History of Mental Health Discussion

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Chapter 3: Contemporary Frameworks

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Learning Objectives

How does psychodynamic theory explain and treat psychological problems?

What treatments have developed from the behavioral model?

What is the biological perspective of abnormality?

How does the humanistic approach differ from other perspectives?

Can assessment of treatment outcomes contribute to a more unified framework?

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Contemporary Frameworks in Psychology

Current models or frameworks of psychopathology

Psychoanalytic theory

Behavioral approaches

Biological approaches

Humanistic-experiential approaches

Each model views the source of abnormal behavior differently; as such, each model presents different types of treatments.

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Freud’s Psychoanalytic (or Psychodynamic) Theory

The dynamic interplay of intrapsychic events—motives, drives, emotions, fantasies, and conflicts—that underlie the surface manifestations of symptoms must be understood to comprehend abnormal behavior.

Psychological symptoms are seen as analogous to physical symptoms, such as fever, only to be understood and treated if the underlying disease process, such as an infection, is identified.

The underlying disease is not physical, but rather a pathological condition, existing among the intrapsychic processes of the mind.

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Basics of Psychoanalytic Theory

The unconscious

The sexual basis of psychological symptoms

Libido, Oedipal conflict

Anxiety and defense mechanisms

The structure of the mind

Id, ego, superego

Stages of psychosexual development

Childhood origins of neurotic symptoms

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Unconscious Motivation

Freud: the mind consists of different levels of activity, with most action occurring outside of conscious awareness

The largest part of the mind is the unconscious: we are unaware and material is normally unavailable.

Unconscious motivation: the basic theme of unacceptable impulses struggling to find expression in various disguises

The basis for all irrational human behavior.

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Figure 3-1 The Iceberg Metaphor of the Mind

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The Sexual Basis of Psychological Symptoms

As patients explored the hidden and disguised bases of their symptoms, it seemed that the trail inevitably led to a sexual conflict.

Initially Freud felt his patients had actually experienced some kind of sexual attack, but he came to believe the patient as a young child had imagined that such events had occurred.

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The Oedipal Conflict

The Oedipal conflict is sexual attraction to the opposite-sex parent, accompanied by competition and antagonism toward the same-sex parent, as in the Greek myth of Oedipus.

Castration anxiety; penis envy

If children have dealt with an especially intense Oedipal conflict, they are vulnerable to re-arousals of the conflict and ineffective repressive defenses in adolescence.

The result can become symptoms of psychological disorders.

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Anxiety and the Mechanisms of Defense (Slide 1 of 3)

Anxiety: a powerful and unpleasant emotion which serves as a signals some impending danger

The danger may be internal

Disturbing, instinctual impulse threatening to break into awareness and be expressed in overt behavior

The danger may be external

A perceived threat of loss of love or physical injury from significant people in the child's life

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Anxiety and the Mechanisms of Defense (Slide 2 of 3)

Defense mechanisms: strategies to prevent anxiety-arousing impulses from entering awareness or being overtly expressed in ways that might evoke retaliation.

There are any number of defense mechanisms

Repression

Reaction formation

Isolation

Projection

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Anxiety and the Mechanisms of Defense (Slide 3 of 3)

Repression: unconsciously but intentionally forgetting memories associated with anxiety-arousing impulses and conflicts

Reaction formation: behaving in a way directly opposite from some underlying impulse

Isolation: separating emotions from intellectual content

Projection: shifting a reaction from an original target to some other target.

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Figure 3-2 The Purpose of Defense Mechanisms

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The Structure of the Mind

Three primary parts of the mind according to Freud:

Id: the source of basic instinctual drives seeking immediate gratification

Ego: mediates between the urgings of the id and the demands of external reality

Superego: an internalized and partially irrational representation of parental or cultural values

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Libido

The sexual instinct is the libido.

All motivation (other than few simple drives, such as hunger and thirst) arise from the libido.

Freud considered many forms of behavior that do not seem related to sex, as sublimated expressions of the libidinal instinct.

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Stages of Psychosexual Development (Slide 1 of 2)

There are biologically determined stages of psychosexual development in which the libido seeks gratification through different zones of the body.

Oral

Anal

Genital (divided thus):

Phallic

Latency

Adult genital

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Stages of Psychosexual Development (Slide 2 of 2)

Fixations at and regressions to these various stages of development influence later personality traits, including features of abnormal behavior.

Fixations: an unusual investment of libidinal energy at a certain psychosexual stage

Regressions: a return to some earlier stage of psychosexual development in the face of some current frustration

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Childhood Origination of Neurotic Symptoms

Little Hans

Neurotic (anxiety-driven) symptoms result from the interplay between instinctual impulses, striving for expression, and defensive strategies.

