Essential Abnormal and Clinical Psychology

Matt Field, Sam Cartwright-Hatton

• Publisher: SAGE Publications Ltd
• Year: 2015
• ISBN:
  9781473934009
• Edition: 1
• Topic: Psychology
• Subtopic: Psychopathology
• Index: Psychology

This essential introduction to abnormal and clinical psychology explores the key areas, controversies and debates in the field and encourages students to think critically.

Key features of this textbook include:

• The latest updates from DSM-5 and ICD-10 and a balanced critique of the diagnostic approach, keeping students at the forefront of the developments and debates in the field
• "Essential Debate" and "Essential Experience" boxes that encourage critical thinking and provide case study examples to help students critique the findings and apply them in practice
• Concise chapters providing students with the essentials they need to get a good grade in their module in Abnormal and Clinical Psychology
• Additional student resources available on the companion website.

Suitable for all students taking Abnormal and Clinical Psychology modules.

1 The Big Issues in Classification, Diagnosis and Research into Psychological Disorders

General introduction

In this chapter, we consider whether it is possible to define what makes some psychological characteristics and behaviours ‘abnormal’. We then introduce the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases, the two most important classification and diagnostic manuals for psychological disorders. We explain how psychological disorders are diagnosed, and think critically about the problems that arise when applying a ‘medical model’ of diseases to psychological disorders. In the second part of the chapter we describe and evaluate research methods that are used to study psychological disorders, before considering how very diverse approaches to psychological disorders actually complement rather than compete with each other.

Assessment targets

At the end of the chapter, you should ask yourself the following questions:

• What distinguishes abnormal from healthy psychological functioning?
• Should we categorise and diagnose psychological disorders in the same way as other medical conditions?
• What types of research methods are used to study psychological disorders, and what are the limitations of those methods?
• What are the main approaches to the understanding of psychological disorders, and can they be integrated?

Section 1: What is abnormal?

Defining abnormality

No two people are the same; we all differ in psychological characteristics such as intelligence, sociability, and our general outlook on life (‘glass half full or glass half empty’). Because people are so different from each other, this makes it difficult to decide what makes someone ‘abnormal’ rather than just ‘different from me’. To start thinking about what makes behaviour abnormal, it is helpful to think of the ‘four Ds’ (Bennett, 2005):

• Deviance (from the norm) This assumes that there is a normal range for specific aspects of psychological function, and that anyone who falls outside that range might be classed as abnormal. For example, let’s imagine that the majority of the population score between 25 and 75 on a 100-point measure of depressed mood. If this was the case, anyone who scored below 25 or above 75 would be considered ‘abnormal’, and the more extreme their score was, the more abnormal they would be.
• Distress This means that a person might be considered abnormal if they feel distressed in some way. This requires us to define ‘distress’, which isn’t too difficult, but what level of distress makes a person abnormal?
• Dysfunctional This means that a person is thinking and/or behaving in a way that is hindering their daily life, for example their relationships or their performance at work or school. Again, we need to set a threshold to determine at what point psychological dysfunction is abnormal: nobody is perfectly functional all of the time!
• Dangerous This means that a person can be considered abnormal if their psychological condition puts them or other people at risk of harm – for example, someone who feels suicidal, or a person with paranoid delusions that drive them to physically hurt other people.

The ‘four Ds’ are not intended to be a prescriptive checklist, but they are a useful way of thinking about which kinds of human behaviour are normal, and which kinds are abnormal. Most psychological disorders fit some but not all of the four Ds. For example, a person with generalised anxiety disorder (GAD; see Chapter 6) is in distress, and this is dysfunctional (it prevents them from engaging in many activities). However, it is difficult to say how ‘deviant’ this is: we all feel anxious from time to time, and GAD is a very common disorder, so is it fair to say that people with GAD are actually any different from ‘normal’ people? Furthermore, most people with GAD are not a danger to themselves or others.

