2. Principles of assessment, classification & treatment Flashcards
what do categorical approaches assume?
assume that the distinctions between categories are qualitative - does the person have this characteristics or not?
what do dimensional approaches consider?
characteristics/qualities as varying along continuum - how much of this characteristic does this person exhibit?
how are diagnoses in psychopathology descriptive?
it identifies a particular problem is present based on a collection of features. the cause of explanation is not inherent in the diagnosis - associated features of possible explanations can be identified, but are not essential to the diagnosis
DSM-classification
categorial, polythetic and descriptive classification system
polythetic
each disorder is defined by a number of symptoms, and not all need to be present to meet the criteria
categorical
classifications are binary
descriptive
describes a pattern
how many diagnoses does the DSM 5 system have and under how many primary headings?
200 specific diagnoses and 22 primary headings
inclusion criteria
the symptoms that must be present to establish a diagnosis
exclusion criteria
diagnoses that can be ruled out if certain conditions prevail
how does the DSM-5 help provide a diagnoses?
lists specific criteria for each diagnostic category - a person can be assigned more than one diagnosis if criteria for more than one disorder is met
why diagnose?
clinical utility
access to funding/service/resources - diagnosis can be the qualifie
research
formalisation of natural cognitive processes
other reasons
clinical utility of diagnoses
informs treatment decision making
prognostic information - likely course and outcome
communication
what does the clinical utility of a diagnosis rely in?
relies on that diagnostic category measuring something meaningful with some consistency
reliabiltiy of clinical diagnosis
consistency of measurements
- interrater reliability - can multiple clinicians apply the classification system and reach the same conclusion?
validity of clinical diagnosis
the meaning or importance of the measurement
- does the diagnosis tell us anything useful
- can we make informed decisions from this information?
- does it meaningfully differentiate amongst similar problems?
purpose of assessment
- To determine if psychopathology is present
- To characterise (or formulate) the ‘problem’
- To inform treatment planning/priorities
- To predict likelihood of risk and guide decision making
- To establish a baseline against which ‘change’ might be monitored
- To establish a shared language from which to progress
principle of assessment
as well as the reliability and validity of diagnostic entities, we should consider the reliability and validity of the methods we use to gather information
best practice of assessment
- a mix of data/methods - consider patters and inconsistencies
- use something with known psychometric properties
the clinical interview
involves client (and if consent permits, corroborators)
clinical interview enables the collection of:
– A wide variety of information (client’s view of problem/symptoms; subjective distress/impairment)
– Different types of information (clinical observations, signs, behavioural assessment)
– Can be structured, semi-structured or unstructured (e.g. SCID)
– Focus can be broad or narrow
what might be covered in a clinical interview?
– Subjective experience of the problem – History of the problem - onset and course – Context of the problem – Impact on functioning – Family and marital history – Social, educational and occupational history – Family history – Medical history – Risk assessment
Observation
may be formal or information primarily qualitative often part of clinical interview can occur in specific contexts - i.e. naturalistic observation at a home, school etc self-monitoring
Mental status examination
key part of clinical interview - documents the clinician’s observations of the person’s presentation during the interview considering factors such as:
– Appearance and behaviour
– Mood and Affect
– Speech and language
– Thought content and process
– Perception
– Cognitive functions – attention, concentration, orientation
Psychological tests
rating scales, inventories, questionnaires, checklists.
features of psychological tests
standardisation and normative data; higher relaibility
normative data can be used for:
generative baseline information and tracking change and assessing severity relative to “normal” or “clinical” levels of functions (normative comparisons)
Examples of psychometric tests
• DASS21 – Depression, Anxiety and Stress Scales
• BDI - Beck Depression Inventory
• MMPI – Minnesota Multiphasic Multiaxial
Inventory
• Y-BOCS – Yale-Brown Obsessive Compulsive Scale
reliability as a psychometric consideration
measurement consistency including of diagnostic decisions (e.g. interrater reliability/agreement, kappa)
validity as a psychometric consideration
degree to which a test/system measures what it is intended to measure (e.g. convergent validity, predictive validity, divergent validity)
standardisation as a psychometric consideration
a fixed procedure (or prescription) for the application of methods to ensure or increase measurement consistency (affects how we give the test, score it, and handle (and report) the data
physiological (or biological assessment)
e.g. blood tests, MRI, CT, fMRI.
– Tests not typically performed by psychologists, but results might be taken into consideration.
– Important to exclude pathology due to medical condition for correct diagnosis/treatment
– many psychological problems have a physical component.
– The relation may be: causal, correlational, or indirect; there may be comorbid condition/s]
what will assessment methods depend on in practice?
