Chapter 2: Current Paradigms in Psychopathology 1

CHAPTER 2

Current Paradigms in Psychopathology

Chapter 2: Current Paradigms in Psychopathology 1

CHAPTER SYNOPSIS

Scientific inquiry is limited by scientists’ human limitations and by the limited state of our knowledge: people see only what they are able to see, and other phenomena go undetected because scientists can discover things only if they already have some general idea about them. A paradigm is a conceptual framework or general perspective. Because the paradigm within which scientists and clinicians work helps to shape what they investigate and find, understanding paradigms helps us to appreciate subjective influences that may affect their work. Several major paradigms are current in the study of psychopathology and therapy:

Chapter 2: Current Paradigms in Psychopathology 1

Genetic.
Neuroscience.
Psychodynamic.
Cognitive Behavioral.

The choice of a paradigm has important consequences for the way in which abnormal behavior is defined, investigated, and treated.

The Genetic Paradigm

The genetic paradigm focuses on questions such as whether certain disorders are heritable and, if so, what is actually inherited. Heritability is a population statistic, not a metric of the likelihood a particular person will inherit a disorder. Environmental effects can be classified as shared and nonshared. Molecular genetics studies involve linkage analysis and association studies.

Research has emphasized the importance of gene–environment interactions. Genes do their work via the environment in most cases. Recent examples of genetic influence being manifested only under certain environmental conditions (e.g., poverty and IQ; early maltreatment and depression) make it clear that we must not just look for the genes associated with mental illness, but also for the conditions under which these genes may be expressed.

The Neuroscience Paradigm

The neuroscience paradigm is concerned with the ways in which the brain contributes to psychopathology. Neurotransmitters such as serotonin, norepinephrine, dopamine, and GABA have been implicated in a number of disorders. A number of different brain areas are also a focus of research. The autonomic nervous system, which includes the sympathetic and parasympathetic nervous systems, is also implicated in the manifestations of some disorders. The sympathetic nervous system prepares us for sudden activity and stress. The parasympathetic helps us to calm down, though these distinctions are not always so clear-cut. The HPA axis is responsible for the body’s response to stress and thus is relevant for several stress-related disorders. Biological treatments, primarily medications, are effective treatments for different disorders, but these treatments are not necessarily treating the cause of the problems. Although the brain plays an important role in our understanding of the causes of psychopathology, we must be careful to avoid reductionism.

The Psychoanalytic Paradigm

The psychoanalytic paradigm derives from the work of Freud and his followers. The contribution of the paradigm has been primarily in treatment. Although Freud’s early work is often criticized, this paradigm has been influential in the study of psychopathology in that it has made clear the importance of early experiences, the notion that we can do things without conscious awareness, and the point that the causes of behavior are not always obvious.

The Cognitive Behavioral Paradigm

The cognitive behavioral paradigm reflects influences from behavior therapy and cognitive science. Treatment techniques designed to alter the consequences or reinforcers of a behavior, such as in time-out or a token economy, are still used today. Exposure is still a key component to cognitive behavioral treatments of anxiety. Cognitive science focuses on concepts such as schemas (a network of accumulated knowledge or set), attention, and memory, and these concepts are part of cognitive behavioral theories and treatments of psychopathology. Cognitive behavior therapy uses behavior therapy techniques and cognitive restructuring. Aaron Beck and Albert Ellis are two influential cognitive behavior therapists. The boundary between what is behavioral and what is cognitive is not always so clear in the cognitive behavioral paradigm.

Factors that Cut Across the Paradigms

Emotion disturbances figure prominently in psychopathology, but the ways in which emotions can be disrupted varies quite a bit. Emotions guide our behavior and help us to respond to problems or challenges in our environment. It is important to distinguish between components of emotion, including expression, experience, and physiology. In addition, mood can be distinguished from emotion. Psychological disorders have different types of emotion disturbances, and thus it is important to consider which of the emotion components are affected. In some disorders, all emotion components may be disrupted, whereas in others, just one might be problematic. Emotion is an important focus in the paradigms.

