19. What Happens When Things Go Wrong: Mental Illness, Part II

Professor Paul Bloom:
The final topic of the course is clinical psychology,
also known as abnormal psychology or psychopathology,
and this, for many of us, is what psychology is really
about. It’s about mental illness.
It’s about clinical psychologists. And we started talking about
this when Dr. Nolen-Hoeksema gave her guest
lecture last week and I want to continue through this today.
It is a topic of tremendous scientific importance but also a
topic of great personal importance for many of us.
Many of the people in this room have been mentally ill,
strictly speaking, at some point in their lives.
Some of you are under some sort of therapy or treatment or
medical intervention right now. Some of you are on Prozac or
Zoloft or Ambien or Wellbutrin or any of those other
medications to deal with psychological problems you are
facing. Others are also talking to
psychiatrists, psychologists,
social workers, and other people.
Many of you who are not at this point mentally ill will become
mentally ill during your stay at Yale.
[laughter] And this is a difficult period
in many people’s lives and it’s a period of people’s lives where
mental illness emerges in many of us.
By one estimate, one half of all college
graduates in the United States – and the number is very high
with college graduates, highly educated people – one
half of you will have some sort of mental illness in your life
serious enough to require some sort of treatment.
Those of you not directly affected with mental illness
yourselves will no doubt experience your loved ones,
your family, your friends getting some sort
of illness, be it Alzheimer’s or schizophrenia or depression or
some sort of anxiety disorder. So the personal importance of
clinical psychology, the personal importance of
understanding what can go wrong and how best to treat it,
simply can’t be underestimated. Now, when we talk about mental
disorders, the scope of this is very broad.
It includes the prototypical schizophrenic which you could
see on the streets of New Haven, somebody walking and gesturing
and talking to themselves and sometimes screaming.
It includes alcohol addiction and cocaine addiction and other
addictions. It includes somebody with Down
syndrome or autism, an old person losing his
memory, a teenager falling into a deep
depression, somebody with a severe social phobia to the
extent that he or she can’t leave the house.
Then there are also very hard cases where it’s difficult to
say one way or another–that guy’s photographing me as I’m
talking and it’s freaking me out [laughs]
[laughter] in kind of a social phobia way.
There’s difficult cases where it’s just hard to tell mental
illness from just bad behavior in general.
So, consider a killer without a conscience or a mobster like
John Gotti. Is he mentally ill?
And this is a question which is a deep one and we’ll wrestle
with it a little bit actually towards the end of this lecture.
What about somebody who acts in a kind of unusual or zany way?
This is originally supposed to be a picture of the character
Kramer on “Seinfeld” but, given his unusual antics in the
last few months, it could be a picture of the
actor who plays him who got into all sorts of trouble.
What about someone who is just kind of wacky?
At what point does wackiness move into the domain of mental
illness? What about unusual lifestyles
such as extreme altruism? Batman devotes most of his life
to helping others. He sleeps one hour a night and
this hour is fraught with nightmares and then he fights
crime. What about somebody,
and this was a case reported in The New Yorker a few
months ago, who has lots of money and a
loving family and has his kidney removed to help a stranger?
And he says, “I have two kidneys.
It’s minor pain, a minor operation.
I could save someone’s life.” And his wife says,
“You’re mentally ill. That’s just crazy to do that.”
Where do we draw the line? And so, there are these great
philosophical and moral questions over the boundaries
and how to think about mental illness.
So, how should we think about mental illness?
Well, there are some answers we could quickly dispense with.
It used to be thought that severe mental illness was a
result of demonic possession. If you read the Gospels,
Jesus Christ wandered around a lot, met crazy people and
exorcised the demons from their bodies.
It was a common way of thinking about craziness.
We now believe that this is not true.
What about–yeah, it’s not true. What about social deviants?
Some people including the psychiatrist Thomas Szasz claim
that when we label somebody as mentally ill this is not a
medical decision. It’s rather a social decision
designed to ostracize people who deviate from society’s norms,
to ostracize them and rid them of moral agency.
It’s not that we disagree with them.
It’s not even that we see them as evil.
Rather, we see them as sick and as such we don’t even have to
accord to them the respect that we accord to criminals.
Now, this is not entirely an unreasonable view.
In many countries around the world, dissidents,
people who argue against the state, are often determined to
be mentally ill and thrown in asylums.
Blacks in the United States who tried to escape from slavery
were described as having a mental illness.
Why would they want to do so unless they were mentally ill?
Up until 1973, to be a homosexual,
to be gay, would count in the official records of how we
classify illness as being mentally ill.
