General Psychopathology

Welcome to the General Psychopathology educational page.

-This page is new, and currently under basic construction-

This project is aimed toward facilitating basic understanding of Psychopathology to include the Diagnostic and Statistical Manual of Mental Disorder (DSM) utility and mental illness descriptions. In addition to these principles, the intention of this page is to encourage referencing and dialogging the different viewpoints (concerns, pros, cons) about this topic. Medical professionals and researchers will mostly likely be concerned with the content of this page. Everyone is invited to participate however.

We intend to create a subsection that provides insight to the next DSM update, the DSM-V.

Any input and assistance in expanding this project is greatly appreciated.

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Sections

* Diagnostic and Statistical Manual of Mental Disorders (DSM)
* Methods for Assessing Psychopathology
* Cultural Considerations
* Treatment

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### Diagnostic and Statistical Manual of Mental Disorders (General)

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\- The DSM-IV-TR is the most recent version which is inclusive of standardly accepted diagnostic criteria for mental disorders. Draft information about the DSM-V can be found here [1]

* The manual is laid out in a "Multi-Axial" format to allow for a systematic encoding and reporting of a patient's clinical presentation. Standard description of the (5) Axes are as follows:

Axis I: Clinical Disorders and Other Conditions That may Be A Focus of Clinical Attention

Axis I is reserved mainly for diagnoses which are considered of clinical attention.

Axis II: Personality Disorder/Mental Retardation

Axis II is dedicated to reporting Personality Disorders and Mental Retardation. It can alternatively be used for noting prominent maladaptive personality features and defense mechanisms. It is important to note that the listing of Personality Disorders and Mental Retardation on a separate axis ensures that consideration will be given to the possible presence of Personality Disorders and Mental Retardation that may otherwise be overlooked, due to attention on Axis I disorders.

Axis II may also be utilized to indicate prominent maladaptive personality features that do not meet the full criteria for a Personality Disorder. Additionally, the habitual use of maladaptive defense mechanisms may be indicated on Axis II.

Axis II Disorders

Paranoid Personality Disorder, Schizoid Personality Disorder,Schizotypal Personality Disorder, Antisocial Personality Disorder, Borderline Personality Disorder, Histrionic Personality Disorder, Narcissistic Personality Disorder, Avoidant Personality Disorder, Dependent Personality Disorder, Obsessive-Compulsive Personality Disorder, Personality Disorder Not Otherwise Specified, Mental Retardation

Axis III: General Medical Conditions

Axis III is reserved for coding and communicating a patient's medical conditions that may be relevant to the psychological condition. Many Axis I disorders include ". . . Due to a General Medical Condition" in which are properly annotated on Axis I and Axis III.

Axis IV: Psychosocial and Environmental Problems

Axis IV is dedicated to reporting psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders (Axes I and II). A psychosocial or environmental problem can be defined as a negative life event, an environmental difference or deficiency, a familial or other interpersonal stress, an inadequacy or social support or personal resources, or other problem relating to the context in which a person's difficulties have developed. So-called positive stressors, such as a job promotion, should be listed only if they constitute or lead to a problem, such as when a person has trouble adapting to the new situation. It should be noted that psychosocial problems may develop as a consequence of a person's psychopathology or may constitute problems that should be considered in the overall management program.

When evaluating for Axis IV problems, the clinician should only note those psychosocial and environmental problems that have been present during the year preceding the current evaluation. However, the clinician may choose to note the aforementioned problems that occurred prior to the previous year if these lucidly contribute to the mental disorder or have become a focus of treatment.

Axis IV Disorders:

Problems with primary support group,Problems related to the social environment,Educational Problems,Occupational Problems, Housing Problems, Economic Problems, Problems with access to health care services,Problems related to interaction with legal system/crime, Other psychosocial and environmental problems

Refer to DSM-IV-TR for a detailed description of each problem.

