Clinical Psychology Flashcards
Deviance
Extent behaviour is rare within society.
Depends on context/culture.
Dysfunction
Extent behaviour interferes with life .
All aspects of everyday life looked at.
E.g. not being productive, not leaving house.
Distress
Extent behaviour upsets the individual.
Look at in isolation as could still function.
Subjective experience.
Danger
Danger to themselves or others and should be assessed.
Could indicate intervention needed.
Duration
Lots of behaviours can fulfil 4 D’s in the short term.
If behaviours persist, psychiatric attention could be required.
Limitations of Deviation
Sometimes statistically rare things are desirable.
Deviation does not account for desirability of a behaviour.
Social norms differ in each culture and context.
Limitations of Distress
It is subjective.
Something that could cause distress to one person, may not for another.
Limitations of Dysfunction
‘Fully functioning’ is subjective as different tests give different results.
Can fully function with some mental disorders.
Limitations of Danger
Could be too late before noticed (danger already occurred).
Normal people do dangerous stuff.
Subjective.
General limitations of the 4D’s
No clear scale between normal + abnormal.
Can be other explanations.
Based on clinicians judgement.
Why are reliable diagnosis essential?
To ensure correct treatment is given.
Why does diagnosis rely on interpretation of symptoms?
There is no obvious measurable physiological signs.
What do classification systems describe?
They describe clusters of symptoms that define disorders. This should lead to better quality diagnosis.
International Classification of Diseases (ICD-10)
- Published by WHO
- Considers each disorder as being part of a family.
Coding of ICD-10
- Coded F for section of the system followed by a digit for the family of the disorder.
e.g. F32 is depression, F31 is bipolar depression, F32.0 is mild depression. - Decimal points make categorisation even more specific.
- Use to guide diagnosis through interview.
DSM-V Diagnostic Criteria
- Needs 2+ of Delusions (1), hallucinations (2), disorganised speech (3), grossly organised, negative symptoms.
- Lasts for a significant portion of a 1 month period. Has to be at least one of (1,2,3).
- For a significant portion, the level of functioning in work, self care, etc must be below level achieved prior to symptoms.
- Continuous disturbance for at least 6 months, at least one month of symptoms. Have to rule out schizoaffective disorder/bipolar depression.
- Rule out drug use and autism.
Reliability of Diagnosis
Reliable if more than one psychiatrist gives same diagnosis (inter-rater reliability).
Unreliable diagnosis means likely incorrect treatment.
Validity of Diagnosis
Extent to which a diagnosis genuinely reflects the underlying disorder.
ICD-10 Diagnostic Criteria
- At least one very clear symptom belonging to a-d group. Or at least 2 from e-h.
- Clearly present for one month or more.
- Can’t be diagnosed with Schizo if any evidence of depressive episode.
Patient Factors
Give inaccurate info (because of memory, denial, shame, etc).
Specific issues like disorganised thoughts.
Clinician Factors
Focus on certain symptom presentation because of the unstructured nature of interview.
Subjective judgement (background, experience, training of clinician).
Schizophrenia
A psychotic disorder marked by severely impaired thinking, emotions, and behaviours.
Positive Symptoms
Add to the patients symptoms.
Hallucinations
Delusions
Thought insertion
Disordered thinking
Negative Symptoms
Subtract from normal behaviour.
Speech poverty
Avolition (reduction in interests, desires and goals)
Features of Schizophrenia
0.3 –> 0.7% chance of developing.
- Males have a higher proportion of negative symptoms.
- 20% respond well to treatment.
- Mood abnormalities are common.
Neurotransmitter SZ Theory
Dopamine is thought to be the key neurotransmitter associated with psychosis.
Patients that abused a large amount of amphetamines showed positive symptoms.
Dopamine - Randrup and Munkvad 1966
- Raised dopamine levels in rats brains by injecting amphetamines. They became stereotyped aggressive and isolated.
