UOW PSYC251: Psychopathology Lecture Notes PDF

UOW PSYC251:Psychopathology L1 Mala Khare  Today’s agenda Subject Introduction: – What do we mean by psychopathology? Models of Clinical Psychology Consultation 6-6.30pm  Prescribed Major Text Hooley, J.M., Butcher, J.N., Nock, M.K....

UOW PSYC251:Psychopathology L1 Mala Khare  Today’s agenda Subject Introduction: – What do we mean by psychopathology? Models of Clinical Psychology Consultation 6-6.30pm  Prescribed Major Text Hooley, J.M., Butcher, J.N., Nock, M.K. & Mineka, S. (2017). Abnormal Psychology (17th Ed). London: Pearson Education Limited. Recommended Readings – Refer to the Subject Outline  Psychopathology – Is the scientific study of psychological disorders Traditionally referred to as abnormal psychology, it studies mental disorders and unusual or maladaptive behaviours. –Includes symptoms, causes, course, development, treatments, strategies, and more.  What is Abnormal? Lay Person’s View: The ‘man on the street’ may define abnormal by reference to cultural or social norm violation Cultural relativism: what is abnormal in one society may be a strength in another. Temporal relativism: what is abnormal at one time may not be so at another. (e.g. Homosexuality, premarital sex, women working, Childcare) Situational relativism: the cultural norm may adjust to a particular circumstance (shouting at music concert) – Unlike temporal, this involves understandings of abnormality changing across contexts or situations rather than across time.  Psychopathology Abnormal behavior is not mental disorder. – Mental disorders involve abnormal behaviors BUT abnormal behavior does NOT always indicate a given mental disorder. – Abnormal behaviour is the expression of Mental Illness (e.g. avoidance in phobia) Behavior is what we see, however there is more to mental disorder than just the behavior.  Defining Abnormality Seemingly simple, but a complex concept  "Abnormal" literally means "away from the norm" w Norms are different for different populations and can change with time & conditions Do people know whether they are abnormal? Yes and no - some people do, they feel their distress, others do not  Myths Associated With Mental Illness People with mental illness are weak w Abraham Lincoln and Winston Churchill battled depression People with mental illness could just snap out of it if they wanted to Creative people are a little “crazy” People with mental disorders are dangerous Most older people are senile Asthma is caused by emotional problems Suicidal individuals rarely talk about suicide Criminals are born “bad”  What is Psychopathology? A branch pf psychology that examines unusual patterns of behavior, emotion & thought – BUT as we will see in later lectures, this is difficult to define These patterns may be associated with the development of psychological disorders  Psychopathology Interested in understanding – Development (causes/aetiology) Biological, Psychological, Social Characteristics/symptoms Diagnostic criteria Prevalence (Among different populations) Comorbidity Motivating and maintaining factors The lived experience Living with mental illness  Psychopathology Assessment – How we measure severity, symptoms, features Mini Mental State exam Beck Depression Inventory Treatment – Psychological Cognitive behavior therapy Systemic family therapy Dialectic behavior therapy Interpersonal psychotherapy – Pharmacological  Labels and terminology – Psychological disorder or psychological abnormality Mental illness is a less preferred term  Abnormal Behavior Defined Definition DSM V – “behavioral, emotional or cognitive dysfunctions that are unexpected in their cultural context and associated with personal distress or substantial impairment in functioning” “behaviour that departs from the norm and that harms the affected individual or others” (Sue, Sue & Sue, 2003) Abnormal Behavior is Defined When there is: A) Psychological dysfunction impairment in cognitive, emotional, or behavioral functioning. – Hard to define “dysfunction” – Sometimes ‘’abnormal’’ behavior is a good thing – People adapt to impairments (fear of open spaces is adapted to by avoiding) – Some impairments are not obvious (e.g., NPD) – Impairment is dimensional: not all or nothing  Abnormal Behavior is Defined When there is: B) Personal Distress Charles Manson – no remorse C) Atypical or unexpected cultural response (deviant) Norms aren’t stable over time: Homosexuality D) Dangerousness Most are not dangerous to others (ASPD can be) but can be to themselves (suicide, impulsiveness) Each of the features (Dysfunction, distress, deviance, dangerousness) of the definition is inadequate when considered in isolation. Boundary between normal & abnormal behavior? What level of depression or anxiety is abnormal? – Difficult to adequately resolve - we do not have a gold standard  Level of Disturbance (how severe) 1. Bizarreness--How extreme is the behaviour? 2. Duration--How long have the symptoms persisted? 1 month(?) 6 months(?) Years(?) 3. Social Functioning--The extent of the effect on social functioning. (Can the person leave the house, hold a job, etc.?)  