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. Drgs 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] "Drving 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.