Lecture 2: Assessment, Classification, and Treatment of Abnormal Behaviour Flashcards

Question

What is the difference between a "Disease Process" and "Clinical Syndromes"

Answer 1

- Strictly speaking, the term *disease* *process* is reserved for conditions with well understood cause and course. - established condition - Inherently medical view - Most mental disorders do not qualify as genuine disease processes, which doesn’t disqualify them as forms of illness. - They [mental disorders] are clinical pictures, or *syndromes.* - behave in a certain way that allows it to recognize it as a disease - does not have a known cause - group of symptoms - not the same as sth like an ulcer - eg if he tells you he has covid, that is a disease process and the symptoms are a manifestation of the immune system trying to get rid of it, we know the course of the disorder, what it is, ** - contrarily, most mental disorders don’t classify as disease processes

Answer 2

- **Features of the DSM** - Specific *diagnostic criteria* are used - those criteria are indicators of the disorder - subset call pathognomic indicators → sth that if it is present, you know what that disease is. - in psych there are very few pathognomic indicators - eg. sb having low mood could be depression, bipolar disorder, or schizophrenia → do not have adequate info to diagnose sb with one disorder - Abnormal behaviour patterns that share features are grouped together.

Answer 3

1. *Atheoretical* - Not tied to any one school of thought (eg. psychoanalysis, behaviourism) 2. *Descriptive* - What is observable in the patient’s presentation? - means we are not making a lot of inferences about things we can not observe - eg. if sb is crying we say their affect is low; can’t say their mood is low bc we don’t know 3. *Polythetic* (Flexibility re criteria) - Same condition can look subtly different - there is more than one way you can meet diagnostic criteria for a certain condition - not everybody that has that diagnosis is similar clinically 4. *Good interrater reliability* - Agreement between clinicians - what good is an instrument of this nature if we use it and draw different conclusions from each other

Answer 4

- *Validity (Construct)* - Can be inadvertently sacrificed in the interests of maximizing reliability. - *Realism vs. Instrumentalism* - in the interests of trying to simplify and pixilize it (break it into its components), the overall image becomes a little distorted - when this happened we say sth has suffered bc of instrumentalism - *Predictive validity* - Diagnosis tells you → Disease course, treatment options, and clinical outcomes (high predictive validity)

Answer 5

- *Dimensional* Rather Than *Categorical* (Hmmmm?) - when we say diagnosis is categorical we mean that ppl fit into 1 or more distinct taxons - eg. you’re depressed or not - all of nothing kind of thing - but not necessarily binary (1 thing) - dimensional is the opposite of categorical → to what degree do they match the person we would typically associate with the disorder - as a rule of thumb you seldom have to meet all the conditions → 1 reason is the same condition could present quite differently from one person to the next → 2nd thing is it could be a matter of degree → eg. the severity or presentation of the disorder may not be the same from one time to another → eg headaches → maybe muscular (tension headaches) → level of discomfort could vary from day to day - should be doubtful of the claim that it is completely dimensions now - Depends on the nature of the disorder - Reorganizing in a Developmental Lifespan Fashion - disorders that are more likely to be encountered early on in life, eg in childhood, tend to come before one’s that manifest later on - Criterion Changes and Replacement of DSM-IV Disorders With More Relevant Disorders - the conditions that have to be met in order to assign a diagnosis to sb have changed a little, and some conditions have been removed or conceptualized to be more relevant - eg. socially or politically motivated to be more relevant

Answer 6

- **Culture-Bound Syndromes:** patterns of psychological distress that are limited to one or only a few cultures. - by contrast there are things that occur almost universally, eg some forms of demensia - Example: **Tajinn-kyofu-sho** (TKS) is a common disorder seen in Japan, characterized by excessive fear that one will behave in embarrassing ways or offend other people. - almost like a social phobia but not quite

