After studying this chapter you should be able to:
•explain how abnormal behaviour has been defined using the criteria of statistical deviance, maladaptiveness and personal distress
•describe broader political and sociocultural factors that influence our perceptions of abnormality and normality
•briefly review the history of mental illness as it has evolved through a number of eras
•describe the classification of mental illness, particularly the use of the Diagnostic and statistical manual of mental disorders
•review some of the current models of psychopathology
•understand the use of the bio-psychosocial model and the diathesis—stress model as multidimensional approaches to understanding psychopathology
•outline two forms of psychopathology (post-traumatic stress disorder and schizophrenia) that are relevant to the South African context.
Melinda, when she first started to read about all the symptoms of different psychological disorders, felt a little nervous, wondering whether she could be diagnosed with some of the conditions described. She was relieved when she talked to some of her friends and found that they had been having similar thoughts. It was also quite reassuring as she began to realise that many people did have some slight symptoms of psychopathology and it was only when these were severe or caused problems in their lives that you could begin to diagnose a disorder. Melinda, like many people, had grown up hearing about ’crazies’. People would sometimes talk about this or that person who was mad, sometimes making a joke about them or saying how dangerous they were. After a while there would be rumours that they had been sent away to the rural areas to be cured — or worse, that they had gone to a mental hospital and wouldn’t be seen for a long time. These things had always seemed rather strange and frightening to Melinda.
Things changed, though, when one of her cousins developed a psychological disorder. Thandi, who was then 24, had just had her first child. Melinda and her family watched as Thandi became more and more withdrawn, and after a while she refused to even look after her own child. Eventually she just stayed in her room most of the time and wouldn’t talk to anyone. Sometimes they would hear her talking to herself as though there were other people in the room with her — but they knew she was alone. Finally, Thandi’s husband took her to the clinic, where she was given some medication for what they said was postnatal depression. As she began to recover, Thandi spoke to Melinda about how awful she had felt during the time of her depression. She said everything had seemed hopeless and pointless. She just couldn’t make herself care about anything — even her own child. She had just wanted to die. Most frighteningly for her, she had started to hear voices telling her to kill herself. She could see now that the voices weren’t real but at the time they had felt that way. Listening to her, Melinda realised psychological disorders looked very different from the inside than from the outside.
The term ’psychopathology’ is derived from the words ’psyche’, meaning mind or soul, and ’pathology’, meaning disease or illness. In essence, then, the term may be understood as referring to the study of mind illnesses or psychological disorders. But how do we define what should be called an illness or pathology of the mind?
In order to make a decision about what should be termed a psychological disorder, we need to establish defining criteria that separate disorders from normal behaviour.
One way of defining psychopathology is to use statistical norms of behaviour and experience to determine what is supposedly normal. Here, anything that falls far from the norm would be deemed abnormal. From this point of view, some behaviours that are relatively rare (e.g. talking to oneself in public) or behaviours that deviate from cultural norms (e.g. public nudity, or hallucinations such as hearing voices that do not exist) are seen as abnormal or as a sign of mental illness. The problem with this definition, however, is that the norm, or what is considered normal behaviour, would depend on our cultural or social perspective. For instance, hearing voices and some forms of public nudity are not considered abnormal behaviours in many African cultures and play an important role in giving cultural meaning to particular life events. Furthermore, what might be considered normal may not always be considered healthy or appropriate behaviour. Racist attitudes are often the norm in many societies, but it would be incorrect to view these as acceptable. In other words, abnormality and statistical deviance cannot always be equated, and the context in which the individual lives needs consideration. Taking this into account, a more accurate way of understanding deviance is the extent to which cultural norms or ideological perspectives are breached.
However, even within a particular cultural context, equating deviance with abnormality is problematic. This is because such a criterion fails to distinguish between positive and negative behaviours that deviate from the norm. For example, deviations from the norm may be due to characteristics like eccentricity, genius or some form of outstanding achievement. These could hardly be viewed as inappropriate or pathological.
The extent to which certain behaviours or experiences are maladaptive to the self or others is also used as a means of defining psychopathology. Here, behaviours that appear to prevent the individual from adapting or adjusting for the good of the individual or group are defined as abnormal. The maladaptiveness criterion is based on the assumption that individuals should change and adapt for the good of the self and to ensure the survival of the individual and the broader community. Common signs of psychopathology such as suicide, depression and fatigue would fit this criterion because they stand in the way of the individual’s personal growth and actualisation.
In a similar way to the criterion of statistical deviance, maladaptiveness is also relative to the particular cultural perspective within which it is being examined. Many West African countries, for instance, still participate in female circumcision ceremonies, a practice viewed by many as abnormal and barbaric. However, from within some of these cultures such practices are viewed as adaptive and are practised for the purpose of instilling cultural beliefs about sexual reproduction and sexuality in their people. In other words, female circumcision is not viewed as abnormal by many individuals within that culture.
One of the main problems with the criterion of maladaptiveness, and also with statistical deviance, is that both these criteria attempt to assess abnormality from a position outside of the individual’s own experience of the apparent problem. This has led to many researchers instead considering the criterion of personal distress as an indicator of psychopathology.
Table 24.1 Some myths about mental illness
Abnormal behaviour is odd and bizarre.
The behaviour of mental patients is most often indistinguishable from that of normal persons.
Mental patients are unpredictable and dangerous.
A typical mental patient is no more dangerous than a normal person.
Mental disorders are caused by fundamental mental deficiencies and are therefore shameful.
Everyone shares the potential for becoming disordered and behaving abnormally.
Abnormal and normal behaviour are different in kind.
Few, if any, abnormal behaviours are unique to mental patients. Abnormality usually occurs when there is a poor fit between behaviour and the situation in which it is enacted.
Suffering often accompanies psychological disorders. In cases where anxiety and depression are the prominent symptoms, people often struggle with unbearable negative thoughts about themselves and their world. In these cases it is fitting that personal distress is associated with what constitutes a mental disorder. But once again there are exceptions. Individuals who suffer from antisocial personality disorder (APD) often do not feel appropriate forms of distress. Individuals with APD are likely to find pleasure in inflicting pain on others and they are often violent and abusive in their relationships with others. Therefore, if we only applied the criterion of personal distress to such cases, they would not be viewed as being abnormal. This would obviously be incorrect.
In addition to this, if personal distress is a criterion of abnormality, this also implies that all personal distress is inappropriate or unhealthy. This is clearly not the case. Distress is often a normal response to difficult or dangerous situations. For example, we would expect an individual to endure an immense amount of personal distress if they were to lose a loved one. This, however, is clearly a healthy response to the situation where distress is an important part of bereavement and the mourning process.
As has been shown in using the criteria of statistical deviance, maladaptiveness and personal distress, there is no clear-cut answer to the problem of what is normal and what is not. This is an ongoing problem in the field of psychology, and is reflected in how the boundaries of what constitutes normality have shifted throughout history. In addition, broader political and sociocultural forces have been shown to have an important impact on how we view mental or psychological disorders. Homosexuality, for instance, used to be a diagnosable mental disorder in many parts of the world. However, since 1973 homosexuality has no longer been regarded as a mental disorder because there were no clear links to be found between mental disorders, abnormality and homosexuality.
•Psychopathology is the study of mind illnesses or psychological disorders.
•There are three widely used criteria for distinguishing disorders from normal behaviour:
”Statistical deviance asks how much the behaviour differs from normal behaviour. However, what is considered normal is culturally defined. Also, some statistically normal behaviour may not be considered healthy or appropriate. In addition, eccentricity and genius are also abnormal.
”Maladaptiveness considers how harmful the behaviour is to the person and to others. However, some behaviours may be viewed as maladaptive in certain cultures but not in others.
”Like statistical deviance, the maladaptiveness criterion takes an objective (rather than a subjective) view. Hence, the criterion of personal distress was included. However, some people with abnormal behaviour feel no such distress, for example when harming others. Also, not all personal distress is abnormal.
24.1PRACTICES OF XHOSA-SPEAKING TRADITIONAL HEALERS IN MANAGING PSYCHOSIS
Source: Mzimkulu and Simbayi (2006)
The study aimed to investigate how amagquira (traditional healers) managed psychosis.
The authors interviewed four traditional healers chosen because they were associated with patients receiving treatment for psychosis in a Cape Town psychiatric hospital.
