clinical psychology Flashcards
define mental health
state of mental well-being that enables people to cope with the stresses of life, realise their abilities, learn and work well, contribute to their community
define mental illness
a clinically diagnosable disorder that significantly interferes with an individual’s cognitive, emotional or social abilities
mental disorder
clinically significant disturbance in an individual’s cognition, emotional regulation, or behaviour that reflects a dysfunction in the psychological, biological, or development processes underlying mental functioning.
Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities
what’s not a mental disorder
→ “an expectable or culturally approved response to a common stressor or loss, such as the death of a loved one”
→ socially deviant behaviour between individual and society
Catergorical vs Dimensional Classification
Categorical
- Better clinical and administrative utility
- Easier communication
Dimensional
- Closely model lack sharp boundaries between disorders, between disorders and normality
- Have greater capacity to detect change, facilitate monitoring
- Can develop treatment-relevant symptom targets - not simply aiming at resolution of disorder
What is the DSM-5-TR diagnostic groupings
Hybrid system, primarily categorical with some dimensional components
Diagnosis of DSM-5-TR
Diagnosis
- Clinical interviews - clinician and client semi/structured
- Text descriptions - how disorders present
- Diagnostic criteria - does presentation match checklist
- Currently presenting symptoms and severity
- Rule out disorder due to general medical condition or effects of a substance
Approach of DSM-5-TR
Approach
- Establish boundary with no mental disorder - cultural norms/clinical significance
- Determine specific primary disorder - multiple diagnoses possible
- Add subtypes - severity/treatment/longitudinal course
define public stigma
(plural of personal stigma) refers to stigma exhibited by the public towards those with a mental disorder
how does public stigma manifest?
- Stereotyped attitudes and beliefs - devaluing language
- Prejudicial affective responses - fear
- Discriminatory behaviours - avoidance of interaction/social exclusion
This is thought to be particularly harmful, and the driving force behind other aspects of stigma
define structural stigma
refers to ingrained stigma manifest at the societal level
what are the ways of structural stigma?
- Is maintained by social institutions (both government, religious, and private) through policy, law, and prescribed ideologies that restrict opportunities for particular groups
- Varies considerably across societies, time and topics
how does Multiple stigmas affect persons living with mental ill-health
- Individuals living with mental ill-health are affected by numerous mechanisms of stigma
- The Mental Illness Stigma Framework outlines that they include perceived stigma, experienced stigma, anticipated stigma, and self stigma
Perceived stigma
- Is experienced by people living either with or without mental ill-health
- An individuals’ perception of public stigmatised stereotypes, prejudicial emotions, discriminatory behaviour or practices, and/or stigmatised structural practices. Distinct from one’s own beliefs
- Higher levels in people with lived experience
- Shares a positive relationship with symptom severity for those living with mental ill-health
- Fundamental substrate of the anticipation and internalisation of public and structural stigma
Experienced stigma
- Refers to the experience of having been the target of expressed negative stereotypes, prejudices and manifest discrimination related to one’s mental ill-health
- May occur in subtle and insidious terms such as chronic exposure to commonplace stigmatising representations of people with mental ill-health in mass media, or in more acute ways such as the experience of being denied significant employment
- Can contribute to withdrawal from future opportunities and shares a relationship with the anticipation of stigma
Anticipated stigma
- The extent to which individuals living with mental ill-health expect to experience stereotyping, prejudice, and discrimination in the future because of their mental health status
- Central to the experience of anticipated stigma is an awareness of public and structural stigma, and how this affects people living with mental ill-health in contexts that are relevant to the self
- Commonly results in withdrawal from opportunities for people living with mental ill-health
Effective approaches to stigma reduction
- Contact: being in contact with someone with mental illness. Positive for both parties and particulary effective for addressing stigma in adulthood. Challenges stereotypes and builds empathy
- Education: being educated about mental illness. This makes sense as familiarity with mental illness is well-established to be associated with decreased stigmatised attitudes and beliefs
define mood
refers to a person’s sustained experience of emotion
define affect
refers to the immediate experience and expression of emotion
define mood disorders
(according to the DSM-5-TR) involve a depression or elevation of mood as the primary disturbance
Can have other abnormalities (psychosis, anxiety, etc)
DSM-5 Major Depressive Episode Criteria
Five or more symptoms present for 2 or more weeks
- Depressed mood
- Anhedonia (inability to feel pleasure in normally pleasurable activities)
