Companion to psychiatric studies Book 1

Companion to Psychiatric Studies

Substance misuse Cannabis

Decades of animal work have explored the neurobiology The relatively limited imaging literature in cannabis users has
of addictive substances. Whilst in many ways these drugs are recently been reviewed (Quickfall & Crockford 2006). There
very different, most of them promote dopamine release in is no consistent evidence of structural abnormalities. However,
subcortical structures such as the ventral tegmental area and xenon inhalation SPECT and some PET studies have consis-
ventral striatum (Bardo 1998), a factor robustly linked to their tently found global reductions in cerebral blood flow that
power to promote self-administration in animal studies. may be most marked in frontal and cerebellar lesions in
Although misused by humans because of their immediately users. This abnormality probably normalises on abstinence.
rewarding properties, in regular high dosage they are all asso- Generalised activations of frontal cortex, limbic regions and
ciated with an increased prevalence of depressive illness. the cerebellum are likely to relate to the effects of the drug,
Cause and effect continue to be debated. It is important to while heavy or dependent users appear to show additional acti-
note that many of these substances have many clinically sig- vations of orbitofrontal cortex and the basal ganglia, similar
nificant non-dopaminergic actions and non-pharmacological to those seen in studies of cocaine and alcohol dependence.
effects (e.g. psychotomimesis, cognitive deficits, structural Tetrahydrocannabinol and cannabidiol seem to produce dif-
brain change). Ketamine may have indirect effects via gluta- ferent effects, in part depending on the experience of the
mate, LSD may inhibit midbrain serotonergic activity and subjects (Fusar-Poli et al 2009).
cannabis might act via effects on acetylcholine, all with impact
on dopamine. These considerations provide a context for the Stimulants
available imaging studies, which are often difficult to inter-
pret because of the natural history of substance misuse and Ecstasy is known to be neurotoxic in animals. Brain structural
extensive comorbidities. abnormalities have been consistently reported in amphetamine
abusers, with lower cortical grey matter volume and higher
Alcohol striatal volume than control subjects. Although these differ-
ences might reflect brain features that could predispose to
Brain shrinkage in alcohol misuse has been reported from the substance dependence, high striatal volumes might also reflect
earliest pneumoenecephalography studies. This has subse- compensation for toxicity in the dopamine-rich basal ganglia
quently been confirmed by many CT and MRI studies, which (Berman et al 2008). There is good evidence for alteration in
also find partial reversibility of abnormalities with abstinence striatal dopamine receptor binding and transporter density in
(Kril & Halliday 1999). This is not simply a result of dehydra- ecstasy and cocaine users (Volkow and Fowler 2000, Reneman
tion, nor reversibility due to rehydration. Neuropathological et al 2002) which normalise on abstinence (Martinez et al
and radiological studies have identified shrinkage of the white 2007), as do reduced levels of the serotonin transporter in
matter, including the corpus callosum and perhaps especially ecstasy users (Cowan et al 2008). Administration of amphet-
the prefrontal cortex. Grey-matter reductions have been amine in amphetamine-addicted subjects tended to increase
reported in dorsolateral prefrontal, subcortical grey matter activity in the ventral striatum and this correlated with eupho-
and medial temporal lobes but age effects may be partly ria rating (Drevets et al 2001), whereas cocaine infusion in
responsible. The hippocampal region may be particularly cocaine-addicted subjects increased activity in the ventral
affected but patients with seizures may account for such find- tegmental area, which correlated with ratings of euphoria
ings. Deficits in memory and executive functions sometimes (Breiter et al 1997). In the latter, it was the post-euphoria
correlate with these structural deficits. Neuropathological rating of craving which correlated with increased ventral stria-
studies in humans report neuronal loss in the dorsolateral cor- tal activity. This is in keeping with reports of reduced striatal
tex but not hippocampal regions, in contrast to animal models activity with increased exposure and as a marker of relapse lia-
of alcohol misuse, where hippocampal neuronal loss is fre- bility. Studies of cocaine-addicted subjects have also reported
quently found. The mechanism of any such damage is widespread grey-matter reductions in prefrontal and temporal
unknown. Partial recovery suggests neurochemical involve- cortices (e.g. Franklin et al 2002).
ment while neuronal loss suggests irreversible brain damage
(Kril & Halliday 1999). Milder abnormalities have been Hallucinogens
reported in offspring, but the extent to which these reflect
genetic effects as opposed to early exposure to alcohol is A small number of studies of psilocybin have reported
unclear. In addition, low D2/3 receptor BP values have been increased metabolism in frontotemporal regions and the ante-
reported in alcoholics, but this may reflect a general predispo- rior cingulate (e.g. Vollenweider et al 1997). There are quite
sition or effect of drug addiction as the same pattern is seen in a few imaging studies of the effects of ketamine, a handful
cocaine addicts, heroin-dependent subjects and methamphet- of which include patients with schizophrenia. Ketamine may
amine abusers (Martinez et al 2007). Wernicke’s encephalopa- precipitate psychotic symptoms by reducing glutamate and
thy, regardless of etiology, is characterised by bilateral indirectly increasing dopamine neurotransmission in the stria-
hyperintensity on T2 scans, especially in the mammillary tum (cf. stimulant challenge studies in schizophrenia), but
bodies, thalamus and periventricular grey matter (Sullivan & the effects are short lived (Carpenter 1999). In a particularly
Pfefferbaum 2009).

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Neuroimaging CHAPTER 4

careful recent study in healthy subjects, ketamine induced a Conclusions and future directions
decrease in ventromedial frontal cortex activity, including
orbitofrontal cortex and subgenual cingulate, which strongly Quantitative imaging methods have established that structural
predicted dissociative effects, and increased activity in cingu- and functional brain abnormalities are associated with most
late, thalamus and temporal cortical regions, which correlated psychiatric disorders. Different patterns of abnormality are
with psychosis scores (Deakin et al 2008). beginning to emerge for what were once thought to be purely
‘functional’ disorders (Table 4.7). It should be emphasised,
Eating disorders however, that there is much overlap between patients and con-
trols, and abnormalities that have been replicated are currently
Structural abnormalities demonstrable only at the group, and not at an individual level.
This may change with time. Brain imaging has already
There are comparatively few structural imaging studies of advanced to the point where structural imaging, preferably
anorexia nervosa and hardly any in bulimia. Early CT studies MRI, is now advocated in the assessment of developmental
in anorexia found enlarged ventricles that were at least delay (Shevell et al 2003) and in the diagnosis of dementia
partially reversible after weight gain and MRI studies suggest according to UK NICE guidelines. This is not yet true of
this is also true of cerebral volumes. Whether or not complete schizophrenia, but sMRI does have the ability to make power-
recovery occurs is uncertain (Kaye 2008). Long-term changes ful predictions of diagnosis (Job et al 2006), fMRI can dis-
could reflect trait or uncorrected state factors such as mood tinguish schizophrenia from bipolar disorder, and fMRI and
or hormonal disruption. PET show promise as predictors of response to antidepressant
and antipsychotic drugs.
Functional abnormalities
Further insights into pathophysiology of possible clinical
There is a far greater functional imaging literature in both relevance is likely to come in particular from imaging studies
disorders. There are replicated reports of a generalised hypo- of the range of phenotypes associated with known genetic
perfusion and ‘hypofrontality’, as well as a ‘hypertemporality’ abnormalities, within and across disorders, and the use of serial
related to food cues – possibly related to anxiety. More imaging to plot the natural history of neurodevelopmental and
impressive is the consistent PET evidence implicating the progressive disorders. The major challenge facing psychiatry is
serotonergic system, including increases in 5HT-1A receptor of course the complexity of the mind/brain. A common action
binding (which is the opposite to what is usually seen in of all antipsychotics is D2 blockade, but how does this trans-
depression) and reductions in 5HT-2A receptor binding in corti- late into improvements in abnormal experiences (hallucina-
cal regions which correlates with harm avoidance (Kaye 2008). tions) and thoughts (delusions) in psychosis? A common
action of antidepressants is prolonging and increasing the levels
of serotonin (and perhaps adrenaline (norepinephrine)), but

Table 4.7 Summary of the best replicated findings in various psychiatric disorders

Disorder Findings

Dementia • Alzheimer’s type: medial temporal lobe and then generalised atrophy
Schizophrenia • Multiinfarct: patchy perfusion deficits, SPECT may be more sensitive than CT or structural MRI

Mood disorders • Ventriculomegaly and reduced grey- and white-matter volume
• Largest and most consistent volume reductions in medial temporal lobes; however, some reductions in prefrontal lobe volume
Autism • Reduced concentrations of phospholipids and N-acetylasparate in frontal and temporal lobes using MRS
Anxiety disorders • Hypofrontality and striatal hyperdopaminergia
Substance misuse
• Ventriculomegaly and reduced brain and hippocampal volume
Eating disorders • Subcortical leucoencephalopathy associated with late-onset illness and treatment resistance
• Best evidence is for medial prefrontal cortex dysfunction

• Increased brain volume

• Greater activity in the insula and amygdala

• Links between functional imaging studies and extensive animal work
• Addiction is associated with low D2/3 transmission in the striatum, including reduced D2/3 receptors, dopamine release

and synthesis

• Increases in 5HT-1A receptor binding and reductions in 5HT-2A receptor binding

91

Companion to Psychiatric Studies

how does this lead to improvements in the mood and cogni- issues will, however, be matched by difficulties in translating
tions of moderate to severe depression? Crucially, why do the associated animal models into human and clinical phenom-
such treatments work for some patients but not for others? ena; hence the interest in the ‘reverse translation’ possibilities
One important recent focus in the literature is trying to bridge of taking simple human resting and conditioning fMRI studies
the conceptual gap between neurophysiology, pharmacology back into animal fMRI studies, which could then be used to
and phenomenology (Kapur 2003). Only time will tell evaluate new potential drugs. Linking animal and human imag-
whether this is a useful approach to understanding psychiatric ing studies like this may also assist in the interpretation of the
disorders. The potential rewards are, however, very high, underlying neurophysiological basis of these effects.
in that such integration might identify physiological biomar-
kers of psychiatric disorders, so allowing better targeting of Translating research findings into clinical practice will, how-
pharmaceutical research programmes. ever, also depend upon collaborating research groups standar-
dising their approaches to data acquisition, processing and
Biomedical imaging in general is poised to play an increasing analysis, and thus facilitating multicenter studies with suffi-
role in the drug discovery and development process. CNS drug ciently large samples to answer key questions. This will permit
candidates fail approval in over 90% of the cases due to poor the construction of normal and abnormal brain reference
targeting, lack of efficacy and/or unacceptable side effects. resources. These could, for example, be useful in cohort stud-
Brain imaging could provide biomarkers of drug targets, dis- ies of those at high risk of psychosis to establish the extent to
ease mechanisms, efficacy and toxicological effects, which in which brain scan results indicate the level of risk, with a view
themselves could later be developed as new diagnostic imaging to informing early intervention and possibly even prevention.
agents and used to guide individualised drug therapy. Such These studies could ultimately be used to define disorders by
markers might include measures of hippocampal atrophy and traditional or novel diagnostic boundaries. It is, at least at pres-
cortical volumes on sMRI, neural network dynamics on fMRI, ent, difficult to envisage genetic and molecular biology tools
PET receptor binding and dosing, and multimodal combina- providing a similarly useful level of phenotype information
tions of these. Methodological variations and reproducibility for clinical practice.

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94

Basic psychology 5

Jeremy Hall Mary E Stewart

Introduction John B Watson (1878–1958) was a leading figure. Behaviourism
was a reaction against the ‘introspectionist’ approach to psychol-
Psychology is the science of behaviour and mental life. ogy, where armchair psychologists sat and recorded their own
As such, key ideas in psychology can be of great benefit in mental processes. Watson argued that such subjective mental
understanding not only normal behaviour but also abnormal states were not amenable to scientific study, being unobservable,
states of mind such as those present in mental disorders. and instead focussed on observable and quantifiable behaviour in
In this chapter we will focus on areas of psychology in which carefully controlled experimental settings. Behaviourists drew on
experimental analysis has led to a greater understanding of the work of the Russian physiologist Ivan Pavlov (1849–1936).
human behaviour. We will start by discussing the mental pro- Pavlov was awarded the Nobel Prize for his work on the physiol-
cesses involved in learning, memory, perception, attention, ogy of digestion, however, in the course of subsequent work on
thought, emotion and motivation. Next we will review the salivation in the dog he noticed that the dogs began to salivate
development of mental faculties through childhood. Finally on seeing the attendant who normally fed them. Pavlov made
we will turn to the scientific study of personality before con- those observations the basis for his subsequent study of condi-
sidering how individual vulnerabilities may interact with the tioning. This type of learning, based on involuntary processes,
environment to lead to the development of mental illness. is known as pavlovian or classical conditioning.

Learning Two other significant figures in the behavioural school of
psychology were Edward Thorndike (1874–1949) and Burrhus
Learning is a change in behaviour as a result of prior experi- F Skinner (1904–1990). Thorndike became famous for his
ence. Historically there have been different views about the study of how cats learned to escape from puzzle boxes; over
importance of learning in shaping the mind. Philosophers of a number of trials the cats were found through trial-and-error
the rationalist school, including Rene Descartes (1596–1650), learning to escape more quickly from the boxes. Thorndike’s
emphasised the importance of innate abilities over acquired so-called law of effect stated that responses were either more
knowledge. In contrast the Empiricist school, of which John likely or less likely to occur according to the consequences that
Locke (1642–1704) was a prominent member, argued that they produced. Skinner continued and extended Thorndike’s
knowledge was derived from experience and learning. study of learning based on the consequences of behaviour,
We now understand that there are both innate and learnt which is termed operant or instrumental conditioning.
influences on mental processes. In this section we shall con-
sider the mental processes involved in learning by examining Classical conditioning
the work of the behavioural psychologists before considering
observational and cognitive approaches to learning. Classical conditioning is the process by which an initially
neutral stimulus (the conditioned stimulus or CS) by virtue
The behavioural school of presentation with a biologically significant reinforcer (the
unconditioned stimulus or US) comes itself to elicit a charac-
The experimental study of learning was greatly advanced by teristic response (the conditioned response or CR). This CR
the Behavioural school, in which the American psychologist often resembles the response produced by the presentation
of the US alone, known as the unconditioned response (UR).
This process is illustrated in Fig. 5.1.

ã 2010, Elsevier Ltd.
DOI: 10.1016/B978-0-7020-3137-3.00005-X

Companion to Psychiatric Studies

UCS (Food) UCR (Salivation) outcome (such as food when hungry) the process is referred
to as positive reinforcement. If in contrast the reward is the
CS (Bell) + UCS (Food) UCR (Salivation) prevention of an unpleasant outcome, the process is referred
to as negative reinforcement. It should be noted that both
CS (Bell) CR (Salivation) positive and negative reinforcement lead to an increase in the
probability that the voluntary action will be performed.
Fig. 5.1 An outline of classical (Pavlovian) conditioning. (U)C, This contrasts with punishment, where the outcome of a vol-
(un)conditioned; S, stimulus; R, response. untary action is unpleasant (such as an electric shock), leading
to a decrease in the probability of the voluntary action being
Experimental studies have revealed that there are cer- performed.
tain conditions which optimally support the acquisition of a
Pavlovian association. Delay conditioning, in which the CS is Operant conditioning can be conducted under a range of
presented for a short duration prior to the onset of the US different schedules of reinforcement. If every action is rewarded
and continues until the termination of the US, supports the conditioning is said to be under a continuous schedule of
formation of strong CS–US associations. Less robust condi- reinforcement. However if only some of the responses are
tioning is seen with simultaneous conditioning, in which the reinforced a partial schedule of reinforcement is established.
CS and US are co-presented. Trace conditioning, in which Partial reinforcement schedules can be delivered on ratio sche-
there is a delay between the offset CS and the onset of the dules, in which the reinforcer is provided after a set number of
US is also less effective than delay conditioning, and at responses, or on interval schedules, in which the first response
extended delays results in greater conditioning to the context after a given time period leads to reinforcement. Both ratio
(environment) than to the CS. and interval schedules can be either fixed or variable. In fixed
schedules the ratio or interval between reinforcers is constant.
Some stimuli are much more likely to be subject to condi- In contrast in variable schedules the ratio or interval is allowed
tioning than others. Thus whilst conditioning may commonly to vary within a set range. Such partial schedules of reinforce-
lead to the acquisition of phobias for snakes or blood, it is rare ment, once established, can maintain very high response rates.
to encounter a car phobic, despite the clearly dangerous nature This is of importance in relation to gambling, where a partial
of cars. This phenomenon, known as stimulus preparedness, reinforcement schedule such as that used in slot machines
derives from the fact that evolution has predisposed us to learn leads vulnerable individuals to continue gambling at a high rate.
associations about specific stimuli that have an established A further property of partial reinforcement schedules is that
biological importance. the behaviour is more resistant to extinction (the partial rein-
forcement extinction effect); thus, if reinforcement is no longer
Once a conditioned association has been acquired, presented, an individual who has been rewarded on a continu-
conditioned responses may also be elicited by stimuli similar ous schedule of reinforcement will normally stop responding
to the original conditioned stimulus. This process is referred sooner than someone who has received partial reinforcement.
to as stimulus generalisation, and can explain why a phobia
developed to a specific stimulus, such as a certain snake, may Observational learning
generalise to all snakes. However with experience stimulus
discrimination may develop such that the subject develops Whilst classical and operant conditioning can explain many
the ability to distinguish between a stimulus that is reinforced types of learning, individuals can also learn without direct
and related stimuli that are not. Higher order conditioning can reinforcement or punishment. Albert Bandura (1925–present)
be established if a new conditioned stimulus is paired with the criticised Skinner and other behaviouralists on the grounds
original conditioned stimulus. Over learning the new stimulus that they did not account for learning by observation without
will also come to elicit the conditioned response, albeit less direct reinforcement. In a classic series of experiments
strongly than the initial CS. Bandura demonstrated that learning can indeed occur by
observation alone. Such learning is referred to as observational
If a conditioned stimulus is repeatedly presented in the learning, vicarious learning, or modelling.
absence of reinforcement, the conditioned response will
decrease in strength over time, a process referred to as extinc- One of Bandura’s most famous experiments involved
tion. This process is of clinical importance in the treatment of an inflatable toy known as a Bobo doll (Bandura et al 1961).
phobias. Extinction does not, however, equate to forgetting. Bandura produced a video of one of his students attacking
Established associations are relearned more rapidly than novel a Bobo doll and then showed this to young children. When
associations, demonstrating that some memory of the CS–US subsequently given access to the Bobo doll the children copied
association persists after extinction. In addition spontaneous the behaviour of the student, attacking the doll. In a more sin-
recovery of the conditioned response may occur over time. ister extension Bandura went on to repeat the experiment
using a live clown rather than the doll (Bandura et al 1963).
Operant conditioning Again the children copied the actions of the student and hit
the live clown after watching the video. These experiments pro-
Operant conditioning differs from classical conditioning in that vide evidence for learning by observation in the absence of
it is dependent on voluntary actions performed by the subject. direct reinforcement. Subsequent studies have established the
Such learning obeys Thorndike’s law of effect, which states optimum conditions for observational learning which include
that a voluntary behaviour that produces a rewarding outcome
is more likely to be repeated. If the reward is a positive

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live modelling, perceived similarity with the modeller, seeing individuals with learning difficulties. One example is the use
the modeller receiving reinforcement and familiarity with the of operant procedures to allow the acquisition of complex
modeller. skills. In shaping, successively closer approximations to a com-
plex behaviour are reinforced in order to achieve performance
Cognitive learning of the behaviour. A clinical example would include language
training in autism in which reward is initially given for any
There are other forms of learning which do not require either utterances, then for imitating sounds and finally for the use
conditioning or modelling. Examples include studying a medi- of specific words. In chaining, a complex behaviour is taught
cal textbook, understanding the concepts therein and reaching by breaking it down into its constituent parts. The complex
new realisations about the topic under study and its relation to behaviour is then built up by bringing the parts together, either
other previously stored information. These forms of learning, forwards or backwards. Backwards chaining can be particularly
which require a degree of conscious awareness on the part effective as the reward associated with successful completion
of the subject, are known collectively as cognitive learning. can be used to reinforce the learning of successively earlier
This broad term encompasses learning based on reason and links in the chain.
intuition. Whilst much of the basis of cognitive learning remains
unclear, the field has given rise to the study of aptitudes and Finally there has recently been considerable interest in the
capacity for learning and learning styles. possibility that abnormalities of conditioning and associa-
tive learning may underlie the development of symptoms of
Clinical applications schizophrenia. This idea actually has a long historical pre-
cedence dating back to Bleuler’s identification of ‘loosening
Learning theory has been particularly influential in understand- of associations’ as a key feature of schizophrenia (Bleuler
ing phobias and anxiety disorders. One important theory of 1911). More recently, Robert Miller, Jeffrey Gray and Shitij
the development and maintenance of such disorders is the Kapur, amongst others, have also provided a formulation of
two-stage model of phobias espoused by Orval Mowrer schizophrenic symptoms based on abnormalities in conditioning
(1907–1982) (Mowrer 1939). In this model the first stage and learning (Miller 1976; Gray et al 1991; Kapur 2003).
involves the classical conditioning of a neutral stimulus paired A core feature of these theories is that patients with schizo-
with a frightening or painful event, leading to conditioned fear phrenia fail to appropriately learn which cues and stimuli
of the neutral stimulus. The second stage then involves oper- in the environment are of motivational significance, instead
ant conditioning, during which the individual learns to reduce attributing significance to neutral or irrelevant stimuli. Such
the fear by avoidance of the relevant object or situation, lead- a mechanism may explain symptoms such as delusions of
ing to the maintenance of avoidant behaviour. Much of the reference, where patients attach emotional and motivational
focus of behavioural interventions in anxiety and obsessional significance to normally inconsequential events.
disorders has sought to overcome this avoidance behaviour in
order to allow for extinction of the conditioned response. Memory
Treatment involves exposure to the feared object or situation.
This is achieved by getting the sufferer to identify a hierarchy Memory is one of the most fascinating and complex of human
of progressively more fear-provoking stimuli to which they are faculties. Our memories play a great part in making us who we
sequentially exposed, beginning with the least anxiety pro- are, and in governing our behaviour and actions. In this section
voking. The subject is additionally taught relaxation techniques we will first consider the different types of memory, with
to practice during the exposure. This process of systematic reference to the anatomical systems which underpin them.
desensitisation paired with reciprocal inhibition (inhibiting We will then consider the processes involved in the encoding,
anxiety with relaxation) has proven effective in treating a storage and retrieval of memories, as well as in forgetting. Finally
range of anxiety-related disorders. we will briefly consider certain types of memory disorders.

