I.
What
is “mental illness”?
A.
Historical
progression
1.
Spiritual
and religious views – e.g., abnormal behavior as “demonic possession”
2.
Gradual
movement to more “scientific” and humane views of mental illness during the
Renaissance and Enlightenment
a.
Estabishment
of asylums – e.g., the monastery of St. Mary of Bethlehem in London became the
notorious “Bedlam”
b.
La
Bicêtre hospital in Paris – patients in chains and shackles, poorly fed, in
dark, in uncleaned and unheated cells
c.
Pinel’s
reforms in France in 1792, after the French Revolution – removing the chains
and creating decent conditions for the mentally ill
3.
The
development of the “medical model” of mental illness
a.
assumption:
mental illnesses have physical, biological causes like physical diseases
b.
The
distinction between “symptoms” and underlying disease
c.
“General
paresis” – a kind of dementia caused by syphilis; in the late 1800s a Viennese
psychiatrist, Richard von Krafft-Ebing, showed a link between syphilis and
general paresis when he showed that inoculating patients suffering from general
paresis with fluids from syphilitic sores did not lead to secondary symptoms of
syphilis – this implied that paretic patients had already been infected with
syphilis
d.
Emil
Kraepelin (1856-1926) –Swiss psychiatrist who created the first modern
classification system, or taxonomy of mental illness; the forerunner of the
Diagnostic Statistical Manual of the American Psychiatric Association
4.
The
development of modern psychotherapy and the fragmentation of approaches to
abnormal behavior in the late 19th and 20th centuries
a.
Freud,
the psychoanalytic perspective, and the development of psychoanalysis
b.
The
behavioral perspective on mental illness – abnormal behavior as learned,
maladaptive behavior
c.
The
genetic-biological perspective and the “diathesis-stress” model – “diathesis”
is a biological or genetic predisposition to an illness; “stress” refers to the
environmental pressures that trigger actual illness
d.
The
humanistic/cultural/normative perspective:
Mental illness as culturally relative and non-normative behavior:
Examples: homosexuality, “acting out” behavior in teenagers; links to existential
philosophy
B.
Three
common-sense criteria of psychopathology
1.
Is
behavior maladaptive? -- that
is, does behavior interfere with one’s happiness and pursuit of common life
goals (such as intimacy, close personal relationships, meaningful work, achievement,
physical health and well-being)
2.
Is
behavior injurious and destructive, either to others or to self. Examples: alcoholism and drug abuse,
depression and suicide, sociopathic or antisocial personality traits
3.
Is
behavior “deviant,” in the sense that it is statistically abnormal in a
negative or maladaptive direction; does behavior break social rules of proper
behavior (Examples: adults who have conversations with imaginary 6-foot-tall
rabbits, people who exhibit their genitals in public places, people who don’t
groom and clean themselves in “normal” ways)
C.
Classifying
and diagnosing mental illness – DSM: The Diagnostic Statistical Manual of the American
Psychiatric Association
1.
The
five axes of DSM – five dimensions of information or classification that are
important in diagnosing mental illness
a.
Axis
1: Specific clinical syndromes or conditions; these are specific kinds of
“mental illness” that have clusters of symptoms and often have a definite time
of onset. Examples: schizophrenia,
depression, panic attacks and their related symptoms
b.
Axis
2: Personality disorders and long-term disorders like retardation; these are
long-term, trait-like disorders that affect individuals in very broad
ways. Examples: antisocial, borderline,
and schizoid personality disorder; some of these can be conceptualized as
extreme version of Big Five traits
c.
Axis
3: General medical condition, particularly as it relates to psychological
conditions. Examples: chronic disease
or pain and its relation to depression; arterial disease, medication, and
impotence; diabetes, thyroid disorders, and mood changes
d.
Axis
4: Environmental problems and stressors.
Examples: family, job, and economic problems. Distinction between a “reactive depression” and an “endogenous
depression” – Is the depression in response to traumatic events?
e.
Axis
5: Global assessment of function and current level of adjustment. Example: Given that you are depressed, are
you still managing to work, go to school, and have relations with friends and
family?
Schizophrenia
A. Kraeplin's description of dementia praecox – early or “precocious” dementia
B.
