Essay // Clinical Psychology: Learning Disabilities, Anxiety, Depression & Schizophrenia and the Effectiveness of Psychotherapy

Part 1 of 5 | Children and Adolescents’ Mental Health Services (CAMHS) & Learning and Intellectual Disabilities

ClinP_Descr_Header_01

CAMHS deal with the psychological issues of people under the age of 18. They are a non-specialist service and often refer to other more specialised departments following the initial assessment of patients. The most common cases tend to be adolescents with depression and anxiety whose manifestations are not different to those of adults and so are treated fairly similarly.

Inclusivism in Learning Disabilities

In 1969, Bengt Nirje adopted and developed the concept of normalisation in Sweden and beautifully described it as…

“making available to all mentally retarded people patterns of life and conditions of everyday living which are as close as possible to the regular circumstances and ways of life of society.”

– Nirje, 1980

Learning Disability is not just an impairment in Cognition

The social impairment of Learning Disabilities – US Statute 111 – 256: Rosa’s Law defines the factual impairment, the imposed or acquired disability and the awareness of being different.

The Normalisation Theory

This theory focuses on the mainstream trends of social devaluation or deviancy making. Some categories of people tend to be valued negatively due to their behaviours, appearances and characteristics, and this places them at the risk of being devalued [according to the Normalisation Theory of Nirje on the societal processes he assumed] – people fulfil various social roles and stereotypes. As part of the deviancy making or social devaluation, the unsophisticated minds of the masses generally do not mean to stereotype, however they seem to do it unconsciously [the unconscious is a concept Sigmund Freud and Jacques Lacan acknowledged in their psychoanalytic theories of mental/psychological activity and mental health problems linked to psychopathic tendencies in people towards others], i.e. deviant groups with social symbols or images that are at a higher risk of being devalued are the focus of the normalisation theory, which is believed to be done with the aim of providing them with the skills they need and eventually change the status of these deviant groups to functional members of society.

Society tends to distance itself from deviant groups without any purpose or belonging, however psychologists provide support for the social integration and valued social participation of people with learning disabilities through exercises that involve learning through imitation. This challenges stereotypes within wider society through direct experiences of spending time with people who are affected by learning disabilities.

While psychology evolves and sophisticated and modern theories about intelligence and communication such as our « Organic Theory » take shape, we hope that observations such as this one may be digested and understood by the masses, that is:

« While the communicative patterns [language] in human primates vary with socio-behavioural and geographical patterns; creativity and IQ remain constant and do not change. Intelligence and creativity cannot be stopped because of linguistic differences, since talented and gifted humans do not choose the location of their birth nor their linguistic heritage but still contribute to the enhancement of our civilisation. »

 

Which concludes that that the intelligence of an invidual when assessed on a range of variables [e.g. perception, fluid intelligence, artistic creativity, reasoning, emotional intelligence, courage, values, etc] cannot be deduced by simply assessing their academic abilities, since human life has various sides to itself. Hence, the true worth and value of an individual may always remain a problem and a mystery to fully assess [since most only assess people on the variables they are interested in, for e.g. a company looking for a secretary will assess the applicant on her ability to handle office politics, and not other abilities essential to exist as a human within civilisation], and this seems to go in line with Jean Piaget’s deduction about the uniqueness of the human organism and mind.

Michel-Ange-Toujours-A-Apprendre-Always-Learning

« I am still learning » – Michael-Angelo at the age of 87 / Image: La Création d’Adam (1508 – 1512)

Neurodevelopmental Disorders & Intellectual Disabilities

Neurodevelopmental disorders are disorders occurring due to the biological dysfunction of the brain that in turn lead to developmental deficits that come in a range that can be very specific to global impairment. These groups however often co-occur together, i.e. one could be affected with Intellectual Disability (ID) and also Autistic Spectrum Disorders. Psychologists are expected to show great care when assessing this group of disorder as they vary in severity. Severity has 4 Specifiers and 3 Domains [Intellectual].

Specifiers: [1] Mild – [2] Moderate – [3] Severe – [4] Profound

Domains [Intellectual]: [1] Conceptual – [2] Social – [3] Practical


Intellectual Domains

The first domain, which is the Conceptual Domain refers to all things learnt at school and required for employment and adequate independent functioning within the community. Secondly, the Social Domain refers to social, developmental and emotional factors associated to age. This manifests in them as being victims of manipulation and abuse by others. Finally, the Practical Domain refers to all skills required to live healthily [also this is subject to interpretation depending on contexts, socio-linguistic and cultural settings].

Intellectual Disability

For one to be qualified as intellectually disabled, we would have to meet all the 3 criteria below:

  • Deficits in intellectual functions, such as reasoning, problem-solving, planning, abstract thinking, judgement, learning [also from experience].
  • Deficits in adaptive functioning that means failure to meet developmental milestones within the socio-cultural standards. Limited function in daily life, participation, communication, independence in multiple environments (i.e. Global).
  • Onset is during developmental period [childhood – another link to the Psychoanalytic theory of Sigmund Freud & Jacques Lacan]


Assessment and Judgement

Careful distinction must be made when assessing patients suspected of suffering from Intellectual Disabilities (ID) between the low end of normal function and ID itself. The most widely used method clinically are IQ assessments and typically suggest any score that is 2 Standard Deviations below the mean [IQ scores of 75 +/-5] and whether the patient has had any clinical experience. Assessment based on the patient’s reasoning in real-life situations are also made. Global Developmental Delay is a term reserved for children under 5 who cannot adequately be assessed, but have missed all their developmental milestones.


Associated Features with Intellectual Disabilities (ID) to look for when diagnosing patients are:

  • Social judgment
  • Assessment of risk
  • Self-management of behaviour – interpersonal relationships and emotions
  • Motivation in school, university or work
  • Lack of communication skills and functional problem behaviours
  • Gullibility [Diagnosis is based on how people and society mistreat them – quite shocking or controversial?]
  • People with Intellectual Disabilities (ID) are also at high risk of suicide


Prevalence of Intellectual Disabilities

In the UK, 1% of people suffer from intellectual disabilities and 0.006% of the population have severe disabilities requiring supported living [that is about 360, 000 people in the UK] – a slight bias with a ratio of 1.6:1 towards males; this is due to the vulnerability of the male brain.


Autism Spectrum Disorders

As psychology evolves more consideration are being given to a dimensional aspect of abnormal behaviour rather than the usual dimensional [i.e. inflexible and sometimes exaggerated in terms of descriptive precisions disregarding individual fluctuations in symptomatic manifestations] constructs of mental disorders. Autistic Spectrum Disorders (ASD) was the first mental disorder to initiate such a shift from categories to dimensions.

  • Autistic Spectrum Disorders (ASD) with Intellectual Disability (ID) = Autism
  • Autistic Spectrum Disorders (ASD) without Intellectual Disability (ID) = Asperger’s Syndrome


Characteristics of Autism Spectrum Disorders

ASD is characterised mainly by deficits in social communication and restricted patterns of behaviour. For a diagnosis of ASD the deficits must appear early in the developmental period [however they cannot be diagnosed until the demands of a particular task exceeds the child’s capabilities] – so more severe it is the earlier it is diagnosed [e.g. Rett syndrome].


[A] Communication in ASD

In ASD, it is common to find persistent deficits in social communication and social interaction across multiple contexts illustrated by:

  • Deficits in social-emotional reciprocity, ranging from abnormal social approach. Failure to initiate or respond to social communications. Reduction in sharing interests, affect and emotions.
  • Deficits in non-verbal communicative behaviours used in normal social interactions. Abnormal or no eye contact, body language or deficits in reading [understanding] gestures. A total lack of facial expression and non-verbal communication.
  • Deficits in developing, maintaining and understanding relationships [e.g. from difficulties in adjusting behaviour to suit context]. Difficulties in sharing imaginative play or in making positive social acquaintances or friends. Hardly any interest in any form or peers.


[B] Behaviour in ASD

It is also fairly normal to notice restricted, repetitive patterns of behaviour, interests, or activities manifested by at least two of the following:

  • Stereotyped or repetitive motor movements, use of objects, or speech
  • Insistence on sameness, inflexible adherence to routines, or ritualised patterns of behaviour. Shows extreme distress at small changes, difficulty in transition, rigidity, insistence on same route taken or foods
  • Hyper or hypo-reactive to sensory inputs or unusual interest in sensory aspects of the environment (indifference or hyper-responsive to pain, temperature, sound, textures, excessive smelling to touching of objects, visual fascination with movements or lights.

ASD may also manifest itself with or without intellectual disability, with a similar scenario for language impairment, and can be associated with medical or genetic conditions or environmental factors [exposure]. ASD can also be associated with another neurodevelopmental, mental or behavioural disorder and can also comprise catatonia.
Features to look out for

  • People with ASD often have uneven profiles or abilities – even the high functioning variants, and this can lead to substantive stress for them
  • They also often have odd motor idiosyncrasies – such as an odd gait, clumsiness and abnormal ambulatory movements.
  • Disruptive, challenging behaviour and injuries are also very common
  • As sufferers of ASD age, they are also more prone to developing anxiety and depression and are likely to end up in a catatonic state


Prevalence

Autistic Spectrum Disorders (ASD) seem to be a genetic disorder, however it involves a variety of genes. 15% of ASD is due to a known mutation in over 90% of concordance studies with twins. Most researchers nowadays suggest that it is inherited and polygenic [lots of genes from genetic ancestry with each adding their weight to the likelihood of the disorder manifesting]. Males are 4 times more likely to suffer from ASD than females, and even high functioning adults with ASD have poor functioning, such as low rates of independent living and employment – older adults tend to become isolated and do not engage in help-seeking behaviours [note that this is different to individuals who may have a solitary personality by conscious choice or a highly selective social circle in personal relationships based on values, in ASD the patients are generally not conscious of the causes of their debilitating condition]

Specific Learning Disorders

Specific Learning Disorders are characterised by the following:

[A] Difficulties learning and using academic skills, as indicated by the presence of at least one of the following symptoms that has persisted for longer than 6 months:

(1) Inaccurate or slow reading
(2) Difficulty understanding meaning in what was read
(3) Difficulties with spelling
(4) Difficulties with written expression
(5) Difficulties mastering number sense, number facts and calculation
(6) Difficulties in mathematical reasoning

[B] The affected academic skills are substantially and quantifiably below the expected level for the chronological age causing interference with academic, occupational or daily living

[C] Learning difficulties begin during school-age years, but will only manifest itself and be diagnosed when the affected person’s capabilities are stretched by demands

[D] It is also independent and not caused by another health or psychological disorder


Specifications of Specific Learning Disorder

SLD generally involves impairment in reading, writing and mathematics. If it is mild in intensity, the person can generally compensate. Moderately affected people however cannot compensate, but will respond to specialist teaching. Finally, severe conditions require specialist teaching in a specialist school as learning will not occur without such arrangements.


Features to look out for in confirming SLD

  • SLD can occur in any individual, even those classed as gifted (IQ 130+)
  • It is usually diagnosed in the early years, but in higher ability individuals it may manifest in odd ways especially when their compensatory methods are undermined
  • Patient generally have difficulties with motor co-ordination
  • It is a life-long condition and does not improve with therapy, but has to be compensated for
  • Patients also tend to have working memory deficits and keep messy environments
  • Early signs include mispronouncing words, struggling to break down words into syllables


Prevalence of Specific Learning Disorders (SLD)

SLD tend to occur in premature children or among societies with a very low birth rate. It is also more common in children with parents that smoke cigarettes [nicotine?] and is 8 to 10 times higher in families with a heritability index of 0.6 and 3 times higher in males [the vulnerability of the male brain once again]. The problems it causes with attention are likely to predict problems with the mathematical and reading components of the brain. SLD usually ends with unemployment, under-employment depression, poorer mental health and suicidal behaviour – support of any kind alters all of these outcomes.

 

_____________________________________

 

Part 2 of 5 | Anxiety Disorders

ClinP_Descr_Header_02

Anxiety disorders are linked to the development of irrational fears of situations that are not life-threatening (Antony & Stein, 2009a). The avoidance of feared situations or experiences also lead to non-adaptive behavioural patterns. People suffering from anxiety disorders generally have fears accompanied by intense physiological arousal displayed by some or all of the following features: accelerated heartbeat, sweating, trembling, sensations of shortness of breath or smothering feelings of choking, chest pain, nausea, numbness or tingling, and chills or hot flushes. Other experiences of dizziness, derealisation (feelings of unreality) or depersonalization (feelings of being detached from the self) are also present in some cases.

In contemporary psychology there are a number of distinctions made between a variety of anxiety disorders based on the developmental timing of their emergence, the classes of stimuli that elicit the anxiety, the pervasiveness and topography of the anxiety response, and the role of clearly identifiable factors in the aetiology [the cause, set of causes, or manner of causation] of the anxiety.

The six main anxiety disorders are described below.


[1] Separation Anxiety

This condition most occurs in children and is generally manifested by a recurrent and persistent fear that is aroused when separation from the parents or caregivers is anticipated or imminent (American Psychiatric Association, 2000; Furr et al., 2009; Pine & Klein, 2008; World Health Organization, 1992). The persistent, excessive worry about losing, or about possible harm befalling a parent is the main characteristic of Separation Anxiety Disorder with nightmares on the similar themes also present in some cases along with recurrent head-aches, stomach-aches, nausea and vomiting. Separation anxiety is also one of the most common causes of school refusal, and sufferers may also display a refusal to sleep without being in close proximity with the parents.


[2] Phobias

Phobic anxiety is the irrational and intense fear aroused when one is faced with an object, event or situation from a clearly defined class of stimuli which is exaggerated in terms of danger posed (American Psychiatric Association, 2000; Blackmore et al., 2009; Hofmann et al., 2009; World Health Organization, 1992). When the person affected is exposed to the phobic stimulus, or anticipates its exposure, panic attacks may arise in adults whereas is children this may lead to excessive crying, tantrums, freezing or clinging. The persistent avoidance of phobic stimuli in phobias is endured with intense distress and this affects an individual’s personal functioning.

In the DSM, specific phobias are subdivided into those associated with animals, injury (including injections), features of the natural environment (such as heights or thunder), in particular situations (such as elevators or flying). These specific phobias are different from social phobias and agoraphobia.

In those affected with social phobias, anxiety is generally mainly aroused by social situations [e.g. public speaking, eating in public where there is the possibility of scrutiny by others and humiliation or embarrassment as a result of acting inappropriately]. In those with agoraphobia, the condition is known to manifest itself with panic attacks in public places, such as being in a queue, or on public transport – hence, these situations tend to be compulsively avoided to prevent the reoccurrence of the panic attacks.


[3] Generalized Anxiety Disorder

One of the main characteristics in general anxiety disorder is the constant feeling that misfortunes of various sorts will occur (American Psychiatric Association, 2000; Bitran et al., 2009; Hazlett-Stevens et al., 2009; World Health Organization, 1992) and the anxiety is not focused on one particular object or situation along with difficulties controlling the worrying process and a belief that worrying is uncontrollable.

General anxiety disorder is mainly composed of nervousness, restlessness, difficulty relaxing, feeling on edge, being easily fatigued, difficulties in concentration, irritability, tearfulness, sleep disturbance and signs of autonomic over-reactivity such as trembling, sweating, dehydrated mouth, light-headedness, palpitations, dizziness and stomach discomfort. [DSM requires some or more of those symptoms to be present]

Case Example of Generalised Anxiety Disorder

Margie, a 10 year old girl was referred to the psychologist after displaying excessive tearfulness in school, the condition which had been gradually amplifying over a number of months and the bouts were unpredictable. Margie would often end up in tears while playing with her friends during break time or when spoken to by the teacher. In the family doctor’s referral letter she was described as a worrier like her mother.

Presentation

in the assessment interview Margie explained that her worries were mainly about a routine daily activities and responsibilities, she would also worry about doing poorly at school and that she had made mistakes which would later be discovered, that her school friend would not like her, that she would disappoint her parents with the way she did her household chores, that she would either be too late or too early for the school bus, that there would not be any space for on the bus and that she would forget her school books. Her worries also extended to health with frequent stomach aches.

The safety of a family also troubled her, she would worry that her house would be struck by lightning, that the river would break its banks and flood the low-lying fens where she lived, washing away her whole house. The future was also a major concern of hers as she worried about failing her exams and being unable to find a satisfactory job, and being unable to find a marital partner or marrying an inadequate person. A continuous feeling of restlessness with the inability to relax was also reported by her.

Family History

The family was very close and Margie was the eldest of four children and the only girl. It was observed during the intake interview that the mother and the father displayed symptoms of anxiety, while the former had been treated with benzodiazepines for anxiety over a number of years. The family also admitted to regularly discuss their problems about their own health and safety and their own worries about the uncertainty of the future.

The father, Oliver was employed by the insurance company and regularly have conversations at the dinner table about the accidents and the burglaries that had befallen his client, and Margie regularly participated in these conversation, being the eldest among her siblings. However the main concern of the parents was about Margie’s tearfulness which they believed was unusual along with her worries and fears which they thought as legitimate. Margie spent a lot of time with her parents’ company but also had a couple of close friends with whom she played at the weekends.

Formulation

Margie was diagnosed with generalised anxiety disorder. The precipitating factor for the condition was not apparent as it had gradually evolved over the course of Margie’s development. The referral however, was precipitated by episodes of tearfulness at school. The predisposing factors in her case comprised of a highly likely possibility of genetic vulnerability to anxiety and exposure to family culture characterised by an excessive concern with safety and oversensitivity to dangerous situations. The ongoing parental conversations about potential threats to the family’s well-being likely maintained the condition along with inadvertent reinforcement of Margie’s tearfulness at school, where her tears were responded to with considerable concern.

The protective factors in the case included good premorbid adjustment, the parents’ and the school’s commitment to solving the problem and the availability of peer group support. [This formulation is diagrammed below]

General Anxiety Disorder Formulation

Treatment

In this particular case, treatment involved family work focused on helping Margie parents reduce the amount of time they spent discussing themes related to danger and threats to their health and safety, and increase the amount engaged in activities and discussions focused on Margie’s strengths and capabilities. The parents were also assisted in coaching Margie into learning relaxation skills and mastery oriented coping self- statements. Eventually Margie showed improvement in her adjustment in school with some reduction in anxiety and tearfulness.

[4] Panic Disorder

In panic disorders, there are recurrent unexpected panic attacks; an ongoing primary fear of further attacks; secondary fear of losing control, going insane, having a heart attack or dying (American Psychiatric Association, 2000; Ballenger, 2009; Hofmann et al., 2009; World Health Organization, 1992). Acute episodes of intense anxiety our experienced in panic attacks, and these reach a peak within 10 minutes. They are characterised by autonomy hyper arousal shown by some of the following symptoms:

– Palpitations

– Sweating

– Trembling or shaking

– Shortness of breath

– Feelings of choking or smothering

– Chest pain or discomfort

– Nausea or abdominal distress

– Dizziness

– Chills or hot flushes

– Parasthesias (Numbness or tingling sensations)

– Derealisation (Feelings of unreality)

– Depersonalisation (Feelings of being detached from oneself)

In panic disorder, patients tend perceive normal fluctuations in autonomic arousal as a stimulus that provokes anxiety, with the belief that these may signal the onset of a panic attack. During a panic attack, patients typically tend to report an irresistible urge to escape the location where the attack occurred and to avoid such situations in the future. Public settings are usually the most common location where panic attacks take place [e.g. queues, public transport, shopping mall, etc] and acute autonomic arousal is only alleviated upon escape from these places or situations – hence secondary agoraphobia often develops when the patient fears leaving the safety of their homes in case of panic attacks occurring in public settings.

[5] Posttraumatic Stress Disorder (PTSD)

Post-traumatic stress disorder (PTSD) tends to occur after a catastrophic trauma such as a terrorist attack, an armed combat/robbery, a natural or man-made disaster, a serious accident that was perceived to be potentially life-threatening for oneself or others, torture, child abuse or rape.

PTSD is mainly composed of:

– Recurrent intrusive traumatic memories

– Intense anxiety in response to these memories and ongoing hyper arousal in anticipation of their recurrence

– attempts to regulate anxiety and hyper arousal by avoiding cues that trigger traumatic memories and attempts to suppress these memories when they intrude into consciousness (American Psychiatric Association, 2000; Ehlers, 2009; Friedman, 2009; World Health Organization, 1992).

Recurrent, traumatic memories include flashbacks, nightmares, or repetitive trauma themed play in the case of children, and these occur in response to internal (psychological) or external (environmental) cues that symbolise the traumatic event or aspects of it. Since patients with PTSD tend to anticipate the recurrence of traumatic memories, they experience chronic hyper-arousal which may in turn lead to difficulties in concentration, sleep difficulties, hyper-vigilance and irritability. In PTSD, the attempts to suppress traumatic memories and the avoidance of trauma-related situations may turn out to be unsuccessful, when such a scenario occurs, the PTSD person generally experiences an increase in the frequency and intensity of past traumatic memories. Emotional numbing is also quite common in chronic cases due to the frequent attempts to keep the trauma-related memory out of consciousness – this eventually leads to the inability to recall the traumatic memories. To some this may seem like a solution but the cost is excessive since emotional numbing does not only result in the exclusion of trauma-related emotions such as anxiety and anger out of consciousness, but also tender feelings such as love and joy – which cease to be experienced by the patient.

