Laurence Grimm & Lindsey L Henninger. Psychology Basics. Editor: Nancy A Piotrowski. Volume 2, Salem Press, 2005.
Psychopathology refers to psychological dysfunctions that either create distress for the person or interfere with day-to-day functioning in relationships or at the workplace. “Psychological disorders,” “abnormal behavior,” “mental illness,” and “behavior and emotional disorders” are terms often used in place of psychopathology.
As a topic of interest, psychopathology does not have an identifiable, historical beginning. From the writings of ancient Egyptians, Hebrews, and Greeks it is clear, however, that ancient societies believed that abnormal behavior had its roots in supernatural phenomena, such as the vengeance of God and evil spirits. Although modern scientists have opposed that view, in the twenty-first century many people who hold fundamentalist religious beliefs or live in isolated societies still maintain that abnormal behavior can be caused by demoniac possession.
The Greek physician Hippocrates (460-377 B.C.E.) rejected demoniac possession and believed that psychological disorders had many natural causes, including heredity, head trauma, brain disease, and even family stress. Hippocrates was wrong when it came to specific details, but it is remarkable how accurate he was in identifying broad categories of factors that do influence the development of psychopathology. The Roman physician Galen (c. 129-198 C.E.) adopted the ideas of Hippocrates and expanded upon them. His school of thought held that diseases, including psychological disorders, were due to an imbalance among four bodily fluids, which he called humors: blood, black bile, yellow bile, and phlegm. For example, too much black bile, called melancholer, was believed to cause depression. Galen’s beliefs have been discredited, but many of the terms he used have lived on. For instance, a specific subtype of depression is named after Galen’s melancholer: Major Depression with Melancholic Features.
A major figure in the history of psychopathology is the German psychiatrist Emil Kraepelin (1856-1926). He claimed that mental illnesses, like physical illnesses, could be classified into distinct disorders, each having its own biological causes. Each disorder could be recognized by a cluster of symptoms, called a syndrome. The way in which he classified mental disorders continues to exert a strong influence on approaches to categorizing mental illnesses. The official classification system in the United States is published by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR (rev. 4th ed., 2000). Many features of this manual can be traced directly to the writings of Kraepelin in the early years of the twentieth century.
Examples of Psychopathology
There is a very broad range of psychological disorders. The DSM-IV-TR lists more than two hundred psychological disorders that differ in symptoms and the degree to which they affect a person’s ability to function.
It is normal for someone to feel anxious on occasion. Generalized anxiety disorder is diagnosed when a person engages in excessive worry about all sorts of things and feels anxious and tense much of the time. Most people who have this disorder function quite well. They can do well at work, have good relationships, and be good parents. It is the fact that they suffer so much from their anxiety that leads to a diagnosis. In contrast, schizophrenia can be completely debilitating. Many people with schizophrenia cannot hold a job, are hospitalized frequently, have difficulty in relationships, and are incapable of good parenting. Common symptoms of schizophrenia include delusions (a system of false beliefs, such as believing there is a vast conspiracy among extraterrestrrial beings to control the government); hallucinations (seeing things that are not there or hearing voices that other people cannot hear); incoherence (talking in a way that no one can understand); or emotions that are expressed out of context (laughing when telling a sad story). The symptoms of schizophrenia make it difficult or impossible for the person to function normally.
Many disorders are marked by both subjective distress and impaired functioning. One such disorder is obsessive-compulsive disorder (OCD). An obsession is a recurrent, usually unpleasant thought, image, or impulse that intrudes into a person’s awareness. Some examples are believing that one is contaminated by germs, picturing oneself stabbing one’s children, or thinking that every bump hit in the road while driving could have been a person struck by the car. Obsessions cause a great deal of distress. Obsessions typically lead to the development of compulsions. A compulsion is a repetitive act that is used by the person to stop the obsession and decrease the anxiety caused by the obsession. People who believe they have been contaminated may wash themselves for hours on end; those who believe that they have hit another person while driving may not be able to resist the urge to stop and look for someone injured. Behavioral compulsions can sometimes occupy so much time that the person cannot meet the demands of everyday life.
Causes of Psychopathology
The most important goal of researchers in the field of psychopathology is to discover the causes (etiology) of each disorder. If the causes for disorders were known, then psychologists could design effective treatments and, it would be hoped, be able to prevent the development of many disorders. Unfortunately, theories of psychological disorders are in their infancy, and there are many more questions than there are answers. There is no general agreement among psychologists as to where to look for answers to the question of etiology. Consequently, some researchers stress the importance of biological causes, other researchers focus on psychological processes in the development of disorders, while still others emphasize the crucial role of learning experiences in the development of behavior disorders. All these approaches are important, and each supplies a piece of the puzzle of psychopathology, but all approaches have their limitations.