Answer 7

- **Culture-Bound Syndromes:** patterns of psychological distress that are limited to one or only a few cultures. - by contrast there are things that occur almost universally, eg some forms of demensia - Example: **Tajinn-kyofu-sho** (TKS) is a common disorder seen in Japan, characterized by excessive fear that one will behave in embarrassing ways or offend other people. - almost like a social phobia but not quite → What are the implications for inter-rater reliability? - The more conditions you have, the more you separate from each other in a fine-grained type of way, the greater the risk of making an error. - There are systematic differences also in terms of culture

Answer 8

- Clinical Psychologist - Psychiatrist - medical doctors who go on to do a specialization to spend additional time focusing on mental illness - Social Workers - clinical social worker → requires additional training and specialization (most social workers are not clinical social workers) - trained along a model more similar to clinical psychologists - takes their emphasis away from systems and on to the individual - Psychiatric Nurses - study and undertake an area of internship to become this - good at assisting treatment of mentally ill individuals but were not fully-registered nurses who could get a job in an intensive care unit or in a surgical unit → their training was quite specific - Family Physicians * - aren’t specifically trained to deal with mental illness - these are the folks that provide the most services, by and large, - eg. if an individual tells you they are on an antidepression medication or a younger individual placed on ADHD meds or adult, the overwhelming majority of ppl have had that given to them by a family physician and not a specialist. → The above all require professional registration (liscensure) → aka a college that protects the public through verification and through making sure they are operating in a skilled and professional manner and work within a legislatively defined *scope of practice* (a list of activities your profession allows you to do, eg. family doctor can’t do open-heart surgery) - college trusts them to practice conscientiously and is not always looking over their shoulder - if you get a compliant from the public to the college director, consequences can be serious: liscense suspension, criminal trial. - are all part of a regulatory body - Bill 30 (The Mental Health Services Protection Act) received Royal Assent in December 2018. - essentially a restatement by gov’t that the ppl provide services of this nature must be confident → credentials necessary are clearly indicated and there is no way around that

Answer 9

→ The above all require professional registration (liscensure) → aka a college that protects the public through verification and through making sure they are operating in a skilled and professional manner and work within a legislatively defined *scope of practice* (a list of activities your profession allows you to do, eg. family doctor can’t do open-heart surgery) - college trusts them to practice conscientiously and is not always looking over their shoulder - if you get a compliant from the public to the college director, consequences can be serious: liscense suspension, criminal trial. - are all part of a regulatory body - Bill 30 (The Mental Health Services Protection Act) received Royal Assent in December 2018. - essentially a restatement by gov’t that the ppl provide services of this nature must be confident → credentials necessary are clearly indicated and there is no way around that

Answer 10

- **Medication** - psychologists in Canada do not prescribe medications - there are some psychologists in the US who have done a masters and can prescribe some medications on a formulae - eg. pharmacists are able prescribe now too - prescribing in alberta would be a way to reduce costs → bc psychologists don’t bill the gov’t directly → so could save money if they were prescribing - there are also places where psychiatrists are not available so might be useful for psychologists in Alberta to be able to prescribe mental health meds - **Electroconvulsive therapy** - exclusively used for cases of extreme depression that had not benefited from other forms of therapy - electrodes on top a person’s head, shock is given - idea is to induce a convulsion → neurological event that is an outward sign of the body twitching a lot → in these days when ppl are given ECTs they’re given short-acting muscle relaxants and are usually sedated, so not an awful lot of convulsive reaction to it - a short shock is delivered to product the seizure - **Psychosurgery** - making physical alterations to the brain, usually by cutting certain areas - not a lot of that - prefrontal lobotomies → were done and are still done, not for psychiatric reasons, and done quite rarely, to prevent communication of neural activity from one region to another - eg. ppl with epilepsy will sometimes undergo this - **Deep brain stimulation**

