Psychopathology An Introduction

Suresh Kumar. M
Department of Clinical Psychology Sri Ramachandra University
MA (Psy), M.Phil (Psy), M.Phil (M&SP), FIAHP.

Course Content
1. Concept of Normality vs Abnormality 2. Various Approaches to Psychopathology 3. Clinical Assessment and Diagnosis 4. Major Types of Mental Illnesses 5. Child Psychopathology

Concept of Normality vs Abnormality

Outline

Deviation from social norms Statistical infrequency Failure to function adequately Deviation from ideal mental health

Deviation from Social Norm

Social norms are a set of rules for behaviour based on a set of moral and conventional standards within society. They are judged by the dominant culture

Statistical infrequency
Under this definition, a persons trait, thinking or behavior is classified as abnormal if it is rare or statistically unusual. With this definition it is necessary to be clear about how rare a trait or behavior needs to be before we class it as abnormal

Statistical Infrequency
Average IQ in the population is 100pts.

The further from 100 you look, the fewer people you find

frequency

70

100

130

IQ Scores

Failure to function adequately

From an individuals point of view abnormality can be judged in terms of not being able to cope with day to day living. Under this definition, a person is considered abnormal if they are unable to cope with the demands of everyday life. They may be unable to perform the behaviours necessary for day-to-day living e.g. self-care, hold down a job, interact meaningfully with others, make themselves understood etc.

Failure to function adequately

From an individuals point of view abnormality can be judged in terms of not being able to cope with day to day living. Under this definition, a person is considered abnormal if they are unable to cope with the demands of everyday life. They may be unable to perform the behaviours necessary for day-to-day living e.g. self-care, hold down a job, interact meaningfully with others, make themselves understood etc.

Failure to function adequately

Rosenhan & Seligman (1989) suggest the following characteristics:
Suffering Maladaptiveness (danger to self) Vividness & unconventionality (stands out) Unpredictability & loss of control Irrationality/incomprehensibility Causes observer discomfort Violates moral/social standards

Deviation from Ideal Mental health

Under this definition, rather than defining what is abnormal, we define what is normal/ideal and anything that deviates from this is regarded as abnormal This requires us to decide on the characteristics we consider necessary to mental health

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Various Approaches to Psychopathology

Outline
One-Dimensional Versus Multidimensional Models Biological Contributions to Psychopathology Psychological Contributions to Psychopathology Cultural, Social and Developmental Factors

One-Dimensional Versus Multidimensional Models

Factors contributing to psychological disorder
Biological
Genetics, brain and neural systems

Psychological
Behavioral and cognitive factors, unconscious processes, learned helplessness

Social
Friends and family, social learning

Developmental
More or less reactivity, critical period

Biological Contributions to Psychopathology

Genetic contributions to psychopathology
Genes are very long molecules of DNA at various locations on chromosomes (23 pairs), within the cell nucleus Most of our behavior and personality is probably polygenic (influenced by many genes) There are no individual genes for mental disorders In general our psychological make-up is heritable up to 50%

Biological Contributions to Psychopathology

The Interaction of Genetics and Environmental Effects
The Diathesis-Stress Model
The diathesis (inherited tendency) interacts with stress we encounter; the more diathesis the less stress needed to initiate the illness

The Reciprocal Gene-Environment Model

Genetic endowment may increase the probability that an individual will experience stressful life events

Biological Contributions to Psychopathology

Neuroscience and its contributions to psychopathology
The Central Nervous System Structures contributing to psychopathology Neurotransmiters

Biological Contributions to Psychopathology

Biological Contributions to Psychopathology

Biological Contributions to Psychopathology

Biological Contributions to Psychopathology

Biological Contributions to Psychopathology

Biological Contributions to Psychopathology

Neuron structure
Cell body, dendrites, axon, synaptic cleft

Neurotransmitters
Chemicals released from axon of one nerve cell that transmit the impulse to the receptors of another nerve cell There are multiple neurotransmitter currents (brain circuits) in the brain Drugs can influence neurotransmitters as agonists (increase the activity of a neurotrasmitter), antagonists (decrease or block) or inverse agonists (effects opposite to effects of a neurotrasmitter)