Using thematic content analysis, Mzimkulu and Simbayi (2006) found the following:
•The healers identified symptoms of psychosis as reflected in the DSM-IV criteria for schizophrenia.
•Aetiological factors were considered to include witchcraft, spirit possession and angry ancestors, as well as inherited vulnerabilities.
•Treatment approaches included induced vomiting, steaming and cleansing.
The study concluded that traditional and Western healing systems will continue to co-exist and that there needs to be continued collaboration between these systems.
A brief history of mental illness
Our current understanding and treatment of psychopathology has emerged from a long history that has undergone many developments and changes. The history of our relationship with mental illness might be understood as evolving through a number of eras.
The early era
Problems with madness and insanity have always been a part of the human condition (Porter, 2002). Skulls dating from 5000 BC have holes burrowed into the cranial region. The dominant understanding of mental illness during this period was informed by a belief that individuals who became psychologically disturbed were possessed by evil, supernatural forces. Presumably, by boring a hole in the patient’s skull, the evil spirits causing the mental disturbance could be driven out.
The ancient era
The first evidence of a shift to a naturalistic view of mental illness can be found in the work of a Greek physician named Hippocrates (460—377 BC). He believed that psychological disorders were the result of imbalances in four essential fluids or humours in the body: blood, phlegm, yellow bile and black bile. For example, he believed that a disproportionate amount of black bile would cause melancholia (a form of depression). He prescribed naturalistic remedies to heal these kinds of problems, such as recommending solitude, a change in diet, or abstinence from sexual activity. Although his understanding of mental illness was later found to be incorrect, his findings marked the rudimentary beginnings of the biomedical approach to understanding psychopathology that emerged centuries later. For this reason, he is often referred to as the father of modern medicine.
During the Middle Ages, the naturalistic approach to understanding mental disorder fell out of favour, and religion dominated all explanations of psychopathology. There was a return to earlier supernatural explanations of mental illness, which now emerged from more organised forms of religious doctrine. Mental illness was seen as a punishment for sins committed, or as a form of demonic possession. The church became the main vehicle through which such so-called possessions could be exorcised. Europe began to witness extensive witch hunts. Individuals appearing to go against the Christian faith were accused of being possessed by the devil and were thought to have various supernatural powers that could cause great harm to others. Many mentally ill people of this era were severely punished or killed as a result.
Figure 24.1 Hippocrates is seen as the father of modern medicine
Formal segregation of mentally disturbed individuals began in the late Middle Ages when the Church, supposedly out of charity, began locking up the so-called insane. The best-known institution for the insane was established in the religious house of St Mary of Bethlehem (often called Bedlam, a term that has come to connote confusion, disorder and chaos) in London late in the 14th century (Porter, 2002).
The Renaissance era
During the Renaissance (1400—1600), patients who were psychologically ill began to be treated more humanely, and ideas related to witchcraft were more openly challenged. Johann Weyer (1515—1588), a German physician, argued that such individuals were not possessed by the devil but were mentally unstable and could not be held responsible for their actions. Later, in 1584, Reginald Scot published Discovery of witchcraft, in which he argued that so-called demonic possessions were medical illnesses and not visitations from evil spirits.
The asylum era
Although the scientific understanding of mental illness began to increase, the institutionalisation of the mentally ill was also on the increase in the 16th century. Patients were housed in asylums that became well known for their inhumane treatment of mental patients. Common treatments included restraining patients for long periods of time, placing them in dark cells and subjecting them to torture-like treatments. Inmates were often subjected to electric shocks, bleeding in order to rid the body of supposedly dangerous fluids, powerful drugs and starvation.
Late in the 18th century, these kinds of treatments were gradually challenged with the emergence of humanitarian reforms across the Western world. In France, Philippe Pinel (1745—1826) put forward the idea that mental patients needed to be treated with kindness and consideration if they were to recover. He argued that their chains should be removed, they should be moved out of the dungeons where they had been incarcerated and placed in sunny rooms. They should also be permitted to do exercise and to partake in other constructive activities. Similarly, in England, father and son William and Henry Tuke established a country retreat where patients could rest peacefully and work in a caring and supportive atmosphere. Many patients were reported to have completely recovered from their mental illnesses once they were treated in a humanitarian fashion. The changes that followed revolutionised the way mental illness was treated during this time. Patients were treated with care and understanding, and, gradually, trained nurses and other professionals were introduced to help in the treatment of mental patients.
Despite these developments, mental patients in some places around the world are still subjected to extreme forms of restraint such as being chained.
The scientific era
Towards the end of the 19th century, scientific discoveries related to mental disturbance began to increase. Central to this breakthrough was the discovery that general paresis (syphilis of the brain), a disease that caused paralysis and insanity, had a biological cause and could be successfully treated. This fuelled the search for other biological causes that might be associated with mental illness and formed the foundation of modern-day psychiatry.
Many other developments occurred during this era in an attempt to identify, understand and treat different forms of psychopathology. Mental disorders were now largely understood to be medical illnesses that could be identified through their signs and symptoms. In 1883, Emil Kraepelin observed that certain symptoms occurred with specific types of mental disease. From this he developed a classification system for a number of disorders, most notably dementiapraecox (known today as schizophrenia) and manic-depressive psychosis (known today as bipolar disorder). Kraepelin’s views about classification were revolutionary and served as a precursor to the Diagnostic and statistical manual of mental disorders that is currently used to make a diagnosis.
Figure 24.2 Emil Kraepelin
The scientific era has also been characterised by the development of many different psychological theories and treatments. In the late 19th century, Sigmund Freud devised a means of treating patients who suffered from hysterical and neurotic conditions. His treatment, known as psychoanalysis, was based on his theory that psychopathology is largely caused by the repression of forbidden wishes or instinctual drives.
Psychoanalysis claimed that psychopathology had its genesis in psychological conflict caused by instinctual drives; in reaction to this, the school of behaviourism emerged in the 1950s. Based on the work of influential theorists like Skinner and Pavlov, behaviourists believed that we could better understand psychopathology by observing how abnormal behaviour is learned and reinforced by the external environment. Behaviour therapy thus sought to change the factors in the environment that tended to reinforce maladaptive behaviours.
Many other forms of psychological treatments have emerged in the past 50 years, all of them claiming to have a better understanding of the human condition and abnormal behaviour. Existential psychotherapy, primal therapy, cognitive-behaviour therapy, gestalt psychotherapy, logo-therapy and neurolinguistic programming are but a few of the treatments developed in this era.
The choice of different treatment modalities remains an ongoing debate in psychology, and a great deal of research is being compiled to find out if some treatments are indeed more effective than others. Often the treatment method that is chosen simply depends on the therapist’s chosen theoretical orientation.
The introduction of psychotropic (mood influencing) drugs in the 1950s has also been seen as an important landmark in the history of mental illness. Drugs such as lithium, chloropromazine and imipramine were hailed as miracle drugs because, for the first time, symptoms associated with mania, psychosis and depression could be controlled through the use of medication. This made it possible for many patients to leave, or altogether avoid being admitted to, psychiatric institutions. Many were able to maintain normal productive lives under continuing medication. In this way, psychopharmacological treatment was able to provide a cost-effective way of managing patients without having to resort to lengthy stays in psychiatric hospitals.
Currently, the status of applied psychology appears to be shifting away from adopting a single theoretical or disciplinary approach for understanding, managing and treating psychological problems. There is a growing awareness that our understanding of psychopathology is always context dependent, and it is this that needs to be addressed first and foremost. It is important to note, for instance, that even this brief historical account of mental illness is not free of a particular context and is largely a history told from a Western perspective, a perspective that dominates much of our thinking in this field.
Alternate understandings of psychopathology
There are other views of psychopathology, and other histories of psychopathology that differ from the dominant Western approach. In China and India, for example, there are traditions of healing that do not share the Western history of trying to separate physical from mental illnesses. In southern Africa, alongside the biomedical or Western view of psychopathology there are other important traditions. Indigenous theories of illness, including theories of psychopathology, will commonly locate the cause of personal problems in difficulties in social relationships. These relationships may be both with living people and with ancestors, who continue to play an important part in social life even after death. In African traditional approaches, ancestors are those family members who have died but who continue to be interested in the affairs of the family and influence them. Religious healing is also very common in southern Africa, and some churches, most notably the Zionist Church, practise a form of religion that combines indigenous beliefs with Christianity, often in charismatic forms.
