Biomedical model, focus on diagnosis

Question 1

Outline the assumptions of the biomedical/biological model

Answer 1

Adopts biological, medical perspective of mental disorders- affects physical structure and functioning of the brain.

No meaningful distinction between mental and physical diseases  

 Symptoms are outward signs of inner physical disorder 

Biological emphasis of treatment  

Primary aim of research into nature of mental disorder is to uncover biological cause.

Question 2

give the first instance of a bioligcal model being used

Answer 2

Kraepelin (1856-1926)- first classification of mental disorders, Compendium der Psychiatrie (1883)

• Emphasized the importance of brain pathology in mental disorders
• Developed a system of classification of mental disorders (basis of our present system)

Question 3

giv the timeline of general paresis and mental disorder treatment

Answer 3

1825- identified as a specific mental health disorder
1879- link between GP and syphillis
1906- blood test for syphillis
1917- malerian treatment for syphillis and gp
1930’s- adoption of CVT, lobotomy
1950’s- psychopharmacutical revolution

Question 4

outline the biological model today

Answer 4

E.g. treatment utilization trends (increase in psychotropic medication)

Language used to describe psychiatric diagnoses and pharmaceutical treatments

• Major tranquilisers –> antipsychotics
• “SSRI’s” and “mood stabilisers” were conceived in pharmaceutical company marketing departments

Grant funding prioritises “the decade of the brain” (1990’s) - all of this emphasises biomedical model

Question 5

oitline types of biological causes

Answer 5

Neurotransmitters and hormones
• Genetics
• Brain dysfunction and neuroplasticity
• Physical deprivation
• Infectious transmissions

Question 6

how do neurotransmitters cause issues?

Answer 6

Excessive production of and release of the neurotransmitter substance into the synapses, causing an excess of that neurotransmitter

• Dysfunction in the processes by which neurotransmitters are deactivated (e.g., reuptake of the neurotransmitter from the synapse into the axon endings, or degradation of certain enzymes)

• Problems with the receptors in the postsynaptic neuron, which could be abnormally sensitive or insensitive.
Imbalances

Question 7

how do drug works to combat neurotransmitter imbalences?

Answer 7

Many of the medications used to treat various disorders act in the synapses

• Certain medications act to increase or decrease the concentration of a certain neurotransmitter in the synaptic gap

blocking the reuptake process

altering the sensitivity of the receptor sites

affecting the actions of the enzymes that break down neurotransmitters

• Agonists – facilitate the action of the neurotransmitter on the postsynaptic neuron
• Antagonists – oppose or inhibit the effects of the neurotransmitter

Question 8

which disorders are believed to be linked to neurotransmitter imbalences?

Answer 8

• Different disorders are thought to stem from different patterns of neurotransmitter imbalances in several brain areas
• Schizophrenia – the dopamine hypothesis argue that elevated levels of this neurotransmitter are related to symptoms
• Depression - amine hypothesis states that low levels of mono amines (noradrenaline and serotonin) are related to symptoms
• OCD – deficiency of the neurotransmitter serotonin

Question 9

Outline hormone imbalences as a cause of biological model

Answer 9

Hormones are chemical messengers secreted by glans in the body which are released in the bloodstream

• Neuroendocrine system  central nervous system (hypothalamus)  pituitary gland (master gland in the body that controls the other glands in the body)
• Hypothalamic-pituitary-adrenal axis (HPA)
• Over activity of the HPA axis and the stress hormone cortisol have been implicated in several disorders, such as depression and anxiety

Question 10

how does a genetic vunerability give rise to mental health issues?

Answer 10

• Abnormalities in the structure and number of chromosomes can be associated with several disorders (e.g., Down syndrome)
• Mental disorders or personality traits are not so much affect by the chromosomes but more by the genes in the chromosomes
• Vulnerabilities to mental disorders are almost always polygenic (influenced by multiples genes)
• Discoveries for “the gene” for a certain mental disorder are normally over-simplistic

Question 11

give the genetics of psychopathology

Answer 11

Behavioral genetics is the field that investigates the degree to which the variability of characteristics in a population arises from genetic versus environmental factors • Behavioral geneticists consider the following:  What is the role of genetics in causing a particular mental disorder?  What is the role of the environment?  What is the role of interactions between genes and the environment?