PTSD may also lead to a subjective sense of foreshortened future to the patient and this may also be accompanied by limited involvement in his/her usual activities.

[6] Obsessive Compulsive Disorder

Obsessive Compulsive Disorder (OCD) is generally characterised by distressing obsessions and compulsive rituals that reduce the anxiety associated with those obsessions [like 2 opposing forces] (American Psychiatric Association, 2000; Matthews, 2009; World Health Organization, 1992; Zohar et al., 2009). Obsessions are stereotyped thoughts, impulses or images that are recurrent and persistent. These cause serious anxiety to the patient since they are experience as senseless, uncontrollable and involuntary, and are linked to issues such as obscenity [this does not mean that healthy people with normal sexual feelings in healthy relationships have OCD], violence and danger [for e.g. some people suffer from irrational fears of the possibility of a catastrophe occurring unless symmetry or order is maintained, or there may be fears of losing control and violently raping or assaulting others, or fears of contamination [hygienic].

These compulsions are ritualistic and repetitive accompanied by stereotyped behaviours such as hand washing, ordering and checking or mental acts such as repeating words silently [which some patients feel compelled to do to regulate the anxiety caused by the obsessions], counting or praying [this should not lead to the belief that all people with faith in God suffer from OCD]. Compulsions are generally excessive attempts or unrealistic ways to avert imagined dangers entailed by these recurrent obsessions that are debilitating and are usually recognized as pointless while repeated attempts are made to resist them [once again this seems to be linked to the unconscious yet active component of mental activity and yet again leads us to Sigmund Freud and Jacques Lacan].


Clinical Features of Anxiety Disorders

The 6 anxiety disorders listed above are classified into the domains of Perception, Cognition, Affect, Arousal, Behaviour and Interpersonal Adjustment. In regards to perception, the disorders vary in the classes of stimuli that elicit the anxiety in the patient.

i)Perception

In cases of Separation Anxiety, the separation itself is the stimulus. Where phobias are the condition present, it is specific creatures [e.g. animals], events [e.g. injury], or situations [e.g. meeting new people] that trigger the anxiety. With Generalized Anxiety Disorder [GAD], the interpretation of multiple aspects of the environment end up being interpreted as potentially threatening. Panic disorder is characterised by somatic sensations of arousal such as tachycardia being perceived as threatening since they are treated as the signals that lead to full-blown panic attacks. In people with PTSD external and internal cues that bring back memories of the trauma that led to the condition elicit anxiety. In Obsessive Compulsive Disorders (OCD) stimuli that evoke obsessional thoughts elicit anxiety [e.g. potentially dirty environments or situations may give rise to obsessional ideas about hygiene and cleanliness, and anxiety about contamination.

ii)Cognition

It is important to note that in all 6 of those listed anxiety disorders, that the central organizing theme around cognition is “detection and/or avoidance of danger”. In children with Separation Anxiety there is the irrational belief that the caregivers or parents will be harmed if the separation occurs. In people affected by Phobias there is a constant fear of being harmed by either the feared object or creature, or being in the feared situation [e.g. being bitten by a god – in the case of Dog Phobia OR being negatively judged by meaningless strangers that have no connection or impact on the life of the patient in the case of Social Phobia]. As for Generalized Anxiety Disorder (GAD), patients tend to catastrophize about any features of their environment [e.g. fears of their house being burnt down, or that they will be the victim of a car crash, or punishment for some wrongdoing, they will be forsaken by those they consider as friends, and so forth – they also believe that their worries are uncontrollable. In Panic Disorder, there is the belief that more panic attacks are imminent and that they might be fatal to the patient. In many cases secondary agoraphobia also develops as they individual develops the belief that remaining in the safety of their homes might lower the probabilities of suffering from a panic attack. As for PTSD, there is the belief that as long as the intrusive memories of the trauma are forced out of consciousness, the danger of re-experiencing the intense fear, distress and horror associated with the traumatic event that led to the condition of PTSD can be avoided. Obsessive Compulsive Disorder (OCD) generally leads to obsessions mainly concerned with dirt and contamination; catastrophes such as fires, illness or death; symmetry, exactness and order; religious scrupulosity; disgust with secretions and bodily wastes [e.g. urine, saliva or stools]; lucky or unlucky numbers and extreme, wild, violent and even dangerous sexual thoughts [risk-taking] – the neutralisation of the threat posed by specific obsession-related stimuli is believed to be achieved through being engaged in specific rituals.

iii)Affect

In all 6 of the mentioned anxiety disorders affective states generally follow the beliefs about threat and danger, and these are characterized by feelings of uneasiness, restlessness and tension. In the case of OCD, outbursts of anger may occur if the patient is restricted from executing his/her compulsive rituals or if compelled to approach the feared stimuli; and in children with Separation Anxiety Disorder (SAD) may display aggressive tantrums if compelled to stay in school without their caregivers or parents. In Post-Traumatic Stress Disorder (PTSD), on top of the affective experiences of tension and uneasiness, emotional numbing arises from repeated attempts to exclude all affective material from consciousness.

iv)Arousal

The pattern of physiological arousal varies depending on the frequency of contact with the feared stimuli. In Separation Anxiety Disorders (SAD), hyper-arousal only occurs when separation is anticipated or imminent. In the case of Specific Phobias hyper-arousal only manifests in the present of the feared object or animal. In General Anxiety Disorder (GAD), a pattern of ongoing hyper-arousal can be observed, while in Panic Disorder and PTSD it is moderate followed by brief episodes of extreme hyper-arousal – these occur during attacks in Panic Disorder and when memories of the traumatic event intrude into consciousness in PTSD. In the case of OCD, specific cues related to the obsessions evoke acute and intense episodes of arousal.

In somatic symptoms the extent to which physiological arousal finds expression varies, for e.g. recurrent abdominal pain and headaches are quite common in Separation Anxiety. Sleep problems also occur in most Anxiety Disorders. In Panic Attacks it is also common to notice full blown attacks with sweating, feelings of choking or smothering, shortness of breath, trembling, nausea, dizziness, chest pains, hot flushes or chills, parasthesias, depersonalization or derealisation.

v)Behaviour

All Anxiety Disorders are characterized by avoidance behaviours, and in Specific Phobia, avoidance may even lead to a constriction in lifestyle [using an Injury Phobia as example, the patient may refuse to take part in any form of physical activity [e.g. sports] or ride a bicycle]. In other cases, the patient sometimes become house bound due to his compulsive avoidance, and this generally occurs in Separation Anxiety Disorder, Generalized Anxiety Disorder, Panic Disorder and PTSD. In those with PTSD, the use of alcohol or drugs to alleviate negative affect and suppress traumatic memories is quite common; and in OCD the patients generally engage in compulsive rituals in a desperate effort to regulate their anxiety associated with obsessional thoughts [it may be fair to note the relation between the Anxiety [as the Signifier] and the Obsessional Thoughts [as the Signified] in a Lacanian perspective here to point out the logic behind the flamboyant Frenchman’s model of Mental Activity based on Freud’s initial Topological Model – the Unconscious, the Preconscious and the Conscious]. These compulsions in OCD genereally include washing, repeating a particular action, checking, removing contaminants, touching, ordering and collecting.

vi)Interpersonal Adjustment

All 6 Anxiety Disorders affect interpersonal adjustment in a precise manner. In cases of Simple Phobia, interpersonal difficulties arise only in those situations where the individual does not conform or co-operate with normal activities [deemed social] so as to avoid the feared stimuli [e.g. a brief episode of marital conflict may occur if a husband refuses to enter an elevator at a shopping mall because of his claustrophobia]. Separation Anxiety Disorder (SAD), Panic Disorder (PD), Generalized Anxiety Disorder (GAD) and Post-Traumatic Stress Disorder (PTSD) sometimes prevent young people from attending school or adults from attending work, and in all those situations friends or family relationships may be seriously compromised. In the case of OCD peers or relatives may sometimes attempt to reduce the sufferer’s anxiety in participative actions in the compulsive rituals or in other cases, they may also exacerbate the anxiety by punishing the patient for his or her compulsive behaviour. In extreme cases, these compulsions can become so extreme that the affected person becomes constricted.


Epidemiology, Risk Factors and Course of Anxiety Disorders

Anxiety Disorders are the most common types of psychological disorders, and the lifetime prevalence rate in adults in the US National Comorbidity Survey Replication was 28.8% (Kessler et al., 2005). There is a consensus that Phobias are the most prevalent anxiety disorders and OCD is the least prevalent across a wide range of epidemiological studies (Kessler et al., 2009; Furr et al., 2009). For Phobias, lifetime prevalence estimates range from 6% to 12%, whereas those with OCD fall below 3%. Generalized Anxiety Disorder (GAD) has a lifetime prevalence of 1% to 6 %, whereas Panic Disorder in adults and Separation Anxiety in children range from 2% to 5%. In National representative samples, the prevalence of PTSD ranges from less than 1% or 2% in Western Europe to almost 8% in the US. The great variability is believed to be due to the fact that PTSD rates depend on the prevalence and traumatic exposure within specific locations geographically and the vulnerability of the populations within these countries to developing PTSD – in populations exposed to terrorism the prevalence is 12% – 16% (DiMaggio & Galea, 2006).

In people suffering from Anxiety Disorders, there is also a high risk of comorbidity [i.e. other anxiety disorders may also be present], and up to 1/3 of those suffering from Anxiety Disorders also suffer from another (Kessler et al., 2009) – they may also occur comorbidly with mood disorders in adults as well as children, substance use disorder in adults and adolescents and disruptive behaviour in young people/children (Furr et al., 2009; Huppert, 2009; Zahradnik & Stewart, 2009).  In cases where substance misuse is also present, the use of drugs or alcohol is quite common in managing anxiety.

OCD is also present in a significant proportion of people with eating disorders such as anorexia nervosa. (Halmi, 2010).

We can observe a clear age and gender difference in the prevalence of Anxiety Disorders (Antony & Stein, 2009a; Furr et al., 2009; Kessler et al., 2009) and across most studies that are available, the modal age of the onset in Separation Anxiety Disorder and Specific Phobias is during the developmental phase in childhood [a stage pointed out by both great Western psychotherapists, Freud and Lacan, and also John Bowlby in his observational research on the development of attachment types in children at this critical stage of development], whereas that of anxiety disorders generally happens during adolescence or adulthood. In both adults and children, there is a tendency for more females to suffer from Anxiety Disorders than males, with the exception to this balance being for OCD which has a similar number men and women suffering from the condition although it is the rarest of anxiety disorders.

Anxiety Disorders tend to show a recurring episodic course with a gradual reduction in prevalence over the course of the life cycle (Kessler et al., 2009). It is also worthy to note that most children with anxiety disorders do not grow up to be adults with anxiety disorders or depression, however most anxious adults do have a history of childhood anxiety disorders. There are a number of risk factors associated with Anxiety Disorders and these include anxiety disorders or psychological disorders in the direct genetic network, an inhibited temperament of behaviour, neuroticism as a trait of personality, a personal experience of psychological problems, a history of over-controlling or critical parents, a history of conflict and violence and a history of stressful life events (Antony & Stein, 2009b; Pine & Klein, 2008). In the scenario of Anxiety Disorders, a behaviourally inhibited temperament is generally the tendency from birth – to become nervous and withdrawn from unfamiliar situations and stimuli. Neuroticism is a trait of personality that gradually develops over the life-span, and it is characterized by the tendency to escape negative affect and includes hostility, anxiety and depression in its manifestations.

In those suffering from Post-Traumatic Stress Disorder (PTSD) the additional factors that increases the risk for development include the severity of the trauma, high-life stress following the trauma, low socio-economic status, low support [from friends or those considered as friends], low intelligence and low educational level (Ehlers, 2009; Ozer et al., 2003). In PTSD, dissociative experiences tends to refer to abnormalities of perception, memory or identity such as derealisation [seeing the world as dream-like], depersonalization [seeing oneself from an external perspective or inability to recall important information]. In the case of parents with PTSD, their children are also at a higher risk of developing the disorder (Pine & Klein, 2008).

 

_____________________________________

 

Part 3 of 5 | Depression

ClinP_Descr_Header_03

The states of being happy or sad are adaptive feelings, and many behaviours that lead to happiness among human beings, such as socializing [with the people that matter to the subject], becoming completely absorbed in productive work and developing longstanding friendships that are meaningful around values and loyalty, are important not only for the emancipation of the individual but also for a harmonious and functional society that embraces the qualities of mankind in all its creative aspects.

Sadness on the other hand is a psychological state commonly preceded by loss [of various kinds, which may range from material objects to valued relationships or abilities/skills and status related to them through accident or disease or other situations], and it is a negative feeling which may also be adaptive, in a sense that it is a reminder to most people [at least for those who are NOT philosophically oriented / cultured or have an understanding of values and loyalty in interpersonal relationships], that valued things or people need to be taken care of if they do not want to lose them in the future, especially the common volatile brain [i.e. the basic Darwinian instinct-guided average brain that lacks reflective abilities, reasoning skills, intuition and insight, while also failing to realises or understand the motivation behind its behaviour until matters have taken a disastrous course]. Sadness is also a way of signalling to others that we as human beings also need care and elicits [to most psychologically healthy human beings with a theory of mind] support that soothes our emotional pain – this is what makes us a superior breed of primates, i.e. our ability to reason and evolve with emotions as a propulsive form of energy for both individual and group, like Alexandre Dumas put it, “Un pour tous et tous pour un!” [French for “One for all and all for one!”].

Some extreme states of mood such as depression and mania are less adaptive than happiness and sadness; and it is now commonly known that during periods of hypomania or mania some patients suffering from Bipolar Disorder [which is characterized by episodes of mania and depression] produce highly creative artistic work (Silvia & Kaufman, 2010). This should not lead us to the conclusion that ALL creative people with extreme ways of exploring and expression their emotions through art suffer from Bipolar Disorder. But for those who do suffer from Bipolar Disorder and produce creative work, this highly valued asset comes at a price, since these individuals generally involve themselves in high-risk behaviours that come with the possibility of severe dehydration and exhaustion during manic episodes.

Seasonal Affective Disorder [or Winter Depression, its colloquial name] is a condition that is believed to be linked genetically to our cave-dwelling ancestors from the prehistoric era, who may have hibernated – an adaptive behaviour for the ancestors. However, in the world of today, depression does not seem to serve any adaptive function, and despite this it remains a highly prevalent condition that affects up to 25% of the population (Kessler & Wang, 2009); because of this prevalence the main focus of this section will be on Major Depressive Disorder. It is quite fundamental to grasp that depression is not simply “feeling sad”, as Major Depressive Disorder is an ongoing condition characterized by episodes of low mood and loss of interest in pleasurable activities along with other symptoms such as poor concentration, fatigue, pessimism, suicidal thoughts, and sleep and appetite disturbance. Depression is a serious public health concern because it radically decreases the quality of life of those affected, is a huge economic burden in terms of reduced productivity [and lack of creativity] among the national work force, and it also has adverse effects on the mental health and adjustment of the children of the depressed people (Garber, 2010; Kessler & Wang, 2009). This section will focus on the clinical features, epidemiology, risk factors and course of depression [suicidal risks will also be discussed].


Clinical Features of Depression

Severity

Depression can be classified as mild, moderate to severe, depending on the degree of impairment

Melancholia

In regards to somatic or melancholic features, in severe depression where there is a loss of pleasure in all activities [known as anhedonia] and a lack of reactivity to pleasant stimuli along with diurnal variation in mood and sleep and appetite disturbance, we tend to qualify such episodes as having melancholic features. Historically [please take note that this is not the case anymore], there was an ongoing view that these symptoms reflected “endogenous”, a genetically determined and biologically based form of depression, as different to a “reactive” depression arising from exposure to stressful life events and environmental adversity (Monroe et al., 2009).

However, the difference between these 2 forms of depression was not supported by empirical research, which instead shows that ALL episodes of depression are preceded by stressful life events, and that in any given scenario, we tend to have a combination of genetic vulnerability and environmental adversity that contribute to the development of depression (Parker, 2009).

Psychotic Depression

When mood disrupting delusions and hallucinations are present, depressive episodes are described as having psychotic features. Mood-congruent delusions are generally firmly held beliefs that are extremely pessimistic in nature and that have no basis in reality [illogical and cannot be explained and justified; for e.g. that a completely innocent individual is guilty of many wrongdoings and deserve to die. Mood-disrupting hallucinations in depression are generally auditory and sometimes involve the hearing of voices in a complete absence of any form of external stimuli [uncontrolled and unimagined and ongoing for months], which has negative advices to the sufferer [e.g. You are a failure, you are guilty of wrongdoing, or evil].

Among children, adolescents and adults, there has been a range of clinical features identified through both clinical observation and empirical research (e.g. Bech, 2009; Brent & Weersing, 2008; Gotlib & Hammen, 2009; Nolen-Hoeksema & Hilt, 2009a). Common clinical features of depression tend to affect the domains of cognition, perception, mood, somatic state, behaviour and relationships. Loss is once again a main thematic feature in depression as pointed out by Psychoanalytic Theories [loss of any kind, e.g. material, emotional, relationship, valued attribute due to sickness/accident, health, etc], and clinical features may be linked to those different domains of mental life.

Perception

In regards to perception, depressed individuals who have suffered some form of loss [internal or external] tend to perceive reality and the world as one where further losses are possible, and individuals who suffer from depression also selectively attend to negative stimuli and features in the environment. This leads them to engage in further depressive cognitive patterns in their thoughts processes and unrewarding behavioural patterns which amplify their depression’s severity – in cases of severe depression, mood-congruent auditory hallucinations are often reported. Psychologists tend to go with the assumption that such severe perceptual abnormality is present only when patients report hearing harsh critical voices or containing depressive contents [as mentioned above]. These auditory hallucinations are also present in schizophrenia, however they are not always mood-congruent like in depression.

Cognition

Depressed patients tend to describe the world and the fabric of reality of their subjective experience in negative terms, this also include descriptions of themselves and their abilities [e.g. occupational and social accomplishments] – this negative evaluation is often portrayed as guilt for not living up to the standards [they set themselves based on their ‘perceived’ abilities] or for letting others down. They perceive their direct environments [peers, network, family, work colleagues or school/university] as hostile, apathetic, critical and unrewarding. The future is also described in very bleak terms by those suffering from depression, and they also report little if any hope that matters will improve. When extreme hopelessness is reported is it usually accompanied with excessive guilt for which the patients believe they should be punished – suicidal ideas and intentions may also be declared. In depressive delusional systems, extremely negative thoughts about the self are generally reported with the world and their future entangled in them.

Besides the content and thoughts being incredibly negative and bleak, depressed patients also tend to display concentration problems and logical errors in their thinking. These mistakes in reasoning are also characterized by a tendency to maximise the significance of negative events and minimize the significance of positive ones. Depressed patients also suffer from memory problems and struggle to remember happy events but instead have global over-general autobiographical memories about both positive and negative events. In addition to these, this category of patients also suffer from concentration, attention and decision-making problems that in turn give rise to difficulties managing leisure activities requiring sustained attention and academic or occupational responsibilities.

Affect

The impact on the patient’s affect tends to lead to low mood, and diurnal variations in mood and anhedonia. The depressed mood is usually reported as a feeling of sadness, loneliness, emptiness and despair. Diurnal variations in mood is usually quite common in severe cases of depression, with the patient’s mood generally being worse in the morning or after waking up. In cases of major depression, as a person moves from mild to moderate to severe depression, the increasing number of symptoms along with the intensity can also lead to intense anxiety. Generally, fears are experienced in the form of “Will this get worse? Am I stuck in this living hell forever? Will I ever be myself again? Will I be able to prevent myself from committing suicide to escape? Irritability is also a characteristics of depression, with the patient sometimes expressing their anger at the source of their loss [e.g. anger at a deceased one for abandoning the grieving person or sometimes at the health professional for not being able to alleviate their depressive symptoms].

Somatic State

The changes in the patient’s somatic state associated with depression include the disturbances of sleep and appetite, the loss of energy, failure to make age-appropriate physiological growth, weight loss, pain symptoms and a loss of interest in sexual activities. Commonly, depressed people struggle to find sleep and eat insufficiently due to their poor appetite; these symptoms are known as vegetative features. The sleep disturbances in depressed people generally involve problems trying to sleep, wakefulness at night or early-morning sleep disruption. Other symptoms such as racing thoughts and engaging in depressive rumination while unable to sleep is also quite common. In atypical cases of depression, patients may sometimes oversleep due to a constant feeling of exhaustion and consume excessive food due to an increased appetite or due to the feeling that eating may temporarily reduce their distress.

Medically unexplained chest, abdominal and back pain along with headaches are some of the additional features of depression. In some cases the pain symptoms are some of the first signs that would be reported to the doctor and it is only when the medical investigations of these symptoms turn out to be negative that depression is suspected to be the cause. All the somatic symptoms mentioned are consistent with research: dysregulation of neurobiological, endocrine and immune functions is associated with depression and the sleep is also affected.

