Classification and Diagnosis of Psychological Abnormality

Susan Cave

• Publisher: Routledge
• Year: 2005
• eBook ISBN: 9781134579983
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

How is psychological abnormality recognised? How many different mental disorders are there, and what are their characteristics? Although there are established guidelines for clinicians working in this area, these have been subject to many criticisms. Exploring how views on this subject have changed over time, and how they vary in different societies, poses important questions about our current practices.
This book provides a brief overview of the current definitions and various explanations for psychological abnormality and then focuses on how society diagnoses and classifies behaviour that is deemed to be 'unusual'. Three key areas of the topic are covered: the procedures involved in the diagnosis and classification of mental disorders (such as schizophrenia); research into the history and origins of multiple personality disorder; and a discussion of the implications of cultural variability (including culture-bound syndromes) for the classification and diagnosis of psychological abnormality.
Classification and Diagnosis of Abnormal Psychology is an introductory text suitable for students and teachers of the AQA Psychology A2 specification and is also useful for other groups who work in the field of mental disorder, such as nurses, social workers and therapists.

1

Introduction

Historical background
Criteria for defining abnormality
Perspectives and models

Historical background

Prehistory and evil spirits

Some form of psychological abnormality has always been recognised. In prehistoric times the evidence that survives suggests that such behaviour was generally attributed to evil spirits. Evidence exists of exorcisms being carried out, and skulls have been retrieved that have neat holes in them. These may have been drilled to allow the evil spirits to escape – a procedure still carried out by some groups today in order to achieve heightened awareness, and known as trephining (or trepanning). It has been argued, however, that the holes discovered are more likely to be healed-over injuries (Maher & Maher 1985). This is because most of the skulls are male, and the holes are in a variety of different sites on the skull, suggesting that deliberate placement did not occur.

Ancient Greece and medical explanations

The philosopher Plato, in the 4th century BC, distinguished natural madness, resulting from physical disease, from that given by divine gift. He insisted that mental disturbance should be treated within the family, which led to special temples being set aside as retreats for the mentally ill.

Hippocrates, a Greek physician writing at the same time (often considered to be the father of modern medicine), described five forms of madness (hysteria, epilepsy, acute mental disturbance with and without fever, and chronic mental disturbance), all of which he considered to be medical in origin and treatable by procedures such as emetics, bleeding, purges and dietary change. These procedures were aiming to reduce the excess of bodily fluids, or humours, which Hippocrates thought were responsible for mental disorder. An excess of black bile was thought to lead to depression (melancholy); an excess of yellow bile to irritability and anxiety (choleric); an excess of phlegm to indifference (phlegmatic); and an excess of blood to mood shifts (sanguinity). Thus some of the modern categories of disorder had clearly been identified even then.

The Greek physician Galen, in the 1st/2nd century AD, studied anatomy in his search for explanations, but is often considered to be the first person to suggest that abnormal behaviour could also have psychological origins (Halgin & Whitbourne 1993).

The Middle Ages and demonology

By the Middle Ages (500–1500) the demonological view had taken over in Europe, and madness again became linked with possession by evil spirits. This represented a reversion to earlier ideas about evil spirits, but the ideas had been embedded in the context of Christianity. Such individuals were more likely to be subjected to exorcism or burnt at the stake than treated medically. The Inquisition was an institution set up by the Roman Catholic Church to discover and suppress heretics (those people who held opinions opposed to those of the church). In 1484, the Inquisition began in earnest with the publication of the Malleus Malleficorum, the witchhunter’s guide to diagnosing witches. This was one of the first books to be printed and widely circulated. According to Spanos (1978) as many as 100,000 persons were dealt with in this way between 1450–1600. Not all were mentally disordered of course (many were eliminated as the result of political or economic rivalry), but it is likely that many would have been.

However, at about the same time there was also the first attempt to provide secure places for mentally disordered persons. Until this time lunatics (as they were generally known) had either been accommodated by their own families or simply cast out to fend for themselves. Bethlem hospital, opened to lunatics in London in 1403, was the first in Europe, and it was followed by another in Spain in 1408, in North America in 1639 and France in 1657.

These two views of madness, as disease or as demonic possession, continued to conflict for many centuries; only recently has the latter approach been replaced by a broader, ‘moral’ view of such behaviour that is less reliant on religion.

The ‘Age of Reason’ and moral treatment

During this period in history, science and rationality were believed to hold the key to making progress with solving human problems. Hence it has become known as the Age of Reason. Physical treatments, based on ‘scientific’ principles and administered by physicians, gradually gave way to moral treatment based on rational argument.

