Clinical psychology
Chapter 1
Introduction and historical overview

Introduction

Psychopathology: the field concerned with the nature, development, and treatment of mental disorders.
Continually developing and adding new findings.

• Tries to remain objective
• Closeness to the subject matter adds to its intrinsic fascination.

Sigma: the destructive beliefs and attitudes held by a society that are ascribed to groups considered different in some manner, such as people with mental illness.
Stigma has four characteristics:

• A label is applied to a group of people that distinguishes them from others
• The label is liked to deviant or undesirable attitudes by society
• People with the label are seen as essentially different from those without the label, contributing to an ‘us’ versus ‘them’ mentality.
• People with the label are discriminated against unfairly

The treatment of individuals with mental disorders throughout recorded history has not generally been good, and this has contributed to their stigmatization.
Mental illness remains one of the most stigmatized of conditions in the twenty-first century.

Defining mental disorder

Mental disorder is one disorder that contains several characteristics.

• The disorder occurs within the individual
• It involves clinically significant difficulties in thinking, feeling, or behaving
• It involves a dysfunction in processes that support mental functioning
• It is not a culturally specific reaction to an event
• It is not primarily a result of social deviance of conflict with society

Four key characteristics that any comprehensive mental disorder definition ought to have:

• Disability
• Personal distress
• Violation of social norms
• Dysfunction

No single characteristic can fully define the concept.
Mental disorder is usually determined based on the presence of several characteristics at one time.

Personal distress

A person’s behavior may be classified as disordered if it causes him or her great distress.

But not all mental disorders cause distress.
And not all behavior that causes distress is disordered.

Disability

Impairment in some important area of life.

Disability alone cannot be used to define mental disorder. Not all disorders involve disability.
Other characteristics that might, in some circumstances, be considered disabilities, do not fall within the domain of psychopathology.

Violation of social norms

In the realm of behaviors, social norms are widely held standards that people use consciously or intuitively to make judgments about where behaviors are situated on such scales as good-bad, right-wrong, justified-unjustified, and acceptable-unacceptable.
Behavior that violates social norms might be classified as disordered.

This is not enough for defining mental disorder. It is too broad and too narrow.
And social norms vary across cultures and ethnic groups.

Dysfunction

Harmful dysfunction. Has a value judgment and a objective component (dysfunction).
A judgment that a behavior is harmful requires some standard, and this

Clinical psychology 
Chapter 3
Diagnosis and assessment

Introduction

Diagnosis can be the first major step in good clinical care.
Having a correct diagnosis will allow the clinician to describe base rates, causes, and treatment.
Hearing a diagnosis can help a person understand why certain symptoms are occurring.

Two concepts that play a key role in diagnosis and assessment:

• Reliability
• Validity

Cornerstones of diagnosis and assessment

Reliability

Reliability: consistency of measurement.

• Inter-rater reliability:
  The degree to which two independent observers agree on what they have observed.
• Test-retest reliability:
  The extent to which people being observed twice or taking the same test twice, receive similar scores.
• Alternate-form reliability:
  The extent to which scores on the two forms of the test are consistent
• Internal consistency reliability:
  Whether the items on a test are related to one another.

Validity

Validity: whether a measure measures what it is supposed to measure.
Unreliable measures will not have good validity.
Reliability does not guarantee validity.

• Content validity:
  Whether a measure adequately samples the domain of interest.
• Criterion validity:
  Whether a measure is associated in an expected way with some other measure.
• Concurrent validity: 
  If both variables are measured at the same point in time.
• Predictive validity:
  Evaluating the ability to measure to predict some other variable that is measured at the same point in the future.
• Construct validity:
  Relevant when we want to interpret a test as a measure of some characteristic or construct that is not observed simply or overtly. Evaluated by looking at a wide variety of data from multiple sources.

The diagnostic system of the American psychiatric association: DSM-5

Diagnostic and Statistical Manual of Mental Disorders (DSM).

