What is Applied Behaviour Analysis?

Introduction

Applied Behaviour Analysis (ABA), also called behavioural engineering, is a scientific technique concerned with applying empirical approaches based upon the principles of respondent and operant conditioning to change behaviour of social significance.

It is the applied form of behaviour analysis; the other two forms are:

  • Radical behaviourism (or the philosophy of the science); and the
  • Experimental analysis of behaviour (or basic experimental research).

The name “applied behaviour analysis” has replaced behaviour modification because the latter approach suggested attempting to change behaviour without clarifying the relevant behaviour-environment interactions. In contrast, ABA changes behaviour by first assessing the functional relationship between a targeted behaviour and the environment. Further, the approach often seeks to develop socially acceptable alternatives for aberrant behaviours.

ABA has been utilised in a range of areas, including applied animal behaviour, schoolwide positive behaviour support, classroom instruction, structured and naturalistic early behavioural interventions for autism, paediatric feeding therapy, rehabilitation of brain injury, dementia, fitness training, substance abuse, phobias, tics, and organisational behaviour management.

ABA is considered to be controversial by some within the autism rights movement due to a perception that it emphasizes indistinguishability instead of acceptance and a history of, in some embodiments of ABA and its predecessors, the use of aversives such as electric shocks.

Definition

ABA is an applied science devoted to developing procedures which will produce observable changes in behaviour. It is to be distinguished from the experimental analysis of behaviour, which focuses on basic experimental research, but it uses principles developed by such research, in particular operant conditioning and classical conditioning. Behaviour analysis adopts the viewpoint of radical behaviourism, treating thoughts, emotions, and other covert activity as behaviour that is subject to the same rules as overt responses. This represents a shift away from methodological behaviourism, which restricts behaviour-change procedures to behaviours that are overt, and was the conceptual underpinning of behaviour modification.

Behaviour analysts also emphasize that the science of behaviour must be a natural science as opposed to a social science. As such, behaviour analysts focus on the observable relationship of behaviour with the environment, including antecedents and consequences, without resort to “hypothetical constructs”.

Brief History

The beginnings of ABA can be traced back to Teodoro Ayllon and Jack Michael’s study “The psychiatric nurse as a behavioural engineer” (1959) that they published in the Journal of the Experimental Analysis of Behaviour (JEAB). Ayllon and Michael were training the staff and nurses at a psychiatric hospital how to use a token economy based on the principles of operant conditioning for patients with schizophrenia and intellectual disability, which led to researchers at the University of Kansas to start the Journal of Applied Behaviour Analysis (JABA) in 1968.

A group of faculty and researchers at the University of Washington, including Donald Baer, Sidney W. Bijou, Bill Hopkins, Jay Birnbrauer, Todd Risley, and Montrose Wolf, applied the principles of behavior analysis to instruct developmentally disabled children, manage the behaviour of children and adolescents in juvenile detention centres, and organise employees who required proper structure and management in businesses, among other situations. In 1968, Baer, Bijou, Risley, Birnbrauer, Wolf, and James Sherman joined the Department of Human Development and Family Life at the University of Kansas, where they founded the Journal of Applied Behaviour Analysis.

Notable graduate students from the University of Washington include Robert Wahler, James Sherman, and Ivar Lovaas. Lovaas established the UCLA Young Autism Project while teaching at the University of California, Los Angeles. In 1965, Lovaas published a series of articles that outlined his system for coding observed behaviours, described a pioneering investigation of the antecedents and consequences that maintained a problem behaviour, and relied upon the methods of errorless learning that was initially devised by Charles Ferster to teach nonverbal children to speak. Lovaas also described how to use social (secondary) reinforcers, teach children to imitate, and what interventions (including electric shocks) may be used to reduce aggression and life-threatening self-injury.

In 1987, Lovaas published the study, “Behavioural treatment and normal educational and intellectual functioning in young autistic children”. The experimental group in this study received up to 40 hours per week in a 1:1 teaching setting at a table using errorless discrete trial training (DTT). The treatment is done at home with parents involved in every aspect of treatment, and the curriculum is highly individualized with a heavy emphasis on teaching eye contact, fine and gross motor imitation, and language. ABA principles were used to motivate learning and reduce non-desired behaviours. The outcome of this study indicated 47% of the experimental group (9/19) went on to lose their autism diagnosis and were described as indistinguishable from their typical adolescent peers. This included passing regular education without assistance, making and maintaining friends, and becoming self-sufficient as adults. These gains were maintained as reported in the 1993 study, “Long-term outcome for children with autism who received early intensive behavioural treatment”. Lovaas’ work went on to be recognised by the US Surgeon General in 1999, and his research were replicated in university and private settings. The “Lovaas Method” went on to become known as early intensive behavioural intervention (EIBI), or 30 to 40 hours per week of DTT.

Over the years, “behaviour analysis” gradually superseded “behaviour modification”; that is, from simply trying to alter problematic behaviour, behaviour analysts sought to understand the function of that behaviour, what antecedents promote and maintain it, and how it can be replaced by successful behaviour. This analysis is based on careful initial assessment of a behaviour’s function and a testing of methods that produce changes in behaviour.

While ABA seems to be intrinsically linked to autism intervention, it is also used in a broad range of other situations. Recent notable areas of research in JABA include autism, classroom instruction with typically developing students, paediatric feeding therapy, and substance-use disorders. Other applications of ABA include applied animal behaviour, consumer behaviour analysis, behavioural medicine, behavioural neuroscience, clinical behaviour analysis, forensic behaviour analysis, increasing job safety and performance, schoolwide positive behaviour support, and contact desensitisation for phobias.

Characteristics

Baer, Wolf, and Risley’s 1968 article is still used as the standard description of ABA. It lists the following seven characteristics of ABA.

  • Applied:
    • ABA focuses on the social significance of the behaviour studied.
    • For example, a non-applied researcher may study eating behaviour because this research helps to clarify metabolic processes, whereas the applied researcher may study eating behaviour in individuals who eat too little or too much, trying to change such behaviour so that it is more acceptable to the persons involved.
  • Behavioural:
    • ABA is pragmatic; it asks how it is possible to get an individual to do something effectively.
    • To answer this question, the behaviour itself must be objectively measured.
    • Verbal descriptions are treated as behaviour in themselves, and not as substitutes for the behaviour described.
  • Analytic:
    • Behaviour analysis is successful when the analyst understands and can manipulate the events that control a target behaviour.
    • This may be relatively easy to do in the lab, where a researcher is able to arrange the relevant events, but it is not always easy, or ethical, in an applied situation.
    • Baer et al. outline two methods that may be used in applied settings to demonstrate control while maintaining ethical standards.
    • These are the reversal design and the multiple baseline design.
    • In the reversal design, the experimenter first measures the behaviour of choice, introduces an intervention, and then measures the behaviour again.
    • Then, the intervention is removed, or reduced, and the behaviour is measured yet again.
    • The intervention is effective to the extent that the behaviour changes and then changes back in response to these manipulations.
    • The multiple baseline method may be used for behaviours that seem irreversible.
    • Here, several behaviours are measured and then the intervention is applied to each in turn.
    • The effectiveness of the intervention is revealed by changes in just the behaviour to which the intervention is being applied.
  • Technological:
    • The description of analytic research must be clear and detailed, so that any competent researcher can repeat it accurately.
    • Cooper et al. describe a good way to check this: Have a person trained in applied behaviour analysis read the description and then act out the procedure in detail.
    • If the person makes any mistakes or has to ask any questions then the description needs improvement.
  • Conceptually Systematic:
    • Behaviour analysis should not simply produce a list of effective interventions.
    • Rather, to the extent possible, these methods should be grounded in behavioural principles.
    • This is aided by the use of theoretically meaningful terms, such as “secondary reinforcement” or “errorless discrimination” where appropriate.
  • Effective:
    • Though analytic methods should be theoretically grounded, they must be effective.
    • If an intervention does not produce a large enough effect for practical use, then the analysis has failed
  • Generality:
    • Behaviour analysts should aim for interventions that are generally applicable; the methods should work in different environments, apply to more than one specific behaviour, and have long-lasting effects.

Other Proposed Characteristics

In 2005, Heward et al. suggested that the following five characteristics should be added:

  • Accountable:
    • To be accountable means that ABA must be able to demonstrate that its methods are effective.
    • This requires the repeatedly measuring the success of interventions, and, if necessary, making changes that improve their effectiveness.
  • Public:
    • The methods, results, and theoretical analyses of ABA must be published and open to scrutiny.
    • There are no hidden treatments or mystical, metaphysical explanations.
  • Doable:
    • To be generally useful, interventions should be available to a variety of individuals, who might be teachers, parents, therapists, or even those who wish to modify their own behaviour.
    • With proper planning and training, many interventions can be applied by almost anyone willing to invest the effort.
  • Empowering:
    • ABA provides tools that give the practitioner feedback on the results of interventions.
    • These allow clinicians to assess their skill level and build confidence in their effectiveness.
  • Optimistic:
    • According to several leading authors, behaviour analysts have cause to be optimistic that their efforts are socially worthwhile, for the following reasons:
      • The behaviours impacted by behaviour analysis are largely determined by learning and controlled by manipulable aspects of the environment.
      • Practitioners can improve performance by direct and continuous measurements.
      • As a practitioner uses behavioural techniques with positive outcomes, they become more confident of future success.
      • The literature provides many examples of success in teaching individuals considered previously unteachable.

Concepts

Behaviour

Behaviour refers to the movement of some part of an organism that changes some aspect of the environment. Often, the term behaviour refers to a class of responses that share physical dimensions or functions, and in that case a response is a single instance of that behaviour. If a group of responses have the same function, this group may be called a response class. “Repertoire” refers to the various responses available to an individual; the term may refer to responses that are relevant to a particular situation, or it may refer to everything a person can do.

Operant Conditioning

Operant behaviour is the so-called “voluntary” behaviour that is sensitive to, or controlled by its consequences. Specifically, operant conditioning refers to the three-term contingency that uses stimulus control, in particular an antecedent contingency called the discriminative stimulus (SD) that influences the strengthening or weakening of behaviour through such consequences as reinforcement or punishment. The term is used quite generally, from reaching for a candy bar, to turning up the heat to escape an aversive chill, to studying for an exam to get good grades.

Respondent (Classical) Conditioning

Respondent (classical) conditioning is based on innate stimulus-response relationships called reflexes. In his famous experiments with dogs, Pavlov usually used the salivary reflex, namely salivation (unconditioned response) following the taste of food (unconditioned stimulus). Pairing a neutral stimulus, for example a bell (conditioned stimulus) with food caused the dog to elicit salivation (conditioned response). Thus, in classical conditioning, the conditioned stimulus becomes a signal for a biologically significant consequence. Note that in respondent conditioning, unlike operant conditioning, the response does not produce a reinforcer or punisher (e.g. the dog does not get food because it salivates).

Environment

The environment is the entire constellation of stimuli in which an organism exists. This includes events both inside and outside of an organism, but only real physical events are included. A stimulus is an “energy change that affects an organism through its receptor cells”.

A stimulus can be described:

  • Topographically by its physical features.
  • Temporally by when it occurs.
  • Functionally by its effect on behaviour.

Reinforcement

Reinforcement is the key element in operant conditioning and in most behaviour change programmes. It is the process by which behaviour is strengthened. If a behaviour is followed closely in time by a stimulus and this results in an increase in the future frequency of that behaviour, then the stimulus is a positive reinforcer. If the removal of an event serves as a reinforcer, this is termed negative reinforcement. There are multiple schedules of reinforcement that affect the future probability of behaviour.

The use of punishments, especially those that inflict sensory or physical pain, is an area of controversy.

Punishment

Punishment is a process by which a consequence immediately follows a behaviour which decreases the future frequency of that behaviour. As with reinforcement, a stimulus can be added (positive punishment) or removed (negative punishment). Broadly, there are three types of punishment: presentation of aversive stimuli (e.g. pain), response cost (removal of desirable stimuli as in monetary fines), and restriction of freedom (as in a ‘time out’). Punishment in practice can often result in unwanted side effects. Some other potential unwanted effects include resentment over being punished, attempts to escape the punishment, expression of pain and negative emotions associated with it, and recognition by the punished individual between the punishment and the person delivering it.

Extinction

Extinction is the technical term to describe the procedure of withholding/discontinuing reinforcement of a previously reinforced behaviour, resulting in the decrease of that behaviour. The behaviour is then set to be extinguished. Extinction procedures are often preferred over punishment procedures, as many punishment procedures are deemed unethical and in many states prohibited. Nonetheless, extinction procedures must be implemented with utmost care by professionals, as they are generally associated with extinction bursts. An extinction burst is the temporary increase in the frequency, intensity, and/or duration of the behaviour targeted for extinction. Other characteristics of an extinction burst include an:

  • Extinction-produced aggression: the occurrence of an emotional response to an extinction procedure often manifested as aggression; and
  • Extinction-induced response variability: the occurrence of novel behaviours that did not typically occur prior to the extinction procedure.

These novel behaviours are a core component of shaping procedures.

Discriminated Operant and Three-Term Contingency

In addition to a relation being made between behaviour and its consequences, operant conditioning also establishes relations between antecedent conditions and behaviours. This differs from the S-R formulations (If-A-then-B), and replaces it with an AB-because-of-C formulation. In other words, the relation between a behaviour (B) and its context (A) is because of consequences (C), more specifically, this relationship between AB because of C indicates that the relationship is established by prior consequences that have occurred in similar contexts. This antecedent-behaviour-consequence contingency is termed the three-term contingency. A behaviour which occurs more frequently in the presence of an antecedent condition than in its absence is called a discriminated operant. The antecedent stimulus is called a discriminative stimulus (SD). The fact that the discriminated operant occurs only in the presence of the discriminative stimulus is an illustration of stimulus control. More recently behaviour analysts have been focusing on conditions that occur prior to the circumstances for the current behaviour of concern that increased the likelihood of the behaviour occurring or not occurring. These conditions have been referred to variously as “Setting Event”, “Establishing Operations”, and “Motivating Operations” by various researchers in their publications.

Verbal Behaviour

B.F. Skinner’s classification system of behaviour analysis has been applied to treatment of a host of communication disorders. Skinner’s system includes:

  • Tact: A verbal response evoked by a non-verbal antecedent and maintained by generalized conditioned reinforcement……
  • Mand: Behaviour under control of motivating operations maintained by a characteristic reinforcer.
  • Intraverbals: Verbal behaviour for which the relevant antecedent stimulus was other verbal behaviour, but which does not share the response topography of that prior verbal stimulus (e.g. responding to another speaker’s question).
  • Autoclitic: Secondary verbal behaviour which alters the effect of primary verbal behaviour on the listener. Examples involve quantification, grammar, and qualifying statements (e.g. the differential effects of “I think…” vs. “I know…”).

Measuring Behaviour

When measuring behaviour, there are both dimensions of behaviour and quantifiable measures of behaviour. In applied behaviour analysis, the quantifiable measures are a derivative of the dimensions. These dimensions are repeatability, temporal extent, and temporal locus.

  • Repeatability:
    • Response classes occur repeatedly throughout time – i.e. how many times the behaviour occurs.
    • Count is the number of occurrences in behaviour.
    • Rate/frequency is the number of instances of behaviour per unit of time.
    • Celeration is the measure of how the rate changes over time.
  • Temporal extent:
    • This dimension indicates that each instance of behaviour occupies some amount of time – i.e. how long the behaviour occurs.
    • Duration is the period of time over which the behavior occurs.
  • Temporal locus:
    • Each instance of behaviour occurs at a specific point in time – i.e. when the behaviour occurs.
    • Response latency is the measure of elapsed time between the onset of a stimulus and the initiation of the response.
    • Interresponse time is the amount of time that occurs between two consecutive instances of a response class.
  • Derivative measures:
    • Derivative measures are unrelated to specific dimensions.
    • Percentage is the ratio formed by combining the same dimensional quantities.
    • Trials-to-criterion are the number of response opportunities needed to achieve a predetermined level of performance.

Analysing Behaviour Change

Experimental Control

In applied behaviour analysis, all experiments should include the following:

  • At least one participant.
  • At least one behaviour (dependent variable).
  • At least one setting.
  • A system for measuring the behaviour and ongoing visual analysis of data.
  • At least one treatment or intervention condition.
  • Manipulations of the independent variable so that its effects on the dependent variable may be quantitatively or qualitatively analysed.
  • An intervention that will benefit the participant in some way.

Methodologies developed through ABA Research

Task Analysis

Task analysis is a process in which a task is analysed into its component parts so that those parts can be taught through the use of chaining: forward chaining, backward chaining and total task presentation. Task analysis has been used in organisational behaviour management, a behaviour analytic approach to changing the behaviours of members of an organisation (e.g. factories, offices, or hospitals). Behavioural scripts often emerge from a task analysis. Bergan conducted a task analysis of the behavioural consultation relationship and Thomas Kratochwill developed a training programme based on teaching Bergan’s skills. A similar approach was used for the development of microskills training for counsellors. Ivey would later call this “behaviourist” phase a very productive one[58] and the skills-based approach came to dominate counsellor training during 1970-1990. Task analysis was also used in determining the skills needed to access a career. In education, Englemann (1968) used task analysis as part of the methods to design the Direct Instruction curriculum.

Chaining

The skill to be learned is broken down into small units for easy learning. For example, a person learning to brush teeth independently may start with learning to unscrew the toothpaste cap. Once they have learned this, the next step may be squeezing the tube, etc.

For problem behaviour, chains can also be analysed and the chain can be disrupted to prevent the problem behaviour. Some behaviour therapies, such as dialectical behaviour therapy, make extensive use of behaviour chain analysis, but is not philosophically behaviour analytic.

Prompting

A prompt is a cue that is used to encourage a desired response from an individual. Prompts are often categorized into a prompt hierarchy from most intrusive to least intrusive, although there is some controversy about what is considered most intrusive, those that are physically intrusive or those that are hardest prompt to fade (e.g. verbal). In order to minimise errors and ensure a high level of success during learning, prompts are given in a most-to-least sequence and faded systematically. During this process, prompts are faded quickly as possible so that the learner does not come to depend on them and eventually behaves appropriately without prompting.

Types of prompts Prompters might use any or all of the following to suggest the desired response:

  • Vocal prompts: Words or other vocalisations.
  • Visual prompts: A visual cue or picture.
  • Gestural prompts: A physical gesture.
  • Positional prompt: For example, the target item is placed close to the individual.
  • Modelling: Modelling the desired response.
    • This type of prompt is best suited for individuals who learn through imitation and can attend to a model.
  • Physical prompts: Physically manipulating the individual to produce the desired response.
    • There are many degrees of physical prompts, from quite intrusive (e.g. the teacher places a hand on the learner’s hand) to minimally intrusive (e.g. a slight tap).

