Clinical Flashcards
What are the 4Ds of diagnosis?
Deviance
Danger
Dysfunction
Distress
4Ds credibility
Using all 4Ds help avoid errors and diagnosis.
DSM focuses on 4Ds, showing each has validity.
Standard test to assess symptoms.
Objectivity
Further diagnosis decision relies on discussion between patients and clinician.
Concept of deviance may be misinterpreted.
Cultural differences, e.g. multi personality is a disorder in USA, but not in UK
Differences
Davis, 5th D, duration is needed
Application
Used by mental health clinicians with classification systems
Developmental psych of classification system
Reflects developmental and lifespan considerations.
Prioritizes disorders occurring early in life (e.g schizophrenia spectrum).
Highlights disorders commonly developed during adolescence (e.g., depression)
What’s ICD
Section F specifically for mental health disorders.
Followed by digit to represent family mental health disorder, a further digit represent specific order eg F32 is depression.
Further categorization, next digit follows decimal represent type of depressions e.g. F32.0 is mild depression.
Finally very specific categorizations added after another decimal followed by further digits F32.0.01 is mild depression with semantic physical symptoms.
Coding allows clinician go from general to specific.
Use symptom to guide diagnosis through clinical interview.
Provide basis of judgment and give details of likely symptoms for each disorder, severity, and duration.
ICD reliability
Study compared reliability of ICD9 and ICD10 diagnoses. ICD10 showed inc PPV for schizophrenia than ICD9.
Study arranged 2 researchers to conduct a joint interview to assess 100 clients for psychosomatic symptoms and got similar results.
Reliability is nothing without validity.
ICD validity
Good predictive validity. Researchers compared different ways of using diagnosis, I see you were reasonably good at predicting disability in 99 people with schizophrenia 13 years later, as measured by the global assessment of functioning questionnaire.
ICD development aims to enhance clinical utility. WHO surveyed clinicians, who preferred simplicity and flexibility. ICD likely to be cautious about adding new disorders. Difficult-to-diagnose disorders merged for simplicity so more user-friendly and improve validity.
What’s DSM?
Adopt similar system of grouping disorders into families with linked disorders grouped together.
Divided into 3 sections, manual instructions, classification of main mental health disorders, and other assessment measures to diagnosis
Making a diagnosis
Clinical interviews.
Ruling out disorders that don’t match.
Difficult cases, take weeks or months to understand the consistency of symptoms overtime.
How reliability and validity are assessed?
Chair of DSM 3 task force introduced kappa. Stats written as a decimal, refers to people who receive same diagnosis when assessed and reassessed, 0.7 indicate a good agreement.
Disorders have been removed and added to DSM over the years .
What are the types of validity?
Descriptive validity–2 people with same diagnosis exhibit similar symptoms.
Ideological validity–share similar casual features .
Concurrent validity-clinician uses more than 1 method to reach same diagnosis.
Predictive validity – accurately predict outcomes of diagnosis.
DSM reliability
Field trial illustrate high agreement between clinician for variety of disorders, researcher reported 3 disorders e.g. PTSD had kappa values 0.62 0.79.
Standards are failing, what can as acceptable reduced overtime, Cooper explains DSM5 task force classified 0.2-0.4 as acceptable.
Researchers explain clinicians in DSM 5 field trials worked as they usually would but DSM3 used carefully screened test clients and clinicians were given training so DSM5 trials had lower reliability.
DSM validity
Concurrent validity of conduct disorder confirmed through child, mother interviews, observed antisocial behavior and questionnaires for teachers. Predictive validity, CD children more likely to have behavioral and educational problems so accurate CD diagnosis can reduce mental health issues linked to CD symptoms.
Influenced by interest of pharmaceutical companies.
Some behavior classified as a disorder for the drug to be prescribed and make benefit.
Not telling cause of disorder, circular arguments, why is a person hearing voices? Because schizophrenia. How do we know if they have schizophrenia? Because they are hearing voices. Simply labels.
Features of schizophrenia
Affect 1% of population, around 70m people worldwide.
Average onset age for men is 18-25, women is 25-35.
Affect men 3x likely.
People with schizophrenia after 10 years, 25% make recovery, 25% improve, 25% improve but need extensive support, 15% hospitalized and 10% percent died.
Pos symptoms of schizophrenia
Delusions-false ideas believe are true and not changeable.
Hallucinations-see or hear things are not true
Thought insertion-affect 20%, thought belongs to someone else
Disorganized speech–train of thoughtsword salad.
