Transcript Part - time MSc course Epidemiology & Statistics Module

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Abnormal Psychology
and
Personality Disorders
An Introduction
Prof. Craig Jackson
Head of Psychology
Birmingham City University
Abnormal?
Core models (with several variations within them) attempt to offer
diagnosis, definitions and frameworks for abnormality
Each approach also attempts to ‘treat’ abnormality in their distinct way
Treating the mentally ill is problematic, not least because of the number of
approaches, cultural variations, lack of consensus and human error involved
in the prognosis and treatment of mental disorders.
Definition & Frame of Reference
Abnormal?
Normal?
Normative
Ideographic Vs Nomothetic
Statistical
Consensus
Social approval
Definition & Frame of Reference
Abnormal behaviours?
Criminal
Mad
Bad
Unethical
Mad – Bad Overlap
Distinguishing
Definition & Frame of Reference
At the risk of offending. . .
Biological
Traditional mode
l
of Disease Deve
lopment
Pathogen
Disease (pa
thology)
Modifiers
Lifestyle
Individual sus
ceptibility
Non-Specific Symptoms
Biological
(Kraepelin, 1855-1926; Tyrer & Steinberg,1998)
Imbalances of neurotransmitters & hormones
Genetic vulnerabilities
Brain dysfunction
Acetylcholine -
Alzheimer’s disease: reduced
Dopamine -
Schizophrenia: reduced
Norepinephrine -
depression: abnormal
Serotonin -
depression: reduced
Biological
Abnormal behaviour results from a physical illness
There is a discrete cause, prognosis and where mental health can be
physically treated
Modern mental health legislation is a result of the medical model
Kraepelin (1856-1926) carefully observed, described and catalogued
symptoms of patients displaying abnormal behaviour resulting in the
development of two major classification systems
DSM V - TR
American Psychiatric Association (also used in the UK)
first published in 1952
DSM system is a multi-axial system allowing an individuals mental state
to be evaluated on five axes:
Axis 1: Presence or absence of clinical syndrome
Axis 2: Presence or absence of stable long-term conditions
(personality disorder/learning disability)
Axis 3: Physical health information
Axis 4: Psychosocial/Environmental Problems
Axis 5: Global level of functioning
range from 1 (persistent violence, suicidal behaviour or inability to
maintain personal hygiene to 100 (symptom free)
DSM V – TR
Axis 1:
Cocaine-related disorders
Axis 2:
Anti-social personality disorder
Axis 3:
Exhaustion; Fatigue
Axis 4:
Drug-using partner; history of cannabis-related use; extremes stress
Axis 5:
Level of current functioning: 50
(frequent trips to A&E, instability, erratic eating behaviour, mood swings)
Psychodynamic & Psychoanalytic
(Freud, 1900; Jung, 1912; Klein, 1927)
The child is father of the man
Effects of early experiences
(Oedipus complex, Electra complex, attachment)
Effects of trauma
(abuse, deprivation)
Anxiety, defence mechanisms & unresolved conflicts
(repression, denial)
Psychodynamic & Psychoanalytic
Abnormal behaviour results from underlying
unconscious conflict or psychopathology
(Wachtel & Messer, 1997)
Model based on Freud’s stages of Psychosexual
Development and the resulting conflict
between the ID, Ego and Superego
Conflict is managed (unconsciously) by
defence mechanisms (e.g. repression, denial and projection)
Mental health problems are a result of either ego anxieties (fixation
during a developmental stage) or the defence mechanisms.
Psychodynamic & Psychoanalytic
Oral Stage (18-24 months) gratification through sucking, crying or oral
exploration. Driven by the ID and therefore selfish pleasure is more
important aspect.
Anal Stage (24-48 months) gratification via anus, infant aware of impact on
others and begins to understand they are rewarded for being good and
punished for being bad. Development of the Ego.
Phallic Stage (48 months-6 years) Superego development characterised by
child’s experiences of sexual conflict (oedipal complex and penis envy).
