PSY 183 Psychodiagnosis 2024 PDF

Introduction to Psychopathology Alan J. Fridlund, Ph.D. NOTICE: These Lecture Notes © Copyright 2014, 2019, 2020, 2023, 2024, by Alan J. Fridlund, Ph.D. All Rights Reserved. For- Profit Reproduction in Whole or In Part Without Written Permission of the Instructor Is a Violation of...

Introduction to Psychopathology Alan J. Fridlund, Ph.D. NOTICE: These Lecture Notes © Copyright 2014, 2019, 2020, 2023, 2024, by Alan J. Fridlund, Ph.D. All Rights Reserved. For- Profit Reproduction in Whole or In Part Without Written Permission of the Instructor Is a Violation of U.C. Regulations and the DMCA and Is Expressly Prohibited.  Notice All Course materials (class lectures and discussions, handouts, examinations, Web materials) and the intellectual content of the Course itself are protected by United States Federal Copyright Law, and the California Civil Code. UC Policy 102.23 expressly prohibits students (and all other persons) from recording lectures or discussions and from distributing or selling lectures notes and all other course materials without the prior written permission of the Instructor (See http://policy.ucop.edu/doc/2710530/PACAOS-100). Students are permitted to make notes solely for their own private educational use. Exceptions to accommodate students with disabilities may be granted with appropriate documentation. To be clear, in this class students are forbidden from completing study guides and selling them to any person or organization. The text has been approved by UC General Counsel. You are granted permission in Psych 183 to download and retain personal copies of these slides solely for your own use.  What Is A Mental Disorder? Definition, Assessment, and Diagnosis The Concept of “Mental Disorder” Depends on Basic Philosophical Assumptions Monism (the world is made of one stuff) ‒ Can be either all “mental” (Idealism, e.g., The Matrix) or all “physical” (Materialism) ‒ The most common form of monism is “Reductive Materialism,” i.e., mental events reduce to brain events; everything is understandable as the result of physiological mechanisms. Dualism (the physical and mental worlds are separate domains) ‒ Mind is different from brain. Philosophical Implications for “Mental Disorder” Monism: Reductive Materialism ‒ Mental disorders are brain disorders, types of medical illness. Dualism ‒ Mental disorders are disorders of mental processes, and do not have a necessary basis in brain or bodily processes. ‒ One dualistic conception, from computers, is that the material world is evident in the hardware of the brain, whereas the world of ideas is evident in the brain’s software, manifest as behavior (Analogy: Mind is to brain as a TV Program is to a TV) : "The mind cannot really become diseased any more than the intellect can become abscessed… It is necessary to return to first principles: a disease is something you have, behavior is something you do.“ ˗ Schizophrenia researcher and mental-health advocate E. Fuller Torrey, M.D. Most psychiatrists doing psychopharmacology act as monists; most psychotherapists act as dualists.  Scope of Mental “Illness” Originally, “mental illness” was synonymous with “insanity” (now strictly a legal term), reserved for psychoses and sudden disabling or bizarre changes in behavior / thinking. “Mental illness” has been broadened: ‒ Now “mental disorder” is preferred to “mental illness” given lack of verified tissue pathology for most kinds of psychopathology ‒ “Mental disorders” now span a wide range of severity: Brain diseases such as: Schizophrenia, Alzheimer’s-type dementia Behavior patterns such as: homosexuality (declassified as a mental disorder in 1993, now considered normal variation), alcoholism, compulsive gambling, pedophilia, psychopathy, intermittent explosive disorder Troublesome or disagreeable conditions such as: premature ejaculation, premenstrual dysphoria (depressed mood), painful intercourse, flying phobias, voyeurism, exhibitionism, insomnia, sleepwalking Many ways of defining mental disorders have been proposed; all have problems, and there is no consistent, logical way of defining psychopathology (see optional Wakefield article, The Concept of Mental Disorder, on Canvas). Why Worry About How To Define Mental Disorder? Mental disorder diagnoses are stigmatizing. Mental disorder diagnoses are sometimes used as tools of political persecution. Mental disorder diagnoses have been used to excuse defendants and others from responsibility for their actions (i.e., Harvard law professor Alan Dershowitz’s “excuse abuse”). Note: “Insanity” is not a diagnostic term. It is a legal term referring to a defendant’s inability to understand the consequences of his/her actions when they committed a crime. The “not guilty by reason of insanity” courtroom defense has been replaced in many legal jurisdictions by “guilty but insane,” a judgment which may affect sentencing but not the “ultimate question” of guilt. Impossible ideal - A valid and consistent definition of “mental disorder” that will not: ‒ assign diagnoses to people who do not