Abnormal psychology

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Abnormal psychology is the branch of psychology that studies unusual patterns of behavior, emotion and thought, which may or may not be understood as precipitating a mental disorder. Although many behaviors could be considered as abnormal, this branch of psychology generally deals with behavior in a clinical context. There is a long history of attempts to understand and control behavior deemed to be aberrant or deviant (statistically, functionally, morally or in some other sense), and there is often cultural variation in the approach taken. The field of abnormal psychology identifies multiple causes for different conditions, employing diverse theories from the general field of psychology and elsewhere, and much still hinges on what exactly is meant by "abnormal". There has traditionally been a divide between psychological and biological explanations, reflecting a philosophical dualism in regard to the mind-body problem. There have also been different approaches in trying to classify mental disorders. Abnormal includes three different categories; they are subnormal, supernormal and paranormal.

The science of abnormal psychology studies two types of behaviors: adaptive and maladaptive behaviors. Behaviors that are maladaptive suggest that some problem(s) exist, and can also imply that the individual is vulnerable and cannot cope with environmental stress, which is leading them to have problems functioning in daily life in their emotions, mental thinking, physical actions and talks. Behaviors that are adaptive are ones that are well-suited to the nature of people, their lifestyles and surroundings, and to the people that they communicate with, allowing them to understand each other.^[4] Clinical psychology is the applied field of psychology that seeks to assess, understand and treat psychological conditions in clinical practice. The theoretical field known as 'abnormal psychology' may form a backdrop to such work, but clinical psychologists in the current field are unlikely to use the term 'abnormal' in reference to their practice. Psychopathology is a similar term to abnormal psychology but has more of an implication of an underlying pathology (disease process), and as such is a term more commonly used in the medical specialty known as psychiatry.

History

Supernatural traditions

Throughout time, societies have proposed several explanations of abnormal behavior within human beings. Beginning in some hunter-gatherer societies, animists have believed that people demonstrating abnormal behavior are possessed by malevolent spirits. This idea has been associated with trepanation, the practice of cutting a hole into the individual's skull in order to release the malevolent spirits. Although it has been difficult to define abnormal psychology, one definition includes characteristics such as statistical infrequency.

A more formalized response to spiritual beliefs about abnormality is the practice of exorcism. Performed by religious authorities, exorcism is thought of as another way to release evil spirits who cause pathological behavior within the person. In some instances, individuals exhibiting unusual thoughts or behaviors have been exiled from society or worse. Perceived witchcraft, for example, has been punished by death. Two Catholic Inquisitors wrote the Malleus Maleficarum (Latin for "The Hammer Against Witches"), that was used by many Inquisitors and witch-hunters. It contained an early taxonomy of perceived deviant behavior and proposed guidelines for prosecuting deviant individuals.

Asylums

The act of placing mentally ill individuals in a separate facility known as an asylum dates to 1547, when King Henry VIII of England established the St. Mary of Bethlehem asylum in London. This hospital, nicknamed Bedlam, was famous for its deplorable conditions. Asylums remained popular throughout the Middle Ages and the Renaissance era. These early asylums were often in miserable conditions. Patients were seen as a “burden” to society and locked away and treated almost as beasts to be dealt with rather than patients needing treatment. However, many of the patients received helpful medical treatment. There was scientific curiosity into abnormal behavior although it was rarely investigated in the early asylums. Inmates in these early asylums were often put on display for profit as they were viewed as less than human. The early asylums were basically modifications of the existing criminal institutions.

In the late 18th century the idea of humanitarian treatment for the patients gained much favor due to the work of Philippe Pinel in France. He pushed for the idea that the patients should be treated with kindness and not the cruelty inflicted on them as if they were animals or criminals. His experimental ideas such as removing the chains from the patients were met with reluctance. The experiments in kindness proved to be a great success, which helped to bring about a reform in the way mental institutions would be run.

Institutionalization would continue to improve throughout the 19th and 20th century due to work of many humanitarians such as Dorethea Dix, and the mental hygiene movement which promoted the physical well-being of the mental patients. "Dix more than any other figure in the nineteenth century, made people in America and virtually all of Europe aware that the insane were being subjected to incredible abuses." Through this movement millions of dollars were raised to build new institutions to house the mentally ill. Mental hospitals began to grow substantially in numbers during the 20th century as care for the mentally ill increased in them.