Latency Stage (6 years-puberty onset) Sexual and aggressive urges
channelled through sport and hobbies.
Genital Stage (Puberty-Adulthood) Individual driven by sex and aggression
but these are balanced and discharged via appropriate means.
Psychodynamic & Psychoanalytic
Oral Stage:
Depression, Narcissism, Dependence
Anal Stage:
OCD, Sadomasochism
Phallic Stage:
Gender Identity Problems, Antisocial Personality
Latent Stage:
Inadequate or Excessive Self-Control
Genital Stage:
Identity Diffusion
Psychodynamic & Psychoanalytic
Positives
• Discovery of the unconscious
• Ideas of transference learn relationships & transfer onto significant others
• Alternative to the medical model
• Without the need for medical intervention - long-term outpatient treatment
• Linked to theory of personality
Negatives
• Freudian processes (e.g. Ego) are unconscious and cannot be tested!
• Theories based on a small group of middleclass Viennese women
• Freud’s theory constantly changed over time and without any reason
• Freud would have been classed as ‘abnormal’ by DSM!
Behavioural
Toxic exposure
Social Learning
Conditioning (secondary gains)
Labelling theory
Cognitive
(Skinner, 1953; Ellis, 1977)
Cognitive distortions
Self schemas
Attributions
Psychosocial
Stress
Gender
Socio-economic class
Race
Disability
Inequality
Neglect, abuse, deprivation
Family discord & breakdown
“Bio” Psychosocial
Dominance of
th
Mainstream in
e biopsychoso
last 15 years
cial model
Hazard
Illness (well-be
ing)
Psychosocial
Factors
Attitudes
Behaviour
Quality of Life
Rise of the per
son as
a “psychologic
al
entity”
Cultural
Prejudice, and discrimination
Social change & uncertainty
Urban stressors – violence and homelessness
Family Systems Model
Family and other social groups are interrelated and
what happens to one individual in the group will affect
another
Good interactions with other people help to prevent
mental health problems (e.g. depression) and bad ones
may increase the risk
Systemic therapy approaches aim to look at the functionality of the
family in terms of both their overall structure (Structural Family
Therapy) and their ability to adjust to the
Demands placed upon them (Strategic Family
Therapy)
The importance of the family systems model is
that it moves beyond the individual
Personality Disorder
Inflexible
Pervasive
Egosyntonic
Maladaptive coping skills
Depression
Anxiety
Distress
Adolescent / Childhood trauma
Diagnosis rare in children
Do you have…
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
An obvious self-focus in interpersonal exchanges
Problems in sustaining satisfying relationships
A lack of psychological awareness
Difficulty with empathy
Problems distinguishing the self from others
Hypersensitivity to any insults or imagined slights
Vulnerability to shame
Haughty body language
Flattery towards people who admire and affirm you
Detesting those who do not admire you
Using other people without considering the cost of doing so
Pretending to be more important than you really are
Bragging / exaggerating (subtly but persistently) achievements
Claiming to be an "expert" at many things
Inability to view the world from the perspective of other people
Deny remorse
Thomas 2012
Personality Disorder
Fixed views and beliefs
Faulty schemata / Dysfunctional schemata
Inflexible behavioural patterns
Social and Personal difficulties
1 in 10 UK population
Personality Disorder – Causes?
Oversensitive temperament at birth
Excessive admiration never balanced with reality
Excessive praise for good behaviours
Excessive criticism for bad behaviours in childhood
Overindulgence and overvaluation by parents & others
Being praised for exceptional looks / abilities by adults
Severe emotional abuse in childhood
Unpredictable or unreliable caregiving from parents
Valued by parents as way to regulate their self-esteem
Groopman & Cooper 2006
Diagnosis
Must satisfy following criteria
as well as specific criteria for
specific PD under
consideration
Subjective and contentious
Some disagreement between
ICD 10 and DSM IV
• Characteristic enduring behaviour and inner
experience deviate markedly from cultural norm, in
more
than
one
of
the
following:
Cognition + Affectivity + Impulse control + Relating
• Inflexible, dysfunctional, maladaptive behaviour
across many social situations
• Personal distress & Impact on social environment
• Deviation is stable & of long duration:onset in adol.