Biological Contributions to Psychopathology

Neurotransmitters
Serotonin
regulates moods, thought processes, regulation of eating, sexual and aggressive behavior Redux (antiobezity)and Prozac (antidepressant)

Gamma Aminobutyric Acid (GABA)

Reduces anxiety, overall arousal and emotional responses (aggressive behavior, hostility)

How neurotrasmitters and drugs influencing them work

Biological Contributions to Psychopathology

Neurotransmitters
Norepinephrine
Controls heart rate, blood pressure, and respiration; contributes to panic attacks, anxiety and mood disorders (beta-blockers)

Dopamine
Activates other neurotransmitters and aids in exploratory and pleasure-seeking behaviors Excess is implicated in schizophrenia and deficit in Parkinsons disease

Biological Contributions to Psychopathology

genetic contributions may lead to patterns of neurotransmitter activity that influence personality psychological treatment can influence neural circuits directly (e.g. OCD) extreme abuse severely impedes intellectual, emotional, and social growth psychosocial factors changes activity levels of neurotransmitters (e.g. sense of control and reaction to GABA antagonist)

Psychological Contributions to Psychopathology

Learned helplessness
Martin Seligman if people believe that they have no control over the stress in their lives, they give up attempting to cope and develop depression

Social learning
people can learn a lot by observing what happens to someone else in a given situation (modeling or observational learning)

Psychological Contributions to Psychopathology

Prepared learning
we became highly prepared for learning about certain types of objects or situations over the course of evolution

Cognitive science and the unconscious

we are not aware of much of what goes on inside our heads

Psychological Contributions to Psychopathology

emotions
components of emotions (physiological reactions, motor expression, action tendency, appraisal (CBT), subjective feeling) emotions (last from several minutes to several hours), mood (more persistent affect), affect (momentary emotional tone) influence of anger and hostility on heart is much stronger than stress alone suppressing emotional reactions has significant physiological consequences

Cultural and social factors

gender differences
women an insect or small animal phobia men alcoholism

social effects
social relationships seem to protect individuals against many physical and psychological disorders

Integrative approach
applying contributions from all the factors to explain causes of a mental disorder in a specific individual integrative approach (Bio Psycho Social)

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Clinical Assessment and Diagnosis

Outline
Assessing Psychological Disorder (systematic evaluation and measurement of psychological, biological, and social factors) Diagnosing Psychological Disorders (the process of determining whether the particular problem afflicting the individual meets all the criteria for a psychological disorder according to the DSM-IV-TR or ICD-10)

Assessing Psychological Disorder

Key Concepts in Assessment
Reliability
The degree to which a measurement is consistent across people (inter-rater reliability) or across time (test-retest reliability)

Validity
Whether something measures what it is designed to measure (e.g. concurrent validity of IQ tests)

Standardization
Process of establishing specific norms and requirements for a measurement technique

Assessing Psychological Disorder

The Clinical Interview
Unstructured interviews Semistructured interviews The Mental Status Exam (careful observation of behavior) Appearance and behavior (overt behavior, posture, expressions) Thought processes (rate, continuity and content of speech) Mood and affect (current and predominant feeling of the individual) Intellectual functioning (type of vocabulary, use of metaphors and abstractions) Sensorium (orientation in time, place and person)

Assessing Psychological Disorder

Physical examination
Psychological disorders associated with medical conditions (e.g. thyroid gland overactive results in anxiety, underactive results in depression)

Behavioral assessment
To assess formally an individuals thoughts, feelings, and behavior in specific situations or contexts

Assessing Psychological Disorder

Psychological testing
Projective testing
Ambiguous stimuli are presented to a person who is asked to describe what he/she sees Rorschach inkblot test Thematic Apperception Test (TAT)

Personality inventories
Minnesota Multiphasic Personality Inventory (MMPI) (scales like anxiety, depression etc.)

