PYB306 Psychopathology 2025

Week 1: Introduction

Changes in the DSM

- Steady increase in pages (947 to 1050 from 20212 to 2022)

- Major increase in cost over 70 years

- DSM increased by only 1 diagnostic category between 2012 and 2022

* Latest release in TR (Text Revision): comprehensively update the descriptive text that is provided for each DSm disorder based on reviews of the literature

What is the DSM-5 and its approach

Diagnostic and Statistical Manual for Mental Disorders, 5th edition (text revision)

Heavily reliant on the harmful consequences (either subjective distress or impairment) and utilises the notion of a syndrome (a cluster of associated features that are recognised through the evaluation of signs and/or symptoms)

Signs are observed in the 'patient' by the diagnostician

Symptoms are reported by the person to the diagnostician

DSM Imperfections

• Process criticisms (field trials, composition of task force).

• The lowering of diagnostic thresholds → pathologising human behaviour

• The introduction of new disorders without a clear scientific basis

• Failure to test/demonstrate validity of diagnostic categories

• Reification of 'disorders'

• Failure to deliver on the promise of neuroscience

• The reduced 'reliability' of many diagnoses

Why use the DSM

• Widely used (ensures common language of diagnosing disorders across healthcare professionals)

• Long History

• An exemplar of an approach

• Learning benefit from "critical acceptance and the controvery

Other classification systems

- The World Health Organisation's International Classification of Diseases

- US NIMH Research Domains Criteria

What is Pyschopathology

- Generally used as a term to describe abnormal behaviour/functioning

- The manifestation of mental disorders/conditions/illnesses

- The science or study of mental disorders

Implications of Psychopathology

Psychologists and students of psychopathology can/should function as scientist-practitioners

i.e. as users/evalautors of science, as contributors to science, via the inegration of science with practice/ to acheive practice-related/relevant objectives

7 possible indicators of psychopathology

1. statistical deviance

2. violation of social norms

3. subjective distress

4. maladaptiveness

5. social discomfort

6. irrational or unpredictable

7. dangerousness

Challanges of psychopathological indicators

1. causes subjective distress - the role of insight?

2. Many people need adjustments to perform daily tasks

3. if statistical rarity is used, how rare should it be? is a rare behaviour necessarily harmful/deviant/distressing? are common behaviours necessarily unharmful etc?

4. social and cultural values change and they require a reference point

Another view of psychopathology

That it arises from "harmful" dysfunction (Wakefield)

A physical or mental mechanism cannot perform its natural/normal function, which causes harm to the person considering the culutre in which they lives

Implies: not every such dysfunction leads to a disorder or is "harmful"... provides for cultural consideration

DSM-5 Definition

"A mental disorder is a syndrome characterised by a 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 function"

What is abnormal behaviour

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

NOT

"an expectable or culturally sanctioned response" nor the product of "social deviance or conflicts with society"

What is not DSM-5 Mental illness

- an expectable and culturally sanctioned response to a particular event (such as the death of a loved one)

- Socially deviant behaviour (such as the actions of political, religious, or sexual minorities)

- Conflicts that are between the individual and society (such as voluntary efforts to express individuality)

Epidemiology

- the scientific study of the frequency & distribution of disorders within a population

- Epidemiological data tell us which disorders are most common

Incidence definition

The number of new cases that appear in a population during a specific time period (e.g. per year)

Prevalance Definition

The number of active cases of a disorders in a population during a specific period

Lifetime Prevalence definition

Total proportion of people from a population who will have the disorder at some point in their lifetime

Other terms: point prevalence, 1-year prevalence

2007 National Survey of Mental Health & Wellbeing (Australia) findings

- 45% of all Australians aged 16-85 will experience a mental health-related disorder during their lifetimes

- Most common conditions: depresssion, anxiety, & substance use

- almost one in 5 adult Australians met criteria for a mental disorder during the 12 months prior to the survey

- More than 3 million Australians experience symptoms of a mental disorder each year

WHO Global Burden of Disease Study: findings

globally, mental illness

- causes 1% of deaths

- Accounts for 47% & 38% of disability in developed and un-(or under-) developed countries

