Summaries Clinical (book + lectures) PDF

Lecture 1 - Introduction Chapter 1 - An introduction to psychopathology Introduction to Psychopathology: Concepts, Paradigms, and Stigma: psychopathology = in-depth study of mental health problems clinical psychology = The branch of psychology responsible for understanding and treating ps...

Lecture 1 - Introduction Chapter 1 - An introduction to psychopathology Introduction to Psychopathology: Concepts, Paradigms, and Stigma: psychopathology = in-depth study of mental health problems clinical psychology = The branch of psychology responsible for understanding and treating psychopathology saying someone is "going crazy" or "acting crazy" means: ○ behaving outside of societal norms ○ It is unclear what are relations of someone's actions ○ A behaviour seems to be irrational ○ A behaviour or an action appears to be maladaptive or harmful to the individual or others careful when determining examples of psychopathology: ○ We cannot simply say something is psychopathology because it is not normal ○ We are still not quite there with science to understand every underlying mechanism of psychopathology (neurologically or biologically) - which complicates things when saying what is and what isn't psychopathology ○ Many behaviours that require clinical treatment are just extreme forms of normal or adaptive behaviour 1.1 A BRIEF HISTORY OF PSYCHOPATHOLOGY Throughout the history different forms of behaviour have been labelled as mad or insane ○ for deviating from normality ○ understood even less of psychology they came up with (in today's view) weird explanations Demonic possession: psychopathology accompanied by changes in personality - first symptoms that are being noticed ‘possessed‘ = their behaviour has changed in such a way that their personality appears to have been taken over and replaced by the personality of someone or something else (a demon) until the eighteenth century often linked to religious beliefs "Treated" by exorcism, etc. The Medical or Disease Model: by the middle of the1 7th century: ○ religious, spiritual, and superstitious explanations of psychopathology were being replaced by more objective, medical explanations - consequence of the new empirical scientific methods being pioneered medical model = an explanation of psychopathology in terms of underlying biological or medical causes started treating is as a disease body-mind dualism: ○ e e es e es es ○ because minds could not be diseased, mental health problems must be located in the body, and more specifically in the brain EMERGENCE OF PSYCHIATRY: ○ = the primary approach of which is to identify the biological causes of psychopathology and treat them with medication or surgery ○ ▪ humane treatment = should kindly treat psychological disorders (not torture but support) - same as moral treatment ○ 1844: American Psychiatric association formed - medically focused VS 1879: American Psychological Association formed - experimental psychology focused ○ after WWI many traumatised soldiers (today known as PTSD) -> veterans administration made -> psychologists developed tests to try to reduce/prevent this trauma in potential future war (choose more suitable soldiers) -> did not help, still a lot of traumatised soldiers in WWII -> emergence of clinical psychology Summaries Page 1  suitable soldiers) -> did not help, still a lot of traumatised soldiers in WWII -> emergence of clinical psychology (psychiatrists were overbooked, needed help) ○ 1947: APA Committee on Training in Clinical Psychology ▪ Report on current programs ▪ Recommend new content ▪ Set up standards: doctorate + clinical internship ○ 1949: Boulder Conference Shakow Report ▪ Fo us o “holy i i y“ of ssessme , he py, d ese h ▪ Clinical psychologists are scientist-practitioners important implications: ○ medical or biological causes underlie psychopathology ▪ not true - maladaptive behaviour can be developed without underlying biological explanation ○ reductionist approach ▪ cannot easily encapsulate the distress felt by sufferers ▪ cannot explain the dysfunctional beliefs and forms of thinking that are characteristic of many psychopathologies ▪ recovery model = broad-ranging treatment approach which acknowledges the influence and importance of socio-economic status, employment and education and social inclusion in helping to achieve recovery from mental health problems ○ impli i ssump io h psy hop hology is used by ‘some hi g o wo ki g p ope ly‘ ▪ not true - might just represent a more extreme form of normal behaviour ▪ influence on how we view people suffering from mental health problems, and indeed, how they might view themselves From asylum to community care: asylums = in previous centuries asylums were hospices converted for the confinement of individuals with mental health problems ○ essentially businesses established for financial profit ○ many expanded to take more and more sufferers in conditions that were not subject to inspection under the relevant legislation of the time ○ medical treatments were usually crude and often painful ○ the nature of the inmates often expanded to include not just those with mental health problem ○ but paupers and individuals from poor backgrounds ○ especially young pregnant women, who were considered to be 'wayward' or 'morally degenerate' ○ the public could buy tickets to view the inmates of asylums Bethlem Hospital - one of the first psychiatric hospitals originally established in Moorfields, London community care = care that is provided outside a hospital setting 19th century: ○ gradual movement towards more humane treatments ○ Philippe Pinel: ▪ first to introduce more humane treatments ▪ started to treat these inmates as sick human beings rather than animals ○ Benjamin Rush and Quaker movement: ▪ Moral treatment: approach to the treatment of asylum inmates abandoned contemporary medical approaches in favour of understanding, hope, moral responsibility, and occupational therapy ○ milieu therapies = the first attempts to structure the hospital environment for patients, which attempted to create a therapeutic community on the ward in order to develop productivity, independence, responsibility and feelings of self-respect ▪ mutual respect between staff and patients ▪ the opportunity for patients to be involved in occupational and recreational activities ▪ patients were more likely to be discharged sooner and less likely to relapse ○ token economy = a reward system which involves participants receiving tokens for engaging in certain behaviours, which at a later time can be exchanged for a variety of reinforcing or desired items ▪ based on operant conditioning ▪ Summaries Page 2  ▪ significant therapeutic gains ▪ their use has been in serious decline since the early 1980s legal and ethical difficulties of withholding desired materials and events not certain whether reinforced behaviours continued after treatment 1963: US Congress passed a Community Mental Health Act ○ people with mental health problems had the right to receive a broad range of services in their communities ▪ outpatient therapy, emergency care, preventative care, and aftercare 1.2 DEFINING PSYCHOPATHOLOGY ○ abnormal psychology = an alternative definition of psychopathology, albeit with stigmatizing connotation el io o o bei g ‘ o m l‘ ○ increasing debates about how psychopathology and those who suffer from it are labelled and perceived by others ○ Many terms in language connected with "abnormal" behaviour ○ service user groups = groups of individuals who are end users of mental health services, services provided by the governmental groups such as NHS ○ The 4 D's of abnormality: ○ deviance (of a norm) ○ dysfunction (social, occupational) ○ distress (in self or others) ○ danger (to self or others) ○ part of forensic psychology ○ (diseased) DEVIATION FROM STATISTICAL NORM: ○ statistical norm = he mean, average or modal example of a behaviour ○ strengths: ○ clear cut-offs ○ frequency of the behaviour is quantifiable ○ limitations: ○ arbitrary cut-offs ○ not all rare behaviours are undesirable (e.g. high IQ) ○ not all abnormal behaviours are rare (e.g. emotions underlying depression) DEVIATION FROM SOCIAL AND POLITICAL NORMS: ○ different cultures often differ significantly in what they consider to be socially normal and acceptable ○ cultural factors seem to significantly affect how psychopathology manifests itself ▪ affect the vulnerability of an individual to causal factors (e.g. poor mental heal more prevalent in low income countries) ▪ produce 'culture-bound' symptoms ateque de nervios = a form of panic disorder found in Latinos from the Caribbean seizisman = a state of psychological paralysis found in the Haitian community ○ strengths: ▪ takes into account the accepted norms ○ limitations: ▪ universal set of norms cannot be established ▪ social norms change over time ▪ norms depend on the context MALADAPTIVE BEHAVIOUR AND HARMFUL DYSFUNCTION: ○ DSM-V: ▪ uses deficits in social, occupational, and educational functioning as one of the criteria for defining many mental health problems ○ harmful dysfunction = ssump io h psy hop hology is defi ed by he “dysfu io “ of o m l process that has the consequence of being in some way harmful ▪ Problem: ▪ we know very little about the brain mechanisms that generate psychopathology symptoms - ve y diffi ul o k ow wh “ o m l“ p o esses migh be dysfu io l ○ strengths: ▪ focus on how maladaptive behaviour is Summaries Page 3  ▪ focus on how maladaptive behaviour is ○ limitations: ▪ some abnormal behaviours are adaptive ▪ not all maladaptive behaviours are considered abnormal (psychopathology) DISTRESS AND DISABILITY: ○ symptoms must cause clinically significant distress or impairment in social, academic, or occupational functioning ○ strengths: ▪ focus on how undesirable the behaviour is for the individual ▪ not bound to norms ○ limitations: ▪ individuals may not see the behaviour as undesirable/distressing/impairing (e.g. personality disorders) ▪ distress may be situationally appropriate ▪ does not provide standards DISEASE: ○ seen as disease caused by physical changes (e.g. in brain activation) ○ especially used within the psychiatry ○ strengths: ▪ may be biological causes ○ limitations: ▪ often no biological cause can be found ▪ causation vs correlation ▪ few good medical tests available ▪ biological reductionism 1.3 EXPLANATORY APPROACHES TO PSYCHOPATHOLOGY