Dopamine - What did Goldman Rakic et al suggest?
Abnormally low dopamine levels in prefrontal cortex may be responsible for negative symptoms of SZ.
Because prefrontal cortex is associated with logical thinking, so low levels could impair an individuals ability to construct grammatical sentences focused on one topic and make decisions on day to day living.
What has the SZ dopamine hypothesis had important implications for?
Development of drug treatments for SZ (antipsychotics and dopamine antagonists).
Dopamine - Neural Correlates
Specific patterns of cortical activity or neural structures which coincide with specific psychological symptoms, and assumed to contribute to those symptoms.
Dopamine - Lieberman et al 1987
75% of patients with SZ show new symptoms or increase in psychosis after taking amphetamines.
Dopamine - Owen et al 1978
Post-mortems find a higher density of D2 receptors in certain areas of the brain in SZ patients.
Dopamine - D2 Receptors
Abnormally high dopamine levels in the frontal lobe, specifically Broca’s area which may have an excess of D2 receptors which may be responsible for the + symptoms of SZ auditory hallucinations due to overactivity of auditory areas of the brain.
Genetic Evidence for SZ
Gottesman 1991:
- Positive relationship between increasing genetic similarity of family members and their increased risk of developing schizophrenia.
Genetic - Concordance rate for Gottesman
MZ twins: 48%
DZ twins: 17%
Siblings: 9%
Parents: 6%
Genetic - MZ twins and Environmental factors
MZ Twins share 100% of genes, although this suggests a strong basis and the existence of candidate genes for schizophrenia. There are no 100% concordance rates, demonstrating there are environmental influences acting on the development of SZ.
Genetic SZ Evaluation
- Failed to isolate single gene that causes SZ.
+ Tienari found that 7% of adoptees with SZ had bio mothers with SZ.
- Harrison and Owen (2003) report up to 6 genes involved in susceptibility to disorder.
- Concordance rate not 100%, there could be other factors.
Neurotransmitter SZ Evaluation:
+ Typical antipsychotic drugs work by blocking dopamine receptors.
+ When Parkinson’s patients dose of DRA is too high, they experience SZ positive symptoms.
- Not all SZ respond to antipsychotic medicine blocking dopamine receptors.
- New atypical drugs (Clozapine) also block serotonin receptors.
Genetic - Estimate for heritability of SZ?
how many genes involved in SZ
DG syndrome
COMT
DISC1
Diathesis-stress model
- 79% suggests a large role of genetic factors.
- 700 genes linked to SZ.
- Genes could mutate, 25% people with DiGeorge syndrome get SZ.
- COMT gene and DiGeorge linked to SZ as DG deletes it, then there is no gene to instruct an enzyme to break down dopamine in prefrontal cortex, results in SZ symptoms.
- DISC1 gene abnormality are 1.4x more likely to develop SZ (kim et al). This creates codes for GABA which regulates dopamine and glutamate in limbic system.
- genes create a vulnerability for SZ than cause it. Could possess SZ genes but biological or env factors trigger it. Genes are the required element.
Social Causation Explanation for SZ
The view that the human world acts as a major cause of SZ.
SC - Social Adversity
Humans have physical needs such as nutrition warmth and shelter but they can also be intellectual, emotional, and social. People who grow up in less fortunate environments can make them more vulnerable to mental disorders in the future.
People from lower socioeconomic groups may not be able to access treatment for schizophrenia.
SC - Urbanicity
Link between urban living and schizophrenia.
William Eaton 1974 suggested that city life is more stressful than rural life, long term stress exposure may trigger a schizophrenic episode.
Stressors linked to city life: noise, light, pollution, crime etc.
Increased population density can make life more competitive, increasing the experience of chronic social defeat.
SC - Social Isolation Robert Farris
Robert Faris 1934 suggested people with SZ withdraw because they feel contact with others is stressful.
Self imposed isolation cuts them off from feedback about what behaviours are inappropriate, no feedback may make them behave strangely.
