Chapter 5: The Nature of Psychopathology
Underlying Cause as Focus of Treatment
- Conceptualizes psychological problems are caused by some underlying process that may/may not be inherently pathological but that at the current time creates difficulties for the person, the manifestation of which are the signs and symptoms. - Focus of assessment is to determine what the causal and contributing factors are in the production of the psychological problem (e.g. personality, interpersonal styles, defensive or coping styles, etc.) - This is the orientation of the psychodynamic schools, interpersonal schools, cognitive schools and the PDM.
Symptoms as the Focus of Treatment
- conceptualizes psychological problems as a group of symptoms or observable behaviours and the cause of the difficulty with the psychological problem as the presence of the symptoms and behaviour. - focus of assessment and treatment is to delineate the symptom picture ad focus on eradicating the symtoms. Assessment instruments and techniques are designed to ferret out the symptoms/elicitors of the symptoms and treatment would focus on symptom or behaviour reduction. - It can be argued that this is the orientation of the behavioural school as well as the orientation of the ICD and DSM. - It can be argued that this perspective has been embraced by managed care and insurance companies that are unlikely to pay for treatment unless it is treatment for a diagnosable disorder
The Diagnostic and Statistical Manual of Mental Disorders (DSM-V)
- developed by the APA - detailed and comprehensive manual that provides specific criteria for the diagnosis of psychological disorders and other informtion relevant to understanding the nature of various mental disorders. Attempts to take a descriptive approach to mental disorders: - diagnostic features - associated features supporting diagnosis - culture-related, gender-related, features Previous versions of the DSM included multiple axes to make a diagnosis but the current one uses 22 broad groups of disorders composed of 400 individual disorders. The National Institute of Mental Health in the US has recently taken the stance that the symptom focused approach to defining disorders (found in the DSM) is no longer appropriate and an approach addressing underlying causal mechanisms must be embraced.
10 Major Categories of Disorders in the ICD-10
1. Organic mental disorders (e.g., various dementias, delirium) 2. Mental and behavioural disorders due to psychoactive substance use (e.g., acute intoxication, dependence syndrome) 3. Schizophrenia, schizotypal, and delusional disorders 4. Mood Disorders (e.g., mania, depressive episodes) 5. Neurotic, stress-related and somatoform disorders (Anxiety and Somatoform Disorders) 6. Behavioural Syndromes associated with physiological disturbances and physical factors (e.g., eating disorders, sleep disorders) 7. Disorders of adult personality and behaviour (personality disorder, sexual disorders) 8. Mental retardation 9. Disorders of psychological development (e.g., speech and language disorders, autism) 10. Behavioural and emotional disorders with onset usually occurring in childhood and adolescence (e.g., conduct disorders, emotional disorders)
The DSM's definition of Normal Behaviour
1. See the self/others in complex, stable, and accurate ways 2. Maintain intimate and satisfying relationships 3. Experience the full range of emotions 4. Regulate emotions and impulses adaptively and flexibly 5. Function in a fashion consistent with morals 6. Appreciate conventional notions of what is realistic 7. Respond to stress resourcefully.
Syndrome
A group or set of signs and/or symptoms that, in combination, reflect a specific health-related condition. The co-occurrence of the signs and/or symptoms is often thought to reflect underlying pathology.
Sign
A problem/abnormality that can be observed by a clinician but not necessarily perceived by the patient. - an "objective manifestation of a pathological condition."
Symptom
An abnormality/complaint perceived by a patient, although the term is often used to refer to any indications of a patient's experience or behaviour that reflects a particular disorder. - a "subjective manifestations of a pathological condition"
Education Purpose of Diagnostic Classification Systems
As an indicator of current knowledge and concpeitons of psychpathology are useful in training and education of clinical psychologists and other health professionals.
Psychological Problems and Interpersonal Processes
Attention is paid closely to issues of capacity, history, and stylistic aspects of relationships with others. - Includes friendships, networks of social support, relationships with family/coworkers. Relationship schemas/representations of others (*object relations*) that an individual develops and the relationship a person has with their self is of interest to the clinician as well. - Importantly, self-esteem and self-regard are issues in numerous kinds of psychopathology whereby the individual's view of the self unrealistically low/how/or too reactive.
Purpose of Diagnostic Classification Systems for Treatment
Careful diagnosis can lead to appropriate and differential treatment
Insurance and Reimbursement Purpose of Diagnostic Classification Systems
Classification systems are used by institutions to provide resources and pay for assessment and treatment of disorders. - Rates of reimbursement for treatment vary according to the disorder, while some are not reimbursed at all.
Psychological Problems and Processes of Regulatory/Coping Behaviour
Clinicians often focus on whether a person can cope with life's demands, but also the manner in which the individual does not attempt to cope and whether it is effective. - There are both adaptive and maladaptive methods of coping in addition to mature and immature defenses that either help/hinder an individual dealing with the internal/external world. - Coping inappropriately can produce or increase psychological or physical problems
Conceptualizations of Psychological Problems
Definitions and conceptualizations of psychopathology have shifted and changed over time. - As knowledge accumulates, theoretical perspectives accommodate to new information, new perspectives appear and re-appear and as values of society shift, definitions of psychopathology shift as well. e.g. Some disorders appear to be decreasing in frequency either due to a decrease in incidence or due to treatment and prevention, or a refinement in diagnosis so that other disorders or problems are no longer lumped together.
