Psychologie Chapitre 5: Diagnostics des Maladies Mentales

Distinction Santé-Maladie Psychique

• Maladie psychique caractérisée par : subjective sense of unease (discomfort, feeling hindered), changes in well-being, behavior, and/or performance.
• Opposed to optimal health, a state of complete mental, physical, and social well-being.
• Important distinction between illness (a diagnosable condition) and life difficulties.
• Modifications are deficits or excesses (e.g., lack of energy in someone usually active).
• Patient may not experience subjective distress but may endanger themselves or others.

Classifications Diagnostiques

• Provide information on the nature, origin, and development of disorders.
• Roles: facilitate communication among researchers, describe and classify disorders for identification, explain etiological factors, offer a prognosis on the disorder's course, and plan interventions and therapeutic strategies.
• Main classifications: DSM-5, CIM-10, 0-5 age classification (specific versions are indicated).
• DSM-5 depression criteria: 5 symptoms present during the past 2 weeks, representing a change from previous states. Either depressed mood OR loss of interest/pleasure is required.

Limitations of Classifications

• Insufficient etiological specificity.
• Binary nature (ill or not ill), lacking dimensions, only categories.
• Failure to consider symptom networks.
• Overreliance on somatic medicine.
• In psychiatry, diagnostics are uncertain as symptoms are not always indicative of a disorder.
• Uncertain prognosis, classifications do not offer a probabilistic approach.

Other Approaches

• Symptom networks, the determining factor is not the quantity or intensity but the interconnectedness of symptoms.
• Dimensional approach assumes individuals are more or less affected and intensity is significant, aiming to reduce intensity. However use is limited if there is no subjective distress from the patient.
• Infra-pathological state, often leading to needs, potentially highly focused (ex: stress management in a specific situation). Evaluation and intervention procedures are largely similar.

Etiology of Disorders

• Psychological symptomatology is not specific; a symptom is not uniquely associated with a disorder.
• Theoretical explanations vary.
• Predisposing Factors: prenatal, genetic, intrauterine, and perinatal factors increase the probability of a disorder.
• Vulnerability factors: developmental phase, early socialization, relational factors, early illnesses.
• Triggering factors: recent events surpassing the individual's adaptation capacity.
• Maintaining factors: reactions of the environment, self-reinforcement, etc. throughout the disorder's progression.

Etiological Models

• Main effect: the disorder is caused by a single independent factor, useful in somatic medicine more than in psychology.
• Interaction effect: two or more factors interact to produce the disorder; these can cause vicious cycles. The disorder would likely not have occurred from the interaction of one factor alone.
• Transactional: the disorder arises from factor interaction but appears only because of prior pre- dispositions or vulnerabilities.

Evaluation Methodology

• Ensure that a true pathology exists and not simply a variation from a norm.
• Avoid preconceptions and use appropriate evaluation tools.
• Pay attention to bias:
  • Leniency: overestimating desirable qualities and underestimating undesirable ones in the patient (especially with affective closeness).
  • Halo effect: judging patient's mental characteristics based on physical characteristics.
  • Logical errors: overgeneralizing from clinical knowledge.
  • Naive theories: "common sense" psychology.
• Evaluation methods: interviews (structured for psychiatric diagnosis or more open-ended), tests (aptitude or projective), self-report/other-report scales/questionnaires, behavioral observation (especially for relational problems).

Patient-Therapist Relationship and Setting

• Importance of the clinical interview context in fostering a strong therapeutic relationship.
• Seating arrangements, seating, lighting, sound-proofing, aesthetic setting, side-profile seating for interviews, triangular seating for multiple-person interviews.
• The patient should be able to explore the environment and the therapist should show any cameras.

Rogers' Variables

• Psychopathology arises from the inability to be oneself in daily life. Encourage self-disclosure without filters.
• Three conditions for a positive interview: congruence and authenticity (therapist’s honesty, self-expression, avoiding blame/judgment/dissociation, self-disclosure, self-awareness of limits).
• Unconditional positive regard: accepting the client as they are (not approval but avoiding judgment), investment in listening without providing advice, letting the client find their own solutions with guidance.
• Empathy: understanding, recognizing, and communicating the client's experiences/feelings; verbalizing perceived internal states, attending to verbal and non-verbal expressions.

Working Alliance

• Agreement on the treatment/evaluation goals, tasks, and emotional bonds to overcome difficulties.
• The working alliance is far more predictive of treatment success than the specific technique used.

Psychoanalysis

• First non-medical approach to mental disorders.
• Focus on the individual's internal life and unconscious aspects to address problems.
• Key figures: Freud, Jung, Adler, Lacan, Gilliéron, Cramer.
• Unconscious motivation, talking cure (rejection of hypnosis), investigation of trauma.
• Key concepts: neurosis (emotional/affective disorders), hysteria (symptoms resembling organic illness), resistance (impeding conscious access to trauma), drive (urge to discharge on an object), pleasure principle (seeking pleasure and avoiding displeasure), reality principle (confronts drives with reality, delays gratification and allows for thought before action, which can cause frustration).

Two Topographies

• First topography: conscious, preconscious (accessible with effort), and unconscious (unavailable content, repressed drives).
• Second topography: Id (primitive, archaic), Ego (emerges from confrontation with the external world, contains conscious perceptions, employs defense mechanisms), Superego (internalized parental authority, constant surveillance).

Psychosexual Development

• Ego develops based on the drive structure of libido through stages:

  • Oral (1st year): erogenous zone = mouth, involving ingestion. Object = mother’s breast.

  • Anal (2nd year): erogenous zone = anal region, involving control and mastery. Ambivalent stage (expulsion/retention of feces).

