Some concept of mental illness exists in perhaps every culture on earth and descriptions of it are found in ancient texts dating back to the Greeks and Romans. Those who have confronted mental illness in themselves or someone close to them can appreciate the extreme pain and dysfunction it can cause. Nonetheless, it is difficult to come up with a precise definition of mental illness. In the most recent version of the Diagnostic and Statistic Manual (DSM), a mental disorder is defined as a psychological pattern that causes distress or dysfunction and that is beyond the norms of the individual’s culture.
This is a difficult question. Even though a mental illness must cause distress or dysfunction, to some extent we judge the pathology of behavior by its relationship to cultural norms. Therefore our concept of mental illness is tied in part to our ideas of what is normal. This raises the question of whether all abnormal behavior is pathological and whether all normal behavior is mentally healthy. Clearly, people can engage in unusual behavior that is not pathological. We do not want to diagnose any kind of original or unconventional behavior as mentally ill. Nor is all normal behavior healthy. Drug abuse, violence, and anorexia can be very common in certain social groups, but all cause distress or dysfunction. Thus, although it can be very easy to recognize mental illness in the most extreme cases (such as acute psychosis or severe depression), there are many circumstances where the boundaries between mental health and mental illness are not so clear.
Delusions are generally diagnosed as a symptom of a psychotic disorder. A delusion is defined as a fixed, false belief that is considered abnormal within the person’s culture. Nonetheless, it is not always easy to separate a delusion from a belief that has become acceptable within a certain subculture. This can be the case even with very bizarre beliefs.
For example, the author David Icke has very successfully promoted the idea that the world is run by a conspiracy known as the Illuminati (a term dating back to earlier conspiracy theories). The Illuminati descend from an alien race of lizard people who came to Earth from another planet and are capable of changing shape and assuming human form. Most of the major political and economic figures in the world today, including George W. Bush, Hillary Clinton, and even the late Princess Diana, are actually considered to be lizard people. There are several different branches of the lizard people, including the Grays, the Adopted Grays, the Crinklies, the Tall Blonds, the Tall Robots, and the Annunaki. George W. Bush is reportedly a member of the Annunaki branch of the lizard people.
Are these beliefs delusional? Most of us would consider these ideas to be false beliefs that are culturally abnormal. Nonetheless, David Icke has many followers and his books have sold very well. Within a certain subculture, therefore, these beliefs are not considered abnormal. Situations such as this illustrate how difficult it can be at times to determine what is and is not a symptom of mental illness.
According to one conspiracy theory, prominent politicians and other leaders in the world are actually alien lizard people called the Illuminati (iStock).
All diagnostic systems depend upon classification. What function does classification serve? Imagine if we had no common, standardized classification system for mental illness. With no common language to describe clinical observations, there could be no coordination among clinicians, researchers, or people working in public policy. There would be no way to research the prevalence, etiology (cause), outcome, or progression of the illness. Without a grounding of scientific data, there would be no way to systematically develop and test treatments. Treatments would be fragmented, ad hoc and untested, ultimately based on personal opinion instead of scientific fact.
Mental illnesses or disorders are classified according to the nature of their symptoms, their causes and their course. The course of an illness refers to its progression over time. DSM-IV-TR has sixteen general categories with multiple diagnoses in each category. Examples of these categories include eating disorders, psychotic disorders, impulse control disorders, mood disorders, anxiety disorders, and mental disorders due to a general medical condition.
DSM refers to the Diagnostic and Statistical Manual. DSM-IV is the fourth edition of the DSM, published in 1994. DSM-IV Text Revision (DSM-IV-TR) was published in 2000. This edition made minimal changes to the diagnoses, but updated the literature review in the manual. The DSM system provides a standardized method to diagnose mental illness. It is developed in coordination with the International Classification of Diseases (ICD) which is published by the World Health Organization (WHO). Diagnoses are provided on five axes, the first axis (axis I) lists specific clinical syndromes, such as schizophrenia or major depression. The second axis (axis II) lists personality disorders and mental retardation, chronic conditions that affect the full range of a person’s psychological functioning. Axis III pertains to medical conditions that might affect the person’s psychological state, axis IV to psychosocial and environmental stressors, and axis V to the person’s general level of adaptive functioning (the GAF score), which ranges from one to one hundred.
Interestingly, the first official psychiatric classification system was developed to help with the U.S. Census. The Census Bureau aimed for an accurate estimation of the U.S. population, including residents of mental hospitals. In 1840, the U.S. Census had only one category for mental illness, idiocy/insanity. By 1880, there were seven categories: mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy. In 1917, the official psychiatric professional associations decided it was time to design their own classification system, taking the diagnosis of mental illness out of the hands of the government.
What would soon become the American Psychiatric Association (APA) joined with the National Commission on Mental Hygiene to develop a nomenclature (system of labels) for mental disorders. This system applied mainly to the most severely ill inpa-tients, those living in mental hospitals. After World War II brought back veterans suffering from the psychological aftereffects of war, the diagnostic systems were expanded to consider the needs of outpatients, those living in the community. The first edition of the DSM was published in 1952, DSM-III came in 1980, DSM-III-R in 1987, and DSM-IV in 1994. The projected publication date of DSM-V is 2013.
Because human psychology and culture are so complex and so variable, it is very hard to come up with a foolproof system for diagnosing mental illness. The first editions of the DSM were strongly influenced by prevailing psychological theories and were poorly linked to empirical research. Some of the diagnoses were controversial and what we would now consider culturally biased. For example, homosexuality was listed as a mental disorder until 1974. While more recent versions of the DSM have made much greater use of empirical research, there are still critics who suggest the diagnoses lack adequate scientific validity. Because of the inevitable flaws in any classification scheme, however, it is assumed that each version of the DSM will eventually become outdated and will need to be replaced by a newer edition.
It is critical to recognize that no matter how complex and sophisticated the classification system becomes, it can only provide guidelines for treatment. Diagnoses are prototypes—they are only ideals—and few patients fit the classification perfectly. In fact, many patients do not quite fit into any diagnostic category. Moreover, it is also critical to remember that the classification system applies to a pattern of symptoms. It does not and can never describe the whole person. For this reason DSM-IV-TR only refers to “individuals with schizophrenia,” for example, and not “schizophrenics.”
DSM-V is scheduled to come out in 2013. However, in early 2010, the American Psychiatric Association published their proposed revisions in order to solicit comments from readers on these changes. Along with changes to the criteria and classification of specific diagnoses, some very general changes were also proposed. For one, the first three axes of the five-axis diagnostic system will be collapsed into one axis. In DSM-IV, axis I is for clinical syndromes, axis II for personality disorders and mental retardation, and axis III for medical disorders that might be relevant to the mental condition. In DSM-V, that will all be coded on one line. Also DSM-V puts much more emphasis on dimensional ratings than any previous DSM edition. In other words clinicians will rate patients in terms of the severity of various clinical traits (such as depression, anxiety, etc), and not just categorize them as either having or not having a particular disorder. Diagnostic categories will be retained in DSM-V, but there will be more room for dimensional ratings. Because the DSM-V system has yet to be finalized, we will focus here on the diagnostic system of DSM-IV and DSM-IV-TR.
DSM-IV-TR includes a section on culture-bound syndromes, which are distinct patterns of emotional or behavioral disturbances that are found only in specific cultures.
While most of the DSM diagnoses can be found across cultures, people from different cultures do vary in the way that they express psychological distress. In many cultures, depression is less likely to involve conscious feelings of sadness and more likely to involve preoccupation with bodily ailments. Likewise, the content of schizophrenic delusions and hallucinations is strongly influenced by cultural themes. Delusions of being the messiah are frequently found in Jerusalem, while delusions of being tracked by the CIA are more likely to be found in the United States. In addition, some cultures have developed unique forms of expressing emotional distress. DSM-IV-TR includes a section on culture-bound syndromes, which refer to distinct syndromes that are found only in specific cultures. Importantly, they are recognized as illnesses or as disturbed behavior within their host culture. Most of these syndromes indicate that the individual is overwhelmed by strong negative emotions. Examples include: Attaque de nervios from Latin American cultures, Koro from Chinese and East Asian cultures, and ghost sickness from Native American peoples.
Some people think that schizophrenia means having multiple personalities, which is actually known as Dissociative Identity Disorder. Schizophrenia involves psychiatric symptoms like delusions, hallucinations, and disorganized behavior.
Schizophrenia is perhaps the most disabling of the major mental illnesses. Although descriptions of similar clinical presentations date back to the earliest periods of written history, the term “schizophrenia” and the current definition of the disorder are relatively recent. The German psychiatrist Emil Kraepelin (1856-1926) first distinguished between manic depressive illness and dementia praecox, or what was later called schizophrenia. The Swiss psychiatrist Eugen Bleuler (1857-1939) coined the actual term “schizophrenia” from the Greek words for “split mind.” According to DSM-IV, schizophrenia is characterized by two or more of the following symptoms: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, and negative symptoms. These symptoms must have been present for at least one month, and result in significant social or occupational impairment and/or reduction in self-care. Some sign of the disorder must have been present for at least six months, and the symptoms cannot be due to another condition (such as substance-induced psychosis or a medical condition).
The DSM-IV diagnosis of schizophrenia describes a range of psychotic symptoms. Psychosis refers to a significant break with reality testing, or the ability to recognize reality as other people who are in similar circumstances typically see it. There are a number of different types of psychotic symptoms:
All the symptoms mentioned so far refer to positive symptoms or problematic traits that are present. In contrast, negative symptoms reflect the absence of healthy traits. Specifically, negative symptoms refer to blunted or flat affect (or emotion) and a dulling of motivation, initiative, energy, and cognitive activity.
Thought disorder is one of the most striking and debilitating aspects of severe psychosis. This refers to the way that thought is organized. Thought disorder does not pertain to the content of the thought process, to what the person is thinking about, but to the way that the ideas are put together. Does the person display a logical and orderly flow of ideas? Or are the ideas jumbled, only loosely related to each other and ultimately impossible to understand?
There are many kinds of thought disorder:
Other terms refer specifically to the organization of the person’s thought and range in severity from mild and fairly normal to entirely incomprehensible.
While thought disorder can be present in many psychiatric illnesses, severe thought disorder is most characteristic of schizophrenia.
The popular understanding of psychiatric terminology is often quite different from the technical meaning of the terms. The term “split personality” is is often confused with schizophrenia. Split personality more accurately refers to dissociative identity disorder (DID), formerly known as multiple personality disorder. While schizophrenia is a diagnosis of psychotic symptoms, DID is classified under the category of dissociative disorders. DID generally develops in childhood as a means of coping with extreme traumatic experiences, such as ongoing sexual or physical abuse. People manage the overwhelming emotions occasioned by the trauma by splitting their conscious experience into multiple identities. There may be the cute little girl, the responsible young man, and the rebellious teenager. Outside of their sense of their own identities, however, people with DID are not typically psychotic. In contrast, people with schizophrenia generally have a consistent sense of their own identity, but have ongoing struggles with psychosis.
At this point in time, schizophrenia is not curable. It is a lifelong disorder. However, it is definitely treatable. Profound advances in the medication of schizophrenia allow us to greatly reduce positive symptoms, such as delusions, hallucinations, and disorganized behavior. Unfortunately, we have fewer tools to treat the negative symptoms. The severity of the illness will vary from individual to individual, however, and some people respond better to treatment than others. Many people with schizophrenia can live in the community, enjoy social relationships, and even perform volunteer or part-time work. The vast majority of people with schizophrenia will need to take psychiatric medication indefinitely, however, to control psychotic symptoms and remain as functional as possible.
Listed below are quotes taken from writings from individuals suffering from mental illness. Each quote illustrates a specific form of thought disorder.
An example of looseness of association (characteristic of schizophrenia) from a woman suffering from this disorder:
A man’s writing style indicates mania in an example of flight of ideas:
People can suffer from psychosis without meeting criteria for schizophrenia. Certain medical illnesses and drugs can cause psychotic symptoms. In fact it can be quite difficult to tease apart the relative contributions of mental illness and drug abuse when a substance user has psychotic symptoms. People with mood disorders, such as major depressive disorder or bipolar disorder, can often present with psychotic symptoms. In addition, people under severe stress can sometimes experience psychotic symptoms. The diagnosis of brief psychotic disorder is characterized by quick, transient psychotic symptoms, after which the person returns to normal, generally without need for further medication.
Bipolar disorder used to be known as manic depression. It is classified as a mood disorder and is characterized by at least one manic episode and typically one or more major depressive episodes. A manic episode refers to a period of at least one week where the person exhibits elevated, euphoric, or irritable mood. The person also displays symptoms of increased activity, with much higher levels of energy, initiative, and impulsivity than normal.
More specifically, three or more of the following symptoms must be present (or four if the mood is only irritable): inflated self-esteem or grandiosity; a decreased need for sleep; an increase in amount of talking or pressure to keep talking; flight of ideas or racing thoughts; distractibility; an increase in goal-directed activity; and an increase in risky, pleasurable behavior. People in manic episodes frequently engage in reckless and excessive spending, sexual activity, or substance abuse. They can also have psychotic symptoms during manic episodes, but the symptoms tend to be mood-congruent (consistent with their elevated, expansive mood). For example, they may have grandiose delusions that they are going to Washington, D.C., to run the State Department. People with bipolar disorder tend to have a higher baseline than people with schizophrenia. Many people are completely symptom-free when not in the middle of an episode and can live entirely normal lives. However, even people who are symptom-free at baseline will need to take medication to maintain their mental health.