• Heritability is an estimate of how much of the variation in a characteristic within a population can be attributed to genetics
• The heritability of Generalized Anxiety Disorder (GAD) is 0.32 in persons from Western countries
• This means a third of the variation in GAD in this population is genetically determined

Question 12

Outine the two ways to study the genetic influence of personality

Answer 12

• Twin studies compare a characteristic, or set of characteristics, in two groups of twins – identical and fraternal

Monozygotic twins are referred to as identical twins as they began life as a single fertilized egg that divided into two

Dizygotic twins are referred to as fraternal twins as they developed from two separate fertilized eggs

• Adoption studies involve studying twins separated at birth and raised in different homes, then comparing them to twins who were raised in the same home

Question 13

outline reason to believe that personality isn’t just soley aused by genes

Answer 13

• Behaviour is not exclusively the result of genes, but rather results from the interaction between genetics and environment
• Epigenetics - Genes can be turned on and turned of by the environment

Genotypes-environment interaction People with different genotypes may be differently sensitive or susceptible to their environments

Question 14

how can brain dysnfunction cause brain disorders

Answer 14

Neuroimaging techniques allow for fine-grain analysis of the brain’s structure and function

• Neuroplasticity – flexibility of the brain to make changes in structure and function as a result of pre and post natal experiences (e.g., stress, diet, diseases, drugs…)
• Understimulated and deprived environments can cause retarded development

Question 15

outline cases where brain dysfunction has been linked to a mental illness

Answer 15

Differences in brain structure (frontal and prefrontal cortex, enlarged ventricles) have been identified in schizophrenia

• Alterations in grey matter volume and neurophysiological activity in the medial prefrontal cortex (MPFC), amygdala, hippocampus, and ventromedial parts of the basal ganglia have been found in cases with recurrent depressive episodes
• Dysfunctions in the orbital frontal cortex and over activity in the basal ganglia and caudate nucleus thalamus have been implicated in OCD

Question 16

why shouldn’t we just take the bioligcal account into consideration when looking at mental health?

Answer 16

Dominic is adopted, and his biological father was an alcoholic; alcoholism has a genetic component. Dominic’s adoptive parents are very religious and don’t drink alcohol.

Suppose scientists determine that, among alcoholics, a particular brain area has an abnormally high level of activity of the neurotransmitter dopamine. Further suppose that Dominic has too much activation of dopamine neurons in this area.

Does this mean that his brain is wired like that of an alcoholic, and he should just resign himself to eventually becoming an alcoholic? How might psychological and social factors affect dopamine levels?

Question 17

outline the biomedical models view of treatment

Answer 17

Treatment research seeks to develop therapies that target underlying biological dysfunction

• The ultimate goal is the discovery of magic bullets — precise therapeutic agents that specifically target the disease process without harming the organism, like penicillin for bacterial infection
• Fall into 3 categories

Brain stimulation therapies  
-ECT
-DBS
-TMS
Surgery  

Pharmacological approaches

• Some earlier techniques have been discredited…

Question 18

insulin shock

Answer 18

Introduced by Sakel in 1933

• Used mainly for schizophrenia in the 1940s and 1950s
• Involved inducing repeated comas via insulin injection over weeks or months
• Risks involved obesity, seizures, brain damage or even death (mortality rate 1-5%)
• Initially thought effective, but randomised controlled trials found that this was not the case (Ackner et al., 1957)
• Feel out of use by the 1960s to be replaced by medication

Question 19

lobotomy

Answer 19

• Prefrontal lobotomy was a common neurosurgical procedure: from 1935-55 over 40.000 were performed
• Involved severing the frontal lobes from the rest of the brain
• Developed by Egas Moniz who won the Nobel prize 1949
• Side effects: up to 4% deaths, inability to control impulses, unnatural tranquillity with absence of feeling

Question 20

What about current methods of treating mental health disrders?

