Clinical Psychology Flashcards
Describe the 4 D’s of diagnosis
Deviance- If Behaviour is rare within society and deviant from norms.
Dysfunction- If behaviour significantly interferes with person’s life so mental illness may be present. The clinician should discuss with the patient all aspects of their everyday life to assess the extent to which problematic behaviour is disturbing this. There may be no obvious day-to-day impact. The clinician should investigate all aspects of the patient’s life as disturbances could be present in areas that aren’t immediately obvious.
Distress- The feature of the diagnostic decision is related to the extent to which behaviour is causing upset to the individual. Should be treated in isolation from other D’s as person may be distressed by situation but able to perform normally in other areas of their life. Subjective experience of patient is important as they may feel no distress even though they have difficulty. Someone may be distressed by something others view as normal or insignificant.
Danger- Danger to themselves and others. If behaviour is putting own and other people’s lives in danger, this may suggest that intervention is needed. This can be considered on scale of severity because many people engage in behaviour that could be considered dangerous, but, if the problematic behaviour is extremely risky and not addressed, then a diagnosis may be necessary.
Some researchers have suggested Fifth D, Duration - as behaviours may be reminiscent of 4 D’s in short-term, but may not be present in long term, if they are, it can be seen as symptom of illness that deserves psychiatric attention.
Describe the function of classification systems
Mental disorders are described as collection of symptoms by medical profession just like other illnesses. World Health Organisation compiled a list of mental disorders in International Classification of Diseases (ICD) in 1948.
Four years later, American Psychiatric Association established its own way of helping professionals reach a diagnosis. In publication known as Diagnostic and Statistical Manual of Mental Disorders. Both versions have been continually reviewed over years with DSM V being published in 2013. ICD’s 10th version was published in 2017.
Reliable diagnoses are essential for guiding treatment recommendations to ensure that a patient receives correct treatment and prognosis (the likely course of a medical condition).
Because mental health disorders don’t have measurable physiological signs like raised blood pressure or temperature, diagnosis often depend on interpretation of behavioural symptoms, and, since this isn’t an exact science, there’s reliability and validity issues that surround diagnosis.
The classification systems: DSM and ICD describe clusters of symptoms that define disorders, derived from clinical practice, field trials, and pooled expertise. If applied properly, should lead to better-quality diagnoses. However, this doesn’t mean they’re universally accepted and there’s many influential critics of these systems.
Describe the function of the Internal Classification for Diseases
ICD-10 Isn’t only concerned with mental health disorders, but with all diseases; it contains a section which is specific for Mental Health Disorders. Within that section, it groups each disorder as part of a family. For example, mood/affective disorders are the family that includes depression in all its forms. These disorders are coded F (For section of system) followed by a digit to represent the family of Mental Health Disorder, in this case 3, which is then followed by a further digit to represent the specific disorder (F32 is depression whereas F31 is bipolar disorder).
Further Categorisation comes at the next digit that follows a decimal point where the type of depression is represented (E.g., F32, 0 is mild depression). Finally, very specific categorisation and can be added after another decimal point followed by further digits (e.g F32.0.01 is mild depression with somatic/physical symptoms. For example, Pain, where F32.0.0.0 is mild depression without somatic symptoms). This coding allows the clinician to go from the general to specific and convey diagnosis to others in easy/systematic way.
Clinician can use the system to guide their diagnosis through clinical interview with the patient. This requires expertise on the part of the clinician as mental disorders are often not clear in their presentation. However, it does provide a basis on which to make judgement, giving details of likely symptoms for each disorder and severity/duration. Allowing diagnosis to be made. In some cases, the diagnosis will be tentative, or provisional but sometimes confident diagnosis can be made as patient clearly presents with symptoms that fit description for ICD manual.
Describe the function of DSM V
The DSM V adopts a similar system of grouping disorders into families with linked disorders grouped together, to enable the clinician to go from a very general diagnosis to a specific one with guidance provided about likely combination of symptoms and their severity. Again, the clinician would use the manual in combination with range of information gained through clinical interview and medical records.
DSM V- Section One: An introduction to the manual with instructions on its use. Section Two: Contains classification of the main mental health disorders: Neurodevelopmental disorders, schizophrenia, bipolar disorders, aggressive, depressive disorders, aggressive disorders, obsessive disorders. Section Three: Contains other assessment measures to aid diagnosis. This is a cultural formulation interview guide to help diagnosis from a different culture from clinician diagnosing them. It includes other conditions that are being assessed for possible future diagnosis.
