Understanding Mental Disorders

Understanding Mental Disorders: A Comprehensive Guide to Diagnosis, Etiology, Assessment, and Classification

Editorial Board

  • Prof. N.K. Chadha
  • Dr. Nupur Gosain

Content Writers

  • Dr. Mandeep Kaur Arora
  • Dr. Sarabjit Kaur Sran

Academic Coordinator

  • Deekshant Awasthi

Syllabus

  • Unit I: Introduction
    • Criteria of Abnormality
    • Causal Factors
    • Classification
    • Clinical Assessment
    • Lesson 1: Diagnosis and Classification (Pages 3–29)
    • Lesson 2: Etiological Factors and Clinical Assessment of Mental Disorders (Pages 30–62)
  • Unit II: Anxiety Disorders and Obsessive-Compulsive Disorder (Clinical Picture and Dynamics)
    • Generalized Anxiety Disorder
    • Social anxiety disorder
    • Specific phobias
    • Agoraphobia
    • Obsessive-Compulsive Disorder
    • Lesson 3: Anxiety Disorders (Pages 65–103)
    • Lesson 4: Obsessive-Compulsive Disorder (Pages 104–123)
  • Unit III: Depressive Disorder and Bipolar Disorders (Clinical Picture and Dynamics)
    • Major Depressive disorder
    • Persistent Depressive disorder
    • Bipolar I
    • Bipolar II
    • Cyclothymia
    • Lesson 5: Depressive Disorders (Pages 127–163)

