Psychopathology: Psychopathology: the thin line that separates sanity from the thin line that separates sanity from

madnessmadness

““To study the abnormal is the To study the abnormal is the best way of knowing the best way of knowing the

normal” normal” W. W. JamesJames

Fun to hear about uncommon Fun to hear about uncommon disorders… disorders…

Limbic psychotic trigger reactionsLimbic psychotic trigger reactionsSudden brain seizure triggered by Sudden brain seizure triggered by

harmless sight or sound causes some harmless sight or sound causes some men to fly into violent ragemen to fly into violent rage

18 cases (14 murders): quiet, 18 cases (14 murders): quiet, unassuming loners suddenly erupt into unassuming loners suddenly erupt into violence, only to just as suddenly recoil in violence, only to just as suddenly recoil in horror at their actions, gripped by horror at their actions, gripped by remorse!remorse!

BUT… BUT…

Historical RootsHistorical Roots

Caused by evil spirits…Caused by evil spirits…Need an Need an openingopening to escape to escape

Witchcraft, demonic possession, full Witchcraft, demonic possession, full moon, supernatural forces…moon, supernatural forces…Exorcism, torture, primitive surgery, Exorcism, torture, primitive surgery,

bloodletting, bitter poisons, starvation, bloodletting, bitter poisons, starvation, noise-makingnoise-making

Today: Medical perspective & Today: Medical perspective & Psychological perspectivePsychological perspective

DebateDebateBiological conditions Biological conditions

vs.vs. Past & present life experiences (natural Past & present life experiences (natural

disasters to abuse, divorce, illness, etc.)disasters to abuse, divorce, illness, etc.)PsychoanalyticPsychoanalytic

Parental influences, unconscious, defense Parental influences, unconscious, defense mechanismsmechanisms

Behaviorial & CB Behaviorial & CB Reward, punishment… perceptions, Reward, punishment… perceptions,

expectations, beliefsexpectations, beliefsANDAND… … Diathesis-Stress ModelDiathesis-Stress Model

““Pibloktoq”Pibloktoq”

Intense excitement, seizures, then Intense excitement, seizures, then coma.coma.Tear off clothing, break furniture, shout Tear off clothing, break furniture, shout

obscenities, eat feces… later forget obscenities, eat feces… later forget

Diagnosis: A Necessary StepDiagnosis: A Necessary Step

DSM-IV Disorders DSM-IV Disorders (we’ll discuss)(we’ll discuss)

AAnxietynxiety- GAD, Panic, phobias, OCD, PTSD- GAD, Panic, phobias, OCD, PTSDSSomatoformomatoform- Hypochondriasis, conversion- Hypochondriasis, conversionDDissociativeissociative- Amnesia, fugue, DID- Amnesia, fugue, DIDMMoodood- Depression, mania, bipolar - Depression, mania, bipolar SSchizophrenicchizophrenic- Paranoid, Disorganized, - Paranoid, Disorganized,

Catatonic, Undifferentiated, ResidualCatatonic, Undifferentiated, ResidualPPersonalityersonality- borderline, antisocial- borderline, antisocial

Who’s crazy here anyway?Who’s crazy here anyway?

However much we may be personally However much we may be personally convinced that we can tell the normal from convinced that we can tell the normal from the abnormal, the evidence is simply not the abnormal, the evidence is simply not compellingcompelling

Rosenhan, 1973 Rosenhan, 1973 “On being Sane in Insane “On being Sane in Insane

Places”Places”

““Hollow, Empty, Thud”Hollow, Empty, Thud”

Described Described true life historiestrue life histories, relationships, etc. , relationships, etc.

Ceased Ceased anyany symptoms, tried to convince staff of sanity symptoms, tried to convince staff of sanity to be discharged (BY THEIR OWN DEVICES)to be discharged (BY THEIR OWN DEVICES)

How many were identified as SANE?How many were identified as SANE?

How long did it take…How long did it take…

……had a close relationship with his mother had a close relationship with his mother but was rather remote from his father but was rather remote from his father during his early childhood. During during his early childhood. During adolescence and beyond however his adolescence and beyond however his father became a close friend while his father became a close friend while his relationship with his mother cooled. His relationship with his mother cooled. His relationship with his wife was relationship with his wife was characteristically close and warm. Apart characteristically close and warm. Apart from occasional angry exchanges, friction from occasional angry exchanges, friction was minimal, the children had rarely been was minimal, the children had rarely been spanked.spanked.

“This white 39-year old male manifests a long history of considerable ambivalence in close relationships, which begins in early childhood. A warm relationship with his mother cools during adolescence. A distant relationship to his father is described as becoming very intense. Affective stability is absent. His attempts to control emotionality with his wife and children are punctuated by angry outbursts and in the case of the children, spankings. And while he says that he has several good friends, one senses considerable ambivalence embedded in those relationships also.”