– Goals of assessment - to make a diagnosis, to inform treatment, forensic reporting, decision making (e.g. risk) – Time – Availability of resources – i.e. tests – Training and experience – Context • inpatient or outpatient • emergency or routine
role of relationship
quality of assessment data obtained will depend on the quality of the relationship formed
time
quality assessments can take time - often multiple occasions of assessment are needed. Cross-sectional assessments can be misleading
assessment is onging
assessment informs diagnosis; diagnosis informs treatment; treatment informs assessment; and so on
treatment
the application of techniques to relieve the symptoms associated it the disorder and provide better adaptive functioning in the individual
spiritual cause of mental illness from historical views
– Exorcism of spirits
– Trephining
– Witchcraft that needed to be “treated”
physical cause of mental illness from historical views
– Rest or exercise
– “Asylums” to provide isolation & rest
Lobotomy
Controversial:
Lobotomy is a type of psychosurgery. Irrevocable severing of parts of brain
However, research concludes that there is still a role for ablative neurosurvery for mental disorders (OCD) in 21st century
what are the controversial physical therapies
lobotomy
insulin coma therapy
electro convulsive therapy
what are the 4 paradigmatic approaches?
biological
psychodynamic
cognitive-behavioural
humanistic
how can the 4 paradigmatic approaches be compared?
- Therapy Goal
- Method
- Treatment Length
- Therapist role
goal of biological treatment
treat physical or brain-based processes that underlie disorder; deliver benefit by altering biology
goal of cognitive-behavioural treatment
change of contingencies and teach more adaptive cognition and skills (behaviours/ responses)
goal of psychodynamic treatment
increase awareness of motives for behaviour including defense mechanisms; allow opportunities for resolution of unconscious conflicts
goal of humanistic treatment
increase emotional awareness through techniques such as reflective listening
biological methods of treatment
diagnosis, medications, scans, blood tests, psychosurgery, ECT
CBT methods of treatment
skills training, guided learning, behavioural rehearsal (role playing), teaching of new cognition, problem-solving
psychodynamic methods of treatment
free-association, dream analysis, focus on childhood
Humanistic methods of treatment
empathy, support, opportunities for exploration of emotions
treatment length of biological treatment
brief with follow up visits
role of therapist in biological treatment
active, direction, diagnostician
psychopharmacology
use of medications to treat psychopathology
psychotropic medications
chemical substances that affect psychological state
major categories of psychotropic medicine
– Antidepressants – SSRIs, SNRIs, Tricyclics, MAOI – Anxiolytics – Benzodiazepines – Sedatives – Mood stabilisers – Antipsychotics – Stimulants
electroconvulsive therapy
induction of seizures by passing electricity through the brain
typically a course of 6-12 sessions over a few weeks
can be bilateral or unilateral
used infrequently and cautiously - typically in “treatment resistant depression”
transcranial magnetic stimulation
A metal coil that contains an electric current is held to the side of the head and stimulates parts of the brain.
Given daily. Lower risks of seizures than ACT. Used in “treatment resistant depression”. Seemingly short term effects
pshyotherapy
The use of psychological techniques and the therapist–client relationship to produce emotional, cognitive, and behavior change
psychodynamic treatment length
long term (years), although newer variants are shorter
therapist role in psychodynamic therapy
passive, non-directive, interpreter
freudian psychoanalysis
– Attend sessions several times a week
– Insight oriented
– Primary techniques – insight, interpretation, transference, dream analysis, free association
Psychodynamic theories
relational/interpersonal focus, for example
– Attachment theory
– Interpersonal psychotherapy
modern psychodynamic perspectives
– Conceive of problems in relational terms - connection to important others as a basic human need
– Patterns of relationship emerge in our earliest relational experiences
– These memories, as a result of development, are procedural in nature
– We form implicit models of self and other and these guide our ongoing patterns of relating
– Interventions help to identify patterns of relating and interaction that are contributing to distress
humanistic therapy length
variable, length not typically structured
therapist role in humanistic therapy
passive, non-directive supporter
client centered therapty
– Carl Rogers (1902–1987) • Viewed three qualities as essential in a therapist: – Warmth – Genuineness – Empathy—emotional understanding
therapists are not experts in humanistic therapy
• Unconditional positive regard
– Valuing clients for who they are
• Therapeutic alliance
– A bond between therapist and client
length of cognitive behavioural therapty?
short term with booster sessions
therapist role in CBT
active, directive, non-judgmental, teacher
Behavioural therapies
• Exposure therapies • Behavioural experiments • Contingency Management • Social Skills training – Assertiveness training – Social problem solving • Aversion therapy – classical conditioning
Systematic Desensitisation
a graduated process of exposure individualised to each client, used in phobia/anxieties. Involves relaxation training, hierarchy of fears and a focus on function freedom from phobia
learning process of systemic desensitisation
systematic, gradual exposure to feared situations while simultaneously maintaining relaxation. t can be in vivo, imaginal or a combination
Cognitive therapties
focus on distortions in thinking. The pattern of thinking and beliefs maintain negative emotional states. Changing the thinking patterns enables change in emotion. Cognitive therapy words to identify and challenge thinking errors and to identify more adaptive thoughts and beleifs
cognitive distortions
- Black and white thinking
- Jumping to conclusions
- Catastrophising – what if..?