Vincent van Gogh (1853-1890) was a Dutch-born painter who is now considered one of the greatest artists of the nineteenth century. Little known in his own day, his work currently sells for millions of dollars. Van Gogh suffered from agonizing bouts of mental illness during which he repeatedly tried to kill himself. He eventually succeeded in 1890 at the age of 37. According to all reports, when he was not in the throes of a psychotic episode, he was calm, cooperative and completely focused on his painting.
Over the intervening century, many people have theorized about the nature of the mental illness that eventually killed him. While we can never be fully confident of any diagnosis made in the absence of the actual patient, van Gogh left a treasure trove of letters, mainly written to or by his devoted brother, Theo. From these letters, we can identify several major depressive episodes with psychotic features.
However, the psychiatrist Dietrich Blumer noted in a 2002 article that van Gogh also wrote of periods of excitement, increased energy, and excessive religious zeal. Although such symptoms might suggest manic episodes, Blumer concluded that van Gogh suffered from temporal lobe epilepsy, greatly exacerbated by his intake of absinthe, a popular but highly alcoholic beverage. It is also possible that he suffered from both illnesses: epilepsy and bipolar disorder. Tragically, his sister also suffered from mental illness (possibly schizophrenia) and was eventually confined to an asylum.
It is well known that the nineteenth century artist Vincent van Gogh suffered from mental illness. The exact nature of his suffering is still a matter of some debate (iStock).
Unlike mania, depression is something many people experience at some point in their life. Therefore the term depression covers a very wide range of experiences. At the most mild end of the spectrum are transient feelings of sadness. Longer periods of sadness following losses or other upsetting events also fall within the normal range of human experience. When feelings of sadness become the constant backdrop of a person’s mood, we are moving into depression.
While feelings of depression following difficult life experiences are still very common, severe depression is markedly different from these milder and more transient types of depression. DSM-IV refers to the most severe form of depression as a major depressive episode. To meet criteria for a major depressive episode, the individual has to exhibit at least five of the following symptoms over a two-week period and the symptoms have to represent a change from the person’s previous state. These symptoms include: consistently depressed mood, diminished interest in activities, significant weight gain or loss (not due to dieting), increase or decrease in sleep (insomnia or hypersomnia), physical restlessness or slowing down (psychomotor agitation or retardation), loss of energy, feelings of worthlessness and guilt, and thoughts of death or suicide. When someone has one or more of these episodes, they are diagnosed with major depressive disorder—presuming the episodes cannot be attributed to another mental disorder such as bipolar disorder or a substance-induced depression.
It has been frequently noted that creative people seem to have a disproportionate rate of mental illness. Studies have since borne this out, particularly among writers. Mood disorders may be the most common form of mental disorder among writers, who have an elevated rate of both depression and bipolar disorder. Consequently, there is a disproportionately higher rate of suicide in these artists. For example, the novelists Ernest Hemingway and Virginia Woolf both committed suicide, as did the poets Anne Sexton and Sylvia Plath. It is not clear why creativity and mood disorders are linked to each other, although researchers have speculated that the intense emotionality of a mood disorder heightens the sensitivity of creative people. Additionally, people with bipolar disorder can be extremely productive and creative when in a hypomanic state. Hypomania is a milder form of mania, when the elevation of mood and the increase in energy and self-confidence have not yet led to functional impairment.
Obsessive-compulsive disorder (OCD) is classified under anxiety disorders. OCD is characterized by obsessions that are repetitive, senseless, and intrusive thoughts that generally increase anxiety, and/or compulsions that are repetitive, senseless behaviors that often serve to reduce the anxiety caused by the obsession. Common obsessions include an unrealistic and excessive fear of danger, of contamination, or of committing hurtful or morally unacceptable actions. Common compulsions include repetitive cleaning, checking, ordering, arranging, and hoarding behaviors.
Although these symptoms can become debilitating—truly taking over a person’s life—an individual with OCD always retains some degree of insight into the pathology of their behavior. This differentiates OCD from a delusion, in which the person is convinced of the truth of his or her belief. In a mild case of OCD, a person may need to perform a specific routine when turning off the computer at work every evening, perhaps taking fifteen minutes more than necessary to complete the task. In an extreme case of OCD, someone can take nine hours to finish a shower, washing each body part multiple times in ritualized ways.
Autism is a disorder first diagnosed in childhood and is included in the category of pervasive developmental disorders. Autism is categorized by deficits or abnormal behavior in three areas: social interaction, communication, and range of interests. Autistic children show avoidance of eye contact and of social interaction in general. They do not develop normal peer relationships and they do not show typical desire to share toys or engage in social play. Their communication skills are also abnormal, with delayed language development, improper use of personal pronouns and stereotyped, or repetitive use of language (“Your parents is coming! Your parents is coming!”). Finally, they show a restricted range of interests, with intense and obsessive focus on particular objects or topics. For example, a person with autism can develop an obsessive interest in trains and memorize the entire schedule of a given transit system. Additionally, there is a rigid adherence to routine and marked distress when the routine is violated. Some of these symptoms relate to another characteristic, one that is well researched but not yet captured in the DSM system.
People with autism frequently suffer from a deficit in theory of mind. This refers to the ability to understand another person’s subjective experience and is a necessary first step in empathy. Because of their impaired theory of mind, people with autism can have a very difficult time making sense of social interaction and often find social situations extremely stressful.
In recent years there has been increasing interest in the diagnosis of Asperger’s syndrome. It is not clear whether Asperger’s syndrome is simply a milder form of autism, or whether it is a truly separate syndrome. As with autism, Asperger’s syndrome is characterized by deficits in social interaction and a restricted range of interests evident from early childhood. However, there is no delay in language development and verbal skills are generally higher in Asperger’s than in autism. Additionally, there is usually no evidence of cognitive delay in Asperger’s, whereas mental retardation is fairly common in autism. People with relatively mild forms of Asperger’s can be very successful, generally in fields that focus on logical analysis, factual information, or manipulation of objects (for example, computer programming, engineering, or mathematics), but they may still have difficulty negotiating social situations.
According to a 2001 article in Wired magazine by Steve Silberman, there has been a significant increase in autism diagnoses nationwide. It is unclear how much this is due to better diagnoses or actual changes in the incidence of the disorder, possibly caused by environmental toxins. In a 2002 report to the California legislature, the M.I.N.D. Institute referenced a 273 percent increase in autism diagnoses in California from 1987 to 1998, which they suggest was not due to changes in diagnostic practices. Moreover, Silberman reported an even larger spike in autism and Asperger’s diagnoses in Silicon Valley, as well as other technology-heavy areas.
One explanation for this involves the concept of assortative mating, first proposed by the psychologist Simon Baron-Cohen. People with Asperger’s or autism traits (otherwise known as autistic spectrum traits) are known to be talented in the kind of logical and analytic thinking integral to computer science. Likewise, an elevated rate of autistic spectrum disorders has been found among the relatives of professionals or students in physics, mathematics, and engineering. Consequently, the huge expansion of the technology industry in the 1980s set the stage for much larger concentrations of people with autistic spectrum features than had existed previously. In this way, men and women with similar genes could come together, marry, and have children. Such parents passed their combined genes onto the next generation, increasing the concentration of autism spectrum genes.
The causes of mental illness are complex and it is not possible to point to one single cause. However, we are aware of many factors that contribute to mental illness; such contributors are known as risk factors. We do know that many forms of mental illness have a genetic component to them and specific genes related to the production of neurotransmitters such as serotonin and dopamine have been associated with several forms of mental illness. We also know that early childhood environment plays an important role; stable, loving environments protect against mental illness and chaotic, neglectful, and traumatic environments raise the risk of it. We also know that high levels of stress in both childhood and adulthood contribute to mental illness.
Some reports show a large increase in autism diagnoses in California’s Silicon Valley starting in the 1980s (Stock).
Particular disorders, such as post-traumatic stress disorder and acute stress disorder, are specifically linked to extremely stressful events. We also know that the physical environment plays a role in mental health and mental illness. Environmental toxins, substances of abuse, and even exposure to substances of abuse in utero can all contribute to the development of mental illness.
The mental health field has gone through wide pendulum swings with regard to the nature/nurture debate. In middle of the twentieth century, there was an excessive emphasis on environmental causes. Phrases such as the “schizophrenigenic mother” and the “refrigerator mother” put unnecessary blame on mothers for disorders such as schizophrenia and autism. Starting in the 1980s, the pendulum swung back toward a biological and genetic approach, in some cases unnecessarily diminishing the impact of the environment. By the beginning of the twenty-first century, however, an integrative approach to the nature/nurture debate has developed. Now it is widely understood that all psychological processes involve the interaction between genetics and environment. Our genetics affect our environment by influencing how we interact with the environment, which in turn shapes how the world responds to us. Moreover, research has shown that the reverse is also true; the environment affects our genes. More specifically, different environmental conditions (for example degree of maternal touch) can affect whether specific genes are turned on or off.
Listed below are eight famous people, all highly accomplished, who have suffered from mental illness. Many organizations serving individuals with psychiatric conditions compile similar lists as a way to reduce the stigma associated with mental illness. The National Alliance on Mental Illness (NAMI), which is an advocacy group for people with mental illness, publishes one such list on its website. Note that some of these diagnoses are controversial as many were made after the person in question died.
Many famous people throughout history have suffered from a mental illness or disability. For instance, President Abraham Lincoln endured major depressive disorder (iStock).
As far as we know, the major mental illnesses are not single-gene disorders. Unlike certain medical and neurological disorders (for example, Huntington’s disease), psychiatric disorders cannot be attributed to any one gene. While multiple genes have been linked to psychiatric disorders (for example, neureulin-1, catechol O-methyl-transferase, and dysbindin genes for schizophrenia), these genes are best understood as risk factors for the disease rather than as definite causes. Not all people with the gene will have the disorder and not all people with the disorder will have the gene. 8 Therefore, geneticists now believe that most psychiatric disorders are related to a whole series of genes, only some of which are currently known. Any one of these vulnerability genes raises the risk of the disorder, but not by a large amount. The greater the number of vulnerability genes that any given person has, the greater the risk of developing the disorder.
Different psychiatric disorders vary as to the relative importance of genetics or environment. The most severe mental illnesses, such as schizophrenia, bipolar disorder, autism, and obsessive compulsive disorder, are seen to have a strong genetic component with environment playing a largely supportive role. Disorders such as post-traumatic stress disorder, dissociative disorders, and various personality disorders have a much stronger environmental component, with genetics playing a more supportive role.
The syndromes discussed in the preceding section are known as axis I disorders. This refers to specific patterns of dysfunction in thought, emotions, and behavior. But not all psychopathology fits into an axis I diagnosis. Sometimes the problem is more widespread and not just restricted to a specific pattern of behavior. In effect, the problem relates to the person’s entire personality. While psychologists and other mental health professionals agree that psychopathology can reflect an ingrained problem with personality, there is less consensus on how to understand personality pathology. In fact, the definition of personality per se is not entirely settled.
While there are multiple approaches to the study of personality, we can provide a general definition by stating that an individual’s personality involves stable patterns of perceiving and interacting with the environment, including the person’s cognitive, emotional, and behavioral responses. This includes the individual’s self-perception, as well as their typical mode of relating to other people. Personality is largely established by late adolescence or early adulthood. It is conservative and difficult to change. Nonetheless, personality is not entirely fixed and there is possibility for change throughout adulthood.
In general personality pathology can be defined as any enduring pattern of personality that causes distress or dysfunction and that falls outside the norms of the individual’s culture. It is possible to divide the large literature on personality pathology into three overall approaches, categorical, dimensional, and schema. The categorical approach suggests that different kinds of personality pathology can be classified into specific categories, as is found in the DSM. The dimensional approach suggests that people vary as to the strength of various personality traits, and that each individual will have a unique profile of high and low scores on measures of these traits. Perhaps the best known dimensional approach is the Five-Factor Model, as described by Paul Costa and Robert McCrae.
The schema approach is somewhat more complex and comes out of both psychoanalytic theory and cognitive psychotherapy. In this view, our personality is shaped by our expectations of ourselves and other people in relationships. This set of expectations, or schemas, operates largely out of consciousness and guides our thoughts, emotions, and behaviors in meaningful situations.
Personality pathology has both environmental and genetic causes. The schema approach addresses the environmental causes of personality pathology, considering how early relationships with parents and other key figures in childhood shape enduring personality traits. The psychiatrist Robert Cloninger suggested that personality is made up of both temperament and character. Temperament refers to biologically based personality traits that are determined by genetics. Character refers to the parts of personality that are most influenced by the environment. In this way, he integrated both genetic and environmental explanations of personality.