Explanatory paradigms = use them to explain mental psychopathology ○ Human beings are multifaceted organisms which consist of a genetically propagated biological substrate which serves as a basis for behaviour and a whole range of functions ▪ Symptoms of psychosis genetically, biologically, behaviourally and psychologically influenced Biological models: GENETICS: ○ the study of heredity and variation of inherited characteristics ○ concordance studies = investigate the probability with which family members or relatives will develop a psych disorder depending on how closely they are related ○ twin studies = studies in which researchers have compared the probability with which MZ and DZ towns both develop symptoms indicative of a psychopathology in order to assess the genetic contributions to that psychopathology ○ limitations - having the same environment for the subjects ▪ Possible solution: studying the offspring of MZ and DZ twins □ if one MZ twin develops psychopathology symptoms and other does not - any genetic element in symptoms should still show up in the children of either of the MZ twins ○ diathesis-stress model = model that suggests a mental health problem develops because of an interaction between a genetic predisposition and our interactions with the environment ▪ Diathesis = an inherited predisposition ▪ stress = a variety of experiences that mat trigger the inherited predisposition ○ Heritability = a measure of the degree to which symptoms can be accounted for by genetic factors ▪ Ranges from 0 to 1 ○ Molecular genetics = genetic approach that seeks to identify individual genes that may be involved in transmitting psychopathology symptoms ○ genetic linkage analysis = a method of identifying individual genes by comparing the inheritance of characteristics for which gene location is knowns (e.g. eye colour) with the inheritance of psychopathology symptoms ○ different methods can often provide very different heritability estimates - heritability gap ▪ explanation: □ twin studies may often erroneously attribute genetic effects to individuals growing up in the Summaries Page 4  □ twin studies may often erroneously attribute genetic effects to individuals growing up in the same family or environments - this factor is not a confound in molecular studies ○ Epigenetics = tells us that environment is also important in triggering or inhibiting expression of genes or even changing the nature of one's DNA NEUROSCIENCE: ○ the scientific study of the nervous system ○ Brain structure and function ▪ Corpus callosum = set of nerves that connects both hemispheres ▪ limbic system □ hippocampus □ mamillary body □ amygdala □ hypothalamus □ fornix □ thalamus ○ Brain neuroscience - important NT: ▪ dopamine □ precursor of other substances - e.g. adrenalin ▪ norepinephrine □ thought to play a role in anxiety ▪ Serotonin □ Low levels are associated with depression ▪ GABA □ thought to play a role in anxiety Psychological models: often view the cause as a perfectly normal and adaptive reaction to difficult or stressful life conditions tend to view mental health symptoms as normal reactions mediated by intact psychological or cognitive mechanisms ○ not the result of processes that are abnormal, 'broken', or malfunctioning PSYCHOANALYTICAL AND PSYCHODYNAMIC MODEL: ○ psychoanalysis = an influential psychological model of psychopathology based on the theoretical works of Freud ○ o e of he fi s ‘ lki g he pies‘ ○ attempt to explain both normal and abnormal psychological functioning ○ 3 psychological forces shape an individual's personality and may also generate psychopathology ▪ id - the concept used to describe innate instinctual needs (esp. sexual) ▪ ego - a rational part of the psyche that attempts to control the impulses of the id □ defence mechanisms = means by which the ego attempts to control unacceptable id impulses and reduce the anxiety that id impulses may arouse denial, repression, regression, reaction formation, projection, rationalisation, displacement, sublimation Summaries Page 5  sublimation ▪ superego - develops out of both the id and the ego □ emp s o i eg e ‘v lues‘ h we le f om ou p e s o so ie y (i eg e id d ego) ▪ if these 3 factors are in conflict – psychopathology ○ stages of development = progressive periods of development from infancy to maturity ▪ oral stage - he fi s 18 mo hs of life b sed o he hild‘s eed fo food f om he mo he □ if the mother fails to satisfy these oral needs, the child may become fixated at this stage □ l e i life: ‘o l s ge h e is i s‘ - extreme dependence on others ▪ can become fixated in different stages -> causes different "abnormal" behaviour in adulthood ▪ concepts are difficult to observe and measure - difficult to conduct objective research on them THE BEHAVIOURAL MODEL: ○ psychopathology can be explained as learned reactions to environmental experiences ○ Learning theory = body of knowledge encompassing principles of classical and operant conditioning also to explain or treat psychopathology ○ Classical conditioning = learning of association between two stimuli, the first of which (CS) predicts the occurrence of the second (UCS) ▪ used to explain the acquisition of emotional disorders □ anxiety □ phobias □ PTSD □ substance dependency ○ Operant conditioning = modification of behaviour as a result of its consequences ▪ Rewarding consequences will increase the frequency ▪ Punishing consequences will decrease the frequency of the behaviour ▪ used extensively to explain why a range of psychopathology - relevant behaviours may have been acquired and maintained ○ Behaviour therapy = e m used fo ll emp s h y d h ge p ie ‘s beh viou b sed o principles of learning theory ○ Behaviour modification = behavioural treatment methods based on operant conditioning principles ▪ Assumes that psychopathology can be unlearnt using normal learning procedures ○ limitations: ▪ many psychopathologies are complex and symptoms are acquired gradually over many years (e.g., obsessive-compulsive disorder) □ it would be almost impossible to trace the reinforcement history of such symptoms across time THE COGNITIVE MODEL: ○ most widely adopted current psychological model of psychopathology ○ psychopathology results from individuals acquiring irrational beliefs, developing dysfunctional or unusual ways of thinking, and processing information in biased ways ○ Cognitive behavioural therapy (CBT): ▪ changing both thoughts (cognitions) and behaviour ▪ Umbrella term for different therapies that share the aim ○ Limitations: ▪ dysfunctional thoughts and beliefs may themselves simply be just another symptom of psychopathology (not necessarily the cause) THE HUMANIST-EXISTENTIAL APPROACH: ○ aim: resolve psychological problems though insight, personal development, and self-actualisation ○ insights into emotional and behavioural problems cannot be achieved unless the individual is able to gain insight into their lives from a broad range of perspectives ○ People not only acquire psychological conflicts and experience emotional distress ▪ they also have the ability to acquire self-awareness, develop important values and a sense of meaning in life, and pursue freedom of choice □ if these abilities are developed and encouraged psychopathology can be resolved ○ uninterested in aetiology and the origins of psychopathology ○ Client centred therapy: ▪ stressing the goodness of human nature ▪ if individuals are unrestricted by fears and conflicts they will develop into well-adjusted and happy individuals ○ Empathy = ability to understand and experience client's own personal feelings and personal meanings ▪ Unconditional positive regard = valuing the clients for who they are without judging them Summaries Page 6 1.4 MENTAL HEALTH AND STIGMA Social stigma = prejudicial attitudes and discriminating behaviour towards individuals with mental health problems as a result of the psychiatric label they were given Perceived stigma/self-stigma = Internalisation by the mental health sufferer of their perceptions of discrimination, can affect feelings of shame and lead to poorer treatment outcomes associative stigma = prejudice and discrimination experienced by families because of the association with the stigmatised individual several (online) campaigns to eliminate stigma and its related problems Summaries Page 7  Lecture 2 - Psychopharmacology Covered in different chapters (4, 5, 6, 7, 8) SUMMARIES BASED ON THE LECTURE Clinical psychopharmacology and clinical psychology: Experimental psychopharmacology = The study of medication- or substance-changes in mood, thinking, and behaviour Clinical psychopharmacology = The use of psychoactive medications in treating psychopathology ○ Psychiatrists ○ Treat patients with psychoactive (=psychotropic) medications ○ Completed 4 years of advanced training in psychopharmacology ○ American Psychological Association ○ P i e Guideli es eg di g Psy hologis s‘ I volveme i Ph m ologi l Issues: 1. should consider their competence, seek consultation if needed 2. should evaluate own feelings and attitudes about the role of medication (can affect communication with patients) 3. should be sensitive to factors which can moderate the interpersonal and biological aspects of pharmacotherapy 4. should identify appropriate level of knowledge and engage in educational experiences to achieve and maintain that level 5. should be sensitive about possible adverse effects of client's medication 9. should explore adherence and feelings about medication 10. should develop a relationship allowing the populations they serve to feel comfortable exploring issues surrounding medication use 17. should maintain appropriate relationship with providers of biological interventions ○ Areas they work on: ▪ Information ▪ Collaboration ▪ (Prescription) ○ Focus on between-person differences ○ In the presentation of psychopathology ○ In participation in treatment ○ In access to treatment ○ In response to treatment ▪ 1. Pharmaceutical factors ▪ 2. Pharmacokinetic factors ▪ 3. Pharmacodynamic factors 1. Pharmaceutical phase when and how medication is administered medication protocol= how the medication is administered IV - fast but prone to faster and severe side effects The effects of administered substances will differ according to ○ Route of administration ○ Dosage of substance (amount, repetition intervals, amount of repetitions) ○ Repeated dosages – the effects can reach a