Which theories and treatments of abnormality exist? - Chapter 2 (Abnormal Psychology)

A theory is a set of ideas that provide a framework. Based on this framework, questions can be asked about a particular phenomenon and information collected and interpreted about this phenomenon. A therapy is a treatment, often based on a theory about a disorder, that deals with the factors that cause the disorder according to the theory.

There are different approaches for explaining psychological complaints. For example, when it comes to anxiety, the biological approach symptoms suggests that the symptoms can be caused by a genetic predisposition to anxiety. The psychological approach seeks the explanation in a person's beliefs, life experience and relationships. The sociocultural approach looks at the cultural values ​​or social environment of a person. These different approaches are often seen as incompatible. People seek either a biological explanation or a socio-cultural explanation. This is also called the nature-nurture debate : is the explanation in someone's nature, or in education (or environment).

Although it is tempting to look for a single explanation, theoreticians often start from the biopsychosocial approach, which recognizes that it is often a combination of biological, psychological and socio-cultural factors. Vulnerability to a disorder can also lie with each of these factors and therefore does not always have to be genetic. Only vulnerability is not enough to develop a disorder, only when another trigger occurs (e.g. stress), the disorder could really develop.

Treatments have also been developed for each approach. The biological approach mainly requires medication, from the psychological and sociocultural approach it usually concerns psychotherapy. Both types of treatment have proved effective and are often used together, in an integrated approach.

Biological approaches

The famous story of Phineas Gage describes how this man, one day through an accident at work, received a thick iron rod through his skull and brain. Miraculously, he survived this accident and he recovered completely physically. His personality, however, had changed completely: from a responsible, friendly and intelligent man, he had suddenly changed into a capricious person who had no respect for social norms. His sense of responsibility was completely gone.

Later research showed that Gage mainly suffered damage to the frontal lobe. People who have damage to this part of the brain often have trouble taking rational decisions in social situations and have trouble processing information about emotions. They can still solve logic and abstract problems, just like Gage still could.

Brain dysfunction is only one of the three possible biological causes of abnormality. The other two are biochemical imbalances and genetic abnormalities. These three causes can also influence each other. For example, brain dysfunction can be the result of genetic factors and this can cause biochemical imbalance.

Brain dysfunction

The brain can be subdivided into three main areas: the hindbrain, midbrain and forebrain. The back brains contain the medulla (controls breathing and reflexes), punch (important for attention and timing of sleep), reticular formation (controls arousal and attention to stimuli) and cerebellum (is involved in coordination of movement) and is crucial for the most basic life functions. The midbrain contains the superior colliculus and inferior colliculus (transmit sensory information and control motion) and the substantia nigra (regulates responses to reward).

The forebrain in humans is relatively large and developed in relation to other organisms. The outer layer of the cerebrum is called the cerebral cortex, which is involved in many of our most advanced thought processes. It consists of two hemispheres that are connected by the corpus callosum. Each hemisphere consists of four lobes: the frontal, parietal, occipital and temporal lobes, each having different functions. Other structures in the forebrain are located just below the cortex and are therefore called subcortical structures. These are the thalamus (sends incoming information from senses to the cerebrum), the hypothalamus (regulates eating, drinking and sexual behavior), the limbic system (regulates many instinctive behaviours, such as reactions to stress, eating and sexual behavior), the amygdala ( part of limbic system, criticism for emotions such as fear) and the hippocampus (part of limbic system, plays a role in memory).

Biochemical imbalance

Neurotransmitters are biochemicals that act as messengers. They bring impulses from one neuron to the next. This happens in the brain and in some other parts of the nervous system. Each neuron has a cell body and several short branches called dendrites. These components receive impulses from nearby neurons. The impulse then moves through a long branch, called the axon, to the synaptic terminal. From there, the impulse stimulates the release of neurotransmitters in the synaptic gap between two neurons. The neurotransmitters bind to special receptors of the next neuron, which initiates an impulse on that basis. This way the pulse from neuron to neuron is passed on.