Behaviour

Depressed patients are characterized behaviourally by the reduced and slow activity levels [psychomotor retardation] that they display, and are often helpless [without any control over their abilities] about their inability in getting involved in activities that could have helped their condition by bringing a sense of achievement or connectedness to meaningful [those chosen by the individual as a person with significance to him/her – note that it is a choice] people in their life. In rare cases some individual become house bound and immobile; such a condition is known as depressive stupor.

One of the major risks of depression is self-harm [a clear distinction is made between non-suicidal deliberate self-harm and suicidal behaviour]. In non-suicidal tendencies, patients may cut or burn themselves to distract themselves from the depressive feelings. In some cases, some have taken non-lethal overdoses to elicit attention and care from their close ones or to simply gain admission to hospital and remove them from the stressful situations that may have been amplifying their depressive symptoms.

Relationships

Depressed patients generally report a deterioration in their relationships with a range of significant figures in their lives from a wide range of environments [from professional to personal], and describe themselves as lonely, et unable or unworthy to take steps to try and engage in some form of contact with others. Surprisingly, when the depressed attempt to overcome their loneliness by talking to others, they tend to come across as repulsive, unpleasant and draining through their depressive behaviour, pessimistic belief and sometimes arrogant narcissistic talks, this drives away those they interact with.


Epidemiology, Risk Factors and Course of Depression

The most common mood disorder is Major Depression, and it has a lifetime prevalence rate of 6 – 25% in international community studies (Kessler & Wang, 2009). In the US National Co-morbidity Survey Replication the lifetime prevalence of DSM-IV Major Depression was 16.6% (Kessler et al., 2005). It is good to note that Depression is less common among pre-pubertal children than adolescents and adults (Brent & Weersing, 2008). Among children the number of boys to girl with depression is equal, however this changes in adolescence and by adulthood; compared with men, about twice as many women have depression (Nolen-Hoeksema & Hilt, 2009b).

In most cases of depression, there are many comorbid disorders also present. In the US, National Comorbidity Replication Survey, 59% of depressed patients suffered from comorbid anxiety disorders and 24% had comorbid substance use disorders (Kessler & Wang, 2009). Depression also tends to follow a chronic relapsing course, with up to 80% of people suffering from recurrent episodes, and it has been found that the median duration of episodes in community samples typically lasts for about 5-6 weeks. In clinical samples depressive episodes tend to last for about 5 to 6 months; the majority of cases however recover within 1 year and about half of patients continue to suffer from fluctuating residual symptoms between those depressive episodes; and for less than 10% of patients, recovery does not occur and chronic depressive symptoms persist and most cases relapse within 5 years (Angst, 2009; Boland & Keller, 2009).

During treatment, as more depressive episodes occur, we tend to notice a decrease in inter-episode intervals and a reduction in the amount of stress required to trigger the onset of further depressive episodes, an issue related to Stress Theories (Boland & Keller, 2009).

NOTE: Stress theories propose that individuals develop depression following exposure to stress. The diathesis- stress theories propose that depression only follows after exposure to stress in people who have specific biological or psychological attributes that render them more vulnerable to stressful life events, and the most vulnerable require the least stress to trigger depression (e,g., Joiner & Timmons, 2009: Joormann, 2009; Levinson, 2009). On the other hand, Stress-generation theory proposes that people with certain personal attributes inadvertently generate excessive stress, which in turn leads to depression (Liu & Alloy, 2010)

The risk factors for depression include a family history of mood disorders, female gender, low socio-economic status involving educational and economic disadvantage, and adverse early family or institutional environment, the depressive temperament, a negative cognitive style, deficits and self-regulation, high levels of life stress, and low levels of support from meaningful others (Garber, 2010; Hammen et al., 2010).

Risk factors for recurrent major depressive episodes identified in the US collaborative depression study of 500 patients, include a history of three or more prior episodes, comorbid dysthymia (often known as Double Depression), comorbid anxiety and substance use disorders, long duration of individual episodes, poor control of symptoms by antidepressant medication, onset after 60 years of age, the family history of mood disorder, and being a single female (Boland & Keller, 2009).

Four small category of people who suffer from depression, deficits the visual processing of light and the season of the year are risk factors for depression (Rosenthal, 2009). These people, who experience regularly recurring depressive episodes in the autumn and winter, with remission in the spring and summer, are generally considered as suffering from Seasonal Affective Disorder. These patients develop symptoms in the absence of adequate light and respond positively to enhanced environmental lighting, often referred to as “Light Therapy or Treatment” (Golden et al., 2005).

In community samples about 3.4% of people with major depressive disorder commit suicide; the rate in clinical samples about 15%; about 60% of completed suicides (studied by psychological autopsy) had suffered from depression (Berman, 2009).

 

_____________________________________

 

Part 4 of 5 | Schizophrenia

ClinP_Descr_Header_04

Before covering the topic of schizophrenia, it is important to take note that the condition is commonly confused to refer to another condition that involves split-personalities, and this is mostly a trend that lives in the world of pop culture and Hollywood. About 40% in the UK equated split or multiple-personality with schizophrenia in a National Survey (Luty et al., 2006). However, after covering this section, we hope that the confusion will be cleared since schizophrenia does not refer to conditions that involve split-personalities [the closest scientific equivalent to this state of being, is a condition known as Multiple Personality Disorder or Dissociative Identity Disorder and are both not as debilitating as schizophrenia with treatment being much more effective].

Schizophrenia refers to a collection of seriously debilitating conditions characterised by positive and negative symptoms in this organisation (Mueser & Jeste, 2008).

Delusions and hallucinations are the principal positive symptoms of schizophrenia. Delusions are strongly held, unfounded, culturally alien beliefs. For example with persecutory delusions, individuals may believe that a group of people conspiring to harm them [this should not lead us to believe that a healthy person with a suspicion caused by the critical analysis of a person or group of people is deluded and is schizophrenic – remember that human beings have individual personalities too]. Hallucinations on the other hand involve experiencing sensations in the absence of external stimuli [e.g. with auditory hallucinations – which are the most common type in schizophrenia – people reported hearing voices that others cannot hear].

The negative symptoms of schizophrenia include flattened affect, alogia and avolition. In the case of flattened affect, the emotional expression of the patient is limited, and with alogia there is an impoverished thought that is inferred from the patient’s speech. Short brief and concrete replies are given to question [this is referred to as poverty of speech], or in some cases speech production is normal but it conveys little meaning and information due to repetition, or being overly abstract [referred to as poverty of content], or being too concrete. When patients suffer from avolition, a lack of goal directed behaviour can be observed. The negative symptoms generally give rise to a restricted lifestyle involving little activity, little social interaction with others and little emotional expression – disorganisation may also affect both speech and behaviour [disorganised, illogical, incoherent, speak are the signs of an underlying formal thought disorder]. Disorganised catatonic behaviour is usually characterised by the complete absence of spontaneous activity or excessive purposeless activity.

Schizophrenia is a debilitating and re-occurring condition that comprises the capacity to carry out normal activities, and also consists of incomplete remission between episodes.  (Hafner & der Heiden, 2008). Symptoms of schizophrenia typically appear in late adolescence or early adulthood, wax and wane over the life course, and have a profound long-term effect on patients and sometimes their families.

Schizophrenia is considered to be the most debilitating of all psychological disorders, since it affects the patient’s capacity to live independently, make and maintain satisfying and enduring relationships, engage in family life, parent children effectively, work productively and enjoy leisure activities. Rates of unemployment, homelessness and imprisonment are very high among people with schizophrenia, although just under 1% of people suffer from schizophrenia, the World Health Organization has rented as second only to cardiovascular disease in terms of overall disease burden internationally (Murray & Lopez, 1996).

Despite these unattractive facts, the scientific advances in our understanding of schizophrenia, along with advances in both psychological and pharmacological approaches to treatment, making it increasingly realistic for people who suffer from schizophrenia to live far more productive lives than were previously possible (Mueser & Jeste, 2008).


Case Example of Schizophrenia

A young man, named Julian was referred for assessment and advice by his doctor. Since returning to his rural home after studying in London for one year, his parents started to worry about his state because of his strange behaviour. After failing as exams, the patient said that he had to ”sort his head out”. Since his return, the parents had noticed a lack of concentration along with incoherent speech during his conversations which happen most of the time – his behaviour was also erratic and unpredictable.

The parents concern grew when Julian suddenly went missing a few weeks prior to the referral. After hours of searching, he was found about 55 Km from their home, dehydrated, exhausted and dressed only in sport shorts, singlet and running shoe. After enquiry, the latter developed the belief that a secret mission in the East had to be undertaken by him; and as he started jogging in the morning, he headed eastwards towards the rising Sun. He even planned to jump onto the car ferry when he reached the coast, across the sea over to Holland, and continue east towards India in his secret mission [reminiscent of a James Bond episode].

Since the episode, Julian has spent much of the time in his room muttering to himself, often becoming quite distressed, and when his parents spoke to him they found it hard to make any sense out of his words.


Family History

Julian was the 19-year-old son of a prominent farmer in a rural English village where the whole family lived in a large amount on an extensive estate. The farm was managed by the patient’s father; who had a traditional authoritarian manner and a positive, if distant, relationship with Julian. While he was incredibly worried about Julian and to the search for him, once the latter was found, the father returned to work unless the care of his son to his wife.

The mother was an artist who dressed flamboyantly, behaved in a theatrical manner and held century, unconventional beliefs [e.g. Conspiracy theories about many issues, was interested in eastern mysticism and believe that faith healing and alternative medicine were preferable to traditional Western medicine]. These characteristics of a personality along with her beliefs affected her treatment of Julian after the ”Running East” episode, where she engaged the latter in intense conversations about mystical meaning of the psychotic experiences that led to him trying to make his way to India on foot. Rather than taking Julian to the accident and emergency department of the local hospital for assessment, she brought him to a feeler and then than homeopathist. It was only of these interventions failed to our view the distress that she took Julian to the doctor, who made the referral to the community mental health team. In the preliminary assessment that was conducted with Julian and both of his parents, the mother responded to the son with intense emotional over involvement (an index of high expressed emotion associated with a relapse in schizophrenia; Hooley, 2007).

With regard to the extended family, according to parents there has never been a family history of psychological disorder. However some members of the mother’s well-to-do family were fairly eccentric and odd, especially her brother, Sedric, and her uncle, William Jr. Williams eccentricities led him into serious conflict with his father, and Sedrick’s odd behaviour underpin his highly conflictual, childless marriage.


Developmental history

Julian on a family farm and went to the local school, his development was what most people would call normal. His Academy former school was above average and he had many friends in his local village, and was a popular child and adolescent who also excelled at cricket. At 18 years old before going to university London, he had no psychological problems.

His first term at college was successful academically and socially, however, the occasional experimental cannabis use that had begun the summer before going to college turn to a regular use once Julian moved to London. During his time at university, the patient also experimented with LSD on a few occasions. In the final term of his first year at college, Julian developed intense fear of exam failure. Other symptoms quickly followed such as difficulty studying effectively and sleeping problems. Julian stopped attending classes regularly and spend more time alone, and was relieved to return home after sitting as exams. Once home he was described as quiet and thought during most of the time prior to the “running East” episode.


Presentation

Julian presented with symptoms such as delusions, hallucinations, disorganised speech and anxiety. At the very start the patient was very reluctant to be interviewed because he believed he had urgent business to attend to in Holland and further afield in India. He also showed signs of being anxiously distressed throughout the interview, explaining that his path was to the east and believed he was being called there by an unknown source. He firmly believes this because of a sign he had seen while out jogging on the morning of the enigmatic “running East” episode. The way in our God will record the sunlight and cast a shadow on the red barn against which it was leaned made a distinctive pattern, which to him meant a special sign indicating that he should go East, first to Holland and then all the way to India. Upon questioning this idea, a clear authoritative voice said that he should leave at once.

At this point in his narrative, stopped mid-sentence and displayed thought blocking, and will strive the topic he was talking about. Upon being asked to continue his story, he began to giggle, and when questioned about the reason behind his amusement, Julian declared to have heard someone say something funny. Julian then spoke about a number of unrelated topics in an incoherent way before experiencing thought blocking again.

Later he expressed the desire to leave soon because people will try to prevent him, as he had heard them plotting about this the day before, and also declare that they had tried to put bad ideas into his head [which he described as frightening]. He was also frightened by periodic sensations that everything was too loud or too bright and coming at him, declaring “it was like doing acid [LSD] all the time… a really bad trip.”


Formulation

In Julian’s case he presented with auditory hallucinations, delusions, thought disorder, anxiety and a significant deterioration in social and occupational functioning which had been present for more than 1 month [symptoms consistent at the time of this essay with a diagnosis of Schizophrenia]. The patient also showed a complete lack of insight and was unable to understand that the voices being heard were hallucinations and that the delusional beliefs were unfounded. Among the major precipitating factors were the experience of recent exam pressure and his transition from living at home to living in London at attending college. The principal predisposing factors were possible genetic vulnerability to psychosis and a history of hallucinogenic drug use.

His psychological condition was maintained by what was likely to be an excessive level of maternal expressed emotion characterised mainly by emotional over-involvement. His delusions were also reinforced by the mother since the latter engaged Julian in long and draining conversations about them. The protective factors in this case were godo premorbid adjustment and a strong family support for the boy.


Treatment

The treatment plan included antipsychotic medication and family will to reduce parental expressed emotion, with an initial brief period of hospitalisation. Julian did recover from his first psychotic episode, and his hallucinations and delusions decrease considerably with medication. Through family Psycho-education, parents develop understanding of this condition and of the requirement of a “low-key” approach to interacting with the boy as he recovered.

However some obstacles were encountered in Julian’s recovery, since he disliked the side effects of the medication, especially the weight gain and reduced sexual drive/function, and so had poor medication adherence – depression also manifested during the remission, when Julian came to realise about the many losses that followed his condition. He was unable to pursue his university studies and thus, could not continue the law career he had dreamed of. He also experienced difficulties in maintaining friendships or to commit to engaging on a regular basis in physical exercises or sports. When his mood was low, Julian would smoke some cannabis to lift his spirits.

The mother found it very difficult to accept the diagnosis of Schizophrenia and continued to hold the belief that his psychotic symptoms were linked to some spiritual or mystical explanation. She even sometimes declared that she thought of her son not as an ill young man, but a gifted seer or a “chosen one” [based on no rational explanation or series of events], and often engaged Julian in intense, distressing conversations about these issues. In the years that followed his initial assessment, poor medication adherence, ongoing cannabis use [which the patient could not tolerate unlike some other users] and exposure to high levels of intrusive parental emotions led Julian to relapse more often than might otherwise have been the case.


Clinical Features of Schizophrenia

A range of clinical features have been identified and associated with Schizophrenia though research and clinical observations (Mueser & Jeste, 2008). The generally concern the domains of perception, cognition, emotion, behaviour, social adjustment and somatic state.


Perception

At the perceptual level, patients suffering with schizophrenia generally describe a breakdown in perceptual selectivity, with difficulties focusing on essential information or stimuli to the exclusion of accidental details or background noise. Most aspects of the environment seem to be salient, however, the inability to distinguish between figure and ground is a serious problem to the sufferer. During an acute psychotic state, internal stimuli such as verbal thoughts are experienced as auditory hallucinations that have the same sensory quality of the spoken word.

Auditory hallucinations can sometimes be experience as extremely loud thoughts, or as thoughts being repeated by another person aloud (thought echo), as voices speaking inside the head or as voices coming from somewhere in the outer environment. The auditory hallucination may occur as third person making comments on the patient’s action, as a voice speaking in the second person directly to the person, or as two or more people talking or arguing – the effect did may also perceive voices to vary along the number of dementia [may be construed as benign or malevolent, controlling or impotent, or knowing or knowing little about the patient, who may sometimes feel compelled to the demands of the voice or not.

When hallucinations are perceived to be malevolent, controlling, all-knowing, where the individual affected feels compelled to obey the demands of the voice, the situation is deemed to be far more distressing than those who do not have these attributes. While auditory hallucinations are the most common features in schizophrenia, hallucinations may okay other sensory modalities too. Somatic hallucinations also often occur in schizophrenia, with many cases including reports of electricity in the body or the feeling of something crawling underneath the skin [these may be qualified as delusional interpretations. For example, a patient reported that the television was activating a transmitter in her pelvis and she could feel the electricity from this closing insects to grow and move around under the skin. Visual hallucinations [seeing visions] are relatively rare in schizophrenia very common in temporal lobe epilepsy.


Cognition

At the cognitive level, delusions are the most common cognitive clinical feature of schizophrenia, and are false, idiosyncratic, illogical and stubbornly maintained erroneous inferences drawn to explain unusual experiences, such as hallucination. [e.g. patient with auditory hallucinations where an authoritative voice commanding the latter to gather the children, was interpreted by the patient that she had been chosen by God to prepare all the children for the second coming of Christ]

Delusions may also arise from unusual feelings associated with psychosis. Persecutory delusions may develop from feelings of being watched. Delusions of thought insertion or thought withdrawal may develop as explanations for feelings that thoughts are not one’s own, or that one’s thoughts have suddenly disappeared. Factor analyses show that delusions fall into 3 broad categories:

Delusions of influence [including thought withdrawal or insertion, and beliefs about being controlled]; delusions of self-significance [including delusions of grandeur or guilt]; and delusions of persecution (Vahia & Cohen, 2008). Delusions may vary in the degree of conviction with which they are held [great certainty to little servant, the degree to which the person is preoccupied with them [the amount of time spent thinking about the belief], the amount of distress they cause.

Particular sets of the may comprise of a confused sense of self, particularly paranoid delusions with the patient holds the belief that they are being persecuted or punished for misdeeds, or delusions of control where there is a belief that their actions controlled by others [e.g. an unknown source or entity].

A lack of insight along with an impaired judgement is quite common during a psychotic episode. This happens when the patient believes that the contents of their hallucinations and delusions are real, and are incapable of coming to terms with the fact that their experiences and beliefs arise from a clinical condition. However in between psychotic episodes, the patient’s insight may improve and in some cases they may acknowledge that their hallucinations and delusions are symptoms of schizophrenia.

Speech in schizophrenic patients is also fairly hard to understand due to the abnormalities in the underlying thought pattern. This formal thought disorder is characterised by

  1. Tangentiality [answers given to questions are off the point]
  2. Derailment [sentences makes sense but hardly any meaning is conveyed by the sequences of sentences because there is a constant jumping from one topic to another, with very loose association between topics and little logic to what is said]
  3. Incoherence [sentences are incorrectly formed so little sense can be made out of them]
  4. Thought blocking [the patient abruptly stop’s in mid-sentence and is unable to complete the train of thought]
  5. Loss of goal [the difficulty in following a logical train of thought from A to B]
  6. Neologisms [inexistent new words are made up that only have idiosyncratic meaning for the patient]

Cognitive impairment or deterioration occurs in schizophrenia and this may either be general or specific. In cases with general cognitive deterioration, we can observe a reduction in overall IQ with many cognitive function also negatively affected. With specific cognitive impairment one or more of the following functions may be impaired: attention, memory, cognitive flexibility, social cognition and executive function, and most commonly the ability and dedication to follow through on a planned course of action. Cognitive impairment remains a better predictor of disability and vocational functioning than positive symptoms.


Emotions

At the emotional level, especially during the prodromal phase, before an acute psychotic episode, anxiety or depression may occur in response to changes in perceptual selectivity and cognitive inefficiency. One of the main functions of relapse prevention is for patients to learn [and eventually master] the ability to identify and manage prodromal changes in affect.

During psychotic episodes that are intense, anxiety or depression may occur in response to hallucinations, delusions, formal thought disorder and other debilitating symptoms. Inappropriate affect may also be present in hebephrenic schizophrenia, where the patient responds to the internal stimuli such as auditory hallucinations [e.g. laughing wildly] and not the external social context. In chronic cases, blunted or flattened affect can also be observed, and in remission [following an episode of psychosis], the sense of loss [e.g. of valued personal relationships, material, career, etc] that comes with increased insight into the reality of the condition may give rise to post-psychotic depression in some cases.

Behaviour

In terms of behaviour, prodromal excitation may occur prior to an acute psychotic episode, characterised by sleep disturbance, impulsive behaviour, and over-reactivity [may include compulsive behaviour]. Avolition also occurs during psychotic episodes with an observable impairment in goal-directed behaviour.

In some chronic cases, it is common to also find catatonic behaviour along with an impairment in the ability to initiate and organise voluntary movement and posture. Catatonia may be either retarded or excited. Excessive purposeless motor activity is the hallmark of excited catatonia and may include stereotypies [repetitive actions], echolalia [repeating the words said by others] or echopraxia [imitating the actions of others] – these tend to occur without the patient being consciously aware of it [not a conscious choice]. In cases where retarded catatonic behaviour is present there is an observable reduction in purposeful activity; patients may display signs of immobility, mutism, adopt odd postures for extended amounts of time, and display waxy flexibility or negativism.

