Intro to Psychological Disorders OCD General Psych 2 Module 43 November 6, 2003 Class #20

Some definitions of abnormality… Stratton & Hayes (1993) These researchers define abnormality as: Behavior which deviates from the norm Most people don’t behave that way Behavior which does not conform to social demands Most people don’t like that behavior Behavior which is maladaptive or painful to the individual Its not normal to harm yourself

What Behaviors Are Abnormal? How do we define what is abnormal? How do we define what is abnormal? The culture’s perspective The culture’s perspective The generation’s perspective The generation’s perspective The individual’s perspective The individual’s perspective

The Culture’s Perspective Deviance Deviance Here, we are looking at the degree in which an individual’s behavior differs from cultural norms Here, we are looking at the degree in which an individual’s behavior differs from cultural norms Standards of acceptability vary from culture to culture Standards of acceptability vary from culture to culture But to be considered disordered, the atypical behavior must also be disturbing to other people But to be considered disordered, the atypical behavior must also be disturbing to other people

The Culture’s Perspective Rationally Unjustifiable Rationally Unjustifiable If someone claims to be hearing mysterious voices and claims to be talking to God (or to a lost relative, etc.) we would likely consider there to be a problem unless they could convince us that the voices were real… If someone claims to be hearing mysterious voices and claims to be talking to God (or to a lost relative, etc.) we would likely consider there to be a problem unless they could convince us that the voices were real…

The Generation’s Perspective Standards of acceptability also vary from generation to generation Standards of acceptability also vary from generation to generation Example: Homosexuality Example: Homosexuality

The Individual’s Perspective Distress Distress Does the individual feel psychological pain? Does the individual feel psychological pain? Disability Disability Does the behavior interfere with the person’s ability to function personally, socially, or occupationally? Does the behavior interfere with the person’s ability to function personally, socially, or occupationally? Many psychologists believe this is the best criterion for determining the normality of behavior – does it foster individual and group well-being? Many psychologists believe this is the best criterion for determining the normality of behavior – does it foster individual and group well-being?

A Little History of Mental Illness… The Good Old Days The Good Old Days Trephination Trephination An operation performed since Stone Age times An operation performed since Stone Age times A circular section of the skull is carved away, leaving a hole in the skull allowing for “evil spirits” to be released A circular section of the skull is carved away, leaving a hole in the skull allowing for “evil spirits” to be released Interestingly, most of these patients survived Interestingly, most of these patients survived Some were considered witches… Some were considered witches… Submerged into water – if they drowned it was felt they weren’t really witches Submerged into water – if they drowned it was felt they weren’t really witches Thousands of women were killed in this manner during 13 th -16 th century Thousands of women were killed in this manner during 13 th -16 th century

The Age of Enlightenment Physiological Treatment Physiological Treatment Bleeding Bleeding Excessive blood in the brain Excessive blood in the brain Fear Fear Put in coffin-like box and submerged in water until bubbles from the patient’s breathing had ceased to come to the surface at which point the person was revived… Put in coffin-like box and submerged in water until bubbles from the patient’s breathing had ceased to come to the surface at which point the person was revived… Drugs Drugs The use of alcohol, opium, and marijuana were used to try to cure these individuals The use of alcohol, opium, and marijuana were used to try to cure these individuals

The Age of Enlightenment Asylums Asylums During this time, places where the mentally ill were cared for began to surface During this time, places where the mentally ill were cared for began to surface Before this, these people were treated as criminals and put in jails or prisons Before this, these people were treated as criminals and put in jails or prisons A medical model where psychological disorders were considered to be sicknesses that could be cured through therapy at a psychiatric hospital became the prevailing viewpoint A medical model where psychological disorders were considered to be sicknesses that could be cured through therapy at a psychiatric hospital became the prevailing viewpoint