Sociocultural factors, such as culture, ethnicity, gender, social support, and relationships are important factors in the study of psychopathology. Some disorders appear to be universal across cultures, like schizophrenia or anxiety, yet their manifestations may differ somewhat and the ways in which society regards them may also differ. Some disorders are more frequently diagnosed in some ethnic groups compared to others. It is not clear whether this reflects a true difference in the presence of disorder or perhaps a bias on the part of diagnosticians. Social relationships can be important buffers against stress and have benefits for physical and mental health. Current research is also examining whether risk factors associated with various disorders differ for men and women. Sociocultural factors have recently become the focus of people working in the other paradigms, and this trend will continue.

Diathesis–Stress: An Integrative Paradigm

Because each paradigm seems to have something to offer to our understanding of mental disorders, it is important to develop more integrative paradigms. The diathesis–stress paradigm, which integrates several points of view, assumes that people are predisposed to react adversely to environmental stressors. The diathesis may be genetic, neurobiological, or psychological and may be caused by early-childhood experiences, genetically influenced personality traits, or sociocultural influences among other things.

LEARNING GOALS

Chapter 2: Current Paradigms in Psychopathology 1

Be able to describe the essentials of the genetic, neuroscience, psychoanalytic, cognitive behavioral, and diathesis–stress paradigms.
Be able to describe the concept of emotion and how it may be relevant to psychopathology.
Be able to explain how culture, ethnicity, and social factors figure into the study and treatment of psychopathology.
Be able to recognize the limits of adopting any one paradigm and the importance of integration across multiple levels of analysis.

KEY TERMS

agonist, allele, amygdala, antagonist, anterior cingulate, autonomic nervous system (ANS), behavior genetics, brain stem, brief therapy, cerebellum, cognition, cognitive behavior therapy (CBT), cognitive behavioral paradigm, cognitive restructuring, corpus callosum, cortisol, diathesis, diathesis–stress, dopamine, ego analysis, emotion, exposure, frontal lobe, gamma-aminobutyric acid (GABA), gene–environment interaction, gene expression, genes, genetic markers, genetic paradigm, genotype, gray matter, heritability, hippocampus, HPA axis, hypothalamus, in vivo, linkage analysis, molecular genetics, nerve impulse, neuron, neuroscience paradigm, neurotransmitters, nonshared environment, norepinephrine, occipital lobe, paradigm, parietal lobe, parasympathetic nervous system, phenotype, polygenic, polymorphism, pruning, psychoanalytic paradigm, psychotherapy, rational-emotive behavior therapy (REBT), reciprocal gene–environment interaction, reuptake, schema, second messengers, septal area, serotonin, serotonin transporter gene, shared environment, somatic nervous system, sympathetic nervous system, synapse, temporal lobe, thalamus, time-out, token economy, ventricles, white matter

LECTURE LAUNCHERS

1.The Manufacture of a Human Chromosome

For years, scientists have been able to create artificial chromosomes for very simple living organisms, such as yeast. A mouse chromosome was created in the lab in 1996. But in 1997, the first artificial human chromosome was created at a lab at Case Western Reserve University in Cleveland (reported in Nature Genetics, April, 1997).

What are the implications of this new technological leap? While researchers involved in the federal Human Genome Program have mapped the location of specific genes on specific chromosomes, creating artificial ones will enable scientists to study the functioning of genes within their normal context. The next big step would be packaging therapeutic genes in an artificial chromosome to introduce them to a cell. The new gene could either generate a medicinal protein or replace a defective gene. The first step in treatment would be using artificial chromosomes to treat blood diseases and diseases that affect the human immune system. Eventually, a wide range of inherited or infectious diseases might be amenable to such gene therapy.

Research in this area has grown considerably. Several websites of interest are:

Chapter 2: Current Paradigms in Psychopathology 1

The Institute for Genomic Research -
Genome Web -
The Genome Database -
National Center for Biotechnology Information -

2.Does Everything Come Down to Serotonin?

