Psychopathology 1

What is psychopathology?

The scientific study of psychological disorders (symptoms, development, contributing factors, treatment); also used for patterns of thought, feeling or behaviour that disrupt functioning or wellbeing

Why do psychologists increasingly prefer 'psychopathology' to 'abnormal behaviour'?

It has been misused to justify discrimination, wrongly implies a clear boundary (experiences are on a continuum), and is stigmatising; we ask whether behaviour is problematic instead

What are two examples of 'abnormal' being misused to justify control?

Homosexuality listed as a DSM disorder until 1973; 'sluggish schizophrenia' used to detain political dissidents in the Soviet Union

What indicators do we use to decide when behaviour is problematic?

Subjective distress, dysfunction/maladaptiveness, deviancy, dangerousness, and irrationality/unpredictability

Why isn't subjective distress enough on its own?

Distress is common and expected after adversity, and may be absent in some disorders (e.g. some personality disorders, mania)

Why isn't dysfunction/maladaptiveness enough on its own?

Impairment may be expected and temporary, depends on culture and context, and some people with intense distress still function well

Why isn't deviancy enough on its own?

Many rare or norm-violating behaviours aren't pathological (e.g. talent, off-grid living), many symptoms are common, and norms vary across time and culture

Why isn't dangerousness enough on its own?

Many dangerous activities aren't pathological, and most people with mental disorders are not dangerous; risk is a separate clinical consideration

Why isn't irrationality/unpredictability enough on its own?

What counts as irrational is subjective and relative to norms (e.g. buying Powerball tickets), and not all disorders involve irrationality

Distinguish mental health, mental health problems and mental disorders.

Mental health = wellbeing and coping with normal stresses; mental health problems = difficulties that impair functioning; mental disorders = clinically recognisable patterns of significant distress and impairment, often requiring treatment

How does culture affect judgements about psychopathology?

It shapes which behaviours seem unusual and how distress is expressed and recognised, but cultures aren't uniform, so avoid blanket statements

How does context matter even for behaviours considered odd across most cultures?

Even behaviours seen as odd across most cultures (drinking urine, public defecation) aren't pathological in circumstances like being stranded without water or a toilet

What is common about depression across cultures?

Hopelessness, sadness, low energy, poor sleep and worthlessness questions worked well in all eight settings; physical symptoms like fatigue and disturbed sleep accompany low mood across cultures

How can depression vary within a culture?

Within groups it varies too: among older Chinese adults low mood may be uncommon, with urban people reporting sleep problems, fatigue and irritability and rural people reporting tearfulness, poor concentration and loss of interest

Why does language matter for identifying depression?

People may not use the word 'depression' (e.g. 'black days'), so surveys can miss them and prevalence comparisons between cultures can be misleading

How can gender and culture combine to shape depression?

Men may hide depression and show risk-taking or aggression; Central Desert Aboriginal men described anger, a weakened spirit, irritability, substance use ('slack', 'shame'), which standard PHQ-9 items missed

How should a health service screen for depression in a community whose culture and language differ from the questionnaire's origin?

Learn how the community experiences depression, check symptom fit, tailor the existing measure with lived experience, and include physical symptoms

A headline says postnatal depression is four times more common in Taiwan than Australia. What is the best response?

Be sceptical and check whether the figures were produced with appropriate methods before accepting the gap as real

What is diagnosis useful for?

Identifying problems, planning interventions, building research knowledge, efficient communication between clinicians, and access to care and resources

How do diagnoses function in the health system?

They can be required for insurance, mental health plans and service access, and help clinicians judge if they have the skills to take a client

What is reification, and why is it a problem?

Treating a diagnostic label as a concrete thing inside a person; it's circular to say symptoms are caused by the diagnosis, because the symptoms are the basis of the label

Which statement is an example of reification?

'His concentration problems are caused by his ADHD' (the label is treated as the cause)

Why is a diagnosis a description, not an explanation?

A diagnosis describes a pattern and guides which research and treatments to consult, but doesn't explain why this person developed it; treat it as a working description and starting point

Why can't we validate mental disorders like physical illnesses?

No independent biological markers or definitive tests exist for mental disorders, so validity is judged by usefulness (description, treatment guidance, predicting course)

In this module, what makes a diagnosis more valid?

Clear clinical description, laboratory research findings, natural history (likely course), and family studies

What are a nosology and a 'zone of rarity'?

Nosology: a classification system grouping symptoms that hang together. Zone of rarity: a rare 'in-between' zone separating natural clusters (which mental health diagnoses usually lack)

How does the DSM's categorical structure differ from reality?

Tidy categories, but real disorders overlap (shared symptoms, comorbidity, varied presentations), so many work like prototypes with multiple ways to qualify

What are the MDD criteria, and what does the 227-ways figure show?

At least 5 of 9 symptoms in the same two weeks (including depressed mood or loss of interest), a change from previous functioning, causing significant distress/impairment; 227 possible symptom combinations

What two criticisms does the 227-ways example illustrate?

