Clinical Psychology

Week 1, 2 & 3

What is Content Creep?

Clinical concepts and terms are increasingly used to refer to benign experiences and a broader range of experiences. E.g. Depression used to refer to normal experiences of sadness; trauma and harm concepts expanded.

What are umbrella terms?

Specific terms are commonly replaced in discourse with ‘mental health’, ‘mental illness’ or ‘distress’.

What is mental health?

State of mental well-being that enables people to cope with the stresses of life, realise their abilities, learn well and work well, and contribute to their community.

• Not just the absence of mental disorder, exists on a complex continuum, with varying degrees of difficulty and distress with different social and clinical outcomes.

What is a mental disorder?

DSM-5-TR: a syndrome characterised by clinically significant disturbance in an individual’s cognition, emotion regulation, or behaviour that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.

• Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities.

What is not a ‘Mental Disorder’?

An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder.

What is Wakefield’s Harmful Dysfunction Analysis (HDA)?

Defines mental disorder by two criteria:

Dysfunction — a failure of an internal neurobiological or mental mechanism to perform its natural (evolved) function.

Harm — this dysfunction results in harm judged by societal standards.

• This model combines biological facts with cultural values to define mental disorder.

What are the approaches to classification models?

Three primary approaches to classification models of mental disorder:

Categorical, Dimensional and Alternative.

What is a categorical model approach?

Divides psychological disorders into categories based on criteria sets with defining features.

What is a dimensional model approach?

Degrees of psychopathological phenomena occur along continuums.

What is an alternative model approach?

Models that do not focus on the mental health and illness concept.

What are the benefits of a categorical classification?

• Better clinical and administrative utility - clinicians are often required to make dichotomous decisions.

• Easier communication.

What are the benefits of a dimensional classification?

• Closely model lack of sharp boundaries between disorders, between disorders and normality.

• Have greater capacity to detect change, facilitate monitoring.

• Can develop treatment-relevant symptom targets-not simply aiming at resolution of disorder (most treatments actually target symptoms, not disorders).

What is the DSM-5-TR as a classification system?

Primarily categorical (disorder diagnoses) with some dimensional components (e.g. symptom severity rating, chapter organisation, new model of classifying personality disorder).

What are some of the diagnostic groupings of the DSM-5-TR?

• Schizophrenia spectrum and other psychotic disorders.

• Depressive disorders.

• Anxiety disorders.

• Dissociative disorders.

How is diagnosis informed? (DSM-5-TR)

Clinical Interviews - clinician and client semi-/structured.

Text Descriptions - in DSM covering how disorders present.

Diagnostic Criteria - does presentation match checklist.

What are the elements of diagnosis? (DSM-5-TR)

• Currently presenting symptoms and severity.

• Rule out disorder due to general medical condition.

• Rule out disorder due to direct effects of a substance.

• Establish boundary with no mental disorder: Clinical significance/Cultural norms.

• Determine specific primary disorder(s): Multiple diagnoses possible.

• Add subtypes/specifiers:

- Severity (mild moderate, severe — with or without psychotic features).

- Treatment relevant (poor insight, atypical, etc.).

- Longitudinal course (with/without full inter-episode recovery, seasonal pattern).

What is a Clinical Picture?

• The psychologist’s comprehensive integration of the client’s symptoms, behaviours, environmental circumstances and life history, styles of thinking, and more.

• The process of developing a clinical picture helps a psychologist understand what a person is experiencing and why.

• A clinical picture is dynamic. It can change as a patient progresses through therapy or as their life circumstances shift.

• A well-developed clinical picture ensures the patient is seen as a whole person, rather than a collection of checkboxes in a diagnostic manual.

Why does the clinical picture matter?

It serves three vital functions: differential diagnosis, case formulation and treatment planning.

What is differential diagnosis?

Many disorders share features. The clinical picture helps rule out “look-alikes".

What is case formulation?

It moves beyond what the person is experiencing to why. This helps in understanding the underlying “mechanisms” of the client’s distress.

What is treatment planning?

Comprehensive information, brought together by the psychologist using their clinical expertise, is likely to result in better treatment plan development.

Case Formulation - What is the presenting problem?

• The client’s reason for coming to therapy.

• The presenting problem is almost always a symptom (subjective experience of client).

• In addition, the clinician discovers the signs (observable to psychologist).

• Symptoms could become the focus or perhaps represent an underlying problem the client hasn’t recognised or considered needing help with.