Swiss
psychiatrist, Eugen Bleuler, invented the term, schizophrenia -- a "split" in the sense of disorganized
thought processes, a split between thought and emotion, a splitting off from
reality
C.
Prevalence
and characteristics of sufferers
1.
During
any year, approximately 1% of adults in the U.S. suffer from schizophrenia
2.
This
disorder accounts for nearly 40% of admissions to state mental hospitals
3.
Typically,
the onset occurs during late teens to twenties; males tend to have a somewhat
earlier onset than females
D.
Symptoms
and clinical description
1.
Positive
symptoms (e.g., hallucinations, delusions, agitation) vs. negative symptoms
(lack of expressiveness, emotion, speech, responsiveness to environment); negative
symptoms are associated with worse prognosis
2.
Disordered
thought: "cognitive slippage," "word salad" and thinking
through associations; delusions (or false beliefs); hallucinations (or false
perceptions)
3.
Emotional
disorders: blunted affect, ahedonia (inability to experience pleasure), inappropriate
affect
4.
Disrupted
care of self: inappropriate grooming or cleanliness; incontinence
5.
Retreat
to inner world: most evident in catatonic schizophrenia
6.
Bizarre
movements and motor behaviors: Manic behaviors, grimacing, strange rituals such
as rocking movements
E.
Subtypes
of schizophrenia
1.
Paranoid:
delusions, hallucinations; may involve delusions of grandeur or of persecution
2.
Catatonic:
extreme withdrawal in some cases; zombie-like behavior and "waxy
immobility"; may alternate with extremely agitated and manic states
3.
Disorganized
(formerly called "hebephrenic"): occurs at earlier age than others;
emotional distortion and blunting; silliness, laughter, peculiar mannerisms
4.
Undifferentiated:
rapidly changing pattern of many of the primary symptoms of schizophrenia;
these symptoms may occur at onset of disorder before more stable patterns have
settled in
II.
The
strange and tragic case of the Genain quads
-- four identical quadruplet girls who were born in the 1930s, each of
whom developed schizophrenia by her mid-20s
A.
Question:
How important was nature vs. nurture in the development and onset of the disorder,
the treatment, and the prognosis for these four sisters?
B.
The
disturbed Genain parents
C.
The
disturbed childhood of the Genain quads: exploitation, hounding, and sexual
abuse
D.
Nora
and Myra were treated better by parents; Hester and Iris were considered
"inferior" and they were mistreated the most
E.
Adolescence
and breakdowns: Hester at 18, Nora at 20, Iris at 22, and Myra at 24
F.
Treatment
at NIMH (the source of the sisters' pseudonyms)
G.
Prognosis
and outcomes for the four sisters
III.
Causes of schizophrenia (etiology --
the study of factors that influence the development of a disease)
A. Biological factors
1.
Genetic
factors -- some facts: Offspring of two schizophrenic parents have a 46% chance
of developing schizophrenia; offspring of one schizophrenic parent has a 17%
chance; siblings of a schizophrenic person have a 9% chance; grandchildren of
schizophrenic person have a 5% chance; nieces and nephews of schizophrenic person
have a 4% chance; first cousins have a 2% chance; Twin studies find a higher
rate of concordance for identical twins (about 28%) than for fraternal twins
(6%), which suggests genetic factors; one adoption study found that 17% of
adopted-away children born to schizophrenic mothers also developed
schizophrenia
2.
Neurotransmitters
and the dopamine hypothesis: Early antischizophrenic drugs (called neuroleptics)
seemed to work by blocking neural circuits mediated by the neurotransmitter
dopamine. Actually, these drugs lower
dompamine to abnormally low levels
3.
Schizophrenics
show strange eye movement patterns – the inability to smoothly track moving
objects visually; these and similar findings suggest neurological deficits,
which are also seen in brain waves and reflex tests
4.
Schizophrenics
are over-represented among people who were premature at birth or who suffered
from obstetrical complications
5.
Brain
abnormalities: enlargement of ventricles (fluid-filled spaces in the brain), enlarged
sulci (fissures); suggests progressive degeneration and atrophy of parts of the
brain
6.
Schizophrenics
more like to be born in winter and early spring months; could be related to
prenatal infectious diseases
7.
