Assessment, Classification, and Diagnosis Flashcards
Our current system has its origins in ___________ with the concept of _______.
medical models; syndromes
Who are the 2 researchers who rly contributed to today’s vision of psychopathology?
Thomas Sydenham & Emil Kraepelin
Thomas Sydenham core ideas (2)
British physician from the 1600s. Tried to identify physical syndromes or diseases to better treat physical ailments.
(1) To him, Disease/syndrome = measurable entity.
(2) Expresses itself as clusters of symptoms that present together. => All symptoms hang together in some way, present at the same time, predictable course, go together.
Emil Kraepelin core ideas (2)
Psychiatrist from the 19th century. Among the first to try to apply Sydenham’s ideas to mental health.
(1) Distinct forms of mental illness are defined as a syndrome. I.e. With clusters of correlated symptoms all/largely present together
(2) Mental disorders are TAXONIC in nature. I.e. mental disorders are CATEGORIES that exist in the real world (either you have it or you don’t).
=> Differentiated psychological conditions based on their signs, symptoms, and natural histories.
Wakefield’s Harmful dysfunction
Looks at natural selection as a basis to define psychopathology.
Disorders have both a biological/evolutionary component & a social component.
What is “Dysfunction” in Harmful dysfunction?
“An organ system performing contrary to its design.” Importantly,notat the peak of its design.
What is “Harmful” in Harmful dysfunction?
[Subjective] Has to cause problems within the environmental context in which the individual is situated.
-> What is adaptive varies across contexts. What’s adaptive will look different. Bound by societal norms (in part).
In the concept of “Harmful dysfunction”, is it still harmful if the person is NOT suffering from the dysfunction?
A person doesn’t THEMSELVES need to perceive that they are suffering from this dysfunction. Can be that dysfunction causes harm to other people
Lillienfeld critique of harmful dysfunction (2)
(1) It’s really hard to differentiate between adaptations (math/arts) & secondary adaptations (feathers). If can’t do math doesn’t mean that something’s wrong
(2) So what are the core features of this organ system that we’re looking at to define psychopathology?
=> Some disorders may represent adaptations, not maladaptations.
Widiger Proposal core idea (2)
(1) Forms of pathologies are constructs.
=> Because mental disorders are constructs, there’s not going to be any single definitions that entirely captures it. Constantly evolving.
(2) We need to consider all of these different ways of thinking (e.g. statistical, harmful dysfunction…) to understand the whole construct of mental illness/psychopathology.
Construct def
Things that we think exist that we cannot measure directly. Way of organizing the world.
=> Idea or theory containing various conceptual elements, typically one considered to be subjective and not based on empirical evidence.
Purposes of a Classification System (4)
(1) Description: Highlight critical features of a diagnoses.
(2) Prediction:May tell you something about course, treatment response, etiology.
(3) Theory: Provides a set of postulates about relationships of different elements to one another. How/why do some symptoms hang together?
(4) Communication:e.g., between clinicians. You want every clinician to have the same definitions.
5criteria (Robins & Guze) proposed for valid classification of disorders
(1) Clinical Description:The disorder has to be characterized by a common set of symptoms that cluster together and are characteristic of the disorder.
(2) Course:People with the disorder should follow a common trajectory, and have a similar onset.
(3) Treatment Response:If a disorder is valid, most people with that disorder will respond similarly to similar treatments.
(4) Family/Natural History:Does the disorder run in families? Considers the course and outcome of the disorder. People with the disorder should follow a common trajectory, and have a similar onset.
(5) Laboratory Studies:Involves data from psychological, biological, and laboratory tests. Look for biological and psychophysiological associations
Limitations of a Classification System (2)
(1) Loss of Uniqueness: common features are more important
(2) Difficulty of boundary cases
Categorical model def
Presence/absence of a disorder. You have the disorder or not.
Categorical model Pros (3)
(1) Advantages for research and understanding.
(2) Simplifies communication. Natural preference among humans to employ categories in speech (not: they’re 3/10 on mood).
(3) Categories better-suited for clinical decision-making: Hospitalize or don’t? Treat or don’t? (3)
Dimensional model def
Rank on a continuous quantitative dimension. Everybody falls SOMEWHERE on the dimension.