Many biochemical theories suggest that specific psychopathologies often have to do with an imbalance of certain neurotransmitters in the synapse. This can be influenced by two factors. The process re-uptake means that the pre-synaptic neuron takes back the neurotransmitter, reducing the amount of the synapse in the synapse. The process of degradation means that the post-synaptic neuron releases an enzyme in the synapse, which breaks down the neurotransmitter. If one of these processes does not function properly, an abnormally high or low concentration of a neurotransmitter in the synapse may result. Psychological symptoms can be the result. It may also be that psychological experiences actually provide for changes in the neurotransmitter system.

There are more than 100 different neurotransmitters. Serotonin plays an important role in emotions and impulses, such as aggressive impulses and anxious behavior. Dopamine is especially important in our experience of rewards. This neurotransmitter can be influenced by substances such as alcohol, which we see as rewarding. Norepinephrine (norepinephrine) occurs only in the brainstem and provides a stimulating effect. When we have too little of this, we feel depressed. Gamma-aminobutyric acid (GABA) inhibits the actions of other neurotransmitters and an imbalance of this transmitter is associated with anxiety symptoms. GABA can be found in many medications that have a calming effect.

The endocrine system

The endocrine system is a system of glands that hormones produce. Hormones also carry information through the body and therefore influence mood, energy levels and reactions to stress. The pituitary gland is the main gland and is just below the hypothalamus. In response to stress, neurons in the hypothalamic secrete corticotropin-release factor (CRF). This is transported to the pituitary gland, where it causes the main stress hormone, ACTH, to be excreted. This goes through the blood to the adrenal glands in the rest of the body, where a variety of hormones is released that prepare the body for response to an emergency. This system is called the hypothalamic-pituitary-adrenal axis (HPA axis). When this is disrupted, people have abnormal physiological responses to stress, making them more susceptible to anxiety disorders and depression.

Genetic abnormalities

Behavioral genetics studies the genetics of personality and abnormality and examines the extent to which behaviours are inherited and through which process genes influence behavior.

Each cell in the body has 46 chromosomes, 23 of the mother and 23 of the father. These are 23 chromosome pairs, one of which determines the gender. The XX combination makes someone a woman, the XY combination a man. When the structure of the chromosomes changes, this can have serious consequences. This creates Down's syndrome because no two but three of chromosome 21 are present. Each chromosome contains genes, in the form of strands of DNA. These genes give instructions to the cells to perform certain functions. Errors on the genes are more common than errors in the structure of the complete chromosome.

When there is an error on a gene, this does not directly lead to a disorder. Often several faulty genes are needed, all of which contribute to the development of a disorder. This is called a polygenetic process. Diabetes, heart disease and epilepsy are the result of such a process.

Interactions between gene and environment

There are several ways in which genes and environment can influence each other. Genetic factors can thus determine what kind of environment we choose for ourselves, because we have a certain temperament or talent that is genetically determined. In addition, the gene and environment can influence each other because the environmental a catalyst acts (reinforcing factor) for a specific genetic tendency. For example, if someone is genetically vulnerable to depression, certain triggers in the environment are still needed to really trigger the disorder. Finally, the study of epigenetics shows that environmental conditions can influence the expression of genes. DNA can be chemically adjusted by different environmental factors, so that genes are 'turned' or 'off' as it were. As a result, cells, tissues and organs will develop differently.

The study of epigenetics is still in its infancy but may well become very important. For example, it could help explain how identical twins, who therefore have the same DNA, can still differ in the way a disorder manifests itself.

Therapy by medication

Medication is probably the most used biological treatment when it comes to abnormality. This relieves symptoms by improving the functioning of the neurotransmitters.

Antipsychotic medicines help to reduce hallucinations and delusions. The first antipsychotics were the phenohiazines, but these had dangerous side effects. Nowadays, atypical antipsychotics are used, which are just as  effective but have fewer side effects.