And many people saw this, and we see this now,
not so much as reflecting a sort of unbiased medical
analysis but rather as reflecting biases that people
have against gay people. And these are political and
social and moral biases. They are not objective medical
judgments. Even now I’ve been recording
every president that has been the president of the United
States in my memory including Bush and particularly Clinton
has been described by his opponents not merely as awful,
evil, terrible, “hate his policies,” but as
mentally ill. Every president at some point
or another, some bright, intelligent person figures to
call him a psychopath and put that in Time magazine.
Now, put aside whether–the extent to which these things are
accurate, point being that we often use medical labels,
particularly labels like “psychopath,” “schizophrenic,”
“delusional,” to ostracize and pick out people we disagree
with. At the same time though,
this is not entirely right. People go too far when they say
there’s no such thing as mental illness.
Some people are mentally ill in a very real sense of “illness,”
in the same sense we would describe somebody as physically
ill if they were to have cancer. This illness damages their
functioning. They cannot function well.
They do not tend to be more creative or more productive or
more vivacious. Rather, for – with very few
exceptions; possibly some exceptions
revolving around mania as Dr. Nolen-Hoeksema discussed –
with very few exceptions being mentally ill is just very bad
for you in every possible way. Moreover, when people are
treated, when people get better, they become more competent,
happier, better able to participate in the world,
and they do not choose to go back to their mental illness,
suggesting that it really is illness in the serious sense.
And so the modern treatment of psychological disorders treats
them as disorders like medical disorders.
Schizophrenia is as much a disease as is cancer and should
be thought of in the same way. There’s a whole field of
abnormal psychology of tremendous scope.
We’ve already discussed many mental illnesses in the context
of other things. So, for instance,
we talked about amnesia in the context of memory and how it
works. We talked about autism in the
context of social reasoning. There are many more and I’m not
going to read through them. These are the major categories
just for people’s interest from The Diagnostic and Standard
Manual. You don’t have to–you’re not responsible for
all of these. And this is an illustration,
which people might find interesting, of sex differences
in these–in the major disorders.
And the patterns, as you could see,
are kind of neat. Women are more prone to have
anxiety disorders and mood disorders.
Men are much more likely to suffer from substance disorders,
particularly alcoholism. Schizophrenia is sort of evenly
matched but antisocial personality disorders,
sometimes known as sociopathy or psychopathy,
is predominantly male. And we’ll turn to that a bit
later. Here are the major ones which I
want to review today. I’m not going to talk about
mood disorders at all because this was the topic of the superb
lecture we heard last week but I want to quickly review
schizophrenia, the class of disorders known as
anxiety disorders, the class of disorders known as
dissociative disorders, and the class of disorders
known as personality disorders. And these are the main
psychological problems. When a psychologist or
psychiatrist does his or her work, they’re predominantly
focused on somebody who has one of these problems.
Some of them are rare but some of them such as anxiety
disorders and the mood disorders are very common. About 1% of the world’s
population suffers from schizophrenia and this is the
most common reason for being in a mental hospital.
And the reason for that is because of its severity,
because of how terrible an illness it is.
Schizophrenics have been described as the lepers of the
twentieth century by people who pointed out that in the last
hundred years people who are schizophrenics are just–there’s
no place for them in society. They’re shunned.
They’re rejected. We have no idea how to treat
them or how to help them. The roots of schizophrenia come
from the terms “split” and “mind” but the idea is there is
a split from reality. It’s important to stress the
sort of etymological point because sometimes people confuse
schizophrenia with something–with split
personality and they somehow think schizophrenia refers to
having multiple personalities. This is incorrect.
A multiple personality disorder is an entirely different
disorder. It’s a sort of dissociative
disorder. Split personality–people with
schizophrenia do not have multiple personalities.
What they have is a problem with relating to reality.
It’s roughly equally split between the genders but it
strikes men earlier and it happens between–around these
ages and as you could see roughly–and,
as you could see, it is the sort of thing that
could make its first occurrence while you’re in college or
university. There are five symptoms –
main symptoms of schizophrenia. Four of them are the positive
symptoms, meaning things that you do, that you have that’s
unusual. One is a negative symptom,
something that you don’t have, something that a schizophrenic
lacks. So, just to walk through them,
a hallucination is an experience, a sensory
experience, that isn’t real. So, the most typical
hallucinations are auditory. Schizophrenics hear voices.
They hear sounds, particularly people telling
them to do things, that aren’t real.
Sometimes there are auditory–there are visual
hallucinations or hallucinations of smell and taste but a typical
hallucination is auditory. Sometimes the voices are seen
from coming from oneself and so you could sometimes stop the
hallucinations by doing things like humming or counting or
holding your mouth open. And some schizophrenics will do
this in an attempt to block auditory hallucinations.
There are delusions. The difference between a
hallucination and a delusion is a hallucination is a sensory
experience that’s wrong, that just didn’t really happen.
A delusion is a belief that isn’t right.
It’s a belief that you shouldn’t be having.
