Models of Mental Disorders, Historical Perspectives and Classification Issues Flashcards Preview

Psychology L3 - Mental Disorders > Models of Mental Disorders, Historical Perspectives and Classification Issues > Flashcards

Flashcards in Models of Mental Disorders, Historical Perspectives and Classification Issues Deck (45):

What do we need to do to understand mental disorders?

Need to examine the contribution of several perspectives

These perspectives are crucially involved in the definitions and approaches towards treatment and etiology


What are the different perspectives?

- sociological / historical factors

Philosophical Foundations
- mind / body problem

Scientific Paradigms
- medical / psychological / social models


Whiteford et al (2013) - Global Burden of Disease Study

- used data from the Global Burden of Diseases, Injuries and Risk Factors Study 2010

- estimated the burden of disease attributable to mental and substance use disorders

- worldwide, mental and substance use disorders accounted for 183.9 million disability-adjusted life years OR 7.4% of total disease burden in 2010

- overall, mental and substance use disorders were the 5th leading disorder category of global disability-adjusted life years

- depressive disorders, anxiety disorders, drug use and then alcohol use disorders


Merikangas et al (2009)

- reviewed the magnitude of mental disorders in children and adolescents from recent community surveys across the world

- a lot of substantial variation in results depending upon the methodological characteristics

- BUT the findings converge in demonstrating that approximately one fourth of youth experience a mental disorder during the past year and about one third across their lifetime

- anxiety disorders - most frequent condition in children
- then behaviour, mood and then substance use

- variation in rates - methodologies & true cultural differences

- Girls - greater rates of mood and anxiety
- Boys - greater rates of behaviour
- Equal ratio for substance use

- ADHD and anxiety states begin in childhood

- Conduct disorders occur in early adolescence

- Mood disorders tend to begin in late adolescence


Historical Perspective

Past - mental disorders = a social label

- characteristics / symptoms have been known throughout history
- e.g. term 'schizophrenia' is relatively new
- only found its way in textbooks at the end of the 19th C
- symptoms have been described as early as 460 BC

Hippocrates (1737) - syndrome called 'stupiditas'
- "The ill person often weeps without reason....he is frightened with reason.....he takes interest in subjects of which he is obviously ignorant....often in things which only interests scholars.....sometimes he sees images as if in dreams..."


Historical Perspective - Melancholia

One of the cardinal forms of madness in earlier times

- name and concept encapsulates the whole history of humoralism
- Melancholia - is black bile
- one of the four humor recognised in Hipporcatic and Galenic medicine


Historical Perspective - Pre and Enlightenment period

Middle ages / prior to Enlightenment
- mentally ill patients were contained to jails

E.g. Bedlam hospitals - people would pay money to visit and observe the mentally ill patients

17th and 18th C - Pinel and Esqurial
- liberated the insane from their chains
- 'traitement morale' - treatment thought empathy and care

Enlightenment - start of the introduction of new scientific methods and novel methods

Until recently, there were some strange and quite unscientific methods


Historical Perspective - Egas Moniz

- developed the method of the 'lobotomy'
- neurological procedure
- consists of cutting or scraping away most of the connections to and from the PRC, the anterior part of the frontal lobes of the brain
- LATER emerged that this resulted in the loss of some important functions
- quite profound consequences - poor way of treating patients now
- at the time, this was viewed quite differently.....


Historical Perspective - 19th C

There was a big debate between proponents of the somatic approach vs psychological approach to psychiatric disorders


Historical Perspective - Somatic vs Psychological Approach


- "psychological disorders are brain disorders"

- mental illness are brain disorders / diseases

- remembered for initiating reforms in treatments for mentally ill P's as well as introducing changes to the existing asylum system

- said you should integrate P's into society and that ST hospitalisation should be combined with close cooperation of natural support systems


Historical Perspective - Somatic vs Psychological Approach


- emergence of the first classification systems

- grouped diseases together based on classification of common patterns of symptoms over time, rather than just be major symptoms