By 1939 there were over 400,000 patients in state mental hospitals in the USA. Hospital stays were normally quite long for the patients, with some individuals being treated for many years. These hospitals while better than the asylums of the past were still lacking in the means of effective treatment for the patients, and even though the reform movement had occurred; patients were often still met with cruel and inhumane treatment.

Things began to change in the year 1946 when Mary Jane Ward published the influential book titled “The Snake Pit” which was made into a popular movie of the same name. The book called attention to the conditions which mental patients faced and helped to spark concern in the general public to create more humane mental health care in these overcrowded hospitals.

In this same year the National Institute of Mental Health was also created which provided support for the training of hospital employees and research into the conditions which afflicted the patients. During this period the Hill-Burton Acts was also passed which was a program that funded mental health hospitals. Along with the Community Health Services Act of 1963, the Hill-Burton Acts helped with the creation of outpatient psychiatric clinics, inpatient general hospitals, and rehabilitation and community consultation centers.

Deinstitutionalisation

In the late twentieth century however, a large number of mental hospitals were closed due to lack of funding and overpopulation. In England for example only 14 of the 130 psychiatric institutions that had been created in the early 20th century remained open at the start of the 21st century. In 1963, President John Kennedy launched the community health movement in the United States as a "bold new approach" to mental health care, aimed at coordinating mental health services for citizens in mental health centers. In the span of 40 years, the United States was able to see an about 90 percent drop in the number of patients in Psychiatric hospitals.

This trend was not only in the England and the United States but worldwide with countries like Australia having too many mentally ill patients and not enough treatment facilities. Recent studies have found that the prevalence of mental illness has not decreased significantly in the past 10 years, and has in fact increased in frequency regarding specific conditions such as anxiety and mood disorders.

This led to a large number of the patients being released while not being fully cured of the disorder they were hospitalized for. This became known as the phenomenon of deinstitutionalization. This movement had noble goals of treating the individuals outside of the isolated mental hospital by placing them into communities and support systems. Another goal of this movement was to avoid the potential negative adaptations that can come with long term hospital confinements. Many professionals for example were concerned that patients would find permanent refuge in mental hospitals which would take them up when the demands of everyday life were too difficult. However, the patients moved to the community living have not fared well typically, as they often speak of how they feel “abandoned” by the doctors who used to treat them. It also has had the unfortunate effect of placing many of the patients in homelessness. Many safe havens for the deinstitutionalized mentally ill have been created, but it is nevertheless estimated that around 26.2% of people who are currently homeless have some form of a mental illness. The placing of these individuals in homelessness is of major concern to their well-being as the added stress of living on the streets is not beneficial for the individual to recover from the particular disorder with which they are afflicted. In fact while some of the homeless who are able to find some temporary relief in the form of shelters, many of the homeless with a mental illness "lack safe and decent shelter".

Explaining abnormal behavior

People have tried to explain and control abnormal behavior for thousands of years. Historically, there have been three main approaches to abnormal behavior: the supernatural, biological, and psychological traditions. Abnormal psychology revolves around two major paradigms for explaining mental disorders, the psychological paradigm and the biological paradigm. The psychological paradigm focuses more on the humanistic, cognitive and behavioral causes and effects of psychopathology. The biological paradigm includes the theories that focus more on physical factors, such as genetics and neurochemistry.

Supernatural explanations

In the first supernatural tradition, also called the demonological method, abnormal behaviors are attributed to agents outside human bodies. According to this model, abnormal behaviors are caused by demons, spirits, or the influences of moon, planets, and stars. During the Stone Age, trepanning was performed on those who had mental illness to literally cut the evil spirits out of the victim's head. Conversely, Ancient Chinese, Ancient Egyptians, and Hebrews, believed that these were evil demons or spirits and advocated exorcism. By the time of the Greeks and Romans, mental illnesses were thought to be caused by an imbalance of the four humors, leading to draining of fluids from the brain. During the Medieval period, many Europeans believed that the power of witches, demons, and spirits caused abnormal behaviors. People with psychological disorders were thought to be possessed by evil spirits that had to be exercised through religious rituals. If exorcism failed, some authorities advocated steps such as confinement, beating, and other types of torture to make the body uninhabitable by witches, demons, and spirits. The belief that witches, demons, and spirits are responsible for the abnormal behavior continued into the 15th century. Swiss alchemist, astrologer, and physician Paracelsus (1493–1541), on the other hand, rejected the idea that abnormal behaviors were caused by witches, demons, and spirits and suggested that people's mind and behaviors were influenced by the movements of the moon and stars.

