classification of psychological disorders. learning objectives v importance of classification v...
TRANSCRIPT
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Classification of Psychological Disorders
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Learning Objectives
Importance of Classification Philosophical underpinnings of two
approaches to classification Purposes of Classification
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Symbols and Language
Words are symbols By convention we all agree on symbols Why I can refer to a pen and we all
know what it is I am referring to If not, have to have pen directly in front
of us. How do we come to establish symbols
or concepts that everyone can agree upon?
Nature of classification
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Classification
Important activity in clinical work and research
Basic part of science Information made more accessible,
meaningful, and less cumbersome
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Classification
Normal vs. Abnormal
Charles Manson
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Classification
Need to further define abnormal Divide “abnormal” into subclasses Mushroom example
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MushroomNot a Mushroom
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Poisonous Edible
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Bach Mai Hospital doctors treat the oldest of two brothers who survived eating poisonous mushrooms, although six of their families members did die.
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Classification Historical
Paradigms have influenced how classification done and what was classified
Hippocrates’ Four humors:
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Hippocrates
1. Black Bile ---- Depression 2. Yellow Bile ---- Tension/Anxiety 3. Phlegm ---- Dull, Sluggishness 4. Blood ---- Mania/Mood Swings
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Historical
Pre-history: Likely simply divided into normal vs abnormal
Ancient Greece: Hippocrates Others over the ages: Jean Fernel
(1497 – 1588); Feliz Platter (1536-1614); Francois Baussier de Sauvages (18thC)
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Philosophical Issues in Abnormal Behaviour
Paradigms Nature of psychopathology,
normalcy, belief in paradigm Historical
– Emil Kraeplin and Neo-Kraeplians– Sigmund Freud
Contemporary: – DSM & ICD– PDM & OPDS
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Two Trends
Symptom as Focus (Kraeplin) Underlying Cause as Focus (Freud)
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Symptom as Focus
Group of Sx or observable behaviors Seen as cause of the difficulties Focus of assessment and treatment is
on eradicating the symptoms Behavior school, ICD, DSM Variant embraced by Managed Care in
US (i.e., insurance company)
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Underlying Cause as Focus
Problems caused by underlying process
Assessment and treatment focuses on underlying process
Orientation of psychodynamic, cognitive behavioral (to degree), and PDM.
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Classification
Basic part of science Want to make information more
accessible, meaningful, and less cumbersome
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Classification - Purposes
Description and need to identify Communication Research Treatment Insurance Theory Development Epidemiological Information
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Diagnosis leads to treatment From medical perspective:
Appendicitis Gas Pains
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Diagnosis does not always lead to proper treatment:
– Alzheimer’s Disease– Depression and “families” of drugs– ALS
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How to Classify?
1. Divide disorders into mutually exclusive and collectively exhaustive subclasses
a. Mutually Exclusive: disorders should be distinct and cannot belong to two different subclasses (e.g., poisonous and edible mushrooms???)
b. Collectively Exhaustive: all disorders must be classified
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How to Classify? Cont’d
2. Subclasses defined by necessary and sufficient conditions
a. Must be characteristics that are necessary for classification
b. Must also be set of sufficient conditions to belong to a subclass
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How to Classify Cont’d
Reliability: Each time you (or someone else) uses the classification system, should get the same result– Need to identify psychological problems in a
clear and reliable manner– Also need agreement among mental health
professionals or can have individuals referring to same term to describe different disorders
E.G., Schizophrenia and “split personality” (i.e., dissociative identity disorder)
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How to Classify Cont’d
Validity: Classification system should say something about the “true world”
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DSM – IV Text Revision
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DSM’S
Categorical Approach to define abnormality
Revised periodically:– DSM first published 1952– DSM II published 1968– DSM III published 1980– DSM III Revised published 1987– DSM IV published 1994– DSM IV Text Revision 2000– DSM V published 2014
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DSM
Over 400 disorders DSM provides descriptive
information not based on any one theoretical perspective (although this is debateable)
Categorical Approach Descriptive features are based on
observable features:
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DSM IV TR
Provides information on:– Diagnostic Features– Associated Features and Disorders– Associated Laboratory Findings– Age-related, Culture-related and
Gender-related features
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DSM 4 & 5
