Understanding Mental Disorders: DSM-5-TR

Abandoning "Normal" and "Abnormal"

• Clinical psychologists have moved away from using "normal" and "abnormal" due to their oversimplified nature
• These terms can lead to unfair judgements
• Human behavior is highly variable based on personal, cultural, and age-related factors
• More compassionate and precise methods are favored such as:
  • Psychiatric diagnosis
  • Investigational approaches
  • Case formulations

Defining "Mental Disorder" According to DSM-5-TR

• A mental disorder involves clinically significant disturbances in emotional, cognitive, or behavioral processes
• These disturbances cause dysfunction in psychological, biological, or developmental systems
• Significant distress occurs in social or occupational functioning
• The DSM-5-TR excludes:
  • Culture-bound behaviors
  • Common stressors like grief
  • Individual-society conflicts

DSM: Signs, Symptoms, and Associated Features

• Signs are outwardly observable phenomena
• Symptoms are subjective experiences reported by the client
• Associated features include prevalence, course, prognostic factors, and common co-occurring diagnoses
• These elements give a comprehensive understanding of a psychological condition

History of the DSM

• 1952: DSM-I started with 102 diagnostic categories heavily influenced by Freudian theories, which provided broad descriptions
• 1968: DSM-II expanded to 182 mental illnesses but lacked clear descriptions and suffered from poor reliability
• 1980: DSM-III was a significant revision marking a change to a biomedical focus, introducing diagnostic criteria, adding disorders such as PTSD and ADHD, and removing homosexuality
• 1997: DSM-IV grew to 297 disorders and introduced "clinically significant distress"
• 2013: DSM-5 refined the approach to 265 disorders
• 2022: DSM-5-TR continues to evolve, aligning with medical classification systems.

Advantages of the DSM

• Establishes a standardized communication system for mental health professionals
• Enables researchers to study patterns of psychological distress systematically
• Supports clinicians in classifying mental disorders more precisely
• Better tailored treatment plants are possible

Categories vs. Dimensions

• The DSM's categorical approach places individuals in strict diagnostic boxes
• The dimensional approach views psychological conditions on a continuous spectrum
• Symptoms appear in varying degrees of intensity, frequency, and duration

Kappa Values for MDD and GAD

• Kappa values for interrater reliability of many DSM disorders are only "fair," ranging from 0.21-0.40
• Clinicians often disagree when diagnosing the same mental health condition
• Low reliability values raise concerns about the validity of common disorders listed in the DSM-5-TR
• The DSM does not provide causes for disorders, but describes signs and symptoms

Research Domain Criteria (RDoC)

• A National Institute of Mental Health (NIMH) initiative
• It aims to develop an objective diagnostic system
• Integrates genetics, neuroscience, and behavioral science
• Biological mechanisms and understanding psychological experiences are a focus
• Six core domains of brain functioning are used

Six Domains of the NIMH RDoC

• Negative Valence Systems
• Positive Valence Systems
• Cognitive Systems
• Social Processes
• Arousal/Regulatory Systems
• Sensorimotor Systems
• The RDoC differs from the DSM by using a dimensional, bottom-up approach focused on biological mechanisms rather than a top-down descriptive method

Case Formulation and Its Primary Elements

• A hypothesis about psychological mechanisms causing and maintaining distress or dysfunction is created
• It's grounded in research-based psychological theories
• Four primary elements:
  • Problem List (signs and symptoms)
  • Mechanisms (factors maintaining the problem)
  • Predisposing Factors (background conditions)
  • Precipitants (events that trigger or worsen the condition)

Case Formulation vs. DSM-5-TR Diagnostic Criteria

• The DSM-5-TR uses a descriptive, symptom-based approach
• The DSM-5-TR only catalogs observable signs and symptoms
• Case formulation creates a comprehensive hypothesis about psychological mechanisms
• Focus is on psychological mechanisms causing and maintaining a person's distress
• Case formulation integrates psychological theories and examines individual context

Iterative Approach to Case Formulation

• Psychological understanding is dynamic and evolving
• Clinicians continuously gather assessment data
• Hypotheses are revised as new information emerges
• Treatment plans can be modified in response
• Psychological assessment is flexible, responsive, and tailored

Formulation of Treatment Plans

• Psychologists select interventions that are guided by the case formulation
• Focus is on addressing hypothesized mechanisms
• Strategies target specific psychological processes
• Plans are tailored to the individual's unique psychological profile
• Designed to address root causes of distress