Lesson 1: Diagnosis and Classification

1.1 Learning Objectives
  • Understand the indicators of defining Abnormality.
  • Understand the need for classification.
  • Understand the types of psychiatric classification.
  • Understand the history of DSM and ICD.
  • Understand the key difference between the International Classification of Disease and Diagnostic Statistical Manual of Mental Disorders.
1.2 Issues in Defining Normality and Abnormality
  • The definition of abnormality or disorder is not universally accepted.
  • No single behavior defines abnormality; instead, several factors indicate it.
Indicators of Abnormality:
  1. Suffering: Psychological suffering is a sign, but not a requirement, for abnormality. A manic patient feels upbeat and may not consider their mood abnormal.
  2. Maladaptiveness: Behavior negatively impacting well-being, work, or relationships. Not all mental illnesses involve dysfunctional behavior (e.g., contract killers with antisocial personality disorder).
  3. Statistical Deviancy: Deviating from the norm statistically. Not sufficient for abnormality as geniuses also deviate from the norm. Value judgements are part of defining abnormality.
  4. Violation of the Standards of Society: Behavior that breaches social norms. Depends on the magnitude and frequency of the violation.
  5. Social Discomfort: A sense of unease experienced by others due to someone's behavior.
  6. Irrational and Unpredictable: Unexpected or unconventional actions that deviate significantly from anticipated behavior.
  7. Dangerousness: Posing a threat to oneself or others. Not every individual with a mental disorder is dangerous.
  • DSM Definition of a mental disorder:
    • Clinically significant behavior or psychological syndrome associated with distress, disability, or significant risk.
    • Cannot be merely an expectable and culturally sanctioned response to a particular event.
    • Must be considered a manifestation of behavioral, psychological, or biological dysfunction.
    • Neither deviant behavior nor conflicts between the individual and society are mental disorders unless they are a symptom of dysfunction.
  • DSM examines abnormal behavior in terms of syndrome.
  • Decisions about abnormal behavior involve social evaluations and are founded on societal norms and values, implying cultural impact.
  • Homosexuality was previously considered a mental illness but is no longer the case.
1.3 Classification of Mental Disorders
  • Classification is essential for science and communication of knowledge.
  • Classification gives a nomenclature (a naming system) and allows organization of information.
  • Enables the study of various disorders, learning more about their causes and potential treatments.
  • Classification of mental disorders has social and political implications.
Types of Classification:
  1. Categorical Approach: Found in the DSM, classifies symptoms biologically and medically with one set of causative factors and no overlap between categories. It is Difficult as treatment may vary in the same disorder.
  2. Dimensional Approach: Classifies disordered thought, affect, and behavior as multiple dimensions. Measures variations in symptom expression against normative behavior. Inconsistencies render the use of the yes-or-no diagnosis and treatment process invalid.
  3. Prototypical Approach: Combines aspects of the categorical and dimensional systems. Establishes basic attributes of an entity while allowing some nonessential variations. Fuzzy categories lead to challenges.
1.3.3 Drawbacks of Classification System
  • Classification simplifies information, leading to a loss of individual details (e.g. background, personality).
  • Psychiatric diagnoses carry stigma.
  • Low mental health literacy results in stereotyping and preconceived notions.
  • Nosology - area of medical science concerned with the classification of diseases.
  • Emile Kraepelin associated cluster symptoms with diagnostic labels, course, and various drugs.
  • Key diagnostic classification systems:
    • International Classification of Disease (ICD-WHO 2017) - 11th edition
    • Diagnostic and Statistical Manual (DSM-5) - American Psychiatric Association
      Emile Kraepelin hypotheses that psychiatric diseases are fundamentally biological problems, which also prompted an early focus on traditional categorization approaches.
1.4 Evolution of Diagnostic Statistical Manual of Mental Disorders
  • American Psychiatric Association released Diagnostic and Statistical Manual of Mental Disorders.
  • The needs for statistical data on mental diseases led to the creation of a classification system.
1.4.1 DSM-1 (1952)
  • Published by the APA.
  • Included 106 mental diseases.
  • Criticized for its psychoanalytic orientation.
1.4.2 DSM-2 (1968)
  • Identified 182 disorders.
  • Mirrored psychodynamic psychiatry.
  • Focused primarily on psycho dynamic psychiatry.
  • Did not fully describe symptoms of particular illnesses.
1.4.3 DSM-3 (1980)
  • Significant turning point in the history of nosology.
  • Used a non-theoretical approach to diagnosis, relying on detailed descriptions of disorders rather than psychoanalytic or biological theories.
  • Allowed for the examination of the validity and reliability of diagnostic criteria.
  • Multiaxial approach emphasizes a comprehensive assessment of the entire person rather than focusing on the disease alone.
1.4.4 DSM-4 and DSM-IV-TR
  • Work on the ICD-10 and the fourth edition of the DSM (DSM-IV), which was released in 1994, was mostly done at the same time in order to ensure maximum compatibility.
  • All modifications to the diagnostic system had to be supported by reliable scientific evidence.
  • The difference between biologically based disorders and psychologically based disorders that was present in earlier editions was erased.
1.4.5 DSM-5
  • Released in 2013 after a decade of collaboration with world leaders working on ICD-11.
  • Split up into three main sections.
  • Uses dimensional axes for assessing severity, intensity, frequency, or duration of certain disorders.
  • Impairment must produce clinically significant suffering or dysfunctions.
  • Incorporates social and cultural impacts, using a "cultural formulation" approach.
  • Focuses on reliability, sometimes at the expense of validity. (Meehl, 1989)
  • Diagnostic categories offer a convenient format for organizing observations, aiding communication, study, and planning.
  • Shortcomings of the DSM System:
    • Propensity for adding new diseases with less scientific backing.
    • Arbitrary standards.
    • Vague diagnostic codes like "Not Otherwise Specified" (NOS).
    • Issue of comorbidity.
1.5 The International Classification of Diseases
  • The ICD classification’s actuarial and epidemiological focus was expanded over time, enabling its use as a tool to assist diagnosis and assessment procedures.
1.5.1 Landmarks in ICD
  • Interest began to grow in collecting the causes of death that might be used in “all countries” in the middle of the 19th century, notably in the year 1853.
  • William Farr proposed a five-group classification of illnesses: diseases that are epidemic, constitutional, local, developmental, and diseases that are a direct result of violence.
  • The ICD-11 provides translations into 43 different languages as well as instructions for using it with various cultural contexts.
1.5.2 Comparison in ICD-11 and ICD-10
  • DSM-5 effective collaboration with the ICD-11.
  • DSM-5 setting up procedures allowing for temporary category modifications as new information becomes available.
1.6 DSM and ICD
  • There are significant parallels between the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the ICD-11.
  • The ICD-11 is more comprehensive than the DSM-5 in terms of both its authorship and its coverage.
1.7 Summary
  • Abnormality is still uncertain; factors like suffering, maladaptiveness, statistical deviancy, risk, violation of societal norms, irrationality, and unpredictability can assist in determination.
  • Taxonomy (system of naming and classification) categorizes items based on shared characteristics.
  • The traditional categorical, dimensional, and prototype approaches to classification are available.

