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1200 Home Page    Contact      Learning Objectives      Term Assignment     
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Lectures 8 & 9......
Instructor
Jeremy Jackson
|     May 5, 2014
Location:
NW 3431
|     New Westminster
Carl Sagan: "Science is a way of thinking much more than a body of knowledge"

Key concepts - you will be responsible for knowing a number of definitions of key concepts. You may be asked to give an accurate definition and example of any of the key concepts. Key concepts are in italics, bolded and colored red throughout the notes.

Discussion exercises and class activities - the lecture notes contain a number of discussion questions and class activities. You should conduct these exercises as soon as they are introduced in the notes. Exercises are in italics, bolded and green throughout the notes.

Critical points - there are some points that require extra emphasis because they are fundamental to the example or concept being discussed. Critical points are bolded, in italics and colored orange.

Movies - throughout the notes I have made short videos explaining various ideas.

Please Watch The Following Video:

 

This is a British quiz show called QI. One of the people in the video is actually manic depressive. Can you tell which one it is?

 

Now Watch:

fry

 

 

Now let's begin by looking more closely at how we actually do define mental disorder.

What Are Mental Disorders?

According to your text a mental disorder is a harmful dysfunction in which behaviour is judged to be atypical, disturbing, maladaptive and unjustifiable. So, the criteria for determining that an individual has a disorder are behavioral. When individuals BEHAVE in a maladaptive, etc., way, by definition, they have a MENTAL disorder.

Notice that the criteria are subjective. When and individual is JUDGED to behave in a maladaptive, etc., way by someone else, by definition, they have a mental disorder. So subjective judgment is involved in determining whether or not someone has a mental disorder.

Now let's look at the individual criteria given in the definition of mental disorder.

Atypical – abnormal, unusual or different to the norm. It follows from this that mental disorders are also defined in relation to a particular social or cultural standard. If we lived in a society in which everyone washed his or her hands 200 times a day, compulsive hand-washing would not be a mental disorder.

Disturbing – not just unusual or abnormal but troubling, unsettling or bothersome. So, perhaps I run 30 miles per day. This is certainly atypical, but not particularly disturbing.

Maladaptive – the behavior makes it difficult for an individual to adapt to their current environment. Obviously then, what is maladaptive will depend upon the environment in which an individual lives. Prostitution, theft and violence would be very maladaptive for an 18-year-old woman living at home with her parents in the British Properties. This same behavior would be adaptive for an 18-year-old woman living on the streets.

Unjustifiable – there is no basis in reality for the behaviour. For example, if one hears voices when no one is present, this is unjustifiable. However, if one hears the voice of God in a church ceremony, this is not unjustifiable.

So now lets take a look at the criteria for Schizophrenia as an example. These criteria are taken from DSM-IV which is a manual that contains definitions of all currently accepted mental disorders. DSM V is a new version of the DSM, but the criteria for schizophrenia are basically the same as DSM-IV.

 

DSM-IV Diagnostic Criteria for Schizophrenia

1) Presence of Psychotic symptoms (two of the following)

a. Delusions

b. Hallucinations

c. Disorganized speech – loosening of associations

d. Grossly disorganized or catatonic behavior

e. Flat or grossly inappropriate affect – alogia, avolition

2) Social occupational dysfunction

3) Continuous signs of disturbance for at least 6 months

NOTE:

Delusions are a belief in the existence of something that is impossible or unjustified.

Perhaps we believe that men get pregnant and women don't.

Hallucinations are perceptions in the absence of appropriate sensations.

Perhaps we see a man in a picture in the wall smiling at us, the frowning, then leaping out of the picture to grab us.

Loosening of association is a loss of the ability to connect ideas/events in a logical way.

Perhaps we say: "I just want to go home and  get a job in a bakery so I can go to medical school and get cleaned up". The connections of ideas here are nonsense.

Alogia is an impoverishment in thinking that is inferred from observing linguistic behavior.

Perhaps we say that: "A nice man came around yesterday and let me give him $500 for a chance to save $100 on a new vacuum cleaner".

Avolition is an inability to initiate and persist in goal directed activities.

We see this when a person moves or acts aimlessly. Their behavior lacks purpose, direction and objective.

Catatonic behaviour is unusual motor behavior including immobility, purposeless agitation, posturing, & stereotyped movements.

Stereotypical movements are movements we repeat over and over again without a clear purpose. So playing with our hair, chewing a lip, rubbing figures together, nodding the head, etc., are examples of such movements.

Notice that the behavior defined as schizophrenic is disturbing. It is very disturbing to be around people that say they see and hear things that are not present (hallucinations). Watch the following video - Heather. Is Heather disturbing?

If you watch you will see that all of the criteria for a mental disorder are present in Heather.