Multiaxial classification system forces the diagnostician to consider a broad range of information.
Axis:

• I clinical disorders
• II Developmental disorders and personality disorders
• III General medical conditions
• IV Psychological and environmental problems
• V global assessment of functioning scale

Removal oaf the multiaxial system

The multiaxinal system developed for DSM-IV-TR is removed in DSM-5.
In place of the first three axes clinicians are simply to note psychiatric and medical diagnoses.

Organizing diagnoses by causes

DSM-5 defines diagnoses entirely on the basis of symptoms.

• Some have argued that advances in our understanding of etiology (causes) could help us rethink this approach.
  But our knowledge base is not yet strong enough to organize diagnoses around etiology.

In the DSM-5, the chapters are reorganized to reflect patterns of comorbidity and shared etiology.

Enhanced sensitivity to the developmental nature of psychopathology

Childhood diagnoses have been moved into other relevant chapters of DSM-5, to

Clinical psychology
Chapter 5
Mood disorders

Mood disorders involve disabling disturbances in emotion.

Clinical descriptions and epidemiology of mood disorders

The DSM-5 recognizes two broad types of mood disorders:

• Those that involve only depressive symptoms
• Those that involve manic symptoms

Depressive disorders

The cardinal symptoms of depression include profound sadness and/or an inability to experience pleasure.

Physical symptoms of depression are also common

• Fatigue and low energy
• Physical aches and pains
  These symptoms can be profound enough to convince afflicted persons that they must be suffering from some serious medical condition, even though the symptoms have no apparent physical cause.
• Although people with depression typically feel exhausted, they may find it hard to fall asleep and may wake up frequently.
  Other people sleep throughout the day.
• They may find that foot tasted bland or that their appetite is gone, or that may experience an increase in appetite.
• Sexual interest disappears
• Some may find their limbs feel heavy
• Psychomotor retardation: thoughts and movements may slow
• Psychomotor agitation: not being able to sit still

Social withdrawal is common.

Major depressive disorder

Major depressive disorder (MDD)

• An episodic disorder: symptoms tend to be present for a period of time and then clear.
  Even though periods tend to dissipate over time, an untreated episode may stretch for 5 months or even longer.
  For a small percentage of people, the depression becomes chronic.
• Major depressive episodes tend to recur, once a given episode clears, a person is likely to experience another episode.
  The average number of episodes is about four. With every new episode that a person experiences, his or her risk for experiencing another episode goes up by 16 percent.

DSM-5 criteria

• Sad mood and loss of pleasure in usual activities
• At least five symptoms (counting sad mood and loss of pleasure)
  • Sleeping too much or too little
  • Psychomotor retardation or agitation
  • Weight loss or change in appetite
  • Loss of energy
  • Feelings of worthlessness or excessive guilt
  • Difficulty concentrating, thinking, or making decisions
  • Recurring thoughts of death or suicide
• Symptoms are present nearly every day, most of the day, for at least 2 weeks.
• Symptoms are distinct and more severe than a normative response to significant loss.

Persistent depressive disorder (Dysthymia)

People wit dysthymia are chronically depressed, more then half of the time for at least 2 years. They feel blue or derive little pleasures from usual activities and pastimes.

DSM-5 criteria for persistent depressive disorder (dysthymia)

• Depressed mood for most of the day more than half of the time for 2 years (or 1 year for children and adolescents).
• At least two of

Clinical psychology
Chapter 7
Obsessive-compulsive-related and trauma-related disorders

Obsessive-compulsive and related disorders

OCD is defined by repetitive thoughts and urges (obsessions) as well as an irresistible need to engage in repetitive behaviors or mental acts (compulsions)

Body dysmorphic disorder and hoarding disorder have symptoms or repetitive thoughts and behaviors.

• People with body dysmorphic disorder spend hours a day thinking about their appearance, and almost all engage in compulsive behaviors such as checking their appearance in the mirror.
• People with hoarding disorder spend a good deal of their time repetitively thinking about their current and potential future possessions. They also engage in intensive efforts to acquire new objects, and these efforts can resemble the compulsions observed in OCD.

For all three conditions, the repetitive thoughts and behaviors are distressing, feel uncontrollable, and require a considerable amount of time.
For the person with these conditions, the thoughts and behaviors feel unstoppable.

These syndromes often co-occur.

