CLINICAL CHARACTERISTICS OF DISORDERS Clinical Characteristics Explanations & Treatments – Anxiety – Biological – Affective – Behavioural – Psychotic – Cognitive 1 Clinical Characteristics • Anxiety: Phobia • Affective: Depression • Psychotic: Schizophrenia Exam Style Questions January 2010 a) Describe the characteristics of a psychotic disorder. (10) b) Evaluate difficulties when identifying characteristics of psychological disorders. (15) June 2013 a) Describe the characteristics of one anxiety disorder. (10) b) To what extent is it valid to identify a disorder from a list of characteristic. (15) June 2014 a) Outline the characteristics of an affective disorder. (10) b) Asses the reliability of identifying a disorder from a list of characteristics. (15) 3 DSM-IV Affective (Mood) Bipolar Anxiety Psychotic OCD Paranoid Unipolar Phobia Residual Dysthamic PTSD Undifferentiated Cyclothamic GAD Catatonic 4 DSM-IV: Depression Essential feature of specific depression: ‘Depression is a low emotional state characterised by significant levels of sadness, lack of energy and poor self-worth, and feelings of guilt’ 5 6 Discussion Carousel: Depression Why do you think depression is known as the common cold of the mind? How is clinical depression different to feeling “down”? What are 3 symptoms you would associate with depression? Why do you think twice as many women as men are depressed? What could the individual do to alleviate their depression? What do you think causes depression? List as many reasons as you can. Do you think depression can be cured? If yes, suggest how. 7 Depression FACT SHEET CASE STUDY • Definition • William • Prevalence • Lewis • Symptoms • Tim • Types of depression • Kay 8 Diagnostic Criteria Under DSM-IVR, a diagnosis of depression requires the presence of a sad, depressed mood, plus 4 (from 8) other criteria including the following: • Physical/behavioural: Difficulty sleeping • Cognitive symptoms: Recurrent thoughts of death/suicide • Motivational: Loss of energy 9 WORD KEY WORDS DEPRESSION DEFINITION Is a condition where the prevailing emotional mood is distorted or inappropriate to the circumstances. Describes a medical condition characterised by severely elevated mood. Associated with bipolar disorder, where episodes of mania alternate with episodes of depression An illness that involves the body, mood, and thoughts and that affects the way a person eats, sleeps, feels about himself or herself, and thinks about things. People with this disorder cannot merely 'pull themselves together' and get better. As categorized by the DSM-IV, it is a form of mood disorder characterised by a variation of mood between a phase of manic or hypomanic elation, hyperactivity and hyper imagination, and a depressive phase of inhibition, slowness to conceive ideas and move, and anxiety or sadness. A mild mood disorder which is sometimes seen as more of a personality trait than an illness. Characterised by repetitive periods of mild depression followed by periods of normal or slightly elevated mood. A form of the mood disorder of depression characterised by a lack of enjoyment/pleasure in life that continues for at least six months. It differs from clinical depression in the severity of the symptoms. While usually it does not prevent a person from functioning, it prevents full enjoyment of life. It also lasts much longer than an episode of major depression. A major depressive episode that occurs without the manic phase. 10 SADGFACES S A D G F A C E S • Sadness, anxiety, or “empty feelings” • Decreased energy, fatigue, being slowed down • Loss of interest or pleasure in activities that were once enjoyed, including sex • Insomnia • Feelings of helplessness/hopelessness • Thoughts of death • Difficulty concentrating • Restlessness • Chronic aches 11 Symptoms Sadness Appetite disturbances Delusions and hallucinations Guilt, worthlessness Fatigue/loss of energy Anhedonia (loss of pleasure) Catatonia Esteem low Sleep disturbances 12 DSM-IV: Phobia Essential feature of specific phobia: ‘marked and persistent fear of clearly discernible, circumscribed objects or situations’. 13 Discussion Carousel: Phobia What is phobia? List different types of phobia? What are 3 symptoms you would associate with phobia? What happens physiologically when someone has a panic attack? What could the individual do to reduce their anxiety levels? What do you think causes phobia? List as many reasons as you can. Do you think phobia can be cured? If yes, suggest how. 14 Phobia FACT SHEET CASE STUDY • Definition • Mr L • Prevalence • Gareth • Symptoms • Rachel • Types of Phobia • Rebekah • Louisa 15 Phobia DSM-IV • Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a • Specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). • Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a Panic Attack. • The person recognizes that the fear is excessive or unreasonable. • The phobic situation(s) is avoided or else is endured with intense anxiety or distress. • The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person's normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia. • Duration is at least 6 months. 