative reinforcement for your running away next time. 3. Biological Preparedness a. Our brains are equipped to learn things very quickly, like in one time. Similar to taste aversions- one time deal. b. Also, there are things that are cross cultural. These were things that were at one point important for survival. c. Took people and used electric shock as UCS and paired them with either pictures of snakes, bees, dogs, and things that don't usually show up as phobic objects like butterflies. Found that with snakes and bees, only took one or two pairings. Suggests that can reproduce in laboratory learning that takes only one time. (99% of all studies with humans are done with college students). B. Behavioral treatments- these are by and large the most effective treatments for simple phobias-probably the most succesful treatment in all of psychology. 1. Systematic desensitization a. Most succesful of these techniquesb. Hierarchy of ten stimuli related to your phobia from least fear provoking to most fear provoking. c. Train patient in relaxation excercise. Routine for conciously relaxing all their muscles and mind. d. When mastered these, you pair the fear provoking stimuli and relaxation excercise starting with the lest fear provoking one. Relax at same time when imagining (not actually coming into contact with the snake) the fear provoking item and when mastered it, you go on to next on list. 2. Flooding a. Force you to confront the actual feared object and they don't do it slowly. b. Much more extreme form of therpay, therefore, but its also quicker. c. If you actually confront the fear, they will immediately see that its not followed by the UCS--> the phobia goes away. d. Slightly less effective but its also harder to get patients to agree with it. e. None of these techniques work for agoraphobia; just simple phobias. 3. Modeling Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 44 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener a. Watch someone else either live or on TV confronting your fear provoking object and then the patient gradually approaches the snake and its like a vicarious distinction trial. 4. Incompatible response training a. Systematic desensitization is one example of this. b. More important that well-trained than which particular one you use. All these techniques are very effective and you don't see symptom substitution. C. Cognitive-Behavioral theory and therapy 1. Similar to behavioral but tries to pay more attention to the specific thought processes going on. 2. Perception of a threat or imminent danger which is out of proportion to true danger--> change cognitions. But, can't use pure cognitive therpay because they know that their fears are irrational--> use behavioral techniques but also have diary of thoguhts and hypothesis tests and etc. D. Physiological theories and therapy 1. All of these theories are vague and not much support. 2. Say that biological basis- for someone with parents who had phobias, he'll have higher chances of also having it. Find higher concordance for MZ twins, but could explain this with their shared environment. (Have done a few adoption studies but these have mostly been done with people who not adopted right away). Tranquilizers and etc. don't really work to help this. 3. Again, none of this lecture applies to agoraphobia. With social phobias, there is some effectiveness with social phobias, but seem to improve when given anti-depressant drugs. Agoraphobia is much harder to treat. Some do respond to anti-depressants but not nearly as dramatic as the other treatments today. So little you can do for agoraphobics, it seems. Class of Tuesday, November 21, 2000: Anxiety Disorders- conclusion I. Obsessions and Compulsions- Etiological theories and therapies- see textbook for this. We won't do it in class. A. Psychoanalytic B. Behavioral C. Cognitive D. Biomedical II. Post Traumatic Stress Disorder A. Symptoms B. Theories and therapies Personality Disorders I. Definition A. Not clear what it means. DSM IV defines it as follows- Long standing problem, usually evident before reach their teens, where there is a defect in personality (personality=consistent way of percieving the world and responding to it and Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 45 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener interpersonal relationships). Hard to agree on what is personality and what constitutes a disorder. B. They don't know that they have a problem. Its dysfunctional because they are making the people around them miserable. Its not a small, circumscribed problem but their whole personality and worldview. Never come to therapy of their own volition but because someone in their life is forcing them to do so, becuase they don't know what's wrong. Wildly innacurrate pictures of themselves. Some, however, may come in on their own and a few have a little insight. C. Outlook for these people are kind of bleak- not very many therapies as of now. II. Types A. Schizoid Personality Disorder 1. Not schizophrenic. But, it might be related somehow. 2. Disturbed, interpersonal relationships- in fact, have very few relationships. Loners, hermits. 3. Many of these personality disorders, have bizarre beliefs which close to delusions and have occasionally periods where they are psychotic. 4. Compare schiz. with schizoid personality disorder a. In schizophrenia there has to be a deteriation- at some point, they were normal and had friends. with schizoid personality disorder, however, never had normal period. b. Also, psychotic episodes are part of schiz., while with most schizoid personality disorder, no pyschotic episodes. 5. Not a lot of data about schizoid personality disorder because they don't really come to therapy. 6. Nevertheless, seems to be slightly more common in guys. Tend not to marry and have chidlren. Women, however, who have it might passively accept a marriage proposal. B. Schizotypal Personality Disorder 1. A lot of eccenctricities, idiosyncracies, flaky ideas, and wierdnesses. 