Figure 24.3 A traditional healer
24.2THE ANTI-PSYCHIATRY MOVEMENT
Anti-psychiatry is a term that was coined by David Cooper in 1967, and is generally associated with phenomenological philosophers like Thomas Szasz, Gregory Bateson and R.D. Laing. It is a sociopolitical movement that rejects the methodologies, medical practices and underlying assumptions of psychiatry (Cooper, 1967).
A key understanding of anti-psychiatry is that mental illness is a myth (Szasz, 1972). The argument is that illness refers to problems in the body’s physical functioning and therefore cannot be applied to a psychological disorder that has no signs of physical pathology. The anti-psychiatry movement argues that doctors tend to view the mentally ill as blameless victims of brain diseases, and to uncritically accept the supposed structural and physiological basis for mental illness (Double, 1992). This has led, they argue, to the inhumane treatment of patients where they are treated as though they are objects (Johnstone, 2000).
In opposing the medical psychiatric view, anti-psychiatry holds an anti-authoritarian position that argues against the use of psychiatric diagnosis, drug treatments, electro-convulsive treatments and involuntary hospitalisation.
As a political force, anti-psychiatry waned during the 1970s. However, due to the growing use and abuse of psychiatric drugs in the general population, anti-psychiatry is currently experiencing a resurgence as a human rights watchdog. Nasrallah (2011) in an editorial for Current Psychiatry notes that antipathy towards psychiatry dates back to maltreatment of the mentally ill two centuries ago. Nasrallah (2011) goes on to list psychiatry’s supposed misdeeds, most of which are historical rather than current. He does, however, acknowledge that ’antipsychiatry helps keep us honest and rigorous about what we do’ and notes that ’the best antidote for antipsychiatry allegations is a combination of personal integrity, scientific progress and sound evidence-based clinical care’ (Nasrallah, 2011, p. 53).
In addition to psychologists and psychiatrists (of whom there are relatively few on the African continent), people in southern Africa may consult indigenous healers such as the isangoma or igqira (indigenous healers), inyanga or ixh-wele (herbalists), or umprofita (prophets in the Zionist church). There are also local categories of illness and spirit possession, some of which will be discussed briefly below. The question of whether different forms of treatment are effective, and of how and whether practitioners from different healing traditions can and should work together, is an interesting and complex one; partly because of the continuing dominance of Western models in psychology (see Chapter 1), we do not know enough about these issues. (For a further discussion on this topic, see Chapter 28; also see Swartz, 1998, and Koenane, 2014.)
An individual’s context and perspective, emerging from factors such as cultural heritage, socio-economic status and racial grouping, are important considerations in determining what kinds of treatment might work best in a given situation. Such a multidimensional approach draws on the strengths of many different models of psychopathology in a way that best helps the patient. In other words, although differences between approaches are acknowledged, this is not viewed as a reason why some approaches cannot be used alongside others. Such an approach is especially useful in the South African context given the important role that culturally derived understandings of mental illness may play in being able to help a patient. From this perspective, a patient may be diagnosed and medicated for a mental disorder while at the same time being encouraged to consult an indigenous healer, with neither needing to take priority over the other. We shall return to this kind of approach in considering some forms of psychopathology that are specifically relevant to the South African context.
•Our current understanding and treatment of psychopathology has emerged from a long history.
•In the early era, people believed that those who were mentally ill were possessed by evil, supernatural forces.
•In the ancient era, a naturalistic view of mental illness emerged. Hippocrates believed that psychological disorders were the result of imbalances in four essential fluids (or humours). Naturalistic treatments were prescribed. This period marked the early beginnings of the biomedical approach to understanding psychopathology.
•During the Middle Ages, the naturalistic approach was replaced by religious understandings. Mental illness was seen as a punishment for sins committed, or as a form of demonic possession. Mentally disturbed individuals were segregated.
•In the Renaissance era, a shift occurred as such individuals began to be seen as mentally unstable and not responsible for their actions.
•In the asylum era, there was increased institutionalisation of the mentally ill, usually under inhumane conditions, and treatment was barbaric. In the late 18th century, these kinds of treatments were gradually challenged with the emergence of humanitarian reforms across the Western world.
•In the late 19th century, the scientific era enabled a better understanding of mental disturbances. Biological causes were identified for some disorders and classification systems developed. A number of psychological theories and treatments emerged, and there were developments in psychotropic medications.
•Current understandings tend to be integrative and sensitive to context.
•Non-Western understandings of psychopathology are also widespread. Many indigenous theories of illness see personal problems as being caused by difficulties in social relationships. The role of ancestors is also valued. Many people in southern Africa consult indigenous or religious healers. In this context, it is best to use a multidimensional approach.
Classification of mental illness
The mostly widely used classification system is the Diagnostic and statistical manual of mental disorders (fifth edition) (American Psychiatric Association, 2013). In its current edition, this classification system is referred to as the DSM-5. Its essential purpose is to help clinicians identify and diagnose mental illness. This is important, both for practitioners and for patients, because it allows for appropriate assessment procedures to be done to clarify the illness and it enables practitioners to communicate clearly with each other about illnesses.
The DSM system has been under development since 1952 (DSM-I), and has undergone a number of changes since its inception (Austin, 2014). The first and second (1968) editions were strongly influenced by a psychoanalytic approach. However, DSM-III (1980) reflected a major shift to a biomedical disease approach to mental disorders (Austin, 2014). This approach also reflected a shift towards an atheoretical stance, as well as a greater reliance on standardised knowledge as opposed to reliance on clinical expertise (Austin, 2014). DSM-IV (1994) drew on research generated by the DSM-III approach and was also based on field trials which compared diagnostic criteria from previous editions as well as the alternative diagnostic approach, the International Classification of Diseases (ICD). Following a text revision in 2000 (DSM-IV-TR), DSM-5 has integrated the most recent research findings. It has a revised structure and has consolidated the classification of disorders (Austin, 2014).
As for the DSM-III, the DSM-5 approach is derived from the biomedical model, where signs and symptoms are grouped together to identify an underlying pathological cause or syndrome. In this way the DSM-5 approach attempts to create a taxonomy (an organised system of categories) for mental disorders. There are a number of important reasons why the classification of mental disorders is helpful both for practitioners and patients. They are as follows (Austin, 2014):
•Classification helps psychologists establish a professional language that ensures that they are communicating about the same categories of mental illness.
•Classification is an essential first step towards research, discussion and treatment of the commonly identified categories of mental illness.
•If commonalities in types of illness are established through classification, the aetiology (causes) of such problems can be shared.
•Classification also makes it possible to perform statistical analyses on groups of disorders in order to establish the epidemiology of the diagnosis.
•Classification enables practitioners and patients to understand the course and prognosis of the illness.
The DSM-5 has, however, attempted to include some dimensional and developmental features of psychopathology. This inclusion attempts to address criticisms that some forms of psychopathology cannot be neatly defined into diagnostic categories.
The previous version of the DSM, the DSM-IV-TR (APA, 2000), evaluated an individual’s behaviour on five axes. Each axis explored a different dimension of the person’s problem. However, in DSM-5, the first three axes (psychiatric syndromes, personality problems, mental retardation in children and medical disorders) have been collapsed into a single list of disorders. The former Axis IV, which reported psychosocial and environmental factors, is now covered by a larger series of V codes. The former Axis V, which gave an indication of overall level of adaptive functioning, is replaced by separate measures of symptom severity and disability.
The DSM-IV-TR system has been criticised for a number of reasons; some of these still apply to DSM-5:
•Its descriptive emphasis. The DSM-5 describes disorders and does not explain why they might occur.
•Its biomedical emphasis. In a quest to ensure that the study of psychopathology is seen to be scientific, the DSM-5 classifies psychopathology in a similar way to how the medical profession diagnoses and classifies diseases and medical problems. In most cases, a medical diagnosis is dependent on some physical abnormality in the body that serves as a confirmation of the illness. To use a medical example, dizziness, fatigue, anxiety and high blood pressure are symptoms that can be used to diagnose hypertension (the underlying pathology or medical illness) in a patient. The question remains, however, whether such an approach can be used in diagnosing psychopathology. Some researchers have challenged this view based on the argument that many forms of psychopathology do not have an underlying physical cause (Hook & Eagle, 2002; Szasz, 1972). They argue that the DSM-IV-TR approach is erroneous because in most cases mental illness is not caused by brain disease and cannot be located in some biological abnormality.
