\Abnormal Psych PSYC3018

Transcription

1 \Abnormal Psych PSYC3018 Lecture'1:'4/3/2014'! Need to know both DSM-IV and DSM-5 criteria be aware of the main gist and differences! Student manual will get a printed version next week in tutorials!! Refresh definitions of abnormality textbook and first year content! What is abnormal psychology? Empirical, description (classification/diagnosis), causation, maintenance, treatment! A mental disorder is one form of abnormal behaviour! Not all psychology is empirical can t all be randomized or empirically investigated! Why is diagnosis important? To understand how to treat, somethings causes we have to describe it with descriptions that are real and that other professionals understand o We need to know if it is a single symptom, part of several disorders? o We don t know when we describe schizophrenia if we are describing it in a reliable way, we need to remember they are constructs under development! E.g. Motivation deficiency disorder does it exist or are you just lazy> Female sexual arousal disorder is it real or does your partner just have no idea! which one is in the DSM - check! How do differentiate between mental health and mental illness?! Historically mental illness defined only as sanity vs madness/insanity o Insanity symptom: distorted external reality ie hallucinations (similar to psychosis, schizophrenia and dementia in today s diagnoses) o 18 th and 19 th C mental asylums, treated by mad doctors/alienists o Anxiety, eating disorders etc not seen as illness seen more as problems of living! What is mental disorder? o Today 400+ categories in DSM or ICD proliferations of disorders and large number of people who treat them o The DSM contains descriptors of symptom clusters! Prevalence of mental disorder: o Many people seek help help-seeking behaviour depends on lots of things, stigma, cost, culture of seeking help, knowledge, belief as to whetehr it will help o To find out how many people have the illness we use psychiatric epidemiology using normative/representative samples o Interviewed about symptoms and then we know irrespective of help-seeking o Point prevalence: right now X percent have Y disease o One- year prevalence X percent had Y disease in o Lifetime prevalence during hteir lifetime X have had major depressive disorder etc o Incidence proportion how many people have Y disease for the first time o What proportion seek help? Was that help successful? How does prevalence vary across gender, age etc o ACCORDING TO THE AUSTRALIAN STUDY:! How do we define mental disorders? o 1 st chapter of DSM general discussion of mental illness o Not merely expectable and culturally sanctioned response o Whatever original cause it is a dysfunction in the individual o Wakefield two important parts of definition (internal dysfunction and socially unexpected/unvalued) o Internal dysfunction if the symptoms are caused by dysfunction you are ill, the symptoms can be the same but the diagnosis different i.e. anorexia vs religious fasting

2 Or anxiety disorder (has an evolutionary root, responding to danger) but is dysfunctional when it is reference to something that poses no danger o Socially unexpected/unvalued internal dysfunction can be socially positively valued (e.g. shamans), " an internal function (e.g. broken leg) but no social value judgment (no one says whether it is good or bad to have a broken leg) = physical illness " no internal dysfunction and negative value judgment = social deviance o Mental disorder somewhere between physical illness and social deviance internal and social judgment! Medicalisation of behaviours that aren t disorders which have been diagnosed and used as a form of social oppression for behaviours which are different social value judgements are used in psychology, that s why it is so important to look for internal dysfunction o E.g. women being diagnosed with pathological independence for women to go to uni, 100 years ago! DSM IV major depression all based on dysfunction, there could be a reason why you are experiencing depressive episode is it a normal reaction to a life event or an illness? Doesn t say anything about cause! DSM IV ignores the cause focuses on sympptoms we don t know anything about WHY you are experiencing these symptoms! Wakefield says problem with DSM today is:! Lecture 2: 6/03/2014 Classification and Diagnosis I Wakefield two components (the pattern is a manifestation of dysfunction internal to the individual) and that this pattern is not accepted or is viewed as harmful (social judgment) Prevalence possibly overestimated because any behaviour pattern is taken as a sign of mental disorder even when those symptoms are normal reactions to events or just a form of deviance with no internal dysfunction Diagnosis two manuals DSM (published by Americna psychiatric association, currently in 5 th edition) and ICD (published by WHO mental disorders first added 1948, 10 th edition) o These classificiation symptoms reflect the medical model but have been very heavily influenced by psychoanalysis o These two manuals are not exactly the same e.g. DSM contains GAD (main symptom is worry), ICD has GAD but makes no mention of worry which is seen as the main symptom in DSM, DSM contains binge eating disorder but ICD does not, mixed anxiety depression in ICD but not in DSM o These are concepts that are still evolving Medical/biological model: o According to medical model there are the following assumptions: o Illness is qualitatively different from health not a grey area where you re not ill or not healthy (e.g. broken leg vs no broken leg) o Different illness are clearly distinguishable (within category of illness there are different diagnoses), occur independently of each other (different, independent causal agents), have specific, identifiable causal agents, respond to specific treatment o If diagnosis is correct, leads to the correct treatment aim is to identify diagnostic categories that have their own specific causes lead to specific treatments syndromes are disease once we know its causes e.g. AIDS being known as HIV (a disease) o Early attempt for classification with causes was Hippocratces ( BCE) " One of first mental illnesses Hysteria (specific to women), an overdry uterus, sexual malfunction (where the first vibrator was developed), shows how there is a strong social component and where psychiatry is used oppressively