16 PIESTRAPS P I E S T R A P S 17 PIESTRAPS Panic Attack Irrational Excessive Shortness of breath Terror Reaction Anxiety Persisted 6months + Specific 18 DSM-IV: Schizophrenia Under DSM-IVR, a diagnosis of schizophrenia requires 2 or more positive symptoms for a period of at least 1 month. Positive symptoms • Auditory hallucinations • Disorganised speech Negative symptoms • Losing emotional response • Inability to feel pleasure • Lack of motivation • Disorganisation Schizophrenia is a serious mental disorder characterised by profound disruption in cognition and emotion 19 Discussion Carousel: Schizophrenia What is schizophrenia? What are 3 symptoms you would associate with schizophrenia? What do you think causes schizophrenia? List as many reasons as you can. Do you think schizophrenia can be cured? If yes, suggest how. 20 Schizophrenia FACT SHEET • Definition CASE STUDY • Carroll • Prevalence • Norma • Symptoms • Types of schizophrenia • Daniel 21 Schizophrenia TYPES 1. Disorganised: delusions, hallucinations, incoherent speech, and large mood swings 2. Catatonic: almost total immobility for hours at a time 3. Paranoid: delusions of various kinds 4. Undifferentiated 5. Residual: mild symptoms SYMPTOMS Positive symptoms • Delusions • Auditory hallucinations • Disorganised speech • Thought disorder Negative symptoms • Losing emotional response • Inability to feel pleasure • Lack of motivation • Poverty of speech • Disorganisation 22 23 CSSTABSHEAD C S S T A B S H E A D 24 CSSTABSHEAD Catatonia , Paranoid, Residual, Undifferentiated Speech disorganised Symptoms – positive/negative Types Auditory hallucination Behaviour disorganised Split from reality Hallucination Emotional response impaired Absence/present Delusions 25 WORD KEY WORDS SCHIZOPHRENIA DEFINITION A severe psychotic disorder characterized by distortions of reality, disturbances of thought and language and withdrawal from social contact The addition of psychotic behaviours If someone has a persecution complex, they suffer from the feeling that other people are trying to harm them. the belief that you are more important or powerful than you really are Inexpressive face, including a flat voice, lack of eye contact, and blank or restricted facial expressions. Inability to carry a conversation; short and sometimes disconnected replies to questions; speaking The absence of normal behaviours Marked primarily by delusions that follow a theme, like persecution or grandeur. Auditory hallucinations may accompany a delusion and are, therefore, usually related to its theme. Symptoms common to other subtypes, like disorganized speech and flattened affect, are not usually prominent in episodes of paranoia, but anger, irritability, and extreme anxiety are. People suffering from these type of delusions become particularly preoccupied with them and may be especially prone to violence. 26 WORD KEY WORDS SCHIZOPHRENIA DEFINITION Marked by disorganized speech, behaviour, and flattened affect is particularly disruptive. Also known as hebephrenic schizophrenia often features fragmented speech and inappropriate or unexpected behaviour that does not reflect ideas expressed verbally. Strange mannerisms, gestures, and surprising behaviour are common. This type of schizophrenia typically causes significant dysfunction in daily life, self-care, and interaction with others, as well as notable thought disturbance and loss of goaldirected behaviour. A form of schizophrenia characterized by a tendency to remain in a fixed state for long periods; the catatonia may give way to short periods of extreme excitement The type given to a lack of catatonia, paranoia, or disorganized speech. A type of schizophrenia that is diagnosed when positive symptoms like delusions, hallucinations, and grossly disorganized behaviour has disappeared. Negative symptoms remain and may be interrupted only briefly by mildly disorganized speech or strange behaviour. When delusions or hallucinations occur, even if infrequently, they are not serious enough to cause severe dysfunction. When someone believes something that is not true. 27 When you see, hear, feel or smell something which does not exist, usually because you are ill or have taken a drug. Exam Style Questions (ESQ) January 2010 a. Describe the