Dimensional model Advantages (4)
(1) Better capture an individual’sfunctioning
(2) Give more info about the person
(3) Preserves more information
(4) Greater reliability–inter-rater, test re-test
Cons of Categorical (1)
Cutoffs in categorical system tend to magnify small differences
Cons of Dimensional
Taking a dimensional approach: Would need a threshold. Cut tend to be arbitrary. Looks a lot like categorical model.
When was the DSM-1introduced?
- Not that long ago. Shows how young the science of clinical psychology is.
DSM-II Characteristics (4)
1968.
(1) Few categories (I and II). Broad descriptions of the disorder.
(2) No requirements for number of symptoms.
(3) Psychoanalysis was the dominant paradigm
(4) Problem for epidemiological research bc no standardized definition. =→ If you care about how frequently things occur in the world across countries, you want to have a standardized definition.
DSM-III Changes (7)
1980.
(1) Define many more forms of psychopathology
(2) Inclusion Criteria:What symptoms do you need to have, and how many?
(3) Duration Criteria:Howlongdo you need to exhibit these symptoms?
(4) Exclusion Criteria:What symptomsrule outa diagnosis?
(5) Multi-Axial Classification
(6) Structured interviews
(7) Theoretical agnosticism
Multi-Axial Classification in DSM-III
Axis I: Presence/Absence - Major Clinical Disorders(e.g., MDD, PTSD)
Axis II: Presence/Absence - Personality Disorders(e.g., BPD, NPD)
Axis III: Medical conditions that might contribute or be relevant to treatment
Axis IV: Psychosocial Stressors (environment)
Axis V: Global Assessment of Functioning (GAF)
What’s the core idea behind the Multi-Axial Classification?
The primary presenting problem would always be the Axis I and that Axis 2 is a secondary consideration that might interfere w the treatment.
Global Assessment of Functioning (GAF) def
A simple rating (0-100) of function/summary score for severity. How well the person is functioning in the world. Very arbitrary.
2 Assumptions introduced in DSM-III
(1) Symptoms are the MOST USEFUL basis for assessment (not based on etiology - freud).
(2) Locus of pathology is IN the individual (disregard environment).
DSM-IV Characteristics (2)
Did not made a lot of massive changes.
(1) Revision process much more public and research based.
(2) Efforts to rely more on the body of research around these forms of psychopathology.
DSM-IV-TR Characteristics (2)
- Did not introduce new diagnoses or specific criteria.
(1) Provided more information on each diagnosis. Narrowing on the constructs they’re talking about.
(2) Provided for the first time in the DSM a broad definition of mental illness.
What’s the definition of psychopathology introduced in the DSM-IV-TR?
Clinically significantbehavioral/psychological syndrome that occurs in an individual which is associated with distress/ disability or significantly increased risk of suffering.
Also: No definition adequately specifies precise boundaries for the concept of mental disorder.
There is NO assumption that each category of mental disorder is a completely discreet entity with absolute boundaries.
DSM-5 Characteristics (3)
- (1) Removed multi-axial system (pple can receive a PRIMARY diagnosis of personality disorder).
(2) Introduced (in some cases) DIMENSIONAL assessment criteria for some diagnoses.
(3) Re-Classified some disorders - Removed others (e.g. OCD/PTSD not anxiety disorder)
Evolution of the number of Categories in the DSM
Grows until DSM-IV-R, diminishes in DSM-5
DSM-I = 106
DSM-II = 182
DSM-III = 265
DSM-III-TR = 292
DSM-IV-TR = 297
DSM-5 = 157
What are two challenges to a Categorical Classification System?
Diagnostic Heterogeneity & Comorbidity
Assumptions of Categorical Classification System that makes the problem of Diagnostic Heterogeneity (2)
(1) We assume that a group of pple that have one disorder will look like another group with the same disorder
(2) A group of pple that have one disorder will look different from another group with another disorder
Diagnostic Heterogeneity
Because of the way we do diagnosis (e.g. 5 out of 9 symptoms) different pple in the same category will have different symptom profiles (sometimes opposite of one another).
Comorbidity def
Simultaneous presentation of MORE than one disease.
Major problem for both research and treatment (simultaneously? one after another?).
=> It is the NORM
Comorbidity patients _____ (2)
(1) tend to have poorer outcomes
(2) shortened life course and poor quality of life.
What are the research implications of comorbidity?
Anything you find to be associated with one disorder may be a result of the comorbid disorder.
