GRE® Psychology Clinical: Clinical and Abnormal Part 1

Kraeplin created one of the first textbooks of co-occurring mental disorders, which he grouped together and classified with common symptoms. He also created the term “dementia praecox” for schizophrenic symptom clusters.

This became the ancestor to our modern Diagnostic and Statistical Manual of Mental Disorders (DSM).

Pinel was one of the first mental health professionals to treat his patients with compassion and kindness. The model set by the Parisian hospital he ran was adopted by many other asylums.

Dorothea Dix

Thomas Szasz

This book espouses the belief that labeling people as mentally ill makes them conform to the norms of society, rather than examining the societal roots of their mental problems. Szasz also espoused the belief that “mental illness” is a social construction.

To hear an excerpt of a speech by Szasz, please go here.

• Incidence is the number of new cases that appear in a population in a given period of time.

• Prevalence is the total number of active cases (old and new) present in a population in a given period of time.

• Lifetime prevalence is the total proportion of people who will meet criteria for diagnosis at some point in their lives.

It’s another term for co-occurrence.

For instance, if an individual meets diagnostic criteria for both obsessive-compulsive disorder (OCD) and alcohol dependence, then that person could be said to have comorbid OCD and alcohol dependence.

Comorbidity is very common in clinical settings, and high rates of comorbidity suggest that many mental disorders are not clear-cut categories.

Something that must be present for a particular illness to occur:

If illness X occurs, then A must have been present.

Something that by itself may cause a particular illness to occur:

B, in the absence of other factors, can result in illness X.

Something that makes it more likely that a particular illness either will occur or will continue:

If C is present, then illness X is more likely to happen or continue.

ICD stands for International Classification of Diseases, published by the World Health Organization (WHO).

• ICD-10 was the 10th revision, widely used for decades.

• ICD-11 is the current version, officially adopted in 2019 and in effect since January 1, 2022.

ICD is the global system for classifying diseases and health conditions.

• The U.S. still uses ICD-10-CM for billing and records, though preparation for ICD-11 is underway.

• Some DSM-5 revisions were made to align more closely with ICD categories.

• While the U.S. and Canada commonly use the DSM for mental health diagnoses, most of the world uses the ICD.

1. Whether the behavior causes subjective distress or suffering to the individual

2. Whether the behavior causes impairment or dysfunction

3. Whether the behavior is atypical or deviant with respect to the individual’s current cultural context

Most definitions include only these 3 Ds (Distress, Dysfunction, and Deviance). But another factor to consider is Danger, whether the behavior can be harmful to one’s self or others.

• Signs: perceived by the clinician

• Symptoms: perceived by the patient

Signs e.g., patient appears disheveled, patient speaks unusually slowly, patient does not make eye contact.

Symptoms e.g., patient feels hopeless, patient experiences intrusive thoughts, patient has suicidal thoughts.

This is a model in which a person has a diathesis to mental illness which can be activated by a stressor/stressors, thus precipitating mental disorder.

Diathesis: i.e., a vulnerability, which may be a distal necessary cause or a contributory cause.

Stressor/stressors: i.e., an experience or experiences that overtax an individual’s resources.

Having a short short (ss) allele for the serotonin transporter gene is a diathesis for depression.

Getting divorced is a stressor.

Refers to attempts to prevent disease or disorder onset, i.e., reducing the incidence of preventable illnesses.

Primary prevention is not (yet) achievable for mental illness.

Challenges include identifying what factors encourage the precipitation of mental illnesses (only some have been identified) and attempting to prevent these situations before they happen, via good public mental health practices (some may not be preventable).

However, some are preventable. For instance, because prenatal malnutrition doubles the risk for an individual developing schizophrenia in adulthood, providing universal prenatal care may help reduce the incidence of schizophrenia.

An unusually high level of negative mood.

An unusually low level of positive mood; inability to feel pleasure.

Rosenhan and several other confederates were admitted into mental health facilties presenting with illnesses. The confederates all received diagnoses and had a difficult time being released, because the staff began to classify their regular behaviors as indicative of illness. Rosenhan interpreted the results to mean that diagnoses exist in the minds of the observers.