This is not an exhaustive list of prompts; the nature, number, and order of prompts are chosen to be the most effective for a particular individual.

Fading

The overall goal is for an individual to eventually not need prompts. As an individual gains mastery of a skill at a particular prompt level, the prompt is faded to a less intrusive prompt. This ensures that the individual does not become overly dependent on a particular prompt when learning a new behaviour or skill.

Thinning a Reinforcement Schedule

Thinning is often confused with fading. Fading refers to a prompt being removed, where thinning refers to an increase in the time or number of responses required between reinforcements. Periodic thinning that produces a 30% decrease in reinforcement has been suggested as an efficient way to thin. Schedule thinning is often an important and neglected issue in contingency management and token economy systems, especially when these are developed by unqualified practitioners (see professional practice of behaviour analysis).

Generalisation

Generalisation is the expansion of a student’s performance ability beyond the initial conditions set for acquisition of a skill. Generalisation can occur across people, places, and materials used for teaching. For example, once a skill is learned in one setting, with a particular instructor, and with specific materials, the skill is taught in more general settings with more variation from the initial acquisition phase. For example, if a student has successfully mastered learning colours at the table, the teacher may take the student around the house or school and generalise the skill in these more natural environments with other materials. Behaviour analysts have spent considerable amount of time studying factors that lead to generalisation.

Shaping

Shaping involves gradually modifying the existing behaviour into the desired behaviour. If the student engages with a dog by hitting it, then they could have their behaviour shaped by reinforcing interactions in which they touch the dog more gently. Over many interactions, successful shaping would replace the hitting behaviour with patting or other gentler behaviour. Shaping is based on a behaviour analyst’s thorough knowledge of operant conditioning principles and extinction. Recent efforts to teach shaping have used simulated computer tasks.

One teaching technique found to be effective with some students, particularly children, is the use of video modelling (the use of taped sequences as exemplars of behaviour). It can be used by therapists to assist in the acquisition of both verbal and motor responses, in some cases for long chains of behaviour.

Interventions Based on an FBA

Critical to behaviour analytic interventions is the concept of a systematic behavioural case formulation with a functional behavioural assessment or analysis at the core. This approach should apply a behaviour analytic theory of change. This formulation should include a thorough functional assessment, a skills assessment, a sequential analysis (behaviour chain analysis), an ecological assessment, a look at existing evidenced-based behavioural models for the problem behaviour (such as Fordyce’s model of chronic pain) and then a treatment plan based on how environmental factors influence behaviour. Some argue that behaviour analytic case formulation can be improved with an assessment of rules and rule-governed behaviour. Some of the interventions that result from this type of conceptualization involve training specific communication skills to replace the problem behaviours as well as specific setting, antecedent, behaviour, and consequence strategies.

Use in the Treatment of Autism Spectrum Disorders

ABA-based techniques are often used to teach adaptive behaviours or to diminish behaviours associated with autism, so much that ABA itself is often mistakenly considered to be synonymous with therapy for autism. According to a paper from 2007, it was considered to be an effective “intervention for challenging behaviors” by the American Academy of Paediatrics, though this has been refuted by more recent papers. ABA for autism may be limited by diagnostic severity and IQ.

Efficacy

Recent reviews of the efficacy of ABA-based techniques in autism include:

  • A 2007 clinical report of the American Academy of Paediatrics concluded that the benefit of ABA-based interventions in autism spectrum disorders (ASDs) “has been well documented” and that “children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior”.
  • Researchers from the MIND Institute published an evidence-based review of comprehensive treatment approaches in 2008. On the basis of “the strength of the findings from the four best-designed, controlled studies”, they were of the opinion that one ABA-based approach (the Lovaas technique created by Ole Ivar Løvaas) is “well-established” for improving intellectual performance of young children with ASD.
  • A 2009 review of psycho-educational interventions for children with autism whose mean age was six years or less at intake found that five high-quality (“Level 1” or “Level 2”) studies assessed ABA-based treatments. On the basis of these and other studies, the author concluded that ABA is “well-established” and is “demonstrated effective in enhancing global functioning in pre-school children with autism when treatment is intensive and carried out by trained therapists”. However, the review committee also concluded that “there is a great need for more knowledge about which interventions are most effective”.
  • A 2009 paper included a descriptive analysis, an effect size analysis, and a meta-analysis of 13 reports published from 1987 to 2007 of early intensive behavioural intervention (EIBI, a form of ABA-based treatment with origins in the Lovaas technique) for autism. It determined that EIBI’s effect sizes were “generally positive” for IQ, adaptive behaviour, expressive language, and receptive language. The paper did note limitations of its findings including the lack of published comparisons between EIBI and other “empirically validated treatment programs”.
  • In a 2009 systematic review of 11 studies published from 1987 to 2007, the researchers wrote “there is strong evidence that EIBI is effective for some, but not all, children with autism spectrum disorders, and there is wide variability in response to treatment”. Furthermore, any improvements are likely to be greatest in the first year of intervention.
  • A 2009 meta-analysis of nine studies published from 1987 to 2007 concluded that EIBI has a “large” effect on full-scale intelligence and a “moderate” effect on adaptive behaviour in autistic children.
  • A 2009 systematic review and meta-analysis by Spreckley and Boyd of four small-n 2000-2007 studies (involving a total of 76 children) came to different conclusions than the aforementioned reviews. Spreckley and Boyd reported that applied behaviour intervention (ABI), another name for EIBI, did not significantly improve outcomes compared with standard care of preschool children with ASD in the areas of cognitive outcome, expressive language, receptive language, and adaptive behaviour. In a letter to the editor, however, authors of the four studies meta-analysed claimed that Spreckley and Boyd had misinterpreted one study comparing two forms of ABI with each other as a comparison of ABI with standard care, which erroneously decreased the observed efficacy of ABI. Furthermore, the four studies’ authors raised the possibility that Spreckley and Boyd had excluded some other studies unnecessarily, and that including such studies could have led to a more favourable evaluation of ABI. Spreckley, Boyd, and the four studies’ authors did agree that large multi-site randomised trials are needed to improve the understanding of ABA’s efficacy in autism.
  • In 2011, investigators from Vanderbilt University under contract with the Agency for Healthcare Research and Quality performed a comprehensive review of the scientific literature on ABA-based and other therapies for autism spectrum disorders; the ABA-based therapies included the UCLA/Lovaas method and the Early Start Denver Model (the latter developed by Sally Rogers and Geraldine Dawson). They concluded that “both approaches were associated with … improvements in cognitive performance, language skills, and adaptive behavior skills”. However, they also concluded that “the strength of evidence … is low”, “many children continue to display prominent areas of impairment”, “subgroups may account for a majority of the change”, there is “little evidence of practical effectiveness or feasibility beyond research studies”, and the published studies “used small samples, different treatment approaches and duration, and different outcome measurements”.
  • An October 2019 report by the United States Department of Defence found that “76 percent of TRICARE beneficiaries in the ACD had little to no change in symptom presentation over the course of 12 months of applied behavior analysis (ABA) services, with an additional 9 percent demonstrating worsening symptoms.”
  • Controversy regarding ABA persists in the autism community. A 2017 study found that 46% of people with autism spectrum undergoing ABA appeared to meet the criteria for post-traumatic stress disorder (PTSD), a rate 86% higher than the rate of those who had not undergone ABA (28%). According to the researcher, the rate of apparent PTSD increased after exposure to ABA regardless of the age of the patient. However, the quality of this study has been disputed by other researchers.
  • A 2019 review article concluded ABA proponents have utilised predominantly non-verbal and neurologically different, children who are not recognised under this paradigm to have their own thought processes, basic needs, preferences, style of learning, and psychological and emotional needs, for their experiment. This also indicates a missing voice of children and nonverbal people who cannot express their view on ABA.

Use of Aversives

Some embodiments of applied behaviour analysis as devised by Ole Ivar Lovaas used aversives such as electric shocks to modify undesirable behaviour in their initial use in the 1970s, as well as slapping and shouting in the landmark 1987 study. Over time the use of aversives lessened and in 2012 their use was described as being inconsistent with contemporary practice. However, aversives have continued to be used in some ABA programs. In comments made in 2014 to the FDA, a clinician who previously worked at the Judge Rotenberg Educational Centre claimed that “all textbooks used for thorough training of applied behavior analysts include an overview of the principles of punishment, including the use of electrical stimulation.” In 2020, the FDA banned the use of electrical stimulation devices used for self-injurious or aggressive behaviour and asserted that “Evidence indicates a number of significant psychological and physical risks are associated with the use of these devices, including worsening of underlying symptoms, depression, anxiety, posttraumatic stress disorder, pain, burns and tissue damage.”

Controversy

The value of eliminating autistic behaviours is disputed by proponents of neurodiversity, who claim that it forces autistics to mask their true personalities on behalf of a narrow conception of normality. Autism advocates contend that it is cruel to try to make autistic people “normal” without consideration for how this may affect their well-being. Instead, these critics advocate for increased social acceptance of harmless autistic traits and therapies focused on improving quality of life. Julia Bascom of the Autistic Self Advocacy Network (ASAN) has said, “ASAN’s objection is fundamentally an ethical one. The stated end goal of ABA is an autistic child who is ‘indistinguishable from their peers’ – an autistic child who can pass as neurotypical. We don’t think that’s an acceptable goal. The end goal of all services, supports, interventions, and therapies an autistic child receives should be to support them in growing up into an autistic adult who is happy, healthy, and living a self-determined life.”

It has been suspected that there might be a publication bias against those research articles share a controversial account of ABA. Publication bias could lead to exaggerated estimates of intervention effects.

What is Antisocial Personality Disorder?

Introduction

Antisocial personality disorder (ASPD or infrequently APD) is a personality disorder characterised by a long-term pattern of disregard for, or violation of, the rights of others. A weak or non-existent conscience is often apparent, as well as a history of legal problems or impulsive and aggressive behaviour.

Antisocial personality disorder is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), while the equivalent concept of dissocial personality disorder (DPD) is defined in the International Statistical Classification of Diseases and Related Health Problems (ICD); the primary theoretical distinction between the two is that antisocial personality disorder focuses on observable behaviours, while dissocial personality disorder focuses on affective deficits. Otherwise, both manuals provide similar criteria for diagnosing the disorder. Both have also stated that their diagnoses have been referred to, or include what is referred to, as psychopathy or sociopathy. However, some researchers have drawn distinctions between the concepts of antisocial personality disorder and psychopathy, with many researchers arguing that psychopathy is a disorder that overlaps with but is distinguishable from ASPD.

Brief History

The first version of the DSM in 1952 listed sociopathic personality disturbance. This category was for individuals who were considered “…ill primarily in terms of society and of conformity with the prevailing milieu, and not only in terms of personal discomfort and relations with other individuals”. There were four subtypes, referred to as “reactions”: antisocial, dyssocial, sexual, and addiction. The antisocial reaction was said to include people who were “always in trouble” and not learning from it, maintaining “no loyalties”, frequently callous and lacking responsibility, with an ability to “rationalise” their behaviour. The category was described as more specific and limited than the existing concepts of “constitutional psychopathic state” or “psychopathic personality” which had had a very broad meaning; the narrower definition was in line with criteria advanced by Hervey M. Cleckley from 1941, while the term sociopathic had been advanced by George Partridge in 1928 when studying the early environmental influence on psychopaths. Partridge discovered the correlation between antisocial psychopathic disorder and parental rejection experienced in early childhood.

The DSM-II in 1968 rearranged the categories and “antisocial personality” was now listed as one of ten personality disorders but still described similarly, to be applied to individuals who are: “basically unsocialised”, in repeated conflicts with society, incapable of significant loyalty, selfish, irresponsible, unable to feel guilt or learn from prior experiences, and who tend to blame others and rationalise. The manual preface contains “special instructions” including “Antisocial personality should always be specified as mild, moderate, or severe.” The DSM-II warned that a history of legal or social offenses was not by itself enough to justify the diagnosis, and that a “group delinquent reaction” of childhood or adolescence or “social maladjustment without manifest psychiatric disorder” should be ruled out first. The dyssocial personality type was relegated in the DSM-II to “dyssocial behaviour” for individuals who are predatory and follow more or less criminal pursuits, such as racketeers, dishonest gamblers, prostitutes, and dope peddlers. (DSM-I classified this condition as sociopathic personality disorder, dyssocial type). It would later resurface as the name of a diagnosis in the ICD manual produced by the WHO, later spelled dissocial personality disorder and considered approximately equivalent to the ASPD diagnosis.

The DSM-III in 1980 included the full term antisocial personality disorder and, as with other disorders, there was now a full checklist of symptoms focused on observable behaviours to enhance consistency in diagnosis between different psychiatrists (‘inter-rater reliability’). The ASPD symptom list was based on the Research Diagnostic Criteria developed from the so-called Feighner Criteria from 1972, and in turn largely credited to influential research by sociologist Lee Robins published in 1966 as “Deviant Children Grown Up”. However, Robins has previously clarified that while the new criteria of prior childhood conduct problems came from her work, she and co-researcher psychiatrist Patricia O’Neal got the diagnostic criteria they used from Lee’s husband the psychiatrist Eli Robins, one of the authors of the Feighner criteria who had been using them as part of diagnostic interviews.

The DSM-IV maintained the trend for behavioural antisocial symptoms while noting “This pattern has also been referred to as psychopathy, sociopathy, or dyssocial personality disorder” and re-including in the ‘Associated Features’ text summary some of the underlying personality traits from the older diagnoses. The DSM-5 has the same diagnosis of antisocial personality disorder. The Pocket Guide to the DSM-5 Diagnostic Exam suggests that a person with ASPD may present “with psychopathic features” if he or she exhibits “a lack of anxiety or fear and a bold, efficacious interpersonal style”.

Epidemiology

As seen in two North American studies and two European studies, ASPD is more commonly seen in men than in women, with men three to five times more likely to be diagnosed with ASPD than women. The prevalence of ASPD is even higher in selected populations, like prisons, where there is a preponderance of violent offenders. It has been found that the prevalence of ASPD among prisoners is just under 50%. Similarly, the prevalence of ASPD is higher among patients in alcohol or other drug (AOD) use treatment programmes than in the general population, suggesting a link between ASPD and AOD use and dependence. As part of the Epidemiological Catchment Area (ECA) study, men with ASPD were found to be three to five times more likely to excessively use alcohol and illicit substances than those men without ASPD. While ASPD occurs more often in men than women, there was found to be increased severity of this substance use in women with ASPD. In a study conducted with both men and women with ASPD, women were more likely to misuse substances compared to their male counterparts.

Individuals with ASPD are at an elevated risk for suicide. Some studies suggest this increase in suicidality is in part due to the association between suicide and symptoms or trends within ASPD, such as criminality and substance use. Offspring of ASPD victims are also at risk. Some research suggests that negative or traumatic experiences in childhood, perhaps as a result of the choices a parent with ASPD might make, can be a predictor of delinquency later on in the child’s life. Additionally, with variability between situations, children of a parent with ASPD may suffer consequences of delinquency if they’re raised in an environment in which crime and violence is common. Suicide is a leading cause of death among youth who display antisocial behaviour, especially when mixed with delinquency. Incarceration, which could come as a consequence of actions from a victim of ASPD, is a predictor for suicide ideation in youth.

Signs and Symptoms

Antisocial personality disorder is defined by a pervasive and persistent disregard for morals, social norms, and the rights and feelings of others. Individuals with this personality disorder will typically have no compunction in exploiting others in harmful ways for their own gain or pleasure and frequently manipulate and deceive other people. While some do so through a façade of superficial charm, others do so through intimidation and violence. They may display arrogance, think lowly and negatively of others, and lack remorse for their harmful actions and have a callous attitude to those they have harmed. Irresponsibility is a core characteristic of this disorder; most have significant difficulties in maintaining stable employment as well as fulfilling their social and financial obligations, and people with this disorder often lead exploitative, unlawful, or parasitic lifestyles.

Those with antisocial personality disorder are often impulsive and reckless, failing to consider or disregarding the consequences of their actions. They may repeatedly disregard and jeopardise their own safety and the safety of others, which can place both themselves and other people in danger. They are often aggressive and hostile, with poorly regulated tempers, and can lash out violently with provocation or frustration. Individuals are prone to substance use disorders and addiction, and the non-medical use of various psychoactive substances is common in this population. These behaviours lead such individuals into frequent conflict with the law, and many people with ASPD have extensive histories of antisocial behaviour and criminal infractions stemming back to adolescence or childhood.

Serious problems with interpersonal relationships are often seen in those with the disorder. People with antisocial personality disorder usually form poor attachments and emotional bonds, and interpersonal relationships often revolve around the exploitation and abuse of others. They may have difficulties in sustaining and maintaining relationships, and some have difficulty entering them.

Conduct Disorder

While antisocial personality disorder is a mental disorder diagnosed in adulthood, it has its precedent in childhood. The DSM-5’s criteria for ASPD require that the individual have conduct problems evident by the age of 15. Persistent antisocial behaviour, as well as a lack of regard for others in childhood and adolescence, is known as conduct disorder and is the precursor of ASPD. About 25-40% of youths with conduct disorder will be diagnosed with ASPD in adulthood.

Conduct disorder (CD) is a disorder diagnosed in childhood that parallels the characteristics found in ASPD and is characterised by a repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate norms are violated. Children with the disorder often display impulsive and aggressive behaviour, may be callous and deceitful, and may repeatedly engage in petty crime such as stealing or vandalism or get into fights with other children and adults. This behaviour is typically persistent and may be difficult to deter with threat or punishment. Attention deficit hyperactivity disorder (ADHD) is common in this population, and children with the disorder may also engage in substance use. CD is differentiated from oppositional defiant disorder (ODD) in that children with ODD do not commit aggressive or antisocial acts against other people, animals, and property, though many children diagnosed with ODD are subsequently re-diagnosed with CD.

Two developmental courses for CD have been identified based on the age at which the symptoms become present. The first is known as the “childhood-onset type” and occurs when conduct disorder symptoms are present before the age of 10 years. This course is often linked to a more persistent life course and more pervasive behaviours, and children in this group express greater levels of ADHD symptoms, neuropsychological deficits, more academic problems, increased family dysfunction, and higher likelihood of aggression and violence. The second is known as the “adolescent-onset type” and occurs when conduct disorder develops after the age of 10 years. Compared to the childhood-onset type, less impairment in various cognitive and emotional functions are present, and the adolescent-onset variety may remit by adulthood. In addition to this differentiation, the DSM-5 provides a specifier for a callous and unemotional interpersonal style, which reflects characteristics seen in psychopathy and are believed to be a childhood precursor to this disorder. Compared to the adolescent-onset subtype, the childhood-onset subtype, especially if callous and unemotional traits are present, tends to have a worse treatment outcome.