Important Symptomology exists on a continuum Best way to remember: – Point of view of the individual Distress Dysfunction – Point of view of the culture Deviance from cultural norms Threatening or troublesome for society Clinical description of abnormal behavior A presenting problem typically refers to that which is first noted as the reason for coming to a clinical setting § function of clinical description is to specify what makes a disorder different from normal behavior & other disorders  18 years old Jenny talks to a psychologist Psychologist: How can I help you? Jenny: softly weeping, is barely audible, avoids looking at the psychologist. Psychologist: Sharing one’s life story is often hard for many people. Especially when one is sad & unsure where to start Jenny: ya…So much has happened. I just do not know where to begin. I saw my boyfriend kissing another girl. Sobs loudly P: Seeing your BF being intimate with another person seems to have really upset you J: How could he? I trusted him. I thought he loved me. I thought he was different from other men like my father. I told him I could never accept a man in my life who was not monogamous, like my mother could…I am not her-I never understood how could she?  Case study 18 years old Jenny seeks counseling “Presenting problems” : 1) psychological distress that Jenny has been experiencing at the BF’s cheating And possibly 2) conflicted feelings about her family of origin Clinical description of abnormal behavior – Prevalence refers to the number of people in the population as a whole who have the disorder – “According to the Singapore Ministry of Health’s public education brochure on depression, close to 9% of the adult population on our island suffer from depression…” Clinical description of abnormal behavior – Incidence refers to the number of new cases of a disorder occurring during a specific period of time (e.g., a year) – Course refers to the pattern of the disorder in time -can be described as chronic, episodic, or time-limited. Related to prognosis – Acute onset refers to disorders that begin suddenly, whereas insidious onset refers to disorders that develop gradually over time  Clinical description of abnormal behavior – Etiology: factors that contribute to the development of Psychopathology-causes of the psychological disorders. » include biological, psychological, & social dimensions Treatment can include psychological, pharmacological, or their combination  Case study Gina, 20 years old was brought by her parents. Parents are exasperated by her rebellious behavior. From the age of 12, she has been to 6-7 psychologists/psychiatrists. Gina is very vocal about her anger towards her parents (“they promised me a trip to Florida, they brought me to Singapore against my wishes, they took me to psychiatrist who put me on drugs…..”) She insists they now ‘abide’ by her wishes or she’d create havoc (break things, put the house on fire…). – In last 1 week, she has done so twice.  Clinical Interview P makes eye contact with Gina, leans towards her with a relaxed body posture & says: I hear you saying your parents promised you a trip to Florida & did not keep the promise. If I can sense right, it has angered you. Why do you think they did not? Gina: Because they are promise breakers! P: Looks at the parents : is that how you see yourselves? Mother: When we said we could take a trip to Florida in December we did not confirm, but it was a suggestion, a thought, something that we were thinking aloud Gina: Interrupts. Oh that is sooo like them, just say, “we did not mean it” Father: I could not take off from office & we sincerely believe we had not ‘promised’’ Gina: I know you just make promises to get me off your hands & when time comes, just back out!!  Interview continues… 45 minutes into the session, she storms out of the room. Mother to the psychologist: For last 8 years, we have tried to get her help. She has been on medication as well as counseling. I just do not know WHAT is wrong? Millions of parents can not fulfill their children’s all demands. They don’t grow up hating their parents. How is that Gina can not let go? What is Gina’s mother asking for?  What is Gina’s mother asking for? – WHY does Gina behave the way she does? – WHY is she different from others? – Possibly she is also interested in knowing: – WHAT caused it? – WHAT can she do to change it?  Assessing Psychological Disorders to determine cognitive, emotional, personality & behavioural factors in psychopathology CLINICAL ASSESSMENT – systematic evaluation & measurement of psychological, biological & social factors in individuals with possible psychological disorder  Psychological Assessment Techniques of assessment include a. clinical interview (more during tutorial 1..) b. mental status exam (MSE) c. physical examination d. behavioral observation & assessment e. psychological tests (Projective tests-Rorschach, Various inventories…… e.g. self report assessment BDI)  Techniques of assessment Mental Status Exam (MSE) is a systematic observation of a patient‘s – 1) Appearance & behavior – 2) Mood & affect (emotional response-lack of or an overreaction) – 3) Thought processes – 4) Intellectual functioning – 5) Sensorium (awareness of environment- orientation with regard to time, place, & personal identity; long- & short-term memory)  Psychologist: Gina suffers from Borderline personality disorder – Diagnosis  Diagnosis in mental health refers to a short-hand way of referring to a number of behaviors and beliefs that commonly co-occur.  