•Its individualistic approach. The DSM-5 adopts an individualistic approach whereby the syndrome is assumed to exist only as an isolated problem in the patient. The group or family context is not given consideration when the diagnosis is being formed.
•Its cultural bias. The DSM-IV-TR system was criticised for creating diagnostic categories that have a Western cultural perspective. The DSM-5 is similarly criticised in terms of criteria which are subject to social and cultural bias. For example, alcohol use disorder contains alcohol use criteria that in certain cultures are considered normal, if not admired (Caetano, 2011). However, DSM-5 has attempted to respond to criticisms of cultural bias by including a cultural formulation to accompany traditional diagnostic labels.
•Concerns about validity and reliability. As with the DSM-IV-TR system (Bertelsen, 2002), concerns have been raised about the reliability and validity of DSM-5. According to Insel (2013), DSM diagnoses have traditionally had reasonable reliability as a common set of criteria are used. However, in terms of validity, DSM diagnoses are weak as they are based on consensus about clusters of symptoms, rather than objective measures. DSM-5 has also been widely criticised for increasing the number of ’disorders’, which may lead to over-diagnosis and/or over-medication (Frances, 2012).
•Labelling. A diagnosis does not describe the person, but only a set of behaviours associated with the person’s problem. This has led to a great deal of controversy in psychology, as classification systems are often blamed for causing the clinician to lose sight of the person behind the diagnosis. In practice, this often has grave consequences as it leads to stigmatisation of the individual where the diagnosis (or label) given creates a number of negative preconceptions and expectations in the patient and in others. Such preconceptions and expectations often have a negative impact on the person’s identity and well-being. As discussed in Box 24.3, Rosenhan (1973) found that hospital staff responded to how a person had been labelled and could no longer respond to them as ordinary human beings.
Given the many issues with the DSM system, some (e.g. Burns & Alonso-Betancourt, 2013) have argued for using the alternative system, the ICD (the International Classification of Disorders), now in its 10th edition (WHO, 2007a). The ICD system is based on a classification system introduced by a French doctor, Jacques Bertillon, in 1893 (Austin, 2014). It was formally established at a conference in 1900 and revised every 10 years after that. With the sixth revision (1948), the World Health Organization (WHO) took over responsibility and in the 1960s the Mental Health Programme of WHO became involved with the goal of improving the diagnosis and classification of mental disorders (Austin, 2014). Several major research projects were launched, including some aimed at setting up assessment tools, resulting in clear criteria for ICD-10. ICD-10 continues to use a multi-axial approach and there are other differences between it and the DSM-5.
It must be noted that both systems have been criticised in terms of the validity of their criteria; this is illustrated by the fact that the systems do not classify and describe mental disorders in the same ways (Austin, 2014). Other approaches to classification include the dimensional model, which sees a disorder as lying along a continuum, while holistic approaches incorporate social and spiritual elements (Austin, 2014).
•The mostly widely used classification system is the Diagnostic and statistical manual of mental disorders (DSM-5).
•The DSM-5 approach has developed from a psychoanalytic (DSM-I and DSM-II) to a biomedical approach (DSM-III to DSM-5); in the biomedical model, signs and symptoms are grouped together to identify an underlying pathological cause or syndrome.
•Classification of mental disorders is helpful to provide a professional language for communicating about clients and to assist with understanding the causes and epidemiology of mental disorders.
•The DSM-5 has abandoned the previous multi-axial approach and has attempted to include some dimensional and developmental features of psychopathology.
•A number of criticisms have been applied to the DSM system:
”its descriptive emphasis
”its biomedical emphasis
”its individualistic approach
”its cultural bias
”concerns about validity and reliability
”labelling and stigmatisation.
•The ICD system (ICD-10) provides an alternative classification model. However, there remain differences between the systems; this illustrates the issues concerning validity of classification systems in general.
Table 24.2 A selection of some of the disorders found in DSM-5
Main defining symptoms
Sub-average intellectual functioning (IQ below 70)
Autistic spectrum disorder
Severely impaired development in social interaction and communication
Persistent eating of non-nutritive substances
Disturbances of consciousness and cognitive ability
Substance use disorders
Maladaptive pattern of substance (e.g. alcohol) abuse
Bipolar I disorder
Manic and depressive mood swings
Recurrent unexpected panic attacks
Persistent presence of obsessive-compulsive thoughts and behaviours (e.g. continual hand-washing)
Motor or sensory impairment that appears to have a psychological cause (e.g. paralysis of the hand)
Intentional production of symptoms in order to assume the ’sick role’
Dissociative identity disorder
The presence of two or more distinct identities in one person
Male orgasmic disorder
Delay or absence of orgasm following sexual excitement
Difficulty initiating or maintaining sleep
The development of symptoms in relation to a particular stressor
Narcissistic personality disorder
Grandiose sense of self-importance
Current perspectives in psychopathology
The biomedical perspective
The biomedical model claims that all mental illnesses have a biological cause. Other factors such as social pressures, the type of parenting, or additional environmental factors are viewed as secondary in the precipitation of mental disorders. Biological abnormalities are understood to occur mainly in three different areas: genetic predisposition, abnormal functioning of neurotransmitters, and structural abnormalities in the brain.
We inherit our genetic predisposition from our parents. Genes, or chemical units, are arranged in a specific order along chromosomes and they are responsible for determining things such as the physical appearance (e.g. eye colour) and the sex of an individual. Most of us have 46 chromosomes. Some researchers have found that abnormalities in genetic makeup can predispose some individuals to particular mental illnesses. Much of the research in this area has been done on twins. It has been found, for instance, that monozygotic, or ’identical’, twins (with the same genetic makeup) whose mother has a mental disorder have a greater likelihood of both developing mental illness. However, this is not the case with dizygotic, or ’fraternal’, twins (who do not share the same genetic makeup). Evidence that genetic predisposition plays a role in the development of mental illnesses has been demonstrated with disorders like schizophrenia (Gottessman, 1991), depression (Caspi, Sugden & Moffitt, 2003) and alcoholism (Goldman, Oroszi & Ducci, 2006).
24.3SANE IN INSANE PLACES
Source: Rosenhan (1973)
David Rosenham conducted a famous study that attempted to explore the validity of psychiatric diagnoses.
A form of participant observation was used in the study whereby eight psychologically healthy individuals were admitted to different psychiatric units after claiming to have been ’hearing voices’. No other symptoms or problems were discussed. After gaining admission, all subjects acted their normal selves and no longer claimed to be hearing voices.
Once the admission to the hospital had taken place, Rosenhan found that no matter what these individuals did, they were perceived as being psychologically ill by the staff in the hospital.
The validity of making a psychiatric diagnosis is questionable as the staff in the hospital failed to distinguish between healthy individuals and those who were genuinely mentally ill.
This is a very well-known study and it is often cited. However, Rosenhan’s experiment has been criticised on various grounds. For example, it may involve poor clinical skills on the part of the psychiatrists involved rather than a problem with classification per se. In addition, in practice, psychiatrists do not determine a person to be ’sane’ or insane’; rather, they seek to diagnose a person with a mental disorder — if the symptoms support this (The Rosenhan experiment examined, 2010). Despite these methodological criticisms, Rosenhan’s study still has relevance today for those involved in mental health work.
Figure 24.4 Similar genetics mean siblings often resemble each other
Abnormal functioning of neurotransmitters
Neurotransmitters are chemical substances in the brain which are responsible for the communication of nerve impulses among the brain cells. An increase or decrease in certain neurotransmitters, like dopamine and serotonin, has been found to be associated with a number of psychiatric illnesses.
Structural abnormalities in the brain
Structural abnormalities occurring in the brain have also been associated with various disorders. It has been well established that different parts of the brain perform different functions related to the individual’s behaviour. For instance, it has been found that the limbic system serves to regulate emotional reactions like fear, aggression and sexual expression. Damage caused to this part of the brain would thus have serious consequences for the individual’s ability to control emotions. Structural abnormalities in the brain may be caused by genetic disorders, birth abnormalities, drug-related brain damage or physical injury.
24.4EXAMPLES OF PSYCHOLOGICAL DEFENCE MECHANISMS
People can use a variety of psychological defence mechanisms in order to avoid feelings of psychological pain or fear.