This tradition is still alive today. Some people, especially in the developing countries and some followers of religious sects in the developed countries, continue to believe that supernatural powers influence human behaviors. In Western academia, the supernatural tradition has been largely replaced by the biological and psychological traditions.

Biological explanations

In the biological tradition, psychological disorders are attributed to biological causes and in the psychological tradition, disorders are attributed to faulty psychological development and to social context. The medical or biological perspective holds the belief that most or all abnormal behavior can be attributed to a medical factor; assuming all psychological disorders are diseases.

The Greek physician Hippocrates, who is considered to be the father of Western medicine, played a major role in the biological tradition. Hippocrates and his associates wrote the Hippocratic Corpus between 450 and 350 BC, in which they suggested that abnormal behaviors can be treated like any other disease. Hippocrates viewed the brain as the seat of consciousness, emotion, intelligence, and wisdom and believed that disorders involving these functions would logically be located in the brain.

These ideas of Hippocrates and his associates were later adopted by Galen, the Roman physician. Galen extended these ideas and developed a strong and influential school of thought within the biological tradition that extended well into the 18th century. 

Medical: Kendra Cherry states: "The medical approach to abnormal psychology focuses on the biological causes on mental illness. This perspective emphasizes understanding the underlying cause of disorders, which might include genetic inheritance, related physical disorders, infections and chemical imbalances. Medical treatments are often pharmacological in nature, although medication is often used in conjunction with some other type of psychotherapy."

Psychological explanations

Underdeveloped Superego

According to Sigmund Freud's structural model, the Id, Ego and Superego are three theoretical constructs that define the way an individual interacts with the external world as well as responding to internal forces. The Id represents the instinctual drives of an individual that remain unconscious; the superego represents a person's conscience and their internalization of societal norms and morality; and finally the ego serves to realistically integrate the drives of the id with the prohibitions of the super-ego. Lack of development in the Superego, or an incoherently developed Superego within an individual, will result in thoughts and actions that are irrational and abnormal, contrary to the norms and beliefs of society.

Irrational beliefs

Irrational beliefs that are driven by unconscious fears, can result in abnormal behavior. Rational emotive therapy helps to drive irrational and maladaptive beliefs out of one's mind.

Sociocultural influences

The term sociocultural refers to the various circles of influence on the individual ranging from close friends and family to the institutions and policies of a country or the world as a whole. Discriminations, whether based on social class, income, race, and ethnicity, or gender, can influence the development of abnormal behavior.

Multiple causality

The number of different theoretical perspectives in the field of psychological abnormality has made it difficult to properly explain psychopathology. The attempt to explain all mental disorders with the same theory leads to reductionism (explaining a disorder or other complex phenomena using only a single idea or perspective). Most mental disorders are composed of several factors, which is why one must take into account several theoretical perspectives when attempting to diagnose or explain a particular behavioral abnormality or mental disorder. Explaining mental disorders with a combination of theoretical perspectives is known as multiple causality. 

The diathesis–stress model emphasizes the importance of applying multiple causality to psychopathology by stressing that disorders are caused by both precipitating causes and predisposing causes. A precipitating cause is an immediate trigger that instigates a person's action or behavior. A predisposing cause is an underlying factor that interacts with the immediate factors to result in a disorder. Both causes play a key role in the development of a psychological disorder. For example, high neuroticism antedates most types of psychopathology.

Recent concepts of abnormality

• Statistical abnormality – when a certain behavior/characteristic is relevant to a low percentage of the population. However, this does not necessarily mean that such individuals are suffering from mental illness (for example, statistical abnormalities such as extreme wealth/attractiveness)
• Psychometric abnormality – when a certain behavior/characteristic differs from the population's normal dispersion e.g. having an IQ of 35 could be classified as abnormal, as the population average is 100. However, this does not specify a particular mental illness.
• Deviant behavior – this is not always a sign of mental illness, as mental illness can occur without deviant behavior, and such behavior may occur in the absence of mental illness.
• Combinations – including distress, dysfunction, distorted psychological processes, inappropriate responses in given situations and causing/risking harm to oneself.