Psychological Problems and Processes of Emotions and Emotional Regulation
Emotion/affect is the major domain affected in psychopathology and is a focus of research and clinical work. - Although any emotion can be viewed as pathological in extreme cases, anxiety, depression, and anger are the most predominant emotions reflective of psychological disorders. *emotional dysregulation* (problem with the ability to control the experience/expression of negative emotions): a significant contributing factor in psychological problems. Reduced emotional expressions (blunted or flat affect), or absence of certain emotions, or inability to process emotional content are considered indicative of some psychological problem
Psychological Problems and Environment
Environment can play a key role in causing and maintaining psychological difficulties, and helping the individual, couple, or family alter the environment can be a focus of treatment.
Psychological Problems that Clinical Psychologists Focus On
How do clinical psychologists determine what behaviour is normal, abnormal or maladaptive? 2 Approaches: - Determine how a person's behaviour is defined as abnormal or maladaptive - What processes clinical psychologists pay attention to when trying to make a determination whether some behaviour is normal or maladaptive
Research Purpose of Diagnostic Classification Systems
In order for appropriate research to be done, it's imperative that good definitions and operationalizations of the constructs exists. - Having different definitions for the same term impedes advances in knowledge through researhc
Communicative Purpose of Diagnostic Classification Systems
In order for clinicians and researchers to communicate effectively about people with particular problems or about psychopathology, there needs to be a common language and definitions of concepts and terms
Past Conceptualizations of Psychopathology
In the *19th c.* Kraeplin attempted to understand psychopathology and categorize disorders into a classification scheme. He suggested that the best way to establish diagnoses and diagnostic entities was to use observable behaviours and symptoms. - His followers developed a *classification system* liting disorders based solely on descripters or observable signs and behaviours, resulting in a *descriptive classification* system exemplified in the DSM. In the *20th c.* Frued proposed diagnostic entities that were based on presumed theoretically derived causes of the signs, symptoms and syndrome (incorporated presumed causes of disorders, rather than descriptors). This is reflected in the *Psychodynamic Diagnostic Manual* and is used in the US while the *Operationalized Psychodynamic Diagnostics* system in Europe. The main difference in these two perspectives is reflected in how the characteristics of psychopathology or maladjustment are viewed. - DSM views symptoms as the essences of the disorder, hence the focus on treatment is on the manifestation or the symtpom level - The psychdynamics focuses on the interplay of psychological and biological variables. The underlying process is thought to cause the existence of signs, symptoms, and syndromes.
Theory Development and the Diagnostic Classification Systems
In the context of well-defined disorders, models and theories of those disorders and psychopathology can be revised, abandoned, or new theories can be espoused.
Psychological Problems and Processes of Development
Most commonly focused on with children or adolescents. The clinicians have to pay attention to the presence/absence of meeting development milestones and the expectations of normal development. *Descriptive psychopathology* (popular in child clinical psychology) takes a developmental perspective
The Operationalized Psychodynamic Diagnosis
OPD-2 is a multiaxial system used in psychdynamic classification/diagnosis commonly used in Germany and other European countries uses 4 Axes to make diagnoses: 1. *Illness experience and treatment assumptions*, reflecting the patient's motivation and markers to evaluate appropriateness of psychodynamic treatment 2. *Interpersonal Relationships*, which focuses on the relationship schemas of an individual and how this can translate into transference and countertransference issues. 3. *Mental Conflicts*: seven basic conflicts 4. *Structure* reflects the degree of integration, the development of an autonomous self that exhibits psychological strength to tolerate conflict or stress.
International Classification of Diseases (ICD-10)
One of the first formal classification systems that included psychological disorders. - was originally developed to classify causes of death using a combination of different european systems. - most commonly used system for clinical work internationally. - developed by the WHO - provides a description of the clinical features of disorders and associated features of the disorder.
Psychological Problems and Processes of Thought/Cognition, Intellectual Functioning, and Information Processing
Paid close attention to by clinical psychologists - Involves thoughts/thought processes as well as intellectual functioning. With many forms of distress, psych. problems, and mental disorders (regardless of severity) compromise cognitive features. Problems with cognitive processing and intellectual functioning are often seen in many neuropsychological issues involving brain damage and other disorders.