Historical Perspective - Somatic vs Psychological Approach


- psychoanalysis and psychiatry
- started off as a neurophysiologist - wanted to look at the neurobiology behind it all
- said that neurology of the brain was not enough
- talked about unconscious motivations etc


Historical Perspective - Somatic vs Psychological Approach


- descriptive psychopathology

- was not satisfied with the popular understanding of mental illness which lead to him questioning both the diagnostic criteria and methods of clinical psychiatry

- believed that symptoms should be diagnosed more by their form rather than by their content

- e.g. hallucinations - should focus more on the form i.e. the fact that the person is experiencing visual phenomena when no sensory stimuli accounts for the it rather than what the P is actually seeing (the content)


History of Psychiatry

- over the 19th - 21st C, the direction of psychiatry has switched between organic and psychological perspectives


What are the different models of Mental Disorders?

- Sociological Approaches
- Medical Model
- Psychological Approaches


Sociological Approaches

- highlighted in the diagnoses - profound cultural factors that take display
- historical and social conventions

a) Coming and going of diagnostic categories e.g. fugue, catatonia and hysteria
- these factors suggest that not all mental disorder represent 'natural' entities
- disorders that experience wide shifts in terms of prevalence, e.g. eating disorders, ADHD

b) Diagnostic procedures are not always 'objective'
- e.g. on being sane in insane places, political use of psychiatric diagnosis, homosexuality

c) Social factors have an important contribution towards incidence
- e.g. depression and schizophrenia
- powerfully constrained by social and cultural factors

d) The problem of labelling and stigma
- e.g. incidence of schizophrenia - ratings - not related / correlated


Sociological Approaches - Thomas Szasz (1960)

'The Myth of Mental Illness'

- "mental illness, of course, it not literally a 'thing' - or physical object - and hence it can 'exist' only in the same sort of way in which other theoretical concepts exist"

For Szasz, disease = something people 'have' AND behaviour = what people 'do'

- diseases are "malfunctions of the human body, of the heart, the liver, the kidney, the brain" while "no behaviour or misbehaviour is a disease or can be a disease"

- by calling certain people 'diseased', you are giving them a pure label

- psychiatry attempts to deny / deprive people of their responsibility as moral agents in order to better control them -> danger of SELF-FULFILLING prophecy!


Medical Model

Opposite of sociological approach?

- "when distress or inappropriate behaviour is thought to be a consequence of a bodily dysfunction, it is called a 'disease'"

Medicine - a disease is normally diagnosed based on bodily dysfunction

Doctors - can perform lab tests, do body imaging, take medical history, do physical exams etc

Once a disease is diagnosed, the doctor generally knows the case, how the disease is likely to run its course and the appropriate treatment to take
- doesn't really apply to mental disorders though!


Medical Model - Mental Disorders?

- mental disorders reflect categorical entities which can be objectively studied and defined

- each category has a unique set of symptoms which define the 'entity'

- there are clear biological / pathophysiological processes


Clinical psychology - what kind of model so they adopt?

Does not endorse a 'disease' model

- a-theoretical in regards to causation
- dimensional approach towards definition (varying degree)
- eclectic in treatment approaches


Concept of Disorder in Clinical Psychology

Characterised through statistical approaches and through the violation of social norms

- however these are not really sufficient!!!!
- people experience fluctuations in mood all the time!!!