Antidepressants reduce the symptoms of depression. SSRIs (selective serotonin reuptake inhibitors) are the most commonly used, they affect the serotonin neurotransmitter system. Newer antidepressants, SNRIs (selective serotonin-norepinephrine reuptake inhibitors), act on both serotonin and norepinephrine. These drugs do have side effects, but they are not dangerous.

Lithium is a metal that can be found in nature. It is used as a mood stabilizer, especially in bipolar disorder. In this disorder, someone alternately suffers from depression and mania (strongly increased mood, feeling of grandiosity, reckless behavior). Also, anti-convulsant are used in the treatment of mania, these have fewer side effects than lithium.

These were the first to be applied against fear barbiturates used, but these are highly addictive and the withdrawal of these can have very dangerous effects. Therefore, more frequently benzodiazepines are used, which reduce anxiety symptoms without seriously affecting one's daily functioning. Unfortunately, these drugs are also very addictive, but the withdrawal symptoms are less serious.

Electroconvulsive therapy and newer brain stimulation

techniques Electroconvulsive therapy (ECT) is an alternative to medication. Although originally developed for the treatment of schizophrenia, it was later discovered that this treatment has an effect in depression, but not in schizophrenia. In this therapy a kind of epileptic seizure is generated by passing a current pulse through the brain. Nowadays there are alternative techniques that work in a more targeted way and have fewer side effects. For example, there is repetitive transcranial magnetic stimulation (rTMS), in which magnetic pulses are focused on specific brain structures. With deep brain stimulation, the vague nerve is stimulated by means of electrodes, which in turn stimulates the target areas in the brain. It seems that especially these newer techniques are effective and that there are few side effects.

Psychosurgery

Psychosurgery means that a brain operation is performed with the aim of stopping certain symptoms. For example, a type of surgery that was sometimes used in psychosis, was in the form of a frontal lobotomy, in which the frontal lobe was separated from the lower brain structures. However, this had serious side effects and nowadays psychosurgery is not commonly used. The biggest problem is that we do not know exactly which part of the brain is responsible for many disorders. It is important to notice that although it is not common, sometimes psychosurgery is used but only in the most extreme cases.

Assessing biological approaches

Biological approaches have had a positive effect on the lives of people with disorders. They can now often lead normal lives and it has become clear that they are not guilty of their behavior, but that they actually have a medically demonstrable problem. However, medication does not always work. For some disorders, such as specific phobias, psychotherapy works better than medication. In addition, there are often side effects, which are sometimes even worse than the disorder itself.

Psychosocial Approaches

Behavioural

focus on the influence of rewards and penalties on the occurrence of behavior. The most important principles are classic conditioning and operant conditioning. Learning can also be prevented by modelling and learning through observation.

Classic conditioning

Ivan Pavlov discovered that the dogs he used in his research did not just drool when they got food, but after a while even when he or one of his assistants walked into the room. He had a neutral stimulus (himself) accompanied by a stimulus that naturally leads to a certain response (the food, which leads to drooling) and eventually the neutral stimulus (Pavlov himself) led to the response in itself. This process is called classic conditioning and here the food is the unconditioned stimulus (US). This stimulus produces the unconditioned response (UR). Pavlov himself served as the conditioned stimulus (CS), and the response that follows is the conditioned response (CR). This phenomenon is used to explain the irrational responses to neutral stimuli.

Operant conditioning

Thorndike discovered that behaviours followed by a reward are strengthened, while behaviours followed by a punishment are weakened. He called this simple observation the law of effect. This led to the development of operant conditioning - the formation of behavior by rewarding desired behaviours and punishing undesirable behavior. Behaviours are taught the fastest through a continuous reinforcement schedule, which means that the behavior must be rewarded or punished every time. However, it can be maintained by a partial reinforcement schedule, where the behavior is only occasionally rewarded or punished. Extinction - the elimination of learned behavior - is the most difficult when the behavior is learned through a partial reinforcement schedule, because then no continuous reward is needed to strengthen the behavior.