In displacement, a person redirects their unpleasant emotions or thoughts onto someone or something else. This is commonly done when it does not feel safe to express these feelings or thoughts directly. You may be angry with a lecturer for a poor mark but be unable to express it, so you go home and get angry with your mother instead. This would be an example of displacement.
Sublimation is the healthy redirection of an emotion. For example, when receiving a bad mark, you may choose to direct more energy into your studies rather than getting angry with your mother.
In projection, a person’s unwanted or unacceptable thoughts or feelings are attributed to someone else, who does not have such thoughts or feelings. Thus, the unwanted material is ’projected’ outward onto an ’innocent’ person. It is also possible for positive thoughts and feelings to be projected. Usually, we project things we do not want to acknowledge about ourselves (e.g. ’I have not made a mistake; it is you who is critical of me and everything I do.’)
Intellectualisation involves removing the emotion from emotional experiences, and discussing painful events in detached and uncaring ways. Individuals may understand all the words that describe feelings, but have no idea what they really feel like.
Denial is the refusal to acknowledge what has happened, is happening, or will happen (e.g. when a man’s wife is having an affair but he says she is not).
Repression involves blocking unwanted or unacceptable thoughts and memories from our minds. It is an unconscious process, thus people have little control over what is repressed. Sometimes, repressed material can be retrieved, but it may be recovered in a distorted form.
Suppression involves consciously trying to put painful thoughts and memories out of our minds.
Reaction formation occurs when unwanted or difficult thoughts are converted into their opposites. An example of reaction formation would be if you were behaving very badly towards someone because you really liked them.
Contemporary psychodynamic perspectives are derived from Freud’s development of psychoanalysis. Those who work from a psychoanalytic point of view believe that the way we relate to others and ourselves is largely influenced by internal forces that exist outside of our consciousness. Freud believed that sexual and aggressive instincts, as well as associated thoughts and feelings, become repressed and unconscious once they are perceived to be forbidden by society. Although such thoughts and feelings are forced into the unconscious, Freud believed that they were still able to exercise partial control over the individual by expressing themselves through symptoms. He viewed the formation of psychological symptoms as a compromise between the expression of forbidden wishes and their total repression.
Freud viewed the personality or psyche as being divided into three parts. namely the id, the ego and the superego (see Chapter 5):
•Id refers to the part containing instincts and drives.
•Ego refers to the part that attempts to control the expression of the id.
•Superego refers to a person’s conscience and the ability to distinguish between right and wrong.
Freud believed that the formation of these mental structures was strongly influenced by early childhood experiences and the quality of children’s relationship with their parents. From this perspective, psychopathology occurs for two main reasons. First, psychological disorders emerge when conflict between the id, the ego and the superego gives rise to distressing symptoms. Second, mental disorders emerge when deficiencies in the ego impede the individual’s ability to repress instinctual drives. In both cases, the individual makes use of psychological defence mechanisms in an attempt to ward off excessive psychological pain and repressed fears (see Box 24.4).
In contemporary psychodynamic thinking, the above still remain the most important causes of psychopathology. However, contemporary approaches also emphasise the importance of internalised object relations in the development of the personality. Internal objects are essentially mental representations that are formed when significant others (or external objects) are internalised by the individual, adding to the nature of the personality. So, for example, one of your internal objects will be an internal representation of your mother and this theory says there will be a dynamic relationship between this object and your own internalised self-object.
Object relations theorists believe that early relationships, particularly with the mother, shape the personality and set the foundation for other relationships in the person’s life. Early trauma or deprivation is also understood to be a key factor in the development of psychopathology. In this way, contemporary psychodynamic perspectives, such as the object relations approach, emphasise the role that emotional relationships and the surrounding environment play in the formation of the personality. Less emphasis is placed here on the role of instinctual drives which are a typical focus of the Freudian approach.
The cognitive-behaviour perspective
Central to the cognitive-behaviour perspective is the idea that cognitions, or learned ways of thinking, directly impact on the individual’s emotions and behaviours. Cognitive therapists believe that irrational beliefs and automatic thoughts are principally responsible for the development of psychopathology (Beck, 1972; Ellis, 1995; Glasser, 1984).
Aaron Beck (1976), a leading cognitive psychologist, showed how this worked in cases of depression. He believed that negative automatic thoughts such as ’I am not a good person’ or ’I am not a good student’ set up a negative cycle of thought, emotion and behaviour in the individual. After accepting such distorted thoughts, a person would look for ways to confirm such thoughts through adopting negative behaviours (e.g. not learning for a test or behaving badly in class). These would, in turn, impact on the person’s emotions, making him/her feel more depressed. This sets up a vicious cycle as the more depressed people feel, the more negatively they think of themselves. According to Beck (1976), depressed persons display distorted negative thoughts about the self, the world and the future. He called this the cognitive triad of depression.
The community psychology perspective
Community psychology is most interested in understanding psychopathology from within the context of the community. As Ahmed and Pretorious-Heuchert (2001, p. 19) state:
[C]ommunity psychology regards whole communities, and not only individuals, as possible clients. There is an awareness of the interaction between individuals and their environments, in terms of causing and alleviating problems.
The emphasis here lies on the importance of the social, political and cultural contexts in understanding, identifying and treating psychological problems.
The importance of the political context
The discipline of community psychology largely developed out of a need to challenge oppressive forces in society (Seedat, Duncan & Lazarus, 2001). For this reason, community psychologists are sensitive to the fact that sociopolitical factors impact on our mental health. Apartheid, for instance, clearly had a tremendous impact on the way that members of the oppressed black population of this country perceived themselves. Racist attitudes and policies depicting black people as stupid, lazy and primitive caused many to think negatively of themselves and identify themselves as inferior to the white population.
The importance of the social context
Community psychologists argue that social factors need to be considered if we are to fully understand the development of psychological problems. This would include factors like the socio-economic status of the community, access to resources and the nature of social interaction within the community. All such factors impact on the mental health of the individual. From this perspective, problems like violence and sexual abuse cannot be understood unless the social context of the community is also considered.
The importance of the cultural context
The community psychology perspective emphasises the fact that an individual’s actions always take place within a cultural context. How an individual experiences distress or makes sense of psychological problems is dependent on deeply ingrained cultural beliefs and practices. Therefore, how we understand various psychological symptoms is often dependent on a particular cultural perspective. For example, in Zulu and Xhosa-speaking communities ukuthwasa is a psychological state associated with an ancestral calling to become an indigenous healer. Individuals afflicted with this condition endure states of emotional turmoil, hear voices (of the ancestors calling the individual to become an indigenous healer) and experience bouts of depression and mania. Although such symptoms share similarities with those used to diagnose mental illness in Western diagnostic systems, it would be incorrect to make use of such a diagnosis without having a full understanding of the cultural meaning of such symptoms.
This should not be taken to mean that mental illness does not exist in non-Western communities. A number of studies using epidemiological research have indicated that psychiatric disorders do exist in non-Western communities (e.g. Kaminer, Grimsud, Myer, Stein & Williams, 2008; Swartz, 1998).
Understanding how mental illness is experienced and treated by different cultures is also inextricably linked to concerns about access to treatment. We know, for instance, that indigenous healers from within a particular community are able to reach communities in ways that Western forms of medicine cannot (Edwards, 2011). As well as helping patients gain better access to treatment, community psychologists also concern themselves with the prevention of mental illness (and other social problems) by facilitating social change and empowerment in the community.
24.5FOUR MYTHS ABOUT MENTAL ILLNESS IN NON-WESTERN COUNTRIES
Source: Swartz (1998)
•Mental illness does not exist in developing countries.
•Mental illness is not recognised as pathological in non-Western communities.
•Mental illness is accepted in non-Western communities in an unstigmatised manner.
•All mental disorders can be cured by indigenous healers.
Integrated approaches to psychopathology
The above perspectives are often used in an integrated way to gain a fuller understanding of psychopathology and its precipitating causes. Two approaches are particularly useful in this regard: the diathesis-stress model and the bio-psychosocial approach.
The diathesis—stress model was first introduced by Meehl (1962). He suggested that some people inherit or develop predispositions (diathesis) to psychopathology. Although this is the case, mental disorders will not emerge until environmental stressors or biological stressors become intense enough to convert predispositions into actual psychological disorders.