Positive aspects of mental disorders

Symptoms - obstacles towards growth and development

Less emphasis on the concepts of 'disorder' and 'disease' as opposed to the potential for growth and self-actualisation


Defining Mental Disorders - Wakefield's Concept of Harmful Dysfunction

There are 2 main notions

1. HARMFUL - value term
- judged negative by sociocultural standards
- social and cultural norms determined whether something can be seen as useful for some

2. DYSFUNCTION - scientific factual term
- refers to the failure of an internal mechanism to perform one of its naturally selected functions


Defining Mental Disorders - Wakefield

Felt that 'disorder' was a hybrid concept comprising a factual and value concept

- factual concept - specifies what has gone wrong
- value component - specifies the resultant harm

A harmful condition however is NOT a disorder unless it involves a failure of a psychobiological mechanism to perform its natural function

Identifying the natural function of a psychobiological trait requires that one identify the evolutionary 'purpose' that explains its existence

E.g. heart attack - an example of dysfunction because the heart was fashioned by evolutionary processes to circulate blood throughout the body


Diathesis (Vulnerability) Stress Model

A predisposition to a given disorder (diathesis) that combines with environmental stressors to trigger a psychological disorder

Underlying vulnerability - can be expresses in many ways


Bio-psycho-social Model

Takes into account predispositions, personal experiences and life circumstances

Environmental triggers? & genetic influences?
--> e.g. genetic factors and smoking a certain types of cannabis leading to the development of psychosis?


Mental Disorders and the Mind / Body Problem


Cartesian Duality: Matter-Mind


Physicalism - Matter > Mind
Idealism - Matter Matter and Mind


Classification Systems - DSM

Diagnostic and Statistical Manual of Mental Disorders

- now onto the 5th revision, DSM-V (2013)
- the standard classification of mental disorders used by mental health professionals in the US
- standardised classification
- well-used
- intended to be applicable in a wide array of contexts
- used by clinicians and researchers of many different orientations (e.g. biological, psychodynamic, cognitive, behavioural, interpersonal, family / systems)


Classification Systems - ICD

International Classification of Diseases

- now onto the 10th revision, ICD-10
- simply a descriptive system
- groups systems together and combines them into a meaningful construct
- the standard diagnostic for epidemiology, health management and clinical purposes
- this includes the analysis of the general health situation of population groups
- used to monitor the incidence and prevalence of diseases and other health problems


Classification Systems

BOTH diagnostic systems are a-theoretical regarding the underlying causes of the disorder!


Definition of Disorder in DSM

A - clinically significant behavioural or psychological syndrome or pattern that occurs in an individual

B - associated with present distress (e.g. a painful symptom) or disability (i.e. impairment in one or more important areas of functioning) or with a significantly increased risk of suffering, death, pain, disability or an important loss of freedom

C - must not be merely an expectable & culturally sanctioned response to a particular event (e.g. the death of a loved one)

D - a manifestation of a behavioural, psychological or biological dysfunction in the individual

E - neither deviant behaviour (e.g. political, religious or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual

Other considerations:

F - no definition adequately specifies precise boundaries for the concept of 'mental disorder'

G - the concept of mental disorder (like many other concepts in medicine & science) lacks a consistent operational definition that covers all situations


Definition of Disorder in ICD-10

"Disorder is not an exact term, but it is used here to imply the existence of a clinically recognised set of symptoms or behaviours associated in most cases with distress and with interference with personal functions"


DSM-V Major Categories

Neurodevelopmental Disorders
Schizophrenia Spectrum and Other Psychiatric Disorders
Bipolar & Related Disorders
Depressive Disorders
Anxiety Disorders
Obsessive-Compulsive and Related Disorders
Trauma- and Stressor-Realted Disorders
Dissociative Disorders
Somatic Symptom and Related Disorders
Feeding and Eating Disorders
Elimination Disorders
Sleep-Wake Disorders
Sexual Dysfunctions
Gender Dysphoria
Disruptive, Impulse-Control and Conduct Disorders
Substance-Related and Addictive Disorders
Neurocognitive Disorders
Personality Disorders
Paraphilic Disorders
Other Mental Disorders


Major Changes to the DSM-V

No more multiaxial assessment system
- previous versions used a system including 5 'axes' or dimensions for diagnostic and treatment purposes

New diagnoses
- Disruptive Mood Disregualtion Disorder & Hoarding Disorder

Revised Diagnoses
- Autism Spectrum Disorder and Post-Traumatic Stress Disorder

Disorders requiring further research
- Attenuated Psychosis Syndrome (a precursor to ScZ)


Disagreement with DSM?