Modelling and learning through observation

In modelling people learn new behaviours by imitating them of people who are important in their lives, such as their parents. This occurs especially when the model person is seen as authoritarian and as similar to the person himself. Learning through observation occurs when a person observes the rewards and punishments that another person receives for his or her behavior.

Behavioural

Therapies focus on identifying the rewards and punishments that contribute to the maladaptive behavior of a person and to changing specific behaviours. We look at the situations in which the behavior occurs the most. Many different techniques exist for behavioral change. Systematic desensitisation therapy is one of them. The patient makes a list of situations that would generate a little more fear. The patient is then asked by the therapist to go through these situations step by step, until it can withstand even the most anxious situation without any problems. Within vivo exposure, the patient is asked to actually experience the anxiety stimulus directly. This often yields better results than just imagining the situation.

Cognitive approaches

Cognitive theories state that it is not just rewards and punishments that motivate human behavior. Instead, our cognitions (thoughts and beliefs) would shape our behavior and emotions. When something happens, we make a causal attribution of the event - we wonder 'why' it happened. These attributions determine what meaning we give to events and what we expect from similar events in the future. When an attribution is about our own behavior, this has consequences for our emotions and our self-concept: whether we blame our behavior on ourselves or on environmental factors can have very different consequences for how we think about ourselves. In addition to the attributions, we also make general assumptions about ourselves, our relationships and the world. These assumptions can be positive, or negative and destructive. When these assumptions are negative, people will respond to situations in an irrational and negative way.

Cognitive therapies

Cognitive therapies help clients identify and defy negative thoughts and dysfunctional beliefs. In addition, they are taught problem solving strategies to deal with concrete problems and they learn alternative ways to think about things. Often cognitive therapies are combined with behavioral therapies, in the form of cognitive behavioral therapy (CBT). In the form of assignments, the client must then test alternative thoughts or try new methods to deal with other situations. In addition, new skills can be learned, such as effective communication.

Psychodynamic approaches

The psychodynamic theories of abnormality suggest that all behavior, thoughts and emotions, normal or abnormal, are influenced by unconscious processes. These theories were first developed by Sigmund Freud. He developed psychoanalysis. This is both a theory of personality and psychopathology, and a method to examine the mind, as a form of treatment of psychopathology. Freud and his colleague Breuer argued that much psychopathology is a result of traumatic experiences of the past that have been tucked away in the subconscious mind (repression).

The Id, Ego and Superego

According to Freud, there are two basic drives that motivate human behavior: the sexual drive (libido) and the aggressive drive. These drives want to be released continuously but can be regulated by three different psychological systems. The id is the system where libido arises, and the drives and impulses of this system seek a direct way out. The id works from the pleasure principle: to get as much fun as possible as quickly as possible, and to achieve as little pain as possible. As children grow older, part of the ID splits and becomes the ego, the system that tries to meet our wishes and needs, but within the rules of society. From the ego develops superego. This is the storage space for the rules of conduct that are learned from the parents and society. The rules take the form of moral standards and living according to these rules reduces feelings of fear. According to Freud, most interactions between these systems happen completely unconsciously, but some find their way to the pre-consciousness. Only very few actually end up in consciousness. Freud also described certain strategies that the ego uses to conceal or change unconscious desires. When an individual's behavior is controlled by these defence mechanisms, or when the strategies are maladaptive, this can result in pathological behavior.

Psychosexual phases

During the development, according to Freud, a child goes through a series of psychosexual phases. In every phase, the sexual drives are focused on the stimulation of certain parts of the body. The parents' responses to the child's efforts to meet certain needs have a major impact on whether a particular phase is properly closed. If this does not happen, then a child canon a certain stage fixated become, so that it remains stuck with worries and problems of that phase.

