Lecture 2
Dale L. Johnson
THEORY
An Integrative Approach to Psychopathology
This chapter is of great importance
for everything that follows in the course. It sets the stage, primes the pump,
and prepares for the future. What is most important is that it departs from
older formuations of abnormal psychology that held that all mental disorders
were caused by poor parenting, or defective learning, or a failure to assert
oneself, or some other one thing. The integrative approach is based in the
results of the scientific method. Hypotheses are formed on the basis of what is
already known, and they are tested. This is done on a small scale and theories
are constructed to deal with the inter-connectiveness of various findings. The
scientific method has shown that all human behavior is complex.
One-dimensional models
These models say a problem is caused
by one thing. This is true for one disorder: Huntington's chorea, a disease
that first shows signs in dance-like movements of the limbs, goes on to
psychosis and ends with an early death. This is a genetic condition caused by a
single dominant gene and the environment is not involved.
Multidimensional
The term
"multidimensional" used to indicate that an understanding of mental
disorders can only come about through the examination of the phenomenon
(symptoms) from a number of perspectives. These include the following:
Behavioral
Biological
Emotional
Cognitive
Social
Developmental
There are other terms that mean
about the same thing: biopsychosocial, behavioral neuroscience, etc.
Genetic Contributions
It has been long suspected that most
of the mental disorders have some genetic component, but proof has been
elusive. As an example, several years ago, a group of researchers published a
report saying they had located the area of a gene for bipolar disorder. The
researchers worked with Amish families who live in Pennsylvania because they
have fairly high rates of bipolar disorder and very large families. A few
months later the researchers wrote another report saying they had expanded
their sample size, and the finding of a gene location disappeared. Also, they
discovered they had made errors in calculation for their first findings. Now,
two decades later, we still do not know about the genetics of bipolar disorder,
but it is clear that more than one gene is involved.
New
developments
The textbook tells us that the
heritability of IQ = 62%. This is impressive, but it is not 100%. What does it
mean? It means that if you want to get really good scores on tests of
intelligence such as the Wechsler Adult Intelligence Scale, or the SAT or the
GRE, you should carefully pick your parents. Smart parents tend to have smart
children. But, is it enough? Suppose smart parents spend their time fighting
with each other, telling the children they are stupid and should shut up, and
neglecting the children's education. The children would not be as bright as if
they grew up in a loving, harmonious household that placed great importance on
communication, reading books, asking questions, and discovering solutions to
problems. What one inherits is important, but so is the environment. The same
is probably true for the various mental disorders, but good research evidence
is lacking.
Behavioral
Genetics
Throughout the course, we will look
at estimates of genetic involvement in the various disorders. For an accurate
and concise summary of what is known about this, see Genetics and Mental
Disorders, a report of the National Advisory Mental Health Council, 1998.
It is available on-line at www.nimh.nih.gov/publist/984268.htm or go to
www.nimh.nih.gov/research/reportmenu.cfm and look for the genetics report. Read
it carefully and know what the various types of genetic research are and what
they can tell us. Get some idea of how the disorders differ in genetic loading.
Also, see if you can find your professor's name among the contributors to the
report.
There are several methods used in
determining the heritablity of human functions (see Durand & Barlow, p. 97
2000 edition; p. 138, 1999 edition). The oldest is the family study method.
This simply checks genealogies for the presence of a pattern of mental
disorder. It has shown clearly that many disorders run in families. A
limitation is that it does not offer a way of sorting out the genetic from the
environmental causes. A more satisfying way of looking at inheritance is the
use of twins. Twin studies are most often used and are reported throughout the
textbook. In these twins are examined for some characteristic; e.g., a
diagnosis of schizophrenia. They are then checked as to agreement--if one twin
has it, does the other? This agreement is called concordance. There are two
types of twins: identical (monzygotic or MZ) and fraternal (dizygotic or DZ).
Identical twins have exactly the same genetic structure, but fraternal twins
are only as much alike as non-twin siblings. Whether a disorder has a genetic
load depends on the differences in concordance between identical and fraternal
twins. Thus, for bipolar disorder the concordance for MZ is 62% and for DZ it
is 8%. For major depression the concordance for MZ is 40% and for DZ it is 17%.
