SOCI/HSOC 277: Exam 1
National Comorbidity Survey
national survey conducted in person in early 90s that studied non institutionalized people. Focused on 19 Axis I/focal disorders aka most common disorders. Led to Four Assumptions
normal sadness versus depression
normal sadness is not a disorder, but the DSM can conflate normal everyday suffering with MD
lifetime prevalence: older vs younger generations
older people actually have a lower lifetime prevalence than young people despite having lived longer, shows that MI prevalence is increasing over time
On Being Sane in Insane Places (Rosenhan) part one
part one: 8 fake patients into 12 different hospitals; told to complain of hearing voices upon admission and then act normally. None of the students were detected and stayed 19 days on average, released as "schizophrenic in remission" showing stickiness of labels. Only patients detected them. Also showed that the pseudopatients got psych symptoms from being there; felt powerless and depersonalized
genetic optimism
people are optimistic that finding the gene for an ailment gives hope for a cure; news stories emphasize that the gene exists, can be found in individuals, and will lead to a cure
mild disorders aren't important
prevalence is way too high.. nearly 50% is crazy treatment needs to be focused on those with serious issues note that high prevalence can cast public doubt on psych
medicalization
process by which non-medical problems become defined and treated as medical problems
which shows higher prevelence of MI: retrospective or prospective?
prospective. ask you what happened in the last year, and come back year after year to get lifetime prevalence. prevalence could be higher (it doubles!) bc you're asking people to remember less time so they won't forget as much critics say if you forgot it must've not been significant
what causes more sympathy: understanding the psychosocial causes of MI or the biological ones?
psychosocial; even clinicians showed lower empathy for biological caused situations than psychosocial ones.
renaissance and 17th century view of mental illness
renaissance: the mad had a gift of perception; seen as artists, valorized as unique perspective 17th century: mad were lacking reason, committing moral error, worthy of segregation
measuring depression
circle is disorder with arrows pointing to the boxes of symptoms; you don't need all symptoms to have diagnosis. A systemic measure of disorder
general definition of mental disorder as included in DSM IV
clinically significant behavioral or psychological syndrome or pattern that occurs in an individual that is associated with present distress or disability or with increased risk of suffering death, pain, loss of freedom -out to be associated with dysfunction and disability? (you could argue that many things are dysfunctional and you could also say that anxiety is evolutionary and depression could be a signal from the brain to look for ways out of a poor situation)
reliability
critical to DSM; the extend to which something we are measuring can be measured similarly at different times and between different people
example of vignette used for public opinion data
(name) is a (race)(man/woman) who has completed (education). They sniffed coke at party once with friends, and for the last few months, they have been snorting in binges that last several days. They lost weight and experience chills when binging. They spent their savings on cocaine. They tried stopping but can't and lost their job because they didn't show up. diagnosis: drug depedence
Four ongoing controversies in MI
-Categorical versus dimensional measures -conflation of normal sadness and depression -are mild disorders important? -the meaning of comorbidity
Causes of comorbidity
-brain: people with anxiety and mood disorders tend to share a hyperactive response to negative emotion/aversion in the amygdala -SNPs (single nucleotide polymorphisms) associated with a range of disorders like ADHD, autism, depression, schizo -genes don't discriminate, some disorders lead to other disorders, etc
dimensional measures
-like the RDoC -mental illness on continuum -each symptom can have its own level of severity -K10 histogram. most people are doing pretty well generally but it is hard to attach meaning
why we should distinguish normal sadness
-pathologizing normal conditions is harmful -distinction improves ability to make prognosis -accurate prevalence estimates -better estimates of need -avoids medicalization
basic characteristics of the DSM
-specific and discrete symptoms (lists) -duration criteria (need to not only experience symptoms, but for a finite period of time) -thresholds of illness (based on number of symptoms and the presence of key symptoms) -differential diagnosis (differentiate between different illnesses) -exclusions (bereavement, things that may produce symptoms of MI but shouldn't be regarded as such) -provides basic definitions of mental disorder
categorical measures
-specific and qualitatively distinct -you either have a MI or you don't -all psychiatrists can reach same assessment
graded nature of risk
-used to predict progression of mild disorders -if mild disorders were really insignificant, they would have an odds ratio of 1 -people with mild disorders shouldn't be at increased risk for negative outcomes (suicide, hospitalization) the study found that mild disorders still presented increased risk for all negative outcomes showing that mild disorders were indeed consequential and important