Too broad (very different presentations share a label) and too narrow (a single label hides differences), promoting reductionistic thinking

Why can diagnostic thresholds feel arbitrary (the 'crayon' problem)?

Symptoms lie on a continuum, so thresholds aren't natural breaks (scoring 38 vs 39 is a trivial difference); dimensional severity ratings address this

How do the 4 Ds map onto the DSM-5-TR definition of a mental disorder?

Distress and dysfunction are central; deviance appears only as a caution (not a disorder unless due to dysfunction); dangerousness has no place in the definition

What is the DSM-5-TR definition of a mental disorder?

A syndrome of clinically significant disturbance in cognition, emotion regulation or behaviour reflecting underlying dysfunction, usually with significant distress/disability; excludes expectable or culturally approved responses and mere social deviance

Why is it hard to decide whether intense grief is a disorder?

Grief can look clinically significant but may be an expectable response; thresholds are unclear, reducing reliability, so clinical judgement is needed

Compare the DSM and ICD: who publishes them and where are they used?

DSM: published by the American Psychiatric Association, used mainly in the US and heavily in research. ICD: published by the WHO, globally applicable, used by most countries and clinicians

What did the global survey of psychiatrists find about DSM vs ICD use?

About 70% use ICD and 23% use DSM; ICD use is lower in the USA (~1%) and Australia (~15%); clinicians favour ICD and researchers favour DSM

Where did the ICD come from?

It began in 1853 as a classification of causes of death, expanded to illness (morbidity), was taken over by the WHO in 1948, ICD-6 added psychiatric disorders; current version is ICD-11

What is the history of the DSM before 1952?

US census counting (1840), APA hospital manual (1917-1923), Army's Medical 203 (1945), then DSM-I in 1952

Why did the 1971 US-UK Diagnostic Project matter?

American psychiatrists diagnosed schizophrenia much more broadly than British ones, so findings don't line up and prevalence is hard to interpret

What was DSM-III's (1980) central innovation?

For the first time each disorder was operationally defined with specific symptoms and diagnostic thresholds; US insurers adopted it and research expanded rapidly

What happened in DSM-IV (1994) and DSM-5 (2013)?

DSM-IV required research for changes and disorders proliferated; DSM-5 aimed for biomarkers and dimensional diagnoses but achieved little because neuroscience wasn't ready and dimensional assessment was vetoed

What was DSM-5-TR (2022)?

Mostly minor changes (corrections, clarifications); added prolonged grief disorder; DSM-5 and DSM-5-TR criteria are generally not meaningfully different

Why does the number of DSM diagnoses differ across editions?

Counting methods differ, and the rise likely reflects splitting broad categories into subtypes rather than genuinely new disorders

Why do the DSM and ICD still differ despite 'harmonisation'?

They have overlapping authors and push toward harmonisation, but differences remain, reflecting different priorities, histories and authorship

Why should the DSM and ICD be used thoughtfully rather than mechanically?

They are tools made by committees and shaped by history, not gospel or a cookbook; clinical judgement and training are needed, and criteria change as science evolves

Case (Alex): apply the 4 Ds.

Distress and dysfunction clearly present; deviance judged in cultural context; no indication of danger but hopelessness and withdrawal need monitoring; the 4 Ds alone don't establish a disorder

Case (Alex): which MDD symptoms does the case support?

Six supported (low mood, reduced appetite, sleep disturbance, fatigue, poor concentration, worthlessness/guilt); anhedonia unclear; psychomotor changes and thoughts of death not mentioned (not the same as absent)

Case (Alex): are the two-week and impairment criteria met?

Yes: symptoms are present in the same two weeks with a clear change from previous functioning; impairment (missed classes, avoidance, withdrawal) counts, but circumstances like the commute or shared room are hardship, not impairment

Case (Alex): what should a clinician check before settling on MDD?

Mania/hypomania history, substance or medical causes, better fit with adjustment or anxiety disorder, and suicide risk; the family's agreement is not a rule-out

Case (Alex): what are the benefits of the MDD label?

Reduces shame and self-blame, opens doors to supports (GP plans, university considerations), guides a plan, and makes the experience less mysterious; helps clinicians communicate and structure assessment

Case (Alex): what are the limitations and risks of the MDD label?

It doesn't explain causes or maintaining factors, MDD is a broad prototype, it may imply medication is the answer, thresholds are arbitrary (affecting access), it can feel stigmatising, and clinicians risk reification, over-reliance and misclassification

Case (Alex): he asks 'Why is this happening to me?' Why doesn't the diagnosis answer that?

The label only describes his symptoms (it's circular as an explanation); a real answer looks at overload, sleep, money, isolation, the avoidance cycle and beliefs about asking for help

What is the balanced take-home view on diagnostic categories?

Distress ≠ disorder; no single indicator suffices; context shapes presentation and recognition; a diagnosis describes rather than explains, so use it as a starting point