Axis V: Global Assessment of Functioning

Axis V defines an individual's "global assessment of functioning" or "GAF score." The Global Assessment of Functioning (GAF) is a numeric scale (0 through 100) used to rate the social, occupational and psychological functioning of adults. Often, a clinician will note a client's GAF score within the Axes as "IV: GAF = ##." The scale used is below:

* 91 - 100 Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is ought out by others because of his/her many positive qualities. No symptoms.

* 81 - 90 Absent of minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members).

* 71 - 80 If symptoms are present, the are transient and expectable reactions to psycho-social stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning(e.g., temporarily falling behind in schoolwork).

* 61 - 70 Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well,has some meaningful relationships.

* 51 - 60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers).

* 41 - 50 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job).

* 31 - 40 Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school).

* 21 - 30 Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day; no job, home or friends).

* 11 - 20 Some danger of hurting self or others (e.g., suicidal attempts without clear expectation of death; frequent violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute).

* 1 - 10 Persistent danger of severely hurting self or others (e.g., recurrent violence)OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death.

The DSM V

In May 2013, the APA will publish the much anticipated DSM V. While nothing has been finalized, there is more transparency and openness in the creation of the latest DSM incarnation than ever before. Detailed information regarding potential changes to the DSM V can be found at the website www.DSMV.org. It is rumored that the most significant change proposed is the inclusion of dimensional assessments for depression, anxiety, cognitive impairment and reality distortion that span across many major mental disorders. This means that while a clincian may diagnose an eating disorder, they can also rate these four dimensions so as to better characterize the patient.

### Methods of Assessing for Psychopathology (General)

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* Pathology is assessed in numerous ways and using a myriad of techniques for information gathering and data synthesis. Some examples of how pathology is assessed include:

The Clinical Interview:

The clinical interview is a valuable tool for gathering key information from the patient. Example categories for such an interview include:,

* Chief complaint
* History of the current illness
* Past history
* Family history
* Educational history
* Social history
* Medical history
* Mental status examination

Using the structure of these categories (interview structures can vary significantly) a clinician can usually formulate a Diagnostic Impression and estimate a Treatment Plan.

Information from other resources can be vital in completing the diagnostic impression. These include records from school, previous treatment records, laboratory work, journals or timelines of difficulties, and reports from friends and family.

Face-to-Face Testing:

This type of testing includes many of the stereotypical psychological tests known in popular culture. Face-to-face tests assess a range of functioning (emotional to intellectual) can be broken down into two categories: projective and objective.

Projective tests tend to be open-ended and attempt to tap into a person's internal, emotional workings. These tests tend to vary in the degree of psychometric robustness. However, some (Exner’s Comprehensive System for the Rorschach and HIT) have developed systematic evaluation systems that are based on normative samples. However, many reviewers of these systems continue to point out inconsistencies among clinicians’ scoring and interpretations.

Objective tests use standardized measures to assess functioning. What is meant by objective is a test that likely 1) has developed its questions or method of gathering information from well established constructs (e.g. cognitive processing speed), 2) is reliable in the sense that taking the test over and over or with different examiners would yield consistent results, 3) gives clinically valuable output (e.g. a degree of symptom presence such as mania), 4) has standardized scores that are based on a sample population representative of the intended test takers.

* Projective tests include: Sentence Completion, House-Tree-Person/Kinetic Drawings,Thematic Apperception Test (TAT) and the Rorschach Inkblot Test.

* Objective tests include: The Wechsler Adult Intelligence Scale (WAIS), Wechsler Intelligence, Scale for Children (WISC), Minnesota Multiphasic Personality Inventory (MMPI) and the Wide Range Assessment of Memory and Learning (WRAML).

Neuropsychological Testing

The focus of this type of testing is likely to relate one's behavior to Central Nervous System (CNS) causes. Specialized tests are used to measure one's performance on tasks and then compare the results to other people who may have verified CNS abnormalities. This process may give additional clues to clinicians about potential early onset of CNS diseases, potential structural abnormality, and potential functional degree of difficulty expected of the patient.

Some of the tests used include:

* Bender Gestalt
* Trail Making Test
* Stroop Test
* Tower of London
* Rey Complex Figure
* Repeatable Battery for Neuropsychological Assessment (RBANS)
* . . . and the list goes on . . .

