ABPSYCH Midterm Coverage PDF

**INTRODUCTION TO ABNORMAL PSYCHOLOGY** **Situational Analysis** Is it Normal or is it Abnormal? - I always double check the locks on my car and door, and the stove and worry about small things. - I talk to myself out loud a lot as I try to resolve my own problems. An outsider, it co...

**INTRODUCTION TO ABNORMAL PSYCHOLOGY** **Situational Analysis** Is it Normal or is it Abnormal? - I always double check the locks on my car and door, and the stove and worry about small things. - I talk to myself out loud a lot as I try to resolve my own problems. An outsider, it could look like I have a psychological disorder (e.g., schizophrenic). - I get depressed for a day sometimes. **What is Abnormal Psychology?** - The scientific study of abnormal behavior in an effort to describe, predict, explain, and change abnormal patterns of functioning. - Many definitions have been proposed, yet none has won total acceptance. - Study of mental disorders and treatment. **Why study Abnormal Psychology?** - Abnormal behavior is part of our common experience. - Lots of questions and complexities. - Preparation for future careers. **Why should you care about psychological disorders?** - Psychological disorders are not that big of a problem. - No one I know has a psychological disorder. - Psychological disorders will happen to someone else who is less deserving than me. - Psychological disorders are fairly rare and uncommon. **What do you mean by Mental disorders?** Who has mental disorders? - Murderers? - People who cut themselves or practice suicidal self-injury? - People who can't pay attention and concentrate? **WAYS OF DEFINING "ABNORMAL"** **Subjective Discomfort** - Feelings of anxiety, depression, or emotional distress. But people we would consider definitely abnormal may not feel subjective discomfort. **Social Nonconformity** - Disobeying societal standards for normal conduct, usually leads to destructive behavior. But it doesn't always. Is being a nonconformist always a disorder? **Statistical Abnormality** - Having extreme scores on some dimensions, such as intelligence, anxiety, or depression. But having a numerically rare characteristics isn't always disorder e.g., having an IQ of 180) **WHAT IS PSYCHOLOGICAL ABNORMALITY?** - Most definitions have certain features in common: **"The Four Ds"** **Deviance --** Different, extreme, unusual perhaps even bizarre. a. Statistical deviance/infrequency b. Cultural deviance-norms. - From what? From behaviors thoughts, and emotions that differ markedly from a society's ideas about proper functioning. - From social norms - Stated and unstated rules for proper conduct. - For example: *Washing your hands 4 times an hour, taking showers a day, and cleaning your apartment twice a day is considered deviant.* **Distress-** Unpleasant and upsetting to the person (causes distress to individual or those around the individual) - This is when a behavior causes anxiety, bad feelings or other negative feelings for either the person or others who come in contact with them. - Example: *Mary is feeling down, doesn't feel like she even get out of bed, hasn't bathed in four days and won't respond to texts from her friends.* - *The death of a spouse* - *Filing for divorce* - *Losing contact with loved ones* - *The death of a family member* - *Hospitalization (oneself or a family member)* - *Injury or illness (oneself or a family member)* - *Being abused or neglected* **Dysfunction-** Causes disruption in societal, occupational day to day functioning. - This is the point at which a person has a significant impairment in a life area, such as work, home, interpersonal or social life is impaired. In the addictions world, this is often called "hitting rock bottom". - Abnormal behavior tends to be dysfunctional -- it interferes with daily functioning. - Culture plays a role in the definition of abnormality. - Examples: *- a troubled teen who expresses anger by hitting others.* - *A teenage couple that deals with conflict by not speaking to each other.* - *A family in which a parent is drinking daily and family members are afraid to talk about what's happening.* - *A teenager with dual- diagnosis who uses drugs to deal with their symptoms rather that deal with what causing them.* **Danger-** Causes interference with life poses risk of harm. - A abnormal behavior may become dangerous to oneself or others. - Behavior may be consistently careless, hostile or confused. - Behaviors are the detrimental to the person or people around them. - Although often cited as a feature of psychological abnormality, research suggest that dangerousness is the exception rather than the rule. - Example: - *during his manic phases of bipolar disorder, Juan will often go to the casino and bet his rent money on roulette, not caring that if he loses he won't be able to pay for his apartment.* **Timeline of Significant Events** 200. **B.C.-** Galen suggest that normal and abnormal behavior are related to four bodily fluids or humors. 400. **B.C-** Hippocrates suggest that psychological disorders have both biological and psychological causes. **1300s-** Superstitions runs rampant and mental disorders are blamed on demon and witches; exorcism are performed to rid victims of evil spirits. **1400s-**Enlightened view that insanity is caused by mental or emotional stress gains momentum, and depression and anxiety are gain regarded by some as disorders. **1400-1800-** Bloodletting and leeches are used to rid the body of unhealthy fluids and restore chemical balance. **1500s -** Paracelsus suggests that the moon and the stars, not possession by the devil, affect people's psychological functioning. 1793. Phillipe Pinel introduces moral therapy and makes French mental institutions more humane. **1825-1875-** Syphilis is differentiated from other types of psychosis in that it is caused by a specific bacterium; ultimately, **penicillin** is found to cure syphilis 1848. Dorothea Dix successfully campaigns for more humane treatment in U.S. menta institutions. 1854. John P. Grey, head of New York's Utica Hospital, believes that insanity is the result of physical causes, thus de- emphasizing psychological treatments. 1870. Louis Pasteur develop his germs theory of disease, which helps identify the bacterium that causes syphilis. **1895-** Josef Breuer treats the "hysterical" Anna O., leading to Freud's development of psychoanalytic theory. **1900-** Sigmund Freud publishes *The Interpretation of Dreams.* **1904-** Ivan Pavlov receives the Nobel Prize for his work on the physiology of digestion, which leads him to identify conditioned reflexes in dogs. **1913-** Emil Kraepelin classifies various psychological disorders from a biological point of view and publishes work on diagnosis. **1920-** John B. Watson experiments with conditioned fear in Little Albert, using a white rat. 1930. Insulin shock therapy, electric shock treatments, and brain surgery begin to be used to treat psychopathology. 1938. B. F. Skinner publishes *The Behavior of Organism*s, which describes the principles of operant conditioning. 1943. The Minnesota Multiphasic Personality Inventory is published. 1946. Anna Freud publishes *Ego and the Mechanisms of Defense.* 1950. The first effective drugs for severe psychotic disorders are developed. Humanistic psychology (based on ideas of Carl Jung, Alfred Adler and Carl Rogers) gain some acceptance. 1952. The first edition of the *Diagnostic and Statistical Manual (DSM-1)* is published. 1958. **-** Joseph Wolpe effectively treats patients with phobias using systematic desensitization based on principles of behavioral science. 1968. **-** *DSM-II* is published. **1980-** *DSM-III* Is published. **1987-** *DSM-III-R* is published. **1990-** Increasingly sophisticated research methods are developed; no one influence- biological or environmental -- is found to cause psychological disorders in isolation from the other. **1994-** *DSM-IV* is published. **2000-** *DSM-IV-R* is published. **2010-** *DSM-5* is published. **DSM-5 DEFINITION** - Behavioral, psychological, or biological dysfunctions that are *unexpected in their cultural context* and associated with present *distress* and *impairment* in functioning, or *increased risk of suffering, death, pain, or impairment.* **What is Treatment?** - Once clinicians decide that a person is suffering from abnormality, they seek to treat it. - Treatment, or therapy, is a procedure designed to change. - All forms of therapy have three essential features: **The Science of Psychopathology** **Psychopathology** - The scientific study of psychological disorders **Specially trained professionals** - Clinical and counseling psychologist - Psychiatrist - Psychiatric social workers - Psychiatric nurses - Marriage and family therapist and mental health counselors **Clinical Psychologist and Counseling** - Received the Ph. D. degree - Course of graduate level-study lasting approximately 5 years which prepares them to; - Conduct research into the causes and treatment of psychological disorders. - Diagnose, assess, and treat these disorders. **Counseling Psychologist** - Tend to study and treat [adjustment and vocational issues] encountered by [relatively healthy individuals.] **Clinical Psychologist** - Usually concentrate on [more severe psychological disorders.] **Psychiatrist** - *Earn an M.D. degree in medical school* - *Specialized in psychiatry during residency training* - Investigate the nature and causes of psychological disorders often from a biological point of view. - Make diagnoses - Offer treatments - Emphasizes drugs or other biological treatment, although most use psychosocial treatments as well. **Psychiatric Social Workers** - Earn a master's degree in social work - Treat disorders often concentrating on family problems associated with them. - Have advanced degrees - Specialize in the care and treatments of patients. **Marriage and Family Therapist and Mental Health Counselors** - 1-2 years earning a master's degree. - Employed -- Provide clinical services by hospitals or clinics. **"PARADIGMS OF ABNORMALITY"** **What is paradigm?** - A pattern of thinking which induces bias - A conceptual framework for analysis of observation (Kuhn) - A set of assumptions that govern our observation processes and analyses - A set of rules that a group of researchers follow in observation and analysis. **A Perspective:** - is a conceptual framework to examine a given phenomenon. - has a set of basic **[assumptions.]