CHAPTER 14
14.1 Psychopathology (sickness or pathology of the mind) refers to problematic patterns of thought, feeling, or behavior that disrupt an individual’s sense of well-being or social or occupational functioning. Many forms of psychopathology are found across cultures; however, cultures differ in the disorders to which their members are vulnerable and the ways they categorize mental illness. Szasz sees mental illness as a myth used to make people conform to society’s standards of normality; labeling theory similarly argues that diagnosis is a way of stigmatizing deviants. Both approaches have some validity but, considering that many disorders are recognized cross-culturally, treatment would be impossible without classification, and accumulating evidence that disorders like schizophrenia are illnesses of the brain suggest that these views understate the realities of mental illness.
14.2 Psychodynamic theorists distinguish among three broad classes of psychopathology that reflect different degrees of functioning: neuroses (enduring problems in living that cause distress or dysfunction), personality disorders (chronic, severe disturbances that substantially inhibit the capacity to love and to work), and psychoses (gross disturbances involving a loss of touch with reality). While nature and nurture are both implicated, neuroses are most closely linked to environmental factors, while psychoses are most closely linked biological abnormalities. A psychodynamic formulation is a set of hypotheses about the patient’s motives and conflicts, ego functioning (adaptive skills), and object relations (ability to form meaningful relationships and maintain self-esteem).
14.3 Cognitive-behavioral clinicians integrate an understanding of thought processes and conditioning. Many psychological problems involve conditioned emotional responses, in which a previously neutral stimulus has become associated with unpleasant emotions. Irrational fears in turn elicit avoidance, which perpetuates them and may lead to secondary problems, such as poor social skills. Likewise, many psychological problems reflect dysfunctional attitudes, beliefs, and other cognitive processes, such as a tendency to interpret events negatively.
14.4 The biological approach looks for the roots of mental disorders in the brain’s circuitry, such as neurotransmitter dysfunction, abnormalities of specific brain structures, or dysfunction anywhere along a pathway that regulates behavior or mental processes. Theorists of various persuasions often adopt a diathesis-stress model, which proposes that people with an underlying biological vulnerability (called a diathesis) may exhibit symptoms under stressful circumstances.
14.5 A systems approach explains an individual’s behavior in the context of a social group, such as a couple, family, or larger group. Most systems clinicians adopt a family systems model, which views an individual’s symptoms as symptoms of family dysfunction. Family systems theorists focus on how families are organized including family roles (parts individuals play in repetitive family dramas), boundaries (physical and psychological limits of the family and its subsystems), and alliances (patterns in which family members side with one another), the ways members preserve equilibrium in the family (family homeostatic mechanisms), the marital subsystem (the relationship between the parents),and problematic communication patterns.
14.6 Evolutionary psychologists could explain psychopathology in at least three ways. First, random variation is necessary and psychopathology is likely to be weeded out by natural selection. Second, psychopathology may be the result of broader evolutionary pressures that regulate the percentage of genes in the population that are functional at certain levels but dysfunctional at others. Third, psychopathology can reflect normal processes gone awry because of abnormal circumstances.
14.7 In descriptive diagnosis, mental disorders are classified into clinical syndromes, constellations of symptoms that tend to occur together. The descriptive approach embodied in DSM-IV tends to be most compatible with a disease model that presumes psychological disorders fall into discrete categories. DSM-IV uses a multiaxial system, placing symptoms in their biological and social context by evaluating patients along five axes: clinical syndromes such as schizophrenia or depression, personality disorders (and mental retardation), medical conditions, environmental stressors, and global level of functioning.
14.8 The two most common disorders that are usually diagnosed in childhood are attention-deficit hyperactivity disorder(ADHD) and conduct disorder. Attention-deficit hyperactivity disorder is characterized by inattention, impulsiveness, and hyperactivity inappropriate for the child’s age, and is more prevalent in boys. ADHD has both biological (genetic) and environmental links such as severe marital discord, low social class, etc.). Both biological and environmental relationships are also true of conduct disorder (in which a child persistently violates societal norms and the rights of others). Ineffectively lax or excessively punative parenting are associated with such delinquent behaviors in children.
14.9 Substance-related disorders are characterized by continued use of a substance (such as alcohol or cocaine) that negatively affects psychological and social functioning. The most common substance-related disorder is alcoholism. Research has clearly demonstrated both environmental and genetic contributions to alcoholism and other substance-related disorders, although researchers are still trying to track down precisely how genetic transmission occurs in different individuals. The best data provide evidence that people who abuse one drug are at risk for abusing several—a suggestion that genes and experience conspire to create a vulnerability to substance abuse in general.
14.10 Schizophrenia is an umbrella term for a number of psychotic disorders that involve disturbances in thought, perception, behavior, language, communication, and emotion. Positive symptoms reflect the presence of something not usually found in the psyche, and include disorganized symptoms (disordered thoughts, speech, and behavior) and psychotic symptoms (delusions and hallucinations). Negative symptoms reflect the absence of something usually found in the psyche and include flat affect, lack of motivation, peculiar or withdrawn interpersonal behavior, and intellectual impairments. Positive and negative symptoms appear to involve different neural circuits and to respond to different kinds of medications. Onset of schizophrenia is usually in the late teens or early twenties.
