Description
As a mental health clinician, answer the questions and then reply to one peer.
POST
Answer to a peer HWilsonMental illness, to me, stems from a multitude of contributions. It comes from a combination of biological, psychological, and environmental factors. Biological factors that can contribute to the development of mental illness include, of course, genetics, brain defects, prenatal damage, etc. Psychological factors that may contribute to the development of mental illness include neglect, severe trauma, etc. Finally, environmental factors that may contribute to mental illness include feelings of low self-esteem, social or cultural expectations, death or divorce, etc. I do not believe that there is one root cause as it varies amongst different individuals, and there are many different types of mental illness. Many believe that the causes of mental illness come solely from genetic and environmental factors and that all other contributors are merely just risk factors (stressful life situations, ongoing medical conditions, traumatic experiences, etc.); however, I believe that each mental illness case is different and cannot be simplified to one simple answer. There are still many studies being done on the development of mental illnesses and disorders, and new discoveries are always being made. Overall, I believe that the root of mental illness is primarily a physical or organic factor, but it is not the sole root cause of the many other components that contribute to its development.
Chapter 1
Introduction and Historical Review
Chapter Outline
• Psychological Disorders and Stigmas
• Defining Psychological Disorder
• History of Psychopathology
• The Evolution of Contemporary Thought
• The Mental Health Professions
2
Defining Stigma?
• Psychology
o
The field concerned with the nature, development, and
treatment of psychological disorders
• Psychopathology
o
The search for the reasons why people behave, think, and feel
in unexpected, sometimes odd, and possibly self-defeating
ways
3
#curestigma
4
Defining Stigma
• Stigma
Destructive beliefs and attitudes held by a society that are
ascribed to groups considered different in some way
o Psychological disorders remain the most stigmatized condition
in the 21st century
o
• Everyday language can contribute to the stigma of the
mentally ill
o
Crazy, Schizo
5
Figure 1.1: Four Characteristics of Stigma
6
Clinical Case: Jack
Jack dreaded family gatherings. His parents’ house would be filled with his brothers and
their families, and all the little kids would run around making a lot of noise. His parents
would urge him to “be social” and spend time with the family, even though Jack preferred
to be alone. He knew that the kids called him “crazy Uncle Jack.” In fact, he had even
heard his younger brother Kevin call him “crazy Jack” when he stopped by to see their
mother the other day. Jack’s mother admonished Kevin, reminding him that Jack had
been doing very well on his new meds. “Schizophrenia is an illness,” his mother said.
Jack had not been hospitalized with an acute episode of schizophrenia for over 2 years.
Even though Jack still heard voices, he learned not to talk about them in front of his
mother because she would then start hassling him about taking his medication or ask him
all sorts of questions about whether he needed to go back to the hospital. He hoped he
would soon be able to move out of his parents’ house and into his own apartment. The
landlord at the last apartment he had tried to rent rejected his application once he
learned that Jack had schizophrenia. His mother and father needed to cosign the lease,
and they had inadvertently said that Jack was doing very well with his illness. The
landlord asked about the illness, and once his parents mentioned schizophrenia, the
landlord became visibly uncomfortable. The landlord called later that night and said the
apartment had already been rented. When Jack’s father pressed him, the landlord
admitted he “didn’t want any trouble” and that he was worried that people like Jack were
violent.
7
Clinical Case: Jack
In reviewing Jack’s case, we see that he has been
stigmatized by many of his family members and others in
the community.
In what ways can community strategies, policy and
legislative strategies, and individual strategies help to
reduce or someday illuminate the stigmatization of
people with mental illnesses?
8
Public knowledge has increased, but
stigma has not decreased
9
Ending Stigma
• Social Media
o
Websites and blogs serve as a medium to share personal
stories, raise awareness, and increase social connectedness
• Public figures speaking about their experiences with
mental illness may help to reduce stigma
• Pete Domenici MH and Addiction Equity Act
Signed into law in 2008, implementation of law in 2010
o Major advance in securing same levels of insurance coverage
for MI as for other illnesses
o
10
Discussion
• Where do you think “mental illness” comes from? Is the
root of mental disorder primarily physical/organic, early
childhood experiences, current environmental forces,
or some other factor?