It is now well recognised that not all fears are acquired in Types of memory
accordance with the two-factor theory (Rachman 1990). Many
people with a fear of flying have never actually flown, so their Memory can be broadly divided into sensory memory, working
fear could not have been acquired by classical conditioning in memory and long-term memory. Sensory memory consists of
the situation itself. Conversely, not everybody who has experi- sensory information retained in an unprocessed form in the
enced a traumatic event while flying (e.g. a hijack) develops a sensory system through which it entered. This form of mem-
phobia. Instead, the observation of someone else (such as a ory is short lived (0.5–3 seconds) but has a large capacity.
parent) being fearful about an object or situation (examples Sensory memory accounts for our ability to recall something
of observational learning) is also a common source of fears after it was spoken, even if it was not originally the subject of
and phobias. This has led to the development of modelling attention. Sensory memory has therefore saved many marriages.
therapy in which a person suffering from anxiety or difficulty
in a certain situation watches someone else coping well with Working memory is also often referred to as short-term
the situation. memory. The latter term is, however, often used very
differently by clinicians, psychologists and researchers and
Behavioural techniques have also been successfully applied therefore the term working memory is to be preferred.
in other areas of psychiatry, including teaching skills to

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Working memory is a temporary store of a subset of sensory paid to their meaning, rather than simply to their phono-
information to which attention has been applied. It is gener- logical content. Encoding is also enhanced if the material
ally considered to have its substrate in the frontal lobes and has a powerful emotional content, a process which may in
cortical areas concerned with sensory processing. Working extreme circumstances contribute to the development of
memory has a limited capacity, typically described as com- post-traumatic stress disorder. This emotional modulation of
prising seven plus or minus two items, and a short duration memory is known to depend on the interaction of the amyg-
of approximately 30 seconds maximum. The capacity of work- dala, a key brain region implicated in emotion processing, with
ing memory can, however, be extended by the process of temporal lobe memory systems (Phelps 2004).
chunking, in which several items are grouped together into a
single cognitive unit. For example, my telephone number con- The transition of memories into longer term storage is not
sists of seven digits. If I tell this number to someone who did instant and requires time during which memories are still
not previously know it, it will require all their working mem- labile and may be subject to disruption. During this time
ory capacity to remember the seven digits. However, for me period memories are stabilized in neurons, initially by changes
this telephone number is a single cognitive unit and therefore in protein phosphorylation and subsequently by alterations in
through the process of chunking it only occupies one item gene expression and the synthesis of new proteins (Kandel
or unit in my working memory. The duration of working et al 2000). Electroconvulsive therapy interferes with these
memory can also be extended by the process of rehearsal in processes, resulting in the retrograde amnesia for recent events
which auditory items are repeated mentally to keep them in seen following treatment. Once established in the long-term
working memory for longer than 30 seconds. This process store memories are of very long duration and may even be
means that when testing longer term memory it is important permanent in health. The duration of long-term memory is,
to provide some form of cognitive distraction between encod- however, difficult to precisely determine, as it is often impos-
ing and retrieval to prevent the subject simply rehearsing the sible to distinguish between true memory loss and failure of
to-be-remembered items in working memory. retrieval of still extant memories.

Long-term memory is theoretically unlimited in capacity Retrieval is the process by which information is recovered
and permanent in duration. The concept of memory having from memory when needed. Retrieval can take various forms.
unlimited capacity may seem strange, however, the capacity For example, full recall of a previously viewed picture implies
of human memory has never clearly been exceeded (there conscious and explicit recollection of the image. However, a
are no examples of people being unable to remember more picture that cannot be recalled may nevertheless be recognized
information due to ‘overload’) and there is not even evidence on viewing. This recognition may vary in confidence from
of asymptotic slowing of the ability to acquire new memories. certainty that the image was previously seen, to a feeling of
Long-term memory can be divided into explicit memory familiarity. Retrieval is optimized if the context in which
and implicit memory. Explicit memories are conscious mem- retrieval is attempted matches that in which the memories
ories that can be brought to mind and described or spoken. were encoded. The organization of the storage of memories,
They include episodic memory, which is the complex memory referred to as schemata, can also influence retrieval suc-
for episodes and events in one’s life, and semantic memory, cess. Highly organized memory schemata facilitate memory
which is memory for facts such as the meaning of words and recall. The schemata in which memories are stored may also
general knowledge. Implicit memories are outside conscious influence the nature of the recalled information. Subjects may
awareness and include memories for procedures, such how to spontaneously fill gaps in memory based on the associated
ride a bicycle, as well as conditioning and priming. Long-term underlying schemata, leading to the formation of reconstructive
memory involves a number of brain regions. The hippocampus memories which can be inaccurate. Emotional factors also influ-
and limbic brain regions are known to play a key role in ence retrieval. Thus depressed subjects show a bias to the
episodic memory, while the temporal neocortex is an impor- retrieval of negative items and events, while strong emotions,
tant substrate for semantic memory. Procedural memories in such as overwhelming anxiety, may impede memory retrieval.
contrast are known to depend upon the basal ganglia and
associated motor circuitry. Forgetting

Memory encoding, storage and retrieval Long-term memories are very enduring. Experimentally it is
hard to distinguish between true forgetting and failure of
In this section we will consider factors that influence the retrieval, leaving open the possibility that long-term memory
encoding, storage and retrieval of memories. The encoding of is actually permanent and any failures of recall are simply due
memories initially requires attention to be applied to the items to imperfect retrieval. Despite the difficulty in distinguishing
to be remembered. Items at the beginning and end of lists are true forgetting from failures of recall two main theories for
particularly well remembered (the so-called primacy and how items may be forgotten from the long-term store have
recency effects) and this may be explained partly in terms of been developed. The first of these, decay theory, argues that
the greater attention afforded to initial items, and the lower memories decay over time. The second theory, interference
amount of distraction for recent items. Encoding is facilitated theory, instead holds that the learning of related items leads
if there is a degree of processing of the information to be to interference with subsequent forgetting of one or both items.
remembered, so words are better remembered if attention is There is, however, unfortunately relatively little experimental
material that allows these theories to be clearly evaluated.

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Memory disorders refers to the influence of cognitive and motivational state
on perception. For example, psychological experiments dem-
There are a range of disorders that can lead to impaired mem- onstrate that an expected stimulus is perceived at a lower
ory. Dementias, such as Alzheimer’s disease, are associated threshold than an unexpected stimulus. An individual’s
with prominent deficits in memory, but this occurs in the con- personality and experience will also influence their per-
text of a more generalised cognitive decline. There are other ceptual set, as demonstrated by the tendency of anxious
disorders of memory, however, in which there are relatively subjects to respond more rapidly to threat-related material
selective deficits in specific types of memory. Episodic mem- than controls.
ory is disrupted acutely in transient global amnesia and chron-
ically in the amnestic syndrome. Transient global amnesia is The active processing of sensory information extends to dif-
characterised by a sudden onset of anterograde and sometimes ferentiating self-generated actions from externally generated
retrograde memory impairment in otherwise healthy indivi- actions. An example is the difference in how I perceive my
duals usually over the age of 40. The affected individual is arm when I move it voluntarily, compared to how I perceive
often bewildered, repeating the same questions. The condition it when it is moved by someone else. In general the brain
is self-limiting and its exact cause is unknown, although some cancels out our perceptual awareness of actions which are
sufferers go on to develop temporal lobe epilepsy. The amnes- self-generated and thus fully predicted through a mechanism
tic syndrome is characterized by chronic anterograde amnesia know as corollary discharge. This effect is also believed to
with variable degrees of retrograde amnesia and preserved explain why we are able to distinguish between internally
working memory. It can result from bilateral hippocampal and externally generated speech. Chris Frith has suggested
damage, for example secondary to hypoxia, or from damage that abnormalities in this type of self-monitoring may underlie
to the diencephalon as seen in Korsakoff’s syndrome. Semantic the development of some of the symptoms of schizophrenia
memory is especially impaired in conditions which result in (Frith 1992). For example, a failure to recognise internal
specific damage to the temporal neocortex such as herpes speech as self-generated may underlie the development of
simplex virus encephalitis or Pick’s disease (focal temporal auditory hallucinations, while experiencing internally gener-
lobe atrophy). Procedural memories are affected by disor- ated actions as if they were externally mediated may lead to
ders of the basal ganglia such as Huntington’s chorea and the development of delusions of control.
Wilson’s disease.
The active nature of perception is reflected developmen-
Perception tally. Thus while some perceptual faculties are innate, many
are acquired actively during development. The role of environ-
Perception is not a passive process, but involves the active mental stimuli in the development of perception has been
interpretation of information derived from the sensory organs most clearly demonstrated in studies of the visual system.
(Noe 2004). Perception is therefore dependent on both the Kittens deprived of normal visual stimulation by eyelid sutur-
‘bottom-up’ processing of sensory information and its ‘top- ing throughout the critical period for visual system develop-
down’ modulation by higher mental faculties. The active ment show major abnormalities in the development of the
nature of perception means that instead of being swamped visual cortex and impaired vision (Thompson et al 1983).
by an array of sensory information we are able to rapidly In addition animals exposed only to stimuli of one orientation
extract and interpret key features in our sensory environment. (horizontal or vertical) during the critical period fail to
However the cost for this expedient is that our perceptual respond to stimuli of the other orientation appropriately in
system can be deceived both in simple illusions and more later life (Blakemore & Cooper 1970).
seriously in some forms of psychiatric illness.
Attention
Examples of the active nature of perception include figure-
ground differentiation, object constancy and the effects of Attention can be defined as the concentration of mental
perceptual set. Figure-ground differentiation is a relatively efforts on sensory or mental events (Solso 1995). At any given
low-level perceptual mechanism which allows for the differen- time the brain only has a limited processing capacity and atten-
tiation of a form, or figure, against a background. In visual per- tion is therefore selective, governing the degree to which
ception a number of features are used to separate figure and different stimuli in our environment are perceived at any given
ground. These include the brightness, colour and shape of time. Attention is particularly focussed on novel or unex-
the figure and its resemblance to known objects, compared pected features of the environment and on items of particular
with the formless and continuous nature of the ground. motivational significance. In contrast neutral items or stimuli
Figure-ground differentiation also occurs in other sensory which are predicted on the basis of previous experience are
modalities, such as the isolation of relevant speech from the less likely to grab attention.
generality of background noise. Object constancy refers to
our ability to perceive objects as unchanged, despite alterations There has been considerable interest in the stage at which
in variables such as proximity and lighting which alter the sensory information is filtered prior to reaching attention.
resultant retinal image. Similar effects are also apparent in Early-filtering models, such as that of Broadbent (1958) argue
auditory perception, for example we perceive the direction that a large amount of relatively unprocessed sensory informa-
of a sound as constant despite head movements. Perceptual set tion enters into a short-term store, and is then selectively
filtered such that only one message is processed more centrally
and becomes the subject of attention. However there is

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evidence that some degree of active processing takes place in processing capacity) or whether there is no such thing as
even for information that is not being consciously attended to. ‘mental logic’.
This is illustrated by the cocktail party effect (Cherry 1953):
in a crowded room background speech is normally filtered Three main types of reasoning task are deduction, induction
out and attention is solely focussed on a single conversation, and probability judgement. Deduction is the drawing of a con-
however if a particular salient word (such as your name) is clusion from a set of premises; induction is the drawing of a
present in the background it is consciously perceived and general rule on the basis of one or a limited number of
attention is refocused. Information that is not the subject of instances; and probability judgements involve a statement
current attention is therefore clearly being processed subcon- about the likelihood of an event occurring. As an example of
sciously such that salient features can be detected. This rea- deductive reasoning, for the premises:
lisation led to the development of late-filtering models, such
as that of Deutsch and Deutsch (1963) which propose that If I pass my exams I’ll study medicine at university
all messages undergo processing, but vary in the extent of this
processing. More recent theories of attention have also sought If I fail my exams I’ll go into politics and become
to account for the observation that individuals are often able to Prime Minister
conduct more than one task at once. This is especially the case
when one of the tasks has become automatic (habitual) I’ve passed my exams
through practise. For example, when we are initially learning
to drive, we are unable to attend to other stimuli. However the valid and perhaps fortunate conclusion is that I will
with practise driving becomes habitual and we are able to study medicine at university. As an example of the problems
concurrently hold a conversation. Current theories therefore that can arise with inductive reasoning, Johnson-Laird and
consider attention as a finite resource, with different tasks colleagues presented subjects with the series of digits ‘2 4 6’
requiring greater or lesser attention depending on factors such and asked them to discover the underlying rule through the
as experience. production of additional examples (Johnson-Laird 1988).
Most subjects set about confirming the possible rule ‘even
There is evidence that attention is impaired in certain psy- numbers increasing by two’ by generating large numbers of
chiatric disorders such as schizophrenia. A number of tasks positive instances of the rule, instead of attempting to discon-
have been used to investigate attention in schizophrenia, firm the rule by generating negative instances such as ‘7 8 9’.
including the continuous performance test (CPT). In a typical Had they done so, they would have eventually discovered that
CPT task subjects view a series of letters or digits briefly the rule was ‘any three increasing numbers’. This confirmatory
presented on a computer screen and participants have to press bias is one of the many biases that are evident from studies of
a button when an infrequent target (such as the number ‘7’) is reasoning. Other biases have been examined in an elegant
presented. Patients with schizophrenia and their genetic rela- series of studies by Kahneman and Tversky (Kahneman et al
tives show impairments on the CPT (Birkett et al. 2007). 1982). For example, the availability bias leads subjects to
Hemsley has developed a model of the origin of the psychotic say that more words begin with the letter ‘R’ than have ‘R’
symptoms of schizophrenia based on abnormalities in atten- in the third letter, because it is easier to generate words
tion and perception (Hemsley 1993). Hemsley argues that a beginning with ‘R’.
key abnormality in schizophrenia is the ‘weakening of the
influences of stored memories of regularities of previous input These reasoning biases can be quite benign in their effects
on current perception’. Specifically he argues that patients and even on occasion lead us to be blissfully ignorant of our
with schizophrenia allocate undue attention to irrelevant or faults. However impairments in reasoning also play an impor-
well-predicted stimuli. Notably this model is closely related tant role in mental illnesses such as depression and schizophre-
to theories of the development of schizophrenia based on nia. In depression a negative reasoning bias is present, leading
abnormalities of associative learning and conditioning, which to evidence being interpreted in an unduly negative manner.
also postulate inappropriate responding to irrelevant stimuli Such negative automatic thoughts are the target of treatment
as a key feature of the disorder (Gray et al 1991; Kapur in cognitive therapy (Beck 1970). Abnormal reasoning is also
2003). evident in schizophrenia, where delusional beliefs are held
firmly despite evidence to the contrary. Phillipa Garety and
Thought and reasoning colleagues have experimentally demonstrated abnormalities
of reasoning in schizophrenic subjects suffering from delusions
An assumption made by many philosophers and psycholo- using the ‘Jumping to Conclusions’ task (Garety et al 1991).
gists is that people use formal logical rules in reasoning. In this task subjects have to decide from which of two hidden
Perhaps the clearest account of such a system was provided jars beads are being drawn. Each of the jars contains beads
by Jean Piaget in his studies of child development (see sec- of two different colours (for example, yellow and black),
tion on Developmental psychology, below). However, there however they differ in the ratio of beads, such that one jar
is now a considerable body of research that demonstrates contains, for example, yellow and black beads in a ratio of
the limits of the adult capacity for reasoning, though the 85:15, while the second jar contains the beads in the ratio of
debate still continues over whether errors are the result of 15:85. The key dependent variable is the number of beads
performance limitations (e.g. working memory being limited the subject has to see before reaching a conclusion regard-
ing which jar they are being drawn from. Patients with delu-
sions typically make this decision on the basis of significantly
less evidence (fewer beads) than control subjects, providing
evidence of a tendency for delusional subjects to ‘jump to
conclusions’ on the basis of inadequate evidence.

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Emotion for example, people with Huntington’s disease and people
suffering from obsessive–compulsive disorder show severe
Many psychiatric disorders are characterised by abnormalities deficits in recognising facial expressions of disgust, whereas
of emotional states. Examples include sadness in depressive people with lesions restricted to the amygdala are especially
disorders, fear in anxiety disorders and paranoia, and disgust impaired in recognising facial expressions of fear (Adolphs
in obsessive–compulsive disorder and some eating disorders. et al 1999). In addition both autism and schizophrenia are also
For many years emotional experience was considered to be associated with impairments in emotion recognition (Ashwin
outside the domain of respectable scientific enquiry in psy- et al 2006; Marwick & Hall 2008).
chology, as emotions were considered not to be overt, quanti-
fiable behaviours. However, a number of techniques have now Theories of emotion
been developed to study emotion processing in both animals
and humans. This has led to significant advances in our under- An influential early theory of emotion, the James-Lange
standing of the neural basis of emotion, and how cognition, theory, stated that physiological responses are central and pre-
emotion and behaviour interact. cede the experience of emotion. William James stated that
‘Common sense says . . . we meet a bear are frightened and
How many emotions are there? run . . . The hypothesis to be defended here is that the order
of the sequence is incorrect . . . the more rational statement
There have been disagreements as to the number of core emo- is we feel afraid because we tremble’ (James 1884). James
tions. The work of Paul Ekman has proved hugely influential thus focused on the experience of emotion as a consequence
in showing that six basic facial expressions are apparently uni- of perception of body state. A contrasting model of emotional
versally recognised across cultures: happiness, sadness, anger, experience was proposed by Walter Cannon (Cannon 1927).
surprise, disgust and fear (Ekman et al 1969; Ekman & Friesen He manipulated peripheral feedback in animals and noted that
1976) (Fig. 5.2). However, some authors have argued against surgical isolation of the viscera did not impair emotional beha-
treating ‘surprise’ as a basic emotion. Therefore, a number of viour and that artificial induction of visceral changes did not
authors now propose that there are five basic emotions (Power appear to produce emotional behaviour. Cannon also pointed
& Dalgleish 1997). Facial expressions of human emotion are out that, in general, sympathetic reactions to arousing stimuli
clearly a key means of communicating emotional states of evo- are too slow to account for the speed of subjective emotional
lutionary relevance (Darwin 1872). However emotion is also reactions. Cannon proposed that emotional stimuli produced
communicated through other modalities including gestures two parallel effects in the brain: one that produced emotional
and the emotional content, or prosody of speech, which are experience and one which produced the somatic changes that
now also attracting considerable study. readied the organism to respond (‘fight or flight’). Thus, in this
model, physiological changes were viewed as a consequence,
Recent studies have shown that certain clinical disorders are not the cause, of emotional experience. More recently there
characterised by a recognition deficit for specific emotions,

Fig. 5.2 An individual posing the six basic A B C
emotional expressions of (A) anger, (B) disgust,
(C) fear, (D) happiness, (E) sadness and
(F) surprise. (Figure kindly supplied by D M Burt, University of

St Andrews.)

DE F

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has been a revival in interest in the role of peripheral feedback the amygdala. However, if the analysis indicates that the stim-
as a result of Damasio’s Somatic Marker Hypothesis, which ulus is not a threat, then the ‘fight or flight’ response is termi-
proposes that somatic feedback (e.g. ‘gut feelings’) influence nated. The amygdala is thus seen as playing a central role in
decision-making processes in man, often in the absence of the perception of threat. Recent neuroimaging studies have
conscious awareness (Damasio 1994). confirmed that the amygdala is activated in threatening situa-
tions, for example when patients with post-traumatic stress
Cognitive appraisal has also been recognised as crucial in disorder are exposed to trauma reminders (Liberzon et al
the perception and experience of emotion. In a widely cited 1999). The amygdala also plays a critical role in memory for-
(though much criticised) experiment, Schachter and Singer mation for emotional experiences (Cahill et al 1995; Hamann
recruited healthy participants who were injected with either et al 1999).
saline or noradrenaline (norepinephrine), and were then placed
in a social situation designed to elicit euphoria or anger Reward
(Schacter & Singer 1962). In one condition a confederate
acted in a playful manner, e.g. played with a hula-hoop, threw In a pioneering experiment, Olds & Milner chronically
paper planes out of the window. In the other condition the implanted electrodes in various brain regions of rats (Olds &
confederate appeared sullen and irritable before storming out Milner 1954). They discovered that the rats would learn to
of the room. Critically, participants were either informed press a lever if rewarded with a brief burst of electrical sti-
fully about the physiological effects of the drug, told nothing mulation in certain regions of the hypothalamus and limbic
or were misinformed (that it was a vitamin supplement). system. The rewarding effect of this electrical stimulation
Those participants who were told nothing or thought they was remarkable. The rats pressed the lever at rates as high as
had received vitamins experienced more extreme emotional five thousand times per hour. They pressed for 15–20 hours
reactions than those who were warned that the drug would until they fell asleep exhausted, and, on awakening, immedi-
induce arousal. The misinformed participants tended to ately restarted lever pressing. When forced to choose between
describe their emotional state as similar to that of the confed- food and self-stimulation, hungry rats often opted for self-
erate whose behaviour they witnessed. Schachter & Singer stimulation. One interpretation of these findings was that the
concluded that subjectively experienced emotion is the result brain stimulation mimicked the natural reward system. Self-
of a cognitive evaluation process in which the participant inter- stimulation was most effective when applied to the medial
prets his own bodily reactions in light of the given situation. forebrain bundle, which connects the ventral tegmental area
with the nucleus accumbens. This pathway utilises dopa-
Motivation mine as a neurotransmitter, and it has been established that
dopamine plays a crucial role in the physiology of reward.
Pressure of space prevents a detailed review of the psychobiol- This has clear relevance for psychiatry in that the dopaminer-
ogy of motivation; however, two topics which have particular gic system is thought to be implicated in the pathophysiology
relevance for psychiatry will be briefly presented: threat and of a variety of psychiatric disorders (e.g. schizophrenia), and
reward. dopaminergic agonists and antagonists are widely used treat-
ments in psychiatry. (Anhedonia, for example, may reflect a
Threat dysfunction of an endogenous reward system.)

Human evolution required the development of an effective Developmental psychology
series of mechanisms to quickly perceive and respond to
threatening stimuli. Cannon (1927) proposed that the per- We now turn to the study of human development. In this
ception of threat triggers intense sympathetic arousal which section, the main Piagetian development stages which describe
mobilises the individual for ‘fight or flight’. Physiological a child’s cognitive development will be outlined and criticised
changes which occur include heart rate acceleration, inhibition in light of more recent evidence. Then two specific devel-
of intestinal peristalsis, pupillary dilatation and the opening of opmental topics of particular relevance for psychiatry will be
respiratory passages. It has become increasingly clear that the discussed: attachment and theory of mind.
limbic system, in particular the amygdala, plays an important
role in the perception and appraisal of threat. LeDoux has pro- Piagetian theory
posed that two parallel neural pathways are activated when a
potentially threatening stimulus is encountered: the ‘low road’ Developmental psychology has been hugely influenced by
and the ‘high road’ (LeDoux, 1996). The stimulus is first pro- the work of the Swiss psychologist Jean Piaget (1896–1980).
cessed in the sensory regions of the thalamus, and a ‘glimpse’ Piaget proposed that the mental life of the child is qualita-
of information about the stimulus is shuttled down a short, tively different from that of the adult. He believed that chil-
‘quick and dirty’ route to the amygdala. This triggers the dren were active contributors to their own learning. By acting
amygdala to start to respond to the possible danger/threat. on the environment a child constructs internal structures,
A slower route involves more detailed processing of the stimuli and it is these structures, and not the environment, that con-
by the cortex. If this cortical analysis confirms that genuine trols the way a child thinks. He proposed that all children go
threat exists, additional signals for action are passed down to

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Basic psychology CHAPTER 5

through a fixed series of developmental stages: sensorimotor; abstract thought. The adolescent develops the ability to form
concrete operational (including preoperational) and formal hypotheses to explain unfamiliar phenomena. During this
operational. developmental stage the individual can think logically and can
do so with respect to abstract objects, and is considered to
Sensorimotor stage have reached cognitive maturity.