plateau – steady state ▪ needed for working of some drugs (have to take medication regularly, as prescribed) 2. Pharmacokinetic phase : the body does something to the medication the body wants to get the medication out of it as quickly as possible Summaries Page 8  the body wants to get the medication out of it as quickly as possible absorption ○ how does the body absorb the med distribution ○ depends on age, gender, BMI, body fat metabolism ○ when a drug gets converted to a slightly different chemical (water soluble) in the liver - excreted through urine ○ genetic variation in metabolism (CYP2D6) ○ poor metabolisers - higher chance of side effects (drugs stay longer) ○ rapid metabolisers - need higher doses (lower efficacy of medicine) ○ based on individual's enzyme levels (not) present -> also relevant for the drug choice some people may be better metabolizers (genetically) for specific medicines age-related variation in elimination ○ with age, you need less drugs (slower elimination) all these factors influence the drug choice, dosage 3. Pharmacodynamic phase: the medication does something to the body - actual medication effects 2 steps: ○ drug action = the drug binds to receptors ▪ genetic variations in the receptors ▪ interaction of the med with the receptors in the brain □ some chemicals interact with each other (affecting the same receptors) e.g., benzodiazepines and alcohol □ additive effect = the effect of both together = the sum of the effects of the two □ synergistic effect = if you add both you get more effect than just the additive effect (can lead to unexpectedly large side effects) ○ drug effect = actual effect of the drug, drug action required a lot of individual variation The occurrence of adverse effects: when tolerance increases, the therapeutic index decreases ○ hus, i e si g he dos ge (be use of ole e) be d ge ous (‘ ossi g‘ he he peu i i dex) addiction to the medicine can be found by comparing the prescribed dosage to the actual usage (due to drug tolerance use higher dosage) Adverse effects: Causes: ○ use of excessive dosages ○ p ie ‘s e io o medi io p o o ol Summaries Page 9  ○ p ie ‘s e io o medi io p o o ol ○ drug-diet interaction ○ drug-drug interaction ○ medical conditions ○ ill-advised polypharmacy ○ poor adherence to the medical protocol Adherence: = he ex e o whi h pe so ‘s beh viou o espo ds wi h g eed e omme d io s (bo h d ugs d ppoi me s) from a healthcare provider dve se effe s used by poo dhe e e is o o ly he p ie ‘s f ul o espo sibili y ○ side effects could make adherence hard ○ often not discussed with the doctor but the decision made by themselves - can have serious consequences ○ do ‘ eed o k ow he whole hi g by he bu jus h ve ge e l ide How to develop this relationship? Build trust, also with family members Appear competent Evaluate the level of adherence carefully Check understanding of the medication protocol Provide information and advice Help simplify the medication protocol Conduct follow-up tests is uss he p ie ‘s beliefs Address your personal opinions about medication use Summaries Page 10 Lecture 3 - Research in clinical psychology Chapter 3 - Research methods nothing really new - read through if you want tho Summaries Page 11 Lecture 4 - Diagnosis and treatment Chapter 2 - Classification and assessment 2.1 CLASSIFYING PSYCHOPATHOLOGY needed because: ○ first step to pursuit knowledge about the causes and aetiology (how different causes relate to different symptoms) ○ to organise services and support for patients ○ provides common language for reporting and monitoring -> allows sharing and comparing the data ○ determining effectiveness of services based on the changes in symptoms (have to be determined, measurable) ○ need for classification of everything in the society assessment is a constant, not a one-time, process The development: Kraepelin the first one to develop a comprehensive classification system for psychopathology ○ separated psychopathology into different and separate pathologies, each with different cause, described by distinct set of symptoms (= a syndrome) ○ idea that it could be described and treated as other medical illnesses first extensive system from World Health Organisation (WHO) ○ added it to the International List of Causes of Death (ICD) - 1939 ○ listing diagnostic categories ○ now known as International Classification of Diseases ○ used most in daily clinical work ○ most common in Europe APA published the first Diagnostic and Statistical Manual (DSM) in 1952 ○ extended from WHO ○ new versions since than ○ more information on which to base diagnosis than WHO (especially from the 3rd version onwards) ○ most influential diagnostic system for clinical and research work ○ most used in the USA and research in general DSM and ICD coordinated to ensure some consistency of diagnosis DSM: Defining and diagnosing psychopathology: rules out simply socially deviant behaviours puts emphasis on distress and disability ○ distress = chronic experience of pain/distressing emotions ○ disability = impairment in one of more important areas of functioning (due to distress) 4 basic objectives of DSM: ○ provides criteria for correct differential diagnosis ○ provides means for distinguishing psychopathology from everyday problems in living ○ provides diagnostic criteria that can be applied systematically ○ provides theoretically neutral diagnostic criteria (not favouring any theoretical approach) provides information about: ○ essential features of the disorder (always present, "basic") ○ associated features (not always present) ○ diagnostic criteria ○ information on differential diagnosis (how to differentiate it from similar disorders) avoids suggestions about the cause unless it has been definitely established ○ diagnosis made entirely on the observable behaviour (symptoms) ○ diagnostic categories are descriptive constructs based on groups of symptoms that define a diagnostic category - not definitions of diseases, no explanatory significance (about the cause) undergoes revision process to account for new research, refine categories General problems with classification: does not deal with causes ○ different psychopathologies have similar symptoms but different causes which could cause different Summaries Page 12  ○ different psychopathologies have similar symptoms but different causes which could cause different treatment needed ○ does not explain the symptoms but just re-describes them (but sounds like an explanation) can lead to stigmatization and be harmful defines disorders as present or not (discrete entities) when truly they are more dimensional -> cut-off points are sometimes arbitrary ○ try to reduce it with looking at the clinical significant (how significant the distress/impairment is for functioning) ○ includes simple dimensional measures of severity to accompany more specific diagnostic criteria in practice comorbidity (= co-occurrence of 2 or more psychological disorders) is common ○ disorders not really independent ○ can represent hybrid disorders (=disorders that contain elements of a number of different ones) or a disorder spectrum (=higher order categorical class of symptoms) ▪ hybrid example: mixed anxiety-depressive disorder (symptoms of anxiety and depression but cannot diagnosed with either - do not reach the threshold; together cause significant distress) ○ gives idea that psychopathology may be a spectrum with hierarchical structure and not numerous discrete disorders hodgepodge collection of disorders (no characteristics common to all; e.g. some psychological, other biological, some short-term other whole-life) -> difficult to form a definition of mental health problem can be seen as categorical or dimensional: ○ categorical - you either have it or you don't ○ dimensional - you are somewhere on the dimension between having it and not ▪ needs a cut-off point of where you will be diagnosed with it ▪ can be uni- or multi-dimensional can be seen as monothetic or polythetic: ○ monothetic - need to have all prescribed symptoms ○ polythetic - needs to have a certain number of symptoms out of a list of them ▪ actually used in practice ▪ people can exhibit different symptoms for the same diagnosis Criticism of the DSM development process: development cannot be completely objective diagnostic categories follow practice rather than guide it number of categories of disorders based on small differences in symptoms due to not taking the cause in mind most experts worried about the false negatives -> more inclusive diagnostic criteria, more of them -> can lead to false positives (over-diagnosis) political and economic factors influence it DSM-5: most comprehensive revision so far ○ provides: ○ essential and associated features ○ diagnostic criteria Summaries Page 13  ○ diagnostic criteria ○ information on differential diagnosis ○ no causes - only a description of observable behaviours benefits: ○ common vocabulary for clinicians, researchers ○ reasonable inter-rater reliability criticisms: ○ reduced number of criteria needed for a diagnosis -> increased number of diagnosed people (more false- positives possible) ○ new disorder categories designed to identify populations at risk for future mental problems: ▪ categories: □ mild neurocognitive disorder (cognitive decline in elderly) □ attenuated psychosis syndrome (potential precursor to psychotic episodes) ▪ risk of medicalising states that are not disorders, facilitate diagnosis of normal developmental process of disorders ▪ can be more harmful than helpful for patients ○ lower rates of diagnosis for certain populations due to changes in diagnostic criteria ▪ e.g. autism spectrum disorder, specific learning disorder, dyslexia (deleted as a diagnostic label) ▪ also doesn't specify different subtypes -> leads to less research about them ○ attempts to align the criteria with neuroscience, but neuroscience may never be able to provide a comprehensive basis for diagnosis (is too reductionist) ○ arbitrary cut-off points (some disorders now seen as dimensional + dimensional measures of severity) -> in the future they want everything to be dimensional but it is too complex to reach consensus at this point ○ some disorders have different causes, so require different treatments ○ there is a lot of heterogeneity within categories ○ lacking temporal perspectives ○ influenced by politics and economics ▪ pharmacy ears from it -> change criteria = changed