Social Adjustment

A marked deterioration in social adjustment is also common in schizophrenia, and the ability for self-care, appropriate dressing, grooming and personal hygiene deteriorates – patients with schizophrenia often look dishevelled and unkempt. A decline in also commonly present in the domains of education and work with a withdrawal from regular patterns of socialisation and difficulty making and maintaining significant relationships. A deterioration with others also occurs and schizophrenia tends to have a negative impact on parent-child, marital and sibling relationships.

Somatic State

Approximately 50% of people with Schizophrenia also have comorbid substance use disorders and almost 75% have significant health problems, with the most common one being Chronic Obstructive Pulmonary Disease (COPD) [usually due to heavy smoking]; heart disease and diabetes due to obesity; HIV/AIDS and hepatitis B and C caused by unsafe sex and intravenous drug use [e.g. heroin]. These drug and medical problems in schizophrenia are lifestyle problems. However, one the positive side, schizophrenia is associated with reduced rates of cancer and rheumatoid arthritis (Tandon et al., 2008a).

 

Epidemiology, Course, Outcome and Risk Factors of Schizophrenia

International epidemiological studies that have been reviewed have allowed for a number of conclusions to be deduced regarding schizophrenia. We know that [luckily] under 1% of the population suffer from schizophrenia, and the lifetime risk of the condition is about 0.7% (Saha et al., 2005). More men than women suffer from schizophrenia: the male-female ratio is about 1.4:1 (McGrath et al., 2004). Schizophrenia has an earlier onset in males (20-28 years) than in females (28-32 years) (Murray & Van Os, 1998). The rates for schizophrenia have also been found to be similar across countries and cultures when diagnostic criteria are used (Mueser & Duva, 2011).

Schizophrenia tends to follow a distinctive course although a considerable variability exists across cases (Jablensky, 2009; Jobe & Harrow, 2010; Mueser & Duva, 2011, Tandon et al., 2009). The onset of schizophrenia generally occurs in late adolescence or early adulthood and may be acute or insidious [onset generally takes place over 5 years, starting with negative and depressive symptoms, followed by cognitive and social impairment and finally positive symptoms]. Longitudinal studies suggest that there is an early deterioration phase that extends over 5-10 years, a stabilisation phase and a final gradual improvement phase. In over 50 – 70% of cases, the condition follows a chronic relapsing course, typically with incomplete remission between episodes. However, up to 40% of patients show one or more periods of complete recovery with good adjustment for at least 1 year, and  4 – 20% of cases show complete remission.

Psychotic episodes may last from 1 – 6 months, although some cases extend up to 1 year. They are usually preceded by a prodromal period of a number of weeks. Psychotic episodes may be lessened and the severity of the symptoms ameliorated through early detection and the use of pharmacological and psychological treatment. Inter-episode functioning may differ greatly and better inter-episode functioning is associated with a better prognosis. The duration of remission between episodes may be lengthened through the use of maintenance medication and psychosocial interventions to reduce stress and improve coping and illness management.

With treatment, usually positive symptoms (hallucinations and delusions) abate between episodes but negative symptoms (blunted affect, alogia and avolition) can be enduring and are more likely to persist during remission. In the stabilisation phase of schizophrenia, positive symptoms become less prominent, while negative symptoms and cognitive deficits become more prominent. The lifespan of people with schizophrenia is also 9 years less than that of the general population, and this is partly accounted for by the high rate of suicide during the first 10 years of the disorder and the high rate of comorbid medical disorders that also tend to occur along with schizophrenia. About 50% of schizophrenics attempt suicide or self-harm, and about 10% commit suicide (Heisel, 2008; Schennach-Wolff et al., 2011).

One of the greatest risk factors for schizophrenia is a family history of psychosis. Other risk factors make a small contribution to the overall risk within the context of associated with genetic vulnerability. However until now, it is important to note that we still do not have any clear consensus or evidence on how these risk factors operate and whether environmental factors remain a stronger prediction of the onset of schizophrenia than genetic factors that only set a predisposition [risk] of possibly developing the condition. Prenatal and perinatal risk factors, such as maternal flu infection and obstetric complications, are likely to have a negative effect or indirect effect on the development of the nervous system in line with the neurodevelopmental hypothesis that states how those affected by such issues while also being genetically predisposed to schizophrenia are even more neurologically vulnerable to psychosis (Murray & Lewis, 1987). Trauma exposure and most demographic risk factors (being unmarried, low-SES urban migrant) are associated with higher levels of stress and lower levels of social support [which increases the risk of psychosis in the genetically vulnerable] according to the Diathesis-Stress Conceptualisation of Schizophrenia (Zubin & Spring, 1977).

In the short term, relapse is more likely in cases where these is heavy cannabis use [along with poor personal/subjective tolerance of the effects on consciousness], poor treatment adherence, frequent contact with insignificant extended family members who may display excessive negative emotional expressions towards the patient [e.g. criticism, hostility and emotional over-involvement] and exposure to acute stress life events (Jablensky, 2009).

A poor outcome is associated with substance use and a longer period of untreated psychosis in people who have poor premorbid adjustment and an early insidious onset with no clear stressful life event preceding their first treated episode. One of the main traits associated with a poor outcome is “Anxiety”, and people with this stress profile are generally more sensitive to and reactive to life’s stressful events, along with populations living in a developing economy, and family-based stress associated with excessive negative expressions of emotion. The symptom profile predictive of a poor outcome is also marked by severe negative symptoms, cognitive impairment and lack of depressive symptoms.

A favourable outcome in schizophrenia is associated with a range of factors (Bota et al., 2011). These include good premorbid adjustment, and a brief duration of untreated psychosis characterised by an acute onset in response to precipitating stressful life events. A family history of affective problems/disorders [rather than schizophrenia] or little psychopathology and a personal symptom profile in which there are affective as well as psychotic features are also predictive of a good prognosis. A better outcome tends to follow those who have a favourable life situation to return to following discharge from hospital.

 

_____________________________________

 

Part 5 of 5 | The Effectiveness of Psychotherapy

 

ClinP_Descr_Header_05

The main help that a psychotherapist provides is psychotherapy, a contractual process where professionals with expert knowledge interact with clients to guide and help them in the resolution of their psychological conflicts, emotional imbalance, psychological problems and address mental health and behavioural difficulties [if any]. Psychotherapy can be offered to both adults and children on an individual, couple, family or group basis.

Often psychotherapists offer therapy as one element of a multimodal programme provided by a multidisciplinary team [e.g. a multidisciplinary adult mental health team may routinely offer a multimodal programme of psychotherapy combined with some mild anti-depressant for depression]. This final section will focus on the evidence base for the overall effectiveness of psychotherapy.


Evidence-based Practice

In today’s trend of mainstream clinical psychology where the mechanical model of early behaviourists has been combined with cognitive psychology to become Cognitive-Behavioural Psychology, there has been a gradual shift from practice guided by descriptions of clinical cases [qualitative, detailed and individual] to “evidence-based” practice guided by the results of empirical studies using the statistical methods of science to make inferences about behaviour [that can be measured at least] on the effectiveness of psychological interventions. This movement has started in part due to the influence of policies derived from the medical field which bases itself on evidence-based medicine [i.e. tested with laboratory-rigour and statistical methodology] (Sackett et al., 1996, 2000).

Evidence practice in medicine as it has been applied to psychology [or should we say behavioural science] involves the judicious and compassionate use of the best available evidence to make decisions about patient or client care. In clinical psychology, this involves considering available scientific evidence about “what works” on one side, and the client’s unique problems, needs, rights and preferences on the other; while also making balanced, compassionate judgements (APA Presidential Task Force on Evidence Based Practice, 2006; Norcross et al., 2006).


Meta-analyses

The most persuasive form of evidence as far as the effectiveness of psychotherapy and other psychological interventions are concerned in regards to empirical measurements and statistical methodology, comes from meta-analyses on controlled trials.

Meta-analysis is a systematic, quantitative approach to reviewing evidence from multiple trials while also reducing the impact of reviewer bias since the data from many trials are synthesised using statistical methods.

In a meta-analysis, effect sizes are calculated for each trial and then averaged across all trials to provide a quantitative index of the effectiveness of a particular form of treatment with a specified population. The effect sizes calculated in meta-analyses express quantitatively the degree to which treated groups improve over untreated control groups [A graphic explanation of the calculation of an effect size in given in FIGURE A.

FIGURE A - EFFECT SIZES

FIGURE A. A Graphic Representation of an Effect Size of 1

 

Table A shows a system for interpreting effect sizes, and using it, it may be seen that .9 is a large effect size, and if such an effect size was obtained in a meta-analysis it would mean that the average treated case fared better than 82% of the cases in the control group. It would also indicate that 71% of cases in the treatment group had a successful outcome compared with 29% of control group cases. Finally, a large effect of .9 would indicate that 17% of the variance in outcome would validly be attributed to the effects of the treatment rather than other factors.

Table A - Interpretation of Effect Size

TABLE A / Note: Adapted from Wampold (2001, p. 53). 1. From Cohen (1988), 2. From Glass (1976). 3. From Rosenthal and Rubin (1982). Binomial effect size display, assuming overall success rate of .5, success rate for treated cases is .5+ correlation with outcome/2, and success rate for untreated cases is .5-correlation with outcome/2. 4. From Rosenthal (1994, p. 239), percentage of variance = d²/(d² +4).

Is Psychotherapy effective? If so, how effective?

Mary Smith and Gene Glass published the first major meta-analysis of psychotherapy result studies in American Psychologist in 1977. They included 375 controlled trials of psychotherapy in their analysis and found an average effect size of .68. They concluded that a typical therapy client was better off that 75% of untreated individuals.

Since that seminal study many meta-analyses have been conducted, and in a synthesis of 68 separate meta-analyses of psychotherapy with children, adolescents and adults with a wide range of different psychological problems, Grissom (1996) found an aggregate effect of .75, indicating that the average treated case fared better than 77% of untreated controls.


Effects of Psychotherapy with Adults

The mentioned meta-analysis conducted by Smith and Glass (1977) also included many studies of therapy with children and young people. In the quest to determining the effects of psychotherapy for adults with psychological problems, Shapiro and Shapiro (1982) conducted a meta-analysis of 143 studies of psychotherapy exclusively involving adult populations. This revealed an effect size of 1.03, meaning that after treatment the average adult who participated in psychotherapy fared better than 84% of untreated control group cases.


Effectiveness of Psychotherapy with Children and Adolescents

The results of 4 broad meta-analyses of studies involving children and adolescents under 18 years with a diverse range of psychological problems receiving a variety of forms of psychotherapy provide evidence for the overall effectiveness of psychotherapy with children (Casey & Berman, 1985; Kazdin et al., 1990; Weisz et al., 1987, 1995). These meta-analyses included more than 350 treatment outcome studies. Effect sizes ranged from .71 to .88, with a mean effect size of .77. This indicates that the average treated case fared better than 78% of control group cases.


Psychodynamic Psychotherapy

Within the psychodynamic tradition, a distinction is made between short-term psychodynamic psychotherapy and intensive long-term psychoanalysis. Short-term psychodynamic psychotherapy involve weekly sessions for periods of 6 – 12 months, while Long-term psychoanalysis involves two or more sessions per week, usually lasting for periods longer than 1 year [Jacques Lacan, one of the main psychoanalytic figures in France, broke from other associations to create his own school where he advocated short psychoanalytic sessions that varied ranging from 10 minutes to more, as he argued that the point of therapy is to shape the patient’s consciousness and depending on the person, this can be achieved by a range of ways, e.g. metaphors or word plays that allows the patient to peer into his own psyche and understand himself]

Two important broad meta-analyses have been conducted to evaluate the effectiveness of psychodynamic psychotherapy with adult mental health problems (Leichsenring et al., 2004; Leichsenring & Rabung, 2011). In a meta-analysis of 17 studies, Leichsenring et al. (2004) found that short-term psychodynamic psychotherapy yielded an effect size of .7 for psychiatric symptoms in patients mainly diagnosed with anxiety and mood disorders when therapy was compared with waiting list or minimal intervention control groups. This indicates that after treatment the average treated case fared better than 76% of controls. In this meta-analysis, the outcome for psychodynamic psychotherapy did not differ from that of other forms of psychotherapy in the 14 studies where such comparisons were made.

In a further meta-analysis of 10 studies, Leichsenring and Rabung (2011) found that Long-term psychodynamic psychotherapy involving more than 50 sessions over periods longer than a year yielded an effect size of .54 for overall effectiveness for complex cases with severe symptomatology, comorbid diagnoses, or personality disorders, when long-term psychodynamic psychotherapy was compared with a range of other therapies including Cognitive-Behavioural Therapy (CBT), dialectical behaviour therapy, family therapy and short-term psychodynamic psychotherapy. This indicates that after treatment the average case fared better than 70% of cases treated with other therapies. The gains made during treatment were sustained at 1 to 8 years after follow up.

The results of these two meta-analyses show that short-term psychodynamic psychotherapy is an effective as other widely used forms of psychotherapy, including Cognitive-Behavioural Therapy (CBT), for common psychological problems such as anxiety and depression in adults; and that long-term psychodynamic psychotherapy is more effective that some other forms of therapy for adults with complex mental health difficulties.


Client-centred Humanistic Psychotherapy

Elliot et al., (2004) conducted a meta-analysis of trials of psychotherapy that fall broadly within the client-centred humanistic psychotherapy tradition [over 90 trials of client-centred, experiential, gestalt and emotionally-focussed therapy were included in the analysis]. Clients in these studies had a wide variety of psychological problems including anxiety, mood, eating and relationship distress. The average duration of treatment was 22 sessions, reflecting about 6 months of therapy. An effect size of .78 was obtained, indicating that the average treated case fared better than 78% of cases in control groups. These results indicate that client-centred humanistic psychotherapy is an effective form of treatment for a range of common psychological problems in adulthood.


Overall Effects of Psychotherapy

FIGURE B summarises the results of meta-analyses, described above, of the effectiveness of psychotherapy from a range of different traditions with adults and children. In this figure, where appropriate, effect sizes from multiple meta-analyses have been averaged, and graphed as success rates based on the system given in TABLE A.

From FIGURE B it can be deduced that meta-analyses of psychotherapy trials yield moderate to large effect sizes that range from .65 to 1.02. When expressed as success rates, the results of meta-analyses indicate that 65 – 72% of people with psychological problems benefit from psychotherapy. Thus approximately two-thirds to three-quarters of people who engage in psychotherapy find that it leads to improvements in their mental health.

FIGURE B - SUCESS RATES WITH ADULTS & CHILDREN

FIGURE B. Success Rates of Psychotherapy with adults and children, and Therapy from other schools of thought [traditions] based on Effect Sizes from Meta-analyses

Comparison of the effects of Psychotherapy and Medical Procedures

In order to make sense of the overall effectiveness of psychotherapy, it may be useful to ask ourselves: Are the moderate to large effect sizes associated with psychotherapy very different from those associated with the medical and surgical treatment of physical illnesses, diseases and medical symptoms?

In a synthesis of 91 meta-analyses of various medical and surgical treatments for a range of medical conditions, Caspi (2004) found an average effect size of .5. This falls in the moderate range of effect sizes (.5 – .8) and not very dissimilar to the effect size of .75 from Grissom’s (1996) synthesis of 68 meta-analyses of psychotherapy trials mentioned at the beginning of this section. Hence, it may be concluded with some certainty that the moderate effect sizes associated with psychotherapy are similar to those associated with the treatment of medical conditions.


Deterioration and Drop-Out

A consistent finding within psychotherapy research literature is that up to 10% of clients deteriorate following treatment (Lambert and Ogles, 2004; Lilienfeld, 2007). In a review of 46 studies on negative outcome in adult psychotherapy, Mohr (1995) found that deterioration was associated with particular client and therapist characteristics and particular features of psychotherapy. Deterioration was much more common among clients with obsessive compulsive disorder or severe interpersonal difficulties. Lack of motivation and the expectation of benefiting from psychotherapy without personal effort were also associated with deterioration. Deterioration was more common when unskilled therapists lacked the empathy and did not collaborate with clients in pursuing their agreed goals. Failure to manage counter transference appropriately and frequent transference interpretations were also associated with deterioration.

Dropping out of psychotherapy is a relatively common event. In a meta-analysis of 125 studies, Wierzbicki and Pekarik (1993) found a mean dropout rate of 47%. Dropout rates were higher for minority ethnic groups, less educated clients, and those with lower incomes. Thus, we can conclude that about 1 in 10 clients deteriorate following therapy and that marginalised clients with particularly troublesome disorders and negative attitudes to psychotherapy are vulnerable to dropping out of psychotherapy and deterioration.


Medical Cost Offset

So, all the evidence that has been reviewed shows that psychotherapy is effective for a range of problems and populations. However, an important factor regarding the delivery of psychological treatment is the financial implication of it [i.e. the cost to the economy and health services]: How much does it cost to provide such a psychotherapy service? From this financial perspective, two questions would be of interest:

First: Do clients who received psychotherapy use fewer medical services and so incur reduced medical costs? This saving would be referred to as the Medical Cost Offset.

Second: Is the Medical Cost Offset associated with psychotherapy greater than the cost of providing psychotherapy? If so, we would be able to conclude that psychotherapy has a total cost offset.

Findings from meta-analyses and narrative reviews of the cost-offset literature provide explanations on these questions. In a meta-analysis of 91 studies conducted between 1967 and 1997, Chiles et al. (1999) found that psychotherapy and psychological interventions led to significant medical cost offsets. Participants in reviewed studies included surgery inpatients, high health-service users, and people with psychological and substance use disorders who received psychotherapy or psychological interventions alone or as part of a multimodal programme. Chiles and his team found that medical cost offsets occurred in 90% of studies and ranged from 20% to 30%. In 93% of studies where data were provided, cost offsets exceeded the cost of providing psychotherapy. Greater costs offsets occurred for older inpatient who required surgery, oncology, and cardiac rehabilitation than for outpatients who required care for minor injuries and illnesses. Structured psychological interventions, tailored to patient needs associated with their medical conditions, led to greater medical cost offsets than traditional psychotherapy.

In a set of meta-analyses from earlier studies involving Blue Cross and Blue Shield US Federal Employees Plan claim files and 58 controlled studies, Mumford et al. (1984) found that 85% of studies medical cost offset for psychotherapy occurred, and this was due to shorter periods of hospitalisation for surgery, cancer, heart disease and diabetes – particularly in patients over the age of 55. In a review of psychological interventions for people with a variety of health-related difficulties, Groth-Marnat and Edkins (1996) found that medical cost offsets occurred when such interventions targeted patients preparing for surgery and patients with difficulty adhering to medical regimens. Medical offset also occurred for smoking cessation programmes, rehabilitation programmes, and programmes for patients with chronic pain disorders, cardiovascular disorders and psychosomatic complaints.

Three other important reviews of medical cost-offset literature, which focussed largely on mental health problems in adults rather than adjustment to physical illness, deserve mention. In a review of 30 studies of psychotherapy for psychological disorders and drug and alcohol abuse, Jones and Vischi (1979) found that medical cost offsets occurred in most cases. In a review of eight cost-effective studies for substance abuse, Morgan and Crane (2010) concluded that family-based treatments can be cost-effective. In a review of 18 studies of psychotherapy for psychological disorders, Gabbard et al. (1997) found that in more than in 80% of studies, medical cost offsets exceeded the cost of providing psychological therapies. Significant cost-offsets occurred for complex problems and in studies of psychoeducational family therapy for schizophrenia and dialectical behaviour therapy for personality disorders this was achieved by reducing the need for inpatient care and improving occupational adjustment.

Therefore, to conclude with all the evidence reviewed here, it is widely accepted today that psychotherapeutic interventions have a significant medical cost offset. Those who participate in psychotherapy use fewer extra medical services at primary, secondary and tertiary levels and are hospitalised less than those who do not receive psychotherapy.

