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What is the historical perspective on psychopathology?

The view of what causes mental health problems has changed over time. We will examine the historical perspective on psychopathology, such as the demonic possession perspective, and the contemporary models of explanation such as the medical or disease model.

What is the Demonic Possession Perspective?

Since many forms of psychopathology seem to appear together with what looks like a personality change in the individual and which is noticed as one of the first symptoms, the historical explanation described these individuals as being 'possessed'. The change in their behavior was attributed to someone/something having taken over their personality. This has led the sufferers to be persecuted and physically abused instead of being cared for. Demonology is a term which describes the belief that someone with symptoms of psychopathology is under the possession of bad spirits.

What is the Medical or Disease Model?

In the 19th century it became clear that many mental or psychological illnesses could be explained in terms of biological or medical accounts. The somatogenic hypothesis describes explanations of psychological problems in terms of physical or biological impairments. It was found that syphilis had a biological cause and that later stages of the disease, such as dementia, gradual blindness, and paralysis, caused dramatic changes in one's personality. This finding was used to explain the mental disorder known as general paresis. Contemporarily, psychiatry is a scientific approach based on medicine to primarily find the biological causes of psychopathology and treating them with medication or surgery.

The medical or disease model supplies important implications for how we view mental health, but there are some important points to keep in mind:

• Often, it is a person's dysfunctional experiences and not biological dysfunctions that account for their experienced psychopathology
• The medical model tries to reduce the complex psychological and emotional aspects of psychopathology to simple biology
• The view that something is broken and needs to be fixed in the individuals is problematic, as psychopathology may just be normal behavior, but then in an extreme form. Labeling psychopathology as a normal process gone wrong or broken can lead to stigmatization of these individuals and lead to perceiving them as second-class citizens
• It is a widespread belief that people with mental health problems are dangerous, hard to talk to and that (some of) their mental health problems are self-inflicted
• Psychopathology should be viewed as dimensional, and not as a discrete phenomenon that is set apart from normal experience. Medical models of mental health can often make a sufferer feel like a victim and powerless regarding their condition and their future life. They can feel socially excluded and often experience low self-esteem and depression after a psychiatric diagnosis.

What is the history of treatment for those with a mental illness?

Not too long ago, prior to the 18th century, mental illnesses were seen as 'madness', and were treated in hospitals like other, non-mental diseases were. With the increase of mental diseases, many hospices were transformed to asylums for the confinement of sufferers of mental health problems. Treatments were unnecessarily cruel and painful, and these asylums not only accepted those with mental issues, but also other people who fell below the societal desirable standards, like poor people and young, pregnant women. These approaches towards the mentally ill are probably part of the roots of the nowadays still running negative stigma towards sufferers of mental illnesses. In the 19th century, people were advocating for more humane treatments. For instance, Philippe Pinel began removing the chains and restraints of patients, and treated the patients as sick people, instead of as animals. The Quaker Movement (UK) developed the moral treatment approach, which abandoned medical approaches and instead implemented understanding, hope, occupational therapy, and moral responsibility during treatments.

Because most of the care started to rely on the (undereducated) nurses and caretakers, many patients were restrained. This often led to patients developing social breakdown syndrome, making the patients aggressive, exerting challenging behavior for the caretakers, and a lack of interest in personal welfare and hygiene. Therapeutic refinements of the hospital environment were the token economy, which consisted of a reward system in which patients could earn 'tokens' for various desired items or privileges, and milieu therapies, which were implemented to develop productivity, feelings of self -respect, independence, and responsibility. This was achieved by mutual respect between staff and patients, and the opportunity for the patients to express themselves with the use of vocational and recreational activities.

Because of modern therapy and medical treatments, many people do not have to a life in a mental health facility. Many individuals, after being treated, return to a state where they can live a normal life. For people who still need some sort of after-care, there are assertive outreach programs available which help people who are recovering from psychosis to live a normal life as independent as possible.

How can psychopathology be defined?

