Introduction to Psychopathology

Alessandra Lemma

• Publisher: SAGE Publications Ltd
• Year: 1996
• ISBN:
  9781446230442
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

I was most impressed by the author?s thoroughness in writing this book. She seems to leave no stone uncovered... [this is] a work which should become a necessity for all counsellors, counselling psychologists, psychiatric nurses and psychotherapists... This is a book to which I will make reference time and time again, and one which will occupy a prominent place in my library? - Counselling, The Journal of the British Association for Counselling

`An invaluable handbook for students of psychotherapy and a good reference for established therapists... I recommend that all therapists have a copy of this book on their shelf? - Psychology, Health & Medicine

Assessment and referral skills are essential for counsellors and psychotherapists. Practitioners need to have an understanding of the clinical manifestations of severe emotional distress. They must, for example, be able to recognize when clients are a suicide risk or when they are suffering from a psychotic episode.

This lively textbook provides a clear overview of the issues involved in our understanding of psychopathology and offers guidelines on appropriate interventions. Alessandra Lemma explores a range of key topics, covering how psychiatric diagnoses and classifications are arrived at, and the issues that can arise when working in conjunction with other mental health practitioners, such as psychiatrists. She addresses the needs of practitioners in relation to some of the more common forms of mental distress - depression, anxiety and eating problems - as well as some of the more controversial diagnoses, such as schizophrenia and `borderline personality disorder?. The book concludes with a discussion of alternatives to mainstream approaches, including those which seek to deconstruct the concept of psychopathology.

Introduction to Psychopathology offers a framework for assessing clients which incorporates a broad range of models and approaches, and which takes into account psychological, social and biological factors. It will be an invaluable resource for students of counselling, counselling psychology, psychotherapy and clinical psychology.

1

What is Psychopathology?

Any attempt to define what psychopathology is presupposes that we really know what normality is. In view of this, any consideration of psychopathology requires an examination of the notions of mental health and illness and their inherent assumptions and biases. This will be the aim of the first part of this chapter. It will be followed by an exploration of some of the functions served by the notion of mental illness.

Throughout history, people’s understanding of psychopathology has constantly shifted; different cultures and historical periods have labelled ‘mad’ those whom other times and societies have regarded as ‘sane’. Indeed, it has been argued that madness is nothing but a label pinned by the respectable on those they cannot tolerate or that society is in actuality so demanding or alienating that it drives the most vulnerable souls to distraction. Psychopathology or madness can even be seen as being merely sophisticated euphemisms for human anguish. Since the ancient Greeks, psychopathological manifestations have been treated by a variety of social organisations including the Church, the law and medicine. In modern Western society medicine is the main source of identification and care for psychopathology. In spite of the attempts of the medical profession to use scientifically loaded terms reified within systems of psychiatric classification, the question of psychopathology has nevertheless remained shrouded in mystery.

The term ‘psychopathology’ generally refers to patterns of maladaptive behaviour and states of distress which interfere with some aspect of adaptation. Implicit in the American Psychiatric Association’s (1994) Diagnostic and Statistical Manual (DSM-IV) definition of ‘mental disorder’ is that the mental condition causes significant distress or disability (impairment in one or more important areas of functioning) and that it is not merely an expected and culturally sanctioned response to a particular event. The effectiveness of the person’s adaptation is thus implicit in the definition.

When people seek professional help this is generally because they are distressed by some aspect of their experience. The overt signs of distress, which may manifest themselves as psychological or physical symptoms, or even both, indicate a sense of ‘dis-ease’ (Ashurst and Hall, 1989) within the person’s internal and external worlds. Language can only give us a poor approximation of another’s experience of their states of ‘dis-ease’, yet it is through the use of labels that we categorise such differing and unique experiences in an attempt to make sense of them.

Notions of health and illness

Within the realm of physical medicine there is little dispute as to the precise nature of health. The physician is not required to make a moral or philosophical decision when declaring someone to be physically ill or healthy. Physical health can be stated in anatomical and physical terms. In medicine, statistical abnormality of physical structure and function is synonymous with pathology. Ideal and statistical norms are roughly equivalent so that no subjective values are involved in determining whether someone is physically ill or not. Equally, medical treatment is generally tailored to the correction of some deviation which is more or less the same for everybody and generally desired.