 

_____________________________________

 

*****

 

Bibliography

  1. American Psychiatric Association (2000). Diagnostic and Statistical Manual of the Mental Disorders (fourth edition, text revision, DSM-IV-TR). Washington. DC: APA.
  2. American Psychiatric Association (2006). American Psychiatric Association practice guidelines for the treatment of eating disorders (third revision). Washington, DC: APA.
  3. Angst, J. (2009). Course and prognosis of mood disorders. In M. Gelder et al. (Eds.), New Oxford textbook of psychiatry (second edition, Vol. 1, pp. 665-669). Oxford: Oxford University Press.
  4. Antony, M., & Stein, M. (2009a). Oxford Handbook of anxiety and related disorders. New York: Oxford University Press.
  5. Antony, M., & Stein, M. (2009b). Future directions in anxiety disorders research. In M. M. Antony & M. B. Stein (Eds.), Oxford handbook of anxiety and related disorders (pp. 667-677). New York: Oxford University Press.
  6. Ballenger, J. (2009). Panic disorder and agoraphobia. In M. Gelder et al. (Eds.), New Oxford textbook of psychiatry (second edition, Vol. 1, pp. 750-765). Oxford: Oxford University Press.
  7. Bech, P. (2009). Clinical features of mood disorders and mania. In M. Gelder et al. (Eds.), New Oxford textbook of psychiatry (second edition, Vol. 1, pp. 632-637). Oxford: Oxford University Press.
  8. Berman, A. (2009). Depression and suicide. In H. Gotlib & C. Hammen (Eds.), Handbook of depression (second edition, pp. 510-533). New York: Guilford Press.
  9. Bitran, S., Barlow, D., & Spiegel, D. (2009). Generalized anxiety disorders. In M. Gelder et al. (Eds.), New Oxford Textbook of Psychiatry (second edition, Vol. 1, pp. 729-739). Oxford University Press.
  10. Boland, R. J., & Keller, M. B. (2009). Course and outcome of depression. In H. Gotlib & C. Hammen (Eds.) Handbook of depression (second edition, pp. 23-43). New York: Guilford Press.
  11. Bota, R., Munro, S., Nguyen, C., & Preda, A. (2011). The course of schizophrenia : What has been learned from longitudinal studies ? In M. Ritsner (Ed.), Handbook of schizophrenia spectrum disorders, Volume II. Phenotypic and endophenotypic presentations (pp. 281-300). New York: Springer
  12. Brent, D., & Weersing, R. (2008). Depressive disorders in childhood and adolescents. In M. Rutter et al. (Eds.), Rutter’s child and adolescent psychiatry (fifth edition, pp. 587-612). London: Blackwell.
  13. Carr, A. (2012). Clinical psychology. 1st ed. New York: Routledge.
  14. Casey, R. J., & Berman, J. S., (1985). The outcome of psychotherapy with children. Psychological Bulletin, 98, 388-400.
  15. Caspi, O. (2004). How good are we? A meta-analytic study of effect sizes in medicine. Dissertation Abstracts International, Section B: The Sciences and Engineering, 65(5-B), 2607.
  16. Chiles, J., Lambert, M. & Hatch, A. (1999). The impact of psychological interventions on medical cost offset: A meta-analytic review. Clinical Psychology: Science and Practice, 6, 204-220.
  17. Cohen, J. (1988). Statistical power analysis for the behavioural sciences (second edition). Hillsdale, NJ: Lawrence Erlbaum Associates.
  18. DiMaggio, C., & Galea, S. (2006). The behavioural consequences of terrorism: A meta-analysis. Academy of Emergency Medicine, 13, 559-566.
  19. Ehlers, A. (2009). Post-traumatic stress disorder. In M. Gelder et al. (Eds.), New Oxford textbook of psychiatry (second edition, Vol. 1, pp 700-713). Oxford: Oxford University Press.
  20. Elliot, R., Greenberg, L. & Lietaer, G. (2004). Research on experiential psychotherapies. In M. Lambert (ed.), Bergin and Garfield’s handbook of psychotherapy and behaviour change (fifth edition, pp. 493-539). New York: Wiley.
  21. Friedman, M. J. (2009). Phenomenology of posttraumatic stress disorder and acute stress disorder. In M. M. Antony & M. B. Stein (Eds.), Oxford handbook of anxiety and related disorders (pp. 65-72). New York: Oxford University Press.
  22. Furr, J. M., Tiwari, S., Suveg, C., & Kendall, P. C. (2009). Anxiety Disorders in Children and Adolescents. In M. M. Antony & M. B. Sten (Eds.), Oxford handbook of anxiety and related disorders (pp 636-656). New York: Oxford University Press.
  23. Gabbard, G. O., Lazar, S.G., Hornberger, J. & Spiegel, D. (1997). The economic impact of psychotherapy: A review. American Journal of Psychiatry, 154, 147-155.
  24. Garber, J. (2010). Vulnerability to depression in childhood and adolescence. In R. Ingram and J. Price (Eds.), Vulnerability to psychopathology: Risk across the lifespan (second edition, pp. 189-247). New York: Guilford Press.
  25. Glass, V. (1976). Primary, secondary and meta-analysis of research. Educational Researcher, 5, 3-8.
  26. Golden, T., Gaynes, B., Ekstrom, D., Hamer, R., Jacobsen, F., Suppes, T., et al. (2005). The efficacy of light therapy in the treatment of mood disorders: A review and meta-analysis of the evidence. American Journal of Psychiatry, 162, 656-662.
  27. Gotlib, H., & Hammen, C. (2009). Handbook of depression (second edition). New York: Guilford Press.
  28. Grissom, R. (1996). The magical number. 7 +/- .2: Meta-meta-analysis of the probability of superior outcome in comparisons involving therapy, placebo and control. Journal of Consulting and Clinical Psychology, 64, 973-982.
  29. Groth-Marnat, G. & Edkins, G. (1996). Professional psychologists in general health care settings: A review of financial efficacy of direct treatment interventions. Professional Psychology: Research and Practice, 27, 161-174.
  30. Häfner, H., & an der Heiden, W. (2008). Course and outcome. In K. Mueser & D. Jeste (Eds.), Clinical handbook of schizophrenia (pp. 100-116). New York: Guilford Press.
  31. Halmi, K. A. (2010). Psychological comorbidity of eating disorders. In W. S. Agras (Ed.), The Oxford handbook of eating disorders (pp. 292-303). New York: Oxford University Press.
  32. Hammen, C., Bistricky, S., & Ingram, R. (2010). Vulnerability to depression in adulthood. In R. Ingram and J. Price (Eds.), Vulnerability to psychopathology: Risk across the lifespan (second edition, pp. 248-281). New York: Guilford Press.
  33. Hazlett-Stevens, H., Pruitt, L. D., & Collins, A. (2009). Phenomenology of generalized anxiety disorders. In M. M. Antony & M. B. Sten (Eds.), Oxford handbook of anxiety and related disorders (pp. 47 – 55). New York: Oxford University Press.
  34. Heisel, M. J. (2008). Suicide. In K. Mueser & D. Jeste (Eds.), Clinical handbook of schizophrenia (pp. 491-506). New York: Guilford Press.
  35. Hofmann, S. G., Alpers, G. W., & Pauli, P. (2009). Phenomenology of panic and phobic disorders. In M. M. Antony & M. B. Stein (Eds.), Oxford handbook of anxiety and related disorders (pp. 34 – 46). New York: Oxford University Press.
  36. Huppert, J. D. (2009). Anxiety disorders and depression comorbidity. In M. M. Antony & M. B. Stein (Eds.), Oxford handbook of anxiety and related disorders (pp. 576-586). New York: Oxford University Press.
  37. Jablensky, A. (2009). Course and outcome of schizophrenia and their prediction. In M. Gelder et al. (Eds.), New Oxford textbook of psychiatry (second edition, Vol. 1, pp 568 – 578). Oxford: Oxford University Press.
  38. Joiner, T., & Timmons, K. A. (2009). Depression in its interpersonal context. In H. Gotlib & C. hammen (Eds.) Handbook of depression (second edition, pp. 322-339). New York: Guilford Press.
  39. Jones, K. & Vischi, T. (1979). The impact of alcohol, drug abuse, and mental health treatment on medical care utilization: A review of the research literature. Medical Care, 17 (Suppl. 12), 43-131.
  40. Joormann, J. (2009). Cognitive aspects of depression. In H. Gotlib & C. Hammen (Eds.), Handbook of depression (second edition, pp. 298-321). New York: Guilford Press.
  41. Kazdin, A., Bass, D., Ayers, W., & Rodgers, A. (1990). Empirical and clinical focus of child and adolescent psychotherapy research. Journal of Consulting and Clinical Psychology, 58, 729-740.
  42. Kessler, R., & Wang, P. S. (2009). Epidemiology of depression. In H. Gotlib & C. Hammen (eds.), Handbook of depression (second edition, pp. 5 – 22). New York: Guilford Press.
  43. Kessler, R., Berglund, P., Demler, O., Jin, R., Merikangas, K. & Walters, E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602.
  44. Kessler, R., Ruscio, A. M., Shear, K., & Wittchen, H. (2009). Epidemiology of anxiety disorders. In M. M. Antony & M. B. Sten (Eds.) Oxford handbook of anxiety and related disorders (pp. 19-33). New York: Oxford University Press.
  45. Lambert, M. & Ogles, B. (2004). The efficacy and effectiveness of psychotherapy. In M.J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behaviour change (fifth edition, pp. 139-193). New York: Wiley
  46. Leichsenring, F. & Rabung, S. (2011). Long-term psychodynamic psychotherapy in complex mental disorders: A meta-analysis. British Journal of Psychiatry, 199, 15-22.
  47. Leichsenring, F., Rabung, S. & Leibing, E. (2004). The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: A meta-analysis. Archives of General Psychiatry, 61, 1208-1216.
  48. Levison, D. F. (2009). Genetics of major depression. In H. Gotlib & C. Hammen (Eds.), Handbook of depression (second edition, pp 165-186). New York: Guilford Press.
  49. Lilienfeld, S. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2, 53-70.
  50. Liu, R. T., & Alloy, L. B. (2010). Stress generation in depression: A systematic review of empirical literature and recommendations for future study. Clinical Psychology Review, 30, 582-593.
  51. Luty, J., Fekadu, D., & Dhandayudham, A. (2006). Understanding of the term ‘schizophrenia’ by the British public. Psychiatric Bulletin, 30, 435-435.
  52. Mathews, C. A. (2009). Phenomenology of obsessive-compulsive disorder. In M. M. Antony & M. B. Stein (Eds.), Oxford handbook of anxiety and related disorders (pp. 56-64). New York: Oxford University Press.
  53. McGrath, J., Saha, S., Welham, J., Saadi, O., MacCauley, C., & Chant, D. (2004). A systematic review of the incidence of schizophrenia: The distribution of rates and the influence of sex, urbanicity, migrant status and methodology. BMC Medicine, 2, 13.
  54. Monroe, S., Slavich, G. M., & Georgiades, K. (2009). The social environment and life stress in depression. In H. Gotlib & C. Hammen (Eds.), Handbook of depression (second edition, pp. 340-360). New York: Guilford Press.
  55. Morgan, T. B. & Crane, D. R. (2010). Cost-effectiveness of family-based substance abuse treatment. Journal of Marital and Family Therapy, 36, 486-498.
  56. Mueser, K. & Duva, S. (2011). Schizophrenia. In D. Barlow (ed.), The Oxford handbook of clinical psychology (pp. 469-503). New York: Oxford University Press.
  57. Mueser, K., & Jeste, D. (2008). Clinical handbook of schizophrenia. New York: Guilford Press.
  58. Mumford, E., Schlesinger, H., Glass, G., Patrick, C. & Cuerton, T. (1984). A new look at evidence about reduced cost of medical utilization following mental health treatment. American Journal of Psychiatry, 141, 1145-1158.
  59. Murray, C., & Lopez, A. (1996). The global burden of disease, injuries and risk factors in 1990 and projected to 2020. Cambridge, MA: Harvard University Press.
  60. Murray, R., & Lewis, S. (1987). Is schizophrenia a neurodevelopmental disorder? British Medical Journal, 295, 681-682.
  61. Murray, R., & Van Os, J. (1998). Predictors of outcome in schizophrenia. Journal of Clinical Psychopharmacology, 18, 25-45.
  62. Noken-Hoeksema, S., & Hilt, L. M. (2009b). Handbook of depression in adolescents. New York: Guilford Press.
  63. Norcross, J., Beutler, L., & Levant, R. (2006). Evidence-based practices in mental health: Debate and dialogue on the fundamental questions. Washington, DC: American Psychological Association.
  64. Ozer, E., Best, S., Lipsey, T., & Weiss, D. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129, 52-73
  65. Parker, G. (2009). Diagnosis, classification and differential diagnosis of the mood disorders. In M. Gelder et al (Eds.) New Oxford textbook of psychiatry (second edition, Vol. 1, pp. 637-645). Oxford: Oxford University Press.
  66. Pine, D. & Klein, R. (2008). Anxiety Disorders. In M. Rutter et al (Eds.), Rutter’s child and adolescent psychiatry (fifth edition, pp. 628-647). London: Blackwell
  67. Rosenthal, N. E. (2009). Issues for DSM-V: Seasonal affective disorder and seasonality. American Journal of Psychiatry, 166, 852-853.
  68. Rosenthal, R. & Rubin, D. (1982). A simple, general purpose display of magnitude of experimental effect. Journal of Educational Psychology,  74, 166-196.
  69. Sackett, D., Rosenberg, W., Gray, J., Haynes, R., & Richardson, W. (1996). Evidence-based medicine: What it is and what it isn’t. British Medical Journal, 312, 71-72.
  70. Sackett, D., Straus, S., Richardson, W., Rosenberg, W., & Haynes, R. (2000). Evidence based medicine: How to practice and teach EBM (second edition). London: Churchill Livingstone.
  71. Saha, S., Chant, D., Welham, J., & McGrath, J. (2005). A systematic review of the prevalence of schizophrenia. PLoS Medicine, 2, 413-433.
  72. Schennach-Wolff, R., Seemuller, F., Musil, R., Spellmann, I., Holler, H., & Riedel, M. (2011). Suicidality and the outcome of schizophrenia. In M. Ritsner (Ed.), Handbook of schizophrenia spectrum disorders, Volume III: Therapeutic approaches, comorbidity and outcome (pp. 365-382). New York: Springer.
  73. Shapiro, D. A., & Shapiro, D. (1982). Meta-analysis of comparative therapy outcome studies: A replication and refinement. Psychological Bulletin, 92, 581-604.
  74. Silvia, P.J., & Kaufman, J.C. (2010). Creativity and mental illness. In J. Kaufman & R. Sternberg (Eds.), The Cambridge handbook of creativity (pp. 381-394). New York: Cambridge University Press.
  75. Smith, M., & Glass, G. (1977). Meta-analysis of psychotherapy outcome studies. American Psychologist, 32, 752-760.
  76. Tandon, R., Nasrallah, H. A., & Keshavan, M. S. (2009). Schizophrenia, “just the facts” 4. Clinical features and conceptualisation. Schizophrenia Research, 110, 1-23.
  77. Vahia, I. V., & Cohen, C. I. (2008). Psychopathology. In K. Mueser & D. Jeste (Eds.), Clinical handbook of schizophrenia (pp. 82-90). New York; Guilford Press.
  78. Wampold, B. (2001). The great psychotherapy debate: Models, Methods, and findings. Mahwah, NJ: Lawrence Erlbaum Associates.
  79. Weisz, J., Weiss, B., Alicke, M., & Klotz, M. (1987). Effectiveness of psychotherapy with children and adolescents: A meta-analysis for clinicians. Journal of Consulting and Clinical Psychology, 55, 542-549.
  80. Weisz, J., Weiss, B., Han, S. & Granger, D. (1995). Effects of psychotherapy with children and adolescents revisited: A meta-analysis of treatment outcome studies. Psychological Bulletin, 117, 450-468.
  81. Wierzbicki, M. & Pekarik, G. (1993). A meta-analysis of psychotherapy dropout. Professional Psychology: Research & Practice, 24, 190-195.
  82. World Health Organization (1992). The ICD-10 Classification of Mental and Behavioural Disorders. Geneva, Switzerland: WHO.
  83. Zahradnik, M., & Stewart, S. H. (2009). Anxiety disorders and substance use disorder comorbidity. In M. M. Antony & M. B. Stein (Eds.), Oxford handbook of anxiety and related disorders (pp. 565-575). New York: Oxford University Press.
  84. Zohar, J., Fostick, L. & Juven-Wetzler, E. (2009). Obsessive-compulsive disorder. In M. Gelder et al. (Eds.), New Oxford textbook of psychiatry (second edition, Vol. 1, pp. 765-774). Oxford: Oxford University Press.
  85. Zubin, J., & Spring, B. (1977). Vulnerability: A new view of schizophrenia. Journal of Abnormal Psychology, 86, 103-126.

2nd of July 2018 | Danny J. D’Purb | DPURB.com

____________________________________________________

While the aim of the community at dpurb.com has  been & will always be to focus on a modern & progressive culture, human progress, scientific research, philosophical advancement & a future in harmony with our natural environment; the tireless efforts in researching & providing our valued audience the latest & finest information in various fields unfortunately takes its toll on our very human admins, who along with the time sacrificed & the pleasure of contributing in advancing our world through sensitive discussions & progressive ideas, have to deal with the stresses that test even the toughest of minds. Your valued support would ensure our work remains at its standards and remind our admins that their efforts are appreciated while also allowing you to take pride in our journey towards an enlightened human civilization. Your support would benefit a cause that focuses on mankind, current & future generations.

Thank you once again for your time.

Please feel free to support us by considering a donation.

Sincerely,

The Team @ dpurb.com

Donate Button with Credit Cards

Essay // Biological & Developmental Psychology: Frontal Lobes, Impulsiveness in Children & Jean Piaget’s Theory

FLD

(Photo: Jez C Self / Frontal Lobe Gone)

Part 1 of 3 | Frontal Lobes (& Frontal Lobe Damage)

 

The Wisconsin Card Sorting Test (WCST; Grant & Berg, 1948; Heaton, Chelune,Talley, & Curtis, 1993) has long been used in Neuropsychology and is among the most frequently administered neuropsychological instruments (Butler, Retzlaff, & Vanderploeg, 1991).

The test was specifically devised to assess executive functions mediated by the frontal lobes such as problem solving, strategic planning, use of environmental instructions to shift procedures, and the inhibition of impulsivity. Some neuropsychologists however, have questioned whether the test can measure complex cognitive processes believed to be mediated by the Frontal lobes (Bigler, 1988; Costa, 1988).

The WCST test, until this day remains widely used in clinical settings as frontal lobe injuries are common worldwide. Performance on the WCST test is believed to be particular sensitive in reflecting the possibilities of patients having frontal lobe damage (Eling, Derckx, & Maes, 2008). On each Wisconsin card, patterns composed of either one, two, three or four identical symbols are printed. Symbols are either stars, triangle, crosses or circles; and are either red, blue, yellow or green.

At the start of the test, the patient has to deal with four stimulus cards that are different from one another in the colour, form and number of symbols they display. The aim of the participant would be to correctly sort cards from a deck into piles in front of the stimulus cards. However, the participant is not aware whether to sort by form, colour or by number. The participant generally starts guessing and is told after each card has been sorted whether it was correct or incorrect.

Firstly they are generally instructed to sort by colour; however as soon as several correct responses are registered, the sorting rule is changed to either shape or number without any notice, besides the fact that responses based on colour suddenly become incorrect. As the process continues, the sorting principle is changed as the participant learns a new sorting principle.

potbIt has been noted that those with frontal lobe area damage often continue to sort according to only one particular sorting principle for 100 or more trials even after the principle has been deemed as incorrect (Demakis, 2003). The ability to correctly remember new instructions with for effective behaviour is near impossible for those with brain damage: a problem known as ‘perseveration’.

Another widely used test is the ‘Stroop Task’ which sets out to test a patient’s ability to respond to colours of the ink of words displayed with alternating instructions. Frontal patients are known for badly performing to new instructions. As the central executive is part of the frontal lobe, other problems such as catatonia – a condition where patients remain motionless and speechless for hours while unable to initiate – can arise. Distractibility has also been observed, where sufferers are easily distracted by external or internal stimuli. Lhermite (1983) also observed the ‘Utilisation Syndrome’ in some patients with Dysexecutive Syndrome (Normal & Shallice, 1986), who would grab and use random objects available to them pathologically.

________________________________________

Part 2 of 3 | Impulsiveness in Children

 

Image: PsyBlog

The Frontal lobe, responsible for most executive functions and attention, has shown to take years [at least 20] to fully develop. The Frontal lobe [located behind the forehead] is responsible for all thoughts and voluntary behaviour such as motor skills, emotions, problem-solving and speech.

In childhood, as the frontal lobe develops, new functions are constantly added; the brain’s activity in childhood is so intense that it uses nearly half of the calories consumed by the child in its development.

As the Pre-Frontal Lobe/Cortex is believed to take a considerable amount of at least 20 years to reach maturity (Diamond, 2002), children’s impulsiveness seem to be linked to neurological factors with the Pre-Frontal Lobe/Cortex; particularly, their [sometimes] inability to inhibit response(s).

The idea was supported by developmental psychologist and philosopher Jean Piaget‘s  Theory of Cognitive Development of Children [known for his epistemological studies] where he showed the A-not-B error [also known as the “stage 4 error” or “perseverative error”] is mostly made by infants during the substage 4 of their sensorimotor stage.

Researchers used 2 boxes, marked A and B, where the experimenter had repeatedly hid a visually attractive toy under the Box A within the infant’s reach [for the latter to find]. After the infant had been conditioned to look under Box A, the critical trial had the experimenter move the toy under Box B.

Children of 10 months or younger make the « perseveration error » [looked under Box A although fully seeing experimenter move the toy under Box B]; demonstrating a lack of schema of object permanence [unlike adults with fully developed Frontal lobes].

gmatter

Frontal lobe development in adults was compared with that in adolescents, e.g. Sowell et al (1999); Giedd et all (1999); who noted differences in Grey matter volume; and differences in White matter connections. Adolescents are likely to have their response inhibition and executive attention performing less intensely than adults’. There has also been a growing & ongoing interest in researching the adolescent brain; where great differences in some areas are being discovered.