Describe the function of DSM IVTR
DSM IV was originally published in 1994 and updated to DSM IV-TR in 2000 and was described as multiaxial tool due to having 5 axes or chapters. Axis 1 described the major clinical syndromes or mental health disorders like schizophrenia and anxiety disorders. Axis 2 described symptoms related to personality disorders. Axis 3 described medical conditions like brain damage or HIV that could be used to explain/mediate onset of clinical issues. Axis 4 described psychosocial and environmental problems that could be implicated in onset or course of mental health disorder I.e., bereavement triggering depression. Axis 5 contained a scale to assess global function (Global functioning is a term that refers to how well one is meeting various problems in living) of an individual. Clinicians could use this scale to assess how well individual was able to do normal activities like washing, dressing, and socialising. Functioning score given to individual helped with diagnosis and was used to assess need and type of treatment which is necessary.
Discuss the reliability of diagnoses
Extent to which clinicians agree on same diagnosis for same patient. Diagnosis is complex, especially as same symptoms can occur across different disorders. Clinicians may see same symptoms but assign cause to different disorders. Would suggest that diagnosis is unreliable. Ward et al (1962) studied two psychiatrists diagnosing the same patient and found that disagreement occurred due to inconsistency of information provided by patient (5%), inconsistency of psychiatrist interpretation of symptoms (32.5%) and inadequacy of classification system (62.5%). Research suggests that main reliability issue was diagnostic tool being used.
Tests on early diagnostic systems showed typically low inter-rater reliability, for example, Beck (1954) found that the same set of symptoms were only diagnosed as the same disorder in about ½ of the cases suggesting low reliability. However, over the years, as systems have developed, further studies show improved reliability Brown (2001) tested reliability and Validity of DSM IV diagnoses for anxiety and mood disorders, found them to be good to excellent. There are still some disorders however, for which a reliable diagnosis is harder to obtain e.g. post-traumatic stress disorder has high degree of symptom overlap with other psychiatric disorders and may remain undiagnosed as result.
Patient Factors-Unreliable diagnosis may occur due to patient factors like information provided by patient to clinician being inaccurate due to memory, shame, or denial problems/ These psychological factors, along with specific issues like disorganised thoughts, psychopathy, or manipulative tendencies, can make diagnosis difficult and likely to differ between clinicians.
Clinician Factors- Unstructured nature of clinical interview can lead some clinicians to focus on certain symptom presentation like nightmares while others may follow different course of questioning like traumatic past event. Can lead to different information being gathered about patient and different diagnosis. The first clinician may diagnose a depressive disorder while the second may diagnose post-traumatic stress disorder. Clinicians use subjective judgement according to how they interpret the symptoms a patient presents. This is largely dependent on background, training, experience of a clinician. For example, a clinician with psychodynamic training may emphasise the importance of early childhood experience and mistake hallucinations for past trauma. While medically trained psychiatrists may explain hallucinations as consequence of excess dopamine in the brain. Diagnosis may be reliable as different clinicians agree on it but doesn’t mean it’s valid. Rosenham found high inter-rater reliability in diagnosing schizophrenia from same set of symptoms, but diagnosis was not valid because people receiving the diagnosis was not mentally ill.
Describe the Validity of Diagnoses
Even if diagnosis can be said to be reliable, it must also be valid. It must genuinely reflect underlying disorder as consequences of misdiagnosis are severe. As diagnosis leads to treatment, wrong treatment may delay recovery and/or worsen condition. Validity can be established in numerous ways.
Concurrent validity (Comparing evidence from several studies testing same thing to see if they’re true) can be tested by looking at other diagnostic tool like comparing ICD and DSM. If there’s a broad agreement about which symptoms constitute which disorder, there’s concureent validity. DSM V has referred consistently to coding in ICD showing strong agreement between two instruments.
Aetiological Validity (Extent to which disorder has same cause or causes, i.e. family history in disorder known to have genetic cause) can be established by examining causes of disorder and matching them to person’s history/experiences like using family history to support diagnosis of genetic cause of disorder.
Predictive validity (Extent to which results from test like DSM or study can predict future behaviour) should be examined. This is where future course of disorder is known and can be applied to person, so diagnosis is checked against outcome to see if it’s valid. If a patient genuinely has depression, improvement should be seen after 8-week course of anti-depressants.