24.6COLLABORATION BETWEEN PSYCHIATRY AND TRADITIONAL HEALERS
Source: Robertson (2006)
Since the advent of democracy in South Africa, the government has been working to draw traditional healers into collaboration with established, Western-based mental health care services. Following the introduction of the Traditional Health Practitioners Bill in 2004, Robertson (2006) investigated the contributions of traditional healers to mental health in South Africa. Robertson (2006) noted that some 70 per cent of South Africans consult traditional healers, even when they may be under medical treatment. In a series of three studies, Robertson (2006) first attempted to document the common diagnostic categories used by indigenous healers and to see how these linked to DSM categories. Robertson (2006) noted that the two systems are inherently different, with the DSM categorising symptoms within a bio-psychosocial framework and the indigenous systems categorising them according to the meaning of the symptoms.
In the second study, psychiatric patients admitted to hospital for the first time were interviewed. Sixty-one per cent of these patients had consulted a traditional healer in the previous 12 months. The patients and their families were mostly satisfied with the services of herbalists, but felt that diviners were expensive and often ineffective. Many patients believed their disorder to have been caused by traditional factors as well as by psychosocial factors like stress.
In the third study, questionnaires were administered to 349 adults in Khayelitsha, Cape Town. Robertson (2006) noted that healers usually gave traditional explanations for problems and often seemed to explain similar problems as having different causes. In addition, the healers also prescribed similar treatments for apparently different problems. The great majority (66 per cent) of patients felt the treatment was effective and 90 per cent said they would consult the healer again.
Robertson (2006) cautions against wide generalisation of his findings due to the limited nature of the sample. However, he noted that ’traditional healers are clearly providing a valued mental health service’ (Roberston, 2006, p. 89). Robertson (2006) goes on to suggest that there are significant differences in the two approaches and that greater collaboration between them should be promoted in order to provide the best service to mental health patients.
In a similar way, the bio-psychosocial approach attempts to integrate biological, psychological and social factors to gain a better understanding of why mental disorders occur.
•The biomedical model claims that all mental illnesses have a biological cause. Biological abnormalities are understood to occur mainly in three different areas: genetic predisposition, abnormal functioning of neurotransmitters and structural abnormalities in the brain.
•The psychodynamic perspective believes that the way we relate to others and ourselves is largely influenced by repressed forbidden wishes:
”Freud viewed the psyche as being divided into three parts: the id, the ego and the superego.
”Psychological disorders emerge when conflict between these parts gives rise to distressing symptoms or when ego deficiencies hinder the individual’s ability to repress instinctual drives.
”People use defence mechanisms to ward off excessive psychological pain and repressed fears.
”Contemporary psychodynamic approaches emphasise the importance of internalised object relations in the development of the personality.
•The cognitive-behaviour perspective says that cognitions, or learned ways of thinking, impact on the individual’s emotions and behaviours:
”Cognitive therapists believe that irrational beliefs and automatic thoughts are principally responsible for the development of psychopathology.
”These set up a vicious cycle in which the depressed person shows distorted negative thoughts about the self, the world and the future (the cognitive triad of depression).
•The community psychology approach understands psychopathology from within the social, political and cultural contexts:
”The political context relates to the need to challenge oppressive forces in society.
”The social context includes the socio-economic status of the community, access to resources and the nature of social interaction within the community, all of which impact on the mental health of the individual.
”The cultural context is the site for an individual’s actions. How an individual experiences distress or makes sense of psychological problems is dependent on cultural beliefs and practices. Treatment choices and access are also culturally determined.
•The above perspectives are often integrated to gain a fuller understanding of psychopathology and its causes. Two useful approaches are the diathesis—stress model and the bio-psychosocial approach.
24.7INTELLECTUAL DISABILITY: A BIO-PSYCHOSOCIAL APPROACH
The bio-psychosocial approach claims that a number of interactive factors play a role in intellectual disability.
The majority of cases of intellectual disability are genetically transmitted. Disease, injury or prenatal factors can also cause structural abnormalities in the brain that are responsible for severe forms of intellectual disability. However, while biological factors are important in understanding intellectual disability, they are not, on their own, sufficient to explain the causes of the disorder.
Psychological factors interact with biological vulnerabilities to influence the development of accompanying disorders. For example, depression frequently accompanies intellectual disability. Depression often occurs owing to a sense of frustration about an inability to perform certain tasks and/or a sense of alienation from mainstream society. Other psychological disorders, such as oppositional deficient disorder or conduct disorder, may occur once individuals realise their limitations.
Biological and psychological factors operate within a particular social context. Environmental factors associated with poverty play an important role in the aetiology of intellectual disability. Limited access to health care facilities during a mother’s pregnancy, poor nutrition during pregnancy, and increased risk of physical injury are all preventable factors that may cause intellectual disability. Once a person suffers from intellectual disability, community support can successfully help in caring for this person. Educational programmes can be used to inform communities about the problems associated with intellectual disability.
Common disorders in South Africa
There are many categories of psychological illness, but two that are particularly relevant in South Africa are post-traumatic stress disorder and schizophrenia.
Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) occurs when a person experiences or witnesses a situation that involves a threat of death or an actual death, which leads to the following symptoms:
•distressing re-experiencing of the event through mental flashbacks to the scene, recurrent distressing dreams, recurrent and intrusive thoughts of the event, and hypersensitivity to cues that may be associated with the event
•avoidance and emotional numbing, where the patient persistently avoids anything that might be associated with the event and experiences a psychic numbing in response to current surroundings
•negative alterations in cognition and mood may be evident in terms of some dissociative amnesia (inability to recall key features of the event) and persistent distorted blame of self and others; also increasing detachment from others or from activities
•increased arousal, where patients have difficulties falling asleep, experience irritability and have exaggerated startled responses.
Given the high rate of crime and violence in South Africa, PTSD has become one of the most frequently diagnosed forms of psychopathology.
These symptoms need to persist for at least one month after the event before post-traumatic stress disorder is diagnosed. The epidemiology of PTSD varies depending on the occurrence of traumatic situations. Given the high rate of crime and violence in South Africa at present, the prevalence rate of PTSD in the general population is thought to be well above most international norms.
The aetiology of post-traumatic stress disorder
The major factors in the aetiology of the disorder are:
•the social environment in which the trauma took place
•the character traits of the individual
•the biological vulnerability of the victim.
The intensity of traumatic reactions appears to be dependent on the suddenness of the threat, its duration and the amount of fear associated with the event. In general, it has been found that young children and the elderly have greater difficulty in coping with traumatic events and are thus at greater risk of developing PTSD. DSM-5 has introduced a ’preschool’ sub-type of the PTSD diagnosis for children under the age of seven years.
Biological theorists have found that patients with a vulnerability to anxiety are at greater risk of developing PTSD. They have also found that patients with PTSD show an increase in the production of catecholamine (the hormone that prepares the body for an emergency) while re-experiencing the trauma.
Psychodynamic psychologists take the view that traumatic events reactivate unresolved conflicts from early childhood. In an attempt to cope with the trauma, the ego constantly repeats the distressing events associated with the trauma in an attempt to master them and reduce the level of anxiety experienced by the victim.
The symptoms of PTSD can fluctuate over time and are more apparent during periods of stress. It is estimated that approximately 30 per cent of patients recover, 60 per cent continue to experience mild anxiety symptoms associated with the trauma, and 10 per cent remain unchanged and may even become worse (Sadock, Sadock & Ruiz, 2014).
24.8AN EXAMPLE OF A CASE OF POST-TRAUMATIC STRESS DISORDER
One evening Uzail, a 28-year-old man, was driving home from work when he was hijacked at gunpoint by two men standing at a traffic light. They ordered him to give them his wallet and threatened to kill him if he made a wrong move. Both men sat in the car and ordered Uzail to drive to a nearby neighbourhood. Uzail was persistently threatened with his life while he drove them to their requested location before they set him free. After the event Uzail was markedly anxious, he was unable to sleep and kept feeling that his attackers would return. For two months following the event, he often had nightmares about the event and experienced flashbacks that made him feel like the events of the crime were constantly being repeated. He also could not tolerate driving in a car, and found that he had grown increasingly angry, hyperactive and irritable since the crime. After consulting a psychologist, he was diagnosed with post-traumatic stress disorder.
