Chapter Overview: The Historical Context of Mental Health

Welcome to Section A (Issues in Mental Health) of your OCR A Level Psychology (H567) Component 03: Applied Psychology course! This chapter lays the foundation for understanding how human society has viewed, defined, diagnosed, and treated mental illness over time.

Don't worry if psychological terms and diagnostic systems seem intimidating at first. We will break everything down step-by-step into clear, bite-sized sections. By the end of these notes, you will master the historical paradigms, the four core definitions of abnormality, how diagnostic manuals work, the classic Rosenhan (1973) study, and the characteristics of three key mental disorders.

1. Historical Views of Mental Illness

Humanity's understanding of mental disorder has shifted dramatically over centuries. We can divide this evolution into distinct historical periods and paradigms:

A. Supernatural / Demonological Paradigm (Prehistory & Antiquity)

  • Belief: Mental illness was seen as the result of demonic possession, evil spirits, sorcery, or divine punishment from displeased gods.
  • Treatments:
    • Trepanning: A surgical procedure where a hole was drilled or scraped into the skull to create an exit route for trapped evil spirits.
    • Rituals: Exorcisms, incantations, and prayers conducted by religious or spiritual leaders.

B. Somatogenic / Biological Shift (Ancient Greece & Rome)

  • Hippocrates (c. 460–370 BCE): Rejected supernatural causes and proposed that mental illness had natural, physical roots (a somatogenic approach).
  • The Humoral Theory: Hippocrates argued that physical and mental health depends on the balance of four bodily fluids (humours):
    1. Blood
    2. Yellow Bile
    3. Black Bile (an excess was believed to cause melancholia or depression)
    4. Phlegm
  • Treatments: Bloodletting, purging with laxatives, dietary changes, and lifestyle adjustments to restore humoural balance.

C. Middle Ages & Renaissance

  • The Middle Ages: A major resurgence of supernatural beliefs. Mental illness was frequently attributed to witchcraft, demonic pacts, or the devil (as documented in texts like the Malleus Maleficarum). Sufferers faced witch trials, chaining, burnings, and aggressive exorcisms.
  • 16th–18th Century (Early Asylums): Sufferers were locked away in specialized institutions known as "madhouses" (such as the famous Bethlem Royal Hospital or "Bedlam" in London). These early asylums focused on containment and public display rather than cure. Patients were kept in filthy, chain-bound conditions and treated like sideshow attractions for paying visitors.

D. The Moral Treatment Movement (18th–19th Century)

  • Philippe Pinel (1745–1826): Working at the Bicêtre and Salpêtrière hospitals in France, Pinel famously unchained inmates and advocated for Moral Treatment—treating patients with dignity, kindness, fresh air, daily purposeful routines, and clean surroundings.
  • William Tuke (York Retreat, UK) and Dorothea Dix (USA): Campaigned for humane institutional conditions and therapeutic environments rather than punitive confinement.

E. 20th Century to Present (Medicalisation & Psychopharmacology)

  • The biological and medical model became dominant. The 1950s saw the development of psychiatric medications (such as chlorpromazine), shifting mental healthcare toward biochemical explanations and standardized diagnostic manuals.

Key Takeaway: Views of mental illness moved from supernatural (evil spirits/trepanning) \(\rightarrow\) biological humours (Hippocrates) \(\rightarrow\) institutional containment (early asylums) \(\rightarrow\) moral reform (Pinel/Tuke) \(\rightarrow\) modern medicalisation & psychopharmacology.

2. Defining Abnormality

How do psychologists draw the line between "normal" and "abnormal" behavior? There is no single universal definition. Instead, OCR requires you to know four core definitions:

1. Statistical Infrequency

  • Concept: Any behavior, trait, or psychological characteristic that occurs rarely within the general population is considered abnormal.
  • Measurement: Assumes human traits follow a normal distribution curve (bell curve). A score falling more than \(2\) standard deviations away from the population mean—representing the top \(2.5\%\) or bottom \(2.5\%\)—is statistically infrequent.
  • Example: Having an IQ score below \(70\) is statistically infrequent and forms part of the diagnosis for intellectual disability.
  • Limitation: Does not distinguish between desirable and undesirable traits. Having an IQ above \(130\) is statistically rare, but it is not a psychological disorder!