With regard to the notion of deviance, on what types of individual differences can somebody be ‘deviant’, in order to be considered abnormal? Perhaps we can start with an extreme depressed mood, but what about intelligence? Is someone abnormal if they are extremely intelligent? As for distress, we need to decide how to define this. It is relatively uncontroversial to say that someone who feels very depressed or anxious is in a state of distress. But we all feel these emotions from time to time, and at certain periods of our lives we may experience them more intensely than others (e.g. when starting a new job, or after a relationship break-up). At what point does distress become a sign of abnormality? Or maybe we shouldn’t talk about the severity of distress, but instead focus on how long people have been distressed?

Dysfunctional behaviour is also tricky. If someone is so paralysed by anxiety or depression that they cannot go to work or talk to their friends, then that is dysfunctional. But many other behaviours are dysfunctional in some sense, and we don’t consider that people who engage in them are abnormal. For example, young people who use fake ID to buy alcohol and then drink it in the park on a school night are doing something dysfunctional (it is illegal, not good for them and won’t help their performance at school). But even though we might not approve of this type of behaviour, many people would not see it as ‘abnormal’.

Finally, defining abnormality based on a person being a danger to themself or others is fraught with difficulty. The vast majority of people with psychological disorders do not intend to harm themselves and they pose no risk to others. On the other hand, some people are just bad tempered and physically aggressive – which makes them a risk to others – but this wouldn’t necessarily make them candidates for a psychiatric evaluation.

The overarching point is that each of these things is very difficult to define because there are no objective measures for them, and that is because our personal network dictates how we view these things. The example of teenage drinking is a case in point here: this might be viewed as dysfunctional by most members of society, particularly schoolteachers (!), but other groups, such as teenagers, may see it as completely normal and even something to aspire to! There are also cross-cultural differences. For example, in some cultures a person who has ‘visions’ and speaks to themself is considered to have magical powers, whereas the same behaviour in many European countries would be considered ‘abnormal’ and cause for psychiatric investigation. Finally, these things have changed over time within cultures. For example, homosexuality was categorised as a psychological disorder until as recently as 1973, but today most people (extreme fringe groups aside) are quite shocked by that historical fact! To give another example, the distinction between someone who suffers from major depressive disorder and someone who is just a bit miserable and pessimistic (but basically ‘healthy’) is always going to be a difficult call to make. Successive revisions of psychiatric diagnostic manuals have generally reduced their thresholds for making this distinction, such that someone who would have been considered miserable but healthy in the 1950s might be diagnosed with a major depressive disorder from 2013 onwards (see Chapter 5). We revisit this issue throughout the book.

Section summary

It is impossible to agree on a universal definition of what makes a person ‘abnormal’. This is because definitions of abnormality are heavily influenced by broad social and cultural factors, and these are constantly shifting. However, it can be useful to think of the ‘four Ds’ (deviance, distress, dysfunctional and dangerous) as a starting point.

Section 2: How are psychological disorders classified?

In this section we describe the two main diagnostic systems for psychological disorders: the Diagnostic and Statistical Manual of Mental Disorders (or DSM for short) and the International Classification of Diseases (ICD) which includes psychological disorders and is published by the World Health Organisation (WHO) (see www.who.int/classifications/icd/en/). We will show how these diagnostic systems have changed over time and explain why they are structured in the way that they are. We will also talk about why we diagnose psychological disorders, and the advantages that diagnosis offers for their management and treatment.

The Diagnostic and Statistical Manual of Mental Disorders

The American Psychiatric Association published the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders in 2013 (DSM-5; American Psychiatric Association, 2013a) after more than 10 years of development and consultation. The previous version of the DSM had separate ‘axes’ for personality disorders and mental retardation (axis 2) and for all other disorders (axis 1), but this distinction was abolished for DSM-5. Disorders are grouped together under the following categories:

• Neurodevelopmental disorders.
• Schizophrenia spectrum and other psychotic disorders (includes Schizophrenia; see Chapter 4).
• Bipolar and related disorders (see Chapter 5).
• Depressive disorders (includes major depressive disorder; see Chapter 5).
• Anxiety disorders (includes Generalised Anxiety Disorder; see Chapter 6), phobias (Chapter 7), panic disorder and social anxiety disorder (Chapter 8).
• Obsessive-compulsive and related disorders.
• Trauma and stressor-related disorders.
• Dissociative disorders.
• Somatic symptoms and related disorders.
• Feeding and eating disorders (includes binge-eating disorder, bulimia nervosa and anorexia nervosa; see Chapter 10).
• Elimination disorders.
• Sleep-Wake disorders.
• Sexual dysfunctions.
• Gender dysphoria.
• Disruptive, impulse-control and conduct disorders.
• Substance-related and addictive disorders (see Chapter 9).
• Neurocognitive disorders.
• Personality disorders (see Chapter 11).
• Paraphilic disorders.

