clinical Flashcards
what is diagnosis and what are the 4 D’s of diagnosis?
Diagnosis - a clinical assessing a patient, deciding wether they show evidence of a mental disorder.
- Deviance (behaviours unusual in society)
- Distress (find their behaviours upsetting)
- Dysfunction (interferes with day to day life)
- Danger (harm themselves or others)
Evaluate the four D’s of diagnosis?
strengths:
- useful as they have practical applications in helping professionals decide wether a patients symptoms needs a diagnosis
- they provide a holistic way to asses someone mental health
- davis argues a fifth D should be added (duration)
weaknesses:
- subjectivity in the application of the four D’s
- distress is subjective and difficult to measure
- because of subjectivity, four D’s may lack validity
- subjectivity reduces reliability, overall reducing scientific status of diagnosis
- issue of social control
What are classification systems and what are the two types?
- They are used by practitioners to help make diagnoses and establish appropriate treatment. Their aim is to provide clear and measurable criteria which can increase reliability.
- The international standard classification of diseases (ICD-10)
- The diagnostic and statistical manual of mental disorders (DSM 5)
What is the medical model of abnormality?
a biological approach which assumes the major source of ‘disturbed’ and ‘abnormal’ behaviour is some form of medical illness.
supporters believe psychological symptoms are outward signs of the inner physical disorder
what are three problems with using the medical model for diagnosis of mental disorders?
- mental illness symptoms are much more subjective than measuring physical symptoms
- the causes of mental illness are largely unknown, so treatments only focus on symptoms not causes
- criticised by the anti-psychiatry movement who argue symptoms may be an understandable reaction to coping with a sick society.
What are some similarities and differences between the ICD-10 and the DSM-5
Similarities:
- both are diagnostic tools
- both regularly updated to account for new research
- attempt to improve psychiatric diagnosis across cultures
- includes categories of mental disorders based on symptoms
- both rely on checklists for behaviour
Differences:
- ICD does not look at other aspects that could influence diagnosis but DSM takes into account psychosocial factors
- ICD is more reductionist than DSM
- DSM is only used for mental disorders but ICD diagnoses physical disorders too
- ICD is an open and free recourse
- DSM is more holistic
What are three four of evidence for the reliability of diagnosis?
Spitzer and Williams:
- early versions of DSM were low in reliability
- experienced psychiatrists only agree on diagnosis about 50% of the time
Ward:
- studied 2 psychiatrists diagnosing the same patient
- 62.5% of disagreements occurred due to inadequacy of the classification system
Brown:
- tested the reliability and validity of DSM 5 diagnoses for anxiety and mood disorders and found them to be good to excellent.
Pederson:
- 71% of psychiatrists agreed with the ICD-10 definition of depression when assessing 116 patients
what are three factors that impact the reliability of diagnosis?
patient factors:
- may give different psychiatrists different information
- lack of standardisation for interviews
Clinician factors:
- practitioners are not completely objective
- practitioner may gather insufficient information
Classification systems:
- DSM has a clear set of criteria which increases reliability
what are three factors that could impact on validity of diagnosis?
patient factors:
- may not disclose all relevant information
- may be embarrasses, ashamed or don’t remember
clinician factors:
- implicit bias in clinical redices validity
classification systems:
- cochrane et al argues classification systems lead practitioners to take on a Eurocentric bias
- they cannot take into account normal behaviour of other cultures
What is the APRC for Rosenhan 1973?
AIM:
- ‘can the sane be distinguished from the insane’
- wanted to see if sane people could be admitted to psychiatric hospitals and wether they would be detected
PROCEDURE:
- eight participants (3 women, 5 men)
- each phoned the admissions of 12 hospitals claiming they were hearing voices
- reported hearing ‘thud’ , ‘empty’ and ‘hollow’
- all were admitted with a diagnosis of schizophrenia expect one who was diagnosed with depression with psychosis
- once admitted, patients behaved normally and recorded their experience using notes
RESULTS:
- all diagnosed with a serious mental health disorder on minimal symptoms
- sanity was never detected - average stay was 19 days
- contact with nurses was ignored around 71% of the time
- normal behaviour was misinterpreted (e.g writing in a notebook was obsessively noting things down)
CONCLUSIONS:
- diagnostic label changed the perception of the person so all their behaviour was interpreted within the context of the label
- psychiatrists could not detect sanity.