Comorbidity

ASPD commonly coexists with the following conditions:

  • Anxiety disorders.
  • Depressive disorder.
  • Impulse control disorders.
  • Substance-related disorders.
  • Somatization disorder.
  • Attention deficit hyperactivity disorder.
  • Bipolar disorder.
  • Borderline personality disorder.
  • Histrionic personality disorder.
  • Narcissistic personality disorder.
  • Sadistic personality disorder.

When combined with alcoholism, people may show frontal function deficits on neuropsychological tests greater than those associated with each condition. Alcohol Use Disorder is likely caused by lack of impulse and behavioural control exhibited by Antisocial Personality Disorder patients. The rates of ASPD tends to be around 40-50% in male alcohol and opiate addicts. However, it is important to remember this is not a causal relationship, but rather a plausible consequence of cognitive deficits as a result of ASPD.

Causes

Personality disorders are seen to be caused by a combination and interaction of genetic and environmental influences. Genetically, it is the intrinsic temperamental tendencies as determined by their genetically influenced physiology, and environmentally, it is the social and cultural experiences of a person in childhood and adolescence encompassing their family dynamics, peer influences, and social values. People with an antisocial or alcoholic parent are considered to be at higher risk. Fire-setting and cruelty to animals during childhood are also linked to the development of antisocial personality. The condition is more common in males than in females, and among people who are in prison.

Genetic

Research into genetic associations in antisocial personality disorder suggests that ASPD has some or even a strong genetic basis. Prevalence of ASPD is higher in people related to someone afflicted by the disorder. Twin studies, which are designed to discern between genetic and environmental effects, have reported significant genetic influences on antisocial behaviour and conduct disorder.

In the specific genes that may be involved, one gene that has seen particular interest in its correlation with antisocial behaviour is the gene that encodes for Monoamine oxidase A (MAO-A), an enzyme that breaks down monoamine neurotransmitters such as serotonin and norephinephrine. Various studies examining the genes’ relationship to behaviour have suggested that variants of the gene that results in less MAO-A being produced, such as the 2R and 3R alleles of the promoter region, have associations with aggressive behaviour in men. The association is also influenced by negative experience in early life, with children possessing a low-activity variant (MAOA-L) who experience such maltreatment being more likely to develop antisocial behaviour than those with the high-activity variant (MAOA-H). Even when environmental interactions (e.g. emotional abuse) are controlled for, a small association between MAOA-L and aggressive and antisocial behaviour remains.

The gene that encodes for the serotonin transporter (SCL6A4), a gene that is heavily researched for its associations with other mental disorders, is another gene of interest in antisocial behaviour and personality traits. Genetic associations studies have suggested that the short “S” allele is associated with impulsive antisocial behaviour and ASPD in the inmate population. However, research into psychopathy find that the long “L” allele is associated with the Factor 1 traits of psychopathy, which describes its core affective (e.g. lack of empathy, fearlessness) and interpersonal (e.g. grandiosity, manipulativeness) personality disturbances. This is suggestive of two different forms, one associated more with impulsive behaviour and emotional dysregulation, and the other with predatory aggression and affective disturbance, of the disorder.

Various other gene candidates for ASPD have been identified by a genome-wide association study published in 2016. Several of these gene candidates are shared with attention-deficit hyperactivity disorder, with which ASPD is comorbid. Furthermore, the study found that those who carry 4 mutations on chromosome 6 are 1.5 times more likely to develop antisocial personality disorder than those who do not.

Physiological

Hormones and Neurotransmitters

Traumatic events can lead to a disruption of the standard development of the central nervous system, which can generate a release of hormones that can change normal patterns of development. Aggressiveness and impulsivity are among the possible symptoms of ASPD. Testosterone is a hormone that plays an important role in aggressiveness in the brain. For instance, criminals who have committed violent crimes tend to have higher levels of testosterone than the average person. The effect of testosterone is counteracted by cortisol which facilitates the cognitive control of impulsive tendencies.

One of the neurotransmitters that has been discussed in individuals with ASPD is serotonin, also known as 5HT.[41] A meta-analysis of 20 studies found significantly lower 5-HIAA levels (indicating lower serotonin levels), especially in those who are younger than 30 years of age.

While it has been shown that lower levels of serotonin may be associated with ASPD, there has also been evidence that decreased serotonin function is highly correlated with impulsiveness and aggression across a number of different experimental paradigms. Impulsivity is not only linked with irregularities in 5HT metabolism, but may be the most essential psychopathological aspect linked with such dysfunction. Correspondingly, the DSM classifies “impulsivity or failure to plan ahead” and “irritability and aggressiveness” as two of seven sub-criteria in category A of the diagnostic criteria of ASPD.

Some studies have found a relationship between monoamine oxidase A and antisocial behaviour, including conduct disorder and symptoms of adult ASPD, in maltreated children.

Neurological

Antisocial behaviour may be related to head trauma. Antisocial behaviour is associated with decreased grey matter in the right lentiform nucleus, left insula, and frontopolar cortex. Increased volumes have been observed in the right fusiform gyrus, inferior parietal cortex, right cingulate gyrus, and post central cortex.

Intellectual and cognitive ability is consistently found to be impaired or reduced in the ASPD population. Contrary to stereotypes in popular culture of the “psychopathic genius”, antisocial personality disorder is associated with both reduced overall intelligence and specific reductions in individual aspects of cognitive ability. These deficits also occur in general-population samples of people with antisocial traits and in children with the precursors to antisocial personality disorder.

People that exhibit antisocial behaviour demonstrate decreased activity in the prefrontal cortex. The association is more apparent in functional neuroimaging as opposed to structural neuroimaging. The prefrontal cortex is involved in many executive functions, including behaviour inhibitions, planning ahead, determining consequences of action, and differentiating between right and wrong. However, some investigators have questioned whether the reduced volume in prefrontal regions is associated with antisocial personality disorder, or whether they result from co-morbid disorders, such as substance use disorder or childhood maltreatment. Moreover, it remains an open question whether the relationship is causal, i.e. whether the anatomical abnormality causes the psychological and behavioural abnormality, or vice versa.

Cavum septi pellucidi (CSP) is a marker for limbic neural maldevelopment, and its presence has been loosely associated with certain mental disorders, such as schizophrenia and post-traumatic stress disorder. One study found that those with CSP had significantly higher levels of antisocial personality, psychopathy, arrests and convictions compared with controls.

Environmental

Family Environment

Some studies suggest that the social and home environment has contributed to the development of antisocial behaviour. The parents of these children have been shown to display antisocial behaviour, which could be adopted by their children. A lack of parental stimulation and affection during early development leads to sensitization of the child’s stress response systems, which is thought to lead to underdevelopment of the child’s brain that deals with emotion, empathy and ability to connect to other humans on an emotional level. According to Dr. Bruce Perry in his book The Boy Who Was Raised as a Dog, “the [infant’s developing] brain needs patterned, repetitive stimuli to develop properly. Spastic, unpredictable relief from fear, loneliness, discomfort, and hunger keeps a baby’s stress system on high alert. An environment of intermittent care punctuated by total abandonment may be the worst of all worlds for a child.”

Cultural Influences

The sociocultural perspective of clinical psychology views disorders as influenced by cultural aspects; since cultural norms differ significantly, mental disorders such as ASPD are viewed differently. Robert D. Hare has suggested that the rise in ASPD that has been reported in the United States may be linked to changes in cultural mores, the latter serving to validate the behavioural tendencies of many individuals with ASPD. While the rise reported may be in part merely a byproduct of the widening use (and abuse) of diagnostic techniques, given Eric Berne’s division between individuals with active and latent ASPD – the latter keeping themselves in check by attachment to an external source of control like the law, traditional standards, or religion – it has been suggested that the erosion of collective standards may indeed serve to release the individual with latent ASPD from their previously prosocial behaviour.

There is also a continuous debate as to the extent to which the legal system should be involved in the identification and admittance of patients with preliminary symptoms of ASPD. Controversial clinical psychiatrist Pierre-Édouard Carbonneau suggested that the problem with legal forced admittance is the rate of failure when diagnosing ASPD. He states that the possibility of diagnosing and coercing a patient into prescribing medication to someone without ASPD, but is diagnosed with it could be potentially disastrous, but the possibility of not diagnosing it and seeing a patient go untreated because of a lack of sufficient evidence of cultural or environmental influences is something a psychiatrist must ignore, and in his words, “play it safe”.

ICD-10

The World Health Organisation’s (WHO’s) International Statistical Classification of Diseases and Related Health Problems, tenth edition (ICD-10), has a diagnosis called dissocial personality disorder (F60.2):

It is characterised by at least 3 of the following:

  • Callous unconcern for the feelings of others;
  • Gross and persistent attitude of irresponsibility and disregard for social norms, rules, and obligations;
  • Incapacity to maintain enduring relationships, though having no difficulty in establishing them;
  • Very low tolerance to frustration and a low threshold for discharge of aggression, including violence;
  • Incapacity to experience guilt or to profit from experience, particularly punishment; and/or
  • Marked readiness to blame others or to offer plausible rationalisations for the behaviour that has brought the person into conflict with society.

The ICD states that this diagnosis includes “amoral, antisocial, asocial, psychopathic, and sociopathic personality”. Although the disorder is not synonymous with conduct disorder, presence of conduct disorder during childhood or adolescence may further support the diagnosis of dissocial personality disorder. There may also be persistent irritability as an associated feature.

It is a requirement of the ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

Psychopathy

Psychopathy is commonly defined as a personality disorder characterised partly by antisocial behaviour, a diminished capacity for empathy and remorse, and poor behavioural controls. Psychopathic traits are assessed using various measurement tools, including Canadian researcher Robert D. Hare’s Psychopathy Checklist, Revised (PCL-R). “Psychopathy” is not the official title of any diagnosis in the DSM or ICD; nor is it an official title used by other major psychiatric organisations. The DSM and ICD, however, state that their antisocial diagnoses are at times referred to (or include what is referred to) as psychopathy or sociopathy.

American psychiatrist Hervey Cleckley’s work on psychopathy formed the basis of the diagnostic criteria for ASPD, and the DSM states ASPD is often referred to as psychopathy. However, critics argue ASPD is not synonymous with psychopathy as the diagnostic criteria are not the same, since criteria relating to personality traits are emphasized relatively less in the former. These differences exist in part because it was believed such traits were difficult to measure reliably and it was “easier to agree on the behaviours that typify a disorder than on the reasons why they occur”.

Although the diagnosis of ASPD covers two to three times as many prisoners than the diagnosis of psychopathy, Robert Hare believes the PCL-R is better able to predict future criminality, violence, and recidivism than a diagnosis of ASPD. He suggests there are differences between PCL-R-diagnosed psychopaths and non-psychopaths on “processing and use of linguistic and emotional information”, while such differences are potentially smaller between those diagnosed with ASPD and without. Additionally, Hare argued confusion regarding how to diagnose ASPD, confusion regarding the difference between ASPD and psychopathy, as well as the differing future prognoses regarding recidivism and treatability, may have serious consequences in settings such as court cases where psychopathy is often seen as aggravating the crime.

Nonetheless, psychopathy has been proposed as a specifier under an alternative model for ASPD. In the DSM-5, under “Alternative DSM-5 Model for Personality Disorders”, ASPD with psychopathic features is described as characterised by “a lack of anxiety or fear and by a bold interpersonal style that may mask maladaptive behaviours (e.g. fraudulence).” Low levels of withdrawal and high levels of attention-seeking combined with low anxiety are associated with “social potency” and “stress immunity” in psychopathy. Under the specifier, affective and interpersonal characteristics are comparatively emphasized over behavioural components.

Treatment

ASPD is considered to be among the most difficult personality disorders to treat. Rendering an effective treatment for ASPD is further complicated due to the inability to look at comparative studies between psychopathy and ASPD due to differing diagnostic criteria, differences in defining and measuring outcomes and a focus on treating incarcerated patients rather than those in the community. Because of their very low or absent capacity for remorse, individuals with ASPD often lack sufficient motivation and fail to see the costs associated with antisocial acts. They may only simulate remorse rather than truly commit to change: they can be seductively charming and dishonest, and may manipulate staff and fellow patients during treatment. Studies have shown that outpatient therapy is not likely to be successful, but the extent to which persons with ASPD are entirely unresponsive to treatment may have been exaggerated.

Most treatment done is for those in the criminal justice system to whom the treatment regimes are given as part of their imprisonment. Those with ASPD may stay in treatment only as required by an external source, such as parole conditions. Residential programmes that provide a carefully controlled environment of structure and supervision along with peer confrontation have been recommended. There has been some research on the treatment of ASPD that indicated positive results for therapeutic interventions. Psychotherapy also known as talk therapy is found to help treat patients with ASPD. Schema therapy is also being investigated as a treatment for ASPD. A review by Charles M. Borduin features the strong influence of Multisystemic therapy (MST) that could potentially improve this imperative issue. However, this treatment requires complete cooperation and participation of all family members. Some studies have found that the presence of ASPD does not significantly interfere with treatment for other disorders, such as substance use, although others have reported contradictory findings.

Therapists working with individuals with ASPD may have considerable negative feelings toward patients with extensive histories of aggressive, exploitative, and abusive behaviours. Rather than attempt to develop a sense of conscience in these individuals, which is extremely difficult considering the nature of the disorder, therapeutic techniques are focused on rational and utilitarian arguments against repeating past mistakes. These approaches would focus on the tangible, material value of prosocial behaviour and abstaining from antisocial behaviour. However, the impulsive and aggressive nature of those with this disorder may limit the effectiveness of even this form of therapy.

The use of medications in treating antisocial personality disorder is still poorly explored, and no medications have been approved by the FDA to specifically treat ASPD. A 2020 Cochrane review of studies that explored the use of pharmaceuticals in ASPD patients, of which 8 studies met the selection criteria for review, concluded that the current body of evidence was inconclusive for recommendations concerning the use of pharmaceuticals in treating the various issues of ASPD. Nonetheless, psychiatric medications such as antipsychotics, antidepressants, and mood stabilizers can be used to control symptoms such as aggression and impulsivity, as well as treat disorders that may co-occur with ASPD for which medications are indicated.

Prognosis

According to Professor Emily Simonoff of the Institute of Psychiatry, Psychology and Neuroscience there are many variables that are consistently connected to ASPD, such as: childhood hyperactivity and conduct disorder, criminality in adulthood, lower IQ scores and reading problems. The strongest relationship between these variables and ASPD are childhood hyperactivity and conduct disorder. Additionally, children who grow up with a predisposition of ASPD and interact with other delinquent children are likely to later be diagnosed with ASPD. Like many disorders, genetics play a role in this disorder but the environment holds an undeniable role in its development.

Boys are twice as likely to meet all of the diagnostic criteria for ASPD than girls (40% versus 25%) and they will often start showing symptoms of the disorder much earlier in life. Children that do not show symptoms of the disease through age 15 will not develop ASPD later in life. If adults exhibit milder symptoms of ASPD, it is likely that they never met the criteria for the disorder in their childhood and were consequently never diagnosed. Overall, symptoms of ASPD tend to peak in late-teens and early twenties, but can often reduce or improve through age 40.

ASPD is ultimately a lifelong disorder that has chronic consequences, though some of these can be moderated over time. There may be a high variability of the long-term outlook of antisocial personality disorder. The treatment of this disorder can be successful, but it entails unique difficulties. It is unlikely to see rapid change especially when the condition is severe. In fact, past studies revealed that remission rates were small, with up to only 31% rates of improvement instead of remittance. As a result of the characteristics of ASPD (e.g. displaying charm in effort of personal gain, manipulation), patients seeking treatment (mandated or otherwise) may appear to be “cured” in order to get out of treatment. According to definitions found in the DSM-5, people with ASPD can be deceitful and intimidating in their relationships. When they are caught doing something wrong, they often appear to be unaffected and unemotional about the consequences. Over time, continual behaviour that lacks empathy and concern may lead to someone with ASPD taking advantage of the kindness of others, including his or her therapist.

Without proper treatment, individuals suffering with ASPD could lead a life that brings about harm to themselves or others. This can be detrimental to their families and careers. ASPD victims suffer from lack of interpersonal skills (e.g. lack of remorse, lack of empathy, lack of emotional-processing skills). As a result of the inability to create and maintain healthy relationships due to the lack of interpersonal skills, individuals with ASPD may find themselves in predicaments such as divorce, unemployment, homelessness and even premature death by suicide. They also see higher rates of committed crime, reaching peaks in their late teens and often committing higher-severity crimes in their younger ages of diagnoses. Comorbidity of other mental illnesses such as Depression or substance use disorder is prevalent among ASPD victims. People with ASPD are also more likely to commit homicides and other crimes. Those who are imprisoned longer often see higher rates of improvement with symptoms of ASPD than others who have been imprisoned for a shorter amount of time.

According to one study, aggressive tendencies show in about 72% of all male patients diagnosed with ASPD. About 29% of the men studied with ASPD also showed a prevalence of pre-meditated aggression. Based on the evidence in the study, the researchers concluded that aggression in patients with ASPD is mostly impulsive, though there are some long-term evidences of pre-meditated aggressions. It often occurs that those with higher psychopathic traits will exhibit the pre-meditated aggressions to those around them. Over the course of a patient’s life with ASPD, he or she can exhibit this aggressive behaviour and harm those close to him or her.

Additionally, many people (especially adults) who have been diagnosed with ASPD become burdens to their close relatives, peers, and caretakers. Harvard Medical School recommends that time and resources be spent treating victims who have been affected by someone with ASPD, because the patient with ASPD may not respond to the administered therapies. In fact, a patient with ASPD may only accept treatment when ordered by a court, which will make their course of treatment difficult and severe. Because of the challenges in treatment, the patient’s family and close friends must take an active role in decisions about therapies that are offered to the patient. Ultimately, there must be a group effort to aid the long-term effects of the disorder.

What is the National Psychological Association for Psychoanalysis?

Introduction

The National Psychological Association for Psychoanalysis (NPAP) is an institution established in New York City by Theodore Reik in 1948, in response to the controversy over lay analysis and the question of the training of psychoanalysts in the States.