Approaches used to gather information about mendal disorders

- Case studies

- Self-report data

- observational approaches

Lecture 1: Summary Part 1

Lecture 1: Summary Part 2

GO READ

Chapter 1, 2 & 3 Summaries

Week 2: Assessmen & Treatment Principles

Diagnosis

identification of a disease

Prognosis

a forecast of the probable course and outcome of a disease or situation

Differential Diagnosis

a list of potential diagnoses compiled early in the assessment of the patient

Provisional Diagnosis

a temporary diagnosis pending further examination or testing

Multi-axial system

- the DSM-IV organizes each psychiatric diagnosis into 5 levels or axes

Purpose(s) of Assessment

The purpose of Psychopathology assessment including how it is framed and delivered, depends to an extent on the underpinning paradigm

It may include a diagnosis:

• To determine if psychopathology is present, and if so, the type

• To help characterise (or feed into a formulation) - build

understanding of the 'problem'

• To inform treatment planning/priorities

• To establish a baseline against which 'change' might be

monitored

• To establish a shared language from which to progress

Purpose of Assessment ll

• A diagnosis may be "required" because

of contextual factors (e.g., to gain access

to the health system)

• For individuals there may be pros and

cons associated with diagnoses

• Accurate diagnosis is important and can

be difficult, and diagnoses carry different

meanings for different people

Principles of Assessment

Since symptoms in psychopathology are rarely

pathognomic, and instead, the same feature

might be common across several conditions, we

need some principles to guide diagnostic

assessments.

Psychologists may consider the reliability &

validity of

• diagnostic entities (DSM categories)

• the underpinning information (e.g., method of

assessment [self report, test, other]), and its

reliability validity)

• verification of information (e.g., corroborated,

converging, or gaps?)

• how the data are combined (e.g., checked for

biases, plausible given other the known facts,

resolving discrepancies).

Reliability

measurement consistency (e.g.,

interrater reliability or diagnostic agreement,

kappa)

Validity

degree to which a test / system measures

what it is intended to measure (e.g., convergent

validity, predictive validity)

Standardisation

a fixed procedure (or prescription)

for application of methods ensuring/increasing

measurement consistency (affects how tests are

administered, scored, and reported).

The Clinical Interview

*involves client (and if consent permits, may

include significant others)

*enables collection of:

• A wide variety of information (client's view

of problem/symptoms; subjective

distress/impairment)

• Different types of information (clinical

observations, signs, mental status - mental

status exam - may involve role playing

"show me how...")

Potentially covers

- family history/geogram

- Strengths, resources, supports

Pyschological Tests

Many feature standardisation &

normative data; have known psychometric properties,

including reliability.

Tests with normative data can be useful for assessing

severity relative to "normal" (normative comparisons)

Tests with known psychometric can be used to evaluate

for statistically significant change overtime (ipsative

comparisons)

Recent DSMs include their own "assessment tools" and

we also see "psychometric" info for some diagnoses

Overarching Factors

Assessment process can be affected by

• Human cognitive biases, personal biases, including

cultural biases

• Procedural/process/interpersonal aspects (e.g.,

time, space, organisational priority; client willingness

to be "assessed", confidentiality, rapport)

• The nature of the beast - no (or very few)

pathognomonic tests for psychopathology, and the

DSM's polythetic approach, means that there can

be different symptoms for the same diagnosis

• Accurately measuring "normal" behaviour, thoughts,

and feelings is challenging - what are our starting

assumptions about consistency of behaviour,

thoughts etc

• The available methods have strengths &

weaknesses.

• Important to understand the attributes of the

methods & appreciate that data may conflict;

judgement is needed for integration of findings and

to offset factors that can reduce accuracy (e.g.,

inaccurate data, bias, premature closure etc).

• A systematic approach for the integrative process

could improve diagnostic accuracy (e.g., a process

for diagnostic reasoning).

Treatment

The application of techniques to relieve the symptoms associated with teh disorder and provide better adaptive functioning in the individual

Paradigmatic Approaches

Psychodynamic

Goals: Increase awareness of unconscious motives and defenses

• Methods: free association, dream analysis, focus on childhood

• Treatment length: long term (yrs),

although newer variants are shorter

• Therapist role: passive,

non-directive, interpreter

(may be aloof).

Biological

• Goals: Treat physical or brain disease processes that

underpin the disorder; deliver benefit by altering biology.