The Learning Approach
Psychologists who work within this model of psychopathology believe that abnormal behavior is learned through past experiences. The same principles that are used to explain the development of normal behavior are used to explain the development of abnormal behavior. For example, a child can learn to be a conscientious student by observing role models who are conscientious in their work. Another child may learn to break the rules of society by watching a parent break the same rules. In each case, observational learning is at work, but the outcome is very different. In another example of a learning principle, a person who is hungry and hears someone preparing food in the kitchen may begin to salivate because the sounds of food preparation have, in the past, preceded eating food and food makes the person salivate. Those sounds from the kitchen are stimuli that have become conditioned so that the person learns to have the same reaction to the sounds as to food (salivation). This learning process is called classical conditioning. In a different example, experiencing pain and having one’s life threatened causes fear. A person who is attacked and bitten by a dog might well develop a fear response to all dogs that is severe enough to lead to a diagnosis of a phobia. Just as the sounds in the kitchen elicit salivation, the sight of a dog elicits an emotional response. The same underlying principle of classical conditioning can account for the development of normal behavior as well as a disorder. There are many other principles of learning besides observational learning and classical conditioning. Together, psychologists use them to account for forms of psychopathology more complex than are exemplified here. Nonetheless, there are many disorders in which a learning approach to etiology seems farfetched. For example, no one believes that mental retardation, childhood autism, or schizophrenia can be explained by learning principles alone.
The Psychological Approach
This model, sometimes called the cognitive approach, holds that many forms of psychopathology are best understood by studying the mind. Some psychologists within this tradition believe that the most important aspect of the mind is the unconscious. The Austrian psychoanalyst Sigmund Freud (1856-1939) believed that many forms of psychopathology are due to intense conflicts of which the person is unaware but which, nevertheless, produce symptoms of disorders.
Many psychological disorders are associated with obvious problems in thinking. Schizophrenics, people with attention-deficit hyperactivity disorder (ADHD), and those who suffer from depression all show difficulties in concentration. Memory problems are central in people who develop amnesia in response to psychological trauma. People who are paranoid show abnormalities in the way they interpret the behavior of others. Indeed, it is difficult to find examples of psychopathology in which thinking is not disordered in some way, be it mild or severe. Within the cognitive approach, depression is one of the disorders that receives the most attention. People who are depressed often show problems in emotion (feeling sad), behavior (withdrawing from people), and thinking. The cognitive formulation assumes that thinking is central, specifically the way depressed people think about the world, themselves, and the future. Dysfunctional thinking is believed to give rise to the other aspects of depression. Most of the research in the field of psychopathology derives from the cognitive perspective. One of the major challenges to this approach is determining whether thinking patterns cause disorders or whether they are aspects of disorders that, themselves, are caused by nonpsychological factors. For example, depressed people have a pessimistic view of their futures. Does pessimism figure into the cause of the depression, or might depression be caused by biological factors and pessimism is just one of the symptoms of depression?
The Biological Approach
The biological (biogenic) approach assumes that many forms of psychopathology are caused by abnormalities of the body, usually the brain. These abnormalities can be inherited or can occur for other reasons. What these “other reasons” are is unclear, but they may include birth complications, environmental toxins, or illness of the mother during pregnancy.
Schizophrenia is one disorder that receives much attention among those researchers who follow the biogenic approach. A great deal of research has been conducted on the importance of neurotransmitters. Nerve cells in the brain are not connected; there is a small space between them. A nerve impulse travels this space by the release of chemicals in one nerve cell, called neurotransmitters, which carry the impulse to the receptors of the next cell. There are a large number of neurotransmitters, and new ones are discovered periodically. Early research on the relationship between neurotransmitters and psychopathology tended to view the problem as “too much” or “too little” of the amount of neurotransmitters. It is now known that the situation is much more complicated. In schizophrenia, the neurotransmitter dopamine has received most of the attention, with many studies suggesting that excessive amounts of dopamine cause some of the symptoms of schizophrenia. In fact, drugs that reduce the availability of dopamine to the cells are successful in alleviating some symptoms of the disorder. However, not all people with schizophrenia are helped by these drugs, and some people are helped by drugs that one would not prescribe if the sole cause of schizophrenia is too much dopamine. Researchers are finding that the way in which dopamine and another neurotransmitter, serotonin, work together may lead to a better biological theory of schizophrenia than the excessive dopamine hypothesis.