The phases of Freud are as follows:

• The oral phase - the first 18 months after birth, in which the child is focused on stimulation of the mouth. A child who fixes on this phase can deeply distrust and develop separation anxiety.
• The anal phase - 18 months to 3 years, in which the child is focused on stimulation of the anus. Children can become fixated when parents are too critical during toilet training, they become stubborn and stingy.
• The phallic phase - 3 to 6 years, in which the child is focused on the genitals. During this phase, arises Oedipus complex, in which boys feels attracted to the mother and hate the father as a rival. They are afraid that the father wants to castrate them, so they put the mother aside and try to become like the father. This leads to a strong superego. Girls are attracted to their father, in the hope that he can give them a penis. Because there is no question of castration anxiety, they will never develop such a strong superego as boys. Not properly closing this phase leads to incorrect gender roles or non-heterosexual orientation and other problems with romantic relationships.
• The latent phase - 6 to 12 years, in this phase the sexual drives are at a low level. Attention is focused on developing skills and interests.
• The genital phase - from the age of 12, the sexual appetites reappear when puberty begins.

Later psychodynamic

Different theories regarding the ego psychology emphasizes the importance of regulating defence mechanisms that ensure a healthy functioning of society. The object-relations perspective integrates aspects of Freud's drive theory with the role that early relationships play in the development of the self-concept and personality

Psychodynamic therapies

The goal of psychodynamic therapies is to help clients develop their maladaptive coping strategies and the sources of their unconscious recognize conflicts. Freud developed the method of free association for this, in which a client talks about what comes to mind. The therapist then looks at which themes always return. When a client resists a particular subject, this is an important indication of the unconscious conflicts, because the most threatening conflicts are suppressed the hardest by the ego. The therapist must assemble all the pieces of the puzzle into an interpretation of the conflict that plays. Sometimes the client accepts this as a revelation, but sometimes resistance is also offered. This is seen again as a sign that the therapist has succeeded in identifying an important unconscious problem.

Also, transference is important. This means that the client responds to the therapist as if he were an important person from the early development of the client. For example, a client can react extremely angry if the therapist is a few minutes late, because he was previously left by a parent. Again, and again treating certain painful memories and releasing emotions (catharsis) ensures that the healing process goes well.

The difference between psychoanalysis and modern psychodynamic therapy is that psychoanalysis often takes several years, whereas psychodynamic therapy focuses more on current events in life and can be completed with 12 sessions.

Interpersonal therapy (IPT) focuses on the pattern of relationships that the client has had with people during his life. The therapist offers more structure to the treatment and gives interpretations earlier. This therapy can also be completed with 12 weeks.

The problem with psychodynamic theories is that the fundamental assumptions are very difficult to test scientifically. The processes that are described are very abstract. The long-term nature of the treatment ensures that many people cannot afford this. People with acute problems also have no benefit, they need faster results.

Humanistic approaches

Humanistic theories assume that people have an innate inclination to be good and to live life to the full. The pressure of society to meet certain standards instead of trying to develop the self as completely as possible hampers this tendency. According to Carl Rogers, people strive for self-actualization, the fulfilment of their potential for love, creativity and meaning. According to him, under pressure from society, people develop a distorted view of themselves, they feel a conflict between their real self and the self they think would please others.

Humanistic therapy

The goal of humanistic therapy is to help people discover their greatest potential through self-exploration. When clients are supported and enabled to grow, they will naturally confront the past if necessary for their further development. In this they are therefore not sent by the therapist. An example of this therapy is Carl Rogers's client cantered therapy (CCT). Reflection is the most important strategy, this is a method whereby the therapist tries to communicate to the client that he understands what the client is going through, but he gives no interpretation. Humanistic therapy therefore shifts the focus from what is wrong with people, to how we can help people develop as fully as possible. However, it is said that the theories are vague and cannot be scientifically tested.

Family system approaches

Family system theories view the family as a complex interpersonal system, with its own hierarchy and rules that determine the behavior of the family members. This system can function well and thus support the growth and well-being of the members, but it can also function poorly and thus cause psychopathology with one or more members. Therefore, if there is a psychological problem, this is due to a poorly functioning family system. This also determines the form that the disorder assumes. In an inflexible family there is a lot of resistance against the outside world and against change within the family. With an enmeshed family member are much too much involved in each other's lives, so they no longer have autonomy. In a disengaged family , the family members do not pay attention to each other and they all function as separate 'units', isolated from the others. In a pathological triangular relationship , parents try to avoid conflicts by always involving the children in all conversations and activities. Family system therapy assumes that the whole family should be treated, because the problem is not only with the person with the disorder. In Behavioral Family Systems Therapy (BFST), cognitive and behavioral techniques are used to learn problem-solving and communication skills. These therapies appear to be especially effective in children, because they are much more dependent on the family than adults.