In the early 18th century lunacy was regarded as an illness, and following the Poor Laws of the late 17th century, lunatics were to be protected in asylums. As these asylums became more and more overcrowded, however, the use of chains and restraints increased. By the late 18th century, as the ‘Age of Reason’ prevailed, religious fervour had cooled off, and the inadequacy of physical treatments had also been recognised. There were several reasons for the latter. First, physical treatments such as the whirling chair had proved ineffective. (This was a device into which patients were strapped and rotated at speed, allegedly until blood ran from their ears.) Second, in the Bethlem scandal of 1814 it was discovered that a patient called James Norris had been kept in irons for 10 years for attacking his ‘keeper’. (As usual, of course, it has been noted that there were two versions of this scandal – that Norris was an extremely violent patient, and that when chained he was kept supplied with reading materials and even had a pet cat. Nevertheless, the case roused public opinion against the use of chains in asylums, especially when such neglect was found to be common).

Third, the madness of King George III (noted in letters dated 1788) had failed to respond to the available medical treatments of bleeding, blistering and purging. His problem turned out to be porphyria, a hereditary disease that produces abdominal pain and mental confusion. At the time, it was unrecognised.

The rejection of the religious and medical approaches to dealing with mental disorder led to a third response to abnormal behaviour; the moral approach. This is considered to have originated with Francis Willis, a clergyman who was called in to treat George III. He placed great emphasis on physical remedies such as diet, exercise, physical restraint (using chairs or straitjackets) when required, and lectures on morality designed to make the patient see the error of his ways. The importance of this is that madness no longer appears to be considered to be purely physical or demonological in its origins. It is also possible, of course, that the use of different treatments does not necessarily indicate a shift in ideas about the origins of mental disorder.

The moral approach was also reflected by Chiarugi in Florence, Italy in 1788. He removed all restraints from patients and provided them with activities to occupy them. This could be considered to be the start of occupational therapy. In the Bicetre hospital in Paris, the superintendent of the incurables ward, a layman called Pussin, had similarly unchained patients and forbidden staff to beat them in 1784. He extended these reforms with the aid of Pinel, who was appointed physician in 1793 (and generally gets the credit for the improvements).

In England, the Quaker William Tuke (1732–1822) opened the York Retreat in 1796, which proved to be highly successful. It was based on moral therapy, an attempt at resocialisation that emphasised kindliness, orderliness and occupation. No physicians were employed there, and restraint was used only if absolutely necessary. The term ‘moral insanity’ was coined by the Englishman Pritchard in 1835 to refer to people who do not live in acceptable ways. It has been suggested (Masson 1988) that this was subsequently used as a convenient excuse to incarcerate unwanted relatives, particularly women who had an inheritance coming to them.

This conflict between the moral and the medical approaches replaced the earlier conflict between the religious and the medical approaches. This diversity can still be seen today in the different therapeutic approaches to mental disorder (see Therapeutic Approaches in Psychology by Susan Cave in the series).

In response to these developments, Parliament passed legislation in 1808 regarding care for the insane, but it was not until the Lunatics Act of 1845 that it became mandatory to provide asylums. These were considered to be centres for cure rather than restraint. Prior to that, many mentally disordered individuals were incarcerated in prisons or the workhouse if they couldn’t afford private care. In America, the physician Benjamin Rush (1745–1813) devoted his career to the study of mental problems, and the reformer Dorothea Dix (1802–1887) campaigned for special humane facilities to be provided for the mentally ill, raising sufficient funds to found 32 mental hospitals.

The modern era and mental illness

Considerable expansion in provision occurred between 1860–1900, and the medical view prevailed once again. The first textbook of psychiatry was published by Kraepelin in 1885, and established abnormal behaviour as a manifestation of mental illness, a physical disease or dysfunction in the individual that should therefore be treated by physical means. To some extent this optimism was lost subsequently, as the asylums became more and more overcrowded and madness became regarded as incurable.

Another pioneer from this period was Freud, who studied hysteria with the neurologist Charcot in Paris. Hypnosis had had some popularity as a treatment for mental problems since it was first introduced by Mesmer some years before in the guise of mesmerism. Freud used it briefly, but then rejected it and developed his own system. Known as psychoanalysis, it was the forerunner of modern psychotherapies, and also reinforced the view that mental illness was curable and need not necessarily be medical in origin.

After World War II (1939–1945), the hospital population reduced again with the advent of drug treatments. The neuroleptics (major tranquillisers) in particular produced a major revolution in treatment and a liberalisation of care. Medicated patients were much better equipped to deal with everyday activities, and many could remain in the community. From the 1950s onwards, with the social psychiatry movement gaining ground, hospitalisation came to be seen as an inappropriate way to deal with the problem of mental disorder. The World Health Organisation adopted the label ‘mental disorder’ to replace the term ‘mental illness’, emphasising the fact that a physical basis had not been found for many of the conditions involved. As a result of this, and the requirement in the Mental Health Act of 1959 and the Community Care Act of 1990 for local authorities to provide more community services, many mental hospitals have now closed.