Answer 11

- Involves implanting electrodes within the part of the brain that affects mood. - During deep brain stimulation, electrical impulses transmitted through the electrodes deep within the brain affect brain cells and chemicals to relieve depression. - The amount of stimulation delivered by the electrodes is controlled by a pacemaker-like device placed under the skin in the upper chest. - A wire that travels under the skin connects the device, called a *pulse* *generator,* to the electrodes in the brain. - Is approved for other conditions, but not for depression by the US Food and Drug Administration (FDA). - It’s still being studied as an experimental treatment. - Deep brain stimulation is an established treatment for essential tremor and Parkinson’s disease. - Some ppl with Parkinson’s who underwent deep brain stimulation reported an improved mood. - Bc of those results, deep brain stimulation is being studies as a possible depression treatment to be used when standard treatments don’t work. Eg. antidepressants, psychological counselling, and electroconvulsive therapy. - Sending electrical impulses to areas of the brain linked with mood affects brain cells and brain chemistry. - Can help ease depression symptoms, but researchers are still investigating exactly how deep brain stimulation improves mood.

Answer 12

- Psychodynamic Therapies - Free association - technique used as a result of Freud’s belief that the contents of the unconscious, which is where a lot of this conflict that results in psychiatrically distressing symptoms arise. - idea is that if you ask a person to respond quickly and without much editing, censorship, then they tell you immediately, the idea is that their response will give you some clues as to what that deep content is that would not emerge otherwise bc it would be deeply censored by the superego. - Transference - a defence mechanism - idea is that you develop a relationship which a person such that they behave toward you as the therapist in a manner that is analogous or similar to a way that they behaved with some other significant figure in their life, specifically a figure with whom there was some sort of unresolved conflict (parent, brother, mother) - you deliberately are trying to create a “transference neurosis” → according to Freud and this followers, the establishment of that transference neurosis is a necessary condition for successful treatment -- Freud found that clients responded to him not only as an individual but also in ways that reflected their feelings and attitudes toward other important people in their lives. - A young female client might respond to him as a father figure, transferring, in an act of displacement, onto Freud her feelings toward her own father. - Displacement - in psychodynamic theory, a type of defence mechanism that involves the transferring of impulses toward threatening or unacceptable objects onto more acceptable or safer objects. - **Transference relationship** - in psychoanalysis, a client’s transfer, or generalization to the analyst, of feelings and attitudes the client holds toward important figures in their life. - the process of analyzing and working through the transference relationship is considered an essential component of psychoanalysis. - Freud believed that the transference relationship provides a vehicle for the re-enactment of childhood conflicts with parents. - Freud termed the enactment of these childhood conflicts the *transference* *neurosis*. - This “neurosis” had to be successfully analzyed and worked through for clients to succeeed in psychoanalysis. - The analyst helps the client recognize transference relationships, especially the therapy transference, and to work through the residues of childhood feelings and conflicts that lead to self-defeating behaviour in the present. - Transference is a two-way street: countertransference - the transfer of feelings that the analyst holds toward other persons in their life onto the client. - most ppl who use the word transference today use it quite differently: saying you’re taking this out on me in certain way, I wonder if this is coming from somewhere else . - eg projection - Modern Psychodynamic Approaches - departs from Freud’s original approach yet some of the language stays with it - vocabularly is one we continue to use even if we use it quite differently Like the older Freudian psychoanalysis, the newer psychodynamic approaches aim to uncover unconscious motives and break down resistances and psychological defences, yet they focus more on the client’s present relationships and encourage the client to make adaptive behaviour changes.