Communicating the Treatment Plan

• Psychologists give a clear rationale for the proposed approach
• Risks and benefits are explained
• Informed consent is given
• Intervention options and potential referrals are discussed
• The aim is to collaborate with the client

Continuous Assessment During Treatment

• Monitoring progress is a continuous, dynamic process
• Data is gathered via formal and informal methods
• Treatment effectiveness is assessed
• The client-therapist relationship is strengthened
• The treatment plan remains responsive to the client's changing needs

Psychotherapy vs. Psychological Treatment

• Psychotherapy aims at inducing changes in behavior, thought, and feelings to improve mental health and functioning
• Psychological treatment uses scientifically supported interventions
• Psychotherapy is a broader term
• Psychological treatment emphasizes evidence-based interventions derived from psychological science

Braakmann's Four Historical Phases of Psychological Treatment Research

• Phase 1 (1920-1954): Birth of psychotherapy research, featuring Freud's early work and Eysenck's spontaneous remission theory
• Phase 2 (1955-1969): Advancing process research, developing sophisticated research methods with controlled trials
• Phase 3 (1970-1984): Expansion of research, developing meta-analysis and introducing the "Dodo bird verdict"
• Phase 4 (1984-Present): Embracing the medical model with Randomized Controlled Trials (RCTs)

Assessing Treatment Effectiveness

• Insight is needed from clients, practitioners, and third-party perspectives
• Assessment methods:
  • Standardized interviews
  • Self-report questionnaires
  • Direct behavioral observations
• Assessment is multifaceted and ongoing

Efficacy vs. Effectiveness of Psychological Treatment

• Treatment efficacy is how well treatments perform in controlled research studies
• It is measured through Randomized Controlled Trials (RCTs)
• Treatment effectiveness examines how interventions perform in real-world settings
• External validity is the ability to generalize study findings
• Efficacy is about controlled precision, while effectiveness is about real-world applicability

Specific vs. Nonspecific Factors in Treatment

• Specific factors are unique interventions that target psychological processes
• Nonspecific factors are common across different therapies
• "Hope" and "working alliance" are nonspecific factors
• The interactional perspective suggests common and specific factors work together

Multicultural Humility

• Clinicians should adopt an empathetic, inquisitive, and open-minded stance
• Acknowledge the potential lack of knowledge about clients' cultural experiences
• Be curious and avoid assumptions
• Actively seek to understand the client's unique cultural background

Psychoeducation

• An educational component of psychological treatments
• Clients are provided information to help them understand themselves, their problems, and their treatment
• It aims to correct misinformation and enhance client understanding

Bibliotherapy

• Clients read informative materials
• A form of psychoeducation
• It can be effective in reducing some psychological problems
• Provides additional insights and self-guided learning

ACT Metaphors

• Acceptance and Commitment Therapy (ACT) metaphors help clients reframe their relationship with emotions
• Emotions are depicted as passengers, and the individual as the driver
• While emotions are valid, they don't control one's life journey
• Encourages psychological flexibility

Between-Session Practice

• Allows clients to review progress
• Self-monitor behaviors and cognitions
• Actively apply skills learned during therapy
• Non-compliance can lead to poorer outcomes

Evidence-Based Treatment (EBT) vs. Evidence-Based Practice (EBP)

• EBT focuses on interventions proven effective through rigorous Randomized Controlled Trials
• EBP integrates scientific evidence with clinical expertise and individual client needs
• Treatments are categorized into hierarchical levels

Hierarchy of Treatment Categorizations

• Well-established treatments (multiple high-quality studies, clear manuals)
• Probably efficacious treatments (preliminary evidence, limited diversity)
• Experimental treatments (not thoroughly tested)
• Possibly efficacious treatments (minimal empirical support)
• Ensures psychological interventions are rigorously evaluated

Resistance to EBT

• Clinicians may view psychotherapy as an "art" rather than a science
• Alternative explanations for client improvement:
  • Placebo effects
  • Spontaneous remission
  • Effort justification
  • Regression to the mean
  • Multiple treatment interference
  • Reporting bias

Disseminating Evidence-Based Treatments

• Ensure accessibility, cost-effectiveness, cultural adaptability, and service availability
• Goals:
  • bridge the gap between research and practical application
  • make effective psychological treatments more universally available

Theoretical Basis of Behavioral Interventions

• Rooted in learning theory
• Focus on observable and measurable behaviors
• Emphasizes operant and classical conditioning, modeling, and skills training
• Reduce maladaptive behaviors, decrease negative emotions, and modify the client's environment

