This report will discuss the concept of abnormality, with the use of a case study, diagnosing Sally with the use of the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), it will give supporting evidence of the diagnosis, and also within this report it will explain treatments required for Sally’s diagnosis.
Section 1 -‘ Normality’ and ‘Abnormality’, DSM 1V, ICD 10, and the Diagnosis of Sally
It is difficult to define what is ‘normal’ and what is ‘abnormal’ as we all have different perspectives, opinions on what is the norm and what is not, how the majority of people think and behave in any given situation could be perceived as the norm.
There are different ways of defining ‘abnormal’ as opposed to our own ideas of what ‘normal’ is. The statistical approach helps us in addressing what is meant by ‘normal’ through a statistical context, although this approach does address what is meant by ‘normal’ within a statistical view however it does not help to define the term ‘normal’ (L.Cryer/Northern college 2000).
Rosenhan and Seligman (1989) they suggested seven major features of abnormality that appear within abnormal behaviour, the more of a feature an individual, shows they are then considered as ‘abnormal’. The first feature is ‘suffering – abnormal
individuals suffering anxiety disorders; say that they are suffering although normal
individuals suffer within some time in their lives maybe, those with personality disorders they do not seem to suffer themselves but do treat others poorly. Maladaptiveness – this is behaviour that prevents from achieving life goals and fulfilling relationships or working effectively. Vividness and unconventionally – this is unusual the behaviour is not the normal behaviour what is expected of people to behave within similar situations. Unpredictability and loss of control – you can usually predict what people will do within certain situations but abnormal behaviour is often unpredictable, uncontrolled inappropriate within the situation. Irrationality and incomprehensibility – this is when there appears to be no reason or cause in why the individual should choose to behave in that way. Observer discomfort – this is social behaviour that is controlled by unspoken rules such as eye contact, if other individuals break the rules we then have the feeling of discomfort, although different cultures may experience different social rules on behaviour. Violation of moral standards – this is when moral standards are violated therefore maybe being judged as abnormal’ (L.Cryer/Northern College 2000).
According to Sue et al., (1994) different definitions of what is’ normal’ and ‘abnormal’ carry different implications, and certainly there is no consensus on what is a best definition. ‘A truly adequate understanding of what abnormality is can probably only be achieved through a comprehensive evaluation of all points of view.’ (Psychology A New Approach 2004 pg.91).
The DSM IV, or The Diagnostic and Statistical Manual of Mental Health as it is called, is a categorical classification system, it is published by the American Association and it covers all mental health disorders. Mental health professionals use the DSM IV manual when working with patients in order to understand their illness better and to enable them to give the best treatment to treat the illness. There is also the World Health Organisation ICD10 this does list all the same disorders as the DSM
although they are under different headings and some are given different names, the ICD does not have an axis like the ICD thus indicating to causes more than purely symptoms (Diagnostic classification systems class handout 2010).
Axis 1 – clinical syndromes, this refers to the diagnosis made by the clinician e.g. anxiety disorders or depressive disorders etc.
Axis 2 – development and personality disorders, diagnostic classifications that may contribute to the understanding of the syndrome diagnosed in axis 1, developmental disorders include autism and mental retardation.
Axis 3 – medical conditions, physical conditions such as brain injury or other medical conditions, physical which can result in symptoms of mental illness.
Axis 4 – psychosocial stressors, dealings within a person’s life, such as a death of a loved one, loss of job or a long-term situation such as shortage of money, which may have had an impact on the person, this is rated on a scale of 1 (none) to 6 (catastrophic).
Axis 5 – global assessment of functioning, this axis rates the highest level of social work related and psychosocial functioning on a scale of 1 to 90 (1 being constant
danger and 90 being good in all areas). This is complete for the person’s current situation and throughout the past 12 months. This axis helps the clinician recognise how the other 4 axis are affecting the person and what kind of changes could be expected. (Diagnostic classification systems class handout 2010).
Within the case study Sally’s behaviour, seems to show that she is suffering from, agoraphobia and compulsive disorder, this type of behaviour is described as being ‘atypical’ due to it being viewed as ‘abnormal’.
Section 2 – Supporting evidence of diagnosis
Biological approach – This looks at the chemical imbalances within the brain, maybe through brain injury or mental illness, could also be through abnormal or faulty genes.