Neg symptoms of schizophrenia
Anhedonia-reduced experience of pleasure
Avolition-reduced motivation
Flatten effect– lack of facial emotions
Individual differences in schizophrenia
Researchers interviewed 60 American, Indian and Ghanaian people with schizophrenia, 70% Americans said voices told them to hurt people, 50% Ghanaian said voices mainly pos, Indian tended hear fam members offering guidance or scolding them.
Diagnosis of schizophrenia pos
Reliably diagnosed use DSM and ICD, field trials of DSM5, kappa value of 0.46 while other researchers quote a high kappa of 0.86, only 3.8% clinicians said lack confidence in their diagnosis of schizophrenia using ICD 10.
Diagnosis of schizophrenia neg
Difficult to diagnose schizophrenia as shares symptoms with other disorders, e.g. hallucinations experienced by depression.
Disordered thinking difficult to identify if patient from a different culture.
What’s hyperdopaminergia?
Dopamine and reserpine alleviate schizophrenia symptoms but induce tremors and rigidity which are symptoms of Parkinson’s. Parkinson’s caused by low dopamine so high dopamine is linked to schizophrenia.
2 possible explanations, low beta hydroxylase enzyme cause dopamine buildup in synapse.
Proliferation of D2 dopamine receptors leads to hyperactivity.
What’s hypodopaminergia?
Antipsychotic drug researches show some symptoms exhibited low dopamine
Serotonin and neg symptoms
Research focus on other neurotransmitters eg GABA, glutamate and serotonin.
Clozapine, bind D1 and D4 dopamine receptors, and binds weakly to D2, effective anti-psychotic
Dopamine hypothesis version 3
Researchers describe dopamine dysregulation in the striatum as common pathway to psychosis. Also suggested focus on pre-synaptic dopamine levels over D2 receptor irregularities.
Interactions among genetic, environmental, and sociocultural factors considered.
Hypothesis explains psychosis proneness, not just schizophrenia, as dopamine isn’t sole factor.
Dopamine hypothesis credibility
Researchers noted clozapine bind serotonin and dopamine receptors, most effective drug treatment for treatment resistant.
Supported by research on rats treated with amphetamines, inc dopamine showed various schizophrenia like symptoms.
Support role of D2 receptors, research her found chlorpromazine act as antagonist at D1 and D2 so excess activity on specific dopamine receptors is implicated in development of symptoms.
Objectivity
Researchers showed apomorphine, a dopamine agonist stimulate D2 doesn’t induce psychotic symptoms in non-psychotic clients or make symptoms worse in those already diagnosed with schizophrenia, the suggestion that hyperdopaminergia is responsible for pos symptoms.
Failed to consider environmental factors
only shows the correlation between schizophrenia and brain activity 
Differences
Dopamine hypothesis describes schizophrenia on biological level, but doesn’t explain why some have unusual dopamine activity. Genetic explanation explains cause of schizophrenia and effect of evolution.
Application
Research into role of neurotransmitter led to effective drug treatment eg clozapine block serotonin receptor and successful in treating both pos and neg symptoms
What are the genetic explanation of schizophrenia?
Schizophrenia as a heritable condition
Gene mutations and deletion
COMT gene
DISC 1 gene
Schizophrenia as a heritable condition
Pass from one generation to the next
Numerous chromosomes appear to be implicated eg 10, 11, 12
13 and 6 has strongest link
Gene variation inc risk of developing schizophrenia
Gene mutation and deletion
Gene mutation can be passed down from parents or happen spontaneously.
Changes may result from environmental factor or cell division error.
Di George syndrome caused by deletion around 30-40 neighboring genes.
25% develop schizophrenia.
COMT gene
Link between schizophrenia and Di George may due to deletion of COMT.
COMT guide creation of enzyme that breaks down neurotransmitter
COMT deletion, poorly regulated dopamine cause schizophrenia.
DISC 1 gene
Abnormality of this gene, 1.4x likely to develop schizophrenia.
Codes for creation of GABA, regulate neurotransmitter.
Susser et al illustrated role of epigenetic factors in schizophrenia, Nazis blocked the distribution of food and baby born during this time are 2x likely to develop schizophrenia due to gene abnormality.
Genetic explanation strengths
Gottesman and Shields, 42% concordance rate for MZ and 9% for DZ.