This stage extends from birth to roughly 18 months. Initially, Criticisms of Piagetian theory
the infant utilises reflex responses such as sucking and grasp-
ing, before gaining more motor control and progressing to initi- Many developmental psychologists would agree with several of
ating his own behaviour. In the first few months of life, in the Piaget’s general claims, such as the propositions that cognitive
mind of the infant, an object only exists as long as it is actively development is influenced by an interaction between biological
perceived, e.g. a toy dropped out of sight no longer exists. and environmental factors, that children play an active role in
However, at around 12 months the object becomes permanent acquiring knowledge and making sense of their world, and
and the child will look for it if hidden. Active experimentation that children’s thinking is sometimes qualitatively different
with objects then commences, for example pressing a toy to from adults. However, some researchers, notably Margaret
make it squeak. Donaldson, have challenged some of Piaget’s views. Donaldson
argued that Piaget underestimated (a) young children’s logical
Concrete operational stage competence and conceptual understanding, (b) the influences
of contextual factors on children’s performance, and (c) the
This stage is thought to extend from about 2 to 12 years of age. extent to which children’s performance depends on their
Piaget proposed that this stage marks the transition between familiarity with the specific contents of the particular task
the literalness of perception and the ability for abstract think- (Donaldson 1978). By way of illustration, the conservation of
ing that characterises the next developmental stage. Between number task described above was repeated by Donaldson,
18 months and 7 years a child is in the preoperational period. however, on this occasion, the transformation (pushing the
During this stage a child begins to represent actions with sym- row of red counters closer together) instead of being carried
bols, which is illustrated by their rapid progress in acquiring out by an adult experimenter was carried out by ‘naughty
language. Similarly, at about 2 years of age children begin to teddy who likes to mess up games’. With this modification,
engage in symbolic play, for example a chair being ridden as many more 4- to 6-year-olds responded correctly that there
a horse. During this period the child is egocentric meaning were still equivalent numbers of red and blue counters.
the child can only describe things from his own perspective. Donaldson argued that in Piaget’s original version of the task
At around age 7 years the child begins to see the perspec- the deliberate nature of the transformation misleads the chil-
tive of other people and also master the principle of conserva- dren into inferring that the action is relevant to the question
tion. Between 7 and 12 years the child enters the full concrete which immediately follows it, and the child misinterprets the
operational stage. For example, in demonstrating the principle question as referring to length (Donaldson 1978). Donaldson
of number conservation, an experimenter lays out a row of six proposed that the young child actively attempts to make sense
red and a row of six blue counters side by side on a table, and of the total situation by attending not only to what is said, but
asks the child ‘are there more red counters or blue counters also to how it is said, and that the child also makes inferences
on the table?’; most children will say that there are the about other people’s intentions (see section on theory of mind,
same number of red and blue counters. Next the researcher below). Donaldson argued that young children are capable of
performs a transformation, such as pushing the red counters logical reasoning, but they are more likely to be able to demon-
closer to each other to destroy the one-to-one alignment with strate this in circumstances where the task makes sense to the
the blue counters (the row of red counters is now shorter child. Several other critics have argued that Piaget seriously
than the blue row). The child is now asked the same question underestimated the capabilities of infants. For example,
as previously. Children younger than 7 years of age typically Gibson and Walk showed that infants as young as 6 months
respond ‘There are more blue counters’ while those over 7 of age could utilise perceptual clues in order to perceive depth
typically reply ‘There are the same number of each’. Piaget (Gibson & Walk 1960). A visual cliff was created using a glass
interpreted this kind of finding as illustrative of the younger table with an apparently solid half (tiling immediately below
child’s inability to reason logically, because of lack of under- the glass) and a ‘cliff’ (tiling several feet below the glass on
standing of general principles such that the number the floor). When mothers were asked to entice their infants
of objects in a set is independent of their spatial layout (but over the visual cliff, very few infants ventured over the appar-
see criticisms below). By 7 years, the child is able to solve ent precipice, suggesting that they had a representation of
problems related to concrete events but has difficulty with depth. Further work also suggests that babies are born with a
abstract thought. predisposition to look at human faces. Johnson and Morton
showed that newborns preferentially look longer at a sche-
Formal operational stage matic face compared with a scrambled face or a blank pattern
(Johnson & Morton 1991). Studies such as these suggest that
This last developmental stage is thought to extend from infants are far more cognitively competent than Piaget initially
12 years onwards. During this phase the child begins to apply proposed.
concrete operations to hypothetical situations, thus showing

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Companion to Psychiatric Studies

Attachment Theory of mind

A safe, secure and loving bond between parent and child As stated above, Piaget proposed that in the concrete opera-
is clearly an important foundation for optimal develop- tional stage of development, children are initially egocentric
ment. We largely learn how to be parents by our own experi- and only at about 7 years can they appreciate the difference
ence as children and by observing others. What type of between another person’s point of view and their own. More
mothers do motherless mothers make? Harlow and colleagues recently, ‘theory of mind’ studies have suggested that children
in Wisconsin conducted a widely cited experiment using rhe- can take the perspective of another person at about 4 years of
sus monkeys (Ruppenthal et al 1976). The experimental age. A theory of mind is the ability to appreciate that minds
monkeys were permitted no contact with their own mothers contain mental states, e.g. beliefs, desires, intentions, and to
from birth. These motherless monkeys gave birth to their use this knowledge to predict another person’s actions. Theory
own babies at 4 years of age. The majority of these monkeys of mind is commonly assessed using tests which evaluate
were totally inadequate as mothers, avoiding and refusing a child’s understanding of false beliefs. For example, two
to nurse the newborns, and intensive care was required by dolls, Sally and Anne, act out a scene: Sally puts a marble
the researchers in order to keep the babies alive. In many cases in a basket before leaving a room and Anne then moves it
the mothers were extremely abusive to their babies, biting and into a box. A child, who watches the scene, is asked where
hitting them. Despite this treatment, the infants persisted in Sally will look for the marble when she returns. Young
attempting to cling to the abusive mothers, sometimes hang- children (3-year-olds and younger) commonly respond ‘in the
ing on the mother’s back where they would be safe from box’, i.e. they refer to the true location of the marble. Older
attack, rather than clinging in front (the normal position children (4-year-olds and above) typically respond ‘in the
for infant monkeys). In a further experiment, Harlow and basket’, i.e. they appreciate that Sally has a false belief
colleagues gave newborn rhesus monkeys the choice of two about the marble’s true location (Baron-Cohen et al 1985).
surrogate mothers; one constructed of wire mesh which This finding has been interpreted as showing that young
mechanically provided milk, and the other covered with cloth children assume that their beliefs are inevitably shared by
but providing no nutrition. The infant monkeys dramatically others, not that beliefs can be true or false and that different
preferred contact with the cloth mother; the wire mother people can have different beliefs. Recently, theory of mind
was only intermittently visited for nutrition. The cloth sur- deficits have been implicated in psychological models which
rogate mother was especially sought when fear-provoking attempt to explain disorders such as autism and schizophrenia
stimuli were brought into or near the cage. Further experi- (Frith 1992; Baron-Cohen 1995).
mental manipulations revealed that rocking cloth mothers
were preferred to stationary ones, and warm cloth mothers Personality
were preferred to cool ones. These animal experiments indi-
cate that maternal neglect and abuse can be ‘learned’ and We all have a basic idea of what we consider ‘personality’
passed on to the next generation, and that warmth and to be, but the precise components of personality are more
tactile contact are critical components of the early mother– difficult to define. Scientists often disagree as to what is the
child bond. definition of personality and what this encompasses. But in
essence what all theories try to do is to simplify and categorise
Subsequent research with human infants has largely sup- aspects of the persona by measurement and assessment.
ported the view that neglect can lead to significant problems
in the later life of the neglected child. Bowlby has been a It has been traditional to categorise personality models into
strong advocate of the view that disturbance of a child’s initial nomothetic or idiographic approaches. The nomothetic approach
attachment to the mother will leave the child less secure in encompasses theories that portray personality in terms of shared
later life (Bowlby 1973). Follow-up studies of children reared attributes, i.e. there are a limited number of variables on which
in inadequate institutional care (such as orphanages which people differ. Within the nomothetic approach there are two
provided nutrition but very little social, physical or emotional main categories: type or trait approaches. Type theories are
care) have shown that many developed significant social categorical in nature, i.e. are non-continuous. An example of
impairments, for example constantly craving attention or, in the type approach within psychiatry is the use of diagnostic
contrast, showing marked apathy towards others (Provence & categories for specific personality disorders: you either have an
Lipton 1962). While early environment is clearly critical in antisocial personality disorder or you do not. The trait approach
terms of learning and socialisation, animal studies also indicate also advocates that there are a limited number of personality
that quality of the early environment directly influences brain variables on which people differ; however, the critical difference
development. Rosenweig and Bennett studied rats that were is the notion that these variables are continuous in nature (akin
either reared in bare surroundings or in a cage that was to individual variation in height and weight). An example of
environmentally enriched (running wheels, apparatus to climb the trait approach is Eysenck’s three dimensions of personality:
on, etc.). After 80 days in the enriched environment, rats had neuroticism, extraversion and psychoticism (Eysenck & Eysenck
developed 23% more neural interconnections than control rats 1975). Theorists who favour the idiographic approach argue that
raised in bare conditions. Evidence such as this indicates that the nomothetic type/trait method loses the individuality of the
the developing brain is markedly influenced by environmental person. For example, two people could have the same scores
stimulation.

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Basic psychology CHAPTER 5

on each of Eysenck’s three dimensions of personality, but be to be, referred to as the ideal self. Congruence between the
viewed by others as quite different people. The idiographic individual’s view of their ideal self and the person’s view
approach considers each individual as unique. Psychodynamic of their real self leads to fulfillment and contentment,
and humanistic theories are examples of idiographic approaches. whist incongruence between the ideal and real self leads to
anxiety and denial.
Idiographic theories of personality
Both the psychoanalytic and the humanistic approaches to
Psychoanalytic approaches personality have received relatively little empirical support.
In contrast more experimental study has been focused on
Psychoanalytic approaches to personality are derived predomi- nomothetic theories of personality.
nantly from the work of Freud, Jung, Horney and Erikson.
These theories emphasise the unconscious. Freud originally Nomothetic theories
proposed that personality was structured into three parts:
the unconscious, the preconscious and the conscious. In this Type theories
model he suggested that material that has been relegated to
the unconscious (repression) originated from the preconscious Type theories seek to identify personality categories. This
or conscious, and should be accessible. However, he later approach to personality is by no means new, and dates
revised his theory in the light of his observation that his back at least to Galen’s description of four temperaments
patients had no conscious awareness that they were repressing (sanguine, choleric, melancholy and phlegmatic) based on
material. He therefore reformulated his theory in terms of Hippocrates’ four humours. More recent examples of type
three constructs: the id, the ego and the superego. According approaches to personality include Type A and Type B Person-
to this theory the id consists primarily of unconscious sexual ality Theory (Rosenman & Friedman 1974). According to this
and aggressive instincts. It operates according to the pleasure theory individuals with Type A personality were considered to
principle, with the aim of maximising pleasure and minimising be excessively time-conscious, insecure about their status,
pain. The id is held to be the original aspect of personality highly competitive, hostile and aggressive, and incapable of
rooted in the biology of the individual. The ego develops as relaxation and were considered to have a higher risk for cardio-
the individual grows and serves to balance the unconscious vascular disease (Rosenman & Friedman 1974). This theory
demands of the id with the realities of the external world. has, however, been subsequently criticized on the grounds that
It is rational, pleasure-delaying, problem-solving and provides these personality features are not highly correlated, and are
direction for the person’s impulses. The superego represents not strongly predictive of heart disease. A further type theory
the internalization of societal or moral values. These come of personality in common use is that used in the diagnostic
particularly from the parents and from authority figures. Freud classification of personality disorders in Diagnsotic and Statis-
suggested that these elements develop through five stages tical Manual of Mental Disorders (DSM-IV) and International
of psychosexual development through which children pass in Statistical Classification of Diseases and Related Health
specified order. The specific stages proposed were the oral Problems (ICD-10).
stage (0–1 years), the anal stage (1–3 years), the phallic stage
(3–5 years), the latency stage (5–12 years) and the genital Trait theories
stage (12–20 years). Disruption of development at any of
these stages was hypothesised to lead to specific later person- Trait theories of personality are based on the assumption that
ality characteristics, such as obsessive–compulsive traits there are a number of stable dimensions to personality which
related to a failure of development at the anal stage. can be assessed across subjects. These personality dimen-
sions are typically rated using standardized questionnaires.
Humanistic approaches A number of trait models of personality have been proposed,
each comprising different dimensions. Ideally personality traits
Humanisitic approaches to personality emphasise our potential should be shown to be replicable, stable over time, present
for growth and development, and see people as naturally striv- across different cultures, heritable and related to underlying
ing to be creative and happy. Many proponents of humanist biological or physiological factors (Costa & McCrae 1992a).
approaches suggest that there is a tendency towards ‘self-
actualisation’ where the individual is able to satisfy the needs One of the most influential trait theories of personality
of the self-concept, and therefore be well adjusted. Two of is that derived by Eysenck (Eysenck & Eysenck 1975) who
the major theorists in this area are Abraham Maslow (Maslow initially postulated two main dimensions of personality,
1968) and Carl Rogers (Rogers 1951). Maslow emphasized neuroticism (N) and extraversion (E), later adding the third
a hierarchy of needs which must be satisfied in order to reach dimension of psychoticism (P). These factors are assessed
‘self actualization’. Lower level needs, such as basic drives in the Eysenck Personality Questionnaire (EPQ). One of
for food and sex, must be satisfied before higher levels of per- the EPQ’s greatest strengths is the almost complete separation
sonal development can be obtained. Rogers believed that we of the extraversion, neuroticism and psychoticism scales fol-
all innately seek to develop in the direction of maturity and lowing factor analysis. These factors are common to most of
positive change. A key concept in Rogerian theory is that the well-known personality questionnaires (Kline & Barrett
we all have a perception of the kind of person we would like 1983) and can be found across cultures (Barrett & Eysenck
1984). These scales have been replicated many times.
One criticism is that the three factors are broad. In addition
the psychoticism (P) scale is not normally distributed and is
very much skewed towards zero, particularly in females, and

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Companion to Psychiatric Studies

has low internal consistency. A revised scale, the EPQ-R, has specificity of these traits is low, and the biological basis of
gone some way towards addressing these issues (Eysenck HA, RD and NS has not been fully substantiated.
et al 1985).
Personality and mood
More recently, a number of investigators have conducted
extensive factor-analytic studies and proposed that five dimen- There are relationships between personality and mood in both
sions are required in order to describe an individual’s personal- healthy volunteers and patient populations. Neuroticism corre-
ity structure accurately (Norman 1963; Costa & McCrae lates positively with negative mood and extraversion correlates
1992a). The main factors derived from this approach are neu- positively with positive mood in healthy volunteers (Costa &
roticism, extraversion, openness, agreeableness and conscien- McCrae 1980; Furnham & Brewin 1990; Kardum & Hudek-
tiousness (Table 5.1). It is proposed that the richness of each Knezevic 1996; Wilson & Gullone 1999). Neuroticism scores
individual’s personality can be described in terms of relative are higher in patients with depression and in patients in remis-
placement on each of these five major dimensions of personal- sion from a depressive episode than in healthy controls (Roy
ity. Many studies using many different methods and question- 1990; Young et al 1995; Hecht et al 1998; Hansenne et al
naires, conducted across different cultures, have generally 1999). High neuroticism scores predict depression in previ-
found these same basic dimensions of personality. There has ously never ill controls (Hirschfeld et al 1983; Hirschfeld
been a growing consensus that these five dimensions provide et al 1989) and are related to a lifetime prevalence of depres-
an economic method for describing a wide variety of individual sion (Kendler et al 1993). Some researchers feel that extraver-
differences. The ‘Big Five’ dimensions of personality can be sion is a protective factor against depression and this may be
measured using questionnaires such as the NEO Personality due to the correlations between extraversion and number and
Inventory (Costa & McCrae 1992b). quality of friendships.

A third trait model of personality is Cloninger’s Tridimen- Diathesis-stress models
sional Model (Cloninger 1986, 1987). Cloninger proposed a
biological model derived from animal research, in which he Differences in personality traits represent a component of the
suggested that three personality traits – harm avoidance variation between individuals in vulnerability to psychiatric
(HA), reward dependence (RD) and novelty seeking (NS) – disorder. Individuals differ quite markedly in their propensity
are heritable and that they relate to the monoamine systems to develop psychiatric conditions following similar stressors.
– serotonin, noradrenaline and dopamine, respectively. To For example, following extreme trauma, some individuals
these ‘temperament traits’ Cloninger later added ‘character may develop conditions such as PTSD, whereas others who
traits’ which reflect acquired features of the personality have experienced exactly the same stressor do not. How is
including self directedness (SD), cooperativeness (C) and this explained? The diathesis-stress model posits that a pre-
self-transcendence (ST). These traits are assessed using the existing vulnerability (diathesis) renders an individual more
Tridimensional Personality Questionnaire (TPQ) and certain susceptible to particular diseases. Diathesis-stress models
combinations, such as high HA and low NS and SD, have been have been proposed for a number of psychiatric conditions,
related to higher vulnerability for psychiatric disorders such as including psychosomatic disorders such as gastric ulcer,
depression (Cloninger et al 2006). However the predictive myocardial infarctions and eczema, and conditions such as
schizophrenia and certain types of severe depression. In these
Table 5.1 The ‘Big Five’ personality dimensions disorders, the interaction between a vulnerability and some
form of physical or psychosocial stress forms the central part
Factor name Scale dimensions of the model.

Extroversion Talkative/silent Diathesis-stress models are now commonplace, not only in
Agreeableness Adventurous/cautious the biomedical approach, but in a range of psychological and
Conscientiousness Sociable/reclusive social models also, though the diathesis or vulnerability factor
Neuroticism is expressed at a psychological (e.g. sensitivity to the experi-
Good-natured/irritable ence of loss) or social level (e.g. a lack of social support from
Not jealous/jealous other individuals) rather than at a physical level. A good illus-
Cooperative/negativistic tration of this is the work of Brown & Harris in relation to
social factors and risk of depression (Brown & Harris 1978).
Fussy, tidy/careless They proposed that certain vulnerability factors (lack of a
Responsible/undependable confiding relationship, loss of mother before age 11, more than
Scrupulous/unscrupulous three children younger than 15 years at home, unemployed
status) rendered women particularly at risk of depression in
Poised/nervous, tense the face of certain severe provoking factors (life events)
Calm/anxious such as deaths, illness/accidents to significant others, job or
Composed/excitable residence change (Fig. 5.3).

Openness to experience Artistically sensitive/artistically insensitive
Intellectual/unreflective, narrow
Imaginative/simple, direct

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Basic psychology CHAPTER 5

Summary and conclusions

With diathesisMorbidity In this chapter we have sought to outline key principles of
psychology of relevance to psychiatry, from basic processes
No diathesis involved in learning and attention to the higher order pro-
perties of cognitive development and personality. We have
Stress focussed on areas of psychology where experimental analysis
Fig. 5.3 Diathesis-stress model. Individuals who have the diathesis, has produced replicable findings as we believe that these form
or vulnerability, show greater morbidity in the presence of stress an important and reliable basis for the understanding of mental
than those who have not. illness. A major goal for future research is to link aetiological
processes associated with mental illness to abnormalities in
specific psychological processes to develop an account of the
development of the symptoms of psychiatric illnesses.

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Social and transcultural aspects of psychiatry 6

Benjamin J Baig

Introduction Social psychiatry

Future generations may view the 21st century as a golden age Social psychiatry relates to the use and understanding of the
for biological psychiatry. The advent of the human genome, discipline of sociology of mental health and mental illness.
increasingly sophisticated neuroimaging techniques and a Here, the main sociological theories in psychiatry will be dis-
greater understanding and applicability of psychopharmacology cussed followed by aspects of the sociology of psychiatric
have led to a proud biological narrative of mental illness. practice.

That schizophrenia was once described as ‘a sane response Sociological theory in psychiatry
to an insane society’ is a maxim left refuted and redun-
dant thanks in part to the advances of science (Laing 1960). The application of sociological theory to psychiatry and mental
Movements such as ‘antipsychiatry’ may be anachronistic in health derives from significant sociological theorists of the
all but extremist followings. The stigma of mental illness 19th and 20th centuries. The relationship between society
has been greatly challenged by biological explanatory models and mental health can be broadly understood in three ways
of disease. Psychiatrists hail the ‘medical model’ as a cause by sociologists, each with a different notion of the ‘social’:
celebre when challenged by alternate ways of working (Shah & • The mental health of people is partially or wholly caused by
Mountain 2007).
societal influences (social causationism)
It is in this context that we must question the importance • The mental health of people is socially negotiated (labelling
of social and cultural factors in clinical psychiatry. To what
extent do such factors affect the shape of mental illness both or social reaction theory)
generically and in clinical practice? Indeed, what should the • Mental health and illness are socially constructed (social
modern psychiatrist know about social and transcultural psy-
chiatry, what place have they in understanding mental illness constructionism)
and how do they affect clinical practice?
Social causationism
This chapter will look at social and transcultural models of
psychiatric illness. Here a ‘social’ model will refer to major The social causationist paradigm accepts that mental illness is
sociological theories which may shape psychiatry. Trans- a valid concept and looks at which social factors may cause
cultural will be taken to mean how differences within and aspects of mental illness. Here membership of particular social
between cultures may lead to different understandings and groups makes people vulnerable to mental health problems. An
interpretations of mental illness. In both cases attention will example of this approach was Durkheim’s study of social con-
be paid to how these factors affect epidemiology, aetiology, ditions which would generate high rates of suicide. Durkheim
clinical presentation, prognosis and treatment of mental illness. (1952) argued that the type of explanations of suicide which
The sociocultural effects on psychiatric practice will also be focused only upon inner emotional experiences or personal
discussed as well as descriptions of key terminology relating
to sociological theory and medicine.

ã 2010, Elsevier Ltd.
DOI: 10.1016/B978-0-7020-3137-3.00006-1

Companion to Psychiatric Studies

reasons were inadequate. Since suicide rates remained rela- study based on social ecology, Mental Disorders in Urban
tively stable in any given society from year to year, he con- Areas, was published by members of the Chicago School (Faris &
cluded that suicide had an existence external to any one Dunham 1939). In exploring the influence of poverty and depri-
instance of it. It was therefore possible to think of suicide as vation, the authors contrasted the prevalence of manic-
a ‘social fact’ which needed to be explained in terms of other depressive psychosis, which appeared to be randomly
social facts. Known as a structuralist approach, two broad distributed across the city of Chicago, with that of people
conceptualisations have underpinned the study of social diagnosed with schizophrenia, who were found predomi-
inequalities and mental health: social stratification and social nantly in poorer areas.
class (Muntaner et al 2000). Social stratification studies use
measures of inequalities, which focus on disparities in social Gender
resources such as years of education, occupation and income
(Bartley et al 1998). Thus it is possible to state that different The findings of community studies have been used to suggest
social strata or different social class conferred different risks that women experience relatively high rates of depression
of completed suicide. Social strata or class could be said to and other psychiatric disorders compared with men. Signifi-
partly cause the ‘social fact’ of suicide. cant work has focused on the higher rates among married
women than men, and a number of studies since have identi-
Psychiatric illnesses display many social fied differences in female rates compared with male rates
causal factors (Gove 1972; Kessler et al 1994). Gender differences have
been attributed to a range of social, familial, personal and mea-
Social class surement artefact explanations. One of the most consistent
findings is of a greater female prevalence of depressive dis-
Mental health is positively correlated with social class. The order and ‘non-specific’ psychological distress which has been
poorer people are, the greater the chances that they will explained with reference to adverse experiences in childhood
be diagnosed as being mentally ill. The correlation indicates and adolescence, sociocultural roles and psychological attri-
the increased probability of mental health problems with butes which predispose individuals to negative life events
decreasing socioeconomic status. Social causationists argue (Nazroo et al 1998).
that greater exposure to the environment and social stressors
associated with poverty increases the incidence of mental Race
health problems. By contrast, the social selection theory sug-
gests that social class is affected by mental disorder. That is, Mental health is racially patterned. Estimates from the UK
mentally ill people ‘drift’ into poverty because their illness suggest that the annual prevalence of hallucinations is higher
makes them socially incompetent. Some evidence suggests in Caribbean than in south Asian or White populations. This
that the validity of the different causal explanations may vary variation is accounted for with reference to cultural differ-
according to the type of mental health problem under investi- ences in experience and is not seen as invariably associated
gation. Social causation may be stronger than social selection in with psychosis (Johns et al 2002). In general terms, the racia-
explaining the inverse association of socioeconomic status to lisation of psychiatric provision reflects continuing disadvan-
severe depression in women, substance abuse and antisocial tages that were rooted in slavery, enforced migration,
personality in men; but, for those who carry a diagnosis of colonialism and racial discrimination. For example, in Australia,
schizophrenia, social selection may be a more relevant explana- aboriginal people are over-represented in psychiatric popula-
tion (Dohrenwend et al 1992). Social class tends to refer to tions. In the USA, Black, Hispanic and Native American
people’s class locations originating from ownership and control groups are over-represented. In England, Irish and Afro-Caribbean
over different types of assets (e.g. property organisation and people are more likely to have mental health problems.
credentials). Occupational status was originally based on the
1911 Registrar General’s Classification of Occupations using Age
a classification of:
The relationship between age and psychiatric illness can be
(i) higher professional and managerial described extensively through a biological paradigm. However,
while the biological effects of ageing give some explanation for
(ii) lower professional, technical and managerial illnesses, the emergence of self harming and aberrant eating
behaviour amongst adolescents and young adults may relate
(iiin) skilled non-manual workers and clerical workers more to sociological factors. Even illnesses such as dementia
can have socially related roots. While the age-related incidence
(iiim) skilled manual workers of dementia is generally deemed to reflect an amplification of
neurological deterioration, the severity of symptoms in
(iv) semiskilled workers dementia is correlated with social stimulation and with earlier
educational experience (Wang et al 2002).
(v) unskilled workers
Living situation
Traditional ‘structural’ approaches to mental health inequal-
ities, such as the community studies of the impact of the envi- There exists utility in examining the interaction of structure
ronment on mental health conducted in the 1950s and 1960s and agency in relation to specific policy and environmental con-
(e.g. Hollingshead & Redlich 1958; Myers & Bean 1968), texts. With regard to this latter point, there is some evidence
suggested links between social conditions and disadvantage that the contextual effects of neighbourhood disadvantage on
(e.g. unemployment, poverty and racism) and psychiatric mor-
bidity. At the outbreak of the Second World War, a prominent

