Psychopathology Summary notes Lecture 1 – Understanding psychopathology
Normal Vs. abnormal
What parameters we use to make judgements around normality and abnormality What is ‘normal’
- Being like the majority?
- Autonomous functioning? Able to function as we would expect for someone of their age and background should
- Accurate reality perception? Are they through their senses perceiving what is around them accurately, seeing and hearing things around them, or seeing and hearing things around them that others can’t, appraisals of what is going on around them
- Regulated moods? Respond as we would expect to situations and stimuli in the environment around them, respond happy/sad appropriately in the time and context
- Adequate interpersonal relationships? Able to maintain relationships, interact with other people as we would expect
So…..What is ‘abnormal’? What is psychopathology?
Statistical infrequency - normal curve
- most people fall in the middle of this normal curve - outliers are rare
- is the way a person is behaving and interacting with the environment around them what we would expect for the different circumstances, time, place or are they an outlier and how is that a different way to responding to the world around them
- how is that impacting their functioning
- is the experience the individual is describing to us something we would expect the majority of people to experience, or more of an outlier experience
Norm violation
- individuals who violate the norms of behaviour, consider them as presenting in an abnormal way
Personal distress
- would expect someone who is experiencing psychopathology/mental illness would be distressed by that situation
- know that not everyone who suffers from mental health is distressed by those difficulties Brief history of treatment of individuals experiencing mental illness in Australia
A threat to public order
- A disused convict barracks with doctors who were themselves convicts
- established for people who were viewed as unmanageable in the broad community - be able to have a place to manage people who were seen as a threat to public
- “mental health largely became a concern when it threatened public order and governments were particularly prominent in the management of the insane”
- focus was not on the treatment of individuals, but rather managing public order - Early treatments were ‘moral’ failings or ‘physical’ problems
- Early admissions: 2/3 police, 1/3 family members who couldn’t care for relatives
Inhumane treatments
- Early approaches were largely focused on maintaining the safety of the public - weren’t focused on improving the wellbeing of the individual who was incarcerated
- Little emphasis was placed on the well-being and/or recovery of the individual with the disorder
- treatments were ineffective, people with mental illness were excluded from society due to threat of public order
- Occurrences of ’shell shock’ during WWI showed that ‘normal’ individuals could succumb to ‘nervous’ illness and created a desire for more humanistic treatment
- Further developments in treatment and the anti-psychiatry movement created interest in psychosocial interventions
- significant developments, treatments became effective, anti-psychotics, anti-depressants were found to be more effective than previously managing these disorders
- introduction of other things such as CBT - optimism around treatment
(De-)Institutionalization
- Stage I: New treatments led to an “open-door” policy, allowing individuals to be treated on an outpatient basis.
- Stage II: Asylums began to close and treatment shifted to the community
New forms of treatment
Introduction & evolution of the DSM
- how mental service access has changed in Australia has also influenced our thinking about who could be impacted by mental health difficulty and our desire over time to manage those difficulties in different ways than we saw in places like Castle Hill
- framework we use to diagnose mental disorders → DSM
- first came out in 1952, but before that there was no internally recognized framework that could diagnose mental disorders
- needs to be some consensus in to how to diagnose mental disorders - DSM-5 latest model
Defining a mental disorder
The recommended approach by DSM is to use the World Health Organisation Disability Assessment Schedule v2.0 Measures Past Month:
• Understanding and communication
• Mobility
• Self-care
• Getting along with others
• Life activities
• Societal participation Considerations for mental disorders
Mental - Is the disorder really ‘mental’?
- What else would we call it…?
- what do we mean by mental
- calling it a mental disorder limits us to what is fundamental/essential to these disorders
- Suggestion to call it a brain-mind disorder
Clinical problems - Clinically significant behavioral problem or physiological syndrome or pattern occurring in an individual
- problematic because framing mental disorder around clinically significant behaviour/problems doesn’t create room for us to think about non clinically significant problems, biases our thinking
- Argument that clinically significant is a classifier that characterizes the problem, syndrome, or pattern and is a separate assessment
- Adding ’clinically significant’ is tautological; it doesn’t create room for non- clinically significant problems, syndromes, or patterns
Distress - Distress comes in lots of different ‘flavors’ – lots of different ways distress can manifest, contextualizing distress is problematic because what level of distress might be considered important when diagnosing a disorder; adding ‘clinically significant’ helps to put it at the right end of the continuum for diagnosis - Increased risk…? Risk factors are not disorders
Context - can’t diagnose a disorder without considering the background of the pt - need to be aware of the context of the individual before jumping to any
conclusions
- Response should not be a common reaction nor a culturally appropriate reaction
Different factors - Behavioral - Psychological or
- Biological
- whilst we don’t know the specific cause of mental disorders, we know that there is not a single cause and can be a combination
- Creates multiple possible categories of dysfunction
- Underlying psychobiological suggests a single common cause (even though the cause is actually unknown).