To read the original Rosenhan article, go here.

To see a brief interview with Rosenhan, go here.

Rosenhan reported that the pseudopatients, rather than being released as never having been ill, were released with a diagnosis of schizophrenia in remission. Rosenhan noted that being labeled “insane” can persist throughout the life-span, which is dangerous. Rosenhan concluded that psychiatric diagnoses exist in the minds of observers: By naming something, we behave as if it is real (so yes, symptoms are real, but how we understand illnesses may be wrong).

Perhaps the most disturbing finding was that pseudopatients averaged less than seven minutes of direct therapeutic care per day, suggesting that patients in general received inadequate clinical care.

Among other issues:

1. The diagnosis of schizophrenia in remission was (and is) quite rare, suggesting that the psychiatrists were aware that these patients’ cases were not standard cases.

2. Because symptoms, which are not externally visible, are used to determine diagnosis, in most situations, treaters must depend on patients to be honest to the best of their ability. The ability to fake an illness does not mean that the illness does not exist.

To read Spitzer’s critique of Rosenhan, go here.

They are forms of Cognitive Behavioral Therapy (CBT).

One of the important strengths of CBT is that it has empirical support. Empirical support means that is has been scientifically tested in clinical trials and found to be beneficial for patients.

• Negative views of the self: e.g., “I suck.”

• Negative views of the world: e.g., “Everybody hates me.”

• Negative views of the future: e.g.,” My life will always suck.”

Negative early experiences can lead to the formation of dysfunctional beliefs or schemas, which may lay dormant until a critical incident of some kind occurs (e.g., losing a job or breaking up with a significant other).

The individual then experiences cognitive distortions about the critical incident (or incidents). These cognitive distortions lead to negative, dysfunctional automatic thoughts and self-talk, which can turn into a negative feedback loop and cause the individual to experience depressive symptoms. Cognitive errors reinforce negative schemas.

He would place dogs in cells with high walls, then electroshock the floor, causing the dogs to try to jump out of the cells. Eventually, the dogs stopped trying to escape: they had learned to be helpless. This is much like people with depression who eventually feel powerless to escape their problems.

1. Identify situations that are troubling

2. Become aware of relevant thoughts and beliefs

3. Identify inaccurate, negative thinking

4. Challenge inaccurate, negative thinking

Repeat until cognitive errors are reduced and adaptive thinking patterns become habitual.

• Empirically validated treatments: Research supports that CBT works for treating many disorders, such as anxiety and unipolar mood disorders.

• For depression, CBT treatment is as successful as SSRIs; plus patients who do CBT have a significantly lower recurrence rate.

• Versatility: CBT has successfully been adapted for use with patients from a variety of cultures. Also, CBT has been successfully used for a variety of uses, such as helping individuals develop healthier sleeping habits.

• Empowering: Patients do homework and actively collaborate on their treatment.

• CBT may not adequately address biological factors.

• Therapists need special training; relatively few patients have access to CBT services. Needs better dissemination!

• Research focuses on patients without comorbidity, so short length of treatment may not be realistic for patients in the community.

• It is challenging, so high drop out rates can be problem.

1. Bipolar and Related Disorders

2. Depressive Disorders

Bipolar and Related Disorders (Bipolar I Disorder; Bipolar II Disorder; Cyclothymic Disorder…)

Depressive Disorders (Major Depressive Disorder; Persistent Depressive Disorder (Dysthymia); Premenstrual Dysphoric Disorder…)

1. depressed mood (dysphoria)

2. general lack of interest in once enjoyable activities (anhedonia)

3. low sense of self-worth

4. hypersomnia or insomnia

5. possible suicidal ideation

6. significant weight loss/gain

7. loss of energy

8. diminished ability to concentrate

9. restlessness

Symptom 1 (dysphoria) and Symptom 2 (anhedonia) are the cardinal symptoms; one or both must be presnt for a DSM-5 MDD diagnosis.

In the DSM-IV, there was a grief/loss exclusion for diagnosing Major Depressive Disorder (MDD). This exclusion has been removed in the DSM-5.