The Pre-Frontal Lobe/Cortex [located behind the forehead] is essential for ‘mentalising’ complex social and cognitive tasks. Wang et al (2006) and Blakemore et al (2007) provided more evidence between the difference in Pre-Frontal Lobe activity when ‘mentalising’ between adolescents and adults. Anderson, Damasio et al (1999) also noted that patients with very early damage to their frontal lobes suffered throughout their adult lives.

skull

2 subjects with Frontal Lobe damage were studied:

1) Subject A: Female patient of 20 years old who suffered damages to her Frontal lobe at 15 months old was observed as being disruptive through adult life; also lied, stole, was verbally and physically abusive to others; had no career plans and was unable to remain in employment.

2) Subject B was a male of 23 years of age who had sustained damages to his Frontal lobe at 3 months of age; he turned out to be unmotivated, flat with bursts of anger, slacked in front of the television while comfort eating, and ended up obese in poor hygiene and could not maintain employment. [However…]

Reflexion

While research and tests have proven the link between personality traits & mental abilities and frontal brain damage, the physiological defects of the frontal lobe would likely be linked to certain traits deemed negative by a subject willing to be a functional member of society [generally Western societies].

However, personality traits similar to the above Subjects [A & B] may in fact not always be linked to deficiency and/or damage to the frontal lobes; as many other factors are to be considered when assessing the behaviour & personality traits of subjects; where [for example] violence and short temper may [at times] be linked to a range of factors and environmental events during development, or other mental strains such as sustained stress, emotional deficiencies due to abnormal brain neurochemistry, genetics, or other factors that may lead to intense emotional reactivity [such as provocation or certain themes/topics that have high emotional salience to particular subjects, ‘passion‘]

 

________________________________________

Part 3 of 3 | Jean Piaget’s Theory of Cognitive Development (0 – 12 yrs)

Jean Piaget’s theory developed out of his early interest in observing animals in their natural environment. Piaget published his first article at the age of 10 about the description of an albino sparrow that he had observed in the park, and before the age of 18, journals had accepted several of his papers about molluscs. During his adolescent years, the young theorist developed a keen interest in philosophy, particularly “epistemology” [the branch of philosophy focused on knowledge and the acquisition of it]. However, his undergraduate studies were in the field of biology and his doctoral dissertation was once again, on molluscs.

For a short while, Piaget then worked at Bleuler’s psychiatric clinic where his interest in psychoanalysis grew. As a results, he moved to France and attended the Sorbonne university, in 1919 to study clinical psychology and also pursued his interest in philosophy. In Paris, he worked in the Binet Laboratory with Theodore Simon on the standardisation of intelligence tests. Piaget’s task was to monitor children’s correct response to test times, but instead, he became much more interested in the mistakes that children made, and developed the idea that the study of children’s errors could provide an insight into their cognitive processes.

Piaget came to realise that through the process and discipline of psychology, he had an opportunity to create links between epistemology and biology. Through the integration of the disciplines of psychology, biology and epistemology, Piaget aimed to develop a scientific approach to the understanding of knowledge – the nature of knowledge and the ways in which an organism acquires knowledge. As a man who valued richness and detail, Piaget was not at all impressed by the reductionist quantitative methods used by the empiricists of the time, however, he was influenced by the work on developmental psychology by Binet, a French psychologist who had pioneered studies of children’s thinking [his method of observing children in their natural setting was one that Piaget followed himself when he left the Binet laboratory].

Piaget later integrated his own experience of psychiatric work in Bleuler’s clinic with the observational and questioning strategies that he had learned from Binet. Out of this fusion of techniques emerged the “Clinical Interview” [an open-ended, conversational technique for eliciting children’s thinking (cognitive) processes]. It was the child’s own subjective judgement and explanation that was of interest to Piaget, as he was not testing a particular hypothesis, but rather looking for an explanation of how the child comes to understand his or her world. The method is not simple, and the team of Piaget’s researchers had to be trained for 1 year before they actually started collecting data. They were trained and educated about the “art” of asking the right questions and testing the truth of what the children said.

Piaget’s career was devoted to the quest for the mechanisms guiding biological adaptation, and also the analysis of logical thought [that derives from these adaptations and interaction with the exterior environment] (Boden, 1979). He wrote more than 50 books and hundreds of articles, correcting many of his earlier ideas in later life. At its core, the theory of Jean Piaget is concerned with the human need to discover and acquire deeper understanding and knowledge.

Piaget’s incredible output of concepts and ideas characterises his attitude towards constant construction and reconstruction of his theoretical system, which was quite consistent with his philosophy of knowledge, and perhaps indirectly to the school of thought of the mind as an “active” entity.

This section will explore the model of cognitive structure developed by Piaget along with the modifications and some of the re-interpretations that subsequent Piagetian researchers have made to the master’s initial ideas. Although many details have been questioned, it is undeniable that Piaget’s contribution to the understanding of thinking processes [cognitive] of both children and adults.

One great argument made by the theorist suggested that if we are to understand how children think we ought to look at the qualitative development of their problem-solving abilities.

Two famous examples from Piaget’s experiments will be considered that explore the thinking processes in children, showing how they develop more sophisticated problem-solving skills.

Example 1 – One of Piaget’s dialogue with a 7-year-old

Adult:    Does the moon move or not?
Child:    When we go, it goes.
Adult:    What makes it move?
Child:    We do.
Adult:    How?
Child:    When we walk. It goes by itself.

(Piaget, 1929, pp. 146-7)

From this example and other observations based on the similar theme, Piaget described a particular period in childhood which is marked by egocentrism. Since the moon appears to move with the child, she concluded that it does indeed do so. But as the child grows and her sense of logic follows, there is a shift from her own egocentric perspective where the child starts to learn to differentiate between what she sees and she “knows”. Gruber and Vonèche (1977) provide a good example of how an older child used her sense of logic to investigate the movement of the moon. This particular child had sent his younger brother for a walk down the garden while he himself remained immobile. The younger child reported that the moon moved with him, but the older boy realised from his observation that the moon did not move and could then disprove this wrong information with his brother.

Example 2 – Estimating the Quantity of a Liquid

FA Piaget Liquid Quantity

FIGURE A. Estimating a quantity of liquid

This example is taken from Piaget’s research into children’s understanding of quantity. Let us assume that John [aged 4] and Mary [aged 7] are given a problem; two glasses, A and B, are of equal capacity [volume] but glass A is short and wide and glass B is tall and narrow [See Figure A]. Glass A is filled to a particular height and the children would then be asked, separately, to pour liquid into glass B [tall and narrow] so that it would contain the same amount as glass A. Despite the striking proportional differences of the 2 containers, John could not grasp that the smaller diameter of glass B requires a higher level of liquid. To Mary, John’s response is incredibly senseless and stupid: of course one would have to add more to glass B. Piaget interestingly saw the depth of the argument that was in the responses of those children. John could not “see” that the liquid in A and the liquid in B are not equal, because his thought processes are using a mechanism that is qualitatively different in terms of reasoning and that is not yet developed [perhaps due to physiological/hardware limitations] and lacks the mental operations that would have allowed him to solve the problem. Mary, the 7 year old girl finds it hard to understand 4 year old John’s stupidity and why he could not perceive his error.

Facing this situation, Piaget brilliantly proposed that the essence of knowledge is “activity” – a line of thought and perspective adopted by many psychologists and intellectuals from the German and French school of Lacan quite opposite to the early British thoughts that assumed the mind to be “passive” and mostly shaped by the effects of the outside environment.  This argument is not only one that embraces human ingenuity and creativity and acknowledges our instinctual drives to thrive and succeed but also characterises the mind as an entity with high creative power instead of simple junction of neurons conditioned to react to stimuli from its environment almost helplessly as the “passive” school assumed it to be. Hence, to Piaget and ourselves, the essence of knowledge is “activity”, he could be referring to the infant directly manipulating objects and in doing so also learning about their properties. It may also refer to a child pouring liquid from one glass to another to find out which has more in it. Or it may refer to the adolescent forming hypotheses to solve a scientific dilemma. In the examples mentioned, it is important to note that the learning process of the child is taking place through “action”, whether physical (e.g. exploring a ball of clay) or mental (e.g. thinking of various outcomes and reflecting on what they mean). Piaget’s emphasis on activity was important in stimulating the child-centred approach to education, because he firmly believed that for lasting learning to occur, children would not only have to manipulate objects but also manipulate and define ideas. The major educational implications of Piaget will be discussed later in this section.

 

Assumptions of Piaget’s Theory of Development: Structure & Organisation

Through his carefully devised techniques, and using observations, dialogues and small-scale experiments, Piaget suggested that children progress through a series of stages in their thinking, each of which synchronises with major changes in the structure or logic of their intelligence. [See Table A]

TA Piaget - Stages of Intellectual Development

TABLE A. The Stages of Intellectual Development in Piaget’s Theory

Piaget named the main stages of development and the order in which the occurred as:

I. The Sensori-Motor Stage [0 – 2 years]
II. The Pre-Operational Stage [2 – 7 years]
III. The Concrete Operational Stage [7 – 12 years]
IV. The Formal Operational Stages [12 years but may vary from one child to the other]

Piaget’s structures are sets of mental operations, which can be applied to objects, beliefs, ideas or anything in the child’s world, and these mental operations are known as “schemas”. The schemas are characterised as being evolving structures, in other words, structures that grow and change from one stage to the next.

The details of each section of the 4 stages will be explored below, however it is fundamental that we first understand Piaget’s concept of the unchanging or “invariant” [to use his own term – this may be related to temperament but here it involves another set of abilities] aspects of thought, which refers to the broad characteristics of intelligent activity that remains constant throughout the human organism’s life.

These are the organisation of schemas and their adaptation through assimilation and accommodation.

Organisation: Piaget used this term to explain the innate ability to coordinate existing cognitive structures, or schemas, and combine them into more complex systems [e.g. a baby of 3 months old has gained the ability to combine looking and grasping, with the earlier reflex of sucking]. The baby is able to perform all three actions together when feeding from her mother’s breast or a feeding bottle, an ability that the new born child did not originally have in his/her repertoire. A further example would be Ben who at the age of 2 had learned to climb downstairs while carrying objects without dropping them, and also to open doors. This means that he could then combine all three operations to deliver newspaper to his grandmother in the basement flat. To note, each separate operation combines into a new action more complex than the sum of the parts.

The complexity of the organisation also grows as the schemas become more elaborate. Piaget described the development of a particular action schema in his son Laurent as he attempted to strike a hanging object. Initially, Laurent only made random movement towards the object, but at the age of 6 months the movements had evolved and were now deliberate, focused and well directed. As Piaget put it in his description, at 6 months old, Laurent possessed the mental structure that guided the action involved in hitting a toy. Laurent had also gained the ability to accommodate his actions to the weight, size and shape of the toy and its distance from him.

The next invariant function, adaptation is characterised by the striving of the organism for balance [or equilibrium] with the environment, and is achieved through the further processes of “assimilation” and “accommodation”. During the process of assimilation, the child’s repertoire of knowledge expands and he/she takes in [learns about] a new experience [and the knowledge acquired with it] and fits it into an existing schema. For example, a child may learn the words “dog” and “car”, and following this enigmatic event, the child may call all animals “dogs” [i.e. different animals taken into a schema related to the child’s understanding of dog], or all vehicles with four wheels are called “cars”. The process of accommodation balances this erroneous process, where the child adjusts an existing schema to fit in with the nature of the environment [i.e. from experience, the child begins to perceive that cats can be distinguished from dogs, and may develop schemas for these 2 different animals – also that cars can be distinguished from other vehicles such as trucks or lorries.

By these two processes, namely assimilation and accommodation, the child achieves a new state of equilibrium which is however not permanent as this balance is generally soon upset as the child assimilates further new experiences or accommodates her existing schemas to another new idea.

Equilibrium only seems to prepare the child for more disequilibrium through further learning and adaptation; these two processes occur together and cannot be thought of separately. Assimilation provides the child with consolidation for mental structures; and accommodation results in growth and change. All adaptations contains the components of both processes and striving for balance between assimilation and accommodation [Remember: Organisation  Adaptation + (Assimilation & Accommodation)] leads to the child’s intrinsic motivation to learn [This is also reminiscent of the psychodynamic school of thought as several processes colliding to find balance in its model of the mental life of the individual mind]. When new experiences are within the child’s response range in terms of abilities, then conditions are said to be at their best for change and growth to occur.


The Stages of Cognitive Development

To adepts of Piaget’s outlook, intellectual development is a continuous process of assimilation and accommodation. We will not describe the four stages identified in the development of cognition from birth to about 12 years old [in normal children]. This order is similar for all children but the age these milestones are achieved may vary from one child to another – with the stages being:

I. The Sensori-Motor Stage [0 – 2 years]
II. The Pre-Operational Stage [2 – 7 years]
III. The Concrete Operational Stage [7 – 12 years]
IV. The Formal Operational Stages [12 years but may vary from one child to the other]


I. The Sensori-Motor Stage (about 0 – 2 years) | Stage 1 of 4

During the sensori-motor stage the child changes from a newborn, who focuses almost entirely on immediate sensory and motor experiences, to a toddler who possesses a rudimentary capacity for thinking. Piaget described in detail the process by which this occurs, by documenting his own children’s behaviour. On the basis of such observations, carried over the first 2 years of life, Piaget divided the sensori-motor stage into 6 sub-stages. [See Table B]

TB Sub-stages of the sensori-motor period

TABLE B. Substages of the sensori-motor period according to Piaget

The first substage, reflex activity, included the reflexive behaviours and spontaneous rhythmic activity with which the infant is born. Piaget called the second substage primary circular reactions. He used the term “circular” to emphasise how children tend to repeat an activity, especially those that are pleasing or satisfying (e.g. thumb sucking). The term “primary” refers to simple behaviours that are derived from the reflexes of the first period [e.g. thumb sucking develops as the thumb is assimilated into a schema based on the innate suckling reflex].

Secondary circular reactions refer to the child’s willingness to repeat actions, but the word “secondary” is used here to point out the behaviours that are the child’s very own. In other words, she is not limited to just repeating actions based on early reflexes, but having initiated new actions, she can now repeat these if they are satisfying. However, at the same time, these actions tend to be directed outside the child (unlike simple actions like thumb sucking) and are aimed at influencing the environment around her.

This is Piaget’s description of his own daughter Jacqueline at 5 months old, kicking her legs (in itself a primary circular reaction) in what gradually ascends to a secondary circular reaction as the leg movement is repeated not just for itself, but is initiated in the presence of a doll.

Jacqueline looks at a doll attached to a string which is stretched from the hood to the handle of the cradle. The doll is approximately the same level as the child’s feet. Jacqueline moves her feet and finally strikes the doll, whose movement she immediately notices… The activity of the feet grows increasingly regular whereas Jacqueline’s eyes are fixed on the doll. Moreover, when I remove the doll Jacqueline occupies herself quite differently; when I replace it, after a moment, she immediately starts to move her legs again.

(Piaget, 1936, p. 182)

In displaying such behaviours, Jacqueline seemed to have established a general relation between her movement and the doll’s, and was also engaged in a secondary circular reaction.

Coordination of Secondary Circular Reactions, being substage 4 of the Sensori-motor period, and as the word “coordination” implies, it is particularly at this substage that children begin to combine different behavioural schema. In the following extracted section, Piaget described how his daughter (aged 8 months) combined several schemas, such as “sucking an object” and “grasping an object” in a series of coordinated actions when playing with a new object:

Jacqueline grasps an unfamiliar cigarette case which I present to her. At first she examines it very attentively, turns it over, then holds it in both hands while making the sound apff (a kind of hiss which she usually makes in the presence of people). After than she rubs it against the wicker of her cradle then draws herself up while looking at it, then swings it above her and finally puts it in her mouth.

(Piaget, 1936, p. 284)

Jacqueline’s behaviour illustrates how a new object is assimilated to various existing schema in the fourth substage. In the following stage, that of tertiary circular reactions children’s behaviours become more flexible and when they repeat actions they may do so with variations, which can lead to new results. By repeating actions with variations, children are, in effect, accommodating established schema to new contexts and needs.

The final sub-stage of the sensori-motor period is known as the substage of Internal Representations and it refers to the child’s achievement of mental representation. The previous substages the child has interacted with the world through her physical motor schema, another way of phrasing it would be that, she has acted directly on the world. In this final substage, she can now act “indirectly” on the world because she has developed the capacity to hold mental representations of the world – that is, she can now think and plan.

As evidence for children attaining the level of mental representation, Piaget pointed out that by this substage children have a full concept of object permanence. Piaget noticed that very young infants ignored even highly attractive objects once they were out of sight [e.g. a child reaching for a toy, but then the toy is suddenly covered with a cloth and it immediately leads to the child losing all interest in it and would not attempt to search for it, and might even just look away]. According to Piaget it was only after the later substages that children demonstrated an awareness [by searching and trying to retrieve the object] that the object was “permanently” present even if it was temporarily out of sight. Searching for an object that cannot be seen directly implies that the child has a memory of the object, i.e. a mental representation of it.

It is only towards the end of the sensori-motor period that children demonstrated novel patterns of behaviour in response to a problem. For example, if a child wants to reach for a toy and comes across an object between herself and the desired toy, younger children might just try and reach for the toy directly and it is possible that the child knocks over the object while reaching for the target toy – this is best described as “Trial and Error” performance. In the later substages, the child might solve the problem by instead first removing the object out of the way before reaching for the desired toy. Such structured behaviour suggests that the child was able to plan ahead, which indicates that he/she had a mental representation of what she was going to do.

An example of planned behaviour by Jacqueline was given where she was trying to solve the problem of opening a door while carrying two blades of grass at the same time:

She stretches out her right hand towards the knob but sees that she is cannot turn it without letting go of the grass. She puts the grass on the floor, opens the door, picks up the grass again and enters. But when she wants to leave the room things become complicated. She put the grass on the floor and grasps the door knob but then she realises that in pulling the door towards her she will simultaneously chase away the grass which she placed between the door and the threshold. She therefore picks it up in order to put it outside of the door’s zone of movement.

(Piaget, 1936, pp. 376-7)

Jacqueline solved the problem of the grass and the door before she opened the door. It is assumed that she would have had a mental representation of the problem, which permitted her to work out the solution, before she acted.

A third line of evidence for mental representations comes from Piaget’s observation of deferred imitation, that is when children carry out a behaviour that is a reflection of copied behaviour that was previously taken in by the developing child. Piaget provides a good example of this:

At 16 months old Jacqueline had a visit from a little boy of 18 months who she used to see from time to time, and who, in the course of the afternoon got into a terrible temper. He screamed and he tried to get out of a playpen and pushed it backward, stamping his feet. Jacqueline stood observing him in amazement, having never witnessed such a scene before. The following day, she herself screamed in her playpen and tried to move it, stamping her foot lightly several times in succession.

(Piaget, 1951, p. 63)

This suggests that if the little boy’s behaviour was repeated by Jacqueline a day later, she would have had to have retained an image of his behaviour, i.e. she had a mental representation of what she had seen from the day before, and that representation provided the basis for her own copy of the temper tantrum.

To conclude, during the sensori-motor period, the child advances from very simple and limited reflex behaviours at birth, to complex behaviours at the end of the period. The more complex behaviours depend on the progressive combination and elaboration of the schema, but are, at the beginning, limited to direct interactions with the world – thus, the name Piaget gave to this period because he thought of the child developing through her sensori-motor interaction with the environment. It is only towards the end of that period that the child is not limited to immediate interaction anymore because she has now developed the ability to mentally represent her world [mental representation], and with this ability the child can manipulate her mental images (or symbols) of her world, in other words, she can now act on her thoughts about the world as well as on the world itself.

 

Revisions of the Sensori-motor Stage

Jean Piaget’s observations of babies during this first stage lasting until 2 years of age, have been largely confirmed by subsequent reseachers, however Piaget may have underestimated children’s mental capacity to organize the sensory and motor information they take in. Several investigators have shown that children have abilities and concepts earlier than Piaget thought.

Bower (1982) examined Piaget’s hypothesis that young children did not have an appreciation of objects if they were not in sight. For this experiment, children a few months old were recruited and shown an object, and shortly after a screen was moved across in front of the object [so that it would be hidden/unseen from the child’s visual field], to then finally be moved back to its original position. This scenario was presented with 2 slight changes: in Condition 1 the object was still in place and hence seen again by the child when the screen was moved back to its original location; and in Condition 2, the object was removed so the child would perceive the object to have disappeared when the screen was moved back. After monitoring the children’s heart rate to measure changes [which reflect surprise]. To go back to Piaget’s assumptions from his qualitative observations, it would be assumed that children of a few months old do not retain information about objects that are no longer present, and if this was the case, we would not register any heart rate change because as there should be no element of surprise [i.e. the child would not expect an object to be there once the screen was moved back to its original location], thus in Condition 2, no reaction should be displayed by the children, however it was found that children displayed more surprise in Condition 2 and Bower inferred that the children would have had an expectation of the object to still be in its position or “re-appear” after the screen was moved back – this would be the evidence that young children must retain a mental representation of the object in their mind [could be interpreted as young children having some basic form of object permanence even if not properly developed at an earlier age than the assumptions of Piaget based on the results of his experimental methods].