have a mental disorder (false positives). ‒ fail to diagnose people who do have a mental disorder (false negatives). Underlying Dichotomies That Drive Attempts to Define “Mental Disorder” Is a condition normal or abnormal? Many different criteria; all these criteria are problematic: ‒ Deviance (statistical, moral, cultural) ‒ Distress (one’s own and/or others’) ‒ Dysfunction (inability, efficiency, maladaptation) ‒ Danger (to self and/or others) Is a person ill or evil? (Disorder or sin or criminal?; e.g., changing procedures regarding child molestation by clergy) Is the professional response to the condition treatment or oppression? ‒ Is the treatment itself harmful, or more harmful than the disorder? ‒ How a society treats people with mental disorders reflects how it regards mental disorders. Most People Have “Prototype” Conceptions of Mental Disorders, Which May or May Not Be Accurate Prototypes come from: Exposure to real-life situations in which mental health services were involved. Indirect experiences (via books, films, TV, friends) in which people are seen to have unwanted conditions requiring mental health intervention. In training as a mental health professional, through classic case studies or supervised clinical experiences. DSM-5-TR – The Current Diagnostic Bible (American Psychiatric Association, 2023)  Current Official View (DSM-5-TR, American Psychiatric Association, 2022) A mental disorder is: ‒ a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual; and that is associated with: present distress (e.g., a painful symptom), or disability (i.e., impairment in one or more important areas of function), or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. ‒ and must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one. How Do We Diagnose Psychopathology? Basic Terminology I Nosology Science or scheme of disease categorization and classification Diagnosis Act of assigning a nosological category to a patient Basic Psychodiagnostic Terminology II Etiology = Cause Course = Trajectory Prognosis = Outcome Signs = Observable markers Symptoms = Patient reports Signs + Symptoms = Syndrome Syndrome + Course = Disorder Emil Kraepelin Disorder + Tissue Damage = Disease* * Very few mental disorders meet criteria for diseases  Why Diagnose At All? Prognosis Treatment implications Communication among professions Establish prospects for contagion or other transmission, and possible prevention Legal reasons (e.g., competence, insanity determinations) Financial reasons (compensation to patient and/or treatment provider) Research  Problems Inherent in the Act of Diagnosis Sacrifices the uniqueness of individual patient. Can falsely imply etiology (cause). Rigidifies treatment alternatives. Iatrogenic illness. Stigmatization. Secondary gain.  Two Kinds of Diagnosis ⚫ Phenotypic ⚫ Genotypic – Signs – Causes – Symptoms (Genes, Germs, – Course Tissue Abnormality) – Outcome Endophenotypic signs (Lab tests, – Response to “subclinical” biomarkers, treatment behavioral tests); Endophenotypic Diagnostic signs may exist even in healthy family members. In physical medicine, progress consists of moving from phenotypic to genotypic diagnosis. In mental health, nearly all diagnosis is phenotypic, based on observed signs and patient-reported symptoms, with some endophenotypic evidence emerging: retinal scans and brain imaging for Alzheimer’s-Type Dementia; cognitive tests (e.g., continuous performance tasks) for Schizophrenia; tests of circadian rhythm instabilities in Bipolar Disorder.  Ingredients of a Diagnosis Symptoms. Signs. Course of illness. Age of onset. Family history. Recent events. Recent behavior. Psychological tests. Laboratory tests (e.g., neuroimaging, hormonal assays, genetic testing). Response to treatment (prior or current).  Multifactorial Nature of Diagnosis No single sign or symptom defines a mental disorder, i.e., is pathognomonic (indicative) of a mental disorder. E.g., trauma is required for Post- Traumatic Stress Disorder (PTSD), but many other factors determine whether a trauma will precipitate PTSD in any given individual. Diagnosis is based on a pattern of signs and symptoms, i.e., a syndrome. The patterns of syndromes and courses of illness that define mental disorders constitute the nosology of mental disorders.  About Diagnoses in General Diagnosis are informed guesses about the disorders that best fit patients. Diagnoses are never set in stone, but are opinions that may change at any time with new information or as patients change how they present to the practitioner. Patients usually require more than one diagnosis, because mental disorders are frequently comorbid, i.e. they co-occur. E.g., Anxiety disorders and Chronic Pain disorders are both frequently comorbid with Substance Abuse or Dependence. Such patients are called dual-diagnosis patients. Features of Current DSM-5-TR Diagnosis Phenotypic diagnosis ‒ Based only on observable signs/symptoms ‒ Abandonment of intra-psychic conjectures and terms like “neurosis” and “internal conflicts” Field-tested for reliability Acknowledgement of