3 approaches to understanding meaning of genes
1. Genetic optimism 2. Genetic essentialism 3. A contigent approach
What are the four assumptions from the NCS
1. Mental illness is common 2. Many disorders are mild 3. Comorbidity is common 4. Treatment is uncommon but increasing
4 reasons for including bereavement
1. remove implication that bereavement lasts only 2 months when experts know its 1-2 years 2. Bereavement is recognized as a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual 3. BRD is more likely to occur in people with past personal/family history of depression. so if you exclude bereavement you're excluding those with fam history of issue 4. the depressive symptoms of BRD respond to same psych and drug treatment as normal depression
key changes in perceptions of metnal illness over 20th century
1950: more perception of psychosis, anxiety, and depression 1996: social deviance, mental retardation, and nonpsychosis. Over time our understanding has grown, thinking of more things like symptoms behaviors etc. As knowledge grows though there are now more things to stigmatize. our definition of mental illness is now broader
DSM I and II
1952/1968; heavily focused on psychodynamic speculation and childhood origins of mental disorder as well as unresolved conflict; discussions based just as much on what caused the symptoms as the symptoms themselves. NON SPECIFIC diagnostic material
DSM III
1980; much more symptom focused now over the DSM I/II; highly detailed and descriptive rather than etiological Theory neutrality was big: set aside psychodynamic theory or intuitions about about was caused the illness; we should be able to describe diagnosis entirely through symptoms allowed for common knowledge/reliability in assessment. Change from II (pamphlet) to III (thick book) was huge
beliefs about treatment
Americans support treatment, starting informally. Highest-lowest: Friends/family religious leader therapist self help group general doctor psychiatrist less common: natural healer, mental hospital
labels and dangerousness
At low levels of perceived dangerousness, the labeled line (of social distance) in the graph is lower than unlabeled. perhaps we give sympathy for MI at a certain point, it is a medical issue. However, at a certain higher level of dangerousness, the labeled line is higher than unlabeled. This means more dangerous percieved people have more social distance with the label than without.
pro including bereavement as disorder
DSM 5 included it because "evidence does not support separation of loss of loved one from other stressors" and that BRD seems related to SMD in that they both get better through therapy, sleep and persistence patterns are similiar
DSM in a survey
National Comorbidity Survey (NCS)
sensitivity
No false negatives; you will not miss any diagnosis of mental illness in your patients
specificity
No false positives (finding mental illness when there isn't one) premised on the idea that mental illness is rare
RDoC vs DSM
RDoC starts with science and moves backward rather than with symptoms and move forward, RDoC is dimensional while DSM is categorical. RDoC is mainly behavior and neuroscience, DSM fulfills aims of consistent diagnosis but not in seeking nature of MI
RDoC
Research Domain Criteria NIMH wnated a science guided metric for mental illness that was a good tool for research (unlike DSM) Dimensions nestled within 5 main domains of functioning
taxon
a group that differs from another group because of a natural thing; a non-arbitrary classification. psych disorders are hard to classify because they are not taxonic; it is also hard bc we only see symptoms
public opinion data on mental illness
The General Social Survey, people don't want to admit to being intolerant of the mentally ill! This is social desirability bias!`
comorbidity
The coexistence of two or more disorders -Same genes may underlie many psych disorders, are the genes truly discrete.. does one disorder cause another? -some say that comorbidity is caused by relationships among symptoms; that there are "bridge" symptoms common among psych disorders. One syndrome doesn't directly cause certain behaviors but the relationships among the disorders themselves -there are v few disorders with completely unique symptoms
assumption 4: treatment is uncommon but increasing
about 1 in 5 in NCS; went up to 17 in NCS-R (from early 2000s serious condition sufferers def increase in seeking treatment; in NCS it was only a quarter but NCS-R was up to 40 (which sounds great but that means that 60% of severe ill people aren't getting treated)
true prevalence
actual rate of disorder
criterion validity
assessment of the relationship between one measure and a different but related one that is valid Takes DSM and correlates it to another similar literature
why are the thresholds of mental illness in the DSM controversial
because when diagnosis is categorial and discrete, when you're either above or below the threshold to have a diagnosis.. that threshold/line is arbitrary. you can't make mental illness on par with physical and make acute diagnoses
network approach
bridge approach to comorbidity. symptoms should be networks or CLUSTERS. Comorbidity is a relationship between SYMPTOMS not DISORDERS NODES!! many different symptom pathways..
