Psychological Disorders: Historical Perspectives, Classification Systems and Models
I. There is no one absolute definition of psychological disorders; moreover, a continuum exists between mental health on the one hand and pathology on the other. Some proposed definitions include:
A. A psychological disorder can be defined as a pattern of behavioral or psychological symp-toms that causes significant personal distress and impairs the ability to function in one or more important areas of life, or both. (American Psychiatric Association, 1994)
B. A psychological disorder may exist when behavior is atypical, disturbing, maladaptive and unjustifiable. (Myers, 1998)
C. A psychological abnormality involves the presence of at least two of the following: distress, maladaptiveness, irrationality, unpredictability, unconventional and statistical rarity, and observer discomfort.
D. Sanity and insanity are legal rather than psychological terms. In most states the legal definition of insanity relates to the ability of the defendent to distinguish right from wrong. This requires an either/or determination on the part of the court.
II. Historical perspectives on abnormal behavior
A. The ancient world
1. Greece
a. Hippocrates (460-377 BC) believed mental illness was the result of natural, as opposed to supernatural, causes.
b. Galen (130-200 AD) divided the causes of mental disorders into physical and psychological explanations.
2. In China in 200 AD, Chung Ching stated that both organ pathologies and stressful psychological situations were causes of mental disorders.
B. The Middle Ages (500-1500 AD)
1. In Europe, abnormal behavior was most frequently viewed as demonic possession. Treatment performed by the clergy involved prayer, laying on of hands, and exorcism.
2. Islamic countries
a. Humane mental hospitals (for example, in Baghdad in 792 AD) were established.
b. The Persian physician IbnSina (Avicenna, 980-1037) wrote The Canon of Medicine, perhaps the most widely studied medical work ever written. The principles he set-out for testing the effectiveness of new drugs and medications still form the basis of modern clinical drug trials.
C.The Renaissance led to the re-emergence of the scientific approach in Europe.
1. The Spanish nun Teresa of Avila (1515-1582) established the conceptual framework that the mind can be sick.
2. Both Johann Weyer (1515-1588) of Germany and Reginald Scot (1538-1599) of England used scientific skepticism to refute the concept of demonic possession.
D. Humanitarian reforms of the 18th and 19th century
1. In France, Philippe Pinel (1745-1826) pioneered a compassionate medical model for the treatment of the mentally ill and established a humane hospital in Paris.
2. In England, William Tuke (1732-1822) introduced trained nurses for the mentally ill and helped to change public attitudes regarding their treatment.
3. In the United States, Benjamin Rush (1745-1813), the founder of American psychiatry, encouraged humane treatment of the mentally ill and the establishment of hospitals for their care.
E. Scientific advances of the 20th century
1. Developments in technology such as MRI and PET scans have added to our knowledge of the biological bases of psychological disorders.
2. Developments in psychopharmacology have provided effective treatments for many psychological disorders.
III. Models (or perspectives) of psychological disorders
A. The biopsychological model
1. This model emphasizes that mental illness needs to be diagnosed on the basis of its symptoms and cured through therapy based on medical intervention.
2. The perspective has gained credibility from recent discoveries that genetically influenced abnormalities in brain structure and biochemistry contribute to a wide range of disorders, including schizophrenia, depression, and anxiety disorders.
a. Medications influence many of the disorders and their symptoms.
b. Schizophrenia, depression and anxiety disorders are often successfully treated medically.
B. The psychoanalytic model
1. Inspired by the views of Sigmund Freud, this perspective emphasizes the role of unconscious conflicts over aggressive and sexual impulses.
2. Psychoanalytic therapy (the "talking cure") dominated early to mid-20th century approaches to treatment, but is currently practiced to a lesser extent.
C. The behavioral model
1. This model emphasizes that psychological disorders have learning as their basis. For example, inappropriate behaviors might have been reinforced and the punishment or extinction of appropriate behaviors may have occurred. Observational learning may also play a role.
2. Behavior therapies rely on learning principles to change maladaptive behaviors.
D. The cognitive model
1. This model, which grew out of dissatistfaction with behaviorism's limits, emphasizes that irrational or maladaptive thought processes are the cause of psychological disorders.
2. The greatest number of practitioners in psychology today use this model.
E. The biopsychosocial model
1. This eclectic contemporary model assumes that biological, psychological, and sociocultural factors interact to produce or exacerbate psychological disorders.
2. Therapists who subscribe to this view may recommend drugs as well as behavioral and cognitive therapies.
IV.The Diagnostic and Statistical Manual of Mental Disorders, 4th edition
A. Published by the American Psychiatric Association, the DSM-IV, as it is known, is a widely used diagnostic classification system. It provides a set of criteria which allows diagnosticians to make assessments.
B. The diagnostic system is based on five axes which are used by clinicians to provide a complete diagnosis.
1. Axis l includes 16 major categories of adult psychological disorders, such as mood disorders and schizophrenic disorders.
2. Axis 2 includes the personality disorders and developmental disorders.
3. Axis 3 includes medical conditions that might affect or interact with the client's psychological disorder, such as hypothyroidism or headaches.
4. Axis 4 is a rating of recent social and environmental sources of stress, such as a death in the family or chronic unemployment.
5. Axis 5 is a Global Assessment of Functioning (GAF) made on a scale that ranges from 1 to 100, where 100 represents unimpaired function and 1 represents severe disfunction.
6. An example of how a therapist might make a complete DSM multiaxial diagnosis is:
a. Axis 1: alcohol dependence
b. Axis 2: dependent personality disorder
c. Axis 3: diabetes
d. Axis 4: death of spouse; unemployment
e. GAF = 60 (moderate symptoms, e.g., occasional panic attacks or moderate difficulty in social, occupational, or school functioning)
C. Criticisms of classification
1. The system relies heavily on the medical perspective.
2. Reliability in diagnosis remains a problem; psychological disorders have "fuzzy borders." Different disorders share certain characteristics, for example, and a person might exhibit some, but not all, characteristics of a particular disorder.
3. Controversy exists regarding the existence of some disorders, such as dissociative identity disorder and premenstrual syndrome.