Approaches

• Somatogenic – abnormality is seen as a result of biological disorders in the brain. This approach has led to the development of radical biological treatments, e.g. lobotomy.
• Psychogenic – abnormality is caused by psychological problems. Psychoanalytic (Freud), Cathartic, Hypnotic and Humanistic Psychology (Carl Rogers, Abraham Maslow) treatments were all derived from this paradigm. This approach has, as well, led to some esoteric treatments: Franz Mesmer used to place his patients in a darkened room with music playing, then enter it wearing a flamboyant outfit and poke the "infected" body areas with a stick.

Classification

DSM-5

The standard abnormal psychology and psychiatry reference book in North America is the Diagnostic and Statistical Manual of the American Psychiatric Association. The current version of the book is known as DSM-5. It lists a set of disorders and provides detailed descriptions on what constitutes a disorder such as Major Depressive Disorder or anxiety disorder. It also gives general descriptions of how frequently the disorder occurs in the general population, whether it is more common in males or females and other such facts. 

The DSM-5 identifies three key elements that must be present to constitute a mental disorder. These elements include:

• Symptoms that involve disturbances in behavior, thoughts, or emotions.
• Symptoms associated with personal distress or impairment.
• Symptoms that stem from internal dysfunctions (i.e. specifically having biological and/or psychological roots).

The diagnostic process uses five dimensions, each of which is identified as an "axis", to ascertain symptoms and overall functioning of the individual. It is important to note that the DSM-5 no longer uses this axis system. These axes are as follows:

• Axis I – Clinical disorders, which would include major mental and learning disorders. These disorders make up what is generally acknowledged as a disorder including major depressive disorder, generalized anxiety disorder, schizophrenia, and substance dependence. To be given a diagnosis for a disorder in this axis the patient must meet the criteria for the particular disorder which is presented in the DSM in that particular disorders section. Disorders in this axis are of particular importance because they are likely to have an effect on the individual in many other axes. In fact the first 3 axes are highly related. This axis is similar to what would be considered an illness or disease in general medicine.
• Axis II – Personality Disorders and a decrease of the use of intellect disorder. This is a very broad axis which contains disorders relating to how the individual functions with the world around him or herself. This axis provides a way of coding for long lasting maladaptive personality characteristics that could have a factor in the expression or development of a disorder on Axis I although this is not always the case. Disorders in this axis include disorders such as antisocial personality disorder, histrionic personality disorder, and paranoid personality disorder. Mental retardation is also coded in this axis although most other learning disabilities are coded in Axis I. This Axis is an example of how the Axes all interact with one another help to give an overall diagnosis for an individual.
• Axis III – General medical conditions and "Physical disorders". The conditions listed here are the ones that could potentially be relevant to the managing or understanding of the case. Axis III is often used together with an Axis I diagnosis to give a better rounded explanation of the particular disorder. An example of this can be seen in the relationship between major depressive disorder and unremitting pain caused from a chronic medical problem. This category could also include use of drugs and alcohols as these are often symptoms of a disorder themselves such as substance dependence or major depressive disorder. Due to the nature of Axis III it is often recommended that the patient visit a medical doctor when he or she is being assessed in order to determine if the problem could potentially require medical intervention such as surgery. When the first 3 axes are used multiple diagnosis are often found which is actually encouraged by the DSM.
• Axis IV – Psychosocial/environmental problems, which would contribute to the disorder. Axis IV is used to inspect the broader aspects of a person’s situation. This axis will examine the social and environmental factors that could affect the person’s diagnosis. Stressors are the main focus of this axis and particular attention is paid to stressors that have been present in the past year; however it is not a requirement that the stressor had to form or continued in the past year. Due to the large number of potential stressors in an individual’s life, therapists often find such stressors via a checklist approach which is encouraged by the DSM. An example of the checklist approach would be examine the individual’s family life, economic situation, occupation, potential legal problems and so on. It is crucial that the patient is honest in this section as environmental factors can have a huge impact on the patient especially in certain schools of therapy such as the cognitive approach.
• Axis V – Global assessment of functioning (often referred to as GAF) or "Children's Global Assessment Scale" (for children and teenagers under the age of 18). Axis V is a score given to the patient which is designed to indicate how well the individual is handling their situation at the current time. The GAF is based on a 100-point scale which the examiner will use to give the patient a score. Scores can range from 1 to 100 and depending on the score on the GAF the examiner will decide the best course of action for the patient.“According to the manual, scores higher than 70 indicate satisfactory mental health, good overall functioning, and minimal or transient symptoms or impairment, scores between 60 and 70 indicate mild symptoms or impairment, while scores between 50 and 60 indicate moderate symptoms, social or vocational problems, and scores below 50 severe impairment or symptoms”. As GAF scores are the final Axis of the DSM the information present in the previous 4 axes are crucial for determining an accurate score.