One
study analyzed home movies of pre-schizophrenic children; they were already
abnormal in their emotions and motor patterns, suggesting early neurological
problems
B. Psychological and social factors
1.
Schizophrenogenic
(schizophrenia-producing) parents: Research suggests that families with
disorganized communication patterns more likely to produce schizophrenic
offspring; families with intrusive, critical, overly emotional communication
patterns more likely to trigger schizophrenic breakdowns in offspring
2.
Correlation
between social class and schizophrenia, with higher rates in lower
classes? Cause and effect could go in
both directions: Lower-class status is stressful and triggers schizophrenia, or
schizophrenic or pre-schizophrenic symptoms lead people to a downward spiral in
terms of social class
III.
Treatments
and outcomes
A.
Anti-psychotic
drugs discovered in the 1950s. The
first – reserpine – was based on an East Indian folk remedy. These drugs had a dramatic effect on
hospitalized schizophrenics. Newer and
better drugs have been developed since.
1. First-time hospitalized
patient has a better than 80% chance of being released within a relatively
short period of time, after drug therapy; however 10% don’t respond to
treatment and may end up permanently hospitalized
2. Although drugs may treat
“florid,” positive symptoms, often patents don’t show “social recovery” – the
ability to maintain normal social and work relationships
B.
Psychosocial
approaches
1. Family therapy – assessing
dysfunctional family communication patterns and intervening; while not a cure
for schizophrenia, this can increase family support and decrease chances of
remission
2. Individual therapy: Again,
while not a cure, this can help patient to learn coping strategies and to
manage emotions and face everyday problems; social skills training; monitoring
medication and its side effects
Mood Disorders
I.
What
are mood disorders?
A.
Two
kinds of abnormal and extreme moods are: mania
(unrealistic excitement, euphoria, and hyperactivity) and depression (extreme and debilitating sadness and dejection)
B.
Unipolar ("one-directional")
mood disorders are much more common and are characterized by depression; Bipolar ("two-directional")
mood disorders are less common and are characterized by both manic and
depressive states; in the past, sometimes called manic-depressive disorder
C.
Prevalence: One recent survey suggested that over the
course of their lives, nearly 13% of males and 21% of females will suffer from
a major depression; for bipolar disorder, the lifetime risk estimates range
from .4 to 1.6%, with no sex difference;
depression has sometimes been called the "common cold" of
mental illness because it is so common
II.
Depression:
Varieties, Symptoms, Causes, and Treatments
A.
Depression
can come in different varieties: Dysthymia
is chronic depressed mood for at least 2 years; dysthymics can have normal
days; not as profound as clinical depression;
Major
depressive disorder is more profound than dysthymia -- more persistent and not mixed with
"good days"; characterized by loss of pleasure and depressed mood and
at least 4 of the following symptoms: fatigue or loss of energy, sleep
disturbances (insomnia or hypersomnia), appetite disturbance and weight loss,
mental sluggishness or agitation, decreased ability to think and concentrate,
intense feelings of worthless and guilt, thoughts of death and suicide
B.
Causes
of depression
1.
Genetics
and hereditary factors: Evidence from 5 twin studies is that, if one twin
suffers from major depression, the chances that the other twin will also suffer
from depression is 2 to 4 times greater for identical than for fraternal twins;
this suggests a genetic component to depression; heritability estimates for depression range from 33% to 45%;
Adoption studies also suggest genetic effects -- one study found that having a
biological relative with depression increased one's chances of developing
depression 7-fold
2.
Biochemical
factors:
a.
Research
focus has been on the neurotransmitters norephinephrine, dopamine, and
serotonin; antidepressant drugs seemed to have their effects on these
neurotransmitters or on their release or uptake at synapses; research evidence is complex, however
b.
Additional
research has focused on hypothalamus, pituitary, and thyroid hormones; thyroid
disorders can mimic depression
c.
Recent
brain imaging studies suggest that depressed people have lower activity in
frontal lobes, particularly on the right side of the brain; consistent with
this is evidence that damage to right prefrontal regions of the brain can lead
to depression
d.
Depressed
people have abnormal sleep patterns: Depressed people enter REM (rapid eye
movement) sleep sooner and have more REM sleep earlier in the night than
non-depressed people do; suggests possible disturbances to sleep-wake cycles
and circadian (daily) rhythms; some of these sleep pattern abnormalities remain
even after depression lifts
3.