What is the APRC for rosenhan second study?
AIM:
- To see if hospitals, who were told they were going to be approached by pseudo-patients, would be able to tell the sane from the insane
PROCEDURE:
- a teaching and psychiatric hospital who were aware about the first study, were informed that over the next three months, one or more pseudo patients would try to be admitted
- each member of staff asked to rate the likelihood that the patients who sought to be admitted were pseudo patients
- no pseudo patients were admitted
RESULTS:
- 193 patients assessed
- 41 rated as pseudo patients by at least two members of staff
- 23 rated as pseudo patients by at least one psychiatrist
Conclusions:
- the staff were unable to detect insanity
evaluate rosenhans study
GENERALISABILITY:
- high because it took place in a range go hospitals across the USA
- Low because it may not generate to current times or countries outside the USA
RELIABILITY:
- High because aspects were standardised such as hearing thud, hollow and empty.
- Low as it was a field experiment so not all variables can be standardised
APPLICATIONS:
- the amount of criteria used to diagnose mental illness increased after, making it more accurate
- people recognised hospitals may not be the best place to treat mental illness
- highlights the dangers of labelling
VALIDITY:
- High internal validity as demand characteristics reduced
- High ecological validity as the setting and tasks were true to life
- Low validity as as there is a lack of control due to it being a field experiment
ETHICS:
- good ethical considerations such as confidentiality. The names of individuals and doctors were not published
- Ethical issues as participants did not know they were part of a study and there was no protection for other patients
What are the three symptoms of schizophrenia?
Positive symptoms - strange and bizarre additions to behaviour
negative symptoms - loss or absence of normal characters
cognitive symptoms - issues to do with information processing
what are the four positive symptoms of schizophrenia?
- DELUSIONS
- false or bizarre beliefs
- delusions of grandeur (I’m the king)
- delusions of persecution (I’m being plotted against)
- thought insertion (thoughts had been implanted by external force)
- thought broadcasting (others can hear my thoughts
- delusions vary across different cultures - HALLUCINATIONS
- perception of stimuli that is not present
- visual, auditory or olfactory
- most common in schizophrenia is auditory - DISORGANISED THINKING/SPPECH
- jumbled speech (word salad)
- loose associations of thoughts
- jump from topic to topic
- invention of new words - ABNORMAL MOTOR BEHAVIOUR
- agitated movement
- catatonia (not moving or responding to others)
What are 6 negative symptoms of schizophrenia?
- lack of energy and motivation
- social withdrawal
- flatness of emotion
- not looking after appearance and self
- lack of pleasure in everyday things
- speaking little
What are three cognitive symptoms of schizophrenia?
- difficulties in concentrating and paying attention
- problems with working memory
- difficulties with executive functioning
What are the features of schizophrenia?
PROP
Onset:
- late teens and mid-30’s
- may be triggered my some aspect of development
- males peak onset in early to mid twenties
- female peak onset is late twenties
Prevalence:
- how common the disorder is
- it is a universal illness
- likelihood of developing schizophrenia is 0.7-1%
- people who experience social problems such as poverty and unemployment are more likely to develop schizophrenia
Prognosis:
- likely course of the disorder
- 25% who have an episode recover and do not have another
- 50% have recurrent episodes
- 25% have symptoms continually
- life expectancy is 10 years younger than average population
- males show more negative symptoms than females
What are the two aspects of neurotransmitters being an explanation of schizophrenia (biological explanation)?