The exclusion originally was included to avoid pathologizing grief. However, MDD often is triggered by exposure to significant stressors. A compelling reason to remove the exclusion is that in a treatment study, treatment seeking individuals who otherwise met criteria for MDD responded to treatment as successfully as did treatment seeking individuals who met the full criteria. Thus a grief exclusion may have been an unintended barrier to beneficial treatment.

• Depressed mood for most of the day for more days than not for at least 2 years (in children and adolescents, at least 1 year).

• Presence (while depressed) of at least 2 of the following symptoms: Poor appetite or overeating; Insomnia or hypersomnia; Low energy or fatigue; Low self-esteem; Poor concentration/difficulty making decision; or Feelings of hopelessness.

• During the 2 year period, the individual has never been free from these symptoms for more than 2 months at a time.

• Symptoms cause clinically significant distress or impairment in functioning.

Also, no history of mania, and the disorder is not better accounted for by schizoaffective, schizophrenia, delusional disorder, or another psychotic illness; not caused by a substance or medical condition.

No

The DSM-5 explains that although there can be wide variation in how the disorder impacts social &/or occupational functioning, "effects can be as great or greater than those of major depressive disorder"

Although the symptoms may be less severe, their longstanding nature can lead to significant impairment as well as an even higher risk for suicide than MDD.

This mental disorder is characterized by periods of depression and mania.

bipolar disorder type I

One or more periods of hypomanic symptoms interspersed with one or more periods of depressive symptoms.

Cerletti and Bini

These doctors introduced electroshock therapy in 1938. The spasms from this treatment were often so severe that their patients were often seriously injured during the therapy.

However, electroshock therapy can now be performed safely and is used as a treatment for some severely depressed patients. (It is reserved for patients who are severely depressed and are not responding to or are unable to take other forms of treatment.)

One which makes a condition worse.

Although most therapies are helpful, some treatments (e.g., debriefing for PTSD; psychoanalysis for schizophrenia) have been found to worsen outcomes. The possibility of iatrogenic treatment is one of the reasons that clinical research trials are very important.

No, insane is a legal term.

Mental health professionals and medical doctors cannot diagnose people as being insane. Determinations of sanity are a legal matter.

Diagnosis with a mental disorder may be used as evidence in determining a defendant's fitness to stand trial, but in and of itself, diagnosis is not sufficient to determine sanity.

(Sane also is a legal term.)

No. Most people who experiment with addictive substances do not become addicted.

However, a minority will, and it is not possible to know for certain in advance whether or not one has a brain that is especially vulnerable to developing addiction.

• reduces addicted individual's accountability

• removes incentive to abstain

• places addicted individual in victim role

• inconsistent with data that say "controlled" use may be achieved

• self-fulfilling prophecy

• In early stage, the drug use is pleasure-based and goal-driven, i.e., drug taking behavior.

• In late stage, the drug use is compulsive and habit-driven, occuring even if there are significant negative consequences, i.e., drug seeking behavior.

In addiction, as time goes on, the individual likes or enjoys the drug less, but craves the drug more and more.

• brought the problem to public awareness

• achieved funding to study alcoholism

• reduces stigma

• promotes treatment development and funding

A lethal neurodegenerative disorder.

Individuals with Alzheimer's disease experience dementia, progressive losses in memory and cognition, social withdrawal, lapses in judgement, and eventually lose their ability for self care.

Post mortem (after death) examination of the brains of people with Alzheimer's disease reveal neurofibrillary tangles, amyloid plaques, and reduced brain volume.

Currently there is no way to cure or to prevent Alzheimer's disease.

Anorexia nervosa | (AN)

According to the DSM-5, the majority of the AN deaths are due either to medical complications (e.g., multiple organ failure) or to suicide.

1. Pica

2. Rumination Disorder

3. Avoidant/Restrictive Food Intake Disorder

4. Anorexia Nervosa (AN can be restricting type OR can be binge-eating purging type)

5. Bulimia Nervosa

6. Binge-Eating Disorder

7. Other Specified Feeding or Eating Disorder

8. Unspecified FEeding or Eating Disorder

anorexia nervosa

• purging

• excessive exercise

• fasting

However, if the individual also meets criteria for anorexia nervosa, you diagnose anorexia nervosa (binging and purging subtype) instead.