** - Determines which methods (data collection, analysis) will be used to study a given phenomenon. - Can also be referred to as an **"approach"** in psychology **Paradigms for Abnormal Behavior** - Biological (Medical Model) - Psychoanalytic - Humanistic/Existential - Behavioral; Cognitive; Cognitive-behavioral - Diathesis-stress **Biological (Medical Model)** - **[Core assumption:]** alterations of biological processes result in abnormal behavior - **Biological processes may include:** 1. Heredity 2. Imbalances of brain chemistry 3. Disordered development of brain structures **[Behaviour Genetics]** - study of how inherited genes contribute to abnormal behavior - **[Genotype]** is the total genetic makeup, composed of genes - **Phenotype** is the observable behavioral profile - The **phenotype can change** over time as a function of the interaction of genes and environment - **Phenotypes** also include observable characteristics that can be measured in the laboratory, such as **levels of hormones or blood cells.** **NOTE:** **Due to the influence of** environmental factors, organisms with identical genotypes, such as identical twins, ultimately **express non-identical phenotypes** because each organism encounters unique environmental influences as it develops. **Examples of phenotypes**: height, wing length, and hair color. **[4 Methods of Behavioral Genetics]** 1. Family method (index cases/probands) - Parent/child & brothers/sisters & nonidentical dizygotic twins share **50% of genes,** - Grandparent/grandchild & uncle/aunt-nephew/niece & half siblings share **25% of genes** - First cousins & great grandparent-great grandchild & great uncle/aunt share **12.5% of genes**, - **general population shares few genes** 2. Twin method (concordance) - **Monozygotic (MZ)** twins share **100%** of genes (identical) - **Dizygotic (DZ)** twins share on average **50%** of genes (fraternal or non-identical) 3. Adoptees method (controls environment) 4. Linkage analysis (what genes are involved) **Imbalances of Brain Chemistry in Nerve Signaling** - Neurons signal information by releasing chemical transmitters from the axon terminal - Chemical molecules bind to receptors on the membrane of adjacent nerve cells - Binding changes the electrical activity of the adjacent cell and can trigger an action potential - A reuptake process in the axon membrane takes up excess chemical for reuse **Abnormal behavior could result from:** - Too much or too little of a specific neurotransmitter owing to changes in synthesis of the transmitter - Too much of a specific neurotransmitter owing to changes in reuptake of the transmitter - Too many or too few receptors on the postsynaptic neuron membrane **Disordered Development of Brain Structures** - abnormal brain development or be caused by damage at an early age- Depending upon the time when these abnormalities or damage occur **(during pregnancy, the perinatal period, or infancy/childhood)** - some of the disorders included in this classification can be completely resolved by appropriate intervention. Others are chronic, but an adequate intervention is nevertheless essential because it is possible to alleviate to a greater or lesser extent, and in some cases possibly eliminate, the negative consequences or symptoms caused by the disorder in question. **EXAMPLE:** - **Intellectual disability** - meets all the criteria to be included in this category, but we feel it merits a separate section. - **Attention Deficit Hyperactivity Disorder (ADHD)** - It is characterized by the presenting symptoms of inattention and /or impulsivity-hyperactivity. Subtypes appear based on whether the predominant symptom is attention deficit, hyperactivity impulsivity, or both equally. - **Inattention** - Lack of attention to detail and committing careless mistakes. - Difficulty sustaining attention in tasks or at play. - Is easily distracted by extraneous stimuli - Does not seem to listen when spoken to directly. - Neither follows instructions nor completes tasks. - Has difficulty organizing tasks and activities. - Avoids, to the furthest extent possible, tasks that require sustained mental effort. - Is careless in daily activities - **Hyperactivity** - Cannot sit still or fidgets with hands and feet. - Gets up in situations in which he or she should remain seated. - Excessive energy. - Runs around or climbs excessively in inappropriate situations (in adults, feelings of restlessness). - Difficulty playing quietly or calmly engaging in leisure activities. - Talks excessively. - **Impulsivity** - Blurts out answers before questions have been completed - Has difficulty awaiting turn - Interrupts or intrudes on others **TAKE NOTE: For the diagnosis of ADHD,** the aforementioned symptoms must have been present **prior to age 12** with a frequency and severity that exceeds what is expected for the individual's age, and must **negatively affect the child's performance** both at school and at home. In addition, the doctor will also ensure that any of these symptoms are not due to another disorder. **[Specific Learning Disorders]** - Cognitive skills are not homogeneous in the same person, but if after proper development a particularly deficient area exists, we are speaking about a specific problem in learning characterized by substantially lower than expected academic performance in relation to a person\'s chronological age, the measure of his/her intelligence and age-appropriate education. It interferes significantly with school performance, hindering adequate progress and the achievement of goals set out in various curricula. - **Reading disorder (dyslexia)** - It is characterized by an impaired ability to recognize words, slow and insecure reading, and poor comprehension. - **Writing disorder (disgraphia)** - The problem may be in writing specific words or in writing in general. - **Calculation disorder (dyscalculia)** - Basic arithmetic skills (addition, subtraction, multiplication and division) are affected more than more abstract mathematical skills (algebra or geometry). **Communication Disorders** - This type of disorder appears when language development does not follow the expected pattern or significant deficits occur in any of its aspects. The linguistic characteristics of each disorder vary depending on its severity and the age of the child. **Expression Disorder** - The ability for oral expression is substantially below the appropriate level for a child\'s mental age. Difficulties may occur in verbal as well as body language. - Its main characteristics are: quantitatively limited speech, limited vocabulary, difficulty acquiring new words, vocabulary errors or errors recalling words, excessively short sentences, simplified grammar, limited use of grammatical structures and types of sentences, omissions of critical parts of sentences, using an unusual word order and deceleration in language development. **Comprehension disorder** - The ability for comprehension is markedly below the appropriate level for a child\'s mental age. Expression is also significantly affected (**this condition is commonly called \"mixed receptive-expressive language disorder\")** because the development of expressive language is derived from the acquisition of receptive skills. - Apart from the characteristics of expression disorder mentioned above, in this disorder **difficulty is seen in understanding words, phrases, or specific types of words**. There can also be a deficit in different areas of auditory processing (sound discrimination, sound-symbol association, retention, recall and sequencing). **Speech disorder(dislalia)** - Its main characteristic is the inability to use the sounds of speech that are developmentally appropriate given a child's age and language. - It may involve errors in the production, use, representation or organization of sounds, such as substitution of one sound for another or omission of sounds **Stuttering** - It is the disruption of normal fluency and temporal structure of speech given a patient's age. - It is characterized by frequent repetitions or prolongations of sounds or syllables. There may also be interjections, word fragmentation, blockage (audible or silent), circumlocutions, words produced with an excess of physical tension and repetition of monosyllables. - It does not usually occur during oral reading, singing or talking to inanimate objects or animals. **Autism Spectrum Disorders (ASD)** - People with ASD process information in their brain differently than others and they develop at different rates in each area. They present with clinically significant and persistent difficulties in social communication (marked difficulty in nonverbal and verbal communication used in interactions, lack of social reciprocity and difficulty developing and maintaining peer relationships appropriate to their developmental level), stereotypical motor or verbal behavior, unusual sensory behavior, and excessive adherence to routines and ritualistic patterns of behavior and limited interests. **Biological Approaches to Treatment** - Argues that abnormal behavior reflects disorders biological mechanisms (usually in the brain) - The approach to treatment is usually to alter the physiology of the brain - Drugs alter synaptic levels of neurotransmitters - Surgery to remove brain tissue (rare) - Induction of seizures to alter brain function (electroconvulsive shock therapy; ECT) **Electroconvulsive therapy (ECT)** - Electroconvulsive therapy (ECT) is a procedure, done under general anesthesia, in which small electric currents are passed through the brain, intentionally triggering a brief seizure. ECT seems to cause changes in brain chemistry that can quickly reverse symptoms of certain mental health conditions. - - **[Electroconvulsive therapy (ECT) can provide rapid, significant improvements in severe symptoms of several mental health conditions. ECT is used to treat:]** - Severe depression, particularly when accompanied by detachment from reality **(psychosis),** a desire to commit suicide or refusal to eat. - [Treatment-resistant depression,] a severe depression that doesn\'t improve with medications or other treatments. - [Severe mania,] a state of intense euphoria, agitation or hyperactivity that occurs as part of bipolar disorder. **Other signs of mania include impaired decision-making, impulsive or risky behavior, substance abuse, and psychosis.