Lecture 1 - Intro and conceptual models Flashcards
What is psychopathology?
The study of mental illness (field), but also illness itself
Etiology = study of the origins
WHY define mental illness?
-easier to treat when know what issue is
-comfort in diagnosis (explains own behaviour)
-standardized treatment
-predict its course
-reduce stigma in communities
….
Medical models/syndromes
Emil Kraepelin
*Syndrome borrowed from
medical models of illness
-Distinct forms of mental illness are defined like a syndrome: with clusters of correlated symptoms that largely present together
*Taxonic: presumes that they are categories that exist in the real world, measurable real-world entities (depression would be as real as chicken pox)
*Medical models have
evolved over time
*Acknowledge illness as
multifactorial/ multiply
determined
*Clinical Psychology working
to catch up
Definitions and Constructs of Mental
Disorders: Harmful Dysfunction (Wakefield, 1992)
*Dysfunction: “an organ system performing contrary to its
design.”
* Importantly, not at the peak of its design (even if being amazing at tennis is contrary to human design, doesn’t make it a disorder). Has to cause harm
Natural selection as basis + social
*Wakefield argues that the brain is designed to perform a number of
functions:
- Thinking
- Feeling
- Emotion Regulation
*Problems with any of these functions indicates a disorder
*Presumes we understand the function and design of the
brain, personality, emotions, etc.
-Dangerous to assume universal definition of adaptive functioning (ex: homosexuality as disorder)… have to recognize contextually bound by societal norms
-Harm does not need to be subjectively perceived (can harm others without person reporting suffering from psychopathology) Ex: people with antisocial personality disorder, someone in manic episode. Might not report distress but still harming others.
Lillienfeld critique
*What is “natural
function?”
*Natural selection
depends on variability
*Some disorders may
represent adaptations,
not maladaptations. Really hard to distinguish between adaptations, adaptively neutral byproducts (doing math, music or art… not necessarily critical for survival but increase human capacity) and secondary adaptations (like feathers) in biology
Widiger’s proposal
*Mental disorders are
constructs
Latent construct
*Construct: things that we think exist but cannot measure directly. Agreed upon and work to refine.
*Not single definition, evolves over time. But doesn’t mean subjective
*Different ways of thinking capture different aspects of psychopathology
Multi-modal approaches
Psychiatric disorder = Environmental influences + activity of susceptibility genes or biological abnormalities
Expressed in self-report, neural function, physiological responses, behaviour
Diagnosis and diagnostic systems: Purposes of a classification system
*Description: Highlight critical features of a diagnoses.
- e.g., Schizophrenia: What are the important symptoms?
*Prediction: May tell you something about course, treatment
response, etiology.
*Theory: Provides a set of postulates about relationships of
different elements to one another.
*Communication: e.g., between clinicians.
Five criteria (Robins & Guze) proposed for valid
classification of disorders:
1. Clinical Description: The disorder has to be
characterized by a common set of symptoms that cluster
together and are characteristic of the disorder.
2. Course: people with the disorder should follow a
common trajectory, and have a similar onset
*3. Treatment Response: If a disorder is valid, most
people will respond similarly to similar treatments.
*4. Family History: Does the disorder run in families? If
so, speaks to validity of a diagnosis.
*5. Laboratory Studies: Look for biological and
psychophysiological associations
Limitations of a classification system
*Loss of Uniqueness: Diagnosis implies that common
features are more important than the ways in which
individuals vary.
*Difficulty of boundary cases:What do you do about the
people who are on the boundary? Do we arbitrarily
decide which group they’re more similar to?
-Procrustean beds.
Categorical vs. dimensional systems
*Categorical: yes or no
- Presence/absence of a disorder
– Either you are anxious or you are not
anxious.
*Dimensional: more scale-like
- Rank on a continuous quantitative
dimension
– Degree to which a symptom is present
– How anxious are you on a scale of 1 to 10?
*Dimensional systems may
better capture an individual’s
functioning
*Categorical approach has
advantages for research and
understanding
Categorical advantages:
*Simplifies communication
* In dimensional model,
everybody falls
SOMEWHERE.
*Natural preference among
people to employ categories
in speech.
*Categories better-suited for
clinical decision-making:
-Hospitalize or don’t?
-Treat or don’t?
*Dimensional: arbitrary cutoffs.