Answer 13

- Behaviour Therapy - Our basic unit of analysis is what the person actually does, including a person’s self-report of their behaviour - we target those behaviours directly → chances are if we can remediate some of these symptoms and signs a person is showing, they’re going to subjectively also report a significant sense of relief. - Systematic desensitization - used for the treatment of phobias, specifically. - you start with a series of approximations to a phobia - eg a very simple line drawing of a spider held at a distance, it coudl be a little fuzzy plush toy of a spider - but before you do that you come up with 2 things: (1) a series of relaxation exercises that will help the person to restore their sense of calm and control (muscle relaxation, deep breathing etc); (2) a list, a hierarchy of things that are ordered in terms of how threatening they are (eg. having a tarantula sit on your hand might be the top of the list, a little cartoony drawing of a spider held at a distance may be on the bottom of your list) - you go slowly up the list, and expose the individual to these things using those relaxation techniques and when and only they have a sense of being able to calm themselves in the presence of that stimuli, do we give them the next thing in the hierarchy. - Gradual exposure - similar to systematic desensitization but it is instead a matter of degree - quantitative instead of qualitative - Token economies - things like money - or in a psychiatric unit, where you can’t be dispensing things like candy or other forms of reward constantly, patients are asked to target certain behaviours, usually in the direction of reducing them, but it could be increasing them will be given some kind of recognition, like a stamp or check mark whenever that behaviour is properly executed. - When they have accumulated enough of them they can be exchanged for a primary reinforcer like an hour with a tv set, time in the gym, chocolate bar - Modelling - demonstrating skills you want a patient to show - can greatly speed the rate to which they acquire that themselves -- after observing the model, the client may be assisted or guided by the therapist or the model in performing the target behaviour. - the client receives ample reinforcement from the therapist for each attempt. - pioneered by Albert Bandura.

Answer 14

- Person-centred therapy (Carl Rogers) - is not person-centred in the sense that he dramatically changed the techniques he was using; it was person-centred in that the client brought to the table whatever they need, in that the focus was on them and not the therapist’s expertise. - Emotion-focused therapy (Greenberg) → both of these techniques emphasize finding a very warm, very accepting and safe environment - underlying assumption in both cases is if you do that, and you provide the person with a space they need to verbally externalize some of the concerns they have, they will discuss them with you and will have a natural tendency to engage in self remediating behaviours and thoughts of doing that.

Answer 15

- Ellis’ Rational Emotive Therapy - more cognitive - based in logical discourse → eg. you think you are undesirable socially because blah blah blah, let’s just look at the logic of that. - therapists actively dispute irrational beliefs and their premises and help clients develop more rational, adaptive beliefs. - Beck’s Cognitive Therapy - grandfather of these things encourage clients to recognize and change errors in their thinking - >cognitive distortions → that affect their moods and impair their behaviour - collaborative empiricism -> more gentle and collaborative - he was very much a scientist and challenged patients to come up with a hypothesis: eg. “well, if it’s true that nobody likes you, let’s test that hypothesis.” - gave patients assignments to carry out between their next meeting eg. asking somebody to go out for coffee, asking their boss for a raise (provided we have given them adequate skills to do that in a way that has a chance of being successful) → come back and let us know how that went → in many cases it is not the person’s actual history that is hindering them from moving forward, but the beliefs or the interpretation they have about that. - Meichenbaum’s Cognitive-Behavioural Therapy - more behaviour-part of things - ntegrate therapeutic techniques that focus not only on making overt behavioural changes but also changing dysfunctional thoughts and cognitions. - draws on assumptions that cognitions and information processing play important roles in the genesis and maintenance of maladaptive behaviour.

Answer 16

- More on a continuum, and multilevelled though individual, family and community. - - Mental wellness as balance of physical, mental, emotional, spiritual - Mental wellness as a continuum - Mental wellness as multilevelled: individual, family, community

Answer 17

- Nonspecific Factors - Are the benefits of psychotherapy due to nonspecific factors that various psychotherapists share in common, such as the mobilization of hope, the attention and support provided by the therapist, and the development of a good working *alliance* between the client and therapist? It appears that both specific and nonspecific factors are involved in accounting for therapeutic change. - the quality of a *working* *alliance*/*therapeutic* *alliance* is one of the single, strongest predictors - it reflects things like commonality, purpose, clarity, communication → is the person able to establish and instill a sense of optimism in the patient, does the patient feel they are being adequately heard and that their concerns are being adequately incorporated into the treatment plans. - The variable that stands out more than any other as important to successful psychotherapy is the quality of *therapeutic alliance.* - Correlation with outcome is typically in the range of 0.20. - it is the one that stands out the most among the broad other ones - Describes virtually all aspects of the relationship between client and therapist.

