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Descriptive Psychopathology and Classification (Defining "…
Descriptive Psychopathology and Classification
Main messages
Helpful and unhelpful aspects and consequences of any system
Use diagnosis in tandem with a person specific formulation ("both-and" versus "either-or")
Observe your own attitudes
Terminology
Symptoms
- Self-reported, subjective experience
Sign
- Objective, observed in the individual
Disease
- Illness characterised by typical signs or symptoms, normally with a known cause (not reallyy used in psychiatry)
Abnormal
- Departure from the norm (statistical or behavioural)
Disorder
- An abnormality of functioning (physical or mental)
Syndrome
- A cluster of sings and symptoms that occur together (often used instead of disorder)
Aetiology
- Study of causation or origin of anything, including disease
Pathology
- The study of the (biochemical) mechanisms that cause disease
Psychopathology
- The study of mental disorders
Classification
A systematic process of arrangement in mutally exclusive groups or categories according to certain criteria
At the root of all scientific behaviour (Taxonomy - biology; Nosology - medicine)
Difficult to think or speak of events without classifying or categorising (e.g. animals)
Medical model of classification
Spefific cause(s) located within the individual
Describable (signs and symptoms)
Predictable course
Predictable outcome (prognosis)
Treatment to change or cure
Critique of the Medical model:
Both internal and external causes relevant (not just internal ones)
Can be unpredictable (not always predictable like the model proposes)
Can hard to describe symptoms and signs
Hard to predict the prognosis (not like stated in model)
Classification: critique
Advantages
Identify homogenous groups (funding)
Communication about groups simpler
Research on groups (epidemiology)
Groups and treatment strategies
Disadvantages
Can lead to assumptions that talking about the same thing when it might actually be different (patients might have different symptoms even though having the same lable)
Labelling/evaluations
Might be different between cultures
A reliable classification system should have mutally exclusive categories
High rates of comorbidity between disorders suggests diagnoses are not exclusive
Symptom based, not causal based
Lack of good inter-rater reliability (in psychological diagnosis)
Peoples diagnosis often changes over time
Categories suggest a "realness" (reification) to the disorders
Grouping signs of distress together gives impression they exist as a real "thing"
We can forget to view them as our current understanding (be humble)
(Implicitly) suggests and internal (mostly biomedical) cause of disorder
Difficult to find physical representation of disorder (no blood tests; frequently no obvious brain pathology...)
Disorders to a large extent socially, historically and culturally bound
homosexuality as mental disorder (DSMI/II)
Underplays social, psychological and political causes
Limits understanding of the problem (e.g. "I have depression" not "I am depressed because of ... ")
A diagnosis provides limited understanding of:
Individuals feelings, beliefs and understanding of psychological distress
The causes of the problem
Blocks and barriers to treatment
Ways to overcome barriers
Planning of treatment, particularly psychological and social
Alternatives to psychiatric systems
Developmetnal psychopathology (Sroufe & Rutter, 1984); Fonagy, Target, Fearon (UCL)
"The study of the origins and couse of individual patterns of behavioual maladaptation"
Risk & protective factors (how & why vs. what)
Attachment (interpersonal becomes intrapersonal)
Meaning making (development as active process; biology shaping and being shaped by experiences)
Continuum of health (ab/normal not categorical)
Life-span spproach (unique adult axperiences)
Clinical formulation (Johnstone and Dallos, 2006)
Individual formulation of a problem
Beliefs about problems
Beliefs about self. other and world
Background
Social context
Describing the problems
Culture
.
Idioms of distress
Ways in which members of a culture may express experiences and distress
Cultural norms may suggest that distress can be expressed in different ways:
Emotional or psychological manifestations
Physical symptoms
Use of metaphor
Euphemism
e.g. Funerals, grief
.
Explanatory models of illness (Kleinman, late 1970s)
Need to understand the explanatory model used by the individual, rather than imposing one's own
Useful questions:
What do you call the problem?
What do you think the problem does?
Why do you think this problem has occurred?
How do you think the problem should be addressed?
How do you want us to help you? Who do you turn to for help?