Neuroimaging is a similar and very much related field. Brain imaging techniques can be used in conjunction with neuropsychological tests. The "pros" of using both techniques to identify illness is that imaging gives visual insight and analysis of brain function, while neuropsych testing can measure the range of expressed behaviors of the person. Imaging techniques afford the opportunity for less cultural biased assessment, whereas normative results from traditional psychological tests have to be carefully designed and used appropriately in order to be less-biasing in their results.

Some of the imaging methods used include:

* Electroencephalogram (EEG)
* Quantitative Electroencephalogram (qEEG)
* Computerized Tomography (CT)
* Magnetic Resonance Imaging (MRI)
* Functional Magnetic Resonance Imaging (fMRI)
* Radiography Imaging (PET / SPECT)
* Diffusor Tensor Imaging (DTI)

Self Reports

Self reports are considered one of the most commonly used methods in psychological assessment. While clinical interviews and projective assessments are technically considered 'Self Reports', they are traditionally Objective Tests which utilize a restricted response format, such as true/false answers or using an ordinal scale (typically from 1-4). Examples of well known self reports include

* The Minnesota Multiphasic Personality Inventory (MMPI)
* The 16 Personality Factor Questionnaire
* California Personality Inventory
* Child Behavior Checklist
* Beck Depression Inventory

Medical Records

Records are a key source of tracking, updating, communicating, and confirming symptoms that may lead to diagnostic management. Likewise, collateral reports, both formal and informal, such as reports from teachers, associates, and other professionals serve to better validate the diagnostic process.

Traditional health records may be maintained on paper and/or electronic form, such as electronic or web based databases.

With technology upgrades, demand for remote doctor consultation, and ever increasing interest in research-based treatments, medical records too are changing to accommodate more efficient care. How so? There is a movement that is shaping the medical record to become streamlined, universally interpretable, and even can offer predictive outcomes and treatment recommendations. Again, how so? <The PKC Corporation> offers tools called Problem Knowledge Couplers. These tool can be grossly described as type of flow-chart based application that takes user input (e.g. the medical chart), compares the data to a database of other charts and archival data, and then offers diagnostic impressions. The goal of these “Problem Oriented Medical Records” is to use the shared knowledge of decades of collected medical data to instantly inform clinicians of the potential prognoses their patient may expect, therefore leading to earlier successful intervention, again based on up to date clinical data from many clinicians. Thus, greatly reducing the liability of longer treatment periods, misdiagnosis, and relying less on the clinician’s individual experience (e.g. as earned from professional education, conferences, reading journals, etc.) and more on the collective experience of many clinicians.

Some of these couplers include:

* ♠Clinical psychology syndromes:
* Depression and Anxiety Diagnosis
* Depression and Anxiety Treatment Choices
* Memory Problem or Confusion Diagnosis

Medical syndromes related to health psychology interventions.

* Diabetes Management
* Failure To Thrive Diagnosis in Children Aged 2 to 5
* Fainting Diagnosis
* Headache Diagnosis
* Menopause Management
* Weight, Diet, and Exercise diagnosis and management
* Sleep problems
* Substance risk / cessation

### Cultural Considerations (General)

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-Mental health and other medical conditions are significantly influenced, created, or modified by the cultural context. In non-jargon, this means that what one culture calls an "abnormal" condition or behavior may vary from another culture.

-Another project is underway to cover the considerations that should be given to one's culture when it comes to psychopathology. See*Culturally Specific Syndromes.

