Lecture 1-‐3: Classification and Diagnosis
• Theoretical approaches to diagnosis, explanation, treatment of “abnormality” or mental disorders
L1: What is Abnormal Psychology?
• Definitions of “abnormality” or “mental disorder”
• Prevalence of mental disorders in the community
• Introduction to Diagnostic and Statistical Manual of Mental Disorders (DSM)
Definition of Abnormal Psychology:
• Scientific study of Psychological disorders/ Mental Disorders/ “Abnormal Behaviour”
o Need an empirical method to study o Description-‐ classification/diagnosis
§ “The Fevers”
§ Motivational Deficiency Disorder
§ Female Sexual Arousal Disorder o Causation
o Maintenance o Treatment
§ Of Psychological/Mental Disorders or “Abnormality”
• Have a problem with the definition o In the biological model/medicine
§ Treat a symptom of the sickness e.g.; fevers
§ Symptoms togetherà constitute a disorder o Need empirical evidence for all the disorders
§ DSM changes/continues to change
§ Do these disorders really exist? If there are many symptoms, can it be classified as a disease
§ Diagnosis and definitions of symptoms change
o Is there a thing such as the motivational deficiency disorder/female sexual arousal disorder?
§ Needs to be more interest in defining the disorder
What is a Mental Disorder?
Historically:
• Does a certain set of behaviours constitute a normal thing?
• Mental illness= “madness, insanity”
o Progression of madness
o Gross distortion of external reality (hallucinations, delusions) or disorganisation of speech, affect, behaviour
o SIMILAR TO today’s diagnosis of psychosis, schizophrenia and dementia
• 18-‐19th Centuries: Small number of patients treated in mental asylums (mental hospitals) by “mad doctors” or “alienists”
o Anxiety, sadness, angst was not classifies as “mental illness”
Today:
• 400 categories of “Mental Disorder”
o Listed in the DSM (Diagnostic and Statistical Manual of Mental Disorders) or the ICD (international classification of Diseases and Health Related Problems)
• Contain descriptions of symptom clusters
o Schizophrenia, Major Depression, Social Phobia, borderline personality disorder, obsessive compulsive disorder etc
§ Treated by psychiatrists, psychologists, clinical psychologists, social workers, counsellors, psychotherapists, psychoanalysts
How many people have mental disorders today?
• Not sufficient to find out the number of people seeking/receiving treatment
o Help-‐seeking is influenced by cultural/financial reasons, education knowledge etc
• Psychiatric Epidemiology:
o Community studies using large “representative samples”
o Interview about symptoms currently in the DSM
• Prevalence (proportional)
o What proportion of the population has a diagnosable disorder with a specified time period?
o Point prevalence
§ X out of Y o One year prevalence
§ 2007, X% of Australians had Y disease o Lifetime prevalence
• Incidence (proportion)
o What proportion of healthy individuals will develop the disorder within a specified time period (new cases)
o Every year, X percent of Australians develop Y disease for the first time
• What proportion of individuals with a diagnosable disorder seeks help?
• What proportion receives help?
• Prevalence/incidence in various sub-‐populations o Men vs. women
o Ethnic groups etc
o Can target populations who are the low risk, high risk
Prevalence cont..
• Lifetime prevalence of mental disorders o In adults (32-‐48%)
o Before age 21: 35-‐49%
• National Survey of Mental Health and Wellbeing o Life time prevalence of mental disorder: 45%
o 45% of Australians will experience a diagnosed disorder
• 7.3 million Australians aged 16-‐85 years experienced an anxiety, affective or substance use disorder at some point
BUT only 1/3 of these people received helpà highest % sought treatment
Thus, a large number of people who suffer from mental disorder DO NOT RECEIVE HELP
• Public health problem of vast proportions
• OR overestimation of the prevalence of mental disorders (definition of disorders)à too lose guidelines
DSM Definition of Mental Disorder:
• A clinically significant behavioural or psychological syndrome or pattern
o Associated with present distress/ disability or a significantly increased risk of suffering death, pain, disability or an important loss of freedom
o MUST NOT BE merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one
o Whatever its original cause, it must currently be considered a manifestation of a behavioural, psychological or biological dysfunction in the individual
§ Must be evaluated by a societal judgement o Need to have BOTH
§ Physical/biological dysfunction and societal judgement
§ Eg; anxiety disorder
• Often hard to tell whether it reflects normal reaction to life event vs. disorder
DSM-‐5 Major Depression:
• Must meet 5 symptoms
• Major Depressive Disorder:
o Single/recurrent depressive episode
• Depressive episode o Depressed mood
o Markedly diminished pleasure/interest in activities
o Significant weight loss or gain
o Insomnia or hypersomnia nearly every day o Fatigue/loss of energy nearly every day