prevalence = more used medicine Alternatives to DSM: some clinical psychologists today object to the medical orientation of classification (DSM, ICD) ot even object to any classification at all RESEARCH DOMAINS CRITERIA (RDoG): ○ classifying in terms of causes ▪ researching causes, relating to observable symptoms ○ conceives psychopathologies as disorders of brain circuits that can be experimentally explored using the tools of neuroscience ○ 2-D 5-by-7 matrix guiding research: ▪ 7 neurodevelopmental units of analysis from basic to more complex ▪ 5 domains of constructs relevant to psychopathology ▪ to understand the neurobiology underlying mental disorders and relationship between causal factors ▪ ○ limitations: ▪ some mental disorders may not be due to dysfunctions of the brain Summaries Page 14  ▪ some mental disorders may not be due to dysfunctions of the brain ▪ mostly focuses on intra-individual variables, does not consider extra-individual (e.g. environment, social context) ▪ still a lot of research needed HIERARCHICAL TAXONOMY OF PSYCHOPATHOLOGY (HiTOP): ○ helps predict comorbidity, higher-order dimensions reflecting associations between lower-order dimensions ○ evidence-based (empirical evidence from different levels of analysis, statistical modelling, validation studies, observed covariation) consensual model drawn by a group of psychopathology researchers and clinicians ○ 5 levels (from broad to specific): ▪ ○ stable across countries and cultures ○ still developing to include some not-yet included psychopathologies ○ limitation: ▪ still relies on DSM/ICD diagnostic categories at the level of syndromes and disorders NETWORK ANALYSES: ○ deals with how the symptoms co-occur -> predicts there is an underlying cause/latent variable which connects the symptoms together ○ assumes disorders emerge from the causal interactions between symptoms -> understanding these causal interactions will enable us to define individual clusters of symptoms which define individual disorders ○ networks of interacting symptoms identified using statistical methods measuring strength of associations and centrality of symptoms ○ example of it on p.65 ○ benefits: ▪ objective measure of interrelation of symptoms ▪ identifies centrally important symptoms (more central = triggers other symptoms = prime target for intervention) ▪ helps explain comorbidity ○ limitations: ▪ does not provide causal relationships (is cross-sectional - correlational) THE POWER THREAT MEANING (PTM) FRAMEWORK: ○ views people as social beings whose distress and troubling behaviour is inseparable from the context they live in ▪ mental health problems = natural reactions to stressful and threatening life events (threat responses) ○ helps people by in therapy giving meaning to client's experiences and providing a road map to recovery ▪ by creating more hopeful narratives ○ radical nondiagnostic and dimensional approach ○ limitations: ▪ so far offers only theoretical framework -> has to be translated to practice ▪ quite controversial (because it is radical) CASE FORMULATION: ○ using clinical information to draw up a psychological explanation of the client's problems and develop a Summaries Page 15  ○ using clinical information to draw up a psychological explanation of the client's problems and develop a plan for therapy ○ treating each client as someone with a unique mental health problem ○ not using diagnostic problem 2.2 METHOD OF ASSESSMENT Reliability and validity of assessment methods: read about it p.67 - 69 can check how good different tests are on COTAN - provides quality control Clinical interviews: usually the first form of contact between the client and the clinician intended to gain the broad insight into the client and their problems always needed for a diagnosis questions used and the content depends on the theoretical orientation of the clinician clinicians have to be very skilful to do it properly and get the information they need , form a diagnosis, understand the causes of the client's problems, and formulate treatment programme to obtain a diagnosis they must use a structured format: ○ e.g. Structured Clinical Interview from DSM-5 (SCID-5) -> client's response to one question will determine the next question to be asked ▪ enables to determine the main symptoms, severity, whether they meet the criteria for which of the disorders ▪ provides reliable diagnosis and severity ratings ○ many clinicians skilled enough to be able to diagnose without the structured interview but then the reliability is much lower can also be used to determine overall levels of psychological and intellectual functioning ○ e.g. Mini Mental State Examination limitations: ○ reliability of unstructured quite low ▪ a lot of variables affecting it ▪ many clients' have low self-awareness -> have to infer information ▪ interviewers prone to biases ▪ some mental problems where sufferers intentionally mislead the interviewer/lie to them Psychological tests: highly structured ways for gathering information about an individual advantages: ○ assess one or more specific characteristics or traits ○ usually rigid response requirements -> questions can be scored by a scoring system ○ they are standardized -> statistical norms established ○ are reliable and valid most based on psychometric approach ○ assume there are stable underlying characteristics or traits that exist in everyone at different levels used for a variety of purposes Personality inventories: Minnesota Multiphasic Personality Inventory (MMPI): ○ self-statements, respond to by true/false/cannot say ○ questions about a range of topics ○ validity and clinical scales ○ scores for each of the scales between 0 and 120 -> above 70 is indicative of psychopathology ○ good reliability and validity ○ takes a long time (a lot of questions) -> refined version with less questions is available Big Five Inventory-2: ○ measure the Big 5 scale (OCEAN) ○ 60 items Specific trait inventories: measure functioning in one specific area/psychopathology used to measure observable and measurable as well as hypothetical constructs (have to be inferred) Summaries Page 16  used to measure observable and measurable as well as hypothetical constructs (have to be inferred) some are underdeveloped: ○ no way to recognize faking ○ poor standardization, validation, reliability Projective tests: standard set of ambiguous stimuli based on psychodynamic view -> people's intentions and desires are unconscious and must be inferred indirectly less reliable and valid than more structured tests Rorschach Inkblot test: ○ symmetrical images (10 of them) -> have to say what they see ○ Exner gave it a structured scoring system ▪ still dependent on the clinician's interpretation ○ can be reliable and valid ▪ especially for Schizophrenia Thematic Apperception test (TAT): ○ 30 photos of people in ambiguous situations -> have to come up with a story about it ○ especially useful for depression, suicidal thoughts, strong aggressive impulses ○ useful as a tool after the client has been formally diagnosed to match them with a suitable form of psychotherapy Sentence completion test: ○ open-ended assessment - provided with first parts of sentences which they have to finish ○ allows identification of topics which have to be furtherly explored, identify biases due to psychopathology, how the client processes information ○ useful for diagnosing PTSD reasons it is being used less and less: ○ psychodynamic approaches are becoming less popular ○ low reliability and validity, not standardized ○ diagnosis based on sparse evidence ○ have cultural biases (especially TAT) ○ require quite a lot of work, time, training Computerised adaptive testing (CAT): select questions for an individual based on their previous answer optimised to the client's symptoms, severity use different items on repeated administration of the test not presented with all items -> shorter Intelligence tests: good psychometrics (reliability, validity) M = 100, SD = 15/16 used for determining disabilities, need for support, brain damage, brain disorders (e.g. Alzheimer's) Weschler Adult Intelligence Scale: ○.one of the most popular ones ○ many different scales limitations: ○ intelligence is an inferred construct -> not objectively exist -> no clear definition ○ concerns about the biases (e.g. culture bias, etc.) ○ provide ability of someone at some point in time, not their capacity to learn, acquire new cognitive abilities ○ IQ scores not static ▪ Flynn effect (increase of average IQ in the past couple of decades) ○ many skills and abilities not included Neurological impairment tests: brain damage chances personality, cognitive abilities -> depends on the areas of the brain that are affected enable determining the nature of cognitive deficits based on brain damage can use different tests + brain imaging (EEG; PET, fMRI) + blood tests, other chemical analyses neurological tests measure cognitive, perceptual and motor performance as indicator of underlying brain dysfunction specific dysfunction = specific area identified (localized) = helps find the right focus of rehabilitation Summaries Page 17  specific dysfunction = specific area identified (localized) = helps find the right focus of rehabilitation strategies Biologically based assessment: Psychophysiological tests: e.g. blood pressure, body T, heart rate provide useful information related to emotionally-based psychological problems (e.g. anxiety) different types: ○ electrodermal responding = electrodes attached on the fingers measure changes in sweat gland activity (galvanic skin response - GST) ▪ emotional responses increase sweat-gland activity ▪ used in variety of ways ▪ indicator of increased physiological arousal (can be caused by a variety of factors) -> problem of lie detectors ○ electromyogram (EMG) = measures the electrical activity in muscles ○ electrocardiogram (ECG) = measuring heart rate ○ electroencephalogram (EEG) = electrodes attached to the scalp measuring underlying electrical activity ▪ used for localising unusual brain patterns -> indicates a problem Neuroimaging techniques: computerised axial tomography (CAT): ○ forms 3D picture of the brain + 2D "slices" ○ in each turn of the ring a narrow "slice" of the brain is X-rayed ○ detects abnormal growths, enlargement of ventricles (tissue degeneration) positron emission tomography (PET): ○ measures structure and function ○ images of chemical