Clinical formulation: critique
Allowes for consideration of client's own view of problem and solution
Broadens the definition of "insight"
May help to explain engagement or disengagement with treatment
Many ways of doing it as there are theories
Low agreement levels between clinicians
How to evaluate? - Truth vs usefulness (useful to whom)
Understanding distress and behaviour
Throughouot history and across cultures human distress and abnormal behaviour understood in many ways:
Spiritual/supernatural forces
Intervention by God, Goddesses or Devils
Humours and elements
Morality
Psychological processes
Biological prosecces
Might miss out on meligious or other influences in mental disorders
Defining "abnormal" behaviour
Several Approaches
Statistical (usualness)
Personal distress
Maladaptive
Cultural relativism
Mental illness
Abnormal - Statistical
Normal: The behaviour is statiistically inside the range of normal experiences (i.e. the average)
Abnormal: The behaviour is rare and outside realm of experience
Critique:
How rare is abnormal - 1% or 10%
Rare behaviours can be beneficial (high IQ)
Abnormal - Personal Distress
Normal: No personal distress experienced
Abnormal: Personal distress experienced
Critique:
Avoids using cultural norms (NB homosexuality)
People may lack self-care and not be distressed (ego-syntonic) - e.g. in psychosis
People may not be in touch with reality
Abnormal - Maladaptiveness
Normal: Behaviour that facilitates willbeing of individuals and their community
Abnormal: Persistent behaviour which impedes wellbeing of individual and/or their community
Critique:
What behaviours should be considered "mad" versus wrong, criminal or deviant?
Helpful behaviours may be distressing
Abnormal - Cultural Relativism
Normal: Behaviour that fits with cultural norms
Abnormal: Behaviour that does not fit with cultural norms
Critique:
Different manifestations of abnormal in different cultures
Power often dictates norms, e.g. USSR branded political dissidents mentally ill
Abnormal - Mental Illness
Normal: Physical processes are healthy
Abnormal: A physical process that is different to healthy processes results in specific behaviour, signs, symptoms
Critique:
No such disease processes clearly identified for mental disorders
No blood test for schizophrenia or depression (even though there are more and more biological markers being discovered)
DSM Principles for Menatal Disorder
Negative consequences for person (critique: defined by self or other?)
Disorder = dysfunction - a condition in which some internal mechanism is not functioning the way it is naturally designed to function (critique: external mechanisms? Faulty functioning vs. protective functioning)
DSM IV "mental disorder" (APA, 1994)
Clinically significant behavioural or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or a significantly increased risk of deth, pain, disability or an important loss of freedom
Must be considered a manifestation of behavioural, psychological, or biological dysfunction in the individual
Deviant behaviour (i.e. political, religious or sexual) nor conflicts between individual and state are disorders unless obviously a dysfunction of individual
.
Has aspects of the following models: personal distress, maladaptive, mental illness, and tries to avoid cultural relativism
Importance of distress and disability/impairment in function
.
Cultural factors incorporated more in DSM-V
Multiaxial system
Axis I
Clinical Disorders (e.g. Depression etc) Other conditions that may be a focus of clinical attention
Axis II
Personality Disorders and Mental Retardation
Axis III
General Medical Conditions
Axis IV
Psychosocial and Environmental Problems
Axis V
Global Assesment of Functioning
DSM V "mental disorder" (APA, 2013)
A mental disorder is a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behaviour that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning
Mental disorders are usually associated with significant distress in social, occupational, or other important activities
An expectable or culturally approved response to a common stressor or loss, such as the deth or a loved one, is not a mental disorder
Socially deviant behaviour (e.g. political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above
Section II
Diagnostic criteria and codes for clinical disorders, personality disorders and intellectual disabilities and GMC (severity indicator - 0-3)
Significant psychosocial and contextual features notation or ICD code
Secction III
WHO's (ICD) Disability Assessment Schedule
Criticism
Gives good overview of people suffering, as well as bringing cultural factors into play
Have "medicalised" every life - e.g. drug companies taking normal distress and turning it into medical distress
People from other countries getting specific illnesses because of diagnosis that come from the western world
Things that have been thought of as mainly psychological, are now seen as biological (e.g. chronic fatigu syndrome)
Do forms of mental illness depend on culture?