In a further experiment, Baillargeon and DeVos (1991) showed 3-month-old children objects that moved behind a screen and then re-appeared from the other side of the screen. The upper half of the screen had a window and in one condition the children saw a short object move behind the screen [the object was small and below the level of the window and hence when it passed behind the screen it was completely out of sight / not visible, until it appeared at the other side of the screen].

In a second condition a taller object was passed behind the screen, and it was high enough to be seen through the window as it passed from one side to the other. Furthermore, Baillargeon and DeVos created an “impossible event” by passing the tall object through the screen without it appearing through the window, and it lead to the children displaying more interest by looking longer at the scenario than that with the small object. This lead to the argument that children reacted so, due to their expectation of the taller object to appear through the window, and hence this would suggest that young children early in the sensori-motor stage have an awareness of the continued existence of objects even when they are out of view. These results along with that of Bower (1982) seem to suggest that young children to have “some” understanding of object permanence earlier than assumed.

Another one of Piaget’s conclusion was also investigated further by another group of researchers who wanted to find out if children only developed planned action [which demonstrated their ability to form mental representations] at the end of the sensori-motor stage. Willatts (1989) placed an attractive toy on a cloth, out of the reach of 9-month-old children; the children could pull the cloth to access the attractive toy. However, the children could not reach the cloth directly since it was not accessible as Willatts placed a light barrier between the child and the cloth [the child had to move the barrier to reach the cloth]. The experiment showed that children were able to access the toy by carrying out appropriate the series of actions [i.e. first moving the barrier, then pulling the cloth to bring the toy within reach]. Most importantly, many of the children carried out the correct actions within the first occasion of being presented with the problem without the need of going through a “trial and error” phase. Willatts argued that for such young children to demonstrate novel planned actions, it may be inferred from such behaviour that they are operating on a mental representation of the world which they can make use of to organise their behaviour before carrying it out [This is also earlier than assumed by Piaget’s experiments].

Another point made by Piaget was that deferred imitation was an evidence that children should have a memory representation of what they had seen earlier. Soon after birth however it was found that babies are able to imitate the facial expression of an adult or the head movement (Meltzoff and Moore, 1983, 1989), however such imitation is performed in the presence of the stimulus being imitated. From Piaget’s experiments, it was initially deduced that stored representations are only achieved by children towards the end of the sensori-motor stage, however, Meltzoff and Moore (1994) showed that 6-week old infants could imitate a behaviour a day after they had seen the original behaviour. In Meltzoff and Moore’s study some children saw an adult make a facial gesture [e.g. sticking out her tongue] and others just saw the adult’s face while she maintained a neutral expression. The next day, all the children in the experiment saw the same adult, however this time, she kept a passive face. Compared to the children who had not seen any gesture, the children who had seen the tongue protrusion gesture the day before were more likely to make tongue protrusions to the adult the second time they saw her. Meltzoff and Moore argued that for the children to be able to perform those actions they would have had to have a mental representation of the action at a much earlier age than Piaget’s experiments concluded

 

II. The Pre-operational Stage (about 2 – 7 years) | Stage 2 of 4

This stage will be divided in 2 periods: (a) The Pre-conceptual Period (2 – 4 years) and (b) the Intuitive Period (4 – 7 years)


(a) The Pre-Conceptual Period (2 – 4 years)

The pre-conceptual period builds on the ability for internal, or symbolic thought to develop based on the latest advancements during the final stages of the sensori-motor period. During the pre-conceptual period [2 – 4 years old], we can observe a rapid increase in children’s language which, in Piaget’s view, results from the development of symbolic thought. Piaget unlike other theorists of language [who suggested that thought emerges from linguistic competence] argued that thought arises out of action and this idea is supported by research into cognitive abilities of deaf children who, despite limitations in language, have the abilities for reasoning and problem solving. Piaget argued that thought shapes language far more than language shapes thought [at least during the pre-conceptual period], and symbolic thought is also expressed in imaginative play.

However there are some limitations in the child’s abilities at the pre-conceptual period (2-4 years) of the pre-operational stage. The pre-operational child is still centred in her own perspective and finds it difficult to understand that other people can look at things differently. Piaget called this the “self-centred” view of the world and used the term egocentrism.

Egocentric thinking occurs due to the child’s belief that the universe is centred on herself, and thus finds it hard to “decentre”, that is, to take the perspective of another individual. The dialogue below gives an example of a 3-year-old’s difficulty in taking the perspective of another person:

Adult: Have you any brothers or sisters?
John: Yes, a brother.
Adult: What is his name?
John: Sammy.
Adult: Does Sammy have a brother?
John: No.

It is quite clear here that 3-year old John’s inability to decentre makes it hard for the child to realise that from Sammy’s perspective, he himself is a brother.

The egocentric trait at this particular period of development is apparent in their flawed perspective taking tasks. One of the most famous experiments carried out by Piaget is the three mountains experiment tasks, and it involves exploring children’s ability to see things from the perspective of another. In 1956, Piaget and Inhelder asked children between the ages of four and twelve [4 – 12 years old] to say how a doll would perceive an array of three mountains from different perspectives [i.e. by placing the doll at different locations].

FJ Piaget III Mountain Task.jpg

FIGURE J. Model of the mountain range used by Piaget and Inhelder viewed from 4 different sides

 

For example in Figure J, a child might be asked to sit at position A, and a doll would be placed at one of the other positions (B, C or D), then the child would be made to choose from a set of different views of the model, the view that the doll could see. When four and five year old children [4 and 5 years old] were asked to do this task, they often chose the view that they themselves could see (rather than the doll’s view) and it was not until 8 or 9 years of age that children could confidently work out the doll’s view. Piaget argued that this should be convincing in asserting that young children were still learning to manage their egocentricity and could not decentre from their own perspective to work out the perspective / view of the doll.

However, several criticisms have been made regarding the 3 mountain tasks, and one researcher, Donaldson (1978) pointed out that the tasks were unusual to use with young children who might not have a good familiarity with model mountains or be used to working out other people’s views of landscapes. Borke (1975) carried out a similar task to Piaget, but instead of using model mountains, he used the layout of toys that young children typically spend time with in play. She also altered the way that children were asked to respond to the question about what a different person’s view would be, and found that children as young as 3 or 4 years of age had some basic understanding of how another person’s perspective would be different from another position. This was much earlier than previously deduced from Piaget’s experiments, and shows that the type of objects and procedures used in a task can have a huge impact on the performance of the children. By using mountains, Piaget may have selected a far too complex content for such young children’s perspective-taking abilities to be demonstrated optimally.


Borke’s Experiment: Piaget’s Mountains Revised & Changes in the Egocentric Landscape

Borke’s main inquisition was about the appropriateness of Piaget’s three mountain tasks for such young children, and was concerned with the aspects of the task that were not related to perspective-taking and whether this might have adversely affected the children’s performance. These aspects were:

(i) the mountain from a different angle or not may not have sparked any interest or motivation in the children
(ii) the pictures of the doll’s views that Piaget had asked the children to select may have been too taxing for their intelligence
(iii) due to the task being unusual in nature, children may have performed poorly because they were unfamiliar with such a task

Borke considered if some initial practice and familiarity with the task would improve the children’s performance, and with those points in mind, Borke repeated the basic design of Piaget and Inhelder’s experiment but changed the content of the task, avoided the use of pictures and gave children some initial practice. She also used 4 three-dimensional  displays: there were a practice display and three experimental displays [see FIGURE B].

FB Borke's 4 three-dimensional displays

FIGURE B. A schematic view of Borke’s four three-dimensional displays viewed from above.

 

Borke’s participants were 8 three-year-old children and 14 four-year-old children attending a day nursery. Grover, a character from the popular children’s television show, “Sesame Street” was used for the experiment as a substitute for Piaget’s doll. There we 2 identical versions of each display (A and B), and Display A was for Grover and the child to look at, and Display B was on a turntable next to the child.

The children were tested individually and were first shown a practice display which consisted of a large toy fire engine. Borke placed Grover at one of the sides of the practice Display A so that Grover could view the fire engine from a point of view [perspective] that was different from the child’s own view of this display.

A duplicate of the fire engine [practice Display B] appeared on a revolving turntable, and Borke briefed the children, explaining that the table could be turned so that the child could look at the fire engine from ANY side. Children were then prompted to turn the table until their view of the Display B matched the exact perspective that Grover had while looking at Display A. If necessary, Borke even helped the children to move the turntable to the correct position or walked the children round Display A to show them the exact view [perspective] that Grover had in view

Once the practice session was over, the child was ready to take part in the experiment itself. This time, the procedures were similar, except no help was provided by the experimenter. Every single child was shown three dimensional displays, one at a time [see FIGURE B].

Display 1 included a toy house, lake and animals
Display 2 was based in Piaget’s model of three mountains
Display 3 included several scenes with figures and animals
Note: There were 2 identical copies of each display, and of course, children had to rotate the second  copy which was on a turntable to match the perspective [view] that Grover had in sight [as prepared in the practice session].

What Borke found was that most of the children in the experiment were able to work out Grover’s perspective for Display 1 [three and four-year-olds were correct in 80% of trials] and for Display 3 [three-year-olds were correct in 79% of trials and four-year-olds, in 93% of trials. However, for Display 2 [Piaget’s mountains], the three-year-olds were correct in only 42% of trials and four-year-olds in 67% of trials. Borke calculated an analysis of variance, and found that the difference between Displays 1 & 3 and Display 2 was significant at p < 0.001. As for errors, there were no significant differences in the children’s responses for any of the 3 positions – 31% of errors were egocentric [i.e. child rotated Display B to show their OWN view/perspective of Display A, rather than Grover’s view].

Borke successfully demonstrated that the task had a major influence on the perspective-taking performances of young children. When the display included toys that the children were familiar with and hence recognisable, and when the response involved rotating a turntable to work out Grover’s perspective, even the comparatively complex Display 3 task was successfully achieved by the children.

This seems to suggest that the poor performance by the children in Piaget’s original experiment involving three mountains was due in part to the unfamiliar nature of the objects that the children were shown.

Borke concluded that the potential for understanding the viewpoint of another was already present in children as young as 3 and 4 years of age, and this seems to be a reliable addition and revision to Piaget’s original assumption that children of this age are egocentric and incapable to taking the viewpoint of others. It now seems clear that although their perspective taking abilities may not be fully developed, they tend to make egocentric responses when they misunderstood the task, but when given the appropriate conditions, they show that they are capable of working out another’s viewpoint.

However, on a final note, it is important to also consider that Borke’s finding that children as young as three years can perform correctly in perspective-taking tasks stands in firm contrast to other researchers who have found that three-year-olds have difficulty realising another person’s perspective when the child and the other person are both looking at the same picture from different point of view [e.g. at the Louvres museum] (e.g., Masangkay et al, 1974).

 

(a) The Pre-Conceptual Period (2 – 4 years)… continued from above

Piaget use the three mountains task to investigate visual perspective taking and it was on the basis of this task that he concluded that young children were egocentric. There are also a variety of other perspective taking scenarios, and these include the ability to empathise with other people’s emotions, and the ability to know what other people are or may be thinking depending on the scene, setting and scenario (Wimmer and Perner, 1983). In other words, young children are less egocentric than Piaget initially assumed.

 

(b) The Intuitive Period (4 – 7 years)

At about the age of four, there is a further shift in thinking where the child begins to develop the mental operation of ordering, classifying and quantifying in a more systematic way. The term “intuitive” was particularly chosen by Piaget because the child is largely unaware of the principles that underlie the operations she completes and cannot explain why she has done them, nor can she carry them out in a fully satisfactory way, although she is able to carry out such operations involving ordering, classifying and quantifying.

Difficulties can be observed if a pre-operational child is asked to arrange sticks in a particular order. 10 sticks of different sizes from A (the shortest) to J (the longest), arranged randomly on a table were given to the children. The child was asked to arrange them in ascending order [order of length]. Some pre-operational children could not complete the task at all. Some other children arrange a few sticks correctly, but could not complete the task properly. And some put all the smaller ones in one and all the longer one in another. A more advance response was to arrange the sticks so that tops of the sticks when order even though the bottoms were not [See FIGURE C].

FC Pre-operational ordering different-sized sticks

FIGURE C. The pre-operational child’s ordering of different-sized sticks. An arrangement in which the child has solved the problem of seriation by ignoring the length of the sticks.

To sum up, the pre-operational child is not capable of arranging more than a very few objects in the appropriate order.

It was also discovered that pre-operational children also have difficulty with class inclusion tasks – those that involve part-whole relations. Let us assume that a child is given a box that contains 18 brown beads and 2 white beads; all the beads are wooden. When asked “Are there more brown beads than wooden beads?” [note that the question does not make sense since all the beads are made of wood but some are brown and some are white], the pre-operational child tends to say that there are “more brown beads”. The child at the intuitive-period of the pre-operational stage finds it hard to consider the class of “all beads” [wooden] and at the same time considering the subset of beads, the class of “brown beads”[wooden + brown].

This findings is generally true for all children in the pre-operational stage, irrespective of their cultural background. Investigators further found that Thai and Malaysian children gave responses that were very similar to those of Swiss children at this stage of life [4 – 7 years old] and in the same sequence od development [the intuitive period].

Here, a Thai boy who was shown a bunch of 7 roses and 2 lotus [all are in the class of flowers], states that there are more roses than flowers [problem with class of all flowers] when prompted by the standard Piagetian questions:

Child: More roses.
Experimenter: More than what?
Child: More than flowers.
Experimenter: What are the flowers?
Child: Roses.
Experimenter: Are there any others?
Child: There are.
Experimenter: What?
Child: Lotus
Experimenter: So in this bunch which is more roses or flowers?
Child: More roses.

(Ginsburg and Opper, 1979, pp. 130-1)

One of the most extensively investigated aspects of the pre-operational child’s thinking processes is what Piaget called “conservation”. Conservation refers to the understanding that superficial changes in the appearance of a quantity do not mean that there has been any real change in the quantity. For example, if we had 10 dolls placed in line, and then they were re-arranged in a circle, it would not mean that the quantity has been altered [i.e. if nothing is added or subtracted from a quantity then it remains the same – conservation].

Piaget’s experiments revealed that children in the pre-operational stage generally find it hard to grasp the concept that an object’s qualities remain intact even if it is changed in shape and appearance. A series of conservation tasks were used in the investigations and examples are given in FIGURE D and PLATE A.

FD Piaget - Tests de Conservation

FIGURE D. Some tests of conservation: (a) two tests of conservation of number (rows of sweets and coins; and flowers in vases); (b) conservation of mass (two balls of clay); (c) conservation of quantity (liquid in glasses). In each case illustration A shows the material when the child is first asked if the two items or sets of items are the same and illustration B shows the way that one item or set of items is transformed before the child is asked a second time if they are still similar.

PA Piaget - Conservation of Number

PLATE A. A 4-year-old puzzles over Piaget’s conservation of number experiments; he says that the rows are equal in number in arrangement (a), but not in arrangement (b) « because they’re all bunched together here ».

If 2 perfectly identical balls of clay are given to a child and if questioned about whether the quantity of clay being similar in both balls, the child will generally agree that it is. However, if one of the balls of clay is rolled and shaped into a sausage [see FIGURE D(b)], and the child is questioned again about whether the amount are similar, he/she is more likely to say that one is larger than the other. When asked about the reasons for the answer, they are generally unable to give an explanation, but simply say “because it is larger”.

Piaget suggested that a child has difficulty in a task such as this because she could only focus on one attribute at a time [e.g. if length is being focussed on, then she may think that the sausage shaped clay, being longer, has more clay it it. According to Piaget, for a child to appreciate that the sausage of clay has the same amount of clay as the ball would require an understanding that the greater length of the sausage is compensated for by the smaller cross section of the sausage. Piaget said that pre-operational children cannot apply principles such as compensation.

A further example to demonstrate this weakness in the child’s reasoning about conservation is through the sweets task [see FIGURE D(a)]. In this scenario, a child is shown 2 rows of sweets with a similar number of sweets in each row [presented with one to one layout] and when asked if the numbers match in each row, she will usually agree. Shortly after, one row of sweets is made longer by spreading them out, and the child is once again asked whether the number of sweets in similar in each row; the pre-operational child usually makes a choice between the rows suggesting that one has more sweets in it. He/she may for example think that the longer row means more objects [logic of the pre-operational child]. At this stage, the child does not realise that the greater length of the row of sweets is compensated for by the greater distance between the sweets.

Compensation is only one of several processes that can help children overcome changes in appearance; another process is known as “reversibility”. This is where the children could think of literally “reversing” the change; for example if the children imagine the sausage of clay being rolled back and reshaped into a ball of clay, or the row of sweets being pushed back together, they may realise that once the change has been reversed the quantity of an object or the number of items in the row remains similar to before. Pre-operational children lack the thought processes needed to apply principles like “compensation” and “reversibility”, and therefore they have difficulty in conservation tasks.

In the next stage, which is the third stage of development known as the “Concrete Operational Stage”, children will have achieved the necessary logical thought processes that give them the ability to use the required principles and handle conservation techniques and other problem-solving tasks easily.

 

Revisions of the Pre-Operational Stage

While Piaget claimed that the pre-operational child cannot cope with tasks like part-whole relations or conservations, because they lack the logical thought processes to apply principles like compensation. Other researchers have pointed out that children’s lack of success in some tasks may be due to factors other than ones associated with logical processes.

The pre-operational child seems to lack the ability to grasp the concept of the relationship between the whole and the part in class inclusion tasks, and will happily state that there are more brown beads than wooden beads in a box of brown and white wooden beads “because there are only two white ones”. Some other researchers have focussed their attention on the questions that children are asked during such studies and found them to be unusual [e.g. it is not often in every day conversation that we ask questions such as “Are there more brown beads or more wooden beads?”]

Minor variations in the wording of the questions that enhances and clarifies meaning can have positive effects on the child’s performance. McGarrigle (quoted Donaldson, 1978) showed children 4 toy cows, 3 black and 1 white, all were lying asleep on their sides. If the children were asked “Are there more black cows or more cows?” [as in a standard Piagetian experiment with a meaningless trap wording of the question] they tended not to answer correctly. McGarrigle found that in a group of children aged 6 years old, 25% answered the standard Piagetian question correctly, and when it was rephrased, 48% of the children answered correctly – a significant increase. From such an observation it was deduced that some of the difficulty of the task was in the wording of the question rather than just an inability to understand part-whole relations.

Donaldson (1978) put forward a different reason from Piaget as a cause for children’s poor performance in conservation tasks, he argued that children have a build in model of the world by formulating hypotheses that help them anticipate future events based on their past experiences. Hence, in the case of the child there is an expectation about any situation, and his/her interpretation of the words she hears will be influenced by the expectations she brings to the situation. When in a conservation experiment, for example, the experimenter asks a child if there are the same number of sweets in two rows [FIGURE D(a)]. Then one of the rows is changed by the experimenter while emphasising that it is being altered. Donaldson suggested that it is quite fair to assume that a child may be compelled to deduce that there would be a link between the change that occurred [the display change] and the following question [about the number of sweets in each row]; otherwise why would such a precise question come from an adult if there had not been any change? If the child is of the belief that adults only carry actions when they desire a change, then he/she might assume that a change has occurred.

McGarrigle and Donaldson (1974) explored this idea in an experiment with a character known as “Naughty Teddy”, and it was this character rather than the experimenter who changed the display layout and the modification was explained to the children as an “accident” [in such a context the child might have less expectation that a deliberate treatment had been applied to the objects, and there would be no reason to believe a change had taken place]. This procedure was setup in such a way because McGarrigle and Donaldson found that children were more likely to give the correct answer [that the objects remained the same after being messed up by Naughty Teddy] in this new context than in the classical Piagetian context.

Piaget was correct to point out the problems that pre-operational children face with conservation and other reasoning tasks. However, other researchers since Piaget have found out that, given the appropriate wording and context, young children seem capable of demonstrating at least some of the abilities that Piaget thought only developed later [even if these abilities are not well developed at such a stage].

Piaget also found that pre-operational children had difficulties when faced with tasks requiring “transitive inferences”. In this case, the children were showed 2 rods, A and B. Rod A was longer than Rod B, and then Rod A was taken out of sight of the children, who were then showed only Rod B and Rod C [B was longer than C]. When the children were then asked which rod was longer, Rod A or Rod C? Young children on the pre-operational stage find such questions hard and Piaget provided the explanation that these children cannot make logical inferences such as: if A is longer than B and B is longer than C, then A must be longer than C.

Bryant and Trabasso (1971) also considered transitive inference tasks and wondered whether children’s difficulties had more to do with remembering all the specific information about the objects rather than making an inference [i.e. for children to respond correctly they would not only have to make an inference but also remember the lengths of all the rods they had seen]. Bryant and Trabasso proposed that it was possible that young children [with brains still growing and developing physiologically] who have limited working memory capacity, were unable to retain in memory all the information they needed for the task.