activity ▪ brighter areas = more activity ○ based on radiation emitted from the participant ▪ eat a radioactive drug -> travels through the body -> more active = more blood (for more glucose) = more radioactive single-photon emission computed tomography (SPECT): ○ measures chemical activity ○ also by radioisotope in the bloodstream ○ provides a 3D image of neurotransmitter activity in the brain magnetic resonance imaging (MRI): ○ placed in a magnet which causes hydrogen in the body to move -> produces electromagnetic signal -> converted into visual pictures of the brain by the computer ○ highly detailed images ▪ can detect smallest lesions and tumours functional magnetic resonance imaging (fMRI): ○ quickly takes brain images -> tiny changes in the brain metabolism are detected -> minute-to-minute information provided about the activity ○ can measure changing brain activity while performing a task some mental health problems do not have significant brain biomarkers (at least not yet found) Clinical observation: direct observation of client's behaviour objective assessment of frequency of behaviours, assessment of behaviour in a context ABC chart = observation method where the observer has to note what happened before the behaviour occurs (A); what the individual did (B), and what the consequences of the behaviour were (C ) which type of coding is used depends on the goal advantages: ○ can be quite objective with the right training ○ can show the purpose of problematic behaviours ○ high ecological (external) validity - measured in the context ○ can suggest possible answers to problem behaviour limitations: ○ time-consuming takes place in specific setting -> may not be generalizable to other contexts Summaries Page 18  ○ takes place in specific setting -> may not be generalizable to other contexts ○ presence of an observer may change the behaviour (can overcome with video-recording behaviour) ▪ can do analogue observations (in a controlled environment -> allows surreptitious observation) ○ poor interobserver reliability if not properly trained, not proper scoring key ○ data can be influenced by observer's expectations self-observation/self-monitoring: ○ client observes and records their own behaviour ○ benefit: ▪ real-time data collection (no biased recall) ▪ sometimes helps even before the intervention because it makes the client more aware of their behaviours -> increases frequency of desirable, decreases of undesirable = reactivity ○ ecological momentary assessment (EMA) = electronic diaries for self-observation ○ for gathering information about client's daily life, aiding diagnosis, planning treatment, evaluating effectiveness of treatment ○ routine outcome monitoring = system of following patient's progress; quality control ▪ many different systems ▪ used to evaluate treatment in mental health care Cultural bias in assessment: most developed on WEIRD cultures ○ may be culturally biased -> provide less accurate picture of the mental health of individuals can manifest in different ways can affect judgement and diagnosis Cultural anomalies: some (ethnic) groups scoring/being diagnosed differently on assessment tests than others stereotypes being carried over into medical practice causes: ○ most assessment tools developed without regard to cultural diversity ○ symptoms manifest differently in different cultures ○ language differences between client and clinician ▪ when assessed in their second language the symptoms assessed as less severe (due to thought organisation) or more severe (due to misuse of words/misunderstanding) ○ cultural differences on the expression and perception of psychopathology due to religion or spirituality ○ cultural differences between the client and clinician ▪ client from ethnic minority may be distrustful of a clinician from ethnic majority ○ what is "normal", which stereotypes are present differs ○ interaction can be influenced by racial and ethnic stereotypes (how the information is interpreted) -> due to confirmation bias ▪ usually due to indirect racism (unaware of) clinicians work on eliminating them through training, etc. -> have to be aware of it and try to avoid it as much as possible DSM tries to prevent them assessments tools should be made as culturally unbiased as possible 2.3 CASE FORMULATION = use of clinical information to draw up a psychological explanation of the client's problem and to develop a plan for therapy ○ each client's problems are uniquely different, require individualised approach -> cannot just diagnose and treat it based on the DSM collaboration with the client, not imposed on them 6 components: ○ creating a list of the client's problems ○ identifying and describing the underlying psychological mechanisms ○ understanding the way in which these mechanisms generate the problems ○ identifying the events that may precipitate the client's problems ○ identifying how these events may have caused the problems through the mechanisms ○ developing a scheme for treatment based on these explanations, predicting obstacles to treatment its construction depends on the theoretical orientation of the clinician ○ cognitive/behavioural model: ▪ ABC approach: □ finding explanations based on cognitive and behavioural causes Summaries Page 19  □ finding explanations based on cognitive and behavioural causes □ identify the Antecedents to the problems -> describe the Beliefs (cognitive factors) triggered by them -> describe Consequences of these events □ understand the factors causing and maintaining these problems, developing therapeutic interventions to deal with them ○ psychodynamic model: ▪ how current problems reflect underlying unconscious conflicts ○ holistic model: ▪ formulations in terms of important relationships between the client and important people in their life (the context) advantages: ○ flexible and idiosyncratic understanding of individual's problems irrespective of given diagnoses ○ collaborative, treats the client with regard ○ based on a theoretical understanding of psychopathology ○ includes information about client's history ○ allows the development of treatment strategies that can be moulded to specific needs of the individual ▪ especially important when the case does not conform to standard diagnostic categories ○ studies show for benefits of the case formulation Chapter 4 - Treating psychopathology 4.1 THE NATURE AND FUNCTION OF TREATMENTS FOR PSYCHOPATHOLOGY characteristics of treatments (each possesses at least some): ○ relief the distress of symptoms by reduction of symptoms -> palliative effect ○ provide self-awareness and insight of the client into their problem ○ enable acquiring coping and problem-solving skills -> helps manage similar problems in the future ○ attempt to identify and resolve the causes of the psychopathology provided treatment depends on: ○ theoretical orientation and training of the therapist ▪ therapists have to continue professional development (CPD) - demonstrate by accredited therapists that they regularly update their knowledge of recent developments in treatment techniques ▪ should also use research literature to update their therapeutic skills ○ nature of psychopathology ▪ certain treatments recommended for certain disorders based in researched effectiveness effectiveness of individual vs group treatments depends on the disorder -> should choose is based on evidence, meta analyses of effective interventions should be an informed choice based on the therapist's orientation, client's wishes and scientific data Theoretical approaches to treatment: most treatments developed around a small number of important theoretical approaches common factors of successful therapies: ○ therapeutic alliance ○ positive, warm attitude towards the client ○ rationale of why the client is suffering, why the treatment will work some more effective with some problems Psychodynamic approaches: aim = revealing unconscious conflicts causing the symptoms ○ therapy designed to identify life events causing the unconscious conflicts, bring them into conscious awareness, work to develop strategies for change PSYCHOANALYSIS: ○ important form of therapy ○ based on Freud ○ not solely therapeutic in its aims ○ belief that bringing unconscious to conscious makes it easier for coping - repression causes anxiety ○ techniques used: ▪ free association - verbalising all thoughts, feelings, images that come to mind (bring them to awareness) Summaries Page 20  awareness) ▪ transference - clients behave towards the analyst as they would towards an important person in their lives (understanding of feelings by acting them out) ▪ dream analysis - analysis of dream meanings (assessing unconscious beliefs and conflicts) ▪ interpretation - interpretation of information from all the sources, helping understanding and dealing with them to the client ○ takes 3-5 sessions a week ○ change expected to take place at a normal maturational rate -> requires 3-7 years for the full therapeutic benefits.other forms can be less intense, briefer (e.g. family therapy) useful for people when other therapies have failed evidence for effectiveness is limited and conflicting today: ○ main focus on relationship patterns that cause/maintain symptoms ○ much briefer Behaviour therapy: stress the need to treat symptoms as behavioural problems rather than just symptoms of other, hidden underlying cause in the bast believed many disorders were from faulty learning (conditioning - behaviourism) -> conditioning principles can be used to unlearn it two strands: ○ therapies on strands of classical conditioning - behaviour therapy ▪ today refers to any treatment attempting to directly change behaviour (not necessarily based on conditioning) ○ therapies on strands of operant conditioning - behaviour modification/analysis BASED ON CLASSICAL CONDITIONING: ○ using principle of extinction (= assumes emotional problems can be unlearnt by disrupting the association between the anxiety-provoking cues or situations and the threat or traumatic outcomes with which they are associated) ▪ done by ensuring that anxiety-provoking stimulus is experienced in the absence of accompanying trauma -> stimulus no longer evokes anxiety (trauma) ▪ techniques: □ flooding - repeated exposure to highly distressing stimuli □ counterconditioning - establishing a stimulus response antagonistic to psychopathology □ systematic desensitisation - gradual and systematic exposure □ collectively known as exposure therapy (confronting the distressing stimuli) goal: to learn the stimulus is no longer threatening ○ principle of reciprocal inhibition (= anxiety eliminated by attaching a response to the anxiety-reducing cue which is incompatible with anxiety) ○ aversion therapy = conditions an aversion to a stimulus to which the individual is inappropriately attracted ▪ for addictions, inappropriate sexual activities, etc. ▪ little evidence for long-term effects BASED ON OPERANT CONDITIONING: ○ used in therapy: ▪ functional analysis - understanding what rewarding/reinforcing factors are maintaining behaviour □ after they are identified they try to be disrupted ▪ using reinforcers to establish new appropriate behaviour ▪ using punishment to supress problematic behaviours ○ techniques: ▪ functional analysis ▪ token economy - participants receiving tokens for engaging in behaviour which can be later exchanged for other desired items □ legal and ethical issues , lack of consensus about the long-term effectiveness -> use declined ▪ response shaping - used to develop new behaviours □ reinforcing regularly occurring behaviour similar to the target one -> reinforcing a behaviour closer and closer to the target response Summaries Page 21  closer and closer to the target response ○ does not have to be done by a therapist ▪ can be used by an individual to manage their own behaviour - behavioural self-control Cognitive therapies: addressing dysfunctional cognitive features -> meaning/interpretation of situation is central treatment: ○ Socratic dialogue ○ identifying dysfunctional cognitions (negative automatic thoughts) ○ challenging dysfunctional cognitions ○ formulating alternative (functional) cognitions ○ testing dysfunctional and functional cognitions in a behavioural experiment factors causing the disorder are not necessarily the ones maintaining it -> should focus on here and now two early forms: ○ rational emotive therapy (RET) ○ Beck's cognitive therapy RATIONAL EMOTIVE THERAPY: ○ addresses how people construe themselves, their life and the world ○ people carry around with them a set of implicit assumptions which determine how they judge themselves and others ▪ many of them may be irrational and cause emotional distress ○ challenges irrational beliefs, persuades the individual to set more attainable life goals BECK'S COGNITIVE THERAPY: ○ theory: depression results when the individual develops a set of cognitive schemas (beliefs) which bias the individual towards negative interpretations of the self, the world, and the future -> depression therapy has to address these schemas, deconstruct them, replace them with more rational ones ○ done by objective assessment of beliefs, providing evidence of the biased views of the world -> enables the individual to perceive their existing schemas as biased, irrational, overgeneralised COGNITIVE BEHAVIOURAL THERAPY (CBT): ○ developed out of early cognitive therapies ○ changing both thoughts and behaviour ○ currently the main choice for many mental health disorders ○ umbrella term for many different therapies with common aim ○ characteristics: ▪ client encouraged to keep a diary of significant events (shows how emotions and events may be interlinked) ▪ client urged to identify and challenge the irrational and dysfunctional assumptions ▪ clients given homework ("behavioural experiments") to test whether their thoughts and assumptions are accurate and rational ▪ clients trained in new ways of thinking, behaving, reacting in situations evoking their psychopathology ○ new forms developed out of earlier ones (progressive developments = waves) ▪ currently the third wave - emphasizes mindfulness, acceptance, changing the function of the experience not the experience itself ▪ first wave (1950s - 1960s) - mostly behaviour therapy ▪ second wave (1970s - 1980s) - cognition became more prevalent in the practice ▪ third wave - not trying to change the content of the cognition but the attitude towards them (e.g. mindfulness) □ to do what is valuable to you despite the negative/unhelpful thoughts ○ mindfulness-based cognitive therapy (MBCT): ▪ emphasizes achieving a mental state characterised by present-moment focus and non- judgemental awareness ▪ wants to improve emotional well-being by increasing awareness to how different things can cause distress ▪ by focusing on the present deal more effectively with stressors, challenges ▪ help by countering avoidance, helping respond reflectively, reducing physical symptoms ▪ applied to a wide array of mental problems ○ acceptance and commitment therapy (ACT): ▪ some aspects of mindfulness Summaries Page 22  ▪ some aspects of mindfulness ▪ developed from Skinnerian approach to understanding behaviour ▪ the individuals should not change their thoughts but just notice and accept them as private events ▪ helps clarify personal values, take action on them, increase psychological flexibility ▪ effect sizes relatively small -> insufficient evidence ○ behavioural activation (BA): ▪ encourages individuals with depression to approach activities they have been avoiding ▪ depression partially caused by avoiding activities which were in the past positively reinforcing ▪ together with the client come up with the goals to achieve and the schedule to achieve them ▪ shows good results ▪ no consensus on whether it is superior to other treatments ○ the new approaches still being evaluated ▪ generally equally effective ▪ can be applied to a broad range of psychopathology ○ superior when treating anxiety and depressive disorders ▪ equally effective in others Humanistic therapies: different types common factors: ○ espouse the need for the therapist to develop a more personal relationship with the client so the client can reach a state of realisation that they can help themselves ○ holistic therapies -> consider the whole person, not just individual symptoms ○ therapy seen as enabling the individual to make own decisions, solve their own problems - not imposing structured treatments/ways of thinking on the individual ○ espouse the need for the therapist-client relationship to be genuine reciprocal and empathetic one ○ increasing emotional awareness GESTALT THERAPY: ○ focuses on individual's experiences in the present moment and the context in which the individual lives their life ○ emphasizes most helpful focus of psychotherapy is on what a person is doing, thinking, and feeling at the present moment (not past or future) ○ similar to mindfulness - awareness practice ○ empty chair technique = client addressing the other chair as if another person was in it, acting out both sides -> explores the relationship with oneself ○ provides emotional well-being and higher sense of hope ○ can be integrated with some other therapies CLIENT-CENTERED THERAPY: ○ assumes that if individuals are unrestricted by fears and conflicts, they will develop into well- adjusted, happy individuals ○ focus on immediate conscious experience ○ founded by Carl Rogers ○ client should become independent, self-directed, and should be pursuing self-growth -> when successful in experiencing and accepting themselves they will be able to resolve their own conflicts and difficulties ○ empathy is the central feature in therapist-client relationship and guiding the client towards resolving their own problems ▪ two components: □ ability to understand and experience client's feelings and meanings □ demonstrating unconditional positive regard (valuing the client, not judging them) ○ not directive -> therapist = understanding listener, offers advice only when asked ○ not just as therapy but also useful for self-growth ○ attempts to eliminate symptoms, not look why they were acquired Family and systemic therapies: involving family members when dealing with psychopathology which may result from the relationship dynamics within the family purposes: ○ helps improve communication between family members ○ resolve conflicts Summaries Page 23  ○ resolve conflicts ○ applies systems theory (family as a social system) -> tries to understand the complex relationships between the members, remould them into those expected for a well-functioning family use different approaches within the therapy depending on the problems and its causes usually focus on how interactions maintain the problem (not identify the cause) make the members aware of the interaction patterns, suggests different ways of responding effective intervention for a number of psychopathologies Drug treatments: used to alleviate symptoms of psychopathology usually the first line of treatments most common drugs: ○ antidepressants - depression and mood disorders ○ anxiolytics - anxiety and stress ○ antipsychotic - psychosis and schizophrenia ANTIDEPRESSANTS: ○ tricyclic antidepressants: ▪ first class (developed in 1960s) ▪ increase the amount of norepinephrine and serotonin available in synaptic transmission ○ monoamine oxidase inhibitors (MAOIs): ▪ effective for some people with major depression not responding to other drugs ▪ used also for panic and bipolar disorder ○ selective serotonin reuptake inhibitors (SSRIs): ▪ selectively affect uptake of serotonin ▪ also called designer drugs ▪ most known: fluoxetine (Prozac), sertraline (Lustral), and citalopram (Cipramil) ○ serotonin and norepinephrine reuptake inhibitors (SNRIs): ▪ block reuptake of norepinephrine and serotonin ○ more effective than placebo for depression ○ not everyone benefits from their use ▪ usually not people with subthreshold and mild depression ○ most people see improvement in symptoms but only some achieve full relief and sustained recovery ▪ common relapse after the drug is discontinued (less with SSRIs) ○ some people quickly stop taking them because of side effects ○ increase in prescribing them in the past years ▪ more diagnosed depression, increased awareness ○ no clear conception how they work ▪ currently: help build neural plasticity, decrease processing of negative emotional stimuli, increase attention to positive emotional stimuli ○ improvement begins several weeks after the drug commencement ○ p.141 common antidepressants + side effects ANXIOLYTICS: ○ benzodiazepines: ▪ increase level of GABA in the brain ▪ important side effects (memory lapses, drowsiness, etc.) ○ prescribed for short periods of time -> encourage dependence, can be abused ○ only offer symptom relief, not psychological and cognitive factors