The Four “P” Model:

The Four P model represents one important way that we can conceptualise clients and their PRESENTING PROBLEMS in the context of their lives. The four P factors comprising this model are:

Predisposing Factors: Factors over a person’s lifetime that may have contributed to development of the presenting problems.

Precipitating Factors: Triggers or events that have initiated or exacerbated the presenting problem.

Perpetuating Factors: Factors that are maintaining the presenting problems.

Protective Factors: What resource areas available to help?

What is the biopsychosocial paradigm?

A systemic approach to understanding client’s problems and life history in biological, psychological, and social/environmental terms.

Non-medical Perspectives - Cultural models: What is the Australian First Nations Model of Social and Emotional Wellbeing?

Culture can influence Aboriginal and Torres Strait Islander people’s decisions about when and why they should seek health services, their acceptance of treatment, the likelihood of adherence to treatment and follow up, and the likely success of prevention and health promotion strategies.

Anti-Psychiatry Perspectives — What do some psychiatrists think?

What do some social theorists think?

Thomas Szasz: Mental illness is a myth (e.g. no disease identified).

J.D. Laing: Psychiatry inappropriately pathologies human distress (e.g. schizophrenia symptoms are a normal response to adversity).

Cultural Model: What is Mad Pride?

• A social and political movement.

• Grounded in protest and challenge of stigma, discrimination, and historical psychiatric practices that infringe on human rights.

• Pride in the self as a complex whole that incorporates madness into identity.

• Reclamation of pejorative terminology. Parallels with LGBTQIA+ Pride movement.

What is culture and psychopathology?

Shared patterns of meaning that are learned within a particular social world.

How to consider culture in the process of psychological practice:

• Understanding the influence of culture on how psychological symptoms are expressed and what is considered to be disorder.

• Understanding the cultural identity of individual clients.

• Being aware of cultural explanations of the individual’s experiences.

• Understanding cultural expectations related to psychological experience and levels of functioning.

• Being mindful of cultural elements of the relationship between the individual and the clinician.

How has Hippocrates influenced medicine? (460-370 BCE)

• Considered the father of Western empirical medicine.

• Rejected supernatural theories of psychopathology.

• Proposed biological, psychological, and social/environmental factors were key to mental illness, prevention, and treatment.

• Imbalance of ‘humors’ (bodily fluids — blood, phlegm, black bile, yellow bile).

• Described mania, melancholy, phrenitis (delirium — inflammation), insanity, paranoia, panic, epilepsy, hysteria and more.

Hippocrates, Hysteria, and the Wandering Womb: What is ‘hysteria’? (in the past)

Hysteria - a ‘female condition’ or a gendered tool to pathologise and control non-conformity?

What did Hippocrates believe?

A broad range of symptoms thought to reflect a ‘wandering womb’. Therefore, only females could be afflicted. Treatment was ‘scent therapy’, sexual activity, pregnancy.

What was believed about the womb in 16th/17th century?

Sexual deprivation or excess fluid in uterus required sexual activity and pregnancy as treatment.

What was believed about the womb in the 19th century?

A catch-all psychological diagnosis for women who defied social norms or male authority. Symptoms ranged from emotional outbursts to physical issues (conversion) to non-conforming behaviour.

• Created and maintained stereotypes of women as irrational and overly emotional.

• Abandoned as a disorder concept due to gender bias and a lack of clinical precision. (but - Functional Neurological Symptom Disorder in DSM).

What is homosexuality as pathological?

Indicative as a sign of a biological defect, developmental failure, morally bad, sinful, a social evil.

Influenced by:

• Powerful institutions - religion (sin) and legal/justice (crime).

• Darwinism & more.

What are culturally-bound syndromes?

A cluster or group of co-occurring relatively invariant symptoms found in a specific cultural group, community, or context.

• Often conceptualised as an illness/affliction within the culture, but not always.

• Often has a cultural explanation, name, method of treatment, and more.

What does longing for country cultivate?

Problems associated with spiritual disconnection Aboriginal people experience when separated or removed from traditional lands.

1. Physical ill health, including weakness, nausea, general “sickness” and somatic complaints;

2. Spiritual ill health;

3. Cognitive disorientation, dissociative fugue;

4. Cultural “ill health” including identity confusion, disorientation, acculturative stress.

What are the four primary domains of stigma (about mental health problems)?

1. Public stigma.

2. Internalised stigma.

3. Structural stigma.

4. Courtesy stigma (stigma by association - e.g. family members).

Intersectional stigma is a fifth and related domain.

