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A label that causes certain people to be regarded as different, defective, and set apart from mainstream members of society.
-Black bile ("melancholic")
-Yellow bile ("choleric")
Key Figures of Reform Movement
Philippe Pinel-ordered removal of chains from women in insane asylum
Jean- Baptiste Pussin
Challenges of the late 20th Century Reform Movement
-Managed Health Care
Influence of Multicultural Psychology
-Cultural values and 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 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
-Cultural assessment for diagnosis/care
-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
-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
-Reported and observable symptoms
-Diagnostic and differential diagnosis
-Case formulation (how YOU understand client)
-Final diagnosis reported using DSM codes
Clinical syndrome that is focus of attention
-More than one dx -- label principle dx
-More info needed -- deferred
-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
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
Psychosocial and environmental problems
-Stressors and negatives
-Problem with primary support group, educational problems, housing problems, economic problems, etc.
Clinician's judgment of level of functioning
-Global Assessment of Functioning (GAF)
-Changes and is monitored
-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.
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
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
-Can be helpful (a lot goes on internally)
-People aren't always best historians
-Social desirability may come into play
-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
-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
-Biased by personal experience
-Gravitate toward diagnosis
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
-Procedure in which clinician evaluates a person in terms of psychological, physical, and social factors that influences functioning
-Standardized series of questions with predetermined wording and order
Mental Status Examination
-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)
-Outward expression of emotion and mood
-Non verbals are important
-Blunted, flat, reactive, heightened (up), overly restricted
-Person's individual experience
-euthymic (happy), dysphoric (down), euphoric, etc.
-Was Affect Congruent with Mood??
-Confabulation (making up memories)?
-Ideas in person's head
(obsessions, delusions, overvalued idea, magical thinking, suicidal, homicidal, phobia)
-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)
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