24.9AN EXAMPLE OF A CASE OF SCHIZOPHRENIA
Sibusiso, a 23-year-old student, was referred to a psychologist by his mother after he claimed that she was poisoning his food. His appearance was unkempt and he appeared agitated when he walked into the psychologist’s consulting rooms. He sat down and began to speak to the psychologist in a very incomprehensible manner. He began by singing the psychologist a song. He claimed that ’a man in the radio’ had told him to sing the song every time he saw a psychologist. He then went on to explain why he had come to the consultation, saying, ’I need to see you because there are aliens on the roof of my house. They come down every night. I see them; they want me to say bad things.’
Sibusiso appeared emotionless and unresponsive to the psychologist’s questions. After a while his speech became more and more disorganised and there seemed to be no way of following what he was saying. He said, ’Did you know that feet ate meat?’ and ’Time is mine and crime is bad too.’ During the session Sibusiso often got up excitedly from his chair and sat down again without any explanation.
On contacting his mother, the psychologist learned that Sibusiso had been unable to carry on with his studies and had taken to locking himself in his room for long periods of time claiming that ’the aliens were going to get him’. She also complained that he was not able to carry out basic chores at home and had stopped contacting his friends. Prior to these changes in his behaviour, Sibusiso was successful in his studies and kept regular contact with a number of his friends.
Schizophrenia shares a number of symptoms with some indigenous forms of so-called illness in South Africa, such as ukuthwasa (ancestral calling) and amafufunyana (spirit possession). This has led to a lot of debate around whether to understand the presenting symptoms from within the context of the indigenous healing system (where traditional healers such as izinyanga and izangoma would be used) or from the perspective of the biomedical model, where the individual showing the symptoms would be diagnosed with schizophrenia. It appears that the answer lies in being able to make use of the strengths of both models.
Schizophrenia is a condition characterised by disorganised and fragmented emotions, behaviours and cognitions. One of the most common misperceptions about schizophrenia is that it refers to people with a ’split personality’. So-called split personality is a disorder usually called dissociative identity disorder and refers to a condition in which an individual develops two or more separate identities or ego states. Each identity exists separately and has its own set of emotional and behavioural characteristics. However, this phenomenon does not occur in schizophrenia. Schizophrenics suffer from a mental disorder that is more correctly characterised by the splitting of emotions and thoughts.
The schizophrenic condition is characterised by gross distortions of reality testing, leaving such individuals feeling disorientated and fragmented, a condition most commonly called psychosis. Schizophrenic symptoms can be divided into two categories: positive and negative symptoms. Positive symptoms refer to the presence of behaviours and feelings normally not present, while negative symptoms refer to the absence of behaviours and feelings usually present in a normal individual. The most common symptoms associated with schizophrenia are listed below. Many of these can be observed in the case of Sibusiso, illustrated in Box 24.9. For a diagnosis of schizophrenia to be made, continuous signs of disturbance need to persist for at least six months.
The positive symptoms of schizophrenia are as follows:
•delusions: fixed ideas or false beliefs that do not have any foundation in reality (e.g. Sibusiso thought his mother was poisoning his food)
•hallucinations: false sensory perceptions that occur in the absence of a related sensory stimulus (e.g. Sibusiso saw aliens and claimed that the radio was giving him a command)
•catatonic behaviour: marked motor abnormalities such as bizarre postures, purposeless repetitive movements and an extreme degree of unawareness (e.g. Sibusiso got up from his chair in a repetitive way)
•disorganised behaviour: an inability to persist in goal-directed activity and the performance of very inappropriate behaviours in public (e.g. Sibusiso sang songs to his psychologist, was unable to follow a line of questioning and was not able to perform basic tasks)
•disorganised speech: speech that is incomprehensible and only remotely related to the subject under discussion (e.g. Sibusiso’s speech was clearly disorganised and incoherent).
Negative symptoms of schizophrenia are as follows:
•flat affect: a lack of emotional responsiveness in gesture, facial expression or tone of voice (e.g. Sibusiso appeared emotionless in his responses to the therapist)
•avolition: a negative symptom that involves the inability to begin and sustain goal-directed activity (e.g. Sibusiso did not appear to be able to perform everyday activities)
•alogia: a speech disturbance in which the individual talks very little and gives brief empty replies to questions (Sibusiso did not display this symptom).
Schizophrenia affects one per cent of the population. It usually begins before the age of 25 and persists throughout life. It is found among all social classes and there is no difference in the prevalence rates of the disorder between males and females. Approximately 20 per cent of schizophrenics are able to lead relatively normal lives, 20 per cent continue to experience moderate symptoms, while 40 to 60 per cent remain severely impaired by the illness for the rest of their lives (Sadock et al., 2014). Unlike psychological problems such as depression, schizophrenic patients often do not return to their previous level of functioning once a psychotic breakdown has occurred. There is usually some deterioration in cognitive and behavioural abilities even after the positive symptoms of schizophrenia have subsided.
The aetiology of schizophrenia
The aetiology of schizophrenia is not known. One of the most convincing biological theories of schizophrenia relates to the levels of the neurotransmitter dopamine at receptor sites in the brain. The dopamine hypothesis claims that excessive levels of dopamine cause schizophrenic-like symptoms. Anti-psychotic medications, which serve to inhibit the level of dopamine in the brain, lend support to this hypothesis as psychotic symptoms are markedly reduced by such medications (Gao & Goldman-Rakic, 2003; Koh, Bergson, Undie, Goldman-Rakic & Lidow, 2003; Weiner, 2003).
Genetic predisposition is also believed to render an individual vulnerable to developing schizophrenia. It has been found that monozygotic twins of a schizophrenic patient have a 47 per cent chance of developing schizophrenia, while dizygotic twins have a 12 per cent chance of developing the illness.
Many psychological theories have been put forward in an attempt to understand schizophrenia. Some psychoanalytic theorists believe that schizophrenia is caused by a defect in the rudimentary functions of a child’s ego, giving rise to intense hostility and anger, which in turn distorts the child’s ability to relate to others around them. This leads to a personality organisation that is very vulnerable to stressful situations. Learning and cognitive-behaviour theorists, on the other hand, believe that schizophrenia develops from learning irrational reactions and distorted ways of thinking from emotionally disturbed parents.
24.10KNOWLEDGE OF AND STIGMA ASSOCIATED WITH MENTAL DISORDERS
Source: Sorsdahl and Stein (2010)
The study explored knowledge of psychiatric disorders, as well as associated attitudes towards stigma, held by South Africans. Thus the study first aimed to establish the ’mental health literacy’ of the participants as this has an important impact on help-seeking behaviour. Negative attitudes towards the mentally ill, and consequent stigmatisation, also impact on help-seeking behaviour.
A series of 10 vignettes were designed, each representing a psychiatric disorder with either subtle or obvious symptoms. One vignette was presented to each of a convenience sample of 1 081 members of the public.
Only 31 per cent of the participants felt that the vignette they read showed a typical mental illness. Nearly half (47%) thought it described a normal reaction while just over one-quarter thought the vignette illustrated a ’weak character’. Schizophrenia was seen as ’most typical’ of a mental disorder. A variety of treatments were endorsed, with seeking help from a health professional being the most commonly endorsed, and taking medication, the least. Levels of stigma varied between disorders, with schizophrenia and substance abuse being the most stigmatised. PTSD was least stigmatised and less likely to be considered a psychiatric disorder.
South Africans have low levels of mental health literacy compared to the developed world. PTSD is met with more sympathy and offers of help than other disorders.
•Post-traumatic stress disorder may occur when a person experiences or witnesses a situation that involves a threat of death or an actual death.
•Symptoms of PTSD include distressing re-experiencing of the event, avoidance and emotional numbing, negative alterations in cognition and mood, and increased arousal.
•The major aetiological factors of PTSD relate to aspects of: the stressor, the social environment in which the trauma took place, the character traits of the individual and the biological vulnerability of the victim.
•Schizophrenia shares a number of symptoms with some indigenous forms of so-called illness in South Africa. It is useful to use both Western and indigenous models in understanding this illness.
•Schizophrenia involves psychosis, which is characterised by disorganised and fragmented emotions, behaviours and cognitions. Schizophrenia is not the same as ’split personality’ or dissociative identity disorder.
•Schizophrenic symptoms can be divided into two categories:
”Positive symptoms include delusions, hallucinations, catatonic behaviour, disorganised behaviour and disorganised speech.
”Negative symptoms include flat affect, avolition and alogia.