3 " Paracelsus: 3 illnesses vesania (toxins), lunacy (the moon phases), insanity (heredity) " Henry Maudsleye masturbatory insanity Emil Kraepelin known as the father of modern psychiatric classication (what we have no is a neo-kraepelian approach) o If we have no reliable knowledge about causation we should clearly describe symtoms and gradually work towards an empirical approach/cause rather than classifying according to hypothesized causes " Describe the onset, course, epidemiology " Staying at an empirical level show that symptoms cluster together to form a syndrome because they reflect a common underlying cause " In 1980s it was a big shock massive number of deaths, no one knew what it was, so a Kraepelinian approach was used until the underlying virus was found A historical example of the medical/biological model: o E.g. General paresis of the insane using the descriptive approach this sort of pattern/syndrome was found to be different to other clusters of insanity, it had a clear deteriorating course, people died within 5 years of onset o They tried to figure out epidemiology (the kinds of people who got it, middle aged men sailors and soldiers) then they found identified biological cause with a bacterium which causes syphilis, not a separate mental illness or diagnostic category, we only knew this once we know the cause o Louis Pasteur s germ theory of disease changed the view that tiny organisms/bacteria make you sick, this changed the way medicine and psychiatry was viewed o Broca and Wernicke also showed association between localized brain damage and specific syndromes Kraepelin: questioned the unitary idea of insanity, he proposed different types of insanity but that we should go slow and just describe them first of all distinguished between two types manic-depressive psychosis and dementia praecox and then expanded in 1915 to many different types of psychoses o He proposed either he knew the cause and categorized accordingly, or that they remained at the level of description with no cause known Eventually all will be categorized by their underlying biological causes: causes are bacterial, localized brain damage, toxins (mad as a hatter, hat makers went mad because they breathed in mercury from their work), heredity BUT none of this happened progress slowed down, no treatment breakthrough (lobotomy, people kept making hypothesized causes o Some very harmful treatments focal sepsis infection, infection could kill you and often treated through removal of infected organs, death rates of about 45% (mainly from postsurgery) o Not one category in today s DSM-V is a disease, they are all syndromes in a medical sense Lecture 3: Classification and Diagnosis II 11/03/2014 Basic assumption of medical model: distinction between health and illness is very clear (easy for physical illness), distinct disorders (independent categories) Psychoanalytic model: revolutionized psychiatry o Thought the human personality had 3 distinct aspects: stage like development id (pleasure), ego (the self), superego (moral self) as the structure of personality central to normal and abnormal

