Week 1 Flashcards
Nosophobia
Also called “Medical Student Syndrome”
It is very common for medicine (and psychology) students to develop fears and symptoms of illness
Occurs in as many as 70-79% of students at some stage during training
A particular problem with ‘personality disorders’
E.g., Mark said x…I do that! I must have X Disorder!
Avoid the temptation of self-diagnosis!
Don’t ‘Psychopathologize’
Increasing awareness of psychological disorders can lead to noticing traits of pathology.
Particularly a problem with personality disorders.
Avoid the temptation to pathologize the behaviour, etc. of others.
E.g., It is not professional and you loose credibility!
Remember that ‘diagnosis’ without sufficient training or assessment may be unethical.
E.g., Would like someone to do that to you?
Ancient Attempts at understanding illness and providing Therapy
Earliest known attempts during Stone Age
Demonic possession ideas shared by many ancient cultures
Greeks, Chinese, Hebrew, Egyptian
Trephining
Use of stone tools to chip a hole in the skull
Early Rational Psychiatry – a glimmer of hope
Reformulation by Hippocrates Rejected notions of demonic possession First classificatory system of mental illness Mania (concept differs today) Melancholia (concept differs today) Phrenitis (inflammation of the brain) Treatments included: vegetarian diet exercise sexual abstinence bloodletting
Middle-Ages Psychiatry
Treatments centred around concept of exorcism, using methods such as prayer, holy water…
Mental illness associated with witchcraft
Renaissance Psychiatry
Rediscovery of scientific method and reason in the enlightenment and renaissance
Belief in possession and witchcraft declines
No coherent theoretical model of mental illness remained
Rise of humanitarianism
Gradual movement into asylums.
Little effective treatment
Towards early 1900’s
Treatments became less about torture and shame and more about
“Talking Cures”
E.g., Breuer, Freud, and More
Stimulation of body parts
E.g., treatment of “hysteria…the wandering womb”!
Modern Account of Abnormality
Defining “Abnormal”
The thoughts, behaviours, and emotions are:
Distressing to self and others
Dysfunctional for self or others
Statistical Rarity (Quantitative) or Deviance (Qualitative)
Defining Abnormal - Distress
Personal Distress
Many DSM criteria specify that the disorder must cause significant distress
E.g., Major Depressive Episode Criteria B
“The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.”
Other person distress
E.g., Antisocial Personality disorder is more distressing to others than self
Pathology is when…
anyone is personally distressed or unduly distressing anyone else
Defining Abnormal - Dysfunction
Psychological Dysfunction
Impairment of functioning Cognitive – Dysfunctional Thoughts E.g., “I am bad” Behavioural – Dysfunctional Behaviours E.g., Gambling away family savings Emotional- Dysfunctional emotions E.g., Uncontrolled rage Interpersonal – Dysfunctional Relationships E.g., Inability to maintain long-term relationship despite desire to do so
Defining Abnormal – Statistical Rarity (Quantitative)
The pattern is a statistical rarity
E.g. Among one million people, the person is the only one with severe fear of tables
Statistical rarity alone is not sufficient to determine pathology
E.g., What about
Defining Abnormal – Deviance (Qualitative)
Atypicality / Culturally Unexpected
There is considerable cross-cultural variation in acceptable behaviour
E.g., Belief in spirits more accepted in Chile
Abnormality of behaviour must be judged in the context of the cultural group to which the individual belongs
E.g., Believing in spirits in Chile is “normal” so cannot be viewed as Abnormal
Note that cultures are made up of diverse subcultures
E.g., Not everybody in Chile believes in spirits
Abnormality is not sufficient to determine disorder!
Eg the history of homosexuality as a ‘mental disorder’ as per the dsm
for example:
The history of homosexuality as a ‘mental disorder’
DSM-I: Sociopathic personality disturbance
DSM-II: Homosexuality
DSM-II (7th printing): Sexual orientation disturbance
DSM-III: Ego-dystonic homosexuality
DSM-III-R: Removal of homosexuality from DSM
DSM-IV: Sexual disorder NOS
Only for persistent distress regarding one’s sexual orientation
DSM-5: No specific mention of “homosexuality” except as an additional area of distress in Pedophilic Disorder….FINALLY!
Assessment of Abnormality
Assessing Disorders
Clinical Interviews Structured interviews (e.g., ADIS or SCID) Unstructured interview Psychological testing Beck Depression Inventory II Observations Behavioural assessments Psychophysiological assessment Heart Rate Neuroimaging CAT, PET, MRI, fMRI
Diagnosis & Formulation
The Concept of “Syndromes”
Certain symptoms are known to co-occur.
A syndrome refers to a collection of symptoms that are frequently observed together.
The good thing about knowing about syndromes is that, if several symptoms are present…this may help you predict other symptoms based on your knowledge of the syndrome.