Crucial feature: a re-arousal of urges, fantasies, and fears from early childhood, a time when loss of parental love or threats of punishment were experienced as catastrophic events.

The responses evoked are not adult modes of problem resolutions. They arise from a child’s view.

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Psychodynamic Treatment

Goal: to make the unconscious conscious, as a way to facilitate greater understanding and insight into the self.

To reach this goal the following techniques are used:

Free association

Resistance

Transference

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Psychodynamic Treatment: Free Association

Patient is instructed to express whatever comes to mind, no matter how seemingly irrelevant, trivial, or embarrassing.

Patient is encouraged to adopt a passive attitude—reporting ideas, feelings, and images that come into awareness.

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Psychodynamic Treatment: Resistance

Patients unconsciously attempting to block insight into unconscious motives and conflicts

Since the way a patient resists is likely to reflect styles of ego defenses used in other situations, insight about these resistances is considered an important therapeutic benefit.

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Psychodynamic Treatment: Transference

The projection of thoughts and feelings from important persons in one’s childhood or later life to the therapist

Transference and counter-transference (the therapist’s reaction to the patient’s projections) become important tools for insight therapy.

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Variations in Psychodynamic Approaches

Students of Freud went on to form their own interpretations of the approach:

Alfred Alder (1870 – 1937)

Inferiority complex

Carl Jung (1875 – 1961)

Collective unconscious

Karen Horney (1885 – 1952)

Basic anxiety

Object-relations theory

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Behavioral Approaches

Behaviorism: An approach to understanding behavior that emphasizes the relation between observable behavior and specifiable environmental events or stimuli

An underlying assumption is that the principles of conditioning could explain all behavior, both normal and abnormal.

Two schools of behaviorism

Classical (Pavlovian) conditioning

Operant Conditioning

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Behavioral Approaches: Operant Conditioning

A form of learning in which the consequences of a response influence its later probability

Operant conditioning involves “voluntary” or emitted behaviors.

Classical or Pavlovian conditioning involves reflexive or elicited behaviors.

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Terms in Operant Conditioning

Reinforcement: a consequence that strengthens or increases the likelihood that a response will be repeated

Primary reinforcers: events, usually biological in nature, which almost always provide reinforcement

Punishment: a consequence that weakens or decreases the likelihood that a response will be repeated

Punishers: types of consequences that weaken or suppress the behaviors that produce them

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Terms in Operant Conditioning: Reinforcement

Consequences can be further organized as to whether the behavioral contingency involves the presentation or removal of something.

Positive: a stimulus added as the consequence of behavior

Negative: a stimulus is removed as the consequence of behavior

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Terms in Operant Conditioning: Discriminative Stimulus

Discriminative stimulus: serves as a signal that a certain response will lead to a reinforcer or a punisher

The organism learns to not only make a response, but to only make it under certain circumstances.

Stop the car in the presence of a red light on the traffic signal; continue forward in the presence of a green light.

Discriminative stimuli serve to guide our actions.

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Operant Conditioning: Three Levels of Selection

Selection by consequences

Skinner: operant conditioning and natural selection were the same process—operating over different time spans and on different aspects of the organism.

Units of selection and units of time

Genes = Generations

Individual behaviors = Moments

Cultural selection = Decades or centuries

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Operant Conditioning and Abnormal Behavior

Shaped because it produces reinforcing consequences

Should be subject to unlearning if the setting conditions and consequences are appropriately changed

The contingencies that maintain a behavior can be shown through the use of a reversal design.

Reversal design: an experimental design in which reinforcement contingencies are changed, reinstated, and changed again—demonstrates the contingencies that maintain a behavior

Modifying Ann’s shyness

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Figure 3-3 Ann’s Shyness

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Behavioral Approaches: Treatment

Contingency management: demonstrated in Ann’s case

Modeling: teaching a behavior by performing the behavior and having the learner imitate it

Systematic desensitization: counter-conditioning procedure in which subjects are gradually exposed to stronger anxiety-producing stimuli while maintaining a state of relaxation

Covert sensitization: form of behavior therapy in which the person is asked to imagine an upsetting scene in order to produce a form of aversion conditioning

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Variations in Behavioral Approaches

Behavioral techniques have been combined with other approaches to produce hybrid treatment options.

Cognitive-behavioral therapies (CBTs) apply behavioral treatment principles to attitudes, beliefs, and thought processes.

Acceptance and commitment therapy (ACT): Patients are taught to recognize the presence of certain bothersome emotions, such as depression or anxiety, and accept their occurrence, often termed mindfulness. Patients also make a commitment to engage in the important behaviors of normal life.