Dimensional advantages:
*Preserves more information
*Greater reliability– inter-rater,
test re-test
*Cutoffs in categorical system
tend to magnify small
differences
The DSM and classification
Before the DSM
Diagnosis was not good… experts in the field arrived at radically different conclusions and definitions
Epidemiological research… couldn’t say how common or rare in the world
DSM-I: 1952
DSM-II: 1968
-few categories
-no requirements for # of
symptoms
-Psychoanalysis was the
dominant paradigm
DSM-III: 1980
-demand for a more biological,
empirical approach
- Inclusion Criteria:What
symptoms do you need to
have, and how many?
-Duration Criteria: How long
do you need to exhibit these
symptoms?
-Exclusion Criteria:What
symptoms rule out a
diagnosis?
-Multi-Axial Classification
Multi-Axial Classification
I. Major Clinical Disorders (e.g.,
MDD, PTSD)
II. Personality Disorders (e.g., BPD,
NPD)
III. Medical conditions that might
contribute or be relevant to
treatment
IV. Psychosocial Stressors–
something with which to record
environmental contexts
V. GAF (global assessment of functioning)– a simple rating of
function/summary score for severity.
Assumptions introduced in DSM-III
*Symptoms are the most useful
basis for assessment
*Nosology based on behavior and
symptoms
*Locus of pathology is in the
individual
-What about family systems?
- Social systems?
DSM-IV
*DSM-IV: 1994
* Introduced “clinically significant
distress or impairment in social,
occupational, or other important
areas of functioning”
DSM 4 when psychoanalysis really mainly taken out (but also in DSM 3… symptoms rather than etiology)
DSM-IV-TR: 2000
*Did not introduce new diagnoses
or specific criteria
*Provided more information on
each diagnosis
*Provided a broad definition of
mental illness
DSM-5
*DSM-5: 2013
*Removed multi-axial system
* Introduced dimensional
assessment criteria for some
diagnoses
*Re-Classified some disorders
*Removed others
Number of Diagnostic Categories per
Edition of DSM
DSM-I 106
DSM-II 182
DSM-III 265
DSM-III-R 292
DSM-IV-TR 297
DSM-5 157
Challenges to categorical classification system
- Heterogeneity
Heterogeneity : very different people in the same diagnostic category (2 people diagnosed with depression with very different symptoms… because need 5 out of 9) - Comorbidity
Comorbidity: simultaneous presentation of more than one disease
-Is the norm
Of people who currently meet criteria for one
disorder, 50% qualify for more than one.
-Over the course of their lifetime, 75%
- Comorbidity affects course, development,
presentation, treatment response, etc.
- Comorbid patients tend to have poorer
outcomes.
Research Implications: Anything you find to
be associated with one disorder may actually
be a result of the comorbid disorder
Why does comorbidity exist?
1. Chance:
Odds of MDD for adult females= 20%
Odds of anxiety disorder for adult females= 20%
- 4% will have both
- Some comorbidity is just chance
But comorbidity greater than chance alone would
indicate.
2. Sampling Bias:
Each disorder associated with a chance of being treated
Individuals with more disorders (i.e., more severe individuals)
are more likely to seek treatment.
Clinical samples, likely biased samples.
BUT, we find high rates of comorbidity in community
samples as well. Not just clinical samples.
-Sampling bias doesn’t account for all.
3. Problems with Diagnostic Criteria: Many criterion sets
overlap.
Suicidal ideation in MDD, Schiz, BPD, AUD, SUD
Sleeplessness in MDD and GAD
Worry in GAD and MDD, etc.
Still can’t totally account for high rates of comorbidity
4. Poorly-drawn diagnostic boundaries:
Multiformity
- People with MDD frequently have panic attacks
Comorbid disorders may in fact reflect a 3rd, independent
disorder (Maybe comorbid = its own disorder? Ex: pure MDD is one, pure GAD is one, and the comorbid between them= it’s own disorder?)
5. Causal explanation: One disorder is a risk factor for another
disorder
Conduct Disorder may lead to adult Substance Use Disorder.
6. Shared Etiological risk factors
-Ex: abuse in childhood predicts a lottt of psychopathologies
Alternative approaches (to DSM): Dimensional/Hierarchical Models
Internalizing…cause distress to themselves vs. (Anxious Mysery: MDD, GAD, Fear: panic disorder, social phobia)
Externalizing… cause distress to others (this is false, but the idea in this model) (Addiction: Substance abuse, drug dependence, Aggression: psychopathy, ODD, CD)
Hierarchical Taxonomy of Psychopathology (HiTOP)
Uses factor analysis to figure out how these variables cluster together)
See graph
Research Domain Criteria (RDoc)
Looking at domains thought to be central to human functioning
Transdiagnostic approach (disregarding diagnoses altogether)
Not for treatment, just for research definitions
See graph