  • Phallic (3-6 years): erogenous zone = urethral, awareness of gender difference, Oedipus complex (rivalry with father, recognition of authority, castration anxiety). Electra complex (female rivalry with mother, desire for father's attention).

  • Latency period (6-12 years): desexualization through repression and sublimation.

  • Genital (puberty): erogenous zone = genitals, sexual drives towards external objects, less self-centered.

Psychodynamic Approaches

• Possible face-to-face, potentially shorter than Classical psychoanalysis, focuses on a specific issue, explorations of current conflicts. Importance of the unconscious, transfer, and early experiences.

Cognitive-Behavioral Approaches

• Focus on correcting learned cognitions and behaviors.
• Combining behaviorism (environment shapes behavior) and cognitivism (individual selects their environment).
• Three waves: 1. behaviorism, 2. cognitive-behavioral, 3. mentalistic/emotion-focused.

Cognitive-Behavioral Model (Aaron Beck)

• Selective selection and interpretation of experience through cognitive schemas.
• Healthy schemas are flexible and varied; unhealthy schemas lead to inflexible rules of information processing, potentially causing maladaptive behaviors/reactions.
• Cognitive biases (automatic thoughts) exist in all, but rigid schemas can cause disorders.
• Types of cognitive bias: arbitrary inference, selective abstraction, overgeneralization, magnification/minimization, personalization, polarized thinking.

Clark's Model

• Focuses on correcting dysfunctional schemas, not on origin of disorders, but also considers genetics, biological vulnerabilities, developmental history, and learning experiences.

Safety Behaviors

• Short-term relief, long-term worsening due to preventing confrontation with anxiety-inducing stimuli, avoidance, speech speed, attention diversion, etc.

Beck's Theory of Depression

• Depression is not self-harm but manifests through cognitive biases.
• Cognitive triad: negative thoughts about the self, the world, and the future.
• Irrational and defeatist thoughts, feeling worthless. Triggered by external/relational factors.

Techniques

• Identify automatic thoughts using Socratic questions, downward arrows (chain inference), recognize emotions/physical tension
• Cognitive techniques for improvement: reframing, decentration, reattribution, etc.
• Behavioral techniques: homework tasks, hypothesis testing, exposure, role-playing, activity scheduling, graded assignments, three-column system.

Mindfulness Approaches

• Focus on immediate mental images and sensory data. Aiming relaxation and self-awareness.
• Formal exercises: body scan, meditation, mindful breathing.
• Informal exercises: practicing conscious awareness during everyday activities.

Systemic and Family Approaches

• Emotional/behavioral difficulties arise from social relationships and context.
• Interventions target the relational system, not the individual.
• Focus on present interactions, not past causes, and positive feedback loops.
• Three generations of Systemic Therapies:
  • Communicational (Palo Alto), structural, strategic.
  • Constructivist/constructionist.
  • Integrative, with individual and family therapy combined.

Systemic Concepts

• Undifferentiated self: immature relating (dependency or detachment), transmitted and built-up across generations.
• Triangulation: including a third person in conflict, potentially creating a scapegoat.
• Homeostasis: resistance to change, maintaining constant conditions in the family system, useful in its own right but harmful if rigid.
• Metacommunication: communicating about the relationship itself. Frequently absent in dysfunctional families.
• Double binds: paradoxical interactions (primary/secondary injunctions, no good solution, tertiary injunction prevents escaping the situation).

Systemic Model

• Individuals are organized into systems governed by rules (drawing on mathematics, cybernetics, physics).
• System characteristics: components (individuals), attributes (size, number), relationships (interactions, interdependence), environment.
• Functional system characteristics: interconnectedness, hierarchical structure (authority/responsibility distribution), equifinality (exchangeability of roles/tasks).
• Cybernetics: self-regulation and control, adaptability in the face of change.
• Interactions and external environment exchanges.

Systemic Theory of Depression

• No specific theory, focusing on relational causes and consequences.
• Relationships contribute and reinforce a depressed state.

Systemic Setting

• Family members are present together.
• Seating arrangement: circle (equal standing).
• "Designated patient" and "primary consumers" are identified.
• Challenging awareness of change processes can be counterproductive.

Systemic Techniques (1st Generation)

• Paradoxical intervention: acknowledging past efforts but predicting further problems.
• Reframing/positive connotation: offering alternative positive interpretations.
• Homework tasks
• Boundary restructuring

Systemic Techniques (2nd Generation)

• Solution-focused, therapist as a system member in a positive dynamic.
• Brainstorming, exception finding, miracle question, externalization of problems.

Systemic Techniques (3rd Generation)

• Integration of various techniques and psychosocial approaches.

Humanistic Approaches

• Carl Rogers: founder of person-centered therapy (PCT).

• Other figures: Maslow, Laing, Perls, Greenberg, Johnson.

• Rogers’s positive view of human nature contrasts with Freud's, emphasizing inherent goodness and self-actualization without inherent control.

Humanistic Personality

• Personal growth and development influenced by the social and physical environment.
• Experiences are symbolized. Potential for growth, self-actualization. Incongruence between self-knowledge/preferences, and environmental expectations can lead to disorders.

Functional/Maladjusted Personalities

• Functional personality: unconditional positive regard (positive regard without behavioral expectations). Openness to experience, emotional regulation, adaptability, organismic trust (listening to internal signals), freedom.
• Maladjusted personality: conditional regard (approval contingent on certain behaviours), defensiveness, planning life to meet others’ demands/expectations, distrust/misinterpretation of organic signals, manipulation, conformity.