Answer 20

• Brain stimulation therapies

Electroconvulsive therapy (ECT)

Deep brain stimulation (DBS)

Transcranial magnetic stimulation (TMS)

Neurosurgery for mental disorders (NMD)

Pharmacological approaches

Question 21

Outline electroconvulsive therapy

Answer 21

• Inducing seizures under general anesthesia, by passing electrical currents (150 volts per second) through a patient’s head
• Every neurotransmitter system is affected, but not entirely clear how it works
• Each year around 100 0000 patients are treated in the US; in the UK the use of ECT is not recommended by NICE except in very particular cases (e.g., last resort for severe depression)
• Used with patients who have not responded to other treatments
• Some studies suggest it might be effective for patients with severe or psychotic level depression and mania
• High relapse rate (e.g., Kellner et al., 2006)

Question 22

TMS

Answer 22

Used for treatment-resistant depression and anxiety

• Electromagnetic coil sends magnetic pulses through the patient’s scalp into the brain these affect the function of neural circuits involved in mood, though unclear how
• Pulses are more focused than ECT: can stimulate brain regions involved in mood
• Meta-analysis by Slotema et al (2010): TMS is effective for acute depression

Question 23

DBS

Answer 23

Deep brain stimulation

• Involves implanting electrodes in specific parts of the brain to deliver electrical stimulation over a period of several months
• Used for severe, treatment-resistant depression and OCD
• Currently only used experimentally, but seems effective (e.g., Mayberg et al., 2005)
• Patients reported a “lifting of the void” and “connectedness”
• Because it requires brain surgery, should be a last resort

Question 24

Outline neurosurgery for brain disorders

Answer 24

Involves destroying or ablating minute areas in the brain that might contribute to mental illness

• Much more focused than prefrontal lobotomy
• Used very rarely for treatment-resistant depression and OCD
• Adverse effects: transient headaches, impaired executive functioning, problems with apathy…
• Only 45 operations were conducted between 1997-2009
• Number of operations has declined due to TMS and DBS

Question 25

outline pharmacutical methods for treating mental health disorders

Answer 25

Psychotropic medication – any medication capable of affecting the mind, emotions and behaviour

• By far the most common form of medical treatment for mental disorders
• Act on the brain and central nervous system
• Change the way neurotransmitters send messages between brain cells through a synapse or crossing.
• Each psychotropic medication is used to treat certain “target” symptoms.

Question 26

what are antipsychotic drugs

Answer 26

Also called neuroletics, are used to treat psychotic disorders (e.g., schizophrenia)

• Reduce or alleviate the intensity of delusions and hallucinations by blocking dopamine receptors
• First generation (conventional) and second generation (atypical)
• Positive results in the reduction of symptoms in clients with schizophrenia when compared to placebo (e.g., Sharif et al., 2007)
• Some side effects: weight gain, diabetes, drop in white-blood cells
• Commonly prescribed: Clorazil, Risperdal, Zyprexa

Question 27

what are antidepressent drugs

Answer 27

Most commonly prescribed psychiatric medication

• Several types, acting on different neurochemicals
• Most common today are the selective serotonin reuptake inhibitors (SSRIs), but no evidence they are more effective than other antidepressants
• Patients tend to improve
• Side effects: nausea, nervousness, insomnia, and sexual problems
• Are used widely in the treatment of other disorders (panic disorder, social phobia, ODC, binge eating…)
• Commonly prescribed: Prozac, Zoloft

Question 28

what about antianxiety drugs>

Answer 28

Used for conditions where anxiety and tension are common components

• Most common are benzodiazepines
• Sedative and muscle-relaxing properties and patients may become drowsy and lethargic
• Highly addictive and relapse rates are very high
  
  • Commonly prescribed: Xanax, Valium

Question 29

What about Lithium

Answer 29

Used for the treatment of bipolar disorder

• How it brings its therapeutic effect is still not certain (hypothesis)
• Dosage is crucial (toxic) and very individual (close monitoring)
• Very effective in bipolar disorder (70 – 80%), but about 50% relapsing within 6 months (Keck & McElroy, 2007)
• Side effects include thirst, gastrointestinal difficulties, weight gain, tremor and fatigue • Commonly prescribed: Eskalith