Now, again, the question of what counts as a delusion and
what counts as accuracy can be a controversial one.
Richard Dawkins titled his recent book The God
Delusion, describing this mass delusion that many people
have that they believe there’s a supernatural being who created
the universe and who is watching them.
Some people find that offensive, to call it a delusion
and people will have different views.
The delusions schizophrenics have tend to be pretty clearly
weird and wrong. They often tend to believe they
are famous people. Many schizophrenics have a
religious bent and believe that they are Jesus Christ.
In 1959, there was a Michigan hospital that had three Jesus
Christs in it and they would meet and talk.
One theme of delusions is what’s called “ideas of
reference.” And ideas of reference are you
think that there’s all sorts of things happening that revolve
around you. You hear people whispering and
you think they’re talking about you.
You pick up the newspaper and you believe that there’s coded
messages in it that are directed towards you.
You might believe that there is some sort of omnipotent,
powerful force conspiring against you or trying to
manipulate you like aliens or the FBI,
the CIA, the government. You might believe that they
have some sort of evil plan in mind for you.
There is disorganized speech. Some schizophrenics babble.
They talk and it’s nonsense. If you listen to a
schizophrenic on the street, sometimes what they’re saying
makes no sense at all, not merely that they’re
conveying ideas that are unreasonable but it’s just
garbled, it’s just a mess.
And sometimes there is disorganized behavior too,
odd motor movements. And the most extreme cases of
this are motor movements described as “catatonic” where
the person doesn’t move, often freezes in a position.
Those are all positive symptoms. A major negative symptom in
schizophrenia is absence of normal thought or affect,
affect meaning emotion. So some schizophrenics might
just not talk. They might have very low
emotional responses. They might not care about
anything. The basic psychological
misfunction–oh, sorry. There are different subtypes of
schizophrenia. There are five major subtypes
but I’m going to focus on the three major ones,
the three most interesting ones.
The first one is paranoid schizophrenia.
So, paranoid schizophrenics believe that others are spying
and plotting against them. And they often have delusions
of grandeur. They often believe that other
people are jealous of them. They might believe they have
supernatural powers. They might believe that they’re
God or a messiah. The catatonic schizophrenics
are unresponsive to their surroundings and often they’ll
just repeat what people say to them,
they won’t generate their own speech.
And finally, the disorganized schizophrenics
are maybe what you most think of when you think of somebody who
is insane. They make no sense.
They have delusions and hallucinations.
They babble. They–their actions–they could
be dangerous. They could be perceived as
dangerous. They’re unable to help
themselves. They’re unable to do anything
in their lives. It’s hard to pin down exactly
what’s at root of all of these problems but a very general
summary is that there is a problem – an inability to put
together your thoughts and perceptions,
to sequence them and coordinate them, to impose a logical
structure and a reasonable, realistic temporal sequence on
your experience. This is the core thing going
wrong but what happens as a result of this is you lose
contact with others, you lose social contact.
Losing social contact means you don’t get much reality checking.
If I start acting weird and nobody cares,
I could just get weirder and weirder,
while if I’m in a good social group of people who care about
me often the situation could be brought under control.
So, schizophrenia is sort of a vicious circle where you have
this cognitive problem. Then you have problems losing
contact with others, exaggerating the cognitive
problem, and so on. A lot of people have studied
the genetics of schizophrenia. It’s clear enough that there is
a powerful genetic component. I could–you can tell how much
at risk somebody is for becoming schizophrenic based on the
schizophrenia and illness of their family members.
In particular, if you have an identical twin
who’s schizophrenic, your odds are about a half of
becoming schizophrenic yourself. At the same time,
and we dealt with this as well when we talked about issues of
sexual orientation, the fact that identical twins
the odds are only 50% means there has to be an environmental
component to it. If it was entirely genetic,
it would be 100%. And so one claim–one way of
looking at it is your genes make you vulnerable to schizophrenia
but whether or not you become schizophrenic depends on what
happens in your environment. You’re sensitive to certain
triggers. Some triggers might happen
early. There is some evidence that
schizophrenia is associated with trauma even at the point of
birth. And there’s some other evidence
that schizophrenia is linked to viral infections.
As an example, there are more schizophrenics
born in the winter, subtle–a subtle difference but
there seems to be a reliable effect of more schizophrenics
born in the winter. More people get sick in the
winter. At times when there’s been some
sort of epidemic or some sort of plague, this seems to cause a
jump in the frequency of schizophrenics born at that
time. There’s some recent research
that ties schizophrenia to the possibility of toxoplasmosis,
which is a disorder carried by cat feces.
The experiment basically involved asking the parents of
schizophrenics one question: “Did you own a cat when your
child was born?” And if the answer was “yes,” it
seemed to correspond to a bit higher odds for schizophrenic
families than for non-schizophrenic families.
A different sort of trigger is stressful family environments.