The greater difference bewteen 62 and 8 (bipolar) than 40 and 17 (depression)
indicates that the heritability of bipolar disorder is greater. Twins are, of
course, usually reared together. This means that the effects of having a common
environment are always present. I once knew a pair of twins, Nina and Tina, who
were so much alike that Head Start teachers could not tell which was which.
Their mother called them, "Y'all" and did not know one from the
other. When I met them they were nearly four years old and neither talked. We
asked the mother to decide which was Nina and which Tina and we bought name
bracelets for them. Teachers referred to them by name, as did the mother. They
were both talking within two months. Apparently it is good to have one's
individuality recognized.
The environmental problem can be
solved by locating twins reared apart. This has been done, and the heritability
results are virtually the same as for twins reared together.
Adoption studies are done to control
for environmental effects. In this a baby separated from the mother early on is
followed into adulthood. Babies born to mothers with mental illness are
compared with babies born to normal mothers. All babies were reared in adoptive
homes that did not include parents with mental illness. The results for
schizoprhenia show that the prevalence is greater for people born to mothers
with schizophrenia.
Today, the emphasis in genetic
studies is on the search for specific genes. To do this, the general area of
the gene on a chromosome must be located. This is done through linkage studies,
linkage-disequilibrium studies, and association studies. Each of these is
dependent on the location of large extended families who include cases of
mental disorder. Complex statistical methods are used to determine location.
Interaction
of genes and environment
Yes, genetics is very important for
an understanding of mental disorders, but how does it work? In the simple and
most commonly used form it is assumed that genetics predisposes a person to
have a disorder, but that the disorder only arises with stress. This is the
diathesis-stress model. The problem is that it really does not help us to
predict who will develop a disorder with any useful accuracy. Only a few people
who have a parent with schizophrenia will ever develop schizophrenia. On the
other hand, it is not clear that stress is a necessary contributing cause of
schizophrenia.
At a more complex level, Nobel Prize
winner, Eric Kandel, has shown that the genetic structure of cells may change
with learning. Thus, the genetic-environment interplay goes both ways.
Furthermore, having a particular gene may increase the probability of
encountering environmental stress; e.g., a person genetically disposed toward
impulsiveness may have more accidents. A person genetically disposed to have
depression may compound troubles by seeking out difficult relationships. This
occurs commonly in borderline personality disorder.
Incidental note: The heritability of schizophrenia or major
depression is about the same as for such activities and preferences as wanting
to be a salesperson, voting conservative, or preferring to go to church on Sunday.
Using twins to determine heritability has revealed that an enormous number of
choices we make or preferences we have are to some degree genetically directed.
Neuroscience and its contribution to
psychopathology
Central Nervous System
In reading the book on this topic,
keep in mind (and in brain) that we are always interested in brain/behavior
interactions. There are few direct connections; i.e., tickle a specific part of
the brain with a bit of electric current and get a very specific emotion or
cognition. Most of the relations are not so simple and are highly complex.
Review the structure of the brain.
This has to do not only with major parts of the brain, e.g., the limbic system,
but also with finer points,e.g., neurtransmitter receptors. We could take this
down in a reductionistic way to the cell level (See Boyce Regensberger's Life
itself, on this).
Also review brain functions. In what
way do different parts of the brain communicate? Is it electrical or chemical?
Neurotransmitters
As you will see in your textbook,
the list of neurotransmitters involved in mental disorders is long, and
growing. These include dopamine, serotonin, gamma aminobutyric acid (GABA) and
norepinephrine, but clearly others are also involved. We have been told, by
researchers, and the pharaceutical manufacturers, that specific
neurotransmitters are linked specifically with certain mental disorders. Thus,
there was great excitement when it appeared that excessive dopamine was the
neurotransmitter for schizophrenia. Drugs could be designed to reduce the
amount of dopamine in the brain and people would be free of symptoms.
