Diagnosis and formulation in clinical psychology

Question 1

What did mental health look like in the dark / middle ages

Answer 1

demonological thinking but in a Christian context

obsession with witchcraft and evil spirits = people were killed, punishment

Rise of asylums

Question 2

1900 to now mental health

Answer 2

• Late 1930s-40s: Electroconvulsive therapy (ECT) unconscious produce a fit like state - some evidence-based that it works - changing the brain waves.
• 1940s-1960s: Lobotomy
• Late 1940s-80s: First psychiatric drugs
  1950s: Fall of the asylums / deinstitutionalisation. Increase in community-based mental health care

Question 3

What do the stages of mental health diagnosis look like now?

Answer 3

1) Primary care = prescription of antidepressants and referral to other services
2) Secondary care = Community-based mental health teams + Psychiatric hospitals (generally very unwell, at risk, or risky patients)
Tertiary care = Specialist services e.g. specialist eating disorder services, forensic mental health, in patient re-hab)

Question 4

How to we form a concept of mental health today using the biopsychosocial model

Answer 4

Biological Factors:
Genetic defects or inherited vulnerabilities; poor prenatal care, head injuries, exposure to toxins, diet, chronic physical illness, or disability - often overlap between these

Psychological Factors:
Personality traits (e.g. perfectionism), stress, cognitive styles, coping strategies, IQ, beliefs, behavior

Social Factors:
Poverty, homelessness, overcrowding, stressful living conditions, adversity, parents with mental ill-health, family or societal norms/expectations/communication styles, severe marital or relationship problems, trauma

Question 5

What is the Stress Vulnerability model? and how does it explain mental health?

Answer 5

The stress vulnerability model proposes that anyone can develop mental health problems, given stress, biological, social, and psychological stressors.

People are more vulnerable to mental disorders if they have been exposed to more stressors, especially in their younger life.

Stress is a limited capacity which gets even more limited as people get older.
Explains why little things can tip us over the edge like a bucket analogy

Question 6

Why is it good to explain the stress vulnerability model to patients

Answer 6

Makes people feel like their not alone. Everyone experiences stress, and their actions can feel irrational but when putting it into this perspective it makes sense.

Question 7

Diagnosis is made using a classification system: What is this?

Answer 7

Classification system is:
1) A comprehensive list of disorders, with
2) Description of the symptoms
3) Guidelines for assigning individuals to disorder

Each disorder is assumed to have its own:
1) Origins
2) Symptoms
3) Course and outcome

Question 8

Name two examples of classification systems

Answer 8

World Health Organisation: ICD-11 – covers both medical & psychological conditions

American Psychiatric Association: DSM-5

Question 9

Lists the current DSM-5 definition of mental disorder (3 things) and 2 things it is NOT

Answer 9

1. Clinically significant disturbance in cognition, emotion regulation or behavior
2. Dysfunction in psychological, biological, or developmental processes
3. Significant distress or disability in social, occupational or other important activities
4. NOT due an expectable or culturally approved response to a common stressors or loss

NOT socially deviant behaviour (e.g. political, religious or sexual) UNLESS it results from a dysfunction in the individual

Question 10

Are diagnoses helpful, valid and representative of what is going on for clinicians and researchers?

Answer 10

Yes, allows clinicans to quickly identify:
-cause of problem
-and effective treatments quickly
-creates a common language for psychologists and clinicans to discuss cases and research
-

Question 11

Are psychiatric diagnosis helpful for the patient?
How?

Answer 11

Yes.
-allows them to understand what is happening / what is expected and potential duration
-normalise experience
-Identify helpful treatment

Question 12

Why does the classification system keep changing? in relation to the rosenhan study

Answer 12

○ Rosenhan et al 1973 study – Attended psychiatric hospitals complaining of hearing voices after not washing or shaving for 5 days; once admitted, they said the voices ‘had gone’. Then continued to behave ‘normally’
○ Admitted for 7-52 days - everything pseudo-patients did was interpreted in light of assumed pathology - all their behaviours were interpreted as in line with mental health disorders despite acting completely normal. Shows how un-reliable diagnosis was.
Led to DSM-III – highly descriptive, symptom checklists – aiming to increase inter-rater reliability of diagnosis

