PowerPoints Abnormal

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What makes behavior "abnormal"

-Distress
-Impairment
-Risk
-Socially/Culturally unacceptable

Stigma

A label that causes certain people to be regarded as different, defective, and set apart from mainstream members of society.

History of Abnormal Psych

-witch hunts
-trepanning (drill hole in brain)
-exorcism

Hippocrates

-470-377 BC
-Black bile ("melancholic")
-Yellow bile ("choleric")
-Phlegm ("phlegmatic")
-Blood ("sanguine")

Benjamin Rush

Used fright to counteract patients' mental illness

Middle Ages

-explanations of abnormality
-asylums (Bedlam)
-treatments

Key Figures of Reform Movement

Vincenzo Chiarugi
Philippe Pinel-ordered removal of chains from women in insane asylum
Jean- Baptiste Pussin

Challenges of the late 20th Century Reform Movement

-Medications
-Deinstitutionalization Movement
-Managed Health Care

Contemporary Trends

-Positive Psychology
-Drug Revolution
-Managed Health Care
-Research

Influence of Multicultural Psychology

-Social conditioning
-Cultural values and influences
-Sociopolitical influences
-Bias in diagnosis

What is culture?

Shared elements involved in perceiving, communicating, believing, passed down from one generation to the next.

Intersection between Clinical Reality and Culture

-Culture affects clinical reality (treatment dependent on culture, stigmatized?, can be 2 different realities)
-Curing the Disease vs Healing the Client
-Ways in which mental illness has meaning--client may not want to be treated for psychological (focus might be on somatic)
-Clinical continues to evolve

C's of Cultural Formulation

-Cultural identity
-Cultural explanation of illness
-Cultural interpretations of social stressors/supports
-Cultural elements between client and clinician
-Cultural element of stigma

Questions about cultural formulation

-Client's cultural identity
-Does client provide a good cultural explanation of problem
-Cultural factors related to psychosocial env that affects functioning
-Does presentation fall into culture-bound syndromes
-Multicultural differences
-Cultural assessment for diagnosis/care

Mental Disorder

-Def: A clinically significant behavioral or psychological syndrome
-Associated with present distress or risk of suffering pain/death
-Is NOT just a response to an event

Deviance

Only a dysfunction if it is a SYMPTOM of dysfunction

DSM-IV

-Classification system based on medical model
-Descriptive, not explanatory
-Doesn't focus on a theory
-Polythetic: different levels of symptoms but still meet criteria of dysfunction
-Multiaxial

Diagnostic Process

-Reported and observable symptoms
-Diagnostic and differential diagnosis
-Case formulation (how YOU understand client)
-Final diagnosis reported using DSM codes

Differential diagnosis

Ruling out all possible alternative diagnoses

Decision tree

Yes/no questions in DSM about client's symptoms that lead to diagnosis

SCID

Structured Clinical Interview for DSM-IV used to diagnose disorders

Axis I

Clinical syndrome that is focus of attention
-More than one dx -- label principle dx
-More info needed -- deferred

Axis II

-Personality disorders - Pervasive, long-term, adolescent onset. Stable over time but leads to impairment
-Mental Retardation - Subaverage IQ (below 70), onset before 18, impairment in adaptive functioning
**borderline is also coded on Axis II

Axis III

Medical conditions relevant to mental disorder
-if no GMC, code None
-Differential: May code on Axis I and II
-Can consider Medical Disorder due to GMC

Axis IV

Psychosocial and environmental problems
-Stressors and negatives
-Problem with primary support group, educational problems, housing problems, economic problems, etc.

Axis V

Clinician's judgment of level of functioning
-Global Assessment of Functioning (GAF)
-Changes and is monitored
-Subjective
-Clinician rates based on worst case scenario (look at severity and level of functioning)

Has full criteria been met for diagnosis?

-Consider number and intensity of symptoms, along with resulting impairment. Code the severity.