Unfortunately for this hypothesis, this revolution has not yet arrived. It is important for the student of abnormal
psychology to know that neurotransmitters are involved in brain function (they
are how the brain functions) and to have some idea about the relations believed
to exist. It is also important that one keep an open mind; research in this
area is still new and ignorance is general. For an excellent review of this
matter see Elliot Valenstein's Blaming the brain (Free Press, 1998).
Psychological Causes of Mental Disorder
No one doubts that being reared in a
hostile, critical, unloving, brutal environment is not conducive to good mental
health. However, whether such rearing causes mental disorder remains an open
question. Psychodynamic theory assumes that mental disorders are caussed by
poor parenting. The proponents of this theory have ignored evidence that more
often than not, people who develop, for example, bipolar disorder, grow up in
loving, caring, kindly homes. This does not fit the theory so rather than
change the theory, proponents of the theory deny the evidence.
One can begin with a different
question. Do people who are abused as children always develop mental disorders?
Some do. However, a recent study of univerity students, published in Psychological
Bulletin, found that many who reported having been abused, never developed
psychiatric symptoms. In Houston, at a treatment center for children who are
known to have been sexually abused, about half show symptoms of post-traumatic
stress disorder and/or depression. The other half are not symptomatic. Why do
some develop symptoms and others not? The question is open for more research.
One example is that reported by Lansford
et al. (2002, A 12-year prospective study of the long-term effects of early
child physical maltreatment on psychological, behavioral, and academic problems
in adolescence. Archives of Pediatric & Adolescent Medicine, 156,
824-830. Maltreated children were identified at age five through interviews
with mothers. Eleven percent of the 585 children had been maltreated. At
follow-up, when children were in high school.
Abused children were compared with those who were not abused. Results
showed abused children were less likely to plan on attending college, were absent more days, and had higher levels
of aggressive, anxiety, depression, dissociation, post traumatic stress, social
problems, cognitive problems than the
non-abused children. These results were obtained even with controls for
socioeconomic factors. The two groups did not differ on the self-report
measure, the Youth Self-Report form of the Child Behavior Checklist. Note that
mothers reported abuse initially and much later reported on behavior problems.
Multiple observer reports of early abuse and of adolescent problems would have
provided more persuasive evidence of long-term effects of child abuse.
It is possible to get a better idea
of the affects of abuse by examining extreme cases. There have been a few
instances of children being deprived of language interaction, of being treated
with a great amount of physical punishment, and of being kept from ordinary
human interactions. These children do not do well. They typically lack language
and acquire it only slowly. Their attitudes and behaviors continue to be
affected, and their growth is impaired. These studies demonstrate that growth
of all human functions is affected by very bad early rearing.
Can a person be driven crazy by
other people or experiences? Again, it is a popular idea that this is so, but
the evidence is lacking. For example, during World War II, men involved in
actual fighting in the South Pacific were less likely to receive a diagnosis of
schizophrenia than men who did not engage in actual warfare. Most likely, the
non-combatants were not put into action because they were perceived by
superiors as vulnerable. Or, commonly, men had psychotic breakdowns shortly
after being drafted into military service. This was typically at about age 19
when men are most susceptible to developing schizophrenia. We will return to
this issue later.
Behavioral and Cognitive Science
The list of things involved in
learning and cognition is long and very important, but I am going to skip this
for now. Your textbook is really good on this matter. You need to know about
+ Conditioning and cognitive
processes
Pavlov
+ Operant learning (Oddly, the
textbook does not mention this very important type of learning. The principles
derived from it are used to create treatment programs for people with severe
mental disorders. These are the token economies and social learning programs.
More on this later.
B. F. Skinner played a
key role in the development of knowledge about this kind of learning.
+ Learned helplessness
Seligman
+ Social Learning
Modeling, observational,
vicarious. Bandura
+ Prepared Learning
Fear of snakes
evolutionary?
+ Cognitive science and the
unconscious.
We collect, store and
act on information that we have not been aware of; e.g., blind sight. Being
“blind”, but able to respond to visual cues.
This is a nneurological condition.
+ Hypnotic suggestion.
+ Implicit memory. The person acts
on the basis of personal past history, but cannot remember the past
events. He knows them, but does not know them. There are different kinds of
knowing.