11
Defining Psychological Disorders: DSM-5
• The disorder occurs within the individual
• It involves clinically significant difficulties in thinking,
feeling, or behaving
• It usually involves personal distress of some sort
• It involves dysfunction in psychological, developmental,
and/or neurobiological processes that support mental
functioning
• It is not a culturally specific reaction to an event
• It is not primarily a result of social deviance or conflict
with society
12
Figure 1.2 Three Characteristics of a
Comprehensive Definition of Psychological
Disorder
13
Defining Psychological Disorders:
Personal Distress
• A person’s behavior causes significant distress
o
Examples of distress:
• Difficulty paying attention
• Emotional pain and suffering
• Not all behaviors of psychological disorders cause
distress
o
E.g., Antisocial personality disorder
• An individual may violate the law without guilt, remorse, or anxiety
• Not all behaviors that causes distress are disordered
o
E.g., Distress of hunger due to religious fasting
14
Defining Psychological Disorders:
Disability and Dysfunction
• Disability
o
o
o
Impairment in an important area (e.g., work, relationships)
• Chronic substance abuse resulting in job loss
• Rejection by peers due to social anxiety
Not all psychological disorders involve disability
Not all disabilities are considered to be psychological disorders
• Dysfunction
o
o
o
Developmental, psychological, and/or biological systems are not working
as they should (impairment)
The behavior impairs a person’s functioning at work, home, school, and/or
social situations
These systems are interrelated
15
Defining Psychological Disorders: Violation of Social
Norms
• Social norms are widely held standards
o
o
Beliefs and attitudes used to make judgments about behaviors
Behaviors that violate social norms may be classified as disordered
• Repetitive rituals performed by people with obsessive-compulsive
disorder
• Talking to nonexistent voices that some people with schizophrenia
experience
• Too broad and too narrow of a definition
o
o
Criminals violate social norms (too broad)
Highly anxious people typically do not violate social norms (too narrow)
• Social norms vary across cultures and ethnic groups
16
Clinical Case: Jose
Jose didn’t know what to think about his nightmares. Ever since he returned from the
war, he couldn’t get the bloody images out of his head. He woke up nearly every night
with nightmares about the carnage he witnessed as a soldier stationed in Fallujah. Even
during the day, he would have flashbacks. He seemed to be sweating all the time now,
and whenever he heard a loud noise, he jumped out of his chair. Just the other day, his
grandmother stepped on a balloon left over from his “welcome home” party. To Jose, it
sounded like a gunshot, and he immediately dropped to the ground.
His grandmother was worried about him. She thought he must have ataque de nervios,
just like her father had back home in Puerto Rico. She said her father had been afraid all
the time and felt like he was going crazy. She kept going to Mass and praying for Jose,
which he appreciated. The army doctor said he had posttraumatic stress disorders (PTSD).
Jose was supposed to go to the Veterans Administration (VA) hospital for an evaluation,
but he didn’t really think there was anything wrong with him. Yet his buddy Jorge had
been to a group session at the VA, and he said it made him feel better. Maybe he would
check it out. He wanted these images to get out of his head.
17
Clinical Case: Jose
• In what ways does Jose’s behavior described in the case
history fit the DSM definition of a psychological
disorder?
• How could Jose’ benefit from treatment?
18
History of Psychopathology
• Supernatural explanations
o
Displeasure of the gods or possession by demons
• Treatment: Exorcism—Ritualistic casting out of evil spirits
• Early biological explanations: Hippocrates (5th Century BC)
o
o
o
o
Mental disturbances have natural causes (brain pathology)
Three categories of mental disorders:
• Mania, melancholia, & phrenitis (brain fever)
Healthy brain functioning depended on balance of 4 humors:
• Blood, black bile, yellow bile, & phlegm
• Melancholy (depression) caused by excessive amounts of sticky thick
black bile
• Schizophrenia arose from too much cold mucus
Treatment: Physicians restored natural balance (e.g., tranquility,
sobriety, care in choosing food)
19
History of Psychopathology: Dark Ages
• Dark Ages (2nd century AD)
o
Christian monasteries replaced physicians as healers
• Return to the belief of supernatural causes
• Witch Trials
Some persecuted, rare
o Later analysis indicated many people accused of being witches
were not mentally ill
o
• Treatments:
Cared and prayed for by monks
o Touched with relics
o Drank potions in the waning phase of the moon
o
20
History of Psychopathology: Lunacy Trials
• Began in 13th century England
• Trials held to determine a person’s mental health
o
o
Orientation, memory, intellect, daily life, habits
Strange behavior attributed to physical illness or injury
• Municipal authorities assumed responsibility for
care of people with psychological disorders in
hospitals
• Lunacy attributes insanity to misalignment of moon