Bedlam Hospital of St. Mary of Bethlehem (established officially in 1500’s) Hospital of St. Mary of Bethlehem (established officially in 1500’s) Bedlam – “lunatics” were treated cruelly…if they became too excited they were chained out of harm’s way and often beaten or doused with water Bedlam – “lunatics” were treated cruelly…if they became too excited they were chained out of harm’s way and often beaten or doused with water Visitors would pay a small fee to be allowed to go in and ridicule the patients for entertainment purposes Visitors would pay a small fee to be allowed to go in and ridicule the patients for entertainment purposes The crowds would often become very noisy and disorderly themselves – hence, the name The crowds would often become very noisy and disorderly themselves – hence, the name

Removing the chains… Philippe Pinel Philippe Pinel Institutes a medical model – that these psychological disorders were sicknesses Institutes a medical model – that these psychological disorders were sicknesses That psychopathology needs to be diagnosed on the basis of its symptoms and cured through therapy That psychopathology needs to be diagnosed on the basis of its symptoms and cured through therapy He removed the chains from the mentally ill and his treatment consisted in large part along the lines of a good diet, encouragement, and the least restrictive setting – in general, many of the components of psychotherapy He removed the chains from the mentally ill and his treatment consisted in large part along the lines of a good diet, encouragement, and the least restrictive setting – in general, many of the components of psychotherapy

The Modern Era Psychological processes Psychological processes Suggestion and hypnotism Suggestion and hypnotism

Bio-psycho-social Perspective Mental disorders are seen as caused by the combination and interaction of: Mental disorders are seen as caused by the combination and interaction of: Biological Factors: Includes physical illnesses and disruptions of bodily processes that may in part be due to genetic predispositions Biological Factors: Includes physical illnesses and disruptions of bodily processes that may in part be due to genetic predispositions Psychological Factors: Includes psychological processes such as our wants, needs, and emotions; our learning experiences; and our way of looking at the world Psychological Factors: Includes psychological processes such as our wants, needs, and emotions; our learning experiences; and our way of looking at the world Sociocultural Factors: Includes the social and cultural context that form the background of the abnormal behavior Sociocultural Factors: Includes the social and cultural context that form the background of the abnormal behavior

Diagnostic and Statistical Manual (DSM-IV) The behavior pattern of all psychological disorders were not clearly described until the publication of the APA’s first diagnostic and statistical manual (DSM-I) in 1952 The behavior pattern of all psychological disorders were not clearly described until the publication of the APA’s first diagnostic and statistical manual (DSM-I) in 1952 DSM-IV defines 17 major categories of mental disorder DSM-IV defines 17 major categories of mental disorder

Purposes of Diagnostic System Designed to determine nature of client’s problems Designed to determine nature of client’s problems Once characteristics are understood, problem’s probable course can be predicted and most appropriate method of treatment can be administered Once characteristics are understood, problem’s probable course can be predicted and most appropriate method of treatment can be administered

Problems With Diagnostic System Some critics believe that now there are too many behaviors are considered to be within “the compass of psychiatry” – only about 60 in DSM-I and now about 400 Some critics believe that now there are too many behaviors are considered to be within “the compass of psychiatry” – only about 60 in DSM-I and now about 400 People’s problems often do not fit neatly in one category People’s problems often do not fit neatly in one category The same symptoms appear as part of more than one disorder The same symptoms appear as part of more than one disorder Possibility of personal bias due to the somewhat subjective nature of diagnostic judgments – some feel these are “value judgments masquerading as a science” Possibility of personal bias due to the somewhat subjective nature of diagnostic judgments – some feel these are “value judgments masquerading as a science” Labeling people may be dehumanizing Labeling people may be dehumanizing

Rosenhan (1973): Does madness lie in the eye of the observer? This study addressed the following question? This study addressed the following question? Do the characteristics of abnormality reside in the patients or in the environments in which they are observed? Do the characteristics of abnormality reside in the patients or in the environments in which they are observed?