- dopamine hypothesis
- excess dopamine (hyperdopaminergia)
- positive symptoms
- high levels of dopamine in the synapse due to low levels of the enzyme beta hydroxylase
- excess number of dopamine receptors
- hypersensitivity of certain dopamine receptors - Dopamine Deficiency (hypodopaminergia)
- negative symptoms
- low levels of dopamine in the mesocortical pathway
evaluate the theory of neurotransmitters as an explanation for schizophrenia
STRENGHTS:
- evidence from drug treatment (drugs to treat schizophrenia work by blocking dopamine)
- people with schizophrenia are more sensitive to dopamine uptake
- evidence that excess dopamine plays a role as drugs used to treat Parkinson’s by increasing dopamine cause schizophrenia like symptoms
- theory explains both positive and negative symptoms
WEAKNESSES:
- not all patients respond to drugs that block dopamine (albert and freidhoff found some people did not improve)
- some drugs work by targeting serotonin not dopamine
- theory cannot prove excess dopamine causes schizophrenia but it may just be a symptom
- reductionist as it focuses purely on neurotrnasmitters
what are five pieces of evidence of genetics being an explanation of schizophrenia?
Hilker: 79% heritability rate for schizophrenia
- 25% of people with DiGeorge syndrome (deletion of 30-40 genes) develop schizophrenia
Wright: as many as 700 genes have been linked to schizophrenia
such as:
The COMT Gene:
- deletion of the comt gene which regulates dopamine levels
- if its deleted there is too much dopamine
The DISC1 Gene:
- people with an abnormality in the DISC1 gene are 1.4 times more likely to develop schizophrenia.
What are the three major types of research that have investigated the role of genetics in schizophrenia?
Family studies:
- wether close biological relatives also have schizophrenia
- difficult to seperate nature and nurture
Adoption studies:
- genetic factor can be looked for in adopted children who are ‘reared apart’ from biological parents
- effects of nature can be separated from nature
Twin studies:
- schizophrenia in monozygotic and dizygotic twins can be compared
- degree to which twins are similar on a particular characteristic is the concordance rate.
What is the APRC of gottessman and sheilds?
AIM:
to see wether schizophrenia had a genetic basis by examining records of patients in a psychiatric hospital over a 16 year period
PROCEDURE:
- identified 57 schizophrenic patients who were a twin
- 24 mz and 33 dz
- collected data from hospital notes, self report questionnaires, interviews and personality tests
- patients split into four categories
RESULTS:
- concordance rates for schizophrenia were higher in females than males
- concordance rates were higher for both mz and dz twins for severe schizophrenia compared with mild schizophrenia
- concordance rate for severe schizophrenia was higher id mz twins (75%) than dz twins (22%)
CONCLUSIONS:
- schizophrenia does have a biological basis as its influenced by genes
- it is not entirely caused by genes as the concordance rates in mz twins was no 100%
evaluate genes as an explanation for schizophrenia
STRENGTHS:
- evidence from twin studies show there is a genetic factor (gottessman and shields)
- more recent research id identifying which specific genes may be linked to schizophrenia (comt gene)
- biological approach has scientific status and credibility
- used to provide genetic counselling (likelihood of family members developing it can be calculated)
WEAKNESSES:
- research methods have flawed methodologies (twin studies, jospeh said mz twins may be raised more similarly than dz twins)
- reductionist. it is not the only factor involved
- confusion into exactly what genes are responsible
- genetic explanation does not lead directly to new treatments.
what is the social causation hypothesis?
It suggests that schizophrenia may be caused by factors within the environment
What are the five environmental risk factors for schizophrenia?
SOCIAL ADVERSITY:
- if a child grows up in an eniroemnt where their needs are not med, may be more likely to develop mh issues
- e.g. poverty, unemployment
URBANICITY:
- schizophrenia is more associated with living in cities that rural.