Clinical descriptions and epidemiology of the obsessive-compulsive and related disorders

Obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is characterized by obsessions or compulsions.

Obsessions: intrusive and recurring thoughts, images, or impulses that are persistent and uncontrollable and often appear irrational to the person experiencing them.
For people with OCD, obsessions have such force and frequency that they interfere with normal activities.
People with obsessions may also be prone to extreme doubts, procrastination, and indecision.

Compulsions: repetitive, clearly excessive behaviors or mental acts that the person feels driven to perform to reduce the anxiety caused by obsessive thoughts or to prevent some calamity from occurring.
Even though rationally understanding that there is no need for this behavior, the person feels as something dire will happen if the act is not performed.
The sheer frequency with which compulsions are repeated may be staggering.
Commonly reported compulsions:

• Pursuing cleanliness and orderliness, sometimes through elaborate rituals- performing repetitive , magically protective acts, such as counting or touching a body part.
• Repetitive checking to ensure that certain acts are carried out.

OCD tends to begin either before age 10 or else in late adolescence/early adulthood.
Slightly more common among women than men.
The pattern of symptoms appears to be similar across cultures.
High comorbidity.

DSM-5 criteria for Obsessive-compulsive disorder

• Obsessions or compulsions
• Obsession are defined by
  • Recurred, intrusive, persistent, unwanted thoughts, urges or images
  • The person tries to ignore, suppress, or neutralize the thoughts, urges, or images
• Compulsions are defined by
  • Repetitive behaviors or thoughts that the person feels compelled to perform to prevent distress or a dreaded event.
  • The person feels driven to perform the repetitive behaviors or thoughts in response to obsessions or according to rigid rules
• The obsessions or compulsions are time

Clinical psychology
Chapter 9
Schizophrenia

Schizophrenia: a disorder characterized by disturbances in thought, emotion and behavior.

>1% prevalence
Slightly more men than women.
Sometimes develops in childhood, but usually appears in late adolescence or early adulthood
people with schizophrenia typically have a number of episodes of their symptoms and less severe but still debilitating symptoms between episodes.

Clinical descriptions of schizophrenia

The range of symptoms in the diagnosis of schizophrenia is extensive, although people with schizophrenia typically have only some of these problems at any given time.
No single essential symptom must be present for a diagnosis of schizophrenia.

Researchers divided symptoms in three

• Positive symptoms
  Delusions, hallucinations
• Disorganized symptoms
  Disorganized behavior, disorganized speech
• Negative symptoms
  Avolition, alogia, anhedonia, blunted affect, asociality

DSM-5 criteria of schizophrenia

• Two or more of the following symptoms for at least 1 month; one symptom should be either 1, 2, or 3:
  1. delusions
  2. hallucinations
  3. disorganized speech
  4. disorganized (or catatonic) behavior
  5. negative symptoms (diminished motivation or emotional expression)
• Functioning in work, relationships, or self-care has declined since onset
• Signs of disorder for at least 6 months; or, if during a prodromal or residual phase, negative symptoms or two or more of symptoms 1-4 in less severe form.

Positive symptoms

Positive symptoms comprise excesses and distortions, such as hallucinations and delusions.
For the most part, acute episodes of schizophrenia are characterized by positive symptoms.

Delusions

Delusions: beliefs contrary to reality and firmly held in spite of disconfirming evidence.
Common symptoms in schizophrenia.

Delusions take several forms including:

• Thought insertion: the belief that thoughts that are not his or hers own have been placed in his or her mind by an external force.
• Thought broadcasting: the believe that his or her thoughts are broadcast or transmitted, so that other know what the person is thinking
• The believe that an external force controls his or her feelings or behaviors
• Grandiose delusions: an exaggerated sense of his or her own importance, power, knowledge, or identity.
• Ideas of reference: incorporating unimportant events within a delusional framework and reading personal significance into the trivial activities of others.

Delusions are also found in other diagnoses,

• Bipolar disorder
• Depression with psychotic features
• Delusional disorder

Hallucinations and other disturbances of perception

Hallucinations: sensory experiences in the absence of any relevant information for the environment.
More often auditory than visual.