** - [Catatonia,] characterized by lack of movement, fast or strange movements, lack of speech, and other symptoms. It\'s associated with schizophrenia and certain other psychiatric disorders. In some cases, catatonia is caused by a medical illness. - [Agitation and aggression in people with dementia], which can be difficult to treat and negatively affect quality of life. - **[ECT may be a good treatment option when medications aren\'t tolerated or other forms of therapy haven\'t worked. In some case ECT is used:]** - During pregnancy, when medications can\'t be taken because they might harm the developing fetus - In older adults who can\'t tolerate drug side effects - In people who prefer ECT treatments over taking medications - When ECT has been successful in the past **Common Psychoactive Drug Treatments** 1. **Anti-anxiety** 2. **Stimulants** 3. **Anti-depressants** 4. **Anti-Manic** 5. **Anti-psychotic** **Flaws with Biological** 1. Factors unrelated to biology may influence thoughts and behaviors. E.g., environmental factors (life-style, abuse) may play role in some mental disorders 2. Multiple factors may influence thoughts and behaviors. **The Psychoanalytic Paradigm** [Core assumption] - abnormal behavior reflects unconscious conflicts within the person - derived from the theories of personality developed by Sigmund Freud (1856-1939) **[Freud's 3-Part Model of the Personality]** - Id: raw energy that powers the mind \- seeks gratification of basic urges for food, water, warmth, affection, sex & aggression; Pleasure principle \- unconscious \- Biological energy → psychic energy = libido \- Primary process if gratification is fantasy - Ego is conscious part of mind that deals w/reality; Reality principle; Secondary process - Superego is final part of the mind to emerge & is similar to the conscience (morals) **Psychodynamics** = interactions of id, ego, & superego in effort to gratify needs. **[5 Stages of Psychosexual Development]** - Personality develops in stages: in each the id derives pleasure from a distinct part of body (erogenous zones) 1. Oral (Birth to 18 months): infant derives pleasure from eating and biting; 2. Anal (18 months to 3 years): the focus of pleasure is the anus; 3. Phallic (3 to 6 years): the genitals are the focus of pleasure; (Oedipus and Electra complexes); heterosexual 4. Latent (6 to 12 years): id impulses are dormant 5. Genital: heterosexual interests are dominant \***Fixation of libido:** Conflicts between id desires and environment in so far as id is either under-gratified or over-gratified \***Fixation results** in permanent personality characteristics and NEUROTIC ANXIETY (vs. objective or realistic anxiety) **[Ego Defense Mechanisms- to reduce anxiety]** - **Repression** - **Denial** - **Projection** - **Displacement** - **Reaction formation** - **Regression** - **Rationalization** - **Sublimation** **Essentials of Classic Psychoanalytic Therapy** - The goal of psychoanalysis is insight (understanding) of the basis for anxiety - Techniques of psychoanalytic therapy: - Free association - Dream analysis - Transference - Interpretation of defense mechanisms **Criticism of Psychodynamic** 1. Freud had no scientific data to support his theories. 2. Freud's theories (unconscious, libido, etc.) cannot be observed. 3. Theory explains behavior (post-hoc) after the fact. 4. Observations not representative of population**.** **The Humanistic/Existential Paradigm** Core assumption: Unlike Freud, people are born naturally socialized - Like Freud, focus on insight about needs - Unlike Freud, places greater emphasis on the persons freedom of choice (free will) rather than on restraining human nature (id) - Like Freud, needs must be self-actualized or feel pain and suffering - Unlike Freud, does not focus on how problems develop but on treatment - Theorists argue we are driven to self-actualize, that is, to fulfill our potential for goodness and growth. - How we meet our needs for love and acceptance and achieve self-fulfillment. - More from early roots of psychology in the field of philosophy **Carl Rogers (1902 -- 1987) Client Centered Therapy** - People can only be understood from the vantage point of their own feelings (phenomenology) - Empathy - Understanding - Acceptance - Unconditional positive regard from self and others - self-actualization **Criticism of Humanistic** - Concepts are too vague - Subjective ideas are too hard to objectify (e.g. an experience that is real for one individual may not be real for another person) - Not a ―real science because it's too much common sense and not enough objectivity **[Behavioral, Cognitive, Cognitive Behavioral Paradigm]** - **Core assumption**: Abnormal behaviors are learned just as normal behaviors are learned either consciously or unconsciously VIA - **Classical conditioning** (Ivan Pavlov) - **Operant conditioning** (B.F.Skinner) - **Modeling** (Albert Bandura) **Behavioral Aspects of C-B Paradigm** - Behaviorism focuses on the study of **[observable]** behavior so that, unlike psychoanalytic and humanistic/existential approaches, the paradigm is **[testable]** - **Classical Conditioning** (Pavlovian conditioning) - US \-\-\-\-\--\> UR (unconditioned response) EX: (US-UNCONDITIONED STIMULUS, UR- UNCONDITIONED RESPONSE) [US -UR Examples] - **Visual** (steep cliff -□ freeze or fight) - **Tactile** (pain from fire -□ flee) - **Olfactory** (rotting animal -□flee) - **Gustatory** (spoiled food -□ fight/eject) Auditory (unexpected noise) -□ freeze) Interoceptive (pain -□ cringe, cry) - **Cognitive** (image of a US -□various) - **temporal association/contiguity with unconditioned stimuli (US) results in learning new behaviors---esp. emotional and involuntary** - pair US with neutral stimulus and it becomes a conditioned stimulus (CS) CS will elicit a CR (conditioned response) which is similar to the UR **[Operant Conditioning]** - **Voluntary behaviors** have consequences (law of effect or principle of reinforcement) - **Positive reinforcement**---increase pleasure - **Negative reinforcement**---decrease pain - **Discriminative stimuli** about the contingency of reinforcement - **Behavior can be shaped** using method of successive approximations **[Positive and Negative Reinforcement and Punishment]** - Both reinforcement and punishment can be positive or negative. In operant conditioning, positive and negative do not mean good and bad. Instead, positive means you are adding something and negative means you are taking something away. All of these methods can manipulate the behavior of a subject, but each works in a uniquely. - Positive reinforcers add a wanted or pleasant stimulus to increase or maintain the frequency of a behavior. For example, a child cleans her room and is rewarded with a cookie. - Negative reinforcers remove an aversive or unpleasant stimulus to increase or maintain the frequency of a behavior. For example, a child cleans her room and is rewarded by not having to wash the dishes that night - Positive punishments add an aversive stimulus to decrease a behavior or response. For example, a child refuses to clean her room and so her parents make her wash the dishes for a week. - Negative punishments remove a pleasant stimulus to decrease a behavior or response. For example, a child refuses to clean her room and so her parents refuse to let her play with her friend that afternoon. **[Reinforcers can be:]** - primary (unlearned) - secondary (learned) - immediate - delayed - environmentally-controlled - self-controlled **Reinforcer Examples:** - [Primary:] - Air - Food - Water - Shelter/comfort for heat & cold - Sex - Pain/fear/anger reduction - Novelty - Safety from danger/obstructions - [Secondary:] - Money - Social acceptance - Power, status **Watson's "Little Albert" Experiment** - In the early 1900s, John B. Watson carried out a controversial classical conditioning experiment on an infant boy called ''Little Albert'' Watson was interested in examining the effects of conditioning on the fear response in humans, and he introduced Little Albert to a number of items such as a white rat, a bunny, and a dog. Albert was originally not fearful of any of the items. Watson then allowed Albert to play with the rat, but as Albert played, Watson suddenly banged a hammer in a metal bar. The sound startled Albert and caused him to cry. Each time Albert touched the rat, Watson again banged the hammer on the bar. Watson was able to successfully condition Albert to fear the rat because of its association with the loud noise. Eventually, Albert was conditioned to fear other similar furry items such as a rabbit and even a Santa Claus mask. While Watson's research provided new insight into conditioning, it would be considered unethical by the current ethical standards set forth by the American Psychological Association. - **A reinforcement schedule is a tool in operant conditioning that allows the trainer to control the timing and frequency of reinforcement in order to elicit a target behavior. It may be continuous or intermittent** - Intermittent schedules are also described as either interval (based on the time between reinforcements) or ratio (based on the number of responses). - Different schedules (fixed-interval, variable-interval, fixed-ratio, and variable-ratio) have different advantages and respond differently to extinction. - Compound reinforcement schedules combine two or more simple schedules, using the same reinforcer and focusing on the same target behavior. **Continuous Reinforcement** - In continuous schedules, reinforcement is provided every single time after the desired behavior. - Candy machines are examples of continuous reinforcement because every time we put money in (behavior), we receive candy in return (positive reinforcement). **Types of Intermittent Schedules** - Fixed interval schedule- an exact amount of time passes between each reinforcement Example: Studying for quiz, getting your weekly salary - Variable interval schedule-a varying amount of time passes between each reinforcement Example: checking email, winning a video game, Your Employer Checking Your Work & Pop quizzes **NOTE: ratio schedules consistently elicit higher response rates than interval schedules because of their predictability** **[Modeling]** - Learning can occur in the absence of reinforcers - Modeling **involves learning** by watching and imitating the behaviors of others & objects (e.g. books, movies) = vicarious conditioning of **both involuntary and voluntary behavior** - Models impart information to the observer - More likely to imitate a model if the observer: - Is similar to the model - Observes the model being reinforced o Perceives the model as coping **Behavior Therapy** - **classical** and **operant conditioning** techniques as well as **modeling** are used to change abnormal behavior, thoughts and