Unit 10

Brief Lecture Notes for Unit 10

Normality and Abnormality

Four definitions of abnormality have been proposed, though all have some weaknesses associated with them.

Normative: Behavior is abnormal if society labels it as such, if it breaks the socially accepted rules of behavior. (Problems with this definition: Different cultures and subcultures have different norms. This definition does not allow for the possibility that an individual is healthier than the society in which s/he lives.)
Statistical: Behavior is abnormal if it is rare or infrequent. (Problems with this definition: Does not distinguish between positive and negative abnormalities. Is of no help with purely internal, mental states, which are generally "uncountable" due to difficulties with self-report.)
Self-definition: Behavior is abnormal if so viewed or labeled by the person her/himself (I am abnormal if I think I am). (Problems with this definition: Some mental illness involve denial or grandiosity. Others involve undue self-criticism.)
Impairment/functioning: Behavior is abnormal if it significantly interferes with normal life functioning (Lieben und Arbeiten). (Problems with this definition: It is too vague to apply in practice without further elaboration. In practice, it boils down to a too-ready deferral of the question to so-called experts. It does not distinguish between internal and external causation.)

Note that a given behavior could be rated as "abnormal" by one (or more) of these definitions, but as normal by one (or more) others. The four definitions don't always point in the same direction.

The problem may be the entire concept of "abnormality". Such language implies the mental health is an all-or-nothing matter (is dichotomous), i.e., one is either normal or abnormal, sane or insane, healthy or ill, adaptive or maladaptive. But in reality, mental health is better represented by a continuum (there are degrees of mental health; most people are moderately well adjusted). In addition, the risk of labelling effects is significant (see the Rosenhan study, "On Being Sane In Insane Places"). As a result, the whole psychodiagnostic enterprise needs to be viewed with some caution and some degree of rational skepticism.

Two Types of Disorders

At the broadest level, we can differentiate between Axis I and Axis II disorders. Axis I conditions are (a) more specific in nature, (b) more disruptive, (c) more likely to have acute onset, (d) more likely to first appear in adulthood. In contrast, Axis II disorders are (a) more generic -- an overall "twist" or "bent" to the personality or temperament, (b) less disruptive, (c) more likely to be of gradual, chronic origin, (d) more likely to appear early in the lifespan (e.g., in childhood or early adolescence). Current diagnostic methods treat these two kinds of disorders separately, so that a person could have both an Axis I and an Axis II disorder, or both, or neither.

The "Big Five" Model of Normal Personality

Psychodiagnostic categories need to be viewed in the context of normal personality diversity (as extreme, pathological, or maladaptive variants of normal personality configurations). One frequently used scheme to depict normal personality variation is the Big Five schema, which posits five dimensions (Openness, Conscientiousness, Extraversion, Agreeableness, Negative Emotionality) along which nonclinical populations can be compared and contrasted. Note that the first letter of each dimension spells out the acronym OCEAN. Indeed, these five dimensions are said to "cover the waterfront" of normal personality variation.

Dimension I: Extraversion

This dimension addresses a person's preference for sociability and interactivity (high Extraversion, or E+) versus solitude and privacy (low Extraversion, or E-). E+ types tend to be quick to self-disclose, to process information out loud, to seek high levels of activity (to be outwardly busy), and to seek generalist work roles. E- types tend to be slow to self-disclosure (or selective about self-disclosure), to process information inwardly, to seek low levels of activity (to be inwardly busy), and to seek specialist work roles.

Dimension II: Openness

This dimension addresses a person's preference for abstract ideas and possibilities (high Openness, or O+) versus concrete realities and facts (low Openness, or O-). O+ types focus on thinking about the world as it might be, are more theory-driven, and tend to focus on the possibility or opportunity side of change (which, depending on their core values, may make them more "liberal"). O- types focus on acting in the world as it is now, are more application- or practice-driven, and tend to focus on the threat or risk side of change (which, depending on their core values, may make them more "conservative"). Under stress, O+ types tend to obsess, O- types to catastrophize. When solving problems, O+ types habitually try to widen or broaden the question (ask the biggest possible question first), while O- types habitually try to narrow the question (ask the smallest possible question first). To some extent, O+ types are more nonlinear, O- types more linear, in thought processes and learning styles.