importance of medical and psychosocial factors Decision-tree approach ‒ Inclusion criteria (Signs/symptoms which, if present, support the diagnosis) ‒ Exclusion criteria (Signs/symptoms which, if present, counter the diagnosis)  What Goes Into a DSM-5-TR Phenotypic Diagnosis? E.g., Inclusion Criteria for Specific Phobia A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging. B. The phobic object or situation almost always provokes immediate fear or anxiety. C. The phobic object or situation is actively avoided or endured with intense fear or anxiety. D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context. E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. What Goes Into a DSM-5-TR Phenotypic Diagnosis (Cont’d)? Exclusion Criteria for Specific Phobia The disturbance is not better explained by: The symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in Agoraphobia). Objects or situations related to obsessions (as in Obsessive-Compulsive disorder). Reminders of traumatic events (as in Post-Traumatic Stress Disorder). Separation from home or attachment figures (as in Separation Anxiety Disorder). Social situations (as in Social Anxiety Disorder). An Example of DSM-5-TR Decision-Tree Diagnosis Major Depression (Code F3?.?) Single Episode ? Recurrent ? (F32.?) (F33.?) Mild? Moderate? Severe? Mild? Moderate? Severe? (F32.0) (F32.1) (F32.?) (F33.0) (F33.1) (F33.?) w/o Psychosis? w/ Psychosis? w/o Psychosis? w/ Psychosis? (F32.2) (F32.3) (F33.2) (F33.3) Informative Medical or Psychosocial Information: ‒ Medical: Lung cancer diagnosed 3 months before, hypertension, back surgery for lower back injury 2 years previous ‒ Psychosocial/Contextual: e.g., patient has child with autistic spectrum disorder, marital conflicts, job stress  Sample “Z-Codes” for Psychosocial Situations That May Need or Complicate Treatment But Are Not Mental Disorders Noncompliance With Treatment Partner Relational Problem Adult Physical / Sexual Abuse Parent-Child Relational Problem Child Neglect Child Physical Abuse / Sexual Abuse Sibling Relational Problem Relational Problem Related to a Mental Disorder or General Medical Condition Occupational Problem Academic Problem Acculturation Problem Relational Problem Bereavement Borderline Intellectual Functioning / Phase of Life Problem Religious or Spiritual Problem Malingering  How Do We Arrive At a Diagnosis? The Process of Clinical Assessment Clinical Assessment Diagnosis Most clinical assessment relies upon the “clinical interview.”  Clinical Interview: Types of Information and Goals ⚫ Lasts about 1 hr; most valuable assessment tool in diagnosis. ⚫ Assess patient’s current and past symptoms (onset, intensity). ⚫ Observe signs from patient’s presentation. ⚫ Obtain personal and family history re: parenting, early childhood and adolescent events, education, abuse/neglect, substance use, medical, social, occupational, financial problem(s). ⚫ Obtain history of mental-health involvement (hospitalizations, school/work counseling, psychotherapy); treatments (including psychotherapy and medications) that have worked/not worked in past. ⚫ Goals: – Assess suitability / readiness for psychotherapy – Determine need for referral to: ⚫ psychiatrist for psychotropic medication (psychologists don’t prescribe in CA) ⚫ primary care physician (PCP) for further medical evaluation ⚫ neurologist for neurological testing and/or neuroimaging ⚫ social worker, vocational counselor, physical therapist, etc.  Signs Noted in Clinical Interview ⚫ Attire & grooming ⚫ General attitude ⚫ Posture – Defiant, compliant, guarded, defensive, sincere, plaintive, ⚫ Physical characteristics resistant, apathetic, etc. – Skin tone / complexion ⚫ Thought content – Weight / stature – Solicited by free inquiry – Symmetry / atrophy / bodily ⚫ Thought processes anomalies – Delusions, hallucinations ⚫ Mannerisms, spasms or tics – Thought boundary violations: ⚫ Speech broadcasting, removal, insertion – Articulation ⚫ Gen’l knowledge – Prosody (tone of voice) – General facts, pop culture ⚫ Consciousness ⚫ Abstract thinking – Level of alertness, fogginess, ⚫ Social judgment hypervigilance ⚫ Insight ⚫ Emotional state (upbeat, ⚫ Cognitive functioning hopeless, frustrated, etc.) – Usually, current mental status via brief screening (e.g., MOCA test) Montreal Cognitive Assessment (MOCA) (Screening Tool for Dementia) MOCA Questions I MOCA Questions II MOCA Scoring Helpful Ancillary Diagnostic Information Info from family members Info from physicians, employers Medical chart if available Previous psychological testing, and case summaries from previous therapists Discharge summaries from hospital stays NOTE: Obtaining this kind of information usually requires the patient to sign release forms to authorize requesting the information; these forms are most often signed at the first session. Family History Is Important in Diagnosis Because It Influences the Risk of Specific Mental Disorders AN – Anxiety Disorder BPD – Bipolar Disorder SZ – Schizophrenia PANIC – Panic Disorder UP – Unipolar Depression ALC – Alcoholism (Male and Female) End