Role of ExpectationsRole of Expectations7 Schizophrenic diagnoses; 1 bipolar7 Schizophrenic diagnoses; 1 bipolar

““I’m fine, no longer experiencing any I’m fine, no longer experiencing any symptoms”symptoms”

Pseudopatients’ behavior caused by Pseudopatients’ behavior caused by situationsituation (e.g. boredom, hunger)(e.g. boredom, hunger)

Interpreted by staff as reflecting Interpreted by staff as reflecting psychopathologypsychopathology

Length of stay 7-52 Length of stay 7-52 days!days!

No one detectedNo one detected EXCEPT…EXCEPT…

• Diagnoses are often not reliable or useful

•Sane needlessly stigmatized / feigned insanity excused

Line betweenLine between

Mental health professionals Mental health professionals determine determine (judge)(judge) where on the continuum behavior where on the continuum behavior lieslies

Which criteria to use?Which criteria to use? Bizarreness of BehaviorBizarreness of Behavior Persistence of BehaviorPersistence of Behavior Social DevianceSocial Deviance Subjective DistressSubjective Distress Psychological HandicapPsychological Handicap Effect on FunctioningEffect on Functioning

Normal Abnormal

Beware!Beware!

Medical Students Disorder is prevalent among psych students

Psychological disorders are just exaggerations of tendencies that all of us have

Being sad, anxious, or proud does not mean we are suffering from depression, narcissism,

anxiety disorder or schizophrenia

Detailed ExamplesDetailed Examples

1.1. AAnxietynxiety- - OCDOCD

2.2. SSomatoform-omatoform- HypochondriasisHypochondriasis

3.3. DDissociative-issociative- DIDDID

4.4. MMood-ood- DepressionDepression

5.5. SSchizophrenicchizophrenic-- SchizophreniaSchizophrenia

6.6. PPersonality-ersonality- borderline, borderline, antisocialantisocial

1. 1. OCDOCDRecurrent, intrusive, unwanted thoughts and compulsive Recurrent, intrusive, unwanted thoughts and compulsive

actionsactions One boy washed hands so much they became raw & One boy washed hands so much they became raw &

bloodiedbloodied One boy ran up and down the stairs 63 times/ dayOne boy ran up and down the stairs 63 times/ day Woman determined to keep eyebrows symmetric, plucked Woman determined to keep eyebrows symmetric, plucked

them all outthem all out Woman spent 8hrs/ day bathingWoman spent 8hrs/ day bathing Man couldn’t leave subway without picking up all litterMan couldn’t leave subway without picking up all litter Man’s apartment stacked to ceiling with dishes, dirty Man’s apartment stacked to ceiling with dishes, dirty

clothes, collected objects he couldn’t throw awayclothes, collected objects he couldn’t throw away

MENTALLY NEUTRALIZE unacceptable thoughts and behaviorsMENTALLY NEUTRALIZE unacceptable thoughts and behaviors

Treatment: “refocusing” to “unlock” the area stuck in its Treatment: “refocusing” to “unlock” the area stuck in its pattern. Label & refocus to constructive activitypattern. Label & refocus to constructive activity

Obsessions & CompulsionsObsessions & Compulsions

Dirt, germs, contaminationDirt, germs, contamination 55%55%

Aggressive impulsesAggressive impulses 50%50%

Need for symmetryNeed for symmetry 37%37%

Bodily concernsBodily concerns 35%35%

Forbidden sexual impulsesForbidden sexual impulses 32%32%

CheckingChecking 79%79%

WashingWashing 58%58%

CountingCounting 21%21%

2. Hypochondriasis2. Hypochondriasis

Guess who?Complained of dizzy spells, numbness in

fingertips, nausea, indigestion, chest pains, and other assorted ailments…

Chronic, unwarranted preoccupation w/ one’s physical health. Highly sensitive to NORMAL bodily sensations

“The whole day was planned out to suit him, to be ready for reading aloud to him, to go on his walks with him, and to be constantly at hand to alleviate his daily discomforts”

““Place your foot in this ice Place your foot in this ice water”water”

Until can’t tolerate itUntil can’t tolerate it

Heart rateHeart rate

TemperatureTemperature

Rate “unpleasantness”Rate “unpleasantness”

Heightened SensitivityHeightened Sensitivity

Hypochondriacs:Hypochondriacs:Removed their Removed their

foot foot soonersooner Rated cold as Rated cold as

moremore unpleasantunpleasant Showed Showed more more

physiological physiological reactivityreactivity to to stimulationstimulation

3. 3. DissociativeDissociative Identity Disorder Identity Disorder

Learn to cope with trauma by Learn to cope with trauma by mentally divorcing part of self from mentally divorcing part of self from pain & sufferingpain & sufferingConstruct alternative identities in which Construct alternative identities in which

to liveto live

9X more prevalent in women9X more prevalent in women

88% victims of sexual abuse88% victims of sexual abuse Ea. May have own voice, speech pattern, Ea. May have own voice, speech pattern,

habits, memories, sexual orientation, habits, memories, sexual orientation, clothing, handwriting, brain-wave, BP, clothing, handwriting, brain-wave, BP, eyeglass prescription, rxns…eyeglass prescription, rxns…

Skeptical?Skeptical?