o Feelings of worthlessness, excessive guilt nearly every day o Diminished ability to concentrate nearly every day o Recurrent thoughts of death, suicide, suicide attempts o 5 or more is needed (including 1 or 2) in a 2 week period
DSM Definition of Mental Disorder:
• All symptoms, including those that are expectable reactions to environmental stressors and those that are forms of social deviance, are considered mental disorders
• The failure to consider whether or not the symptoms of psychiatric disorders are actually harmful internal dysfunctions is the single most serious flaw in current psychiatric thinking
Summary:
• Changes in concepts of “mental disorder”
• Historical definition: “insanity, madness”
• Today: 400+ disorders in DSM
• Today’s definition involves two components:
o Dysfunction internal to the individual o Seen as socially unaccepted/harmful
• DSM fails to apply its own general definition of mental illness to specific diagnostic categories o Prevalence of mental disorder in the community may be overestimated (because
diagnosis is based on symptoms only, ignoring the question of internal dysfunction)
L2: Classification and Diagnosis I
Current Classification Systems:
• International Classification of Diseases and Health Related problems (ICD):
o WHO
o Mental Disorders first added in 1948 o Currently in its 10th edition
• Diagnostic and Statistical Manual of Mental Disorders (DSM) o American Psychiatric Association
o 1st Edition published in 1952 o Currently in its 5th edition (2013)
• Currently reflect the ‘medical” model
• Previously influenced by psychoanalysis
The medical model:
• Classification and diagnosis of illnesses is based on several assumptions:
o Illness is qualitatively different from health o Different illness are:
§ Clearly distinguishable from each other
§ Occur independently from each other
§ Have specific, identifiable causal agents
§ Respond to specific treatment
o Caused by an individual illness and will respond to specific treatment
• Aetiologically based diagnosis is the ultimate goal of medical (psychiatric) classification:
o Aim is to identify diagnostic categories (syndromes) that have their own specific causes, lead to specific treatments
§ A “syndrome” is only a “disease” once we know its cause (eg; AIDS)
§ Distinguishable from health BUT also distinguishable from each other
• Early attempts for aetiologically based classification of various types of “insanity” were based on hypothesised causes
o Application to mental illness o Hippocrates
§ Hysteria (observed in women): the cause is the uterus o Paracelsus (16th C)
§ Vesania, lunacy, insanity o Henry Maudsley (1867)
§ Masturbatory insanity
• Extreme perversion of feeling and derangement of thought, failure of intelligence, nocturnal hallucinations and suicidal and homicidal propensities
The medical/biological model:
• Louis Pasteur and the germ theory of diseases
• P. Broca (1824-‐1880), C. Wernicke
o Identified associations between specific syndromes (expressive vs. receptive aphasia) o Localised damage to the brain
• Came to CONCLUSION (apply biological model to mental health)
o Can identify and categorise according to underlying biological causes
§ Bacterial/viral infections
§ Brain damage
§ Toxins
§ Heredity
o These would lead to effective treatment or prevention
• BUT progress slowed down markedly in early 20th C o No treatment breakthrough
o Some very harmful treatments
§ Infections: “focal sepsis (Henry Cotton, 1907-‐1930_
§ Hypothesis: Chronic infection releases toxins into the body, reaching the brain and causing insanity
§ Treatment: remove infected organ (s)
§ Teeth, tonsils, colons, testicles, ovaries, uterus
§ Death rates of about 45% (mainly from infections post-‐surgery)
§ Lobotomy
• THUS, biological medial model could not fulfil its promise
The psychoanalytic model:
• Very influential in psychiatry during 1940s to 1970s o Revolutionised the concept of mental illness
§ No clear dividing line between normal and abnormal (major challenge to medical model
• Pathological is extreme manifestation of “normal”
§ Include conditions other than psychotic states
• “Neuroses”: anxiety, depression, various phobias
§ No clear dividing line between different categories of mental disorder (neuroses and psychoses) – challenged the medical model’s qualitative def.
o Extended client base to those with milder conditions o Proliferation of mental health professions
§ Asylums to outpatient practices
Development of the DSM:
• DSM-‐1 (1952), DSM-‐II (1968)
o Strongly influenced by psychoanalytic theory
• DSM-‐I (1952)-‐ Depressive Reaction o Very psychoanalytically based
o Seen as a defence mechanism (unconscious anxious processes going on and being suppressed)
§ Feelings you cannot deal with get pushed down to the bottom o If the doctors cannot agree what illnessà cannot decide on treatment
DSM-‐I (1952), DSM-‐II (1968)
• Problematic reliability o Inter-‐rater reliability:
§ Can we agree on the diagnosis?