Psychological
and social causes
a.
Stressful
life events contribute can trigger depression;
Examples: events that threaten self-esteem (failing, being fired),
threatening and chronic diseases, death of loved one, breakup of important
relationship, loss of job
b.
According
to one classic study (Brown & Harris, 1978) four factors buffered women against
depression: having an intimate relationship, have 3 or fewer children at home,
having work outside of home, and having serious religious commitment; one
common thread here may be the importance of social support
c.
Certain
personality traits place one at more or less risk for depression: People high
on Neuroticism are more vulnerable, whereas people high on Extraversion are
less vulnerable; recall that these two Big Five traits are mood-related --
Neuroticism is "negative affectivity" and Extraversion is "positive
affectivity"; people who are pessimistic and who attribute negative events
to stable, internal causes ("I am stupid," "I am boring")
are more prone to depression
d.
A
number of studies suggest that early parental loss -- through death or
separation -- is a risk factor for depression; also disturbed, unhappy family
relationships can be a risk factor
e.
Aaron
Beck's cognitive theory sees depression as caused by dysfunction, unrealistic
beliefs learned from parents and teachers early in life; he describes the
"negative cognitive triad" of depressed people: 1) negative thoughts
about self ("I'm ugly and worthless"), 2) negative thoughts about
others and one's social environment ("no one loves me"), and 3)
negative thoughts about the future ("I'll always be a failure"); an
unresolved question: are such thoughts and beliefs causes or consequences of
depression?
f.
The
learned helplessness model of depression: animal research by Martin Seligman
and his colleagues suggested that when animals are exposed to uncontrolled
punishments, they develop symptoms and behaviors much like human depression
g.
Attibutional
models (Abramson, Seligman, and Teasdale, 1978) combine learned helplessness
and cognitive processes to explain human depression; when people are exposed to
uncontrollable negative events they make attributions (i.e., try to mentally
explain the events); depressed people are prone to explain negative events in
internal, global, and stable terms
h.
Sex
differences in depression: biological (genetic, hormonal) theories have been
offered but found unsatisfactory; sex
differences emerge in adolescence; one hypothesis is that women engage in more
ruminative strategies whereas men engage more in distraction strategies when
facing problems; many girls experience bodily dissatisfaction in adolescent and
sex-role conflicts; also women may face more societal stresses such as lower
status, high workloads in family life, and greater physical and sexual abuse
C.
Treatments
1.
Drugs:
since 1960s tricyclics have been used; they are often effective, but can have
unpleasant side effects such as dry mouth, constipation, sexual dysfunction,
and weight gain; in the past decade or so, selective serotonin reuptake
inhibitors (SSRIs such as Prozac and Paxil) have frequently been prescribed
(and some would argue, over-prescribed) for depression; have fewer side
effects; antidepressant drugs can sometimes take weeks to build up in the
bloodstream and take effect; patients may be tempted to stop taking drugs
prematurely
2.
Electroconvulsive
shock therapy: used in acute cases where patients are suicidal; Remission of
symptoms usually occurs after 6 to 12 treatments; although effective, shock
therapy is usually augmented by drugs
3.
Cognitive-behavioral
therapies train people to identify their depressive beliefs and automatic
self-defeating thoughts, to recognize them as distortions of reality, to
challenge them, and to replace them with more positive thoughts; many studies
have shown that such therapy can be quite effective in treating depression
III.
Bipolar
disorder: Varieties, Symptoms, Causes, and treatment
A.
Varieties
and symptoms
1. Bipolar disorders can be
confused with depression, particularly if the bipolar patient suffers the
depressive stage first
2. In "Bipolar I
disorder" person has full-blown manic episodes; in "Bipolar II
disorder" the mania is more muted
3. In manic stages, bipolar
person may be full of energy and have thoughts and ideas racing through brain;
person may be brash and place self in compromising situations (e.g., engage in
promiscuous and risky sexual behavior); symptoms of depressed stage are like
those of unipolar depression
4. Some bipolar people show
"rapid cycling" with many manic and depressive cycles in one year;
others cycle over a much longer time; The composer Robert Schumann, who
suffered from bipolar disorder, had three depressions and two manic episodes
from 1833 to 1856; his greatest musical productivity was during the manic
periods; in his final depression he was committed to an insane asylum, where he
committed suicide by self-starvation
B.