Question 13

List some of the disadvantages of psychiatric diagnosis

Answer 13

Still have ongoing problems with reliability

Ignores individuality of people’s psychological issues ( possibility that the same symptom may occur as a result of different causes)

Problems with being ‘labelled’
(Prejudice and discrimination, jobs, friends, housing, insurance etc. may all be more difficult to get if you’ve got a psychiatric record)
(Creates a sense of “Us and them” / “ill” or “not ill”)

Question 14

List Coma’s 4 D’s

Answer 14

1. Deviance
2. Distress
3. Dysfunction
4. Danger

Question 15

What is Deviance

Answer 15

Anything different or abnormal
-takes into account different norms of different societies
-example of abnormal behaviour that goes against societal norms ‘repeated swearing that is associated with tourettes

Question 16

Limitations of ‘deviance’ as a measure

Answer 16

Norms of behaviour differ across different cultures and different periods of time.

Abnormal behaviours are not that uncommon. A study suggested 20-55% of adults have psychological problems at some point in their lives that would meet official criteria for diagnosis (Kessler et al, 2005)

Question 17

Define ‘Distress’
Who is most likely to experience distress?
And to what extent?

Answer 17

non-specific symptoms of stress, anxiety and depression.

People experiencing psychological disorders such as phobias, do report that their disorder causes them distress.

In many cases, it is the degree of distress which causes them to seek help.

Question 18

Criticisms of ‘distress’

Answer 18

• Not all distress is abnormal or problematic - difficult emotions are normal and necessary.

Question 19

Define ‘dysfunction’

Answer 19

behaviour which:
upsets
distracts or confuses
a person that it interferes with an important part of their life.

people diagnosed with obsessive compulsive disorder (OCD) often report that it interferes with their lives.

Question 20

Criticisms of ‘dysfunction’

Answer 20

Some level of dysfunction is relatively normal, at what point do we diagnose and treat?

For example: Sometimes people undergo a great deal of unhappiness or deprivation to serve some higher goal e.g.

• protest fasting of Ghandi, would not be considered an indicator of abnormal psychological processes

Question 21

Define ‘Danger’

Answer 21

when behavior represents a threat to the safety of the person or others.

Dangerousness is often cited as a criterion in defining abnormality.

Question 22

Criticisms of ‘Danger’

Answer 22

Mental health service users are much more likely than others to be victims of violence.

Parker et al. (1995) looked at 700 murders and found that 22 (3%) were committed by people who had been in contact with psychiatric services in the last year.

Question 23

List the 5 models of mental health

Answer 23

1. Biomedical Model
2. Psychoanalytic model
3. Behavioural model
4. Cogntive-Behavioural model
5. Systemic / Interpersonal model

Question 24

Benefit of wide range of models

Answer 24

If working in a specific therapeutic model, you would normally follow that model.
The picture/formulation will look different depending on which model you are working from and how the client is perceiving themselves at that time.

so drawing across models to make sense of the person’s problem.

Question 25

Define Biomedical model of mental health

Answer 25

Explains illness in terms of: biochemical imbalances, genetics, epigenetics, congenital risk factors, abnormal physical development, physical effects of pathological activities e.g. impact of drugs

Question 26

Advantages and disadvantages of biomedical model

Answer 26

+ Use of scientific methods and quantitative techniques (CAT scans, PET scans MRI scans)
+ Physical treatment = drugs

Disadvantages=
- Reductionist - not multifactorial – focuses only on organic factors
-Assumes pathology only - ○ Not all psychological distress is pathological e.g. exam stress
Potential for stigma/exclusion – ‘labelling’ people as mentally ill

Question 27

Define Psychoanalytic model for mental health

Answer 27

-early experiences +
- and psychological ‘defence’ mechanisms
-* Talking treatment, unpicking unconscious/subconscious processes influencing emotions/behaviour

Question 28

Advantages and disadvantages of psychoanalytic model

Answer 28

+* Highlighted potential roles of
○ the unconscious
○ early life experiences
○ Relationship between patient and therapist
○ Theory has evolved over time and many people find beneficial