Schizophrenics seem to really have more stressful family
environments than non-schizophrenics.
Now, we have to be careful about this.
We have to bring–we have to return to the sort of
methodological cautions we had in mind when we talked about
individual difference research in general.
Remember we talked about the worst study in the world and one
of the features of this was it was failing to pull apart cause
and effect. It might be that having a
difficult family environment ups your odds of becoming
schizophrenic. On the other hand,
it might also be that schizophrenic children or
children who will become schizophrenic are difficult to
deal with in certain ways causing a family environment.
So, it’s not clear whether the effect is from difficult family
environment to later schizophrenia or from
schizophrenia to difficult family environment.
There used to be a very popular theory of schizophrenia,
which is that it was caused by excess dopamine.
Dopamine, you’ll remember, is a neurotransmitter.
And there is some reason to take this seriously.
Drugs that reduce dopamine provide some help in reducing
symptoms. And if I give you a drug that
shoots up your dopamine that will turn you into a temporary
schizophrenic. You get what’s called
“amphetamine psychosis” and it’d give you–it can give you
schizophrenic-like symptoms, hallucinations,
delusions, that sort of thing. This–There might be something
to this theory but we know now it can’t be complete for at
least two reasons. First, it doesn’t explain the
negative symptoms. It explains hallucinations and
delusions and so on but it doesn’t explain the loss of
affect, the quietness, the stillness.
Also, there seemed to be some sort of structural brain
differences involving enlarged cerebral ventricles,
involving reduced frontal lobe activity, suggesting that the
problem with schizophrenia is a lot more complicated than others
might have it, than the dopamine theory would
have it. I’ll end with a mystery.
And this mystery is discussed nicely in the Gray textbook.
The symptoms of schizophrenia, the prevalence of
schizophrenics, is similar wherever you go but
less industrialized countries have a better rate of recovery
from schizophrenia than industrialized countries.
And nobody really knows why. I listed here three
possibilities. One is that the families that
were–that–in a less industrialized country there’s
more latitude and so there’s less critical- less criticism.
There’s less use of antipsychotic medication.
Antipsychotic medications help with the symptoms but they might
also impair recovery. And finally,
if you think of schizophrenia as a transient disorder,
maybe that will in some sense, in some way,
make that more likely to actually happen. The second sort of disorder I
want to talk about, much more common than the 1%
that’s schizophrenia, is the classic disorders known
as “anxiety disorders.” The primary disturbance in
anxiety disorders is anxiety; you have a lot of anxiety.
It’s persistent, either anxiety or maladaptive
behaviors to reduce anxiety. Now, everybody experiences
anxiety. If you didn’t experience
anxiety, you’d be a very strange person and you probably wouldn’t
function very well in the world, but you have an anxiety
disorder when you experience too much of it, it’s uncontrollable,
it’s unreasonable and it messes up your life.
And there’s quite a few anxiety disorders.
The simplest one is this generalized anxiety disorders
where–and this is about one in twenty people will get it at
some point in their lives and you worry all the time.
You’re just very anxious. You’re just worried all the
time and it could be paralyzing. It could give you physical
symptoms like headaches, stomachaches,
muscle tension and irritability.
There is some evidence that generalized anxiety disorder has
a genetic component, that it’s somehow related to
major depression. And it does seem to have its
possible roots in some sort of childhood trauma.
And so the model some people give for this is when you are
young something really bad happens to you.
This makes you hyper-vigilant. You don’t trust the world,
bad things could always happen around the corner.
And because you’re hyper-vigilant you are more
prone to develop generalized anxiety disorder after a
difficult life event. A second sort of anxiety
disorder, which we already discussed in class are phobias
and phobias are intense, irrational fears.
They could focus on objects, events, and social settings.
Here’s a nice diagram of different phobia,
different things, and their proportion of people
who are afraid of it. And the point of this diagram
isn’t with the details. It’s really–It’s rather to
give you a feeling for the fact that some things most everybody
is afraid of or a lot of people are afraid of and some things
not many at all. The big phobic object we know
from previous lectures is snakes.
About 40% of the population say they’re afraid of snakes.
How many people here are afraid of snakes?
Okay. And then there’s a really
terrifying thing, mice.
How many people are afraid of mice?
Mice are the worst things in the world.
[laughter] And then cats and if you’re
afraid of cats that’s really unusual.
Not many people are afraid of cats.
There is a classical conditioning model of phobias,
which we are all familiar with, but we are all familiar with
why it is not a very good theory.
A lot of people who are afraid of snakes have never had a bad
experience with snakes. Moreover, a lot of people who
have had bad experiences with things like car crashes and
being electrocuted on a socket or a shooting,
seeing a gun during a shooting, do not develop phobias.