• Exclude other mental disorders
• Exclude organic brain / neuropsychological disease
DSM V - Axis II
Cluster A
Paranoid PD + Schizoid PD + Schizotypal PD
Cluster B
Antisocial PD + Borderline PD
Histrionic PD + Narcissistic PD
Cluster C
Avoidant PD + Dependent PD
Obsessive Compulsive PD
NoS
PD not otherwise specified
7 deadly sins…
Hotchkiss et al. 2003
SHAMELESSNES: the inability to process shame in healthy ways.
MAGICAL THOUGHTS: Narcissists see themselves as perfect, using distortion and illusion
known as magical thinking. They also use projection to dump shame onto others.
ARROGANCE: A narcissist who is feeling deflated may re-inflate by diminishing others
ENVY: A narcissist may secure a sense of superiority by using contempt to minimize others.
ENTITLEMENT: Narcissists hold unreasonable expectations of particularly favourable treatment
and automatic compliance because they consider themselves special. Failure to comply is
considered an attack on their superiority, and the perpetrator is considered an "awkward" or
"difficult" person. Defiance of their will is a narcissistic injury that can trigger narcissistic rage.
EXPLOITATION: Can take many forms but always involves the exploitation of others without
regard for their feelings or interests. Often the other is in a subservient position where resistance
would be difficult or even impossible.
POOR BOUNDARIES: Narcissists do not recognize that they have boundaries and that others
are separate and are not extensions of themselves. Others either exist to meet their needs or may
as well not exist at all. Those who provide “Narcissistic supply” to the narcissist are treated as if
they are part of the narcissist and are expected to live up to those expectations.
Paranoid PD
Suspiciousness + Mistrust of others + Paranoid
Hyper-sensitive /easily offended
Vigilant scanning to confirm their beliefs
Guarded + Constricted emotional lives
Incapacity for emotional relationships
Isolated lifestyle
Subtypes
Fanatic + Malignant + Obdurate
Querulous + Insular
Schizoid PD
Tendency to insularity
Emotional coldness
Secrecy
No interest in social relationships
Sexually apathetic
Avoidant attachment styles
Subtypes
Languid + Remote + Depersonalised + Affectless
Antisocial PD
Disregard for others
Violation of others' rights
Psychopathy
Sociopathy
Lack of remorse + Lack of empathy
Irresponsible work behaviour
Promiscuity
Lying / stealing
Boundary violations
Subtypes
Covetous + Reputation defending + Risk taking
Nomadic + Malevolent
Borderline PD
Variability of mood
Unusual instability of mood
Idealisation & Devaluation of others
Chaotic relationships
Disturbed sense of self
Subtypes
Discouraged + Petulant + Self-destructive + Impulsive
Histrionic PD
Excessive emotionality
Need for approval
Seductiveness
Attention-seeking + Exhibtionist
Lively, dramatic, flirtatious
Manipulative behaviour
Successful and high-functioning
Subtypes
Theatrical + Infantile + Vivacious + Appeasing
Tempestuous + Disingenuous
Obsessive Compulsive PD
Preoccupation with orderliness
Perfectionism
Mental and personal control
Lack of flexibility, openness, efficiency
Routine & rule obsessed
Conscientious
Subtypes
Conscientious + Puritanical + Bureaucratic
Parsimonious + Bedeviled
Anxious (avoidant) PD
Social inhibition
Inadequacy
Sensitivity to negative evaluations
Avoidance of social interaction
Socially inept
Shyness + Low self-esteem
Subtypes
Conflicted + Hypersensitive + Phobic
Self-deserting
Dependent PD
Pervasive dependence on others
Reliant on others to fulfill emotional needs
Low view of self
Feel inadequate
Feel helpless
Subtypes
Disquieted + Accommodating + Immature
Ineffectual + Selfless
Other PD
Narcissistic
Passive-Aggressive
Eccentric
Haltlose
Psychoneurotic
Immature
Unspecified
Mixed and Other
Narcissistic PD
Unprincipled narcissist
Deficient conscience; unscrupulous, amoral, disloyal, deceptive,
Amorous narcissist
Sexually seductive, enticing, glib and clever; declines real intimacy
Compensatory narcissist
offsets deficits by creating illusion of being superior, exceptional,
Elitist narcissist
Feels privileged and empowered by virtue of special childhood status and pseudo
achievements
Fanatic narcissist
heroic or worshipped person with a grandiose mission.