1. Having developed an anxiety disorder as a child or having had obsessional traits as a child.

2. Environmental: Being in a culture or setting in which thinness is valued/idealized (e.g., modeling).

3. Genetic: Having a first degre relative with AN. Monozygotic (identical) twins have a higher concordance rate than dizygotic (fraternal) twins.

4. Possibly brain abnormalities, but it is unclear if abnormalities are the result of or a cause of AN.

In addition, being female, being Caucasian or Asian, negative affect (neuroticism), dieting, body dissatisfaction, dieting, and perfectionism also are individual risk factors. Childhood sexual abuse also has been implicated in some research.

Yes! Anorexia nervosa is much more common among females. It is estimated that for every 1 male with AN, there are 10 females.

autism

No

In the DSM-IV, the diagnosis Asperger's Syndrome (a very high functioning form of autism,) has been subsumed into the diagnosis of Autism Spectrum Disorder.

No. Although it is common for people who have autism to have an intellectual disability, many individuals who meet criteria for autism do not meet criteria for an intellectual disability.

Intellectual Disability

A condition associated with moderate to severe intellectual disability.

In addition, individuals with Down syndrome seem to age more quickly, have increased risk for developing dementia/Alzheimer's disease, and have shortened average lifespans.

There is a high rate of cardiovascular problems. Also, there are distinctive physical features (e.g., almond shaped eyes) associated with Down syndrome.

Trisomy (three copies instead of two) of chromosome 21.

A disorder in which a baby lacks a liver enzyme necessary to process phenylalanine, an amino acid found in many foods, including breast milk and cow's milk.

It is a recessive disorder, occuring in approximately 1 in 12,000 births. In most cases, if it is detected soon after birth, special diet can allow the individiual with PKU to have a normal life. If it is not caught and addressed early in life, severe brain damage and intellectual disability occurs.

A disorder characterized by the pervasive expression of extreme, abnormal personality constructs that interfere with normal social functioning.

Abuse and neglect are risk factors for developing personality disorders.

People who experienced abuse and/or neglect as children are 4 times more likely to develop a personality disorder than are people who were not abused or neglected (Johnson, et al., 1999).

This relationship is especially pronounced in Histrionic Personality Disorder, Narcissistic Personality Disorder, Borderline Personality Disorder, and Antisocial Personality Disorder.

antisocial personality disorder

Important critiques of ASPD include that it has good reliability but lacks validity and that a diagnosis of ASPD in many cases is just a diagnosis of criminality, not mental illness.

Psychopathy is more challenging to consistently diagnose/quantify, but it is more predictive of recidivism, especially violent recidivism.

Decompression Therapy

For more information on decompression therapy and psychopathy, please read this resource.

30%

Psychopathy Checklist - Revised | (PCL-R)

Robert Hare

Hare developed the PCL-R for use with caucasian men, and it lacks validity when used to assess Latino or Black men, or when used to assess women. This is highly problematic because PCL-R scores often are used in making legal determinations, such as sentencing and parole.

• Exaggerated self importance

• Excessive, constant need for others' admiration

• Lack of empathy for others

This personality disorder is one of the more volatile personality disorders; it is characterized by interpersonal issues, identity problems, fear of abandonment, and often self-injurious behavior.

1. Frantic efforts to avoid real or imagined abandonment.

2. A pattern of unstable and intense interpersonal relationships characterized by alternating betwen extremes of idealization and devaluation (This is referred to as splitting).

3. Identity disturbance--markedly, persistently unstable self-image.

4. Impulsive behavior in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, driving, eating).

5. Recurrent suicidal or self-mutilating behavior.

6. Affective instability/marked reactivity of mood.

7. Chronic feelings of emptiness.

8. Inappropriate, intense anger/difficulty controlling anger.

9. Transient stress-related psychotic-like symptoms (paranoid ideation, severe dissociation).

Dialectical Behavioral Therapy | (DBT) Marsha Linehan developed DBT in order to help severely suicidal patients. DBT combines elements of CBT and eastern philosophy with acceptance therapy.

