What is psychopatho?
Things that are considered:
- Statistical deviation => ex: Einstein
- Subjective distress => ex: mania
- Personal dysfunction => “harmful dysfunction”
=> “Harmful dysfunction”: A disorder = failure of a person’s internal mechanisms to perform their functions as defined by social values and meaning (both sct pov and social values)
- Scientific Component: Dysfunction = “an organ system performing contrary to its design”, Brain functions: thinking, feeling, emotion regulation
- Social Component: Judged as causing harm in own env context, What is pathological is influenced by sociocultural norms (shifts over time) ex: homosexuality
*One question is where do we draw the line
Historical Perspectives (5)
- Earliest views: Supernatural causes (e.g., “possession”)
Treatment: Trephination - Hippocrates (460 – 377 B.C.E.): Natural causes (mental dx = due to brain pathology) => Four humors (blood, phlegm, bile, and black bile) to explain personality
- Galen (129– 198 C. E.) => Two sources of mental disorder: physical and psychological, Early form of talk therapy
- Middle Ages in Europe
Treatment: Clergy - Renaissance Period => Rise of asylums, Humanitarian reform: Philippe Pinel (1745 – 1826)
Medical Model
Emil Kraepelin => Adopted medical model and applied to mental health
- Syndromes = groups of symptoms tgt
- Assumes mental dx are taxonic in nature (cat in the real world)
*Mental illnesses are therefore categorical, discrete, measurable entities
=> Categorical Taxonomy: “see it in front of you” + create boundaries (cat vs dog & depression vs dipolar)
DSM Definition of Mental Dx and Assumptions
Is a syndrome, clinically significant, reflects dysfunction, distress or disability, expectable or culturally approved resp, socially deviant
Assumptions introduced into DSM:
- Mental illness is an illness like any other => But only medical domain with symptom-based dx (can’t do blood test or etc)
- Guides physical intervention => Who treats: Psychiatrist, physician & What treatments: Pharmacological interventions
- Different dx are discrete, separate categories => Mental illness is discontinuous with normal beh
=> Categorical (Presence or absence of dx) vs Dimensional (Rank on continuous quantitative dimension)
Evolution of DSM (1-3)
- DSM-I: 1952
- DSM-II: 1968
=> Early DSMs had: Fewer categories, No clear requirements (# of sx)/definition for dx, Grounded in psychodynamic theory (ex: Freud), Very poor reliability
- DSM-III: 1980 => Demand for more empirical approach with atheoretical stance, Adopted a medical model: Inclusion/Duration/Exclusion criteria
Assumptions introduced: Sx (not etiology) are most useful basis for assessment, Locus of pathology is in the individual (internal so don’t look at env), Multi-Axial Assessment
*Multiaxial Assessment: Axis I. Major Clinical Disorders (e.g., MDD, PTSD), Axis II. Personality Disorders (e.g., BPD, NPD), Axis III. Medical conditions that might contribute or be relevant to treatment, Axis IV. Psychosocial stressors, Axis V. GAF – simple rating of function/summary score for severity
Evolution of DSM (4-5)
- DSM-IV: 1994 => Largely unchanged from DSM-III
Biggest change: Empirical process (ex: panel of experts, more research based): Introduced “clinically significant distress or impairment in social, occupational, or other important areas of functioning”
- DSM-5: 2013 (DSM-5-TR: 2022) => Removed multi-axial system and Introduced dimensional assessment criteria for some dx
Added new disorders (ex: Binge eating disorder)
Re-classified some disorders (ex: OCD, PTSD)
Removed others (ex: Hypochondriasis)
=> Increasing #of Cat from 106 to 297 in DSM-IV to 157 in DSM-5
Purpose of Classification (5)
- Facilitates communication among mental health professionals
- Allows for treatment and intervention recommendations
- Promotes research about dx and tx
- Allocation of resources and services*
- Provides sense of understanding to the individual (validating at first)
Issues with Classification & Dx - Arbitrary Criteria
- DSM attempts to draw a line between what is considered ”normal” vs. “pathological” => made arbitrarily (not always scientific) *Don’t necessarily do a good job at identifying pathology
- For most diagnoses, the majority of people end up in the “Not Otherwise Specified” (NOS) category
Issues with Classification & Dx - Low Reliability
- In order for classification system to be useful, clinicians need to arrive at the same diagnosis for a given person => However, diagnosis is highly unreliable
Issues with Classification & Dx - High Comorbidity
- Refers to the presence of two or more disorders in the same person => VERY high degree of comorbidity among mental dx
=> What can this mean?
- One dx causes the onset of the other
- Both dx may be a consequence of some third variable
- Overlap of sx present in different dx
- There are no separate disorders => what the prof argues for
Issues with Classification & Dx - Heterogeneity
- DSM diagnostic categories are polythetic => + sx but only need some
- Many ways to have the same disorder (ex: 636,120 ways to have PTSD)
- Two individuals with the same diagnosis can share very few or even no sx in common => occur in over half (58.3%) of DSM-5 dx
*Heterogeneity exists even within same sx criterion
Issues with Classification & Dx - Overmedicalization of Human Emotion
- Over pathologizing normal, common human emotions => “The Myth of Mental Illness” – Thomas S. Szasz (ex: Prolonged Grief Disorder)
- But also increasing # of categories, loosening boundary conditions => easier to get dx, loose sx
=> Is abnormal the new norm? =? a lot of ppl have mental illness
Issues with Classification & Dx - Influence of Big Pharma
- Concerns over influence of DSM’s financial associations with industry, such as pharmaceutical companies
- 69% of DSM-5 task force members report having ties to the pharmaceutical industry
Issues with Classification & Dx - Negative Impact of Labeling
- Psychiatric labels stick => Study: “On being sane in insane places” Rosenhan, 1973
Eight “pseudopatients”, Called hospitals reporting voices in their head (“empty”, “hollow”, “thud”) and all were admitted to psychiatric hospitals with dx of schizophrenia => once admitted, behaved as they “normally”
=> Average length of stay: 19 days (ranged from 7 to 52) AND Administered 2100 pills
Discharged with dx of “schizophrenia in remission” *Saw dx when none existed
*The stickiness of diagnostic psychological labels
- Public stigma toward mental dx
- Psychological effects => self-esteem and self-efficacy
Alternative Approaches
- Dimensional/Hierarchial Models => Internalizing and Externalizing (env factors) *Dimensions correlates w/ each other still
- the “P” factor
- Research Domain Criteria (RDoC) => trans-diagnostic dimensional approach but too biological* (doesn’t account for social/env. factors)