- Decrease/increase in appetite, significant weight gain/loss
- Persistently increased or decreased sleep
- Agitation or retardation
Fatigue/low energy
DSM-5 Major Depressive Episode Specifiers
- Psychotic features (mood congruent/mood incongruent)
- Melancholic features
- Catatonic features
- Postpartum onset
- Anxious distress
- Seasonal pattern
DSM-5 Major Depressive Disorder Criteria
- Presence of a major depressive episode
- Episode not better explained by another diagnosis
- NO HISTORY of mania, hypomania, or mixed episode (unless substance/medical illness related)
Epidemiology
- Family history of MDD increases risk 1.5x-3x
- Up to 20%-25% of patients with major medical comorbidity (diabetes, cancer will develop MDD)
- Often comorbidity with one or more anxiety disorders
Panic Disorder (point 1)
- Recurrent unexpected panic attacks - abrupt surge of intense fear/discomfort that reaches a peak within minutes, and during which time 4 (or more) of the following symptoms occur:
*panic attacks can occur from a calm or anxious state
- Palpitation, heart pounding/accelerated heart rate
- Sweating
trembling/shaking - Sensations of shortness of breath
- Feeling of choking
- Chest pain/discomfort
- Nausea/abdominal distress
- Chills or heat sensations
- Feeling dizzy/light-headed/faint
- Paresthesias (numbess or tingling sensation)
- Derealisation (feelings of unreality)/depersonalisation (being detached from oneself)
- Fear of losing control
- Fear of dying
*culture-specific symptoms (e.g. neck soreness, headache, uncontrollable screaming/crying) may be seem but such symptoms should not count as one of the required symptoms
Anxiety and Anxiety-related disorders
- Panic disorder (PD)
- Specific phobia
- Social anxiety disorder (SAD)
- Generalised anxiety disorder (GAD)
- Obsessive -compulsive disorder (OCD)
- Posttraumatic stress disorder (PTSD)
- Acute stress disorder
Panic Disorder (point 2, 3 and 4)
- At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
- Persistent concern or worry about additional panic attacks or their consequences (e.g. losing control, having heart attack, “going crazy”)
- A significant maladaptive change in behaviour related to the attacks, such as avoidance
- The disturbance is not attributable to the physiological effects of a substance (e.g. medication) or another medical condition (e.g. hyperthyroidism)
- The disturbance is not better explained by another mental disorder
Panic disorder epidemiology
30%-50% people affected will have agoraphobia
Avoidance of situations where escape would be difficult
50%-60% have lifetime major depression
⅓ with current depression
20%-25% have history of substance dependence
Generalised Anxiety Disorder
DSM-5-TR Diagnostic Criteria
- Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance)
- The individual finds it difficult to control the worry
- The anxiety and worry are associated with 3 (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):
- Restlessness/feeling on edge
- Being easily fatigued
- Difficulty concentrating/mind blankness
- Irritability
- Muscle tension
- Sleep disturbance
People living with GAD experience:
- Excessive worry more days than not
- For at least 6 months
- About a number of events
- Difficult to control the worry
3 or more of the following symptoms:
- Restlessness, easily fatigued, difficulty concentrating, irritable, muscle tension, sleep disturbance
Comorbidity
- 90% have at least one other lifetime disorder, such as panic disorder or depression (not typically neuro-developmental or personality disorders, although this is possible)
- 66% have another current such disorder
- Worse prognosis over 5 years than panic disorder
Beck’s Cognitive Model of Depression
- Schema (beliefs, rules and assumptions) based on early experience
- Negative events establish negative/dysfunctional schema
- Critical incidents trigger negative schema - governs information processing e.g. failing an exam
- Activation of schema leads to negative automatic thoughts (NATs) that are cognitive ‘fuel’ for depression
- The negative triad: a cognitive pattern involving negative thoughts about the self, the world, and the future
The ABC Cognitive Model of Emotion and Behaviour
A = Activating Event
What was happening when negative feelings where experienced
B = Belief
Beliefs or thoughts about the Activating Event
C = Consequence
Feelings (emotions and physiological experience of emotion)
Behaviour performed
define psychosis
The term ‘psychosis’ is an umbrella term meaning ‘out of touch with reality’
Can refer to a variety of clusters of symptoms
These symptoms can occur not only in schizophrenia spectrum disorders, but also in a range of disorders including:
Organic presentations like dementia
Substance use: amphetamine psychosis, and so on.
define psychosis at the disorder level
- Symptom configuration (e.g. delusional disorder vs schizophrenia)
non bizzare vs bizzare delusions - Duration (e.g. schizophrenia vs schizophrenaiform disorder)
< or > than 6 months - Relative pervasiveness - in terms of both duration and the clinical picture - of psychotic symptoms vs affective symptoms (e.g. bipolar disorder and schizoaffective disorder)
define schizophrenia
- The term ‘schizophrenia’ refers to “split mindedness” or “a mind torn asunder” (bleuler)
- Schizophrenia it is not multiple personalities as is commonly perceived (DID)
what does schizophrenia involve?