4 o Psychosexual stages: oral, anal, phallic, latency, genital each stage requires a resolution of conflict o Conflict within the personality we are only aware of the ego which attempts to mediate between conflicting motivations o Unresolved conflict! cause anxiety, distress, guilt, shame o Way to deal with anxiety ego avoids pains of unresolved conflict through defence mechanisms which represses id into unconscious (pushing out of consciousness eg) " Distortion, repression, displacement, sublimation (directing energy to something else), projection, reaction formation (opposite reaction e.g. love/hate) o Ego is there to protect you from unconscious a normal process we all experience But defence mechanisms can create suffering: sometimes not successful, when applied rigidly or excessively o E.g. displacement! depression (e.g. turning anger away from killing father to self) o Reaction formation! overprotective or dependence Freud very different to medical model (which distinguishes between illness and health as a clear distinction, not a specific cause like toxins), he is talking about a continuum, the difference is in the extent of the behaviour (how excessive or obsessive it is) not the quality of the behaviour o In psychoanalytic model symptoms are not central (like in the medical model where they are grouped into syndromes and a central cause is found) o In psychoanalysis: same conflict can lead to different symptoms, or two people may have same symptoms with different conflicts or different symptom profile can develop overtime o Therefore, according to Freud the treatment is to gain insight into unconscious Psychoanalysis: very influential in 1940s-1970s argued no clear dividing line between normal and abnormal (very dimensional), pathological manifestations were extreme manifestations of normal, not just talking about insanity (it was about what Freud referred to as the psychopathology of everyday life), neuroses introduced rather than just psychosis, no clear dividing line between different categories of mental disorder, extension of client base to more mild conditions o E.g. psychosis just a very severe form of defence mechanisms being applied DSM-I (1952) and DSM-II (1968): o Very strongly influence by psychoanalysis firstly organic (biological) conditions vs reactive conditions (psychological reaction) e.g. reactive depression, psychotic reactions (viewed as extreme manifestation of defence mechanisms such as paranoid schizophrenia where they use defence mechanism of projection o Psychoneurotic disorders (reaction) thought of as anxiety Problems with psychoanalytic model: o No clear cut off between health and illness problematic in terms of 3 rd parties like insurance companies (private health insurance won t help yout here, no provision for health or a cure) o Not easily testable, empirical and difficult to measure not good for empiricism of medicine o DSM-I and DSM-II had problematic reliability (giving same measure everytime, interrater reliability for the same patient but different doctors) and problematic validity (based on unproven theories about aetiology little evidence o E.g. Depressive reaction DSM-I: o Very ambiguous, people couldn t give same diagnosis, what is loss? What if the patient had no self-deprecation? DSM-III (1980): Neo Kraepelinian approach, reflects medical model (DSM III seen as one of most important development in psychology/psychiatry)

5 o No aetiological assumptions (helped improve validity and reliability), clear explicit description of symptoms, based on patient report, direct observation and measurement, not about assumptions about patients unconscious (had to be observable), back to medical model o Imposition of Kraepelinian approach onto Freudian approach Very different to Freud s description of medicine much clearer and detailed DSM-III and beyond: o Better reliability (we could agree and count symptoms and how many and count duration) o Validity: we can agree but we could all be wrong, is what we describe something as depression correct (even if it is reliable) o Problems: comorbidity is very common (patterns of coexistence e.g. GAD tend to have social phobia and tend to have depression means that the disorders aren t independent to each other very rare that a person has only one disorder, the norm is to have many), diagnostic instability is high (people shouldn t be moving from disorder to disorder suggests they aren t independent, e.g. having anxiety and getting better and then get another disorder once better), lack of treatment specificity (if they are distinct they should have specific treatments they respond to e.g. anti-depressants used for eating disorders, addictions, depression, anxiety etc), no DSM mental disorder classified as a disease Lecture 4 Does psychotherapy work? 13/03/2014 Cause Treatment Supernatural Spirits, starts, past lives Exorcism, prayer Biological (dominant for psychiatry) Internal physical problems bleeding, diet, celibacy, exercise, rest, medication Sociocultural (social work) Poverty, prejudice, cultural norms Fix social ills Psychological (psychologists) Beliefs, psychological dysfunction, something wrong with beliefs, values, goals Talking therapy and psychotherapy Psychological models (break down of psychological approach) Psychoanalytic Unresolved conflict Insight Behavioural Learned responses to stimuli New learning Humanistic Thwarted self-actualization Empathy, unconditional Cognitive Negative core beliefs, biased thinking positive regard Cognitive restructuring, new ways of thinking How do we know if psychotherapy works? o Previously it was sufficient if the client reported they got better, but we don t know about dropouts (why did people leave), client report is not specific enough o Why do we need Empirically Supported Treatment (EST)? " Need for accountability in the psychological profession