What is public stigma?

• Links beliefs, emotions and behaviours.

• Negative stereotyped beliefs, prejudicial emotions and discriminatory behavioural responses relating to people living with mental health problems.

What is structural stigma?

• Built into society’s rules.

• Refers to societal-level laws, systems and practices that discriminate against people living with mental illness.

How do laws create structural stigma?

Formal rules can permit or produce unequal treatment.

Example: In Australia, a person assessed as mentally disordered can be detained and treated involuntarily if deemed necessary.

How do policies create structural stigma?

Organisational requirements can create exclusion or disadvantage.

Example: Life insurers may impose higher premiums, condition-specific exclusions or benefit limits after someone discloses a past or current mental health condition.

How do systems create structural stigma?

Access pathways and institutional arrangements can embed inequity.

Example: Chronic underfunding of mental healthcare relative to physical healthcare produces poorer access and longer waiting times.

How do practices create structural stigma?

Routine procedures can discriminate even without explicit prejudice.

Example: Health professionals sometimes dismiss or attribute physical symptoms to a person’s. mental illness (known as diagnostic overshadowing) rather than adequately investigating them.

What is Corrigan’s Paradox?

• Stigma may damage or energise.

• People may: experience damaged self-esteem, react with protest and righteous anger or seem indifferent.

• Explained by: awareness, agreement (context is important), and group affiliation (identity).

What is stigma by association?

How do other barriers affect stigma?

What works to reduce stigma and discrimination?

Positive contact: with people with lived experience.

Psychoeducation: improving knowledge and understanding about mental health problems, support, treatment, and recovery, and about stigma’s harmful effects. This dispels myth, builds our capacity to support others and ourselves. Sophistication is required.

Modelling: of support and helping behaviours.

Storytelling: with recovery narratives.

Human rights: education.

Coming out: Disclosure.

Connection: with community.

• Individual and group psychological therapies are useful to address internalisation of stigma, including cognitive, acceptance-based, narrative enhancement, self-compassion approaches.

What is mood?

A pervasive and sustained ‘background’ emotional state.

• Subjectively experienced and described by the person.

• Examples: depressed, anxious, irritable, euphoric.

What is affect?

The observable expression of emotion.

• Assessed by the clinician during interaction.

• Described in terms of range, intensity, stability, and appropriateness.

• Examples: flat, constricted, labile, congruent.

What is the DSM-5 Major Depressive Episode Criteria?

Five or more symptoms present for > 2 weeks:

• Depressed mood.

• Anhedonia.

• Decrease or increase in appetite OR significant weight loss or gain.

• Persistently increased or decreased sleep.

• Psychomotor agitation or retardation.

• Fatigue or low energy.

• Feelings of worthlessness or inappropriate guilt.

• Decreased concentration or indecisiveness.

• Recurrent thoughts of death, suicidal ideation, or suicide attempt.

What are the DSM-5 Major Depressive episode specifiers?

• Psychotic features (mood congruent or mood incongruent).

• Melancholic features.

• Catatonic features.

• Postpartum onset.

• Anxious distress.

• Seasonal pattern (Seasonal Affective Disorder [SAD] or winter depression).

What is the disorder criteria for ‘Major Depressive Disorder’?

• Presence of a major depressive episode.

• Episode not better explained by another diagnosis.

• No history of mania, hypomania, or mixed episode (unless substance or medical illness related).

What are predisposing risk factors?

Increases susceptibility to a specific mental disorder.

What are precipitating risk factors?

Increases susceptibility to and contributes to the occurrence of a specific mental disorder.

• Precipitating factors are the immediate factors or events that have caused the individual to experience symptoms ‘now’.

What are perpetuating risk factors?

Maintains the occurrence of a specific mental disorder and inhibits recovery. These are the factors that are causing a person’s symptoms to continue or progressively worsen.

What are protective factors?

Any characteristic or event that reduces the likelihood of the occurrence or recurrence of a mental disorder, either on its own or when risk factors are present.

What are anxiety and anxiety-related disorders?

• Panic disorder (PD).

• Generalised anxiety disorder (GAD).

What is a panic disorder?