Question 30

give some advantages of the biomedical model

Answer 30

• Suggests a clear mechanism for most disorders: discredited ‘possessions’ and supernatural explanations
• Has been particularly effective in delivering insights into disorders with a clearer biological base (e.g., schizophrenia)
• Absolves patients of responsibility, guilt or blame for their condition, since there is an objective biological explanation
• Drug treatment has revolutionised patient care: it is generally effective and faster than other therapies • Treatment based on the scientific method: in theory this means treatments should only be adopted if proven effective

Question 31

give some limitations

Answer 31

• No room within its framework for the social, psychological, and behavioral dimensions of illness
• Causality
Both brain → mind and mind → brain causality occur (Kendler, 2005), and the presence of a correlation between psychological and biological events does not make psychological events biological events (Miller, 2010).

• Reductionism: is psychology really biology?
Despite the extraordinary resources devoted to biological research in the biomedical model era, scientists have yet to identify a single psychological experience that can be fully reduced to biology (Gold, 2009).

• Assumes universality
• All psychological phenomena, including mental disorders, are biological. Therefore, the claim that ADHD or anorexia nervosa has a “biological basis” is a tautology, as obvious and uninformative as noting that a circle is round

Question 32

outline how the biomedical model is contriversial

Answer 32

• Mental disorders are brain diseases caused by neurotransmitter dysregulation, genetic anomalies, and defects in brain structure and function.
Yet, scientists have not identified a biological cause of, or even a reliable biomarker for, any mental disorder
• Psychotropic medications work by correcting the neurotransmitter imbalances that cause mental disorders.
However, there is no credible evidence that mental disorders are caused by chemical imbalances, or that medicines work by correcting such imbalances

• Advances in neuroscience have ushered in an era of safer and more effective pharmacological treatments

Conversely, modern psychiatric drugs are generally no more safe or effective than those discovered by accident a half-century ago

Biological psychiatry has made great progress in reducing the societal burden of mental disorder  However, mental disorders have become more chronic and severe, and the number of individuals disabled by their symptoms has steadily risen in recent decades • Educating the public that mental disorders are biologically-based medical diseases reduces stigma  But despite the public’s increasing endorsement of biological causes and treatments, stigma has not improved and shows signs of worsening

Deacon, 2010

Question 33

what is the DSM

Answer 33

Diagnostic and Statistical Manual of Mental Disorders
• Published by the American Psychiatry Association

• Constantly reviewed
• Summarises all the diagnoses
• Organises the diagnosis into a classification system
• Specifies what symptoms must be present to make a given diagnosis

Question 34

give the history of the DSM

Answer 34

• There have been several revisions since it first published in 1952: currently in its fifth edition
• Gradually including more mental disorders

DSM II = 85 disorders
DSM III = 265 disorders
DSM III-R = 292 disorders
DSM IV = 297 disorders

• Some have been removed and are no longer considered mental disorders (e.g., homosexuality)

Question 35

give the revisions of DSM I

Answer 35

• DSM I (1952)

Established mainly by psychoanalysts and grounded in psychodynamic formulations of mental disorders There was no diagnostic criteria – disorders were described using “prototypes,” which are narrative descriptions of disorders.

Example: “Depressive Reaction”

“The anxiety in this reaction is allayed, and hence partially relieved, by depression and self‐depreciation. The reaction is precipitated by a current situation, frequently by some loss sustained by the patient, and is often associated with a feeling of guilt for past failures of deeds. The reaction in such cases is dependent upon the intensity of the patient’s ambivalent feeling toward his loss (love, possession) as well as upon the realistic circumstances of the loss. (American Psychiatric Association, 1952, pp. 33–34)

Question 36

give the revisions of DSM II

Answer 36

1950’s - 1960’s - psychoanalysis still dominated. Psychoneurotic problems became defined as ‘neurotic’ disturbances (e.g. hysteria)

In 1973, homosexuality was removed, replaced by ‘sexual orientation disturbance’

There was little in the way of clear descriptions of ‘disorders’. All ‘symptoms’ were defined as ‘symbolic’ (of unconscious processes)

• Example: “depressive neurosis” “This disorder is manifested by an excessive reaction of depression due to an internal conflict or to an identifiable event such as the loss of a love object or cherished possession” (American Psychiatric Association, 1968, p. 40).