Underpinning these responses to abnormal behaviour, Halgin and Whitbourne (1993) have identified three different explanations for that type of behaviour: mystical; scientific; humanitarian. These are equivalent to the religious, medical and moral views identified earlier. The mystical view is that it results from demonic possession; the scientific view is that it results from biological factors such as faulty genes or brain disease, or psychological factors such as learning or stress; the humanitarian view is that it results from social conditions. Treatments have broadly speaking been either ‘medical’ or moral/religious, illustrating physical and mental (psychological) approaches, respectively. What is interesting here is the similarity in the way that mental disorder has been dealt with over time. Although the approaches have been reframed according to prevailing societal values (e.g. religious/moral) they have remained much the same for centuries.

Although a detailed discussion of the explanations for abnormal behaviour is not the aim of this book, it is important to understand that there are differences and similarities in the ways in which society as a whole, and hence the mental health professionals, have responded to abnormal behaviour. These are apparent in the attempts to define and classify (see Chapter 2), and in the different models used to understand abnormal behaviour, which we will be discussing in the rest of this chapter. Finally, most of what has been written about the history of mental disorder has focused on the way in which society has varied in its treatment of those whom it has labelled as abnormal. A more difficult issue to address is whether there has been any real change in the nature of the behaviours that evoke such labels. Would the same people have been considered abnormal today and in prehistoric times, for example? This is something to bear in mind as you read the rest of this text.

Criteria for defining abnormality

As indicated earlier, any discussions in this area depend on the existence of an agreed definition of what constitutes abnormal behaviour. Such a definition should ideally be able to cover all behaviours that are generally agreed to be abnormal; should exclude all normal behaviours; should provide a basis for objective measurement of behaviour; and should be applicable to everyone irrespective of culture. Measurement is dealt with in more detail in Chapter 2, and culture in Chapter 4. Here we are concerned primarily with the selection of behaviours to be included in a set of criteria for mental disorder.

Progress exercise

Ask a sample of people (about six should do) from different backgrounds what types of behaviour they would regard as abnormal. Then ask them which of those behaviours are criminal (bad) and which are ‘mad’. What types of behaviour have they identified? How much agreement is there? Is there an overlap between ‘mad’ and ‘bad’? How can they be distinguished?

Legal criteria

It might be thought that the legal system, which is responsible for making compulsory treatment orders for those who display abnormal behaviour, would have agreed a suitable definition. The law differs in different countries; in Britain the 1983 Mental Health Act offers the following definition of mental disorder: ‘Mental illness, arrested or incomplete development of mind, psychopathic disorder and any other disorder or disability of mind.’

Mental illness is not defined further, but is left up to the judgement of the professionals involved in treating such disorders. The underlined statement is similarly vague. ‘Arrested or incomplete development of mind’ is further defined as a state ‘which includes severe/significant impairment of intelligence and social functioning and is associated with abnormally aggressive or seriously irresponsible conduct on the part of the person concerned.’ Psychopathic disorder is ‘a persistent disorder of, or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned.’

Some of these definitions give indications of the kinds of behaviours that are regarded as troublesome – impaired intelligence (though not always); impaired social functioning; abnormally aggressive and seriously irresponsible behaviours. However, the qualifiers (impaired, abnormally, seriously) leave a great deal of scope for subjective judgement. What is judged to be impaired social functioning by one person may be considered acceptable by another. Consider regular bouts of excessive drinking, for example.

Progress exercise

In the light of the legal criteria, consider what level of intelligence you think constitutes ‘severe/significant impairment’. Is it an IQ of 50, or 75 for example?

What is ‘ abnormal’ aggression, and what is normal aggression? Does it have to involve physical violence, and if so to what degree? When is aggression justified?

What is ‘seriously irresponsible conduct’? Should it include such behaviours as being seriously in debt? Not paying maintenance for children? Using ‘dirty tricks’ to eliminate business rivals?

Statistical criteria

In an attempt to address some of the issues raised earlier, statistical criteria have been introduced for some behaviours, based on the normal distribution curve (see Figu...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of illustrations
• Preface
• Acknowledgements
• 1. Introduction
• 2. Classification, assessment and diagnosis
• 3. Multiple personality disorder (MPD)
• 4. Cultural and subcultural issues in abnormality
• 5. Conclusion: Synoptic issues and debates
• 6. Study aids
• Glossary
• Bibliography
• Index