Why does comorbidity exist? (4)
(1) Chance
(2) Sampling Bias (Individuals with more disorders -more severe individuals - are more likely to seek treatment)
(3) Pb with diagnostic criteria: many criteria overlap
(4) Poorly-drawn diagnostic boundaries: a) Multiformity, b) Causation (one can be a risk factor for another), c) Shared Etiological risk factors
But all of this doesn’t account for all the variance
_____ samples are more biased than ______ samples.
Clinical, community
Multiformity
Disorders express themselves in multiple ways, some of which can mimic other disorders.
Nosology
Branch of medical science that deals with the classification of diseases
What did Thomas Achenbach to obtain a new classification of mental disorders?
Conducted a factor analysis to see which symptoms correlate with one another.
How did Achenbach’s classification looked like?
2 underlying dimensions of psychopathology: internalizing (distress to themselves) & externalizing (distress to other pple)
=> Shared factors that underlie the expression of many more specific forms of dysfunction.
What are the problems with Achenbach’s classification? (2)
(1) There are more disorders than just the one he described. Where do those fit?
(2) Some disorders do not load cleanly onto this.
(3) Internalizing & externalizing factors are also correlated to one another.
How did Achenbach explain comorbidity?
Comorbid disorders share this underlying latent factor that predisposes them to any kind of internalizing disorder.
=> E.g. in the early conceptualization, MDD, GAD and panic disorder all load onto internalizing.
How does Hierarchical Taxonomy of Psychopathology (high top) explain the association between internalizing and externalizing?
Above internalizing & externalizing is just some general liability to have psychopathology.
=> Some pple are more likely to have psychopathology.
=> That can manifest in multiple ways, but there’s some shared factor (P) that is a higher order dimension that underlies the more specific internalizing or externalizing.
How does the RDoC (Research Domain Criteria) model work?
Transdiagnostic approach: Approach disregarding diagnosis altogether and just looking at the ways in which across diagnosis, dysfunction can be expressed.
=> Talk about dysfunction of core systems that pple/animals have evolved to have.
RDoC (Research Domain Criteria) is another approach to resolving issues of _________ and _________.
heterogeneity - comorbidity
RDoC (Research Domain Criteria) looks at domains that are thought to be central to human functioning. E.g. (5)
(1) Negative Valence systems: responsible for AVERSIVE situations (acute threat = fear, potential threat = anxiety…)
(2) Positive Valence systems: responsible for POSITIVE situations (reward valuation…)
(3) Cognitive Systems (e.g. Attention)
(4) Systems for Social Processes (e.g. Attachment formation/maintenance)
(5) Arousal and Regulatory Systems
(e.g.) How would RDoC (Research Domain Criteria) model explain MDD?
Difficulties/abnormalities with reward valuation in MDD
Is RDoC (Research Domain Criteria) categorical or dimensional?
Ultimately agnostic about whether we need to keep categorical system.
Epidemiology
Describe frequency/distribution of traits/diseases in a population. Study of the determinants, occurrence, and distribution of health and disease in a defined population.
Prevalence
The % of people in a population with a disorderat a particular point in time.
e.g., past month, year, or lifetime
Incidence
The % of people who develop a disorder FOR THE FIRST TIME during a specific time period.
=> 1st onset cases.
E.g. “past month incidence” = how many pple had their first episode of the disorder in the past month.
Prevalence calculus
Incidence x Chronicity
Risk Factor (epidemiology)
Variable/correlate associated with an increased risk of disease or infection.
=> Psychologists use this term to mean predictor, or cause.
If I say that the 1-year-prevalence of MDD is 6.7. What does that mean in simple words?
6.7% of pop has had in the past year diagnosed/could be diagnosed with MDD.
Diathesis-Stress Models def
Early 1960s. Rosenthal. Stop debate nature vs nurture: interaction with one another. Bring it together in this model.
=> Genetic vulnerability + stress in environment = psychopathology
=> If a no diathesis + no stress = no disorder (…).
Categorical formulation.
Diathesis def
Vulnerability/predisposition to develop a disorder. e.g. genetics, attachment styles…
Stress in Diathesis-Stress Models def
Exposure to experiences/factors that overwhelm an organism ability to maintain homeostasis.
What’s a challenge with the Diathesis-Stress model?
Assumes that the diathesis and stress are INDEPENDENT from one another.
BUT we have a lot of evidence for gene environment correlations (no independence).
Give an example of how Diathesis & Stress are interdependent: Stress generation
E.g. Stress is strongly associated w dev of depression BUT it’s not only exposure to stress.