Following the lead established by Sigmund Freud, the NPAP offered training to the three core disciplines of medicine, social work and psychology, as well as to graduates from the humanities.

Brief History

Over the following decades, inevitably dissensions emerged in the organisation, and other non-medical training institutions were set up in the United States.

Current Ideology

The organisation currently sees itself as a vibrant professional association of analysts representing a diversity of theories that comprise contemporary psychoanalytic inquiry. The NPAP’s diverse membership is active in research, publication, legislation, public education, and cultural affairs, thus ensuring a psychoanalytic contribution to the community at large. The NPAP also publishes the highly respected and internationally recognised journal The Psychoanalytic Review, the oldest continuously published psychoanalytic journal in the United States.

Mindful of a legacy reaching directly back to Freud, the Institute today offers comprehensive psychoanalytic training grounded in the classical tradition, expanded by contemporary insights, and designed to prepare candidates for the professional practice of psychoanalysis.

What is the Psychoanalytic Quarterly?

Introduction

The Psychoanalytic Quarterly is a quarterly academic journal of psychoanalysis established in 1932 and, since 2018, published by Taylor and Francis.

The journal describes itself as “the oldest free-standing psychoanalytic journal in America”.

Brief History

The Psychoanalytic Quarterly was established by Dorian Feigenbaum, Bertram D. Lewin, Frankwood Williams, and Gregory Zilboorg. In the opening issue they described the journal’s aims:

This Quarterly will be devoted to theoretical, clinical and applied psychoanalysis. It has been established to fill the need for a strictly psychoanalytic organ in America…A close collaboration with associates abroad will be maintained. At the same time, a prime objective of the magazine is to stimulate American work and provide an outlet for it.

The first issue’s lead article was Libidinal Types by Freud, one of three articles by Freud translated by Edith B. Jackson and published in the journal in its first year. However, the new journal upset Ernest Jones in England, who saw it as a competitor to The International Journal of Psychoanalysis, which he edited. The new journal was also watched carefully by Smith Ely Jelliffe and William Alanson White of the National Psychological Association for Psychoanalysis (NPAP), which published Psychoanalytic Review:

the Quarterly […] is very excellent and I wish they would get on with it. I suspect that Lewin and his crows would get into hot water if someone read his paper and was after pornographic stuff; they could make it very hot. I do not know if I should warn Feigenbaum about it, as it might also include others, as you know the R. C. gentry are not asleep. The Quarterly has no special prospects. They will have to dig into their jeans or find an angel…

What is an Other Specified Feeding or Eating Disorder?

Introduction

Other specified feeding or eating disorder (OSFED) is a DSM-5 category that, along with unspecified feeding or eating disorder (UFED), replaces the category formerly called eating disorder not otherwise specified (EDNOS) in the DSM-IV-TR.

It captures feeding disorders and eating disorders of clinical severity that do not meet diagnostic criteria for anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), avoidant/restrictive food intake disorder (ARFID), pica, or rumination disorder.

OSFED includes five examples:

  1. Atypical anorexia nervosa.
  2. Atypical bulimia nervosa of low frequency and/or limited duration.
  3. Binge eating disorder of low frequency and/or limited duration.
  4. Purging disorder.
  5. Night eating syndrome (NES).

Brief History

In 1980, DSM-III was the first DSM to include a category for eating disorders that could not be classified in the categories of AN, BN, or pica. This category was called Atypical Eating Disorder. Atypical Eating Disorder was described in one sentence in the DSM-III and received very little attention in the literature, as it was perceived to be uncommon compared to the other defined eating disorders. In DSM-III-R, published in 1987, the Atypical Eating Disorder category became known as Eating Disorder Not Otherwise Specified (EDNOS). DSM-III-R included examples of individuals who would meet criteria for EDNOS, in part to acknowledge the increasingly recognized heterogeneity of individuals within the diagnostic category.

In 1994, DSM-IV was published and expanded EDNOS to include six clinical presentations. These presentations included individuals who:

  • Met criteria for AN, but continued to menstruate;
  • Met criteria for AN, but still had weight in the normal range despite significant weight loss;
  • Met criteria for BN but did not meet frequency criterion for binge eating or purging;
  • Engaged in inappropriate compensatory behaviour after eating small amounts of food; or
  • Repeatedly chewed or spit out food, or who binged on food but did not subsequently purge.

A disadvantage of DSM-IV’s broad EDNOS category was that people with very different symptoms were still classified as having the same diagnosis, making it difficult to access care specific to the disorder and conduct research on the diversity of pathology within EDNOS. Furthermore, EDNOS was perceived as less severe than AN or BN, despite findings that individuals diagnosed with EDNOS share similarities with full-threshold AN or BN in the degree of eating pathology, general psychopathology, and physical health. This perception prevented people in need from seeking help or insurance companies from covering treatment costs. DSM-5, published in 2013, sought to address these issues by adding new diagnoses and revising existing criteria.

Epidemiology

Few studies to date have examined OSFED prevalence. The largest community study is by Stice (2013), who examined 496 adolescent females who completed annual diagnostic interviews over 8 years. Lifetime prevalence by age 20 for OSFED overall was 11.5%. 2.8% had atypical AN, 4.4% had subthreshold BN, 3.6% had subthreshold BED, and 3.4% had purging disorder. Peak age of onset for OSFED was 18-20 years. NES was not assessed in this study, but estimates from other studies suggest that it presents in 1% of the general population.

A few studies have compared the prevalence of EDNOS and OSFED and found that though the prevalence of atypical eating disorders decreased with the new classification system, the prevalence still remains high. For example, in a population of 215 young patients presenting for ED treatment, the diagnosis of EDNOS to OSFED decreased from 62.3% to 32.6%. In another study of 240 females in the US with a lifetime history of an eating disorder, the prevalence changed from 67.9% EDNOS to 53.3% OSFED. Although the prevalence appears to reduce when using the categorisations of EDNOS vs. OSFED, a high proportion of cases still receive diagnoses of atypical eating disorders, which creates difficulties in communication, treatment planning, and basic research.

Classification

The five OSFED examples that can be considered eating disorders include atypical AN, BN (of low frequency and/or limited duration), BED (of low frequency and/or limited duration), purging disorder, and NES. Of note, OSFED is not limited to these five examples, and can include individuals with heterogeneous eating disorder presentations (i.e. OSFED-other). Another term, UFED, is used to describe individuals for whom full diagnostic criteria are not met but the reason remains unspecified or the clinician does not have adequate information to make a more definitive diagnosis.

Atypical Anorexia NervosaIn atypical AN, individuals meet all of the criteria for AN, with the exception of the weight criterion: the individual’s weight remains within or above the normal range, despite significant weight loss.
Atypical Bulimia NervosaIn this sub-threshold version of BN, individuals meet all criteria for BN, with the exception of the frequency criterion: binge eating and inappropriate compensatory behaviours occur, on average, less than once a week and/or for fewer than 3 months.
Binge Eating Disorder of Low Frequency and/or Limited DurationIn this sub-threshold version of BED, individuals must meet all criteria for BED, with the exception of the frequency criterion: binge eating occurs, on average, less than once a week and/or for fewer than 3 months.
Purging DisorderIn purging disorder, purging behaviour aimed to influence weight or shape is present, but in the absence of binge eating.
Night Eating SyndromeIn NES, individuals have recurrent episodes of eating at night, such as eating after awakening from sleep or excess calorie intake after the evening meal. This eating behaviour is not culturally acceptable by group norms, such as the occasional late-night munchies after a gathering. NES includes an awareness and recall of the eating, is not better explained by external influences such as changes in the individual’s sleep-wake cycle, and causes significant distress and/or impairment of functioning.

Though not defined specifically in DSM-5, research criteria for this diagnosis proposed adding the following criteria (1) the consumption of at least 25% of daily caloric intake after the evening meal and/or (2) evening awakenings with ingestions at least twice per week.

Treatment

Few studies guide the treatment of individuals with OSFED. However, cognitive behavioural therapy (CBT), which focuses on the interplay between thoughts, feelings, and behaviours, has been shown to be the leading evidence-based treatment for the eating disorders of BN and BED. For OSFED, a particular cognitive behavioural treatment can be used called CBT-Enhanced (CBT-E), which was designed to treat all forms of eating disorders. This method focuses not only what is thought to be the central cognitive disturbance in eating disorders (i.e. over-evaluation of eating, shape, and weight), but also on modifying the mechanisms that sustain eating disorder psychopathology, such as perfectionism, core low self-esteem, mood intolerance, and interpersonal difficulties. CBT-E showed effectiveness in two studies (total N = 219) and well maintained over 60-week follow-up periods. CBT-E is not specific to individual types of eating disorders but is based on the concept that common mechanisms are involved in the persistence of atypical eating disorders, AN, and BN.

What is an Unspecified Feeding or Eating Disorder?

Introduction

Unspecified feeding or eating disorder (UFED) is a Diagnostic and Statistical Manual of Mental Disorders (DSM-5 category of eating disorders that, along with other specified feeding or eating disorder (OSFED), replaced eating disorder not otherwise specified (EDNOS) in the DSM-IV-TR.

UFED is an eating disorder that does not meet the criteria for: anorexia nervosa, bulimia nervosa, binge eating disorder, or OSFED. Individuals with EDNOS have similar symptoms and behaviours to those with anorexia and bulimia, and can face the same dangerous risks.

Signs and Symptoms

Rather than providing specific diagnostic criteria for EDNOS, the fourth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) listed six non-exhaustive example presentations, including individuals who:

  • Meet all criteria for anorexia nervosa except they have regular menses.
  • Meet all criteria for anorexia nervosa except their weight falls within the normal range.
  • Meet all criteria for bulimia nervosa except they engage in binge eating or purging behaviours less than twice per week or for fewer than three months.
  • Use inappropriate compensatory behaviour (such as purging, excessive exercise, or fasting) after eating small amounts of food while retaining a normal body weight.
  • Repeatedly chew and spit out large amounts of food without swallowing.
  • Meet criteria for “binge eating disorder”: recurrent binge eating and no regular inappropriate compensatory behaviours.

Despite its subclinical status in DSM-IV, available data suggest that EDNOS is no less severe than the officially recognized DSM-IV eating disorders. In a comprehensive meta-analysis of 125 studies, individuals with EDNOS exhibited similar levels of eating pathology and general psychopathology to those with anorexia nervosa and binge eating disorder, and similar levels of physical health problems as those with anorexia nervosa. Although individuals with bulimia nervosa scored significantly higher than those with EDNOS on measures of eating pathology and general psychopathology, those with EDNOS exhibited more physical health problems than those with bulimia nervosa.

Diagnosis

Although no longer in the DSM-5, the three general categories for an EDNOS diagnosis are subthreshold symptoms of anorexia or bulimia, a mixture of both anorexic or bulimic symptoms, and clinically-significant disordered eating behaviours that are not described by anorexia and bulimia. EDNOS is no longer considered a diagnosis in DSM-5. Because some diagnostic criteria were loosened and new diagnoses were introduced in DSM-5, those displaying symptoms of what would previously have been considered EDNOS are now classified under anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant/restrictive food intake disorder(ARFID), other specified feeding or eating disorder (OSFED), or unspecified feeding or eating disorder (UFED).

Epidemiology

Although EDNOS (formerly called atypical eating disorder) was originally introduced in DSM-III to capture unusual cases, it accounts for up to 60% of cases in eating disorder specialty clinics. EDNOS is an especially prevalent category in populations that have received inadequate research attention such as young children, males, ethnic minorities, and non-Western groups.

Treatment

When treating any eating disorder, including unspecified disorders, it is important to include a registered dietician or nutritionist working with the treatment team. Even though eating disorders are a psychological diagnosis, psychologists are not certified or licensed in dietetics or nutrition, so it is important that psychologists are not practicing outside their bounds of competence. Medical Nutrition Therapy is vital in the treatment and management of eating disorders. The dietician assists the patient by creating a meal plan that is tailored to their individual needs and treatment goals. The dietician will also provide psychoeducation that challenges nutrition misinformation and will ideally create a space where the patient feels comfortable asking questions.

What is Analytical Psychology?

Introduction

Analytical psychology (German: Analytische Psychologie, sometimes translated as analytic psychology and referred to as Jungian analysis) is a term coined by Carl Jung, a Swiss psychiatrist, to describe research into his new “empirical science” of the psyche.

It was designed to distinguish it from Freud’s psychoanalytic theories as their seven-year collaboration on psychoanalysis was drawing to an end between 1912 and 1913. The evolution of his science is contained in his monumental opus, the Collected Works, written over sixty years of his lifetime.

The history of analytical psychology is intimately linked with the biography of Jung. At the start, it was known as the “Zurich school”, whose chief figures were Eugen Bleuler, Franz Riklin, Alphonse Maeder and Jung, all centred in the Burghölzli hospital in Zurich. It was initially a theory concerning psychological complexes until Jung, upon breaking with Sigmund Freud, turned it into a generalised method of investigating archetypes and the unconscious, as well as into a specialised psychotherapy.

Analytical psychology, or “complex psychology”, from the German: Komplexe Psychologie, is the foundation of many developments in the study and practice of Psychology as of other disciplines. The followers of Jung are many, and some of them are members of national societies in diverse countries around the world. They collaborate professionally on an international level through the International Association of Analytical Psychologists (IAAP) and the International Association for Jungian Studies (IAJS). Jung’s propositions have given rise to a rich and multidisciplinary literature in numerous languages.

Among widely used concepts owed specifically to Analytical psychology are: anima and animus, archetypes, the collective unconscious, complexes, extraversion and introversion, individuation, the Self, the shadow and synchronicity. The Myers–Briggs Type Indicator (MBTI) is based on another of Jung’s theories on psychological types. A lesser known idea was Jung’s notion of the Psychoid to denote a hypothesised immanent plane beyond consciousness, distinct from the collective unconscious, and a potential locus of synchronicity.

The approximately “three schools” of post-Jungian analytical psychology that are current, the classical, archetypal and developmental, can be said to correspond to the developing yet overlapping aspects of Jung’s lifelong explorations, even if he expressly did not want to start a school of “Jungians”. Hence as Jung proceeded from a clinical practice which was mainly traditionally science-based and steeped in rationalist philosophy, anthropology and ethnography, his enquiring mind simultaneously took him into more esoteric spheres such as alchemy, astrology, gnosticism, metaphysics, myth and the paranormal, without ever abandoning his allegiance to science as his long-lasting collaboration with Wolfgang Pauli attests. His wide-ranging progression suggests to some commentators that, over time, his analytical psychotherapy, informed by his intuition and teleological investigations, became more of an “art”.

The findings of Jungian analysis and the application of analytical psychology to contemporary preoccupations such as social and family relationships, dreams and nightmares, work-life balance, architecture and urban planning, politics and economics, conflict and warfare, and climate change are illustrated in a growing number of publications and films.

Background

Jung began his career as a psychiatrist in Zürich, Switzerland. Already employed at the Burghölzli hospital in 1901, in his academic dissertation for the medical faculty of the University of Zurich he took the risk of using his experiments on somnambulism and the visions of his mediumistic cousin, Helly Preiswerk. The work was entitled, “On the Psychology and Pathology of So-Called Occult Phenomena”. It was accepted but caused great upset among his mother’s family. Under the direction of psychiatrist Eugen Bleuler, he also conducted research with his colleagues using a galvanometer to evaluate the emotional sensitivities of patients to lists of words during word association. Jung has left a description of his use of the device in treatment. His research earned him a worldwide reputation and numerous honours, including Honorary Doctorates from Clark and Fordham Universities in 1909 and 1910 respectively. Other honours followed later.

Although they began corresponding a year earlier, in 1907 Jung travelled to meet Sigmund Freud in Vienna, Austria. At that stage, Jung, aged thirty-two, had a much greater international renown than the forty-nine year old neurologist. For a further six years, the two scholars worked and travelled to the United States together. In 1911, they founded the International Psychoanalytical Association, of which Jung was the first president. However, early in the collaboration, Jung had already observed that Freud would not tolerate ideas that were different from his own.

Unlike most modern psychologists, Jung did not believe in restricting himself to the scientific method as a means to understanding the human psyche. He saw dreams, myths, coincidence and folklore as empirical evidence to further understanding and meaning. So although the unconscious cannot be studied by using direct methods, it acts as a useful working hypothesis, according to Jung. As he said, “The beauty about the unconscious is that it is really unconscious.” Hence, the unconscious is ‘untouchable’ by experimental researches, or indeed any possible kind of scientific or philosophical reach, precisely because it is unconscious.

The Break with Freud

It was the publication of a book by Jung which provoked the break with psychoanalysis and led to the founding of analytical psychology. In 1912 Jung met “Miss Miller”, brought to his notice by the work of Théodore Flournoy and whose case gave further substance to his theory of the collective unconscious. The study of her visions supplied the material which would go on to furnish his reasoning which he developed in Psychology of the Unconscious (Wandlungen und Symbole der Libido) (re-published as Symbols of Transformation in 1952) (C.W. Vol. 5). At this, Freud muttered about “heresy”. It was the second part of the work that brought the divergence to light. Freud mentioned to Ernest Jones that it was on page 174 of the original German edition, that Jung, according to him, had “lost his way”. It is the extract where Jung enlarged on his conception of the libido. The sanction was immediate: Jung was officially banned from the Vienna psychoanalytic circle from August 1912. From that date the psychoanalytic movement split into two obediences, with Freud’s partisans on one side, Karl Abraham being delegated to write a critical notice about Jung, and with Ernest Jones as defender of Freudian orthodoxy; while on the other side, were Jung’s partisans, including Leonhard Seif, Franz Riklin, Johan van Ophuijsen and Alphonse Maeder.

Jung’s innovative ideas with a new formulation of psychology and lack of contrition sealed the end of the Jung-Freud friendship in 1913. From then, the two scholars worked independently on personality development: Jung had already termed his approach analytical psychology (1912), while the approach Freud had founded is referred to as the Psychoanalytic School, (psychoanalytische Schule).

Jung’s postulated unconscious was quite different from the model proposed by Freud, despite the great influence that the founder of psychoanalysis had had on him. In particular, tensions manifested between him and Freud because of various disagreements, including those concerning the nature of the libido. Jung de-emphasized the importance of sexual development as an instinctual drive and focused on the collective unconscious: the part of the unconscious that contains memories and ideas which Jung believed were inherited from generations of ancestors. While he accepted that libido was an important source for personal growth, unlike Freud, Jung did not consider that libido alone was responsible for the formation of the core personality. Due to the particular hardships Jung had endured growing up, he believed his personal development and that of everyone was influenced by factors unrelated to sexuality.