2. Imagine a person who believes in astrology and then magnify it and this is close to what we are talking about. 3. Generally, these people are not suffering or experiencing a lot of functional difficulties. And so, this helps us differentiate between a schizotypal personality disorder and a psychosis. There is, however, always a judgment call involved because one person's quirk is another person's interest. C. Paranoid Personality Disorder 1. Bears some resemblence to schiz. As well- and so, is it just a matter of degree or what? Well, they don't respond to drugs which suggests that its a different disorder. 2. Suspicious and paranoid but not to the point where the beliefs are patently absurd. May believe that their neighbor is making phony phone calls and etc. though not believe that aliens after them. 3. Emotional coldness and tightness--> not many intimate relationships. A lot of sexual jealousy--> accuse their spouses of having affairs. 4. Interferes with social and occupational functioning. Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 46 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener 5. These first three disorders are grouped as lowest functioning of the personality disorders by psychoanalysts. D. Narcissistic Personality Disorder 1. Incredibly inflated view of their own talents, beauty, charm, and etc. 2. They tend to think that they are the best in every area. 3. So preoccuppied with thinking about this and fantasies that they are not able to get stuff done--> their reality is in stark contrast with their views of them. 4. Extremely manipulative and exploitative and they think that they are doing this person a favor. All of their psychic energy is channeled towards selfaggrandizement not only to others but also to oneself. 5. Constantly lie even when there is no obvious benefit. Bragging and etc. E. Histrionic personality disorder 1. Very dramatic and overly emotional. They have to be the center of attention. More often in women than in men. Has to be the flirt and the bell of the ball. [Something shallow and flighty about their emotions and seem sometimes to fake an emotion to get a response]. Also, women are more often to get the diagnosis. In males, is very often a gay person. 2. These people are quite likely to come to therapy because they want attention. They drive the therapist crazy because want the pity, empathy, or etc. of their therapist rather than a deep desire for change and insight. Women can be very seductive with their therapist. 3. Often have substance abuse and depression. F. Avoidant Personality Disorder 1. Controversial disorder- in and out of DSM- not sure if its a separate disorder. Also, hardly any data on it. 2. Avoids people but not like schizoid who doesn't have interest in others. The avoidant desperately wants others in his life but they are so afraid of rejection and abandonment that can't get into a relationship. Tend to be supersensitive in their interpersonal relationships. Interpret everything as insult and etc. Tend to agree with everything in order not to be abandoned. 3. Since anxious of rejection, they avoid people to maintain equilibrium and selfesteem. It's a conscious fear but not conscious for them that they are unreasonable. Class of Tuesday, November 28, 2000: Personality Disorders II I. Types (continued) A. Obsessive-Compulsive Personality Disorder 1. Not the same as OCD! 2. They tend not to have any true obsessions, and their compulsions are not as strong as OCD. 3. Extremely neat and methodical and uptight and cold. Tend to be cheap, stingy. They are beyond neat. 4. Importance of rules for their own sake. They think there has to be rules and punishments. Tend to be cold interpersonally. Not show spontaneous joy. If you see any emotion, it tends to be the more negative ones. Get anxious and Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 47 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener their neatness and etc. may be an attempt to reduce the anxiety. They are disapproving of everyone else's sloppiness. B. Antisocial Personality Disorder 1. We'll get back to this later. C. Dependent Personality Disorder 1. Very controversial, new diagnosis. 2. People who are overly willing to let other people take care of them. More like weak and helpless than greedy or manipulative. Interested a lot in social approval- let everyone else make a decision for them because afraid that will get disapproval if make wrong decision. They tend to be like doormats- they are exploited and used by others. 3. Controversial because almost all of the cases that were referred to were women in difficult marriages who wouldn't leave because couldn't take care of themselves- people objected because they said it is a societal problem and so you shouldn't make it a medical problem. D. Borderline personality disorder 1. We'll get back to this. E. Passive-Aggressive Personality Disorder 1. This is not in the current DSM, though it was in all of the previous ones. 2. It's so widely believed in by clinicians--> most therapists would give this diagnosis if it was called for. 3. Theory is that they resent anything you want them to do in the way of work or responsibility, but rather than tell you this, they passively, indirectly mess up by being deliberately stupid or slow. It doesn't help them, because everyone is always furious with these people. II. Etiological theories A. Freud 1. Referred to this whole class of disorders as character disorders or borderline conditions. 2. Included alcoholism, cleptomania, drug abuse problems, or other impulsive type problems. 3. Thought that these were midway between pyschotic and neurotic conditions. Recognized that sometimes they could look like psychotic and other times like neurotic, but this is part of the problem- instability in the image they present. 