Negative symptoms

The negative symptoms of schizophrenia consists of behavioral deficits.
Include:

• Avolition
• Asociality
• Anhedonia
• Blunted affect
• Alogia

Negative symptoms tend to endure beyond an acute episode and have profound effects on the lives of people with schizophrenia.
The

Clinical psychology
Chapter 11
Eating disorders

Clinical description of eating disorders

Anorexia nervousa

DSM-5 criteria for anorexia nervousa

• Restriction of food that leads to very low body weight; bodyweight is significant below normal
• Intense fear of weight gain
• Body image disturbance

Amenorrhea: loss of menstrual period

Two types of anorexia nervosa:

• Restricting type
  Weight loss is achieved by severely limiting food intake
• Binge-eating/ purging type
  The person has also regularly engaged in binge eating and purging.

Typically begins in the early to middle teenage years, often after an episode of dieting and the occurrence of life stress.
Lifetime prevalence: less than one percent
10 time more frequent in women than in men.

• Women with anorexia are frequently diagnosed with depression, obsessive-compulsive disorder, phobias, panic disorder, substance use disorder, and various personality disorders.
• Men with anorexia nervosa are also likely to have a diagnoses of a mood disorder, schizophrenia, or substance use disorder.

Suicide rates are quite high for people with anorexia

Physical consequences of anorexia nervosa

Self-starvation and use of laxatives produce numerous undesirable biological consequences in people with anorexia nervosa.

• Blood pressure falls
• Heart rate slows
• Kidney and gastriontestinal problems
• Bone mass declines
• Skin dries out
• Nails become brittle
• Hormone levels change
• Mild anemia may occur
• some people loose hair, and they may develop lanugo, a fine, soft hair on their bodies.
• Levels of electrolytes are altered. These are essential to neural transmission, and lowered levels can lead to
  • Tiredness
  • Weakness
  • Cardiac arrhythmias
  • Sudden death

Prognosis

Between 50 and 70 percent of people with anorexia eventually recover.
Recovery often takes 6 to 7 years, and relapses are common before a stable pattern of eating and weight maintenance is achieved.

Anorexia nervosa is a life-threatening illness.

Bulimia nervosa

DSM-5 criteria for bulimia nervosa

• Recurrent episodes of binge eating
• Recurrent compensatory behaviors to prevent weight gain, for example, vomiting
• Body shape and weight are extremely important for self-evaluation

Involves episodes of rapid consumption of a large amount of food, followed by compensatory behavior, such as vomiting, fasting, or excessive exercise, to prevent weight gain.

Binge has two characteristics:

• It involves eating and excessive amount of food within a short period of time
• It involves a feeling of losing control over eating

Bulimia nervosa is not diagnosed if the bingeing and purging occur only in the context of anorexia nervosa and its extreme weight loss.
The diagnoses in such a case is anorexia nervosa, binge-eating/purgning type.

The key difference between anorexia and bulimia is weight loss.
People with bulimia do not lose a tremendous amount of weight.

In bulimia, binges typically occur in

Clinical psychology
Chapter 13
Disorders of childhood

Most theories of childhood disorder, consider childhood experience and development critically important to adult mental health.

Classification and diagnosis of childhood disorders

Before making a diagnosis of a particular disorder in children, clinicians must first consider what is typical for a particular age.

Some childhood disorders are unique to children.

The more prevalent childhood disorders are often divided into two broad domains,

• Externalizing disorders
  Characterized by outward-directed behaviors
  • Attention-deficit/hyperactivity disorder
  • Conduct disorder
  • Oppositional defiant disorder
• Internalizing disorders
  Characterized by more inward-focused experiences and behaviors
  • Childhood anxiety disorder
  • Mood disorders

Children and adolescents may exhibit symptoms form both domains.

Across cultures, externalizing behaviors are consistently found more often among boys and internalizing behaviors more often among girls, at least in adolescence.

Childhood disorders involve an interaction of genetic, neurobiological, and psychological factors.