2. Deviation from Social Norms

  • Concept: Behavior is abnormal if it violates the implicit (unwritten) or explicit (written/legal) rules, moral expectations, and acceptable standards of a given society.
  • Limitation: Cultural relativism and context-dependency. Social norms change over time and differ across cultures. There is a risk that non-conformists or eccentric individuals are pathologized simply for not conforming to social expectations (as noted by critics like Thomas Szasz).

3. Failure to Function Adequately (Rosenhan & Seligman, 1989)

  • Concept: An individual is considered abnormal when their behavior prevents them from coping with the everyday demands of life (such as keeping a job, maintaining hygiene, or sustaining personal relationships).
  • Key Features / Criteria:
    • Personal distress: The person experiences intense suffering or anxiety.
    • Maladaptive behavior: Behavior that interferes with reaching life goals.
    • Unpredictability & irrationality: Out-of-control or illogical behavior.
    • Observer discomfort: Causing unease or distress to others nearby.
    • Violation of moral standards: Breaking moral codes.

4. Deviation from Ideal Mental Health (Marie Jahoda, 1958)

Instead of looking for what is wrong or abnormal, Jahoda identified what makes someone psychologically healthy. If an individual lacks one or more of these criteria, they deviate from ideal mental health.

Jahoda's Six Criteria:

  1. Positive self-attitude: High self-esteem, self-respect, and self-acceptance.
  2. Self-actualisation: Striving to realize one's full personal potential and growth.
  3. Integration: Resilience and the capacity to resist and cope with stress.
  4. Autonomy: Independence, self-reliance, and self-determination.
  5. Accurate perception of reality: Seeing the world realistically, without delusions or distorted perspectives.
  6. Environmental mastery: The ability to adapt, succeed in work, build loving relationships, and solve life problems.

Memory Trick for Jahoda's 6 Criteria: Remember P-S-I-A-R-E (\(\textbf{P}\)ositive attitude, \(\textbf{S}\)elf-actualisation, \(\textbf{I}\)ntegration, \(\textbf{A}\)utonomy, \(\textbf{R}\)eality perception, \(\textbf{E}\)nvironmental mastery).

Key Takeaway: Statistical infrequency focuses on numbers/curves; Social norms focuses on societal rules; Rosenhan & Seligman focuses on coping with daily life; Jahoda focuses on positive psychological well-being.

3. Categorising Mental Disorders

To diagnose mental illness reliably, clinicians use standardized classification systems:

  • DSM (Diagnostic and Statistical Manual of Mental Disorders): Published by the American Psychiatric Association (APA). Widely used in the United States and international psychological research.
  • ICD (International Classification of Diseases): Published by the World Health Organization (WHO). A global manual that categorizes both physical diseases and mental disorders.

Key Diagnostic Issues:

  • Reliability: Consistency of diagnosis.
    • Inter-rater reliability: Do different psychiatrists assess the same patient and reach the exact same diagnostic conclusion?
    • Test-retest reliability: Does the same diagnostic tool produce consistent results over time?
  • Validity: Accuracy of diagnosis. Does the classification manual identify a real, distinct clinical condition?
    • Concurrent validity: Agreement between different diagnostic tools assessing the patient at the same time.
    • Predictive validity: Whether the diagnosis correctly predicts the future course of the disorder and treatment response.
  • Stigma & Labelling: Once a patient receives a psychiatric label, it can lead to prejudice, discrimination, depersonalisation, and a self-fulfilling prophecy (where the person acts according to the label). Labels are notoriously "sticky" and hard to remove.

4. Key Research: Rosenhan (1973) "On being sane in insane places"

This is your mandatory classic study for this topic. Be sure to know the numbers, procedure, and findings accurately!

Aim

To test whether psychiatric staff in natural hospital settings could reliably distinguish the sane from the insane, and to investigate the institutional experiences and effects of labelling on psychiatric patients.

