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Week 1: Psychopathology Fundamentals, Diagnostic classification and…
Week 1: Psychopathology Fundamentals, Diagnostic classification and etiology
Identify criteria for abnormal behaviour
Psychopathology: the study of mental disorders
Mental health disorders: wide range of mental health disorders of dysfunction
Psychopathology: scientific study of mental health disorders including
Efforts to understand genetic, biological, psychological and social causes (origin)
Effective classification schemes (nosology)
Course across all stages of development (development)
Manifestations of behaviors indicative of clinical treatment
Psyche = soul, pathos = suffering, -ology = study of
Psychopathology synonym for
mental illness
Mental illness: wide range of mental health conditions (disorders) characterized by
psychological dysfunction and abnormal behavior
Why is it difficult to define an abnormal behaviour?
No universal agreement of what abnormality is/mental disorder
Mental illness is multifactorial
Single behaviour/symptoms cannot make someone abnormal
Culture (and society) plays significant role in determining what is/not abnormal
Abnormal behavior indicators
The more that someone has difficulties in these areas, the more likely the person has some form of psychiatric condition
1.Personal (Subjective) Distress
: Emotional suffering has a significant impact on person's functioning
Subjective distress: element of abnormality but it is not a necessary condition to consider abnormal
3. Statistical deviance
: Rare/infrequent behaviour or thinking that deviates from average or majority
but may not be true for all cases: geniuses
some things are getting more common: eg depression
while some are extremely rare as well!
2. Maladaptive Behaviour
: Inability to adapt to stressors and everyday demands of life impacting well-being
issues of subjectivity
4. Social normal deviance
: deviance from social norm/cultures
however not all socially different behaviors abnormal eg wrong dress code for significant social event
Social discomfort does not make behaviour abnormal - eg violation of personal space
consider whether Irrationality and unpredictability define abnormality
I think maybe not only these factors? maybe other factors eg culture might actually be affecting it
are symptoms defined by social norms or culture?
Hallucinations (symptoms) or visions (faith)
5. Dangerousness
danger to oneself or another person
Dangerousness exception and not a norm for people with mental illness
Doesn't mean all dangerous activities done are considered abnormal: Crimes largely committed by persons without psychiatric disorders
Plea of sanity
Abnormal key points
No one element is sufficient to define or determine abnormality
Definition of psychological disorder based on all criteria
Atypical behavior and thinking significantly distressing, harmful to oneself or others and disruptive to daily life functioning
Culture is an important factor to consider
Perception of abnormality fluctuate as society's constantly evolving views
Understand diagnostic classification approaches for psychiatric disorders (ICD and DSM)
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(2013)
Standard guide in the US
For Singapore: used mainly in psychiatric settings, research and academia
DSM facts
DSM-I and DSM-II shaped by psychoanalytic tradition: diagnoses based on psychodynamic processes, not on observable behaviour
DSM-III: Influenced by biomedical tradition: inclusion of explicit diagnostic criteria increase reliability
DSM-III, IV and IV-TR: based on categorical, multi-axial system
Axis 1: Clinical syndromes
Axis II: Personality disorders
Axis 3: Medical conditions
Axis 4: Psychosocial and environmental factors
Axis 5: Global Assessments Functioning (GAF)
DSM-5
Replaced multiaxial (Axis I to V) and categorical classification of mental disorders of previous DSMs with a dimensional approach
Disorders viewed and
ranked on a continuum
VS present/absent
Dimensions: allows clinician to rate disorders along a continuum of severity
Allows for gender related differences in diagnosis
Lists criteria for each specific category (inclusion and exclusion)
More comprehensive with more subtypes of disorders
Culture and classification
incorporates influence of cultural factors in both expression and recognition of symptoms of mental disorders
Includes glossary of cultural concepts of distress
International Classification of diseases, 11th edition (ICD-11)
ICD in Europe and many other countries
For Singapore: ICD system used by Ministry of Health and hospital administrators for purpose of measuring and keeping track of disease in the population and to calculate subsidies and reimbursements to public hospitals
ICD facts
First Ver. International List of Causes of Death (ILCD): Classified causes of death not illnesses
Sixth Ver: International Statistical Classification of Disease: to include diseases and psychiatric disorders
ICD-11 shares many similarities with DSM-V
Do we need to note the differences between DSM and ICD?
