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Lecture 3

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University of Toronto St. George
Hywel Morgan

Lecture 3: Theoretical Perspectives Biological Models: A. The Role of the Nervous System B. The Role OF Chemistry C. Genetics and Behaviour D. 3. Biological• Emphasises role of: i) nervous system in mental disorders ii) brain malfunction iii) neurotransmitter imbalance iv) genetic factors• Many mental disorders show a high degree of concordance amongst close relatives.• Techniques for observing brain functions have improved (MRI, PET) Psychosocial Theories: A. Psychodynamic Theories B. Behavioural Theories C. Cognitive Theories D. Humanistic Theories Assessment – When the psychologist gather information on a new patient (kind of problems, current conditions, responses to various psychological tests).• Diagnosis – identification of the person’s problem(s).• Psychologists and other mental health professionals have an agreed-upon system for describing and classifying mental disorders.• Most widely used – Diagnostic and Statistical Manual of Mental Disorders – IV (DSM-IV) First step in identifying psychopathology is assessment-what am I looking at? Explore details. Going to compare your behaviour to others behaviour is an assesment. Second step is diagnosis. Third step is treatment. In this order but all three steps are ongoing processes. Diagnosis: • Benefit-research shows that if you are diagnosed having schizophrenia, psychotherapy is not the paramount therapy for this. Will not work very well. Treatment selected would be a pharmalogical intervention Classification and Diagnosis Diagnosis benefit is in the selection of the treatment. Contenscious issue in psychlogy. There is a harm, when we provide a diagnosis for someone who has a mental disorder, the most harm is stigma. Ex/ someone giving diagnosis for schizophrenia. That person is labelled chizophrenia. That person lifetime label, negative connation. The acknowledgement of the disorder is made. Typically, schizophrenia does come back, have acute episodes. Like depression tends to come back. In mental health do apply same labels, stigmizing, unlike flu. Ex. Cancer, ongoing battle but those people are not labelled. Don’t label people as their order,-most harm. DSM5- current classification. To divide statiscal norms and look at behaviours outside of these statistical norms. DSM3- revised to reflect different statistics. No different diagnostics. DSM4- new categories, some removed and do not exist. Ie multiple disorder replaced. DSM4 TR- text revision, new version same categories, no different statistics only txt revised. More elaborative text. DSM5- may 2013- make more norrmative statistical data, whats average and what most people do. Twenty year time span to do more research. Classification- to identify syndromes of abnormal behaviour is the goal of a classification system. Syndromes are a set of symptoms that occur together regularly. The DSM 5 is the goal of this throughout the incaranation- identify symptoms that go together. Can purchase dsm but cannot diagnose unless have an md. It is not the tool the rest of the world uses, only in north america. ICD world uses- international classification of disease, version ten. DSM is published by the american psychiatric association not psychology because it is a medical tool, outlining syndromes and their diagnostic. Psychologist have input. WHO-world health organization- division of united nations, significant overlap between DSM and ICD. Goal was to make it compatible with ICD, hundred percent amking it the same classification system. Problem next year is that ICD 11 comes out next year, introduced by the world health organization. Biological asssessment and diagnosis Biological functioning is an important way • Genetic • Neurochemical • Imaging- of the brain to determine if it is structurally or functionally astound. If you have a psychopahology disorder, more likely tha you will receive on of these imaging process, looking at botht the structure and function of the brain o Structural- is there a part of the brain that looks different statistically to other brains. Ie.smaller, damaged. • Have found ethical ways, most common method is CT scan-computerized tomography, 2d image, x ray machine, x rays from different angles. MRI- magnetic resonance imaging, doesn’t use x rays so no radiation. Strong magnets, changing polarity of the electrons (strong magnets) high definition picture of the tissue inside. • Why don’t we stop using CT scans? because cheaper o Functional- do different parts function differently statistically from other people. Functional imaging looking at the brain that are functioning properly. Function imaging-PET scan-what parts of the brain are active using radiation-positron emmision tomagraphy. The brain uses glucose when there is activity. Pet scan not so much used anymore because new method-fMRI, perfarble and expensive. Function magentoic resonance, measure what parts of the brain are more active to an adjusted mri procedure. What makes a good classifiction system? • Was developed in germany not North America, german scientist first to develop cateogries. 1. Categories should be clearly defined. DSM 5 does a better job of this. In order to be diagnosed with major depressio, must have a certain number of symptoms over a specific period of time-so well defined. IDC uses this to. DSM5- criteria is broader, an intend on doing that was that more people will recive treatment, argument against it is that it may not be a psychopatholoy disorder. 