Issues that affect reliability and validity centre on the interpersonal exchange between client (or patient) and clinician in diagnostic interview. Clinician may be affected by implicit biases (Positive or negative mental attitude held towards person, thing or group, held at unconscious level) in interpretation of information. For example, a clinician may be more ready to diagnose a female with depression due to prevalence in female population, so is likely to see symptoms being more consistent in females than men. More likely to diagnose females with depression than men. May be exacerbated if gender of clinician differs from patient.
Describe what Schizophrenia is
Refers to spectrum of psychological disorders characterised by abnormalities involving distortion of thought, perception, emotion, and social withdrawal. Positive and negative schizophrenia symptoms have been differentiated by researchers.
Describe the symptoms of schizophrenia
Positive (Type 1) Symptoms add to patient experience. These include delusions (Not factual to belief), hallucinations, disorganised thinking/speech, and abnormal motor behaviours. Negative (Type 2) symptoms subtract from normal behaviour. Behaviours persist longer and result in huge burden of care compared to positive symptoms. These may include a lack of energy and enthusiasm, poor speech, motivation, and social withdrawal.
For a diagnosis of schizophrenia to be given by clinician, then presenting patient must have described two or more of the key symptoms above being present for high proportion of last month. Of symptoms described by patient, at lead one must be delusions (Not factual beliefs), hallucinations (Perceptual experiences that occur in absence of external stimulation of corresponding sensory organ), disorganised thinking/speech (Inability to connect thoughts, resulting In disorganised language that seems loosely connected), disorganised behaviour (Unexpected, changes rapidly, out of context for situation), negative symptoms (Loss of normal functioning).
Clinicians must be careful and consider other issues in the patient’s life to make accurate diagnosis. If a patent is also displaying signs and symptoms of disturbed mood like mania or depression, then symptoms of schizophrenia must have existed before disturbed mood for schizophrenia to be diagnosed. Also, clinician must consider whether brain damage or substance misuse issues could account for altered behaviour.
Delusions- Belief held by individual that, despite not being true, cannot be changed by others even where clear evidence can be demonstrated that challenges the belief. Examples of common delusions held by people with psychotic disorders are grandiose delusions (Individual believes that they have remarkable qualities like fame or superpowers). Persecutory delusions where individuals report that others are out to harm them in one way. And referential delusions where individual believes that certain behaviours or language from others is being directed as them personally. One very specific example is thought insertion where individuals’ belief that thoughts have been implanted within them by an external force which they have no control over.
Hallucinations- Experienced in same way as perception of external stimulus such as hearing or seeing something around you. But can happen without an actual stimulus being present. For example, person with psychotic illness may hear voices talk to them that aren’t real or see someone in front of the, when there’s no one there. Hallucinations can occur in any sensory modality. However, it is thought that the most common type associated with schizophrenia are auditory hallucinations (Hearing things that aren’t there). The hallucination must be experienced when patient is fully awake/conscious to be classified as actual symptom of disorder.
Disorganised thinking/speech- Best diagnosed from speech where ideas are loosely connected or completely unconnected. In very severe cases, a person’s language must be completely incomprehensible due to difficulty making connection between thoughts, this may be referred to as “Word Salad” where words are tossed around during an individual’s speech. Disorganised thinking/speech may mean that person randomly skips from topic to topic during conversation and answers questions with bizarre statements that don’t seem to fit.
Abnormal motor behaviour/grossly disorganised behaviour (Including catatonia)- Behaviour of individuals will be categorised as abnormal for many different reasons but any motor movement that severely affects ability to cope with daily life is categorised as grossly disorganised. This ranges from fidgeting to childish “Messing About” or even bizarre dressing. Within this category of symptoms, catatonia is included (Significant decrease in individual’s response to movement). They may it completely still in odd postures or refuse to speak to others. They may show repetitive movements like foot-tapping or hair twirling with no real meaning.
Negative Symptoms- Of all psychotic disorders, negative symptoms are mostly associated with schizophrenia. Two of the most negative symptoms are diminished emotional expression and avolition Diminished emotional expression is characterised by patient showing less and less emotion in general use of non-verbal communication like facial expressions, eye contact and gestured. Avolition is a psychological state characterised by general lack of motivation to complete usual, self-motivated activities like work. Symptoms In this category are negative due to effect on normal function
Describe the features of schizophrenia
Prevalence and Onset
Likelihood of schizophrenia development is somewhere between 0.3 and 0.7 % depending on factors like racial/ethnic background, where in the world they live and country of birth.