• How much depression/self deprecation is needed?
How often?
• What if guilt is not present? What qualifies as a loss etc?
• Problematic validity
o Is this really what “depression” is?
§ Based on unproven theories about etiology: depression as a defence from unacceptable unconscious ambivalent feelings
§ What’s different to hysteria?
DSM-‐III (1980) and Beyond:
• Emil Kraker: Father of psychoanalytic classification
• Reflects medical/biological model
• Should think about what we know o Description of symptoms
• No theoretical assumptions about causation
• If causation is not known: Description of symptoms:
o Patient report, direct observation, measurement o Would lead to the same diagnosis
o Clear explicit criteria and decision rules
§ Improved reliability
§ Validity
DSM-‐5 Major Depression:
• Only classified by symptoms IN ORDER to improve reliability
• BUT, still not known whether it is depression or not
• Major Depressive Disorder:
o A single or recurrent depressive episode
• Major Depressive Episode:
o Depressed mood most of the day/nearly every day o Markedly diminished pleasure/interest in activities o Significant weight loss or gain
o 5 or more is needed, (including 1 or 2) in a 2-‐week period
DSM-‐III (1980) and beyond:
• Improvement in reliability (we can all agree)
• Validity? (we can all be wrong)
o Aim: Identiify independent groups of symptoms (Syndromes) each refelecting a specific cause
• Problems:
o Comorbidity is common (not independent of each other) o Diagnostic instability is high
o Lack of treatment specificity
§ Borders between categories are “beginning to collapse under the weight of the evidence”
§ No DSM mental disorder qualifies as a “disease”
Classification: A work in progress
• Changes in DSM o Hysteria: out o Homoesexuality: out o GAD: in
o Binge Eating Disorder (BED): in o Asperger’s Disorder: in, then out again o Psychpathy: out, but sneaking back in o ICD and DSM are not the same:
§ GAD, BED, Mixed Anxiety-‐Depression o What about anger?
§ Disorders of emotion missing
L3: Anger
• Strange to not have a disorder for one of the “basic” emotions
• Arguably first identifiable negative emotion to develop in infants (emerges at 4 months)
• The most commonly occurring negative emotions
o Scherer & Tannerbaum: large scale telephone survey in which respondents were asked about a recent situation that had evoked a very strong feeling for them
o Anger (17%) most frequently reported negative emotion
o Schrerer, Wranik, Sangsue, Tran and Scherer (2004), however, ruled out this qualification. They surveyed a large sample between the ages of 12 and 60 (asking respondents to report on an event that had provoked
o Still the most frequently reported negative emotion (12.5%) o Additionally examined emotion blends-‐ anger feared top of the list Why is anger a “clinical” or “abnormal” issue?
• Problem anger is rampant
o Any anger for which it is an issue/seek treatment
• 8% of the normal population reported that anger had been a problem for them for six month sor more
• As many clients seek mental health services for anger as do for depression and anxiety o Posternak & Zimmermann (2003)
§ ¼ displayed aggression What damage?
• Mediator in forms of aggression from domestic violence through to assault, murder and rape
• Interferes with judgement, problem solving and negotiation; leads to risky behaviours
• Risk factor in hypertension/heart-‐related illness
• Road rages: 1/3 of crashes, 2/3 of driving accidents
Anger and Relationships:
• Uniquely responsible for the neuroticism partner effect over and above depression and anxiety (Renshaw, Blais & Smith, 2010)
o The more neurotic your partner, the less satisfaction you gain
• More predictive of divorce 5 years later than “poor communication”
• Anger is uniquely predictive
• Tafrate, Kassinove & Dundin (2002) found that subjects with higher trait anger were significantly more likely to be unmarried (and unemployed)
• Greenglass (1996) – individuals with higher trait anger reported receiving less support from family members/less trust in their close relationships
• Most crucial part of suffering
Comorbidity:
• No 1. Comorbid issues is drug and alcohol issues (over 50%)
• No. 2 issue is anxiety (about a third)
• Depression and dysthymia (about 15%)
• Vast majority of angry individuals are not DEPRESSED
• Bipolar about 5%
Anger and the DSM-‐V:
• Both everywhere and nowhere
• Travels across the full gamut of psychological disorders-‐ no anger disorder proper, or an anger disorders section
Everywhere:
• Possible symptom of:
o Mania (Bipolar Disorder)
o (Pediatric) Major Depressive Disorder (MDD) o Premenstrual Dysmorphic Disorder
o PTSD o GAD
• Axis-‐II Disorders/Personality Disorders:
o Borderline o Antisocial o Paranoid
o Not surprisingly are the PDs that are the most frequent in angry samples (along with Narcissistic PD)