2. Categories exist. Synptoms do occur together regularly. The feature in each categories also exist b,c occur together. DSM doe s good job of this.. Illusions and halucinations for schizophrenia. Does the cateogry exsist. Problem: does hallucinations only occur with szchizophrenia.A: no. they symptoms that occur in this category may occur in another- symptom overlap. System overlap- could lead to mis diagnos. 1. Has good reliability. Test and test retest. Diagnosis is made and same symtoms are shown then same diagnosis should be made.two different people diagnosis you with the same thing-measures good reliabiliy. DSM reliable or unreliable? It is reliable b,c clearly defined, certain degree of realibilty on DSM, not a hundred percent. Is it consistent across time and pp who are assessing 1. Is it valid? Is it measuring what It is intending to. For DSM, there is low validity because of the symptom overlap and mis diagnosis. The treatment wont work so continue to assess and there is a change of disorder which isnt depression anymore. 2. Is the classification have clinical utility. Is ti usefull? DSM is a method, it is useful depite its flaws with validity. Diagnostic Systems • Emprically driven- empirical means we have numerical data and compare numerical data from all people. This is the problem with DSM because diagnotic statistical manuel, they lie, not empircally drived system. It is useful but not empircally driven. Trying to move towards that. DSM is a clinically drived system • Clinically driven - DSM and ICD which means system derived by consensus. DSM is a system drived by a study group that got together professionals and experts in the fields. Drived system in secrecy- criticism. DSM is good, useful, all we have there are crtisisms. Consensus are made from experts have seen a lot of things, havt used statistics but trying to get there. because really difficult to define DSM IVAXES -the first axes on DSM 4 is primary and complaints. • Existing disorders- DSM4 is the axes one- primary and complaints. Comorbid-depression and anxiety uncommon to see. Comorbid disorders went on axes 1. on axes 2- present personality disorders, personality disorders got a separte section on DSM 4, not the case on DSM 5 and go in the respective sections with similar symotpms. This is because there was an acknowldgemetn that personality disorders are permenent. Personality disorder can be treated but it’s a part of who you are and not going away. AXES three 1. Relevant physical conditions- separate sections b,c phsycial conditions looked like psychological conditions and vice versa. Ie.make noise and front of child, may not be deaf but autism. Deaf is phsycial condition and autism is psychological 2. Severity of psychological stressors- fourth diagnosis received on dsm 4. has prognostic value so doesn’t go away- prognosis:this si what will happen. Whats going in the environment has prognostic value, if a lot of stress then prognosis is not positive. Lots of stress will be difficult to treat axes 1 and axes 2 disorders. All of these things condiered on dsm 5 on one axes.Axes 5 has been eliminated, on dsm 4 used to provide global assessment 3. Global asessment of functioning- how well you are functioning right now, a disorder that prevents you to go to work, be social. Axes 1 through 4 is included in the same diagnosis. THE DSM:psychiatry;s deadliest scam Movie-house of cards Started so psychologists and psychiatrists can be accepted with other scientists. Only three disorders that still exist today Dsm 11- 172 disroders for government money DSM11- not scientific by freud. New diseases are being invented not discovered. Mental disorders are voted in and out ie.homosexulaity-added and removed for politial reasons. Science is a fabrication. Dsm3-1980: freudian psychology- biologically still not scientific. Increased to 259. Chemical imbalance theory -how depression is caused. Medical field promoted the chemical imbalance theory of why these disorders happen No test out there about chemical imbalance No definition for the concept of mental disorder Dsm 4 1990: still no defintion. 374. 120 million diagnosed To test to identify a illness Public kept in the dakr, diagnosis within couple of minutes They percieve a problem must be seen as legitimate and must be solved. Justify drug treatment 42000 deaths using these drugs. Mainstream drugs that the risks are downplayed --> suggested sucidial causes is drugs, alternate is depression. Not sure which one. -50's discovered multiple personality because was very rare. So rare couldn’t study it or report it. Famous case study-sybil 80s-90s- now common to be included in dsm 3 , Hospital in ottawa only for multiple disorder so common. Dsm 4 changed the name, PsychologicalAssessment DSM 5- reorganized categories, added 'hoarding' • diagnosis can be wrong so assessment ongoing process. Usually, first interaction is assessment.Average length of time for an assessment in canada a doctor has with a patient is about 12-15 mins to make an assessment. Not sufficient time for an accurate assessment. Psychological assessment is usually more thorough, 3 hours minutes could be all day or 2 days. Quite lengthy for a mental disorder. DSM not always accurate. There are three tools in assessment, ways to assess a client for abnormal