(“luna”) and stars
21
History of Psychopathology: Asylums
• Asylums (15th century)
o
Establishments for the confinement and care of people with psychological
disorders
• Priory of St. Mary of Bethlehem (founded in 1243)
o
o
o
One of the first mental institutions
The wealthy paid to gape at the patients
Origin of the term bedlam (wild uproar or confusion)
• Treatment non-existent or harmful at asylums
o
Benjamin Rush (father of American psychiatry) recommended:
• Drawing copious amounts of blood to relieve brain pressure
• Fear as a cure (e.g., convince patient that death is near)
22
History of Psychopathology: Reforms
Philippe Pinel (1745–1826)
Dorothea Dix (1802–1887)
• Pioneered humane treatment
in asylums
• People should be approached
with compassion and dignity
• Crusader for improved
conditions for people with
psychological disorders
• Worked to establish 32 new
public hospitals
Moral Treatment
• Small, privately funded,
humanitarian mental hospitals
• Friends’ Asylum
(Pennsylvania, 1817)
• Patients engaged in purposeful
activities (e.g., gardening)
• Took many of the people
whom private hospitals could
not accommodate
• Small staffs at public hospitals
could not provide necessary
individual attention that was a
hallmark of moral treatment
23
History of Psychopathology: Biological
Origins
• Early systems of classifying mental disorders led to
reemergence of biological perspective
• General paresis and syphilis
o
o
o
o
Deterioration of mental and physical abilities, and progressive paralysis
(general paresis)
Some people with general paresis also had syphilis
In 1905, biological cause of syphilis found:
• Causal link between infection, damage to the brain, and
psychopathology
Biological causes of psychopathology gained credibility
24
History of Psychopathology: Genetics
• Early investigations into genetics of MI led to
emphasis on eugenics
• Galton’s (1822–1911)
Originator of genetic research with twins
o Work lead to notion that mental illness can be inherited
o Nature (genetics) and nurture (environment)
o Eugenics
o
• Promotion of enforced sterilization to eliminate undesirable
characteristics from the population
• Many state laws required people with psychological disorders to be
sterilized
25
History of Psychopathology: Biological
Approaches to Treatment
• Insulin-coma therapy
o Sakel (1930s)
• Electroconvulsive therapy (ECT)
o Cerletti and Bini (1938)
o Induce epileptic seizures with electric shock
• Prefrontal lobotomy
o Moniz (1935)
o
Destroys tracts connecting frontal lobes to other areas of
brain
o Often used to control violent behaviors
o Led to listlessness, apathy, and loss of cognitive abilities
26
History of Psychopathology: Psychological
Approaches
• Mesmer (1734–1815)
o
o
o
Hysteria caused by a disruption of a universal magnetic fluid in the body
Used rods and stares to influence the fluid and induce behavioral change
Early practitioner of hypnosis
• Charcot (1825–1893)
o
His support legitimized hypnosis as treatment for hysteria
• Breuer (1842–1925)
o
o
Used hypnosis to facilitate catharsis in Anna O.
Cathartic Method
• Release of emotional tension triggered by expressing previously forgotten
thoughts about an earlier emotional trauma
• Freud
27
History of Psychopathology: Freud
• Psychoanalytic theory
Psychopathology results from unconscious conflicts
o Mind is divided into three principle parts: Id, ego, superego
o Id, ego, and superego continually in conflict
• Conflict generates anxiety
o Defense mechanism
o
• Strategy used by ego to protect itself from anxiety
28
History of Psychopathology: Psychoanalytic
Therapy
• Goals of Psychoanalysis
Understand early-childhood experiences, the nature of key
relationships, and the patterns in current relationships
o Therapist is listening for core emotional and relationship
themes
o
• Transference
o
Responding towards an analyst in a similar way as towards
important people in the person’s past
• No formal research on the causes and treatment of
psychological disorders
29
History of Psychopathology:
Behaviorism
• Behaviorism
Focus on observable behavior
o Emphasis on learning
o Did not account for emotions and thoughts
o
• John Watson built on Pavlov’s work
o
Conditioned Stimulus, Conditioned Response, Unconditioned
Stimulus
• Skinner built on work of Thorndike
Emphasized contingencies associated with behavior
o Positive and Negative reinforcement
o Shaping behavior
o
30
History of Psychopathology: Rises of
Behaviorism
• Three types of learning:
Classical Conditioning
o Operant Conditioning
o Modeling
o
• Early Behavior Techniques
Systematic desensitization
o Aversion Therapy
o Modeling
o
• People can learn even without obvious reinforcers
31
History of Psychopathology: Importance of
Cognition
• Prominence in the 1960’s
• How we think, or appraise, a situation influences our
feelings and behaviors
o
We do not just engage in behavior, we also think & feel
• Cognitive Therapy
o
How people construe themselves and the world is a major determinant of
psychological disorders
• Goal: Focus on changing maladaptive thoughts so an
individual will act differently and feel better
• Beck’s Cognitive Therapy
• Ellis’ Rational-Emotive Behavior Therapy
32
Discussion
• What are your thoughts on reality tv?