The Initial Study (Main Investigation)

  • Sample / Pseudopatients: \(8\) sane individuals (\(3\) women, \(5\) men), including David Rosenhan himself, a graduate student, three psychologists, a pediatrician, a psychiatrist, a painter, and a housewife.
  • Setting: \(12\) different psychiatric hospitals across \(5\) US states (ranging from old and underfunded public institutions to modern, well-funded private clinics).
  • Standardised Admission Procedure:
    • Pseudopatients telephoned the hospital requesting an appointment, complaining of hearing voices of the same sex that were unfamiliar and said the words: "empty", "hollow", and "thud".
    • All life histories, personal relationships, and family backgrounds were described 100% truthfully. Only their names and employment/psychological backgrounds were falsified to protect identities.
  • Ward Behavior:
    • Immediately upon admission, the pseudopatients completely stopped displaying any pseudo-symptoms.
    • They behaved entirely normally, spoke politely to staff, and followed ward routines.
    • They took covert written notes of their observations (which they later did openly when staff paid no attention).
    • To be discharged, pseudopatients had to convince the hospital staff on their own that they were sane.
  • Findings of the Initial Study:
    • Admission Rate: \(100\%\) were admitted.
    • Diagnoses: \(11\) admissions were diagnosed with Schizophrenia; \(1\) admission (at a private hospital) was diagnosed with Manic-Depressive Psychosis.
    • Length of Hospitalization: Ranged from \(7\) to \(52\) days, with an average (mean) stay of \(19\) days.
    • Discharge Diagnosis: All pseudopatients were discharged with a label of Schizophrenia "in remission" (meaning the illness was temporarily inactive, but the label remained).
    • Detection: Zero hospital staff members detected their sanity. However, genuine patients frequently suspected they were sane: \(35\) out of \(118\) real patients voiced suspicions (e.g., "You're not crazy. You're a journalist, or a professor checking up on the hospital").
    • Stickiness of Diagnostic Labels: Normal everyday behaviors were misinterpreted through the lens of mental illness:
      • Writing in notebooks was recorded in nursing notes as: "Patient engages in writing behavior".
      • Waiting outside the cafeteria before mealtime was described as an "oral-acquisitive syndrome".
    • Depersonalisation & Powerlessness: Daily face-to-face interaction between patients and medical staff (psychiatrists/doctors) averaged less than \(7\) minutes per day. When pseudopatients politely asked staff when they might be discharged, staff made eye contact only \(23\%\) of the time and walked on without stopping.

The Secondary Study (The Follow-up Control Study)

  • Context: Staff at a prestigious teaching hospital claimed that such diagnostic errors could never happen at their institution. Rosenhan agreed to a follow-up test.
  • Procedure: Staff were warned that over the next \(3\) months, one or more pseudopatients would attempt to gain admission to their hospital. Staff were instructed to rate each incoming patient on a scale regarding whether they were a genuine patient or a pseudopatient.
  • Results: Out of \(193\) genuine patients admitted during this period:
    • \(41\) patients were alleged to be pseudopatients with high confidence by at least one staff member.
    • \(23\) patients were suspected by at least one psychiatrist.
    • The Reality: Rosenhan sent \(0\) pseudopatients!

Conclusions

  1. Psychiatric diagnosis lacks validity. Clinicians cannot reliably distinguish the sane from the insane in psychiatric institutions.
  2. In standard admission settings, clinicians show a strong Type I error (a false positive—diagnosing a healthy person as sick).
  3. When primed to look for impostors, clinicians reverse their bias and show a Type II error (a false negative—suspecting genuine sick patients are healthy).
  4. Psychiatric labels are profoundly "sticky": once applied, all subsequent behaviors are interpreted to match the label.

5. Application: Characteristics of Mental Disorders

In Section A exams, you must be able to describe the specific clinical characteristics and diagnostic thresholds (using standard DSM-5 criteria) for three distinct categories of mental disorder:

A. Affective Disorder: Major Depressive Disorder (MDD)

Affective disorders primarily involve severe disturbances in mood and emotion.

