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

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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

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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

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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.

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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?

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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

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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,)

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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

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CLASSIFICATION IN PSYCHOPATHOLOGY DIFFERING
VIEWS
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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.

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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

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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.

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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.

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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.

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FAST FORWARD TO 1994

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

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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

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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.

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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

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DEFINITION OF MENTAL DISORDER IN THE DSM
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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.

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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.

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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.

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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

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WHY WOULD WE WANT TO HAVE A CLASSIFICATION SYSTEM?

• Fundamental to all scientific activity
• Permits systematic investigation
• Description
• Comparison
• Prediction
• Enables communication

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CLASSIFICATION

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

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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?
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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

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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

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POTENTIAL NEGATIVE CONSEQUENCES OF DIAGNOSIS

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