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adult psychological well-being are mediated by people’s per- stressors as mental health-promoting strategies. It can be
ceptions of localities (particularly urban ones) as chaotic and shown that placing former patients in a work environment
threatening places. People living in ‘socially disorganised’ local- with training can decrease their propensity to readmission to
ities are more likely to be exposed to ‘ambient hazards’ and hospital (Burns et al 2007).
experience psychological distress because of uncontrollable life
events and psychosocial insults. They are more likely than Social reaction or labelling theory
others to be affected negatively by stresses such as unemploy-
ment, family disruption, violence and crime, and to have fewer The social reaction or labelling theory paradigm emphasises
supportive relationships. A study of an inner-city area of that mental health is socially negotiated.
Manchester found that higher symptoms scores are associated
with less neighbourliness/security, fewer leisure opportunities, Social reaction theory emanates from a version of sociology
and a sense reported by residents that their area is in decline called ‘symbolic interactionism’ where emphasis is placed on
(Huxley & Rogers 2001) There is also some indication that the socially adopted roles of individuals. A failure to act appro-
the mental health of the population can be improved by priately in a role becomes a critical point of understanding for
improvements to housing and the local area. For example, those involved. Labelling theory was developed in relation to
re-housing on the grounds of mental health has been shown mental illness by Thomas Scheff. Scheff argued that behaviour
to impact favourably on anxiety and depression (Elton & Packer commonly thought of as symptomatic of mental illness should
1986). Provision of financial resources and reconstruction of be seen as a form of deviance, and chronic mental conditions as
housing has been found to make a critical difference to recovery a distinctive social role. According to Scheff, societal reaction
from mental health emergencies that arise from major disrup- to the breaking of ‘residual rules’ was ‘the single most impor-
tion to or destruction of living environments (Wang et al 2000). tant cause of careers of residual deviance’ (1966: 92–93).
Residual rules were ‘numerous and unnameable’ acts that
Social stress cannot be placed into clear-cut categories but were taken-
for-granted unspoken rules of social interaction. Under most
The psychosocial perspective refers to a number of related circumstances acts of residual deviance are ignored by others,
approaches which place greater emphasis on precipitating than and it is only under certain circumstances that they are noted
on predisposing factors, and upon attempting a reduction of publicly.
the prevalence rather than the incidence of mental health
problems. The concept of stress provides a means of linking Social reaction theorists emphasise that in certain situations
aspects of an individual’s social situation with the occurrence rule breaking is accepted, ignored or ‘normalised’, whereas at
or reoccurrence of mental ill health. The term ‘stress’ refers other times it is labelled as deviant. For instance, during a
both to the characteristics of a person’s circumstances (e.g. period of grief, a bereaved person may not eat or sleep, wear
‘stressors’, ‘life events’, ‘stress situations’) and responses that sombre clothing and be tearful. However, if such behaviour
people make to those circumstances (‘stress reactions’). Social exists without an obvious social stressor this behaviour would
stress theorists are also concerned with the distribution and be seen as deviant. Once action is taken in the wake of this
deployment of coping resources (social support, self-esteem, labelling it sets in chain a process of negotiation about a deviant
a personal sense of control) and strategies (behavioural and role. Under these circumstances, the labelled person starts to
cognitive devices to manage external and situational demands) take on the role of being a mentally ill person. This role is
among different groups in the population. maintained by the views of others and the new identity that
the mentally ill person ascribes to herself.
One of the most sophisticated developed theories of
negative stressors is the life events model which encompasses The methodological emphasis of labelling theorists, as their
the work of George Brown and his colleagues in relation to name implies, is on investigating the process and consequences
depression (Brown & Harris 1978). Here, the Brown and of labelling. Rather than what caused people to act oddly in
Harris model of depression holds that certain ‘vulnerability the first place (primary deviance), their main interest is in
factors’, namely early maternal loss, lack of a confiding rela- how symptoms become diagnosed as mental illnesses so that
tionship, more than three children under the age of 14 at the person takes on a deviant role (secondary deviance). The
home and unemployment, are social risk factors for affective answer given is in terms of contingencies. That is, the same
illness. behaviour will be ignored in some circumstances, whereas in
other circumstances it will provoke concerns and the need
Implications for clinical psychiatry for expert help. The transition between these two sets of
circumstances can be linked to either a one-off crisis or a series
The social causationist paradigm is highly relevant to clinical of gradual shifts.
psychiatric practice. While genetics and altered neurotransmit-
ter metabolism may be relevant to the aetiology of any psychi- Labelling theorists have pointed out that a deviant role can
atric illness, it is clear that social causes play an important role. emerge either rapidly or following a lengthy period when
The ability of the psychiatric practitioner to address social oddity is present but a problem is denied. For example, in
aetiology will allow the modification of social risk factors in one study it was found that the partners of men eventually
the construction of a valid management plan. Social psychia- diagnosed as schizophrenic ignored or rationalised symptoms
trists have looked at the use of work placements, the improve- for varying periods of time before they sought professional
ment in housing conditions and the alleviation of social help, in order to maintain the men in ascribed masculine roles
(Yarrow et al 1955). This picture is consistent with the

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findings of community surveys that the prevalence of symp- sick. ‘Being sick’ is not simply a ‘state of fact’ or ‘condition’,
toms exceeds the incidence of formal diagnosis (‘the clinical it contains within itself rights and obligations based on the
iceberg’). More recent evidence suggests that auditory halluci- social norms that are associated with it. When adopting the
nations are widespread in community samples, and that voice sick role, the sick person is exempt from normal social roles
hearers who have not been diagnosed as suffering from schizo- and the sick person is not responsible for their condition.
phrenia have various ways of living with the experience In addition, when the sick role is adopted the sick person should
(Epstein et al 2002; Jones et al 2003). try to get well and they should seek technically competent help
and cooperate with the medical professional.
Of great interest to labelling theorists are the circumstances
under which primary deviance is confirmed and amplified by Implications for clinical psychiatry
contact with professionals and lay people. Relatives or other
‘significant others’ change from tolerating, denying or ignoring A clear implication for psychiatry of social reaction theory is to
problem behaviour and begin to acknowledge its existence. understand why and how patients present to mental health
Those who are more relationally distant are more willing to services at a certain point in time. Prodromal schizophrenia
identify and attach a label of mental illness. Mental illness is (a primary deviance) may be present for a considerable time
recognised in families before professionals are invited to rub- before relatives, friends or non-healthcare professionals usher
ber stamp this lay decision-making. The combination of label- the patient towards services (secondary deviance). Different
ling from professionals and significant others defines the societies will have different thresholds for presentation of
deviant person in a new role: of psychiatric patient. The final prodromal illness.
phase of the process entails the labelled person accepting or
internalising the ascribed deviant identity. Mental hospitalisa- The acceptability of physical health symptoms as opposed
tion strips them of their old identity in what Goffmann calls to mental health symptoms can often lead to the expression
a ‘status degradation ceremony’ and is replaced by a new iden- of distress through the physical manifestation of anxiety symp-
tity and social role. Being a patient can then become a ‘career’. toms seen as a primarily medical problem. Here it is social
factors which may promote physical ill health as being more
While generally a deviant role takes a while to emerge and acceptable than mental health.
to be confirmed and internalised, there has been some experi-
mental evidence that it can occur very rapidly. For example, A third tier of implication for mental health professionals of
in one study, confederate ‘pseudo-patients’ were admitted this theory relates to patients who are chronically maintained
to psychiatric facilities by presenting with isolated auditory within health services. The so-called ‘professional patients’
hallucinations. In all other respects the confederates did not may be an example of self labelling. The work of Goffman
act oddly once admitted. Despite this, the psychiatric staff led to an acceptance of the effect of institutionalisation and
treated them as if they were mentally ill and reframed their an eventual move towards non-hospital-based care. The need
actions in this light. For example, when the confederates were for both patients and professionals alike to avoid labelling
seen keeping field notes, their actions were recorded as mental illness as an identity has led to increased social capability
‘indulges in writing behaviour’ (Rosenhan 1973). following a process of deinstitutionalisation.

The popularity of labelling theory as propounded by sociol- Social constructionism
ogists such as Thomas Scheff has declined in part because
supporting empirical evidence is weak and because of the One of the most influential theoretical positions evident in the
ambiguity of key concepts upon which the theory rests. sociology of health and illness in recent years has been social
For example, the way in which residual rules are defined lacks constructionism.
precision, and social reaction is applied in an overly determin-
istic way. Nonetheless, aspects of labelling theory still retain • Social reality is problematised to some degree
relevance in the arena of mental health. There is certainly • Scientific and other realities are viewed wholly or partly as
strong evidence that being in an institutional setting both
induces oddity and socially disables residents. Also, the ascrip- a product of human activity
tion of psychiatric deviance is commoner in social groups that • Power relationships are inextricably bound up with the
are relatively powerless. However, these findings need to be
set against others. Moreover, the confederates in the experi- ways in which reality is defined
ment noted above did not, once the study was over, continue
to act oddly because they had taken on the role of a psychiatric In relation to the field of mental health, the social construc-
patient and been confirmed in this role by the staff. tionist position is interested in the categories used to describe
or account for primary deviance. It is concerned with under-
The ‘sick role’ was a concept described by Talcott Parsons standing the ways in which concepts, constructs or representa-
in 1951. Parsons argued that being sick means that the sufferer tions about mental health emerge as products of communal
enters a role of ‘sanctioned deviance’. From a functionalist exchange between social groups. There is a particular empha-
perspective, when sick you are not being a productive member sis within this approach on analysing dominant professional
of society. Therefore, this deviance needs to be sanctioned, representations and the interests that are served by them.
which is the role of doctors and other medical professionals. The method of investigation associated with social construc-
tionism is deconstruction or discourse analysis. Accordingly,
The sick role concerns the social aspects of falling ill. Here, social constructionists emphasise that reality (about mental
the individual who has fallen ill is not only physically sick, but health or anything else) is socially constructed and thus bound
now adheres to the specifically patterned social role of being up with the material and cognitive interests of social groups.

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The social constructionist is interested in examining how As a consequence, there is no independent way of validating
variations in human experience and conduct come to be repre- the diagnosis. It has the same explanatory value as the notion
sented as illness categories and how diagnoses inscribe a of evil. Given that evil has been medicalised, the decon-
version of reality on some people but not others. structionist would be interested in the social history of this
professional interest in certain types of antisocial action.
Some examples from social constructionism
These are some specific examples of how psychiatric diag-
Social constructionists researching mental health have made noses might be understood within a social constructionist
two main critical points. The first is that concepts (or con- framework. Some deconstructionists, like Szasz, have argued
structs) that are fragile, incoherent, illogical or invalid may still that the whole body of knowledge that follows from a commit-
survive or may even be actively promoted in society. The ment to the notion of mental illness has arisen in order to
second point they make is that constructs serve the interests ensure the individual and collective advancement of psychiat-
of the social groups utilising them (e.g. mental health profes- ric professionals and to protect the social order. In this way,
sionals, relatives of identified patients, drug companies). Some he argues, professional knowledge, professional advancement
examples from the field of mental health are given below. and social control are intimately entwined.

Constructionists problematise the factual status of mental Implications for clinical psychiatry
illness (e.g. Szasz 1961). They analyse the ways in which men-
tal health work has been linked to the production of psychiat- The social constructionist viewpoint, while undoubtedly
ric knowledge. Schizophrenia has the status of an illness and unpopular in contemporary psychiatry, has several important
yet the diagnosis lacks both conceptual validity and reliability. if uncomfortable implications. The advent of evidence-based
Two people with different symptoms can both be diagnosed as practice has led physicians where possible to use high-impact
schizophrenic — it is a disjunctive construct. Despite large well-validated controlled trials as a bedrock of sound practice.
amounts of research funding over the past hundred years for It must be noted that the visibility of published research
investigations that have tested a variety of environmental and relates more often to positive rather than negative findings.
biological hypotheses, the aetiology of the disease remains Pharmaceutical companies will release data which supports
highly contested. There is no biological marker (analogous the efficacy of their products and may withhold the corollary.
to a blood test to diagnose diabetes) for schizophrenia. One Thus, the social reality of drug efficacy is subject to the eco-
possible explanation for the continuation of a weak construct nomic reality of the pharmaceutical industry. Pharmaceutical
is the role it plays in supporting the mandate of psychiatry in companies may seek drug licenses for specific disorders (such
society and the comfort it gives to the relatives of mad people. as social phobia) which in turn may validate the social reality
of such disorders. Psychiatry is perennially subject to debate
Agoraphobia emerged at the time when the social emanci- about the validity of diagnoses such as ADHD and chronic
pation of women became a possibility. For this reason the fatigue. The prevalence of these diagnoses varies widely among
meaning of the condition can be understood as part of a con- societies and leads to the question about whether they repre-
text that problematised the use of public space, not just as a sent a social necessity to describe aberrant behaviour in a
set of symptoms within its individual sufferers. Here de palatable fashion. Much debate in psychiatry in recent years
Swann (1990: 144) makes this point: has related to whether psychopathy or antisocial personality
disorder should be seen within a psychiatric or criminal justice
Women appearing in the streets alone had to be women who went to framework. Here, it is not the presence of atypical biology
work out of necessity, women whose husbands could not provide for which drives the debate but the political and economic reality
their families single handedly; such women could not possibly be of the situation. Homosexuality was previously seen as falling
decent. Once this line of demarcation had become established, it also under a psychiatric umbrella but due to the social shift in per-
came to imply a licence for men to allow themselves impertinence ception it no longer is. Paedophilia may yet be incorporated
towards women who appeared in public unaccompanied. Thus, into a psychiatric framework. In both of the above cases it
a woman could not afford to go out on those streets. . .. is sociology, not biology, which drives the workload of the
clinical psychiatrist.
The way in which psychiatric knowledge about women is
generated is, according to some feminist scholars, imbued The sociology of psychiatric practice
with sexual role stereotypes and notions of female inferiority.
These points are made contentiously in the work of Ehrenriech Professionals and interprofessional relationships
and English. Their key argument is that male doctors have
historically defined women’s problems as illness or sickness Attempts to understand mental health professionals have
and have promoted a notion of femininity which itself is drawn upon a number of theoretical strands from within the
viewed as pathological. This combination has resulted in sociology of the professions.
female dependence on male experts and in lives of inactivity.
Some sociological theorists (Durkheim, Talcott Parsons)
Like schizophrenia, the concept of psychopathy is incoher- have viewed professional groups as providing a disinterested
ent because it covers so many people who have different symp- and integrative societal function. From this perspective profes-
toms but can share the same label and has no biological marker. sions are a source of community for one another and stability
The definition is inevitably circular. People are deemed to for the wider society they serve. They regulate their own
be psychopathic because of their antisocial acts and their
antisocial acts are explained by the actor’s psychopathy.

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Companion to Psychiatric Studies

practices and practitioners (through, for example, ‘peer Interprofessional relationships
review’) and ensure good practice through the setting of codes
of conduct and punishing errant colleagues. Followers of this The shifting location of mental health services has had a major
approach to the sociology of professions have tended to take impact on how professionals organise their work and the way
claims of special knowledge and altruism at face value and in which they relate to patients and each other. The territorial
have focused on categorising professions in terms of traits base of the asylum and hospital has to a large extent been
and descriptions of their work. replaced by the need to negotiate one-to-one relationships in
a domestic or community context. Mental health workers have
However, other theorists (such as Weber) stress the devel- been faced with the need to change their working practices
opment of professional strategies to advance their own social and the way in which they interact. In particular, work outside
status, persuade clients about the need for the service they the hospital has brought with it a philosophy of multidisci-
offer and corner the market in a service sector in a way that plinary working, which had already operated, in theory at least,
excludes competitors. From this perspective two aspects are in inpatient settings. The basic tenets of multidisciplinary
particularly noteworthy: collective social advancement rests working are:
upon social closure, and professionals exercise power over
others through professional dominance. Social closure refers • that each member of the mental health team has special
to a situation where a monopoly is gained to work in a skills to contribute to the management of patients
specialised way with a particular group so that other occupa-
tional groups seeking a similar role are excluded. In order for • that these are contributed in co-operation and liaison with
professionals to maintain their social status they must convince other mental health workers
those outside their boundaries that they are offering a unique
service, and as a consequence they develop various rhetorical • that this leads to the establishment of corporate consensual
devices to persuade the outside world of their unique and goals in delivering a service
special qualities. To do this they need to justify a peculiar
knowledge-base that has a technical rationality that is not Multidisciplinary working is to produce a ‘seamless’ service
easily understood or deployed by competitors. across primary, secondary and community care sectors. How-
ever, there are suggestions that rather than entailing mutuality
Professional dominance refers to the exercising of power and cooperation, interprofessional relations are characterised
over others in three senses: by defensiveness, lack of role clarity and conflict. Much of
the conflict centres on bids for professional dominance or
• Professions have power over their clients. An imbalance autonomy. For example, clinical psychologists have developed
of specialised knowledge keeps the user in a state of a training and consultancy role, seeking higher levels of remu-
ignorance, insecurity and vulnerability. This imbalance is neration, adopting medical titles (‘Consultant Psychologist’)
reinforced by the tendency of professionals to operate and accepting direct referrals from GPs. Psychiatric nurses
within their own territory rather than that of their clients now have more therapeutic skills which can be viewed as a
(e.g. treatment in hospital rather than in the client’s means of countering claims of uniqueness of skills made by
own home). the other main groups of mental health workers.

• Professionals exercise power over their new recruits This debate has been rekindled recently by those question-
(e.g. trainees are dependent on their superiors for career ing the future role of psychiatrists upon the 200th anniversary
progression). of the coinage of the term psychiatry. Concern has been raised
by many eminent British psychiatrists about the role of the
• Professionals seek to establish a dominant relationship profession. The importance of strong diagnostic assessment
over other occupational groups working with the same and the role of a psychiatrist as the leader in the clinical team
client group. have been greatly emphasized in this debate. While such
discussion has not sought to undermine the importance of
Authors such as Scull point to the segregation of the mad in multidisciplinary working, there has been vehement defence
the 19th century and delegation by the State of powers to of the medical model in relation to the model of distributed
the medical profession to keep madness under control. The responsibilities and leadership (Craddock et al 2008). It can
role of psychiatrists is seen as one of social control employed be questioned whether such a debate echoes the need for
by the State to contain the threat of one section of a poor professional dominance as described above.
underclass – the mad. Scull also makes use of the notion of
closure when explaining the dynamics of how doctors purged The asylum system
lay administrators from the asylums and sought upward mobil-
ity for themselves. Modern professions are not simply the During the 19th century in Europe and North America, most
dominant or most important providers of a particular service; countries developed centrally regulated asylum systems. The
instead they effectively monopolise a service market. emergence of large asylums in most localities was associated
with the need to control non-productive deviance in increas-
During the 19th century, mad-doctors manoeuvred to ingly urbanised and complex capitalist societies. The mentally
secure such a position for themselves and acceptance of their ill were ‘warehoused’ in asylums to remove their negative
particular view of the nature of madness, seeking to transform impact on socioeconomic order and efficiency, just as orphans,
their existing foothold in the marketplace into a cognitive the physically sick and the elderly were placed in poorhouses.
and practical monopoly of the field, and to acquire for those Professionals at that time took little or no interest in sane peo-
practising this line of work the status ‘owed’ to professionals ple who were frightened or sad (the neuroses). This changed
(Scull 1979:129).

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Social and transcultural aspects of psychiatry CHAPTER 6

after the First World War, when the ‘shell shock’ problem Transcultural psychiatry
altered the focus of professional interest. Warfare ensured that
stress-induced problems, later to be called ‘battle neurosis’ The term ‘transcultural psychiatry’ was first coined in 1956 at
or ‘post-traumatic stress disorder’, recurringly shifted pro- McGill University by a group of psychiatrists and anthropolo-
fessional attention away from madness and towards neurosis gists. While the term ‘cultural psychiatry’ may also be pre-
during the 20th century. This also expanded the range of inter- ferred, this chapter will take transcultural psychiatry to mean
ventions offered or preferred by professionals to include talk- cross-cultural aspects of mental health and illness. Interest in
ing treatments. As a result, psychiatric treatment became transcultural psychiatry has increased due to several important
more eclectic, although it remained dominated by biomedical geographical and social factors. The increase in migration
interventions. between developing and developed countries has seen new
and varied ways in which mental illness may present. The
During periods of peacetime, the focus on madness influx of both Asian and Afro-Caribbean populations into
returned, along with biological treatments in institutional set- Europe has necessitated clinicians to be aware of important
tings. After the Second World War, the old asylum system clinical and social differences in how patients should be man-
came into crisis for a number of reasons: aged. The acceleration in economic development and conse-
quent development of mental health services in low and
• The expansion of the remit of psychiatry and its associated middle income countries has given necessary credence to a
professions to include talking treatments with neurotic broader view of the definitions of mental illness. The inclusion
patients in community settings, increased expectations that of culture-bound syndromes in the Diagnostic and Statistical
mental health services should shift away from biomedical Manuel of Mental Disorders IV (DSM IV 1994) is an example
treatments inside institutions. of how a previously globalised view of diagnosis requires
modification. Lastly, an increasing sensitivity to ethno psy-
• In the wake of the widespread cultural shock of the Nazi chopharmacology must lead clinicians to an awareness of
concentration camps, Western liberal democracies which medications may be optimal for which ethnic groups.
witnessed a popular disquiet about segregation. Also, Migration of both healthcare workers and patients ultimately
lessons about the disabling impact of institutionalisation requires an understanding of transcultural psychiatry. From a
(‘institutional neurosis’) were drawn from observations in sociological perspective, the very existence of differences in
the camps of ritualised, rigid and stereotyped behaviour of the epidemiology, presentation, treatment response and man-
their inmates. agement of mental disorder among cultures leads to important
understanding of such disorders within any one culture.
• Large institutions were expensive and placed a large fiscal
burden upon government budgets. Deinstitutionisation Transcultural psychiatry originally had four main aims.
offered itself as a cost-cutting exercise. First, it would provide a framework for cross-cultural compar-
isons. Second, it would provide a forum for the dissemina-
• Doubts about institutional life were reinforced by research tion of psychiatric knowledge among countries and cultures.
on its negative impact from social psychiatry, sociology and Third, it would provide a framework in which international
from dissent within clinical psychiatry (‘antipsychiatry’). programmes for mental health could be integrated and harmo-
nised in terms. Last, it allowed the consideration of global
• A new social movement of mental health service users that mental health problems at a global level thus incorporating
was critical of hospital-based biomedical regimens relevant international authorities (Mead 1959).
emerged internationally.
While the extent and variation in the presentation of mental
The above list does not contain any allusion to the so-called illness across the world may be limitless, this chapter will look
‘pharmacological revolution’. It is a commonly reported mis- at four important aspects of transcultural psychiatry; the effect
conception that the increasing use of neuroleptic drugs (major of migration on mental health, culture bound syndromes and
tranquillisers) during the 1950s led to a process of deinstitu- the variation in service provision for different sociocultural
tionalisation. In some countries, bed numbers began to drop groups. Initially, several important concepts will be discussed
before the introduction of the drugs. In others, bed numbers as a basis for the understanding of culture and the methodologies
actually increased despite this introduction. The drugs also used in the study of transcultural psychiatry.
have been used on a variety of populations that were not
deemed to be mentally ill (such as people with learning diffi- Core concepts
culties and older people). The drugs were only relevant in
giving psychiatric staff more confidence in dealing with The discipline of anthropology gives the basis of an under-
community-based patients; they do not explain the policy of standing of culture. For psychiatry, Keesing and Strathern’s
deinstitutionalisation (Rogers & Pilgrim 2001). (1998) definition of culture stresses ‘systems of shared ideas,
systems of concepts and rules and meanings that underlie
One of the most significant accounts about the asylum sys- and are expressed in the ways that human beings live’. Any
tem was written by Erving Goffman, a Canadian sociologist. given culture requires shared world view in order to manage
Goffman described the asylum as a ‘total institution’ and the social cohesion. Culture allows the use of a set of rules of
process by which it takes efforts to maintain predictable and any human group and the imparting of these rules to its
regular behaviour on the part of both ‘guard’ and ‘captor,’ sug-
gesting that many of the features of such institutions serve the
ritual function of ensuring that both classes of people know
their function and social role, in other words of “institutiona-
lising‘ them. The book concludes that adjusting the inmates
to their role has at least as much importance as ‘curing’ them.’