•Schizophrenia affects one per cent of the population; it usually begins before the age of 25 and persists throughout life. It is found among all social classes and both genders.
•The aetiology of schizophrenia is not known. Various theories have been put forward including biological and genetic aspects, as well as psychological aspects.
Abnormal behaviour can be defined using the criteria of statistical deviance, maladaptiveness and personal distress. In addition to these criteria, broader political, sociocultural and historical factors are important in understanding the nature of normality or abnormality. While classifying mental illnesses is a complex task, this process cannot explain why various psychological problems occur. The bio-psychosocial model and the diathesis—stress model offer us broad theoretical frameworks that allow a number of different perspectives to be used to illuminate the multidimensional nature of psychopathology.
adjustment disorder: a disorder found in the DSM-IV-TR that refers to the development of symptoms in relation to a particular stressor
alogia: a common symptom associated with schizophrenia involving a speech disturbance in which the individual talks very little and gives brief empty replies to questions
anti-psychiatry: a sociopolitical movement that rejects the methodologies, medical practices and underlying assumptions of psychiatry
avolition: a common symptom associated with schizophrenia involving the inability to begin and sustain goal-directed activity
behaviour therapy: a means of treating patients that seeks to change the factors in the environment that tend to reinforce maladaptive behaviours
biomedical model: a perspective in psychopathology that claims that all mental illnesses have a biological cause
bio-psychosocial approach: a perspective in psychopathology that attempts to integrate biological, psychological and social factors to gain a better understanding of why mental disorders occur
catatonic behaviour: a common symptom associated with schizophrenia involving marked motor abnormalities such as bizarre postures, purposeless repetitive movements and an extreme degree of unawareness
cognitive-behaviour perspective: a perspective in psychopathology that has as its central notion the idea that cognitions, or learned ways of thinking, directly impact on the individual’s emotions and behaviours
conversion disorder: a disorder found in the DSM-IV-TR that refers to motor or sensory impairment that appears to have a psychological cause
delusions: a common symptom associated with schizophrenia involving fixed ideas or false beliefs that do not have any foundation in reality
dementia: a disorder found in the DSM-IV-TR that refers to disturbances of consciousness and cognitive ability
denial: a psychological defence mechanism whereby individuals refuse to acknowledge what has happened, is happening, or will happen
diathesis—stress model: a perspective in psychopathology that proposes that some people inherit or develop predispositions (diathesis) to psychopathology, although mental disorders will not emerge until stressors become intense enough to convert predispositions into actual psychological disorders
disorganised behaviour: a common symptom associated with schizophrenia involving both an inability to persist in goal-directed activity and the performance of inappropriate behaviours in public
disorganised speech: a common symptom associated with schizophrenia where speech is incomprehensible and only remotely related to the subject under discussion
displacement: a psychological defence mechanism whereby individuals displace unwelcome feelings onto other individuals
dissociative identity disorder: a disorder found in the DSM-IV-TR that refers to the presence of two or more distinct identities in one person
factitious disorder: a disorder found in the DSM-IV-TR that refers to the intentional production of symptoms in order to assume the sick role
flat affect: a common symptom associated with schizophrenia involving the lack of emotional responsiveness in gesture, facial expression and/or tone of voice
hallucinations: a common symptom associated with schizophrenia involving false sensory perceptions that occur in the absence of a related sensory stimulus
intellectualisation: a psychological defence mechanism whereby individuals remove all emotion from their emotional experiences
maladaptiveness: one way of defining psychopathology that, in order to determine what is abnormal, uses the extent to which certain behaviours or experiences are maladaptive to the self or others
male orgasmic disorder: a disorder found in the DSM-IV-TR that refers to the delay or absence of orgasm following sexual excitement
narcissistic personality disorder: a disorder found in the DSM-IV-TR that refers to a grandiose sense of self-importance
neurotransmitters: chemical substances in the brain that are responsible for the communication of nerve impulses among the brain cells
obsessive-compulsive disorder: a disorder found in the DSM-IV-TR that refers to persistent obsessive-compulsive thoughts and behaviours
panic disorder: a disorder found in the DSM-IV-TR that refers to recurrent unexpected panic attacks
personal distress: unbearable negative thoughts
pica: a disorder found in the DSM-IV-TR that refers to persistent eating of non-nutritive substances
projection: a psychological defence mechanism whereby individuals take something of themselves and place it outside of themselves, onto others
psychoanalysis: a means of treating patients who suffer from hysterical and neurotic conditions based on Freud’s theory that psychopathology is largely caused by the repression of forbidden wishes or instinctual drives
psychodynamic perspectives: approaches to psychopathology that believe that the way we relate to others and ourselves is largely influenced by internal forces that exist outside of consciousness
reaction formation: a psychological defence mechanism whereby individuals turn painful or threatening reactions into their opposite
repression: a psychological defence mechanism whereby individuals unconsciously put painful thoughts and memories out of their minds
schizophrenia: a disorder found in the DSM-IV-TR characterised by disorganised and fragmented emotions, behaviours and cognitions
statistical deviance: one way of defining psychopathology that uses statistical norms of behaviour and experience to determine what is supposedly normal, and therefore what is abnormal
sublimation: a psychological defence mechanism whereby individuals redirect emotions into more positive activities
substance abuse: a disorder found in the DSM-IV-TR that refers to a maladaptive pattern of substance use
suppression: a psychological defence mechanism whereby individuals consciously try to put painful thoughts and memories out of their minds
Multiple choice questions
1.According to the criteria of statistical deviance, a behaviour is abnormal when it:
a)deviates from previous family patterns
b)deviates from the norm of a specified social or cultural group
c)deviates from maladaptiveness
d)deviates from personal distress.
2.Hippocrates (460—377 BC) adopted a naturalistic approach to understanding mental illness. He believed that:
a)mental illness was primarily caused by natural spirits
b)mental illness could be cured by nature
c)mental illness was caused by imbalances in the natural fluids of the body
d)mental illness resulted from the fusion of blood, phlegm, yellow bile and black bile.
3.Classification of mental disorders is important because:
a)it provides a common language for professional communication
b)it aids research and treatment
c)it helps with understanding the course of a disorder
d)all of the above are correct.
4.The DSM-5 approach has been criticised for:
a)establishing a professional language that does not ensure better communication about the same categories of mental illness
b)being too complex in its approach
c)developing too many disorders
d)establishing a bio-psychosocial approach.
5.Reginald Scot claimed that:
a)so-called spirit possessions were medical illnesses and not visitations from evil spirits
b)so-called medical illnesses were spirit possessions and were not the result of biological disease
c)general paresis was the main cause of mental illness during the 1800s
d)the classification of dementia praecox was the main reason that medical science was able to explain spirit possession.
6.Genetic predisposition appears to explain some of the reasons why some individuals display mental illness while others do not. This is most clearly observed in studies that show that:
a)abnormal DNA cannot cause mental illness
b)monozygotic twins of a mentally ill mother have a greater likelihood of developing mental illness relative to the general population
c)dizygotic twins of a mentally ill mother have a greater likelihood of developing mental illness relative to the general population
d)dopamine can cause mental illness.
7.From a psychoanalytic perspective, psychopathology occurs when:
a)conflict between the id, the ego and the superego gives rise to distressing symptoms
b)deficiencies in the ego impede the individual’s ability to repress instinctual drives
c)instinctual drives take over the superego
d)both a and b are correct.
8.Researchers have found that patients with PTSD show an increased production/risk of _________ while re-experiencing trauma.
d)both a and b are correct.
9.Delusions can be best defined as:
a)distortions in perception
b)fixed ideas or false beliefs that do not have any foundation in reality
c)fixed distortions in perceptual activity
d)fixed ideas and beliefs that are only found in schizophrenia.
10.Studies show that __________ of patients diagnosed with PTSD will continue to experience mild anxiety symptoms associated with the precipitating trauma.
a)50 per cent
b)10 per cent
c)60 per cent
d)20 per cent.
1.Choose a behaviour that you consider abnormal. Using the criteria of maladaptiveness, statistical deviance and personal distress, consider which criterion best fits the chosen behaviour.
2.Why do we need a classification system for mental illness?
3.What are the main limitations of the DSM-5 system?
4.How do community psychologists understand psychopathology? Use an example to illustrate your answer.
5.How do positive symptoms of schizophrenia differ from negative ones?
6.List and describe the positive symptoms of schizophrenia.