Not universally regarded as the best system

Tom Insel (NIH Director) 2013
- weakness of DSM-V is its lack of validity
- DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure


Current Research Strategies - Problems with Current Diagnostic Categories

The validity of major diagnostic categories - continues to be debated

E.g. there is discussion concerning the 'at-risk syndrome' for ScZ in DSM-V

There is general agreement that mental disorders are likely to constitute heterogeneous syndromes - the heterogeneity impedes the identification of causative biological pathways


Current Research Strategies - Alternative / Complimentary Approaches

Focus on symptoms
(Deconstructing Schizophrenia) / Research Domain Criteria

Identification of Endophenotype / Biomarker

Developmental Perspectives / Early Intervention


Research Domain Criteria (RDoC)

- research framework for new ways of studying mental disorders

- integrates many levels of information (from genomics to self-report) to better understand basic dimensions of functioning underlying the full range of human behaviour from normal to abnormal

- conceptualises mental illnesses as brain disorders
- mental disorders = disorders of brain circuits
- study underlying brain circuits

Assumes that the dysfunction in neural circuits can be identified with the tools of clinical neuroscience - e.g. electrophysiology, functional neuro-imaging and new methods for quantifying connections in vivo

Also assumes that data from genetics and clinical neuroscience will yield bio-signatures that will enhance clinical symptoms and signs for clinical management


RDoC Framework

Consists of a matrix where the rows represent specified functional constructs (concepts representing a specified functional dimension of behaviour) characterised in aggregate by the genes, molecules, circuits etc used to measure it

Constructs are in turn grouped into higher-level domains of functioning

These constructs are reflected in contemporary knowledge about major systems of emotion, cognition, motivation and social behaviour

Currently, there are 5 domains in the RDoC matrix:
- Negative Valence Systems
- Positive Valence Systems
- Cognitive Systems
- Systems for Social Processes
- Arousal / Regulatory Systems


Current Research Strategies

Major research efforts to identify certain genes and how they relate to different disorders

Rapid progress in neuroscience and brain imaging
- result - close relationships between physiological parameters and changes in mental states

Trying to incorporate modern theories of how the brain works


What criteria does a biomarker need to fulfil to be an endophenotype?

- the endophenotype is associated with illness in the population

- the endophenotype is heritable

- the endophenotype is primarily state-independent

- within families, endophenotype and illness co-segregate


Gall (1825)

Pathophysiological processes of cognitive dysfunctions and symptoms were so far related to circumscribed alterations in anatomical and functional dysfunctions of certain brain regions

RESULT = close relationships between physiological parameters and changes in mental states

Challenges the dichotomy of 'mental' and 'physical' disorders?


Mental disorders are network dysfunctions?

The brain as a self-organising system?
- cognition and consciousness are the result of interactions between disturbed neuronal processes

- pathophysiology are the result of disturbed network dynamics - the physiology of disturbed function


Adolescence and Psychopathology

Adolescent brain - more plastic that it will ever be

- capable of remarkable adaptability in light of many social, physical, sexual and intellectual challenges that the developmental phase brings
- ALSO - peak time for clinical onset of most mental illness
- 1 in 5 adolescents have a mental illness that will persist into adulthood
- mental illnesses emerging before adulthood - impose a 10-fold higher cost that those that emerge later in life
- mental health costs are the highest single source of global economic burden in the world
- mood disorders - most likely to persist into adulthood


Youth Mental Health - a neglected topic?

Pat McGorry

- young people - have the most to lose
- mental heath field has not appreciated that the timing and pattern of mental ill-health impacts so strongly on young people

A key paradox of the developed world is that while material well-being & physical health have dramatically improved, the mental health of young people in transition from childhood to adulthood has been steadily declining over recent decades

Urgent need to seek out common risk factors, late and early neurodevelopmental processes, pathophysiologies and novel treatment strategies