Intelligence testing
Stanford-Binet test Wechsler test (verbal scales, performance scales)

Rorschach inkblot test

Assessing Psychological Disorder

Neuropsychological testing
Measuring language abilities, attention, memory, perception, motor skills, learning and abstraction to detect possible brain dysfunction Luria-Nebraska Neuropsychological Battery Halstead-Reitan Neuropsychological Battery

Neuroimaging
Structural (computerized axial tomography (CAT), magnetic resonance imaging (MRI)) Functional (measuring metabolic changes (PET, fMRI))

Assessing Psychological Disorder

Psychophysiological assessment
Electroencephalogram (EEG) ERP (event-related potentials) Skin conductance response Heart rate Respiration Electromygraphy (EMG)

Diagnosing Psychological Disorders

Some concepts
classification (assignment into categories) taxonomy (system of classification in science) nosology (naming system for medical and psychological phenomena)

Approaches to classification
classical categorical approach (clear-cut differences, different cause) dimensional approach (continuum) prototypical approach (defining, essential characteristics)

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Major Types of Mental Illnesses

Outline
Anxiety Disorders Mood Disorders Schizophrenia Personality Disorders Behavioral Disorders Substance Used Disorders Organic Mental Illnesses

ICD-10
A diagnostic hierarchy

F0F1F2F3F4F5F6F7-

- Organic - Substance-related - Schizophrenia & delusional disorders - Mood [affective] disorders - Neurotic, stress-related & somatoform dis. - physiological.. (inc eating disorders) - personality disorders - mental retardation etc

Neurotic Illnesses
Class of mental illnesses which create distress to the individual without any psychotic symptoms. Eg. Anxiety spectrum disorders

Anxiety Disorders
Anxiety Disorders
distressing, persistent anxiety or maladaptive behaviors that reduce anxiety

Generalized Anxiety Disorder

client is tense, apprehensive, and in a state of autonomic nervous system arousal

Phobia
persistent, irrational fear of a specific object or situation

Anxiety Disorders
Agoraphobia (with Panic Disorder): Intense, irrational fear that a panic attack will occur in a public place or in an unfamiliar situation Intense fear of leaving the house or entering unfamiliar situations Can be very crippling Literally means fear of open places or market (agora) Agoraphobia (without Panic Disorder): Fear that something extremely embarrassing will happen away from home or in an unfamiliar situation.

Anxiety Disorders
Obsessive-Compulsive Disorder
characterized by unwanted repetitive thoughts (obsessions) and/or actions (compulsions)

Panic Disorder
Panic Attack: Feels like one is having a heart attack, going to die, or is going insane Symptoms include vertigo, chest pain, choking, fear of losing control

Anxiety Disorders
Adjustment Disorder
When ongoing stressors cause emotional disturbance and push people beyond their ability to effectively cope Usually suffer sleep disturbances, irritability, and depression Examples: Grief reactions, lengthy physical illness, unemployment

Dissociative Disorders
Dissociative Disorders
conscious awareness becomes separated (dissociated) from previous memories, thoughts, and feelings

Dissociative Amnesia
selective memory loss often brought on by extreme stress

Dissociative Disorders
Dissociative Fugue
flight from ones home and identity accompanies amnesia

Dissociative Identity Disorder

rare dissociative disorder in which a person exhibits two or more distinct and alternating personalities formerly called multiple personality disorder

Stress Disorders
Occur when stresses outside range of normal human experience cause major emotional disturbance Symptoms: Reliving traumatic event repeatedly, avoiding reminders of the event etc Acute Stress Disorder: Psychological disturbance lasting up to one month following stresses from a traumatic event

Post-Traumatic Stress Disorder (PTSD)

PTSD lasts more than one month after the traumatic event has occurred; may last for years Typically associated with combat and violent crimes (rape, assault, etc.)