Abnormal Psychology is a term that is often used to refer to psychopathology. This definition has a negative connotation, suggesting that an individual is malfunctioning, and this term therefore attaches a stigma to an individual who experiences psychopathology. Service user groups therefore advocate to change these labels. Two examples are the Rethink and Time to Change programs, which aim to educate people about mental health, and fight against discrimination and negative stigmas.

What are statistical norms used for?

In clinical psychology, the statistical norm, which often refers the average, is used to decide whether symptoms meet diagnostic criteria. For example, mental retardation is often diagnosed by an IQ score significantly below the norm of 100. This is problematic, as individuals with exceptionally high IQ scores, which are also statistically rare, would not be considered as exhibiting psychopathology.

What kind of political or societal norms are there?

Often, there is a tendency within societies for the members of that society to label a behaviour or activity as indicative of psychopathology if it is far removed from what we consider to be the social norms for that culture. It is quite difficult to use deviations from social norms as evidence for psychopathology, as distinct cultures have very different views on what is socially normal. For example, in the Soviet Union, during the 1970 and 1980s, political dissidents who were active against the communist regime were regularly diagnosed with schizophrenia and incarcerated in psychiatric hospitals. Also, cultural factors are a major influence on how psychopathology manifests itself in the individual. This includes the degree of vulnerability of an individual to causal factors, and the 'culture-bound' symptoms of psychopathology. Two examples of 'culture-bound' effects are Ataque de Nervios, a form of panic disorder found in Latinos from the Caribbean and Seiziman, a state of psychological paralysis found in the Haitian community.

What is maladaptive behaviour?

Maladaptive behaviour might involve behaving in a way that is a threat to the health and well-being of the individual and to others. We cannot define psychopathology solely in terms of maladaptive behaviour, as it is not the only criterion by which psychopathological conditions are defined. The problem by defining psychopathology solely in terms of maladaptive behaviour is that not all maladaptive behaviours can be labelled as psychopathology. For example, murders or terrorists show maladaptive behaviours, but they do not all have mental health problems. Moreover, some psychopathological disorders such as height phobia, water phobia, or snake phobia might have an adaptive function, as they could protect individuals from potentially life-threatening situations.

What about distress and impairment?

A useful way of describing psychopathology is the degree of clinically significant distress or impairment in social, academic, or occupational functioning. With the use of this criterion, the individual can judge his or her own 'normality', which enables self judgment of their needs instead of society-enforced judgment. Yet, this approach does not define the single standard by which behavior should be judged. Often, a person exhibiting psychopathology does not report experiences of personal distress, for example because they do not want to admit that they are behaving unusual, when they don't experience any personal distress (for example during antisocial personality disorder sufferers) or when they don't experience any distress (for example when abusing substances).

What are explanatory approaches to psychopathology?

To understand many mental health problems, different paradigms are used to gather information about the brain and mind. Symptoms can be explained at various levels, some of which are genetics, behaviour, biology or cognition. These different paradigms are categorized under biological and psychological models.

What are the biological models of psychopathology?

Genetics is the study of heredity and the inheriting of characteristics and is therefore often used to look at the role that heredity plays in psychopathology. Included methods are concordance studies, which look at different family members and the relation between a psychological disorder and the amount of shared genetic material, and twin studies, where monozygotic twins (identical genes) and dizygotic twins (50% shared genes) are used to examine if there is a genetic explanation for psychopathology. Many psychopathologies don't occur spontaneously due to a person's genes. Rather, they are a result of the combination of a genetic predisposition and some environmental influence. This is also known as the diathesis stress model, which suggests that problems develop from an interaction between the expression of our genes and the environment we experience. This model also supports the measure of heritability, which measures the degree to which some quality is explained by our genes, ranging from 0 to 1.