There are some gender differences in prevalence, i.e., males are more likely to develop higher proportion of negative symptoms and have longer duration for disorder which are both associated with poor prognosis. Episodes of psychosis associated with schizophrenia tend to appear between late adolescence and mid-thirties, with peak of onset being around mid-twenties for males and late twenties for females. Often, episodes develop gradually and may not be obvious at first. Patients who show psychotic episodes earlier than in late adolescence appear to have worse prognosis over the long-term.
Prognosis
It’s very difficult to predict course of illness in patients with schizophrenia- Approximately 20% of those diagnosed will respond well to treatment, with a small number regaining a good quality of life. However, a large % will remain chronically ill and require regular treatment/interventions to support them. Doctors yet, haven’t found a way to accurately predict what an individual’s prognosis will be after diagnosis.
Other features- There’s other common features associated with diagnosis of disorder. For example, many patients will show general cognitive function deficits in areas like working memory, language functioning and speed of information processing. Mood abnormalities are also common Many patients describe periods of low mood, similar to those experienced in depressive episodes as well as inappropriate mood displays like laughing for no reason.
Describe the biological/neurotransmitter explanation of schizophrenia
It’s a long-established idea that schizophrenia may, at least be explained by an increase in certain neurotransmitters in areas of the brain.
The key neurotransmitter thought to be associated with psychosis is dopamine. Very early on in the development of research in this area. It was noted that patients who had abused large amounts of the drug amphetamine often showed positive symptoms of psychosis like hallucinations and delusions. Randrup and Munkval (1966) raised dopamine levels in rats by injecting them with amphetamine. The rat’s behaviour changed, becoming more stereotyped, aggressive, and isolated, showing that changing the dopamine levels resulted in psychotic type behaviour consistent with schizophrenia patients. By investigating the action of the drug they’ve found that amphetamine acts on brain in way that increases dopamine. This sparked beginning of development of dopamine hypothesis of schizophrenia. In 1967, a paper published by J.M. Van Rossum made significant link between overstimulation of dopamine receptors and schizophrenia. As research methods used to study the brain develops, so does biological theories that centre on workings of the brain.
The most recent version of dopamine hypothesis centres on hypersensitivity of certain dopamine receptors in the brain, which means that patients with disorder are likely to overreact to presence of neurotransmitter. Research by Lieberman et al (1987) states that about 75% of patients with schizophrenia show new symptoms or an increase in psychosis after using drugs like amphetamine (Stimulates central nervous system and increase activity + energy, also supresses appetite and causes sleeping difficulty) and methylphenidate (Psycho-stimulant drug that acts on central nervous system. It is used to medically treat attention-deficit hyperactivity disorder in children and adolescents) which mimic the action of dopamine in the brain. However, only a small proportion of people who regularly use these drugs suffer from psychotic symptoms, which suggests that there’s something different about people’s brains reactions to dopamine that may explain schizophrenia development. This is supported by the fact that postmortem explanations on the brains of people who have had schizophrenia show a higher density of dopamine receptors in certain parts of brain (Cerebral cortex) than do patients not suffering from it (Owen et al 1978), suggesting that they’re more sensitive to action of dopamine than people who have not had schizophrenia. Recent research has found that number of receptors may only account for about 6% increase from what’s normally found in the brain.
People diagnosed with schizophrenia may have higher number of D2High receptors (Seeman,2013). These receptors have a high affinity to dopamine which means they’re more likely to bind to neurotransmitter when it’s present in synapse, accounting for higher degree of sensitivity shown by brains of schizophrenics in response to dopamine-type drugs.
Describe and Evaluate the genetic explanation for Schizophrenia
Another biological explanation for schizophrenia is that there’s evidence of strong heritable factor in development of the disorder. The risk of developing schizophrenia at some point in your lifetime for general population is less than 1%. If you have second degree relative like aunt/uncle or niece/nephew with illness, risk increases between 2-6%. If you have first degree relative like parent, sibling, dizygotic twin with schizophrenia, risk increases between 6-17%. However, the biggest risk seen was in people with monozygotic twin with schizophrenia where there was 48% chance of being diagnosed with illness too (Gottesman,1991). The greater the degree of genetic relatedness, the higher the risk of developing the disorder, suggesting strong genetic element to schizophrenia.