The schema approach is used here to refer to any theory that sees personality as derived from a set of expectations of self and others that guides cognitive, emotional, and behavioral responses in relevant situations. Depending on the theoretical orientation, such expectations might be termed schemas, representations, or internal working models. Schemas grow out of early childhood experiences and, by adulthood, they are difficult, but not impossible, to change. For example, if a child’s mother is loving, empathic, and emotionally stable, the child will learn that the world is safe, understandable, and benevolent. The child will learn to approach the people he or she encounters in an open and friendly way, which will in turn elicit similarly positive responses. Likewise, if the child is raised in a rejecting, hurtful, and neglectful environment, this will teach the child a suspicious and pessimistic view of the world. Such a negative outlook will guide the child’s behavior, thus eliciting negative and rejecting responses from others, further confirming the child’s pessimistic schemas.
This general model of personality pathology has received empirical support from a huge range of research and has been integral to the development of many types of psychotherapy. However, it does not lend itself well to diagnosis and so has had little impact so far on diagnostic schemes. Moreover, it only accounts for the learned aspects of personality, and not the inborn or biological aspects.
The general concept of schemas grew out of psychoanalytic theory. In the beginning of psychoanalysis, in the late nineteenth and early twentieth centuries, the focus was largely on the battles between drives and defenses, between sexual and aggressive instincts, and the need to inhibit them. With time, noted psychoanalysts such as Otto Rank, Melanie Klein, D.W. Winnicott, Harry Stack Sullivan, and W.R.D. Fairbarn expanded that rather narrow focus to include their patients’ characteristic ways of engaging with the world around them. To some degree, all of these pioneering psychoanalysts linked the personality traits of their adult patients to their early childhood relationships with parents. This approach later became known as object relations, and included an assumption that early childhood relationships impacted adult personality by etching a particular picture of the world into the patient’s mind.
One of the controversies that has persisted throughout the history of psychology has to do with the extent to which personality is learned or inborn. Although there is considerable evidence supporting the impact of early childhood relationships on adult personality, there is also solid evidence that many personality traits—such as shyness, extraversion, sensation-seeking, and even impulse control—are genetically determined. In the early 1990s, Robert Cloninger proposed that personality reflected the combination of both temperament and character. He defined temperament as inborn, genetically transmitted traits that influence the way we process information. He proposed three specific traits of temperament: harm avoidance, novelty seeking, and reward dependence. He later added persistence, which refers to the tendency to persevere toward a goal despite setbacks.
Both harm avoidance, which involves the tendency to avoid risk, and novelty seeking, which involves the tendency to seek out stimulation even if it involves risk, have received considerable support in the literature and do seem to have a genetic component. Harm avoidance may be mediated by the neurotransmitter serotonin, while novelty seeking has been associated with both dopamine and norepinephrine.
Cloninger’s concept of character is very similar to the schema approach described above. He believed character to involve learned patterns of interacting with the environment, reflecting concepts of the world that were in large part formed in early childhood. Cloninger proposed three character traits: self-directedness, (initiative, responsibility, and personal agency); cooperativeness (helpfulness, pro-social orientation); and self-transcendance (spiritually-inclined, able to rise above self-absorption). His Temperament and Character Inventory (TCI) is a self-report questionnaire with seven scales measuring the four temperament and three character dimensions.
Cloninger’s distinction between temperament and character suggests that some personality traits are learned while others are inborn. This leads to the question of which personality traits fall into which category. Genetic studies suggest that many genes code for either behavioral activation or inhibition. In other words, many of the genes that influence personality seem to code for either sensation seeking, impulsive, and extraverted traits, or anxious, harm avoidant, and introverted traits. Psychiatric disorders such as alcohol abuse, borderline and antisocial personality disorder, and attention deficit disorder are associated with behavioral activation genes, while other disorders or traits such as depression, anxiety, and introversion are associated with behavioral inhibition genes.
While personality traits related to behavioral activation or inhibition appear to have a strong genetic influence, traits related to trust, morality, empathy, and capacity for intimacy appear to be more strongly influenced by the environment.
The psychiatrist Kenneth Kendler and his colleagues have conducted a series of twin studies to investigate the heritability (or genetic basis) of various personality traits and psychiatric syndromes. Twin studies work by comparing monozygotic (identical) twins, who share 100 percent of their genes, with dizygotic (fraternal) twins, who share only half of their genes. If more monozygotic than dizygotic twins have the same diagnosis, we can assume that the disorder has a genetic component. By using very complex statistical analyses on a sample of 2,794 Norwegian twins, Kendler and colleagues determined that the ten DSM-IV personality disorder diagnoses were about 25 percent attributable to genetics and about 75 percent due to non-genetic causes, such as the environment. Moreover, the authors performed factor analysis to identify common factors that might influence risk for more than one diagnosis.
Factor analysis works by identifying groups of disorders where twins are similarly alike or different; if twins are alike on personality disorder X, are they also alike on personality disorder Y? In this way, the authors identify factors or groupings of disorders that may share either genetic or environmental influence. Three genetic factors were identified in this study: an overall negative emotionality factor, an impulsivity /poor behavioral control factor, and an inhibition/avoidance factor. Interestingly, the environmental contributions did not seem to group together. In other words, the environmental risks appeared to be unique for each personality disorder.
Genes account for some of our personality traits, but environment is also important (iStock).
We diagnose personality pathology by grouping pathological personality traits into categories. The DSM approach to personality disorders is the official diagnostic system of the mental health field. The DSM system defines a personality disorder as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time and leads to distress or impairment.” DSM-IV-TR lists ten personality disorders grouped into Clusters A, B, and C. The eleventh diagnosis, Personality Disorder Not Otherwise Specified, is intended as a catch basin diagnosis for people who do not fit the other ten diagnoses.
Two additional personality diagnoses, depressive and passive-aggressive (negativis-tic), are listed in the appendix as awaiting further study. Cluster A disorders, which include paranoid, schizoid, and schizotypal personality disorders, are characterized by odd or eccentric traits. Cluster B disorders, including histrionic, borderline, narcissistic, and antisocial personality disorders, are seen as impulsive and emotionally erratic. Cluster C disorders include avoidant, dependent, and obsessive-compulsive personality disorders and are associated with high anxiety.
The DSM-IV diagnoses have shown high inter-rater reliability and internal consistency. In other words, different raters reliably diagnose people in similar ways and the different criteria of each diagnosis strongly correlate with one another. Moreover, they have been shown to predict to many important clinical features (e.g., suicidality, drug abuse, interpersonal problems, criminal activity). In other words, the DSM personality diagnoses are clinically relevant. Nonetheless, there are problems with this system. For one, the categorical approach does not account for severity. It does not say whether you are mildly or severely borderline, which may matter more than the discrete diagnoses. Secondly, the diagnoses are not mutually exclusive, and people may meet criteria for more than one diagnosis. Thirdly, the diagnoses are far from exhaustive and many types of personality pathology are not easily diagnosed in DSM-IV.
While the categorical approach (as seen in DSM) tries to establish a comprehensive list of personality types, a dimensional approach looks at key personality traits that vary from person to person. The Five Factor Model of personality has received considerable attention in the research literature. As presented by Paul Costa and Robert McCrae, the Five Factors include openness to experience, conscientiousness, extra-version, agreeableness, and neuroticism (OCEAN). These traits were first identified from factor analytic studies, in which rating scales composed of large lists of emotional words were analyzed to see which words grouped together.
The psychological traits grouped into five different categories. The labels for these categories have varied slightly across different studies, but the OCEAN labels are now widely accepted. Even though there is good evidence that these traits are associated with clinically relevant outcomes, are stable over time, and have some genetic component to them, it is important to note that they are derived from statistical analyses of word lists and not from clinical observations. Therefore, their usefulness in clinical settings may be limited. The Five Factor Model has also been criticized because it is does not provide an actual theory of personality, only a set of empirical findings.
Borderline Personality Disorder, in its full form, is one of the most severe of the DSM personality disorders. Classified as a Cluster B personality disorder, it is characterized by highly erratic and tempestuous behavior. To meet criteria for the DSM-IV diagnosis, the person must meet at least five of the following criteria: frantic efforts to avoid real or imagined abandonment; a pattern of very intense and unstable interpersonal relationships with swings between idealizing and devaluing others; identity disturbance reflected in a strikingly unstable sense of self; marked impulsivity in at least two areas (e.g., sex, substance abuse, binge eating); recurrent suicidal behavior, gestures or threats, or self-mutilating behavior (such as cutting or burning the self without intent to die); chronic feelings of emptiness; poorly regulated anger with inappropriate anger outbursts; and transient and stress-induced paranoid ideation or severe dissociative symptoms. Much research has linked Borderline Personality Disorder with a history of severe trauma, such as childhood sexual abuse, although not all people with this disorder report such histories.
In effect, narcissism refers to a very fragile and unstable sense of self. In order to compensate for their fragile self-esteem, narcissistic people become preoccupied with their self-image and are intensely sensitive to perceived shame or humiliation. Typical narcissists have a grandiose sense of self, with an inflated sense of self-importance and an elevated need for attention, status, and recognition. In order to meet criteria for the DSM-IV diagnosis of Narcissistic Personality Disorder, an individual must meet five of the following nine criteria: has a grandiose sense of self-importance; has a preoccupation with fantasies of unlimited success; carries a belief that he or she is special and only can be understood by other special, high status individuals or groups; need for excessive admiration; displays a sense of entitlement—the assumption that others should accommodate to the person’s needs and desires; is interpersonally exploitative; lacks empathy; is often envious of others or believes others are envious of him or her; and exhibits arrogant, haughty attitudes or behaviors.
Some concern with self-esteem, social status, and accomplishment is a universal part of human psychology. Moreover, there are few people who are entirely free of egotistical or insecure behavior. Thus we can see Narcissistic Personality Disorder as an extreme point on a range of behavior that includes normal human tendencies. Moreover, there is a fair amount of research that shows that some degree of narcissism can be adaptive. In a 1984 study by Robert Emmons, several narcissistic traits were correlated with measures of adaptive personality traits, such as self-confidence, extraversion, initiative, and ambition. Moreover, in a 2008 study by Eric Russ and colleagues, the authors identified three subtypes of narcissistic personality disorder, which they labeled grandiose/malignant, fragile, and high-functioning/exhibitionistic. The third subtype showed significantly less psychopathology and much higher adaptive functioning than the other two groups. Thus, some degree of narcissism may be adaptive with regard to ambition, initiative, and self-confidence. People with severe narcissistic traits, however, have significant interpersonal, emotional, and even occupational difficulties.
People with antisocial personality disorder (ASPD) have a severe deficit in morality. They are characterized by callous and exploitive behavior and by a lack of empathy or remorse. In keeping with the often impulsive and reckless behavior associated with this disorder, ASPD is classified as a Cluster B personality disorder. A related term for this type of personality is psychopathy. Unsurprisingly, people with ASPD are particularly common in prison populations. According to DSM-IV, a person with this disorder demonstrates a pervasive pattern of disregard for the rights of others as evidenced by at least three of the following criteria: repeatedly engaging in illegal behavior; frequently lying, using aliases, or conning others for personal profit; demonstrating impulsivity and lack of future planning; exhibiting irritability and aggressiveness; showing reckless disregard for the safety of self and others; being consistently irresponsible, with repeated failures to sustain employment or fulfill financial obligations; lacking remorse, as evident in indifference to, or rationalization of, hurting, mistreating, or stealing from others. This definition has been criticized, however, for being too focused on behavior instead of personality traits and also for requiring evidence of conduct disorder (a childhood variant of ASPD) before the age of fifteen.
Although some degree of narcissism can be adaptive, high levels of narcissism can cause significant problems. Narcissistic traits appear to be highly susceptible to the environment, to the kind of feedback or values that people pick up from their social milieu. Thus, there can be a cultural component to narcissistic traits.
In a 2008 study, the psychologist Jean Twenge and colleagues compared scores on the Narcissistic Personality Inventory (NPI) from 16,475 college students who participated in studies conducted between 1979 and 2006. Using the technique of meta-analysis, in which data from multiple studies are pooled together, the authors found a significant increase in NPI scores over the last several decades. Using norms from the early 1980s, in 2006 the average student’s score had increased from the 50th to the 65th percentile. Moreover, the mean score among college students in 2006 was essentially equivalent to that of a sample of celebrities reported in a 2006 study by Mark Young and Drew Pinsky. Interestingly, the change in NPI scores may be largely due to an increase in narcissism among women. While men have traditionally scored higher than women on the NPI, by 2006 women were closing the gap.
Schizotypal personality disorder is quite different from the three personality disorders listed above. Classified as a Cluster A disorder, people with schizotypal personality disorder tend to be inhibited and socially withdrawn, which is in sharp contrast to people with Cluster B disorders. In general, schizotypal personality disorder is characterized by discomfort with social situations and odd, eccentric behavior.
The DSM-IV diagnosis requires five of the following nine criteria: ideas (but not delusions) of reference; odd beliefs or magical thinking (e.g., suspiciousness, telepathy); unusual bodily experiences; odd thinking and speech (e.g., vague or overelabo-rate); suspiciousness or paranoid ideation; inappropriate or constricted affect (expression of emotion); odd, eccentric or peculiar behavior or appearance; lack of close friends other than close relatives; and excessive social anxiety.