Rule outs

R/O -- when you have a suspicion but cannot confirm diagnosis

Provisional Dx

Strong presumption

NOS

Not Otherwise Specified

Culture "ADRESSING"

Age
Disability
Race
Ethnicity
Sexual Orientation
SES
Indiginous
Nationality
Gender

Cultural Competency

Knowledge
Skills
Awareness

Culture and Diagnosis

-Remember that personality disorders may present differently, depending on how connections are made within the culture
-Health issues may be private
-Stressors could include SES or type of support group

Example: Culture and Schizophrenia

-1% prevalence
-Universal, so must be genetic component

Neurobiology of adaptation and learning

-Brain adapts to emotion, stress, trauma, therapy, experience, cultural learning---The Brain is Influenced by CULTURE

Clinical Method of Making Decisions

Aggregating data from clients through interviewing to make decisions/judgments

Actuarial Method of Making Decisions

Aggregating data from empirical evidence to make decisions/judgment

Self Report

-Can be helpful (a lot goes on internally)
-People aren't always best historians
-Social desirability may come into play

Meehl, 1954

-Said that equations are better than clinical judgment

Goldberg, 1968 and Leli & Filskov, 1984

-Proved better than clinicians in judgment

Einhorn, 1978

-Studied Lymphoma and survival time and found that clinical judgment produced no relation to survival time

4 Ways to Aggregate Information as a Clinician

I: Actuarial & Self-report - ex: BDI
II: Clinical & Self-report - Client subjectively reports symptoms, and questions must be good
III: Clinician & Actuarial - Clinicians sorted data
IV: Clinician & Informal - Case conceptualization with no actual data

Clinical Guidelines

-Guidelines: Rely on standard set of items (like BDI), but not often used in practice
-Practice: More judgment that works = More practice (???)
-Matching: If practiced technique matches diagnosis and yields positive results (Pitfall: not being comfy w/technique)

When Do Clinicians Make Valid Judgments

-When based on theory
-When it 's a rare event that does not fit actuarial formula
-When it's a complex event, and nuances are noticed

Why Don't Clinicians Follow Rules

-Lazy
-Time constraints
-Biased by personal experience
-Gravitate toward diagnosis
-Overconfident

Benefits of Actuarial Judgment

-Stats are consistent, but clinicians may vary
-Stats based on predictive power, but clinicians weigh issues differently
-No self-fulfilling prophecies (leading ?s)
-Stats don't see skewed sample of humanity
-Stats can't be overconfident in judgments

Pros and Cons of Client Self-Report

Pros: Client is expert, easy to administer, good psychometric qualities
Cons: It's all relative, lack expertise when evaluating own symptoms, dishonesty

Pros and Cons of Clinician Report

Pros: Nonverbals, more objective than client, can handle rare events, use of theory
Cons: Theory can negatively influence what you see/don't see, reliability isn't great, inconsistency

Westen & Weinberger Reading, 2004

-All judgment is clinical and subjective, because it is humans that come up with formula
-Clinical aggregation may be inferior but it's needed to frame hypothesis, create formulas, and think about client

Psychological Assessment

-Procedure in which clinician evaluates a person in terms of psychological, physical, and social factors that influences functioning

Unstructured Interview

-Series of open questions

Structured Interview

-Standardized series of questions with predetermined wording and order
-Ex: SCID

Mental Status Examination

-MSE
-Assess appearance, speech, mood, affect, thought content, sensorium, awareness, etc.
-Remember culture can affect MSE

Appearance and Behavior

-Physical appearance (malodorous, disheveled, thin, under the influence
-Attitude (suspicious, guarde, proximity)
-Motor behavior (hyperactivity, psychomotor agitation/retardation, catatonia)

Abnormal Speech

-Look to culture first
-Rate, rhythm, pitch, quantity, pressured, variation

Affect

-Outward expression of emotion and mood
-Non verbals are important
-Blunted, flat, reactive, heightened (up), overly restricted

Mood

-Person's individual experience
-euthymic (happy), dysphoric (down), euphoric, etc.
-Was Affect Congruent with Mood??

Thought Process

-Goal directed?
-Illogical?
-Tangentiality?
-Confabulation (making up memories)?
-Mania?

Perceptual Experiences

Hallucinations and are they related to GMC

Thought Content

-Ideas in person's head
(obsessions, delusions, overvalued idea, magical thinking, suicidal, homicidal, phobia)

Cognition

-assessed with neuropsychological tests
-mini MSE administered

Orientation

-Is client aware of time, place, person, event
-AOX3 (Alert and oriented with time, place, person)
-AOX4 (Alert and oriented with time, place, person, event)

Insight and Judgment

-Understanding of illness, events, self, world
-Ability to make decisions/plans
-Compliance with treatment
-Impulsiveness

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