Emotions
Emotions are involved in all mental
disorders, and everything else. I will only say one thing about this area,
although it deserves much consideration. Emotions and cognitions are separate
only in psychology textbooks. Emotions have cognitive components, and vice
versa. For example, I become angry about something another person has done. The
other person has smashed into my new, dent-free car and it was not my fault. I
am angry. Does this mean the other person made me angry? No, that is not
possible. Another person cannot make one angry. I made myself angry. When I saw
what had happened to my car I made a judgment: it is wrong for my car to be
smashed. I value that car, and I value having a car that is free of dents. The
world is wrong now because what I have judged to be right and good has been
violated. I could have looked at the dented car and judged that dents in cars
do not matter. I don't care if it is totally smashed. I value other things, but
not that. If this is the judgment, there is no anger, my world is not violated,
it is not wrong. But don't take my word for it, try it out for your own
emotions. Try anger, joy, fear, etc. For an interesting discussion of this, see
Robert Solomon's The Passions. Solomon is a UT-Austin professor of
philosophy who writes about experiential matters.
Cognition enters into the matter of
emotions in another way. We sometimes have emotional experiences that are
extremely unpleasant, and we declare (to ourselves) "I will never let that
happen to me again." Thus, if the experience was related to flying in an
airplane, I will never go up in an airplane again. This judgment is common in
anxiety disorders, and may be present in a wide variety of mental disorders.
Cultural, Social, and Interpersonal
Factors
The relation of culture to mental
disorders remains a fascinating mystery. There are many definitions of culture.
I like Redfield's of 1940: "An organization of conventional understandings
manifest in act and artifact, which, persisting through tradition,
characterizes a human group." There is no doubt that culture is involved
in the definition of mental disorder and its treatment. The mystery is in
finding cross-cultural patterns of culture and mental disorder relations.
Years ago I was invited to be part
of a study of the way the Navajo (Westen New Mexico and Arizona American
Indians) categorized mental illnesses. The project director interviewed many
Navajo leaders and obtained names of people whose behavior was regarded as
deviant by the Navajo people. He learned the names of the types of behavior,
names of behavior syndroms. My job was to go out into the Navajo country, find
the people whose behavior was deemed deviant, and interview them and their
relatives. I did this for three summers. We found that the Navajo had a complex
system of psychiatric classification and that the disorders they identified
were treated in specific ways according to their system of healing. This was
primarily though Sings conducted by specialist healers. Their categories were
different from ours, but they over-lapped. For example, one Navajo category was
I'chaa (the moth) which was comprised of various kinds of loss of
consciousness. It included grand mal seizures and fainting spells. This
over-laps with our "epilepsy," but we wouldn't include fainting
spells as a type of epilepsy. Their disorder was called "the moth"
because it was believed that if a person was involved in incest by having sex
with a relative or being the offspring
of an incestuous relationship, then eventually a moth would grow just behind
the forehead and would flutter its wings and be attracted to fires. The person
would have a seizure and fall into the fire,
something that is likley to happen if one lives in a small, round house.
The Navajo healers were interested
in how Modern America handled similar cases. For example, they had no objection
to my taking a young woman with i'chaa to the public health doctors for
treatment of her epileptic seizures, in part because ways of treating i'chaa
have been lost. Today, many Navajo singers work with doctors in public health
clinics to combine Navajo and modern treatments.
Culture defines illnesses and their
treatment. The wise practitioner always wants to know how an illness is defined
by the patient and the patient's family, and shapes treatment around this
belief. There is no evidence, however, that treatments found to be effective in
treating mental disorders for majority population patients are any less effective
for patients of minority ethnic groups. Thus, in a recent study, it was found
that cognitive-behavior therapy was just as effective for Puerto Rican
adolescents who were depressed, as for adolescents in Pittsburgh or London or
Los Angeles.
Gender
Many disorders show gender effects.
Women are more likely to have become depressed, men are more likely to have an
antisocial personality disorder. Just as important, some mental disorders
(schizophrenia and bipolar disorder) do not show gender differences.