This lead–gives rise to a much more plausible theory known as
the “preparedness theory,” which says that we have evolved
to be sensitive to certain phobic objects,
objects that were dangerous to us in our evolutionary history.
And we’re prone to develop phobic responses to this.
The final anxiety disorder is obsessive-compulsive disorder.
Obsessions are irrational disturbing thoughts that intrude
into your consciousness. This is–hits about two to
three percent of the population and it leads to compulsions,
repetitive actions performed to alleviate the obsessions.
For instance, you might be obsessed with the
idea of being dirty, your hands are dirty,
you’re filthy. That might lead to compulsive
washing. You might believe that God is
angry at you and that might lead to compulsive prayer.
Cleanliness and religion are common themes of
obsessive-compulsive disorder. You often know,
rationally, that these are unreasonable behaviors but you
can’t help yourself from doing them.
Sometimes I get the worry that I left my door unlocked and I
run back and checked it–check it.
But I feel it’s a little bit of OCD coming on because I know I
locked it, but did I really lock it?
And then you get–now I’m worried if I locked my door.
Checking and washing. Checking is what I’m talking
about here- most common compulsions, and it seems to
have a neuropsychological phenomena.
At least it’s related to heightened neural activity in
the caudate nucleus. What’s interesting is you might
think obsessive-compulsive disorder is a very sort of
Freudian, psychoanalytic sort of disorder
but actually it’s treated quite well with drugs,
drugs that affect the serotonin level.
Serotonin, being a neurotransmitter,
can often do good work for obsessive-compulsive disorders.
So, if you develop a disorder, an OCD problem,
you might find yourself being cured simply with medications. We’ve talked about
schizophrenia and anxiety disorders.
Any questions or thoughts so far?
Yes. Student: What’s the
difference between OCD and Tourette’s or are they
[inaudible] Professor Paul Bloom:
It’s a good question. The question was the
relationship between OCD and Tourette’s.
Tourette’s is–I don’t know much about it but it’s a very
specific neurophysiological syndrome that doesn’t have–you
don’t have obsessive thoughts. What it leads to is involuntary
tics and tremors and sometimes sort of shouted obscenities or
taboo words. And it seems to be very
specific to that while OCD is much broader and involves both
behaviors but also the behaviors are in the service of thoughts.
That’s one way of thinking about the difference.
Yes. Student: Can individuals
have multiple disorders like be bipolar and schizophrenic?
Professor Paul Bloom: Yes.
The question is can individuals have multiple disorders?
Absolutely, and in fact some disorders are “comorbid.”
And that’s just a fancy way of saying they often go together.
So, if you have a severe depression for instance,
which is a mood disorder, you may also have an anxiety
disorder. So yes, having one
unfortunately doesn’t immunize you against having another.
Yes. Student: Where does
superstition [inaudible] Professor Paul Bloom:
The question was about superstitions.
I think–it’s an interesting question which I have never
thought of before. I think it depends on the
severity of superstitions. So, if you just have a
superstition saying “Step on a crack, break your mother’s
back,” which has never been
scientifically proven, [laughter]
but suppose you–and then so you’re just kind of “Oh,
I kind of–I just kind of–” or it’s bad luck to break a mirror
and that’s it, you just have it and it doesn’t
make a big deal to you, that’s harmless.
On the other hand, if your superstition is such
that you develop weird rituals; you might have to carefully
walk so you don’t step on any other–on any cracks or you
might have to do–or if you do you might have to go back and
start your whole walk to work over again.
When it gets to that level it could creep into OCD.
And often obsessive-compulsive disorders have a religious or a
magical manifestation where you believe there are certain things
you must do or terrible things will happen and in that way you
could view them as extreme and build from superstitions,
but simple superstitions don’t tend to be of that type.
Yes, in back. Student: [inaudible]
Professor Paul Bloom: The question is “are people with
schizophrenia dangerous?” As a rule statistically,
it tends not to be the case. They tend to be more likely
victims than harmful. They tend to be fairly helpless.
You can have a case where a schizophrenic might harm
somebody. A paranoid schizophrenic,
for instance, might develop a delusion to
harm somebody and so there are definitely such cases but for
the most part, again, they are more victims
than oppressors. They’re more–they’re very
vulnerable because they aren’t capable of dealing with other
people. They often aren’t capable of
defending themselves. One more.
Yes. Student: How permanent
are the effects of the medications?
Professor Paul Bloom: The question is,
“How permanent is the effect of the medication?”
Do you mean for schizophrenia? Student: Do they have to
stay on the medication for [inaudible]
Professor Paul Bloom: Yes.
In general, I think. I can’t think of any exceptions.
The effects of medication are temporary.
Now, that doesn’t mean if you have a bout of OCD or depression
you have to be on medication the rest of your life.