Due to Sally being in a high demanding job, therefore giving Sally high levels of stress, this then leading on to Sally having a high level of cortisol (hormone) within her system. The result of this would mean Sally would have feelings of anxiety causing social phobia. Possibly due to her parents, maybe having high demanding jobs themselves, and also maybe liking everything neat and tidy as can be, this could of genetically caused Sally a pre-disposition to anxiety and stress leading to obsessive-compulsive disorder.
Cognitive approach – This looks at the thought processes of an individual, and whether their thought process is distorted, or whether the person has a misguided perception of reality.
Due to Sally’s age and job her perception is disturbed, Sally tends to focus on the wrong things. Sally has irrational thoughts that have manifested through an obsession with germs and being immaculate. Sally’s social phobia is because of her network of peers thus making her feel inferior and causing Sally more anxiety, which is being challenged through the obsessive-compulsive disorder.
Behaviourist approach – This looks at the theory that all behaviour can be explained through observable stimuli and responses. Learning through reinforcement and consequences. Positive reinforcement is given for good behaviour and negative reinforcement is given for bad behaviour.
This is a suitable approach as it tries to explain individual differences to different reinforcement experiences. Sally’s parents may have been very strict, and she may have been under pressure when she was young to do well academically, to gain their approval, Sally may also of been possibly conditioned from her parents, to be neat and tidy, this has been reinforced causing her anxiety, and this has manifested as a obsession with high standards, up to the point where nobody can clean a cup as good as herself, this behaviour has affected Sally, and caused her to become reclusive, suffering agoraphobia as she finds it hard to keep up with appearances.
The psychodynamic approach – This includes all the theories in psychology, that can be seen as human functioning, based upon the interaction of drives and forces within the person, particularly the unconscious. This defence mechanism for dealing with Sally’s early childhood experiences, this is a suitable approach as it provides answers which could explain the workings of the unconscious mind.
Sigmund Freud (1909) divided the mind into the conscious mind and unconscious mind, unconscious is the id or instincts and the superego Freud used the idea of the unconscious in order to explain certain kinds of neurotic behaviour. Freud (1923) believed that personality has three components, and that all behaviour is a product of their interaction, which are the id, which is present at birth; this is the impulsive and subjective part of personality. Ego, which is developed from the id, helps us to cope, this operates on reality, and then there is the superego, which is the last component to develop, this consists of our conscience, our moral judgements. According to Freud (1923) human development goes through stages of psychosexual, which are, oral, anal, phallic, latent and genital, failure in successfully passing through the psychosexual stages of development can lead to ‘symptoms that allow the repressed conflict, or feelings to manifest in more acceptable ways, Sally seems to be fixated
within the anal stage. Aidan Sammons (2010) this therefore could go onto developing psychological problems.
Sally may have shame and also guilt her superego may be in charge of her ego, Sally may also have had authoritarian parents, which has caused the anxiety. Sally’s id has
to have everything immaculate and have the fancy things in her life. Sally may also have repressed memories causing her anxiety, possibly due to her being brought up within either a messy or immaculately clean house.
The humanistic approach – This looks at the basic survival needs, Maslow’s hierarchy of needs (1954), this is where basic needs are satisfied then safety followed by love
and belonging, next it is the need for self esteem and last the need for self-actualisation, Sally’s parents may of put conditions on the love that she received from them, the love they did give, may have been focused or based on her achievements, rather than giving her the unconditional love, which maybe Sally needed from them, or maybe even craved for. According to Maslow (1954) he assumed, that the higher needs of the hierarchy would only emerge when the lower needs are met. Sally maybe did not reach self-actualisation through her personal life, although she has achieved this through her professional life.
Section 3 – Treatments
Biological treatment – Sally’s treatment would be anti-anxiety drugs (anxiolytics) such as valium, these are minor tranquillisers, which help to relax and reduce tension which Sally may have. Although with these drugs there are drawbacks, as Sally could become addictive and would need to have the dose reduced over a period of time, they
also have side effects, which could include, drowsiness, tremors and convulsions. Also these drugs are only effective with reducing anxiety within the short term, and would not get rid of any underlying problems that Sally may have.