What is a ‘mental disorder’?
- The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (the DSM-5) is used as the current authoritative listing of mental disorders. It broadly defines mental disorder as:
o “clinically significant disturbance in an individual’s cognition, emotion regulation or
behaviour…usually associated with significant distress or disability in social, occupational or other important activities” (DSM-5)
- What does not define a mental disorder
o “an expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder.” (DSM-5)
Mental disorders are constructs
- In Parkinson’s there is a clear biological thing going on that allows for diagnosis - diagnosis of tuberculosis also reflects biological process going on
- for mental disorders, there are no clear biological markers that inform our diagnosis, definitive markers - we infer that someone is experiencing this disorder based on our understand of their behaviours, thinking
processes, social functioning
- mental disorders are inferred constructs based on this evidence around us, they are not directly diagnosable
Mental Disorders are ”Fuzzy”
- if an individual has a certain disorder, is there a chance that they will meet the criteria for another disorder - these disorders overlap
- comorbidity is the rule rather than the exception - we expect that if someone meets the diagnostic criteria
for one disorder, they are highly going to meet a diagnostic criteria for another
- symptoms that characterize mental illnesses are often not unique to a single mental health disorder
- mental disorders are not only fuzzy in their comorbidity at the broad level, but also when you draw down to looking at symptoms
- symptoms are not necessarily symptoms of one mental disorder
- in the diagnostic criteria itself, a lot of ways to meet the criteria for a mental disorder
The case against diagnosis/classification
Diagnoses:
Lead to bias or restricted thinking - leads us to think about disorders in a categorical way
- Diagnostic boundaries are rarely distinct and diagnoses change over time.
Examples: PTSD, Multiple Personality D/O
Are associated with jargon - Are clinicians in fact talking about the same construct? Jargon may mask what is actually being discussed.
- risk not being on the same plane as someone else, need to ensure two people are talking about the same construct
Inhibit research - See the case for RDoC. If we only study conditions meeting specific criteria, we may be missing a big part of the picture.
Can be stigmatising and have personal implications
- How does this affect existing experience? If a brain disorder, is brain
”broken”? If not a brain disorder, is something wrong with ”you”?
Some institutions and people contend that mental disorder is a myth - Thomas Szasz
- anti-psychiatry movement - General thesis:
o Psychology and psychiatry rely on an assumption that emotional distress, family and personal turmoil are societal constructions.
o myths, made up mental illnesses
o Above is an unproven hypothesis that is actively promoted by drug companies, among others.
- Response: See Kendler (2016). Few cases seem to be entirely socially constructed.
Why Diagnose or Classify Psychopathology?
Diagnoses:
- Facilitate Communication: among clinicians, between science and practice
- Facilitate Care: contained concepts allows for the identification of treatment and effectiveness of treatment, and prevention of mental disorders, description of experience, possible etiology and prognosis.
- Research: test treatment efficacy and understand etiology
- Information Management: measure and pay for care and helpful in terms of planning mental health services Terminology: Descriptive psychopathology
Signs Objective findings observed by a clinician in the behaviour or presentation of the individual - Tachycardia
- Pressured speech - Poor eye contact
Symptoms subjective complaints reported by a patient, only they can confirm this - Low mood
- Anxiety - Paranoia
Syndrome signs, symptoms and events that occur in a particular pattern and indicate the existence of a disorder
- Bipolar disorder - Depression
Disorder - A syndrome which can be discriminated from other syndromes;
- To be labelled a disorder means there is a distinct course to the syndrome and the age and gender characteristics of the disorder have been described to some extent. In some cases prognosis may also be known.
- in psychology we use disorders
Disease - For a disorder to be labelled a disease, there has to be indications of abnormal physiological processes or structural abnormalities (e.g., Parkinson’s Disease) - don’t have clear underlying biological processes in psychology
Assessment of Psychopathology
- Pen and paper tests – checklist of symptoms relating to DSM (e.g., BDI) - Clinical interviews (e.g., SCID)
- Behavioural assessment (e.g., AX-CPT)
- Activity Diaries such as in area of substance use and try to understanding pattern - Psychological tests (e.g., MMPI)
- Medical tests (e.g., MRI) - Psychophysiological tests
- Neuropsychological tests (e.g., WAIS) - Context is important.
-
Current approach to diagnosis - Checklist:
- MDE -> must have 5/9 Additional qualifiers:
- The symptoms cause clinically significant distress or impairment (one has to be met) in social, occupational, or other important areas of functioning
- The episode is not attributable to…substance or to another medical condition - The occurrence is not better explained by…{other psychiatric condition}
- Not explained by stressor-specific response - Not explained by culturally-appropriate response - Must be made by a clinician
- May include a number of procedures as previously described