Disadvantages
-* Time-consuming and expensive
* Hard to test (all internal phenomenon, and ‘unconscious’)
* Lacking in empirical evidence base (although people are working on this)

Question 29

Define Behavioral Model

And what treatment is used for this model

Answer 29

• Explains illness as the result of learned behaviour (classical and operant conditioning)
• Treatment involves ‘unlearning’ behaviour or learning or reinforcing new, more ‘desirable’ behaviours

Question 30

Advantages and disadvantages of Behavioural Model

Answer 30

+ Testable can observe behaviour

Limitations
-* Reductionist – assumes that humans are just stimulus-response
-limited impact Token theory.
(use of tokenism in institutions to reward/punish good/bad behaviour – only lasted as long as the rewards were there)

Question 31

Define Cognitive-behavioural model

Answer 31

• Explains illness as the result of negative thoughts / cognitive biases that affect emotions & behaviour

Treatment involves (CBT) changing thoughts, correcting biases, changing behaviour

Question 32

Pro’s and cons of Cognitive behaviour model

Answer 32

+ Used methodological and scientific rigour in its development & evaluation
+ Testable (self-report, observation)
+ Empirically effective
+ Range of adaptations for specific psychological problems
+Widely used (dominant therapy currently)

Cons=
disregards:
○ biological aetiology
○ emotions
○ patients wider social context

• Battle of thoughts vs. accepting

Question 33

Define Systemic / interpersonal model
and treatment

Answer 33

• Explains illness as the result of social context (e.g. family and wider systems)
• Treatment involves analysing and changing patterns of interaction

Question 34

Pros and cons of systemic / interpersonal model

Answer 34

+Effective with a wide range of problems in children and adults
+emphasizes the importance of social context within psychiatric disorders.

-Vague – various models & theories
-Risk of losing sight of the individuals in the system?
-Potential difficulties in getting whole system to engage?

Question 35

Downside of formulation of different models?

Answer 35

• Reliability/subjectivity - one clinician may create different formulation to another:
  Supervision, continuous professional development (CPD), working in multi disciplinary teams

Question 36

Stigma and discrimination within mental health disorders.

-Explain demographic inequalities in regard to not taking up treatment

Answer 36

Demographic inequalities treatment:
-Low treatment rates in black ethnic minority groups
-

Question 37

STIGMA around mental illness

Describe the findings of Attitudes to Mental illness survey by (NHS digital, 2011)

Answer 37

§ 50% would feel uncomfortable talking to their employer about their mental health

§ 30% wouldn’t feel comfortable disclosing mental ill-health to a friend or family member

§ 16% agreed that one of the main causes of mental illness is a lack of self-discipline and willpower

Question 38

Explain the problem with Black and minority groups and mental illness

And why are black ethnic groups more likely to be diagnosed with SZ.

Answer 38

Lack of cultural understanding.

Some black cultures explain mental health through witchcraft and spirits. When this is relayed to a western doctor it can seem like a bigger problem however that is just what their culture believed. But it can come across as signs of SZ.

People from black and minority ethnic backgrounds, particularly young men, are:
-less likely to seek help from professional mental health services
-more likely than others to be diagnosed with schizophrenia

Question 39

What can be done about black minority health care?

Answer 39

Unconcsious bias training. Training about different cultural views on mental health.

What may be seen as dysfunctional in one culture, may be functional in another: in some cultures what we consider psychosis/voicing hearing/hallucinations is seen as divine/spiritual/shamanism

Question 40

Roles of adversity in adult mental health

-what is the prevalence in england of common mental health disorders?

Who is more suseptible to these disorders?

Answer 40

1 in 6 in England had a common mental disorder (e.g. depression, anxiety)

	○ More common in:
		§ People living alone
		§ Those with poor physical health
		§ Unemployed
		§ Young women (16-24 years) ,

Question 41

The effects of prejudice and discrimination on mental well-being

Answer 41

Encountering prejudice and discrimination, either on mental health grounds or on other grounds such as ethnicity, class, gender or sexuality can be a significant obstacle to mental well-being or recovery.

Question 42

Potential role of stigma in illness

Answer 42

“Many people find that the hardest part of recovery is overcoming prejudice, discrimination, lowered expectations and the pressure to subscribe to a ‘sick role’”.