When people have ideas of reference, they believe that events in the environment pertain to them, although there is actually no connection. For example, someone might walk into a room and think everyone in the room is talking about him or her. People with schizotypal personality disorder have an elevated incidence of schizophrenia in their families, and therefore probably share some genetic loading with schizophrenia.
By definition, a psychiatric disorder in DSM-IV needs to cause distress or dysfunction and must be outside the norms of one’s culture. Nonetheless, there are circumstances when people may meet criteria for a DSM-IV personality disorder, but they are shielded from distress or dysfunction from a protective environment. For example, people who are very powerful, wealthy, or famous may be protected from the negative social consequences of behavior that would not be tolerated in less privileged individuals. In fact the newspapers are full of reports of outrageous behavior on the part of celebrities and politicians. If these people continue to succeed in their lives in spite of such behavior, does their behavior still meet criteria for a personality disorder? Such a question is not easily answered, but we can assume that those individuals who truly do suffer from personality pathology will not be able to modify their behavior when it does start to cause negative consequences. Healthier people will be able to adapt as needed.
The APA is proposing fairly radical changes to the diagnosis of personality disorders. For one, they want to collapse the diagnosis of personality disorders into axis I along with all other psychiatric and even medical disorders. They also remove most of the actual diagnostic categories, leaving only five personality types, specifically antisocial/psychopathic, avoidant, borderline, obsessive-compulsive, and schizotypal. Each patient will also be evaluated in terms of the severity of his or her impairment in self and interpersonal functioning. This will determine the maturity and stability of their understanding of themselves and other people. Finally, patients will be rated on six broad personality trait domains, including negative emotionality, introversion, antagonism, disinhibition, compulsiveness, and schizotypy. Each broad domain has a series of trait facets. For example, under disinhibition, there are the trait facets of impulsivity, distractibility, and recklessness. While this system takes into account much of clinical theory and research, it is also very complex—which might make it hard to apply in real world settings.
In general, the term addiction refers to a state of obsessive desire or craving for something or some activity, beyond the point of normal use and to the extent of causing harm. As early as 1964, the World Health Organization discouraged the use of the word “addiction” in a mental health context, stating that the word had become too colloquial and was not sufficiently precise. Consequently, the major diagnostic systems, DSM and ICD, diagnose substance abuse and dependence rather than addiction. Nonetheless, addiction remains a widely used term, within the field as well as the popular culture. While use of the word “addiction” generally refers to a chemical substance, such as heroin or cocaine, people also speak of behavioral addictions, such as compulsive gambling or addiction to sex. In fact, a new category of behavioral addictions is being considered for DSM-V.
One of the key assumptions of DSM-IV is that psychopathology has to cause distress or dysfunction. In other words it has to be self-defeating. But what about behavior that causes gross distress and dysfunction to others? If the individual benefits by his or her behavior but other people suffer, does that count as psy-chopathology? This quandary shows how difficult it can be at times to determine what does and does not constitute psy-chopathology. Additionally, it illustrates the difficulty in distinguishing between psychopathology and extreme immorality.
Joseph Stalin (1879-1953) is a case in point. Stalin was appointed general secretary of the Communist party in 1922 and gained complete control over the Soviet Union when Vladimir Lenin died in 1924. He retained absolute power until his death in 1953. Within five years of Lenin’s death, he was responsible for the execution of several million people. Stalin brooked no opposition to his regime. Anyone suspected of opposing him or of even having the potential to oppose him might be deported to Siberia, tortured, and/or executed. He has also been accused of causing or at least greatly exacerbating famines that killed millions of people.
Historians now believe that Stalin was responsible for the death of—at minimum—20 million people. Would Stalin meet DSM-IV criteria for Antisocial Personality Disorder? It appears that Stalin met at least five DSM-IV criteria for Antisocial Personality Disorder. He repeatedly broke the law before he was in power; and after attaining power he simply created the law to suit his needs. He lied and conned others to maintain his position of absolute power. As a mass murderer he was clearly irritable and aggressive. He showed reckless disregard for the safety of others; he showed lack of remorse for the mistreatment of others.
Stalin also demonstrated aggressive and illegal behavior in his youth, which may meet criteria for conduct disorder before the age of 15. However, he was a brilliant and immensely successful politician. Despite having murdered tens of millions of people, he was able to hold onto power until his death at age 74. Thus, his genocidal behavior may not have caused distress or dysfunction to himself, although it certainly did to others.
Soviet Union dictator Joseph Stalin committed horrible crimes during his rule. Would his behavior meet criteria for antisocial personality disorder? (iStock)
What do recent statistics say about drug use in the United States?
The data below come from the 2007 National Survey on Drug Use and Health, conducted by SAMHSA, a division of the U.S. Department of Health and Human Services. Data are based on interviews with 67,870 subjects aged 12 or older. Two main findings stand out. For one, recreational use of substances is extremely widespread, affecting almost half the U.S. population. Nonetheless, use of highly addictive substances, such as heroin and methamphetamine, is far less common than use of less addictive substances, such as marijuana and pain relievers. Secondly, there is a large difference between lifetime use and recent use, suggesting that recreational drug use is either infrequent or temporary for most people.
Almost half the U.S. population uses an illicit substance at some point in their life. If we include alcohol, the proportion of people who engage in recreational substance use is far higher. Many people can use psychoactive substances without harm. Addiction, however, is an entirely different animal. Severe addiction, particularly to the most addictive substances such as heroin, cocaine, or methamphetamine, lays waste to peoples’ lives. Careers, physical health, families, and even whole communities can be destroyed by drug addiction. Furthermore, approximately 10 percent of people with substance dependence commit suicide, generally in the midst of a substance-induced depression.
The term addiction is somewhat of an umbrella term referring to any kind of compulsive use or excessive dependence on a substance or activity. In the DSM-IV, substance abuse is characterized by excessive use which continues despite significant negative consequences. More specifically, substance abuse requires recurrent use of the substance, resulting in failure to meet major role obligations; exposure to situations that are physically hazardous (e.g., drunk driving); recurrent legal problems; and continued use despite repeated negative social consequences.
Substance dependence is a more severe disorder. In addition to causing social, occupational, and/or financial problems, substance dependence also requires a physiological addiction to the drug. The two most important features involve tolerance and withdrawal. Additionally, there can be an increase in the amount of substance used over time, a persistent desire to cut down, or unsuccessful efforts to do so, considerable amounts of time spent in pursuit of the substance, sacrifice of important life activities because of substance use, and/or the continued use of the substance despite clear physiological or psychological damage from it.
People with substance abuse continue to use drugs despite negative consequences, while people with substance dependence also experience drug tolerance and withdrawal (Stock).
When people develop tolerance, they have become desensitized to the drug and require more and more of the substance to achieve the same effect. Different drugs vary as to how likely they are to cause tolerance. For example, tolerance for amphetamine and opiates is generally stronger than that for alcohol. In fact, people who abuse opiates, such as heroin or morphine, can develop a tolerance for the analgesic (pain-killing) effects that can last for years after the end of the substance abuse. Consequently, people with a history of opiate abuse or dependence often require much more opiates to treat pain than the average person.
Withdrawal refers to physiological symptoms that occur when the substance is discontinued. Because the brain has become adapted to the chemical, removal of the chemical sends the brain into a disregulated state. Withdrawal can be extremely painful as well as dangerous. Depending on the substance, withdrawal symptoms can include changes in heart rate, vomiting, confusion, pain, and even seizures. The effects of withdrawal are generally opposite to the effects of intoxication. For example, people become energetic and euphoric during cocaine intoxication, but experience fatigue and depression during cocaine withdrawal.
Few people suffering from substance dependence would say that addictions are pleasurable. Many addicts will say that the use of the drug was initially pleasurable, but that as the addiction set in, the pleasure was counterbalanced by craving. At this point, they used the drug to reduce the discomfort of craving or withdrawal as much as to bring pleasure.
A growing body of research points to the central role of the dopamine system in chemical, and even behavioral, addictions. Drugs such as cocaine, amphetamine, and nicotine have a direct effect on the dopamine system. Other drugs, such as heroin and marijuana may have an indirect effect on this system. The dopamine neurons originate deep in a region of the midbrain called the ventral tegmental area. These dopamine neurons course through the middle of the brain, connecting with a small structure in the forebrain known as the nucleus accumbens.
This system is known as the mesolimbic dopamine tract and is a central part of the dopamine reward system, which seems to be involved in the activation of the organism to pursue rewarding stimuli. In other words, this system is central to an animal’s experience of desire and motivation. Activation of the reward system stimulates pleasurable feelings of euphoria, energy, and enthusiasm. Many drugs of abuse directly stimulate this chemical system, providing an immediate and intensely pleasurable experience. In effect, they mimic the brain’s natural chemicals.
Unfortunately, nature allows no free lunch. Over time, activating the dopamine reward system by outside chemicals changes the structure of the brain, reducing its ability to regulate the dopamine system.
Drugs of abuse act on the brain’s neurotransmitters, the chemical messengers that coordinate interactions between neurons (brain cells). Because of the direct effect of substances of abuse on neurotransmitters, there is often a dramatic change in neurotransmitter function. For example, in response to foreign chemicals that mimic the activity of neurotransmitters, the neurons may decrease production of their own neurotransmitters. Receptor sites may die off. This change of the actual structure of the neurons contributes to the addictive process. When the brain makes less neurotransmitter or is less able to process it, craving sets in. Drug tolerance, the need for more and more of the same drug to achieve the same psychological effect, is also related to the changes in the neuron’s structure. Moreover, changes to the neurons can lead to a reduction in brain volume, in other words, brain shrinkage. This is associated with cognitive, emotional, and physiological deterioration.
There are at least two ways that drugs can vary in their addictive potential. One is the drug’s half-life, which refers to the time it takes for the drug to pass through the body. Drugs with a short half-life often have very quick effects, but also have sharp withdrawal reactions, which can contribute to addiction. Drugs with longer half-lives have a less quick and intense high and cause less abrupt withdrawal syndromes. However, their withdrawal syndromes can last longer as it takes more time for the drug to fully clear the system. The intensity of the dopamine spike that a drug causes also affects its addiction potential. Although drugs such as cocaine, nicotine, and amphetamine all cause an increase in dopamine activity, they vary tremendously in terms of the strength of the spikes they cause.
Methamphetamine (also known as meth, crystal meth, ice, and crank) is a fairly new drug of abuse that has swept out from the West Coast, across the center of the United States, and is now moving into the East Coast. Although its popularity in the United States is fairly recent, it was first developed in the nineteenth century and used by the Japanese and the Germans during World War II. It is a devastatingly addictive drug, which can make short shrift of substance abusers in relatively little time.
One of the reasons it is so powerfully addictive is that it causes a dopamine spike much stronger than cocaine and vastly larger than nicotine. This spike is ten to 12 times higher than baseline levels and five to ten times higher than the spikes caused by natural rewards such as food or sex. Moreover, it lasts for hours. Tragically, this greatly enhanced release of dopamine damages the dopamine neurons in a process called neurotoxicity. Changes in the dopamine neurons takes place within days of use, both within humans and animals, and the effects can last for months or years.
The table below shows the percentages of the U.S. population that met criteria for substance abuse or dependence for each of the drugs listed during 2007. Consider that each percent of the population (ages 12 and up) is equal to almost 2.5 million people. In other words, in 2007 more than 22 million people had some kind of substance abuse or dependence. These data come from the 2007 National Survey on Drug Use and Health for subjects aged 12 or older conducted by SAMHSA, of the U.S. Department of Health and Human Services. Substance abuse and dependence are based on DSM-IV criteria.
2007 Statistics on U.S. Drug Abuse or Dependence
| Drug | Abuse or Dependence | Dependence |
| Any Type | 9.0 | 4.7 |
| Alcohol | 7.5 | 3.4 |
| Marijuana/Hashish | 1.6 | 1.0 |
| Cocaine | 0.6 | 0.5 |
| Heroine | 0.1 | 0.1 |
| Hallucinogens | 0.1 | 0.0* |
| (e.g., LSD, PCP, Ecstasy) | ||
| Inhalants | 0.1 | 0.0* |
| Non-Medical use | 0.9 | 0.6 |
| of Therapeutics | ||
| Pain Relievers | 0.7 | 0.5 |
| Tranquilizers | 0.2 | 0.1 |
| Sedatives | 0.1 | 0.0* |
| Stimulants | 0.2 | 0.1 |
*Incidence too low to report.
A fair amount of research in the past few decades has pointed to a genetic component to addiction. Specific genes related to the neurotransmitter serotonin have been linked to early-onset alcoholism, though it is unclear if this is related to alcoholism per se, or to poor behavioral control. In addition, Kenneth Kendler and colleagues have performed twin studies looking at the relative contribution of genes and environment to the abuse of, or dependence on, six different substances: cannabis (marijuana), cocaine, hallucinogens, sedatives, stimulants, and opiates. From their comparison of 1,196 male-male twin pairs, the authors concluded that on average, each form of drug addiction was about 55 percent attributable to genetics and 45 percent attributable to environment.
Drugs and crime are closely linked, partly because people often lose their jobs because of their addiction and turn to crime (iStock).