Schizophrenia involves disruption in various aspects of perceiving, thinking, feeling and behaviour. Phenomena associated with schizophrenia can be classified into two major groups of symptoms - positive symptoms and negative symptoms
Positive symptoms - additive to normal experience
Negative symptoms - deficit in normal function
what are positive symptoms
Hallucinations
- A percept in the absence of the environmental stimuli.
- Hallucinations occur in any sensory modality, of which auditory is the most common then visual
Delusions
- A false belief - both bizzare/non bizzare
- Persecutory
- Ideas (delusions) of reference
- Grandiose (plus religious)
- Somatic delusions
- Passivity phenomena e.g. thought insertion, thought withdrawal, thought broadcasting, delusions of control (made actions, made feelings, made impulses, mind reading)
what is positive thought disorder
- Clanging - speech pattern based on phonological association rather than semantic or syntactic
- Circumstantiality - speech including unnecessary or irrelevant detail, goal is eventually reached
- Flight of ideas - sequence of loosely associated concepts are articulated. Sometimes rapidly changing from topic to topic
- Derailment - speech train steers off-topic to unrelated things
- Incoherence - incomprehensible speech
- Pressure of speech - excessive spontaneous speech production and rapid rate, difficult to interrupt
what are negative symptoms of schizophrenia
- Avolition - lack of motivation to achieve goals
- Alogia - includes poverty of speech (less speech than normal), poverty of content of speech (less content than normal - vague), latency of speech and thought blocking
- Anhedonia - inability to experience pleasure
- Affective flattening - dulled emotional expression
- Inattention - disturbance in selective attention
other symptoms of schizophrenia
- Catatonia - immobility, waxy flexibility, excitement
- Incongruent or inappropriate affect - display incongruent with person’s emotion or inappropriate to context
- Bizarre behaviour - no rational basis
DSM-5 schizophrenia diagnostic
- Two or more of the following for a significant portion of time for a 1-month period:
- Delusion
- Hallucination
- Disorganised speech
- Grossly disorganised or catatonic behaviour
- Negative symptoms - For a significant proportion of time since onset, disturbance in functioning (self-care, interpersonal, work)
- Continuous signs of disturbance for at least 6 months, with at least one month of active symptoms
- Schizoaffective disorder/bipolar ruled out
- No mania/mood disturbance or only briefly - Rule out substance or medical condition.
Specify if:
- First episode, currently in:
- Acute episode, partial or full remission
- Multiple episode, partial or full remission
- Continuous
- Also - severity of primary symptoms
History of schizophrenia
Benedict Augustine Morel (1890) - ‘demence precoce’
Based on observations of individuals displaying a set of symptoms and experiencing early onset and deteriorating course
Emil Kraepelin (1898) - ‘dementia praecox’
Symptoms emphasised were hallucinations, delusions, negativism, attentional difficulties, stereotypies, and emotional dysfunction
Paul Eugen Bleuler (1908/11) - ‘schizophremoa’
Disagreed splitting of associative processes in thought, affect and action - this seen as the core of the disorder
Four “A”s were Bleuler’s primary symptoms:
1. Disturbances in Association (cognition)
2. Disturbances in Affectivity (mismatched affect and emotion)
3. Ambivalence (conflicting attitudes and feelings)
4. Autism (withdrawal from reality)
Schneider (1959) - emphasised ‘first rank symptoms’ and made the diagnosis on cross section
11 first rank symptoms: Hearing one’s voice out loud; hallucinary voice talking about him or her; hallucinations in the form of running commentary; somatic hallucinations produced by external agencies; thought withdrawal; thought insertion; thought broadcasting; delusional perception (ideas or reference); made feelings, actions and impulses
Problems with Schneider’s approach: symptoms are not specfic to schizophrenia
Aetiological Theories
Expressed Negative Emotion
Stress-vulnerability model
Biological models
E.g. genetics including gene-environment interactions
Expressed emotion
Genetic studies
Dopamine
Scanning studies/structural abnormalities
Personality and Mental-ill Health
Three ways personality relates to mental health issues and disorder:
Vulnerability
Personality disorder
Other personality-related disorder
vulnerability within personality and mental-ill health disorders
People differ in susceptibility to mental health issues and disorders
Genes
Environmental stress
Personaility
Rarely does one factor work alone
Genetic effects operate via personality
Genetic effects require environmental contribution
Environmental effects require genetic vulnerability
diathesis-stress models for personality
Most mental disorders involve the combined action of a personality vulnerability (‘diathesis’) and environmental stress
From this ‘diathesis-stress’ perspective:
No disorder with diathesis
No expression of diathesis without stress
Both diathesis and stress vary by degrees
Level of stress required to trigger disorder depends on degree of diathesis
Stress may come in different forms
Traumatic experiences
Major life changes (including positive)
Accumulation of ‘hassles’
Some diatheses may require specific types of stressor
E.g. relationship or achievement related
depression diathesis within personality disorder
Dependency (interpersonal sensitivity)
Susceptibility to interpersonal stressors