Causes
1.
Genetics
and heredity: Evidence for genetic factors is stronger for bipolar disorder than
for depression; A recent summary found that 9% of first degree relatives of
people with bipolar disorder will also have it, which is about 9 times the rate
in the general population; twin studies
show that 67% of identical twins but only 20% of fraternal twins are concordant
(the same) for bipolar disorder; this suggests a heritability of around 80% or
more.
2.
Like
research on depression, research on bipolar disorder has focused on
neurotransmitters and hormones; evidence is mixed; one recent hypothesis
focuses on disorder with the "biological clock" that regulates
circadian and longer body rhythms
3.
Like
unipolar depression, bipolar episodes can be triggered by stressful life events
C.
Treatment
1. Drugs: lithium salts often help people with
bipolar disorders; such drugs are termed mood
stabilizers; even if lithium does not completely prevent relapses, it leads
to fewer episodes; unfortunately lithium can have unpleasant side effects such
as lethargy, decreased muscular coordination, diarrhea, digestive upset; also,
lithium drugs can be toxic and lead to kidney damage; thus blood levels must be
carefully monitored; more recently anticonvulsant drugs have been used to treat
bipolar disorder, and they may help patients who don't respond to lithium or
who have unacceptable side effects
I.
Biological
approaches
A.
Electroconvulsive
shock therapy – begun in 1938 by Italian doctors, Cerletti and Bini
1.
Used
to treat depression and mania; can be effective, although the way it works is
still not understood
2.
Bilateral
ECT sends current across entire brain; ECT would cause convulsions and loss of
consciousness; today anesthesia and muscle relaxant drugs are used; patient
usually awakens within several minutes; may experience amnesia; repeated
treatments are usually required
3.
Unilateral
ECT sends current across only one side of brain; this can lessen side effects
B.
Psychosurgery
1.
Prefrontal
lobotomy – tissue in the frontal lobe of brain is lesioned (i.e., destroyed);
first used in 1935 by Portuguese physician, Antonio Moniz; practiced
extensively in the U.S. during 1940s and 1950s; use declined with advent of
antipsychotic drugs
2.
Lobotomy had many devastating side effects,
including dullness, inability to control impulses, lack of feelings; today this
surgery is generally considered unethical and is not used except in extreme
cases (intractable psychosis or in case of severe pain)
3.
Tragic
real-life case: Rosemary Kennedy, sister of President John Kennedy
C.
Drug
treatments
1.
Antipsychotic
drugs; most work by blocking dopamine receptors in brain
2.
Antidrepressant
drugs; 1) monoamine oxidase inhibitors (originally discovered as a treatment
for depression after being used for treatment of tuberculosis) – these drugs
work by inhibiting the enzyme monoamine oxidase, which breaks down
neurotransmitters like serotonin and norepenephrine in synapses; 2) Tricyclic
antidepressants; operate by inhibiting re-uptake of serotonin and
norepinephrine in synapses; may have side effects such as fatigue, dizziness,
blurred vision, constipation, and sexual dysfunction; 3) Selective serotonin
reuptake inhibitors (SSRIs); best known example is Prozac
3.
Antianxiety
drugs (tranquilizers); barbiturates and benzodiazepenes (e.g., Valium, Xanax);
can produce drousiness and lethargy; can be habit forming; these drugs probably
have their effects by stimulating the neurotransmitter GABA
4.
Lithium
and other drugs used to stabilize moods; lithium first used by Australian, John
Cade, in the late 1940s; can be toxic and blood levels must be carefully
monitored; can have unpleasant side effects such as gastrointestinal upset,
lethargy, coordination problems, and weight gain
II.
Psychodynamic
therapies
A.
Classic
Freudian techniques: Free association, dream analysis, analysis of resistance;
Goal: to make conscious what was formerly unconscious, to “dig up” repressed
material and expose earlier traumas to the light of conscious reflection
B.
Transference
and counter-transference: Patient may “project” other relationships and
emotional syndromes onto patient-therapist relationship; therapist may do the
same and engage in counter-transference
C.