Dahoun et al concluded DISC 1 link with pre synaptic dopamine dysregulation. Egan et al, link between dec dopamine activity in pre frontal cortex and COMT, inheriting 2 inc risk of schizophrenia by 50%
Inc genetic understanding help with genetic counseling.
Genetic explanation weaknesses
Twin study results must be treated with caution, also likely to be treated more similar leave the DZ.
Fail to consider environment.
Social causation of schizophrenia
Social adversity
Urbanity
Social isolation
Social defeat hypothesis
Social adversity
Physical, intellectual, emotional and social basic needs.
poverty make people more vulnerable to mental disorders, may also lack treatment access causing even more vulnerable.
Urbanicity
Long term exposure to stress.
Competitive
Social isolation
People with schizophrenia withdrawal social life.
Lack corrective feedback, behave strangely.
Immigration and minority status
1st and 2nd generation has greater risk, inc people from same ethnicity lead to dec risk.
Marginalization
SGI, weaker ethnic and cultural identity
Social defeat hypothesis
Consider social factors further.
Social defeat occur when expose to hostile confrontation.
Excluded from majority.
Researchers proposed social defeat hypothesis to explain link between social defeat and dopamine, when rat placed into another rat’s cage, resident normally attacks intruder, intruder show inc dopamine
Social explanation strengths
Meta analysis of data from 4 studies, at the extreme 2.3x risk, pos correlation with population density.
Questionnaire, marginalized people have weak identity, assimilated people have strong but weak ethnic identity have higher risk, ethnic identity may be a protective factor.
Understanding help state control these factors
Social explanation weaknesses
Supporting evidence data is correlational.
Social drift hypothesis, schizophrenia find hard to do job so drift into lower social class, schizophrenia cause urbanicity.
Fail to consider genetic factors.
Drug treatment for schizophrenia:FGAs
Chlorpromazine, dopamine antagonist reduce pos symptoms by blocking postsynaptic dopamine receptors without activating.
Most effective FGAs bind D2 receptors.
40% gain no relief and many still experience neg symptoms.
Side effect, stiff face and body movement.
Drug treatment for schizophrenia:SGAs
Clozapine, blocks dopamine like FGAs but also block serotonin and glutamate receptors.
Reduce pos and neg.
Relief up to 60%.
Side effect, fatal blood condition.
Regular blood test.
Risperidone, more recently developed, bind to dopamine and serotonin, bind more strongly to dopamine than clozapine.
Protocol
Patel et al, early medication, more effective.
First 7 days, reduce hostility, return to normal functioning.
Once symptoms start to disappear, maintenance dose is given, occur in 60-80% who don’t take maintenance dosage and 18-32% who do.
Dosage should be maintained for at least 12 months after remission.
Drug treatment for schizophrenia credibility
Good empirical evidence, Zhao et al, 17 of antipsychotics tested had sig lower relapse rate than placebo.
Supported by dopamine hypothesis, antipsychotic affect neurotransmitter to bring change to symptoms.
Objectivity
Patel et al, 20% show minor improvements after multiple FGA trials, 45% experience partial or inadequate improvements and side effects.
Drug treatment research conducted on animals
Supporting evidence may be selectively reported, exaggerated effectiveness
Differences
CBT lack side effects but have to talk about their problems.
Both CBT and drug take time to be effective, CBT long term, antipsychotic short term.
CBT beneficial in long term, longer antipsychotics, likely develop severe side effects and if stop taking, symptoms return
Application
Previously, no choices but in institutional care, now still have chance to remain in community.
What’s cognitive behavioral treatment?
Combine cog approach with learning theory.
Takes place in anywhere between 5-20 sessions.
Cognitive behavioral treatment:irrational beliefs
Client lack necessary coping skills to manage symptoms eg stress management tech, can trigger relapse.
Reduce the stress of situation by altering the way how they think and feel.
Therapist help self awareness, understand more about their condition.
Cognitive behavioral treatment:delusions
Help to understand how delusions and hallucinations affect feelings and behavior.
Understand origin of symptoms can be helpful.
Behavioral experiment
Challenge perceived reality.
Allow clients test if delusion is real.
Difficult to talk client of of their beliefs so set up a situation where they can test eg ask them to keep a record of evidence.
Discuss evidence to debunk beliefs.
Help to differentiate.
Behavioral activation
Schizophrenia is associated with motivational deficits.
Reduce by reward pos behavior.
Sense of self may also be addressed, more than just schizophrenic.