Supporting Social Causation Evangelos SZ
+ Research shows a significant correlation between urban dwelling and SZ.
Evangelos Vassos et al’s meta analysis from 4 studies conducted in Sweden, Netherlands and Denmark including nearly 24,000 SZ cases.
Correlated urban to rural location with SZ risk and found that there was a 2.37 higher risk of SZ for people living in the most urban environments.
Shows relative risk of SZ increases in line with population density.
Competing argument against Evangelos Vassos et al
The data is correlational so it isn’t possible to say that SZ is caused by urbanicity or adversity.
Evidence Against Social Causation
Evidence from MZ/DZ twin studies
It is reductionist.
We know there is some genetic contribution to the development of SZ.
Suggests that role of environmental factors may only trigger the onset of SZ in people genetically predisposed to the condition.
This is the diathesis-stress SZ model.
Social Causation Application SZ
Draw attention to factors which affect mental health at the community level.
Social Causation Evaluation Conclusion
Evidence suggests that environmental factors relating to urbanicity like lack of social cohesion and ethnic identity play an important role in determining who is likely to develop SZ later in life. Supporting research should be viewed with caution as it is correlational meaning we do not know the direction any effect.
One Biological Treatment SZ
Drug Treatments
If SZ caused by an excess or a deficiency of a certain neurochemical, then medication can be used to correct this imbalance.
BIO T - First Generation Antipsychotics SZ
Chlorpromazine:
- First antipsychotic medication.
- Dopamine antagonist, reducing positive symptoms by blocking postsynaptic dopamine receptors without activating them.
- Most effective ones bind to D2 receptors.
- 40% gain no relief and still experience - symptoms
- Side effects are stiff/slow writhing movements of body that you can’t control. Leading to poor compliance and subsequent relapse.
BIO T - Second Generations Antipsychotics SZ
Clozapine:
- Blocks dopamine in the same way as FGA but acts on serotonin and glutamate receptors.
- Reduces both + and - symptoms.
- Side effect is a blood condition called agranulocytosis.
- Provides relief for up to 60% of people.
- Regular blood tests to avoid side effects.
BIO T - Support for Drug Treatments SZ
Ying Jiao Zhao et al 2016:
- Meta analysis of 18 antipsychotics using data from 56 randomised control trials with 10,000+ people.
- Found that 17 of the antipsychotics had significantly lower relapse rates than placebo.
- Drug treatments can be helpful to allow SZ people to avoid emotional and financial costs of hospital treatments.
Competing Ying Jiao Zhao et al 2016 SZ
Krishna Patel et al:
- 20% of people with SZ show negligible improvement after multiple FGA trials.
- 45% experience only partial or inadequate improvement and unacceptable side effects
Application of Drug Treatments SZ
De-intstitutionalisation:
Antipsychotic drugs meant that in the 1950’s people had a chance of staying in the community
Non-Biological Treatment CBT
A form of therapy combining a cognitive approach with learning theory concepts which aim to change behaviour.
NON BIO T - Irrational Thoughts CBT
CBT aims to identify irrational thoughts and try to change them.
Reducing stress of situations by altering how they think and feel can help prevent decompensation
Therapist builds self-awareness by helping them understand more about the condition. This allows them to identify what causes decompensation and initiate coping strategies like meditation.
NON BIO - Delusions CBT
CBT can help SZ patients to make sense of how their delusions and hallucinations impact their feelings and behaviour.
If i client hears voices and believes they are demons, they will be afraid. Offering non-bio explanations for these can help reduce the anxiety.
NON BIO T - Behavioural Experiments ‘reality testing’ CBT
D+H can be combatted by verbally challenging the clients’ perceived reality.
Reality testing is where they client tests whether the delusions are real.
Evidence collected from experiments can be discussed and used to debunk erroneous beliefs, helping to show the individual the difference between confirmed and perceived reality.