How does the “diagnosis” help Gina’s mother? — Diagnosis implies it is a ‘condition’ — Possibly a relief that they are not alone Diagnosing & Classifying Psychological Disorders – International Classification of Diseases (ICD-10); published by the World Health Organization – Diagnostic and Statistical Manual of Mental Disorders (DSM); published by the American Psychiatric Association; currently the DSM 5  Functions of classification system (DSM) 1. Provides diagnostic criteria for mental disorders 2. Inform effective treatment selection 3. Administrative functions e.g. Medical aids, legal system, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies & policy makers 4. It provides vocabulary for professionals to communicate. It is clinical shorthand. 5. Provides information on prognosis  Diagnostics and Statistics Manual Results from “field trials” for new edition, DSM-V, were released in May 2012 Kappa used to measure how much diagnosing clinicians agree on a diagnosis using the criteria in the DSM. 1 means perfect agreement, 0 means no agreement at all New Scientist 19th May 2002  Diagnostics and Statistics Manual Some diagnoses showed good reliability Some very common syndromes, however showed diagnosis agreement little better than chance. – Major Depressive Disorder: Kappa = 0.32 – Generalised Anxiety Disorder: Kappa = 0.2 Whilst the APA said they would accept anything 0.2 and above, many researchers would consider this far to low a threshold to say that a diagnosis was reliable.  DSM classification & Cultural considerations : Possible questionable validity in a different cultural context – Culture determines how a disorder is expressed. May not be reflected in the diagnostic system. (e.g. somatic expression of depression) – dhat, (India) is characterized by anxiety, hypochondria, discharge of semen, whitish urine colour, weakness, & exhaustion. Similar conditions exist in Sri Lanka & China  Is one (e.g., Gina in this case study) likely to suffer from any negative effects of her diagnosis?  Negative effects of her diagnosis? Labeling: Tends to be reductionistic May lead to stigmatization, or person taking on the sick role & identifying with the label Instrument of social control: gives mental health professionals control over people’s lives Labels are “sticky” (Rosenhan study) David Rosenhan’s study (1972)  DSM is a valuable tool but has the potential for misuse  Clinical Assessment in Singapore Language – “Stress” is often used term to describe anxiety, depression.. NS Traditional healers Somatization Living arrangements……  Formulation In order to treat a client effectively, a diagnosis is NOT ENOUGH In order to intervene in a helpful, and not harmful, way the therapist must UNDERSTAND the likely causes & nature of the issue A full & coherent narrative as to how this problem or issue arose & is being maintained is a MUST before considering treatment.  The Four P Formulation Format PREDISPOSING FACTORS PRECIPITATING FACTORS PERPETUATIN PROBLEM PROTECTIVE G FACTORS OR ISSUE FACTORS  Perpetuating factors keep the problem going (e.g. avoidance, substance use). Factors that make a person vulnerable to developing the presenting problem are called predisposing factors. Factors that triggered the current episode of the problem are called precipitating factors. Protective factors are those which represent strengths, social supports & positive patterns of behaviour.  Case Study 27 years old Katie gave birth to a baby girl 6 weeks ago. Yesterday she drove alone to the doctor for baby’s 1st appointment. On the way she suddenly started to freak out, her heart was pounding & she was perspiring profusely. She had to stop the car in the middle of the road & ask for help. She was taken to the hospital where tests showed no physical abnormality. Dr.: Have you been through any major stress lately? Lineal question (a straightforward Q)  Diagnosis Katie appears to have experienced a panic attack, which in itself is not a mental disorder, but can occur within the various mental disorders (e.g., panic disorder, PTSD, Agoraphobia) DSM V: Panic attack specifier- An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, & during which time 4 or more symptoms occur (Listed next page):  Palpitations, pounding heart, or accelerated heart rate. Sweating. Trembling or shaking. Sensations of shortness of breath or smothering. A feeling of choking. Chest pain or discomfort. Nausea or abdominal distress. Feeling dizzy, unsteady, lightheaded, or faint Feelings of unreality (derealization) or being detached from oneself (depersonalization) Fear of losing control or going crazy Fear of dying Numbness or tingling sensations (paresthesias) Chills or hot flushes  Predisposing Factors Factors that make a person vulnerable to developing the presenting problem Katie: I have always been anxious-worry over everything –TEMPERAMENT? Mum too worries a lot & cautions me to take care- GENETICS? MODELLING? “Sheltered” childhood, mum discouraged me from having friends which angered me but I know she loves me as she was looking out for me, doing everything for me, I feel guilty that I have not been a “grateful” daughter -Environment?  