115

Companion to Psychiatric Studies

descendents through the medium of tradition, art, symbols and changing prejudices through ‘race awareness’ training. This
and rituals (Helman 2007). Enculturation represents the works on the premise of challenging the stereotypical and
growing up in any given culture and the adoption of its views. negative views about minority ethnic groups held by powerful
Acculturation describes the process of migrants who undergo individuals, like professionals. However, what tends to be
a transition from their initial culture to the acquisition of the missing from analyses based on prejudice is a consideration
cultural beliefs of a new environment. of the impact of inequality – how the latter is manifested in
mental illness rates, services and professional responses to
An ethnic group is a group of human beings whose members black and other minority groups. In contrast to prejudice,
identify with each other, through a common heritage that is racism implies a sociological rather than a psychological analy-
real or presumed (Banks 1996). Ethnic identity is further sis and emphasises the roles of institutions in perpetuating
marked by the recognition from others of a group’s distinc- disadvantage, and the need to combat institutional racism
tiveness and the recognition of common cultural, linguistic, through antiracism measures. A key focus of the debate about
religious, behavioral or biological traits, real or presumed, as race and psychiatry relates to the type of contact that
indicators of contrast to other groups (Eriksen 2001). Afro-Caribbean young men have with mental health services.

Ethnicity is an important means through which people can Afro-Caribbean people are much more likely than white
identify themselves. The term race or racial group refers to people to make contact with mental health services via the
the categorisation of human populations into groups on the police, courts and prison, and, once contact has been made,
basis of heritable characteristics (Arash 2001). The most there is evidence of their over-representation in compulsory
widely used human racial categories are based on traits such admission and in receiving a diagnosis of schizophrenia com-
as skin colour, cranial or facial features and hair texture, and pared with white people (Bhui et al 1995). At the other end
self-identification. of the spectrum there is evidence to suggest that black people
are under-represented in outpatient and self-referred services
Conceptions of race may vary by culture and over time, and and less likely than other groups to be referred by general
are often controversial for scientific as well as social and poli- practitioners (e.g. Harrison et al 1988).
tical reasons. The controversy ultimately revolves around
whether or not the concept of race is biologically based; the The pathways by which young black men come to the atten-
ways in which political correctness might contribute to either tion of mental health services have led some commentators
the affirmation or the denial of race; and the degree to which to suggest that the ‘criminalisation’ and medicalisation of
perceived differences in ability and achievement, on the basis black people are closely connected processes which implicate
of race, are a product of inherited traits or sociocultural psychiatry as part of a larger social control apparatus which
factors. regulates and oversees the lives of black people (Francis
1988). The multiple contacts, judgements and processes
It can be argued that although race is a valid concept in which are involved in referral to psychiatric services may also
other species, it cannot be applied to humans, as while racial imply a process of ‘transmitted discrimination’ in which con-
categorisations may be marked by phenotypic or genotypic tingencies and the subtle discriminatory acts and views may
traits, the idea of race itself, and actual divisions of persons be transferred from one agency to another. Differences in
into races or racial groups, can be seen as social constructs. the processes of referral, labelling and help-seeking are all
likely to be implicated. Black people may express their distress
An important methodology underlying the basis of anthro- at times in a culturally idiosyncratic way. Much of the psy-
pology is that of ethnography. Ethnography involves the chiatric literature suggests that the manifestation of ‘mental
descriptive study of the behaviour of a group or community illness’ predisposes Afro-Caribbeans towards police arrest
over a significant time span. Researchers in this area will often because they present in a particularly disturbed way, and the
embed themselves within the studied group. place in which behaviour takes place is also deemed to be
important. Bean (1986) suggests that if a greater part of young
The discipline of epidemiology is central to the quantitative Afro-Caribbean social life takes place in public, then ‘mad’
understanding of transcultural psychiatry. The four principal behaviour is more likely to be detected and dealt with by
aims of transcultural psychiatry, as noted above, hinge on the agents such as the police, than is the case for white people,
ability to objectively compare both mental illness and health who have more of an ‘indoor culture’. The tendency to label
services among different countries and cultures. Descriptive a person mentally ill increases with the cultural distance
epidemiology serves to describe the distribution of health between the labeller and labelled, suggesting that members
states within a population. Analytical epidemiology serves to of minority ethnic groups are more likely to be labelled men-
explain such a distribution. The reporting of incidence and tally ill than dominant indigenous groups by members of the
prevalence can lead to comparative studies of disease fre- public as well as by professionals.
quency; a descriptive process. Such data can then be used
to look at hypothesized risk factors be they genetic or
environmental.

Transcultural psychiatry and migration Culture-bound syndromes

Transcultural psychiatry is concerned with how different Culture-bound syndromes are recurrent geographically spe-
ethnic groups are treated by mental health workers socialised cific patterns of aberrant behaviour and troubling experience
in the ways of the ‘dominant culture’ (Rack 1982; Fernando which may or may not relate to the nosological structure of
1988). This position advocates initiatives aimed at challenging

116

Social and transcultural aspects of psychiatry CHAPTER 6

international psychiatric classificatory systems. While culture- central nervous system’s energy reserves’, which was attribu-
bound syndromes may wrongly be seen as central to trans- ted to the stresses of civilization and urbanisation and the pres-
cultural psychiatry, a description of notable syndromes will sures placed on the intellectual class by the increasingly
be discussed here due to their prominence in classificatory competitive business environment. Typically, it was associated
systems and relevance to postgraduate training programmes. with upper class individuals. In China a similar syndrome is
known as shenjing shuairuo. In Japan the condition is known
Such syndromes are considered as illnesses indigenous to as shinkeisuijaku.
that culture that are not recognized outside that particular cul-
ture. The inclusion of these in the DSM IV marks a significant Amok is from the Malay/Indonesian/Filipino meaning ‘mad
acknowledgement of globalised psychiatry along with the with rage’ The phrase is particularly associated with a specific
increased levels of migration necessitating clinicians across sociopathic syndrome in Malaysian culture. In a typical case of
the world to recognize not only cultural variations but non- running amok, a male who has shown no previous inclination
westernised models of psychiatric diagnostic systems. DSM to violence will acquire a weapon and, in a sudden frenzy,
goes on to describe these as having localised, folk, diagnostic attempt to kill or seriously injure anyone he encounters. Norse
categories that frame coherent meanings for certain repetitive, ‘Berserkers’ and the Zulu battle trance are other examples of
patterned and troubling sets of experiences and observations. the tendency of certain groups to work themselves up into
a killing frenzy.
A parallel view is that certain disorders such as anorexia
nervosa or even paranoid schizophrenia could be recognized Susto, a ‘fright sickness’, is indigenously attributed to ‘soul
as themselves culture-bound syndromes of the westernised loss’ resulting from traumatic experiences. Among Native
or developed world. Here international classificatory systems Indian populations of Latin America, susto may be concep-
would fall under the definition of a social construct. tualised as a case of spirit attacks. The onset of the disease
generally follows a sudden frightening experience such as an
Common features of a culture-bound syndrome include: accident, witnessing a relative’s sudden death, or other poten-
categorisation as a disease in the culture (i.e. not a voluntary tially dangerous events. Symptoms of susto are thought to
behaviour or false claim); widespread familiarity in the cul- include nervousness, anorexia, insomnia, listlessness, despon-
ture; and the condition is usually recognized and treated by dency, involuntary muscle tics and diarrhoea.
the folk medicine of the culture.
Ghost sickness is native to American Indian tribes and
Ultimately the very presence of such syndromes impeaches believed to be caused by association with the dead or dying
the validity of a comprehensive classificatory system and and is sometimes associated with witchcraft. It is considered
whether such a system can ever be exhaustive. to be a psychotic disorder of Navajo origin. Its symptoms
include general weakness, loss of appetite, a feeling of suffoca-
Below we describe several significant culture-bound tion, recurring nightmares and a pervasive feeling of terror.
syndromes. The sickness is attributed to ghosts (chindi) or, occasionally,
to witches.
Genital retraction syndrome is where an individual is over-
come with the belief that genitals are retracting into the Wendigo psychosis is a culture-bound disorder which
body, shrinking, or may be imminently removed or disappear. involves a craving for human flesh and the fear that one will
A penis panic is an event in which males in a population sud- turn into a cannibal. This once occurred frequently among
denly believe they are suffering from genital retraction syn- Algonquian Indian cultures, though has declined with the
drome. In South-East Asia this is known as Koro. In China, Native American urbanisation.
the term used for the condition is shook yang and a similar
syndrome has been described in western and southern Africa Latah is a condition of hyper startling found in the Middle
in the last decade. East and South-East Asia and is found mainly in adult women.
The afflicted have a severe reaction to being surprised in which
Piblokto or Arctic hysteria appears in Eskimo societies. Seen they lose control of their behaviour, mimic the speech and
mostly in Eskimo women, symptoms include screaming, actions of those around them and sometimes obey any com-
uncontrolled wild behaviour, depression, coprophagia, insensi- mands given them. Similar conditions have been recorded
tivity to extreme cold (such as running around in the snow within other cultures and locations, such as among French-
naked) and echolalia. It has been suggested that it may be Canadian lumberjacks in Maine (Jumping Frenchmen of
linked to vitamin A toxicity as the Eskimo diet provides rich Maine) and the Ainu of Japan.
sources of vitamin A such as liver of arctic fish.
Hwabyeong is a Korean term meaning ‘anger illness’ and
Dhat syndrome is found in the Indian subcontinent where manifests as a wide range of physical symptoms, in response
males report that they suffer from premature ejaculation or to emotional disturbance. Seen mostly in menopausal females,
impotence, and believe that they are passing semen in their sufferers report symptoms such as a heavy feeling in the chest,
urine. The discharge of semen leads to marked feelings of guilt perceived abdominal mass, sleeplessness, hot flushes, cold
and dysphoria associated with what the patient assumes is flushes and blurred vision. They may also demonstrate symp-
‘excessive’ masturbation. Often the patient describes the loss toms such as anxiety, depression, obsessive–compulsiveness,
of a white fluid while passing urine. Other somatic symptoms as well as anorexia, paranoia or fearfulness, absent-mindedness
like weakness, easy fatiguability, palpitations, insomnia, low and irritability.
mood, guilt and anxiety are often present. Males sometimes
report a subjective feeling that their penises have shortened. Taijin kyofusho, seen in Japan, means the disorder of fear of
interpersonal relations and has been described as a vicious
Neurasthenia denotes a condition with symptoms of cycle of self examination and reproach which can occur in
fatigue, anxiety, headache, impotence, neuralgia and depressed
mood. It was explained as being a result of exhaustion of the

117

Companion to Psychiatric Studies

people of hypochondriacal temperament. Sufferers of taijin patients had lower rates of and slower times to remission and
kyofusho report a fear of offending or harming other people. response, which may be accounted for by social disadvantage
The focus is on avoiding harm to others rather than to oneself. (Lesser 2008). When looking at patients who had already
Further features include the phobia of blushing, the phobia of accessed care, there appeared to be no differences in health-
a deformed body, the phobia of eye contact and the phobia of care usage between different ethno-racial groups. Such find-
having foul body odour. ings would suggest that disparities stem from racial and
ethnic differences in treatment seeking rates and that more
Brain fag derives from West Africa and generally manifests emphasis should be placed on ensuring that treatment is
as vague somatic symptoms, depression and difficulty con- available and accessible (Elwy et al 2008).
centrating. It has similar symptoms to the Trinidadian illness
studiation madness. The term ‘fag’ is believed to have been Implications for clinical psychiatry
derived from ‘fatigue’. This American usage declined by the
1950s. The modern African usage was first described in In an increasingly globalised world the awareness of cultural
1960. Brain fag occurs most commonly in sub-Saharan Africa. variation in the presentation of mental illness has direct impli-
cations for the clinical psychiatrist. The presence of migrant
The features of Ataque de nervios include uncontrollable communities necessitates clinical adaptability of practitioners
shouting, attacks of crying, trembling, heat in the chest and to take into account variation in presentation and management
head, and verbal and physical aggression. The syndrome is seen of patients from diverse populations. Sensitivity to diverse cul-
in Latin American and Latin Mediterranean groups. Dissocia- tural norms is essential for national health policy and strategy
tive experiences, seizures and fainting are also seen. It is often and psychiatry, more than other medical specialties, reflects
seen as a result of family stress. It may most closely relate to a such cultural diversity. The acknowledgement of culture-
westernised diagnosis of panic disorder. bound syndromes may fundamentally undermine assumed
diagnostic nosological systems and may ultimately lead to a
Bouffee deliriante, seen in West Africa and Haiti, relates to more universal understanding of biological mechanisms for
sudden outbursts of agitated and aggressive behaviour, confu- disease. Psychiatrists themselves must also look to their own
sion and psychomotor excitement. It can be accompanied by prejudices and assumptions regarding ethnicity and race in
visual and auditory hallucinations and some paranoid ideation. our globally diverse modern world.

Zar is a generic term referring to the experience of spritual Conclusion
possession, which may inlcude dissociative episodes that
include laughing, hitting, singing or weeping. Apathy and with- The fields of social and cultural psychiatry span diverse aca-
drawal may also be seen. Such symptoms may be seen across demic disciplines and capture the interests of sociologists,
east Africa and the Middle East. anthropologists and political scientists as well as the clinical
psychiatrist. In this chapter, discussion has related primarily
Service provision and ethnic groups to core concepts and implications for modern psychiatric
practice.
A fallacious assumption in healthcare services would be that
increasing financial prosperity would lead to equal improved Sociological theory allows different paradigms for the
access of mental health care by different ethnic groups within understanding of mental health and mental illness. While the
any society. However, there exist obvious disparities in the 21st century may be noted for its advances in a biological
way in which ethno-racial groups utilise services in developed understanding of mental illness, the sociocultural paradigm
countries. Recent studies suggest that significant disparities gives a powerful and complementary paradigm as to the why
remain in wealthy societies. In the USA, significant differ- and how of modern psychiatry. The understanding of genetics
ences in terms of access to and quality of depression treat- and neurochemistry of mental disease may be redundant if
ments were found; 40% of non-Latino whites did not access healthcare services and clinical practice are not tailored to
any treatment compared to 69% of Asians, 64% of Latinos the social character of both patient and population. For psy-
and 59% of African Americans. Receipt of treatment was less chiatry to succeed in its aims of alleviating clinical distress,
likely from individuals who obtained care even when the modern psychiatrist must reflect on the prejudice and
controlling for socioeconomic variables (Alegr´ıa et al 2008). assumption of the limits of clinical practice.
Within specific ethnic groups disparities also exist. In a group
of Hispanic patients in the USA, those who spoke English
were compared to those who only spoke Spanish. When given
a 14-week course of an antidepressant, Spanish-speaking

Further reading

Alegr´ıa, M., Chatterji, P., Wells, K., Cao, Z., American Association of Physical Banton, M., 1977. The idea of race, Westview
Chen, C.N., Takeuchi, D., et al., 2008. Anthropologists, 1996. AAPA statement on Press, Boulder, CO.
Disparity in depression treatment among biological aspects of race. Am. J. Phys.
racial and ethnic minority populations in the Anthropol. 101, 569–570. Barkan, E., 1998. Borders, Exiles, Diasporas
United States. Psychiatr. Serv. 59 (11), (Cultural Sitings), Stanford University
1264–1272. Press.

118

Social and transcultural aspects of psychiatry CHAPTER 6

Carr, J.E., Tan, E.K., 1976. In search of the true Ehrenreich, B., English, D., 1978. For her own Lesser, I., Rosales, A., Zisook, S., et al., 2008.
amok: amok as viewed with the Malay good: 150 years of the experts’ advice to Depression outcomes of Spanish- and
culture. Am. J. Phychiatry 133 (11), women, Pluto, London. english-speaking Hispanic outpatients in
1295–1299. STAR*D. Psychiatr. Serv. 59 (11),
Encyclopaedia Britannica, 2007. Anthropology: 1273–1284.
Cooper, R.S., Kaufman, J.S., Ward, R., 2003. the study of ethnicity, minority groups, and
Race and genomics. N. Engl. J. Med. 348, identity, Encyclopaedia Britannica. Parsons, T., 1951. The social system, Routledge &
1166–1170. Kegan Paul, London.
Goffmann, E., 1961. Asylums, Penguin,
Editorial, 1956. Transcultural Research in Mental Harmondsworth. Scull, A., 1977. Decarceration: community
Health Problems 1 (April). treatment and the deviant – a radical view,
Gove, W., Tudor, J.F., 1972. Adult sex roles and Prentice-Hall, Englewood Cliffs, NJ.
mental illness. AJS 78, 812–835.

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Neuropsychology 7

Jeremy Hall Ronan E O’Carroll Chris D Frith

Introduction impact on neuropsychological test performance. In recent
years greater attention has been placed on exploring specific
Neuropsychology is the study of brain–behaviour relation- syndromes or symptoms rather than ‘illnesses’. For example,
ships, and has traditionally utilised the classical lesion-based rather than trying to explain ‘schizophrenia’, attempts have
approach – relating focal brain damage to patterns of preserved been made to explain specific features (e.g. paranoid
and impaired cognitive functioning. In the majority of psychi- delusions) in neuropsychological terms.
atric disorders, however, focal brain lesions are rare, and the
real challenge of neuropsychology in relation to psychiatry is Clinical neuropsychology also has an important role to play
to understand abnormal behaviour in terms of dysfunctional in the assessment of cognitive impairment in clinical practice.
processing of information. This is more likely to be related to The development of neuropsychological measures allows for
abnormally functioning brain systems than to localised brain the valid and reliable assessment of treatment efficacy. This
damage. Historically, within psychiatry, the role of the is particularly important as ‘negative features’ (including cog-
neuropsychologist was limited to an attempt to aid in the dif- nitive impairment) are becoming increasingly recognised as
ferential diagnosis of ‘organic’ versus ‘functional’ psychoses. important targets for pharmacological treatment of psychiatric
However, in an overview of 34 studies, the mean ‘hit rate’ disorders.
(classification accuracy) of patients with schizophrenia versus
brain-damaged patients was 54%, prompting Green (1996) Scope of the chapter
to state ‘the contributions of clinical neuropsychology to the
study of schizophrenia appear to be modest at best’. The study of brain–behaviour relationships in man is a huge
area, therefore this chapter will focus on issues of particular
Over the past decade, however, neuropsychology has led to relevance for psychiatry. Rapid progress in neuropsychology
considerable advances in the study of psychiatric disorder, to has occurred over the last decade via the use of functional
the extent that neuropsychology is now seen as an essential brain imaging techniques (SPECT, PET and fMRI) as these
discipline for the study of psychiatric disorder. This progress techniques can be used to provide validation of localisation of
has been achieved through reliable and precise quantification function suggested by neuropsychological findings. These
of discrete components of cognitive function and behaviour developments are covered in Chapter 4, on Neuroimaging.
in relation to normal and abnormal mental states, e.g. study The present chapter begins with a review of historically impor-
of cognitive function in ‘high risk’ individuals (Byrne et al tant single-case studies that were crucial in establishing the
1999) and in the development of neuropsychological models field of neuropsychology. The issue of localisation of function
of mental disorder (Gray et al 1991; Kapur 2003; Frith 1992). via neuropsychological instruments will be addressed. Major
neuropsychological findings in relation to schizophrenia and
The determination of brain–cognition relationships is no depression will be summarised. The new field of ‘cognitive
easy undertaking in psychopathological states. Many neuropsy- neuropsychiatry’ will be outlined. Recent findings on memory
chological studies in major psychiatric disorder are conducted for emotional material will be presented. The chapter con-
on patients who are taking psychotropic medication, and such cludes with a brief overview of psychometric issues, followed
drugs may well have confounding effects on measures of cogni- by a summary of the most commonly used neuropsychological
tive functioning. Most psychiatric disorders involve affective instruments in clinical research and practice.
status, therefore mood and motivation may also critically

ã 2010, Elsevier Ltd.
DOI: 10.1016/B978-0-7020-3137-3.00007-3

Companion to Psychiatric Studies

Single-case studies rail track. Gage was using a large iron bar (over 1 metre long and
weighing over 13 pounds) as a tamping rod to pound down on a
The traditional approach within neuropsychology has been the protective layer of sand, placed over a layer of explosive powder
lesion approach, whereby inferences about brain–behaviour containing a fuse, in a hole drilled in the rock. However, tragi-
relationships are derived from the observations of behavioural cally on this occasion, Gage ‘tamped’ the explosive powder
abnormality in patients who have suffered selective brain before the protective layer of sand had been inserted. The
damage. Historically, the field has been driven by key observa- tamping caused a spark to ignite the powder, and the iron rod
tions on single cases. Single-case studies avoid the averaging was blown upwards, through Gage’s left cheek and through
artefact, i.e. that data derived from group studies represent his brain, exiting at the top of his head before landing more than
the average of a group, and may tell us little about particular a hundred feet away. Gage was thrown to the ground, but
individuals within the group. Advocates of the group-studies apparently remained conscious. He spoke within a few minutes
approach argue that the single-case approach violates the core and his workmates sat him in a cart and drove him to a local
assumption of the scientific method – replicability – in that hotel where the doctor was called. The doctor later related that
the individual case is considered unique. In this section, some Gage ‘talked so rationally and was so willing to answer questions
of the most influential of these single-case studies will be that I directed my enquiries to him in preference to the men
briefly reviewed. who were with him at the time of the accident. . . . Gage then
related to me some of the circumstances, as he has since done;
Language function — the case of Tan and I can safely say that neither at the time nor on any
subsequent occasion, save once, did I consider him to be other
During the 19th century Gall and Spurzheim established the than perfectly rational’ (Dr Williams’ account, cited in Damasio
field of phrenology. Although later discredited, it is important 1994). Remarkably, Gage survived this major injury and was
historically in that it attempted to relate certain behaviours to pronounced cured in less than 2 months. While the story is
specific brain areas. The relationships could be inferred by unusual, the case is particularly famous owing to Harlow’s
examination of the surface of the skull: a bump on the skull description of the resulting changes in Gage’s behaviour, which
indicated a well-developed underlying region; for example has become established as a classical account of the behavioural
‘selfish propensities’ were thought to be located in the region sequelae of frontal lobe injury.
above the right ear. In 1861 Broca published a landmark paper
where he described the form of production aphasia which was His physical health is good, and I am inclined to say that he has
later to bear his name. At postmortem, one of his patients, recovered. He has no pain in head, but says it has a queer feeling
‘Tan’ was shown to have sustained damage to the third convo- which he is not able to describe. Applied for his situation as foreman,
lution of the left frontal lobe. During his life, Tan could barely but is undecided whether to work or travel. His contractors, who
produce more than a few words; in fact his most common regarded him as the most efficient and capable foremen in their
utterance was ‘tan’, hence his name. Broca concluded that employ previous to his injury considered the change in his mind so
damage to a specific brain region had led to a specific beha- marked that they could not give him his place again. The equilibrium
vioural abnormality. This was a crucial observation, as at the or balance, so to speak, between his intellectual faculties and animal
time the notion of equipotentiality was popular, namely that propensities, seems to have been destroyed. He is fitful, irreverent,
it was not the site of brain damage that was important, rather indulging at times in the grossest profanity (which was not his
it was the volume of damage that was critical. Wernicke later previous custom), manifesting but little deference for his fellows,
proposed that a particular type of receptive aphasia was asso- impatient of restraint or advice when it conflicts with his desires, at
ciated with damage in an area in the left posterior temporal times pertinaciously obstinate, yet capricious and vacillating, devising
lobe. Thus, the belief that certain aspects of behaviour were many plans for future operations, which are no sooner arranged than
associated with discrete brain regions began to become they are abandoned in turn for others. . . . His mind is radically
established. changed, so that his friends and acquaintances said he was ‘no longer
Gage’.
Executive function – the case of Phineas
Gage Thus Gage became a changed man – he was ‘no longer Gage’
and was not considered employable in his previous position.
Seven years following Broca’s publication describing Tan, He then took a variety of different jobs, including a position
JM Harlow published a paper in the Publications of the as a circus attraction at Barnum’s museum in New York,
Massachusetts Medical Society with the graphic and descrip- showing his wounds and tamping iron. He died following a
tive title: ‘Recovery from the passage of an iron bar through series of convulsions in 1861, 13 years after sustaining his brain
the head’. In it the case of Phineas Gage is described. (Damasio, injury. Gage exhibited marked changes in his social behaviour
1994, provides an excellent, detailed description of the case.) (as eloquently described by Harlow) in the face of apparently
The damage to Gage’s brain occurred in 1848 when he was preserved other cognitive abilities, e.g. attention, perception,
working for a railway company in Vermont. The workmen were memory, language and intelligence. During his lifetime the
using explosives to clear a path through rocks in order to lay the exact location of the brain injury was clearly not known.
However, following his death, Gage’s skull and the tamping
iron were placed in a medical museum in Harvard Medical
School. Recently, Damasio et al (1994), in a paper entitled
‘The return of Phineas Gage’, photographed the skull from a
variety of angles, measured the distances between the areas

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Neuropsychology CHAPTER 7

Fig. 7.1 When Gage died in 1861 no autopsy was conducted, but above average intelligence level, with intact perception, atten-
his skull was examined in 1994 and the trajectory of the iron bar tion and short-term memory. He also had preserved proce-
was inferred. The reconstruction shows that the damage was largely dural learning (such as mirror drawing), but had no conscious
in the ventromedial frontal brain area. (From Damasio 1994. Reproduced recollection of previous learning having occurred, demonstrat-
ing the classical dissociation between impaired explicit and
with the permission of the American Association for the Advancement of preserved implicit memory. It is now widely accepted that
Science and Professor H Damasio, Dornsife Neuroscience Imaging Centre and the critical regions for the laying down of new explicit or
Brain and Creativity Institute, University of Southern California.) declarative memories involve the hippocampus and hippocam-
pal gyrus (Squire 1987). HM’s case was particularly influential
in establishing the critical role of temporal lobe structures in
episodic or declarative memory functioning in man. To give a
specific example of HM’s deficit, when his father died, HM
continued to ask where his father was, only to experience grief
on each occasion of hearing of his father’s death. This inability
to lay down new explicit memories leads to the subjective
experience for the amnesic as of a continual awakening from
sleep or a dream, in a present without a past. As HM stated,
‘Every day is alone, whatever enjoyment I’ve had, and whatever
sorrow I’ve had’.