Evaluation of genetic explanation
Family studies have established inherited component in schizophrenia, as lifestime risk increases when level of genetic similarity with a sufferer increases. However, research has failed to isolate a single recessive or dominant genes that seems to cause illness (Tamminga and Schultz 1991). Many researchers believe that a disorder as complex as schizophrenia probably results from expression of multiple genes rather than a singular gene.
Gotessman (1991) found that, in DZ twins, the concordance rate is only 17% but for MZ was 48%. MZ twins share 100% of same genes while DZ only share 50%, the fact that MZ twins show increased concordance suggests that genes must play significant role in development of schizophrenia. But, this could be accountable to higher risk of birth complications in twins than in other pregnancies or possibility that MZ twins are raised more similarly than DZ twins or siblings are likely to experience identity confusion (Joseph 2004), product of environment rather than genetics.
Can be applied to early intervention for schizophrenia and having people with close genetic relation to schizophrenics being monitored/treated for schizophrenia so that the symptoms don’t worsen or remain untreated.
Describe Neuroanatomical Theory of schizophrenia
In 1919, Kraeplin first suggested that schizophrenia was a ‘brain-based’ illness, but there was limited opportunity to test and study brains of schizophrenics until after death. Since 1980’s when there were advances in use of brain-imaging techniques in research, psychologists have been interested in whether schizophrenia had any anatomical components. There’s multitude of research that finds that schizophrenic patients had enlarged ventricles in the brain- These are cavities in the brain that contain cerebrospinal fluid. Johnstone et al (1976) used CAT scans to compare the brain structure of group with schizophrenic patients, and group of matched controls, and found that those with schizophrenia had significant enlargement in ventricular areas.
It’s been found that enlarged ventricles are most associated with negative symptoms of schizophrenia and with patients who have the worst outcomes. There’s wealth of evidence that supports this explanation of schizophrenia. For example, Giedd et al (1999) found that patients with early-onset schizophrenia showed significant developmental increases in ventricular size throughout a longitudinal study using MRI scan of brains at various intervals. There was a significant increase in size of ventricles throughout adolescence as disorder progressed, and there was relationship between severity of negative symptoms measured in patients and the increase in ventricle size. However, criticism of explanation is that it’s difficult to identify cause and effect as brain abnormalities may be result of developing schizophrenia rather than cause of illness.
Describe Cognitive Theory of Schizophrenia
Begins by attributing type 1 (Positive Symptoms) of schizophrenia to biological causes. Experience of hallucinations and delusions is thought to be associated with biological factors like increased dopamine levels, but, when patient tries to make sense of experience, they begin to experience other symptoms of disorder.
When patient experience hallucination, they may look to others to confirm their perception, when others cannot do this, patient may become wary and believe they’re keeping information from them. This can, in turn, create further delusions of persecution or paranoia as patient can feel that others are deliberately denying experience, they believe they’re having. Therefore, many symptoms of schizophrenia are seen as mistaken attempt by patient to understand the experiences resulting from abnormal biological functioning in the brain.
Frith (1979) published work suggesting that schizophrenia results from patient’s increased ‘self-awareness’ whereby there is an inability to filter out unnecessary cognitive ‘noise’ created by internal information processing. As part of our general, day-to-day experience, we ignore many cognitive processes that go at level beyond conscious awareness. We don’t consciously process every thought, decision, or perception because this would become exhausting, and is not necessary. Argued that schizophrenic patients are unable to ignore minor processes, as such, they experience in increased level of cognitive awareness that they cannot make sense of. Foe example, having experience of being told to check watch to make sure you’re not late for work. We may unconsciously keep checking our watch when we know we’re due to arrive at work soon, but this is often something we would think about. Someone with schizophrenia may experience this thought as voice telling them to check their watch. When they try make sense of this but cannot, this can lead to further delusions and worsening symptoms.
Describe Social Drift Theory of schizophrenia
Evidence has been suggested that schizophrenia is more prevalent in lower societal classes and has been explained by social drift hypothesis. Theory suggests that symptoms of schizophrenia make it difficult for patients to achieve in jobs, education and maintain relationships so they drop to lower social and economic classes in society. Consequently, there’s greater concentrations of people with schizophrenia in more deprived areas than in affluent areas. People with schizophrenia also drift unto more urban areas because they can gain better access to support services than those in rural areas. For example, there’s generally more cheap housing, food kitchens and social services available in cities than in small towns or villages, which can encourage people with schizophrenia to drift into these different social areas.
