Chapter 7 (Lecture)

Question 1

what is nosology?

Answer 1

The study of how medicine classifies illnesses

Question 2

Nosology classification methods

Answer 2

• one method of classification is by cause - often used for physical/medical illnesses, but difficult to use in mental health (due to lack of biomarkers)
• DSM concentrates on symptoms and clusters of symptoms (rather atypical in medicine)
• mental disorders are classified according to symptoms (the patterns of thoughts, moods, and behaviours) that people exhibit
• this is a descriptive or symptom-based approach: key assumption is that symptom typical of a particular disorder stem from the same underlying condition (or disorder) - this has been the approach since the DSM-III (1980)

Question 3

Symptom-based classification - two key issues that represent a challenge to this approach

Answer 3

two key issues that represent a challenge to this approach to classification include:
1. symptom overlap
2. heterogeneity

Question 4

What is Symptom Overlap?

Answer 4

some symptoms (like anhedonia) are common to many mental illness (like schizophrenia, MDD) - some are especially common (anxiety/tension)

Question 5

What is heterogeneity?

Answer 5

Individuals with the same diagnosis may display very different symptoms and present differently (wide variety of symptoms for each disorder)

• DSM criteria usually require only some of the noted criteria (MDD diagnosis based on 5/9 potential markers)

Question 6

Implications of symptom-based classification

Answer 6

1. symptom overlap - poses a challenge in discerning the dividing lines between different mental disorders (are the distinctions accurate or meaningful?)
   - may cause us to question definitions and distinctions between disorders
2. heterogeneity - diversity of presentations/behaviours/symptoms makes it difficult to explain behaviours and determine the best treatments
   - Diagnoses are short-hand (like a label) and sometimes approximate: given range of symptoms and variation, are these two cases or individuals experiencing the same disorder?

Question 7

OCD and PTSD are both similar and different

Answer 7

• distinct disorders, separate chapters in the DSM-5, different core symptoms that differ meaningfully
• some underlying similarities (anxiety, worry, fear)

Question 8

What is OCD?

Answer 8

OCD can be described as a manifestation of anxiety revolving around obsessive and intrusive thoughts
- widely misunderstood, partially due to media depictions

Two primary components:
1. Obsessions: disruptive, anxiety producing thoughts and/or mental images - uncontrollable thoughts - common themes related to contamination, sex, religion, precision violence, harm
2. Compulsions: repetitive actions or thoughts which are performed in order to help relieve anxieties stemming from obsessions - these could be repetitive cleaning, counting, checking on things
- when severe, can prevent individuals from completing normal routines, and can result in serious impairment

Question 9

7 types of obsessions + misc

Answer 9

1. Aggressive obsessions
   - fear might harm self or others
   - violent or horrific images
   - fear of blurting out insults
2. Contamination obsessions
   - concerns or disgust w bodily waste or secretions
   - excessive concern w environmental contamination
   - excessive concern w household items
   - excessive concerns w animals
   - concerned will get ill
3. Sexual obsessions
   - forbidden or perverse sexual thoughts, images, or impulses
   - content involves children or incest
   - content involves homosexuality
4. Somatic obsessions
   - concern with illness or disease
   - excessive concern w body part or aspect of appearance (body dysmorphia)
5. Religious obsessions
   - excess concern w right/wrong - morality
6. Obsession w need for symmetry or exactness
7. Hoarding/saving obsessions
8. Miscellaneous obsessions
   - need to know or remember
   - fear of saying certain things
   - fear of not saying just the right thing
   - fear of losing things
   - lucky and unlucky numbers
   - bothered by certain sounds

Question 10

6 compulsions + misc

Answer 10

1. cleaning/washing compulsions
   - excessive cleaning of things or cleaning self
2. checking compulsion
   - checking locks, stoves
   - checking that nothing terrible will happen
   - checking that did not make mistake
   - checking tied to somatic obsessions
3. Repeating rituals
   - rereading or rewriting
   - need to repeat routine activities (in and out door, up and down from chair)
4. Counting Compulsions
5. Ordering/Arranging Compulsions
6. Hoarding/Collecting Compulsions
7. Miscellaneous compulsions
   - mental rituals (other than checking/counting)
   - excessive list making
   - need to tell, ask, or confess

Question 11

OCD prevalence and tendencies

Answer 11

• estimated to affect 1-3% of US population
• OCD often thought as chronic (or persistent) - lasting throughout a person’s lifetime, rather than being episodic
• people with OCD may avoid people, places, things that trigger obsessive thoughts (avoidance is part of the disorder, similar to anxiety)

Question 12

What is PTSD?