Psychiatric classification development
Early 19th Century:
Post mortem studies to identify biological basis of mental illness
Late 19th Century/early 20th Century
Emil Kraepelin (Medical approach: brain dysfunction will lead to abnormal behaviour; Similar aetiologies and pathologies will lead to symptom clusters)
Karl Jasper ("General Psychopathology" - some symptoms manifestation of person's lefe and others are bilogical illness. Psychotic symptoms due to biological disorder)
1918 - Statistical manual for use of institutions of the insane (22 chategories)
Mid to late 20th Century
World Health Organisation (WHO) - ICD6 (1948)
American Psychiatric Association - DSM I (1952)
DSM-III: multiaxial, more medical (less psychodynamic), homosexuality out, subdividion of categories & explicit in/exclusion criteria (easier to research)
DSM-IV (1994); ICD-10 (1992)
21st Century
DSM-V (2013)
Expanded chapter on cultural formulation including a cultural formulation interview
Refers to gender rather than sex throughout
ICD-11 (2015)
DSM-V
Structural changes (multiaxial?)
Shifting criteria
12 month knowing client
NOS to CNEC
New diagnoses
Premenstrual dysphoric disorder
Name changes
Hypochondriasis to illness anxiety disorder
Gender identity disorder to Gender dyssphoria
Reclassification of diagnoses
OCD and PTSD removed from Anxiety disorders and given own chapters
Emphasis on studies in behavioural genetics and neuroimaging
Deleted/merged diagnoses
Female hypoactive disorder and Sexual desire disorder now Female sexual interest/arousal disorder
Substance dependence and Substance abuse now Substance use disorder
Codes (ICD similar)
New/Changed Disorders
Hoarding Disorde
r (new diagnosis)
The symptoms include persistent difficulty in discarding possessions due to a strong perceived need to save items and discarding them. This results in the accumulation of a large number of possessions that fill up and clutter key living areas of the home, to the extent that their intended use is no longer possible.
.
Problem in what is defined as distress, and where to draw a line in how many items are too many
Binging Disorder
The disorder is characterised by recurrent over-eating episodes and a sense of loss of control at the time. Sufferers don't have the extreme dieting, vomiting and laxative misuse seen in people who have bulimia. It is the loss of control over eating that is the distressing feature of dinge eating disorder, or BED.
.
Is it related to bulimia?
Skin Picking Disorder
Sufferers of the disorder are diagnosed according to five criteria including recurrent skin picking that causes skin lesions; repeated attemppts to cut down or stop, and that the skin picking causes significant distress or problems in social situations, work, or other important areas in life.
Somatic Symptom Disorder
People can be diagnosed with the new disorder if their physical symptoms are distressing and/or disruptive to theri daiy ife for at east six months, and they also have one of the following: disproportionate thoughts about the seriousness of theri symptoms; or a high level of anxiety about theri symptoms or health; or they devote exessive time and energy to their symtoms or health concerns.
Internet Addiction Syndrome
Internet addiction is a newly identified condition associated with loss of control over internet use. It leads to negative psychosocial and physical results, such as impairment of academic failure, social deficits, criminal activities and even death. This consists of three main subtypes: excessive faming, sexual preoccupations, and e-mail/text messaging
ICD-10 (WHO) & DSM-IV (APA)
Broadly similar
ICD-10 less categorical and more descriptive
Both used widely in research
Mulitaxial diagnostic system
Move to try and integrate the two systems
ICH-10 mulitaxial system
Axis I: Clinical psychiatric syndromes (psychiatric disorders, personaltiy disorders, and mental retardation, but not disability
Axis II: Specific disorders of development
Axis II: Intellectual level
Axis IV: Associated medical conditions
Axis V: Associated abnormal psychosocial conditions
Axis VI: Global Social Functioning
Multiaxial classification benefits
Comprehensive and systematic evaluation
Convenient format for organising and communicating information
Captures complexity of clinical situations and the heterogeneity of people with the same diagnosis
Encourages use of biopsychosocial model
WHO (1947): good health is "a state of complete physical, mental and social well-being"
Wellbeing is affected by cultural, biological/physical, social and psychological helath (each of these factors has equal weighting, and has an influence on, and is influences by the other)
Critique: How often is this process really done?
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Biopsychosocial model of health and illness
(Engel, 1980)