ICD-10

The major international nosologic system for the classification of mental disorders can be found in the most recent version of the International Classification of Diseases, 10th revision (ICD-10). The ICD-10 has been used by World Health Organization (WHO) Member States since 1994. Chapter five covers some 300 mental and behavioral disorders. The ICD-10's chapter five has been influenced by APA's DSM-IV and there is a great deal of concordance between the two. WHO maintains free access to the ICD-10 Online. Below are the main categories of disorders:

• F00–F09 Organic, including symptomatic, mental disorders
• F10–F19 Mental and behavioral disorders due to psychoactive substance use
• F20–F29 Schizophrenia, schizotypal and delusional disorders
• F30–F39 Mood [affective] disorders
• F40–F48 Neurotic, stress-related and somatoform disorders
• F50–F59 Behavioral syndromes associated with physiological disturbances and physical factors
• F60–F69 Disorders of adult personality and behavior
• F70–F79 Mental retardation
• F80–F89 Disorders of psychological development
• F90–F98 Behavioral and emotional disorders with onset usually occurring in childhood and adolescence
• F99 Unspecified mental disorder

Perspectives of Abnormal psychology

Psychologists may use different perspectives to try to get better understanding on abnormal psychology. Some of them may just concentrate on a single perspective. But the professionals prefer to combine two or three perspectives together in order to get significant information for better treatments.

• Behavioral- the perspective focus on observable behaviors
• Medical- the perspective focus on biological causes on mental illness
• Cognitive- the perspective focus on how internal thoughts, perceptions and reasoning contribute to psychological disorders

Cause

Genetics

• Investigated through family studies, mainly of monozygotic (identical) and dizygotic (fraternal) twins, often in the context of adoption. Monozygotic twins should be more likely than dizygotic twins to have the same disorder because they share 100% of their genetic material, whereas dizygotic twins share only 50%. For many disorders, this is exactly what research shows. But given that monozygotic twins share 100% of their genetic material, it may be expected of them to have the same disorders 100% of the time, but in fact they have the same disorders only about 50% of the time
• These studies allow calculation of a heritability coefficient.

Biological causal factors

• Neurotransmitter [imbalances of neurotransmitters like norepinephrine, dopamine, serotonin and GABA (Gamma aminobutryic acid)] and hormonal imbalances in the brain
• Genetic vulnerabilities
• Constitutional liabilities [physical handicaps and temperament]
• Brain dysfunction and neural plasticity
• Physical deprivation or disruption [deprivation of basic physiological needs]

Socio-cultural factors

• Effects of urban/rural dwelling, gender and minority status on state of mind
• Generalizations about cultural practices and beliefs may fail to capture the diversity that exists within and across cultural groups, so we must be extremely careful not to stereotype individuals of any cultural group

Systemic factors

• Family systems
• Negatively Expressed Emotion playing a part in schizophrenic relapse and anorexia nervosa.

Biopsychosocial factors

• Illness dependent on stress "triggers".^[32]

Therapies

Psychoanalysis (Freud)