Sally may benefit from having antidepressant drugs as these drugs would help to lift Sally’s mood, and they also increase serotonin activity, these kind of drugs are effective for anxiety disorders, due to clinical researchers findings that two antidepressant drugs Anafranil and Prozac, do reduce obsessive compulsive disorder
(Grilly, 2002;Rapoport, 1991, 1989). Studies have also found that between 50 and 80 percent of people with obsessive compulsive disorder have improvements when taking Anafranil or Prozac (Grilly 2002) although within eight weeks of taking the drugs symptoms are cut by half almost, but do not usually disappear fully (DeVeaugh-Geiss et al., 1992). There are side effects with these drugs which are tiredness, confusion or dizziness, loss of co-ordination, also it can increase the thoughts of suicide, According to Healey (1999) claims that roughly 250 000 people worldwide have tried to commit suicide whilst they were taking Prozac, and within in that number 25 000 actually succeeded. The survivors had explained that they did not feel
like that before they started taking the Prozac, they described they felt agitated, strange and had unstoppable urges of committing violent acts, Healey (1999).
Cognitive treatment – This is achieved through therapy; it would focus on Sally’s irrational thoughts that she may be having, and her distorted perception. Due to this kind of therapy is good way of changing any hopelessness ideas, and any overly self-
critical images, that Sally maybe experiencing. According to Brandsma et al., (1978), this type of therapy has produced behaviour change, within clients who are self demanding, and who feel guilty with not living up to expectations. Haaga and Davison (1989) believe this type of therapy is effective in treating anxiety disorders. Sally would benefit from combined cognitive behavioural therapy, as ‘cognitive therapists have developed approaches, to obsessive compulsive disorder that combine cognitive and behavioural techniques’ (Freeston et al., (1996) Cromer pg.127
Behavioural Treatment – This is in the form of therapy, cognitive behavioural (CBT), this would focus on changing Sally’s behaviour, of being obsessed with germs and once this has been alleviated, maybe then Sally would feel more likely to get out of the house more, and to also feel less anxious about peer pressure. This type of therapy would maybe also help in changing the way Sally thinks and alleviate her worries, anxiety and emotional distress she is encountering, the therapist would also help Sally to examine her self-beliefs, perceptions and thinking patterns, and also how these are impacting on her emotional well-being and actions within her life.
There is another treatment which is flooding this is a type of therapy which uses classical conditioning, it is when the client is forced to confront the object or the situation which has caused them distress, continued exposure of the feared stimulus would eventually weaken and extinguish the feared response, Emmelkamp et al. (1992) discovered that types of mental disorders e.g. Depression or schizophrenia, are not successful with this type of treatment due to there are no obvious feared external
stimulus to work with, although flooding is a successful technique, with helping people to overcome some certain types of phobias. This technique may not be suitable for Sally ‘flooding works by confronting a feared stimulus, however sometimes patients anxiety is more abstract e.g. fear of failure (Lynda Turner 2009 pg.87).
There is also systematic desensitisation treatment which is a technique used under relaxed conditions, to treat phobias and anxiety, by exposing the client to the threatening situations until the anxiety has extinguished, According to Davison (1968)
research has shown that systematic desensitisation therapy is a very effective treatment for people with anxiety as their main symptom, so Sally would maybe benefit from this technique.
Psychodynamic treatment – This involves aiming to uncover repressed conflict, this would benefit Sally, as this technique is aimed for the client, to be able to make sense of their own distress, and to have an understanding of the deep emotions, which Sally has had hidden, within her unconscious mind. Within this type of treatment there are
different techniques, Sally would benefit from any of theses, which are transference, regression and free association.
Humanistic treatment – Within this form of therapy it would be essential that Sally would see her therapist as being genuine and honest, the therapist would need to have an unconditional, positive regard for Sally at all times and make her feel liked. Within the therapy session the therapist would attempt to understand Sally’s situation and
empathize with her. This is achieved by asking Sally to explain her points of view. These are general principles of Rogerian (1959) therapy. The humanistic treatment stresses the importance of understanding and maintaining positive, purposive meaning, achieving potential, joy and your unique self-identity and personal growth (Dr.D.Kraft 2009). Another kind of humanistic therapy would be within a group setting that is Gesalt therapy (Perls 1969).
A diagnosis of a person who is ‘normal’ or ‘abnormal’ can not be done by using only one of the approaches, there are too many different aspects that come under different approaches, and also different methods of treatment, which are combined to treat a disorder. Using medication may be prescribed for a person suffering depression, along with treatment from a psychotherapist, to get to the direct cause of the problem. Using all or as many of the approaches as possible to diagnose a person with a mental health problem, will enable the professional, to give them the right diagnosis, and also the best possible treatment for the illness. Sally would immensely benefit from this within her life.