Also people vulnerable to depression BEHAVE IN WAYS that create more stress in their lives/generate interpersonal stress which erodes their social support networks.
What are two ways in which Diathesis & Stress are interdependent?
(1) Stress generation
(2) “Scars” as vulnerability
Give an example of how Diathesis & Stress are interdependent: “Scars” as vulnerability
Having BEEN ALREADY ill will make you think about the world in a more negative way → may exacerbate the effects of subsequent stressors.
Vulnerability may shape perception of the stress.
Equifinality
Getting to the same point via many different pathways.
Pple who get a disorder, get it from different causes.
Common idea in developmental psychology.
Final common pathway def
Multiple etiological factors might converse on one final step of an etiological process.
Multifinality
A single risk factor can lead to many diff outcomes.
E.g. child abuse associated w almost ALL forms of psychopathology.
Syndromes def
Collections of signs and symptoms that COMMONLY CO-OCCUR across individuals.
Disorders def
Syndromes that can’t be easily explained by other conditions.
E.g, obsessive-compulsive disorder (OCD) is considered a disorder when symptoms can’t be attributed to specific phobias or other causes.
Diseases
Disorders where both pathology and causation are reasonably well understood.
The approach to diagnostic validation outlined by Robins and Guze is considered a specific instance of _________.
construct validation
What did Rosenthal Study about labeling theory showed?
Diagnosis can become self-fulfilling prophecies, where ambiguous or mild behaviors get interpreted as severe mental illness due to the diagnostic label.
E.g. Pseudopatients were admitted to psychiatric hospitals, showing no psychopathology but were diagnosed with schizophrenia in remission.
=> but Flaws in this study
Statistical Model of mental disorder
Equates disorder with statistical rarity. Defines disorders as conditions that are infrequent in the general population.
=> not good (no cutoffs)
Subjective Distress Model of mental disorder
The core feature distinguishing disorder from nondisorder is psychological pain or distress.
=> not good (mental disorders might be ego-syntonic, lack distress)
Biological Model of mental disorders
Disorder = biological or evolutionary disadvantage to the organism.
Some mental disorders are associated with biological disadvantages, like increased suicide risk in major depression.
=> doesn’t account for e.g. frontline combat roles =/ disorder
Need for Treatment model
Disorders as conditions necessitating medical intervention according to health professionals.
=> not good (e.g. pregnancy)
What does harmful dysfunction fail to explain? (2)
(1) Flu: can be viewed as adaptive responses rather than failures in an evolutionarily selected system.
(2) Phobias: exhibit coordinated physiological reactions that could have been evolutionarily selected for specific threats.
Roschian Analysis
Defining mental disorder explicitly is impossible due to intrinsically fuzzy boundaries and lack of defining features.
Mental disorders organized around prototypes.
4 Weaknesses of DSM-I and DSM-II
(1) Interrater Reliability Issues: no clear criteria
(2) Theoretical Biases: influenced by psychoanalysis
(3) Theoretical Frameworks: considered psychopathology as reactions to life events
(4) Neglect of Contextual Factors (e.g. co-occurring medical conditions, life stressors…)
DSM-III‐R and DSM-IV moved away from a _______ approach to a _______ approach in diagnosis.
monothetic, polythetic
=> Signs and symptoms are not necessarily essential or sufficient for a diagnosis.
DSM‐III‐R (1987) and DSM‐IV (1994) main changes (4)
(1) Shift from Monothetic to Polythetic Approach
(2) Absence of Pathognomonic Indicators => no single symptom or sign could definitively establish or exclude the presence of a disorder
(3) Relaxation of Hierarchical Exclusion Rules (cuz difficult to apply + no robust research)
(4) Inclusion of Culture-Bound Syndromes (conditions can vary across cultures => unique or variants)
Attenuation paradox
Overemphasizing reliability may sometimes sacrifice validity, limiting the accuracy of diagnoses.
=> DSM diagnoses utilizing limited items to represent broader concepts might show high internal consistency but low validity.
Szasz’s vision of mental disorder
Lesion argument. Mental disorders are merely deviations from social norms WITHOUT identifiable brain or body lesions, contrasting it with physical disorders defined by recognizable anatomical deviations.
Cons of Szasz’s view (lesion argument)
Inadequacy of the lesion account of physical disorder. Lesions are not always identifiable anatomical deviations, and their existence doesn’t define a disorder.
Disorder as a Pure Value Concept
Sees disorder as solely based on social norms and values.