The overarching aim in life, according to Jungian psychology, is the fullest possible actualisation of the “Self” through individuation. Jung defines the “self” as “not only the centre but also the whole circumference which embraces both conscious and unconscious; it is the centre of this totality, just as the ego is the centre of the conscious mind”. Central to this process of individuation is the individual’s continual encounter with the elements of the psyche by bringing them into consciousness. People experience the unconscious through symbols encountered in all aspects of life: in dreams, art, religion, and the symbolic dramas enacted in relationships and life pursuits. Essential to the process is the merging of the individual’s consciousness with the collective unconscious through a huge range of symbols. By bringing conscious awareness to bear on what is unconscious, such elements can be integrated with consciousness when they “surface”. To proceed with the individuation process, individuals need to be open to the parts of themselves beyond their own ego, which is the “organ” of consciousness. In a famous dictum, Jung said, “the Self, like the unconscious is an a priori existent out of which the ego evolves. It is … an unconscious prefiguration of the ego. It is not I who create myself, rather I happen to myself’.

It follows that the aim of (Jungian) psychotherapy is to assist the individual to establish a healthy relationship with the unconscious so that it is neither excessively out of balance in relation to it, as in neurosis, a state that can result in depression, anxiety, and personality disorders or so flooded by it that it risks psychosis resulting in mental breakdown. One method Jung applied to his patients between 1913 and 1916 was active imagination, a way of encouraging them to give themselves over to a form of meditation to release apparently random images from the mind in order to bridge unconscious contents into awareness.

“Neurosis” in Jung’s view results from the build up of psychological defences the individual unconsciously musters in an effort to cope with perceived attacks from the outside world, a process he called a “complex”, although complexes are not merely defensive in character. The psyche is a self-regulating adaptive system. People are energetic systems, and if the energy is blocked, the psyche becomes sick. If adaptation is thwarted, the psychic energy stops flowing and becomes rigid. This process manifests in neurosis and psychosis. Jung proposed that this occurs through maladaptation of one’s internal realities to external ones. The principles of adaptation, projection, and compensation are central processes in Jung’s view of psyche’s attempts to adapt.

Innovations of Jungian Analysis

Philosophical and Epistemological Foundations

Philosophy

Jung was an adept principally of the American philosopher William James, founder of pragmatism, whom he met during his trip to the United States in 1909. He also encountered other figures associated with James, such as John Dewey and the anthropologist, Franz Boas. Pragmatism was Jung’s favoured route to base his psychology on a sound scientific basis according to historian Sonu Shamdasani. His theories consist of observations of phenomena, and according to Jung it is phenomenology. In his view psychologism was suspect.

Displacement into the conceptual deprives experience of its substance and the possibility of being simply named.

Throughout his writings, Jung sees in empirical observation not only a precondition of an objective method but also respect for an ethical code which should guide the psychologist, as he stated in a letter to Joseph Goldbrunner:

I consider it a moral obligation not to make assertions about things one cannot see or whose existence cannot be proved, and I consider it an abuse of epistemological power to do so regardless. These rules apply to all experimental science. Other rules apply to metaphysics. I regard myself as answerable to the rules of experimental science. As a result nowhere in my work are there any metaphysical assertions nor – nota bene – any negations of a metaphysical nature.

According to the Italo-French psychoanalyst Luigi Aurigemma, Jung’s reasoning is also marked by Immanuel Kant, and more generally by German rationalist philosophy. His lectures are evidence of his assimilation of Kantian thought, especially the Critique of Pure Reason and Critique of Practical Reason. Aurigemma caracterises Jung’s thinking as “epistemological relativism” because it does not postulate any belief in the metaphysical. In fact, Jung uses Kant’s teleology to bridle his thinking and to guard himself from straying into any metaphysical excursions. On the other hand, for French historian of psychology, Françoise Parot, contrary to the alleged rationalist vein, Jung is “heir” to mystics, (Meister Eckhart, Hildegard of Bingen, or Augustine of Hippo) and to the romantics be they scientists, such as Carl Gustav Carus or Gotthilf Heinrich von Schubert in particular, or to philosophers and writers, along the lines of Nietzsche, Goethe, and Schopenhauer, in the way he conceptualised the unconscious in particular. Whereas his typology is profoundly dependent on Carl Spitteler.

Scientific Heritage

As a trained psychiatrist, Jung had a grounding in the state of science in his day. He regularly refers to the experimental psychology of Wilhelm Wundt. His Word Association Test designed with Franz Riklin is actually the direct application of Wundt’s theory. Notwithstanding the great debt of analytical psychology to Sigmund Freud, Jung borrowed concepts from other theories of his time. For instance, the expression “abaissement du niveau mental” comes directly from the French psychologist Pierre Janet whose courses Jung attended during his studies in France, during 1901. Jung had always acknowledged how much Janet had influenced his career.

Jung’s use of the concept of “participation mystique” is owed to the French ethnologist Lucien Lévy-Bruhl:

What Rousseau describes is nothing other than the primitive collective mentality which Lucien Lévy-Bruhl has brilliantly called “participation mystique”

which he uses to illustrate the surprising fact, to him, that some native peoples can experience relations that defy logic, as for instance in the case of the South American tribe, whom he met during his travels, where the men pretended they were scarlet aras birds. Finally, his use of the English expression, “pattern of behaviour”, which is synonymous with the term archetype, is drawn from British studies in ethology.

The principal contribution to analytical psychology, nevertheless, remains that of Freud’s psychoanalysis, from which Jung took a number of concepts, especially the method of inquiring into the unconscious through free association. Individual analysts’ thinking was also integrated into his project, among whom are Sándor Ferenczi (Jung refers to his notion of “affect”) or Ludwig Binswanger and his Daseinsanalyse [de], (Daseinsanalysis). Jung affirms also Freud’s contribution to our knowledge of the psyche as being, without doubt, of the highest importance. It reveals penetrating information about the dark corners of the soul and of the human personality, which is of the same order as Nietzsche’s On the Genealogy of Morality (1887). In this context, Freud was, according to Jung, one of the great cultural critics of the XIXth century.

Divergences from Psychoanalysis

Jungian Analysis, as is psychoanalysis, is a method to access, experience and integrate unconscious material into awareness. It is a search for the meaning of behaviours, feelings and events. Many are the channels to extend knowledge of the self: the analysis of dreams is one important avenue. Others may include expressing feelings about and through art, poetry or other expressions of creativity, the examination of conflicts and repeating patterns in a person’s life. A comprehensive description of the process of dream interpretation is complex, in that it is highly specific to the person who undertakes it. Most succinctly it relies on the associations which the particular dream symbols suggest to the dreamer, which at times may be deemed “archetypal” in so far as they are supposed common to many people throughout history. Examples could be a hero, an old man or woman, situations of pursuit, flying or falling.

Whereas (Freudian) psychoanalysis relies entirely on the development of the transference in the analysand (the person under treatment) to the analyst, Jung initially used the transference and later concentrated more on a dialectical and didactic approach to the symbolic and archetypal material presented by the patient. Moreover his attitude towards patients departed from what he had observed in Freud’s method. Anthony Stevens has explained it thus:

Though [Jung’s] initial formulations arose mainly out of his own creative illness, they were also a conscious reaction against the stereotype of the classical Freudian analyst, sitting silent and aloof behind the couch, occasionally emitting ex cathedra pronouncements and interpretations, while remaining totally uninvolved in the patient’s guilt, anguish, and need for reassurance and support. Instead, Jung offered the radical proposal that analysis is a dialectical procedure, a two-way exchange between two people, who are equally involved. Although it was a revolutionary idea when he first suggested it, it is a model which has influenced psychotherapists of most schools, though many seem not to realise that it originated with Jung.

In place of Freud’s “surgical detachment”, Jung demonstrated a more relaxed and warmer welcome in the consulting room. He remained aware nonetheless that exposure to a patient’s unconscious contents always posed a certain risk of contagion (he calls it “psychic infection”) to the analyst, as experienced in the countertransference. The process of contemporary Jungian analysis depends on the type of “school of analytical psychology” to which the therapist adheres, (see below). The “Zurich School” would reflect the approach Jung himself taught, while those influenced by Michael Fordham and associates in London, would be significantly closer to a Kleinian approach and therefore, concerned with analysis of the transference and countertransference as indicators of repressed material along with the attendant symbols and patterns.

Dream Work

Jung’s preoccupation with dreams can be dated from 1902. It was only after the break with Freud that he published in 1916 his “Psychology of the Unconscious” where he elaborated his view of dreams, which contrasts sharply with Freud’s conceptualisation. While he agrees that dreams are a highway into the unconscious, he enlarges on their functions further than psychoanalysis did. One of the salient differences is the compensatory function they perform by reinstating psychic equilibrium in respect of judgements made during waking life: thus a man consumed by ambition and arrogance may, for example, dream about himself as small and vulnerable person.

According to Jung, this demonstrates that the man’s attitude is excessively self-assured and thereby refuses to integrate the inferior aspects of his personality, which are denied by his defensive arrogance. Jung calls this a compensation mechanism, necessary for the maintenance of a healthy mental balance. Shortly before his death in 1961, he wrote:

In order to secure mental and even physiological stability, it is necessary that the conscious and unconscious should be integrated one with the other. This is so that they evolve in parallel. (Pour sauvegarder la stabilité mentale, et même physiologique, il faut que la conscience et l’inconscient soient intégralement reliés, afin d’évoluer parallèlement).

Unconscious material is expressed in images through the deployment of symbolism which, in Jungian terms, means it has an affective role (in that it can sometimes give rise to a numinous feeling, when associated with an archetypal force) and an intellectual role. Some dreams are personal to the dreamer, others may be collective in origin or “transpersonal” in so far as they relate to existential events. They can be taken to express phases of the individuation process (see below) and may be inspired by literature, art, alchemy or mythology. Analytical psychology is recognised for its historical and geographical study of myths as a means to deconstruct, with the aid of symbols, the unconscious manifestations of the psyche. Myths are said to represent directly the elements and phenomena arising from the collective unconscious and though they may be subject to alteration in their detail through time, their significance remains similar. While Jung relies predominantly on christian or on Western pagan mythology (Ancient Greece and Rome), he holds that the unconscious is driven by mythologies derived from all cultures. He evinced an interest in Hinduism, in Zoroastrianism and Taoism, which all share fundamental images reflected in the psyche. Thus analytical psychology focusses on meaning, based on the hypothesis that human beings are potentially in constant touch with universal and symbolic aspects common to humankind. In the words of André Nataf:

Jung opens psychoanalysis to a dimension currently obscured by the prevailing scientism: spirituality. His contribution, though questionable in certain respects, remains unique. His explorations of the unconscious carried out both as a scientist and a poet, indicate that it is structured as a language but one which is in a mythical mode. (Jung ouvre la psychanalyse à une dimension cachée par le scientisme ambiant : la spiritualité. Son apport, quoique contestable sur certains points, reste unique. Explorant l’inconscient en scientifique et poète, il montre que celui-ci se structure non comme une langue mais sur le mode du mythe).

Principal Concepts

In analytical psychology two distinct types of psychological process may be identified: that deriving from the individual, characterised as “personal”, belonging to a subjective psyche, and that deriving from the collective, linked to the structure of an objective psyche, which may be termed “transpersonal”. These processes are both said to be archetypal. Some of these processes are regarded as specifically linked to consciousness, such as the animus or anima, the persona or the shadow. Others pertain more to the collective sphere. Jung tended to personify the anima and animus as they are, according to him, always attached to a person and represent an aspect of his or her psyche.

Anima and Animus

Jung identified the archetypal anima as being the unconscious feminine component of men and the archetypal animus as the unconscious masculine component in women. These are shaped by the contents of the collective unconscious, by others, and by the larger society. However, many modern-day Jungian practitioners do not ascribe to a literal definition, citing that the Jungian concept points to every person having both an anima and an animus. Jung considered, for instance, an “animus of the anima” in men, in his work Aion and in an interview in which he says:

“Yes, if a man realizes the animus of his anima, then the animus is a substitute for the old wise man. You see, his ego is in relation to the unconscious, and the unconscious is personified by a female figure, the anima. But in the unconscious is also a masculine figure, the wise old man. And that figure is in connection with the anima as her animus, because she is a woman. So, one could say the wise old man was in exactly the same position as the animus to a woman.”

Jung stated that the anima and animus act as guides to the unconscious unified Self, and that forming an awareness and a connection with the anima or animus is one of the most difficult and rewarding steps in psychological growth. Jung reported that he identified his anima as she spoke to him, as an inner voice, unexpectedly one day.

In cases where the anima or animus complexes are ignored, they vie for attention by projecting itself on others. This explains, according to Jung, why we are sometimes immediately attracted to certain strangers: we see our anima or animus in them. Love at first sight is an example of anima and animus projection. Moreover, people who strongly identify with their gender role (e.g. a man who acts aggressively and never cries) have not actively recognised or engaged their anima or animus.

Jung attributes human rational thought to be the male nature, while the irrational aspect is considered to be natural female (rational being defined as involving judgment, irrational being defined as involving perceptions). Consequently, irrational moods are the progenies of the male anima shadow and irrational opinions of the female animus shadow.

Archetypes

The use of archetypes in psychology was advanced by Jung in an essay entitled “Instinct and the Unconscious” in 1919. The first element in Greek ‘arche’ signifies ‘beginning, origin, cause, primal source principle’, by extension it can signify ‘position of a leader, supreme rule and government’. The second element ‘type’ means ‘blow or what is produced by a blow, the imprint of a coin …form, image, prototype, model, order, and norm’, …in the figurative, modern sense, ‘pattern underlying form, primordial form’. In his psychological framework, archetypes are innate, universal or personal prototypes for ideas and may be used to interpret observations. The method he favoured was hermeneutics which was central in his practice of psychology from the start. He made explicit references to hermeneutics in the Collected Works and during his theoretical development of the notion of archetypes. Although he lacks consistency in his formulations, his theoretical development of archetypes is rich in hermeneutic implications. As noted by Smythe and Baydala (2012):

his notion of the archetype as such can be understood hermeneutically as a form of non-conceptual background understanding.

A group of memories and attitudes associated with an archetype can become a complex, e.g. a mother complex may be associated with a particular mother archetype. Jung treated the archetypes as psychological organs, analogous to physical ones in that both are morphological givens which probably arose through evolution.

Archetypes have been regarded as collective as well as individual, and identifiable in a variety of creative ways. As an example, in his book Memories, Dreams, Reflections, Jung states that he began to see and talk to a manifestation of anima and that she taught him how to interpret dreams. As soon as he could interpret on his own, Jung said that she ceased talking to him because she was no longer needed. However, the essentialism inherent in archetypal theory in general and concerning the anima, in particular, has called for a re‐evaluation of Jung’s theory in terms of emergence theory. This would emphasise the role of symbols in the construction of affect in the midst of collective human action. In such a reconfiguration, the visceral energy of a numinous experience can be retained while the problematic theory of archetypes has outlived its usefulness.

Collective Unconscious

Jung’s concept of the collective unconscious has undergone re-interpretation over time. The term “collective unconscious” first appeared in Jung’s 1916 essay, “The Structure of the Unconscious”. This essay distinguishes between the “personal”, Freudian unconscious, filled with fantasies (e.g. sexual) and repressed images, and the “collective” unconscious encompassing the soul of humanity at large.

In “The Significance of Constitution and Heredity in Psychology” (November 1929), Jung wrote:

And the essential thing, psychologically, is that in dreams, fantasies, and other exceptional states of mind the most far-fetched mythological motifs and symbols can appear autochthonously at any time, often, apparently, as the result of particular influences, traditions, and excitations working on the individual, but more often without any sign of them. These “primordial images” or “archetypes,” as I have called them, belong to the basic stock of the unconscious psyche and cannot be explained as personal acquisitions. Together they make up that psychic stratum which has been called the collective unconscious. The existence of the collective unconscious means that individual consciousness is anything but a tabula rasa and is not immune to predetermining influences. On the contrary, it is in the highest degree influenced by inherited presuppositions, quite apart from the unavoidable influences exerted upon it by the environment. The collective unconscious comprises in itself the psychic life of our ancestors right back to the earliest beginnings. It is the matrix of all conscious psychic occurrences, and hence it exerts an influence that compromises the freedom of consciousness in the highest degree, since it is continually striving to lead all conscious processes back into the old paths.

Given that in his day he lacked the advances of complexity theory and especially complex adaptive systems (CAS), it has been argued that his vision of archetypes as a stratum in the collective unconscious, corresponds to nodal patterns in the collective unconscious which go on to shape the characteristic patterns of human imagination and experience and in that sense, “seems a remarkable, intuitive articulation of the CAS model”.

Individuation

Individuation is a complex process that involves going through different stages of growing awareness through the progressive confrontation and integration of personal unconscious elements. This is the central concept of analytical psychology first introduced in 1916. It is the objective of Jungian psychotherapy to the extent that it enables the realisation of the Self. As Jung stated:

The aim of individuation is nothing less than to divest the self of the false wrappings of the persona, on the one hand and the suggestive power of primordial images on the other.

Jung started experimenting with individuation after his split with Freud as he confronted what was described as eruptions from the collective unconscious driven by a contemporary malaise of spiritual alienation. According to Jung, individuation means becoming an individual and implies becoming one’s own self. Unlike individuality, which emphasizes some supposed peculiarity, Jung described individuation as a better and more complete fulfilment of the collective qualities of the human being. In his experience, Jung explained that individuation helped him, “from the therapeutic point of view, to find the particular images that lie behind emotions”.

Individuation is from the first what the analysand must undergo, in order to integrate the other elements of the psyche. This pursuit of wholeness aims to establish the Self, which include both the rational conscious mind of the ego and the irrational contents of the unconscious, as the new personality centre. Prior to individuation, the analysand is carefully assessed to determine if the ego is strong enough to take the intensity of this process. The elements to be integrated include the persona which acts as the representative of the person in her/his role in society, the shadow which contains all that is personally unknown and what the person considers morally reprehensible and, the anima or the animus, which respectively carry their feminine and masculine values. For Jung many unconscious conflicts at the root of neurosis are caused by the difficulty to accept that such a dynamic can unbalance the subject from his habitual position and confronts her/him with aspects of the self they were accustomed to ignore. Once individuation is completed the ego is no longer at the centre of the personality. The process, however, does not lead to a complete self-realisation and that individuation can never be a fixed state due to the unfathomable nature of the depths of the collective unconscious.

