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UNDERSTANDING PSYCHOPATHOLOGY

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Title: UNDERSTANDING PSYCHOPATHOLOGY


1
UNDERSTANDING PSYCHOPATHOLOGY
  • Classification of Mental Disorders Definitions,
    Controversies and Debates

2
CLASSIFICATION OUTLINE
  • Views on mental disorders
  • Szasz Rosenhan Menninger DSM
  • Classification why bother ?
  • The DSM a brief history
  • The current DSM
  • Description
  • Critique

3
WHATS AT STAKE?
  • At least one in four people will experience a
    mental disorder during their lifetime
  • Personal costs
  • Pain and suffering
  • Stigma
  • Loss of freedom
  • Loss of rights

4
WHATS AT STAKE?
  • Societal costs
  • Mental health costs
  • Health costs
  • Loss of productivity
  • Intangible losses (e.g., impaired social and
    political engagement)

5
THE GLOBAL BURDEN OF DISEASE STUDY (1996)
  • Assessed disability outcomes of 107 diseases by
    calculating Disability Adjusted Life Years
    (DALYs)
  • DALY sum of years a) lost because of premature
    death or b) lived with disability.
  • One DALY one lost year of healthy life
  • Results underscored the global burden of mental
    disorders

6
GLOBAL BURDEN OF MENTAL DISORDERS (1996)
  • Among the 15 leading causes of disability in
    developed countries are 5 mental health problems
  • Major depression
  • Alcohol abuse
  • Schizophrenia
  • Self-inflicted injuries
  • Bipolar disorder

7
THE SURGEON GENERALS REPORT BASIC MESSAGES
  • Mental disorders are real conditions
  • research has documented the devastating impact of
    mental disorders on individuals and families
  • in established market economies, mental illness
    is the second leading cause of disability and
    premature mortality

8
THE SURGEON GENERALS REPORT BASIC MESSAGES
  • Mind and body are inseparable
  • mind refers to all mental functions related to
    thinking, mood, and purposive behavior
  • mind is seen as derived from activities within
    the brain
  • goal demonstrate how mental disorders and their
    treatment are reflected in physical changes in
    the brain.

9
THE SURGEON GENERALS REPORT BASIC MESSAGES
  • Mental health is fundamental to health
  • indispensable to personal well-being, family and
    interpersonal relationships, contributions to
    community or society
  • definitions of mental health?

10
THE SURGEON GENERALS REPORT BASIC MESSAGES
  • Mental disorders can be treated effectively
  • evidence based medicine
  • Stigma creates major barriers to successful
    treatment outcome
  • knowledge reduces stigma, and fresh approaches to
    dissemination of research results is needed

11
THE SURGEON GENERALS REPORT BASIC MESSAGES
  • Mental disorders can be treated effectively
  • single, explicit recommendation of the report
    Seek help if you have a mental health
    problem or think that you have symptoms of a
    mental disorder (Satcher, 2000,
    p. 5,)

12
VIEWS OF ABNORMAL BEHAVIOR MENTAL DISORDERS
as...
  • Myth (Szasz, 1960)
  • Violation of social norms
  • Statistical deviance
  • Unexpectable distress or disability
  • Whatever professionals treat
  • Harmful dysfunction
  • Biological disadvantage

13
CLASSIFICATION IN PSYCHOPATHOLOGY DIFFERING
VIEWS
14
KRAEPELINS VIEW ON MENTAL DISORDERS
  • Mental disorders are the result of biological
    dysfunction.
  • Careful observation of symptoms leads to
    meaningful classification.
  • By uncovering the physical causes appropriate
    treatments are found.

15
REVIVAL OF SOMATOGENESIS IN THE 18 CENTURY
  • Emil Kraepelin (1856-1926) classification of
    mental disorders based on the presumed underlying
    causes.
  • Dementia praecox (schizophrenia) --chemical
    imbalance
  • Manic-depressive dis.-- metabolic imbalance

16
Karl Menninger (1958) The unitary concept of
mental illness
  • Suppose that instead of putting so much emphasis
    on different kinds of illness we tried to think
    of all mental illness as being essentially the
    same in quality, and differing, rather,
    quantitatively.

