Week 1: diagnosis of psychopathy and the mental status examination

What is psychopathy?

Study of mental disorders

Including efforts to understand their genetic, biological, psychological, and social causes; nosology; course across stages of development; manifestations; treatment

Same as differential diagnosis

Catch all term, general term for mental health problems

Nosology

Effective classification schemes

What is abnormal?

Hard to define

How do we know something is problematic?

Better question that “what is abnormal?”

Decreased/impaired functioning in 2+ areas of life

Distress (personal or interpersonal)

Be sure to compare client to themselves NOT others (their baseline)

How do we differentiate one problem from another?

Different symptoms and (potentially) causes

Carefully and consistently define what symptoms fall into each category

Reasons for diagnosis and classifications

Communication among professionals

Facilitates scientific research

Easy information retrieval

Should supply additional information about the person (description)

Prediction of future behavior

Why are diagnoses SO important?

A diagnosis means something to us

ex: depression = lack of sleep, withdrawal, low motivation, etc.

helps us create a hypothesis about other symptoms or behaviors

Reasons against diagnoses:

Not theoretically based (doesn’t tell us why it is happening)

May emphasize power differentials in the therapeutic relationship (we are holding the power of deciding how to label someone)

May encourage individuals to take a sick role (internalizing label and defining themselves as this label)

Every person and situation is unique (labels can obscure this individuality)

Diagnoses can be helpful BUT…

Is not perfect and does have drawbacks

Requirements for a classification system

1. Reliable and consistent between and within raters

2. Describes all domains of behaviors it includes

3. Categories are homogeneous

4. Has predictive and clinical validity

What does reliable and consistency between and within raters mean?

Enough detail and the ability to distinguish diagnoses so that raters can come to the same diagnosis

What does describing all domains of behavior mean?

It is thorough, it includes all information and details

What does categories are homogenous mean?

Each categories is clear and the diagnoses within it are similar AND it is different from the other categories

What does having predictive and clinical validity mean?

They meet ALL other 3 conditions

Usefulness

Types of classification systems

Hierarchical

Categorical

Dimensional

Hierarchical classification system

A major class of disorders that is divided into subtypes

Ex: anxiety —> GAD, specific phobia, separation anxiety

Categorical classification system

Distinct classes that are internally coherent

Different, distinct, little buckets

Dimensional classification systems

Multiple dimensions on which individuals are ordered

Score at different points on dimensions that are meaningful when put together (big five personality test)

What are the current classification systems?

Diagnostic and statistical manual of mental disorders

International classification of disease

DSM

Developed by the American Psychiatric Association

Primary system used in the US

Focused on mental disorders, through medical model lens

Currently on 5th edition (Text Revision)

ICD

Developed by the World Health Organization

Used primarily worldwide (used for billing in US)

Codes that translate to DSM diagnosis

Includes full range of medical and mental health problems (EVERYTHING)

10th edition in US, 11th edition everywhere else

DSM-I

1952

Theoretically based

Psychoanalytic

106 disorders

DSM-II

1968

182 disorders (broader range of dxs)

Still psychoanalytic

DSM-III

1980

Became medically focused

265 disorders (5 axes) (change in disorder names)

Assumed dxs were biologically caused

DSM-III-R

1987

Updated diagnostic criteria

DSM-IV

1994

Over 300 diagnoses

Began to rely on more research and less on experts (rich, white men)

Increased requirement for empiricism

DSM-IV-TR

2000

Text was updated but no major dx changes

DSM-5

2013

Changed several diagnoses (removed and added some dxs)

Eliminated the axes

Incorporated dimensional components (less categorical, more dimensional)

DM-5-TR

2022

Naming updates

Minor shifts in diagnoses and one new diagnoses

Development of the DSM

Evaluation through conferences

Task force and work groups conduct lit reviews and research

Propose revisions

Field trials conducted to establish reliability

Public comment period (then reviewed by work groups)

Draft new diagnostic criteria and text

Reviewed by executive committee and approved by APA board

What type of system is the DSM-5-TR?

Tried to make it all 3 systems

Hierarchical: neurocognitive disorders (since DSM-III)

Categorical: founded in this system

Dimensional: least used but we are beginning to think this way

Evaluating the DSM-5 as a classification system

Good communication among professionals

Facilitates scientific research

Easy information retrieval

Descriptive - supply additional information about the person

Predictive of future behavior

How do we obtain data for a diagnosis?

The big three:

1. Observations: looking at patient, their behavior, appearance, ways of interacting. What are they doing? What are they NOT doing?

2. Tests: assessments

3. Interviews: asking questions, listening to the answers

   Other: records, collateral information (parent, spouse, etc)

What is the mental status examinations?

Neuropsychiatric portion of a physical exam - not limited to psych

Consistently used by MH professionals in conjunction with clinical interview

Depth and specific content varies based on context

Simply a record of observations at a SPECIFIC time

Changes over time (these changes can be VERY meaningful)

Structure of the MSE:

10 basis areas:

Appearance, behavior, speech, mood and affect, thought process, thought content, perception, sensorium, cognition, judgement and insight

MSE Step 1: Appearance

General description of the patient

Sufficient detail

Include level of cooperation and attitude, grooming, physical characteristics, signs of illness/disease, gait, odor

MSE Step 2: Behavior

Level or cooperation/attitude, psychomotor activity, eye contact, mannerisms, ability to follow directions, compulsions

Can be vey specific and should include general behaviors and mannerisms

MSE Step 3: Speech

Quality and quantity (a lot or a little)

Rate (noticeably fast or slow)

Volume and pitch: could mean medical or mental issues

Fluency and rhythm: „um“ and/or „huh“, pauses or hesitations

NOT just content

MSE Step 4: Mood and Affect

Mood: what patient reports, durations, intensity, depth, changeability (euphoric, depressed, sad, anxious, fine, etc.)

Affect: what is observed by the clinician, visible display of emotion, varies over the course of interview, range, congruence with content, appropriateness, reactivity, facial expressions (flat, blunted, constricted, full)

MSE Step 5: thought process

How a person puts together ideas, the way they think, thought patterns

Loosening of associations, flight of ideas, racing thoughts, tangentially/circumstantiality, coherence, neologisms, thought blocking, vague vs clear

Looking for unusual thoughts or patterns

MSE Step 6: thought content

What a person is thinking

Looking for notable or clinically concerning content

Delusions (thoughts), ideas of reference, mistrustfulness, subclinical paranoia, preoccupations or obsessions, suicidal ideation, homicidal ideation, poverty of content (not a lot of thoughts, feel blank mentally)

MSE Step 7: perception

Generally related to the sensory system

Hallucinations (sensory), depersonalization and derealization

Types of hallucinations

Visual, auditory, gustatory, olfactory, tactile

Most common: auditory and visual

Circumstances of hallucinations

Hypnopompic or hypnogogic, severe stress, grief, etc

MSE Step 8: sensorium

May be early in report or later

Evaluation of gross brain function or wakefulness

How „on it“ is the person?

Level of awareness, interaction with environment, fluctuations (Comatose, alert, falling asleep)

Can be affected by substance used, medical treatment or conditions, etc

MSE Step 9: cognition

More specific measure of brain functioning

Orientation (time, place, person, situation), attention, memory, visuospatial skills, executive functioning, intelligence

What most standardizes mental status instruments measure (What „mental status measure“ is referring to)

MSE Step 10: judgement and insight

Judgement is related to real life events as assessed by history and/or hypothetical questions, based on px report of how the events were/would be handled

Insight is the awareness of illness and recognition of reality. Does the px have a good understanding of that is going on with them and/or their illness? (Denial, acceptance, behavior changes)