A. Recurrent unexpected panic attacks.

Panic Attack - an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:

1. Palpitations, pounding heart, or accelerated heart rate.

2. Sweating.

3. Trembling or shaking.

4. Shortness of breath or smothering.

5. Feelings of choking.

6. Chest pain or discomfort.

7. Nausea or abdominal distress.

8. Feeling dizzy, unsteady, light-headed, or faint.

9. Chills or heat sensations.

10. Parethesias (numbness or tingling sensations).

11. Derealisation (feelings of unreality) or depersonalisation (being detached from oneself).

12. Fear of losing control or going crazy.

13. Fear of dying.

What is the criteria for a panic disorder?

B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:

• Persistent concern or worry about additional panic attacks or their consequences.

• A significant maladaptive change in behaviour related to the attacks.

C. The disturbance is not attributable to the physiological effects of a substance or other medical condition.

D. The disturbance is not better explained by another mental disorder.

What is Generalised Anxiety Disorder (GAD)?

A. Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities.

B. The individual finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):

1. Restlessness or feeling keyed up or on edge.

2. Being easily fatigued.

3. Difficulty concentrating or mind going blank.

4. Irritability.

5. Muscle tension.

6. Sleep disturbance.

What do people with GAD experience?

• Excessive worry more days than not:

• For at least 6 months.

• About a number of events.

• Difficult to control the worry.

3 or more of the following symptoms:

• Restlessness, easily fatigued, difficulty concentrating, irritable, muscle tensions, sleep disturbance.

What is the Tripartite Model of Depression and Anxiety?

One model that attempts to explain why anxiety and depression can co-occur yet also have distinguishing features.

Negative Affect:

• General distress, negative emotions.

• Common to both anxiety and depression.

Positive Affect:

• Low PA (anhedonia, lack of pleasure) is specific to depression.

Anxious Arousal:

• Physical symptoms like tension, palpitations, sweating.

• More specific to anxiety.

How does the DSM and HiTOP compare?

E.g. James, a 35 year old, struggles with excessive worry, restlessness, and muscle tension. These are prominent symptoms of GAD. Over time, he also develops persistent sadness, low energy, and feelings of worthlessness. These are common symptoms of ‘major depressive disorder’.

• The DSM model sees this as two separate disorders that are co-occurring. Treatment might focus on two distinct conditions.

• The HiTOP model sees these as part of a shared internalising spectrum rather than two separate disorders. Treatment could focus on core emotional dysregulation rather than treating two distinct conditions.

Biological Models - What is the HPA Axis?

• Consists of the hypothalamus, pituitary gland, and adrenal glands.

• It regulates the body’s response to stress by controlling cortisol release.

• Under normal conditions, the HPA Axis also helps maintain homeostasis, control inflammation, control circadian rhythms and more.

How can the HPA Axis be negatively impacted?

• Chronic stress can lead to prolonged activation of the HPA axis, raising cortisol levels.

• Dysregulation disrupts stress hormone balance and affects neurotransmitters.

• Linked to mood changes and alterations in brain structures like the hippocampus.

• Overactivation heightens arousal and vigilance, increasing worry and fear responses.

What is Beck’s Core Mechanism: The Negative Cognitive Triad?

• In Beck’s cognitive model, depression develops and is maintained by biased patterns of thinking.

• E.g. unhelpful automatic thoughts arise quickly in response to life events and feel true. They reinforce depression.

• Negative view of self - negative view of world and negative view of future.

What is psychosis?

• Umbrella term meaning ‘out of touch with reality’.

• Can refer to a variety of clusters of symptoms.

• These symptoms can occur not only in schizophrenia spectrum disorders, but also in a range of disorders including:

• Organic presentations like dementia.

• Substance use: amphetamine psychosis, and so on.

How are varying psychosis disorders separated from one another?

Symptom configuration - delusional beliefs that are either non-bizarre or bizarre delusions.

Duration - < or > than 6 months.

Relative pervasiveness. - in terms of both duration and the clinical picture - of psychotic symptoms versus affective symptoms. Which is the core?

What is schizophrenia?

• Refers to split mindedness.

• It is not multiple personalities.

• Involves disruption in various aspects of perceiving, thinking, feeling and behaviour. Phenomena associated with schizophrenia can be classified into two major groups of symptoms — positive symptoms and negative symptoms.

Positive symptoms — additive to normal experience.

Negative symptoms — deficit in normal function.

What are the positive symptoms of psychosis?

Hallucinations

• A perception in the absence of environmental stimuli.

• Hallucinations occur in any sensory modality, of which auditory is the most common then visual.

Delusions

• A fixed and false belief that is not amendable to change in light of conflicting evidence.

• Can be bizarre or non-bizarre.

What are the different types of delusions?