As readers work their way through the textbook, they will notice that serotonin features prominently in etiological theories for many mental disorders. Low levels of serotonin have been associated with everything from eating disorders, depression, and alcoholism to suicide and aggression.

On the other hand, animal studies have demonstrated repeatedly that environment plays a tremendously important role in serotonin levels. For example, Suomi and colleagues at the National Institute of Child, Health, and Human Development have found that childhood environments affect monkeys' behavior and serotonin systems. Monkeys with low serotonin levels are markedly aggressive and impulsive, take physical risks, and, when provided access to alcohol, drink excessively. In the wild, such monkeys are rejected by their peers, fail at mating, and often die at a young age. Lest we assume that biological factors fully account for the monkeys' behavior, however, consider the impact of environmental factors on serotonin levels. Monkeys raised without their mothers (with only peers for support) had low serotonin levels as early as 14 days of age and continuing into adulthood. Future research by this lab will include exploring whether ideal rearing environments can ameliorate the negative effects of low serotonin levels.

3.Does the Neuroscience Paradigm Make Other Paradigms Obsolete?

The 1990s were proclaimed the “decade of the brain.” Much of the research conducted has helped to highlight the impact of neuroscience on our understanding of mental illness. With this in mind, students might expect that the discovery of biochemical causes for various mental disorders invalidates the psychological paradigms. If symptoms can be explained by neurochemical changes or a “chemical imbalance,” is there still a role for paradigms that emphasize talking, thinking, and behaving in the etiology and treatment of these same disorders?

In the discussion of obsessive-compulsive disorder in Chapter 6, the text mentions a recent study (Baxter et al., 1992) that found both a medication (fluoxetine or Prozac) and a form of behavior therapy (response prevention) resulted in the same changes in brain function on PET scan in patients who improved following treatment. These findings illustrate an interconnection between the biological and behavioral paradigms, as a psychological treatment can be shown to have a direct impact on a biological process.

Another discussion of obsessive-compulsive disorder (OCD) highlights the role of psychodynamic therapy in a disorder believed to be mainly biologically caused. In “Psychodynamic psychiatry in the ‘Decade of the Brain,’” Gabbard (1992, American Journal of Psychiatry, 149, 991-998) emphasizes the way in which mind and brain interact in mental disorders. While noting the strong biological components of OCD and the lack of empirical evidence favoring psychodynamic therapy in the treatment of the disorder, Gabbard illustrates ways in which psychodynamic principles can nonetheless be valuable. Consider the following case, described by Gabbard:

A 29-year-old man with OCD is so obsessed with avoiding contamination that he insists that his mother move in with him and care for him 24 hours a day; his father is not allowed in the house. His mother must follow a 58-step ritual in making dinner, and if one step is not followed, she must discard the meal and begin again. While the patient had been prescribed clomipramine, he stopped taking it after one dose and eventually was hospitalized by his parents. The following interchange occurred with his therapist:

When he came to the hospital, I asked him why he was seeking treatment. He responded, “I'm determined to be dependent – I mean, independent.” I commented to him that he had first said “dependent,” and I inquired, “Is there perhaps a part of you that would like to be dependent?” Mr. A responded, “You mean on my mother?” I replied that I thought he would know better than I. Mr. A reflected a moment and said, “Well, she does take pretty good care of me.”

Mr. A's slip of the tongue provided a glimpse into the unconscious motivations for his resistance to treatment. Any kind of successful treatment threatened his dependent relationship with his mother. If clomipramine were likely to help him, then he would not take it.

Mr. A reportedly improved during his stay in the hospital, discovering that the hospital setting had successfully reduced his anxiety about sexual feelings toward his mother.

While this treating psychiatrist noted the importance of medication in the standard treatment of OCD, he used this case as an illustration of the role of psychodynamic principles, both in understanding the unconscious wishes accompanying the biologically driven symptoms, and in handling noncompliance with the biologically based intervention.