What could happen is, for instance,
somebody–if you had a mild depression, go on something like
Prozac or Wellbutrin, use that time to kind of get
your life back together, cheer up a bit,
and then when they go off the medication they are fine.
But as Professor Nolen-Hoeksema pointed out, unless they’ve
developed coping skills they’re likely to relapse and get the
problem again. So, the physical effects of
medication are always temporary, particularly with anybody with
schizophrenia, but they can often help people
get out of a problem, anxiety or depression.
Okay. Dissociative disorders.
I’ll show you a movie clip and then we’ll go back and talk a
little bit about it. Let me ask you a question that
might seem somewhat uncaring. How many of you think he’s
faking? How many of you [laughter]
are confident there are many people living inside his head
as–in the way it’s depicted? Okay.
How many of you are unsure? How many of you have two minds?
There is one part of you struggling– [laughter]
It’s–let’s go–we’ll go back to him.
Dissociative disorder are disorders involving
dissociation. And what people mean by that is
literally a dissociation of memory;
that is, you become somehow unaware, separated from some
part of your identity or history and you’re unable to recall
those parts of your identity and history except sometimes under
special circumstances. Now, some degree of
dissociation is normal. There is–I will–I have here
in, actually, Dr.
Nolen-Hoeksema’s excellent abnormal psychology textbook a
checklist of dissociative experiences many of which normal
people have: “Not sure whether one has done something or only
thought about it.” Anybody ever have that?
Common. “So involved in the fantasy
that it seems real.” [laughter]
“Feeling as though one’s body is not one’s own.”
I will also add that experiments with pharmaceuticals
can often lead to dissociative experiences.
[laughter] “Driving a car and realizing
that one doesn’t remember part of the trip.
Talking out loud to oneself when alone.”
Okay. “Not recognizing one’s
reflection in a mirror.” Okay.
That’s not very common [laughter]
but it is–it’s within the normal range but then you get
more severe cases and there is three different types:
dissociative amnesia, dissociative fugue,
and dissociative identity disorder.
Dissociative amnesia is illustrated in a story of a
woman who sees something terrible and as a result her
memory of that experience was no longer accessible.
It’s often known as “psychogenic amnesia.”
The only thing wrong in here is you have memory loss.
And sometimes it’s a selective memory loss but sometimes it
could be global. It’s as in these movies cases
where you lose your memory because something terrible has
happened and you would get it back later but you have a
temporary loss of identity. The idea is that something so
terrible has happened you separate yourself from your
previous identity and your memory.
Over half of people charged with homicide claim to have some
degree of dissociative amnesia. The problem here is that many,
many, many of those cases involve alcohol and drugs,
which can lead to some sort of alcoholic blackout.
Also, people could be lying. If you’re charged with murder,
it’s often a reasonable thing to say, “I don’t remember any of
this,” to just kind of–and–as a way
to distance yourself from it. Dissociative fugue is kind of
weird and interesting. The guy’s wife leaves him for
another man. Six months later he was
discovered tending bar in Miami Beach and calling himself
Martin. And he totally wiped out his
past memory and developed a new identity.
This is also known as “psychogenic fugue.”
So, it’s global amnesia but there’s also identity
replacement. You leave home,
you develop a new identity, and it’s called a fugue state.
This is my favorite mental disorder.
If I had to get a serious mental disorder,
I would get this because I’d get to travel.
When it wears off your old identity comes back and your new
identity is forgotten. Then there’s dissociative
identity disorder and this is a story of this woman who goes
back and forth from her regular personality to a personality of
Donna who is only six years old. This was originally known as
“”multiple personality disorder” and the idea is you have two or
more distinct people in one head.
It is–there are–It is a rare and controversial disorder but
it includes some very famous cases and has been illustrated
in many movies and books including the wonderful movie
Primal Fear where–Ed Norton’s first big movie,
highly recommend it. And it’s been tried as a
criminal defense. The Hillside Strangler claimed
to be two people but he was still convicted,
both of them. It typically starts early,
the pattern of dissociation. Mostly it’s women.
And mostly, it involves some sort of recollection of torture
or sexual abuse. Also, and to get back to your
question, can you have more than one mental disorder at the same
time, people with dissociative
disorder often show symptoms of posttraumatic stress disorder or
PTSD. What causes it?
Well, it is often argued to be the cause–caused by severe
abuse, often sexual or physical abuse.
The problem is most people who get abused don’t develop
dissociative identity disorder. And one idea is that it’s abuse
plus some sort of genetic or biological predisposition to
dissociate and in fact, people with dissociative
identity disorder seem to be very susceptible.
They’re easier to hypnotize than other people.
And so it might begin as sort of a self–an act of
self-hypnosis. You put yourself in a hypnotic
trance to cope with some terrible situation and you begin
to develop new and separate and distinct personalities.