feelings. **[CLASSICAL CONDITIONING BASED TREATMENTS]** - Exposure (extinction) - Systematic desensitization - Aversive conditioning **[Extinction] -** is the decrease in the conditioned response when the unconditioned stimulus is no longer presented with the conditioned stimulus. When presented with the conditioned stimulus alone, the individual would show a weaker and weaker response, and finally no response. EXAMPLE: Conditioned **[taste aversions]** can also be affected by extinction. Imagine that you ate some ice cream right before getting sick and throwing it up. As a result, you developed a taste aversion to ice cream and avoided eating it, even though it was formerly one of your favorite foods. **[Aversive Conditioning]** - a technique used in behavior therapy to reduce the appeal of behaviors one wants to eliminate by associating them with physical or psychological discomfort. - the client is exposed to an unpleasant stimulus while engaging in the targeted behavior, the goal being to create an aversion to it. EXAMPLE: In adults, aversive conditioning is often used to combat addictions such as smoking or alcoholism. One common method is the administration of a nausea-producing drug while the client is smoking or drinking so that unpleasant associations are paired with the addictive behavior. In addition to smoking and alcoholism, aversive therapy has also been used to treat nail biting, sex addiction, and other strong habits or addictions. **[Systematic Desensitization]** - is a **treatment for phobias** in which the individual is trained to relax while being exposed to progressively more anxiety - **provoking stimuli**. - **Flooding is a form of desensitization** that uses repeated exposure to highly distressing stimuli until the lack of reinforcement of the anxiety response causes its extinction. - This therapy aims to remove the fear response of a phobia, and substitute a relaxation response to the conditional stimulus gradually using counter conditioning. - **Exposure can be done in two ways:** 1. **In vitro** -- the client imagines exposure to the phobic stimulus. 2. **In vivo** -- the client is actually exposed to the phobic stimulus **"ASSESING PSYCHOLOGICAL DISORDERS"** - For a mental health professional to be able to effectively help treat a client and know that the treatment selected worked (or is working), he/she first must engage in the **assessment** Of the client **[Assessment]** - **collecting relevant information in an effort to reach a conclusion** --To understand the individual (idiographic) --To predict behavior --To plan treatment --To evaluate treatment outcome **[Clinical Assessment]** - collecting information and drawing conclusions through the use of observation, psychological tests, neurological tests, and interviews to determine the person's problem and the presenting symptoms. - This collection of information involves learning about the client's skills, abilities, personality characteristics, cognitive and emotional functioning, the social context in terms of environmental stressors that are faced, and cultural factors particular to them such as their language or ethnicity. - - The specific tools used in an assessment depend on the clinician\'s theoretical orientation - **Hundreds of clinical assessment tools have been developed and fall into three categories:** - Clinical interviews - Tests - Observations **[Characteristics of Assessment Tools]** - Reliability, - Validity - Standardization **Reliability-** is a synonym for **dependability** or **consistency**. **I**n the language of psychometrics reliability refers to **consistency in measurement**. And whereas in everyday conversation reliability. - always connotes **something positive**, in the psychometric sense it really only refers to something that is consistent---not necessarily consistently good or bad, but **simply consistent.** - A good tool will always yield the same results in the same situation - **Two main types**: Test--retest reliability -- yields the same results every time it is given to the same people - Interrater reliability -- different judges independently agree on how to score and interpret a particular tool - A test may be reliable in one context and unreliable in another. There are different types and degrees of reliability. But reliability is not an all-or-none matter - Theoretically, each test contains some error -- the portion of the score on the test that is not relevant to the construct that you hope to measure. - Error could be the result of poor test construction, distractions from when the participant took the measure, or how the results from the assessment were marked. - Reliability indexes thus try to determine the proportion of the test score that is due to error **[Sources of Error Variance]** - Test construction - Test administration - Test scoring and interpretation - Other sources of error **[Types of Reliability]** 1. Test-Retest Reliability - is an estimate of reliability obtained by correlating pairs of scores from the same people on two different administrations of the same test. - It is also known as time sampling reliability since it measures the error associated with administering a test at two different times. - This is used when we measure only traits or characteristics that do not change over time. (e.g. IQ) Example: You took an IQ test today and you will take it again after exactly a year. If your scores are almost the same (e.g. 105 and 107), then the measure has a good test-retest reliability. - **Error variance** -- corresponds to the random fluctuations of performance from one test session to the other. - Clearly, this type of reliability is only applicable to stable traits. - Test-retest reliability is a measure of reliability obtained by administering the same test twice over a period of time to a group of individuals. The scores from Time 1 and Time 2 can then be correlated in order to evaluate the test for stability over time. Example: Let's say the person takes the MMPI on Tuesday and then the same test on Friday. Unless something miraculous or tragic happened over the two days in between tests, the scores on the MMPI should be nearly identical to one another. What does identical mean? The score at test and the score at retest are correlated with one another. If the test is reliable, the correlation should be very high (remember, a correlation goes from -1.00 to +1.00, and positive means as one score goes up, so does the other, so the correlation for the two tests should be high on the positive side). **NOTE:** However, even in measuring variables such as these, and even when the time period between the two administrations of the test is relatively small, various factors (such as experience, practice, memory, fatigue, and motivation) may intervene and confound an obtained measure of reliability. **[Types of Reliability]** Interrater reliability - (also called interobserver reliability) measures the degree of agreement between different people observing or assessing the same thing. You use it when data is collected by researchers assigning ratings, scores or categories to one or more variables. - The same test conducted by different people - Outside of clinical assessment, when our car has an issue and we take it to the mechanic, we want to make sure that what one mechanic says is wrong with our car is the same as what another says, or even two others. If not, the measurement tools they use to assess cars are flawed. The same is true of a patient who is suffering from a mental disorder. If one mental health professional says the person suffers from major depressive disorder and another says the issue is borderline personality disorder, then there is an issue with the assessment tool being used (in this case, the DSM and more on that in a bit). Example: A team of researchers observe the progress of wound healing in patients. To record the stages of healing, rating scales are used, with a set of criteria to assess various aspects of wounds. The results of different researchers assessing the same set of patients are compared, and there is a strong correlation between all sets of results, so the test has high interrater reliability. **[VALIDITY]** SITUATIONAL JUDGEMENT TEST - You are a squad leader on a field exercise, and your squad is ready to bed down for the night. The tent has not been put up yet, and nobody in the squad wants to put up the tent. They all know that it would be the best place to sleep since it may rain, but they are tired and just want to go to bed. What should you do? A. Tell them that the first four men to volunteer to put up the tent will get light duty tomorrow. B. Make the squad sleep without tents. C. Tell them that they will all work together and put up the tent. D. Explain that you are sympathetic with their fatigue, but the tent must be put up before they bed down. E. We all sleep without the tent - There are multiple ways to answer an SJT (e.g., pick the best/worst; respond to each option on a 1-5 scale of effectiveness), and furthermore, there is more than one way to score an SJT (two scoring options, among others, are agreement with subject matter expert responses and agreement with the consensus response). - SJTs are historically and substantively related to tests of practical intelligence, tacit knowledge, and other tests that ask respondents about solving hypothetical problems one might face in the real world. - In fact, the specific test items for measures of practical intelligence look a lot like SJT items (e.g., the Wagner and Sternberg, 1991, measure of the practical intelligence of managers). - Validity is the extent to which a test measures what it claims to measure. It is vital for a test to be valid in order for the results to be accurately applied and interpreted. - as applied to a test, is a judgment or estimate of how well a test measures what it purports to measure in a particular context. - It is a judgment based on evidence about the appropriateness of inferences drawn from test scores (strength and usefulness). **Three specific types**: - Face validity -- a tool appears to measure what it is supposed to measure; does not necessarily indicate true validity - Predictive validity -- a tool accurately predicts future characteristics or behavior - Concurrent validity -- a tool\'s results agree with independent measures assessing similar characteristics or behavior **[Face Validity]** - is the simplest and least scientific form of validity and it is demonstrated when the face value or superficial appearance of a measurement measures what it is supposed