Autonomy (personal achievement)
Susceptibility to achievement stressors
Self-criticism
Pessimistic attributional style
Internal = low self-esteem
Stable = hopelessness
Global = helplessness
schizophrenia diathesis within personality disorder
Schizotypy + survey example items
Social anhedonia - “when someone else is depressed it brings me down also” (reversed scored)
Physical anhedonia - “one food tastes as good as another to me”
Perceptual aberration - “I have felt as though my head or limbs were somehow not my own”
Magical thinking - “if reincarnation were true, it would explain some unusual experiences I have had”
This diathesis may be typological
Non-schizotypes may be at zero risk of schizophrenia
additional examples diathesis on personality
Anorexia nervosa
Perfectionism
Bipolar disorder
Hypomanic temperament
Obsessive-compulsive disorder
Thought-action fusion
Panic disorder
Anxiety sensitivity
illustrative item diathesis on personality
Perfectionism
“If I do not set the highest standard for myself I am likely to end up on a second-rate person”
Hypomanic temperament
“I am frequently so hyper that my friends kiddingly ask me what drug I’m taking”
Thought-action fusion
“Having a bad thought is almost as sinful to me as a bad action
Anxiety sensitivity
“It scares me when I feel faint”
paranoid personality disorder
linked to risk of psychosis
- pervasive distrust and suspiciousness of others that their motives are interpreted as malevolent
indicated by 4 (or more) of the following
- suspects, without sufficient basis, that others exploit, harm or deceive
- preoccupied with unjustified doubts about the loyalty or trustworthiness of associates
- reluctant to confide in others because of unwarranted feat that the information will be used against them maliciously
- reads hidden demeaning or threatening meanings into benign remarks or events
- persistently bears grudges
- perceives attacks on their character or reputation that are not apparent t others and is quick to react angrily/counterattack
- has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner
what is OCD linked to?
anxiety and depression
what is borderline disorder linked to?
acting out
narcissistic personality disorder
- a pervasive pattern of grandiosity (fantasy or behaviour), need for admiration, and lack of empathy
indicated by five (or more) of the following:
- has a grandiose sense of self-importance
- preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love
- believes that he or she is “special” and unique and can only be understood by, or should be associated with, other special or high-status people
- requires excessive admiration
- sense of entitlement
- interpersonally exploitative
- lacks empathy
- often envious of others or believes that other are envious of them
- shows arrogant, haughty behaviours or attitudes
avoidant personality disorder
a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity negative evaluation
4 (or more):
- avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval or rejection
- unwilling to get involved with people unless certain or being liked
shows restraint within intimate relationships because of the fear of being shamed or ridiculed
- preoccupied with being criticised or rejected in social situations
- inhibited in new interpersonal situations because of feelings of inadequacy
- views self as socially inept, personally unappealing, or inferior to others
- unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing
dissociative identity disorder (multiple personalities)
Controversial diagnosis
≥ 2 distinct personalities that switch
1 host personality
2 or more ‘alters’
Alters may differ in many ways
Usually relatively uninhibited, often child-like
May have different allergies, optical prescriptions, handedness
- disruption of identity characterised by two or more distinct personality states, involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behaviour, consciousness, memory, perception, cognition, and/or sensory-motor functioning - can only be observed by others or reported by individual
- recurrent gaps in the recall of everyday events
- symptoms cause clinically significant distress or impairment in important areas of functioning
- not a normal part of a broadly accepted cultural or religious practice
- not attributable to the physiological effects of a substance or another medical condition
reasons for controversy of DID
The disorder offends our sense of self-continuity and coherence
Apparent explosion of cases
Epidemic, prior under-diagnosis or fad?
Geographic focus on USA dramatic/theatrical quality of some living with DID
Alternations in symptoms
Animal alters, increases in average number of alters
Dominant theory: (“traumatic”)
People with DID usually report suffering extreme trauma
They also tend to score high on ‘suggestibility’ (to hypnosis)
‘Dissociation’ = ‘internal avoidance’ or compartmentalisation
Patients become rehearsed and skilled in this defence and construct alter personalities to deal with complexities and threats of life experience
Another theory (“sociocognitive”)
The disorder may not be a naturally occuring splitting or fragmentation of the personality
It may instead be caused by therapists and culture
Therapists (poorly skilled) inadvertently may use leading questions in suggestible unstable people may create apparently distinct personalities: iatrogenic
Culture sanctions this manner of expression of psychological distress through creative mass media and news
Treatment implication involve ignoring post-traumatic symptomatology