Modern
focus on relationships and “object relations”; trying to reeducate client about
relationships
III.
Behavioral
therapies
A.
Overview: Much more of a focus on the “here and now”
than Freudian therapies; Behavior problems are seen a resulting from
maladaptive learning; client needs to “relearn” behaviors, or extinguish maladaptive
emotions or behaviors
B.
Examples: 1) Systematic desensitization – training a
person to relax in the presence of an anxiety-producing stimulus; used to treat
phobias, 2) “Flooding” and “implosion”
--in vivo (real-life) vs. in vitro (imagined) exposure to anxiety-provoking or
phobic stimuli; shows people they can manage anxiety, 3) Aversion therapies –
punishing behavior or pairing it with aversive stimuli; Antabuse as a treatment
of alcohol abuse
IV.
Cognitive
therapies
A.
Albert
Ellis’s rational emotive therapy: attempts to challenge client’s maladaptive
thought processes, such as “Everyone must like me” or “I must be well-informed
about everything”; often such thoughts are expressed in terms of “I should” or
“I ought” or “I must….”; therapist may challenge irrational beliefs and give
“homework assignments” for reinforcing new beliefs
B.
Aaron
Beck’s cognitive therapy for depression: clients taught to identify automatic
depressive thoughts (e.g., “my presentation was a disaster”) and how they 1) selectively perceive evidence,
2) overgeneralize negative information, 3) magnify negative events and
“catastrophize,” and 4) engage in black-and-white kinds of thinking; therapist
may help client plan events and resume pleasurable activities; this approach
works on both beliefs and behavior
V.
Humanistic
and existential therapies
A.
Roger’s
client-centered (or person-centered_therapy: Goal is to become aware of “true
self,” others’ expectations, and how we give up the “true self” to gain others’
esteem. Client-centered therapists
engage in “unconditional positive regard” and strive to be authentic; therapist
reflects back client’s concerns and feelings but does not play an authoritarian
role or impose interpretations on client
B.
Existential
therapies (e.g., May, Yalom): Core issues of life are: 1) death, 2) meaningless
and meaning, 3) aloneness, 4)
choice and responsibility. These
therapies have a link to the views of existential philosophers such as Sartre
and Camus; distinguishing between
“authentic” and “inauthentic” ways of dealing with the existential dilemmas
that all people face
VI.
Some
common goals, themes, and cores to all therapies
A.
Forming
a nurturing, open relationship with a nonjudgmental person; finding social
support for change
B.
Committing
to change: The very fact of seeing a therapist – particularly if one freely chooses
to do so – commits a person to reevaluate life and seek change
C.
Gaining
feedback about one’s life and behavior; engaging in reflection and
self-examination; learning that one is not alone or the only one in the world
with a given problem
D.
Obtaining
instruction for possible new behaviors, thought processes, and relationship
patterns; using the therapeutic relationship to “try out” new patterns of
thinking and relating to others
I.
Four
perspectives
A.
Behavioral/Learning
B.
Biological/Genetic/Darwinian
C.
Freudian/Psychodynamic
D.
Humanistic/Existential
II.
Some
basic philosophical questions about human nature
A.
Human
beings: basically good, neutral, or evil?
B.
Determinism
and free will: Do people choose their behavior, or is their behavior determined
by biological and environmental factors?
Related question: Do people passively respond to the environment, or can
they actively change themselves and their surroundings?
C.
Malleability: Can people change, or is our nature (our
personality, our abilities, our behavior) fixed and set?
III. Each perspective’s answers to the three
philosophical questions
D.
Behavioral/Learning: Neutral, determined,
malleable
E.
Biological/Genetic/Darwinian:
Mixed, determined, fixed
F.
Freudian/Psychodynamic:
Evil, determined, fixed
G.
Humanistic/Existential:
Neutral or good, people have choice, malleable
IV.
Views of mental health
A.Adaptive behavior that brings rewards and avoids
pain and punishment
B. to be physically healthy, to survive and reproduce
C. to be aware of unconscious motives and earlier traumas; Freud’s “love
and work”; to employ positive rather than negative defenses
D.to grow, to love, to be authentic; to strive for
complete actualization; to find liberating alternatives to social constraints