to measure. - Item seems to be reasonably related to the perceived purpose of the test. Often used to motivate test takers because they can see that the test is relevant Examples - An IQ test containing items which measure memory, mathematical ability, verbal reasoning and abstract reasoning has a good face validity. - An IQ test containing items which measure depression and anxiety has a bad face validity. - A self-esteem rating scale which has items like ―I know I can do what other people can do and ―I usually feel that I would fail on a task - has a good face validity. - Inkblot test that low face validity because test takers question whether the test really measures personality. **[Predictive validity]** - is when a tool accurately predicts what will happen in the future. - Examples of test with predictive validity are career or aptitude tests, which are helpful in determining who is likely to succeed or fail in certain subjects or occupations. - Let's say we want to tell if a high school student will do well in college. We might create a national exam to test needed skills and call it something like the Scholastic Aptitude Test (SAT). We would have high school students take it by their senior year and then wait until they are in college for a few years and see how they are doing. If they did well on the SAT, we would expect that at that point, they should be doing well in college. **Standardization** - Ensures consistency in the use of a technique - Provides population benchmarks for comparison - Examples include structured administration, scoring, and evaluation procedures **[Methods of Assessment]** - Observation- Systematic observations of behavior - Observational skills play an important part in most assessment procedures. - Sometimes the things that we observe confirm the person's self-report, and at other times the person's overt behavior appears to be at odds with what he or she says **Several kinds of observation:** - Naturalistic - Analog - Self-monitoring **[Naturalistic Observation]** - data collection in a field setting, without laboratory controls or manipulation of variables. These procedures are usually carried out by a trained observer, who watches and records the everyday behavior of participants in their natural environments. **[Analog Observation]** - tool by which a subject is observed in an artificial setting. Typically, types of settings in which analog observation is utilized include clinical offices or research laboratories, but, by definition, analog observations can be made in any artificial environment, even if the environment is one which the subject is likely to encounter naturally. **Naturalistic and analog observations** - Naturalistic observations occur in everyday environments - Can occur in homes, schools, institutions (hospitals and prisons), and community settings - Most focus on parent--child, sibling--child, or teacher--child interactions - Observations are generally made by "participant observers" and reported to a clinician - If naturalistic observation is impractical, analog observations are used and conducted in artificial settings **[Naturalistic and analog observations Strengths and Weaknesses:]** **Reliability is a concern** - Different observers may focus on different aspects of behavior **Validity is a concern** - Risk of "overload," "observer drift," and observer bias - Client reactivity may also limit validity - Observations may lack cross-situational validity **Example:** Have you ever noticed someone staring at you while you sat and ate your lunch? If you have, what did you do? Did you change your behavior? Did you become self-conscious? - Likely yes, and this is an example of reactivity. **[Cross-Situational Validity]** - Behavior being specific to particular situations, observations in one setting cannot always be applied to other settings Example: significant other only acting out at the football game and not at home. **[Overload] -** observer may unable to see or record all the important behaviors or events **[Self-monitoring]** -- people observe themselves and carefully record the frequency of certain behaviors, feelings, or cognitions as they occur over time **Rating Scales** - A rating scale is a procedure in which the observer is asked to make judgments that place the person somewhere along a dimension. - Ratings can also be made on the basis of information collected during an interview. - Rating scales provide abstract descriptions of a person's behavior rather than a specific record of exactly what the person has done**.** **[Methods of Assessment]** - Clinical Interview - These face-to-face encounters often are the first contact between a client and a clinician/assessor. Used to collect detailed information, especially personal history, about a client - **Allow the interviewer to focus on whatever topics they consider most important** - Focus depends on theoretical orientation - **Conducting the interview** - Can be either structured, unstructured and semi-structured - structured interview, clinicians used a specific set of questions according to an interview schedule - unstructured interview, clinicians ask open-ended questions - semi-structured in which there is a pre-set list of questions, but clinicians can follow up on specific issues that catch their attention. - **Assessment Interviews** - **Face-to-face interaction** - **Unstructured interviews** - **Structured interviews** **[Mental Status Examination ]** - **is used to organize the information collected during the interview and systematically evaluates the [ ] patient through a series of questions assessing appearance and behavior.** The latter includes grooming and body posture, thought processes and content to include disorganized speech or thought and false beliefs, mood and affect such that whether the person feels hopeless or elated, intellectual functioning to include speech and memory, and awareness of surroundings to include where the person is and what the day and time are. The exam covers areas not normally part of the interview and allows the mental health professional to determine which areas need to be examined further. - **Limitations:** - May lack of validity or accuracy - Individuals may be intentionally misleading - Interviewers may be biased or may make mistakes in judgment - Interviews, particularly unstructured ones, may lack reliability - Psychological tests and inventories - **Psychological tests** assess the client's personality, social skills, cognitive abilities, emotions, behavioral responses, or interests. They can be administered either individually or to groups in paper or oral fashion. - **Intelligence tests** - Designed to indirectly measure intellectual ability - Typically comprised of a series of tests assessing both verbal and nonverbal skills - **General score is an intelligence quotient (IQ)** - Represents the ratio of a person\'s **"mental"** age to his or her **"chronological"** age - Strengths: - **Are among the most carefully produced of all clinical tests** - Highly standardized on large groups of subjects - Have very high reliability and validity - Weaknesses: - Performance can be influenced by nonintelligence factors (e.g., motivation, anxiety, test-taking experience) - Tests may contain cultural biases in language or tasks - Members of minority groups may have less experience and be less comfortable with these types of tests, influencing their results **[Personality Inventories]** - ask clients to state whether each item in a long list of statements applies to them, and could ask about feelings, behaviors, or beliefs. - Designed to measure broad personality characteristics - Focus on behaviors, beliefs, and feelings - Usually based on self-reported responses - Most widely used: Minnesota Multiphasic Personality Inventory - **For adults**: MMPI (original) or MMPI-2 (1989 revision) - **For adolescents:** MMPI-A - NEO-PI-R **Minnesota Multiphasic Personality Inventory (MMPI)** - Consists of more than 500 self-statements that can be answered "true," "false," or "cannot say" - Statements describe physical concerns, mood, morale, attitudes toward religion sex, and social activities, and psychological symptoms - Assesses careless responding and lying **[NEO-PI-R]** - standard questionnaire measure of the Five Factor Model (FFM), provides a systematic assessment of emotional, interpersonal, experiential, attitudinal, and motivational styles - a detailed personality description that can be a valuable resource for a variety of professionals. - concise measure of the five major domains of personality - Neuroticism, Extroversion, Openness, Agreeableness, and Conscientiousness. Six facets define each of the five domains, and the measure assesses emotional, interpersonal, experimental, attitudinal, and motivational styles (Costa & McCrae, 1992). - These inventories have the advantage of being easy to administer by either a professional or the individual taking it, are standardized, objectively scored, and can be completed electronically or by hand. **Personality inventories** - Strengths and weaknesses: - Easier, cheaper, and faster to administer than projective tests - Objectively scored and standardized - Appear to have greater validity than projective tests - However, they cannot be considered highly valid -- measured traits often cannot be directly examined -- how can we really know the assessment is correct? - Tests fail to allow for cultural differences in responses **Projective tests** - Require that clients interpret vague and ambiguous stimuli or follow open-ended instruction - Mainly used by psychodynamic practitioners - Most popular: - Rorschach Test - Thematic Apperception Test - Sentence completion tests - Drawings **Thematic Apperception Test (TAT)** - which asks the individual to write a complete story about each of 20 cards shown to them and give details about what led up to the scene depicted, what the characters are thinking, what they are doing, and what the outcome will be. From the response, the clinician gains perspective on patient's worries, needs, emotions, conflicts, and the individual always connects with one of the people on the card. (1893-1988), Developed **by Henry Murray** **Clinical Test: Sentence-Completion Test** - "I wish - "My fathe[r ] **Clinical Test: Drawings** Draw-a-Person (DAP) test - "Draw a person" - "Draw another person of the opposite sex" - Strengths of Projective Tests 1. Some people may feel more comfortable talking in an unstructured situation than they would if they were required to participate in a structured interview or to complete the lengthy MMPI. 2. Projective tests can provide an interesting source of information regarding the person's unique view of the world, and they can be a useful supplement to information obtained with other assessment tools. 