- Personalisation
- Emotional reasoning – I feel it, therefore it must be true
CBT is a combination of
both cognitive and behavioural therapies
example of CBT for social phobia involves…
– Relaxation component
– Exposure component – behavioural experiments, reducing safety behaviours
– Social skills component
– Cognitive component
• Challenging presumptions about others’ perspective
• Deconstructing social post-mortem
third wave CBT
mindfulness based CBT. Involves Acceptance and Commitment Therapy and Dialectical Behaviour Therapy
Family and couples therapy
Focus on changing relationships rather than the individual. May focus on communication processes - negotiation, conflict resolution, patterns of interaction. It is underpinned by various systems theories and may be used alone or in adjunct to individual therapy
Blended tratment
an eclectic or integrative treatment approach: drawing from each of the mentioned approaches depending on the disorder being treated or stage of treatment
- Perhaps consistent with a biopsychosocial aetiological model?
- Difficult to evaluate/replicate? How to describe? “evidence-base”?
Early views about treatment efficacy
- Eysenck: psychotherapy does virtually nothing
- Up to 2/3rds of people improve with no treatment (in fact, it is usually less than this); “spontaneous recovery”
- What is “no treatment” and “treatment”
- Role of extra-therapeutic factors/external factors
General statistics of treatment efficacy
- Works for many but not all people
- Meta-analysis (Smith and Glass, 1977) suggests that those who receive psychotherapy generally do better than those who don’t
- The average client is better off than 80% of individuals who remain untreated (fig 3-1 of your text book)
- Two-thirds of clients who seek therapy improve, only one-third who do not seek therapy improve
- Most improvement occurs in the first six months
when do benefits of psychotherapy diminish
• Many benefits of psychotherapy diminish in the year or two after treatment ends (Westen &
Bradley, 205)
YAVIS!
Clients improve more when they are “Young, attractive, verbal, intelligent and successful”
how do we know what works?
- Hard to know what the active ingredients are
- Treatment fidelity, especially in eclectic therapy can complicate
- The selection of “trial participants” and their representativeness (esp. comorbidities)
- Nature of trial (Effectiveness and efficacy)
efficacy studies
tightly controlled
– e.g. treatment versus no treatment
– High internal validity, lower external validity
effectiveness studies
correlated
– Cannot identify cause and effect
– May yield useful descriptive information
common factors of different treatments
While a lot of research has examined individual models of treatment, research has consistently found that the benefits arise from factors that are shared across treatment modalities
Much of the effectiveness of different psychotherapies can be explained by common factors rather than the specific content of the model
how are positive outcomes of treatment predicted?
– Therapist warmth, empathy and genuineness
– The client’s rating of therapy relationship is the single most important aspect (Sloane, et, 1975)
Common factors in brief psychotherapies
- Assessment and treatment is offered soon after problem identification
- Therapeutic alliance is established quickly & used effectively
- Client encouraged to express strong emotions or troubling experiences
- A flexible approach is used to choose therapeutic techniques
- Goals of therapy are limited and specific (narrowly focused) & therapist is directive
placebo effect
Beliefs/expectations about treatment efficacy play a role; some treatment gains may be attributable to a
placebo effec
solutions to placebo effect
- Placebo-control groups
- Double-blind studies (difficult to conduct because the therapist knows which therapy they are using).
- Meta analysis
what should a therapist adopt in determining a treatment for a specific disorder?
different treatments are more effective for particular disorders. Clients should be informed about research evidence and treatment alternatives. Thus therapists should adopt a scientistpractitioner
model of service delivery; irrespective of treatment approach (single-case experimental design)
Treatment decision making
Concept of evidence based practice – “the integration of best available research with clinical expertise in the context of patient characteristics, culture and preferences”
treatment choices should be guided by…
– Evidence (in a broad sense)
– Client characteristics
– Client preferences
– Culture
Holistic treatments
In addition to treating specific symptoms,
treatments may target broader factors that may
exacerbate, prolong or complicate mental illness
– Housing
– Employment
– Social engagement and social support
– Domestic and family violence
what are the stats of treatment seeking?
ABS (2008) National Survey of Mental Health
and Wellbeing
– Only 35 per cent of Australians with anxiety and
depression access treatment.
– Men are less likely to seek help than women, with
only 1 in 4 men who experience anxiety or depression
accessing treatment.
what are some potentailly harmful psycholitical therapies?
- critical incident stress debriefing
- scared straight
- recovered memories
- boot camp
critical incident stress debriefing
involves process trauma too soon and may cause increased risk for PTSD
scared straight
Seasoned inmates scare youth about consequences of criminality. This may increase conduct problems
Recovered memories
Encouragement to ‘recover’ memories of trauma. This may lade to false memories being created
boot camp
Delinquent youth attend military style camps. This may increase conduct problems
potential harm of all therapies
All therapies have the potential for harm; biological, psychological and social therapies can have aversive or unintended effects; clients need to be informed of risks (known and unknown).
Primary prevention
improve environments to prevent new cases of mental illness
secondary prevention
early identification and intervention to prevent deterioration
why do prevention models exist?
to promote wellbeing in
– Workplaces
– Schools
– Or more broadly in the community
prevention rather than treatment?
- Prevention studies yield some positive results with primary and secondary school groups (e.g.,Durlack & Wells, 1997)
- Fair results noted in the general population
- Effectiveness probably weakened when aimed at preventing symptoms not causes.
- Generally most effective for anxiety, mood, and eating/sleep disorders