behaviour/psycpathology. To apply a DSM diagnosis to assessment: o Interview-ask questions o Observation-don’t need to be verbal, useful for clients who are not verbal, useful for children. • Social workers, psychaitraist will use above methods o This is where the profession began (freud didn’t do this) 70 years now: compare to other people (gather data and get average). Taking averages and comparing individual data points. Difficult to get deviation, arbitary. The third method is testing, psychological testing. Other professions beginning to use it. Every two years, a pendium is published for past tests, thousands to choose from. Good at compiling statistical data to compare. Early 1940s, psychology took off. Behaviourist movement because were collecting data. Why did it took off in 1940? Became more applied to compare people for occupation skills. Testing began with children not adults. When going to hospital, seen by a nurse intially, determines severity of disorder-triarge. Takes basic symptoms and go to triarge. If not normal then will be sent to a heart specialist, cardiologist. Do the same thing in psychology, process cause referral. Referral comes from.. • Social worker • Psychologist • Physician-a lot of the times a referral is sent from a physician to a psychologist. Family doctor will send to an expert. Important for an assessment to be included bc gives clues to what the problem maybe, clients understanding of the problem, their motivation and willingness for the client to do something about it. • Legal system-court mandate assessment and therapy, low motivation to do something, common. Being a problem for other people. How does legal system enhance this motivation? Court says must, no choice, not free to do something else.Anormal person can stop at any time during the therapeutic session, however motivation- if you participate there will be less punishment. Generally, low levels of motivation, other cases a parent bringing child into therapy. Referral leads to a formal assessment, a triarge to find out where to send patient to. Referral provides a therapist with an orientation of major problems. Basic information in the referral, not a formal assessment just the basics. • Basic information are primary symptoms, duration, the onset and medical status (can mimick or complicate) • Cautious: the specialist may already have a working plan is a good thing but could be bad, why? Is biased from the referral. Potential for observer bias. When client comes for assessment with idea that working hypothesis that they have this particular disorder can lead to an error in validity, called observer bias. Going to keep testing until find proof that they have a pyscopathology, for a particular illness. Malingering-people can present symptoms with a disorder they do not have. They are not lying intentionally. Ie/alzheimers disease, people will not go seeking for help if they have this so if in old age with bad memory not because ofAlzheimers. Some people will hurt themselves to get into a hospital for medical attention, Munchhausen, disorder. • Common method for children is observation and for adults is interview. Referral process: formal assessment will take three methods: (all three may be used depending on the degree of the symptoms, typically all three are used, in children using more observational) Assessment ongoing process-sooner rather than later because of insurance purposes, usually after first visit. Doesn’t make sense to get paid to socialize if theres no disorder. 1. Observation-type of things your're doing… • General appearance and attire -deportment, how you carry yourself, what your wearing (already a lot of info), how client presents yourself. Physical, personalty, and social characteristics.Are there obvious extremes in the appearance ie/ appear dischiviled, havt slept in a while, washed hair or shaved, this is a concern. Maladaptive behaviour- not trying anymore, don’t need to be verbal to see it. Extremely thin and young women, working hypothesis would be eating disorder before questioning. Ie/excess bruises and violence-domestic violence, should be open minded could be something else another common disorder for children- epilpsy. Want to rule out medical issues, a neurologist. Does their deportment (clothes, what they bring with them) fit their age, SES, educational level? • Gestures and expressions-look for subtle difference different then the norm. facial expressions, body language. Can pickup on behaviour and personality presentation by looking at body language could be subtle. Fear, anxiety expressions should be addressed immidiently. In order for therapy to be successful, a relationship has to develop between therapist and the client. Relationship must be a bond. Intial assessment, client is nervous, need to pickup on that to build a relationship, there needs to be motivation to work with therapist if not working then treatment will be low, prognosis would below, not good. Build a rapport. • Motor act- movements, gross (large) and fine (small) motor acts.Area of responsivity, give info about neurological, phsyciological and pharmalogical states and info about client's state. Is the client overrative, moving, fidgeting. Other reasons:substance abuse, phsyciological reason-chemical imbalance of some kind. Extreme- hyperactive, opposite side..underactive, non responsive-working hypothesis: depression, neurological disorders, catatonic • Verbalization- not talking about content (that’s in interview), context and structure of verbalization, how they are saying it, is it age appropriate, SES and educational level. Neologism-people making new words that don’t exist, or putting words in a sentence that don’t go together. Incoherence- grammatically correct but words should not go together. Tangential speech-babble, frequency and duration not normal, unimportant topics. Indication of neurological dysfunction or psychosis. More intution, can learn through experience, more art if testing is science, get good at it with practice. Pick up- picking up a behavior,..i just saw that. Something that a person did that doesn’t seem right but no stats to compare with, appears to be abnormal. Some people are hardwired to pick up on others behaviour. It is easy because no need to go into a book, just looking at what others are doing. Simple but requires a degree of intuition and experience. Psychologsts do get good at this, no need for verbal interaction. Warnings: 1. observer bias. Only picking up things you expect to see.Another type is, paradigm you have been trained in, theoretical perceptive you have been trained in provides a bias, this is how I see and interpret behaviour. 1. Only looking at this behaviour in three hours, at one point in time most often an artificial environment. "I bring you in an assessment and you are anxious so clearly anxiety disorder" 1. Interview Ask questions and expect responses. The questions are based on information that comes from the referral. Howeverm the types of questions asked are often generated from theroetical perspectives. If trained in psychoanalysis then will ask childhood, past history. If cognitive behavioural pov then will most likely to ask recent, current behaviour. 1. Identifying data-behaviour you are observing appropriate to educational level, age, SES.Age, name, rapport, want to know educational level, born and raised, first language, other languages. Provides a context. a. Can get detailed, want to know background, current residence, residence condition, occupation 2. Next thing to know is the presenting problem-"whats going on?" first time to see doctor, registeration forms. Psychologist want face to face, may have other questions. "want to hear details in you words." already have a good idea from referral. "what time did you get out of bed this morning?"..trouble sleeping, how many days for..etc. 3. Super important-family history, background. Disorders have family history, concordance rates. Othe family members have similar disorder ,genetic influence. If you don’t like therapist your working with, go find another one because client is consumer of this service. If therapist says then unethical. To develop a rapport, reduce anxiety, make a connection, tell details of process. Two types of interviews: • Standardized (structured)- have been sructured over a long period of time. Ie/in substance abuse clinics, multiple page booklets to fill out that is structured like a questionaire, survey. They are exhaustive-4 pages of what the problem is. On family history, take a long time to adminster. On average 12 pages long. High degree of accuracy in the interview assessment. Not going to miss anything, experience of other people, these are all the questions needed to be asked. Bad thing- they will lose interest in you, need interaction in first meeting, no rapport being developed. Cant deviate, need to ask all these questions. Good- because not going to miss anything. • Non-standardized (unstructured)- interview technique where persons responses can drive what the next question will be. There is not a set of standardized question that needs to be asked. "from referral need to explore this.." based on their response generates another question. Good for rapport, having a conversation, an interaction is being developed on a personal level. Bad-miss stuff, answers they are providing are generating a working hypothesis-could be incorrect, didn’t even do a history background. Most common method is the interview in assessment. Usually generates, working hypothesis about diagnosis. In the interview, psychologist determines what type of testing needs to be conducting. Will use mixture of both of the two types of interviews. There are set number of questions to be asked but exploring other issues in detail. Some like to use non standardized usyally are the ones with lots of experience and will not miss anything. 1. Tests Standardized approach, quantifiable approach to psychology. Collected statistically norms and will compare them, are empirical. standard to which compares the client to thus offering a degree of precision and objectivity. Not obtainable with other assessment approaches. Number of tests advised, not readibly accessible by interview, give much more objective estimate and precise estimate of what your intelligence level is, measure memory, fantasy, personality. Two groups of psychological tests, thousands developed put into two groups. o Think and feel- can have dysfunction in these domains. They overlap significantly. Ie/ depression-feeling sad:mood/motion disorder. The way you feel can influence the way you feel. • Cognitive tests-disorder in the way you thing. People who score high on personality disorders (I am depressed) score low on cognitive tests (not thinking properly). Performing developmentally and intellectually range- mentally retarded. • Personality tests
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