4. Proposed some specific etiologies for some specific ones but no one really believes in it anymore and he didn't concentrate on these so much. 5. He does mention, though, that many of these people have parents who have character disorders. He doesn't, however, specifiy whether it's learned or etc. 6. Neo-Freudians have much more to say about these disorders. B. Neo-Freudians 1. Recognize other motives than sexual and aggressive. 2. Talk about the need for social approval and need for acheivement. Class of Thursday, November 30, 2000: I. Antisocial Personality Disorder A. Symptoms Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 48 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener 1. A lifelong pattern of using and manipulating other people. 2. In its most extreme version, may involve violence. But, it tends not to be that way. Also, called sociopath and psychopath. It starts early- not just lie to get out of trouble but even when there is no obvious benefit. They have serial relationships- married six or seven times, with children all over the place who they don't take care of. 3. Tend to be common, petty criminals. A lot of little violations. Seldom see planned murder with these people. 4. Frequently drug abusers. Totally charm you when they are picking your pocket. Very manipulative and have almost an instinctive knowledge about how to push your buttons. Even if they aren't actually breaking the law, they have a lot of little petty violations. 5. Don't appear to suffer any remorse over their actions. This is considered to be the most distinctive feature of the disorder. 6. Devoid of anxiety. Dr. Stewart, however, has seen a lot of anxiety with these people. B. Course 1. Generally starts very early in life. Certainly by the time of teens, it has reared its head. But, in DSM IV, can't officially give this disorder to anyone under 18 (I think) because don't want to hang a label on someone who was just hanging out with the wrong crowd and then will later get better. 2. Seem to get better when they reach middle age- known informally as "psychopathic burnout"- seem to get to age when can't drink anymore without getting sick and can't engage in same kind of roughhousing that did when younger. Also, seems that don't move to less physical crimes like internet fraud and etc., but that some seem to get better overall. 3. Diagnosed in far more men than women. Rather uncommon in women, though some feel that slightly increasing in women in last decade or so. In old days, sexual promiscuity would give women this label and now have different criteria. Also, its called anti-social because it hurts people or society--> sexual promiscuity in women is not necessarily violating the rights of others. C. Etiological theories 1. Psychodynamic a. These theories have to do with formation of the superego, which is way that resolve oedipal conflict in the phallic stage. There wasn't an adequate father figure for them to introject. Maybe father in jail or etc. and no one to take his place. Or, one's father may have been a pyschopath--> you introjected him into your psyche. 2. Behavioral a. Assume that comes about through faulty learning. b. Set out to determine whether they were somehow impaired in their ability to learn, took a group of control and group of antisocial and had to learn sequence of lever pressing. Trick was that when made certain kinds of wrong answers, you would get electric shock. Other wrong answers just gave you feedback that got answer wrong. Overall, found that both Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 49 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener groups took same number of trials where mastered correct sequence. But, when broke down the mistakes, found that there was big difference; normal group learned to avoid the levers that produce shock very quickly (more quickly than learn the actual sequence of levers), while antisocials did not master the trick of avoiding the shock--> think that have learning impairment of how to escape from aversive situations. Maybe they are just not bothered by electric shock. Some evidence to suggest that this correct; monitored heart rate and galvanic skin response (more anxious--> clammier hands) and found that control group was most anxious and when learnt how to avoid it, anxiety decreased. But, anti-socials had very little anxiety. Everyone has argued about the meaning of these results since then. c. In another study, did same generally, but instead of wrong giving electric shock, they had to pay money when hit wrong letters--> the antiscocials were faster than the control group. And so, its not a general deficit in escape learning. 3. Physiological- this theory depends a lot on the behavioral one and their research. a. Genetic i. Some evidence, though not clear cut, for genetic contribution. ii. Problem with the studies: didn't usually have true antisocials. Just took criminals, basically. Not everyone in jail have antisocial personality disorder. Also, not everyone who has antisocial disorder goes to jail. Instead, their data has implications for heritability of unsuccesful criminal behavior (because got caught). b. Affective i. If there is going to be a defect, its probably not in a learning mechanism, but rather something to do with arousal, affect, and emotionality. Tend not to feel dysphoric emotions- tend not to be sad or truly angry even when fightng with people. Also, their positive emotions are less intense and shallow than others. And so, maybe they just don't have anxiety and this may be the problem. ii. Another possibility-Amygdala (in the limbic system)- plays a role in fear conditioning and fear response and escape learning. It's the tip of the hippocampus. When lesion it in animal, see lack of ability to learn to escape. If stimulate the amygdala, you can get rage attacks from the animal. And so, maybe antisocials have some problems with their amygdala. iii. These factors have also been proposed to explain risky behaviormaybe trying to arouse themselves by doing these risky. c. Cortical immaturity i. Particularly the frontal cortex which important for judgment and decision making and strategy planning. Might have impairment here because don't seem good at these things. Use criminals also for these studies and found some slightly reduced density of cells in frontal cortex but its very weak evidence- don't know if its result of drug Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 50 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener abuse or etc. Maybe these people are just slower developers and when get to middle age and we see that burnout, maybe it's them finally finishing developing. We won't talk about treatment because there isn't any. II. Borderline Personality Disorder A. Symptoms 1. Very hard to describe them, except that their emotions are all over the placesob once minute and then lauhging. Get the feeling that they are overdoing itthe things don't seem that funny to others. 