Attention-deficit/hyperactivity disorder

Clinical descriptions, prevalence, and prognosis of ADHD

DSM-5 criteria for attention-deficit/hyperactivity disorder

• Either A or B
• A. Six or more manifestations of inattention present for at least 6 months to a maladaptive degree and greater that what would expected given a person’s developmental level, e.g., careless mistakes, not listening well, not following instructions, easily distracted, forgetful in daily activities
• B. Six or more manifestations of hyperactivity-impulsivity present for at least 6 months to a maladaptive degree and greater than would be expected given a person’s developmental level e.g., fidgeting, running about inappropriately (in adults, restlessness), acting as is ‘driven by a motor’, interrupting or intruding, incessant talking.
  • Several of the above present before age 12
  • Present in two or more settings, e.g., at home, school, or work
  • Significant impairment in social, academic, or occupational functioning
  • For people age 17 or older, only five signs of inattention and/or five signs of hyperactivity-imupulsivity are needed to meet the diagnoses.

Although children with ADHD are usually friendly and talkative, they often miss subtle social cues.

Children with ADHD can know what the socially correct action is in hypothetical situations but be unable to translate this knowledge into appropriate behavior in real-life social interactions.

DSM-5 includes three specifiers to indicate which symptoms predominate

• Predominantly inattentive: children whose problems are primarily those of poor attention
• Predominantly hyperactive-impulsive: children whose difficulties result primarily from hyperactive/impulsive behavior
• Combined: children who have both sets of problems

The combined specifier comprises the majority of children with ADHD.

A difficult differential diagnosis is between ADHD and conduct disorder, which involves gross violation of social norms.
These two

Clinical psychology
Chapter 15
Personality disorders

The personality disorders are a heterogeneous group of disorders defined by problems in forming a stably positive sense of self and with sustaining close and constructive relationships.
People with personality disorders experience difficulties with their identity and their relationship in multiple domains of life, and these problems are sustained for years.
Their personality problems are evident in cognition, emotion, relationships, and impulsive control. The symptoms of personality disorders are pervasive and persistent.

Classifying personality disorders

The DSM-5 approach to classification

In the DSM-5, the 10 different personality disorders are classified in three clusters, reflecting the idea that these disorders are characterized by:

• Odd or eccentric behavior
• Dramatic, emotional or erratic behavior
• Anxious or fearful behavior

Many people with psychological disorder will also experience a personality disorder.
Comorbid personality disorder are associated with more severe symptoms, poorer social functioning, and worse treatment outcomes for may conditions.

Diagnostic reliability

• One issue in assessing personality disorders is whether people can accurately describe their own personalities.
• Many of the personality disorders may not be as enduring as the DSM asserts.

Using structured interviews and multiple informants can improve reliability.

Comorbidity

Personality disorders tend to be comorbid with each other.

Alternative DSM-5 model for personality disorders

Reducing the number of personality disorders, incorporating personality trait dimensions, and diagnosing personality disorders on the basis of extreme scores on personality trait dimensions.

Two types of dimensional scores

• 5 personality trait domains
• 25 more specific personality trait facets.

Key strengths:

• Richer sense of detail than do the personality disorder diagnoses
• Personality traits tend to be more stable over time than are personality disorder diagnoses
• Including personality traits help link the DSM with a broad research literature of personality

Alternative DSM-5 criteria for Personality disorder

• Significant impairments in self and interpersonal functioning
• At least one pathological personality trait domain or facet
• Personality impairments are persistent and pervasive
• Personality impairments are not explained by developmental stage, sociocultural environment, substance abuse, another psychological condition, or a medical condition.

Odd/eccentric cluster

Odd/eccentric cluster includes:

• Paranoid personality disorder
• Schizoid personality disorder
• Schizotypal personality disorder

Paranoid personality disorder

DSM-5 criteria for Paranoid personality disorder

• Presence of four or more of the following signs of distrust and suspiciousness, beginning by early adulthood and shown in many contexts
  • Unjustified suspiciousness of being harmed, deceived, or exploited
  • Unwarranted doubts about the loyalty or trustworthiness of friends or associates
  • Reluctance to confide in others because of suspiciousness
  • The tendency to read hidden meanings into the benign actions of others
  • Bears grudges for

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