Question 37

give the DSM III revisions

Answer 37

• DSM III (1980)

It relied to a much greater extent on empirical data to determine which disorders to include and hot to define them

It used specific diagnostic criteria to define disorders

It dropped allegiance to a particular theory of therapy or psychopathology

It introduced the multiaxial assessment that remained until the DSM 5 (e.g., axis I included more episodic disorders such as mood or anxiety disorders and axis more stable and lasting (e.g., personality disorders)

Significantly longer: 265 disorders

Translated into 20 languages

Question 38

give the DSM III-R revisions

Answer 38

• DSM III-R (1987)

Renamed, added, and deleted categories (Post-traumatic stress disorder was introduced to account for repeated trauma in Vietnam veterans; pressure groups altered the course of the DSM – egodystonic homosexuality removed

Made changes to diagnostic criteria

Increased reliability by incorporating data from field trials and diagnostic interviews

Question 39

give the DSM IV and the DSM IV-R revisions

Answer 39

• DSM IV (1994)

Conservative approach: The reasons for changes in diagnosis would be explicitly stated and clearly supported by data

Neurosis as a term is no longer in existence

Inclusion of a clinical significance criterion to almost half of all the categories, which required symptoms cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning”

• DSM IV-TR (2000)

Minor changes, mainly related to prevalence rates, course, and etiology

Cultural and ethnic considerations included

Question 40

Outline claims made by the DSM V

Answer 40

• Substantial revision in the last 20 years

• Defines a mental disorder as a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behaviour that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.
• The DSM-5 does not include all possible mental disorders
• The client’s cultural and social context must be considered
• Making diagnoses requires clinical judgment, not just checking off the symptoms in the criteria
• Diagnoses are made on the basis of :
-The clinical interview
-DSM-5 text descriptions
-DSM-5 criteria
- Clinician judgment

Question 41

Outline revisions made by DSM V

Answer 41

ADDED: 
Premenstrual dysphoric disorder  
Disruptive mood dysregulation disorder  
Binge eating disorder 
 Mild neurocognitive disorder  
Somatic symptom disorder  
Hoarding disorder   

• Some revisions: The “bereavement exclusion” was dropped
Autism spectrum disorder (autism, Asperger’s and related developmental disorders)

Question 42

Outline critisisms of the DSM

Answer 42

• Diagnoses cover too much of normal life
“…patients worried about having a medical illness will be diagnosed wih somatic symptom disorder, normal grief will be misidentified with major depressive disorder, the forgetfulness of old age will be confused with mild neurocognitive disorder, temper tantrums will be labelled disruptive mood dysregulation disorder, overeating will be label binge eating disorder”. Frances, 2010
• Diagnoses cover too much of normal life
• Controversial cut-offs
• Nonempirical influences
• Limitations on objectivity

Question 43

what is the ICD-10`

Answer 43

International Classification of Diseases (ICD) - 10
• ICD-10 chapter V: Mental and behavioural disorders
• Part of the International Classification of Diseases
• Produced by the World Health Organization (WHO)
• Another commonly used guide (Europe and other parts of the world)
• DSM coding systems corresponds with the codes used in the ICD
• This not true at all times because the two publications are not revised synchronously:

Question 44

give some advantages of classification

Answer 44

Facilitates communication between researchers and clinicians by providing a common professional language
• Emphasis on empirical research
• A way of talking about difficult things and a framework for offering help: time off work with sick pay or benefits if needed, and access to services.
• Diagnoses provide a way of talking about groups of people when we are looking at where and when certain problems tend to occur, or what might help
• Decisions about allocation of resources in health services
• Some people welcome a diagnosis because it implies that they are not alone in what they are experiencing

Question 45

give some limitations to classification

Answer 45

• Many patients feel that the diagnosis had disempowered them and led to them being excluded from mainstream society
• Being seen as mentally ill can cause more distress for many people than their original problems (Horn et al., 2007)
• People seen as mentally ill are often avoided, treated harshly and subject to discrimination (employers are less likely to offer work to someone if they know that they have a psychiatric diagnosis)
• Feelings of hopelessness and decreased confidence (can’t do much about it)
• Can deflect attention away from underlying social and emotional problems