3. To whatever extent a person's relationships with other people are governed by unconscious cognitive and emotional events, projective tests may provide information that cannot be obtained through direct interviewing methods or observational procedures. Limitations of Projective Tests 1. Lack of standardization in administration and scoring is a serious problem. 2. Little information is available on which to base comparisons to normal adults or children 3. Some projective procedures, such as the Rorschach, can be very time-consuming 4. The reliability of scoring and interpretation tends to be low. 5. Information regarding the validity of projective tests is primarily negative **Response inventories** - Usually based on self-reported responses - Focus on one specific area of functioning - Affective inventories (example: Beck Depression Inventory) - Social skills inventories - Cognitive inventories **Social Skills Inventory (SSI)** - also known as the **Self-Description Inventory**, assesses 6 basic social skills that underlie social competence. It **evaluates verbal (social) and non-verbal (emotional) communication skills** and identifies strengths and weaknesses. As such, the SSI acts as a reliable and valid abilities **measure of Emotional Intelligence**. The instrument is useful in individual and couples counseling, management and leadership training, and health psychology. **Cognitive flexibility inventory (CFI)** - was developed to be a brief self-report measure of the type of cognitive flexibility necessary for individuals to successfully challenge and replace maladaptive thoughts with more balanced and adaptive thinking. It was designed to measure three aspects of cognitive flexibility: **(a)** the tendency to perceive difficult situations as controllable; **(b)** the ability to perceive multiple alternative explanations for life occurrences and human behavior; and (c) the ability to generate multiple alternative solutions to difficult situations. **Response inventories** - Strengths and weaknesses: - Have strong face validity - Not all have been subjected to careful standardization, reliability, and/or validity procedures (Beck Depression Inventory and a few others are exceptions) **Psychophysiological tests** - Measure physiological response as an indication of psychological problems - Includes heart rate, blood pressure, body temperature, galvanic skin response, and muscle contraction - Most popular is the polygraph (lie detector) - Strengths of Physiological Procedures 1. **Psychophysiological recording procedures** do not depend on self-report and, therefore, may be less subject to voluntary control. 2. Some of these measures can be obtained while the subject is sleeping or while the subject is actively engaged in some other activity. **Limitations of Physiological Procedures** 1. The recording equipment and electrodes may be frightening or intimidating to some people. 2. There are generally low correlations between different autonomic response systems. 3. Physiological reactivity and the stability of physiological response systems vary from person to person. 4. Physiological responses can be influenced by many other factors. Some are person variables, such as age and medication, as well as psychological factors, such as being self-conscious or fearing loss of control. 4\. Neurological and neuropsychological tests - **Neurological tests** are used to diagnose cognitive impairments caused by brain damage due to tumors, infections, or head injuries; or changes in brain activity. '**'Diagnosing and classifying abnormal behaviors''** **Note:** Before starting any type of treatment, the client/patient must be clearly diagnosed with a mental disorder **[Clinical diagnosis]** - is the process of using assessment data to determine if the pattern of symptoms the person presents with is consistent with the diagnostic criteria for a specific mental disorder outlined in an established classification system such as the DSM-5 or International Classification of Diseases 10 (ICD-10) Be Aware! - Any diagnosis should have clinical utility, meaning it aids the mental health professional in determining prognosis, the treatment plan, and possible outcomes of treatment (APA, 2013) - Receiving a diagnosis does not necessarily mean the person requires treatment. This decision is made based upon how severe the symptoms are, level of distress caused by the symptoms, symptom salience such as expressing suicidal ideation, risks and benefits of treatment, disability, and other factors (APA, 2013). Likewise, a patient may not meet the full criteria for a diagnosis but require treatment nonetheless. **SYMPTOM** - refers to an observable behavior or state. - there is no implication that an underlying problem necessarily exists or that there is a physical etiology. - the simplest level of analyzing a presenting problem. **Signs and Symptoms** of mental illness can vary, depending on the disorder, circumstances and other factors. Mental illness symptoms can affect emotions, thoughts and behaviors. - Feeling sad or down - Confused thinking or reduced ability to concentrate - Excessive fears or worries, or extreme feelings of guilt - Extreme mood changes of highs and lows - Withdrawal from friends and activities - Significant tiredness, low energy or problems sleeping - Detachment from reality (delusions), paranoia or hallucinations - Inability to cope with daily problems or stress - Trouble understanding and relating to situations and to people - Problems with alcohol or drug use - Major changes in eating habits - Sex drive changes - Excessive anger, hostility or violence - Suicidal thinking **SYNDROME** - the next higher level of analysis - this term is applied to a constellation of symptoms that occur together or co-vary over time. - the term carries no direct implications in terms of underlying pathology. - Whether, in fact, certain sets of symptoms co-vary with one another is an empirical question. **DISORDER** - like a syndrome, refers to a cluster of symptoms, - but the concept includes the idea that the set of symptoms is not accounted for by a more pervasive condition. **Classification Systems** - provide mental health professionals with an agreed-upon list of disorders falling into distinct categories for which there are clear descriptions and criteria for making a diagnosis. - People suffering from delusions, hallucinations, disorganized speech, catatonia, and/or negative symptoms are different from people presenting with a primary clinical deficit in cognitive functioning that is not developmental but has been acquired (i.e., they have shown a decline in cognitive functioning over time). The former suffers from a schizophrenia spectrum disorder while the latter suffers from a NCD or neurocognitive disorder. The latter can be further distinguished from neurodevelopmental disorders which manifest early in development and involve developmental deficits that cause impairments in social, academic, or occupational functioning (APA, 2013). These three disorder groups or categories can be clearly distinguished from one another. - **The most widely used classification system in the United States** is the Diagnostic and Statistical Manual of Mental Disorders currently in its 5-TR edition and produced by the American Psychiatric Association (APA, 2013). Alternatively, the **World Health Organization (WHO) publishes** the International Statistical Classification of Diseases and Related Health Problems (ICD) currently in its 11th edition **[A Brief History of the DSM]** - The DSM-5 was published in 2013 and took the place of the DSM IV-TR (TR means Text Revision; published in 2000) - The Herculean task of revising the DSM began in 1999 when the APA embarked upon an evaluation of the strengths and weaknesses of the DSM in coordination with the World Health Organization (WHO) Division of Mental Health, the World - Psychiatric Association, and the National Institute of Mental Health (NIMH). This collaboration resulted in the publication of a monograph in 2002 called A Research Agenda for DSM-V. The result was a ―common language for communication between clinicians about the diagnosis of disorders along with a realization that the criteria and disorders contained within were based on current research and may undergo modification with new evidence gathered ―both within and across the domains of proposed disorders (APA, 2013). - Lists approximately 400 disorders **Elements of a Diagnosis** - The DSM 5 states that the following make up the key elements of a diagnosis (APA, 2013) 1. **Diagnostic Criteria and Descriptors** - Diagnostic criteria are the guidelines for making a diagnosis. When the full criteria are met, mental health professionals can add **severity and course specifiers** **to indicate the patient's current presentation.** If the full criteria are not met, designators such as ―other specified or ―unspecified can be used. If applicable, an indication of severity (mild, moderate, severe, or extreme), **descriptive features,** and course (type of remission -- partial or full -- or recurrent) can be provided with the diagnosis. The final diagnosis is **based on the clinical interview, text descriptions, criteria, and clinical judgment.** 1. **Response** - first objective in the treatment - Response is clinically defined as an improvement from the initial onset of your illness. -The goal herein would be to report less symptoms. - What does matter is that you experience feeling better. Getting to a response level will be easy for some, moderate for others, and harder for those with treatment resistant depression. When it comes to a response, don\'t compare yourself with another person\'s experience. Instead, focus on your biology and biography to set realistic goals 2. **Remission** - The second goal in treating - Remission is clinically defined as the experience of **being symptom-free from illness**. This differs from response in that you not only report an improvement from when you started treatment, but also describe the presence of well-being, optimism, self-confidence and a return to a healthy state of functioning. It is important to follow your treatment plan so you can achieve a full state of remission. Not doing so can lead to a partial remission - an experience of significant improvement where mild symptoms still exist. It is **VERY IMPORTANT** to know that if you\'re still experiencing depressive symptoms, you have not reached a full remission. Partial remission signals the need to continue with your treatment for depression. This is where most children and adults with unipolar or bipolar disorders lose their way. They stop taking their medication or interrupt psychotherapy because they \"feel better\"\... but in actuality, they haven't achieved a full remission. 