Narcissistic Personality Inventory
Raskin & Terry 1988
Measures 7 factors over 40 items (fixed choice)
Authority
Superiority
Exhibitionism
Entitlement
Vanity
Exploitativeness
Self-sufficiency
Raskin, R.; Terry, H. (1988). "A principal-components analysis of the Narcissistic Personality Inventory and
further evidence of its construct validity". Journal of Personality and Social Psychology, Vol 54(5), 890-902.
Narcissistic Personality Inventory
Score high on the NPI?
More likely to:
Cheat in games and sports
Cheat in relationships
Take more resources for self
Leave fewer resources for others
Value material things
Obsess about appearance
Narcissistic Personality Inventory
US undergraduate students
Twenge et al., 2008
Narcissistic Personality Inventory
Legal Defence
Diagnosis or suspicion of PD
not a legal defence
May be a mitigating factor
Does not prevent individual
from knowing law and ethics
Questions about PD
Treatment locations
Prison v. Hospital
Nicola Edgington case
Ethicality of treatment
Mental Health Act
Use to treat individual if harm to
themselves or others
Long term process
What right do we have to
change a fundamental?
Questions about PD
Relatively new area
Contradictory status
Curable / incurable
Whose role?
Cultural diversity weakens clarity of diagnosis
Some References
Bennett, P. (2005). Abnormal and Clinical Psychology – An Introductory Textbook (2nd Ed.) Open University Press: Berkshire & New York
Butcher, J.N., et al (2008) Abnormal Psychology: concepts. Ch 2. Pearson.
Carr, A. (2001). Abnormal Psychology, Psychology Press: Hove & New York
Ellis, A. (1977). The basic clinical theory of rational-emotive therapy, in A. Ellis & R. Grieger (eds) Handbook of Rational-Emotive Therapy.
New York: Springer
Freud, S. (1900). The Interpretation of Dreams. New York: Wiley
Jung, C.G. (1912) Symbols of Transformation. New York: Bollingen, no. 5
Kraepelin, E. ([1883] 1981) Clinical Psychiatry (trans. A.R. Diefendorf). Delmar, NY: Scholar’s Facsimiles and Reprints
Moffatt, G. Wounded Innocents and Fallen Angels: Child Abuse and Child Aggression. Westport, CT: Praeger, 2003.
Nevid, J.S., et al (2008) Abnormal Psychology in a changing world. (7th Ed.) Ch 2. Pearson.
Pantziarka, P. Lone Wolf: True Stories of Spree Killers. London: Virgin Books, 2000.
Segal, L. (1991). Brief Therapy: the MRI approach. In A. Gurman and D. Kniskern (eds ), Handbook of Family Therapy (vol.2, pp. 17-199).
New York: Brunner Mazel
Skinner, B.F. (1953). Science and Human Behaviour. New York: Macmillan
Tyrer, P. & Steinberg, D. (1998). Models of Mental Disorder: Conceptual Models in Psychiatry (3rd edn). Chichster: Wiley
Wachtel, P. & Messer, S. (1997). Theories of Psychotherapy: Origins and Evolution. Washington, DC: APA
Watson, J.B, & Rayner, R. (1920). Conditioned emotional reaction. Journal of Experimental Psychology, 3: 1-14
Watzlawick, P., Weakland, J.H. and Fisch, R. (1974). Challenge: Principles of Problem Formulation and Problem Resolution. New York: W.W.
Norton.