Psychopathology

Mental disorder (definition)

A syndrome involving a clinically significant disturbance in cognition, emotion regulation, or behaviour, caused by a psychological, biological, or developmental dysfunction, usually causing significant distress or impairment

Mental disorder - important exclusion

Normal/culturally-approved responses to stress or loss, and social deviance/conflict with society, are NOT mental disorders unless they stem from an actual underlying dysfunction

Syndrome

A cluster of symptoms that co-occur often enough to suggest an underlying condition, but the exact cause is unknown (unlike a "disease" where the cause is known)

Clinically significant disturbance

Raises the bar/threshold for diagnosis - not just mild issues

Dysfunction (in mental disorder definition)

A deviation from statistical norms; an internal mechanism failing to do its naturally-selected job

Why "usually" is used in the mental disorder definition

A deliberately vague qualifier that improves reliability by sidestepping debates over who decides what counts as "distress" or how much harm is needed

Why "culturally" is used in the mental disorder definition

Links to Social and Emotional Wellbeing (SEWB), a holistic view of health

Social and Emotional Wellbeing (SEWB)

A holistic view of health used by many Aboriginal and Torres Strait Islander peoples, understanding mental illness through cultural and spiritual factors, not just biology

Connection to Country and mental health

Being disconnected from Country for long periods can weaken spiritual ties and contribute to depression

Potentially helpful aspects of DSM diagnosis

A shared communication tool, adds useful information, guides treatment decisions

Potentially unhelpful aspects of DSM diagnosis

Risk of labelling, stigma, can overshadow the person's lived experience

The Rosenhan Study (1973)

"On Being Sane in Insane Places" - 8 people with no mental illness history faked hearing voices to get admitted to psychiatric hospitals; all 8 were admitted and stayed an average of 3 weeks

Rosenhan Study - key finding

Once a diagnostic label is applied it can stick even when the person shows no further symptoms; diagnosis can be shaped by setting and expectation, not just objective symptoms

Categorical Model (of diagnosis)

"You either have it or you don't" - a disorder is present/absent, with a person qualitatively different from someone without it

Categorical Model - disadvantages

Assumes disorders are neatly distinct even though symptoms often overlap; creates an artificial binary cutoff; people right on the boundary get no support; misses chances for early intervention

Dimensional Model (of diagnosis)

Symptoms exist on a continuum; people differ by degree, not by kind

Dimensional Model - disadvantages

Cutoffs become arbitrary and clinician-dependent, making data-sharing/communication difficult; access to funding/interventions often still needs a yes/no decision

DSM's Compromise Model

Combines a categorical diagnosis with dimensional ratings for severity, intensity, frequency, or duration, allowing a more individualised picture

Polythetic diagnostic criteria

Because clinical presentations are so varied (heterogeneous), a diagnosis can be reached through multiple different combinations of symptoms

Polythetic criteria example

There are 636,120 different ways to meet diagnostic criteria for PTSD

DSM-5 field trials

Two independent clinicians interviewed the same patient using a computerised checklist to test diagnostic reliability

Kappa (in diagnostic reliability)

A statistic measuring degree of agreement between assessors after correcting for chance (i.e. correcting for the base rate of the disorder)

Kappa interpretation scale

Below 0.40 = Poor; 0.40-0.59 = Fair; 0.60-0.74 = Good; above 0.74 = Excellent

DSM-5's reliability bar

The DSM-5 team argued the reliability bar should be set similarly to medical diagnostic procedures, at 0.60-0.80

"Gold standard" for diagnosis

Ideally based on aetiology (cause) or pathophysiology (biological mechanism), but this is often unavailable for mental disorders; DSM criteria are meant to be guidelines, not rigid rules

Sources of assessment information

Clinical interviews, questionnaire data, behavioural observation, reports from other professionals, interviews with family

Five purposes of psychological assessment

Diagnosis and problem identification, treatment planning, treatment evaluation, forensic applications, personnel selection applications

Unstructured clinical interview

Free-flowing, no fixed format

Semi-structured clinical interview

Some fixed questions, some flexibility

Structured clinical interview

Fully standardised/fixed questions

Confirmation bias (in interviews)

The tendency to only look for evidence that fits your first hunch about a diagnosis; something clinicians must watch out for

Three core problems applying diagnostic criteria in real life

Most people don't present with symptoms of just one condition; huge variation within a single diagnostic category (heterogeneity); multiple different pathways can lead to the same diagnosis

"Artificial" comorbidity

When overlapping symptoms of conditions like depression, anxiety, PTSD, and ADHD make it look like someone has multiple disorders when it might be one condition being misread, or genuine overlap