The notion of mental illness is the cornerstone of a working hypothesis which was set up in order to determine to what extent the medical model could explain and provide remedies for psychological disturbances. What often gets lost when we talk about mental illness or psychopathology is that all models are nothing more than ‘abstractions. They are our inventions created to place facts, events and theories in an orderly manner and are therefore not necessarily either true or false’ (Siegler and Osmond, 1974: 71). Although the application of the medical model to the understanding and treatment of psychological disturbances is still widely subscribed to, it has also been severely criticised.

Definitions of health and illness in psychiatry are highly problematic. Normality in the context of mental health has been variously defined, for example: as the absence of disease; as an ideal state of mind; as the average level of functioning of an individual within the context of a total group; as a capacity to function autonomously and competently; as a subjective sense of contentment and satisfaction; and as an ability to adjust to one’s social environment effectively. As will be immediately apparent, all such definitions, besides their vagueness, presuppose that other factors are clear; for instance, that we know what constitutes mental illness or an ideal state of mind. Such definitions can therefore only be subjective. Mental health is not the converse of mental illness, and is generally conceptualised as something wider than the absence of mental illness. For example, Maslow (1968) equated mental health with a process of self-actualisation and defined it as the person’s use and exploration of, their talents and potentials. This comprised ten components including, for example, acceptance of self and others and autonomy. While few would dispute that these are laudable qualities which some might choose to strive towards, the problem in adopting them as criteria for mental health is that, on the basis of such a definition, the majority of the population could be considered to be maladjusted.

As Kakar (1982) has suggested, mental health is a label which covers different perspectives and concerns, such as the absence of incapacitating symptoms, integration of psychological functioning and feelings of ethical and spiritual well-being. It is clear, however, that culture will play an important part in determining both the perception and level of concern in the case of each of these qualities. For example, Fernando (1991) has pointed out that in the cultures of Asia, Africa and pre-Columbian America, in contrast to Western culture, there may be less concern about varieties of inner experience or altered states of consciousness, whereas in the West these would be seen as abnormal experiences and in some cases as evidence of illness.

Mental health or normality has proved challenging to define and some authors suggest that normality may in fact not even be something to which we should aspire. Indeed, Donald Winnicott (1945: 150) wrote that ‘we are poor indeed if we are only sane’, which suggests that the need for normality is perhaps exaggerated. This is echoed by another psychoanalyst, Joyce McDougall (1990), in the evocative title of her book Plea for a Measure of Abnormality, where she argues that ‘to be caught in the grip of an overly powerful social ego, over reasonable and over adapted is no more desirable than the dominance of unleashed instinctual forces. The point at which [the norm] becomes the straightjacket of the soul and the cemetery of the imagination is a delicate one to define’ (1990: 484). McDougall thus suggests that, faced with the inherent difficulty of the human enterprise, we may well respond by an over-adaptation to the world of external reality by becoming what she calls ‘supernormal’. It is not that such authors glorify madness, but rather that they point to the equally undesirable aspect of what we might otherwise call normality and, of course, remind us of the corresponding difficulty in defining normality.

Defining mental illness has proved as difficult a project as defining mental health. In Hamlet, Polonius hints at the problem when he concludes that to try ‘to define true madness, what is’t but to be nothing else but mad’. Despite the attendant problems, attempts at defining mental illness have none the less persisted. In Britain, in the Mental Health Act 1983, section 1, mental disorder is defined as ‘mental illness, arrested or incomplete development of mind, psychopathic disorder and any other disorder or disability of mind’. Four categories of mental disorder are specified as follows:

• mental illness: not defined
• severe mental impairment: ‘a state of arrested or incomplete development of mind which includes severe impairment of intelligence and social functioning and is associated with abnormally aggressive or seriously irresponsible conduct on the part of the person concerned.’
• mental impairment: defined in the same way as severe mental impairment except that the phrase ‘severe impairment’ is replaced by ‘significant impairment’.
• psychopathic disorder: ‘a persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct.’

Such definitions are clearly problematic as one might well ask what constitutes ‘abnormally aggressive behaviour’ or ‘seriously irresponsible conduct’. Unlike general medicine, where statistical abnormality is synonymous with pathology, in psychiatry an individual may well exhibit very unusual behaviour and yet not be diagnosed as mentally ill. Whether a person is thus labelled may therefore be under the influence of other factors. Sarbin and Juhasz (1967, 1978) for example, have suggested that psychiatrists are more likely to judge reported hallucinations as pathological, that is, as symptoms of schizophrenia, when the hallucinating individual has already been devalued in some way, as for example when he or she is of low social status and poor education. It was convincingly argued by Scheff (1966) that everyone performs actions that do not correspond with our definitions of normal behaviour but that only in certain circumstances do they receive a stigmatising label. Along with Szasz (1961) and Goffman (1961), he argued that diagnostic labelling occurs after the person has violated social norms. While this is a very important and interesting hypothesis, there is unfortunately no conclusive evidence to support it.