Most categories contain a number of specific disorders that are related to each other. For example, the ‘Anxiety Disorders’ category contains 12 different disorders including Generalised Anxiety Disorder (GAD). The distinctive features of each disorder are then listed, together with any exclusion criteria. When we talk about ‘features’ we can distinguish between ‘symptoms’ (which the patient can report on, and is often distressed by) and ‘signs’ (which are directly observed, usually by a clinician). The diagnostic criteria for GAD are shown in Box 1.1.

When we look at these features it is helpful to think back to how these relate to our conceptions of ‘abnormality’ which we discussed in the previous section. In particular, some of the ‘four Ds’ are evident in the criteria for GAD: sufferers feel distress, and the anxiety is dysfunctional. However, it is difficult to get an idea of how deviant these features are: Would you say that someone who had these symptoms is different from another person who is ‘normal’? Do you think different people would agree on this?

Box 1.1 Example of DSM diagnostic criteria

The DSM-5 (American Psychiatric Association, 2013a) characterises generalised anxiety disorder as follows:

1. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
2. The individual finds it difficult to control the worry.
3. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past six months):
   • restlessness or feeling keyed up or on edge;
   • being easily fatigued;
   • difficulty concentrating or mind going blank;
   • irritability;
   • muscle tension;
   • sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
4. The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
5. The disturbance is not attributable to the physiological effects of a substance, or another medical condition.
6. The disturbance is not better explained by another psychological disorder

The International Classification of Diseases

The tenth version of the International Classification of Diseases was published by the World Health Organisation in 1992 (World Health Organisation, 1992). Another revision is now underway and is likely to be published in 2017. Unlike the DSM, which is published by a psychiatric association and is limited to mental disorders, the ICD is a broad diagnostic bible for every kind of medical condition imaginable. A subsection is devoted to ‘Mental and Behavioural Disorders’, and within this are different categories of disorders (e.g. ‘Mood Disorders’; ‘Neurotic, Stress-Related and Somatoform Disorders’), and within these categories sit the specific disorders. As with DSM-5, specific disorders are described in terms of their characteristic signs and symptoms, and any exclusion criteria that they might have. The ICD-10 criteria for Generalized Anxiety Disorder are shown in Box 1.2, and you can compare them with the DSM-5 criteria for the same disorder in Box 1.1.

We can see that both classification systems highlight the importance of ‘worry’ and physical indicators of anxiety, and both specify that symptoms need to be present for at least six months in order for a diagnosis to be made. Both DSM-5 and ICD-10 require symptoms to cause impairment or distress, and they specify the requirement to rule out other medical conditions or psychological disorders as causes of the symptoms (these criteria are explicit in ICD-10, but they are listed elsewhere in the manual rather than alongside the criteria for individual disorders). There are some differences too: the DSM-5 criteria are explicit that worry sh...

Table of contents

• Cover
• Half Title
• Publisher Note
• Title Page
• Copyright Page
• Contents
• Illustration List
• Illustration List
• Table List
• About the Authors
• Acknowledgements
• Foreword
• Preface
• Companion Website
• 1 The Big Issues in Classification, Diagnosis and Research into Psychological Disorders
• 2 How are Psychological Disorders Treated?
• 3 Childhood Disorders
• 4 Schizophrenia
• 5 Mood Disorders
• 6 Generalised Anxiety Disorder
• 7 Specific Phobias
• 8 Panic Disorder and Social Anxiety Disorder
• 9 Substance Use Disorders
• 10 Eating Disorders
• 11 Personality Disorders
• References
• Index