Somatoform Disorders
Hypochondriasis: Person is preoccupied with fears of having a serious illness or disease Interpret normal sensations and bodily signs as proof that they have a terrible disease No physical disorder can be found Somatization Disorder: Person expresses anxieties through numerous physical complaints Many doctors are consulted but no organic or physical causes are found

Somatoform Disorders
Pain Disorder: Pain that has no identifiable organic, physical cause Appears to have psychological origin Conversion Disorder: Severe emotional conflicts are converted into physical symptoms or a physical disability Caused by anxiety or emotional distress but not by physical causes

Psychotic Illnesses
Psychosis: Loss of contact with reality marked by hallucinations, delusions, disturbed thoughts and emotions, and personality disorganization

Other Psychotic Illnesses

Organic Psychosis: Psychosis caused by brain injury or disease Dementia: Most common organic psychosis; serious mental impairment in old age caused by brain deterioration Known as senility at times Alzheimers Disease: Most common cause of dementia; symptoms include impaired memory, confusion, and progressive loss of mental abilities Ronald Reagan most famous Alzheimers victim

Delusional Disorders
Marked by presence of deeply held false beliefs (delusions) Usually involve delusions of grandeur, persecution, or jealousy Paranoid Psychosis: Most common delusional disorder Centers on delusions of persecution

Mood Disorders
Mood Disorders
characterized by emotional extremes

Depression
a mood disorder in which a person, for no apparent reason, experiences two or more weeks of depressed moods, feelings of worthlessness, and diminished interest or pleasure in most activities

Mood Disorders
Mania
a mood disorder marked by a hyperactive, wildly optimistic state

Bipolar Disorder
a mood disorder in which the person alternates between the hopelessness and lethargy of depression and the overexcited state of mania formerly called manic-depressive disorder

Mood Disorders - Depression

Altering any one component of the chemistrycognition-mood circuit can alter the others

Brain chemistry

Cognition

Mood

Mood Disorders - Depression

1 Stressful experiences

4 Cognitive and behavioral changes

2 Negative explanatory style

The vicious cycle of depression can be broken at any point

3 Depressed mood

Suicide
Drug or alcohol abuse Prior suicide attempt Depression or other mood disorder Availability of a firearm Severe anxiety or panic attacks Family history of suicidal behavior Shame, humiliation, failure or rejection

Who does it?

Gestures

Suicidal behavior usually progresses from suicidal thoughts, to threats, to attempts. A person is unlikely to make an attempt without first making threats. Thus, suicide threats should be taken seriously

Schizophrenia
Schizophrenia
literal translation split mind a group of severe psychotic disorders characterized by:
disorganized and delusional thinking disturbed perceptions inappropriate emotions and actions

Schizophrenia
Delusions
false beliefs, often of persecution or grandeur, that may accompany psychotic disorders Hallucinations
false sensory experiences such as seeing something without any external visual stimulus

Schizophrenia
Subtypes of Schizophrenia
Paranoid: Hebephrenic: Preoccupation with delusions or hallucinations Disorganized speech or behavior, or flat or inappropriate emotion Immobility (or excessive, purposeless movement), extreme negativism, and/or parrotlike repeating of anothers speech or movements Schizophrenia symptoms without fitting one of the above types

Catatonic:

Undifferentiated or residual:

Schizophrenia
Lifetime risk 40 of developing schizophrenia 30 for relatives of a schizophrenic 20
10 0
General population Siblings Children Fraternal Children Identical twin of two twin schizophrenia victims

Schizophrenia vs. Schizoaffective disorder Disorder schizoaffective

Schizoaffective disorder
symptoms of schizophrenia are predominant and also have an added mood disorder

Personality Disorders
Personality Disorders
disorders characterized by inflexible and enduring behavior patterns that impair social functioning usually without anxiety, depression, or delusions

Personality Disorders
Antisocial Personality Disorder
disorder in which the person (usually male) exhibits a lack of conscience for wrongdoing, even toward friends and family members may be aggressive and ruthless or a clever con artist

Eating Disorders: Eating Disorder Anorexia Anorexia Nervosa

Hypothesized causes
Family history of OCD Being perfectionistic, irrational about expectations for body Feelings of mastery over body Cultural emphasis on being thin

Eating Disorders: Eating Disorder Bulimia Bulimia Nervosa

Recurrent binge eating followed by purging, fasting, and/or intense exercising Hypothesized causes
Lower levels of serotonin (creates feeling of satiety) Dieting in some extreme cases can lead to onset Normative influence: approval by peers

Eating Disorders: Substance Use Disorders Bulimia Nervosa

Alcohol Opioids Cannabionoids Sedatives or hypnotics Cocaine Other stimulants including caffeine Hallucinogens Tobacco Volatile Solvents Other Psychoactive Substances