An astonishing study: On being sane in insane places The brave volunteers… The brave volunteers… EIGHT sane people! EIGHT sane people! A pediatrician A pediatrician A painter A painter Two housewives Two housewives One graduate student One graduate student Three psychologists (including David Rosenhan) Three psychologists (including David Rosenhan)

What did they do? The procedure The procedure Participants telephoned 12 psychiatric hospitals for an urgent appointment (in five USA states) Participants telephoned 12 psychiatric hospitals for an urgent appointment (in five USA states) When arriving at admissions they gave false name and address When arriving at admissions they gave false name and address But did give other ‘life’ details correctly But did give other ‘life’ details correctly

What else did they do? They complained of hearing unclear voices … saying “empty, hollow, thud” They complained of hearing unclear voices … saying “empty, hollow, thud” Said the voice was unfamiliar, but was the same sex as themselves Said the voice was unfamiliar, but was the same sex as themselves

What happened? All were admitted to hospital All were admitted to hospital All but one were diagnosed as suffering from schizophrenia All but one were diagnosed as suffering from schizophrenia Once admitted the ‘pseudo-patients’ stopped simulating ANY symptoms Once admitted the ‘pseudo-patients’ stopped simulating ANY symptoms They had agreed to stay until they convinced the staff they were sane!! They had agreed to stay until they convinced the staff they were sane!!

What happened on the wards? Took part in all ward activities: Took part in all ward activities: The pseudo-patients were never detected The pseudo-patients were never detected All pseudo-patients wished to be discharged immediately All pseudo-patients wished to be discharged immediately BUT – as they had agreed to before the experiment – they waited patiently until they were diagnosed as ‘fit to be discharged’ BUT – as they had agreed to before the experiment – they waited patiently until they were diagnosed as ‘fit to be discharged’

How did the ward staff see them? Normal behavior was misinterpreted… Normal behavior was misinterpreted… Writing notes was described as… Writing notes was described as… “The patient engaged in writing behaviour” “The patient engaged in writing behaviour” Arriving early for lunch described as… Arriving early for lunch described as… “Oral acquisitive syndrome” “Oral acquisitive syndrome” Behavior distorted to ‘fit in’ with theory Behavior distorted to ‘fit in’ with theory

The pseudo-patient’s observations… If they approached nurses or attendants with simple requests: If they approached nurses or attendants with simple requests: 88% ignored them completely – walked away with head averted 88% ignored them completely – walked away with head averted Only 10% even made eye contact Only 10% even made eye contact Just 2% stopped for a chat Just 2% stopped for a chat 1283 attempts 1283 attempts

The pseudo-patient’s observations… If they approached the psychiatrists with simple requests: If they approached the psychiatrists with simple requests: 71% ignored them – walked away with head averted 71% ignored them – walked away with head averted Only 23% made eye contact Only 23% made eye contact Just 2% stopped for a chat Just 2% stopped for a chat 185 attempts 185 attempts

How long did they stay in hospital? The shortest stay was 7 days The shortest stay was 7 days The longest stay was 52 days The longest stay was 52 days The average stay was 19 days The average stay was 19 days

They were treated in the same way as the real patients... Given total of 2100 medication tablets Given total of 2100 medication tablets They flushed them down the toilets They flushed them down the toilets Noted that other patients did the same and that this was ignored as long as patients behaved themselves !! Noted that other patients did the same and that this was ignored as long as patients behaved themselves !!

DID ANYONE SUSPECT? What do you think – did anyone suspect it was a hoax? What do you think – did anyone suspect it was a hoax?