• Does “reality” TV shows depicting psychological
disorders educate or perpetuate stigma?
33
Have We Learned from History?
• We have made several advancements and still have
much to learn!
• People with psychological disorders are more likely to
be housed in jails than in a hospital due to gaps in
available services
• Many are unable to work and thus have very little
income, limiting housing resources
• Medications have unpleasant side effects
34
Clinical Case: Felicia
Felicia didn’t like to think back to her early school years. Elementary school was not a very
fun time. She couldn’t sit still or follow directions very well. She often blurted out answers
when it wasn’t her turn to talk, and she never seemed to be able to finish her class papers
without many mistakes. As if that wasn’t bad enough, the other girls often laughed at her
and called her names. She still remembers the time she tried to join in with a group of
girls during recess. They kept running away, whispering to each other, and giggling. When
Felicia asked what was so funny, one of the girls laughed and said, “You are hyper, girl!
You fidget so much in class, you must have ants in your pants!”
When Felicia started fourth grade, her parents took her to a psychologist. She took a
number of tests and answered questions. At the end of these testing, the psychologist
diagnosed Felicia with attention-deficit/hyperactivity disorder (ADHD). Felicia began
seeing different psychologist, and her pediatrician prescribed the medication Ritalin. She
enjoyed seeing the psychologist because she helped her learn how to deal with the other
kids’ teasing and how to do a better job of paying attention. The medication helped, too-she was able to concentrate better and didn’t seem to blurt out things as much anymore.
Now in high school, Felicia is much happier. She has a group of close friends, & her grades
are better than they have ever been. Though it is still hard to focus sometimes, she has
learned a number of ways to deal with distractibility. She is looking forward to college,
hoping she can get into the top state school. Her guidance counselor has encouraged her,
thinking her grades and extracurricular activities will make for a strong application.
35
Clinical Case: Felicia
• Felicia’s case history reflects the plight of many
elementary school children. Because these children
have a disorder that makes them appear different, they
are singled out and stigmatized by their peers.
• How might school systems address this problem?
36
Summary
• Tx for MI have changed over time, but not always for the better
o Exorcisms aren’t effective
o Asylums were cruel & unhelpful
• Pioneering work by Pinel, Dix, and others made asylums more
humane
o This ushered in an era known for moral treatment
• These good ideas did not last as the mental health hospitals
became overcrowded and understaffed
• For a more intensive history of psychopathology:
o
orical_context_supernatural_model_biological_model_abnor
mal_psychology&b=83&c=3.
37
Chapter 2
Current Paradigm in Psychopathology
Chapter Outline
• The Genetic Paradigm
• The Neuroscience Paradigm
• The Cognitive Behavioral Paradigm
• Factors that Cut Across the Paradigms
2
Medical Student Syndrome
• Just as medical students often “diagnose” themselves as having
many of the diseases they read about in such detail, Abnormal
Psychology students frequently see themselves in the symptoms
of mental illness described in this course.
• A study by Hardy & Calhoun (1997, Teaching of Psychology, 24,
192-193) indicated that students who were going to major in
psychology reported more worry about their psychological wellbeing than students majoring in another field. This study
showed, however, that after completing a course in abnormal
psychology, the same students were less concerned about the
possibility that they might have a psychological disorder.
3
Paradigm
• Paradigm (Thomas Kuhn)
• A conceptual framework or approach within which a scientist works
• A set of basic assumptions
• A general perspective
• An approach to conceptualizing the study of a subject and how to
interpret data
• No one paradigm offers the “best” conceptualization of
psychopathology
• One of Kuhn’s important arguments is that scientists’
investigations are directed by the assumptions from which they
begin
• Sometimes the assumptions facilitate the discovery of
interesting phenomena
• Other times the assumptions stand in the way
4
Notion of a Paradigm
• Major paradigms current in study of psychopathology & therapy:
Biological (Genetic and Neuroscience)
o Cognitive/Behavioral
o Psychodynamic
o Humanistic
o
5
Genetic Paradigm
• Almost all behavior is heritable to some degree
• Genes do not operate in isolation from the
environment.