Littlewood and Lipsedge (1989), discussing a wide range of behaviour, have suggested that it is not necessarily the performance of certain behaviours per se which invite pathological labels but their performance outside a prescribed social context. While reporting hallucinatory experiences as being real is negatively valued in modern Western society, there are some exceptions to this, for instance when such experiences occur in a religious context. Such factors point to a fundamental problem in defining mental illness, namely that statistical data in psychiatry may be misleading in that they can be based on assumptions which include unacknowledged value judgements.

The contamination of the raw facts of someone’s behaviour by the psychiatrist’s or other mental health practitioner’s own subjective judgement leads to a number of worrying situations whereby one person may be labelled mentally ill in one institution or even country and not in another; political dissenters who were labelled as mentally ill in the former Soviet Union are a prime but sinister example of this possibility (Fulford et al., 1993). It was with such factors in mind that critics of the medical model and the political use of psychiatric diagnosis in the 1960s and 1970s, such as David Cooper, Ronald Laing and Thomas Szasz, argued the importance of clearly distinguishing between organic and mental illness and suggested that the latter is no more than a mere label to stigmatise non-conforming individuals. Szasz argued that madness was erroneously termed mental illness. Rather, he said, it was more appropriate to refer to it as ‘problems in living’ but that the label of illness was awarded by the medical profession in order to legitimise its own authority. The essential message was that mental illness could not be considered in a value-free scientific framework but rather needed to be understood in its sociopolitical context.

The above position is hard to refute and several lines of evidence converge to support it. The way we define mental illness changes with time and depends on the rules by which a given society lives which include the behavioural norms that determine within that society what a person can or cannot do: where, when and with whom. A historical perspective on the concept of deviance, in the sense of deviating from given societal and cultural norms, soon highlights that the norm has always had a sociotemporal dimension. How a particular society defines deviance, which may be couched in terms of mental illness, depends on how wide a range of behaviour that society allows to be acceptable. How a society explains deviance from the so-called norm will, in turn, depend on its own prevailing beliefs. Historically, such deviance has been variously explained by possession by evil spirits, as a loss of divine grace, as a result of early or severe toilet training, as a function of biochemical imbalance, to name but a few of the accounts put forward. Accordingly, the same behaviour has received different labels at different times in history. Raimbault and Eliacheff (1989), in their study of anorexia, have shown how changing cultural environments have determined whether the individual who self-starves is seen as saintly, hysterical, sick or mad.

Finally, how a society manages deviance will, once again, be according to the nature of that society. A more traditional society will handle deviance quite differently from a large industrialised society, which may make it harder for the person who has deviated to become reintegrated into that particular society. Warner (1994), in a very thorough study and critique of our ways of dealing with schizophrenia in the West, has argued that the outcome of schizophrenia is better in the non-industrial world, despite the low priority given to psychiatric care in such countries. Warner explains such results in terms of the opportunities offered to the individual in the non-Western world to find a valued social role, particularly through work, and therefore to be reintegrated within the community. In industrial societies, on the contrary, little leeway is given to adapting the job to the abilities of the worker. It is therefore more difficult for individuals to regain a valued social role within their communities from which they may have become estranged during the period of their psychotic episode (see Chapter 9).

Such studies point to the importance of understanding behaviour in its cultural context and highlight the ways in which the overall worldview within a culture, appertaining to health, religion, psychology and spiritual concerns, determine the meaning within that culture of mental health and illness. Fernando (1991) has argued that the current medical model of psychiatric illness in the West is one that is relatively, if not completely, free from religious, ethical and spiritual aspects of the culture in which it is based. However, in the medical traditions of Asian culture, for instance, medicine, religion and ethics are integrated together. Jean Pouillon (1972), the French anthropologist, argues that there are many different approaches throughout different cultures to the concept of sickness that depend to some extent on a three-way relationship between the sick individual, the healer and the conception of sickness itself. Crucial to this argument is the idea of another anthropologist, Levi-Strauss (1955), that in some cultures termed ‘exorcistic’ all pathology is regarded as alien to the self and so to be removed by the healer on behalf of society. In other cultures termed ‘endorcistic’ pathology is regarded as potentially helpful to the self and so to be integrated into the self. Western medicine and hence psychiatry can thus be seen as a product of an ‘exorcistic’ culture where the primary aim of treatment is to ‘get rid’ of a person’s experiences of mental anguish or suffering rather than helping the person to integrate them into the self.