More recently the patient CW has been extensively studied
since becoming amnesic. He was a world expert on Renaissance
music, and tragically in 1985 the herpes simplex virus infected
his brain. His life was saved with antiviral drugs, but the virus
destroyed large regions of both temporal lobes (Wilson et al
1995). CW was left with devastating memory impairment as a
result of this temporal lobe damage. Wilson et al (1995)
claimed that CW has the most severe anterograde amnesia ever
studied. CW’s wife described his cognitive state in a TV docu-
mentary ‘The Mind Machine’ (Blakemore 1988) as follows:

of bone damage and a variety of bone landmarks, and recon- CW’s world now consists of a moment with no past to anchor it and
structed the skull, brain and most likely trajectory route of no future to look ahead to. It is a blinkered moment. He sees what is
the tamping iron (Fig. 7.1). The bar did not damage brain right in front of him but as soon as that information hits the brain it
regions necessary for motor function or language, but appeared fades. Nothing registers. Everything goes in perfectly well. . . he
to have particularly destroyed the ventromedial prefrontal perceives his world as you or I do, but as soon as he’s perceived it and
region, and this led to the marked changes in Gage’s ability looked away it’s gone for him. So it’s a moment-to-moment
to plan for the future, conform to social conventions and to consciousness as it were . . . a time vacuum.
decide upon the most appropriate courses of action (Damasio
1994). This moment-to-moment experience of consciousness is gra-
phically depicted in the diary record which he has obsessionally
Memory function – the cases of HM recorded for over 10 years (Fig. 7.2).
and CW
Both HM and CW suffer from amnestic disorder (Box 7.1).
The search for the ‘engram’, the brain location of the memory The sufferer will often have clear recollection of episodes
trace, has a long history. Lashley, working on monkeys, spent in their distant past, but will be unable to recall events that
over 30 years carrying out selective ablations of different brain happened half an hour ago. There are a variety of possible
areas in an attempt to produce amnesia, and in 1951 he con- causes of amnestic disorder. In some instances, notably in
cluded that he had failed to find the location of the memory Korsakoff’s syndrome, patients attempt to cover up their mem-
trace. Ironically, 2 years later, the neurosurgeon Scoville con- ory loss via confabulation, i.e. using their preserved language
ducted a bilateral temporal lobectomy on the patient HM in and intellectual abilities to create elaborate stories in an effort
an attempt to treat his intractable epilepsy. Unfortunately, to compensate for the memories they have lost. The memory
the operation, though successful in reducing the frequency of loss in amnestic syndrome is thought to be largely irreversible.
seizures, caused a new form of devastating disability: it ren-
dered HM amnesic (Scoville & Milner 1957). The essential features of amnestic syndrome are devastat-
ingly impaired anterograde memory function, with a variable
HM was investigated for over 50 years until his death in degree of impaired retrograde memory function (usually sur-
2008, making his probably the most studied case in the history rounding the time of the brain insult) in the presence of pre-
of cognitive neuroscience. He was unable to recall any new served other cognitive functions. This has often been
experiences from the time of his operation, but remained of demonstrated by the use of an intellectual minus memory quo-
tient discrepancy. For example, a person who has a Wechsler
intelligence quotient of 120 with a memory quotient of 70
would have a 50-point discrepancy, which would be consistent

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Companion to Psychiatric Studies

Fig. 7.2 Diary extract from CW
reveals the horror of his constant sense
of ‘awakening’ and his inability to lay
down new conscious memories.

(Reproduced, with permission, from Blakemore
1988.)

with an amnestic profile. Amnestic disorder can result from a impairment, but rather have widespread cognitive impair-
variety of causes of cerebral pathology. Korsakoff’s syndrome, ments. A striking feature in amnestic syndrome is preserved
a consequence of chronic alcoholism and thiamine deficiency, implicit memory performance. For example, amnestic patients
leads to selective atrophy of the mamillary bodies, and this typically perform normally on implicit tasks such as the pur-
can lead to the development of an amnestic syndrome. Many suit rotor or incomplete figures task, yet will have no explicit
patients with alcohol-induced persisting dementia are misclas- memory of having performed these tasks. Such evidence has
sified as suffering from amnestic syndrome; however, they been important in clarifying the neural substrates that subserve
often do not have specific and isolated anterograde memory different components of memory function in man (Fig. 7.3)
(Squire 1987).

Box 7.1 Localising measures?

Defining features of the amnestic syndrome Case studies such as those outlined above were important in
establishing the relationship between certain aspects of beha-
• Intact immediate memory viour and localised brain damage. Subsequent work led to a
• Intact intelligence crude ‘mapping’ of the brain in terms of neural substrate for
• Intact semantic memory psychological functions, e.g. left hemisphere dominance for
• Severe and permanent anterograde amnesia (impaired memory speech and language, right hemisphere dominance for visuospa-
tial abilities, right temporal lobe damage leading to visuospatial
for new information) memory impairments, left temporal lobe damage impairing
• A degree of retrograde amnesia (loss of memory of the period verbal memory functioning and frontal lobe damage leading to
problems in executive functioning. However, identifying lesion
before brain damage)
• Intact procedural memory

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Neuropsychology CHAPTER 7

Fig. 7.3 A taxonomy of memory functioning. (After Memory

Squire 1987.)

Declarative Procedural

Episodic Semantic Skills Priming Simple Other
(working) (reference) classical
conditioning

location using neuropsychological measures has largely fallen Neuropsychology in major
out of favour for three main reasons. First, most neuropsy-
chological tests are extremely complex and tap a variety of psychiatric disorder
cognitive functions, e.g. perception, attention, working memory
and require some motor response, thus activity in widely In the following sections some of the major contributions of
distributed brain regions is required for successful task comple- neuropsychology to the understanding of schizophrenia and
tion. Second, developments in high-resolution structural and depression will be summarised.
functional neuroimaging provide more accurate ways of deter-
mining localised brain damage or metabolic abnormality. Third, Schizophrenia
for many psychiatric disorders there has been no consensus over
putative localised disturbance of the central nervous system. Schizophrenia has been described as perhaps the most devas-
To take the example of schizophrenia, various authors have tating illness known to man, because it appears in early adoles-
proposed that schizophrenia is characterised by cognitive test cence and can drastically impair the subsequent life of the
abnormalities indicative of either dysfunction of the frontal sufferer and his or her family. In the 1960s, there was a wide-
lobe, temporal lobe, left or right hemisphere, basal ganglia, spread view that schizophrenia was a socially created disorder,
etc. (Blanchard & Neale 1994). The extreme case is put by and family dynamics, and in particular the ‘schizophrenogenic
Meehl who stated ‘I conjecture that whatever is wrong with mother’, was often blamed. The finding of ventricular enlarge-
the schizotaxic CNS is ubiquitous, a functional aberration pres- ment (Johnstone et al 1976) shifted the balance back to
ent throughout, operating everywhere from the sacral cord to viewing schizophrenia as a brain/neuropsychological disorder.
the frontal lobes’ (Meehl 1990, p. 14). Many current workers Prior to this time, it was widely believed that neuropsycholog-
would surely agree with Shallice et al (1991) who proposed that ical impairment was not an important feature of schizophrenia.
from a neuropsychological perspective, the attempt to under- (However, it must be emphasised that when differences have
stand the nature of the information processing impairment in been found in brain morphology between patients with schizo-
psychiatric disorder should precede the attempt to localise it. phrenia and matched controls, the degree of between-group
overlap has usually been large.) Neuropsychological abnormal-
‘Frontal lobology’ ities are now widely reported in many patients diagnosed with
schizophrenia. The most consistent findings are of impairments
Perhaps the most extreme example of attributing psychiatric in memory, attention and executive functioning (Heinrichs &
disturbance to a localised brain region is the case of the puta- Zakzanis 1998; Fioravanti et al 2005). Importantly, these
tive involvement of the frontal lobes. David (1992) provoca- abnormalities are often observed in patients who are drug-free
tively entitled this exercise ‘frontal lobology’ and described it (Saykin et al 1994) and are also present in unaffected relatives
as ‘psychiatry’s new pseudoscience’. He lists the psychiatric (Byrne et al 1999; Sitskoorn et al 2004; Snitz et al 2006).
conditions which have been ascribed to frontal lobe dys-
function; the list includes personality disorders, obsessions, Palmer et al (1997) posed the question ‘Is it possible to be
delusions, depression, mania, conduct disorder, schizophrenia, schizophrenic yet neuropsychologically normal?’. They gave a
catatonia, thought disorder, anorexia nervosa and hysteria, comprehensive neuropsychological battery to 171 outpatients
‘All of psychiatry, not to mention human life is there’ (David with schizophrenia and compared them with 63 healthy con-
1992, p. 244). As David points out, the frontal lobes are trols. Two experienced neuropsychologists conducted blind
thought to be the seat of thought, intellect, creativity, etc., ratings of the test results. Only 27% of the patients were
and as psychiatric disorders are, by definition, problems at classified as neuropsychologically ‘normal’. This indicates that
the highest level of thought, it is an unhelpful tautology to significant cognitive impairment in schizophrenia is, in fact,
state that such disorders are manifestations of frontal lobe the norm.
pathology. Additionally, even if a particular disorder was
shown to be associated with frontal lobe abnormality, how Pre-existing cognitive impairment?
does this further our understanding, given that the frontal
lobes constitute approximately one-third of the brain? ‘Localis- Several studies have also confirmed that low intelligence and
ing a disturbance to this region is rather like directing a visitor poor educational achievement precede early-onset schizophrenic
to an address marked Europe’ (David 1992, p. 244). psychosis. Jones et al (1994) used the subjects from the National
Survey of Health and Development, a random sample of over

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Companion to Psychiatric Studies

5000 births in England, Scotland & Wales during the first week Ravens progressive matrices raw scoremethod for assessing the course of cognitive impairment over
of March 1946. Out of this sample, 30 cases of schizophrenia time. Early longitudinal studies showed no progressive deterio-
arose between ages 16 and 43. Children who developed schizo- ration, but were limited by a number of significant methodo-
phrenia in later life were significantly impaired on nonverbal logical weaknesses including the lack of an operationalised
and verbal intelligence tests from the age of 8 and on arith- diagnosis of schizophrenia at a time when the diagnosis of
metic/mathematic skills from the age of 11. This result clearly schizophrenia was notoriously broad in the USA. More
indicates the presence of detectable cognitive abnormalities in recently, well-designed longitudinal studies have again pro-
childhood, which pre-dated the development of the illness. duced conflicting results, with some supporting the notion of
David et al (1997) capitalised on a remarkable sample of progressive decline and others not. Russell et al (1997) in a
50 000 males conscripted to the Swedish Army between 1969 paper entitled ‘The myth of intellectual decline in schizophre-
and 1970. Tests of cognitive functioning were recorded at con- nia’ examined the childhood IQ of adult patients with schizo-
scription. In later life, 195 subjects were admitted to hospital phrenia (participants had IQ assessments on two occasions,
with schizophrenia. Low IQ emerged as a clear risk factor for with a 19-year interval between assessments). The authors
those later diagnosed with schizophrenia, and poor performance reported that measured IQs were one standard deviation below
on verbal tasks and a mechanical knowledge test conferred a sig- the general population mean on both occasions, but there was
nificantly increased risk of schizophrenia, even after taking into no significant difference between child and adult IQs. The
account general intellectual ability. In a more recent Swedish authors concluded that intellectual deficit observed in adult
study, data were analysed from nearly 200 000 male conscripts, patients is lifelong and predates the onset of schizophrenia.
and over a 5-year period, 60 men developed schizophrenia. Poor However, in a recent 33-year follow-up of patients who had
intellectual performance at 18 was associated with elevated risk initially been assessed for intellectual function soon after illness
for schizophrenia, and importantly this increased risk was not onset, it emerged that patients with schizophrenia showed a
attributable to prenatal adversity or childhood circumstances highly significant intellectual deterioration over time compared
(Gunnell et al 2002). with non-schizophrenic patient controls (Fig. 7.4) (Morrison
et al 2006). This result suggests that while intellectual
Taken together, the results of these and other studies impairment may precede illness onset, in many patients with
provide strong supportive evidence for the view that neuropsy- schizophrenia a further intellectual decline often occurs after
chological abnormalities pre-date the development of schizo- the illness develops. This view has received further support
phrenia. It is tempting to interpret these findings as evidence from a meta-analysis of studies of IQ in schizophrenia which
of a neurodevelopmental abnormality in those individuals found strong evidence of both premorbid IQ impairments and
who develop schizophrenia in late adolescence/early adult- a significant decline in IQ associated with the onset of frank
hood. This association could be directly causal – i.e. with cog- psychosis (Woodberry et al 2008).
nitive impairment leading to false beliefs and perceptions - or
alternatively, could act via an indirect mechanism, with any Are neuropsychological impairments
factors which cause low IQ (such as abnormal brain develop- in schizophrenia important?
ment) increasing later risk for schizophrenia (David et al
1997). Individuals who are at high genetic risk of developing Is impaired cognitive test performance in patients with schizo-
schizophrenia exhibit memory and executive impairments phrenia an epiphenomenon, e.g. simply reflecting lack of moti-
(Byrne et al 1999) together with reductions in hippocampal/ vation or distraction by hallucinations? In order to convince
amygdala complex volume (Lawrie et al 1999). Taken together, sceptics that the neuropsychological impairment is important,
these findings add support to the view of schizophrenia as a one would have to demonstrate a clear relationship between
neurodevelopmental disorder. However, it must be borne in cognitive test performance and ‘real-life’ functional outcome.
mind that some individuals who develop schizophrenia, do so
after a successful adolescence/early adulthood (e.g. attaining 50
scholastic and academic excellence), therefore pre-existing
cognitive impairment cannot explain all presentations of schizo- 40
phrenia, and again this suggests that a variety of aetiologies may Matched controls
lie under the broad umbrella term of schizophrenia.

Is schizophrenia associated with intellectual 30
decline?
Patients with
While there is increasing evidence of the presence of cognitive 20 schizophrenia
impairments which precede illness onset, there is more contro-
versy regarding whether there is further cognitive deterioration 10
following development of the illness. The published literature
examining the subsequent course of impairment is inconsistent. 0 Baseline 33-year
Cross-sectional studies have provided evidence both for and
against progressive deterioration but are, of course, vulnerable follow-up
to sources of bias which produce differences that are not due
to within-subject changes. Longitudinal studies are the best Fig. 7.4 Evidence of intellectual decline occurring in patients with
schizophrenia after the onset of the disorder. (Adapted from Morrison et al

2006.)

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Neuropsychology CHAPTER 7

Green (1996) reviewed studies that used cognitive measures Theory of mind
as predictors of functional outcome. The most consistent
finding to emerge was that verbal memory functioning was In addition to reading expressions, social interactions are
associated with all types of functional outcome. (Verbal enhanced by the ability to predict what people are going to
memory was the cognitive domain which showed the greatest say and do on the basis of their desires and beliefs. This realisa-
impairment in the meta-analysis by Heinrichs & Zakzanis tion that what people do is based on mental states such
1998.) Sustained attention/vigilance was also found to be as desires and beliefs is known as having a theory of mind
related to social problem-solving and skill acquisition. (Premack & Woodruff 1978) and the ability (largely uncon-
Psychotic symptoms were not significantly associated with scious) to make inferences about other peoples’ desires and
outcome measures in any of the studies that were reviewed. beliefs is known as mentalising (Frith & Frith 2008). There
Green (1996) concluded that deficiencies in verbal memory are several laboratory tests available for measuring theory of
and vigilance may prevent patients from attaining optimal mind ability (see e.g. Marjoram et al 2006) but standardised
adaptation and hence may act as rate-limiting factors in terms tests are not yet available. It is now well established that
of rehabilitation. Addington & Addington (1999) used a video- autism is associated with defects in theory of mind (Baron-
taped measure of interpersonal problem-solving skills in out- Cohen et al 2000) and more recently similar problems have
patients with schizophrenia and found that better cognitive been demonstrated in patients with schizophrenia (Bora et al
flexibility and verbal memory were positively associated with 2009). These problems are not simply the consequence of
interpersonal problem-solving ability. In addition other aspects low IQ (Bora et al 2009) or reduced executive function
of cognitive function known to be impaired in schizophrenia, (Pickup 2008). There has been considerable interest in relating
such as emotion perception and social cognition, have also theory of mind problems to specific symptoms of schizophre-
been found to relate to functional outcome (Couture et al nia. Persecutory delusions, for example, seem plausibly to
2006). The evidence thus strongly supports the view that relate to the false attribution of malevolent intentions and
cognitive impairment in schizophrenia is important and is beliefs to others and, hence, to excessive mentalising. In con-
directly related to functional outcome for many patients. trast, negative symptoms might relate to a failure of mentalis-
ing. However, while some studies report such relationships
The neuropsychology of schizophrenia: (e.g. Blakemore et al 2003) in general the literature on this
a new look point remains confusing (see Harrington et al 2005).

Traditional neuropsychological tests demonstrate convincingly Self-monitoring
that schizophrenia is associated with a whole range of cognitive
deficits. However, these deficits are by no means specific to Many of the symptoms of schizophrenia, such as delusions of
schizophrenia and clearly do not explain many of the key control and thought broadcasting, can be seen as resulting from
features of the disorder. These key features include hallucina- a misattribution of the source of stimulation. All overt actions,
tions, delusions and problems with social interactions. Such such as moving one’s arm or speaking, cause sensations, but
features are not typically seen in the neurological patients for these do not normally reach awareness (Blakemore et al
whom traditional neuropsychological tests were developed. 2002). The implication of these results is that a self-monitoring
In this section we will consider some of the techniques now process distinguishes between events caused by the self and
available for exploring these features. independent events with an external cause. A failure of this
self-monitoring can account for many symptoms of schizo-
Reading emotional expressions phrenia, in particular the first rank symptoms of Schneider
(Feinberg 1978; Frith 1987; Frith 1992). Evidence from both
Social interactions are considerably aided by the ability to read behavioural and imaging experiments give some support
the emotional expressions of others. Advances in the study of for these ideas (e.g. Ford & Mathalon 2004; Frith 2005;
this ability stem from Ekman’s demonstration of six basic Lindner et al 2005; ). However, at present the assessment of
emotions and the precise dispositions of facial muscles that self-monitoring requires sophisticated laboratory equipment,
create these expressions (Ekman & Friesen 1976, 1978). Test such as eye movement monitors and force transducers, rather
materials for assessing the ability to recognise the basic emo- than the paper and pencil tests typically employed by
tions are now widely available (Young et al 2002). Several neuropsychologists.
studies have demonstrated that patients with schizophrenia
have difficulty reading these emotional expressions, especially Belief formation
negative emotions such as fear (Marwick & Hall 2008). In
addition to the basic emotions, personality dispositions can The delusions associated with schizophrenia are typically
also be reliably attributed to particular faces. For example, bizarre beliefs which are resistant to argument or counter-
there is good agreement that certain faces look more trust- evidence. However, this problem with the formation of beliefs
worthy and approachable than others, although there is no evi- does not seem to be associated with marked impairment of
dence that these attributions have any validity. Patients with standard tests of logical reasoning (Kemp et al 1997). More
schizophrenia do not attribute trustworthiness and approach- recently belief formation has been considered as part of a more
ability in the normal way and this observation may well have general system by which we acquire knowledge about the
relevance to some of their problems with social interactions world. This knowledge acquisition is a continuous process in
(Hall et al 2004; Baas et al 2008). which new evidence from our senses is used to update our
beliefs about the state of the world. In this framework learning

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and belief formation is a probabilistic rather than a logical The performance of the ‘questionable patients’ correlated with
process. There is increasing evidence that patients with schizo- the degree of global cognitive decline (as measured by the
phrenia perform abnormally on probabilistic learning tasks and MMSE) over the next 8 months. At 32-month follow-up an
that these problems can be related to fronto-striatal circuits in equation based on initial PAL and graded naming test per-
the brain where the neurotransmitter dopamine has a major formance was used to predict those who would proceed to
role (see Fletcher & Frith 2009 for a review). It remains to develop dementia, and the algorithm was 100% accurate. This
be seen whether these learning abnormalities can be related is an impressive finding; however, the algorithm clearly has to
specifically to the development of delusions. Increasingly be tested prospectively on new samples of patients.
sophisticated computerised tasks are currently being developed
to assess learning and belief formation, and using Bayesian Cognitive bias
learning frameworks it is now possible to estimate specific para-
meters of the learning process. These developments will greatly Studies using affectively toned stimuli reveal that depressed
enhance our ability to assess abnormalities of belief formation in patients have consistently shown a memory bias towards nega-
schizophrenia and other disorders. tive material. Lloyd & Lishman (1975) reported that when
depressed patients were required to recall pleasant or unpleas-
Depression ant experiences from their past in response to cue words, the
more severe the depression the quicker the patient recalled
Memory impairment unpleasant relative to pleasant memories. Ridout et al (2003)
have recently shown that this bias extends to memories for
The only neuropsychological functions to feature in the socially meaningful stimuli (emotional facial expressions): clin-
DSM-IV diagnostic criteria for major depression are con- ically depressed patients showed superior memories for sad
centration and decision-making difficulties. However, many faces, whereas non-depressed healthy controls showed the
studies have reported a variety of neuropsychological impair- opposite pattern, superior memory for happy expressions
ments in depression, particularly deficits in memory, executive (Fig. 7.5).
functioning and psychomotor functioning (Veiel 1997). Mem-
ory impairment in depression can be so severe that patients Teasdale (1983) proposed that this mood-congruent mem-
can be misclassified as having dementia – ‘depressive pseudo- ory bias may be an important mechanism in the maintenance
dementia’. Such a misdiagnosis can have catastrophic conse- of depression. If an individual is in a depressed state, a
quences in that a treatable, potentially fatal condition is mood-congruent memory bias means that negative memories
missed. Lezak (1995) has described the separation of depres- are more accessible, and recall of these memories may help
sion from dementia as perhaps the ‘knottiest problem of maintain or exacerbate the depressed mood. This may then
differential diagnosis’. lead to recall of more negative memories, thus creating a
self-perpetuating vicious circle. Williams et al (1996) have also
Knopman & Ryberg (1989) suggested that elaborate encod- described the phenomenon of overgeneral retrieval style in
ing may provide a substantial benefit to non-demented sub- depression, where patients have marked difficulty in retrieving
jects but not to patients with Alzheimer’s disease and specific events from their past. This is seen where depressed
developed the Delayed Word Recall Test or DWR. This test patients have a significantly longer latency to produce a specific
involves presentation of 10 words individually; subjects are autobiographical memory in response to a positive cue word,
required to read each word and construct a sentence using e.g. ‘happy’ (Fig. 7.6).
each word; the process is then repeated and, after a 5-minute
filled delay, memory (free recall) of the 10 words is tested. Percentage correct recognitions 100
Both Knopman & Ryberg (1989) and Coen et al (1996) Depressed
reported almost perfect separation of patients with early
dementia from matched controls, using a <3/10 cutoff. How- 90 Controls
ever, both studies used healthy participants as controls. When
the comparison was repeated using dementia patients versus 80
age-matched, clinically depressed patients, using the recom-
mended <3/10 cut-off, 44% of depressed patients would have 70
been misclassified as having dementia (O’Carroll et al 1997).
This finding highlights the degree of memory impairment that 60
can exist in depression, and that extreme caution should be
employed when considering categorical cut-off scores derived 50
from studies that have compared patients with dementia with
healthy controls. 40 Neutral Sad
Happy
Recently, Swainson et al (2001) have reported impressive
findings using a computerised visuospatial paired associative Valence of emotional facial expression
learning test (PAL) which accurately distinguished Alzheimer
patients from depressed and healthy control subjects. The Fig. 7.5 Dissociation in memory bias for positive or negative
measure also revealed a sub-group of questionable dementia facial expressions in depressed patients versus matched
patients who performed similarly to the Alzheimer patients. controls. Depressed patients show superior memory for sad
faces whereas healthy controls show the opposite tendency.

