Introduction

Question 1

What is a diagnosis?

Answer 1

A means of understanding a disorder by identifying clusters of features that reliably co-occur

Question 2

What should a diagnosis system do?

Answer 2

Indicate causes

Indicates course of the problem

Indicates optimum treatment

Question 3

Two widely used diagnostic systems

Answer 3

Diagnostic and Statistical Manual (DSM-5)

International Classification of Diseases (ICD-10)

Question 4

Problems with diagnosis

Answer 4

Clinicians routinely disagree about the case diagnoses

Problems with artificially allocating people to groups that they do not naturally fit

Question 5

Alternatives to diagnosis for psychological problems

Answer 5

Symptom-centred

Dimension-based

Formulation based approaches

Question 6

Symptom-centred approach

Answer 6

Can address some symptoms successfully without addressing others

Question 7

Problems with the symptom-centred approach

Answer 7

Effective in reducing frequency and distress of the symptom but doesn’t necessarily lead to recovery from the wider disorder

This is a problem if residual symptoms result in a relapse

Question 8

Dimension-based approach

Answer 8

Reduction in unhelpful traits (eg. a reduction in clinical perfectionism)

Commonly used when working with personality disorder pathology

Single or combined dimensional traits used to identify pathological/positive personality types

Question 9

Formulation-based approach

Answer 9

Commonly used in clinical psychology

Understanding of an individual or disorder based on the interaction of individual and common biopsychosocial factors

Question 10

The formulation based approach should…

Answer 10

Make sense

Be as simple as possible

Never be assumed to be true

Indicate what changes are needed to help the individual reduce/remove the psychological problem

Question 11

What structure is the formulation approach based upon?

Answer 11

Antecedent

Behaviour

Consequences

Question 12

Padesky & Mooney (1990)

Answer 12

The CBT hot cross bun

Homeostatic system, whether healthy or not

Common themes can be found across individuals which map closely to diagnoses

Question 13

4 parts of the Hot Cross Bun

Answer 13

Cognitions/beliefs

Behaviour

Biology/physiology

Emotions/feelings

Question 14

Is formulation better than diagnosis?

Answer 14

Psychologists almost universally see formulation as better than diagnosis as it is based on knowledge of the individual and judgement rather than a more mechanistic approach

Question 15

What are the two criteria to consider to see if the formulation approach is better than the diagnostic approach?

Answer 15

Are we good judges of what will work?

Are our formulations good enough to help the patient?

Question 16

Grove et al (2000)

Answer 16

Meta-analysis

Found that mechanistic approaches are better than clinician judgement

Doesn’t get better with age or experience

Question 17

Walfish et al. (2012)

Answer 17

The average therapist thinks that they are better than 80% of other therapists

Question 18

Kuyken (2006)

Answer 18

Beware of the assumption that formulation is more effective than diagnosis

There is a risk that we seek evidence that it works and we ignore evidence that it does not

Question 19

Schulte (1997) and Schulte et al. (1992)

Answer 19

Slim evidence is that diagnosis works better than formulation

Measured by patient outcomes

Question 20

Kuyken et al. (2005)

Answer 20

Only about 40% of therapists did formulations that were rated as good enough

Beware the assumption that we are any good at formulation

Question 21

Models of psychological therapies

Answer 21

Psychoanalytic

Behavioural

Systemic

Congnitive-behavioural

Question 22

Psychoanalytic models

Answer 22

First proposed in the 1890s

Assumptions are largely about unconscious processes and how they manifest in the here and now

Therapy based on the assumption that the unconscious motivations can be understood and conflicts can be resolved with the aid of the therapist interrupting unconscious messages in communication and behaviour

Question 23

Behavioural models types

Answer 23

Classical conditioning

Operant conditioning

Question 24

Classical conditioning

Answer 24

First proposed in the 1900s

Based on Pavlov’s work

Widely related to anxiety disorders

Basis of many exposure-based therapies

No assumption of unconscious processes

Question 25

Exposure-based therapies

Answer 25

Imaginal exposure

Systematic desensitisation

Flooding

Question 26

Operant conditioning

Answer 26

First proposed in the 1910s

Based on Thorndike’s and Skinner’s work

Relevant to a range of disorders

Basis of a lot of therapeutic techniques

Question 27

Limitations of operant conditioning

Answer 27

Punishment rarely works effectively

Limited by genetic loadings

Question 28

Systemic models

Answer 28

First proposed in the 1940s

Different models of therapy

Relevant to a range of disorders

Therapy is usually at the level of:

• Family
• Couple
• Institution

Question 29

Cognitive-behavioural models

Answer 29

First proposed in the 1960s

Based on the work of Beck and Ellis

Used for pretty much everything

Often work best when the behavioural changes are used to create cognitive changes

Question 30

Ways to determine the impact of therapies

Answer 30

Single cases

Case series

Uncontrolled pre-post design

Randomised controlled trial (RCT)

Meta-analysis

Question 31

NICE guidelines will only recommend a therapy at the ‘A’ level if it has what?

Answer 31

RCT evidence based on meta-analyses

Question 32

Persons (1989) case formulation components

Answer 32

List the clients problems

Identify and describe the underlying psychological mechanisms that might be mediating the problems

Understand the way in which the psychological mechanisms generate the client’s problems

Identify the kinds of events which may have precipitated the client’s problems

Develop a scheme of treatment based on these explanations and predict any obstacles to treatment

Question 33

Tarrier (2006) advantages of case formulation approach

Answer 33

Allows a flexible and idiosyncratic understanding of each client’s individual problems irrespective of individual diagnoses they may have been given

It is collaborative and treats the client with regard

It is firmly based on theoretical understanding of psychopathology (unlike diagnosis which is based on a description of symptoms)

It can include information about a client’s past history and the client’s personal, social and family history

It allows the development of treatment strategies that can be moulded to the specific needs of that individual client (especially advantageous when treating complex cases that do not easily conform to standard diagnostic categories)