Psychoanalytic theory is heavily based on the theory of the neurologist Sigmund Freud. These ideas often represented repressed emotions and memories from a patient's childhood. According to psychoanalytic theory, these repressions cause the disturbances that people experience in their daily lives and by finding the source of these disturbances, one should be able to eliminate the disturbance itself. This is accomplished by a variety of methods, with some popular ones being free association, hypnosis, and insight. The goal of these methods is to induce a catharsis or emotional release in the patient which should indicate that the source of the problem has been tapped and it can then be helped. Freud's psychosexual stages also played a key role in this form of therapy; as he would often believe that problems the patient was experiencing were due to them becoming stuck or "fixated" in a particular stage. Dreams also played a major role in this form of therapy as Freud viewed dreams as a way to gain insight into the unconscious mind. Patients were often asked to keep dream journals and to record their dreams to bring in for discussion during the next therapy session. There are many potential problems associated with this style of therapy, including resistance to the repressed memory or feeling, and negative transference onto the therapist. Psychoanalysis was carried on by many after Freud including his daughter Ana Freud and Jacques Lacan. These and many others have gone on to elaborate on Freud's original theory and to add their own take on defense mechanisms or dream analysis. While psychoanalysis has fallen out of favor to more modern forms of therapy it is still used by some clinical psychologists to varying degrees.

Behavioral therapy (Wolpe)

Behavior therapy relies on the principles of behaviorism, such as involving classical and operant conditioning. Behaviorism arose in the early 20th century due to the work of psychologists such as James Watson and B. F. Skinner. Behaviorism states that all behaviors humans do is because of a stimulus and reinforcement. While this reinforcement is normally for good behavior, it can also occur for maladaptive behavior. In this therapeutic view, the patients maladaptive behavior has been reinforced which will cause the maladaptive behavior to be repeated. The goal of the therapy is to reinforce less maladaptive behaviors so that with time these adaptive behaviors will become the primary ones in the patient.

Humanistic therapy (Rogers)

Humanistic therapy aims to achieve self-actualization (Carl Rogers, 1961). In this style of therapy, the therapist will focus on the patient themselves as opposed to the problem which the patient is afflicted with. The overall goal of this therapy is that by treating the patient as "human" instead of client will help get to the source of the problem and hopefully resolve the problem in an effective manner. Humanistic therapy has been on the rise in recent years and has been associated with numerous positive benefits. It is considered to be one of the core elements needed therapeutic effectiveness and a significant contributor to not only the well being of the patient but society as a whole. Some say that all of the therapeutic approaches today draw from the humanistic approach in some regard and that humanistic therapy is the best way for treat a patient. Humanistic therapy can be used on people of all ages; however, it is very popular among children in its variant known as "play therapy". Children are often sent to therapy due to outburst that they have in a school or home setting, the theory is that by treating the child in a setting that is similar to the area that they are having their disruptive behavior, the child will be more likely to learn from the therapy and have an effective outcome. In play therapy, the clinicians will "play" with their client usually with toys, or a tea party. Playing is the typical behavior of a child and therefore playing with the therapist will come as a natural response to the child. In playing together the clinician will ask the patient questions but due to the setting; the questions no longer seem intrusive and therapeutic more like a normal conversation. This should help the patient realizes issues they have and confess them to the therapist with less difficulty than they may experience in a traditional counseling setting.

Cognitive behavioral therapy (Ellis and Beck)

Cognitive behavioral therapy aims to influence thought and cognition (Beck, 1977). This form of therapy relies on not only the components of behavioral therapy as mentioned before, but also the elements of cognitive psychology. This relies on not only the clients behavioral problems that could have arisen from conditioning; but also there negative schemas, and distorted perceptions of the world around them. These negative schemas may be causing distress in the life of the patient; for example the schemas may be giving them unrealistic expectations for how well they should perform at their job, or how they should look physically. When these expectations are not met it will often result in maladaptive behaviors such as depression, obsessive compulsions, and anxiety. With cognitive behavior therapy; the goal is to change the schemas that are causing the stress in a persons life and hopefully replace them with more realistic ones. Once the negative schemas have been replaced, it will hopefully cause a remission of the patients symptoms. CBT is considered particularly effective in the treatment of depression and has even been used lately in group settings. It is felt that using CBT in a group setting aids in giving its members a sense of support and decreasing the likelihood of them dropping out of therapy before the treatment has had time to work properly. CBT has been found to be an effective treatments for many patients even those who do not have diseases and disorders typically thought of as psychiatric ones. For example, patients with the disease multiple sclerosis have found a lot of help using CBT. The treatment often helps the patients cope with the disorder they have and how they can adapt to their new lives without developing new problems such as depression or negative schemas about themselves.

According to RAND, therapies are difficult to provide to all patients in need. A lack of funding and understanding of symptoms provides a major roadblock that is not easily avoided. Individual symptoms and responses to treatments vary, creating a disconnect between patient, society and care givers/professionals.