(After Ridout et al 2003.)

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Neuropsychology CHAPTER 7

Mean response time in seconds 14 Is poor neuropsychological test performance
Depressed in depressed patients an artefact of poor
Controls motivation?

12 Many writers have attributed observed neuropsychological
impairment in depression to the non-specific effects of moti-
10 vational deficits. Few studies have tested this hypothesis
experimentally. Richards & Ruff (1989) randomly assigned
8 two groups of subjects, depressed and non-depressed, to either
motivation or non-motivation conditions (motivation involved
6 encouragement – a monetary incentive and performance feed-
back). The authors reported that performance (as measured
Positive Negative by improvement on a simple card-sorting task) was signifi-
cantly enhanced for the subjects in the motivation condition.
Valence of memory Crucially, motivation did not significantly affect neuropsy-
chological test performance, and the authors concluded that
Fig. 7.6 Significant latency for positive specific autobiographical although depressed patients may be less motivated, this
memories demonstrated by patients with clinical depression. (After reduced motivation does not fully account for the observed
neuropsychological impairments in depression.
Ridout et al 2003.)

It is commonly observed that patients tend to produce cat- What is the neurobiological substrate of memory
egorical memories, e.g. ‘at weekends’, rather than specific impairment in depression?
events, ‘last Friday night at the party’, despite repeated
prompting. Williams et al (1996) propose that this difficulty Several studies have reported significant atrophy in medial
in progressing beyond categorical to specific autobiographical temporal lobe structures in patients with chronic depression.
memories – ‘mnemonic interlock’ – may serve the function It has been proposed that chronically raised cortisol levels in
of controlling affective state, in avoiding painful specific auto- depression can facilitate hippocampal neuronal death, which
biographical memories, e.g. of a romantic dinner with a lover in turn may cause dysregulation of the hypothalamo-pituitary-
who has now left. adrenal (HPA) axis. As well as showing temporal lobe atrophy
in treatment-resistant patients (Fig. 7.7), Shah et al (1998)
Effortful versus automatic processing showed a significant positive correlation between left hippocam-
in depression pal density and performance in delayed verbal recognition in
treatment-resistant, chronically depressed patients. Patients
Several authors have proposed that depressed patients experi- who had recovered from their depression had normal MRI scans.
ence particular difficulty on memory tasks that require elabo-
rate or effortful organisation and processing of material to be Bipolar disorder
remembered, but that they do not show problems in memory
tasks on which ‘automatic’ memory processes are presumed to Surprisingly the neuropsychology of bipolar disorder has
be involved. In line with this proposal, Weingartner (1986) received generally less study than that of schizophrenia or
reported that depressed patients demonstrate impairments depression. Recent evidence suggests that a broad range of
on delayed free recall (effortful) with no impairment on recog- cognitive abilities are impaired during illness episodes, includ-
nition memory (relatively automatic), whereas demented ing memory, attention and executive function (Quraishi &
patients perform poorly in both conditions. However, Lachner Frangou 2002). Some residual impairments are also present
et al (1994) provided evidence which challenges the in the euthymic state, particularly in the domains of verbal
Weingartner model. They compared three groups (demented, memory and attention (Cavanagh et al 2002; Quraishi &
depressed and healthy subjects) who were in their seventies Frangou 2002), and deficits in memory function are also seen
on five verbal recall and two recognition memory tasks. They in the unaffected relatives of subjects with bipolar disorder
found that both delayed recall and recognition after long delay (McIntosh et al 2005). In addition, a more severe course of
were the measures which best discriminated between the illness and a greater number of illness episodes have been
demented and the depressed patient groups. It is interesting associated with more impaired neuropsychological functioning,
to note that the recognition measure was more discriminating suggesting that repeated manic episodes may be neurotoxic
than free recall, selective reminding or serial learning, all pre- (Cavanagh et al 2002; Moorhead et al 2007). The pathophysi-
sumably more ‘effortful’ than a recognition memory task. ological mechanisms are not fully understood, though hyper-
Lachner et al (1994) make the pertinent point that the label- cortisolaemia may be implicated and may result in impaired
ling of some cognitive tasks as effortful versus automatic is neuropsychological functioning (McAllister-Williams et al
often ambiguous: ‘In future research, the tasks cognitive capac- 1998). Relatively few neuropsychological studies have been
ity requirements should be examined empirically to avoid conducted on manic patients. Preliminary work suggests that
inconsistencies by subjectively estimating capacity demands’ both manic and depressed patients are impaired on tests of
(Lachner et al 1994, p. 10). memory and planning, but differences have been noted in

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Fig. 7.7 Bilaterally reduced grey-
matter density in medial temporal
cortex in treatment-resistant,
chronically depressed patients
compared with 20 normal controls. The
image is the result of subtracting values
between depressed and healthy
participants. The Z value represents
the magnitude of the difference; lighter
colour indicates greater difference.

(Reproduced, with the permission of Elsevier
Limited, from Doris A et al, Lancet 1999; 354:
1369–1375.)

attentional shifting, with manic patients having difficulty with Subsequent anterograde memory impairment may be due to
inhibition of behavioural response and attentional focus, and the deleterious effects of stress hormones (e.g. long-term
depressed patients impaired in their ability to shift the focus hyper-cortisolaemia) on the hippocampal function. Several
of their attentional bias (Murphy & Sahakian 2001). The same MRI studies have now shown that PTSD is associated with
authors confirmed the affective bias for negative material in reduction in volume of the hippocampus, a brain area critically
depression, but also demonstrated the opposite affective bias involved in new learning and memory (e.g. Bremner 1999).
for positive stimuli in mania.

Memory for emotional material Dual representation theory of PTSD

Emotion lies at the heartland of psychiatry, and abnormalities Brewin (2001) has recently developed a dual representation
of emotional processing are evident in a variety of disorders, theory of PTSD. Importantly, PTSD is viewed as a failure
perhaps most notably in post-traumatic stress disorder of adaptation, the inability to adapt following exposure to a
(PTSD). PTSD is a condition where exposure to an intense traumatic event. Brewin proposes that two memory systems
frightening emotional experience leads to lasting changes in are critical for our understanding of PTSD: verbally accessible,
behaviour, affect and cognition. Typically after a life-threatening declarative memory (VAM) and a situationally accessible, non-
incident (e.g. a violent assault, rape or wartime experience), declarative memory (SAM). VAM memories are hippocam-
the individual displays re-experiencing of the event(s), e.g. pally dependent, whereas SAM memories are non-hippocampally
via intrusive, distressing thoughts, images, ‘flashbacks’ or dependent, and involve the amygdala. In PTSD, it is proposed
nightmares. The individual may exhibit phobic avoidance that a considerable amount of trauma information resides solely
and/or physiological reactivity to reminders of the trauma. in the SAM system, and these SAM memories are particularly
Increased arousal in terms of sleep disturbance, irritability vulnerable to reactivation by trauma cues, e.g. flashbacks in
and exaggerated startle response are common. In addition, response to sight or smells of trauma reminders (Brewin 2001).
the individual may exhibit a restricted range of affect, sense
of a foreshortened future and may lose interest in previ- VAM memories can be retrieved either automatically or
ously rewarding hobbies or activities. PTSD is characterised using deliberate, strategic processes, so that they can be edited
by intrusive distressing memories of the traumatic event. and interact with the rest of the person’s autobiographical
Paradoxically, it is also often associated with marked impair- memory. VAM memories are readily available for verbal com-
ments in learning and memory for new material. Patients often munication with others and involve cognitive appraisals. SAM
complain that they remember what they do not want to, yet memories, in contrast, contain information from more exten-
cannot remember what they now wish to. Heightened arousal sive but lower level perceptual processing of the traumatic
at the time of encoding may result in modulation (strengthen- scene and the person’s bodily responses. These SAM mem-
ing) of the memory trace, possibly via noradrenaline (norepi- ories are difficult to communicate to others and are difficult
nephrine) release in the amygdala (Cahill & McGaugh 1998). to control, because people cannot always regulate their expo-
sure to sights, sounds and smells that can act as reminders of
the trauma. Brewin proposes that stress (possibly via effects

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Neuropsychology CHAPTER 7

of stress hormones such as cortisol) leads to an impairment of therapeutic procedures should aim to ‘fill in the gaps’ in
the hippocampus-dependent declarative (VAM) memory sys- VAM memory, e.g. via prolonged exposure, focusing on times
tem. The resultant VAM memories are thus fragmented and of peak emotion during the trauma, and attempting to build up
incomplete. In contrast emotional and sensory information a detailed narrative. Over time, this process provides the
are encoded particularly well in the SAM system during times declarative memory system with a retrieval advantage.
of stress, possibly via noradrenergic/amygdala effects acting to
strengthen encoding (Cahill & McGaugh 1998). This results in Cognitive neuropsychiatry
detailed sensory memories which are not encoded for context,
e.g. time, and when retrieved, they are re-experienced in the Cognitive neuropsychiatry is a relatively new discipline which
present. aims to further understanding of psychopathological states
via careful analysis of information processing (Halligan &
It is proposed that during normal recovery from trauma, David 2001). One major thrust in this area is to focus on par-
early flashbacks etc. lead to copying of extra information from ticular signs and symptoms (e.g. specific delusions) rather than
non-declarative (SAM) to declarative systems (VAM). As this attempt to explain broad illness categories. The following
is a limited-capacity system, little information is transferred at examples of delusional misidentification syndromes illustrate
any one time, but over time as the person attends to the this approach.
images etc., information is receded into a contextualised
declarative memory, where the experience is clearly labelled The Capgras syndrome involves the belief that impostors
as having occurred in the past. This leads to inhibition of the have replaced people to whom the sufferer is emotionally
amygdala from responding inappropriately, as it is now recog- close (e.g. a loved one or a relative). It is believed that the
nised that threat is no longer present. Brewin (2001) proposes impostors have assumed the roles of the persons they imper-
that in PTSD the declarative system (VAM) fails to make a sonate and behave like them. Some patients who suffer from
good memory trace of the event and sensory information Capgras syndrome may threaten, harm or even kill the sup-
remains relatively isolated in the non-declarative memory sys- posed impostor. Up to 40% of cases are associated with
tem (SAM). These memories are re-experienced as in the organic disorders, e.g. head injury and dementia. Right cerebral
present, and, with a failure of adaptation, progressive sensitisa- hemisphere dysfunction has also frequently been reported in
tion over time occurs. The emotions that accompany SAM patients suffering from Capgras syndrome. Ellis & Young
memories consist mainly of fear, helplessness, horror and (1990) presented a cognitive account of Capgras syndrome.
shame. This leads to an overturning of basic assumptions, e.g. They proposed two distinct routes to facial recognition: one
views of the world as benevolent and the self as worthy change for the actual identification of the face, and the other to give
to the world being seen as a dangerous place with the self the face its emotional significance. They proposed that proso-
viewed as powerless, inferior and worthless. Brewin (2001) pagnosia results from a disruption of the first route, whereas
thus presents a theoretical model of PTSD (Fig. 7.8) that com- Capgras syndrome is ‘a mirror image’ of prosopagnosia. Thus,
bines findings from cognitive psychology and neuroscience. It they propose that Capgras patients have an intact primary
can inform therapeutic interventions, as it suggests that route to face recognition but have a disconnection or damage
within the route that gives the face its emotional significance.
Verbally accessible Situationally accessible Ellis et al (1997) demonstrated that people with the Capgras
memory (VAM) memory (SAM) delusion fail to show autonomic discrimination between famil-
(Declarative) (Non-declarative) iar and unfamiliar faces. Their model proposes that to the per-
son with Capgras syndrome, the impostor’s face looks identical
Hippocampus Amygdala but the emotional feelings associated with their face are abnor-
dependent dependent mal. Put another way, the patient receives a veridical image
of the person they are looking at, which stimulates the appro-
Stress impairs Stress enhances priate semantic data about the person, but the patient lacks
VAM encoding SAM encoding another set of confirmatory information which may carry the
(via cortisol effects?) (via noradrenergic/ appropriate affective tone for a loved one. The patient then
amygdala action?) adopts a rationalisation strategy, i.e. the person looks the same
but somehow does not feel the same, and therefore the person
must be an impostor. The Capgras patient mistakes a change in
themselves for a change in others. Recent work in this area is
reviewed by Ellis & Lewis (2001).

Fragmented Detailed sensory Psychometric issues—reliability and
incomplete SAM memories, validity
VAM memories not encoded for
context (time) When evaluating a particular neuropsychological measure, one
must pay particular attention to the test’s reliability and valid-
Fig. 7.8 Brewin’s dual-representational model of post-traumatic ity. The reliability of a test refers to the accuracy, consistency
stress disorder.

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and stability of test scores across situations. It is important CAMCOG
to remember that a test score is always an approximation of
an individual’s hypothetical true score – i.e. the score an indi- The CAMCOG (Roth et al 1986) contains the MMSE with
vidual would receive if the test were perfectly reliable. The some additional coverage of perception, memory and abstract
difference between this hypothetical true score and the thinking. The psychometric properties of the CAMCOG are
obtained test score is termed the measurement error. A reliable satisfactory; the test–retest reliability of the scale as a whole
test will have a small measurement error and consistent results is high (0.86), as is its internal consistency (coefficients range
should be obtained both within and between measurement from 0.82 to 0.89). CAMCOG scores are, unsurprisingly,
sessions (e.g. test-retest reliability). While great care is taken affected by age, sociocultural factors and hearing and visual
in ensuring reliable measurement in many areas of biological deficits.
psychiatry (e.g. neuroimaging, endocrine measurement), a sur-
prisingly lax attitude is often taken towards the quantification Measures of current intellectual ability
of behaviour in neuropsychological assessment. Some research-
ers will cavalierly embark on a project with no or superficial The wechsler adult intelligence scale,
training in neuropsychological test administration, often paying third edition (WAIS-III)
scant attention to the detailed administration instructions that
are provided, with the result that substantial measurement The WAIS tradition started with the publication of the
error is introduced. Wechsler-Bellevue Intelligence Scale in 1939. This was revised
and renamed the Wechsler Adult Intelligence Scale (WAIS) in
The validity of a test is the extent to which a test measures 1955, which in turn was revised as the WAIS-R in 1981. Like
what it is supposed to measure, e.g. a prospective memory test its predecessors the recently published WAIS-III is likely to
should measure prospective memory! There are several forms represent the ‘gold standard’ against which other measures of
of validity. Construct validity refers to the extent to which per- intellectual ability are gauged. The WAIS-III was developed
formance on a test fits into a theoretical schema about the attri- and co-normed with the Wechsler Memory Scale, third
bute the test attempts to measure. Predictive validity refers to edition (WMS-III) (see below). Wechsler originally described
whether performance on the test accurately predicts some exter- intelligence as the ‘capacity of the individual to act pur-
nal criterion (e.g. final degree outcome). Incremental validity is posefully, to think rationally, and to deal effectively with his
the term used to describe what the test adds to the predictive environment’. The WAIS-III has normative data from 2450
validity already provided by other measures. Criterion-related individuals aged 16–89. The traditional Wechsler approach
validity is based on the test’s correlation with a similar measure; has been to administer a number of subtests, each tapping
if the related measure is administered at the same time, the different aspects of intelligence, and then to reduce these
degree of association is termed concurrent validity. to composite Verbal, Performance and Full-Scale IQ scores
(VIQ, PIQ and FSIQ, respectively), each with an age-adjusted
Neuropsychological measures mean of 100 with a standard deviation of 15. This approach
has been retained in the WAIS-III. Verbal IQ is calculated
In this section, some commonly used neuropsychological based on the sum of the following subtests: Vocabulary,
measures in the broad domains of cognitive screening, current Similarities, Arithmetic, Digit Span, Information and Compre-
and premorbid intelligence, memory, language, visuospatial hension. Performance IQ is calculated from the sum of the
functioning, attention and executive functioning will briefly be following subtests: Picture Completion, Digit Symbol coding,
presented. Finally, computerised neuropsychological assessment Block Design, Matrix Reasoning and Picture Arrangement.
systems will be reviewed. However, factor analytic studies have suggested that the sub-
tests do not fall neatly into verbal and performance IQ; rather,
Cognitive screening measures four factors emerge: Verbal Comprehension, Perceptual Orga-
nisation, Working Memory and Processing Speed. With the
Mini mental state examination (MMSE) addition of three further subtests (Symbol Search, Letter-
Number Sequencing and Object Assembly) it is also possible
The MMSE (Folstein et al 1975) is probably the most fre- to calculate scores on these four indices. The WAIS-III is a sig-
quently used screening scale and is often used as part of a nificant improvement on its predecessors, with better norms,
larger battery for a comprehensive assessment of dementia. improved artwork for visually presented items and impressive
It is a very brief and easily administered instrument and takes reliability coefficients for IQ scales and indexes (0.88–0.97).
about 5–10 minutes in total. It tests orientation, information
and visuoconstructive abilities; total scores can range between Wechsler abbreviated scale
0 and 30. In their original study, Folstein et al reported a high of intelligence (WASI)
test–retest reliability of 0.83 when retesting was conducted
by a different examiner, and 0.89 when the same examiner The WASI is an abbreviated version of the full WAIS-III and
was used. High test–retest reliability has been confirmed by thus is useful in cases where a brief measure of intellectual
later studies. Caution is required when interpreting scores function is required. The WASI consists of four subtests:
obtained from poorly educated individuals. Level of education Vocabulary, Similarities, Block Design and Matrix Reasoning.
has consistently been shown to be related to MMSE score. The four-subtest form can be administered in 30 minutes

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Neuropsychology CHAPTER 7

and results in FSIQ, VIQ and PIQ scores. The PIQ score is the test taps previous word knowledge; as the test only
obtained from the Matrix Reasoning and Block Design sub- requires the reading of single words, patients do not have to
tests. The Vocabulary and Similarities subtests compose the provide the word’s meaning, and it is argued that the test
Verbal Scale and yield the VIQ. An estimate of general intel- therefore makes minimal demands on current cognitive ability
lectual ability can be obtained from the two-subtest form, (Nelson & Willison 1991). The development of the NART
which can be given in about 15 minutes. This short form arose from the clinical observation that oral reading is com-
includes Vocabulary and Matrix Reasoning and provides only monly preserved in dementia (whereas reading for meaning
the FSIQ score. A particular strength of the WASI is that is commonly impaired). However, the test is now used to
two parallel forms can be used, so that practice effects on estimate premorbid ability in a wide range of conditions.
repeated testing are avoided.
To qualify for use as a measure of premorbid ability a test
Raven’s progressive matrices must fulfil three criteria. First, as with any psychological test,
it must possess adequate reliability. The NART has high
The progressive matrices consist of a series of visuospatial split-half reliability/internal consistency, test–retest reliability
problem-solving tasks, thought to tap general intelligence and inter-rater reliability (Crawford 1992). Second, it must
(‘g’) that is relatively independent of education or cultural have high criterion validity. The NART is normally used to
influence. The standard progressive matrices have been most provide an estimate of general premorbid IQ against which
widely used in clinical practice and research and consist of current performance is compared. Thus to meet the second
60 items. (Children’s and advanced sets are also available.) requirement the NART must be capable of predicting a sub-
The test is untimed but usually takes around 40 minutes stantial proportion of IQ variance. In most studies using the
to complete. Test–retest reliability is above 0.8 and internal WAIS or WAIS-R as the criterion variable the NART pre-
reliability is above 0.7. An extremely useful feature of the dicted well over 50% of IQ variance. The final criterion for a
matrices is the publication of a normative rate of decay profile putative measure of premorbid ability is that test performance
(the normal pattern of failing more items as the test becomes be relatively resistant to the effects of neurological or psychiat-
progressively more difficult). This allows the detection of ric disorder. NART performance appears to be largely resistant
individuals who are faking poor performance, e.g. in com- to the effects of many neurological and psychiatric disorders,
pensation claims (Gudjonssen & Shackleton 1986). (A pro- e.g. depression, acute schizophrenia, alcoholic dementia,
gressive matrices type subtest has now been included in the closed head injury and Parkinson’s disease (Crawford 1992;
WAIS-III, entitled ‘matrix reasoning’, and of the performance O’Carroll 1995). Mixed findings have been found in samples
subtests, has the highest correlation with overall full-scale IQ, with probable dementia of the Alzheimer type. It is becoming
r ¼ 0.69.) increasingly clear that NART performance can be substantially
impaired in many cases of moderate to severe dementia. There
Measures of premorbid intellectual ability is a danger associated with the indiscriminate use of measures
such as the NART in a variety of conditions where it is not
When one assesses an individual’s cognitive ability, there is clear that oral pronunciation is preserved. For example, both
usually no record of that individual having been previously Crawford et al (1988) and O’Carroll et al (1992) found
assessed; therefore one must infer whether cognitive deterio- evidence of marked impairment in NART performance in
ration has occurred. For example, if an individual’s current patients with Korsakof’s syndrome, suggesting that it is inappro-
full-scale intelligence quotient is measured at 85 (one standard priate to estimate premorbid ability in Korsakoff’s syndrome
deviation below the mean), is that a significant deteriora- using the NART. Despite this, a number of studies have since
tion from a premorbid level, or has that individual always been published using the NART in this patient group to estimate
functioned at this level? Traditionally clinicians have used premorbid ability. The NART can be seen as a quick and easy
background information to help inform their opinion (e.g. way of estimating intellectual ability for subject matching in
based on occupation, years of full-time education, etc.). How- research studies. If the condition under investigation impairs
ever, over the last 20 years, measures have been developed reading/pronunciation ability, such subject matching is inevitably
which aim to formalise and improve the accuracy of this esti- flawed.
mation of premorbid ability. These measures are largely based
on the observation that reading ability is largely preserved in The cambridge contextual reading test (CCRT)
the face of organic impairment and is highly correlated with
intellectual ability in the general population. It has been proposed that asking elderly demented individuals
to read aloud a list of 50 irregular words is not the best way of
The national adult reading test (NART) maximising their performance, in that the unusual words are
not presented in context. In the CCRT the NART words are
To date the NART has been the test most widely used to embedded in sentences to provide a meaningful context for
estimate premorbid ability. The NART is a single-word, oral the examinee, e.g. ‘the bride bought a beautiful bouquet’
reading test consisting of 50 items. All the words are irregular, (Beardsall 1998). This results in improved accuracy of pronun-
that is they violate grapheme-phoneme correspondence rules ciation by patients with dementia. Unfortunately, the CCRT
(e.g. chord). Because the words are irregular, intelligent guess- has not been normed against current measures of intelligence
work should not provide the correct pronunciation, therefore (e.g. WAIS-III) so that it is not possible to readily use the
CCRT to estimate premorbid intelligence level.