characteristics of a psychotic disorder. (10) b. Evaluate difficulties when identifying characteristics of psychological disorders. (15) June 2013 a. Describe the characteristics of one anxiety disorder. (10) b. To what extent is it valid to identify a disorder from a list of characteristic. (15) June 2014 a. Outline the characteristics of an affective disorder. (10) b. Asses the reliability of identifying a disorder from a list of characteristics. (15) 28 Diagnosis Purpose • To identify groups of similar sufferers so that psychiatrists and psychologists may develop explanations and methods to help those groups • Billing purposes. The government and many insurance companies require a diagnosis for payment Techniques • Observation • Interview • Psychological tests (e.g. IQ tests) • Brain scans 29 Exam Style Question Plan and prepare a response to the question January 2010 a) Describe the characteristics of a psychotic disorder. (10) b) Evaluate difficulties when identifying characteristics of psychological disorders. (15) 30 b. Evaluate difficulties when identifying characteristics of psychological disorders 1. 2. 3. 4. 5. 6. 7. Highly subjective Method: Self-Report Overlap between disorders Symptoms may not always be evident Ethnocentricism Gender Bias Type 1 & 2 Error 31 Evaluate difficulties when identifying characteristics of psychological disorders 1. 2. 3. 4. Highly subjective - a lot of the descriptions of characteristic refer to "excessive" or "irrational", but these are subjective not objective descriptions. This could lead to poor validity and reliability. Requires self-report from individuals who may not perceive their behaviour as abnormal or dysfunctional, or who may be prone to lying/disordered thoughts and social desirability. Validity is an issue here too. Significant overlap between disorders e.g. loss of pleasure is a factor in depression and schizophrenia, whilst bipolar disorders and schizophrenia can feature delusions and disordered actions. Anxiety is also somewhat common amongst people who are depressed, due to feelings of worthlessness and pessimistic depressive thought patterns. Symptoms may not always be evident in psychiatric evaluations: such as loss of pleasure in daily activities, or disordered actions. Thus it's unobservable. However you do of course have the patient to recall these. 32 5. Ethnocentrism: This questions the international validity of diagnoses. For example they may be biased to certain countries, certainly the DSM is an American invention by the APA and therefore may bring into play wrong diagnoses based on racism. 6. Gender bias: Ford and Widiger (1989) raised the fundamental question of why those involved in diagnosing and classifying disorders are predominantly men, when those being diagnosed and treated are mainly women? The issue with this is that normal stereotypical gender roles might be incorrectly labelled as pathological. When presented with identical case histories (apart from gender control), 354 psychologists diagnosed women mainly with histrionic personality disorder, whereas men were more likely to be diagnosed with anti-social personality disorder. 7. Type 1 and type 2 Errors: Rosenhan's study brought psychiatrists type 2 errors to light (diagnosing someone with an illness when in fact they do not have one). • Type 1 errors on the other hand consist of diagnosing a patient without an illness when in fact they do have one. • Obviously Type 2 would be the safer option, to ensure extra tests and care is taken (just incase the patient really does need it), nevertheless it is a waste of time. 33 Exam Style Question Plan and prepare a response to the question June 2013 (A) Describe the characteristics of one anxiety disorder. (10) (B) To what extent is it valid to identify a disorder from a list of characteristic. (15) 34 b. To what extent is it valid to identify a disorder from a list of characteristic. (15) Validity of diagnosis: Does the person diagnosed have real symptoms with a real underlying cause? (the illness is not socially constructed, the person is not faking) Diagnoses may be consistent but what if they are wrong? • • • • Fundamental attribution error: There is a tendency of practitioners of overemphasizing dispositional rather than situational causes of behaviour when diagnosing patients. Self-Fulfilling prophecy: The labelling of patients with certain disorders may affect the practioners perceptions of them (compare with researcher bias), patients may act the label that has been given to them. The label itself may simplify a problem that is highly complex Insanity defense: People may fake mental illness in order to avoid punishment Co-morbidity: There are significant individual differences for mental disorders. An individual may have multiple mental disorders 35 Research Evidence: 1. Szaz 1967: Many disorders may be culturally constructed. If the biological causes of the mental disorder are known, the individual may be diagnosed with mental disorder (the mental illness criterion). If there is no biologically underlying cause of the disorder, it is better to claim that the individual has problems with living. 