Dimension III: Agreeableness

This dimension measures cooperative (high Agreeableness or A+) versus competitive (low Agreeableness or A-) approaches to interactions with others. A+ types usually describe themselves as empathic, sensitive, harmony-seeking; they like tasks and situations in which "everyone wins". A- types usually describe themselves as impersonal, analytical, outcome-driven; they like tasks and situations in which there are clear winners and losers. Correlated to the above, A+ types tend to decide subjectively ("with the heart") on the basis of personal values (but may find it hard to see the dark side of something they value, or may overidealize valued persons and situations), while A- types tend to decide objectively ("with the head") on the basis of impersonal logic (but may fail to factor in subjective or emotional considerations, or may strike others as too cold-bloodedly analytical).

Dimension IV: Conscientiousness

This dimension measures convergent, task oriented (high Conscientiousness or C+) versus divergent, process oriented (low Conscientiousness or C-) work styles. C+ types usually describe themselves as organized, structured, systematic, early starters with steady work habits; they lose efficiency in low structure situations (needing stability), and usually adopt a "work first, play later," serious minded stance to life. C- types usually describe themselves as spontaneous, flexible, adaptable, "feast or famine" workers who rely on bursts of enthusiasm or energy; they lose efficiency in high structure situations (needing autonomy), and usually adopt a "mix work and play", fun loving stance to life. (Note: all of us can be both serious minded and fun loving; but C+ types tend to keep the humor inside, C- types to keep the seriousness inside. This dimension measures what shows on the outside, which is not always the most important aspect of the person.) C+ types tend to focus heavily on image management (how they look to others), while C- types tend to neglect or ignore such considerations. C+ types can easily be too rigid or inflexible, while C- types can struggle with disorganization or procrastination.

Dimension V: Negative Emotionality

This dimension measures characteristic responses to stress. (It does not measure anxiety proneness in a clinical sense; both poles are normal personality variants.) High Negative Emotionality or N+ types are more emotionally labile (have a wider emotional range or more mood swings), experience and express anxiety directly (verbally), and tend to be more prone to such mood states as worry, self-doubt, and guilt. Low Negative Emotionality or N- types are more emotionally stable (have a narrower emotional range or fewer mood swings), experience and express anxiety indirectly (they engage in "anxiety binding" or the "somatization" of anxiety), and tend to be less prone to negative mood states. While our culture probably values N- over N+, it should be stated clearly that N+ is not only a normal variant but can be an adaptive one (it is, among other things, arguably more authentic, can lead to greater levels of compassion for fellow strugglers, and so forth).

Implications

One influential theory of learning styles suggests that there are four basic ways to learn: by reading/thinking, discussing/listening, watching/observing, and doing/experiencing... and that your preferences are likely linked to your personality. Let's explore this in more depth.

There are two ways to use the Big Five system to identify your likely learning style. The first is the so-called "quadrant" system, which examines your scores on the dimensions of Extraversion and Openness.

The four quadrants

Here are some thoughts about how the four quadrants might differ in terms of learning styles and motivations:

The E- O+ quadrant:

Enjoys learning about abstract concepts, ideas, and theories
Learns best by reading and thinking creatively about ideas on her/his own
Wants to know what interesting interconnections exist between theories, or what new speculations a theory will open up
Loses interest when material is cut-and-dried and purely practical in scope
Is best evaluated by exams that emphasize literary capability, open-endedness, and creative synthesis of ideas, such as essay exams

The E+ O+ quadrant:

Enjoys learning about possibilities that can be explored or debated in the world of people-interaction
Learns best by talking and disputing in a fast-paced, process-oriented group context
Wants to know what others think about ideas, and how new perspectives can emerge through the dialectic process of give-and-take
Loses interest when information is too didactic, structured, detail-bound, or presented in a format that stifles or discourages interactive learning
Is best evaluated by oral presentation formats like speeches, debates, group discussion, group dynamics, group projects