Moreover, there appeared to be a genetic vulnerability to developing drug addiction in general, but not to developing an addiction to any particular drug. Similarly, there was a general effect of environment, influencing the likelihood of any kind of drug abuse/dependence rather than abuse of a specific drug. Interestingly, opiate addiction seemed more heavily influenced by environment (78 percent) than genetics (23 percent). Perhaps opiates are less available than other drugs and, as a result, opiate abuse is heavily dependent on exposure to drugs in the environment.
There is considerable evidence of an association between trauma and neglect in childhood and addiction in adulthood. In other words, adults with addiction report a higher incidence of childhood trauma and neglect than adults without addiction. Both psychological and neurobiological research show that inadequate parenting and harmful childhood experiences can deeply interfere with the development of mature self-control, including the ability to regulate emotion and behavior. In these circumstances, drug use can be very attractive because it serves (at least at first) to reduce negative emotion and enhance positive emotion. In the absence of effective emotional regulation skills, any shortcut to positive emotion can be very appealing. Moreover, people with poor impulse control are less likely to monitor their drug use. As a result, recreational drug use is more likely to escalate into addiction.
The table below shows the incidence of substance abuse or dependence in 2007, both for illicit drugs and alcohol. As is clear in the chart, substance use disorders start in the early teens, peak at age 21, and then subside after that. The abrupt decline after age 21 is consistent with research suggesting many people conquer their substance problems without treatment. These data come from the 2007 National Survey on Drug Use and Health for subjects aged 12 or older, conducted by SAMHSA of the U.S. Department of Health and Human Services. Classification of substance abuse and dependence is based on DSM-IV diagnostic criteria.
For a number of different reasons, drug addiction does contribute to crime. For one, the addiction may destroy the person’s ability to hold a job, removing the means to pay for the drug. In this situation, drug addicts may turn to crime in order to obtain the money needed to pay for their drug. Common forms of criminal activity include robbery, drug dealing, and prostitution. Secondly, many drugs of abuse impair judgment and impulse control, which increases the likelihood of reckless and criminal acts. In fact, it has been estimated that 55 percent of car accidents and more than 50 percent of murders involve alcohol intoxication. Thirdly, most Western countries outlaw the most common drugs of abuse. Unfortunately, this fails to erase demand for the drugs (though many argue that it does decrease demand). Consequently, the market for illicit drugs goes underground and becomes the domain of criminals. Competition within the illicit drug trade has led to a tremendous amount of violence, dating back to the days of Al Capone in the 1920s.
Drug addiction is not a psychotic disorder. People are always aware of their drug use and of their choice to use. Thus, we cannot say addicted individuals have no choice and no control over their drug use. Nonetheless, it is important to realize that addiction changes the brain. In the most addictive drugs, the cravings are overwhelming and the ability to inhibit self-destructive behavior is very weak. This is because the parts of the brain that monitor behavior, employ social judgment, and inhibit harmful actions are significantly compromised at the same time that the reward system is on overdrive. Therefore, it is fair to say that addicted individuals have some control over their behavior but far, far less control than a non-addicted person.
The motivation to change is a major factor in addiction treatment. Some addicts have little to no motivation to change their behavior. Or their motivation may not be sustained. In 1994, James Prochaska, John Norcross, and Carlo DiClemente published their model of the stages of change, which describes six different stages that people go through when deciding to change addictive behaviors. This work has been widely integrated into addiction treatments.
The first stage is called pre-contemplation. At this point the individual does not believe he or she has a problem and is resistant to suggestions to change. There may be considerable denial about the extent of the problem.
The next stage is called contemplation. In this stage, the individual is aware there is a problem and is beginning to consider taking action to change. The third stage is known as preparation. The person is now taking steps in preparation of change. For example, he or she may start researching drug treatment options or talking to family and friends about the need to stop using the drug. Nonetheless, there is still ambivalence about giving up the substance.
The fourth stage is termed action. At this point, the person takes actual steps to stop the substance use. This may involve joining a twelve-step group, an outpatient treatment center, or even getting admitted for inpatient treatment. The person also recognizes the need to change a broad array of psychological and social patterns associated with the addiction.
In the fifth maintenance phase, the person has successfully stopped using the substance. Still, there is ongoing risk of relapse and the person needs to take care to prevent backsliding. There will be need for ongoing support and treatment, often in the form of a twelve-step group such as Alcoholics Anonymous (AA). There is also need for continuing attention to ways of handling emotions, relationships, and responsibilities.
In the final phase, termination, the person has successfully mastered the addiction. The temptation to use is no longer a significant danger. Nonetheless, people do not necessarily travel through these stages in a straightforward manner, and there is frequently movement back and forth between the stages.
Fortunately, there are many treatments for addiction. Medications are available to treat withdrawal, decrease drug cravings, or reduce enjoyment of the substance. Psy-chosocial treatments include a wide variety of therapies designed to help the addicted individual choose to stop using the drug, combat cravings, and handle the emotional and interpersonal challenges of daily life without resorting to substances.
Treatments vary from the least to the most restrictive. Depending on the severity of the addiction, including the motivation to stop the drug, the level of functioning in the community, the presence of co-existing psychiatric or medical problems, and the level of family support, the addicted individual may need more or less structure in their treatment. Higher functioning individuals with less debilitating addictions may be successfully treated in an outpatient setting or a twelve-step program such as Alcoholics Anonymous.
People whose addiction has more thoroughly taken over their lives may need greater structure, such as inpatient detoxification (where they are helped through the withdrawal process), inpatient rehab (where their addiction is addressed in a shortterm residential setting), or longer term therapeutic communities, where the patient may stay for up to one to two years.
A number of pharmacological agents (medications) are used to treat withdrawal. In general, withdrawal is treated with a drug that is similar to the drug of abuse. In this way, the individual is weaned off the chemical substance slowly. Common medications for alcohol withdrawal include a class of antianxiety drugs known as benzodiazepines, particularly diazepam (brand name Valium) and chlordiazepoxide (Librium). Withdrawal from opiates, such as heroin, opium, morphine, or oxycodone (OxyContin), is often treated with methadone or clonidine. Methadone maintenance is the most common pharmacological treatment of opiate addiction, serving to reduce craving and withdrawal. Naltrexone is also used to reduce craving by blocking the reinforcing effects of both opiates and alcohol.
Methadone is a long-acting opiate that is dispensed to opiate-addicted individuals under the supervision of licensed methadone maintenance clinics. Because it is longer acting than most opiates of abuse, it is easier for the individual to maintain steady blood levels of the drug, which reduces the incidence of withdrawal and craving. It also gives much less of a high than other opiates, so it is less likely to be used as a recreational drug. There is considerable research that methadone maintenance reduces the crime, violence, medical problems, and mortality associated with severe opiate addiction. Nonetheless, there is controversy around methadone maintenance because many individuals may stay on methadone for many years rather than becoming entirely drug-free. Alternative medications to treat opiate addiction include buprenorphine and LAAM. LAAM, however, is no longer available in the United States or Europe due to rare cardiac side effects.
Disulfiram (brand name Antabuse) is used to treat alcoholism by causing uncomfortable physical reactions to alcohol. Disulfiram interferes with the metabolism of alcohol. Drinking alcohol after taking disulfiram causes nausea, vomiting, and many other unpleasant symptoms. As the medication stays in the system for at least a week, it can be a potent motivator not to drink. However, long-term use of this medication is not advised because it can cause liver damage. Additionally, drinking while on disulfiram is potentially fatal, so it is not recommended for impulsive patients, those who might drink despite knowledge of the consequences. Finally, this treatment is only useful with highly motivated patients, those who are willing to take the medication and avoid alcohol. Someone who is poorly motivated to stop drinking will simply stop taking the Antabuse.
There are many psychological treatments for addictions. Group therapies are useful in decreasing the stigma of the addiction, confronting denial of the problem, and providing encouragement and support for the struggle toward sobriety. As social animals, we are all highly suggestive to peer influences and tend to conform to group norms. In group therapies, this universal tendency can be put to constructive use. Individual therapies focus on the skills needed to live without substances. Such therapies provide education about the effects of addiction, build coping skills to handle cravings and avoid relapse, and help the person to rebuild relationships and handle stress without using substances.
Group therapy has been proven effective for treating addictions (iStock).
Motivational Interviewing (MI) is a relatively recent technique developed by William Miller and Stephen Rollnick. MI addresses clients’ ambivalence about changing their behavior. In this brief intervention, clients are asked to consider the pros and cons of substance use and to identify their own personal goals. In a nonjudgmental and reflective manner, counselors aim to guide clients toward greater motivation to change.
While most treatments of substance abuse depend on mental health professionals, twelve-step programs are entirely member run. Alcoholics Anonymous (AA) was the first twelve-step program. Started in 1935 by Bill Wilson and Dr. Robert Smith, a New York stockbroker and an Ohio surgeon, AA now has over two million members in over 150 countries worldwide. AA offers support groups for alcoholics who wish to stop drinking alcohol. Members can attend daily meetings or even multiple meetings per day, depending on availability of meetings. The original publication, entitled Alcoholics Anonymous, was first published in 1939 and is now in its fourth edition. It offers specific guidelines on how to change behavior and maintain sobriety, including the twelve-step program toward recovery. The twelve steps include such measures as admitting that one is powerless over alcohol, asking for help from a higher power, taking an honest moral inventory of oneself, and making amends for past misbehavior. Numerous other twelve-step programs have arisen, such as Narcotics Anonymous, Overeaters Anonymous, Sex Addicts Anonymous, and Gamblers Anonymous.
Fundamentally, psychotherapy involves talking. Patients bring their psychological difficulties into treatment. Therapists aim to reduce a patient’s suffering via verbal discussion. Granted, psychotherapy involves far more than just conversation, but it is distinguished from other kinds of therapies—such as physical, speech, occupational, or medical therapy—by its emphasis on talking. In fact, Anna O., one of the world’s first psychotherapy patients, described it as the “talking cure.” Anna O. (a.k.a. Bertha Papenheimer) was one of Sigmund Freud’s case histories, written up in his 1895 Studies on Hysteria.
There are at least three mechanisms through which psychotherapy helps people feel better: social support, insight, and skills building. A large body of research shows the powerful effect of social support in just about all aspects of psychological health. When people are under stress, it is extremely helpful for them to talk out their problems with another person. Nonetheless, psychotherapy provides more than just social support. Otherwise, there would be no need for trained professionals—friends and family would do just as well. Psychotherapy also helps people gain insight. It helps them learn about their motivations, emotions, and behavior, along with their effect on others.
With greater self-understanding, people are better equipped to handle life’s challenges. Additionally, some people lack the necessary psychological skills to function well in life. For example, they could have difficulty managing anger, negotiating conflict, maintaining positive emotion, confronting anxiety-provoking stimuli, or controlling self-destructive impulses. Psychotherapy can teach people new skills to better handle these challenges.
Originally, there was little scientific data to back up psychotherapists’ claims about the effectiveness of psychotherapy. People had to rely on the testimony of psychotherapists which, for many skeptics, was not particularly convincing. The empirical study of psychotherapy started in the 1950s, however, and within a few decades grew into a large movement. There now exists an entire field of psychotherapy research and there is substantial data supporting the positive effects of psychotherapy. Consequently, we can now state with confidence: Yes, psychotherapy does work.
In 1995 the magazine Consumer Reports published a large study on the effects of psychotherapy. The mental health questionnaire was sent out as part of a larger study polling readers on their opinions of appliances and services. Out of the 180,000 people sent the questionnaire, 22,000 responded and 7,000 answered the mental health questions. Of these, 3,000 people had discussed emotional problems with family, friends, or clergy; 4,100 had turned to some combination of mental health professionals, support groups, or family physicians; and 2,900 had consulted a mental health professional, most frequently a psychologist (37%), psychiatrist (22%), or social worker (14%).
The survey showed very positive results for psychotherapy when provided by a trained mental health professional. Ninety percent of those who felt very poor or fairly poor at the start of treatment reported feeling very good, good, or at least so-so at the time of the survey. Moreover, people who stayed in therapy longer did better. People treated by psychologists, psychiatrists, and social workers did better than those treated by other professionals, and the difference was larger over time. No specific type of therapy worked better than any other.
It is important to note, however, that this is a very different kind of study than most psychotherapy research. Most psychotherapy studies are highly controlled efficacy studies, with fixed length therapies, manualized treatments, and specific criteria for selecting patients. This effectiveness study is much less controlled but much more representative of the real world. Patients pick their own therapists, present with all manner of problems, and stay in therapy as long as they and their therapist agree to continue. Moreover the therapist can tailor the treatment to the patient, which might account for the lack of difference between types of treatments. If a treatment is not working, the therapist may have switched to another approach.
Although new types of psychotherapy are constantly arising, there are perhaps three major schools of psychotherapy: psychoanalytic or psychodynamic approaches, cognitive-behavioral approaches, and humanistic approaches. Additional schools of psychotherapy include family systems approaches and group psychotherapy.
Psychoanalysis started under Sigmund Freud (1856-1939). Although there have been many developments since his death in 1939, certain pillars of the discipline remain. Psychoanalysis aims to alleviate emotional distress by bringing unconscious patterns of thought, emotion, and desire into awareness. This is done through long-term exploration of the person’s mental processes in a one-to-one relationship with the psychoanalyst.