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Biological Approaches

Biological science has made great progress in understanding the physical bases for behavior.

Research into the anatomy and neurochemistry of the brain provides insights into their role in emotions, emotional disorders, and avenues for treatment.

Although behavior is not possible without biology, it is less clear whether a particular biological state results in any specific behavior.

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Biological Approaches: Major Concepts

Heredity

Chromosomes and genes

Twin and adoption studies

Estimates of genetic influences

The brain and nervous system

Cortical function

Neurotransmission and neurotransmitters

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Biological Approaches: Heredity

Chromosomes are elongated bodies in cells that carry genetic information.

23 pairs of chromosomes in human body cells

Genes are units of hereditary information carried in a chromosome by DNA.

Alleles are alternate forms of genes.

Genotype: the total set of inherited characteristics, determined by a person’s genetic makeup

Phenotype: the observable characteristics that result from the interaction between genotype and environmental influences

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Figure 3-4 Male Chromosomes

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Figure 3-5 Chromosomes Consist of Strands of DNA

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Figure 3-6 DNA Replication Prior to Cell Division

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Research Methods for Studying Hereditary Influences

Mental disorders are not inherited in a direct manner, but there is evidence that heredity plays an important role in psychopathology.

By collecting information from studies about family members who have mental disorders, the distribution of the disorder in the family pedigree can provide information about the genetic involvement in the disorder.

Linkage studies

Twin studies

Adoption studies

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Research Methods: Linkage Studies

These studies suggest modes of inheritance by examining whether the disorder appears in certain patterns—on one side of a family or in a line from mother to son.

Large pedigree studies remain particularly useful for the study of rare gene variants, which provide investigators with a focus for subsequent sequencing.

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Figure 3-7 Example of a Family Pedigree of Alzheimer’s Disease

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Research Methods: Twin Studies

There are two types of twins:

Identical (monozygotic – MZ): results from the splitting of a single fertilized ovum—the twins have the same genetics

Fraternal (dizygotic – DZ): results from the simultaneous fertilization of two separate ova—the twins are as genetically alike as any sibling pair

It is assumed the differences in degree of behavioral similarity between identical and fraternal twins will be largely due to the greater genetic similarity of the identical twins, given that both MZ and DZ twins share roughly equal environments.

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Research Methods: Adoption Studies

Another method of assessing genetic influence is to compare children who have been removed from their biological parents at or shortly after birth and adopted or raised by foster parents.

If an adoptee is more like the adopting parents than the biological parents, we infer environmental influences.

If the adoptee is more like the biological parent than the adoptive parents, we infer genetic influences.

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Estimates of Genetic Influences

For most behavioral traits, genes may account for about half of the variability between people, while environmental factors account for the other half.

Calculations of heritability do not tell us to what extent either genetics or environment “causes” a trait, nor whether any individual will develop the trait, because biological traits are influenced by both genetic and environmental factors.

Phenylketonuria (PKU)

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Figure 3-8 Process Involved in Producing Behavior

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The Human Brain: Divisions

Hindbrain: the oldest part of the brain; controls the basic physical functioning, such as heartbeat, respiration, blood pressure, and balance.

Midbrain: controls sleep, waking, and many basic reflexes.

Cerebral cortex: involved with seeing, hearing, fine motor control, speech and language, learning, and other higher functions

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Figure 3-9 Localization of Cortical Functions in the Brain

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The Human Brain: Neurotransmission

Neurons: individual nerve cells

Dendrites: a neuron’s branching fibers that receive input

Axon: part of the neuron that carries neutral impulses to other cells

Synapse: a tiny gap separating neurons, across which neurotransmitters provide chemical communication between cells

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Figure 3-10 Neuronal Communication

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Biological Treatments

The attempt to address assumed underlying biological causes

Convulsive therapies

Psychosurgery

Pharmacology

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Biological Treatments: Convulsive Therapies (Slide 1 of 2)

Early in the 1900s, observations were noted that mentally disturbed people showed improvement in their symptoms after recovering from a convulsion.

In recent decades, electroconvulsive therapy (ECT) has been restricted almost entirely to serious mood disorders.

ECT is more effective in the short term than antidepressant medications in the treatment of severe depression.

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Biological Treatments: Convulsive Therapies (Slide 2 of 2)

Magnetic seizure therapy: stimulation of brain regions by magnetic fields at sufficient strength to result in convulsions

Repetitive transcranial magnetic stimulation (rTMS): repeated magnetic pulses at subseizure levels of intensity; promising but not as effective as ECT

Vagus nerve stimulation: approved by the FDA for use with treatment-resistant depression; uses implanted electrodes in specific brain areas.