First – Lets just consider what Comorbidity means
The presence of any DSM diagnosis increases the likelihood of an additional diagnosis
Specific examples
Specific phobias
E.g., Having a phobia of spiders may also mean having a phobia of another creature or anxiety disorder such as social anxiety
Personality Disorder
E.g., Having Narcisstic Personality Disorder makes diagnosis of depression more likely
Problems with Diagnosis
Problems with reliability
E.g., assessments may be inconsistent in detecting disorder
Problems with validity
E.g., assessments may not be detecting the intended disorder
Self-fulfilling prophecy
E.g., if the client believes it the assessment may simply mirror this belief
Diagnostic bias
E.g., We see what we want to see at time
Lets consider an example of these
Example: Anxiety & Depression
The DSM system sees anxiety and depressive disorders as distinct conditions. But... High comorbidity High overlap of symptoms Difficulty in psychometric separation Treatment approaches Response to treatment (GAD and MDD)
Categorical vs Dimensional
CATEGORICAL =
Categorical
Discrete syndromes
Distinct boundaries with other disorders
Distinct boundaries between normal and abnormal
Categorical vs Dimensional
DIMENSIONAL =
Dimensional
Traits occur along a spectrum of intensity
Traits occur in a finite proportion of the general population
The Formulation Approach
An alternative to the diagnostic approach
Commonly utilized in clinical psychology
E.g., it is taught to all clinical masters students at Griffith University
Involves a focus on the etiology and maintaining factors relating to a patient’s psychopathology.
Defining Case Formulation
“…a hypothesis that relates all of the presenting complaints to one another, explains why these difficulties have developed and provides predictions about the patient’s condition.”
Aims of Case Formulation
Integration of information
Explanation of current and historic problems
Provides a blueprint for guiding therapy
Provides predictions about future challenges
Enhances understanding and empathy
What’s Included in Formulation – The Four + 1 P’s
Presentation (symptoms and problems)
Predisposing factors (past traumas)
Precipitating factors (triggering events)
Perpetuating factors (maintaining factors)
Protective factors (reduces the problem or distress)
A valid comparison then!
Lets compare the usefulness of a Diagnosis approach to Formulation approach
John has depression
Provide your understanding of what is going on for John using each approach!
Diagnosis-Based Treatment
E.g., BDI-II
Major Depressive Disorder
ASSESSMENT > DIAGNOSIS > TREATMENT
Formulation Based Approach
eg
Regenting Parent > Core Belief: “UNLOVABLE” > John’s Wife asks for a divorce > (Negative auto thoughts <> Depression symptoms <> )
The DSM Diagnostic System
Pre-History of the DSM
Emil Kraepelin
`1855-1926 Research training under Wundt Kraepelin (1902) Psychiatric textbook (6th ed) Dementia praecox Manic-depressive insanity
DSM-I & DSM-II – based on consensus between psychiatrists
DSM-1
APA (1952)
128pp
106 diagnoses
DSM-II
APA (1968)
134pp
182 diagnoses
Feighner Criteria – DSM-III
Feighner et al. (1972)
Diagnostic criteria for use in psychiatric research
15 mental disorders with sufficient research support to establish credibility – These are at the end of slides
Argued that previous problems had been the result of a lack of clear, unambiguous criteria
DSM-III
APA (1980)
494pp
265 diagnoses
Introduced multiaxial diagnoses
Based on scientific evidence rather than clinical consensus
Specific criteria for each diagnosis
Term “neurosis” excluded
DSM-III-R
APA (1987) 567pp 292 diagnoses Update to DSM-III based on large amount of research since 1980 Controversial diagnoses included in appendix or excluded Premenstrual syndrome Masochistic personality disorder Paraphilic rapism
DSM-IV
`APA (1994) 886pp 365 diagnoses Work commenced in 1988 Concept of clinically significant impairment introduced Average of 8 criteria per diagnosis Attempted to address criticism of lack of referencing in earlier editions 5 Sourcebooks of evidence
DSM-IV-TR
APA (2000)
943pp
365 diagnoses
Revision of text without new diagnostic criteria
DSM-5
APA (2013)
947pp
Alternative Diagnostic Systems
PDM = Psychodynamic Diagnostic Manual
CCMD-3 = Chinese Classification of Mental Disorders
CFTMEA = French Classification of Child and Adolescent Mental Disorders
GC-3 = Third Cuban Glossary of Psychiatry
GLADP = Latin American Guide for Psychiatric Diagnosis
ICD-10-AM
ICD-10-AM is the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification. It consists of a tabular list of diseases and accompanying index.
ICD-10-AM was developed by the National Centre for Classification in Health and has been in use since 1998. It was developed with assistance from clinicians and clinical coders to ensure that the classification is current and appropriate for Australian clinical practice. ICD-10-AM is a derived version of the World Health Organization (WHO) ICD-10. It uses an alphanumeric coding scheme for diseases and external causes of injury. It is structured by body system and aetiology, and comprises three, four and five character categories. ICD-10-AM is updated on a regular basis, with the regular updates of ICD-10 being included as part of the updating process.
Feighner et al. Diagnoses
Primary Affective Disorder -------Depression -------Mania Secondary Affective Disorder Schizophrenia Anxiety Neurosis Obsessive Compulsive Neurosis Phobic Neurosis Hysteria
Antisocial Personality Disorder Alcoholism Drug Dependence (Excluding Alcoholism) Mental Retardation Organic Brain Syndrome Homosexuality Transsexualism Anorexia Nervosa