Distinguish between risk factors and causes
Aetiology (etiology)
Scientific investigation of factors or causes that are responsible for, or related to, the development of disorders
Risk factors
Factors that make individuals at risk or prone to the development of a disorder
What must you identify
Identify vulnerable groups
Develop preventative interventions
Predisposing, Precipitating and perpetuating factors
Predisposing factors:
Occurs early in life and may have effects several years later
eg John loss of his parent at age 5 may predispose him to depression
Precipating factors
: Occurs shortly before onset of disorder
eg Barry (John's best friend's) migration to Canada precipitated John's first onset of depression
Perpetuating factors
: Occur after onset of disorder and cause it to be maintained
eg John has been withdrawing himself and lying in bed the whole day, which leads to lack of meaningful engagement and perpetuates his depression
Understand the key aetiological paradigms for psychiatric disorders
Biological perspective (Mental disorders as diseases)
Categories of biological factors relevant to abnormal behaviour
Genetic vulnerabilities
Vulnerability to psychiatric conditions almost always polygenic and influenced by
1. Abnormalities in some of gene on chromosome
Abnormalities in structure or number of chromosomes associated with malfunctions and disorders (Down Syndrome)
2. Naturally occurring variations of genes (Polymorphisms)
Genes may not fully determine development of a mental disorder: they affect behaviour indirectly
Neurodevelopmental Hypothesis (NDH)
Evidence of NDH in Schizophrenia
Genetic factors
Linkage and association studies identified 12 chromosomal regions containing 2181 known genes and 9 specific genes being involved in aetiology of schizophrenia
Many studies found downregulation in myelin and oligodendrocyte-related genes, which are important in formation and maintenance of myelin sheaths
Associations with genes involves in glutamatergic and dopamine neurotransmission
Interaction between genes and environment: genes related to hypoxia at childbirth are found to be associated with risk for schizophrenia
Genetic vulnerabilities
Genotype:
Person's genetic make-up (what you inherit)
Phenotype:
person's observable characteristics resulting from interaction of genotype and environment (what is expressed)
Genotype-environment interaction
Genetic factors are
not necessary and sufficient
to cause psychiatric condition
Can contribute to vulnerability to develop psychopathology in presence of environmental stressor
eg Phenylketonuria (PKY)- induced intellectual disability, due to build up of phenylalanine (amino acid) . It can be prevented by altering diet from early age
Behaviour genetics (psychogenetics)
Study of influence of person's genetic composition on its behavior and interaction of heredity
Family history:
Observe samples of relatives of person and compare incidence in family VS rate in population
Twin method:
Compare rates of disorders in identical twins (monozygotic) VS rates in non-identical (dizygotic) twins
In a study of "life time risk of schizophrenia according to the relationship to an affected individual" - ranking of lifetime risk is
MZ twins
Child of two affected parents
Sibling
Child of one affected parents//parent
Adoption method:
Adopted children with normal biological parents VS children with biological parents with disorder
Methods allowing examination of environmental influences
2 more items...
Brain dysfunction and neural plasiticity
Different psychiatric conditions associated with different neuroanatomical regions to various extents
Examples of different locations
Obsessive compulsive disorder (OCD):
Associated with dysregulation of cortico-straito-thalamo-cortical (CSTC) circuit as well as at basal ganglia
Schizophrenia
: Decreased grey matter volume
Stroke:
Person with stroke at the frontal region may present with personality changes
Developmental systems approach
Different aspects influence each other
Genetic activity
Environment
Neural activity
Behaviour
Neuro-transmitter and hormonal abnormalities in brain and central nervous system (CNS)
Neurotransmitter imbalances can result in abnormal behaviour
Different types of neurotransmitter imbalances
Overproduction
: Excessive production and/or release of neurotransmitter into synapse
Deactivation
: Dysfunction in deactivation of neurotransmitter in synapse
Abnormally sensitive or insensitive receptors
What are some examples that you can think of that results from neurotransmitter imbalances?
