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Handouts Abnormal Psychology Day 1 Jason Go
Industrial Psychology
University of San Carlos
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Day 1: Defining and Assessing Psychopathology
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Abnormality and Psychopathology
Deviance ! Different from societal norms ! Relative to culture ! Relative to context/situation ! Examples: o Eating ones own hair; deviant? o Looting, theft; deviant? o Hearing voices, speaking strange words; deviant?
Distress/Discomfort ! “Something feels not right” ! Caution: Not a good criteria; low sensitivity ! Examples: o Senakulo, “Pagpapapako sa Cruz”; Deviant? Distressful? o Burning houses, drowning pets; Deviant? Distressful?
Dysfunction ! Deficits in one or more aspects of life ! Interferes with daily functioning ! Gambling disorder, internet addiction
Danger ! Danger towards self, others, property ! Caution: Most patients with disorders are not violent/destructive
Disease vs. Disorder
Signs vs. Symptoms vs. Syndrome
Some Psychiatric Diseases
- Some forms of mental retardation (e., Down’s syndrome, hydrocephalus)
- Certain forms of dementia (such as Alzheimer’s, Pick’s, and dementia due to other general medical conditions; i., GPI)
- Amnestic disorders due to general medical conditions
- Certain forms of sleep disorders, (e., sleep apneas)
- Certain forms of communication disorders (e., some aphasias)
- Certain forms of perceptual and sensory disorders (e., alexias, proposagnosia)
Historical Perspectives ! Ancient societies o Focus on supernatural, evil spirits o Trephination = drilling holes in the skull o Ancient Chinese = Yin and Yang o Egyptians = “wandering uterus” ! Greek Period o Naturalistic approach to abnormal behavior o Hippocrates
- Importance of observing cases of abnormal behavior
- Developed first biogenic theory suggesting abnormalities of humors
- Developed one of the first classification systems o Plato argued that care of mentally ill was a family responsibility and influenced the treatment located in retreats ! Medieval Period o Back to supernatural causes o Witchcraft, political accusations of being witch ! Renaissance Period o Rise of asylums, "madhouses“ o First asylum: Bethlehem Hospital in London (Bedlam) o Benjamin Rush: from asylum to human therapy
Southeast Asia and Philippines ! “Amok” o endemic to Southeast Asia o 1893: First recorded info by W. Gilmore Ellis, medical superintendent in Government Asylum of Singapore ! “Latah” o Special case of petit mal seizure o Possible root word of “nanlalata” (body weakness) ! “Mali-mali” o Described in 1910 by Musgrave and Sison ! “ataque de nervios” o Common to Hispanics and colonies ! “Lanti” o Loss of soul due to mental illness
Philippines ! 1782: Hospicio de San Jose o Confinement of mentally-ill sailors o Run by nuns, custodial care ! “enagenacion mental” o Insanity or dementia caused by stress o Sisa of Rizal’s Noli Me Tangere ! “neurosis con trastornos mentales” o Insanity due to organic cause o Late Spanish period ! American Regime o November 1904: Insane Department of San Lazaro
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Hospital o 1917: Dr. Elias Domingo = first Filipino psychiatrist o 1928: National Psychopathic Hospital, now known as National Center for Mental Health
Contemporary Perspectives ! Biological/Somatic ! Psychodynamic ! Behaviorist ! Cognitive ! Cognitive-neuroscience ! Humanist-existentialist ! Sociocultural ! Family systems
Behaviorist Perspectives ! Responses are learned ! Symptoms have underlying stimulus ! Even abnormality can be learned
Criticism Against Behaviorist ! Oversimplification o It reduces life to small measurable units of behavior o Ignores deeper workings of the mind ! Determinism o Argues that there is no free will o Argues that whatever we do is due to learning history ! The Issue of "Control" o Suggests that behavioral engineering could be used for totalitarian regime where people are coerced by reinforcement o Control actually refers to predictability and using scientific laws
Cognitive Perspectives ! Faulty schema causes pathology ! Abnormality stems from mental processing ! Cognitive patterns and distortions
Criticisms of Cognitive Perspective ! It is unscientific since theory is based on inferring forces that cannot be observed ! Recognizing that life is not rational may not be enough to produce therapeutic change ! Changing thinking may not be appropriate or right ! Basis of how cognitive therapy works is unknown
Cognitive-Neuroscience ! Puts basis on cognitive perspective ! Brain scan, genetic studies, endocrine system ! Genotype vs. Phenotype
Biopsychosocial Perspective ! “Eclectic approach” ! “Integrationist approach”, “Interactionist” ! Consideration of precipitating, predisposing, and perpetuating factors