Lesson 2: Etiological Factors and Clinical Assessment of Mental Disorders

2.1 Learning Objectives
  • Understand the importance of Diathesis Stress Model.
  • Understand Biological viewpoints and related causal factors.
  • Understand Psychological viewpoints and Psychological causal factors.
  • Understand Sociocultural viewpoints and related causal factors.
  • Understand the difference between assessment and diagnosis.
  • Understand the Psychological assessment to assess psychopathology.
  • Understand the neurobiological assessment to assess psychopathology.
2.2 Introduction
  • Researchers prefer to refer to risk factors than causes when attempting to explain their existence in causal terms.
  1. Necessary Cause: A condition that must exist for a disorder (like disorder Y) to emerge (e.g., cause X). If X is absent, Y is not present.
  2. Sufficient Cause: A condition that ensures the occurrence of a problem (e.g., disorder Y). If X is present., Y is present.
  3. Contributing Cause: A factor that raises the risk of a condition (e.g., disorder Y) arising. If X is present, the liklihood of Y increases.
  • Distal Causes: Occur early in childhood and might not manifest for many years.
  • Proximal Causes: Are present before a disorder’s symptoms manifest.
  • Reinforcing Contributory Cause: A condition that tends to maintain maladaptive behavior that is already occurring.
2.3 Diathesis Stress Model
  • Diathesis is a term used to describe a tendency to develop a disorder.
  • Various mental disorders are thought to manifest when a stressor acts on a person who is predisposed to that disorder or who is vulnerable to it.
  • Integrative, biopsychosocial perspective acknowledges that biological, psychological, and sociocultural elements all interact and have a role in psychopathology and treatment.
2.4 The Biological Viewpoint and Biological Causal Factors
  • Neurons, or nerve cells, must be able to interact with one another effec- tively for the brain to operate properly.
  • Neurotransmitters come in a wide variety; some promote the likelihood that the post-synaptic neuron would “fire” (generate an impulse), while others suppress the impulse
2.4.1 Imbalances of Neurotransmitters and Hormones
  • Fundamental assumption of the biological perspective today is that abnormal behaviour can result from imbalances in neurotransmitters in the brain
  • Chemical circuits are neural connections between various regions of the brain made up of neurons that are sensitive to a specific neurotransmitter and tend to group together.
  • While more than a hundred neurotransmitters have been investigated so far, five distinct types have received the greatest attention in relation to psychopathology: Norepinephrine, dopamine, serotonin, glutamate, and gamma-aminobutyric acid (known as GABA).
  • Agonists are drugs that promote the effects of a neurotransmitter on the postsynaptic neuron imbalances in hormones.
    • Norepinephrine: Role in emergency and attention.
    • Dopamine: Implicated in pleasure, cognitive processing and addictive diseases
    • Serotonin: Impacts actions, mood and thought process
    • Glutamate: Excitatory Neurotransmitter implicated in schizophrenia.
    • GABA: Linked to reducing anxiety.
2.4.2 Hormonal Imbalance
  • Hormonal abnormalities have also been connected to some types of psychopathology
  • Hormones affect a variety of events including fight-or-flight reactions, sexual responses, physical growth, and many other physical manifestations of mental emotions.
  • Hypothalamic-Pituitary-Adrenal Axis (HPA axis).
    1. Corticotrophin-releasing hormone (CRH). A message-carrying hormone.
    2. ACTH stimulates the adrenal gland’s cortical portion
    3. Cortisol, in turn, causes the hypothalamus and pituitary to release less CRH and ACTH.
2.4.3 Genetic Factors
  • Genes, which are made up of extremely long DNA (deoxyribonucleic acid) molecules and are found at diverse positions on chromosomes, have an impact on the metabolic processes mentioned above.
  • The chain-like structures called chromosomes that make up a cell nucleus and house the genes.
  • A genotype-environment correlation occurs when a child’s genotype influences their environmental experiences.
Methods for Studying Genetic Influences:
  • Family History (or Pedigree) Method: Examine samples of relatives of each proband or index case to determine whether the incidence rises proportionately to the strength of the genetic connection.
  • Twin Method: Compare the concordance rates (proportion of twins sharing the same condition) between identical (monozygotic) and non-identical (dizygotic) twins.
  • Adoption Method: Study individuals with a certain disorder who were adopted away shortly after birth and compare their rates of disorder with those of their biological parents and adoptive parents.
  • Linkage Analysis and Association Studies: Compare the frequency of known genetic markers in individuals with and without a specific disorder.
  • Shared environmental influences are those that Children in a family that experience similar environmental effects are said to be more alike.
  • Nonshared environmental Influences are those environmental effects that the kids in a family don’t share.
2.4.4 Brain Dysfunction and Neural Plasticity
  • Rarely are particular brain lesions with discernible brain tissue anomalies the root cause of psychiatric illnesses.
  • Neural plasticity is when the brain is flexible enough to adapt its structure and function in response to pre- and postnatal experiences, stress, food, illness, medicines, maturation, and other factors
2.5 The Psychological Viewpoints

#### 2.5.1 The Psychodynamic Perspectives

  • The first methodical approach to demonstrating how human psychological processes might lead to mental diseases can be observed in Freud’s psychoanalytic theory.
  • He created therapeutic approaches like free association and dream analysis to get to know both the conscious and unconscious facets of mental activity. The unconscious element on motivations influences conudct i.e., how often the underlying causes of behavior are concealed from conscious consciousness.
  • Criticisms of psychoanalytic theory focus on its inability to explain abnormal behavior scientifically and lack of empirical data.
2.5.2 The Behavioural Perspective
  • The behavioural approach makes an effort to explain the emergence, development, and eventual extinction of nearly all types of behaviour using a small number of fundamental principles. Maladaptive behaviour, which is defined in terms of distinct, visible, unpleasant behaviours, is the product of learning that has gone wrong.
  • For a behavior therapist, the goal of therapy is to alter particular behaviours and emotional reactions—to get rid of unfavourable ones and develop preferable ones.
2.5.3 The Cognitive-Behavioural Perspective

  • The cognitive-behavioural perspective has significantly influenced modern clinical psychology. The idea that adjusting one’s thoughts about oneself and others might change behaviour has received support from numerous researchers and physicians. In this cognition that influence behaviour.

  • The phrase “negative cognitive triad” was first used by Beck (1967) to characterise the themes of automatic negative thinking.

  • Few cognitive distortions are:

    • Absolutistic Thinking
    • Overgeneralization
    • Selective Abstraction
    • Negative Prediction
    • Personalization
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