Now, of the many things I’m going to talk to you,
I’ve talked–spoken about, some have been very
controversial. One issue of controversy which
we talked about was the existence in nature of so-called
“repressed memories.” This is another very
controversial case related to the repressed memory case.
In a recent poll, less than one quarter of
psychiatrists believe there is such a thing as dissociative
identity disorder. Why would you doubt that?
Well, there are some curious statistics.
Between 1930 and 1960, there were two cases in the
United States. In the 1980s,
there were 20,000 cases. You cannot go elsewhere from
the United States and find people with dissociative
identity disorder. It seems to be an American
phenomena. And it varies by therapists.
Some therapists, indeed some hospitals,
some medical units go decades without ever seeing anybody that
approaches dissociative identity disorder.
Other therapists, virtually every patient they
have has multiple personalities. One worry based on these facts
is dissociative identity disorder is in a sense real,
that Richard really does believe he’s moving from
personality to personality but he didn’t come in to therapy
with that problem. Rather, his therapist gave it
to him. The claim is that it’s the
result of suggestion by the therapist.
The therapists, and they’re typically good
people who wish to help, but the therapists might be in
the grips of a theory involving repression and multiple
personalities and different selves and encourage,
either tacitly or overtly, their patients to develop these
separate personalities. Related to this,
it’s not clear to what extent dissociative identity disorder
is an extreme version of normal psychopathology–sorry,
of normal psychology. So people, from the philosopher
Dan Dennett to the psychologist Judith Harris,
have pointed out that we’re different selves in different
situations. We can consciously play act the
different selves but we could also just shift personalities
depending on whether we’re with our friends or our family or
with strangers. The claim is that dissociative
identity disorder, however dramatic it looks,
might merely be an extended version of this where people as
well are to some extent play acting to make their therapists
and doctors happy. Any questions about
dissociative identity disorder? Yes.
Student: [inaudible] Professor Paul Bloom:
Yes. Dissociative amnesia–the
question involves the relationship between
dissociative amnesia and the retrograde and anterograde
amnesia discussed before. Those other amnesias are the
result of brain damage. They tend to be if not
permanent long lasting and severe.
Dissociative amnesia is apparently caused by specific
life events and can often be very short-lived.
They’re, of course, all brain events but in the
crude sense the dissociative amnesia is more of a
psychological happening than the other sorts of amnesias that we
talked about involving Korsakoff syndrome and the patient “HM”
and so on. Other questions.
Yes, in back. Student: [inaudible]
Professor Paul Bloom: Yes.
What happened in 1960–There was a very famous case.
I think the case was the case of Sybil.
Does anybody know? The teaching fellows are
nodding but there was a very famous case which I think was of
Sybil which was made into a movie and discussed and had a
huge influence on people and then they started to believe
that it was real. There is a type–The fourth and
final type of disorder is something which is not actually
discussed in the Gray textbook but it has to do with
personality and this is interesting because it probably
extends to some extent to many of these people–the people in
this room. Personality,
as you remember, is your way of dealing with the
world, in particular the way you have of dealing with other
people. The notion of personality
disorders is that some personalities are so bad that
they veer off into mental illness so one personality
disorder is a narcissistic personality disorder.
Everyone likes to talk about themselves and thinks they’re
terrific to some extent, some people to a little bit too
much, but if it’s really extreme they could talk–they–you could
get labeled with a narcissistic personality disorder.
You might have an avoidant personality disorder,
dependent, histrionic, borderline.
Borderline is really bad. When people describe you as a
borderline personality disorder, that just means you’re just
awful to be with, you’re kind of awful.
[laughter] There is the paranoid
personality disorder which is not that you’re paranoid
schizophrenic, very clearly no signs of
schizophrenia, no hallucinations,
nothing like that. You are just paranoid.
You’re just–to a greater extent than normal,
you think other people are against you and plotting against
you. The most interesting
personality disorders in my mind have to do with violence and
crime and they have to do in particular with something called
“antisocial personality disorder.”
Now, most murderers are not mentally ill in a medical sense.
They’re not mentally ill according to how clinicians
categorize things. To some extent,
most people who kill are just normal people being driven by
normal desires, rage, jealousy,
hate, just taken to an extreme. Even mass murderers do not as a
rule appear to be substantively different from a psychological
point of view. In every society–and honestly,
I wrote the lecture on this quite a while ago but,
given the recent events, they stand as a perfectly good
example of what I’m going to say.
In every society there is a notion of somebody who has been
deeply humiliated, usually male,
and he’s been humiliated over and over again.
He sees himself as losing status and losing status and
losing status and he tries to get it all back,
to gain face with one act of terrible violence where he takes
his revenge over everybody and then is known as–and as a
result, even though he might die,
he probably will die, makes his way to a level of
social status he would have never gotten before.
The American term for this used to be “going postal” and–but
this is an old idea. Stone Age tribes in Papua,
New Guinea, had a term for this.