14.11 Most theorists adopt a diathesis-stress model of schizophrenia. Heritability of schizophrenia is at least 50 percent. According to the dopamine hypothesis, positive symptoms of schizophrenia reflect too much dopamine activity in subcortical circuits involving the basal ganglia and limbic system, whereas negative symptoms reflect too little dopamine activity in the prefrontal cortex. Glutamate may also play a role, at least in some individuals with schizophrenia. Other data implicate abnormalities in the structure and function of the brain, such as enlarged ventricles and corresponding atrophy (degeneration) in the frontal and temporal lobes. Environmental variables, notably expressed emotion (criticism, hostile interchanges, and emotional over-involvement by family members), play an important role in both onset and relapse. Prenatal and perinatal events that affect the developing nervous system may also be involved in some cases of schizophrenia, such as prenatal malnutrician and exposure to viruses, and birth complications.
14.12 Mood disorders are characterized by disturbances in emotion and mood. The most severe form of depression is major depressive disorder, characterized by depressed mood and anhedonia (loss of interest in pleasurable activities). Dysthymic disorder refers to a chronic low-level depression lasting more than two years, with intervals of normal moods that never last more than a few weeks or months. In bipolar disorder, individuals generally have alternating manic and depressive episodes. Mania is characterized by symptoms such as abnormally elevated mood, grandiosity, and racing thoughts.
14.13 Genetic factors increase the vulnerability to mood disorders, particularly bipolar disorder. Serotonin and norepinephrine have been implicated in both major depression and bipolar disorder. Both childhood and adult negative experiences also play a significant role in the etiology and course of mood disorders. According to cognitive theories a trio of dysfunctional thought patterns called the negative triad (pessimism, negative interpretation, and low self regard), plays a crucial role in depression. Depressed people tend to automatically and implicitly interpret neutral or positive information as negative, through cognitive distortions. According to psychodynamic theory, depression can be rooted in identification with a depressed or belittling parent, or an attachment history that predisposes a person to object relation difficulties. Depression has equivalents in all cultures, but the way it is viewed and experienced varies across them considerably.
14.14 In anxiety disorders, people experience frequent, intense, and irrational anxiety. Generalized anxiety disorder is characterized by continuous, persistent anxiety and excessive worry about life circumstances that are not triggered by any particular circumstances. A common type of phobia (irrational fear) is social phobia, which occurs when the person is in a specific social or performance situation. Panic disorder is characterized by attacks of intense fear and feelings of doom or terror not justified by the situation. Agoraphobia involves a fear of being in places or situations from which escape might be difficult. Obsessive-compulsive disorder is marked by recurrent obsessions (persistent thoughts or ideas) and compulsions (stereotyped rituals performed in response to an obsession). Post-traumatic stress disorder is marked by flashbacks and recurrent thoughts of a psychologically distressing event outside the range of usual human experience.
14.15 As in other disorders, heredity and environment both contribute to the etiology of anxiety disorders as do adult and childhood stressors. Behaviorist theories implicate classical conditioning and negative reinforcement of avoidance behavior in the etiology and maintenance of anxiety disorders. Cognitive theorists emphasize negative biases in thinking, such as attention to threatening stimuli. A comprehensive cognitive-behavioral model suggests that patients develop classically conditioned fear of their own autonomic responses, which, combined with fearful thoughts, perpetuates anxiety and can trigger panic episodes.
14.16 Eating disorders are characterized by dysfunctional eating-related thoughts and behaviors and are most prevalent in women. Anorexia nervosa is characterized by a distorted body image, along with self-starvation, excessive exercise, and/or food elimination behaviors that result in an individual losing 15 percent or more of ideal body weight. Bulimia is characterized by binging followed by purging. Research on etiology points to vulnerabilities caused by genetics and cultural norms for thinness. Personality is also implicated in that people with anorexia tend to be overly-controlled and inhibited, those with bulimia under-controlled and impulsive, and both are often high functioning, perfectionistic, and self-critical.
14.17 Dissociative disorders are characterized by disruptions in consciousness, memory, sense of identity, or perception. In dissociative identity disorder, at least two distinct personalities are displayed within the person. Dissociative disorders show little or no genetic influence, but almost always reflect a history of severe (usually sexual) childhood trauma. Personality disorders are characterized by enduring maladaptive patterns of thought, feeling, and behavior that lead to chronic disturbances in interpersonal and occupational functioning. Borderline personality disorder is marked by extremely unstable interpersonal relationships, dramatic mood swings, an unstable sense of identity, intense fears of separation and abandonment, manipulativeness, impulsive behavior, and self-mutilating behavior, and is more prominent in women. Antisocial personality disorder is marked by irresponsible socially-disruptive behavior, lack of empathy, and lack of remorse, and is more prominent in men. Borderline personality disorder is related to a genetic tendency toward negative affect and impulsivity, troubled attachment history, and sexual abuse. Antisocial personality disorder is related to genetics, absent or criminal male role models, and physical abuse.
14.18 Using classification systems to diagnose mental illness has been challenged by researchers and theorists in recent years. One reason for this is that people often experience multiple problems simultaneously making it difficult to apply a single diagnosis. Furthermore, teasing apart the roles of nature and nurture in the etiology of psychological disturbances is more difficult than it may first appear, because each affects the other. Inherited characteristics typically determine which environmental events are psychologically toxic, and environmental events can translate into changes in the brain.