Classical psychoanalysis involves three to five sessions per week, during which the analysand (patient) lies on a couch with the psychoanalyst sitting behind, out of view. This arrangement is intended to create a relaxed and reflective state of mind, in which the analysand can access the depths of his or her mind. The analysand is instructed to express whatever thoughts pop into awareness, a process known as free association. Psychoanalysts also believe that early childhood experiences and relationships have profound influence on adult relationships. Through the process of free association, unconscious childhood feelings and beliefs can emerge to be understood and reworked with the tools of a mature adult mind.
While psychoanalytic theory has had tremendous influence on the mental health field as a whole, the practice of classical psychoanalysis has become far less common than it was in its heyday in the first half of the twentieth century. Psychodynamic psychotherapy has adjusted to the financial and schedule constraints of modern life. In typical psychodynamic therapy, there are one to two forty-five- to fifty-minute sessions per week. Both therapist and patient sit up and face each other. There is no couch. The emphasis on unconscious patterns of thought, emotion, and desire is retained, however, as well as the belief that patterns learned in childhood influence adult emotional experiences and ways of relating to others.
As with psychoanalysis, psychodynamic therapy tends to be of indefinite length (often for many years) and relatively non-directive. The therapist aims to guide self-exploration, rather than provide answers or educate the patient in new modes of behavior. In other words, both psychoanalysis and psychodynamic therapy provide social support and promote insight, but neither one teaches specific skills.
Transference and counter-transference are central concepts to both psychoanalysis and psychodynamic psychotherapy. Early in the development of psychoanalysis, Freud realized that analysands can develop inappropriately intense feelings about their analysts. He quickly recognized this transference to be part of the clinical material, believing the patient is likely to “transfer” his or her psychic conflicts onto the analyst. Through exploring the analysand’s feelings about the analyst, much can be learned about the inner workings of the analysand’s mind.
Counter-transference occurs when the analyst develops inappropriate and intense feelings about the analysand. In the early days of psychoanalysis, counter-transference was seen mainly as a negative, reflecting childish responses on the part of the analyst that were best suppressed and controlled. In current approaches to psychodynamic work, counter-transference is now incorporated into the therapeutic work. When working with either transference or counter-transference, however, it is extremely important that the analyst proceed with tact and care. Direct discussion of the relationship between therapist and patient can be awkward and stressful, and the therapist must introduce such topics carefully and in a constructive manner.
In the last few decades, newer schools of psychoanalysis, such as the interpersonal and relational schools, have moved from a one-person to a two-person psychology. This means that contemporary psychoanalytic therapists no longer believe in the blank screen model of psychoanalysis. In this model, the patient’s experience within the therapy is seen solely as a product of the patient’s mental processes. The therapist is simply a blank screen onto which the patient projects his or her own feelings and thoughts. The therapist makes no contribution to the patient’s experience.
Contemporary psychoanalytic thinkers now believe that both therapist and patient contribute to the therapeutic relationship. The therapist is a living, feeling, and reacting human being. No matter how controlled the therapist’s behavior may be, it is impossible to remove the human element from a therapist’s technique.
Moreover, the emotional experience of the therapist can be a very valuable source of information, both about the interpersonal process within the therapy and the patient’s emotional experience. For example, if the therapist starts feeling annoyed and irritated during the session, this might reflect passive-aggressive behavior on the part of the patient. Likewise, if the therapist starts feeling sad, this may reflect unacknowledged sad feelings on the part of the patient. Clearly the therapist’s counter-transference needs to be interpreted with caution, so the patient is not unfairly held accountable for the therapist’s emotional state. Consequently, both psychoanalysis and psychodynamic therapy require years of training.
According to psychoanalytic theory, we use defense mechanisms to protect ourselves from feelings and thoughts that make us anxious. Through these mental manipulations, we keep ourselves blissfully unaware of uncomfortable information. In her classic 1936 book, The Ego and the Mechanisms of Defense, Anna Freud (1895-1982) listed ten defense mechanisms. Anna Freud was the youngest of Sigmund Freud’s six children.
| Defense Mechanism | Explanation |
| Displacement | Here the person expresses feelings toward one person or situation that are really aimed at another. For example, a child might express anger at her babysitter when she is really angry at the parent who left to go on a business trip. |
| Introjection | In introjection, people internalize the person or action that has caused anxiety, thus moving from the passive to the active role. For example, a child who has been bullied may start to bully other children as a way of mastering his or her sense of powerlessness. This is similar to the process of identifying with the aggressor. |
| Isolation | In isolation, the intellectual awareness of an event is disconnected from emotional experience. The person is aware of everything that happened, but is completely out of touch with the emotional meaning of the event. |
| Projection | When people project emotion onto another person, they are attributing their own emotion to that person. In effect, they are saying, “I don’t hate you. You hate me.” |
| Regression | In regression, a person avoids anxiety by reverting back to an earlier developmental stage. For example, adolescents afraid of their budding sexuality might regress to their pre-sexual childhood. |
| Repression | Sigmund Freud believed repression to be the primary defense mechanism used to ward off threatening mental content. In repression, disturbing emotions, thoughts and memories are pushed entirely out of awareness. |
| Reaction Formation | Here the person expresses the opposite feeling from what is truly felt. For example, a rageful person becomes overly solicitous of the other person. An unconsciously rebellious person becomes excessively compliant. |
| Reversal or Turning against the Self Sublimation |
When people cannot bear feeling negative emotions toward another person, they might turn the emotion inward, for example, berating and punishing themselves rather than acknowledging the real source of their anger. Here the person redirects the forbidden impulse into a socially valued activity. For example, childhood aggression may be sublimated into a career as a surgeon. |
| Undoing | When people are terribly ambivalent about something, they may express one emotion with one action and then undo their action as a way of expressing the opposite emotion. |
Behavioral psychotherapy came out of the academic tradition of behaviorism. Behaviorism proposed two primary ways by which people learn a new behavior: classical and operant conditioning. These principals were established through scientific research conducted in the early twentieth century. It was not until the 1950s, however, that behaviorist principals were adapted into psychotherapy techniques.
In classical conditioning, people learn to respond to a neutral object or event (the conditioned stimulus or CS) in a new way when it is paired with an emotionally meaningful object or event (the unconditioned stimulus or UCS). For example, we may develop strong feelings about a particular song (CS) because we associate with an emotionally important time in our life (UCS), such as a romantic break up or great vacation. The new learned reaction is known as the conditioned response (CR).
Classical conditioning techniques are extremely effective in the treatment of anxiety disorders. In these disorders, the people have learned to associate various stimuli with fear. To treat the anxiety disorder, it is necessary to dissociate the feared object (e.g., dogs) from the fear reaction. In this way, the conditioned stimulus (dogs) is disconnected from the conditioned response (fear of dogs). Techniques such as flooding and systematic desensitization expose people to their feared objects, either gradually (systematic desensitization) or all at once (flooding). When no harm comes from the exposure to the object, the fear response diminishes. The conditioned stimulus becomes decoupled from the conditioned response and, voilá, the person is no longer afraid of dogs. Further, a new association can be created between the formerly feared object and feelings of relaxation and calm. In other words, a pairing is made between the conditioned stimulus and a new (positive) conditioned response. Relaxation training, involving techniques such as deep breathing, visualization of a pleasant scene, and progressive muscle relaxation, can be used to help the person feel relaxed when in the presence of the formerly feared object.
One of the most commonly used techniques to help people unlearn fear conditioning is called systematic desensitization. People are first asked to create a hierarchy of situations in which they might feel anxious. For example, people who are afraid of dogs might first list thinking about a dog, then seeing a picture of a dog, then seeing a dog from far away, then seeing a dog in a cage, then seeing a dog ten feet away, then five feet away, then standing right next to a dog, and then finally petting the dog. Using a scale from 0 to 100, each situation is scored as to how much anxiety it elicits. Imagining a dog might get a rating of 5, seeing a picture of a dog a score of 10, and touching a dog a score of 65.
The client is then taught relaxation strategies, in order to learn to feel calm when in the anxiety-provoking situation. Next the client is exposed to the situations listed on the hierarchy, starting with the least anxiety-provoking (imagining the dog) and gradually moving up the list to the most anxiety-provoking (petting the dog). At each point, clients are instructed to use relaxation techniques until they can tolerate each step on the hierarchy without undue anxiety. This is an extremely effective technique, and it is used to help people overcome all manner of anxiety problems, including the fear of flying, public speaking, heights, or test taking.
According to the principles of operant conditioning, the likelihood that a behavior will be repeated depends upon the consequences of that behavior. Rewarded behaviors are more likely to be repeated, punished behaviors are less so. Therefore, you can change behavior by modifying its consequences.
Behavioral modification, as championed by B.F. Skinner (1904-1990) in the 1950s, relies on the principals of operant conditioning. It employs carefully designed rewards (or positive reinforcement) to encourage desirable behavior. Likewise, removal of key rewards reduces incentive for undesirable behavior. Alternatively, punishment can be used to decrease frequency of undesirable behavior. Punishment is used less frequently than positive reinforcement, however, because it tends to elicit negative reactions. In sum, behavioral modification changes behavior by manipulating the rewards and punishments that motivate people to perform the behavior.
Such techniques are used in child rearing and animal training as well as the treatment of emotionally disturbed children and individuals with mental retardation. Oper-ant conditioning techniques are also widely used in situations requiring some degree of social control, for example in prisons, schools, and even the workplace. They are less frequently used in individual therapy, as such techniques are most useful for people who lack internal motivation to change their behavior. For the most part, people seeking out psychotherapy on their own do so because they are already motivated to change.
Behaviorism dominated American academic psychology well into the 1960s, at which point the cognitive revolution brought the mind back to scientific respectability. Previously, behaviorists had thoroughly dismissed subjective experiences as unworthy of scientific attention. Taking advantage of this movement, psychologists such as Aaron Beck (1921-), Albert Ellis (1913-2007), and Martin Seligman (1942-), developed a new form of psychotherapy, known as cognitive psychotherapy.
One of the cornerstones of behavioral therapy involves identifying the consequences of various behaviors. If you want to change a person’s behavior, you have to consider what is reinforcing that behavior. Are there positive consequences that motivate the person to perform the behavior? Often the answer is not so obvious.
One of the basic techniques of behavioral therapy is functional behavioral analysis. In this process the behavior is observed carefully and a log is kept of the antecedents (what happened before?), behaviors (what exactly did the person do?), and consequences (what happened afterwards?), otherwise known as the ABCs.
After the target behavior has been studied this way, it is possible to identify what reinforces the behavior. For example, a toddler may throw up every night and the parents do not know why. Functional behavioral analysis might show that the toddler throws up at night after the parents put the child down to sleep. First the child cries to get her parents back into the room. The parents resist for a while but when the mother gives in, the child vomits. At that point the mother spends up to 45 minutes with the child, cleaning her up and soothing her. This functional analysis makes clear that vomiting is reinforcing for the child because it brings her mother’s attention. The treatment for this kind of problem would be to change the contingencies of the child’s crying. Instead of entering the room to reassure the child in response to the child’s crying, the parent should enter the room at a fixed time interval. This way the child’s crying loses the power to control the parents’ behavior. The parent first enters the room at a frequent rate, so that the child is only left alone for short time periods. The parent then spaces out the time intervals so that the child slowly adapts to falling asleep without the parent. This process is the basis of the Ferber method, a well-known technique for conditioning babies to sleep through the night.
All three branches of cognitive therapy start from the premise that psychological distress can be linked to maladaptive thoughts. Negative thoughts stimulate negative emotions, which in turn motivate self-defeating behavior. The negative consequences of these patterns reinforce the problematic thoughts, creating a vicious cycle. Unlike psychoanalytic treatment, which explores psychological distress in an open-ended, nondirective way, cognitive therapists actively identify unhealthy thought processes, and train patients to restructure their thoughts into healthier responses.
In cognitive therapy, therapists point out how patients experience the world through the filter of cognitive distortions. These are habitual ways of thinking that contribute to a depressive mindset. Information is distorted to maintain a negative and pessimistic world view. In his book Feeling Good: The New Mood Therapy the psychiatrist David Burns listed the following cognitive distortions.
Humanistic therapies arose in the middle of the twentieth century, to some extent in reaction against the two reigning pillars of American psychology. Behaviorism dominated academic psychology, and psychoanalysis dominated clinical psychology. Humanistic therapies—as championed by psychotherapists such as Carl Rogers (1902-1987), Fritz Perls (1893-1970), Victor Frankl (1905-1997) and Rollo May (1909-1994)—were considered the third force in psychology, providing an alternative to the two earlier movements. While psychoanalysis focused on the relief of psychological conflict, and behaviorism focused on changing behavior, humanistic psychology emphasized the potential for growth. Concepts such as self-actualization, unconditional positive regard, and the search for meaning highlighted the basic human need to find fulfillment, happiness, and meaning in life.