  • Core Emotional Symptoms:
    • Persistent low, depressed mood lasting most of the day.
    • Anhedonia: Markedly diminished interest or pleasure in all or almost all daily activities.
    • Feelings of worthlessness or excessive, inappropriate guilt.
  • Somatic / Physiological Symptoms:
    • Significant unintended weight loss or gain / changes in appetite.
    • Insomnia (inability to sleep) or hypersomnia (excessive sleeping).
    • Psychomotor agitation (restlessness) or psychomotor retardation (slowed movements/speech).
    • Fatigue or persistent loss of energy.
    • Recurrent suicidal ideation or thoughts of death.
  • Diagnostic Threshold (DSM-5): At least \(5\) symptoms present during the same \(2\)-week period, representing a change from previous functioning. At least one of the symptoms must be either depressed mood or anhedonia.

B. Psychotic Disorder: Schizophrenia

Psychotic disorders involve a break with reality, characterized by distorted thinking, perceptions, and beliefs.

  • Positive Symptoms (excesses/distortions of normal functioning):
    • Hallucinations: Sensory experiences occurring without external stimuli (most commonly auditory hallucinations, such as hearing voices).
    • Delusions: Firmly held false beliefs resistant to counter-evidence (e.g., persecutory delusions that one is being hunted, or grandiose delusions of possessing divine powers).
    • Disorganised Thinking & Speech: Incoherent speech, derailment (jumping randomly between topics), or "word salad".
  • Negative Symptoms (deficits/loss of normal functioning):
    • Affective Flattening: Reduced range and intensity of emotional expression in face and voice.
    • Avolition: Severe lack of motivation and inability to initiate or persist in goal-directed activities.
    • Alogia: Poverty of speech (diminished speech output).
    • Anhedonia: Inability to experience pleasure.
  • Diagnostic Threshold (DSM-5): At least \(2\) or more characteristic symptoms present for a significant portion of time during a \(1\)-month period (at least one must be delusions, hallucinations, or disorganised speech), with continuous signs of disturbance lasting for at least \(6\) months.

C. Anxiety Disorder: Specific Phobia / Agoraphobia

Anxiety disorders involve excessive, irrational fear and apprehension out of proportion to actual danger.

  • Core Cognitive & Emotional Characteristics:
    • Marked, persistent, and disproportionate fear or anxiety triggered by the presence or anticipation of a specific object or situation (e.g., spiders, heights, enclosed spaces) or open public spaces (agoraphobia).
    • Recognition (in adults) that the fear is excessive or unreasonable.
  • Behavioural & Physiological Symptoms:
    • Active Avoidance: The individual goes to extreme lengths to avoid the phobic stimulus.
    • Physiological Panic Response: Immediate autonomic arousal upon exposure (rapid heart rate/palpitations, sweating, trembling, hyperventilation).
  • Diagnostic Threshold (DSM-5): The fear, anxiety, or avoidance is persistent, typically lasting for \(6\) months or more, and causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Common Examiner Pitfalls & Revision Checklist

  • Don't mix up definitions and manuals: Definitions of abnormality (e.g., Jahoda, Statistical Infrequency) are theoretical models. Categorising disorders refers to diagnostic manuals (DSM and ICD).
  • Don't misreport Rosenhan's procedure: Pseudopatients never faked symptoms once inside the hospital. They acted completely normally and told the truth about their lives.
  • Remember the exact words: The pseudopatients in Rosenhan (1973) complained only of hearing the words "empty", "hollow", and "thud".
  • Remember the secondary study: When evaluating diagnostic validity, always mention Rosenhan's follow-up study where \(0\) pseudopatients were sent and \(41\) real patients were suspected of faking!
  • Reliability vs Validity: Reliability = consistency between clinicians (agreement). Validity = accuracy (diagnosing a real, genuine condition).
  • Use precise symptom categories: When explaining Schizophrenia, clearly distinguish between positive symptoms (hallucinations, delusions) and negative symptoms (avolition, affective flattening, alogia).