Notions of health and illness can only really be considered in the context of particular cultural worldviews. In the West, Fernando (1991: 16) argues, ‘health is felt as something that is attained by control and domination’, in keeping with a worldview that emphasises control of emotions by reason, and of nature by people. By contrast, the Western concept of health is a matter of overcoming illness. The worldviews of Africa and Asia, however, promote ‘a sense of health arising from acceptance’ (Fernando, 1991: 16). Together with this there is a striving for harmony both within the person and between people and their environment, in nature and the spirit – a way of thinking that is often dismissed in the West as superstitious. A cross-cultural perspective thus emphasises the importance, when discussing the concepts of mental health and illness, of remaining aware that a true picture of cross-cultural difference is often distorted by the imposition of value judgements of the constituent cultural system. The application of the Western medical model to people from other cultures is therefore problematic.

The problem of classification and diagnosis

Classification

Classification refers to the dividing of a given set of abstract entities into sub-classes and is the fundamental activity of any science. Our current systems of psychiatric classification are derived from medical classificatory models described in France and Germany in the second half of the nineteenth century and the early twentieth century when leading clinicians defined some of the major syndromes of psychiatry. These included, most notably, Kraeplin in Germany who assumed that there were groups of symptoms and signs occurring together with sufficient regularity to merit the term disease.

The aims of classification are twofold: by permitting adequate description, it is argued that classification enables communication, and by grouping together entities assumed to share common characteristics it allows the possibility of general laws and theories to be inferred. Kraeplin’s classificatory system forms the basis of the descriptions of syndromes and diagnostic categories still used today. The existing categories are now established within ‘the bibles of psychiatry’ (Ussher, 1991), namely the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, APA, 1994) and the International Classification of Diseases (ICD 10). In this book we shall refer to the DSM-IV classificatory system.

DSM-IV is a manual of ‘mental disorders’, but as Frances points out ‘it is by no means clear just what is mental disorder or whether one can develop a set of definitional criteria to guide inclusionary and exclusionary decisions from the manual’ (1994: VII). Furthermore, ‘mental’ implies a mind-body dichotomy that is becoming increasingly outmoded and untenable – any division between purely mental and purely physical disorders ignores that these conditions often result from an interaction that belies the distinction. Unlike earlier classificatory systems, DSM-IV provides specific diagnostic criteria to enhance reliability, even though it is admitted that most diagnostic criteria are based on clinical judgement and have not been validated through empirical research (APA, 1994).¹

Classificatory systems hold the appeal of clarity but they also present difficulties. First, ‘the correlation of a particular word with a particular meaning derives not from any natural divisions in reality but from convention, and any vocabulary reflects established, though possibly arbitrary, distinctions’ (Mullen, 1979: 26). In order to classify the variant presentations of emotional distress we invariably divide our observations into manageable units and assign a label to each, but this process is, of necessity, an arbitrary one which cannot capture the subtlety of experience. Though the separations, it can be argued, facilitate comprehension and communication, they may also place limitations on what can be observed.

Secondly, an examination of psychiatric classificatory systems also requires some consideration to be given to the question of the challenges posed by any attempt to study the human mind. The mind as an object of study is problematic. In any science, whatever is to be studied and spoken of must become in effect an ‘object’ for the scientist. However, unlike other sciences, those seeking to study the minds of others cannot directly contemplate their object, ‘for the mind of the other is never an object for us and can only be apprehended in its productions such as speech, actions and writing’ (Mullen, 1979: 27). The problems inherent in such an enterprise are great for, as Merleau-Ponty (1962) observed, the existence of other people creates difficulties in our pursuit of objective thought. If the mind of the other is to be the object of any study, we have to acknowledge that the consciousness that we are trying to study also has us as an object of its consciousness, thereby placing us as an object within our object. This immediately imposes restrictions on any attempt to study the mind of another objectively. This, in turn, raises an impo...

Table of contents

• Cover Page
• Title
• Copyright
• Dedication
• Contents
• Acknowledgements
• Preface
• 1. What is Psychopathology?
• 2. Developmental Psychopathology
• 3. Assessment
• 4. The Management of Referrals
• 5. Depression
• 6. Suicide and Self-harm
• 7. Anxiety
• 8. Eating Problems
• 9. Psychosis
• 10. Personality Disorders
• 11. Conclusion
• References
• Index