The biological approach is a highly technical field, and it relies heavily on advances in technologies for studying the brain. Powerful new tools for studying the brain are invented at a rapid pace. For example, researchers are now able to use neuroimaging techniques to watch how the brain responds and changes from second to second.
Heredity appears to be important in understanding who develops what kind of psychological disorder, but it is often unknown exactly what is inherited that causes the disorder. The fact that schizophrenia runs in families does not reveal what is being passed on from generation to generation. The fact that inheritance works at the level of gene transmission places hereditary research squarely within the biological approach.
One method for addressing the question of whether a disorder can be inherited is by studying twins. Some twins are identical; each twin has the same genes as the other. Other twins share only half of their genes; these are fraternal twins. If one identical twin has schizophrenia and the disorder is entirely inherited, the other twin should also develop schizophrenia. Among identical twins, if one twin is schizophrenic, the other twin has a 48 percent chance of having the same disorder, not a 100 percent chance. For fraternal twins, if one is schizophrenic, there is a 17 percent chance that the other twin will have the disorder. If neither twin has schizophrenia, and no one else in the immediate family has the disorder, there is only a 1 percent chance of developing this form of psychopathology.
Two important points can be made. First, genes matter in the transmission of schizophrenia. Second, the disorder is not entirely due to heredity. Researchers who focus on heredity have found that some other disorders seem to have a genetic component, but no mental illness has been found to be entirely due to heredity. Clearly, there are other factors operating, and the biological approach must be integrated with other approaches to gain a full picture of the etiology of psychopathology.
The Biopsychosocial Approach
As its name suggests, the biopsychosocial approach seeks to understand psychopathology by examining the interactive influences of biology, cognitive processes, and learning. This is the most popular model of psychopathology and, in its most basic form, is also referred to as the diathesis-stress model. A diathesis is a predisposing factor, and the diathesis may be biological or psychological. When discussing biological diatheses, most theories assume that the diathesis is present at birth. A problem with the regulation of neurotransmitters, which may lead to schizophrenia or depression, is one example. An example of a psychological diathesis is when a person’s style of thinking predisposes him or her to a disorder. For instance, pessimism—minimizing good things that happen, maximizing negative events, and attributing failures to personal defects—may predispose a person to depression. The stress aspect of the diathesis-stress model refers to the negative life experiences of the person. An early, chaotic family environment, child abuse, and being raised or living in a high-crime neighborhood are examples of stressful environments. From this perspective, a person will develop a disorder who has a predisposition for the disorder, in combination with certain life experiences that trigger the disorder.
Because the biological, learning, and psychological approaches have all contributed to the understanding of psychopathology, it is no surprise that most psychologists want to combine the best of each approach—hence, the biopsychosocial model. Given the present state of knowledge, each model represents more of an assumption about how psychopathology develops rather than a single theory with widespread scientific support. For virtually every psychological disorder, psychologists debate the causes of the disorder.
Culture and Psychopathology
The importance of understanding the cultural context of psychopathology cannot be overstated. To be sure, some disorders that span populations—depression, mental retardation, and schizophrenia are examples—but a population both defines what should be considered abnormal behavior and determines how psychopathology is expressed. “Cultural relativism” refers to the fact that abnormality is relative to its cultural context; the same behavior or set of beliefs can be viewed as abnormal in one population and perfectly familiar and normal in another population. When viewed from an American perspective, the remedies, rituals, and beliefs of a witch doctor may seem to reflect some disorder within the witch doctor rather than a valued and culturally sanctioned means of treatment within that culture. No doubt members of a given tribal population in South America may regard the behavior of North American adolescents on prom night as grossly abnormal.
Some disorders only exist in certain cultures. A disorder known as pibloktoq occurs in Eskimo communities. The symptoms include tearing off one’s clothes, shouting obscenities, breaking furniture, and performing other irrational and dangerous acts. The afflicted individual often follows this brief period of excited behavior by having a seizure, falling into a coma for twelve hours, and, upon awakening, having no memory of his or her behavior.
Some disorders may be very similar across two populations but contain a cultural twist. For instance, in the United States, the essential feature of social anxiety disorder is a fear of performance situations that could lead to embarrassment and disapproval. In Japan and Korea, the main concern of people with social anxiety disorder is the fear that one’s blushing, eye contact, or body odor will be offensive to others.