The aim of humanistic therapy is less the reduction of psychopathology, than the realization of human potential. Emphasis is less on the past, as with psychoanalysis and psychodynamic therapies, and more on the present. Moreover, there is a spiritual side to humanistic psychotherapy that is completely absent in the two other movements
There is a fair amount of overlap between humanistic and psychodynamic psychother-apies, however, and many of the pioneering humanistic psychologists were initially trained in psychoanalysis. Both types of therapy engage the patient in one-on-one discussions with a psychotherapist. Both presume that verbal exploration of emotionally relevant thoughts, feelings, and problems can help people improve their lives. Finally, both types of treatment focus on how people deal with emotions and relate to other people.
The empty chair technique is a popular technique used in Gestalt therapy, a branch of psychotherapy founded by Fritz Perls (1893-1970). Clients are asked to address an empty chair as if speaking to somebody with whom they have some interpersonal difficulty. They are then asked to tell that person everything that they are feeling. In this way, they can figure out what they are actually feeling, practice putting those feelings into words, and identify the fears that keep them from communicating directly with the person in question. Interestingly, the empty chair technique has similarities with the behavioral technique of systematic desensitization. By practicing a feared conversation without the actual person present, the client is asked to confront something anxiety-provoking at a lower level of anxiety. If the person can master the anxiety at that lower intensity, presumably he or she can move from there onto the more challenging situation. Hopefully, the person can progress from talking to the empty chair to a conversation with the actual person.
The second half of the twentieth century was a time of considerable innovation in psychotherapy and many new branches of psychotherapy broke off from their origin in traditional psychoanalysis. Family therapists challenged the emphasis on the individual, a fundamental part of all earlier forms of psychotherapy. In family systems theory, it is believed that families operate as systems and that no one member of the family can be understood in isolation from the other members of the family. This is particularly true for married couples, or for children who live with and depend upon their parents.
The theory behind family therapy is that individuals do not operate in isolation but, instead, are part of a complex family system. It is therefore important for the therapist to understand the entire family in order to treat one of its members (iStock).
Although there are many strains of family therapy, including the structural family therapy of Salvador Minuchin, the strategic family therapy of Jay Haley, and the experiential family therapy of Carl Whitaker and Virginia Satir, all family therapists believe in bringing the entire family (or key members) into the room. By working with the family as a whole, therapists can achieve very different effects than can be accomplished in individual therapy alone.
Family therapists address the patterns of interaction between family members. Are the mother and the oldest child allying together against the father? Is the child acting out at school to force his estranged parents to talk to each other? Are the parents failing to set adequate boundaries with their children, giving the children too much power? Family therapy works by helping family members gain insight into their problematic patterns and then work together to change. Unlike psychodynamic therapy, family therapy addresses the present patterns of interaction with far less emphasis on the past, although past history is recognized if it has contributed to present patterns.
Although there is a fair amount of data that shows that the different types of therapy are equally effective, research also suggests that certain kinds of psychotherapy are best with specific psychological problems. Behavioral therapy is most effective for anxiety disorders such as phobias, panic disorder, and obsessive-compulsive disorder. Cognitive therapy is highly effective in mild to moderate depression. Impulsive and compulsive behaviors, such as pathological gambling, self-injurious behaviors, and poor anger management, respond well to skills-building therapies, using both behavioral and cognitive components.
People with mild to moderate personality disorders respond to long-term, insight-oriented treatments, such as psychodynamic therapy, although people with severe personality disorders may also need skills-building treatments. For example, dialectical behavioral therapy (DBT) is specifically designed to treat borderline personality disorder. It is based on behavioral principles and makes use of functional behavioral analyses, but also addresses the poor emotional regulation and problematic interpersonal relationships associated with this disorder.
A number of studies suggest that patients are equally satisfied after talking to non-professionals as they are after talking to trained mental health professionals. Certainly with short-term problems that are not particularly severe, many people can provide reassurance and support without years of professional training. In order to help people with more serious, complex, or entrenched problems, however, training is unquestionably important. The 1995 Consumers Reports study showed that, in general, people were happier and improved more from treatment with trained mental health professionals than from treatment with nonprofessionals. Moreover, the difference between the two grew the longer people stayed in treatment.
There is a large literature on the predictors to treatment outcome in psychotherapy, in other words, what factors contribute to the success or failure of psychotherapy. Both therapist and patient factors contribute. Among therapist factors, personality variables such as genuineness and empathy (as perceived by the patient) are very important. Positive expectations of therapy outcome are also important. If the therapist believes that the therapy can help, this contributes to a positive outcome. Among patient variables, motivation to change, hope, and positive expectations of the therapy promote positive results. General functioning level and degree of social support also contribute to therapy outcome. Patients who function better in the world and have more supportive relationships tend to do better in therapy. Many studies also stress the centrality of the therapeutic alliance. In other words, when both patient and therapist feel a positive bond and have shared goals for therapy, the therapy is more likely to succeed.
Choosing a therapist is an important decision but there are no hard and fast rules for picking a therapist that will best meet a patient’s needs. Because therapeutic alliance is such an important component of treatment outcome, it makes sense to pick a therapist with whom one feels comfortable. As in any relationship, this is to some extent a personal decision. A therapist may provide a perfect fit for one person, but not click as well with his or her friend. When seeking treatment for help with specific problems, it also makes sense to find someone with expertise in that area. As noted above, some problems are best treated with specific types of therapy, for example, anxiety disorders respond very well to behavioral therapy.
In many cases, however, the different types of therapy may be equally effective, so the theoretical orientation of the therapist (for instance whether they are psychody-namic, humanistic, or cognitive-behavioral) may be mainly relevant in terms of patient-therapist fit. For example, people might consider whether they want a therapist who is directive (structures the treatment) or exploratory (promotes open-ended discussion), who does or does not give homework assignments, who talks a good deal or who is more interested in listening, who delves into childhood relationships or who focuses on solving current problems, or who provides short-term or long-term psychotherapy (weeks to months vs. years).
The personality style of the therapist will also affect the type of therapy that is provided. Some therapists are gentle and supportive, while others tend more toward “tough love.” Some patients may prefer the first type of therapist, while others may find such a therapist too soft and prefer to be challenged.
The different schools of therapy have different philosophies about the length of therapy. Cognitive-behavioral therapies tend to be short term, while humanistic and psychodynamic therapies tend to be longer. Psychoanalysis often goes on for many years. Research suggests that minor and relatively recent problems may not require long-term treatment while more severe, complex and long lasting problems will take more time. The length of the treatment also depends on the preferences of the patient.
Some patients are happy with resolution of the presenting symptom and choose to stop treatment as soon as there is symptomatic improvement. Other patients are interested in greater self-exploration and personality development, and stay in therapy much longer. In the 1995 Consumer Reports study, patients who stayed in therapy longer tended to be more satisfied with their treatment. Of course, this could reflect a selection bias because people who were more satisfied with their treatment may have chosen to stay in therapy longer.
Modern advances in psychopharmacology (psychiatric medication) have radically changed the lives of the mentally ill. Once doomed to a life of anguish, utter dysfunction, and often squalid conditions, many people with mental illness can now live satisfying lives in the community. Although modern psychopharmacology has brought tremendous benefits, it is not without complications.
All medications have side effects, some of which can be quite dangerous. Secondly, the drugs are only effective if they are taken as prescribed. Non-adherence to medication is probably the single greatest reason for treatment failure. Finally, clinical trials (research into the efficacy and safety of certain medications) are extremely expensive. Because of this, they are currently covered primarily by private industry, specifically the pharmaceutical industry, whose profit motive leaves them far from impartial. Consequently, some professionals and patients are concerned about the safety of taking medications, especially for long periods of time.
Although there are quite a few drugs that do not fit neatly into any one category, the main categories of psychiatric drugs are antipsychotics, antidepressants, antianxiety drugs, and mood stabilizers. For each class of drug, specific neurotransmitters are involved.
Antipsychotic drugs treat psychotic symptoms. These drugs are divided into two general categories, typicals and atypicals. Typicals date back to the early 1950s when chlorpromazine (Thorazine) was developed in a Parisian laboratory. These medications—which include such drugs as haloperidol (Haldol), thioridazine (Mellaril), and fluphenazine (Prolixin)—operate on the dopamine neurotransmitter system, specifically on the D2 neurotransmitter receptors.
Typical antipsychotics are highly effective drugs, but have a range of problematic side effects. Anticholinergic effects, including dry mouth, blurred vision, and confusion, are found in low potency typicals, such as chlorpromazine and thioridazine. Extra-pyramidal side effects (EPS) are more common in high-potency typicals, such as haloperidol and fluphenazine. Symptoms of EPS include muscle tremors and stiffness.
Atypical antipsychotics include risperidone (Risperdal), olanzapine (Zyprexa), que-tiapine (Seroquel), ziprasidone (Geodon), and aripiprazole (Aricept). The atypicals entered the market in the 1990s, although the first atypical, clozapine (Clozaril), was introduced considerably earlier but fell out of favor due to the risk of agranulocytosis, a potentially fatal disorder of the white blood cells. Atypicals work on a range of neurotransmitters, including serotonin, dopamine, and norepinephrine. While atypicals are less likely to cause the kinds of side effects associated with typical antipsychotics, they bring their own side-effect profile. Most importantly, atypicals have a higher risk of metabolic syndrome, characterized by insulin resistance, high blood pressure, weight gain, and high blood sugar. Metabolic syndrome raises the risk of diabetes and heart disease. With the advent of atypicals, clozapine received new attention. It is now considered perhaps the most effective antipsychotic medication. Because of its side effect profile, however, it is only used after other drugs have failed.
All drugs are given a generic name, which is a unique name for their chemical structure, and a trade name, which is essentially a brand name. When the drug’s patent runs out, other manufacturers can produce the drug but only under its generic name. The table below lists commonly used drugs and their uses.
With the arrival of atypical antipsychotics, it was widely assumed that the new generation of drugs was superior to the old generation. Not only did the atypicals have a more benign side effect profile than the typicals, atypicals were assumed to be more effective in treating both the positive and negative symptoms of schizophrenia. (Positive symptoms refer to the active psychotic symptoms, and negative symptoms to the social withdrawal, reduced energy, and emotional flattening associated with schizophrenia.)
Although some psychologists are licensed to prescribe medications, psychiatrists or primary care doctors prescribe most psychiatric drugs (iStock).
The CATIE study is a landmark study published in 2005 that challenged assumptions about the superiority of atypicals over typicals. This study showed no difference in efficacy between three atypical antipsychotic medications (quetiapine, risperidone, ziprasidone) and perphenizine (Trilafon), a mid-potency typical antipsychotic. While olanzapine (Zyprexa) proved superior to perphenizine, it also had the highest rates of metabolic side effects. Of note, this study was funded by the National Institute of Mental Health, a government institution. The study received no funding from pharmaceutical companies.
Antidepressant medications treat depression. Currently, the most popular antidepres-sants are the serotonin repuptake inhibitors (SSRIs), which work on the serotonin neurotransmitter system. Commonly prescribed SSRIs include fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa), and paroxetine (Paxil). SSRIs are very effective and safer than other classes of antidepressants but they do have side effects, the most bothersome being sexual side effects. SSRIs are also helpful in the treatment of anxiety conditions and obsessive-compulsive disorder.
Prior to the arrival of the SSRIs in the 1980s, heterocyclics were the most frequently prescribed class of antidepressants. Commonly used heterocyclics include imipramine (Tofranil), amitriptyline (Elavil), and nortriptyline (Pamelor). Hetero-cyclics, which get their name from the ring structure of the drugs’ molecules, hit both the serotonin and norepinephrine neurotransmitter systems, with an emphasis on norepinephrine. They also impact the histaminic and and acetylcholine neurotransmitter systems. Heterocyclics have more dangerous side effects than SSRIs. They are more lethal on overdose and can have notable cardiac side effects.
Another class of antidepressants is monoamine oxydase inhibitors (MAOIs). MAOIs were discovered in the early 1950s and their potentially lethal effects came to light in the early 1960s. MAOIs can cause a hypertensive crisis, in which blood pressure shoots up high enough to cause a stroke.
These crises can be brought on by mixing an MAOI with another medication, such as opioids or SSRIs, or by eating tyramine-rich foods. Aged cheese, cured meats, sausage, and liqueurs are all rich in tyramine. Although MAOIs are the most dangerous of the anti-depressants, they are also extremely effective. For those patients with treatment-resistant depression who can follow a low tyramine diet, MAOIs may be a reasonable option. Examples of MAOIs include phenelzine (Nardate) or tranylcypromine (Parnate).
There are at least two classes of antianxiety medications, barbituates and benzodi-azepines. Both drug classes act on the GABA neurotransmitter system. Barbituates, such as secobarbitol (Seconal) and pentobarbital (Nembutol), are the older class of drugs. Today, they are rarely prescribed as conventional antianxiety medications because of their problematic side-effect profile. Barbituates have a high risk of addiction and high lethality on overdose. They also have cardiac effects at high doses and can dangerously depress respiration (suppress breathing). Barbituates are still found to be useful in controlled settings, however, as when sedating a patient before an invasive procedure.
