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What makes behavior "abnormal"

-Socially/Culturally unacceptable


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)


-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)

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

-Deinstitutionalization Movement
-Managed Health Care

Contemporary Trends

-Positive Psychology
-Drug Revolution
-Managed Health Care

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


Only a dysfunction if it is a SYMPTOM of dysfunction


-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

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


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
-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


Not Otherwise Specified


Sexual Orientation

Cultural Competency


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

-Time constraints
-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

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

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)

Abnormal Speech

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


-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??

Thought Process

-Goal directed?
-Confabulation (making up memories)?

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)


-assessed with neuropsychological tests
-mini MSE administered


-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

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