3. **Recovery** -Recovery is clinically defined as the absence of symptoms for **at least 4 months** following the onset of remission. -Recovery presents with periods of improvement and growth as well as with setbacks and stumbling blocks. So, essentially, you\'ll have good days and you\'ll have bad days. And yes, the human experience is one where you\'ll feel depressed, fatigued and hopeless from time to time. It\'s important to monitor yourself by assessing your physical and emotional experiences with the tools you\'ve learned in psychotherapy. It is also imperative to keep up with your medication if that\'s part of your treatment plan. Research states that over 50% of children and adults who have a mood disorder will not achieve recovery because they don\'t tend to this stage of treatment, which is sometimes called the continuation phase of treatment. **Relapse and Recurrence** - Relapse and Recurrence are terms commonly used to describe a return of depressive symptoms. In truth, though, they are distinctly different experiences. 4. **Relapse** is defined as a full return of depressive symptoms once remission has occurred - but before recovery has taken hold. 5. **Recurrence** refers to another depressive episode after recovery has been attained. **[Subtypes and Specifiers]** - Subtypes denote ―mutually exclusive and jointly exhaustive phenomenological subgroupings within a diagnosis (APA, 2013). For example, non-rapid eye movement (NREM) sleep arousal disorders can have either a sleepwalking or sleep terror type. Enuresis is nocturnal only, diurnal only, or both. Specifiers are not mutually exclusive or jointly exhaustive and so more than one specifier can be given. For instance, bingeeating disorder has remission and severity specifiers. Somatic symptom disorder has a specifier for severity, if with predominant pain, and/or if persistent. Again, the fundamental distinction between subtypes and specifiers is that there can be only one subtype but multiple specifiers. **Principle Diagnosis** - is used when more than one diagnosis is given for an individual (when an individual has comorbid disorders). The principal diagnosis is the reason for the admission in an inpatient setting or the reason for a visit resulting in ambulatory care medical services in outpatient settings. The principal diagnosis is generally the main focus of treatment. **Provisional Diagnosis** - If there's not enough information is available for a mental health professional to make a definitive diagnosis, but there is a strong presumption that the full criteria will be met with additional information or time, then the provisional specifier can be used. - In 1893, the International Statistical Institute adopted the International List of Causes of Death which was the first edition of the ICD. - The World Health Organization was entrusted with the development of the ICDin 1948 and published the 6th version (ICD 6), which was the first version to include mental disorders. The ICD-10 was endorsed in May 1990 by the 43rd World Health Assembly. And is now ICD-11 **The WHO states:** - ICD is the foundation for the identification of health trends and statistics globally, and the international standard for reporting diseases and health conditions. It is the diagnostic classification standard for all clinical and research purposes. ICD defines the universe of diseases, disorders, injuries and other related health conditions, listed in a comprehensive, hierarchical fashion that allows for: - **[easy storage, retrieval and analysis of health information for evidence-based decision-making; ]** - **[sharing and comparing health information between hospitals, regions, settings, and countries;]** - **[and data comparisons in the same location across different time periods.]** **The ICD lists many types of diseases and disorders to include Chapter V: Mental and Behavioral Disorders. The list of mental disorders is broken down as follows:** - Organic, including symptomatic, mental disorders - Mental and behavioral disorders due to psychoactive substance use - Schizophrenia, schizotypal and delusional disorders - Mood (affective) disorders - Neurotic, stress-related and somatoform disorders - Behavioral syndromes associated with physiological disturbances and physical factors - Disorders of adult personality and behavior - Mental retardation - Disorders of psychological development - Behavioral and emotional disorders with onset usually occurring in childhood and adolescence - Unspecified mental disorder **Harmonization of DSM-5 and ICD-11** - As noted earlier, the ICD-11 is currently in development with an expected publication date of 2018. According to the DSM-5, there is an effort to harmonize the two classification systems for a more accurate collection of national health statistics and design of clinical trials, increased ability to replicate scientific findings across national boundaries, and to rectify the issue of DSM-IV and ICD-10 diagnoses not agreeing (APA, 2013). **Is DSM-5 an Effective Classification System?** - The framers of DSM-5 followed certain procedures in their development of the new manual to help ensure that DSM-5 would have greater reliability than the previous DSMs - A number of new diagnostic criteria were developed and categories, expecting that the new criteria and categories were in fact reliable. - Some critics continue to have concerns about the procedures used in the development of DSM-5 - Adding a new category, **"autism spectrum disorder,"** that combines certain past categories such as **"autistic disorder" and "Asperger's syndrome"** - Viewing "obsessive-compulsive disorder" as a problem that is different from the anxiety disorders and grouping it instead along with other compulsive-like disorders such as "hoarding disorder," "body dysmorphic disorder," "hair-pulling disorder," and "excoriation (skin picking) disorder" - Viewing "posttraumatic stress disorder" as a problem that is distinct from the anxiety disorders (see Chapter 6) - Adding a new category, "somatic symptom disorder" - Replacing the term "hypochondriasis" with the new term "illness anxiety disorder" - Adding a new category, "premenstrual dysphoric disorder" - Adding a new category, "disruptive mood dysregulation disorder" - Adding a new category, "binge eating disorder" - Adding a new category, "substance use disorder," that combines past categories "substance abuse" and "substance dependence" - Viewing "gambling disorder" as a problem that should be grouped as an addictive disorder alongside the "substance use disorders" - Replacing the term "gender identity disorder" with the new term "gender dysphoria" - Replacing the term "mental retardation" with the new term "intellectual developmental disorder" - Adding a new category, "specific learning disorder," that combines past categories "reading disorder," "mathematics disorder," and "disorder of written expression" - Replacing the term "dementia" with the new term "neurocognitive disorder" - Adding a new category, "mild neurocognitive disorder" **Can Diagnosis and Labeling Cause Harm?** - Misdiagnosis is always a concern - Major issue is the reliance on clinical judgment - Also present is the issue of labeling and stigma - Diagnosis may be a self-fulfilling prophecy - Because of these problems, some clinicians would like to do away with the practice of diagnosis 1. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) includes eliminating the multi-axial system 2. removing the Global Assessment of Functioning (GAF score); reorganizing the classification of the disorders; and changing how disorders that result from a general medical condition are conceptualized. 3. Many of these general changes from Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) to DSM-5 is summarized in the report Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health 4. This report will supplement that information by providing detail specifically about changes to disorders of childhood and their implications for generating estimates of child serious emotional disturbance (SED). **Elimination of the Multi-Axial System and GAF Score** - There were five different axes. - Axis I consisted of mental health and substance use disorders (SUDs); - Axis II was reserved for personality disorders and mental retardation; - Axis III was used for coding general medical conditions; - Axis IV was to note psychosocial and environmental problems (e.g., housing, employment); and - Axis V was an assessment of overall functioning known as the GAF. The GAF scale was dropped from the DSM-5 because of its conceptual lack of clarity (i.e., including symptoms, suicide risk, and disabilities in the descriptors) and questionable psychometric properties (American Psychiatric Association, 2013). - Although the impact of removing the overall multi-axial structure in DSM-5 is unknown, there is concern among clinicians that eliminating the structured approach for gathering and organizing clinical assessment data will hinder clinical practice (Frances, 2010). However, the direct impact on the prevalence rates of childhood mental disorders is likely to be negligible as it will not affect the characteristics of diagnoses. - **Axis I** includes all mental health conditions except **personality disorders** and **mental retardation**. This is typically the initial complaint for which a client seeks medical attention. If the client does not have a mental health diagnosis that belongs on Axis I, V71.09 is placed in the diagnosis spot to show there is no diagnosis. - A person can suffer from more than one disorder listed under Axis I and all are listed. This axis describes clinical symptoms that cause significant impairment. Disorders are grouped into different categories including adjustment disorders, **anxiety disorders**, childhood disorders, cognitive disorders, dissociative disorders, eating disorders, factitious disorders, impulse control disorders, mood disorders, psychotic disorders, sexual and gender identity disorders, sleep disorders, somatoform disorders, substance related disorders, adjustment disorders, and **pervasive developmental disorders.