The field of molecular genetics is also involved in finding which individual genes are involved in the transmission of symptoms seen in psychopathology. A common method used is genetic linkage analysis, which examines the role of genes by linking some gene responsible for a specific characteristic (e.g., eye colour) with psychopathology symptoms. So, if some eye color is strongly co-occurring with a psychopathology symptom in a family, it is quite likely that the genes important for this symptom is found on the same chromosome as the one for eye colour. A downside to this method is that some symptom is often not relatable to a single gene, but instead to a greater number of genes interacting. Another subfield of genetics is the field of epigenetics, which does not focus on the altering of the genetic code, but on the expression of current existing genes. There can be many reasons why some genes are or aren't expressed at a certain point in an organism’s life, the field of epigenetics is concerned with finding out what can alter the expression of a gene and what implications these differences in expression might have on the individual.

Neuroscience seeks to understand psychopathology by looking at an individual's biology to help explain symptoms, where the bigger focus is on the brain structure, its function, and also the neuroendocrine system, since hormones contribute a lot to behavior. The two brain hemispheres are connected by the corpus callosum, which is a bundle of nerve fibres. The cerebral cortex, the outer layer of tissue, consists of four lobes. The occipital lobe, found at the back of the brain, is associated with visual perception. The temporal lobe can be found behind the temples to the side of the head, and it's involved with functions such as hearing, memory, emotion, language, illusions, and processing tastes and smells, and the parietal lobe is associated with visuomotor coordination. Located at the front of the head is the frontal lobe, which is known to be important for higher cognitions like problem solving, controlling voluntary movements, willpower, and planning.

Especially the frontal lobes are often implicated in many psychopathologies, since they have such a major executive function over behaviour. Below these lobes many other structures can be found, and some of them are collectively known as the limbic system, which is thought to be involved in emotion and learning. The limbic system consists of the mammillary body, thalamus, fornix, hypothalamus, amygdala, and the hippocampus. The hippocampus is known for being involved in spatial learning, and the amygdala is crucial for processing emotions and learning from them. Especially the frontal lobes are often implicated in many psychopathologies since they have such a major executive function over behaviour. Below these lobes many other structures can be found, and some of them are collectively known as the limbic system, which is thought to be involved in emotion and learning.

The main method of communication between brain structures and thus neurons, is with neurotransmitters. These are chemicals that are the main part of regulating brain functioning. For example, dopamine is often associated with schizophrenia and psychotic symptoms. Serotonin is linked to depression and mood disorders, and norepinephrine and Gamma-aminobutyric acid (GABA) are thought to play a role in anxiety symptoms.

What are the psychological models of psychopathology?

Psychological models try to provide psychological explanations of psychopathology. These models view mental health problems as normal reactions to adaptations to stressful life conditions.

Sigmund Freud (1856-1939), neurologist and psychiatrist tried together with Joseph Breuer to explain symptoms such as hysteria and paralysis that could not be explained by medical causes. Using hypnosis, the symptoms of Freud's clients eased just talking about repressed experiences and emotions. On these cases, Freud built his theory of psychoanalysis. This theory tries to explain normal and abnormal psychological functioning regarding defence mechanisms being used against anxiety and depression. He coined the concept of three psychological forces:

1. ID: describes innate instinctual, especially sexual, needs
2. EGO: rational; tries to control the id's impulses with ego defense mechanisms that also reduce the anxiety that the id impulses may generate.
3. SUPEREGO: develops out of the other two psychological forces, and is responsible for integrating 'values', such as those learned from society or our parents.

Freud said that psychological health can only be reached if all three forces are in balance and that we develop defence mechanisms to avoid conflicts between the three forces or conflicts arising from external factors.

Freud believed that by the way children go through stages of development they could develop psychopathology. Failing to adjust to a particular stage of development could lead to the individual becoming fixed on this stage. The stages are:

• Oral stage: refers to the first 18 months of life where the child is dependent on the food from the mother. Failing to receive food could lead to 'oral stage characteristics', such as extreme dependence on others.
• Anal stage: (18 months to 3 years)
• Phallic stage: (3 to 5 years)
• Latency stage: (5-12 years)
• Genital stage: (12 years to adulthood)

The concepts of the psychoanalytic approach are difficult to observe, measure, and objectively define, which is why this theory is not applied by many psychologists today.