The E- O- quadrant:

Enjoys learning about concrete facts and details
Learns best by quietly observing, in a traditional and structured setting
Wants to know what facts and procedures are important; what can be depended on to be useful
Loses interest when forced to be talkative, to learn interactively, or to deal with open-ended questions and speculations about theories and possibilities
Is best evaluated by traditional exams that emphasize right and wrong answers, such as multiple choice exams

The E+ O- quadrant:

Enjoys learning about practical, hands-on information that can be applied to pragmatic, concrete, real-world problems
Learns best by observing and doing -- learning just enough to see what's going on and then jumping in and trying things
Wants to know what practical use information will be; what will work in the here and now; what can be put to use immediately
Loses interest when forced to deal at length with abstract words, concepts, theories that seem far removed from the world of immediate experience
Is best evaluated by observing a hands-on demonstration of skills and competencies in a realistic setting with meaningful (not purely arbitrary) consequences or impacts or results

Axis I Disorders: An Overview

Not all Axis I disorders will be covered in this class. For our purposes, four clusters or categories of Axis I disorders will be considered:

Anxiety disorders, in which the primary symptom is elevated anxiety or a closely related cluster of symptoms that are associated with anxiety
Somatoform disorders, in which the primary symptom is one in which physical (or mental, e.g., memory or self-identity) impairments exist which cannot be explained in normal medical (physiological or organic) terms
Affective disorders, in which the primary symptom involves mood disturbances (e.g., depression)
Cognitive disorders, in which the primary symptom involves serious distortions in thought processes and loss of normal reality contact

One of the challenges of this unit will be to recognize examples of the various specific Axis I disorders in clinical "case study" material. The steps are as follows:

Is there any Axis I disorder present at all? (See the four criteria for an Axis I disorder, above.)
If yes, which of the four general types is it?
What is the specific diagnosis (among the specific syndromes or subtypes found within that cluster or category)?

The Anxiety Disorders

For our purposes, the terms "fear" and "anxiety" need to be differentiated. "Fear" means a normal, rational, proportionate response to an objective threat. "Anxiety" means irrational anxiety (there is no actual threat) or disproportionate anxiety (the fear reasponse is "blown out of proportion" to a substantial, uncontrollable degree).

If fear but not anxiety is present, there is no Axis I disorder. However, since a catchall phrase is needed to code (e.g., for insurance purposes) those who desire short-term counseling support to deal with fear responses in the face of rational objective threat situations, the term adjustment disorder is often used to refer to these "normal" responses to life challenges.

If anxiety is present, it can be categorized as either specific (the anxiety trigger can be identified in specific terms) or free-floating (anxiety that is nonspecific and seems to "come out of nowhere" in an unpredictable manner). This determination leads to two distinct groupings of disorders.

Free-floating anxiety can be characterized as either exogenous (originated, at the outset, by some initial environmental event or trauma) or endogenous (its origin is unknown and may be related to a biochemical neurotransmitter imbalance, possibly of genetic origin). Exogenous anxiety that was originally triggered by a traumatic life event is usually characterized as post-traumatic stress disorder or PTSD. Exogenous anxiety in response to non-traumatic events is closely akin to the adjustment disorder condition noted above (the boundary between normal fear and abnormal anxiety is, of course, vague and hard to specify). Endogenous anxiety that is associated with recurrent panic attacks is called, not surprisingly, panic disorder; if panic attacks are absent, a diagnosis of generalized anxiety disorder (which is hard to distinguish from very high levels of the normal N+ personality trait) is usually made.

If the anxiety is specific and not free-floating, if a pattern of obsessive thoughts predominate (with compulsive behavior as a secondary, anxiety-management symptom cluster), the diagnosis is one of obsessive-compulsive disorder or OCD. Absent these symptoms, the condition is some kind of phobia. Two general types are social phobias (the fear is one of some kind of negative social evaluation) and simple phobias (all other types).