Answer 18

- Civil Commitment (Psychiatric Commitment) - Mental Health Act — Form 1, 8, 10 - form 1 → for involuntary certification: if a physician, psychiatrist, encounters an individual who is clearly mentally ill and poses an immediate danger to themselves or others that will not voluntarily seek psychiatric services, they can be involuntarily committed to a psychiatric hospital. - can be for a specific period of time: 48 hours, or longer if a second physician signs a certification - form 8 → a document that is filled out by a police officer, peace officer and gives them the authority to apprehend a person without arresting them and transfer them to a hospital for a formal examination. - when they are convinced that this individual is in need a psychiatric service, and they pose some sort of danger and risk it will be enacted - form 10 → similar to a form 8 but is issued by a judge. - an argument is made in court and the warrant is issued by a judge and it’s handed to a peace officer that then apprehends the individual - Having a mental disorder alone is not enough! - has to be some sort of adverse outcome that is then likely to occur in the event that it is not treated. - Patient must have a mental disorder or appear to be suffering from a mental disorder. - Patient likely to cause harm to themselves or others. - Unsuitable for admission to a facility other than as a *formal* *patient* - they won’t do it voluntarily.

Answer 19

- Legal Commitment (NCRMD: Not Criminally Responsible on Account of Mental Disorder) - someone who is accused of a crime, generally serious, however they were not in the right mind and did not have the capacity to form intent. - actus reas → to prove that they actually did it - mens rea → guilty mind → if it seems likely that your actions were motivated by significant psychiatric illness, then the finding of guilt might not take place → so not guilty in the legal sense - Clear evidence - Imminent Risk - Limited Time

Answer 20

- Community Treatment Orders (CTOs) - a bit like psychiatric probation - eg you’re an individual, maybe you had a NCRMD finding prior, however you’re not treated and you stabilize very well - the problem is, if you don’t comply with your treatment, either in the form of psychotherapy, medication, abstaining from street drugs, there is a relatively high risk that you will relapse and consequently pose a risk to yourself and others again - can then be released from a psychiatric facility under a community treatment order → means that if all the sudden you’re not showing up to see your doctor, the doctor can notify the police through the form, submit it to court and that will result in your apprehension and return to the psychiatric facility.

Answer 21

- Difficult bc of sth called the “Post hoc problem” → means we’re examining these people after we already know they have done sth. - when we are trying to predict risk we want to take some people before they’ve done anything wrong and determine what those risk factors are → much more complicated undertaking - Over-prediction of Dangerousness due to the Inaccurate Prediction in General. - occur at a very low rate, like homicide - but if we’re talking about juveniles who may get arrested for shoplifting, they tend to under-predict in that sense bc it has a high base rate associated with it. - Psychopathy: Psychopathy Checklist - a list of 20 items which can be scored 0, 1, 2 by the psychologist after meeting with the patient and doing a pretty comprehensive review of their psychiatric and criminal history - gives us a number from 0-40, indicating how closely they resemble the archetypical psychopath - psychopath - individual who is at a high risk of engaging in a variety of different criminal behaviours - the higher you are on that, the greater the risk that you will commit further things - is not a risk assessment, is a measure of the degree to which one resembles an archetypical psychopath. - does tend to predict subsequent criminality pretty well tho - The *Post Hoc* Problem - Leaping From the General to the Specific - we know a person is criminal in some broad sense and therefore we assume they’re going to be a murderer, child molester, and everything else. - sometimes offending tendencies can be quite specific. - Defining Dangerousness - more a legal issues than a psychological one - bears on the level of tolerance a court of society will have for some kind of misbehaviour - Based-Rate Problems: Rare Events are Difficult to Predict - eg. homicide vs shoplifting - when sb tells us they’re going to do sth dangerous in the form of a threat, we’ll act on it bc making a threat by itself may be criminally actionable - but reality is that most ppl who are planning to do nasty stuff don’t tell us - Unlikelihood of Disclosure of Direct Threats of Violence - Behaviour in the Community vs. Behaviour in the Hospital - someone is really motivated to get out of the hospital may display really good behaviour - but when they get into the stimulus environment, into the broader community, it inevitably carries more opportunities to offend and other complicating factors like the availability of street drugs, then all bets are off. - is why we tend to release ppl back into the community very gradually