A closer look at Post Traumatic Stress Disorder (PTSD) and cultural factors:

It is important to note that PTSD is treated and assessed using measured developed and normed on western cultures. Stress is often manifested differently by different cultures. For example:

* Bhutanese refugees found that most often distress is conceptualized in terms of angered gods, dissatisfied spirits or some form of witchcraft.
* Youth in Palestine with trauma histories reported a preponderance of conversion fits, behavioral problems and psychosomatic complaints.
* "Weak Heart" syndrome among Khmer refugees that closely resembles PTSD and panic disorder.
* Salvadorian refugees often describe their distress in terms of nervios (nerves; matters of mind, body and spirit) and calor (heat; one of several bodily phenomenon included in nervios).
* Rural Guatamalans are more likely to understand war-related distress in terms of susto ("fright sickness") and the previously noted nervios.
* Afghans describe their war-related distress in terms of jigar khun ("blood liver," dysphoria associated with experiences of loss), asabi (a combination of nervousness and anger) and fisha-e-bala (feeling highly pressured or stressed).

## Treatment (General)

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A variety of treatments have come from a long history of experimentation, research, and practice. Several methods of psychopathology treatment will be listed here:

Psychotherapy:

* Psychoanalysis

The original development of Psychoanalysis (also known as psychoanalytic psychotherapy) is commonly attributed to the Austrian physician Sigmund Freud, although modern psychoanalysis combines the research and ideas of hundreds of other practitioners and psychological theorists. Moreover, psychoanalysis is devoted to the study of human psychological functioning and behavior through 1) a method of investigation of the mind and the way one thinks; 2) a systematized set of theories about human behavior; and 3) a method of treatment of psychological or emotional illness. It should be noted that there are at least 22 theoretical orientations of psychoanalytic thought and Psychoanalytic treatment are known to vary as much as the differing theories do.

Freudian psychoanalysis, as developed by Freud himself, refers to a specific type of treatment in which the "analysand" (analytic patient) verbalizes their thoughts, including free associations, fantasies, and dreams, from which the analyst formulates the unconscious conflicts causing the patient's symptoms and character problems, and interprets them for the patient to create insight for resolution of the problems.

* Behavioral Therapies (Cognitive, Behavioral Analysis, Exposure)

Cognitive behavioral therapy (CBT) aims to help the patient overcome difficulties by identifying and changing ineffectual thinking, behavior, and emotional responses. This is done by helping patients develop skills to modify beliefs, identify distorted thinking, relate to others in different ways and change behaviors. It is based on the theory that a thought or idea must precede a mood, meaning there must be something that a person thinks that leads them to feel a certain way. This, in turn, will lead to the way in which people act and that these actions are heavily influenced by the way individuals see themselves and think others see them. CBT is a relatively short-term form of psychotherapy (a type of counselling) that can be used for the treatment of a wide range of psychological disorders. Oftentimes, CBT involves 'homework' which is completed by the patient in between sessions as well as frequent meetings with a clinician.

Behavior analysis (or applied behavior analysis aka ABA) is a school of psychology based upon the foundations and principles of behaviorism. ABA is the process of systematically applying interventions based upon the principles of learning theory to improve socially significant behaviors to a meaningful degree, and to demonstrate that the interventions employed are responsible for the improvement in behavior. Behavior analysis has proven to be a particularly effective learning tool for helping children with autism or developmental delays acquire and maintain new skills.

Exposure therapy is a type of behavior therapy in which the patient confronts a feared situation, object, thought or memory. Sometimes, exposure therapy involves reliving a traumatic experience in a controlled, therapeutic environment. The goal of exposure therapy is to reduce the distress, physical or emotional, felt in certain situations. Exposure therapy may be used in dealing with anxiety, phobias, and post-traumatic stress.

* Family and Couples Therapy

Family therapy, also known as couple and family therapy and family systems therapy, is a type of psychotherapy that focuses on working with couples and families to nurture development and change within their environment. Theoretically, change is viewed in terms of the interacting systems between family members (since all family members are part of the system). Further, Family and Couples therapy emphasizes family relationships as a determining factor in psychological health.

Psychopharmacology:

* Medications may be used alone or in conjunction with psychotherapies

Psychosurgery:

* Historically, psychosurgeries evolved from experimentation and blunt dissection.
* Brain surgery is still used to intentionally alter behaviors and medical conditions.

