Current understanding of Mental Illness 

focuses on a _______

Holistic Understanding

-MI is complicated and disorder occurs at multiple levels

1. evolutionary perspective
2. statistical persepctive (deviance)
3. pragmatic (whatever professionals treat)
4. skeptical antipsychiatry view (ppl diagnose to get ride of bad behavior)
5. value view (determined by social norms)
6. harmful dysfunction model 

- model used to define mental illness

Wakefield (1992)

Harmful Distress

Distress discovered by self-report (subjective) and behavioral observations

1. says nothing about cause/etiology
2. bad inter-rater reliab: inconsistent & biased reporting, temporarily unstablity w/in the person
3. comorbidity between disorders 
4. limited predictive validity
5. limited relation to tx
6. definitions are arbitrary and hard to measure
7. biased by culture

• cultural/social (opportunities)
• interpersonal/environmental (reinforcement)
• mental
• organ (hypofrontality)
• cellular/molecular (serotinergic)
• genetic/epigentic (5-HTTLPR)

Examples of mental level phenomenon

associated with MI

• Metacognitive beliefs 
• depressogenic thoughts
• basic neurocognition, motivation, affect
• poor attention
• autonomic or basic functions
• decreased reactivity

Reasons holistic understanding of MI is

better than previous definitions (7)

• help thoerize and test models of etiology (etiology)
• object & performance-based assessments (inter-rater reli)
• isolates more specific unit of analysis (comorbidity)
• identifies core neurodevelopmental or vulnerability features (predictive valid)
• new entry points for tx (tx relation)
• objective, ratio based measures (arbirtrary)
• quanitify influences of various sources (culture)

Issues with conceptual overlay, not a public policy

• where is bx and self-report, critical for diagnosis?
• creates confusion, who is the expert to tx and R?
• how does causality work (each level effects each other)
• one path to MI from simple to broad? (equifinality/multifinality)
• social & professional issues: what level do you diagnose & tx, insurance, legal responsibility? 

• cities became center of civilization
• large populations of indigent ppl w/ mental illness
• gov't charged with their car
• Islamic culture: scientific wave created scientific method
• Asylums

Asylums: a natural laboratory

-superintendents were medical doctors trained in experimental science

Organizations for professionals

caring for the  mentally ill

Thomas Kirkbride

Pennsylvania Hospital for the Insane

"Kirkbride" Plan-privacy, socialization, sun, air

-stoped blaming individual

19th century understanding of

psychopathology: summary

-recognition that organs of the nervous system are related to MI

-recognition that clearly defined exogenous agents can cause MI

20th century treatments (3)

(non pharmacological)

1908: Antibiotic for synphilis

1953: Psychosurgeries (lobotomy)

1938: ECT (based on faulse observation that schizo & epilepsy don't co-occur & correct observation that epilepsy are euthymic post-seizure)

1952: chlorpromazine (AP), started as anesthetic for surgery, sedetive effect used in schizo but found the calming effects (putatively) occur above and beyond the sedative side effects

1955: Impiramine (AD), Tricyclic 5-HT reuptake inhibitor made psychosis worse but helped depression

1957: Benzodiazepine (Tranquilizer), muscle relaxation and helped fear/anxiety. Improved neg affect w/ lots of disorders (psychosis, OCD, trauma, and addicts)

Extrogenous chemicals can alter neurochemistry

to alter MI

Effect of drugs: 93% of state inpatient beds were lost

1955: community mental healthy study act enacted by congress to get info on effects of deinstitutionalization

1965-Community Mental Health Act: grants to establish local community mental health

Forensic system

7.5-15% of ppl incaracerated have severe MI

Emil Kraepelin: founder of modern psychiatry

• Assumption that MI was biological in nature
• categorical system (≈20 diagnoses)
• seperated dementia praecox from manic depression
• don't know cause but know the symptoms

dementia praecox: persistent & psychotic symtpoms and deteriorating state

manic depression: intermittent psychotic symptoms and erratic course 

(1st time these had been split, psychotic by nature meaning symptoms had to with a seapartion from the body

-continuum or spectrum w/ broad categories

(Freud example)

• Healthy: efffective for handling anxiety, well functioning w/ work or love
• neurosis: ineffective for handling anxiety, problems w/ work or love
• psychosis: ineffective for keeping engaged w/ reality, considerable problems w/ work or love

continuum in population (e.g. Eysenck)

• Neuroticism: tendency to experience negative emotions
• extroversion: tendency to enjoy positive events
• psychoticism: vulnerability to reality disturbances

• Categorical
• DSM, ICD
• Hierarchical
• psychodynamic systems
• coping strategies/ defense mechanisms
• hybrid DSM systems
• Dimensional 
• symptom-based assessments
• Big 5

first in 1900

most recent 1999

Chapter 5: mental & Behavioral Disorders

• Category checklist for DSM is very clearly defined algorithms, ICD is less clear
• ICD gives more room for clinician interpretation 
• ICD has less behaviorally ranked symptoms
• DSM has x our of y symptoms in z categories (not this detailed in ICD)