** - **Axis II** includes mental retardation and personality disorders. This axis describes long-term problems that are overlooked under Axis I. Many of these disorders, such as autism, are typically first evident in early childhood. These problems may not require immediate attention, but can complicate treatment and should be taken into account by the clinician. Mental retardation is characterized by intellectual impairment and deficits in other areas such as self-care and interpersonal skills. Axis II contains a rating scale for mental retardation. - **Personality disorders** cause significant problems in how a patient relates to the world and specifically include paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, antisocial personality disorder, borderline personality disorder, **[histrionic personality disorder]**, narcissistic personality disorder, avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder. - **Axis III** addresses any major medical conditions that may be relevant to treatment of the mental health disorder. These include physical and medical conditions that may influence or worsen Axis I and Axis II disorders. Some examples may include HIV or AIDS, hypothyroidism**, celiac disease** and brain injuries. - **Axis IV** is used to report psychosocial and environmental factors affecting the person that can result from or contribute to Axis I, II, and III disorders. Some examples of these factors include: (1) problems with primary support group (divorce); (2) problems with social environment (death of a friend); (3) educational problems; (4) housing problems; (5) economic problems; (6) occupational difficulties; (7) legal difficulties; and (8) transportation difficulties. These are some categories a clinician will look at to see how the client is doing in life situations. Any social or environmental problems that may impact Axis I or Axis II disorders are accounted for in this assessment. These may include such things as unemployment, re-location, divorce, or the death of a loved one. - **Axis V: Global Assessment of Overall Functioning.** Axis V codes the ―level of function the individual has attained at the time of assessment, and, in some cases, is used to indicate the highest level of function in the past year. This rating helps the clinician understand how the above four axes are affecting the person, and what type of changes could be expected. This is coded on the Global Assessment of Functioning scale, which is a 0-100 scale, with 100 being ―superior functioning in a wide range of activities and 0 being ―persistent danger of severely hurting self or others It measures a patient's overall level of psychological, social, and occupational functioning on a hypothetical continuum. **Disorder Reclassification** - DSM-IV and DSM-5 categorize disorders into ―classes with the intent of grouping similar disorders (particularly those that are suspected to share etiological mechanisms or have similar symptoms) to help clinician and researchers use of the manual. From DSM-IV to DSM-5, there has been a reclassification of many disorders that reflects a better understanding of the classifications of disorders from emerging research or clinical knowledge. Table 3 lists the disorder classes included in DSM-IV and DSM-5. In DSM-5, six classes were added and four were removed. As a result of these changes in the overall classification system, numerous individual disorders were reclassified from one class to another (e.g., from ―mood disorders to ―bipolar and related disorders or ―depressive disorders. The reclassification of disorder classes will not have a direct effect on any SED estimation; however, it does warrant consideration when documenting disorders that may have changed classes 42 of particular note for childhood mental disorders, the DSM-5 eliminated a class of - disorders usually first diagnosed in infancy, childhood, or adolescence. Those disorders are now placed within other classes. **[Classifying Abnormal Behavior]** - **Culture and Classification** - The DSM-IV-TR encourages clinicians to consider the influence of cultural factors in both the expression and recognition of symptoms of mental disorders. - People express extreme emotions in ways that are shaped by the traditions of their families and other social groups to which they belong. - The diagnostic manual attempts to sensitize clinicians to cultural issues by including a glossary of **[culture-bound syndromes.]** - These are patterns of erratic or unusual thinking and behavior that have been identified in diverse societies around the world and do not fit easily into the other diagnostic categories that are listed in the main body of DSM-IV-TR. - Culture-bound syndromes have also been called **[idioms of distress.]** - In other words, they represent a manner of expressing negative emotion that is unique to a particular culture and cannot be easily translated or understood in terms of its individual parts. - One syndrome of this type is a phenomenon known as ataques de nervios panic attacks, which has been observed most extensively among people from Puerto Rico and other Caribbean countries. - Descriptions of this experience include four dimensions, in which the essential theme is loss of control---an inability to interrupt the dramatic sequence of emotion and behavior. - **Culture and Classification** - **These dimensions include:** 1. emotional expressions (an explosion of screaming and crying, coupled with overwhelming feelings of anxiety, depression, and anger), 2. bodily sensations (including trembling, heart palpitations, weakness, fatigue, headache, and convulsions), 3. actions and behaviors (dramatic, forceful gestures that include aggression toward others, suicidal thoughts or gestures, and trouble eating or sleeping), and 4. alterations in consciousness (marked feelings of ―not being one's usual self, accompanied by fainting, loss of consciousness, dizziness, and feelings of being outside of one's body). **[TREATMENT OF MENTAL DISORDERS]** **Seeking Treatment** - **[Who seeks treatment?]** Would you describe the people who seek treatment as being on the brink, crazy, or desperate? Or can the ordinary Juan in need of advice seek out mental health counseling? The answer is that anyone can. - David Sack, M.D. (2013) writes in the article 5 Signs Its Time to Seek Therapy, published in Psychology Today, that ―most people can benefit from therapy at least some point in their lives, and though the signs you need to seek help are obvious at times, we often try ―to sustain \[our\] busy life until it sets in that life has become unmanageable. **[So, when should we seek help?]** - First, if we feel sad, angry, or not like ourselves. We might be withdrawing from friends and families or sleeping more or less than we usually do. - Second, if we are abusing drugs, alcohol, food, or sex to deal with life's problems. In this case, our coping skills may need some work. - Third, in instances when we have lost a loved one or something else important to us, whether due to death or divorce, the grief may be too much to process. - Fourth, a traumatic event may have occurred, such as abuse, a crime, an accident, chronic illness, or rape. Finally, if you have stopped doing the things you enjoy the most. **Sack (2013) says**, ―If you decide that therapy is worth a try, it doesn't mean you're in for a lifetime of head shrinking. A 2001 study in the Journal of Counseling Psychology found that most people feel better within seven to 10 visits. In another study, published in 2006 in the Journal of Consulting and Clinical Psychology, 88% of therapy-goers reported improvements after just one session. **Psychologists** - can recognize behavior or thought patterns objectively, more so than those closest to you who may have stopped noticing --- or maybe never noticed. A psychologist might offer remarks or observations similar to those in your existing relationships, but their help may be more effective due to their timing, focus, or your trust in their neutral stance. **[Treatment: How Might the Client Be Helped?]** - Begin with assessment information and diagnostic decisions to determine a treatment plan - Use a combination of idiographic and nomothetic information Other factors: - **Therapist\'s theoretical orientation Current research** - **General state of clinical knowledge -- currently focusing on empirically supported, evidence-based treatment** **[The Effectiveness of Treatment More than 400 forms of therapy in practice, but is therapy effective?]** - **Difficult question to answer: How do you define success?** - **How do you measure improvement?** - **How do you compare treatments?** - People differ in their problems, personal styles, and motivations for therapy - Therapists differ in skill, knowledge, orientation, and personality - Therapies differ in theory, format, and setting **[Therapy outcome studies typically assess one of the following questions:]** - **Is therapy in general effective? Are particular therapies generally effective?** - **Are particular therapies effective for particular problems?** **[The Effectiveness of Treatment]** - **Is therapy generally effective?** - Research suggests that therapy is generally more helpful than no treatment or than placebo - In one major study using meta- analysis, the average person who received treatment was better off than 75% of the untreated subjects **[Does Therapy Help?]** - **Some clinicians are concerned with a related question:** - Can therapy can be harmful? - It does have this potential - Studies suggest that 5-10% of patients get worse with treatment - Generally, therapy-outcome studies lump all therapies together to consider their general effectiveness - Some critics call this the "uniformity myth" An alternative approach examines the effectiveness of particular therapies - There is a movement **("rapprochement")** to look at commonalities among therapies, regardless of clinician orientation **[Uniformity myth]** - **What specific treatment, by whom, is the most effective for this individual with that specific problem, and under which set of circumstances?** - Studies now being conducted to examine the effectiveness of specific treatments for specific disorders: - "What specific treatment, by whom, is the most effective for this individual with that specific problem, and under which set of circumstances?" Recent studies focus on the effectiveness of combined approaches -- drug therapy combined with certain forms of psychotherapy -- to treat certain disorders