Social Effects on Health and Behavior
Socio-Economic
Status
A person's socio-economic status
(SES), as indexed by parental education and occupation, is one of the best
predictors of how that person will fare in life. Measures of SES seem to be
related to nearly everything. For example, they predict school performance
about as well as IQ measured in the preschool years. People of low SES have a
shorter life expectancy. SES may be measured in several ways, but sociologists
(the experts on this matter) prefer to use occupational status. Thus, a lawyer
has a higher status than a plumber, even though the plumber may have a higher
annual income. In my own work with children, I have used the Hollingshead
measure which combines occupational status and education of both parents of a
child. This measure is a excellent predictor of behavior.
In examining ethnicity effects it is
essential that SES be considered as well. In the USA many people of minority
ethnic status also have lower SES status. Unless SES is controlled, behavior
may be attributed to minority status
when it is actually a function of SES.
Social
Network
This is complex and it is difficult
to find consistent patterns of relations between social network and other
variables. For example, most research shows that having a social network that
is larger (more people in one's network of friends) is negatively related to
presence of depression. However, we found in research in San Antonio with
Mexican American women that a broad social network was positively related to
depression; that is, the more people in the network the more likely the person
is depressed. However, these networks were made up primarily of relatives. The
women told us that having so many relatives and so many obligations to them was
a burden. We found, as have others, that the important thing for successful
coping is to have one or two confidants, intimate friends (or a spouse) rather
than a broad network. A little, consistent support goes a long way toward sound
mental health.
Social
Stigma
There is no doubt that people with
mental disorders are stigmatized. This has been true for a very long time and
in all parts of the world. It is interesting now to see people who are in the
public eye come forward to acknowledge that they have a mental disorder. These
include Patty Duke and Rod Steiger (actors), William Styron (writer), Kay
Jamison and Norman Endler (psychologists), Lionel Aldridge and Earl Campbell
(professional football players) and so on. The testimonials of thse people has
reduced some of the stigma associated with mental disorder. There is also
evidence of stigma in media presentations; for example, I recall reading that
John Elway (Broncos quarterback) had a "schizophrenic afternoon,"
meaning he did poorly in the first half of a game and very well in the second
half. His perfomance was "split" and uninformed sports writers still
assume that schizophrenia refers to a "split personality." It does
not and the sports writer's ignorance of this leads to stigmatizing comments.
In general, people who have a
psychiatric disorder prefer first person language. This means that one says
"a person with manic-depression" rather than "a
manic-depressive." It is less stigmatizing to think that it is a person
who has a disorder than to think of the person as being characterized by the
disorder, as though there is nothing else to him or her.
Global Incidence of Psychological
Disorders
A study recently reported by the
World Health Organization found that world-wide the ten greatest sources of disability
included depression, schizophrenia and bipolar disorder. Depression rates are
very high in underdeveloped countries, and expected to increase.
The disorders discussed in the
textbook occur everywhere in the world. However, there are differences in rates
by nation. Attention Deficit Hyperactivity Disorder is virtually unknown in
some parts of the world, but is regarded as a sizable problem in the USA.
Principle of Equifinality
This principle means we must usually
consider a number of paths to a given outcome. That is, depression may have
multiple causes, even in cases of bereavement after the loss of a loved one. In
this instance, it seems that the loss of a loved one would be a sufficient
cause of depression. But why does one person have such a loss, grieves, and
recovers quite quickly while another person goes into a deep and lasting
depression? Is one person more resilient? Is the other somehow predisposed? In
understanding the mental disorders all of the possible causes must be explored.
One More
Thing
We have seen that genetics and psychosocial matters play a
role in the development of abnormal behavior. Now, because of recent research
we must add another important cause. Gerns, that is bacteria and viruses (to
say nothing of prions at this point) are involved in the development of many
kinds of abnormal conditions. One is the role of bacteria (helicobacter pylori)
in the development of stomach ulcer. Another is the mounting evidence that at
least some forms of schizophrenia have a viral cause. Quite likely other
disorders such as obsessive compulsive disorder will be found to have a viral
or bacterial basis. How important bacteria and viruses will be found to be in
the cause of other disorders remains to be seen.