• Methods: diagnosis, medications,

psychosurgery, ECT, etc

• Treatment length: brief* with some follow up visits

• Role of therapists: active, directive, diagnostician

Humanistic/ Experimental

Goal: increase emotional

awareness through techniques

such as reflective listening

• Methods: empathy, support,

opportunities for exploration of

emotions

• Length: variable, length not

typically structured

• Therapist role: passive, non-

directive supporter

Cognitive Behavioural

Goal: Change contingencies &

teach more adaptive cognitions &

skills (behaviours/responses)

• Methods: skills training, guided

learning, behavioural rehearsal

(role playing), teaching of new

cognition, problem solving

• Length: short term with booster

sessions

• Therapist role: active, directive,

non-judgemental, teacher.

Combined Therapy

Combination of biological and

psychological therapy

• E.g., medication and

psychotherapy for depression or

schizophrenia.

• Consistent with a biopsychosocial

approach (treating multiple

possible drivers?)

• Extent of "integration" with this

approach.

Eclectic Therapy

Combined across psychological

paradigms (most commonly)

• E.g., Interpersonal therapy or

multimodal therapy.

• Employs techniques from different

paradigms rather than from one

perspective only; considered more

'client-centric.'

• A 'common' answer given by

psychologists to the question:

What therapy do you use?

Potential Harm in Therapies

All therapies carry a risk of harm or negative consequences

Some examples

• Side effects/unintended/unwanted effects

- medication side effects & withdrawal challenges, memory loss in ECT

- increased discussion of weight / food in eating disorders might further narrow focus on this life aspect with detrimental effects

• Breach of trust issues

• E.g., boundary violations, breaches of confidentiality, errors of professional judgement, power dynamics

• Loss of liberties

• E.g., treatment 'against one's will'

Harmful 'Psychological' Therapies

Effectiveness of Psychotherapy

• A landmark 1977 meta-analysis supports the

Modified (abbreviated) evidence hierarchy

effectiveness of psychotherapy (.85 SD units).

Limitations of Psychotherapy

the "file drawer" problem and other limitations for meta-analyses

• pooled results might pool across "adverse" therapies, or the studies

might not have been designed or powered to detect potential harms

• individual patient outcomes cannot be predicted

Efficacy VS Effectiveness

Efficacy studies (RCTs) are tightly

controlled

• e.g. treatment versus no treatment

• High internal validity, lower external

validity

Effectiveness studies (pragmatic trials) are

correlational

• Cannot identify cause & effect

• May yield useful descriptive information

Placebo

Beliefs/expectations about treatment

efficacy play a role; some treatment

gains may be attributable to a placebo

effect

Some solutions:

• Placebo-control groups

• Double-blind studies (difficult to

conduct because the therapist knows

which therapy they are using).

• Meta-analysis

Critical focus: Look for

these features when

evaluating the literature

Common Factors

There are some aspects of treatment that may be "in common"

• These factors predict a positive response, irrespective of the

psychotherapeutic approach.

Examples of common factors

that predict a better outcome

• Assessment and treatment is offered soon

after problem identification

• Therapeutic alliance is established quickly &

used effectively

- Therapist attributes such as

warmth, support, empathy

(impacts on alliance)

• Illness attributes (severity, type etc)

• Client attributes (resources/supports)

• Client encouraged to express strong

emotions or troubling experiences

• A flexible approach is used to

choose therapeutic techniques

• Goals of therapy are limited and

specific (narrowly focused) &

therapist is directive

Prevention

Therapy for self improvement as one avenue for mental health promotion, Could

we also study high functioning people, and find out what factors contribute to this?

• Prevention can be offered via universal (primary), selective (secondary) and

indicated programs

• Prevention studies yield some positive results with primary and secondary

school groups (e.g., Durlack & Wells, 1997)

• The benefits appear greatest for the prevention of anxiety, mood, and

eating/sleep disorders

• Evidence-based preventive programs and policies are now available for

implementation or await translate/implementation (WHO, 2004)