4.Future of Psychodynamic Psychotherapy

In a special issue of Psychotherapy (1992, 29), clinicians from various theoretical orientations were asked to describe the changes they anticipated in their paradigm. Hans Strupp, writing on “The future of psychodynamic psychotherapy” (pp. 21-27), notes that psychodynamic thinking continues to be based on the notion of unconscious conflict, while paying greater attention to incorporating issues related to interpersonal experiences and emphasizing the client's subjective experience. Strupp identified the following trends in psychodynamic therapy:

Chapter 2: Current Paradigms in Psychopathology 1

Increasing attention to disturbances and arrests in infancy and early childhood (in contrast to Freud's emphasis on the Oedipal period).
Focus on treatment of personality disorders and “difficult” patients, as opposed to the “classical” neurotic conditions that Freud viewed as the primary focus of analysis.
Focus on the dyadic character of the therapeutic relationship, resulting in re-definition of the concepts of transference and counter transference.
Recognition of the importance of the patient-therapist relationship or alliance, which is more collaborative and “human” than the detached “blank screen” of classical analysts.
Utilization of the advances made in neuroscience and pharmacotherapy, in combination with psychotherapy.
Wider acceptance of group, family, and marital therapy.
Renewed emphasis on briefer forms of psychotherapy, largely in response to societal pressures.
Attempts to devise specific treatments for specific disorders, partly due to developments in the area of managed care and the investigative model of clinical trials for testing the efficacy of new drugs.
Development of treatment manuals.
Continued search for the mechanisms of change in psychotherapy.

Strupp sees these developments as “[infusing] psychodynamic psychotherapy with renewed vitality and vigor” (p. 25).

5.Carl Rogers (1902-1987)

Carl Rogers died suddenly in 1987 at the age of 85, following surgery for a broken hip. Obituaries from the Los Angeles Times (February 6, 1987) and the American Psychologist (1988, 43, 127-128) offer a glimpse into the life of this influential champion of the humanistic paradigm. Rogers was born Jan. 8, 1902, in Oak Park, Illinois. He received his doctorate from Columbia University Teachers College in 1931. Rogers founded the Center for the Study of the Person in La Jolla, California in the 1960's, where he remained active until his death. Those who knew Rogers describe him as a quiet but intent listener who was able to convey his real interest in and empathy for the phenomenological world of the individual. While caring deeply about individual persons, he doubted authority, institutions, credentials, and diagnosis. Accused in the 1940s of “destroying the unity of psychoanalysis,” Rogers successfully pioneered the new method of nondirective, client-centered therapy, turning the tables on the authority of analysts.

One of Rogers' most important contributions was his concern with conducting research in psychotherapy. He was one of the first to assert that therapists should demonstrate that their methods work; he even went so far as to tape therapy sessions at a time when the analytic relationship was considered almost sacred. Friends report that on his 80th birthday, Rogers announced that he would devote the rest of his life to working toward world peace, and to that end traveled to the Soviet Union in 1986 and led workshops in Hungary, Brazil, and South Africa.

DISCUSSION STIMULATORS

1. “Medical Student's Syndrome”

Just as medical students often “diagnose” themselves as having many of the diseases they read about in such detail, Abnormal Psychology students frequently see themselves in the symptoms of mental illness described in this course. A study by Hardy & Calhoun (1997, Teaching of Psychology, 24, 192-193) indicated that students who were going to major in psychology reported more worry about their psychological well-being than did students who were majoring in another field. This study showed, however, that after completing a course in abnormal psychology, the same students were less concerned about the possibility that they might have a psychological disorder.

Because of the potential to diagnose family members as well as themselves, it is important to be sensitive in lecturing about various topics. It is good practice to give the class information about a student counseling center or other psychological services early on in the course. Still, be prepared during office hours to answer questions that are more personal than academic in nature, and have referral sources available for such times.