Case Study # ! Explain Liona’s case using any of the contemporary perspective ! Give at least one predisposing, precipitating, and perpetuating factors in the situation ! Propose a plan of care for Liona
After having arguments with her family, Liona usually isolated
herself from others and would become preoccupied by her sense of insecurity and dislike of herself. At these times Liona was most likely to experience suicidal thoughts. Specifically, Liona said that she would feel like the world was coming down on her and would then think about suicide by letting herself drown in the pool at school. In fact, 3 months before her intake evaluation, Liona had
made a suicidal gesture by superficially scratching her wrist with a razor blade. Liona had told no one about this incident, and no one had noticed the scratches on her wrist. Two months later, Liona had jumped into the school’s pool during swimming practice. Although she had not thought about drowning herself before getting in the pool, while she was underwater, Liona found that she couldn’t catch her breath. For a moment, Liona thought about just letting herself sink to the bottom to drown and wondered what that would be like. Later, a classmate to whom she confided about her concerns with her boyfriend persuaded her to see the school psychologist. Although Liona had not decided to see the school psychologist on her own, she felt relieved by the opportunity to express the feelings she had been having.
Cognitive Distortions
- All or Nothing Thinking
- Overgeneralization
- Mental filter
- Discounting the positives
- Jumping to conclusions
- Magnification or Minimization
- Emotional Reasoning
- “Should Statements”
- Labeling
- Personalization and Blame
Clinical Assessment
Assessment techniques
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! Clinical interview (Interview and MSE) ! Clinical tests, psychiatric ratings
! Neurophysiological assessments
! Observation
! Self-monitoring
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Unflinching eyes: great desire for intimacy; infringement on privacy
Too little: interviewer not interested or honest
Less than 100% desirable (70-90%)
Sit at an angle (not head-on) to be able to comfortably look away & break eye contact
Body posture should convey receptiveness
Slight forward lean
Arms relaxed and not folded across chest
Facilitation: verbal or nonverbal communication which encourages patient to elaborate - Patient’s last word may be repeated - A questioning look is given - Head nod - “Uh huh.” - A question is asked - Avoiding interruptions or changes in topic
Open-ended questions
Patient retains freedom in selecting nature and amount of information
Closed/direct questions
Specify precise information needed
Patient less likely to tell own story or bring up new topics
Support
Verbal & nonverbal expressions that indicate physician’s interest, concern & willingness to help patient
Offered after patient has expressed feelings
Clarification
Response that asks patient for further information & explanation
Confrontation
Brings patient face-to-face with or calls attention to some aspect of his behavior, appearance or manner that is inconsistent & contradictory
Silence
Nonverbal communication that may express range of responses from total disinterest to active concern
Gives patient chance to explore & express deeper concerns that are less obvious
Reflection
Active listening technique: requires interviewer to hear, understand, remember, summarize & rephrase
Summarizes essential aspects of message of patient through fresh words & simple language
Encourages patient to explore and organize ideas and emotions
Effects of reflection
Communicates understanding
Gives patient opportunity to change interviewer’s perception
Provides patient with chance to bring up new topics
LEVELS of REFLECTION
Emotional levels
Factual reflection
Surface feeling reflection
Underlying feeling reflection
####### FACTUAL REFLECTION
Summarizes objective information
Demonstrates superficial understanding
Encourages patient to continue surveying situation
####### SURFACE FEELING REFLECTION
Includes facts and feelings
Recognizes emotions at about same intensity as communicated by patient
####### UNDERLYING FEELING REFLECTION
- Emotions not explicitly stated by patient
- Moves interaction to deeper level of understanding
- Essentially an educated guess
- Patient may not be ready to accept validity even if accurate
####### CASE VIGNETTE
Mr. A is a 55 year old bank manager. He is married with four children. In one of your sessions, he tells you this. “After spending two weeks in the hospital, I don’t know how I’m going to pay our regular household bills, much less all of these medical bills. I knew going into the hospital would cost some money, but I never dreamed it would be this much!” REFLECTIONS
- Factual reflection: “Having to go to the hospital has put quite a strain on your family budget.”