Differential diagnosis

The process of figuring out what makes each condition more or less likely, using specific rule-in/rule-out criteria

ADHD differential diagnosis criterion

Traits must have been present during the developmental period, before age 12

PTSD differential diagnosis criterion

Symptoms must follow experiencing, witnessing, or learning about a traumatic event

GAD and MDD overlapping symptoms

Difficulty concentrating, sleep disturbance, fatigue, and psychomotor/restlessness changes appear in both Generalised Anxiety Disorder and Major Depressive Disorder

Jacob et al. (2021) meta-analysis finding

People with depression are 12x more likely to also meet criteria for an anxiety disorder

Comorbidity - impact on outcomes

Linked to worse outcomes: symptom severity, functional impairment, quality of life, and treatment response

Predisposing, precipitating, perpetuating factors

A framework used alongside the biopsychosocial model to explore a client's presentation, history, and life context

Biopsychosocial Model

A framework for understanding why someone presents the way they do, split into Biological, Psychological, and Social domains

Biopsychosocial Model - Bio domain

Genetics, physical health, hormones, cognition (e.g. family history of depression, chronic illness, high stress)

Biopsychosocial Model - Psycho domain

Temperament, personality, cognitive style, core beliefs (e.g. high neuroticism, negative self-concept, rumination)

Biopsychosocial Model - Social domain

Parenting style, socioeconomic status, social support, cultural norms (e.g. authoritarian parents, divorce, loneliness, role renegotiation)

Biopsychosocial Model - key takeaway

Biological, psychological, and social factors don't act alone - they compound each other

Transgender (definition)

Gender identity doesn't match the sex assigned at birth

Trans Pathways Study (2017)

Surveyed 859 trans/gender-diverse youth and 194 parents/guardians about mental health

Trans Pathways Study - key statistics

72.2% diagnosed with anxiety, 74.6% diagnosed with depression at some point, 79.9% had self-harmed, 48.1% had attempted suicide, 22.7% diagnosed with an eating disorder

Minority Stress

Chronic stress from stigma/discrimination faced by minority groups; explains high rates of mental health difficulty in trans youth

Common experiences of trans youth (Trans Pathways)

89% experienced peer rejection, 74% bullied, 68.9% experienced discrimination, 65.8% lacked family support, 22% experienced accommodation issues/homelessness

Circle of Control/Influence/Concern model

A framework for focusing energy on what can actually be changed - Concern (can't change, e.g. media messaging), Influence (e.g. parental acceptance, peer bullying), Control (e.g. internalised stigma, self-concept, coping)

Therapist practical actions for trans clients

Ask about and consistently use correct pronouns, educate staff, be affirming and validating, link with gender-friendly health professionals, foster hope

Delayed sleep-wake cycle intervention limit

Sleep/wake times cannot be shifted by more than 30 minutes per night

Reframing a controlling statement to a family (example)

Instead of "You should be using Heath's chosen name and pronouns" (controlling), ask "What might it be like for Heath if you used his chosen name and pronouns?" (invites empathy/reflection)

Family systems principle in therapy

Never sideline or ostracise families - they're on their own journey too; provide education and space that supports change

Substance use and mental health question

Whether substance use is a mental health disorder, maladaptive coping, or both; substance use can precede and increase risk of developing other mental health conditions

SUD and mental illness comorbidity outcome

People with both a substance use disorder and mental illness have greater combined severity and worse outcomes than those with just one

Predisposing factors (Michael's case)

Family history of substance use, societal attitudes to substance use, impulsivity/reward sensitivity, external locus of control

Precipitating factors (Michael's case)

Relationship breakdown, loss of accommodation, lack of alternative coping strategies, ease of access to alcohol

Perpetuating factors (Michael's case)

Lack of accommodation, lack of positive social support, poor treatment engagement, lack of alternative coping, dependence itself

Hierarchy of Needs approach to treatment

First priority is safe, stable accommodation (basic needs first, like Maslow); second priority is addressing dependency, supporting reduction in use, and addressing physical health

Why survival mode blocks treatment

You can't effectively treat substance use or mental health issues while someone is still in survival mode (unsafe/unstable housing)

Motivational Interviewing - when it's relevant

Becomes relevant once a baseline level of safety/stability is achieved, not before

Lesson from Michael not continuing therapy

Even a well-delivered, person-centred intervention may not lead to someone continuing treatment; this is not necessarily a failure - respecting autonomy and readiness for change is part of ethical practice

Depressive disorders - disturbance in mood can include

Elevation, sleep disturbance, impulsive/reckless behaviour, withdrawal, sadness, hyperactivity

Types of depressive disorders (DSM)