2. Very instable in their interpersonal relationships. Never see them taking a middle position. Always either black or white and can switch back and forth in matter of minutes. 3. Great deal of drug abuse. All kinds of self-destrutive behaviors like sexual promiscuity, drugs, risky and sometimes criminal behaviors and lots of suicide attempts and suicide gestures. 4. Have an incredibly intense fear of abandonment. They latch on to the therapist or spouse or etc.. They are so demanding and extremely manipulative. Total pattern of instability. They know, however, that something is wrong because they are incredibly unhappy. When they are very stressed out, they may exhibit transient psychotic symptoms like delusions almost. A great deal of suicidal ideation and frequent attempts of it which may either be sincere or manipulative gestures. Class of Tuesday, December 5, 2000: I. Borderline Personality Disorder (cont.) A. Etiological theories- not very many of them a. Freudian i. Freud didn't really speak about this disorder. Rather, spoke generally about personality disorders as a whole which he called character disorders or borderline disorders. ii. Thought in middle between psychosis and neurosis. iii. Failure of ego development- have some ego because would otherwise be schizophrenic. Pre-oedipal disorders. Probably stuck in oral stage and have weak ego. Not have normal structures to distinguish reality from fantasy and to employ defense mechanisms adaptively. b. Object relations theory i. Considered a psychodynamic model, but different from the others; sort of cognitive dynamic model. Concentrate on early cognitive developments which enable infant to understand that he/she is separate from the rest of the world. Also talk about the developmental sequence by which develop object constancy. Some of the most important developments occur in first year of life; recognizing one's boundaries and object constancy. These are crucial milestones not just for cognition but for mental health in general. If parenting is inconsistent, then this disorder could result in the baby. ii. Infants need to recognize that the same mom who is sweet and etc. Is also the person who makes you do stuff when don't want to. Too anxiety Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 51 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener provoking to reconcile good mom and bad mom-> splitting- repress some of the discrepant cognitions so that left with either totally good or totally bad mom. And so, they have instability because they are constantly switching back and forth between the good image of you and the bad image of you. You never developed the idea that you can trust other people. c. Physiological i. No specififc or carefully articulated model. Tend to look at emotional instability so prominent in these individuals and wonder whether this isn;t a severe form of mood disorder. And so, have occasionally used lithium or anit-depressants. Some have responded to it, but doesn't cure the disorder; just makes them more stable. B. Treatment for personality disorders 1. Symptomatic approach a. Target symptoms and work on each one with medication and/or skills training. b. Seems like a behavioral approach because identifies maladaptive stuff and targets them. 2. Supportive Psychotherapy a. Not to analyze their defenses but to strengthen defenses so that person can cope better. And so, with borderline, try to institute a more mature defense than splitting. You want to hold their defenses together to prevent the descent into occasional psychosis or instability and fear. Then, hopefully you can make progress in other ways. Substance Use Disorders I. DSM-IV diagnoses- no phsyiological tests are used for diagnosis of substance abuse. Rather its based on personal reports. Many in this field don't use the DSM-IV, but instead want actual data on withdrawal and tolerance by monitoring the drug use. A. Substance abuse= Maladaptive abuse which causes distress or impairment in social or occupational functioning. Manifested in one of the following ways1. Recurrent use in situations in which it is physically hazardous. For instance, having lung cancer and continuing to smoke. 2. Failure to perform a major obligation- missing work to get high and etc. 3. Having legal problems as a result of abusing the substance. 4. Repeated social problems as a result. There is room for judgment in this diagnosis because sometimes its hard to decide whether person is abusing or not. B. Substance dependence 1. Tolerance (= need to take higher and higher amounts in order to get same effect) is one criterion. 2. Withdrawal (=unpleasant syndrome which occurs when stop taking drug that dependent on; usually the opposite effects of the drug that taking) is another one that can get you the diagnosis. 3. Taking larger amounts of it than what normally do. 4. Persistent desire to quit or repeated unsuccessful efforts to quit. 5. Lot of time spent obtaining, using, or recovering. Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 52 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener 6. Important social or recreational activities given up because of it. 7. Persistent use even though its causing you physical harm. 8. Just need 3 or more of these criteria to get the diagnosis. C. Abused substances 1. Alchohol 2. Amphetamines 3. Caffeine 4. Cannibus (marijuana) 5. Inhalants 6. Opiodes 7. Sedatives 8. Etc.. 9. Almost all substance abusers abuse more than one drug. 10. Interestingly, nicotine is not in here. D. Intoxication 1. This diagnosis is given to refer to the time when have accute effects of the drug; while its in your body. E. Other conditions- result of extreme abuse or long term consequences of abuse even after off the drug for many years. 1. Intoxication delirium- ingested so much that consciousness altered. 2. Withdrawal delirium- occurs after it has left your system- for instance, delirium tremuns- when severe alcoholics who stop drinking and get hallucinations, specifically tactile and that bugs crawling all over you. Insomnia and etc. for some 3. Amnestic disorder- after many years of abuse, memory is shot- chronic alcoholism or marijuana often have this. 4. Psychotic disorders- Class of Thursday, December 7, 2000: Substance Use Disorders (cont.) I. Other clinical features associated with substance abuse A. Polydrug abuse 1. Many people who abuse drugs abuse more than one. And so, alcoholics tend also to be smokers. Pot smokers tend to be drinkers or smokers. B. Dual-diagnoses 1. Where patient has both substance abuse disorder and some other mental disorder like depression and alcohol dependence. a. Maybe the same vulnerability is involved in both. b. Or,... c. Or,... C. Medical problems 1. Very widespread among people who abuse and become addicted to drugs. a. They are abusing multiple drugs in many cases--> if drinking and smoking, for instance, the consequences are heightened when they are combined more than their individual dangers. 2. They tend to neglect their health, and one of the first things to go is nutrition. Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 53 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener 3. None of the problems are benign and they carry medical risks beyond just dependence. D. Family/interpersonal issues 1. In substance dependence, for instance, they forget to feed children or drink away their paycheck--> a lot of difficulty. 2. Everyone with substance use disorders have family/interpersonal problems. The particular drug may also increase violent and aggressive behavior. People who were dependent and then try to quit have increase in irritation and frustration and all kinds of negative behavior. 3. Family may encourage or condone or at least let people get away with their drug abuse. For instance, a wife may call and say he's sick but really hung over. Many claim that this contributes to the problem. 4. Also, if put someone in rehab and then send them home. They relapse in a couple of days and they didn't really leave the house during that time--> something at home triggered it. E. Affective symptoms 1. During inotoxication and in between and long term there is affective effectsanxiety and irritability. F. Societal issues 1. All of society affected by it- drunk drivers kill people, crime involved in smuggling drugs, and money being used to help cancer patients who smoked themselves to lung cancer. II. Etiological theories A. Psychodynamic theories 1. Freudian views a. Freud saw these as being manifestation of unconcious neurotic conflict. b. Mostly talked about alcoholism; he said it was fixation in oral stage. Person is trying to symbolically return to babyhood, which is why they are turning to the bottle. You want to be taken care of and nurtured. This is what happens to many alcoholics- someone else has to clean up after them and make them hot meal and etc. Its about dependency needs or oral gratification. c. There are other ways of administering drugs rather than mouth; this is problem for Freud. And so, for people who stuck needle in arm, he said they were a massochist. Cocaine can be administered through the nose- he believed that nose is phallic symbol and so he said that taking cocaine through nose is symbolic masturbation. 2. Self-medication a. Many people have this hypothesis today; originated in psychodynamic theory- people who take drugs already had problem before they got addicted- they feel better from whatever pre-existing problem, biological or otherwise. i. Using animal studies, you can create two populations of rats; one with normal amount of dopamine receptors and one without. The one without the normal amount had addictive or dependent behavior and Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 54 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener for the other ones its almost impossible to get them to take enough drugs to get them addictive. B. Behavioral theories- many different ones, and we'll group them into 3 categories 1. Operant Reinforcement a. Positive reinforcement i. Involved in both the taking of drugs and dependence; drugs make people feel good. Nobody abuses chemotherapy drugs, for instance. Some people, however, do not react well to alcohol. Yet, these people are less likely to develop alcohol problems. Balance of positive and negative effects changes as become more addicted- heroine, for instance, gives one a euphoria and relaxes a person. But, when become dependent on it, the aversive effects become more salient. b. Negative reinforcers i. -removal of negative symptoms, such as when drinking takes away your sadness or etc. 2. Social learning theories a. Claim that we learn to use drugs based on social learning. b. There are certainly cultural differences in the rates of disorders. France, for instance, has higher alcohol abuse than Saudi Arabia. c. Virtually no one takes up drinking or smoking when become an adult. And, if you ask teenagers why they started, they say because they were curious or etc. And not because of peer pressure- this just means that they don't see it as resulting from peer pressure. Women are less likely to become alcoholics- is this a result of fact that its more looked down upon for women to be drunk or is it result of fact that they don't have the enzymes to break down the alcohol. 