They call it “running amok” and this is–and every society has
this. So, there’s normal murderers,
there’s mass murderers, and then there’s the
interesting cases like serial killers like Dahmer or Son of
Sam, Ted Bundy, John Wayne Gacy,
even the imaginary Hannibal Lecter.
Many of these sort of serial killers do have some sort of
mental illness but the mental illnesses are all over the
place. There was a guy,
Jerome Brudos, who had such a severe fetish
for women’s feet that he killed young women and severed their
feet and then kept their feet around his house.
Son of Sam was pretty clearly a paranoid schizophrenic.
He did his murders because a barking dog told him to.
Jeffrey Dahmer is a cannibal killer and he killed people so
he could eat them and then–and I asked one of my colleagues in
clinical–colleagues what exactly was wrong with him and
the person immediately responded,
“He has a severe eating disorder.”
[laughter] So, it’s–it was a joke.
It was in very, very bad taste. [laughter]
A lot of [laughter] murderers claim to have
dissociative disorders, “it wasn’t me who killed the
guy, it was my alter ego, Fred.”
It’s not clear how often they’re telling the truth,
if ever or whether this is a way of escaping responsibility.
There is a mental illness–There’s an extreme,
specific version of a personality disorder that
revolves around violence, and this is known as
“antisocial personality disorder.” It is–it used to be called
moral insanity. Now it’s often called
psychopathy. Some people make a distinction
between psychopath and sociopath.
For the purposes here others don’t, and for the purposes here
I’m going to blend them into one category.
Then I’ll use the term “psychopath.”
They’re typically male. They are defined as selfish,
callous, impulsive, they’re sexually promiscuous.
They seem to lack love, loyalty, normal feelings of
affiliation and compassion, and they get into all sorts of
trouble because they’re easily bored and they seek out
stimulation. Now, when you hear this,
you’ve got to realize that this sort of person is not
necessarily an unattractive person to imagine or think about
or even under some circumstances to encounter.
You have to avoid the temptation when you think about
psychopath to think about a guy like this, to think about
Hannibal Lecter. The most famous psychopath,
of course, is James Bond who is a perfect psychopath in every
regard as played by him also by Sean Connery.
The Roger Moore and Timothy Dalton characters were not
psychopaths. I could give a whole course on
that. Is this an illness?
Well, again, this is one of the hard cases.
Psychopaths don’t come in for treatment.
James Bond would never go to a therapist and say,
“I have a problem with promiscuity and my life of
adventure. [laughter]
Why is it that I don’t have this need to settle down and
have kids and be a one-woman man?”
They don’t have a problem with it.
Other people often have a problem with it but it’s not
clear that’s enough to make it a mental disorder.
Also, a lot of psychopaths are reasonably successful.
Now, this gets complicated because psychologists study
psychopaths but the psychopaths that they study are by
definition unsuccessful psychopaths.
And what some people have argued is the real psychopaths,
the successful ones, are the ones that run the
world, that excel in every field because they are successful
enough that they don’t look like psychopaths.
They have no conscience, no compassion,
love, loyalty. They are cold-blooded and
ambitious but they don’t go around making this so obvious
that we throw them in prison. And so, it’s an interesting and
subtle and complicated case. The final section – and I’ll
start this and we’ll go five minutes into this and then
move–continue it next week with the final class – concerns
therapy. Now, the most interesting thing
for us to deal with is the question of, “Does therapy
work?” And there’s a lot to be said
about this. The history of therapy has been
gruesome and unsuccessful. Again, to be mad was to be
viewed as to be in league with the devil and so people with
mental illnesses were tortured to death,
burnt, sent out to sea and so on.
In the eighteenth century they were thought of as degenerates
and sent away from society. In the nineteenth century there
was a brief blast of compassion where Pinel tried to have mental
hospitals and then there were all sorts of–since then all
sorts of medical treatments that were considerably less
successful and this brief video will summarize some of the
previous medical treatments. I often wonder a hundred years
from now how they’re going to look at our current therapies
and then whether they’ll see them as equally barbaric and
stupid as we look at the therapies in the past.
What I’ll begin next lecture with is a very quick discussion
of what therapies work of the ones currently available and
then I’ll end the class. And this will be a somewhat
short class. I’ll end the class with a
discussion of happiness. There is an optional thing I’ll
add, which is your reading responses are done and you’ll
have the opportunity to make comments on the class in
anonymous evaluations but what I’m kind of interested in is if
people could send me an e-mail, and this is entirely optional,
about the most interesting thing that we’ve covered in this
class. I’m curious what people think
it is and it’s something which I could try to build up on for
future classes. So, again, this is optional.
Just give it a subject heading “Intro Psych” and send it to me
if you choose to do it and I’ll see you on Wednesday.

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