17
Menningers unitary concept
  • Mental illness, then, is seen by us as an
    impairment in self-regulation, whereby comfort,
    production, and growth are temporarily
    surrendered for the sake of survival at the best
    level possible, and at the cost of emergency
    coping devices which may be painful.

18
Menningers unitary concept
  • There are no natural mental disease entities.
  • Mental illness lies on the same continuum with
    mental health.
  • Different syndromes reflect differing degrees
    of disorganization and its course.

19
MENNINGER ON THE FUTURE OF PSYCHIATRIC
CLASSIFICATION
  • The trend toward a unitary concept of mental
    illness is clearly apparent in psychiatric
    historyIt spares us some grievous errors and
    offenses against our patients. It enables
    rational therapeutic programming.

20
FAST FORWARD TO 1994
  • The fourth edition of the Diagnostic and
    Statistical Manual for Mental Disorders (DSM)
    recognizes 357 diagnoses.

21
THOMAS SZASZ THE MYTH OF MENTAL ILLNESS (1960)
  • There are diseases of the brain--they need to be
    studied as part of neurology, not psychiatry
  • The concept of mental illness represents an
    epistemological error (i.e., an error in how we
    organize and express knowledge) and is useless

22
THOMAS SZASZ THE MYTH OF MENTAL ILLNESS (1960)
  • Mental illness is a name for problems in
    living.
  • Psychosocial, ethical, and legal deviations are
    claimed to be correctible with medical action.
  • If we accept that mental illness stands for
    problems in living,, we do not need a
    classification scheme for mental disorders.

23
ROSENHAHN (1973) If sanity and insanity exist,
how shall we know them
  • The normal are not detectably sane
  • The label sticks
  • Stigma has severe consequences

24
DEFINITION OF MENTAL DISORDER IN THE DSM
25
A MENTAL DISORDER IS...
  • A clinically significant behavioral or
    psychological syndrome that occurs in an
    individual and that is associated with
  • present distress or disability or with
  • a significantly increased risk of suffering
    death, pain, disability, or an important loss of
    freedom.

26
A MENTAL DISORDER IS...
  • In addition, this syndrome must not merely be an
    expectable or culturally sanctioned response to a
    particular event.
  • Whatever the original cause, it must currently be
    considered a manifestation of behavioral,
    psychological, or biological dysfunction in the
    individual.

27
A MENTAL DISORDER IS...
  • Neither deviant behavior (e.g., political,
    religious, or sexual) nor conflicts that are
    primarily between the individual and society are
    mental disorders unless the deviance or conflict
    is a symptom of dysfunction as described above.

28
CLASSIFICATION
  • A procedure for constructing groups or
    categories and for assigning entities to these
    categories on the basis of their shared
    attributes or relations. Millon, 1991

29
WHY WOULD WE WANT TO HAVE A CLASSIFICATION SYSTEM?
  • Fundamental to all scientific activity
  • Permits systematic investigation
  • Description
  • Comparison
  • Prediction
  • Enables communication

30
CLASSIFICATION
  • Is influenced by cultural convention
  • Is influenced by the purpose of the classification

31
What data from the stream of on-going clinical
events and processes ought to be selected to
serve as basic units of the classification scheme?
32
BASIC ELEMENTS IN PSYCHIATRIC CLASSIFICATION
SCHEMES
  • Causal factors (e.g., traumatic event)
  • Signs
  • objectively recorded changes in state or
    functioning that indicate the presence and
    character of clinically relevant processes or
    events (e.g., biological markers observable
    behavior)
  • Symptoms
  • self-reported behaviors, feelings, cognitions
  • Traits
  • inferred stable dispositions of broad generality

33
PRACTICAL IMPLICATIONS OF CLASSIFICATION OF
MENTAL DISORDERS
  • Diagnosis as a short-hand for a patients problem
  • Diagnosis as the required step for delineating
    the proper treatment
  • Diagnosis as the required ingredient for
    obtaining treatment and/or insurance reimbursement

34
POTENTIAL NEGATIVE CONSEQUENCES OF DIAGNOSIS
  • Stigma
  • Self-fulfilling prophecy
  • The person becomes the disorder (e.g., Ramon is
    a schizophrenic -- versus Ramon has schizophrenia)
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