3. Opponent-process models a. Developed by Richard Solomon in the 70's. Based on observation that because body has a lot of homeostatic mechanisms which try to maintain constant level of biological and psychological variables, people who use drugs tend to develop compensatory levels which are opposite of the effects of the drugs- if you take stimulants, for instance, nervous system will depress itself to slow you down. This compensatory response is thought to underlie both tolerance (need more doses because nervous system oppsoing the drug) and withdrawal (stop drug and then you are feeling the opposing effects of the nervous system). b. The first effect of a drug that you'll experience is the stimulating effect of the drug which then wears off while drug metabolizes. But, at same time, the nervous system is opposing the drug and takes some time for this to kick in, and lasts longer than the original drug effect. The A process is the one directly caused by the drug. The B process is caused by the nervous system's attempt to compensate. The effects of both are additive--> the person experiences the sum of these two effects. The high starts wearing off when B kicks in and eventually just have B- this is, in essence, withdrawal effects. With repeated administration of the drug, the B process gets bigger as well as longer lasting. Some say that the A process Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 55 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener gets smaller, while others say it doesn't really change. [This model also accounts for other seemingly illogical behaviors; take for instance chilly peppers- first get burning sensation and this is A and then later it tastes good and this is B. Also invoked to account for why people like skydiving- more time you go, fear diminishes and thrill gets bigger]. c. At least the B process, and maybe the A process, isconditionable- in other words, conditioned stimuli can come to evoke B and maybe A. i. Conditioned abstinence problem= people who have been addicted to opiodes and have been in treatment for some time and go back to old environment and when see some symbol which associated with their drug problem, they can get feelings of the B process. C. Biomedical theories Class of Tuesday, December 12, 2000: Substance Use Disorders (conclusions) I. Treatments A. Biomedical- biological, probably genetic, vulnerability to drug abuse. Inheerited variations in permability of neuromembranes to different susbstances or number or efficacy of neurotransmitter receptors. For example, may have inherited a smaller number of dopamine receptors and they can be more likely to develop heroine addiction. Also, avilability of enzymes which break down those substances can make you more or less susceptible because if can't break down alcohol, for instance, the drug will have magnified effects and stay longer in system--> may not ever take the drug again. 1. Detox a. Responsible clinicians combine any possible treatments--> think that stand better chance. Detox occurs when people abusing or dependent on drugs which cause very distression or very dangerous withdrawal stuff like heroine. Almost always performed in hospital. Try to get you to stop using the drug or taper off over time (so that don't threaten their life if take it away too quickly). Want to give them time to gte most of the drug out of body. Help them cope with the side effects during detox. 2. Drugs a. Sometimes use agonous drugs- drugs that occupy the same receptor as abused drug and initiate similar processes- and so, may use methodone sometimes to treat heroine addiction- won't get immediate rush but more gradual (--> won't be reinforced as much). Also, will have to come and get this substitute from a medical place and will get health care and etc. Also, nicotine patches and etc. b. Antagonous drugs- binds with the receptor but prevents neuron from responding in same way with drug- for instance, naloxone will prevent you from getting any effects from heroine. And so, this should hopefully extinguish the behavior. However, when you take naloxone, you go into heroine withdrawal. Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 56 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener c. May use anti-depressants, sometimes because it helps to treat the depression that often results when treating the drug. Also, has effects on the craves and urges--> use them nowadays to help smoking cravings. d. In combination with behavioral treatment, may use antabuse-it makes you get sick when drink alcohol--> will reduce probability of your drinking and you may learn to avoid the negative effects by not doing it anymore. Problem is that its hard to get them to agree to it. B. Behavioral 1. Aversive conditioning- consequences are so unpleasant that it punishes the behavior. Some give electric shocks. 2. Covert desensitisation- based on systematic desensitization for phobias. Asked to imagine the negative consequences. 3. Stimulus satiation- make them smoke an entire carton of cigarrettes, let's say, all at once and will be so sick that will develop aversion. Efficacy of all the treatments don't seem to be very good and no big differences in efficacy. In first 6 months to year, may get very good efficacy rates (30-60%), but problem is long term- every interval after that, get more people falling back under addiction. After 3-5 years, only 30% still abstinent. Rate of people who spontaneously quit on their own range from 3-20%. Hard to trust the data, particularly for illegal drugs and long term studies and every organization which does studies have their own agenda, including the NIH. Class of Thursday, December 14, 2000: Dissociative Disorders I. Dissociative amnesia A. Psychodynamic explanation for dissociative and somatoform disorders seem the most likely, according to Dr. Stewart. B. In dissociative disorders, in general, conciousness, identity, and perceptions all disrupted so that have strange symptoms where one aspect seems to get deranged. C. With