Answer 12

Similar to OCD due to the intense sensations of anxiety and tension (but not the same at all)
- typically arises following a single traumatic event or repeated trauma over a period of weeks, months, or years (diverse route to emergence)
- these events involve experiencing or witnessing severe harm, injury, danger, or death
- symptoms brought on by trauma, including second-hand experience of trauma (a loved one experiencing trauma)
- we are familiar with combat-related PTSD, but accidents, abuse, and violent crime can also trigger PTSD (a wider range of experiences are now understood to be traumatic)

Question 13

PTSD Symptoms

Answer 13

• “dissociative” episodes (flashbacks, nightmares) associated with triggers
• nightmares
• negative moods
• sleep disruption
• constantly feeling tense
  Reliving trauma is a key component, which may bring on or intensify symptoms

Question 14

Similarities between OCD and PTSD

Answer 14

• anxiety (symptoms of worry or fear)
• attempts to avoid triggers (avoidance)
• OCD may also manifest following experiences of trauma (or may emerge independently)
• similar treatments for both: psychotherapy (CBT) and exposure-based therapies
• both are similar to anxiety, and were previously grouped within anxiety disorders in earlier DSM editions

Question 15

Differences between OCD and PTSD

Answer 15

• core features are distinct: obsessions and compulsions are very different experiences than “flashbacks”
• OCD is not always triggered by a traumatic incident

Question 16

Somatic Symptom and Illness Anxiety Disorder

Answer 16

• These two disorders involve concerns about one’s health, substantial anxiety, excessive worry, rumination (repetitive thinking or dwelling on negative feelings and distress) and avoidance

Somatic Symptom Disorder: describes individuals who have anxiety and/or a fixation on somatic symptoms such as headache and pain
- was previously “conversion disorder” (distress or internal conflict “converted” into physical dysfunction) before that “hysteria”
- people may or may not have a diagnosis for a physical illness that is causing their symptoms
- the diagnosis of this disorder is related to an “excessive and abnormal” psychological reaction to the physical symptoms

Illness Anxiety Disorder: this disorder is characterised by excessive worry about the possibility of becoming ill, previously known as hypochondriasis
- “easily alarmed about personal health status” may perform excessive health-related behaviours (checking for signs of illness)
- may extensively use health system, but concerns are rarely alleviated through care/visits, often feel medical assessments has been inadequate
- may be extra-sensitive to bodily sensations, including more likely to report side effects of medications

Question 17

Clinical Perspectives (positivist and constructivist)

Answer 17

Study of assumptions about knowledge are often based on two broad frameworks:

1. Positivist Framework: sees scientific knowledge as always improving, assumes that we can acquire concrete knowledge about a topic using technology and reason (THERE IS AN OBJECTIVE TRUTH)
2. Constructivist Perspective: sees knowledge as fluid and contextual. Our understanding of a phenomena is influenced by our social position and experiences. Our decisions about what to study and how we think about it are influenced by culture, politics, scientific trends, and other factors (“TRUTH” IS SUBJECTIVE, AND DEPENDENT UPON SOCIAL CONTEXT AND EXPERIENCE, AND WILL EVOLVE/CHANGE)

Question 18

Epistemology

Answer 18

The study or a theory of the nature and grounds of knowledge especially with reference to its limits and validity

• ways of looking at or knowing the world
• what counts as valid knowledge, as “truth”
• rules for knowing things about the world

Question 19

Positivism

Answer 19

• strongly associated with natural sciences (think physics)
• one reality/truth exists (there is an objective external reality)
• reality can be measured objectively and accurately
• concerned with verifiable observation and measurement, prediction and control
• assumptions reduce complexity and context - tends to fragment human experiences

Question 20

Positivism –> Post-positivism

Answer 20

• increased acknowledgement of (and ability to deal with) complexity/context
• increased recognition of social construction and subjectivity
• increased opposition to positivism and critiques from: feminist research, social justice research, indigenous ways of knowing and knowledge/perspectives

Question 21

Post-Positivism

Answer 21

• all observations is fallible and has error
• all theory is revisable
• still a goal to capture reality/truth but recognition that we can never really get there
• all scientists are biased but through transparency can approach the goal of objectivity

Question 22

constructivism

Answer 22

• all understanding is constructed by humans in social interaction with each other
• multiple meanings are possible
• aim: understanding these constructions and how they are produced (language, interactions, symbolism, structures)
• employing a social science perspective
• even science (or medicine) is cultural knowledge system, constantly evolving and subject to social influences