Eating Disorders: Substance Use Disorders Bulimia Nervosa

Harmful use Dependence Psychotic illness Mood disorders Personality disorder

Eating Disorders: Organic Mental Illnesses Bulimia Nervosa

Dementia Alzheimer's Disease Huntington's Chorea Pics Diseases Vascular Dementia

Delirium Mood, Psychotic and Personality Disorders due to Organic causes

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Child Psychopathology

Eating Disorders: Outline Bulimia Nervosa

Various conditions occurs at the early period of development Behavioral illnesses occurs in early adolescent period

Mental Retardation
Significantly sub average level of intellectual functioning
Social and adaptive functioning

Ranges
Borderline (70 90) Mild (50 69) Moderate (35 49) Severe (20 34) Profound (Below 20)

Pervasive Developmental Disorders

Autistic disorder Retts disorder Aspergers disorder Childhood disintegrative disorder

Autism
Part of pervasive developmental disorders Children with autism generally have problems in three crucial areas of development 1. social interaction 2. language 3. behavior Subnormal intelligence in two third of the patients

Social skills
Fails to respond to his or her name Has poor eye contact Appears not to hear you at times Resists cuddling and holding Appears unaware of others' feelings Seems to prefer playing alone retreats into his or her "own world

Language
Starts talking later than other children Loses previously acquired ability to say words or sentences Does not make eye contact when making requests Speaks with an abnormal tone or rhythm may use a singsong voice or robot-like speech Can't start a conversation or keep one going May repeat words or phrases verbatim, but doesn't understand how to use them

Behavior
Performs repetitive movements, such as rocking, spinning or hand-flapping Develops specific routines or rituals Becomes disturbed at the slightest change in routines or rituals Moves constantly May be fascinated by parts of an object, such as the spinning wheels of a toy car May be unusually sensitive to light, sound and touch and to pain

Aspergers Disorder
At the milder end of this Autism spectrum. Different from Autism.*

Age of onset
Noticed between 3 to 5 years of age or even later More common in boys Incidence as high as 1 in 500

Retts Disorder
Decreased social interest and skills Brief period of normal functioning Stereotyped movements Psychomotor retardation Mental retardation

Onset & Occurrence

Two to ten years of age when skills are lost Very rare More common in girls

Attention Deficit Hyperactivity Disorder

Pattern of inattention, impulsivity and hyperactivity Overactivity Impulse control problems Limited attention span Accident prone Irritable Emotionally labile Normal intelligence

Onset & Occurrence

Before 7 years Lasts at least 6 months 3 to 5% of the children of elementary school age Up to five times more common in boys

ADHD: Hyperactive type

Excessive motor activity Impulsivity
waiting turns, waiting to be called on act without thinking

Low frustration tolerance

temper tantrums social problems/ immaturity

Conduct Disorder
Behavior that violates social norms Aggressive behavior towards others Aggressive behavior towards animals Lying and stealing Property destruction Truancy from school Running away Not follow parental rules

Oppositional Defiant Disorder

Pattern of negative defiant behavior toward adults Does not violate social norms in contrast to conduct disorder

Oppositional Defiant Disorder

Argumentative and angry Easily annoyed and loses temper Noncompliant with the request of adults

Enuresis
Voiding in inappropriate settings Diagnosed age 5 onwards 7% of the boys and 5% of the girls Association with ADHD.

Encopresis
Passage of stools outside of the toilet Diagnosed after 4 years of age Three times more common in boys Lack of control Constipation with overflow in continence

Selective Mutism
Child who speaks in some social situations and not in others One month lasting at least Severe enough Mostly girls May communicate with hand gestures Different from normal shyness

Separation Anxiety Disorder

Normal in infants and toddlers Fear of loss of major attachment figure particularly mother Refusal to be alone as a result May be expressed as an unrealistic fear of child or parent being injured, kidnapped, or killed. Frequent Complaints of somatic symptoms.

Eating Disorders in Children

Anorexia and Bulimia: onset can be preteen Pica
eating non-food items lead poisoning

Rumination disorder
infants regurgitating and re swallowing food usually neglected or stresses infants

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