A substantial body of research supports DBT as significantly reducing the risk of suicide for individuals who have Borderline Personality Disorder.

histrionic personality disorder

Paranoid

schizoid personality disorder

The need to be taken care of.

This is the period of time (usually 6 months or more) in which the patient exhibits a mixture of positive and negative schizophrenic symptoms.

A fixed belief that is not amenable to change in light of conflicting evidence.

delusions of grandeur

The unfounded belief that you are being or will be harmed, these delusions usually involve the mentally ill person believing they are the center of a plot.

• Biological: Antipsychotic medication, either typical or atypical (atypicals are generally better tolerated)

• Psychological: CBT to address hallucinations and delusions; social skills training; supportive therapy

• Social: Family counseling; psychoeducation about schizophrenia

Avoid psychoanalysis / psychodynamic treatment for schizophrenia because it can be iatrogenic!

This was the original name for schizophrenia, which literally means early dementia.

• delusions

• hallucinations

• disorganized behavior

• disorganized speech

• catatonic behavior

Currently schizophrenia is not curable, but good early intervention can help individuals who have schizophrenia have longer periods between episodes, and for the episodes to be less severe. Also treatment can help people function better between episodes.

It helps explain the role of stress in the home environment in relapse for people who have schizophrenia. EE is measured by interviewing a patient's family member with whom she or he lives.

A one-on-one interview is conducted by a researcher. The researcher assesses criticism (disapproval) of, hostility (animosity) towards, and emotional over-involvement (intrusiveness) with the patient. High levels of EE, especially criticism, is a risk factor for relapse High EE also is predictive for relapsee in other disorders.

For additional information on EE, consult work by George Brown and work by Jill Hooley.

negative

One way to remember negative symptoms is to think of them as something that should be present that is missing.

Avolition, anhedonia, alogia, flattened affect, & asociality.

Slightly over 1 %.

schizoaffective

1. prodromal phase

2. active phase

hallucinations

• A non-bizarre delusion is one which (although highly improbable) is possible, or seemingly possible, in the context of the individual's culture.

• A bizarre delusion is one which is implausible and not understandable to same-culture peers and does not derrive from ordinary life experiences.

Non-bizarre delusion - For instance, a persecutory delusion in which the individual thinks that the CIA is watching him or that someone is trying to poison him.

Bizarre delusion - For instance, a delusion in which the individual thinks aliens are inserting or withdrawing thoughts from his or her head.

Literally, a neologism is a new word. (New words do arise in living languages.) However, in clinical and psychological research, the word neologism is used to describe non-words that seem word-like. Use of neologisms can be a symptom of some types of brain damage or of thought disorder. Thought disorder is a common symptom of schizophrenia.

They occur when an individual speaks in such a way that his or her sentences have semantic connections but lack logical connection.

For instance: "It's cold today. My cold is better, but I got it from the nurse. She is a big blonde who drinks Manhattans. I live in Manhattan with famous people."

Loose associations, also referred to as cognitive slippage or derailment, are a sign of thought disorder. Thought disorder is a symptom of disorganized behavior in schizophrenia spectrum disorders.

Auditory hallucinations are the most common types of hallucinations, such as hearing voices, but hallucinations can occur in any of the five sensory modalities.

Often, dopamine is misunderstood as being primarily pleasure-related. Evolutionarily, dopamine is better understood as marking that something is important and needs our attention, motivating us to address survival needs (food, partner, etc.) According to the aberrant salience hypothesis: release of excess dopamine in the striatum of some individuals leads them to experience a false sense of salience/meaningfulness—ascribing importance to unimportant stimuli, then their brains try to construct a narrative to explain the feeling that the stimulus has meaning—an attempt at meaning-making. Thus, delusions are a post hoc explanation to make sense of assignment of salience.

residual schizophrenia

reactive

It's a period before meeting criteria for diagnosis of a schizophrenia spectrum illness, in which the individual is begining to exhibit some symptoms, such as social withdrawal and odd behavior.

schizophrenia