• Emphasized hierarchical approach
• viewed psychopathology as dimensional, but w/ distinct categories
• Diagnoses meant as a guideline
• Categories mainly descriptive in nature
• based on APA's psychoanalytic orientation

• improved compatibility w/ ICD
• Shift from psycho-analysis to psychodynamic thought
• focus on fit between personality & environment

• DSM-II drifted from behavioral & medical sciences and allienated psychiatry from science
• Efficency: Post WWII lots of mental health professionals (most not psychiatrists or trained in psycho-analysis) were seeing patients
• Legal: Diagnoses were not defensible in court

Spitzer & Fleiss (1975) created Kappa to show DSM-II was crap

Kappa=(Po-Pc)/(1-Pc)

Interpreting Kappa for dichotomous decisions

% agreement= 100, Kappa = 1.00

% agreement= 75, Kappa = .5

% agreement= 50, Kappa = 0

% agreement= 25, Kappa = -.5

% agreement= 0, Kappa = 1.00

Greater than .90 = uniformly high

.6-.9 = only satisfactory

.4-.75 = no better than fair

less than .4 = poor

• Changes made from DSM-II to III
• steer away from psychoanalytic to be more consistent w/ larger med and bx science
• limited use of psychoanalytic terms (neurosis, moved these disorders to Axis II)
• criteria focus on "atheoretical behavior"
• symptoms: maladies reported by patient
• signs: maladies detected by clinicians

Fixed from DSM-II to III

The Feigner Criteria: Behavioral-based criteria for 14 disorders developed

Changes made from DSM-II to III

• Schedule for affective disorders and schizophrenia (SADS)
• semi-structured clinical interview for the DSM-III (SCAD)
• diagnostic interview schedule (DIS)
• mini-international neuropsychiatric interview (MINI)
• composite international diagnostic interview (CIDI)

Kappa: >.7 = good

.5-.7=fair

<.5=poor

SCID=most of Axis 1 in fair to good range but differed a lot between sites (Williams, 1992)

Multi-axial system

• axis I: mental illness
• axis I: stable metnal illness
• III: medical
• IV: psychosocial & environmental factors
• V: GAF

40= highest if you have psychotic symptoms

20=highest if you have suicidal ideations

10=highest if suicidal

DSM III

DSM-IV

III (1980): homosexuality deleted

IV (1994): clinical significant criteria included for 1/2 of disorders

-empirically baed: 3 step review process

Hierarchical bc they are somewhat stable

[image]

-individual cognitive, affective and other genetic characteristics that contribute to a relatively stable set of behaviors

-thought to occur through social learning, genetics, and environmental factors

• Adaptive Coping Strategies: Level 4
• ways of dealing w/ stress, satisfactory to self & others
• Neurotic Coping Strategies: Level 3
• manipulate emotive & cog processes w/in the ind, when used chronically not adaptive
• Immature or Borderline Coping Strategies: Level 2
• manipulate cog and emotive processes b/ individuals instead of wihin an ind
• Psychotic Coping Strategies: Level 1
• distortion of reality to cope

Hierarchical defense mechanisms

Adaptive Coping strategies

- Altruism

-sublination: indirect expression of instincts w/out adverse consequences or displeasure

-suppression: temporary loss of painful emotion

 hierarchical defense mechanisms

Neurotic Coping Strategies

-repression: awareness lost but emotion retained

-intellectualization: awareness retained but emotion lost

-dissociation: both awareness and emotion lost

hierarchical defense mechanism

immature or borderline coping strategies

-projection: external attribution of internal psych processes

-passive aggression: implicit aggression w/ intent of changing others behavior

-acting out: instinctive expression (toward another) to avoid awareness of cog or emotive process

Hierarchical defense mechanism

Psychotic coping strategies

-Projection: external attribution of internal psych processes and out of touch with reality

-denial: frank rejection of reality

-hierarchical defense mechanisms in the DSM-IV

-followed really successful adults  and assessed defense mechanism levels

-DSM-IV was decently reliable

-if clinicians are given disorders and told to sort and resort them you come up w/ an outline of where disorders fit from broad to more narrow (hierarchical)

Other hierarchical diagnostic system

(not defense mechanisms)

Dimensional approach

• Neuroticism: enduring tendency to have neg emotions
• extraversion: end tend to have positive emotions, especially w/ social relations
• opennesses to experience: end tend to show creativity and ingenuity
• agreeableness: end tend to be pleasent and accommodating in social situations
• conscientiousness: end tend to act w/ ones conscience

-FFM more reliable but validity worked into DSM bc of impairment criteria

But.. FFM is valid in that it converges w/ DSM

-psychometric methods can be used to assess FFM but not w/ DSM