Shadow

The shadow is an unconscious complex defined as the repressed, suppressed or disowned qualities of the conscious self. According to Jung, the human being deals with the reality of the shadow in four ways: denial, projection, integration and/or transmutation. Jung himself asserted that “the result of the Freudian method of elucidation is a minute elaboration of man’s shadow-side unexampled in any previous age.” According to analytical psychology, a person’s shadow may have both constructive and destructive aspects. In its more destructive aspects, the shadow can represent those things people do not accept about themselves. For instance, the shadow of someone who identifies as being kind may be harsh or unkind. Conversely, the shadow of a person who perceives himself to be brutal may be gentle. In its more constructive aspects, a person’s shadow may represent hidden positive qualities. This has been referred to as the “gold in the shadow”. Jung emphasized the importance of being aware of shadow material and incorporating it into conscious awareness in order to avoid projecting shadow qualities on others.

The shadow in dreams is often represented by dark figures of the same gender as the dreamer.

The shadow may also concern great figures in the history of human thought or even spiritual masters, who became great because of their shadows or because of their ability to live their shadows (namely, their unconscious faults) in full without repressing them.

Persona

Just like the anima and animus, the persona (derived from the Greek term for a mask, as would have been worn by actors) is another key concept in analytical psychology. It is the part of the personality which manages an individual’s relations with society in the outside world and works the same way for both sexes.

The persona … is the individual’s system of adaptation to, or the manner assumed in dealing with the world. Every calling or profession, for example, has its own characteristic persona […] Only the danger is that (people) become identical with their personas: thus the professor with his textbook, the tenor with his voice. One could say with little exaggeration, that the persona is that which in reality one is not, but which oneself as well as others think one is.

The persona, which is at the heart of the psyche, is contrary to the shadow which is actually the true personality but denied by the self. The conscious self identifies primarily with the persona during development in childhood as the individual develops a psychological framework for dealing with others. Identifications with diplomas, social roles, with honours and awards, with a career, all contribute to the apparent constitution of the persona and which do not lead to knowledge of the self. For Jung, the persona has nothing real about it. It can only be a compromise between the individual and society, yielding an illusion of individuality. Individuation consists, in the first instance, of discarding the individual’s mask, but not too quickly as often, it is all the patient has as a means of identification. The persona is implicated in a number symptoms such as compulsive disorders, phobias, shifting moods, and addictions, among others.

Psychological Types

Analytical psychology distinguishes several psychological types or temperaments.

  • Extravert.
  • Introvert.

According to Jung, the psyche is an apparatus for adaptation and orientation, and consists of a number of different psychic functions. Among these he distinguishes four basic functions:

  • Sensation: Perception by means of the sense organs.
  • Intuition: Perceiving in unconscious way or perception of unconscious contents.
  • Thinking: Function of intellectual cognition; the forming of logical conclusions.
  • Feeling: Function of subjective estimation.

Thinking and feeling functions are rational, while the sensation and intuition functions are irrational.

Note: There is ambiguity in the term ‘rational’ that Carl Jung ascribed to the thinking/feeling functions. Both thinking and feeling irrespective of orientation (i.e. introverted/extroverted) employ/utilise/are directed by in loose terminology an underlying ‘logical’ IF-THEN construct/process (as in IF X THEN Y) in order to form judgements. This underlying construct/process is not directly observable in normal states of consciousness especially when engaged in thoughts/feelings. It can be cognised merely as a concept/abstraction during thoughtful reflection. Sensation and intuition are ‘irrational’ functions simply because they do not employ the above-mentioned underlying logical construct/process.

Complexes

Early in Jung’s career he coined the term and described the concept of the “complex”. Jung claims to have discovered the concept during his free association and galvanic skin response experiments. Freud obviously took up this concept in his Oedipus complex amongst others. Jung seemed to see complexes as quite autonomous parts of psychological life. It is almost as if Jung were describing separate personalities within what is considered a single individual, but to equate Jung’s use of complexes with something along the lines of multiple personality disorder would be a step out of bounds.

Jung saw an archetype as always being the central organising structure of a complex. For instance, in a “negative mother complex,” the archetype of the “negative mother” would be seen to be central to the identity of that complex. This is to say, our psychological lives are patterned on common human experiences. Jung saw the Ego (which Freud wrote about in German literally as the “I”, one’s conscious experience of oneself) as a complex. If the “I” is a complex, what might be the archetype that structures it? Jung, and many Jungians, might say “the hero,” one who separates from the community to ultimately carry the community further.

Synchronicity

Carl Jung first officially used the term synchronicity during a conference held in memory of his sinologist friend, Richard Wilhelm in 1930. It was part of his explanation of the modus operandi of the I Ching. The second reference was made in 1935 in his Tavistock Lectures. For an overview of the origins of the concept, see Joseph Cambray: “Synchronicity as emergence”. It was used to denote the simultaneous occurrence of two events with no causal physical connection, but whose association evokes a meaning for the person experiencing or observing it. The often cited example of the phenomenon is Jung’s own account of a beetle (the common rose-chafer, Cetonia aurata) flying into his consulting room directly following on from his patient telling him a dream featuring a golden scarab. The concept only makes sense psychologically and cannot be reduced to a verified or scientific fact. For Jung it constitutes a working hypothesis which has subsequently given rise to many ambiguities.

I chose this term because the simultaneous occurrence of two meaningfully but not causally connected events seemed to me an essential criterion. I am therefore using the general concept of synchronicity in the special sense of a coincidence in time of two or more causally unrelated events which have the same or a similar meaning, in contrast to synchronism, which simply means the simultaneous occurrence of two events. Synchronicity therefore means the simultaneous occurrence of a certain psychic state with one or more external events which appear as meaningful parallels to the momentary subjective state -and, in certain cases, vice versa.

According to Jung, an archetype which has been constellated in the psyche can, under certain circumstances, transgress the boundary between substance and psyche.

Jung had studied such phenomena with the physicist and Nobel Prize winner, Wolfgang Pauli, who did not always agree with Jung, and with whom he carried on an extensive correspondence, enriched by the contributions of both specialists in their own fields. Pauli had given a series of lectures to the C.G. Jung Institute, Zürich whose member and patron he had been since 1947. It gave rise to a joint essay: Synchronicity, an a-causal principle (1952) The two men saw in the idea of synchronicity a potential way of explaining a particular relationship between “incontrovertible facts”, whose occurrence is tied to unconscious and archetypal manifestations:

The psyche and matter are ordered according to principles which are common, neutral, and incontrovertible.

Borrowing the notion from Arthur Schopenhauer, Jung calls it Unus mundus, a state where neither matter nor the psyche are distinguishable. whereas for Pauli it was a limiting concept, in two senses, in that it is at once scientific and symbolic. According to him, the phenomenon is dependent on the observer. Nevertheless, both men were in accord that there existed the possibility of a conjunction between physics and psychology. Jung wrote in a letter to Pauli:

These researches (Jung’s research into alchemy), have shown me that modern physics can symbolically represent psychological processes down to the minutest detail.

Marie-Louise von Franz also had a lengthy exchange of letters with Wolfgang Pauli. On Pauli’s death in 1958, his widow, Franca, deliberately destroyed all the letters von Franz had sent to her husband, and which he had kept locked inside his writing desk. However, the letters from Pauli to von Franz were all saved and were later made available to researchers and published.

Synchronicity has been is among the most developed ideas by Jung’s followers, notably by Michel Cazenave, James Hillman, Roderick Main, Carl Alfred Meier and by the British developmental clinician, George Bright. It has been explored also in a range of spiritual currents who have sought in it a scientific rigour.

Although Synchronicity as conceived by Jung within the bounds of the science available in his day, has been categorised as pseudoscience, recent developments in complex adaptive systems argue for a revision of such a view. Critics cite that Jung’s experiments that sought to provide statistical proof for this theory did not yield satisfactory result. His experiment was also faulted for not using a true random sampling method as well as for the use of dubious statistics and astrological material.

Post-Jungian Approaches

Andrew Samuels (1985) has distinguished three distinct traditions or approaches of “post-Jungian” psychology – classical, developmental and archetypal. Today there are more developments.

Classical

The classical approach tries to remain faithful to Jung’s proposed model, his teachings and the substance of his 20 volume Collected Works, together with recently published works, such as the Liber Novus, and the Black Books. Prominent advocates of this approach, according to Samuels (1985), include Emma Jung, Jung’s wife, an analyst in her own right, Marie-Louise von Franz, Joseph L. Henderson, Aniela Jaffé, Erich Neumann, Gerhard Adler and Jolande Jacobi. Jung credited Neumann, author of “Origins of Conscious” and “Origins of the Child”, as his principal student to advance his (Jung’s) theory into a mythology-based approach. He is associated with developing the symbolism and archetypal significance of several myths: the Child, Creation, the Hero, the Great Mother and Transcendence.

Archetypal

One archetypal approach, sometimes called “the imaginal school” by James Hillman, was written about by him in the late 1960s and early 1970s. Its adherents, according to Samuels (1985), include Gerhard Adler, Irene Claremont de Castillejo, Adolf Guggenbühl-Craig, Murray Stein, Rafael López-Pedraza and Wolfgang Giegerich. Thomas Moore also was influenced by some of Hillman’s work. Developed independently, other psychoanalysts have created strong approaches to archetypal psychology. Mythopoeticists and psychoanalysts such as Clarissa Pinkola Estés who believes that ethnic and aboriginal people are the originators of archetypal psychology and have long carried the maps for the journey of the soul in their songs, tales, dream-telling, art and rituals; Marion Woodman who proposes a feminist viewpoint regarding archetypal psychology. Some of the mythopoetic/archetypal psychology creators either imagine the Self not to be the main archetype of the collective unconscious as Jung thought, but rather assign each archetype equal value.[citation needed] Others, who are modern progenitors of archetypal psychology (such as Estés), think of the Self as the thing that contains and yet is suffused by all other archetypes, each giving life to the other.

Robert L. Moore has explored the archetypal level of the human psyche in a series of five books co-authored with Douglas Gillette, which have played an important role in the men’s movement in the United States. Moore studies computerese so he uses a computer’s hard wiring (its fixed physical components) as a metaphor for the archetypal level of the human psyche. Personal experiences influence the access to the archetypal level of the human psyche, but personalized ego consciousness can be likened to computer software.

Developmental

A major expansion of Jungian theory is credited to Michael Fordham and his wife, Frieda Fordham. It can be considered a bridge between traditional Jungian analysis and Melanie Klein’s object relations theory. Judith Hubback and William Goodheart MD are also included in this group. Andrew Samuels (1985) considers J.W.T. Redfearn, Richard Carvalho and himself as representatives of the developmental approach. Samuels notes how this approach differs from the classical by giving less emphasis to the Self and more emphasis to the development of personality; he also notes how, in terms of practice in therapy, it gives more attention to transference and counter-transference than either the classical or the archetypal approaches.

Sandplay Therapy

Sandplay is a non-directive, creative form of therapy using the imagination, originally used with children and adolescents, later also with adults. Jung had stressed the importance of finding the image behind the emotion. The use of sand in a suitable tray with figurines and other small toys, farm animals, trees, fences and cars enables a narrative to develop through a series of scenarios. This is said to express an ongoing dialogue between the conscious and the unconscious aspects of the psyche, which in turn activates a healing process whereby the patient and therapist can together view the evolving sense of self.

Jungian Sandplay started as a therapeutic method in the 1950s. Although its origin has been credited to a Swiss Jungian analyst, Dora Kalff it was in fact, her mentor and trainer, Dr. Margaret Lowenfeld, a British paediatrician, who had developed the Lowenfeld World Technique inspired by the writer H.G. Wells in her work with children, using a sand tray and figurines in the 1930s. Jung had witnessed a demonstration of the technique while on a visit to the UK in 1937. Kalff saw in it potential as a further application of analytical psychology. Encouraged by Jung, Kalff developed the new application over a number of years and called it Sandplay. From 1962 she began to train Jungian Analysts in the method including in the United States, Europe and Japan. Both Kalff and Jung believed an image can offer greater therapeutic engagement and insight than words alone. Through the sensory experience of working with sand and objects, and their symbolic resonance new areas of awareness can be brought into consciousness, as in dreams, which through their frames and storyline can bring material into consciousness as part of an integrating and healing process. The historian of psychology, Sonu Shamdasani has commented:

Historical reflection suggests the spirit of Jung’s practice of the image, his engagement with his own figures, is indeed more alive in Sandplay than in other Jungian conclaves.

One of Dora Kalff’s trainees was the American concert pianist, Joel Ryce-Menuhin, whose music career was ended by illness and who retrained as a Jungian analyst and exponent of sandplay.

Process-Oriented Psychology

Process-oriented psychology (also called Process work) is associated with the Zurich-trained Jungian analyst Arnold Mindell. Process work developed in the late 1970s and early 1980s and was originally identified as a “daughter of Jungian psychology”. Process work stresses awareness of the “unconscious” as an ongoing flow of experience. This approach expands Jung’s work beyond verbal individual therapy to include body experience, altered and comatose states as well as multicultural group work.

The Analytic Attitude

Formally Jungian analysis differs little from psychoanalysis. However, variants of each school have developed overlaps and specific divergences through the century, or more, of their existence. They share a “frame” consisting of regular spatio-temporal meetings, one or more times a week, focusing on patient material, using dialogue which may consist of elaboration, amplification and abreaction and which may last on average three years (sometimes more briefly or far longer). The spatial arrangement between analyst and analysand may differ: seated face to face or the patient may use the couch with the analyst seated behind.

In some approaches alternative elements of expression can take place, such as active imagination, sandplay, drawing or painting, even music. The session may at times become semi-directed (in contrast to psychoanalytic treatment which is essentially a non-directive encounter). The patient is at the heart of the therapy, as Marie Louise von Franz has it in her work, “Psychotherapy: the practitioner’s experience”, where she recounts Jung’s thinking on that point. The transference is sought out (contrary to psychoanalytic treatment which distinguishes positive and negative transferences) and, the interpretation of dreams is one of the central pillars of Jungian psychotherapy. In all other respects, the rules correspond to those of classical psychoanalysis: the analyst examines free associations and tries to be objective and ethical, meaning respectful of the patient’s pace and rhythm of unfolding progress. In fact, the task of Jungian analysis is not merely to explore the patient’s past, but to connect conscious awareness with the unconscious such that a better adaptation to their emotional and social life may ensue.

Neurosis is not a symptom of the re-emergence of a repressed past, but is regarded as the functional, sometimes somatic, incapacity to face certain aspects of lived reality. In Jungian analysis the unconscious is the motivator whose task it is to bring into awareness the patient’s shadow, in alliance with the analyst, the more so since unconscious processes enacted in the transference provoke a dependent relationship by the analysand on the analyst, leading to a falling away of the usual defences and references. This requires that the analyst guarantee the safety of the transference. The responsibilities and accountability of individual analysts and their membership organisations, matters of clinical confidentiality and codes of ethics and professional relations with the public sphere are explored in a volume edited by Solomon and Twyman, with contributions from Jungian analysts and psychoanalysts. Solomon has characterised the nature of the patient – analyst relationship as one where the analytic attitude is an ethical attitude since:

The ethical attitude presupposes special responsibilities that we choose to adopt in relation to another. Thus, a parallel situation pertains between caregiver and child and between analyst and patient: they are not equal partners, but nevertheless are in a situation of mutuality, shared subjectivity, and reciprocal influence.

Jungian Social, Literary and Art Criticism

Analytical psychology has inspired a number of contemporary academic researchers to revisit some of Jung’s own preoccupations with the role of women in society, with philosophy and with literary and art criticism. Leading figures to explore these fields include the British-American, Susan Rowland, who produced the first feminist revision of Jung and the fundamental contributions made to his work by the creative women who surrounded him. She has continued to mine his work by evaluating his influence on modern literary criticism and as a writer. Leslie Gardner has devoted a series of volumes to analytical psychology in 21st century life, one of which concentrates on the “Feminine Self”. Paul Bishop, a British German scholar, has placed analytical psychology in the context of precursors such as, Goethe, Schiller and Nietzsche.

The Franco-Swiss art historian and analytical psychologist, Christian Gaillard, has examined Jung’s place as an artist and art critic in his series of Fay lectures at the Texas A&M University. These scholars draw from Jung’s works that apply analytical psychology to literature such as the lecture “On the Relation of Analytical Psychology to Poetry”. In this presentation, which was delivered in 1922, Jung stated that the psychologist cannot replace the art critic. He rejected the Freudian art criticism for reducing complex works of art to Oedipal fantasies of their creators, stressing the danger of simplifying literature to causes found outside of the actual work.

Criticism

Since its inception, analytical psychology has been the object of criticism, emanating from the psychoanalytic sphere. Freud himself characterised Jung as a “mystic and a snob”. In his introduction to the 2011 edition of Jung’s “Lectures on the Theory of Psychoanalysis”, given in New York in 1912, Sonu Shamdasani contends that Freud orchestrated a round of critical reviews of Jung’s writings from Karl Abraham, Jung’s former colleague at the Burghölzli hospital, and from the early Welsh Freudian, Ernest Jones. Such criticisms multiplied during the 20th century, focusing primarily on the “mysticism” in Jung’s writings. Other psychoanalysts, including Jungian analysts, objected to the cult of personality around the Swiss psychiatrist. It reached a crescendo with Jung’s perceived collusion with Nazism in the build up and during World War II and is still a recurrent theme. Thomas Kirsch writes: “Successive generations of Jungian analysts and analysands have wrestled with the question of Jung’s complex relations to Germany.” Other considered evaluations come from Andrew Samuels and from Robert Withers.

The French philosopher, Yvon Brès, considers that the concept of the collective unconscious, “shows also how easily one can slip from the psychological unconscious into perspectives from a universe of thought, quite alien from traditional philosophy and science, where this idea arose.” (“Le concept jungien d’inconscient collectif “témoigne également de la facilité avec laquelle on peut glisser du concept d’inconscient psychologique vers des perspectives relevant d’un univers de pensée étranger à la tradition philosophique et scientifique dans laquelle ce concept est né'”).

In his Le Livre Rouge de la psychanalyse (“Red Book of psychoanalysis”), the French psychoanalyst, Alain Amselek, criticises Jung’s tendency to be fascinated by the image and to reduce the human to an archetype. He contends that Jung dwells in a world of ideas and abstractions, in a world of books and old secrets lost in ancient books of spells (fr: grimoires). While claiming to be an empiricist, Amselek finds Jung to be an idealist, a pure thinker who has unquestionably demonstrated his intellectual talent for speculation and the invention of ideas. While he considers his epistemology to be in advance of that of Freud, Jung remains stuck in his intellectualism and in his narrow provincial outlook.[clarification needed] In fact, his hypotheses are determined by the concept of his postulated pre-existing world and he has constantly sought to find confirmations of it in the old traditions of Western Medieval Europe.