2. Rosenhan's ( 1973) classic study shows this when nearly all psuedopatients were incorrectly diagnosed with schizophrenia. 8 sane people could get admitted to mental hospitals merely by claiming to hear voices. Rosenhan (1973): When a teaching hospital was told to expect pseudo-patients, they suspected 41 out of 193 genuine patients of being fakers. 3. 36 • Temerline (1970): Clinically trained psychiatrists were influenced in their diagnosis by hearing the opinion of a respected authority. (expert influence). Participants watched a video-taped interview of a healthy individual. The authority claimed, even though the person only seemed to be neurotic (distress where behaviour is not outside social norms, patient has not lost touch with reality) he was actually psychotic (behaviour is outside social norms, loss of touch with reality) • Chapman & Chapman (1967): Beginning clinicians observed draw-aperson test drawing randomly paired (unknowingly to participants) with symptom statements of patients. Although the relationship between symptoms and drawings were absent, participants rated a high associative strength between symptom and drawing characteristics (e.g. paranoia and drawing big eyes) • Lipton & Simon (1985): 131 patients were randomly chosen at a New York hospital. Initially there were 89 patients diagnosed with schizophrenia, eventually only 16. Initially, there were 15 diagnosed with depression, eventually there were 50. 37 Exam Style Question Plan and prepare a response to the question a. Outline the characteristics of an affective disorder (10 marks) b. Asses the reliability of identifying a disorders from a list of characteristics (15 marks) 38 Asses the reliability of identifying a disorders from a list of characteristics (15 marks) Reliability of diagnosis: Will different diagnosticians using the same classification system arrive at the same diagnosis? The consistency of diagnoses. We would expect all psychiatrists to diagnose the same set of symptoms in the same way. The reliability of earlier systems for diagnosis, e.g. DSM-II, was very poor, but it has been improved in revisions of the systems, e.g. DSM-IV-TR. 39 Asses the reliability of identifying a disorders from a list of characteristics (15 marks) • Pedersen et al., (2001) researchers compared the consistency of diagnoses and found that 71% of psychiatrists agreed with the ICD-10 definition of depression when assessing 116 patients (inter-rater relibility). • Beck (1962): Agreement between two psychiatrists on diagnosis for 153 patients was 54 %. This was due to vague criteria for diagnosis and different ways of psychiatrists to gather information • Cooper et. al. (1972): When shown the same video clips, New York psychiatrists are twice as likely to diagnose schizophrenia than London psychiatrists. London psychiatrists were twice as likely to diagnose mania or depression than New York psychiatrists • Di Nardo (1993): Two clinicians separately diagnosed 267 people seeking treatment for anxiety and stress disorders. They found higher reliability for obsessive compulsive disorder but lower reliability for major depression 40 Conclusion • There is a large amount of research supporting the view that the reliability and validity of diagnosis are poor. This is due to many reasons, e.g. a possible social construction of mental illness, poor diagnostic tools, the possibility of faking, social influence, errors in attribution by practitioners and labeling • Ethnocentricism: There are significant individual and cultural differences for the symptoms of mental disorders. An individual may have multiple mental disorders • Ethical Issues: A wrong diagnosis may lead to a social stigma. Counter argument • There are methodological problems with the studies on validity and reliability (researcher bias, generalisability, ecological validity). • Revised diagnostic tools are higher in reliability than earlier versions, e.g. DSM-IV-TR. • Many people do seek help voluntarily for disorders (which may mean that the disorder is valid). • The reliability of diagnosis is high for some disorders, e.g. obsessive compulsive disorder. • There are many similarities of disorders across cultures. • Diagnostic systems do not classify people, but the disorders that they have.