Benzodiazepines have largely taken the place of barbituates in the treatment of anxiety. Medications such as alprazolam (Xanax), lorazepam (Ativan), clonazepam (Klonopin), and diazepam (Valium) have far lower risk of death on overdose and tend to be less addictive than barbituates. Nonetheless, benzodiazepines can still be addictive and abrupt discontinuation of the drug can put a person into withdrawal. The drug’s half-life (amount of time needed for the drug to clear the body) influences the addiction potential. Benzodiazepines with a short half-life, such as alprazolam, have higher risk of withdrawal and addiction than those with longer half-lives, such as clonazepam.
Mood stabilizers help patients with bipolar disorder avoid the highs of mania and the lows of depression. They literally stabilize the mood. The most common mood stabilizers are lithium, valproic acid (Depakine), and carbamazepine (Tegretol). It remains a bit of a mystery how mood stabilizers work. Unlike the other classes of psychiatric drugs, mood stabilizers are not clearly linked to specific neurotransmitters. Some mood stabilizers alter the sodium channels in the cell membrane and some seem to work on the GABA neurotransmitter system. Most mood stabilizers also function as antiseizure medications (anticonvulsants), including carbamazepine and valproic acid. Additional antiseizure medications that are used to stabilize mood include gabapentin (Neurontin), lamotrogine (Lamictal), and topiramate (Topamax). Mood stabilizers also treat agitation and impulsivity.
In the late 1980s during the explosive growth of the SSRIs, there was idle talk of drugs replacing psychotherapy. Today, few people think that medications will ever replace psychotherapy. Medications treat symptoms and they are enormously helpful with the most severe mental illnesses. However, they cannot replace the human element that is so central to the effectiveness of psychotherapy. Moreover, medications and psychotherapy treat different problems. Medications are extremely effective with psychosis, mania, severe depression, anxiety, and agitation. Alternatively, psychotherapy is effective with problematic personality traits, disturbed self-image, and impaired interpersonal skills. Specific psychotherapies are also effective in the treatment of anxiety disorders and mild to moderate depression. Although medications generally work more quickly on depression and anxiety, psychotherapy tends to have more long-lasting effects and certainly has fewer side effects.
The process of developing drugs and bringing them to market is long, complex, and expensive. Basic biochemical research, which may take place in universities or in government or industry laboratories, can suggest directions for drug development. Most actual drug development takes place in industry laboratories, paid for by the extremely large and wealthy pharmaceutical industry. Once a drug is developed, it must be tested for efficacy, safety, and tolerability. Efficacy reflects how well it treats the target symptoms. Safety relates to the absence of dangerous side effects, otherwise known as adverse events. Tolerability reflects a patient’s ability to tolerate the drug. A drug may be safe—that is not dangerous—but still intolerable. For example, it may cause nausea or headaches.
In the United States, the Food and Drug Administration (FDA) requires several phases of testing before a drug can be FDA approved for the treatment of a particular condition. In Phase I studies, the drug must prove tolerable and safe in a small sample of healthy volunteers (twenty to eighty subjects). In Phase II studies, the drug must prove tolerable and safe in a larger sample of patients (100 to 300 subjects) with some evidence of efficacy. In Phase II, the drug must show efficacy, tolerability, and safety in a larger sample of patients (1,000 to 3,000 subjects).
Although psychiatric medications have been shown to be safe and tolerable in clinical trials and most have been used for years by many thousands of people, some prescription drugs become drugs of abuse. Which medications are most likely to be misused this way? Opiates and benzodiazepines are the classes of medications that are most likely to be abused. Antidepressants, antipsy-chotics, and mood stabilizers are less frequently abused. Data from the U.S. government agency SAMHSA list sedatives, pain relievers, stimulants, and tranquil-izers as the most common candidates for prescription drug abuse. Drugs with a quick onset of action, a tendency to cause euphoric feelings, and a short half-life are more vulnerable to misuse.
The standard method for testing the efficacy of a new drug is through the use of randomized controlled trials (RCTs). In an RCT, a large sample of patients are randomly assigned to receive either the test treatment or a comparison treatment. The comparison drug may be another active drug or may be a placebo (sham treatment that looks like an active drug). Studies must also be double-blinded, that is neither doctor nor patient should be able to tell whether the patient is taking the drug or the placebo. At the end of a set period, symptom improvement is compared across groups. The efficacy of the drug reflects the improvement of symptoms in patients taking the active treatment, rather than the placebo.
Placebo controls are necessary because many patients improve just by suggestion. The placebo effect refers to the improvement seen in patients on placebo. It can be enormously reassuring just to see a doctor and receive pills, even if there is no active ingredient in the pills. The placebo effect is a real phenomenon and can reach 30 to 40 percent in some treatment studies. Therefore, it is necessary to include a placebo control in a treatment study in order to prove that patient improvement is due to the active ingredient in the drug and not just to the placebo effect.
FDA regulations ensure that each drug brought to market has shown safety and efficacy compared to a placebo or a comparison drug. FDA regulations do not require comparisons among multiple drugs to determine which drug works best. Pharmaceutical companies have financial incentives to show their own medications in the best light. Consequently, they have no incentive to spend millions of dollars on high quality, objective studies that could potentially reflect badly on their own product. It is no coincidence, therefore, that the CATIE study, which punctured the illusion that newer is necessarily better, was financed by the National Institute of Mental Health and not by private industry. Clearly independent sources of funding are needed to support high quality and impartial drug-to-drug comparisons.
The pharmaceutical industry has had a profound effect on the practice of psychiatry. Ever since the 1980s, the U.S. government has moved more toward deregulation of industry. With this philosophical and political shift, the pharmaceutical industry has gained more freedom to market directly to consumers and engage in joint research with academic centers.
Along with the tremendous advances in psychiatric medications, the pharmaceutical industry has grown extremely profitable and has become integrated into all aspects of psychiatric research, publishing, and training. While there has been some reaction against this in recent years, the pharmaceutical industry still wields enormous influence on prevailing opinion about which drugs are most useful for which conditions.
Unfortunately, there is little in the way of independent investigation, such as the CATIE study, to give unbiased information about the relative effectiveness of different medications. This is not to suggest that clinical research sponsored by the pharmaceuticals is invalid, only that it is far from impartial and few companies are likely to publish studies that might adversely affect their bottom line.
In his 2006 study by Robert Kelly and colleagues (see illustration), the authors looked at 301 articles involving data on 542 drugs (many studies looked at the same drugs). Whether the outcome of the study was favorable or not favorable for each drug was recorded along with the source of research funding. As is shown above, for drugs in studies funded by the drug manufacturer, 78 percent of the studies showed favorable results. For drugs in studies funded by the manufacturers’ competitors, only 28% of the studies had favorable outcomes. Finally, for drugs in studies that received no funding from pharmaceutical companies, 48 percent of the outcomes were favorable.
In other words, when a drug company did not fund the study, the likelihood of a positive outcome was about 50/50. In the other situations, however, it appears the dice were loaded. How does this happen? Does this mean that the research by pharmaceutical companies is not valid? Most authors believe that the problem is less due to poor science than to selective publication. Drug companies are more likely to publish studies that support their product and less likely to publish studies that fail to do so.
Drug studies tend to show more favorable outcomes when research funding comes from the drug’s manufacturer.
ECT stands for electroconvulsive therapy, otherwise known as shock therapy. Electrodes are placed at several locations on the skull and a small pulse of electricity is sent through the electrodes into the brain. This causes a seizure, generally of twenty to thirty seconds in duration. Despite its scary reputation, ECT is very effective in severe depression. It is particularly effective in melancholic depression or depression with a lot of neurovegetative symptoms. This refers to the physical symptoms of depression, such as loss of energy, sleep and appetite disturbance, impaired concentration, and physical slowing. The side effect profile of ECT is reasonable, especially if done infrequently. The most common side effect is loss of memory from around the time of the treatments. ECT is frequently used in the elderly.
Compared to many biological treatments used in psychiatry, ECT is quite old, dating back to the 1930s. Over its long history, the use of ECT has been considerably refined and it is now used much more carefully than it was fifty years ago. In the past, ECT was commonly used with a much wider range of disorders than it is now. Sometimes it was used simply for behavioral control. Today it is mainly used to treat depression, although it can also treat mania and psychosis.
Much higher dosages of electricity were used in the past than are used today. Bilateral ECT, in which electrodes are placed on both sides of the head, was the norm, while unilateral ECT is frequently used today. Unilateral ECT tends to have fewer side effects though it is not as powerful as bilateral ECT.
Finally, muscle relaxants were not commonly used, so patients could get hurt during seizures, even breaking bones. Currently, patients are given muscle relaxants and put under general anaesthesia prior to ECT. When they wake up they have no memory of the procedure. Additionally, electronic monitoring machines help ensure that breathing and heartbeat remain normal throughout the procedure.
Popular or pop psychology is aimed at a popular audience and communicated through the mass media. It addresses topics related to psychology—such as romantic relationships, stress management, child rearing, and sexuality—and can be found in magazine articles, radio or television talk shows, popular books, and various Websites. The benefit of pop psychology is that it is accessible to a very wide audience and can be an effective vehicle for translating psychological knowledge to the general public. The downside is that there is little to no quality control. The information may or may not be backed by solid psychological science or clinical experience.
While the term “pop psychology” is relatively new, the concept is certainly not. As long as there have been human beings, there has been interest in human behavior. Along with this comes a pervasive desire to obtain advice from those who seem to know more about life’s challenges than the ordinary person. In ancient Greece, people consulted oracles for such advice. For many centuries, religious figures filled this function, although soothsayers, fortune-tellers and other occult figures also came into play. In more recent times, advice columnists have made use of the mass media to provide advice to the lovelorn, the depressed, or people who are otherwise troubled. Since the rise of the professional mental health fields, speakers with academic or medical credentials have gained in popularity. Unfortunately not all people in the popular psychology industry who present with medical or academic credentials actually have training related to the topic they are discussing.
No credentials are necessary to become successful within the field of popular psychology. While licensed psychologists need to complete many years of rigorous training before they are legally able to call themselves a psychologist, a talk show host need only master the (admittedly very difficult) art of popular entertainment before giving advice to the general public. Some psychologists or mental health professionals do enter the field of popular psychology, but there is nothing stopping someone with a doctorate in French literature from using the appellation “Dr.” and appearing on a daytime pop psychology television show. Thus, much of popular psychology functions more as entertainment than as scientifically based psychological knowledge.
Dr. Joyce Brothers (1929—) was one of the earliest popular psychologists, an actual psychologist who brought her expertise to the general public through various mass-media outlets. She began her career on a television talk show in 1958, entitled Dr. Joyce Brothers. Over the next forty-five years, many other television and radio shows followed. She also wrote at least thirteen books with titles such as What Every Woman Ought to Know about Love and Marriage and Dr. Brothers’ Guide to Your Emotions. Dr. Brothers was trained as a psychologist, holds a Ph.D. in psychology from Columbia University, and has been licensed in the state of New York since 1958.
Ann Landers and Abigail Van Buren are the pen names of twin sisters who ended up as enormously successful advice columnists from the 1950s into the 1990s. Born in 1918 in Iowa, neither sister had any formal training in psychology or a related field. Esther “Eppie” Friedman Lederer (1918—2002) assumed the Ann Landers advice column for the Chicago Sun-Times in 1955. She continued until 1987, at which point she switched to the Chicago Tribune. Married to a wealthy businessman named Jules Lederer, who was also the founder of Budget-Rent-A-Car, she had amassed a wide range of contacts, which she mined for her column. Her plain-spoken, common sense advice appealed to a great many people and her column was eventually syndicated to over 1,000 newspapers. In 1956, her twin sister Pauline “Popo” Friedman Philips, began a rival column, “Dear Abby”, in the San Francisco Chronicle under the pen name Abigail Van Buren. Although neither sister had any training in the mental health field, they took care to clarify the limits of their knowledge and abilities, and often advised their readers to seek professional help if their problems seemed beyond the scope of a newspaper advice column.
Phillip McGraw (1950—) is a widely known television personality, best known as Dr. Phil. He received a Ph.D. in clinical psychology from the University of North Texas in 1979. Dr. Phil was licensed in Texas and opened a practice for a short while, but moved out of the business of psychotherapy into both popular and forensic psychology. In the mid-1990s, he met the famous talk show host Oprah Winfrey through his work in forensic psychology, a branch of psychology involved with the legal system. He was hired to help with her defense against a lawsuit by cattlemen who claimed she defamed the beef industry on one of her shows. Soon he was appearing regularly on her television show. In 2002 he started his own talk show, which was named Dr. Phil. While still living in Texas, Dr. Phil allowed his psychology license to lapse. When he moved to California to pursue his television career, he did not obtain a license in California as the state licensing board determined that his show was more entertainment than psychology and, therefore, his current practice did not require that he be licensed.
Dr. Laura is another popular media personality. She works primarily in radio but has also published a number of books. Laura Schlessinger (1947—) has a doctorate in physiology from Columbia University but also obtained a post-doctoral certificate in Marriage, Child, and Family Counseling from the University of Southern California. She states she was in private practice for twelve years. Dr. Laura is known for her socially conservative views and for combining moral, religious, and mental health considerations into her responses to viewers. This departs from the official practice of professional psychologists, who must distinguish between their personal and professional views when dealing with patients.