The environment shapes how our genes are expressed
o Our genes also shape our environments
o
• Relationship between genes and environment is
bidirectional
o
Nature via nurture (Ridley, 2003)
6
Genetic Paradigm: Important Genetic Terms
• Genes
o
Carriers of genetic information (DNA)
• Gene expression
o
Proteins influence whether the action of a specific gene will occur
• Polygenic
o
Multiple genes expressions interacting with a person’s environment
• Heritability
o
Extent to which variability in behavior is due to genetic factors
• A population statistic, not a metric of the likelihood a particular
person will inherit a disorder
• Heritability estimate ranges from 0.00 to 1.00
• Group, rather than individual, indicator
7
Genetic Paradigm: Important
Environmental Terms
• Shared environment
Events and experiences that family members have in common
o E.g., Income level, child-rearing practices, parent’s marital
status and quality
o
• Nonshared environment
Events and experiences that are distinct to each family
member
o E.g., Relationships with friends, events unique to the person
o
8
Genetic Paradigm: Behavior Genetics
• Study of the degree to which genes and environmental
factors influence behavior
o
Not how genes or the environment determine behavior
• Genotype
o
o
Genetic makeup inherited by an individual
Unobservable
• Phenotype
o
o
o
Expressed genetic material
Observable behavioral characteristics (i.e., level of anxiety)
Depends on interaction of genotype and environment
9
Genetic Paradigm: Molecular Genetics
• Identifies genes and their functions
• Identifies differences between people in the sequence
of their genes and in the structure of their genes
• Recent examples of genetic influence being manifested
only under certain environmental conditions make clear
that we must not look just for the genes associated
with MI but also for the conditions under which these
genes may be expressed
Poverty and IQ
o Early Maltreatment and Depression
o
10
Evaluation of the Genetic Paradigm
• Two Challenges:
Understanding how genes and environments reciprocally
influence one another
o Recognizing the complexity of the task
o
• Several genes contributing to a specific disorder
• Each individual gene or genetic mutation may reveal a very small
effect
• Putting all the small genetic pieces together to tell the gene via
environment story for psychological disorders remains a very big
challenge
11
Neuroscience Paradigm
• Looks at ways in which the brain contributes to
psychopathology
• Psychological disorders are linked to aberrant
processes in the brain
• Three major components:
o Neurons and neurotransmitters
o Brain structure and function
o Neuroendocrine system
12
Neuroscience Paradigm: Neurotransmitters
• Serotonin and dopamine
o
Implicated in depression, mania, and schizophrenia
• Norepinephrine
Communicates with the sympathetic nervous system
o Implicated in anxiety and other stress-related conditions
o
• Gamma-aminobutyric acid (GABA)
Inhibits nerve impulses
o Implicated in anxiety
o
Glial Cells – interact with neurons and control how neurons work
– have been implicated in disorders such as dementia and
schizophrenia
13
Neuroscience Paradigm: Neurotransmitters
& Psychopathology
• Ways in which neurotransmitters may contribute to
psychopathology
Excessive or inadequate levels
o Errors in the synthesis of neurotransmitters at the metabolic
level
o Insufficient reuptake
o Faulty neurotransmitters receptors
o
14
Neuroscience Paradigm: Brain Structure and
Function
• Surface of cortex (gray matter)
Frontal, parietal, occipital, temporal lobes
o Prefrontal cortex – regulates the amygdala
o
• White matter
o
Consists of fibers that connect cells in cortex with other areas
• Ventricles
o
Cavities in the brain filled with cerebrospinal fluid
15
Figure 2.8: Subcortical Structures of the
Brain
• Subcortical structures
implicated in different forms
of psychopathology:
o
o
Anterior cingulate
Hippocampus
o
o
Hypothalamus
o
o
Memory
Regulates metabolism,
temperature, perspiration, blood
pressure, sleeping, and appetite
Amygdala
o
Attention to emotionally salient
stimuli
16
Neuroscience Approaches to Treatment
• The use of psychiatric drugs continues to increase
• Antidepressants were the third most commonly
prescribed medication for any type of health issue in
2013
• A person could hold a neuroscience view about the
nature of a disorder and yet recommend psychological
intervention
Biological treatments are not treating the cause of the
problems
o Ignores more complex views of behavior
o
• Nonbiological interventions can influence brain
functioning
17
Cognitive Behavioral Paradigm
• Rooted in learning principles and cognitive science
o
Influences from Behavior Therapy & Cognitive Science
• Problem behavior continues if it is reinforced
o
o
Escape or avoidance
Access to desirable objects or events
• To alter behavior, modify the consequences
Time out
• Period of time without reinforcer
o Behavioral activation
• Engage in tasks that are positively reinforcing
o Exposure
• Anxiety will extinguish if the person can face the situation
long enough with no actual harm occurring
o
18
Cognitive Behavioral Paradigm: Cognitive
Science
• Behaviorism criticized for ignoring thoughts and emotions
• Cognition
o
Mental processes of perceiving, recognizing, conceiving, judging, and
reasoning
• Schema
o
o
Organized network of previously accumulated knowledge
If new information doesn’t fit a scheme
• Reorganize the schema
• Construe information to fit schema
19
Cognitive Behavioral Paradigm: The Role of
the Unconscious
• Cognitive neuroscientists have explored how the brain
supports behavior outside conscious awareness
• Implicit memory
A memory formed without conscious awareness
o A person can, without being aware of it, be influenced by prior
learning
o People with social anxiety and depression have trouble with
implicit memory tasks
o
20
Evaluating the CBT Paradigm
• Some cognitive explanations do not appear to explain
much
• Thoughts are regarded as causing the other features of
the disorder, such as sadness
• Where do negative schemas came from?