Precipitating Factors Factors that triggered the current episode of the problem TRIGGERS – Birth of a baby Increased responsibility-overwhelm Reminder of ‘’issues” with mother  PANIC ATTACK CYCLE Physical Sensations Eg: Sweaty Palms, Heart Racing Feelings of panic and Interpretations terror “I am going to faint”  Perpetuating Factors AVOIDANCE – means that thoughts like “If I go to the mall, I will have a Panic Attack and faint” are never challenged. Never have the opportunity to prove them wrong COGNITIVE ERRORS – E.g.: Catastrophic Thinking : “If I faint in the mall, that would be so embarrassing I would never recover from it”  Case Study Katie is now avoiding driving, being alone & going to the malls in the fear that she may have another such episode & not be able to take care of herself & the baby. “Fear of the fear”  Protective Factors represent strengths, social supports and positive patterns of behaviour. ACCEPTANCE – Katie has accepted the problem may not be purely medical EARLY DETECTION – This issue has only just developed therefore the habits of avoidance and cognitive errors are less likely to be deeply ingrained COMMITMENT TO TREATMENT – Katie has committed to treatment and so has proven her motivation to work on this issue  Models of Clinical Psychology Why does one develop psychological illness and how is it treated? Different Approaches/models to understanding Abnormal Behaviour  Historical Conceptions of Abnormal Behavior Psychological Disorders occur & have occurred – In all cultures – Across all time periods Concept of Causes (why) & Treatment (how to cure) has differed across – Time periods – Cultures Historical Conceptions of Abnormal Behavior Three Dominant Traditions: – Supernatural – Biological – Psychological  The Biological Tradition Currently dominant paradigm in psychiatry Mental disorders viewed as diseases caused by genetics & brain abnormalities – Genetic contributions may lead to patterns of neurotransmitter activity that influence personality – Research has not found any genes causing mental illness Medication treatment vastly dominant – effective drugs for treating severe psychotic disorders emerged in the 1950s  Genetic Contribution to Psychopathology – Less than 50% – Depends on disorder – Difficult to be precise because of interactions with other factors – Does NOT account for abnormal behavior if no biological cause is found (e.g., phobias) – Ignore environmental/societal/cultural influence  Enormous financial incentives for the promotion of biological models & use of drugs over psychotherapy Emergence of Competing Alternative Psychological Models- 20th century  Modern day Major Psychological Models Psychoanalytic Theory (late 1890 – 1950s) – Freud, psychoanalysis, psychodynamic theory Humanistic Theory (1940s-) – Rogers, self-actualization, Client centered, Gestalt Behavioral Model (1920s – 1970s) – behavior therapy, Pavlov, Watson, Skinner Cognitive-behavioral therapy (1960s – present) – Beck, Ellis, Bandura-observational learning Systems – Family Therapy  The Interaction of Genetic and Environmental Effects The diathesis‐stress model –The diathesis (inherited tendency) interacts with stress we encounter; the more diathesis the less stress needed to initiate the illness Reciprocal gene‐environment model- we have a genetically determined tendency to create the very environmental risk factors that trigger genetic vulnerabilities (depression, divorce)  The Interaction of Genetic and Environmental Effects Learning can change the genetic structure of cells. Environmental factors influence dormant genes & there are changes in the brain’s biochemical functioning  Environment Mitigates Genetics Francis et. al. (1999) Newly born rat pups of fearful and easily stressed mothers Randomly placed with biological or calm mothers Rat pups placed with calm mothers, were more calm and supportive as adults  Extreme abuse severely impedes intellectual, emotional, and social growth Psychosocial factors- can change brain structure & function – (e.g., treatment of OCD via exposure & response prevention can result in the normalization of brain function)  Differing Approaches to Abnormal Behaviour No one theory accounts for all mental disorders all of the time There are limitations of each model  Stigma of Psychopathology is culturally, Socially, & Interpersonally Situated – help‐seeking behavior  To summarize… Multiple Causation – Is the rule, not the exception in explaining normal and abnormal behavior Take a Broad, Comprehensive, Systemic Perspective to understanding causes & treatment