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Biological Treatments: Psychosurgery

Frontal lobotomy: a procedure (about 1935) separating the frontal lobes from the deeper parts of the brain as a treatment for violent, agitated, depressed, or dangerous patients

Although only about one-third of his subjects improved, Antonio Moniz was awarded the Nobel Prize in Medicine in 1949 for developing the procedure.

Psychosurgery remains an experimental practice and is not a part of standard biological treatment at the present.

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Biological Treatments: Pharmacology (Slide 1 of 3)

The focus is the use of drugs, which impact neurotransmission in the brain.

Over 11% of American adults received psychotropic medications in 2002.

The drug revolution has resulted in symptom relief, but none of the medications correct or resolve the biological condition presumed to underlie the symptoms.

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Biological Treatments: Pharmacology (Slide 2 of 3)

Before 1900, alcohol, heroin, cocaine, and various other sedative/hypnotic and stimulant substances were used as treatments for mental disorders.

By 1950, benzedrine (an amphetamine) had been used for hyperactivity, and lithium salts had been used to treat mania.

Anti-psychotic and anti-depressant drugs were developed in the 1950s, when reductions in psychological symptoms were noted after the use of antihistamine and tuberculosis medications, respectively.

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Biological Treatments: Pharmacology (Slide 3 of 3)

The revolutionary development of antipsychotic and antidepressant medications also led to the development of biological theories of the disorders they treat.

Dopamine hypothesis of schizophrenia: the disorder is caused by excessive dopamine activity in the brain

Catecholamine hypothesis of depression: the mood disorder resulted from a relative depletion of norepinephrine in the brain

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Biological Treatments: Pharmacology and Potential Complications

Significant concerns about medication side effects

Tardive dyskinesia: the occasional long-term side effect of phenothiazine treatment of schizophrenia, involving rhythmical, stereotyped movements and lip smacking

Agranulocytosis: a potentially fatal blood disease associated with the use of newer antipsychotic medications.

Additional medications are frequently prescribed to help patients control the side effects of psychotropic medications; relapse is high once medications are discontinued

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Humanistic-Experiential Approaches (Slide 1 of 2)

Psychological symptoms explained as the existential anxiety produced by blockage of growth or the result of inauthentic subjective experiences.

People are seen as valued human beings who struggle with the problems of their existence, and who are free to make their own choices.

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Humanistic-Experiential Approaches (Slide 2 for 2)

Various humanistic writers disagree in regards to the question of whether people are basically good, bad, or neither.

Abraham Maslow and Carl Rogers argue that people are basically motivated toward self-fulfillment and constructive personality growth.

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Approaching an Integrated Model

Increased reliance on outcome assessment has resulted in efforts to empirically identify effective treatments

That trend may combine with the tendency within science to refine a paradigm and move the study of psychopathology toward a more unified model.

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Chapter Summary (Slide 1 of 4)

The psychodynamic framework explains the psychological symptoms in terms of intrapsychic events, such as motives, fantasies, and conflicts.

Freud held that conflicts about sexuality play an important role in all neurotic disorders.

Other investigators differed with Freud and proposed psychodynamic theories of their own, renouncing the idea that sexual conflicts lay behind all neurotic disorders. They suggested that other factors, such as strivings for superiority and basic anxiety arising from a conflict between needs for affection and hostility, should be the targets of therapy.

FINAL THOUGHTS

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Chapter Summary (Slide 2 of 4)

The behavioral framework explains psychological symptoms as the result of personal experiences and learning histories, interacting with the current set of prevailing contingencies of reinforcement and punishment. It proposes that symptoms are treated by providing new learning experiences and altering contingencies to favor the development of more adaptive behaviors.

FINAL THOUGHTS

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Chapter Summary (Slide 3 of 4)

The cognitive approach modifies the behavioral perspective to include beliefs, expectations, attitudes, and thought patterns as sources of problems and targets to modify.

The biological approach explains psychological symptoms as the result of underlying biological or chemical abnormalities. It proposes that symptoms are treated medically, usually with psychotropic medication.

FINAL THOUGHTS

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Chapter Summary (Slide 4 of 4)

Humanistic-experiential approaches explain psychological symptoms as the existential anxiety produced by blockage of growth or the results of inauthentic subjective experiences. Treatment involves the freely-chosen acceptance of responsibility for one’s own life experience.

Increased reliance on outcome assessment has resulted in efforts to empirically identify effective treatments. That trend may combine with the tendency within science to refine a paradigm, moving the study of psychopathology toward a more unified model.

History of Mental Health Discussion

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