o Spread is even-‐ no single PD adequately characterises the group as a whole
o High Trait Anger, and of individuals who present for anger-‐management, do not have PDs
Nowhere:
• Anger has no “section” and no real disorder
• But there a few semblances of anger disorders, which have led many to believe DSM has anger covered
• Intermittent Explosive Disorder:
o Most commonly diagnosed to people presenting with anger issues, even without aggression
§ Recurrent behavioural outbursts representing a failure to control aggressive impulses as manifested by either
• Verbal outbursts or physical aggression w/out damage, twice a week for at least three weeks
• Behavioural outburst that do result in damage/injury, three times in 12 months
§ Aggression is disproportionate to provocation
§ Aggression is not pre-‐meditated
• Impulsive
• Not committed to tangible objective
§ At least six year olds
§ Caused by no other medical reason
This is an aggression disorder, not an anger disorder
§ MDD: Either Depressed mood or loss of interest or pleasure, as indicated by subjective report of observation
§ Specific Phobia: marked fear or anxiety about specific object
§ Diagnosis would not apply to the angry individual who is rarely aggressive
Compared to major depressive disorder:
• Symptoms are based off behavioural and lack of impulse o As opposed to mood/frame of mind
• Emphasis of aggression (over emphasis) in academic community: violence is mentioned 10 times more than ager in abnormal texts
• Fails to include angry individuals who have distressing and/or impairing levels of angry mood, resentful brooding or chronic irritability but do not satisfy the behavioural criteria for aggressive outbursts
• In an analysis of 25 outpatients who complained about anger, ONLY 2 complained of aggression problems
Over-‐emphasis on “impulse control”
• DSM appears to be suggesting that the aggression in ED is caused by a general impulse-‐control problem
• DSM-‐5
o IED appears to be quite common, regardless of presence of ADHD, impulse control and conduct disorders
o Very old school view in the DSM
• Treatment implications are that you would presumably recommend behavioural control, rather than cognitive treatment
Affective vs. instrumental aggression:
• False dichotomy in practice
o Most, if not all angry aggression can be seen to serve some purpose (operate on the world)à aggression develops in part via operant learning
• Parents with children (compliance, subordination), husbands with their wives etc
• Even behaviours as seemingly pointless as slamming doors etc appear to function as dramatic displays intended to coerce or intimidate
Oppositional Defiant Disorder:
Anger:
• Pattern of angry/irritable mood o Touchy/easily annoyed o Loses temper
o Angry/resentful
• Argumentative/defiant behaviour
• Argues with authority figures and refuses to comply with respects
• Often deliberately annoys others
• Blames other for his/her mistakes or misbehaviour
• Vindictiveness
o Spiteful/ vindictive at least twice w/in past 6 months
• Lasts at least 6 months – exhibited during interaction with at least one individual who is not a sibling
Child-‐like behaviour:
• Vindictiveness
• Not strictly exclusive to children, but sounds like it is intended
• 4-‐8 unlikely to apply to adults
• 6-‐8 imply ‘deliberate malice’ which is unrelated to anger (more related to psychopathy or antisocial traits)
Disruptive Mood Dysregulation Disorder:
• Depressive order section
o Severe recurrent temper outbursts (out of proportion) o 3 or more tries weekly
o Inconsistent with developmental level
o The mood between outbursts is persistently irritable or angry o Not be made after 18, age of onset before 10
• Not an anger disorder but to prevent children being diagnosed as bipolar
• Average angry client
o Not violent or impulsive (IED)
o Don’t commit malicious acts against authority (ODD) o Haven’t been a brat since childhood (DMDD) o Don’t have a probem
Anger: The Misdiagnosed Emotion:
• Lachmund, DiGiuseppe & Fuller (2005)
• Constructed a GAD vignette with anxiety, but replaced with anger o Sent at random to psychiatrists/psychologists
• Social Phobia: 80% got it right, 18% for another anxiety disorder
• BUT in social anger
o 20% put IED despite no aggression mention
o Over 80% diagnosed with PD despite no PD traits (borderline etc)
• Frequency of seeing patients for anxiety and anger are the same
• No medicare rebates
• Very under-‐researched emotion
o Anxiety and depression are referenced about 25 times more than anger
Why is anger so neglected?
• Common anger fallacies in the psychological community (and treatment implications) o Impulse problem/classically conditioned/social skills problem etc
• Angry individuals often shirk therapy, so the demand has lagged
• Mental health workers are reluctant to confront it