why is descriptive epidemiology of MI important
budget planning, health promotion programs, ID at risk populations, facilitate research, know approx how many americans are mentally ill
Type 2 errors
calling the healthy sick
Type I errors
calling the sick healthy
clinical prevalence
census of those being treated for mental disorder, issue is that it doesnt capture those who aren't getting treatment (barriers to care) can misrepresent what disorders are most prevalent bc people tend to get treated for some disorders over others
validity
degree to which an instrument measures what it is intended to measure. measured indirectly. DSM III was definitely more reliable but was it valid?
illnesses with high perceptions of violence
drug dependence is high harm to self AND others depression is low harm to others, high to self schizo is high in both (higher to self tho)
social construction
every culture has ideas about what abnormality is; we aren't indifferent to abnormality; we will always be socially constructing what mental illness is
bereavement
focal point of normal sadness controversy; the idea that people who have depressive symptoms as a result of grief will eventually get better while the person who has randomly brought on depression won't and will respond better to Prozac. Some argue that it doesn't matter what brought on depression
benefits of categorical over dimensional
for diagnosis, good for treatment, isn't perfect but is def useful, categories can create unity in a group. diagnostic decisions are categorical even if MI isn't
where did people tend to go for psych treatment (according to NCS/NCS-R)
general practitioners
contigent approach to genes
has different implications based on what disorder is being discussed. genetic arguments on depression tend to focus on its causes while those on schizophrenia are on its dangerousness. Genes may increase tolerance of somethings (depression) while decreasing tolerance of others (schizo)
genetic essentialism
idea is that genetic arguments not only make someone appear not responsible for their actions, it might actually INCREASE the stigma by emphasizing differentness and contagion within families they also increase seriousness. if something is seen as genetic, it is seen as more severe/consequential
negative valence domains
in RDoC, fear
positive valence domains
in RDoC, things that are ordinarily good but may turn bad like a positive motivation is good but can be impaired in mental illness
assumption 2: many disorders are mild
in the 26% 12 month prevalence of MI, 40% were mild. if you suffer from one disorder, it is likely mild. The most common MI are mild (anxiety is usually not severe)
On Being Sane in Insane Places part two
informed staff of set of hospitals that over 3 months, one or more pseudopatients would try to gain admission when in reality no fake patients were admitted. out of 193 people admitted that time, 41 were alleged to be fake by staff (19 by both staff and psychiatrist). Showed unreliability of diagnoses
face validity
instrument appears to measure what it is supposed to; most important for DSM
labels: they do a lot, but it's complex
labeling symptoms as a psych disorder fundamentally changes perceptions. they can make things worse or better (if you know someone is ill you may be more tolerant of their behavior, "cut them a break")
problems with diagnoses
limit information; confound the attributes of people (like their symptoms) with judgement about those attributes allows for professional dominance of psychiatry (DSM created business model where only limited group of professionals can diagnose people)
assumption 3: comorbidity is common
many people have multiple MI simultaneously; strong correlation with severity of MI and number of disorders, comorbidity is strong both in categories (ie within anxiety disorders) and out of categories. people can accumulate disorders in life
normal sadness
mild, proportionate to what's happening, and transient (goes away) real depression used to be regarded as sadness without cause
rise of genetic model
more informed public with more info, popularity of genetic arguments for traits are widely accepted as true, public accepts genes as facts of human nature
causes of mental illness as perceived by general american public
more so than 1950, 1996 survey showed Americans supported more genetic/chemical imbalance/neurobiological causes, and STRESS was biggest explanation. other causes: social, character, god's will
perceptions of violence in the mentally ill
more violent behavior is associated with mental illness now than before, we are tying mental illness and violence closer together now :( race/ethnicity/education did not sway perceptions of violence tho gender did (people fear men more)
dimensional spectrum
retardation to bipolar disorder certain disorders more related than others shows the symptoms that are related/shared with certain disorders rather than multiple comorbid disorders, a person gets a point on the spectrum
21st century view of mental illness
sees it much more as an illness with genetic causes, however stigma has not gone away. It has simply changed form.