The Somatoform Disorders

All such disorders involve some loss of, or significant alteration, in either physical or mental functioning (but not loss of reality contact as would characterize the cognitive disorders, below).

Because many of the somatoform disorders "mimic" true organic disorders (those with physical rather than psychological causes), and because it is possible in some cases to present fraudulent symptoms of this nature, it is important to rule out causes other than a psychiatric disorder.

If there are no discrete functional symptoms but merely an excessive level of anxiety about health issues, the diagnosis is one of hypochrondriasis. (Because of the specialized nature of this disorder, it is not usually grouped - as would have been expected - with the phobias, even though in some ways it has as much in common with the anxiety disorders as with the somatoform disorders.)

If there are discrete functional symptoms that involve a psychological cause (e.g., displaced anxiety), then:

1. If organic causation is also involved (e.g., a "stress related illness" or a physical illness that is caused by or exascerbated by stress), then the diagnosis is that of psychosomatic illness. In reality, by one estimate, over 80% of physical illnesses have at least some emotional component; however, the term "psychosomatic illness" is reserved for those in which the anxiety component is obvious and central.

2. If no organic causation is involved, the condition is known as hysteria (or conversion disorder) if the symptoms are physical, or as dissociative disorder if the symptoms are cognitive. Examples of dissociative disorders include psychogenic amnesia and multiple personality disorder.

Affective Disorders

These disorders involve a distortion of mood states outside of the normal range of "highs" and "lows" that most people experience. There are two general types: unipolar disorders, in which the mood extremes are in only a single direction (lows but not highs, or more rarely, highs but not lows), and bipolar disorders in which both extremes (highs and lows) are experienced in a cyclic fashion.

Bipolar disorders that involve clinical extremes to the point that the highs (manic states) involve actual loss of reality contact, and the lows (depressive states) involve serious major depression and possible suicide risk, are known as bipolar affective disorder proper (used to be called manic depression). A bipolar condition that involves mood swings outside the normal range, but not to the extremes above, is typically called cyclothymia. If, in addition, the mood swings seem strongly linked to the calendar year (cycles of light and darkness associated with the changing seasons), a term often used is seasonal affective disorder or SAD.

Unipolar disorders can involve only highs, but for our purposes we will examine only the unipolar depressive conditions (moods do not cycle above the normal high range, but do dip below into clinically depressive states). Depressive states, like anxiety states (see above), can be characterized as either exogenous or endogenous. Exogenous depression that is generally self-limiting (would "go away on its own" but may require short-term counseling support in some cases, such as a protracted normal grief reaction) is yet another form of an adjustment disorder: hence adjustment disorders can involve either predominant anxiety or predominant depression, and tend to "straddle" the two categories of the anxiety and the affective disorders.

Among depressive states that are endogenous, or exogenous but not self-limiting, there are three types:

1. A chronically low mood in which there are no distinct ups and downs and no cyclic pattern: dysthymia.

2. A depressive condition involving a clear cyclic pattern, with serious mood troughs (often associated with high suicide risk) alternating with relatively normal mood states: major depression.

3. If both states are present (a generally dysthymic mood state with cyclic troughs of extreme depression also present), both diagnoses may be made simultaneously - a condition sometimes known as "double depression".

Cognitive Disorders

These include primarily the schizophrenias. Characteristic symptoms include "positive" symptoms in which something unwanted is added to normal cognition, such as:

1. Overinclusive thinking -- an inability to keep one's mind "on track" and to stop the flow of free associations that can be voluntarily inhibited by normal individuals

2. Ideas of reference, in which events that normal individuals would call unimportant, random, meaningless, or insignificant are invested with extreme personal significance

3. Delusions, or ideas that are not supported by observation or objective reasoning, but which are deeply held (and not part of a consensual subculture)

4. Hallucinations, or sensory experiences in the absence of an external stimulus

A range of "negative" symptoms in which something desired is missing are also often found in these syndromes, such as:

1. Flat (or inappropriate) affect - the person seems to have no emotional capabilities, or they are expressed in ways that do not fit the outward context

2. Sizothymia - extreme levels of social withdrawal (not just shyness or introversion, but an apparent lack of any normal interest in even the most routine of social interactions)

3. Lack of behavioral flexibility which, in the most extreme cases, can become literal catatonia

Classically, there are four major types of schizophrenia:

1. Paranoid schizophrenia in which a strong pattern of delusional thinking (often, delusions of persecution) are the major, but not the only, defined symptom

2. Disorganized or hebephrenic schizophrenia in which the other positive symptoms (particularly overinclusive thinking) predominate; delusions, if they are present, are usually not so tightly centered around ideas of persecution

3. Catatonic schizophrenia, in which the negative symptoms generally predominate (often but not always including literal catatonia or extremely decreased behavioral responsiveness)

A fourth, undifferentiated type is used when a clear diagnosis among the other three types cannot reliably be made.

Paranoia (as opposed to paranoid schizophrenia) is a term sometimes used to refer to a condition in which delusional thinking is the only symptom, with no other evidences of cognitive distortion. In practice, it is difficult to distinguish from paranoid schizophrenia, above.

Schizoaffective disorder is a term used to distinguish conditions in which both schizophrenic symptoms and extreme mood swings (such as might be characteristic of manic depression) are present. In this syndrome, the usual flat affect of the schizophrenias is markedly absent. Loss of reality contact is central and far more profound than the brief cognitive symptoms sometimes associated with the extremes of the manic states in bipolar affective disorder. Mood swings are more erratic and less obviously cyclic. This pattern somewhat straddles the categories of the cognitive and the affective disorders and is a difficult diagnosis to make.

Axis II Disorders

The Axis II disorders, of which there are many (13 or more), can generally be grouped into the following four categories.

The Narcissistic/Histrionic Cluster

Think of these as a pathological variant of extreme E+. These individuals tend to be unduly self-focused and have a need to be in the limelight or in the center of others' attention. They seem outwardly friendly, warm, and engaging but usually come over time to strike others as fickle, flighty, superficial, and egocentric.

The Antisocial/Borderline Cluster

Think of these as a pathological variant of extreme A-. These individuals lack a normal capacity for empathy and essentially view others as means to an end rather than ends in themselves -- as objects to be used, not as people to be valued. If intelligent and sufficiently socially skilled, they may maintain an outward demeanor that can take others in (e.g., the typical "con artist"). Underneath, however, they usually strike others who get to know them better as heartless, ruthless, uncaring, and hostile.

The Schizoid/Schizotypal Cluster

Think of these as a pathological variant of extreme E-. These individuals show little or no desire for even the most basic social interaction and are habitual loners. (Unlike social phobics, they appear not to regret the fact and seem to have no need or wish for more human contact.) They lack the usual social motivations and may also show some "oddities" or "eccentricities" of speech and thought (but not to the point of an actual break with reality or of the kinds of clear symptoms associated with the Axis I cognitive disorders). Others usually see them as reclusive, eccentric, withdrawn, and inaccessible.

The Dependent/Avoidant Cluster

Think of these as a pathological variant of extreme A+. These individuals have an extreme need to please others and may be very anxious about what others think of them. They may be markedly passive and may find it very difficult to act independently or autonomously. They may have a "smothering" need for others or may be markedly insecure about how others view them. Others usually see them as caretaker types who are unduly unassertive, fearful, needy, and lacking in self-confidence and self-reliance.

Case Study

Click here for a representative case study (to be discussed in class). Your goal is to attempt a psychological diagnosis of the individual in question:

1. Does this person have an Axis I disorder? Why or why not? If so, which kind?

2. Does this person have an Axis II disorder? Why or why not? If so, which kind?

3. Apart from the above, how would you rate, evaluate, or classify this person in terms of the Big Five dimensions of normal personality?