o
Focus on understanding mechanisms that sustain negative
schemas in different psychopathologies
21
Additional Paradigms
• Psychodynamic (Psychoanalytic Paradigm)
o
Object relations, Attachment theory
• Humanistic
Carl Rogers, Abraham Maslow
o Primary thinking was that everyone strives for selfactualization
o Symptoms of MI are caused by those things that block selfactualization and trying to live a life that you think others
would have you live
o
22
Factors that Cut Across the Paradigms:
Emotion and Psychopathology
• Emotions
o
Influence how we respond, Help us organize our thoughts and
actions, Guide our behavior
• 85% of psychological disorders include disturbances in
emotional processing of some kind (Thoits, 1985)
o
Most psychopathology includes disturbances of one or more
component of emotion
• Emotions (affect) are fairly short-lived states
o
Lasting a few seconds, minutes, or at most hours
• Moods are emotional experiences that endure for a
longer period of time
23
Ideal Affect
• Kinds of emotional states that a person ideally wants to
feel
• Vary depending on cultural factors
Western cultures value happiness as their ideal state
o East Asian cultures value less arousing positive emotions, such
as calmness, more than happiness
o
• Shown to be linked to drug use
More people in the US seek treatment for cocaine and
amphetamines – stimulants associated with excitement
o More people in China seek treatment for heroin, a drug that
has calming effects
o
24
Factors that Cut Across the Paradigms:
Sociocultural Factors and Psychopathology
• Gender, race, culture, ethnicity, and socioeconomic status
o
o
o
o
Some disorders affect men and women differently
No country or culture is without psychopathology of some sort, but the
conceptualization and meaning of the symptoms may vary
Drugs and their effects vary by ethnicity
Poverty is related to antisocial personality disorder, anxiety disorders, and
depression
• Environmental factors can trigger, exacerbate, or maintain the
symptoms that make up the different disorders
• Culture influences symptoms expression, availability of
treatment, and the willingness to seek treatment
25
Additional Cultural Considerations
• Some disorders appear to be universal across cultures,
like schizophrenia or anxiety
o
Yet their manifestations may differ somewhat and the ways in
which society regards them may also differ.
• Other disorders, like eating disorders or hikikomori
(which in Japanese culture refers to those who pull
away from others and into themselves, seeking a life of
extreme isolation and confinement − the recluses,
loners, or hermits), may be specific to particular
cultures.
26
Interpersonal Factors and Psychopathology
• Social Relationships
o
o
Important buffers against stress
Have benefits for physical and mental health
• How the quality of relationships influences different disorders
o
o
Relative closeness, support offered, degree of hostility
The role of trauma, serious life events, and stress in psychopathology
• Counselor’s Role
o
It is important that clinicians help clients build and maintain healthy social
relationships
• A counselor could use the following to help individual’s build
healthy relationships:
o
Object relations theory, Attachment Theory, Couple Therapy, Family
Therapy, Interpersonal Therapy
27
Diathesis-Stress
• Integrative paradigm
o
Genetic, neurobiological, psychological, and environmental
• Diathesis
o
Underlying predisposition
• Can be biological or psychological
o
Increases risk of developing disorder
• But does not guarantee a disorder will develop
• Stress
o
Environmental, or life, disturbances
• May occur at any point after conception
• Triggering event
o
How a diathesis may be translated into an actual disorder
28
Imagine for a second, a college student named Mary.
Mary is a second-semester college freshman at a highly
competitive Ivy League school. She is a pre-med student
who spends a great deal of time studying and worrying
about her future. She recently did poorly on a series of
important exams. Following these perceived failures, she
began to display signs of depression including, depressed
mood, lack of interest in previously enjoyed activities,
increased sleep, weight gain, and thoughts about death.
She visits the college counseling center and is diagnosed
with Major Depressive Disorder.
29
• Psychopathology unlikely to result from one single factor.
• There are many things that may have contributed to Mary’s
depression. Let’s think about these things for a moment.
• Did Mary seek out the stressful situations that triggered her
onset of depression?