More problematic has been, at times, the ad hominem criticism of academics outside the field of analytical psychology. One, a Catholic historian of psychiatry, Richard Noll, wrote three volumes but was able to publish only the first two in 1994 and 1997. Nolls argued that analytical psychology is based on a neo-pagan Hellenistic cult. These attacks on Jung and his work prompted the French psychoanalyst, Élisabeth Roudinesco, to state in a review: “Even if Noll’s theses are based on a solid familiarity with the Jungian corpus […], they deserve to be re-examined, such is the detestation of the author for the object of his study that it diminishes the credibility of the arguments.” (“Même si les thèses de Noll sont étayées par une solide connaissance du corpus jungien […], elles méritent être réexaminées, tant la détestation de l’auteur vis-à-vis de son objet d’étude diminue la crédibilité de l’argumentation.”). Another, a French ethnographer and anthropologist, Jean-Loïc Le Quellec, criticised Jung over his alleged misuse of the term archetype and his “suspect motives” in dealings with some of his colleagues.

What is the American Board of Professional Psychology?

Introduction

The American Board of Professional Psychology (ABPP) is the primary organisation for specialty board certification in psychology.

Mission Statement

“The mission of the American Board of Professional Psychology is to increase consumer protection through the examination and certification of psychologists who demonstrate competence in approved specialty areas in professional psychology.”

Brief History

1947-1999

The American Board of Professional Psychology was founded and incorporated in 1947, as the American Board of Examiners in Professional Psychology (ABEPP). When established, ABEPP replaced a committee that was formed by the American Psychological Association (APA) to explore the development of a credentialing body for individual psychologists. According to Bent, Goldberg & Packard, APA had come to realise that a membership organisation, such as itself, could not advocate for its members at the same time that it performed certification functions designed to protect the public. Determining that a distinction should be made between basic and advanced levels of competence, ABEPP focused its attention to the latter and identified three fields of certification:

  • Clinical Psychology;
  • Personnel-Industrial (later becoming Industrial Psychology, and then Industrial/Organizational Psychology); and
  • Personnel-Educational (later becoming Counselling and Guidance, and then Counselling Psychology).

In order to recognize those psychologists already working in applied and practice areas, persons deemed to have sufficient experience and training (and awarded Bachelor of Arts degrees prior to 31 December 1935) were allowed to be “grandfathered” without examination. Those requiring examination were administered both written and oral components.

In 1968, the current name – American Board of Professional Psychology – was adopted, and a fourth specialty – School Psychology – was introduced. In 1972 multimember regional boards were implemented – Northeast, Midwest, Mideast, Southeast, Intermountain West and Far West. In 1974, the ABPP Board of Trustees (BOT) authorized the establishment of the National Register of Health Service Psychologists. Throughout the 1980s and early 1990s, new specialty boards were recognised – Clinical Neuropsychology (1984), Forensic Psychology (1985), Family Psychology (1991) and Health Psychology (1991). As new specialties were introduced, each seated a trustee on the BOT. As the 1990s progressed, additional specialties were identified – Behavioural Psychology (1991), Psychoanalysis in Psychology (1996), and Rehabilitation Psychology (1997). Specialty Academies were also introduced as definitive membership organisations for specialists certified by ABPP.

2000-Present

During the early 2000s, ABPP implemented several initiatives to further its mission. The Early Entry Option was created for graduate students, interns, and residents to start the board certification process early in their careers. In 2008, ABPP began to convene an annual conference with workshops. As a means of raising funds to support education on board certification, the American Board of Professional Psychology Foundation was formed in 2010. In 2015 ABPP seated its first Early Career Psychology (ECP) trustee. Maintenance of Certification was implemented in 2015, requiring that psychologists board-certified on or after 01 January 2015 undergo a formal review, ensuring their commitment to lifelong learning. Psychologists who received their board certification prior to 2015 received the option to opt-in to maintenance of certification or to waive the requirement.

Certification Requirements

There are various requirements to obtain the ABPP certification, which are referred to as diplomas in the specialized area. The minimum requirements include:

  • A doctoral degree.
  • Licensure within the psychology field.
  • At least five years of experience.

In addition to the minimum requirements, there are also additional specialisations demonstrated by the candidate. The candidate must also demonstrate the following:

  • Specialised Training.
  • Evidence of substantial experience.
  • Continuing education in one of the thirteen specialty areas.

A review of the candidate’s work as well as an oral examination are also required to obtain ABPP certification. Some specialties require an additional written exam in addition to the oral component.

Recognised Specialties

In 2018, ABPP recognises the following psychology specialties (year of affiliation with ABPP in parentheses):

  • Behavioural & Cognitive (1992).
  • Clinical Child & Adolescent (2003).
  • Clinical Health (1991).
  • Clinical Neuropsychology (1984).
  • Clinical (1947).
  • Counselling (1947).
  • Couple & Family (1990).
  • Forensic (1985).
  • Geropsychology (2014).
  • Group (1997).
  • Organisational & Business Consulting (1948).
  • Police and Public Safety (2011).
  • Psychoanalysis (1996).
  • Rehabilitation (1997).
  • School (1968).
  • One subspecialty is also recognised under the umbrella of Clinical Neuropsychology – Paediatric Neuropsychology.

Board of Trustees

The Board of Trustees consists of:

  • A representative from each of the specialty boards.
  • Members of the Executive Committee (President, President-Elect, Past-President, Treasurer and Secretary).
  • The Executive Officer.
  • A Public Member.
  • An Early Career Psychologist trustee.
  • A trustee from the Council of Presidents of Psychology Specialty Academies (CPPSA).
  • The Editor of the ABPP newsletter, The Specialist, serves as an ex-officio member of the Board of Trustees.

What is Binge Eating Disorder?

Introduction

Binge eating disorder (BED) is an eating disorder characterised by frequent and recurrent binge eating episodes with associated negative psychological and social problems, but without the compensatory behaviours common to Bulimia Nervosa, OSFED, or the Binge-Purge subtype of Anorexia Nervosa.

BED is a recently described condition, which was required to distinguish binge eating similar to that seen in bulimia nervosa but without characteristic purging. Individuals who are diagnosed with bulimia nervosa and binge eating disorder exhibit similar patterns of compulsive overeating, neurobiological features of dysfunctional cognitive control and food addiction, and biological and environmental risk factors. Some professionals consider BED to be a milder form of bulimia with the two conditions on the same spectrum.

Binge eating is one of the most prevalent eating disorders among adults, though there tends to be less media coverage and research about the disorder in comparison to anorexia nervosa and bulimia nervosa.

Brief History

The disorder was first described in 1959 by psychiatrist and researcher Albert Stunkard as “night eating syndrome” (NES). The term “binge eating” was coined to describe the same bingeing-type eating behaviour but without the exclusive nocturnal component.

There is generally less research on binge eating disorder in comparison to anorexia nervosa and bulimia nervosa.

Signs and Symptoms

Binge eating is the core symptom of BED; however, not everyone who binge eats has BED. An individual may occasionally binge eat without experiencing many of the negative physical, psychological, or social effects of BED. This may be considered disordered eating rather than a clinical disorder. Precisely defining binge eating can be problematic, however binge eating episodes in BED are generally described as having the following potential features:

  • Eating much faster than normal, perhaps in a short space of time.
  • Eating until feeling uncomfortably full.
  • Eating a large amount when not hungry.
  • Subjective loss of control over how much or what is eaten.
  • Binges may be planned in advance, involving the purchase of special binge foods, and the allocation of specific time for binging, sometimes at night.
  • Eating alone or secretly due to embarrassment over the amount of food consumed.
  • There may be a dazed mental state during the binge.
  • Not being able to remember what was eaten after the binge.
  • Feelings of guilt, shame or disgust following a food binge.

In contrast to bulimia nervosa, binge eating episodes are not regularly followed by activities intended to compensate for the amount of food consumed, such as self-induced vomiting, laxative or enema misuse, or strenuous exercise. BED is characterised more by overeating than dietary restriction. Those with BED often have poor body image and frequently diet, but are unsuccessful due to the severity of their binge eating.

Obesity is common in persons with BED, as is depression, low self-esteem, stress and boredom. Those with BED are also at risk of Non-alcoholic fatty liver disease, menstrual irregularities such as amenorrhea, and gastrointestinal problems such as acid reflux and heartburn.

Causes

As with other eating disorders, binge eating is an “expressive disorder” – a disorder that is an expression of deeper psychological problems. People who have binge eating disorder have been found to have higher weight bias internalisation, which includes low self-esteem, unhealthy eating patterns, and general body dissatisfaction. Binge eating disorder commonly develops as a result or side effect of depression, as it is common for people to turn to comfort foods when they are feeling down.

There was resistance to give binge eating disorder the status of a fully fledged eating disorder because many perceived binge eating disorder to be caused by individual choices. Previous research has focused on the relationship between body image and eating disorders, and concludes that disordered eating might be linked to rigid dieting practices. In the majority of cases of anorexia, extreme and inflexible restriction of dietary intake leads at some point to the development of binge eating, weight regain, bulimia nervosa, or a mixed form of eating disorder not otherwise specified. Binge eating may begin when individuals recover from an adoption of rigid eating habits. When under a strict diet that mimics the effects of starvation, the body may be preparing for a new type of behaviour pattern, one that consumes a large amount of food in a relatively short period of time.

Some studies show that BED aggregates in families and could be genetic. However, very few published studies around the genetics exist.

However, other research suggests that binge eating disorder can also be caused by environmental factors and the impact of traumatic events. One study showed that women with binge eating disorder experienced more adverse life events in the year prior to the onset of the development of the disorder, and that binge eating disorder was positively associated with how frequently negative events occur. Additionally, the research found that individuals who had binge eating disorder were more likely to have experienced physical abuse, perceived risk of physical abuse, stress, and body criticism. Other risk factors may include childhood obesity, critical comments about weight, low self-esteem, depression, and physical or sexual abuse in childhood. A systematic review concluded that bulimia nervosa and binge eating disorder are more impacted by family separations, a loss in their lives and negative parent-child interactions compared to those with anorexia nervosa. A few studies have suggested that there could be a genetic component to binge eating disorder, though other studies have shown more ambiguous results. Studies have shown that binge eating tends to run in families and a twin study by Bulik, Sullivan, and Kendler has shown a, “moderate heritability for binge eating” at 41%. More research must be done before any firm conclusions can be drawn regarding the heritability of binge eating disorder. Studies have also shown that eating disorders such as anorexia and bulimia reduce coping abilities, which makes it more likely for those suffering to turn to binge eating as a coping strategy.

A correlation between dietary restraint and the occurrence of binge eating has been shown in some research. While binge eaters are often believed to be lacking in self-control, the root of such behaviour might instead be linked to rigid dieting practices. The relationship between strict dieting and binge eating is characterised by a vicious circle. Binge eating is more likely to occur after dieting, and vice versa. Several forms of dieting include delay in eating (e.g. not eating during the day), restriction of overall calorie intake (e.g. setting calorie limit to 1,000 calories per day), and avoidance of certain types of food (e.g. “forbidden” food, such as sugar, carbohydrates, etc.). Strict and extreme dieting differs from ordinary dieting. Some evidence suggests the effectiveness of moderate calorie restriction in decreasing binge eating episodes among overweight individuals with binge eating disorder, at least in the short-term.

In the US it is estimated that 3.5% of young women and 30% to 40% of people who seek weight loss treatments, can be clinically diagnosed with binge eating disorder.

Diagnosis

International Classification of Diseases

BED was first included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1994 simply as a feature of eating disorder. In 2013 it gained formal recognition as a psychiatric condition in the DSM-5.

The 2017 update to the American version of the ICD-10 includes BED under F50.81. ICD-11 may contain a dedicated entry (6B62), defining BED as frequent, recurrent episodes of binge eating (once a week or more over a period of several months) which are not regularly followed by inappropriate compensatory behaviours aimed at preventing weight gain.

Diagnostic and Statistical Manual

Previously considered a topic for further research exploration, binge eating disorder was included in the DSM in 2013. Until 2013, binge eating disorder was categorized as an Eating Disorder Not Otherwise Specified, an umbrella category for eating disorders that don’t fall under the categories for anorexia nervosa or bulimia nervosa. Because it was not a recognised psychiatric disorder in the DSM-IV until 2013, it has been difficult to obtain insurance reimbursement for treatments. The disorder now has its own category under DSM-5, which outlines the signs and symptoms that must be present to classify a person’s behaviour as binge eating disorder. Studies have confirmed the high predictive value of these criteria for diagnosing BED.

According to the World Health Organization’s ICD-11 classification of BED, the severity of the disorder can be classified as mild (1-3 episodes/week), moderate (4-7 episodes/week), severe (8-13 episodes/week) and extreme (>14 episodes/week).

One study claims that the method for diagnosing BED is for a clinician to conduct a structured interview using the DSM-5 criteria or taking the Eating Disorder Examination. The Structured Clinical Interview takes no more than 75 minutes to complete and has a systematic approach which follows the DSM-5 criteria. The Eating Disorder Examination is a semi-structured interview which identifies the frequency of binges and associated eating disorder features.

Treatment

Counselling and certain medication, such as lisdexamfetamine and selective serotonin reuptake inhibitor (SSRIs), may help. Some recommend a multidisciplinary approach in the treatment of the disorder.

Counselling

Cognitive behavioural therapy (CBT) treatment has been demonstrated as a more effective form of treatment for BED than behavioural weight loss programmes. 50% of BED individuals achieve complete remission from binge eating and 68-90% will reduce the amount of binge eating episodes they have. CBT has also been shown to be an effective method to address self-image issues and psychiatric comorbidities (e.g. depression) associated with the disorder. The goal of CBT is to interrupt binge-eating behaviour, learn to create a normal eating schedule, change the perception around weight and shape and develop positive attitudes about one’s body. Although this treatment is successful in eliminating binge eating episodes, it does not lead to losing any weight. Recent reviews have concluded that psychological interventions such as psychotherapy and behavioural interventions are more effective than pharmacological interventions for the treatment of binge eating disorder. A meta-analysis concluded that psychotherapy based on CBT not only significantly improved binge-eating symptomatology but also reduced a client’s BMI significantly at posttreatment and longer than 6 and 12 months after treatment. There is the 12-step Overeaters Anonymous or Food Addicts in Recovery Anonymous. Behavioural weight loss treatment has been proven to be effective as a means to achieve weight loss amongst patients.

Medication

Lisdexamfetamine is a US Food and Drug Administration (FDA)-approved drug that is used for the treatment of moderate to severe binge eating disorder in adults.

Three other classes of medications are also used in the treatment of binge eating disorder: antidepressants, anticonvulsants, and anti-obesity medications. Antidepressant medications of the selective serotonin reuptake inhibitor (SSRI) have been found to effectively reduce episodes of binge eating and reduce weight. Similarly, anticonvulsant medications such as topiramate and zonisamide may be able to effectively suppress appetite. The long-term effectiveness of medication for binge eating disorder is currently unknown. For BED patients with manic episodes, risperidone is recommended. If BED patients have bipolar depression, lamotrigine is appropriate to use.

Trials of antidepressants, anticonvulsants, and anti-obesity medications suggest that these medications are superior to placebo in reducing binge eating. Medications are not considered the treatment of choice because psychotherapeutic approaches, such as CBT, are more effective than medications for binge eating disorder. A meta-analysis concluded that using medications did not reduce binge-eating episodes and BMI posttreatment at 6-12 months. This indicates a potential possibility of relapse after withdrawal from the medications. Medications also do not increase the effectiveness of psychotherapy, though some patients may benefit from anticonvulsant and anti-obesity medications, such as phentermine/topiramate, for weight loss.

Blocking opioid receptors leads to less food intake. Additionally, bupropion and naltrexone used together may cause weight loss. Combining these alongside psychotherapies like CBT may lead to better outcomes for BED.

Surgery

Bariatric surgery has also been proposed as another approach to treat BED and a recent meta-analysis showed that approximately two-thirds of individuals who seek this type of surgery for weight loss purposes have BED. Bariatric surgery recipients who had BED prior to receiving the surgery tend to have poorer weight-loss outcomes and are more likely to continue to exhibit eating behaviours characteristic of BED.

Lifestyle Interventions

Other treatments for BED include lifestyle interventions like weight training, peer support groups, and investigation of hormonal abnormalities.

Prognosis

Individuals suffering from BED often have a lower overall quality of life and commonly experience social difficulties. Early behaviour change is an accurate prediction of remission of symptoms later.

Individuals who have BED commonly have other comorbidities such as major depressive disorder, personality disorder, bipolar disorder, substance abuse, body dysmorphic disorder, kleptomania, irritable bowel syndrome, fibromyalgia, or an anxiety disorder. Individuals may also exhibit varying degrees of panic attacks and a history of attempted suicide.

While people of a healthy weight may overeat occasionally, an ongoing habit of consuming large amounts of food in a short period of time may ultimately lead to weight gain and obesity. Bingeing episodes usually include foods that are high in fat, sugar, and/or salt, but low in vitamins and minerals, as these types of foods tend to trigger the greatest chemical and emotional rewards. The main physical health consequences of this type of eating disorder are brought on by the weight gain resulting from calorie-laden bingeing episodes. Mental and emotional consequences of binge eating disorder include social weight stigma and emotional loss of control. Up to 70% of individuals with BED may also be obese, and therefore obesity-associated morbidities such as high blood pressure and coronary artery disease type 2 diabetes mellitus gastrointestinal issues (e.g. gallbladder disease), high cholesterol levels, musculoskeletal problems and obstructive sleep apnoea may also be present.

Epidemiology

General

The prevalence of BED in the general population is approximately 1-3%, with BED cases usually occurring between the ages of 12.4 and 24.7, but prevalence rates increase until the age of 40. Binge eating disorder is the most common eating disorder in adults.

The limited amount of research that has been done on BED shows that rates of binge eating disorder are fairly comparable among men and women. The lifetime prevalence of binge eating disorder has been observed in studies to be 2.0% for men and 3.5% for women, higher than that of the commonly recognised eating disorders anorexia nervosa and bulimia nervosa. However another systematic literature review found the prevalence average to be about 2.3% in women and about 0.3% in men. Lifetime prevalence rates for BED in women can range anywhere from 1.5 to 6 times higher than in men. One literature review found that point prevalence rates for BED vary from 0.1% to 24.1% depending on the sample. This same review also found that the 12-month prevalence rates vary between 0.1% to 8.8%.