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The spot the word test (STW) Auditory Recognition Delayed, General Memory and Working
Memory. It is therefore possible to obtain accurate quantifica-
Most of the premorbid estimate measures involve accuracy tion of various components of memory functioning. However,
of oral pronunciation. These methods are clearly inappropri- a major limitation of the WMS-III is the lack of a matched,
ate for people with articulation/pronunciation difficulties. parallel version. In neuropsychological practice, it is common
Additionally, it has been proposed that highly intelligent self- to reassess an individual in order to determine the extent of
educated people who are well read may well be familiar with deterioration, treatment efficacy, etc. However, when one
a word (and its meaning) yet may make pronunciation errors. re-administers the same memory test, considerable savings
In order to overcome these difficulties the STW test was occur. Indeed the WMS-III technical manual reports that
developed (Baddeley et al 1993). The STW is a lexical deci- when the test was re-administered within 2–12 weeks, the
sion task in which the examinee has to identify ‘real’ words mean index scores increased by roughly 0.33–1 standard
from a series of word/pseudo-word pairs (e.g. stamen/floxid). deviation from first to second testing.
This is an interesting development; however, use of the
STW is currently mainly limited to research applications, as The auditory verbal learning test (AVLT)
(1) regression equations have yet to be developed to provide
estimates of premorbid ability, and (2) there is insufficient The AVLT is one of the most widely used word-learning tests
evidence on the STW’s relative sensitivity in cases of acquired in clinical research and practice (Rey 1964). Five presentations
cognitive impairment. of a 15-word list are given, each followed by attempted recall.
This is followed by a second 15-word interference list (list B),
The wechsler test of adult reading (WTAR) followed by recall of list A. Delayed recall and recognition are
also tested. A key feature of the AVLT (and its successor, the
The WTAR is a NART equivalent, a 50-item word pronunci- California Verbal Learning Test) is that it affords the opportu-
ation test, developed to provide an estimate of premorbid nity to measure rate of learning, as opposed to recall of a single
intellectual functioning of adults aged 16–89, with the particu- stimulus, or series of stimuli. An equivalent form of AVLT has
lar advantage of having been developed and co-normed with been provided by Crawford et al (1989).
the WAIS-III and WMS-III. Thus, one can directly compare
WTAR-predicted scores with those obtained from WAIS-III The california verbal learning test (CVLT)
and WMS-III. The WTAR provides tables of statistical signifi-
cance in interpreting predicted minus obtained values. For In an attempt to expand upon the assessment of learning
example, a 68-year-old woman produced a WTAR-predicted and retrieval strategies, the CVLT evolved from the AVLT
IQ of 85, which compared with an obtained IQ score of 60. and was developed in an attempt to provide an instrument
This 25-point discrepancy is considered to be statistically sig- ‘reflecting the multifactorial ways in which examinees learn,
nificant at the 1% level. The correlation between WTAR and or fail to learn, verbal material. The CVLT’s assessment of
WAIS-III Verbal IQ across the standardisation age groups learning strategies, processes and errors is designed for use in
ranged from 0.66 to 0.80, and for full scale IQ from 0.63 to both clinical and research practice’ (Delis et al 1987). A vari-
0.80, with an expected lower correlation with Performance ety of memory measures are obtainable from this measure,
IQ (0.45–0.66). The WTAR correlates well with other mea- including short-term and long-term free recall and recognition,
sures of reading (including the NART), range 0.73–0.90. In serial learning curves, learning strategy (i.e. semantic versus
the UK the WTAR was also completed by 80% of the parti- serial clustering), etc. The CVLT also has the added advantage
cipants in the WAIS-III UK standardisation study. Given this of presenting the stimuli in an everyday, relatively non-
co-norming procedure, it is likely that the WTAR will become threatening manner, e.g. learning two shopping lists. The reli-
widely used to estimate premorbid intellectual ability. ability data for the principal measures appear to be adequate,
although some of the scores which are derived from them have
Measures of memory poor reliability. The normative database consists of 273 neuro-
logically intact individuals, with a mean age of 58.9 (15.4)
The wechsler memory scale, 3rd edition years. This mean age for controls is considerably higher than
(WMS-III) that normally employed for psychometric test development.
A computerised scoring procedure is also available (Delis
The WMS-III builds upon the success of its predecessors, the et al 1987).
original Wechsler Memory Scale (WMS) and the Wechsler
Memory Scale Revised (WMS-R) and is generally considered The rivermead behavioural memory test (RBMT)
to be a considerable improvement. As stated above, the
WMS-III was developed and co-normed with the WAIS-III. The RBMT was specifically designed to try and detect
Normative scores for the WMS-III were obtained from 1250 impairment of everyday memory function by providing test
adults, age range 16–89 years. Eleven subtests are presented items that resembled activities in everyday life, e.g. remem-
and eight memory indices are calculated, each with an age- bering to deliver a message, remembering to retrieve a personal
normed mean of 100 and a standard deviation of 15. The belonging after an interval. The RBMT has the important
memory indices are: Auditory Immediate, Visual Immediate, advantage of having four matched parallel versions, thus allow-
Immediate Memory, Auditory Delayed, Visual Delayed, ing for repeated assessment to determine the effects of dis-
ease progression and/or clinical intervention. An additional

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Neuropsychology CHAPTER 7

important advantage of the RBMT is the careful work the from memory; a names test, which is a verbal recognition test;
authors have undertaken in order to ensure the measure’s and finally, the peoples test, where the subject is required to
validity. They assessed validity in three ways: (1) by demon- learn an association between a series of photographs and
strating a high correlation between the RBMT and other stan- names. Normative data from 238 subjects is provided, aged
dard memory tests; (2) by demonstrating a high correlation from 16 to 97 years. One of the stated aims of the authors
between RBMT scores and subjective ratings of memory was that Doors and People should ‘provide an unstressful test
impairment; and (3) most importantly, by demonstrating a high that is acceptable to a wide range of subjects, extending from
correlation between RBMT score and observer ratings of patients suffering from dementia or dense amnesia to healthy
memory lapses (Wilson et al 1989). In general, the RBMT is young normal subjects’ (Baddeley et al 1994, p. 4). However,
well tolerated on account of its ‘everyday feel’ and the fact that some elderly, cognitively impaired subjects find this test quite
it consists of a number of brief, relatively non-threatening sub- demanding.
tests. The initial normative data were provided from 118 sub-
jects aged 16–69 years. Cockburn & Smith (1989) recruited Measures of language dysfunction
additional normative data from 119 people aged 70–94 years,
with a mean age of 80.5 years. A limitation of the RBMT is that Naming
it may be rather insensitive to mild impairments of memory.
In order to improve the sensitivity of the test, the extended The Boston Naming Test (BNT) is one of the most widely
RBMT (RBMT-E) was developed. Versions A and B of the orig- used measures of naming. The original version of this test
inal RBMT were combined to make version 1 of the RBMT-E, included 85 items; however, the shortened version produced
and versions C and D were combined to make version 2 of in 1983 is used more frequently (Kaplan et al 1983). This test
the RBMT-E. The RBMT-E is useful in separating out those consists of 60 line drawings of objects of graded difficulty,
individuals who scored at the upper range of the original RBMT. ranging from very common objects (e.g. a tree) to less familiar
objects such as an abacus. Although the original normative data
The rey complex figure test (CFT) are scanty, several studies have provided supplementary
norms; these studies have been comprehensively reviewed
This test has been widely used, particularly because of the recently by D’Elia et al (1995).
dearth of adequate visuospatial memory tests. A complicated
figure is presented and the subject is requested to copy it. Vocabulary
The original and copy are then removed and the subject is
asked to draw the figure again from memory, after varying The most widely used instrument for the assessment of vocab-
delay intervals. There have been many variants on administration ulary ability is the Vocabulary subtest of the WAIS-III scales.
and scoring criteria, e.g. immediate, 3-minute or 30-minute Performance on this test is greatly influenced by education
delay. Spreen & Strauss (1998) provide useful normative data and sociocultural factors rather than age. Vocabulary is the
up to 93 years of age. Test–retest reliability following a retest subtest of the WAIS-III and has the highest correlation
interval was reported as 0.76 for immediate recall and 0.89 for with total IQ scores: Verbal IQ r ¼ 0.83, Performance IQ
delayed recall. r ¼ 0.65 and Full scale IQ r ¼ 0.80.

The recognition memory test (RMT) Verbal comprehension

The RMT is a widely used instrument, particularly in amnesia The most widely used test of verbal comprehension is the
research. It consists of two subtests: recognition memory for Token Test. The original version of this test consists of 62
50 words and recognition memory for 50 faces. Following items, but a 36-item short-form is more commonly used in
the presentation of the words and faces, the testee is required clinical practice (De Renzi & Faglioni 1978). The materials
to perform an immediate two-choice recognition task; this is consist of tokens which differ in colour, shape (squares and
generally considered to be less stressful and anxiety provok- circles) and size (large and small). The examinee has to follow
ing than many other memory measures (taking approximately verbal instructions which increase in complexity from simple
15 minutes to complete). The original normative data consists commands (e.g. ‘Touch a circle’; ‘Touch the red circle’) to
of 310 control inpatients without cerebral disease, aged 18–70 commands such as ‘Before touching the yellow circle, pick
years (Warrington 1984); however, additional norms are up the red square’. The test authors recommend that scores
provided in D’Elia et al (1995). be adjusted for years of education. Adjusted scores of between
25 and 28 are regarded as indicating mild comprehension
The Doors and People Test problems, and 17–27 moderate problems; scores below this
are classified as severe, or very severe.
The Doors and People Test was devised in order to provide
comparable measures of visual and verbal memory that test Visuoconstructional ability
both recall and recognition, that do not provide floor or ceiling
effects and that include both learning and forgetting measures. The Block Design subtest of the WAIS-III is widely used for
The test consists of four sections: a doors test, where single assessing visuospatial constructional abilities. Block Design is
doors have to be recognised against three competing distrac- often administered in its own right (rather than as part of
ters; a shapes test, where diagrams have to be reproduced

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Companion to Psychiatric Studies

the complete WAIS-III), and can be interpreted with refer- in psychological, not anatomical terms. Executive functions
ence to an age-controlled standard score of 10 with a standard describe higher-order cognitive processes including initiation,
deviation of 3. Visuoconstructional abilities can also be planning, hypothesis generation, cognitive flexibility, decision
assessed by means of copying or free drawing. The Rey making, judgement and feedback utilisation that are necessary
Complex Figure (described above) is the most widely used for effective and socially appropriate behaviour (Spreen &
copying test. Strauss 1998). For patients who have problems in these areas
the term ‘dysexecutive syndrome’ is preferred as it stresses
Assessment of attention the psychological nature of the difficulties the patients experi-
ence rather than the putative area of the brain that has been
The test of everyday attention (TEA) damaged.

The TEA consists of eight subtests (standardised in a similar Verbal fluency
way to the WAIS-III and WMS-III to have an-age adjusted
mean of 10 with a standard deviation of 3) which measure sus- Verbal fluency tests, and in particular initial letter fluency, are
tained, selective and divided attention (Robertson et al 1996). widely used as tests of executive dysfunction. Initial letter flu-
For example, in the Map Search subtest, which was designed ency, also referred to as the Controlled Oral Word Association
as a measure of visual selective attention, the examinee has Test (COWAT), requires the generation of words from initial
to search for symbols (e.g. a knife and fork representing eating letters (normally F, A and S) under time constraints, normally
facilities) on a tourist map of a city. The Elevator Counting 60 seconds per letter (Benton & Hamsher 1978). Fluency tests
subtest, which was designed to measure sustained attention, are reliable, quick to administer and even patients with quite
is a tone counting task in which the examinee is asked to imag- severe deficits can understand the task requirements. In an
ine they are in an elevator in which the floor-indicator has area replete with failures to replicate, studies of initial letter
failed (thus counting the tones is the only way to establish fluency have been remarkably consistent in demonstrating
which floor the elevator is on). A related subtest, designed to impaired fluency following left or bilateral frontal lobe dam-
measure auditory selective attention, requires the examinee age. Frith et al (1991) also reported that verbal fluency tasks
to ignore distracter tones which are of a higher pitch. activated left frontal brain regions during PET scanning.

The TEA was normed on 154 healthy participants aged Behavioural assessment of the dysexecutive
between 18 and 80. In addition to reflecting current thinking syndrome (BADS)
on the fractionation of attention it is designed to be eco-
logically valid, i.e. many of the subtests are designed to mimic Many formal neuropsychological tests fail to detect executive
everyday activities. Another advantage is that it has three par- problems because they are highly structured. Shallice &
allel versions; this avoids the interpretative problems encoun- Burgess (1991, pp. 727–728) note, ‘The patient typically has
tered when attempting to measure change using the same a single explicit problem to tackle at any one time. The trials
test materials. Selected subtests from the TEA have been used tend to be very short, task initiation is strongly prompted by
in their own right to test specific hypotheses in research stud- the examiner and what constitutes successful trial completion
ies: e.g. if one is interested in distractibility, the elevator is clearly characterised’. The Behavioural Assessment of the
counting task with distraction may be a useful measure. Dysexecutive Syndrome (BADS) represents an ambitious
and systematic attempt to capture the core elements of the
Behavioural inattention test (BIT) dysexecutive syndrome (Wilson et al 1996). The BADS
battery consists of six subtests and was normed on a sample
This is a comprehensive battery for testing visual neglect of 216 healthy participants with an age range of 16 to 87.
(Wilson et al 1987). The BIT includes conventional tests (star Subtests include the Rule Shifts Cards Test in which a previ-
cancellation, letter cancellation, figure copying, line crossing, ously established response set (responding ‘yes’ to red cards,
line bisection and representational drawing) and behavioural ‘no’ to black) has to be inhibited in favour of responding in
subtests (picture scanning, telephone dialling, menu reading, terms of whether or not a card matches the colour of the card
article reading, telling and setting the time, coin sorting, immediately preceding it. The Action Program Test is a
address and sentence copying, map navigation and card sort- planning task in which the solution requires the client to utilise
ing). The test manual reports impressively high coefficients various everyday materials e.g. plastic, cork and wire. The
for inter-rater reliability (0.99), test-retest reliability (0.99) Modified Six Elements Test assesses scheduling and time
and parallel form reliability (0.91). Among the six con- management by requiring clients to tackle three different tasks
ventional tests included in the battery, star cancellation has within the time limit; there are two versions of each task,
substantially greater sensitivity than the other tests. and the rules prohibit tackling these contiguously (Shallice &
Burgess 1991).
Executive functioning
The inter-rater reliability of the BADS is excellent; correla-
The term ‘frontal lobe’ test is unsatisfactory as it implies a tions between raters ranged from a low of 0.88 on one index
simple relationship between cognitive task and neural sub- from the Modified Six Elements Test, to unity, or near unity,
strate, which is often not the case (e.g. see section, above, on on most of the other tasks. A useful supplement to the formal
localising measures). Cognitive measures should be described BADS subtests is the Dysexecutive Questionnaire (DEX).

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Neuropsychology CHAPTER 7

The DEX covers dispositional and cognitive changes and colour of ink in which the word is written. The number of
comes in two forms: one for completion by the client, the correct responses made in 120 seconds is recorded. (The dif-
other by a relative or carer. Large discrepancies between client ference between the neutral and conflict condition is often
and carer reports of change are common when working with taken as a measure of interference.) The task is thought to
clients who have executive problems. The DEX provides one tap the ability to inhibit well-established responses, an ability
means of quantifying this lack of insight; DEX results can also thought to be impaired in brain damage, particularly frontal
form a basis for discussion when counselling patients and their brain damage. Trenerry et al (1988) provide limited normative
families. data for two age bands – 18–49 years and 50þ – together with
percentile scores and ‘probability of brain damage estimates’.
Wisconsin card sorting test (WCST) Clearly there are vast differences in speed of processing
between 50 and 80 years of age, and further age-banded norms
This is a widely used test of set-shifting ability, an ability that are required. The principle of the Stroop task is widely used in
is thought to be compromised in patients who have suffered cognitive psychology research, e.g. the use of an ‘emotional
frontal lobe damage. There are several versions of the task. Stroop’ paradigm, where particularly salient words interfere
In the standard condition, four target cards are placed in front with the colour-naming task.
of the examinee: one showing one red triangle, one with two
green stars, one with three yellow crosses and one with four Hayling and Brixton tests
blue circles. The examinee is then given 128 cards and asked
to sort the cards under the target cards according to a set These two tasks were developed to tap particular behaviours
criterion (colour, form or number) and the examiner provides that are commonly exhibited by patients following frontal lobe
feedback as to whether the decision was right or wrong. For damage. The Hayling test provides a measure of initiation
example, the examinee could turn over the first card which speed as well as performance on a response suppression task.
had two blue triangles on it, this could be placed under the In section 1 the examinee has to complete a sentence, e.g.
target card with four blue circles (sorting by colour), under ‘The job was easy most of the . . .’. The appropriateness of
the target card with two green stars (sorting by number) or the response and latency to respond are recorded. In section 2
under the target card with one red triangle (sorting by form). the subject is asked to give a word which is completely uncon-
The sorting ‘rule’ is not made explicit by the examiner, and nected, e.g. ‘The dog chased the cat up the . . .’ and an appro-
the examinee learns via the feedback provided after each trial priate response could be ‘kettle’. The Brixton test consists of
whether they are correct or incorrect. After 10 consecutive a stimulus booklet with an array of 10 circles numbered from
correct responses, the rule is changed without the examinee’s 1 to 10. One of the circles is filled in blue. The examinee turns
knowledge, and the examinee must now learn the new rule. the pages and is asked where the next blue circle is likely to
It is normal practice to score performance in terms of number appear, by trying to see a pattern or rule from what they have
of correct categories attained (runs of 10 consecutive correct seen on previous pages. Thus the Brixton test measures
responses) and also in terms of percentage of perseverative concept or rule attainment.
errors. While the WCST has been widely used (Spreen &
Strauss 1998), several researchers have queried the task’s sen- Normative data for the Hayling and Brixton tests are avail-
sitivity to frontal lobe pathology. Furthermore, some authors able from 121 healthy controls. The raw scores are converted
have reported finding the full test quite stressful for the failing to scaled scores. Test-retest reliability for the Hayling and
examinee, who receives persistent feedback that they are Brixton tests fall in the range 0.62–0.71. Patients with anterior
making errors. Accordingly, Nelson developed the modified lesions performed poorly on both tasks (Burgess & Shallice
Wisconsin Card Sorting Test, a shorter task using 48 rather 1997).
than 128 target cards (Nelson 1976). Nelson provided data
indicating that this abbreviated measure was also sensitive to Computerised neuropsychological
frontal lobe damage, a claim that was subsequently challenged
by van den Broek (1993). assessment

Stroop test of attentional conflict Neuropsychological assessment requires training, and a detailed
evaluation can take several hours, after which the tests must be
The Stroop test measures the ease with which a person can scored, and compared with reference norms, and a report writ-
shift his/her perceptual set to changing demands, and criti- ten. Thus detailed neuropsychological assessment can be an
cally, to suppress a habitual response in favour of an unusual extensive and time-consuming process. In addition, appropri-
one. There are several versions of the Stroop task, the most ately trained clinical neuropsychologists are relatively scarce.
widely used being that developed by Trenerry et al (1988). Traditional ‘paper and pencil’ neuropsychological testing always
In the neutral condition, the examinee is required to read includes a degree of error (e.g. stop-watch recording of an
aloud a list of colour name words. The conflict condition is examinee’s performance invariably incorporates variability in
provided by having colour words written in an incongruous col- the examiner’s reaction time!). Additionally, such assessment
our of ink, e.g. the word green written in red ink. The exam- is limited in terms of the temporal sensitivity of measurement
inee is required to inhibit the dominant, automatic tendency possible. Computerised neuropsychological assessment solves
to read the word name, and instead name the incongruent many of the problems outlined above. The measures do not
require a highly trained administrator, parallel forms are often

137

Companion to Psychiatric Studies

available, and measurement of responses can be very precise, visuospatial associative learning test and reported it to be par-
e.g. in milliseconds. This degree of measurement precision may ticularly useful in the early detection of Alzheimer’s disease.
be particularly advantageous in neuropsychological research on
psychiatric disorders, where one may be interested in subtle The limitations of computerised assessment include the
changes in cognition and behaviour (e.g. biases in retrieval, fact that the software and hardware can be expensive. In addi-
quantification of the effects of interference or distracters). tion the response format often requires selection from a num-
ber of multiple choices using a touch screen response. Verbal
A computerised method of test administration has several responses, e.g. in testing of free recall for long-term memory
advantages: all the information is presented in a standardised assessment, still require oral or written output. The issue of
and consistent manner, responses are accurately recorded portability of computerised assessment has largely been solved
and complex analysis and scoring may be undertaken quickly, via the use of laptop or notebook PCs. There was initial con-
eliminating examiner error. The Cambridge Neuropsychologi- cern that the computerised format may be daunting, particu-
cal Test Automated Battery (CANTAB) (Sahakian & Owen larly for elderly patients. However, as computers have
1992) is an example of such a computerised assessment sys- become so widely integrated into day-to-day activities in soci-
tem. CANTAB consists of a series of tests tapping visual ety, these concerns have lessened considerably. Furthermore,
memory, attention, working memory, planning, set-shifting, in studies where methods of assessment have been compared,
simple and choice reaction time, using a touch-sensitive screen no clear preference for the traditional paper and pencil
response format. In the parallel battery, four different versions approach has been found.
of some of the tasks are available, thus allowing repeated test-
ing of the same individual to assess change over time in order Conclusion
to track deterioration or evaluate treatment efficacy. A partic-
ularly valuable feature of the CANTAB battery is the use of The neuropsychological study of psychiatric disorders is still
tests whose neurobiological basis has been investigated in a in its infancy. Exciting novel attempts to explain abnormal
range of modalities, including animal models. An example is behaviour in terms of dysfunctional information processing
the intra/extra-dimensional set shifting test of executive func- are rapidly being developed. However, it is critical that such
tion, in which the different forms of set-shifting tested in the models are explicitly amenable to experimental testing and
task have been shown to depend on different frontal lobe refutation. Increasingly sophisticated sets of neuropsychologi-
regions in marmosets (Dias et al 1996). The CANTAB mea- cal measures have been developed which allow for the sensi-
sures have been used to study the pattern of neuropsychologi- tive, reliable and valid assessment of specific components of
cal impairment in a variety of conditions, including Parkinson’s cognitive functioning. This affords the opportunity for rigorous
disease, Alzheimer’s disease, frontal and temporal lobe dam- testing of brain–behaviour relationships in man. The next
age, etc. The parallel forms have afforded the opportunity to decade should result in significant advances in our knowledge
examine within-subject change over time, e.g. the effects of of the neuropsychological underpinnings of psychiatric dis-
diurnal mood variation on neuropsychological status in depres- order, as well as a more sophisticated understanding of the
sion (Moffoot et al 1994). As described in the section on effects of treatments on cognition and behaviour.
depression, Swainson et al (2001) used the CANTAB

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