In another scenario, children were faced with the similar task in an investigation of transitive inferences, however this time they were trained to remember the lengths of the rods [they were trained on the comparisons they needed to remember, i.e., that A was longer than B, and B was longer than C]. It is only when Bryant and Trabasson were satisfied that the children could remember all the information were they asked the test question [i.e. which rod was longer? A or C?]. The experimenters found that children could now answer correctly. So, the difficulty that Piaget noted in those tasks was more to do with forgetting some of the information needed to make the necessary comparisons, rather than a failure in making logical inferences.

 

III. The Concrete Operational Stage (about 7 – 12 years) | Stage 3 of 4

At the age of about 7 years old, the thinking processes of children change once again as they develop a new set of strategies which Piaget called “concrete operations”. These strategies are considered concrete because children can only apply them to immediately present objects. However, thinking becomes much more flexible during the concrete operational period because children lose their tendency to simply focus on one aspect of the problem, rather now, they are able to consider different aspects of a task at the same time. They now have processes like compensation and reversibility [as explained earlier in understanding volume], and they now succeed on conservation tasks. For example, when a round ball of clay is transformed into a sausage shape, children in the concrete operational stage will say, “It’s longer but it’s thinner” or “If you change it back, it will be the same.”

Conservation of number is achieved first [about 5 or 6 years], then this is followed by the conservation of weight [around 7 or 8], and the conservation of volume is fully understood at about 10 or 11 years old. Operations like addition and subtraction, multiplication and division become easier at this stage. Another major shift comes with the concrete operational child’s ability to classify and order, and to understand the principle of class inclusion. The ability to consider different aspects of a situation at the same time enables a child to perform successfully in perspective taking tasks [e.g. in the three mountains task of Piaget, a child can consider that she has one view of the model and that someone else may have a different view].

However, there are still some limitations on thinking, because children are reliant on the immediate environment and have difficulty with abstract ideas. Take the following question: “Edith is fairer than Susan. Edith is darker than Lily. Who is the darkest and who is the fairest?” Such a problem is quite difficult for concrete operational children who may not be able to answer it correctly. However, if children instead are given a set of dolls representing Susan, Edith and Lily, they are able to answer the question quickly. Hence, when the task is made a “concrete” one, in this case with physical representations, children can deal with the problem, but when it is presented verbally, as an abstract task, children have difficulty. Abstract reasoning is not found within the repertoire of the child’s skills until the latter has reached the stage of formal operations.

 

Revisions of the Concrete Operational Stage

A great amount of Piaget’s observations and conclusions about the concrete operational stage have been broadly confirmed by subsequent research. Tomlinson-Keasey (1978) found that conservation of number, weight and volume are acquired in the order stated by Piaget.

As in the previous stage, the performance of children in the concrete operational period may be influenced by the context of the task. In some context, children in concrete operational period may display more advanced reasoning that would typically be expected of children in that stage. Jahoda (1983) showed that 9-year-olds in Harare, Zimbabwe, had more advanced understanding of economic principles than British 9-year-olds. The Harare children, who were involved in the small business of their parents, had strong motivation to understand the principles of profit and loss. Jahoda set up a mock shop and played a shopping game with the children. The British 9-year-olds could not provide any explanation about the functioning of the shop, did not understand that a shopkeeper buys for less than he sells, and did not know that some of the profit has to be set aside for the purchase of new goods. The Harare children, by contrast, had mastered the concept of profit and could understand trading strategies. These principles had been grasped by the children as a direct outcome of their own active participation in running a business. Jahoda’s experiment, like Donaldson’s studies (1978), indicated the important function of context in the cognitive development of children.

 

IV. The Formal Operational Stage (12 years old) | Stage 4 of 4

During the third period of development, the Concrete operations stage, we have seen that the child is able to reason in terms of objects [e.g., classes of objects, relations between objects) when the objects are present. Piaget argued that only during the period of Formal Operations that young people are able to reason hypothetically, now they no longer depend on the “concrete” existence of objects in the real world, instead they now reason with verbally stated hypotheses to consider logical relations among several possibilities or to deduce conclusions from abstract statements [e.g. consider the syllogistic statement, “all blue birds have two hearts”; “I have a blue bird at home called Adornia”; “How many hearts does Adornia have?” The young person who has now reached formal operational thinking will give the correct answer by abstract logic, which is: “Two hearts!” Children within the previous stage will generally not get past complaining about the absurdity of the scenario.

Young people are now also better at solving problems by considering all possible solutions systematically. If requested to formulate as many combinations of grammatically correct words from the letters A, C, E, N, E, V, A, a young person at the formal operational stage could first consider all combination of letters AC, AE, AN, etc., verifying if such combinations are words, and then going on to consider all three letter combinations, and so on. In the earlier stages, children would attend to such tasks in a disorganised and unsystematic fashion.

Inhelder and Piaget (1958) explained the process of logical reasoning used by young people when presented with a number of natural science experiments. An example of one of their task, “The Pendulum Task” can be seen in Figure E.

FE Piaget - Pendulum Prob

FIGURE E. The pendulum problem. The child is given a pendulum, different lengths of string, and different weights. She is asked to use these to work out what determines the speed of the swing of the pendulum (from Inhelder and Piaget, 1958).

 

The young person as the participant here is given a string [that can be shortened or lengthened], and a set of weights, and then asked to figure out what determines the speed of the swing of the pendulum. The possible factors are the length of the string, the weight at the end of the string, the height of the release point and the force of the push. In this particular scenario the solutions to the solving the problem are all in front of the participant, however the successful reasoning involves formal operations that would also have to incorporate a systematic consideration of various possibilities, the formulation of hypotheses (e.g., “What could happen if I tried a heavier weight?”) and logical deductions from the results of trials with different combinations of materials.

The other tasks investigated by Inhelder and Piaget (1958) included determining the flexibility of metal rods, balancing different weights around a fulcrum, and predicting chemical reactions. These tasks mimic the steps required for scientific inquiry, and Piaget argued that formal scientific reasoning is one of the most important characteristic of formal operational thinking. From his original work, carried out in schools in Geneva, Piaget claimed that formal operational thinking was a characteristic stage that children or young people reached between the ages of 11 and 15 years – having previously gone through the earlier stages of development.

 

Revision of the Formal Operational Stage

Piaget’s claim has been rectified by recent research, more researchers have found that the achievement of formal operational thinking is more gradual and haphazard than Piaget assumed – it may be dependent on the nature of the task and is often limited to certain domains.

FF Piaget - Proportion of boys at different Piagetian stg

FIGURE F. Proportion of boys at different Piagetian stages as assessed by three tasks (from Shayer and Wylam, 1978).

Shayer et al. (1976; Shayer and Wylam 1978) gave problems such as the pendulum task [FIGURE E] to school children in the UK. Their results [see FIGURE F] showed that by 16 years of age only about 30% of young people had achieved “early formal operations” [Is this shocking compared to French speaking Europe where Piaget implemented his theory? Could this provide a partial explanation to the lack of personality, emotion, creativity, openness, depth and sophistication in some populations? Interesting questions…]. Martorano (1977) gave ten of Piaget’s formal operational tasks to girls and young woman aged 12 – 18 years in the USA. At 18 years of age success on the different tasks varied from 15% to 95%; but only 2 children out of 20 succeeded on all ten tasks. Young people’s success on one or two tasks might indicate some formal operational reasoning, but their failure on other tasks demonstrated that such reasoning might be limited to certain tasks or contexts. It is highly likely that young people only manage to achieve and apply formal reasoning across a range of problem tasks much later during their adolescence.

Formal thinking has been shown by some researchers as an ability that can be achieved through training, FIGURE G shows the results of such a study by Danner and Day (1977), where they mentored students aged 10 years, 13 years and 17 years in 3 formal operational tasks. As expected, training had a limited effect on the 10-year-olds, but it had marked effects at 17 years old. In summary, it seems that the period from 11 – 15 years signals the beginning of the potential for formal operational thought, rather than its achievement. Formal operational thought may only be used some of the time, in the domains we are generally familiar with, are trained in, or which have a great significance to us – in most cases formal thinking is not used. After all, we tend to know areas of life where we should have thought things out logically, but in retrospect realise we did not do so [without any regrets sometimes].

FG Piaget - LvL of availability of formal thought

FIGURE G. Levels of availability of formal thought. Percentage of adolescents showing formal thought, with and without coaching (from Danner and Day, 1977).

The Educational Implications of Jean Piaget’s Theory of Cognitive Development

Piaget’s theory was planned and developed over many decades throughout his long life, and at first, it was slow to make any productive impact in the UK and the USA, but from the 1950s its ambitious, embracing framework for understanding cognitive growth was becoming the accepted and dominant paradigm in cognitive development.

Whatever the shortcomings are with Piaget’s theory, it impossible to deny his ingenious contributions, as his approach provided the most comprehensive description of cognitive growth ever put forward on earth. It has had considerable impact in the domains of education, most notably for child-centred learning methods in nursery and infant schools, for mathematics curricula in the primary school, and for science curricula at the secondary school level.

Piaget argued that young children’s thinking processes are quite different from that of an adult, and they also view he world from a qualitatively different perspective. It goes with the logic that a teacher must make a firm effort to adapt to the child and never assume that what may be appropriate for adults should necessarily be right for the child. The idea of “active learning” is what lies at the heart of this child-centre approach to education. From the Piagetian perspective, children learn better from actions rather than from passive observations [e.g., telling a child about the properties of a particular material is less effective than creating an environment in which the child is free to explore, touch, manipulate and experiment with different materials. A good teacher should recognise that each child needs to construct knowledge for him or herself, and active learning results in deeper understanding.

 

JeanPiaget

« Our real problem is: what is the goal of education? Are we forming children who are only capable of learning what is already known? Or should we try to develop creative and innovative minds capable of discovery from the preschool age through life? » – Jean Piaget (1896 – 1980)

So, how can a teacher promote active learning on the part of the pupil? First, it should be the child rather than the teacher who initiates the activity. This should not lead us to allow the child a complete freedom to do anything they want to do, but rather a teacher should set tasks which are finely adjusted to the needs of their pupils and which, as a result, are intrinsically motivating to young learners. For example, nursery school classrooms can provide children with play materials that encourage their learning; set of toys that encourage the practice of sorting, grading and counting; play areas, like the Wendy House, where children can develop role-taking skills through imaginative and explorative play; and materials like water, sand, bricks and crayons that help children make their own constructions and create symbolic representations of the objects and people in their lives. From this range of experiences, the child develops knowledge and understanding for herself, and a good teacher’s role is to create the conditions in which learning may best take place, since the aim of education is to encourage the child to ask questions, try out experiments and speculate, rather than accept information and routine conventions unthinkingly – this also allows the child to learn and be creative about her subjective experience which is unique and different to any other child.

(1919) Jaroslava &amp; Jiri by Alphonse Mucha (1860 - 1939)

(1919) Jaroslava & Jiri, The Artist’s Children by Alphonse Mucha (1860 – 1939)

Secondly, a teacher should be concerned with the process rather that the end-product. This is in line with the belief that a teacher should be interested in the reasoning behind the answer that a child gives to a question rather than just in the correct answer. Conversely, mistakes should not be penalised, but treated as responses that can give a teacher insights into the child’s thinking processes at that time.

The whole idea of active learning resulted in changed attitudes towards education in all its domains. A teacher’s role is not to impart information, because in Piaget’s view, knowledge is not something to transmitted from an expert master teacher to an inexpert pupil. It should be the child, according to Piaget, who sets the pace, where the teacher’s role is to create situations that challenge the child [creatively] to ask questions, to form hypotheses and to discover new concepts. A teacher is the guide in the child’s process of discovery, and the curriculum should be adapted to each child’s individual needs and intellectual level.

In mathematics and science lessons at primary school, children are helped to make the transition from pre-operational thinking to concrete operations through carefully arranged sequences of experiences which develop an understanding for example of class inclusion, conservation and perspective-taking. At a later period, a teacher can also encourage practical and experimental work before moving on to abstract deductive reasoning. Through this process, a teacher can provide the conditions that are appropriate for the transition from concrete operational thinking to the stage of formal operations.

The post-Piagetian research into formal operational thought also has strong implications for teaching, especially science teaching in secondary schools. The tasks that are used in teaching can be analysed for the logical abilities that are required to fulfil them, and the tasks can then be adjusted to the age and expected abilities of the children who will attempt them.

Considering the wide range of activities and interests that appear in any class of children, learning should be individualised, so that tasks are appropriate to individual children’s level of understanding. Piaget did not ignore the importance of social interaction in the process of learning, he recognised the social value of interaction and viewed it as an important factor in cognitive growth. Piaget pointed out that through interaction with peers, a child can move out of the egocentric viewpoint. This generally occurs through cooperation with others, arguments and discussions. By listening to the opinion of others, having one’s own view challenged and experiencing through others’ reactions the illogicality of certain concepts, a child can learn about perspectives other than her own [egocentric]. Communication of ideas to others also helps a child to sharpen concepts by finding the appropriate words.

SigmundFreudYouthAge

 

« Everyone knows that Piaget was the most important figure the field has ever known… [he] transformed the field of developmental psychology. »

(Flavell, 1996, p.200)

« Once psychologists looked at development through Piaget’s eyes, they never saw children in quite the same way. »

(Miller, 1993, p.81)

« A towering figure internationally. »

(Bliss, 2010, p.446)

________________________________________

*****

References

  1. Anderson, S.W., Bechara, A., Damasio, H., Tranel, D., Damasio, A.R. (1999) Impairment of social and moral behaviour related to early damage in human prefrontal cortex. Nat Neurisci, 2(11), 1032-7
  2. Baillargeon, R and DeVos, J. (1991). Object permanence in young infants: further evidence. Child Development, 62, 1227-46.
  3. Blakemore, S.J., Den Ouden, H., Choudhury, S., Frith, C. (2007). Adolescent development of the neural circuitry for thinking about intentions. Social Cognitive and Affective Neuroscience, 2(2), 130-9
  4. Bliss, J. (2010). Recollections of Jean Piaget. The Psychologist, 23, 444-446.
  5. Boden, M. A. (1979). London: Fontana.
  6. Borke, H. (1975). Piaget’s mountains revisited: Changes in the egocentric landscape. Developmental Psychology, 11, 240-3.
  7. Bower, T.G.R. (1982). Development in Infancy, 2nd San Francisco: W. H. Freeman
  8. Bryant, P. E. and Trabasso, T. (1971). Transitive inferences and memory in young children. Nature, 232, 456-8.
  9. Butler, M., Retzlaff, P., & Vanderploeg, R. (1991). Neuropsychological test usage. Professional Psychology: Research and Practice, 22, 510-512
  10. Danner, F. W. and Day, M. C. (1977). Eliciting normal operations. Child Development, 48, 1600-6.
  11. Demakis, G. J. (2003). A meta-analytic review of the sensitivity of the Wisconsin Card Sorting Test to frontal and lateralized frontal brain damage. Neuropsychology, 17, 255-264
  12. Diamond A. (2002). Normal development of prefrontal cortex from birth to young adulthood: cognitive functions, anatomy, and biochemistry. In: Stuss DT, Knight RT, editors. Principles of frontal lobe function. New York: Oxford University Press. P 466-503
  13. Donaldson, M. (1978). Children’s Minds. London: Fontana.
  14. Eling, P., Derckx, K., & Maes, R. (2008). On the historical and conceptual background of the Wisconsin Card Sorting Test. Brain and Cognition, 67, 247-253
  15. Flavell, J.H. (1996). Piaget’s legacy. Psychological Science, 7, 200-203.
  16. Giedd, J.N., Blumenthal, J., Jeffries, N.O., Castellanos, F.X., Liu, H., Zijdenbos, A., et al. (1999). Brain development during childhood and adolescence: a longitudinal MRI study. Nat Neurosci, 2, 861-863
  17. Ginsburg, H. and Opper, S. (1979). Piaget’s theory of intellectual development: An introduction. Englewood Cliffs, NJ: Prentice-Hall.
  18. Grant, D.A. and Berg, E.A. (1948). A Behavioural Analysis of Degree Impairment and Ease of Shifting to New Responses in Weigh-Type Card Sorting Problem. Journal of Experimental Psychology, 39, 404-411
  19. Gruber, H. & Vonèche, J.J. (1977). The Essential Piaget. London: Routledge & Kegan Paul.
  20. Heaton, R.K., Chelune, G.J., Talley, J.L., Kay, G.G., & Curtis, G. (1993). Wisconsin Card Sorting Test manual: Revised and expanded. Odessa, FL: Psychological Assessment Resources
  21. Inhelder, B. and Piaget, J. (1958). The growth of logical thinking from Childhood to Adolescence. London: Routledge & Kegan Paul.
  22. Jahoda, G. (1983). European ‘lag’ in the development of an economic concept: a study in Zimbabwe. British Journal of Developmental Psychology, 1, 113-20.
  23. Lhermitte, F. (1983) “Utilization Behaviour” and its relation to lesions of the frontal lobes. Brain, 106, 237-255
  24. Martorano, S. C. (1977). A developmental analysis of performance on Piaget’s formal operations tasks. Developmental Psychology, 13, 666-72.
  25. Masangkay, Z.S., McCluskey, K.A., McIntyre, C. W., Sims-Knight, J., Vaughn, B. E. and Flavell, J.H. (1974). The early development of inferences about the visual percepts of others. Child Development, 45, 237-46.
  26. McGarrigle, J. and Donaldson, M. (1974). Conservation accidents. Cognition, 3, 341-50.
  27. Meltzoff, A and Moore, M. (1983). Newborn infants imitate adult facial gestures. Child Development, 54, 702-9.
  28. Meltzoff, A.N and Moore, M. K. (1989). Imitation in newborn infants: exploring the range of gestures imitated and the underlying mechanisms. Development Psychology, 25, 954-62.
  29. Miller, P.H. (1993). Theories of Developmental Psychology (3rd edn). Englewood Cliffs, NJ: Prentice-Hall.
  30. Miller P, Wang XJ (2006) Inhibitory control by an integral feedback signal in prefrontal cortex: A model of discrimination between sequential stimuli. Proc Natl Acad Sci USA, 103(1), 201-206
  31. Norman, D.A., & Shallice, T. (1986). Attention to action: Willed and automatic control of behaviour. (Center for Human Information Processing Technical Report No. 99, rev. ed.) In R.J. Davidson, G.E. Schartz, & D. Shapiro (Eds.), Consciousness and self-regulation: Advances in research, (pp. 1-18). New York: Plenum Press
  32. Piaget, J and Inhelder, B. (1956). The Child’s Conception of Space. London: Routledge & Kegan Paul.
  33. Piaget, J. (1929). The Child’s Conception of the World. New York: Harcourt Brace Jovanovich.
  34. Piaget, J. (1936/1952). The Origin of Intelligence in the Child. London: Routledge & Kegan Paul.
  35. Piaget, J. (1951). Play, Dreams and Imitation in Childhood. London: Routledge & Kegan Paul.
  36. Shayer, M. and Wylam, H. (1978). The distribution of Piagetian stages of thinking in British middle and secondary school children: II. British Journal of Educational Psychology, 48, 62-70.
  37. Shayer, M., Kuchemann, D.E. and Wylam, H. (1976). The distribution of Piagetian stages of thinking in British middle and secondary school children. British Journal of Educational Psychology, 46, 164-73.
  38. Smith, P., Cowie, H. and Blades, M. (2003). Understanding children’s development. 4th ed. pp.388-416.
  39. Sowell ER, Thompson PM, Holmes C.J., Jernigan, T.L., Toga A.W. (1999). In vivo evidence for post-adolescent brain maturation in frontal and striatal regions. Nat Neurosci, 2, 859-861
  40. Willatts, P. (1989). Development of problem solving in infancy. In A. Slater and G. Bremner (eds), Infant Development. Hillsdale, NJ: Lawrence Erlbaum
  41. Wimmer, H. and Perner, J. (1983). Beliefs about beliefs: representations and constraining function of wrong beliefs in young children’s understanding of deception. Cognition, 13, 103-28.

Actualisé: 12 Juillet 2018 | Danny J. D’Purb | DPURB.com

____________________________________________________

While the aim of the community at dpurb.com has  been & will always be to focus on a modern & progressive culture, human progress, scientific research, philosophical advancement & a future in harmony with our natural environment; the tireless efforts in researching & providing our valued audience the latest & finest information in various fields unfortunately takes its toll on our very human admins, who along with the time sacrificed & the pleasure of contributing in advancing our world through sensitive discussions & progressive ideas, have to deal with the stresses that test even the toughest of minds. Your valued support would ensure our work remains at its standards and remind our admins that their efforts are appreciated while also allowing you to take pride in our journey towards an enlightened human civilization. Your support would benefit a cause that focuses on mankind, current & future generations.

Thank you once again for your time.

Please feel free to support us by considering a donation.

Sincerely,

The Team @ dpurb.com

Donate Button with Credit Cards