There are numerous examples of culturally based psychopathologies; the DSM-IV-TR lists twenty-five of them in an appendix. Moreover, throughout the manual, a brief statement accompanies the description of most disorders on the roles of ethnic and cultural factors that are relevant for the given disorder, which can help the clinician arrive at an accurate diagnosis.
The major forms of treatment for psychological disorders can be grouped according to the most popular models of psychopathology. Thus, there exists behavior therapy (learning approach), cognitive therapy and psychoanalysis (psychological approach), and somatic treatment, such as the use of medications (biological approach). Consistent with the biopsychosocial model, many therapists practice cognitive behavior therapy while their clients are taking medication for their disorders. These treatments, as well as the models from which they derive, represent common and popular viewpoints, but the list is not exhaustive (for instance, family systems is a model of disorders, and the treatment is family therapy). The link between models of psychopathology and treatment is not as strong as it appears. Therapists tend to adopt the treatment belief of “whatever works,” despite the fact that all therapists would prefer to know why the person is suffering from a disorder and why a specific treatment is helpful. In addition, even if the therapist is sure that the problem is a consequence of learning, he or she might have the client take medication for symptom relief during therapy. In other words, psychologists who are aligned with a specific model of psychopathology will still employ an array of treatment techniques, some of which are more closely associated with other models.
Based on learning theory, behavior therapy attempts to provide new learning experiences for the client. Those with problems that are fear-based, such as phobias, may benefit from gradual exposure to the feared situation. If social anxiety is determined to be caused by a deficit in social skills, a behavior therapist can help the person learn new ways of relating to others. If the disorder is one of excess, as in substance abuse, the behavior therapist will provide training in self-control strategies. The parents of children who show conduct disorders will be taught behavior modification techniques that they could use in the home. Behavior therapy focuses on the client’s present and future. Little time is spent discussing childhood experiences, except as they clearly and directly bear on the client’s presenting problem. The therapist adopts a problem-solving approach, and sessions are focused on a learning-theory-based conceptualization of the client’s problems and discussions of strategies for change. Homework assignments are common, which leads behavior therapists to believe that therapy takes place between sessions.
The basic tenet of cognitive therapy is that psychological problems stem from the way people view and think about the events that happen to them. Consequently, therapy focuses on helping patients change their viewpoints. For example, with a patient who becomes depressed after the breakup of a relationship, the cognitive therapist will assess the meaning that the breakup has for the person. Perhaps he or she holds irrational beliefs such as, “If my partner does not want me, no one will,” or “I am a complete failure for losing this relationship.” The assumption is that the patient’s extreme, negative thinking is contributing to the depression. The therapist will challenge these beliefs and help the patient substitute a more rational perspective; for example, “Just because one person left me does not mean that the next person will,” and “Even if this relationship ended, it does not mean that I am a failure in everything I do.”
Cognitive therapy has some similarity to behavior therapy. There is a focus on the present, history-taking is selective and related to the presenting problem, and homework assignments are routine. Indeed, because the two approaches have many things in common, many therapists use both forms of treatment and refer to themselves as cognitive-behavioral therapists.
Somatic therapy is the domain of physicians (psychiatrists) because this form of treatment requires medical training. By far the most common example of somatic therapy is the use of psychotropic medications, medicine that will relieve psychological symptoms. Less common examples are electroconvulsive shock treatment, in which the client is tranquilized and administered a brief electric current to the brain to induce a convulsion, and brain surgery, such as leucotomy and lobotomy (rarely practiced).
The use of medications for psychological disorders has become enormously popular since 1970. Three main reasons are that the biological approach to understanding psychopathology is becoming more prominent; new drugs are being released each year that have fewer side effects; and a great deal of research is being conducted to show that an ever-increasing number of disorders are helped by medication. The use of medication for psychological disorders is not viewed as a cure. Sometimes drugs are used to help a person through a difficult period. At other times they are an important adjunct to psychotherapy. Only in the most severe forms of psychopathology would a person be medicated for the rest of his or her life.
Which Therapy is Best?
Researchers approach the question of which therapy is best in the context of specific disorders. No one therapy is recommended for every disorder. For instance, behavior therapy has proven to be highly successful with phobias, cognitive therapy shows good results with depression, and a trial of medication is usual for schizophrenia and bipolar disorder.
No matter what the presumed cause is of a specific disorder, a common practice is to provide medication for symptom relief, along with some form of psychotherapy to improve the person’s condition over the long run.