Now watch this video about a man called Gerald - Gerald

Go through each of the DSM-IV criteria given above for schizophrenia and identify them in Gerald. That is, identify delusions, hallucinations, disorganized speech, grossly disorganized behavior (for instance, notice the stereotyped movement of curling the hair), flat or inappropriate affect (affect means mood/emotion), etc.

The DSM-IV Classification System for Mental Disorders

DSM-IV is a hierarchical classification system for categorizing, and defining mental disorders. The new version of DSM, DSM-V follows most of the key principles of DSM-IV. So the discussion below is still pertinent to the way in which we look at mental disroders today.

For example, the following is a partial representation of mental disorders and how they are classified into a hierarchical set of categories.

dsm

 

Now lets look at one more example from DSM-IV:

Obsessive Compulsive Disorder is defined as recurrent obsessions or compulsions sufficiently severe to cause marked distress, be time-consuming, or sufficiently interfere with the person’s normal routine, occupation or social activities.

Obsessions are persistent ideas, thoughts, impulses or images that are experienced as intrusive and senseless. Generally, individuals have repetitive thoughts of violence, contamination or doubt.

Compulsions are repetitive purposeful, intentional behaviors that are performed in response to an obsession. The point of a compulsion is to reduce anxiety that results from an obsession. One is obsessed about contamination, to reduce the obsession and the anxiety about being contaminated, clean compulsively.

The following video is a good example of a typical OCD case: OCD

It's important to notice that this person's OCD is: a) Atypical - relative to our own, current social norms washing hands 200 times a day is abnormal, b) Disturbing - it is very unsettling to be around a person that behaves in this sort of way, c) Maladaptive - she lost her job, husband and relationship with her child as a result of the disorder, and d) Unjustifiable - it is unnecessary to be as clean as she needs to be.

Now, why do we need a classification system like the DSM-IV? Where did the idea come from?

One of the main reasons for DSM manuals is the problem of subjectivity. A very important series of studies that illustrated subjectivity in the diagnosis of mental disorders was done by David Rosenhan starting in 1973. Watch - Rosenhan.

These studies created a severe reaction in the clinical and research community. One of the consequences of this reaction was an attempt to make diagnosis less subjective. In fact, we might view DSM-IV as a partial reaction to the concerns about subjectivity in diagnosis. So how does DSM deal with subjectivity? It contains written, public criteria for (definitions of) mental disorders. Once the criteria are written down and made public, judgment about what a particular disorder is becomes much less individual/clinician specific. In fact, it might not be unreasonable to view DSM-IV as an operational definition of mental disorders. If you want to know what schizophrenia is, you simply consult the operational definition given within DSM-IV.

PROBLEM

As I said earlier in the notes, not all psychologists are operationists (most are not). Some psychologists object to the idea of defining mental disorders in the way they are defined in DSM-IV. They say that these definitions are arbitrary, made-up, or do not get at what mental disorders really are. Typically, people that make this case are construct validity theorists. They believe that it makes sense to theorize about what schizophrenia, depression, OCD, etc., really are. To CV theorists, it is acceptable to entertain multiple different theories about the nature of mental disorders at any given time. To the operationist, mental disorders are what they have been defined to be in DSM. There is one DSM that we all must use and hence, just one definition of what schizophrenia really is.

Now, it is very common for the CV theorist to theorize that mental disorders like depression for instance MAY BE illnesses. As a result, these psychologists tend to search for brain abnormalities that are present in depressed people and theorize that these brain abnormalities may actually be what depression really is. If you think depression, alcoholism, schizophrenia, ADHD, etc., are illnesses or MAY BE illnesses, then you are a CV theorist.

Operationists on the other hand do not think this way. They argue that since mental disorders are defined as behavioral problems, they can not be illnesses, diseases or any other kind of physiological abnormality. If an illness exists it is a potential CAUSE of the mental disorder, not what the mental disorder really is. Thomas Szasz is an operationist. Watch the following video to see how he views the issue of mental illness - Szasz on ADHD

Szasz makes a number of claims in the video, but the one in which I am most interested is the claim that behavioral problems are, by definition, not illnesses. This kind of statement makes Szasz an operationist because he is arguing that the definition of mental disorder excludes the possibility that it could be an illness. He is essentially arguing that it is not admissible to theorize that mental disorders may be illnesses.

Remember what a mental disorder is – it is a maladaptive, disturbing, atypical, unjustified behavior. Now let's look at the definition of an illness. An illness is a physiological abnormality that results in an unhealthy condition of the body or mind. This definition makes it clear that an illness is not a mental disorder. This is because an illness is a physiological abnormality. We do not check a person’s physiological state in order to determine if they have OCD. The diagnosis of OCD is based upon the behavior of the individual. This is the sense in which a mental disorder and illness/disease are different. The criterion for an illness/disease is physiological; the criteria for a mental disorder are behavioral.