maintaining anxiety -> symptoms return when individuals stops taking the drug ○ nowadays usually first use SSRIs or SNRIs - effective + less side effects, withdrawal symptoms ANTIPSYCHOTICS: ○ relieve psychosis and schizophrenia symptoms -> individuals do not need to be institutionalized ○ two groups: ▪ first-generation drugs: □ developed in 1940s/1950s □ reduce many positive and disorganisational symptoms □ little effect on negative symptoms □ reduced relapse □ did not cure the cause □ some people do not respond well to them Summaries Page 24  □ some people do not respond well to them □ quite severe side effects (tremors, slurred speech, high blood sugar) ▪ second-generation drugs: □ 1970s and 1980s □ more people respond well to them □ improvement in positive and negative symptoms □ less side-effects ○ effect by reducing activity of dopamine type 2 receptors ○ not a cure for psychosis ○ long-term use associated with clinical benefits over the longer term (prevent worsening symptoms) ○ p.143 most common ones + side effects problems with drug treatments: ○ can medicalise mild psychopathologies which could be just considered everyday problems of living ○ mostly tested on people with severe symptoms -> may be ineffective for mild ones ○ long-term prescription can lead people to believe the symptoms are unchangeable - their life will depend on medication -> prevents them from trying to find the cause of them ○ some proof it can worsen the long-term course of a disorder ▪ due to drug tolerance/not providing insight into the symptoms most likely to be successful over the longer term when combined with psychological treatment Modes of treatment delivery: TRADITIONAL PSYCHOTHERAPY: ○ usually one-to-one therapist-client model GROUP THERAPY: ○ useful when: ▪ the same problem/psychopathology ▪ presence of others influences psychopathology (e.g. family therapy) ○ advantageous for individuals that: ▪ need to work out their problems in presence of others ▪ need comfort and support ▪ benefit from observing and watching others ○ different types: ▪ experiential groups ▪ encounter groups □ encourages therapy and self-growth through disclosure and interaction ▪ self-help groups □ brings together people sharing a common problem in attempt to share information and help support each other □ e.g. Alcoholics Anonymous ○ interventions used in one-on-one adapted to groups ○ cost-effective and effective for managing symptoms COUNSELLING: ○ aims to promote personal growths and productivity and alleviate any personal problems which may reflect underlying psychopathology ○ counsellors receive specialised training for support, guidance, intervention techniques ○ primary task is to give the client an opportunity to explore, discover and clarify ways of living more satisfyingly and to help the clients learn to reach their own goals ○ use a range of theoretical approaches ▪ different orientation = focus on different outcome ○ some specialised in certain areas (e.g. marriage, etc.) -> have specific titles ○ established in a range of organisations to supplement community mental health services, provide direct support to people ○ can be directed to people with certain medical conditions (e.g. HIV) DIGITAL TECHNOLOGIES: ○ reduced need for continual face-to-face therapeutic interactions ○ many computer-based treatments for common health problems ▪ used on their own with some support Summaries Page 25  ▪ used on their own with some support ○ helpful for cost and time-effective treatment, wider access to it ○ computerised CBT (CCBT): ▪ highly developed software packages delivered via interactive computer interface/over the interne/via telephone (using interactive voice response system) ▪ for mild and moderate severity ▪ valuable and effective way of treatment ▪ flexible access, reduction in waiting lists, savings in therapist time ▪ issues: □ clients finding it difficult to engage without support - too mechanical and impersonal □ no therapist-client relationship □ no proof for superiority for CCBT over GP care, low uptake when offered support is critical for it to be effective and fully engaged with ○ mental health apps: ▪ evaluation of their usefulness still needed -> no real evidence of their efficacy ▪ effect restricted to mild and moderate depression ○ e-therapy: ▪ involves use of e-mail and internet technology ▪ together with face-to-face sessions ▪ used for: □ enhancing weekly sessions, monitoring treatment, behaviours, etc. □ communication in case of a crisis □ easier contact with the therapist □ shy clients in person can be more open here □ easier to have more regular contact with the therapist □ when geographic and social factors make it difficult to meet face-to-face ▪ limitations: □ miscommunication □ cannot ensure confidentiality □ difficult to intervene in emergencies ▪ useful and effective ▪ cost effective ○ use of video-based communication/on-line therapy ○ virtual reality environments: ▪ interactive computer environment ▪ problems interacting with the world are at the centre of many mental health problems -> virtual reality exposure (VRE) is helpful - can identify triggers, safe form of exposure ▪ used in treatment of a range of psychopathologies ▪ effective, can supplement or enhance more traditional forms of therapy ▪ usually used with the therapist present ▪ can be adapted to specific symptoms Improving access to psychological therapies (IAPT): large-scale initiative aim: to increase the availability of evidence-based interventions achieving the goal by: ○ training practitioners (community health workers) in psychological therapies - psychological well-being practitioners ○ improving access and reducing waiting times for treatment ○ increasing client choice and satisfaction economic contribution - people will not need as much treatment, will get back to work, social and family functioning 4.2 EVALUATING TREATMENT deciding how effective treatment is - problems: ○ compare treatments with different assumptions of what is successful therapy ○ have to decide what constitutes therapeutic gain (improvement on which measures?) ▪ each theoretical orientation has different Factors affecting the evaluation of treatments: help recovery: sympathetic therapist, believes of the client, etc, hinder recovery: unsupportive home environment, poorly structured intervention, etc. Summaries Page 26  hinder recovery: unsupportive home environment, poorly structured intervention, etc. internal validity = whether a treatment works because of the principles it contains ○ examined in treatment outcome studies SPONTANEOUS REMISSION: ○ remission in symptoms which is not due to the treatment ○ many people get better over time even without therapy due to positive life changes ○ treatment has to show significantly greater improvement rates PLACEBO EFFECTS: ○ individuals getting better because they expect to get better, not because of the treatment ○ sometimes are quite large but only short-lived ○ structured therapies lead to greater improvement ○ have to use placebo conditions for determining internal validity UNSTRUCTURED ATTENTION, UNDERSTANDING, AND CARING: ○ improvement in symptoms when simply talking about them (to a therapist or a friend) -> social support has beneficial effect itself ○ in therapies have to evaluate what specifically of it makes the client feel better ○ in effectiveness of therapies need to control for the amount of attention or empathy the client is receiving from the therapist ▪ befriending - control condition for attention, understanding and caring used in treatment outcome studies □ approximately the same amount of therapist contact as the treatment conditions □ therapist only befriends the client, does not attempt to directly tackle any symptoms - discuss neutral topics Methods of assessing the effectiveness: some therapies say it is not possible to objectively measure their methods -> see therapy as trying to reconstruct the client's meaning of the world, not eliminate symptoms ○ no well-defined criteria, difficult to objectively measure Randomised controlled trials (RCT): comparing effectiveness of the treatment being assessed with a variety of control conditions, and with other forms of therapy and treatment participants randomly assigned to the conditions control groups: ○ no treatment - "waiting list" control group ▪ ethically problematic ○ expectancy and relationship control group ▪ placebo effects and beneficial effects of contact with the therapist ○ comparative treatment group ▪ alternative therapy known to have beneficial effects ○ for the new to be seen as effective it has to show greater improvement in the no treatment and expectancy and relationship control conditions and improvement at least equivalent to the comparative treatment group problems of RCT: ○ practical limitations ▪ dropping out of participants □ problematic when systematic, more in some conditions than others ▪ costly, time consuming ▪ does not account participant's preferences for therapy type ▪ do not provide information about the effectiveness of a treatment for the particular client in the particular setting ○ have to be free from bias - usually doesn't happen ▪ allegiance of researchers to psychotherapy being tested - experimenter bias (favours effectiveness) ▪ bias in scientific publishing - usually only publish significant results □ many studies showing no effect of the treatment not published ▪ commercial interests influence whether a study is published or not ○ often do not tell what percentage of participants exhibited recovery/clinical significant change to the point where they would no longer be diagnosed -> only tell us about the statistical significance of the Summaries Page 27  point where they would no longer be diagnosed -> only tell us about the statistical significance of the treatment ▪ clinical significance = percentage of participants who exhibited recovery to the point where they no longer meet the criteria for clinical diagnosis ▪ recovery rates = percentage of people no longer diagnosable once they have finished treatment ▪ statistical and clinical significance is not the same -> should determine if the therapy makes the client functional again Meta-analyses and systematic reviews: benefit: ○ comparing effectiveness of studies using different methods, participants, etc. -> compares size effect across studies used for answering the question whether psychotherapies are more