• What genetic or neurobiological aspects might have been at
play?
• What type of early-childhood experiences might predispose a
person to depression?
• What personality traits might put a person at risk for developing
depression?
• What social and cultural influences might contribute to
depression?
• What do you think contributed to her depression?
30
Paradigm Shift?
A current debate in clinical psychology involves
treatments referred to as the “power therapies.” The
common element among these treatments is the claim
that they work very quickly for a variety of problems.
31
Power Therapies
• EMDR: Eye Movement Desensitization and Reprocessing – proponents claim
that by helping the patient simulate rapid eye movements while discussing
blocked emotional information, they are able to better process the
information, alleviating emotional distress and reducing negative responses
to emotionally traumatic experiences.
• TFT: Thought Field Therapy – this treatment was formulated to treat
psychological distress by helping the patient balance the body’s energy
system. This is achieved through sequential tapping on specific acupuncture
points. According to proponents of TFT, by tapping on these points according
to certain “algorithms,” patients experience a reduction in panic, phobias,
addictive urges, anger and other negative emotions.
32
Power Therapies Cont’
• EFT: Emotional Freedom Techniques – this therapy relies on tapping “energy
meridians” to treat negative emotions, trauma and pain. Proponents of this
therapy say it can be used for a variety of problems.
• BSFF: Be Set Free Fast – is another therapy that uses an algorithm focused on
acupuncture points to help relieve unresolved negative emotions and beliefs
that are the cause of problems.
• TAT: Tapas Acupressure Technique – proponents of this technique claim that it
reduces distress due to trauma as well as allergies. It also relies on
acupressure points to relieve distress.
33
Additional Resources
• Back from Madness: The Struggle for Sanity (FHS, 53
min, color, #BVL6299)
• Bellevue: Inside Out (FHS, 76 min., #BVL11870)
• The Marketing of Madness: Are we all Insane?
(Topdocumentaryfilms.com) (2:58 hr)
34
Chapter 3
Diagnosis and Assessment
Chapter Outline
• Cornerstones of Diagnosis and Assessment: Reliability
and Validity
• Diagnosis
• Psychological Assessment
• Neurobiological Assessment
• Cultural and Ethnic Diversity and Assessment
2
Diagnosis
• Diagnosis
o Agreed-on definitions and classification of disorders by
symptoms and signs
o Psychopathology is diagnosed on basis of symptoms
o Clinical interviews and assessment procedures are used to
make dx
• Advantages of diagnosis:
o First step in thinking about causes of sx and planning
treatment
o Facilitates communication among professionals
o Advances research for causes and treatments
3
Reliability
• Consistency of measurement
• Measured from 0 to 1.0
o Higher the number the better the reliability
• Types of Reliability
o Interrater
o Test-retest
o Alternate Forms
o Internal Consistency
4
Validity
• Whether a measure measures what it is supposed to
measure?
o Does a hostility questionnaire actually measure
hostility?
• Unreliable measures will not have good validity
o An unreliable measure does not yield consistent results.
Therefore, it will not relate very strongly to other
measures.
• Reliability does not guarantee validity
o Height can be measured reliability, but it is not a valid
measure of anxiety
5
The Diagnostic System of the American
Psychiatric Association: DSM-5
• Diagnostic and Statistical Manual of Mental Disorders
(DSM)
o Published by American Psychiatric Association
o First edition published in 1952
o Revised 5 times
• Current edition: DSM-5
o Released in 2013
6
DSM-5
• For each psychological disorder, the DSM-5 provides:
o Diagnostic criteria for a diagnosis
• Criteria have become more detailed and concrete over
time
o Description of associated features
• Laboratory findings, results from physical exams
o Summary of research literature
• Age of onset, course, prevalence, risk and prognosis
factors, cultural and gender factors, differential diagnosis
7
DSM-5
• Defines diagnoses on the basis of symptoms
o Our knowledge base is not yet strong enough to
organize diagnoses around etiology
• Chapters are organized to reflect patterns of
comorbidity and shared causes
o E.g., Obsessive-compulsive and other related disorders
8
DSM V: Ethnic and Cultural Considerations
• Culture can influence:
o Risk factors, symptom experience, stigma, willingness to
seek help, and availability of treatments
• DSM-5 cultural sensitivity:
o Discussion of culture-related issues for most disorders
o Cultural formation interview questions for clinicians
o Description of how syndromes present across cultures
9
DSM V: Cultural Concepts of Distress
• DSM-5 Appendix describes 9 syndromes observed in
specific regions or cultures:
o E.g., Shenjing shuairuo (China): characterized by
weakness, mental fatigue, negative emotions, and sleep
problems
• Cross-cultural approach
o Identify broad syndromes that can be identified across
cultures
• Culture-specific approach
o Cultural concepts of distress are key in understanding
disorders
10
Criticisms of the DSM: Too Many Diagnoses
• Number of diagnoses continues to increase
o Should relatively common reactions be pathologized?