Classical Conditioning Terms

• US (Unconditioned Stimulus): A stimulus that naturally triggers a response
• UR (Unconditioned Response): The unlearned response to the US
• CS (Conditioned Stimulus): A previously neutral stimulus that triggers a response after association with the US
• CR (Conditioned Response): The learned response to the CS

Operant Conditioning Terms

• S^D (Discriminative Stimulus): Signals reinforcement/punishment availability
• R (Response): Behavior occurring in the presence of the discriminative stimulus
• O (Outcome): Consequence of the response

Five Guiding Principles of Behavioral Treatment

• Maladaptive behavior stems from classical and operant conditioning
• Behaviors are the problem
• Focus on behavior-maintaining processes
• Adaptive behavior can replace maladaptive behavior using learning principles
• Treatments are client-specific

Historical Contributions

• Watson and Rayner (1920) demonstrated the conditioning of emotional responses
• Mary Cover Jones (1924) showed how learned fears could be "reconditioned"
• B.F. Skinner modified the behavior of hospitalized psychotic individuals

Stages of Behavioral Treatment

• Define target behavior and conduct baseline assessment
• Functional analysis and treatment planning are next
• Implementation is next, and treatment happens in natural settings
• Outcome assessment and reformulation as necessary

Applications

• Skill deficits are adressed
• Training in social skills and assertiveness is done
• Anxiety and fear are reduced
• Exposure therapy and progressive muscle relaxation
• Behavioral activation

Aversion Therapy

• Pairing an unpleasant stimulus with an undesirable behavior
• Raises ethical concerns due to the use of aversive stimuli
• The APA ethics code deems aversive conditioning incompatible

Strengths and Limitations

• High treatment efficacy is a strength
• Efficient and focused interventions can be performed
• Limitations:
  • limited effectiveness for severe mental health conditions
  • potential ethical concerns
  • significant client effort

Behavioral Definitions

• Assertiveness training: Expressing thoughts, needs, and feelings respectfully
• Aversive conditioning: Pairing an unpleasant stimulus with an undesirable behavior
• Awareness training: Logging problem habits
• Behavioral activation: Engaging in rewarding activities
• Behavioral treatment: Techniques from learning theory
• Competing response practice: Engaging in incompatible behavior
• Contracting: Written agreement specifying relationships between behaviors and consequences
• Contingency management: Manipulating consequences
• Covert sensitization: Aversion therapy relying on imagery
• Cue exposure: Weakening the stimulus-response link
• Danger-based expectations: Client's prediction of being exposed to a feared situation
• Exposure and response prevention: Exposing and preventing compulsive behaviors
• Exposure hierarchy: List of feared situations

CBT Contributors

• Aaron T. Beck developed techniques like the pie graph method and cognitive therapy
• Albert Ellis pioneered Rational Emotive Behavior Therapy (REBT)
• Albert Bandura introduced social learning theory
• Julien Rotter complemented Bandura's work with locus of control

Cognition

• The mental processes of thinking, understanding, and interpreting
• Cognitive perspective postulates that thoughts influence emotions and behaviors
• Cognitive-Behavioral Treatment (CBT) improves functioning by correcting maladaptive thinking
• CBT centers on the ABC Model: Activating event, Beliefs, and Consequences

Cognitive Model Treatment Implications

• Adaptive and rational thinking is useful
• Teach clients to use adaptive and rational thinking
• Interpretative beliefs can be systematically restructured using the ABC model

Contrast Between Destructive and Constructive Negative Emotions

• Destructive emotions like depression and anxiety paralyze
• Immobilization is result
• Constructive emotions promote growth and problem-solving

CBT Process

• Therapists and clients work to identify and modify maladaptive thought patterns together
• Examine the beliefs that perpetuate psychological challenges
• CBT now emphasizes cultural sensitivity

CBT Outcomes

• CBT addresses responses to problems and disorders
• Negative emotional patterns should be transformed
• Thinking strategies should be developed

Dysfunctional Beliefs

• They are irrational and distorted, creating distress
• All-or-nothing thinking
• Overgeneralization

CBT: A Skill-Based Treatment

• Teaches clients practical techniques for managing challenges
• Focuses on active learning and developing strategies
• Structured, goal-oriented sessions
• Homework and behavioral experiments are used

Active CBT Processes

• Self-monitoring forms
• Thought records

REBT vs Beck's Cognitive Therapy

• REBT aggressively challenges irrational beliefs
• Beck's therapy is collaborative

Strengths and Limitations of CBT

• High effectiveness across psychological settings
• Practical efficiency