5 most studied neuro-transmitters
Norepinephrine (Noradrenaline)
Dopamine
Serotonin
Glutamate
Gamma Aminobutyric Acid (GABA)
Neurotransmitter and Hormone Imbalances
Hormones produces psychophysiological responses
Effects of hypothyroidism
Decrease thyroid function common cause of lethargy, depression, short term memory loss
Mental health issue are common in thyroid disorders
Effects of cortisol imbalances
Associated with depression and post-traumatic stress disorder (PTSD)
Effects of Oestrogen, Progesterone and Testosterone
Protect against loss of memory, cognition and progression of dementia
Postpartum depression:
Decrease progesterone after childbirth causes low moods of postpartum depression
Menopause
: Increase risk of mental health problems
In men
Increase oestrogen can cause depression or mood swings
Decrease oestrogen can cause depression, fatigue, mental fogginess
Type of neurotransmitter and common dysfunction
1. Dopamine
Function: Influences movement, learning, attention, sensations of pleasure
Oversupply:
Schizophrenia
Undersupply:
Parkinson's disease, depression
2. Serotonin (5-HT)
Function: Affects mood, appetite, sleep and anxiety
Undersupply:
Depression, sleep and eating disorders
3. Acetylcholine
(ACh)
Function: Enables muscle action, learning and memory
Oversupply
: Muscle contraction, Convulsions
Undersupply
: Alzheimer's disease
1 more item...
4. Norepinephrine OR Noradrenaline
Function: Helps control alertness and arousal
Oversupply:
Stress and panic disorder
Undersupply
: Depression
5. Gamma-amino butyric (GABA)
Oversupply
: Involved in sleep and inhibits movement
Undersupply:
Seizures, tremors and insomnia
6. Endorphins
Function: Involved in Pain relief
Oversupply:
Insensitivity to pain
2 more items...
Undersupply
: Pain hypersensitivity, immune problems
Apply the biopsychosocial approach for psychiatric disorders
Psychological paradigms
Psychodynamic
Psychodynamic theory: theorized that person's behavior results from interaction of
Id (pleasure principle)
Source of instinctual drives
Ego (Reality principle)
Mediates between demands of Id and realities of external world
Superego (Judicial branch)
Outgrowth of internalising taboos and moral values of society
Mental disorder occurs when Id, Ego and Superego are in conflict, or one s overly dominant or underdeveloped
Relationship between the Superego and Id
Overuse of immature/neurotic ego defense mechanisms:
Neurotism
Failure/Disintegration of ego defenses or use of pathological mechanisms
: Psychosis
Psychodynamic stages
Different stages where the Id, ego and superego are formed
Oral stage (first 18 months)
Anal stage (18-36 months)
Phallic stage (3-6 stage)
Latency stage (6 years- puberty)
Genital stage (puberty on)
Each stage produces certain amount of conflict and anxiety
If not resolved, normal development may not be interrupted and child may be stuck (fixation) at that stage
Ego defense mechanisms: Strategies used by ego to defined itself against anxiety
Displacement
: Discharging pent-up feelings, often of hostility, on objects less dangerous than those arousing the feelings
Fixation:
Attaching oneself in an unreasonable or exaggerated way to some person, or arresting emotional development on a childhood or adolescent level
Projection:
Attributing one's unacceptable motives or characteristics to others
eg saying that other people was jealous instead of voicing that they are the ones being jealous instead
Rationalization
: Using contrived explanations to conceal or disguise unworthy motives for one's behaviour
Reaction formation
: Preventing the awareness or expression of unacceptable desires by an exaggerated adoption of seemingly opposite behaviour
Behaving in unconscious desire -- instead of being nice to someone you are cold to them instead
Regression
: Retreating to an earlier developmental level involving less mature behaviour and responsibility
Repression
: Preventing painful or dangerous thoughts from entering consciousness
Sublimation
: Channeling frustrated sexual/aggressive energy into substitutive activities
What is the difference between sublimation VS displacement
Sublimation: more socially appropriate/mature manner
Displacement: more immature displacement
Cognitive-behavioural
Cognitive behavioural perspective
Thoughts --> emotions/feelings --> behaviour
Maladaptive thoughts lead to negative emotions, which predisposes the person to develop mental health conditions
Cognitive behavioural perspective
Helps patients restructure their negative thought patterns to modulate emotions and thereby acquire adaptive behaviour
Powerful impact on contemporary clinical psychology
Strongly supported by empirical evidence
What kind of conditions are suitable for CBT? Which type are not?