Treatment Summary

Works for many but not all people

• The average client is better off than 80% of individuals who remain

untreated

• Two-thirds of clients improve, only one-third who do not seek therapy

improve

• Most improvement occurs in the first six months

Lecture 2 Summary

At the end of this lecture, you should

• Have a broad understanding of methods used in the

assessment of psychopathology (i.e. the sources of

information); and their pros & cons

• Have an understanding of various treatment approaches

for psychopathology - including "classic" psychological

paradigms

• Be aware of some of the limitations of our understanding

of treatment effectiveness and efficacy

• Have a general understanding of the "treatability" of

psychopathology

GO READ

Chapter 4 & 16 Summaries

Week 3: Mood Disorders

Mood

A pervasive and sustained emotional response

Euthymia

'Normal' mood

Dysphoria/Dysthymia

Experience of an unpleasant (usually low) mood

Depression

Pervasive and sustained low mood and related behaviours & symptoms

Mania

Elavated mood, inflated self-esteem and associated symptoms

Hypomania

Increased energy but less severe features than mania

Euphoria

Intense feeling of well-being, excitement, over-confidence & over optimism

Mood Disorders: Impacted domains

Distinguishing Depression from 'normal' sadness

- Presence of "sad, empty or irritable mood, accompanied by somatic and cognitive changes". What differs is their duration, timing, severity and presumed aetiology

- Mood change is pervasive and persistent (does not improve, even temporarily

- Mood change may occur without precipitating event or it may appear disproportionate for the circumstances

- Mood is impacting (reducing) the ability to function day to day

- Mood change is accompanied by the additional cognitive, somatic, and behavioural signs and symptoms (mood change alone may not warrent diagnosis)

- Nature or quality of mood chamge may be different than whats experienced with normal sadness

DSM 4 to 5 categoisation of depression and bipolar

DSM-IV (4)

- Mood disorders = depressive + bipolar disorders (formerly known as manic-depressive disorder)

DSM-5

- Two different categories: Depressive Disorders, Bipolar and related disorders

DSM-5 Overview of Depressive Disorders

Added:

- Disruptive Mood Dysregulation Disorder

- Premenstrual Dysphoric Disorder

- (DSM-5-TR added Unspecified Mood Disorder)

Retained 'classic' condition

- Major Depressive Disorder (including MDE)

Merged (i think?)

- Persistent Depressive Disorder WITH

- Depressive disorder due to other medical condition; substance-or medication-induced

Removed

- 'Bereavement Exclusion'

DSM-5 Diagnosis Criteria for Major Depressive Episode (MDE) / Major Depressive Disorder (MDD)

1 Major episode in the absence of any history of manic episodes

A. An episode is >5 of 9 symptoms indicative of change over a 2-week period *Including either (1) depressed mood, or (2) loss of interest or pleasure

PLUS

B. cause significant distress or impairment

C. Not attributable to other disorders/substances

DSM-5 Diagnosis Criterion A elements for MDE/ MDD

DSM-IV's exludement of Bereavement

(i.e. for major depression episodes following the death of a loved one in the 2 months; do not = MDE/MDD

Exluded bereavement because it does not typically result in MDE/MDD. - Very highly disagreed/ talked about change

Persistent Depressive Disorder (PDD; "Dysthymia")

- A more chronic, mild presentation

- Over a period of >2 years, exhibit a dperessed mood for most of the day, more days than not

>2 symptoms of 6 Symptoms

poor appetite or overeating

insomnia/hypersomnia

low energy or fatigue

low self-esteem

poor concentration/ decision making

feelings of hopelessness

Would NOT diagnose PDD if

- symptoms absent for more than 2 months at a time during 2-year period

- if at any time during first 2 years meets criteria for MDE/MDD, then given MDD diagnosis

- Presence of manic episode

Disruptive Mood Dysregulation Disorder

- Children 6-18 years old

- Chronic, severe, persistent irritability and frequent episodes of extremely out-of-control behaviour

*Allen Frances named this new diagnosis and the worst change to the DSM 5 as it will "turn temper tantrums into a mental disorder"

Premenstrual Dysphoric Disorder (PMDD)

- Moved from DSM IV 'Further study criteria' to a recognised condition in the DSM 5

- Severe form of PMS, characterised by mood lability, irritability, dysphoria, anxiety, difficulty concentrating, changes in appetite and sleep, pain, etc.