1817-19701817-1970**: < 200 cases: < 200 casesFaking for personal gain? UndetectedFaking for personal gain? UndetectedTherapists now more sensitive?Therapists now more sensitive?Therapists overdiagnose OR suggest Therapists overdiagnose OR suggest

& reinforce& reinforce

Billy MilliganBilly Milligan

4. Depression: “The common 4. Depression: “The common cold”cold”

Universal; 2x women; 12-21% will Universal; 2x women; 12-21% will experienceexperience

Emotional, Cognitive, Motivational and Emotional, Cognitive, Motivational and Somatic symptoms Somatic symptoms without discernible without discernible cause, >2 wkscause, >2 wks Profound sadnessProfound sadness Diminished interest in food, sex, social banterDiminished interest in food, sex, social banter Intense worthlessness, guilt, self-blameIntense worthlessness, guilt, self-blame Restlessness, agitationRestlessness, agitation Depleted energyDepleted energy Recurring thoughts of suicide & deathRecurring thoughts of suicide & death

A cause?A cause?

Power & controlPower & controlActionAction consequence consequenceImagine feeling unable to have an effect Imagine feeling unable to have an effect

on life eventson life events

If expect bad things to happen over which If expect bad things to happen over which you have little controlyou have little control

Feel hopeless about making positive changes in Feel hopeless about making positive changes in your lifeyour life

Learned Helplessness in Learned Helplessness in HumansHumans

More likely to become depressed if More likely to become depressed if attribute failure to:attribute failure to:INTERNAL: “It’s my fault”INTERNAL: “It’s my fault”STABLE: “It won’t change”STABLE: “It won’t change”GLOBAL: “It affects my whole life”GLOBAL: “It affects my whole life”

Expectation one cannot control Expectation one cannot control important life outcomes important life outcomes pessimism, hopelessness, despairpessimism, hopelessness, despair

Explanatory Styles and Explanatory Styles and DepressionDepression

First-year collegeFirst-year college Two years later, Two years later,

p’s w/ negative p’s w/ negative style style (internal, (internal, stable, and global)stable, and global) were more likely were more likely to experience a to experience a major or minor major or minor depressive depressive disorder.disorder.

5. Schizophrenia5. Schizophrenia

““I wish you a happy, joyful, healthy and I wish you a happy, joyful, healthy and fruitful year, and many good wine years fruitful year, and many good wine years to come as well as a healthy and good to come as well as a healthy and good apple year, and sauerkraut and apple year, and sauerkraut and cabbage and squash and seed yearcabbage and squash and seed year

To E. Bleuler, 1911To E. Bleuler, 1911NoteNote “Split mind” = “Split mind” = split between split between

thoughts, perceptions, behaviors, emotions thoughts, perceptions, behaviors, emotions and other brain functions (NOT Selves)and other brain functions (NOT Selves)

““I felt like I was the only sane I felt like I was the only sane person in a world gone crazy”person in a world gone crazy”

1. Incoherent thinking/ word salad

2. Delusions- “influence”- thoughts being broadcast in public, stolen, controlled; also reference, persecution, grandeur.

3. Hallucinations- sensations w/out stimulation (e.g. Son of Sam’s barking dog)

4. Disturbance of affect- flattened/ inappropriate

5. Bizarre behavior- withdrawal, exile, self-talk, statue poses, backwards, circles, lack self-insight

Next time: treatmentNext time: treatment

Charles MansonCharles Manson

Reactions of People with Reactions of People with Social Phobias ISocial Phobias I

Social PhobiaSocial Phobia An intense fear of An intense fear of

situations that invite situations that invite public scrutinypublic scrutiny

Socially phobic and Socially phobic and non-phobic adults non-phobic adults prepared a speech.prepared a speech.

Both groups showed Both groups showed increased heart rate in increased heart rate in anticipation of the anticipation of the speech.speech.

Anxiety Disorders Anxiety Disorders Reactions of People with Reactions of People with

Social Phobias IISocial Phobias II

However, only However, only those with social those with social phobia reported phobia reported feeling more feeling more anxious.anxious.