dissociative amnesia, loses memory of significant personal history or events, not due to some obvious physical cause. No evidence of medical problem, but rather something anxiety producing or traumatic about the information that they forget. Seems like it is some form of repression. D. In most extreme form, person forgets who they are. Interestingly, they still remember language and skills that they developed. And so, though not remember who they are, they can still play the piano or something. This argues, then, against any biological cause. E. Example: if get mugged or raped, may not remember that event or some period of time following this event. F. In very severe cases, person ends up in the hospital because they go to like emergency room because they realize that they don't know who they are. II. Dissociative fugue A. In addition to dissociative amnesia, the person leaves home and goes to new city or country and set up a new life. Adopt a whole new identity some times, while in others they just move and don't know why they moved or how. When people Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 57 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener found out who they were, it seemed to be cases where they were running away from very stressful or anxiety producing events. III. Depersonalization Disorder A. Experiences episodes of depersonalization; somehow not themselves or detached from themselves or outside of themselves watching as though they were a spectator. The patients themselves are very vague in their descriptions and that's why the diagnostic criteria sound vague also. B. If someone just has one symptom of it or one experience, wouldn't give this diagnosis. C. Seems to be more common in women and seems associated with stressful lives or trauma. D. Tend to be wifty people with tons of other vague complaints that don't seem to hang together, particularly memory gaps and questions about their identity. IV. Dissociative Identity Disorder (multiple personality) A. Dr. Stewart has never seen such a case, nor has any teacher she had whom she respected. The author of the article we read thought that many of these diagnoses are iatrogenic illnesses= caused by the physician. B. Develop alternative personalities and some have been documented with 35 different personalities. Have different names, ages, sexes, and abilities. C. Until 1985, there were only 200 documented cases in all of history. Then, thousands began coming out of the woodwork. And so, Dr. Stewart says the proliferation of the diagnosis is because of therapist incompetency. D. More common in women, most of whom have history of severe abuse, particularly sexual. Happens early in childhood many times- it's like a forced hypnosis which the child stumbles upon and then it gets reinforced and they build up personalities which provide way to handle traumatic events. E. Experience depression, self mutilation, and etc.. F. Following a number of tv movies on the topic, there was an explosion of diagnoses of MPD. They were colorful, unusual characters and several books in 60's were major bestsellers. Then, however, a couple of doctors linked this disorder with satan worship. Would hypnotize them and said that they had been abused sexually and had participated in ritual murders of little children. The authorities did a massive investigation and concluded that none of it had happened because not one patient could produce even a single shred of evidence that it had happened. Then, they sued this doctor because he had convinced them to commit themselves to the hospital and he pumped them with drugs and got them to accuse their spouses and parents of being satan worshippers and child murderers and there were a lot of divorces and lost custody of children and some spouses went to jail. (Around 300 people were treated by this doctor). And so, this diagnosis has fallen into disrepute. These patients seem to be impressionable and it seems like the doctors have created it with their suggestions. V. Etiology and treatment A. Seem to be defending from anxiety producing events or feelings or etc.. B. No real effective treatment for any of these. Class of Tuesday, December 19, 2000: Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 58 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener Somatoform Disorders Get notes that missed from beginning of class!! Read this section in the book!! I. Somatization disorders A. Symptoms 1. They are not malingering (i.e., faking the pain)- rather, they are really experiencing the pain just that there does not seem to be any physiological cause. 2. They tend to go around from one doctor to the next and make demands from the doctor about what they want. They shop around until find one that will do what they want. They often have a number of doctors and if they get prescription, they take the prescription and don't tell the other doctors--> subject to drug interactions. 3. Go through various procedures and even exploratory procedures. 4. Almost always women. Clinical impression is that they have been doing this all of their lives. B. Etiological theories 1. Psychodynamic models a. Somatization as defense mechanism; there is some unacceptable impulse and it arouses anxiety--> to defend against the wish and the anxiety--> displace their anxiety onto some part of the body. Also, which part of the body is affected will be symbolic of the conflict. i. Problem: Freud was not treating patients with full range of symptoms but rather a few dramatic symptoms--> hard for us to see how someone with many things bothering them is symbolic of all of those body parts. b. Others have suggested that somatization is a form of depression. Depressed patients often come in with physical complaints--> people with somatization are hiding depression. Many of these people have full depression or dysthymia. Anti-depressants, however, cannot completely cure the disorder (can get rid of some of the pain stuff, though). c. Another theory is that they want sympathy and attention; unconscious way of getting it. After all, they seem to never get well even if physician goes along with what they want. Also, they come back to the doctor with vague descriptions of efficacy of the medicine and then ask for other drugs. 