Introduction Flashcards
What is a diagnosis?
A means of understanding a disorder by identifying clusters of features that reliably co-occur
What should a diagnosis system do?
Indicate causes
Indicates course of the problem
Indicates optimum treatment
Two widely used diagnostic systems
Diagnostic and Statistical Manual (DSM-5)
International Classification of Diseases (ICD-10)
Problems with diagnosis
Clinicians routinely disagree about the case diagnoses
Problems with artificially allocating people to groups that they do not naturally fit
Alternatives to diagnosis for psychological problems
Symptom-centred
Dimension-based
Formulation based approaches
Symptom-centred approach
Can address some symptoms successfully without addressing others
Problems with the symptom-centred approach
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
Dimension-based approach
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
Formulation-based approach
Commonly used in clinical psychology
Understanding of an individual or disorder based on the interaction of individual and common biopsychosocial factors
The formulation based approach should…
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
What structure is the formulation approach based upon?
Antecedent
Behaviour
Consequences
Padesky & Mooney (1990)
The CBT hot cross bun
Homeostatic system, whether healthy or not
Common themes can be found across individuals which map closely to diagnoses
4 parts of the Hot Cross Bun
Cognitions/beliefs
Behaviour
Biology/physiology
Emotions/feelings
Is formulation better than diagnosis?
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
What are the two criteria to consider to see if the formulation approach is better than the diagnostic approach?
Are we good judges of what will work?
Are our formulations good enough to help the patient?
Grove et al (2000)
Meta-analysis
Found that mechanistic approaches are better than clinician judgement
Doesn’t get better with age or experience
Walfish et al. (2012)
The average therapist thinks that they are better than 80% of other therapists
Kuyken (2006)
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
Schulte (1997) and Schulte et al. (1992)
Slim evidence is that diagnosis works better than formulation
Measured by patient outcomes
Kuyken et al. (2005)
Only about 40% of therapists did formulations that were rated as good enough
Beware the assumption that we are any good at formulation
Models of psychological therapies
Psychoanalytic
Behavioural
Systemic
Congnitive-behavioural
Psychoanalytic models
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
Behavioural models types
Classical conditioning
Operant conditioning
Classical conditioning
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
Exposure-based therapies
Imaginal exposure
Systematic desensitisation
Flooding
Operant conditioning
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
Limitations of operant conditioning
Punishment rarely works effectively
Limited by genetic loadings
Systemic models
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
Cognitive-behavioural models
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
Ways to determine the impact of therapies
Single cases
Case series
Uncontrolled pre-post design
Randomised controlled trial (RCT)
Meta-analysis
NICE guidelines will only recommend a therapy at the ‘A’ level if it has what?
RCT evidence based on meta-analyses
Persons (1989) case formulation components
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
Tarrier (2006) advantages of case formulation approach
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)