On release… The pseudo-patients were diagnosed as The pseudo-patients were diagnosed as Schizophrenia “IN REMISSION” Schizophrenia “IN REMISSION”

Rosenhan (1973b): The follow up study A teaching & research hospital was told of the first study and warned that … A teaching & research hospital was told of the first study and warned that … Over the next three months ONE OR MORE pseudo-patient would attempt to be admitted in their hospital as well… Over the next three months ONE OR MORE pseudo-patient would attempt to be admitted in their hospital as well…

What happened? Staff members rated ‘new patients’ on scale as ‘how likely to be a fraud’… Staff members rated ‘new patients’ on scale as ‘how likely to be a fraud’… 193 patients ‘assessed’ 193 patients ‘assessed’ 41 rated as a pseudo-patient (by staff) 41 rated as a pseudo-patient (by staff) 23 rated as pseudo-patient (by psychiatrist) 23 rated as pseudo-patient (by psychiatrist) 19 rated as pseudo-patient (by both) 19 rated as pseudo-patient (by both)

How many of these SUSPECTS were pseudo-patients? NONE NONE No pseudo-patients were sent No pseudo-patients were sent Staff were rating their regular intake Staff were rating their regular intake

Rosenhan’s conclusion….. “It is clear that we are unable to distinguish the sane from the insane in psychiatric hospitals”… “It is clear that we are unable to distinguish the sane from the insane in psychiatric hospitals”… In the first study In the first study They were unable to detect ‘sanity’ They were unable to detect ‘sanity’ In the follow up study In the follow up study They were unable to detect ‘insanity’ They were unable to detect ‘insanity’

Rosenhan’s study highlighted… The depersonalisation and powerlessness of patients in psychiatric hospitals The depersonalisation and powerlessness of patients in psychiatric hospitals That behavior is interpreted according to expectations of staff and that these expectations are created by the labels SANITY & INSANITY That behavior is interpreted according to expectations of staff and that these expectations are created by the labels SANITY & INSANITY

A comment… Although, the pseudo-patients described their stay in the hospitals as a negative experience Although, the pseudo-patients described their stay in the hospitals as a negative experience This is not to say that REAL patients have similar experiences This is not to say that REAL patients have similar experiences Real patients do not know the diagnosis is false & are NOT pretending Real patients do not know the diagnosis is false & are NOT pretending

Some questions… Was this study ethical? Was this study ethical? Why might the reports of the pseudo- patients have been unreliable? Why might the reports of the pseudo- patients have been unreliable?

The power of labels to stigmatize… Page (1977) Page (1977) Is the room still available for rent? Is the room still available for rent? Yes – over 95% of the time Yes – over 95% of the time I’m just about to be released from the mental hospital and was wondering is the room still available for rent? I’m just about to be released from the mental hospital and was wondering is the room still available for rent? Yes – only about 25% of the time Yes – only about 25% of the time I’m calling for my brother who is about to be released from jail and was wondering is the room still available for rent? I’m calling for my brother who is about to be released from jail and was wondering is the room still available for rent? Yes – only about 25% of the time Yes – only about 25% of the time

Obsessive-Compulsive Disorder (OCD) To be diagnosed with OCD, a person must have recurrent obsessions and compulsions that are disabling To be diagnosed with OCD, a person must have recurrent obsessions and compulsions that are disabling Significantly interfere with a person’s routine, making it difficult to work, or to have a normal social life or relationships Significantly interfere with a person’s routine, making it difficult to work, or to have a normal social life or relationships

Prevalence and Onset Prevalence Prevalence Life-time prevalence Life-time prevalence Afflicts 2%-3% of population some time in their lives Afflicts 2%-3% of population some time in their lives Group differences Group differences No sex differences No sex differences Knows no geographic, ethnic, or economic boundaries Knows no geographic, ethnic, or economic boundaries Onset Onset About two-thirds develop the disorder before they are 25 years old and only 15% after the age of 35 About two-thirds develop the disorder before they are 25 years old and only 15% after the age of 35 Onset after 40 is very rare Onset after 40 is very rare

Obsessions Constant, intrusive, unwanted thoughts causing distressing emotions such as anxiety or disgust Constant, intrusive, unwanted thoughts causing distressing emotions such as anxiety or disgust Examples: Examples: Thoughts of violence (person feels he/she will hurt someone) Thoughts of violence (person feels he/she will hurt someone) Thoughts of contamination (germs) Thoughts of contamination (germs) Thoughts of uncertainty (did I lock the door?) Thoughts of uncertainty (did I lock the door?)