* A Corpus callosotomy is a procedure used to prevent seizure activity (epilepsy) from spreading between the left and right hemispheres.
* Gamma knife surgery is used to non-invasively alter structures with precision.

Evidence-Based Practice

The term evidence-based treatment (EBT), evidence-based practice (EBT) or empirically-supported treatment (EST) refers to preferential use of mental and behavioral health interventions for which systematic empirical research has provided evidence of statistically significant effectiveness as treatments for specific problems. There is a threefold rationale for the use of EBT/EBP which 1) aims to improve quality and accountability for practice, 2) create a shared vocabulary and concepts for practice and 3) stimulate evelopment of evidence base for treatment. Historically, EBT/EBP has favored time-limited therapies such as CBT and because of this, and other reasons, there has been some controversy over the use of EBT/EBP as a tool for managed care companies to manage costs rather than best treat patients. Recent research has found validity for both behavioral and psychoanalytic therapies.

## Treatment Environments

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* Inpatient care - is psychological care given to a patient at a hospital or residential facility. Patients are admitted both voluntarily or involuntarily. Moreover, hospitalization is typically for major diagnostic, surgical or therapeutic services, where the individual’s condition or response to medication must be closely monitored. For example, if the patient is suicidal, destructive, or poses a risk to others, a hospital stay may make sense. If the patient has a chemical dependency or alcohol problem, a inpatient hospitalization may be required during the detoxification stage to monitor symptoms during withdrawal.

* Outpatient Care - can be defined as any psychological care service where the patient is not confined to the care facility. Thus, Outpatient care may be provided in a doctor's office, clinic, the patient's home or even a hospital outpatient department. It should be noted that outpatient treatment at a clinic or hospital is often supplemented by medications administered at home. Moreover, outpatient services have become the typical care environment for most mental health and chemical dependency treatments

* Partial hospitalization - also called a therapeutic day program, can occur all day during the week, provide evening programs, but no overnight care. This type of care provides therapy and support while guiding the transition to the patient’s home environment. Partial Hospitalization treatment is utilized for mental health treatment, as well as alcoholism and chemical dependency treatment.

## Organizations / References Closely Related to Psychopathology

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\- There are many groups whose focus is on aspects of psychopathology, which include research, education, treatment, advocacy, and policy. A snapshot of these organizations is listed:

* United States Government: In 2001, the President of the United States issued an Executive Order supporting community-based services and programs for individuals with disabilities. Within this order, the President’s New Freedom Commission On Mental Health was formed. http://www.mentalhealthcommission.gov/background.html. The Commission conducted a year of study and informed the President that mental illness is shockingly common, recovery from mental illness is a real possibility, but the systematic delivery and accessibility of services was imperfect. A lengthy report by Hogan (2003) lists ideas for what a transformed mental health system would look like.
* Society for Research in Psychopathology
* American Psychopathology Association
* National Alliance on Mental Illness (NAMI): advocates for people with mental illness, their family and friends, and other support resources. NAMI offices are local, within communities.

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### References

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* A Report on the Public Comments Submitted to the Presidents' New Freedom Commission on Mental Health. (2003). For full text: http://www.mentalhealthcommission.gov/reports/reports.htm.
* American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, DC: American Psychiatric Association.
* Andreasen, N. C., & Black, D. W. (2006). Introductory textbook of psychiatry. Washington, DC: American Psychiatric Pub.
* Carlson, N. R. (2008). Foundations of physiological psychology. Boston, Mass.: Pearson/Allyn and Bacon.
* Culturally Specific Syndromes
* Groth-Marnat, G. (2009). Handbook of psychological assessment. Hoboken, N.J.: John Wiley & Sons.
* Hogan, M. F. (2003). Achieving the promise: Transforming mental health care in America : final report, July 2003. Rockville, Md: President's New Freedom Commission on Mental Health.
* PKC Corporation. (2010). Problem knowledge couplers software for better health. Retrieved from http://pkc.com/available_couplers.aspx
* PKC Corporation. (1998). A Problem oriented approach to the computerized patient record. Retrieved from http://pkc.com/papers/pomr.pdf