Disruptive mood dysregulation disorder, major depressive disorder, persistent depressive disorder (dysthymia), premenstrual dysphoric disorder, substance/medication-induced depressive disorder, depressive disorder due to another medical condition, other specified depressive disorder, unspecified depressive disorder

Disruptive Mood Dysregulation Disorder (DMDD)

Children up to age 12 presenting with persistent irritability and frequent episodes of extreme behavioural dyscontrol

Why DMDD was added to the DSM-5

Evidence highlighted that these clients' presentations are phenomenologically different to those with bipolar disorder

Premenstrual Dysphoric Disorder (PMDD)

Identified in a small cohort of women who presented with severe, sometimes incapacitating emotional reactions within the late luteal phase of the menstrual cycle

MDD Criterion A

Five or more specific symptoms present during the same 2-week period, representing a change from previous functioning; at least one symptom must be depressed mood or loss of interest/pleasure

MDD symptom - depressed mood

Depressed mood most of the day, nearly every day, by subjective report or observation by others

MDD symptom - anhedonia

Markedly diminished interest or pleasure in almost all activities, most of the day, nearly every day

MDD symptom - weight/appetite change

Significant weight loss when not dieting or weight gain (e.g. more than 5% of body weight in a month), or decreased/increased appetite nearly every day

MDD symptom - sleep change

Insomnia or hypersomnia nearly every day

MDD symptom - psychomotor change

Psychomotor agitation or retardation nearly every day, observable by others (not just subjective restlessness or feeling slowed down)

MDD symptom - fatigue

Fatigue or loss of energy nearly every day

MDD symptom - worthlessness/guilt

Feelings of worthlessness or excessive/inappropriate guilt (possibly delusional) nearly every day, not merely self-reproach about being sick

MDD symptom - cognitive difficulty

Diminished ability to think or concentrate, or indecisiveness, nearly every day

MDD symptom - suicidality

Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan

MDD Criterion B

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

MDD Criterion C

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

Wakefield (2015) on the bereavement exclusion

Argued its removal was based on a misrepresentation - the exclusion did not actually prevent an MDD diagnosis after bereavement

Previous DSM bereavement exclusion rule

MDD could still be diagnosed during bereavement if symptoms lasted more than 2 months or involved severe impairment, worthlessness, suicidality, psychosis, or psychomotor retardation

Medication argument re: bereavement exclusion

Response to antidepressants does not prove someone has MDD, and evidence for medication helping in normal grief is weak

DSM-5 and the bereavement exclusion

The exclusion was removed, but clinicians are still advised to distinguish normal grief from MDD using clinical judgment

MDD - genetic complexity

Not thought to reflect the influence of a single gene; genetically complex

MDD - genome-wide association findings

Over 100 gene loci have been found to be associated with increased risk of MDD

MDD - twin study heritability estimate

40-50%

Iproniazid

A tuberculosis drug from the 1950s that displayed antidepressant effects, leading to the 5-HT (serotonin) hypothesis of depression; works by inhibiting monoamine oxidase, the enzyme that breaks down norepinephrine and serotonin

Iproniazid trial result

Of 17 patients, 70% showed some favourable response after 5 months

Imipramine

A tricyclic antidepressant that blocks the pump used to recycle neurotransmitters; discovered while trying to replicate the success of chlorpromazine, the first widely used antipsychotic

Reserpine

A drug found to deplete brain serotonin stores; its sedative/lethargic depressive effects were hypothesised to be due to serotonin depletion

Monoamine/metabolite measurement findings

Low monoamine levels have been found in some depressed groups, taken as support for biological models, but findings are inconsistent - low monoamine levels are not a reliable characteristic of depression across all cases

Possible explanation for inconsistent monoamine findings

There may be multiple pathways to depression - some depressed individuals show relatively low monoamine levels, others do not

Monoamine depletion studies

Studies where monoamine levels are transiently reduced and restored while measuring mood impact

Monoamine depletion studies - key finding

Some but not all participants in remission from depression experience a transient return of symptoms during depletion; those in remission via SSRIs are more likely to relapse when serotonin specifically is depleted

Problems monoamine depletion studies pose for biological models

When depletion type is matched to antidepressant response, many participants show no or only mild symptom exacerbation; depletion usually does not induce depressive symptoms in healthy people with no history of depression

Tianeptine paradox

An antidepressant shown to be effective despite enhancing (rather than reducing) serotonin uptake - a conflicting finding for simple biological models of depression

Kirsch et al. (2008) study

Obtained data on all clinical trials for four new-generation antidepressants (published and unpublished), rather than relying only on published data like earlier meta-analyses

Kirsch et al. (2008) - key finding

Antidepressants showed a small to medium effect size overall, with greater efficacy evidence in participants with particularly high levels of depression