effective than no treatment ○ found that they are more effective than no treatment but the effect sizes do not differ between the different psychotherapies - they are equally effective What treatments are effective? more effective than no treatment but the effect sizes do not differ between the different psychotherapies - they are equally effective DODO BIRD VERDICT: ○ described all therapies being equally beneficial ○ because they all contain some important common factors - common factors theory ▪ contextual model: □ one of common factors models □ therapy working through: therapist-client bond (empathetic, caring person) - therapeutic alliance client's expectations and hope specific ingredients of the individual therapy used to stimulate healthy outcomes beneficial to the client ▪ common, but not necessarily causal factors for recovery □ to prove causality studies must show temporal relationship between the factor and the outcome, dose-response association, no third-variable evidence new statistical tools allow for more detailed distinctions ○ some therapies more effective for some mental health problems than for others; some even harmful in some cases (cause negative response to treatment in some clients/groups) client's satisfaction: ○ usually satisfied if: ▪ significant beneficence from psychotherapy ▪ psychotherapy alone does not differ in effectiveness from its combination with medication ▪ psychologists, psychiatrists, social workers do not differ in their effectiveness as therapists ▪ longer the durations of treatment = larger positive gains ○ does not purely reflect the effectiveness of the treatment but also other psychological factors that extend beyond the original purpose of the treatment Summaries Page 28 Lecture 5 - Mood disorders Chapter 7 - Depression and mood disorders Depression = a mood disorder involving emotional, motivational, behavioural, physical and cognitive symptoms Mania = emotion characterised by boundless frenzied energy and feelings of euphoria Bipolar disorder = a psychological disorder characterised by periods of alternating episodes of mania and depression ○ diagnosis can change from major depressive disorder to bipolar if a manic episode happens (reverse is not possible) Depression: ○ emotional experiences ○ restricted to negative ones ○ Only very rarely experiencing pleasant or positive emotions ○ Anxiety is commonly experienced ○ motivational deficits ▪ a loss of interest in normal daily activities or hobbies ▪ social withdrawal ▪ reduced appetite and sexual desire ○ behavioural symptoms, ▪ slowness of speech and behaviour generally ▪ physically inactive ▪ decreased ergy ▪ tiredness ▪ fatigue ▪ characteristic postures and movements ○ sleep disturbance ▪ middle insomnia = waking up during the night and having difficulty getting back to sleep ▪ terminal insomnia = waking early and being unable to return to sleep) ▪ hypersomnia = oversleeping ○ regular headaches, indigestion, constipation, dizzy spells and general pain ○ cognitive features - the most disabling of the symptoms: ▪ extremely negative views of themselves, the world around them, and their own future this generates pessimistic thinking ▪ impaired ability to think, concentrate or make decisions Major depression = relatively extended periods of clinical depression which cause significant distress to the individual and impairment in social or occupational functioning Reification = treating and thinking about something abstract (e.g. depression) like it is a physical thing -> e.g. there is no proof depression really exists (e..g due to a brain area) Diagnosis always based on the present and the past: ○ present: current symptoms, etc. ○ past: family history, previous symptoms unipolar = without symptoms of other disorders 7.1 MAJOR DEPRESSION The Diagnosis and Prevalence of Major Depression: Major depressive episode =presence of five or more depressive symptoms during the same two period as stated by the DSM5 Summaries Page 29  stated by the DSM5 ○ ○ ○ 2 main types of depressive disorder based on the criteria for a major depressive episode ▪ major depressive disorder, single episode most patients relapse ▪ major depressive disorder, recurrent ○ requires the presence of dysfunctional symptoms ▪ such as feelings of worthlessness, suicidal ideation, and impairment of daily functioning ○ bereavement-related symptoms are now no longer excluded from the diagnostic criteria ○ major depression is a relatively 'pure' diagnosis ▪ the cause of depression cannot be attributed either to some other diagnosable disorder □ such as the consequences of substance abuse □ or to specific biological environmental factors or other life events DYSTHYMIC DISORDER: ○ = a form of depressive disorder in which the sufferer has experienced two years of depressed moods for more days than not ○ fewer symptoms but longer durations ○ ○ only two or more of the symptom criteria for major depression ○ double depression = MDD + dysthymic disorder; constant depressive mood (fewer symptoms) with episodes of MDD (more, worse symptoms) OTHER DEPRESSION-RELATED DISORDERS: ○ seasonal affective disorder (SAD) = regularly occurring depression during the winter with a remissions coming the spring ▪ connected to melatonin ○ Chronic fatigue syndrome (CFS) = mood fluctuations and symptoms such as extreme fatigue, muscle pain, chest pain, headaches and light sensitivity ○ premenstrual dysphoric disorder (PMDD) = women experience severe depression symptoms between 5 and 11 days prior to the menstrual cycle ▪ Symptoms then improve significantly withing days of the onset of menstruation ○ disruptive mood dysregulation disorder (in kids) highly comorbid with anxiety Summaries Page 30  highly comorbid with anxiety ○ ca. 60% ○ Mixed anxiety/depressive disorder = diagnosable levels of distress, impairment of daily living skills, and reduced health-related quality of life ▪ neither the depression nor the anxiety is clearly the predominant feature prevalence rates for major depression: ○ from 5.2% to 20.6% lifetime risk for major depression: ○ 20% for men ○ 30% for women ○ Possible reasons: ▪ the stigmatising of psychopathology in many non-Western societies □ unwilling to report symptoms of major depression ○ higher levels of somatisation (the expression of psychological distress in physical terms) in non- Western countries The Aetiology of Depression and Mood Disorders: Risk factors of depression ○ Challenging life experiences ○ biologically, genetically, or psychologically mediated risks ▪ being the offspring of a depressed mother ▪ negative information-processing biases ▪ being female (Kuchner, 2016) Biological theories: GENETICS: ○ first-degree relatives of major depression sufferers are around 2 to 3 times more likely to develop depressive symptoms ○ heritability: 30-40% ○ the genes contributing to this inherited component appear to be diverse ▪ serotonin transporter gene (SLC6A4) can enhance or terminate the action of the brain neurotransmitter serotonin ○ also influenced by gene 5-HTT ○ a gene may increase the risk of depression only when it interacts with certain environmental risk factors ○ Neurochemical factors: ▪ major depression is often associated with low levels of these neurotransmitters: □ serotonin □ norepinephrine □ dopamine ○ associated with some form of monoaminergic dysfunction ▪ impaired monoamine pathway activity alone is unlikely to be sufficient to cause depression ○ Levels of neurotransmitters can be influenced by different kinds of drugs: ▪ tricyclic drugs – block reuptake of both serotonin and norepinephrine ▪ monoamine oxidase (MAO) inhibitors - inhibits MAO enzyme which degrades serotonin, norepinephrine, dopamine ▪ selective serotonin reuptake inhibitors (SSRIs) ▪ serotonin-noradrenaline reuptake inhibitors (SNRIs) BRAIN ABNORMALITIES: Summaries Page 31  ○ anterior cingulate cortex (ACC) = frontal part of the cingulate cortex resembling a collar from around the corpus callosum ▪ ACC activation is present when effortful emotional regulation is required in situations where behaviour is failing to achieve a desired outcome ▪ decreased ACC activation is also reported in major depression may reflect a deficit in the 'will-to- h ge‘ ○ depression is associated with significantly lower levels of activation in the prefrontal cortex ▪ important in maintaining representations of goals and the means to achieve them ▪ may result in the failure to anticipate incentives ○ dysfunction in the hippocampus ▪ important in adrenocorticotropic hormone secretion ▪ critical in learning about the context of affective reactions ▪ may result in the individual dissociating affective responses from their relevant contexts ▪ may manifest itself as feelings of sadness occurring independently of contexts ○ structural and functional abnormalities in the amygdala ▪ directing attention to affectively salient stimuli and prioritising the processing of such stimuli ▪ especially increased amygdala activation □ result in the depressed individual prioritising threatening information for processing and interpreting such information negatively ○ Decreased grey matter ▪ prefrontal cortex ▪ orbitofrontal cortex ▪ ACC ▪ basal ganglia ○ White matter lesions can occur in late-life depression SEROTONIN: ○ different serotonin synthesis in people with depression ▪ connected with low levels of serotonin ▪ studied with radioactive serotonin precursors -> can see serotonin products BUT is correlational ○ depression medications stimulate serotonin (act like serotonin/prevent reuptake/increase production) ○ depression not only due to low-serotonin ○ lowering serotonin levels can induce acute symptomatic relapse in recovered patients -> can induce depressions symptoms ▪ tryptophan depletion (TD): experimental procedure giving amino-acid mixture for breakfast (with or without tryptophan) Summaries Page 32  giving amino-acid mixture for breakfast (with or without tryptophan) tryptophan = essential AA needed for production of serotonin -> less serotonin produced if it is not present results: does not make symptoms worse, does not increase depression not in everyone larger effect in women than men (also smaller serotonin production in general) -> explains more depression in women ◊ women respond with mood change (goes away after a couple of hours when they eat normally again) change in mood in MDD remission patients - the same symptoms then when