2. Behavioral theories a. In many cases, there are secondary gains which the therapist may not see like the person gets the chance to take off more sick days and etc.. And so, the behavior is reinforced. Also, get attention and sympathy from friends and may get you out of obligations. b. Women learn these behaviors from their mothers who used them. There is some evidence for this, since mothers of people with it have higher rate than rest of population. c. Often, its a long-standing pattern. If ask them what happened when they did not feel well, find out that they could stay home and their mothers Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 59 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener would tend to them and care for them and buy them toys and etc.. And so, rewarded for sickness behavior. So, learning it not only by modeling but also by positive reinforcement. d. Failure to learn more adaptive methods of coping. 3. Cognitive a. Its a failure of thought processes; they are not experiencing any more symptoms than anyone else, but instead focusing on them more and attending to them more. 4. Biomedical approach a. They have some sort of physiological pathology and we don't know yet what it is. As time goes on, we are finding out more physical things which we thought were psychological. b. Maybe they have a more accute sensory system so feel things which others don't. Most people, for instance, are not aware that your heart skips a beat every so often. C. Treatment 1. Depens on who you talk to. Some think that you should confront them and make the unconscious concious. Dr. Stewart's experience is that it doesn't work because resistant to insight. 2. Others say to use supportive psychotherapy- support their defenses and don't try to break them down. Strengthen their defenses and help them handle their anxiety better. Hard for Dr. Stewart to say if it works. 3. Behaviorists try to change system of reinforcement or model more appropriate behavior. It works occasionally. 4. Cognitive therapists try to change how they think- get them to defocus on their bodily symptoms. 5. Another method is to try ask questions and say that if its going to hurt even if you are at home, then why not go to work. Dr. Stewart- its hard to know if this works. 6. No biological treatment at this point. Anti-depressants help a little but don't cure it, and anti-anxiety drugs don't either. II. Pain disorder A. Symptoms 1. Feel pain and either no physiological pathology to account for it, or their is some pathology but not serious enough to account for the severity of their pain. 2. More problematic because not having pain that is totally impossible while with somatization have so many problems spread over in vague ways (which makes it seem like its a manifestation of something else). Also, hard to tell a person that not have enough pathology to explain the amount of pain. Also, their are many physiological things which cause pain and we don't know why. 3. More women than men, though not as lopesided as somatization disorder. 4. Often have identifieable injury. 5. Not as whiny as somatization patient and usually don't have a long history of it. 6. The pain can be in any part of the body. Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 60 of 61 PSY 2414 Abnormal Psychology Dr. Karen Stewart Fall 2000 Notes by Marc Diener 7. They can describe their pain feelings pretty well, in contrast to the somatization patient. B. Etiological Theories C. Therapy 1. In a pain clinic, don't try to distinguish between true physiological pain and psychogenic pain. Pain killers not a viable chronic approach. And so, use behavioral methods. Almost all of them based on idea of relaxation. If you are anxious, muscles tighten up and makes any pain worse. Some use progressive muscle relaxation or hypnosis (extremely effective because uses muscle relaxation and diverting attention away from pain). 2. Divert attention from the pain. Sometimes can do it with just a good video or television show. For someone suffering from pain 24 hours a day, even 10 minutes of relief is very helpful. 3. Psychodynamic theory- they are unconsciously inflicting pain on themselves in repsonse to some unacceptable wish. And so, want to make them aware and make em realize that not handling it in adaptive way. III. Hypochondriasis A. Take one or 2 symptoms which probably really have and conclude that they have a disease. IV. Conversion disorder A. This is the classic Freudian patient B. Used to be called hysterical conversion C. Loss of physical function with no apparent phys. Basis. D. Hysterical blindness, paralysis, loss of sensation and etc. Were most popular traditionally. E. Very rare to find such a case by now. This led Freud into psychiatry. F. More common in women and groups with low eduaction socioeconomic status and strict fundamentalist religions, especially ones where expression of sexuality is taboo. Also, more common in people who not goood in recognizing and talking about their feelings- alexothymia= without words to talk about their mood. G. Psychodynamic model has best explanation- result of unacceptable urge or impulse whihc displaced onto body part symbolic of the conflict. No one else has come up with a plausible explanation of this disorder, which brings us back to the traditional psychoanalytic stuff, closing the circle for the course. 1. Glove anasthesia= couldn't feel hand, which psychodynamics said its because of masturbation or so won't kill anyone. Downloaded from: www.yumesorah.com PSY2414SteNotes1.pdf Page 61 of 61 ...
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This note was uploaded on 02/19/2008 for the course PSY 2414 taught by Professor Schnall during the Fall '07 term at Yeshiva.

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