Bipolar Disorders: DSM-5 Overview

Bipolar I

At least one manic episode + Depressive episode

Bipolar II

- Depressive episode

- hypomania: episodes of increased energy, not severe enough to qualify manic episodes

- severity and duration

Cyclothymia

Chronic, but less severe form of bipolar disorder

-Symptoms of mani and depression rather than episodes

Manic Episode

A. At least a week of (or any period of time if hospilatisation due to) abnormally & persistenly elevated, expansive, or irritable mood and persistently increased goal-directed activity/energy: feature is present for most of the day, nearly every day of this period

B. ≥3 of 7 signs/symptoms (≥4 if mood is irritable)

C. Sufficiently severe to cause marked impairment in functioning, OR to necessitate hospitalisation, OR with psychotic features

D. Not attributable to effects of a substance or due to another medical condition

Manic Episode (Criterion B Elements)

3 or more of these symptoms (or 4 if mood is 'irritable)

1. inflated self-esteem or grandiosity

2. decreased need for sleep

3. increased talkativeness or pressure of speech

4. Flight of ideas or racing thoughts

5. Distractibility

6. Increased goal-directed activity / psychomotor agitation

7. Excessive involvement in activities with high potential for painful consequences

Hypomanic Episode

Same symptoms as manic episode (3 or more) except:

- Lasts at least 4 consecutive days

- unequivocal change in function but not severe enough to cause 'marked impairment' in function or trigger hospitalisation

Cyclothymic Disorder

- Chronic, fluctuating mood disturbance for 2 years or more

- Numerous periods of hypomanic & depressive symptoms (not enough to meet criteria for episodes)

- Never symptom-free for more than 2 months

- Onset usually in adolescnece or early adulthood

Specifiers (Bipolar example)

with...

Anxious distress

mixed features

melancholic features

atypical features

mood-congruent psychotic features

mood-incongruent psychotic features

catatonic features

peripartum onset

with seasonal pattern

with rapid cycling (BP I/II)

Reification

- a general criticism of DSWM, applicable for many disorders

- That the criteria are mistakenly taken for the conditi0on, when they are not. The criteria merely describe the condition, but it is not the condition. A description of something is not the same as the thing itself

Mood Disorders: Interim Summary

Prevalnce of Depressive Disorders

- one of the most commonf orms of psychopathology

-Mean (age of onset) = 32 years

-Comorbidities: anxiety, substance abuse (and 'physical' illness)

Course & outcome of depressive disorders

Cuurse & outcome of Bipolar

Prevalence of Depression & Bipolar**

Australia

43% had a lifetime mental disorder

21% had a 12-month mental disorder

- 17 anxiety disorders ( most common)

- 7.5% "affective" [mood] disorder

- 4.9% depressive episode

- 1.5% dysthymia

- 2% bipolar I/II

for "affective" disorders [and anxiety too] figures show

- women > men *for some BP-related conditions

- Younger > older

Health economics of depression in Australia

- $12.6B in costs per year

- 6 million working days of lost productivitry

- accounts for approximaterly 10% of all disability

- 80% odf suicides preceded by a mood disorder

Factors in depressive disorder

- Negative/stressful life events:

- interpersonal loss

- loss of "social roles"

- feelings of entrapment, humiliation, defeat

- stress generation: increase prevalence of stressful life events

or specific groups, there may be additional significant social influences such as dispossession, cultural genocide, displacement, segregation, "stolen generation"

Psychological factors in depresive disorders

Cognitive vulnerability, Maladaptive schemas

1. assign global, personal meaning to failures

2. overgeneralise conclusions about self from events

3. drawing arbitrary inferences about oneself without supporting evidence

4. selective recall of events with consequences

Psychological factors in depresive disorders (cont.)

Causal attributions

- Depressogenic attribution style: internal, stable, global

Response styles:

- ruminative style

- distracting style

Goal attainment

- generalised goals

- pessimistic attitude

Psychological (behavioural) theories of depression

depressed people experience

- less positive reinforcement (verbal, social)

- more negative events

- reduced behaviour

Psychological factors in bipolar

Precipitating factors

- schedule-disrupting events

- goal attainment events

Social factors can influence recovery/relapse

- emotional climate within families

- social support

Biological Factors (depression and bipolar)

Genetics

- Monozygotic (MZ) twims = high concordance rates than Dizygotic

- genetic contribution especially influential in bipolar 1 disorder [approx. 8-10% of first-degree relatives of a person with Bipolar 1 will develop this condition, compared to the 1% risk for the general population]

Depressive Disorders Approaches (therapies)

Bipolar Disorders Approaches

Mood 'stabilizers'

- Lithium carbonate

- Anticonvulsant medications

Psychotherapy

- Cognitive therapy

Interpersonal and social rhythm therapy