Behavioural
Concepts of
Classical conditioning
Operant conditioning
Observational learning (modelling)
How does maladaptive behaviour arise from learning
Maladaptive behaviour is the result of learning that has gone awry
eg Phobia of travelling in public transport and eventually public spaces: Develops anxiety attach once in MRT, leaves place which reduces anxiety (operant conditioning)
Generalises it to other modes of transportation (classical conditioning)
Children acquire new fears by observing a parent behaving fearfully with some object or situation that child did not initially fear (observational learning)
Behavior therapy
focuses on changing specific behaviors and emotional responses, by eliminating undesirable reactions and learning desirable ones
Eg Treating phobias by prolonged exposure to the feared object/situation.
Derived from principles of extinction of classical conditioning
Eg Teaching skills to persons with intellectual and developmental disabilities (IDD): Using token economy, forward and backward chaining etc
Training methods use operant conditioning
Behavioral approach well known for specificity and measurable outcomes
Social perspective
Factors with detrimental effects on a child's socioemotional development
Early deprivation
Problems in parenting style
Marital discord and divorce
Low socio-economic status and unemployment
Maladaptive peer relationships
Prejudice and discrimination
What does social perspective consider?
How environmental factors can influence the occurence of mental health conditions
Programmes to improve social conditions
Community facilities for early detection, treatment and long-range prevention
Cultural considerations
Ideas about normal and abnormal differ in different places around the world
Individual personality development reflects the larger society
Symptoms of psychiatric conditions manifested in different cultures: somatic vs emotional presentation
Certain symptoms consistently found among similarly diagnosed clinical groups (eg schizophrenia)
Prevalence of psychiatric conditions: vary widely across cultures (eg depression, alcohol and drug addictions)
Protective factors and Resilience
Protective factors:
Influences that modify person's responses
Resilience:
Ability to successfully adapt to very difficult circumstances
Mental health professionals can harness patients protective factors and strength to help them build up resilience against mental health conditions
Distinguish between incidence and prevalence
[Frequency of Psychiatric Disorders]
Epidemiology
Definition of epidemiology
: Scientific study of frequency and distribution of diseases and disorders within a population
2 terms important in epidemiology
Incidence
no. of new cases of a disorder that appear in a population during a specific period of time
Prevalence
Number of active cases (old and news) present in a population
Prevalence figures typically expressed in percentages
Types of prevalence estimates
Point Prevalence
: Proportion of active cases of a disorder in a given population at a given point in time
1-year prevalence
: Proportion of active cases of a disorder in a given population throughout the entire year
Lifetime prevalence:
Proportion of people in given population affected by a disorder at some point during their lives
Explain burden of disease
DALY = YLD + YLL
DALY: Disability Adjusted Life Year
Measures of disease burden, expressed as cumulative number of years lost due to ill-health, disability or early death
YLL: Years of Life Lost
YLD: Years Lived With Disability
According to the graph: Abnormal Psychology (17th ed)
Depressive disorders is on the highest on the list
Singapore Burden of Disease
Cancer: 15%
Musculoskeletal disorders: 15%
Cardiovascular diseases: 14%
Mental disorders: 8%
Other non-communicable: 7%
Neurological disorders: 6%
Diabetes and kidney diseases: 6%
Unintentional injuries: 5%
Respiratory infections and tuberculosis: 5%
Sense organ disease: 4%
Chronic Respiratory Diseases: 3%
Others: 12%
Burden of mental illness in Singapore
Proportion of total YLDs caused by mental disorders, males vs females, Singapore
Schizophrenia is considered the most burdening
People with schizophrenia has negative condition that may result in functional implication
The percentage of total YLD is the highest for schizophrenia, followed by depressive disorders, bipolar disorder than anxiety disorder
What occurred in the Mental hospital care in 20th century
Deinstitutionalization movement
Large numbers of mental hospital closures and shift to community-based residences
Global movement: Asia, Europe, U.S
Considered more humane and cost effective
Some issues for patients and society