Compulsions Compulsions are urges to do something to lessen discomfort Compulsions are urges to do something to lessen discomfort Rituals are the behaviors in which these people engage in to accomplish this Rituals are the behaviors in which these people engage in to accomplish this

Common OCD Compulsions Cleaning Cleaning Fear of germs, etc. Fear of germs, etc. Repeating Repeating Feel harm will occur if they don't Feel harm will occur if they don't Completing Completing Exact order until perfection Exact order until perfection Being meticulous Being meticulous Exact place for things (ex: appearance of room, etc.) Exact place for things (ex: appearance of room, etc.)

OCD Compulsions Avoiding Avoiding Exaggerated avoidance of anxiety producing stimuli Exaggerated avoidance of anxiety producing stimuli Counting Counting Compelled to count things (like how many steps it takes to get somewhere) Compelled to count things (like how many steps it takes to get somewhere) Hoarding Hoarding Constant collection of useless items Constant collection of useless items Slowness Slowness Tasks done extremely slowly Tasks done extremely slowly Excessive and Ritualized praying Excessive and Ritualized praying May pray literally all day long in a ritualized manner May pray literally all day long in a ritualized manner

Physiological Explanations Scarcity of serotonin Scarcity of serotonin In certain brain structures there are high levels of brain activity (orbital frontal, etc.) In certain brain structures there are high levels of brain activity (orbital frontal, etc.) Brain damage Brain damage Genetics Genetics

Common Treatments for OCD No treatment No treatment Cognitive-Behavioral Therapy Cognitive-Behavioral Therapy Antidepressant Medications Antidepressant Medications

If you can wait 40 years… Skoog and Skoog (1999) Skoog and Skoog (1999) No treatment No treatment 83% showed some improvement while 20% showed complete recovery 83% showed some improvement while 20% showed complete recovery

Cognitive-Behavioral Therapy This type of therapy is based on learning (reconditioning specific behaviors) and changing the beliefs (thinking processes) of the individual suffering from OCD… This type of therapy is based on learning (reconditioning specific behaviors) and changing the beliefs (thinking processes) of the individual suffering from OCD… Systematic desensitization Systematic desensitization Expose them to what is making them anxious at increasing intervals…the idea here is that by facing the thing that they fear a little at a time they will eventually conquer the fear Expose them to what is making them anxious at increasing intervals…the idea here is that by facing the thing that they fear a little at a time they will eventually conquer the fear May have to start some off by having them imagine the situation May have to start some off by having them imagine the situation

Cognitive-Behavioral Therapy Response prevention Response prevention Preventing the person from doing the compulsion or mental act Preventing the person from doing the compulsion or mental act Relaxation techniques Relaxation techniques Cognitive techniques such as self-talk are often combined with the above techniques Cognitive techniques such as self-talk are often combined with the above techniques

Cognitive-Behavioral Therapy Effectiveness: Effectiveness: 60-80% of those using the cognitive- behavioral treatments improve (show at least a partial reduction in symptoms) 60-80% of those using the cognitive- behavioral treatments improve (show at least a partial reduction in symptoms)

Antidepressant Medications Drugs that influence (increase) serotonin levels have been used effectively Drugs that influence (increase) serotonin levels have been used effectively Prozac, Zoloft, Paxil, Anafranil, etc. Prozac, Zoloft, Paxil, Anafranil, etc. Drawbacks: Drawbacks: High doses of these drugs may be required in the treatment of OCD High doses of these drugs may be required in the treatment of OCD It can take several weeks to feel their beneficial effects It can take several weeks to feel their beneficial effects Additionally, there are potential side effects to consider Additionally, there are potential side effects to consider

Prognosis The disease is chronic for most people even with drug treatment The disease is chronic for most people even with drug treatment Most take medication indefinitely, and about 85% of people relapse within one or two months after discontinuing usage Most take medication indefinitely, and about 85% of people relapse within one or two months after discontinuing usage