Question 23

Positivism and Constructivism’s view in relation to mental health

Answer 23

• positivism or post-positivism: mental illness is objective and concretely knowable, and its true nature will be discovered in the future, resolving debates about diagnosis and treatment
• constructivism: mental health and illness can only be understood in relation to social context, and what is agreed upon as truth today will change with time - and scientific consensus will be influenced by evolving evidence, socio-cultural forces, scientific trends, and changing research funding priorities

in the field of mental health:
- the constructivist or contingent nature of knowledge is evident in the evolving nature of diagnostic criteria and definitions of mental disorders in each new version of the DSm (disorders removed or redefined, new ones added, criteria revised)

This highlights how scientific understanding and medicine is not truly an objective “truth” but rather an evolving cultural system of knowledge

Question 24

Sex differences in OCD

Answer 24

males more affected in childhood
females slightly more affected in adulthood

Question 25

Debating OCD symptom dimensions - autogenous vs reactive AND core dimension model

Answer 25

Autogenous vs reactive symptoms model (internal vs external triggers): Autogenous symptoms: self-generated triggers (sexual or aggressive thoughts) Reactive symptoms: réponse to external stimuli (triggers regarding contamination or symmetry) Core dimension model: defines dimensions based on symptom theme - the focus or content of the obsessions and compulsion - allows for possibility of heterogeneity of symptoms, yet still identifies core or key dimensions in classification of OCD, two examples: 1. harm avoidance motivation (leads to checking believed to ensure safety, like checking smoke alarms or locks) 2. fear of incompleteness (actions or intentions have not been correctly achieved)

Question 26

Diagnostic criteria for PSTD include:

Answer 26

- direct or indirect experience of a traumatic event - two defining symptoms of PTSD include hyperarousal (being highly vigilant and alert) and re-experiencing of events related to the trauma

Question 27

PSTD and its dissociative subtype

Answer 27

Some people w PSTD experience dissociation Dissociation: psychobiological defence mechanism where normal integration of consciousness, memory, identity, perception, emotion, body representation, motor control and behaviour is disturbed - temporary psychological escape in times of extreme trauma or stress - symptoms of dissociation include: disengagement, emotional construction, depersonalisation (feeling outside own body), derealisation (feeling things around you are strange and unfamiliar), and identity dissociation - about 15-30% of people w PSTD experience symptoms of dissociation - they may be diagnosed with PTSD-DS (dissociative subtype) - there is research evidence supporting this distinction, including difference in duration and severity of the illness, differences in brain activity (imaging studies), and correlations with severity and type of trauma - also associated with greater disease severity, more comorbidities, and greater illness burden - it is thought that the severity of PSTD-DS is in part due to the cognitive impairment associated with dissociation

Question 28

Difficulties associated with dissociation and cognitive impairment of PTSD-DS include:

Answer 28

- lowered attention, memory, executive function - poorer social cognition - poorer treatment response (especially with exposure-based treatment)

Question 29

more on PTSD-DS

Answer 29

- some researchers do not believe that PTSD-DS is a meaningful distinction in diagnosis (little difference stemming from subtype) - and argue including the subtype in the DSM-5 was a mistake - some studies do NOT show differences in treatment outcomes when people with PTSD and PTSD-DS are compared Conclusion: current literature on effects of dissociative symptoms on treatment is inconsistent - so is it worth it to view it as a separate subtype, distinct from PTSD?

Question 30

Conceptual Issues

Answer 30

Typically the experience of a particular mental illness (and specific symptoms) predates the creation of a diagnostic category - later society tries to make meaning of the experience (primarily through medicine) and it is "named" (as a condition) - process of creating and formalising categories and classifications of illness is complex (and social): OCD and PTSD have a similar social trajectory as "disorders" Are the symptoms and components of OCD inherent to the human condition (having existed for a long time)? - some researchers say yes (and the it is only recently it has been named/classified as OCD), perhaps it was a form of "madness" before, or not seen as an illness at all (just eccentricity, within the normal range of behaviour)

Question 31

conceptual issues continued

Answer 31

- while our current cultural context influences our interpretation of these symptoms (re-conceptualizing them as particular disorders), an alternative view asks whether our social environment has changed in a fundamental way that has caused the emergence of new mental health disorders? - newly emerged conditions resulting from highly complex and rapidly changing society (social and environmental stressors) = unique social environment leads to truly new conditions and disorders - we can look at this debate through the social trajectory of PTSD: what are we seeing common or unique experiences of war and trauma over time - likely a combination of "timeless" symptoms and new phenomena resulting from changing social/political context