US vs UK study
showed the unreliability of psych disorders (professionals coming to v different conclusions) -US psychiatrists tended to apply diagnosis of schizophrenia to a much wider variety of conditions than UK -Hospital diagnosis of schizophrenia in US was higher than its project diagnosis (hospital overdiagnosed) -London did better job at separating mood disorders from affective disorders as their hospital vs projects
Stigma
social distance is a great way to measure stigma.. Americans are more willing to befriend mentally ill but still likely to reject them. especially the closer/more personal they get (like marrying into the family)
which do psychiatrists tend to favor, specificity or sensitivity? why?
specificity. since specificity leads to no false positives. False positives are worse than false negatives because with false positives a huge chunk of healthy people get a diagnosis whereas with false negatives only a small portion of ill people get diagnosed as healthy
two notions of deviance
statistical notions: frequently occurring behaviors are normal, infrequently occurring behaviors are not. Mental illness ought to be rare ideal notions: judgements on what characteristics are good or bad regardless of prevalence; judgements about behavior we deem desirable or not (ex: we know depression is bad/deviant bc happiness is desirable)
discriminant validity
test whether one measure is unrelated to another it is supposed to be unrelated to
comorbidity controveries
the DSM doesn't draw clear distinction so there are too many "things" we can qualify for, and there is not a lot of discrimination in nature between different disorders
mild disorders are important
the definition of a case is not synonymous with the need for treatment, mild cases can lead to serious problems in the future; mild disorders still had higher rates of hospitalization, work disability, suicide attempt, etc than those without a diagnosis.. Psych disorders also tend to worsen with age
20th century view of mental illness
the mad are sick, we provide treatment but we have no real tolerance, still great deal of shunning and social distance
labels: they do nothing
the stigma is not surrounded on the label but on the behavior itself (like schizophrenia)
the public and theory neutrality
they don't stand for it. if you ask them to think about depression, certain symptoms will be elevated over others. more consistent with network approach. public seeks causal relationships among symptoms
assumption 1: mental illness is common
total lifetime prevalence of MI is 46, most common category is anxiety disorders
reification and its process
trying to make something concrete that is not in nature concrete Process: assess specific symptoms, split symptoms along arbitrary cut points, promote criteria as valid some say diagnoses are a reified measurement, based in artificial measurements and reduces information
vignettes
used to see people's perceptions of the mentally ill through providing stories of mentally ill people, varied the demographics so that that wouldn't affect their view of the person.. although how we perceive weakness in men/women differed
construct validity
using testable hypothesis
coercion into treatment
we believe treatment should be mandated/required and that people should be forced to be admitted to hospital if dangerous to self or others part of stigma
cycle of construction
what is mental illness? provide workable answer -> conduct research based on that answer -> get findings based on research, leading to -> what is mental illness, get workable answer its a cycle
involutional melancholia
what the DSM I called major depression