Recent studies found that eating disorders which included anorexia nervosa, bulimia nervosa and binge-eating disorder are common among sexual and gender minority populations, including gay, lesbian, bisexual and transgender people. This could be due to the minority stress and discrimination this population experiences.

Due to limited and inconsistent information and research on ethnic and racial differences, prevalence rates are hard to determine for BED. Rates of binge eating disorder have been found to be similar among black women, white women, and white men, while some studies have shown that binge eating disorder is more common among black women than among white women. However, majority of the research done around BED is focused on White women. One literature review found information citing no difference between BED prevalence among Hispanic, African American, and White women while other information found that BED prevalence was highest among Hispanics followed by Black individuals and finally White people.

Worldwide Prevalence

Eating disorders have usually been considered something that was specific to Western countries. However, the prevalence of eating disorders is increasing in other non-Western countries. Though the research on binge eating disorders tends to be concentrated in North America, the disorder occurs across cultures. In the USA, BED is present in 0.8% of male adults and 1.6% of female adults in a given year.

The prevalence of BED is lower in Nordic countries compared to Europe in a study that included Finland, Sweden, Norway, and Iceland. The point prevalence ranged from 0.4 to 1.5% and the lifetime prevalence ranged from 0.7 to 5.8% for BED in women.

In a study that included Argentina, Brazil, Chile, Colombia, Mexico, and Venezuela, the point prevalence for BED was 3.53%. Therefore, this particular study found that the prevalence for BED is higher in these Latin American countries compared to Western countries.

The prevalence of BED in Europe ranges from <1 to 4%.

Co-Morbidities

BED is co-morbid with diabetes, hypertension, previous stroke, and heart disease in some individuals.

In people who have obsessive-compulsive disorder or bipolar I or II disorders, BED lifetime prevalence was found to be higher.

Additionally, 30 to 40% of individuals seeking treatment for weight-loss can be diagnosed with binge eating disorder.

Underreporting in Men

Eating disorders are oftentimes underreported in men. Underreporting could be a result of measurement bias due to how eating disorders are defined. The current definition for eating disorders focuses on thinness. However, eating disorders in men tend to centre on muscularity and would therefore warrant a need for a different measurement definition. Further research should focus on including more men in samples since previous research has focused primarily on women.

What is Child and Adolescent Psychiatry?

Introduction

Child and adolescent psychiatry (or paediatric psychiatry) is a branch of psychiatry that focuses on the diagnosis, treatment, and prevention of mental disorders in children, adolescents, and their families.

It investigates the biopsychosocial factors that influence the development and course of psychiatric disorders and treatment responses to various interventions. Child and adolescent psychiatrists primarily use psychotherapy and/or medication to treat mental disorders in the paediatric population.

Brief History

When psychiatrists and paediatricians first began to recognise and discuss childhood psychiatric disorders in the 19th century, they were largely influenced by literary works of the Victorian era. Authors like the Brontë sisters, George Eliot, and Charles Dickens, introduced new ways of thinking about the child mind and the potential influence early childhood experiences could have on child development and the subsequent adult mind. When the Journal of Psychological Medicine and Mental Pathology, the first psychiatric journal in English, was published in 1848, child psychiatry didn’t exist as its own field yet. However, some of the earliest works on the possibility of nervous disorders and “insanity” in children were published in the Journal and several medical writers directly referenced works such as Jane Eyre (1847), Wuthering Heights (1847), Dombey and Son (1848), and David Copperfield (1850), to illustrate this new conceptualisation of the child mind. Until that time, it was generally accepted that children were free from nervous disorders and the “passions” that affected the adult mind.

As early as 1899, the term “child psychiatry” (in French) was used as a subtitle in Manheimer’s monograph Les Troubles Mentaux de l’Enfance. However, the Swiss psychiatrist Moritz Tramer (1882-1963) was probably the first to define the parameters of child psychiatry in terms of diagnosis, treatment, and prognosis within the discipline of medicine, in 1933. In 1934, Tramer founded the Zeitschrift für Kinderpsychiatrie (Journal of Child Psychiatry), which later became Acta Paedopsychiatria. The first academic child psychiatry department in the world was founded in 1930 by Leo Kanner (1894-1981), an Austrian émigré and medical graduate of the University of Berlin, under the direction of Adolf Meyer at the Johns Hopkins Hospital in Baltimore. Kanner was the very first physician to be identified as a child psychiatrist in the US and his textbook, Child Psychiatry (1935), is credited with introducing both the specialty and the term to the anglophone academic community. In 1936, Kanner established the first formal elective course in child psychiatry at the Johns Hopkins Hospital. In 1944 he provided the first clinical description of early infantile autism, otherwise known as Kanner Syndrome.

Maria Montessori together with It:Giuseppe Ferruccio Montesano and Clodomiro Bonfigli, two distinguished child psychiatrists, created in 1901 in Italy the “Lega Nazionale per la Protezione del Fanciullo” (National League for the Protection of Children). She gradually developed her own pedagogic method, initially based on the “intuition that the question of the ‘mentally deficient’ was more pedagogic than medical”. In 1909, Jane Addams and her female colleagues established the Juvenile Psychopathic Institute (JPI) in Chicago, later renamed as the Institute for Juvenile Research (IJR), the world’s first child guidance clinic. Neurologist William Healy, M.D., its first director, was charged with not only studying the delinquent’s biological aspects of brain functioning and IQ, but also the delinquent’s social factors, attitudes, and motivations, thus it was the birthplace of American child psychiatry.

From its establishment in February 1923, the Maudsley Hospital, a South London-based postgraduate teaching and research psychiatric hospital, contained a small children’s department. Similar overall early developments took place in many other countries during the late 1920s and 1930s. In the United States, child and adolescent psychiatry was established as a recognised medical speciality in 1953 with the founding of the American Academy of Child Psychiatry, but was not established as a legitimate, board-certifiable medical speciality until 1959.

The use of medication in the treatment of children also began in the 1930s, when Charles Bradley opened a neuropsychiatric unit and was the first to use amphetamine for brain-damaged and hyperactive children. But it was not until the 1960s that the first NIH grant to study paediatric psychopharmacology was awarded. It went to one of Kanner’s students, Leon Eisenberg, the second director of the division.

The discipline has relatively flourished since the 1980s, in large part, because of contributions made in the 1970s, even if the outcomes for patients have been disappointing at times. It was a decade during which child psychiatry witnessed a major evolution as a result of the work carried out by, Eva Frommer, Douglas Haldane, Michael Rutter, Robin Skynner and Sula Wolff, among others. The first comprehensive population survey of 9- to 11-year-olds, carried out in London and the Isle of Wight, which appeared in 1970, addressed questions that have continued to be of importance for child psychiatry; for example, rates of psychiatric disorders, the role of intellectual development and physical impairment, and specific concern for potential social influences on children’s adjustment. This work was influential, especially since the investigators demonstrated specific continuities of psychopathology over time, and the influence of social and contextual factors in children’s mental health, in their subsequent re-evaluation of the original cohort of children. These studies described the prevalence of ADHD (relatively low as compared to the US), identified the onset and prevalence of depression in mid-adolescence and the frequent co-morbidity with conduct disorder, and explored the relationship between various mental disorders and scholastic achievement.

It was paralleled similarly by work on the epidemiology of autism that was to enormously increase the number of children diagnosed with autism in future years. Although attention had been given in the 1960s and ’70s to the classification of childhood psychiatric disorders, and some issues had then been delineated, such as the distinction between neurotic and conduct disorders, the nomenclature did not parallel the growing clinical knowledge. It was claimed that this situation was altered in the late 1970s with the development of the DSM-III system of classification, although research has shown that this system of classification has problems of validity and reliability. Since then, the DSM-IV and DSM-IVR have altered some of the parsing of psychiatric disorders into “childhood” and “adult” disorders, on the basis that while many psychiatric disorders are not diagnosed until adulthood, they may present in childhood or adolescence (DSM-IV). The American Psychiatric Association’s DSM is now on its fifth edition (DSM-5).

People in the field are sometimes referred to as “neurodevelopmentalists”. As of 2005 there was debate in the field as to whether “neurodevelopmentalist” should be made a new speciality.

In terms of patient outcomes, there is evidence that, in the United Kingdom at least on the 70th anniversary of the NHS, mental health remains a medical “Cinderella” (low priority) and the more so Child and Adolescent Health services which have been through repeated reorganisations and underinvestment all of which leads to disruption and loss of adequate provision.

“Modern neuroscience, genetics, epigenetics, and public health research has presented the tantalizing possibility that it can now be said with relative certainty that much (certainly not all) is understood about why some children struggle and others soar. Although it is an oversimplification, it can now be suggested that it is possible to understand how environmental factors, both negative and positive, influence the genome or epigenome, which in turn influence the structure and function of the brain and thus human thoughts, actions, and behaviors.”

Classification of Disorders

Not an exhaustive list:

  • Developmental disorders:
    • Autism spectrum disorder.
    • Learning disorders.
  • Disorders of attention and behaviour:
    • Attention deficit hyperactivity disorder.
    • Oppositional defiant disorder.
    • Conduct disorder.
  • Psychotic disorders:
    • Childhood schizophrenia.
  • Mood disorders:
    • Major depressive disorder.
    • Bipolar disorder.
    • Persistent Depressive Disorder.
    • Disruptive Mood Dysregulation Disorder.
  • Anxiety disorders:
    • Panic disorder.
    • Phobias.
  • Eating disorders:
    • Anorexia nervosa.
    • Bulimia nervosa.
  • Gender identity disorder:
    • Gender identity disorder in children.

Disorders are often comorbid. For example, an adolescent can be diagnosed with both major depressive disorder and generalised anxiety disorder. The incidence of psychiatric comorbidities during adolescence may vary by race, ethnicity and socioeconomic status, among other variables.

Clinical Practice

Assessment

The psychiatric assessment of a child or adolescent starts with obtaining a psychiatric history by interviewing the young person and their parents or caregivers. The assessment includes a detailed exploration of the current concerns about the child’s emotional or behavioural problems, the child’s physical health and development, history of parental care (including possible abuse and neglect), family relationships and history of parental mental illness. It is regarded as desirable to obtain information from multiple sources (for example both parents, or a parent and a grandparent) as informants may give widely differing accounts of the child’s problems. Collateral information is usually obtained from the child’s school with regards to academic performance, peer relationships, and behaviour in the school environment.

Psychiatric assessment always includes a mental state examination of the child or adolescent which consists of a careful behavioural observation and a first-hand account of the young person’s subjective experiences. The assessment also includes an observation of the interactions within the family, especially the interactions between the child and his/her parents.

The assessment may be supplemented by the use of behaviour or symptom rating scales such as the Achenbach Child Behaviour Checklist or CBCL, the Behavioural Assessment System for Children or BASC, Connors Rating Scales (used for diagnosis of ADHD), Millon Adolescent Clinical Inventory or MACI, and the Strengths and Difficulties Questionnaire or SDQ. These instruments bring a degree of objectivity and consistency to the clinical assessment. More specialised psychometric testing may be carried out by a psychologist, for example using the Wechsler Intelligence Scale for Children, to detect intellectual impairment or other cognitive problems which may be contributing to the child’s difficulties.

Diagnosis and Formulation

The child and adolescent psychiatrist makes a diagnosis based on the pattern of behaviour and emotional symptoms, using a standardized set of diagnostic criteria such as the Diagnostic and Statistical Manual (DSM-IV-TR) or the International Classification of Diseases (ICD-10). While the DSM system is widely used, it may not adequately take into account social, cultural and contextual factors and it has been suggested that an individualized clinical formulation may be more useful. A case formulation is standard practice for child and adolescent psychiatrists and can be defined as a process of integrating and summarising all the relevant factors implicated in the development of the patient’s problem, including biological, psychological, social and cultural perspectives (the “biopsychosocial model”). The applicability of DSM diagnoses have also been questioned with regard to the assessment of very young children: it is argued that very young children are developing too rapidly to be adequately described by a fixed diagnosis, and furthermore that a diagnosis unhelpfully locates the problem within the child when the parent-child relationship is a more appropriate focus of assessment.

The child and adolescent psychiatrist then designs a treatment plan which considers all the components and discusses these recommendations with the child or adolescent and family.

Treatment

Treatment will usually involve one or more of the following elements: behaviour therapy, cognitive behaviour therapy (CBT), problem-solving therapies, psychodynamic therapy, parent training programmes, family therapy, and/or the use of medication. The intervention can also include consultation with paediatricians, primary care physicians or professionals from schools, juvenile courts, social agencies or other community organisations.

In a review of existing meta-analyses and disorders on the four most frequent childhood and adolescent psychiatric disorders (anxiety disorder, depression, ADHD, conduct disorder), only for ADHD was the use of medication (stimulants) considered to be the most efficacious treatment option available. For the remaining three disorders, psychotherapy is recommended as the most effective treatment of choice. A combination of psychological and pharmacological treatments is an important option in ADHD and depressive disorders. Treatments for ADHD and anxiety disorders produce higher effect-sizes than do interventions for depressive and conduct disorders.

Training

In the United States, Child and adolescent psychiatric training requires 4 years of medical school, at least 4 years of approved residency training in medicine, neurology, and general psychiatry with adults, and 2 years of additional specialised training in psychiatric work with children, adolescents, and their families in an accredited residency in child and adolescent psychiatry. Child and adolescent sub-speciality training is similar in other Western countries (such as the UK, New Zealand, and Australia), in that trainees must generally demonstrate competency in general adult psychiatry prior to commencing sub-speciality training.

Certification and Continuing Education

In the US, having completed the child and adolescent psychiatry residency, the child and adolescent psychiatrist is eligible to take the additional certification examination in the subspecialty of child and adolescent psychiatry from the American Board of Psychiatry and Neurology (ABPN) or the American Osteopathic Board of Neurology and Psychiatry (AOBNP). Although the ABPN and AOBNP examinations are not required for practice, they are a further assurance that the child and adolescent psychiatrist with these certifications can be expected to diagnose and treat all psychiatric conditions in patients of any age competently. Training requirements are listed on the web site of The American Academy of Child & Adolescent Psychiatry.

Shortage of Child and Adolescent Psychiatrists in the United States

The demand for child and adolescent psychiatrists continues to far outstrip the supply worldwide. There is also a severe maldistribution of child and adolescent psychiatrists, especially in rural and poor, urban areas where access is significantly reduced. As of 2016, there are 7991 child and adolescent psychiatrists in the United States. A report by the US Bureau of Health Professions (2000) projected a need by the year 2020 for 12,624 child and adolescent psychiatrists, but a supply of only 8,312. In its 1998 report, the Centre for Mental Health Services estimated that 9-13% of 9- to 17-year-olds had serious emotional disturbances, and 5-9% had extreme functional impairments. In 1999, however, the Surgeon General reported that “there is a dearth of child psychiatrists.” Only 20% of emotionally disturbed children and adolescents received any mental health treatment, a small percentage of which was performed by child and adolescent psychiatrists. Furthermore, the US Bureau of Health Professions projects that the demand for child and adolescent psychiatry services will increase by 100% between 1995 and 2020.

Cross-Cultural Considerations

Steady growth in migration of immigrants to higher-income regions and countries has contributed to the growth and interest in cross-cultural psychiatry. Families of immigrants whose child has a psychiatric illness must come to understand the disorder while navigating an unfamiliar health care system.

Criticisms

Subjective Diagnoses

One criticism against psychiatry is that psychiatric diagnoses lack complete “objectivity,” particularly when compared with diagnoses in other medical specialties. However, for several major psychiatric disorders interrater reliability, which shows the degree to which psychiatrists agree on the diagnosis, is generally similar to those in other medical specialties. In 2013, Allen Frances said that “psychiatric diagnosis still relies exclusively on fallible subjective judgements rather than objective biological tests.”

Traditional deficit and disease models of child psychiatry have been criticised as rooted in the medical model which conceptualises adjustment problems in terms of disease states. It is said by these critics that these normative models explicitly characterise problematic behaviour as representing a disorder within the child or young person and these commentators assert that the role of environmental influences on behaviour has become increasingly neglected, leading to a decrease in the popularity of, for example, family therapy. There are criticisms of the medical model approach from within and without the psychiatric profession: it is said to neglect the role of environmental, family, and cultural influences, to discount the psychological meaning of behaviour and symptoms, to promote a view of the “patient” as dependent and needing to be cured or cared for and therefore undermines a sense of personal responsibility for conduct and behaviour, to promote a normative conception based on adaptation to the norms of society (the ill person must adapt to society), and to be based on the shaky foundations of reliance on a classificatory system that has been shown to have problems of validity and reliability.

Prescription of Psychotropic Medications

Since the late 1990s, use of psychiatric medication has become increasingly common for children and adolescents. In 2004 the US Food and Drug Administration (FDA) issued the Black Box Warning on antidepressant prescriptions to alert patients of a research link between use of medication and apparent increased risk of suicidal thoughts, hostility, and agitation in paediatric patients. The most common diagnoses for which children receive psychiatric medication are ADHD, ODD, and conduct disorder.

Some research suggests that children and adolescents are sometimes given antipsychotic drugs as a first-line treatment for mental health problems or behavioural issues other than a psychotic disorder. In the United States, the usage of these drugs in young people has greatly increased since 2000, especially among children from low-income families. More research is needed to specifically assess the efficacy and tolerability of antipsychotic medications in paediatric populations. Because of the risk of metabolic syndrome and cardiovascular events with long-term antipsychotic use, use in paediatric populations is highly scrutinized and recommended in combination with psychotherapy and effective parent-training interventions.

Electroconvulsive Therapy

In 1947, child neuropsychiatrist Lauretta Bender published a study on 98 children aged between four and eleven years old who had been treated in the previous five years with intensive courses of electroconvulsive therapy (ECT). These children received ECT daily for a typical course of approximately twenty treatments. This formed part of an experimental trend amongst a cadre of psychiatrists to explore the therapeutic impact of intensive regimes of ECT, which is also known as either regressive ECT or annihilation therapy. In the 1950s Bender abandoned ECT as a therapeutic practice for the treatment of children. In the same decade the results of her published work on the use of ECT in children was discredited after a study showing that the condition of the children so treated had either not improved or deteriorated. Commenting on his experience as part of Bender’s therapeutic program, Ted Chabasinski said that, “It really made a mess of me … I went from being a shy kid who read a lot to a terrified kid who cried all the time.” Following his treatment, he spent ten years as an inmate of Rockland State Hospital, a psychiatric facility now known as the Rockland Psychiatric Centre.