- Eaton argues city life is more stressful and long term exposure to stressors can trigger schizophrenia
- vassos meta analysis found risk of schizophrenia was 2.37 times high for people living in the most urban areas compared to most rural areas
SOCIAL ISOLATION:
- Faris suggested cultural isolation may lead to symptoms
- people don’t get any feedback on their behaviour (what’s normal or not)
IMMIGRATION AND MINORITY STATUS:
- immigrants are at greater risk of developing schizophrenia
- may be due to stress due to discrimination and poorer living conditions
FAMILY DYSFUNCTION + CHILDHOOD TRAUMA:
- popovich suggests childhood trauma may interact with other pre existing risk factors to trigger schizophrenia in vulnerable individuals
Evaluate the social explanation of schizophrenia
STRENGHTS:
- helps to explain some features of schizophrenia (why black immigrants are more likely to be diagnosed than white british)
- supported by research evidence (vassos) so higher scientific credibility
- useful applications (importance of community)
- helps explain how biological factors can interact with environmental factors (diathesis-stress model)
WEAKNESSES:
- some of the reproach is correlational so no cause and effect (vassos)
- it is difficult to isolate specific environmental factors to see if they cause schizophrenia
- it is not a complete explanation as it claims environmental factors can only trigger onset.
what are the seven standards which the HCPC set out for clinical practitioners?
- character
- health
- standards of proficiency
- standards of conduct, performance and ethics
- standards of continuing personal development
- standards of education and training
- standards for prescribing
What are the two treatments we look at for schizophrenia?
- drug treatment
- cognitive treatment
why is drug treatment used for schizophrenia and how does it work
WHY?
- based on the medical model
- if schizophrenia is due to a biological basis such as genes or neurotransmitters, treatment should also have a biological basis
HOW?
- typical drug block the receptor site for the neurotransmitter dopamine so the effects of dopamine are not picked up by the brain
- more recent frugs block serotonin receptors and have fewer side effects
evaluate the use of drug therapy for schizophrenia
STRENGHTS:
- drug treatment has been effective in reducing symptoms (Meltzer found haloperidol gave significant improvements in all areas of functioning compared to a placebo)
- more effective than other forms of therapy as it reduces symptoms more quickly
- useful to help people manage symptoms and hopefully avoid hospitals
- helped patients live relatively normal lives (not have to live in hospitals)
- appropriate due to it being a biological basis for a genetic condition
WEAKNESSES:
- reductionist as it ignores all psychological or social factors
- effectiveness is questionable as it surpasses systems without addressing the cause
- relapse is an issue so drugs are not a long term cure
- ethical issues as drugs often have unpleasant side effects
- patients are often reluctant to take drugs
- not effective in treating negative symptoms
describe cognitive behavioural therapy
- assumes patients have irrational thoughts and beliefs
- CBT helps to challenge these thoughts and therefore change a patients behaviour
how is CBT used to treat schizophrenia?
- it can help target cognitive symptoms swell as delusions and hallucinations
- aim to help reduce the stress felt by the patient and help them manage an understand their symptoms
3 techniques:
- belief modification (delusional thinking is challenged directly)
- focussing and reattribution (help with auditory hallucinations)
- normalising the experience of the person (look at their experience rationally and not as a catastrophe)
evaluate the use of CBT as a treatment for schizophrenia
STRENGTHS:
- research shows CBT can be helpful in treating schizophrenia (sensky compared CBT with non specific befriending therapy and found CBT was more effective in reducing both positive and negative symptoms)
- CBT can work well for those who did not respond to medication
- CBT is the most ethical treatment (empowers patients, self help strategies they can use on their own and become independent)
WEAKNESSES:
- reductionist as it focuses on thought processes but does not address underlying cause
- effectiveness may be limited as patients need good insight into their condition and have good problem solving skills
- effectiveness is hard to judge as most studies compare CBT to a control treatment. CBT may not be superior rather than control treatment is inadequate.