Persecutory, grandiose, erotomanic, somatic, nihilistic, referential.

What are persecutory delusions?

Belief that others are spying on or planning to harm them.

What are grandiose delusions?

Belief in having exceptional abilities or fame.

What are erotomanic delusions?

Belief that. someone, often of higher status, is in love with them.

What are somatic delusions?

False belief about body function or sensation.

What are nihilistic delusions?

Belief that oneself, others, or the world does not exist.

What are referential delusions?

Belief that ordinary events have special personal meaning.

What are negative symptoms of psychosis?

Avolition — lack of motivation to achieve goals.

Alogia — includes poverty of speech (less speech than normal), poverty of content of speech (less content than normal - vague), latency of speech and thought blocking.

Anhedonia —inability to experience pleasure.

Affective flattening — dulled emotional expression.

Inattention — disturbance in selective attention.

What are some other symptoms of psychosis?

Catatonia - immobility, rigidity, and unusual posturing, as well as abnormal speech and movement patterns.

Incongruent and inappropriate affect — display incongruent with person’s emotion or inappropriate to context.

Bizarre behaviour — no rational basis.

What is the diagnostic criteria for schizophrenia?

A. Two (or more) of the following, each present for a significant portion of time during a 1 month period. At least one of these must be (1), (2), or (3):

1. Delusions.

2. Hallucinations.

3. Disorganised speech.

4. Grossly disorganised or catatonic behaviour.

5. Negative symptoms.

What is the history of psychosis/schizophrenia?

Descriptions of psychotic experiences occur throughout historical and religious texts. Explanations of psychosis in these sources are often supernatural.

What did Benedict Augustine Morel discover about schizophrenia?

• Morel was first to rigorously describe what we now understand as schizophrenia.

• His observations focused on individuals exhibiting a specific set of symptoms, marked by an early onset and a deteriorating course of illness.

• He recognised the progressive nature of the disorder, which led to the term “demence precoce” (early dementia), referring to the early onset of cognitive decline.

How did Emil Kraepelin change dementia?

Key features of dementia praecox for Kraepelin were:

Early onset: Symptoms typically appear in late adolescence or early adulthood.

Progressive deterioration: The illness often leads to cognitive decline over time.

Symptom clusters: Focused on the hallucinations, delusions, emotional dysfunction, and cognitive impairments.

Distinction from other disorders: Kraepelin differentiated schizophrenia from manic-depressive psychosis (bipolar disorder) and others based on the course and long-term outcome.

What was Paul Eugen Bleuler’s view on schizophrenia?

Disagreed with Kraepelin — based on his observation that schizophrenia does not necessarily display early onset, deteriorating course and therefore not characteristic of a dementia.

What is part B of the schizophrenia diagnostic criteria?

For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).

What is part C of the schizophrenia diagnostic criteria?

Continuous signs of the disturbance persist for at least 6 months. This 6 month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

What is part D of the schizophrenia diagnostic criteria?

Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.

What is part E of the schizophrenia diagnostic criteria?

The disturbance is not attributable to the physiological effects of a substance or another medical condition.

What is part F of the schizophrenia diagnostic criteria?

If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).

For schizophrenia, what must be used to identify an episode?

Specify if:

The following course specifiers are only to be used after a 1 year duration of the disorder and if they are not in contradiction to the diagnostic course criteria.

What is a first episode (currently in acute episode)?

First manifestation of the disorder meeting the defining diagnostic symptom and time criteria. An acute episode is a time period in which the symptom criteria are fulfilled.

What is a first episode (currently in partial remission)?

Partial remission is a period of time during which an improvement after a previous episode is maintained and in which the defining criteria of the disorder are partially fulfilled.

What is a first episode (currently in full remission)?

Full remission is a period of time after a previous episode during which no disorder-specific symptoms are present.

What are multiple episodes (currently in acute remission)?

Multiple episodes may be determined after a minimum of two episodes.

What are the other types of multiple episodes?

Currently in partial remission & currently in full remission.

Why must the symptoms be continuous?

Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the majority of the illness course, with subthreshold symptom periods being very brief relative to the overall course.

What are the Four A’s?

Emphasised splitting of associative processes in thought, affect and action — this is seen as the core of the disorder. Four “A’s” were Bleuler’s primary symptoms.

1. Association

2. Affect

3. Ambivalence

4. Autism

What is association?

1. (disorganised thinking)— impaired logical connections in thought, leading to disorganised speech and thought disorder.