Question 32

"social trajectory" of a disorder

Answer 32

- story of how it "emerges" or comes to attention in society - is it considered treatable? - how it comes to be officially recognised (e.g., in the DSM) as a condition Often a contentious or disputed process - differing views and perspectives from those living with the condition and those in positions of authority (governments, clinicians) The way "combat-induced trauma" has evolved to be viewed differently now than it was in the Second World War provide an illustration of these processes

Question 33

The emergence of PSTD

Answer 33

War has been an enduring feature of human social life for millennia, but PTSD is a new diagnosis - why? - is war fundamentally different now than in the past? - consider how war and military service has evolved As a condition is legitimised or delegitimised as a diagnostic category, consider the role of various actors (patients, physicians, governments, militaries)

Question 34

WW1 - the emergence of PTSD

Answer 34

WW1 - understood as "shell shock", very broad range of symptoms with both biological and psychological explanations - military response: attempts to screen recruits and soldiers to root out those "predisposed" to shell shock - questioned whether they were truly sick or wounded (deserving of compensation and treatment, or not) - post-ww1: shell shock diagnosis declined, and was banned - militaries argued non-medical conditions were cause (cowardice, poor morale), enacting screening to reduce problems stemming from psychological weakness, setting up barriers to claiming compensation

Question 35

WW2 - emergence of PTSD

Answer 35

WW2: combat neurosis and battle exhaustion diagnoses Explanation: even healthy individuals could break down under stress of war - symptoms: restlessness, irritability, aggression, fatigue, sleep difficulties, anxiety rather than the tremors, blindness, and paralysis of shell shock - military response: quick attention to problems, rest, and return to duty Post-WW2: some former soldiers received compensation for psychiatric injury, but American psychiatry relied on psychoanalysis which located problems in ex-soldiers childhood experiences instead of combat related stress/trauma - subsequently combat neurosis diagnoses decline

Question 36

1960s Vietnam War

Answer 36

Emerging understanding of the effects of trauma - but the lack of a diagnostic category made accessing treatment difficult - as the war grew more unpopular, veterans became sympathetic figures, illustrating that conditions in the war were producing mental health problems (a changed understanding) - DSM-II did not have a diagnostic related to combat trauma: resulting in a lack of access to mental healthcare for ex-soldiers

Question 37

Addition of PTSD to DSM-III in 1980

Answer 37

- advocacy led to inclusion of PTSD in DSM-III in 1980 partially due to demands that the APA recognise suffering and illness related combat - cause was attributed to the experience of war, (being inherently insanity provoking or distressing) not the characteristics of the individual - flashbacks and dissociative episodes recognised as new and key symptoms - soon, a range of traumatic event other than war were understood to be causes of PTSD

Question 38

The emergence of PTSD - Initially understood

Answer 38

Initially understood in relation to extreme stressors such military combat, rape, severe assault, and natural or manmade disasters Has evolved to include hearing hate speech, learning of a relatives death, or watching a catastrophe unfold on TV The latter are unfortunately relatively common in recent decades

Question 39

Conclusion

Answer 39

- debates related to OCD and PTSD: previously grouped together with "anxiety" disorders, changes provoked debates related to nosology and diagnosis - debates about subtypes: heterogeneity raises questions about boundaries of diagnosis and disorders - are they all one condition or are they different, this brings us to questions of positivism and constructivism - the idea of the "social trajectory of a disorder": influence of social and political context in shaping medical definitions is extensive - all these points add to our understanding of the nature of mental health and illness

Question 40

heterogeneity

Answer 40

the fact that people who are diagnosed with the same disorder often exhibit different symptoms. - For instance, many people who share a diagnosis of schizophrenia may in fact behave quite differently

Question 41

executive function

Answer 41

Several cognitive processes related to organising thoughts, managing time, decision making, problem solving, and remembering details. These processes are important for goal-directed behaviour

Question 42

nosology

Answer 42

a branch or aspect of medicine concerned with how illnesses and diseases are classified and categorised

Question 43

depersonalisation

Answer 43

a feeling of being outside, or as if you do not belong to your own body may feel as if the world around them is a dream or somehow an altered reality

Question 44

derealization

Answer 44

a feeling as though things around you are strange or unfamiliar often feel detached from the events around them, as if they are not part of them