Psychological Problems and Processes of Perception
Perceptual processes involve cognitive processes that give rise to perceptual experiences. - In the severe range of psychopathology, perceptual difficulties are important indicators of psychopathology. - At less extreme levels, individuals respond to others based on inaccurate perceptions or they perceive the world as hostile, dangerous, or depressing,
Psychological Problems: What Processes Are Affected
Psychopathology can be thought to be problems/difficulties that affect numerous processes in people's functioning - In some cases, the amalgamation of the behaviours can reflect problems in a person's personality, whereas in others the problems may be seen outside of/separate from the person's personality - Not all clinical psychologists will place a great emphasis on personality, but personality variables are the key features for assessment treatment and research
Diagnostic Classification Systems
Represent current conceptualizations of psychopathology and provide a means by which clinical and psychologists can define/identify psychological disorders. *classification systems* are a basic part of scientific attempts to understand the nature of areas of inquiry and these classification systems (*nosologies*) attempt to make information meaningful, accessible, and less cumbersome - always under revision
3 Major Approaches ti Defining Psychological Problems
Statistical/Normative Approach - a judgement is made whether a person's behaviour conforms to the standards, expectations, and norms of a particular society/social group. - If a person's behaviour falls outside of the norm, that person's behaviour is considered to be abnormal, problematic, and in need of amelioration. - This approaches defines a large portion of individuals exhibit psychological problems and can benefit from treatment, however it fails to include cultural considerations and people who fall outside the norm but are neither problematic nor maladjusted. Subjective Interpretation (Psychological Pain) - individuals make judgments as to whether their own behaviour is abnormal, maladjusted, or in need of changing - the individual can then make a judgment of whether a behaviour that is considered normal within the social group is in fact abnormal/maladaptive to themselves. - this approach is usually what bring the majority of patients to a therapists office. Judgments of Maladaptive Functioning - An expert makes a judgment as to whether a person's behaviour is abnormal or maladaptive. Usually based on whether the behaviour interferes with the patient's ability to work and or/maintain relationships. - Doesn't rely on statistical norms or the individuals discomfort to make a decision about abnormality/maladaptiveness. - The judgment is made based on the client's functioning within work and interpersonal relationships. - individuals may not agree with the expert's opinions and later choose not to seek help. - If forced into therapy, the client is more likely to be unmotivated and very difficult to work with in this context.
What is Normal Behaviour?
Super hard to define and is payed less attention to than abnormal behaviour. This leaves us with a weak understanding of normal or health personality. - Jourard first tried to conceptualize normal personality in terms of expression of values (eg. ability to meet/satisfy needs with behaviour that conforms to both the norms of a society and the requirements of a person's conscience) - Ryff proposed that 6 dimensions of psychological well-being: positive relationships, autonomy, personal grwth, self-accptance, purpose in life, and environmental mastery. The DSM is the only formal diagnostic manual that attempts to describe this
Current Conceptualizations of Psychopathology
The diagnostic schemes currently in use are good indicators of current views of psychopathology. - historically, the se views are rooted in the field of medicine (psychiatry) and set the standard for later defitnitions of mental disorders used by clinical psychologists ad other mental health professionals. Most commonly used Systems: - the International Classification of Disease (ICD-10), *Chapter V* - the Diagnostic and Statistical Manual (DSM-V) The PDM has also been published as a supplementary classification system complementary to the ICD or DSM because it incorporates etiological and/or causal components not found elsewhere
Descriptive Purpose of Diagnostic Classification Systems
The provide good descriptions of disorders so that the disorders and problems can be identified reliably and validly. - Knowing what does/doesn't constitute a particular disorder in order to do meaningful research and clinical work.
Mental Disorder
There is no generally agreed-upon definition of mental disorder. - Has various definitions depending on the society, theoretical orientation or the purpose for the need to define it. ICD: a disorder is normally thought of a term used to imply the existence of a clinically recognizable set of signs, symptoms or behaviours that produce distress or interference with personal functions DSM: no definition adequately specifies precise boundaries of the concept of mental disorder, a disorder generally constitutes a manifestation of behavioural, psychological, or biological dysfunction in an individual.
Is Homosexuality a Disorder?
Until the 1980's, homosexuality was considered to be a psychological disorder but in 1980, homosexuality was removed from the list of disorders within the APA's diagnositc manual. - It is a perfect example of how societal values can influence what is defined as abnormal and what is defined as abnormal is not necessarily static.
Epidemiological Purpose of Diagnostic Classification Systems
Vital in assessing increases/decreases in disorders in population. - It's important to keep track of changes in incidence/prevalence of different kinds of disorders.
Issues in Defining Psychological Problems
What is defined as abnormal does not always represent formal psychological disorders. - most problems that come to the attention of psychologists might be better labelled as *problems in living* rather than an actual diagnosis. - The majority of problems that clinical psychologists study, assess, and treat will meet diagnostic criteria for some disorder, they also deal with many problems that don't constitute a formal diagnosis - e.g. Relationship problems, personal difficulties, achievement problems, physical problems, problems that reflect normal but distressing processes. It's incorrect to assume that abnormal behaviour is entirely negative or pathological. Majority of the time, it's intertwined with a person's personality, relationships, and general environment. The abnormal behaviour could have been adaptive at one point in time.
Philosophical Underpinnings of Orientations to Psychopathology
Working from one of various theoretical orientations provides the clinical psychologist with a philosophical stance, tools, techniques, and skills in order to deal with particular clinical or research issues. - It involves the views of the nature of psychopathology, how people function normally, and how people function abnormally. - Adherence to a particular paradigm influences the actual work that will performed by a clinician