According to Szasz there are two implications of the operationist view:

1) The word disorder must not be taken to mean the same thing as illness. Alcoholism is a disorder, not an illness.

2) People can misrepresent/lie/deceive about having a disorder, and, in principle, there is no way to prove them wrong. Now, the reality of mental disorders is that they are subjective, they are not physiological, and they can be faked. This reality is created by DSM-IV. This is the set of rules that defines and classifies mental disorders.

In the following, I am going to ask you to think like an operationist, not a CV theorist. The following diagram shows exactly how the operationist views the problem of mental disorders. Watch the video: "the medical model" for an explanation of this diagram.

medicalmodel

Now, this diagram makes reference to a number of concepts that we must define clearly in order to understand the operationist viewpoint on mental disorders.

1) A criterion is a defining characteristic of something. A criterion for a mental disorder is a basis upon which we determine that an individual has the disorder. If the person does/has A, and B, they have the disorder. A and B are the criteria. So, for example, if a person has delusions, they have schizophrenia. If a person has a lump in the lung (A), and the lump contains malignant cells (B), it follows that the person has lung cancer. A and B are the criteria for lung cancer. They define what it is.

2) A symptom is a condition that occurs relatively frequently when the disease or disorder is present. For example, people that have lung cancer tend to be prone to shortness of breath and fatigue. Of course, a symptom cannot, by definition, be a criterion. A criterion is always present when the disease or disorder is present. A symptom is only present relatively frequently. Not all people with lung cancer have shortness of breath and fatigue. More importantly though, to say that a person has shortness of breath and fatigue is not to say that they have lung cancer. These are just indications that they MAY have lung cancer. But there is one very important logical implication of the difference between symptom and criterion that you must know. We determine the symptoms of a disorder by conducting empirical research. We might, for example, identify a group of people with lung cancer, and a group of people without lung cancer, and assess the frequency of fatigue and shortness of breath in these two groups of people. If the people with lung cancer have shortness of breath and fatigue more frequently than the people without lung cancer, according to our definition of a symptom, we can conclude that fatigue and shortness of breath are symptoms of lung cancer. Notice that we could not determine the relative frequency of fatigue and shortness of breath IF WE WERE NOT ALREADY ABLE TO IDENTIFY A GROUP OF PEOPLE WITH LUNG CANCER. This means we must already have a clear definition of lung cancer – have clear criteria for lung cancer – in order to empirically discover the symptoms of lung cancer. REMEMBER – IN THE OPERATIONIST VIEW, THE CRITERIA MUST COME BEFORE THE SYMPTOMS. We must define schizophrenia before we can empirically discover what the symptoms of schizophrenia are.

3) A cause of a disorder/disease is an environmental or physiological factor that gives rise to the disorder/disease. There are often multiple causes of a disease or disorder. In psychology we talk about genetic causes, long-term environmental causes and short-term stressors. We say that these three types of causes interact to give rise to a disease/disorder. Of course a cause of a disorder is not a criterion for a disorder. Just because I am a smoker, and smoking causes lung-cancer, does not mean that I have lung cancer. It is critical that you understand that the same logic applies to cause as to symptom. If the disease/disorder is not already defined, there is no way to empirically determine what the cause of the disease/disorder is. This is like saying: I have a problem with my golf swing. I’m not going to tell you what it is, but I want you to tell me what the cause of the problem is.

In my opinion, looking at mental disorders from an operationist point of view is much more clear and easy to understand. Your text takes mostly a CV theory position so can be rather confusing at times. Just remember that when reading your text, symptoms, criteria and causes may not be clearly distinguished from each other. Now go ahead and read through your text.

Discussion Question On Mental Disorders

Is ADHD an illness? Make reference to the diagnostic criteria, cite research on the question that you find in the text or on the Internet, talk about Thomas Szasz, Rosenhan, and the CV theory and operationism positions. Bring in commentary from websites you have found. Take a position. Answer the question and defend your answer.

Your posts must:

a) Be clear and to-the-point. Try not to go on too long but also make sure you relate your answer to concepts discussed in the lecture and text.

b) DO NOT use colloquial (meaning conversational) language. Please do not use slang or short-forms for words. So don't say things like "This dude at Mickey D's totally messed-up." Do not use acronyms like "lol". If you would like to contribute to a discussion of someone else's post that is fine. Do not be personal.

c) Address the point that is being made, not the person.

d) Always say why you think something you do. Never just say "I think X" and leave the point hanging. Explain why you think X and not Y. Opinions are not that valuable here - reasons and evidence are.

e) Examples are important. Give examples and explain why they are examples of the issue you are talking about.

Remember, these posts are for marks so think them through before you post. I will be reading the posts and may make comments from time to time.

Good luck.

 

 

 

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