The behavioral model explains psychopathology in terms of learned reactions to life experiences. The learning theory, based on principles of classical conditioning (e.g., dog salivating) and operant conditioning (e.g., Skinner's box), explain how dysfunctional behavior can be acquired just like adaptive behaviour. For example, many emotional disorders are explained by classical conditioning such as specific phobias or even post-traumatic stress disorder (PTSD).

Behavior therapy is based on the principles of classical conditioning and operant conditioning, the goal of which is to unlearn behaviors or emotions that are maladaptive. Behavior modification therapy focuses on the principles of operant conditioning.

The cognitive model describes how psychopathology develops through the acquisition of irrational beliefs, the development of dysfunctional ways of thinking and information processing biases. According to Albert Ellis (1962), people judge their own behavior according to the irrational beliefs they developed, which cause emotional distress (e.g., anxiety). Aaron Beck developed a successful cognitive therapy against depression, which rests on the idea that people develop unrealistic expectations that guide their view of themselves, the world and their future.

When the dysfunctional beliefs which maintain the symptoms of psychopathology are identified, they can be changed and replaced by functional cognitions. Cognitive behavior therapy aims at changing behaviors and cognitions. Even though this approach has been widely adopted and successful, there is not much known about the origin of the dysfunctional thoughts. The dysfunctional thoughts could merely be a symptom of psychopathology rather than a cause of it.

The humanistic-existential approach works with the view that individuals can acquire insight into their lives from a wide spectrum of perspectives, and only by gaining this insight can they achieve insights into their emotional and behavioral problems. Then, psychopathology and conflicts can be resolved.

Client-centered therapy is an approach in which the therapist makes use of empathy and unconditional positive regard to help the client achieve a sense of positive self-worth.This approach places little emphasis on the acquisition of psychopathology but tries to place the client from a phenomenological perspective, such as one consisting of fears and conflicts, into one that is functional (e.g., where the client feels self-worthy). This form of therapy is used only by some clinical psychologists, as the humanistic and existentialist approach is hard to evaluate.

What are perspectives on mental health and stigma?

Many still hold negative views of those with mental illnesses. This might be explained due to a lack of knowledge, which is why it is important that people are educated about mental health, so that sufferers will feel less stigmatized and be treated the same as anyone else.

What are the types of mental health stigma?

There are two types of mental health stigma: social stigma which is directed at others who are suffering from some sort of mental health problem, and perceived stigma (or self-stigma) which are the internalized feelings of discrimination a sufferer experiences due to their condition. The latter can be quite discouraging and result in a negative impact on possible treatment outcomes. Some of the biggest stigmas are that 1) patients are often dangerous, 2) that some disorders are self-inflicted, and 3) that sufferers are often hard to talk to.

Who hold stigmatising beliefs?

Stigmatising beliefs about individuals with mental health problems are held by a broad range of individuals within society. This happens regardless of whether they know someone with a mental health problem, have a family member with a mental health problem, or have good knowledge and experience of mental health problems.

What causes stigmas?

Misguided views that the mentally ill are dangerous or shouldn't be part of the society might be the basis why some still think that these people should be excluded and treated differently. Current views on mental health can still be stigmatizing, such as the medical model which implies that sufferers are different from others, or the fact that a label is put on those suffering from a mental issue does not help to alleviate any negative stigma. Another source of misguided views on mental health are the media.

Why are stigmas a problem?

Stigma can be discriminating, which results in social exclusion, low self-esteem, poor social support, and poor subjective quality of life. All of these factors have a huge impact on the treatment of mental disorders, like slowing down the recovery or even worse demotivating the sufferer from undergoing any treatment.

How can stigmas be eliminated?

Much is done to eliminate stigma, like the Time to Change campaign (UK), which attempts to educate people about mental health with the use of blogs, videos, TV ads and events. Campaigns like these that are made to make contact between individuals with and without mental illnesses, have been shown to improve the attitudes towards people with mental health problems, promote people's behavior for anti-stigma engagement, and lastly increase the willingness of people to be open about any mental health problem they might experience in the future.