Answer 22

**Legal Bases of the Insanity Defence** - The M’Naughten rule - Schizophrenic with paranoid feature - He killed Robert Drummen, secretary to PM - He was clearly paranoid and said they were doing everything they could to disrupt his safety, ability to make a living and peace of mind and felt the only way he could escape that was by shooting the wrong person. - people do not bear criminal responsibility if, by reason of a mental disease or defect, they either have no knowledge of their actions or are unable to tell right from wrong. - NGRI (not guilty by reason of insanity) - R. v. Swain (1991) - Has to do with whether or not a person is intoxicated at the time they committed the offence - for the most part, voluntary intoxication is not a viable defence against being held criminally accountable unless it puts you into a psychotic state or if you did not know you were taking the substance - eg sb slipped it into your drink - NCRMD (not criminally responsible on account of mental disorder) - if mens rea is not intact, then they can’t form intent - if can't appreciate the nature and wrongness of your actions at the time -> eg you're hallucinating Not Criminally Responsible Reform Act (2014)

Answer 23

**Unfit to stand trial if:** - Incapable of participating in their own defence - eg sb who is horribly paranoid and they believe that their lawyer is the devil or secretly in league with the prosecutor and is not acting in their best interests - will not cooperate with their lawyer, including not disclosing details of the alleged offense in a way that allows lawyers to do their job. - Can’t distinguish between pleas - they do not have a good appreciation of what it means to plead guilty vs not guilty even if they broadly understand that their saying in one case that the did it, and that they didn’t do it in another → they may not understand that those comments may have grave consequences for what happens to them after the fact legally. - Doesn’t understand the purpose of trial - Cannot communicate with counsel rationally or make critical decisions on counsel’s advice - if the counsel says “look, I don’t want you taking the stand bc you don’t come across very well rn, and if you scare the judge or jury this can go against you” and they insist on doing it anyway. - eg. Ted Kazinski, the unibomber. - Is unable to take the stand to testify - so incoherent or frightened or so disorganized they couldn’t give a clear testimony NOT CRIMINALLY RESPONSIBLE - NCRMD (not criminally responsible on account of mental disorder) - if mens rea is not intact, then they can’t form intent - mental conditions stop person from appreciating the nature and wrongfulness of one's actions - Not Criminally Responsible Reform Act (2014) - reconsidered the criteria under which people could be considered for an NCRMD defence

Answer 24

- - Duty to Warn (*Tarasoff* ruling) - Tarosoff case → Tatiana Tarasoff at uni of California and Rosenjeet Poudar → he developed a hyperfixation on Tatiana after taking some folkloric dancing with them → they briefly dated but it was clear to Ms. Tarasoff early on that she didn’t want to pursue this relationship - but he wasn’t having it → he wasn’t letting it go → admitted to his psychologist that the was planning to kill her as a result of her rejection of his romantic interests → psychologist was duly concerned about that → phoned campus security and consulted with his supervisor → he was shut down and told to let it go and not to bother people anymore → Mr. Poudar did what he said he was going to do and fatally stabbed her. - The investigation was centred around who had the responsibility to tell her - The psychologist had informed the police, but did not have the ability to contact Ms. Tarasoff directly - FINDING: if you as a mental health professional receive a threat to a third party, not only do you tell the police, but you must try to tell that person against whom the threat is made bc even if the campus police had not taken the threat seriously, presumably she may have acted in a way to protect herself or her apartment, had that information been made available.

Lecture 2: Assessment, Classification, and Treatment of Abnormal Behaviour Flashcards

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