DSM 4 – 5 axes
DSM 5 - No Axes – Different Disorders
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Pros and Cons
Pro:– Reliability has improved over previous
editions– Provides information on research and
reliable and valid information– Axis IV and V very good in terms of
attempting to take into account many factors
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Pros and Cons
Con:– Only first 3 Axes tend to used and
even then Axis 2 used inappropriately– Labeling and stigma still issue– Biological tests not used– Fees paid based on diagnosis and
some patients diagnosed inappropriately
– Doesn’t lead to differential treatment decisions for most part
– Still very subjective
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DSM IVTR (p. XXXIV)
“ DSM-IV is a categorical classification that divides mental disorders into types based on criteria sets with defining features….. In DSM-IV there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder”
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Diagnosis and Formulation
Diagnosis: Assigning diagnostic category
Formulation: Attempt to explain genesis, maintenance, and process related information for treatment
Struct. Interview Diagnosis Assessment Formulation
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Most clinicians agree that need both, although likely majority indicate that formulation is actually more important
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Other Diagnostic Manuals in Use
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Other Diagnostic Manuals in Use
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Psychodynamic Diagnostic Manual (PDM)
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PDM
DSM provides one level of description– Some argue don’t measure some of the
most important things PDM:
– there is more to people than what is described in DSM
– Attempts to describe and categorize elements not found in DSM
– Attempts to provide information that will improve comprehensive treatments
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PDM
Not developed to supplant DSM but to supplement DSM
Developed from a theoretical perspective: Current Psychodynamic Theory:– Psychoanalysis– Object Relations– Attachment Theory
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PDM
Diagnostic framework Describes the whole person:
– Surface and deeper levels of personality, person’s emotional and social functioning
– Based on current neuroscience and treatment outcome studies
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PDM Developed By
American Psychoanalytic Association
American Academy of Psychoanalysis
International Psychoanalytic Association
American Psychological Association Division 39
National Membership Committee on Psychoanalysis in Clinical Social Work
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PDM
The elements include:– Personality patterns– Social and emotional capacities– Unique mental profiles– Personal experiences of individuals
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PDM- Rationale
Human behaviour is complex DSM simplifies behaviour too much Want to direct focus on full range
of affect, thought, behaviour in context of an individual’s own unique history
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PDM- Rationale Cont’d
Consistent with idea that: Rather than thinking of
people having discrete disorders (i.e., ego dystonic, separate, outside of self), see disorders as result of some process (personality, incorporation of upbringing, etc.) and the process is what is important
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PDM Dimensions
1. Personality Patterns and Disorders (P Axis)
2. Mental Functioning (M Axis)3. Manifest Symptoms and Concerns
(S Axis)
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P Axis
Person’s location on Continuum: Healthy -----------------Disordered
Ways in which person organizes mental functioning and interacts with world
Maxim: Need to understand person in order to understand problem
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P Axis
Includes many of the Axis II diagnoses from DSM
Adds other ones that are seen as extremely important:– Depressive Personality Disorder– Sadistic and Sadomasochistic PD– Masochistic (Self-defeating) PD– Somatizing PD– Dissociative PD
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M Axis
Detailed look at emotional functioning– E.G., Information processing, self-
regulation, relationships, emotional expression, learning, coping/defenses, etc.
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S Axis
Using the DSM categories, focus on personal experience of difficulties
Need to be seen in context of personality and mental functioning
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PDM
Attempt to develop a thorough and comprehensive diagnostic picture
Takes whole person into account
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PDM
Published in 2006 so little early to evaluate
Welcomed by most clinicians as an addition to aid in treatment planning
Aids in formulation:– Diagnosis doesn’t give you all relevant
information for treatment– Need to determine etiology, maintenance
factors, process-related issues, history of relationships, etc. which guide treatment
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Other Classification Systems ICD – 10 McLemore and Benjamin’s
Interpersonal Diagnosis Operationalised Psychodynamic
System
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Classification
Discrete?– Can people be placed in a neat
diagnostic box or not?
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Discrete Categories
Female
Not Pregnant
Male
Pregnant
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Classification
Continuous?– Are the disorders on a continuum?
Nondepressed Depressed
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Discrete Categories?
Not Depressed
Abnormal
Depressed
Normal