• Comorbidity
o Presence of a second diagnosis
o 45% of people diagnosed with one DSM-IV disorder
meet criteria for a second disorder
o Many risk factors increase risk for multiple disorders
11
12
Criticisms of the DSM:
Categorical vs. Dimensional Classification
• Categorical classification
• DSM-5
• Do the symptoms fit the
category or not?
• One threshold with actual,
hard boundaries
• A threshold can provide
helpful treatment guidance
• Dimensional classification
• The degree of an entity that
is present (i.e., severity)
• A way to also describe
subthreshold symptoms
• DSM-5 added severity ratings
for nearly all disorders
13
Assessment: Clinical Interviews
• Establish rapport
• Empathize with client experiences
• Encourage client to elaborate on concerns
14
Assessment: Clinical Interviews
• Structured interviews
o Standardized interview
o All interviewers ask the same questions in a
predetermined order
o Good interrater reliability for most diagnostic categories
o E.g., Structured Clinical Interview for DSM (SCID)
• Most clinicians assess DSM symptoms in an informal
manner
15
Assessment: Personality Inventory
• Self-report questionnaire
• Standardized
o A person’s responses can be compared with the
statistical norms
• MMPI-2 (Minnesota Multiphasic Personality Inventory)
• Yields profile of psychological functioning
• Validity scales to detect lying and faking “good” or “bad”
• Big Five Inventory-2
o Assesses the broad five domains of personality:
• Openness to experience, conscientiousness,
extraversion, agreeableness, neuroticism
16
Assessment: Personality Inventory
• Projective Personality Tests
o Psychological assessments presenting standard stimuli
(inkblots or drawings) that are ambiguous enough to allow
variations in responses
o Assumption is that because stimulus materials are
ambiguous, person’s response are determined primarily by
unconscious processes and will reveal true attitudes,
motivations, thoughts, and behaviors
• Rorschach Inkblot Test
• Thematic Apperception Text
•
l
17
Assessment: Intelligence (IQ) Tests
• Assess current cognitive ability
• Used to predict school performance, diagnose learning disabilities or intellectual
ability, and included in neuropsychological examinations
• Highly reliable and good validity
• Explain only a small part of school performance
• Impacted by stereotype threat (cultural bias)
• Ex: Wechsler Adult Intelligence Scale (WAIS-IV), The Wechsler Intelligence Scale
for Children (WISC-IV), Stanford-Binet
18
Assessment: Behavioral and Cognitive Assessment
• Aspects of the environment
• Characteristics of the person
• Frequency and form of problematic behaviors
• Consequences of problem behaviors
• Methods: Direct observation, interviews and self-report
measures, and other methods of cognitive assessment
19
Assessment: Behavioral Observation
20
Table 3.7:
Psychological Assessment Methods
Table 3.8:
Neurobiological Assessment Methods
Neurobiological Assessment:
Brain Imaging
• Computerized Axial Tomography (CT or CAT)
o Brain structure
o Detects differences in tissue density or structural
abnormalities
• Magnetic Resonance Imaging (MRI)
o Brain structure
o Similar to CT but higher quality
23
Neurobiological Assessment:
Brain Imaging
• Functional MRI (fMRI)
o Brain structure and function
o Measures blood flow in the brain, proxy for neural
activity
• BOLD signal=blood oxygenation level dependent
• Positron Emission Tomography (PET)
o Brain structure and function
o More invasive than fMRI
24
CT Scans
fMRI Scans
Copyright ©2018 John Wiley & Sons, Inc.
25
PET Scans
Copyright ©2018 John Wiley & Sons, Inc.
26
Neurobiological Assessment:
Neuropsychological Assessment
• Luria-Nebraska battery
o Assesses motor skills, tactile and kinesthetic skills,
verbal and spatial skills, expressive and receptive
speech, etc.
27
Cultural and Ethnic Diversity
and Assessment
• Measures developed for one culture may not be valid
or reliable for another
o Not simply a matter of language translation
• Guidelines for translating and adapting tests exist, but
are not always followed
• Cultural biases may cause a clinician to over- or
underestimate problems in members of a culture
28
Strategies to Avoid Bias
• Increase graduate students’ cultural awareness
• Ensure participants understand task
• Distinguish “cultural responsiveness” from “cultural
stereotyping”
o Conclusions should be tentative and alternative
hypotheses should be entertained
29
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