PSYC 365: Chapter 9

Why have Clinical Psychologists virtually abandoned the terms “normal” and “abnormal”? 

• It was once commonplace to use the term “abnormal” to label behaviors, thoughts, and emotions (and even people) that seem to require intervention of one sort or another.

• Clinical psychology has evolved to recognize that human diversity and cultural diversity are too broad to be contained—or constrained—by the metaphor of abnormality

ADVANTAGES of the DSM-5-TR: 

1. Communication: some degree of compatibility when clients diagnosed by any mental health professional → Research sharing 

2. Research: diagnoses enables research involving clients with patterns of distress/dysfunction associated with similar disorders

3. Treatment: classification of mental disorders leads clinicians to administer effective treatment that follows less effective treatment procedures

LIMITATIONS of the DSM-5-TR: 

1. Reliability Issues: interrater reliability of many prevalent DSM-5-TR disorders remains fair – Reliability data raises concerns about validity of common disorders listed in DSM5

2. Use of Descriptive Criteria:  causes of disorders not well understood; DSM-5-TR describes signs and symptoms only → any behaviors could become a psychiatric illness 

3. Ambiguous Criteria: DSM-5-TR has ambiguous diagnostic criteria // conditions to meet criteria not specified // Clinicians provide own (varied) interpretations // threatens valid

4. Sociocultural Context: DSM-5-TR overlooks sociocultural context and clinical interpretations of mental illnesses (highlights impact of culture on diagnosis // contains a cultural formulation interview helping clients)

5. Categories Versus Dimensions: Validity threatened by lacing clients into diagnostic categories – Degrees/dimensions of atypical behavior in question 

6. Overinclusiveness: scope of some disorders too broad (some childhood difficulties included as mental disorders) 

7. Additional Concerns: “Disorder” and “symptom” suggest presence of (unsubstantiated) medical disease // Stigmatizing of persons, promoting essentialism // Creating an “untreatable” impression, and damaging social and professional relationships

DSM-5-TR : catalogs mental disorders 

• Disorders are classified by types, descriptions, and diagnostic criteria 

• Disorders influenced  by biological, developmental factors listed as beginning 

• Approximately 265 disorders listed; grouped in section II 

• Criteria include a disorders signs, symptoms, and associated features 

• Diagnostic codes given for ease of data collection and billing using International Classification of Diseases (ICD) 

DSM-5-TR Categories: 

• Neurodevelopmental Disorders – begin in childhood (e.g., autism, ADHD).

• Schizophrenia Spectrum and Other Psychotic Disorders – distortions in thinking/perception (e.g., schizophrenia).

• Bipolar and Related Disorders – mood swings between mania and depression.

• Depressive Disorders – persistent sadness, loss of interest (e.g., major depressive disorder).

• Anxiety Disorders – excessive fear or worry (e.g., generalized anxiety disorder, phobias).

• Obsessive-Compulsive and Related Disorders – repetitive thoughts/behaviors (e.g., OCD).

• Trauma- and Stressor-Related Disorders – following trauma or stress (e.g., PTSD).

• Personality Disorders – enduring maladaptive personality traits (e.g., borderline, antisocial).

• Substance-Related and Addictive Disorders – problems from drug or alcohol use.

DSM-5-TR Criteria

Symptoms must cause clinically significant distress or impairment
in social, occupational, academic, or other important areas of functioning

ICD-11

the worldwide standard for diagnosing and classifying all diseases, including mental disorders, while the DSM-5-TR is a more detailed manual used mainly by mental health professionals in North America

Exclusionary Criteria:

Conditions or factors that must NOT be present for a person to be diagnosed with a certain disorder. They help clinicians avoid misdiagnosis.

Research Domain Criteria (RDoC): 

an initiative of the national Institute of Mental Health  

• Promotes research integrating genetics, neuroscience, and behavioral science 

• Leads to objective diagnostic system of “biotypes” aligning with biologically based treatments 

• RDoC includes six domains with sets of constructs – Problems understood in terms of neurobiological processes to determine treatment

(1) Negative Valence Systems: response to adverse situations 

(2) Positive Valence Systems: response to receiving rewards

(3) Cognitive Systems: attention, perception, memory, communication, control

(4) Social Processes: how we relate to others 

(5) Arousal/Regulatory System: regulation of hunger, thirst, sleep, sex, energy

(6) Sensorimotor Systems: execution of motor behaviors 

In what ways do the Research Domain Criteria (RDoC) differ from the DSM-5- TR? 

• RDoC is dimensional; DSM-5-TR is categorical 

• RDoC approach works from the ground up starting with brain–behavior relationships and linking these to clinical signs and symptoms; DSM-5-TR works from the top down, starting with categories and determining what fits into those categories 

• RDoC is grounded in biological theory; DSM-5- TR is a descriptive diagnostic system

DRAWBACKS of the RDoC: 

• It conceptualizes psychological signs, symptoms primarily as dysfunctions in brain systems

•  The RDoC initiative privileges biological methodology, assuming their reliability and validity 

• The RDoC assumes identified domains, constructs are exclusively markers of psychological distress and dysfunction. 

• However, the RDoC brings together clinical and basic sciences to identify aspects of mental illness that span different areas including executive functioning, perception, and emotion

Case Formulation:

 a hypothesis about particular psychological mechanism leading to, maintaining psychological distress/dysfunction 

• It is principle-driven; is grounded in research-based psychological theories 

1. Problem List: outlines the presenting problem 

2. Hypothesis about Mechanisms: for treatment problems 

3. Predisposing factors: leading to psychological problems 

Precipitants: events that trigger/worsen clients problem

Multicultural Consideration: 

• Case formulation reflects sociocultural variables during the clinical interview

• Psychologists assess degree of clients assimilation or acculturation  

• Context of behavior within a broad context also assessed (behaviors atypical in one community may be considered adaptive on another)

Iterative Approach: 

• Psychologist gathers assessment data when case formulation is complete 

• Suggested intervention is based on client’s self- monitoring 

• Case formulation and treatment revised if other precipitating factors found 

• Process is iterative, as testing and revising formulation are repeated throughout treatment – Several iterations may be required to achieve desired results

Evaluation of the Case Formulation Approach 

Strengths: 

• Rooted in cognitive, behavioral theory; researched

• Tailored to suit individual clients (not all clients) // Considers sociocultural factors 

• Typical and atypical behaviors exist on continuums 

• Iterative approach allows revision of hypotheses 

Drawbacks: 

• Little research available evaluating case formulation: its usefulness and outcomes 

• Unknown reliability 

• Clinicians must remain updated on relevant research, theories

Treatment Planning:

• Selection of intervention guided by case formulation 

• Allows psychologist to devise a treatment course – Addresses hypothesized mechanisms identified in case formulation

Communicating the Treatment Plan:

• Clinician provides rationale for treatment plan // Explains risks and benefits to get client’s buy-in // Interventions and alternate plans discussed // Referral to psychiatrist if medications required

Monitoring Progress:

• Client and therapist collect data to monitor process and outcome of therapy – Formal and informal methods used 

• Allows client and therapist to monitor improvement, or modify treatment plan – An iterative process 

• Monitoring progress strengthens client-therapist relationship and confidence