Emotion-oriented approaches

The emotion-oriented approaches focus attention on how people understand and regulate their emotions. The poor regulation of emotions is seen as the core of many types of psychopathology, including depression, anxiety, substance abuse and most personality disorders. Techniques of behavioral and cognitive therapy are combined with mindfulness to help people accept, understand and regulate their emotions. The most well-known emotion-oriented therapy is dialectical behavior therapy (DBT), which focuses on the problems with dealing with negative emotions and controlling impulsive behavior. This therapy was originally used for the treatment of borderline personality disorders, but is now mainly used in people with eating disorders and people with problems in emotion regulation and impulse control. Accepting one's own feelings, thoughts and past and learning to live in the moment are the key to positive change.

Sociocultural approaches

According to socio-cultural approaches, we have to look beyond the individual and even the family, towards the entire society, to understand psychological problems. For example, socio-economic disadvantage is a risk factor for a lot of mental health problems, such as substance abuse, violence, depression and anxiety. Even when it comes to war, hunger or a natural disaster, these are serious risk factors for, among other things, post-traumatic stress disorder. Social norms that stigmatize certain groups (such as sexual minorities) also ensure that the members of these groups are more at risk of problems such as anxiety, depression and substance abuse. Society can also influence the types of psychopathology that arise by having implicit or explicit rules for which type of abnormal behavior is acceptable. Some disorders are even unique to a particular culture.

Cross-cultural problems in treatment

Usually people who go into therapy are treated with one of the treatments described in this chapter, with few adjustments for different cultures. However, this can cause problems if, for example, a client comes from a collectivist culture, where the individual is never considered separate from certain groups such as family, ethnic group or religion. Also expression of emotions, important in some treatments, is seen as negative in some cultures, such as in Japan. In addition, tensions can arise when the client clearly comes from a lower socio-economic class than the therapist. Many studies suggest that people from Latino, Asian and Native American cultures are more comfortable with structured and action-oriented therapy, such as behavior therapy or cognitive behavioral therapy.

When it comes to the treatment of children, cultural norms can be a problem when the rest of the family needs to be involved in the therapy. Parents often expect the therapist to "heal" the child and find it unacceptable that they should learn behavioral techniques themselves.

Although it is not self-evident that it is good for the treatment as therapist and client come from the same culture (they can still have different value systems), the relationship between client and therapist and the client's beliefs about the effectiveness of the treatment. important for how much the client is committed. Clients often feel more at ease with a therapist who has the same gender as herself. Many cultural groups, including within modern, industrialized countries, have their own forms of therapy. Often people from these groups seek help from both a healer from their culture and from a therapist who uses one of the treatment methods described in this chapter.

Prevention programs

Preventing the development of disorders before they start is called primary prevention . This can be done, for example, by intervening in the characteristics of the neighbourhood in which people live. Secondary prevention attempts to detect a disorder in an early phase and then to inhibit the development of the disorder, so that it does not arise in its entirety. Tertiary prevention mainly focuses on people who already have a disorder and tries to prevent them from having a relapse. This form of prevention also tries to keep the impact that the disorder has on a person's life as small as possible.

Common elements in effective treatments

Successful therapies have a number of components in common. The first is a positive relationship with the therapist. In addition, it is important that the therapist gives a good explanation or interpretation of why the client is affected by the disorder. It is therefore important that the client accepts and believes this interpretation, because then he will commit more to the treatment and the chances of recovery will increase. It is also important that the client painful emotions or memories confronts and thus stops them from avoiding or denying them.