- Surface feeling reflection: “Right now you are really worried about your financial health.”
- Underlying feeling reflection: “As you face all of these bills you are doubting your ability to be a good husband and father.”
####### INTERVIEW TECHNIQUES
- Interpretation
- Focuses on interviewer’s insights on underlying cause of patient’s problem - Eg, “You are having trouble because your expectations are too high.”
- Interpretation
- Used cautiously until interviewer knows the patient & has established rapport
- Diminishes discussion of feelings
- Increases intellectual explanations
JARGON and HUMOR
- Counterproductive
- Dehumanizing
- Confusing form of resistance
####### TRANSFERENCE
- Displacement of feelings and attitudes from important relationships in the patient’s past to the physician
- May be positive or negative
- Patient views physician as all-powerful or ever-caring parental figure
- Disappointed by any deviation from total availability of physician
- Patient views physician as harsh, punitive parent or authoritarian who gives orders but does not care about patient’s well-being - React with counter-productiveness (hostility, suspiciousness, competitiveness) COUNTERTRANSFERENCE
- Transference of the doctor toward the patient
- Eg, Overly critical, erotic fantasies
- Negative transference reactions from patient may elicit inappropriately angry responses from physician, rather than an attitude of curiousity or understanding
####### EFFECTIVE LISTENING
- Waiting patiently through periods of silence or tears
- Hearing not only what the patient says but what he’s trying to say & what he leaves unsaid
- Using both ears & eyes to detect confirming or conflicting data in verbal content & affect
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• Avoiding looking away from patient as he speaks
• Sitting still
• Limiting number of mental excursions into one’s own fantasies
• Controlling feelings toward patient that interfere with an
accepting sympathetic non-judgmental attitude
• Having sufficient awareness and resolution of one’s own
conflicts to avoid reacting in a way that interferes with the patient’s free expression of thoughts and feelings
• Avoiding subtle verbal or non-verbal expressions of disdain or
judgment toward the content of the patient’s story even when the content affects the therapist’s sensibilities
IMPEDIMENTS to LISTENING
• Anxiety
• Fatigue
• Impatience
• Inattentiveness
• Restlessness
• Daydreaming
TERMINAL PHASE of INTERVIEW: GUIDELINES 1. Give patient chance to ask questions 2. Summarize what transpired during the interview 3. Inform patient about plans for the future 4. Thank patient for sharing necessary information
####### INTERVIEWING CHILDREN
• Based on child’s use & understanding of language
• Children usually respond to patient & nurturing doctor who
understands their method of communication
• Play & fantasy may be helpful in establishing rapport
• Illness and hospitalization
- May be frightening to child
- May result in major concerns about separation from family
####### INTERVIEWING ADOLESCENTS
• Usually respond best to directly & simply stated questions
• Best approached in a warm & respectful manner that is not
condescending or overly familiar
• Illness & hospitalization create special concerns about his
ability to engage in relationships & activities
INTERVIEWING ELDERLY
• Usually respond best to interviewer who conveys sincere
interest by being patient & gentle
• Direct questions about sensitive issues are best asked when
rapport & trust are established
• Illness and hospitalization create special concerns about
separation from and loss of significant others
####### CONCLUSIONS
The psychiatric interview ...
• is a professional communication that employs organized &
structured means of gathering data.
• aims to determine the nature of the problem, develop &
maintain therapeutic relationship, encourage the patient to talk honestly, & communicate information about the problem & treatment plan.
• focuses on content & process aspects.
• is divided into 3 phases namely, initial, middle, and terminal.
• becomes successful because of certain techniques.
• involves transference & countertransference issues.
• in children, adolescents, & elderly involves special
considerations apart from those of young adults.
THE MENTAL STATUS &
MINI-MENTAL STATUS
EXAMINATIONS
####### MENTAL STATUS EXAMINATION
Sum total of examiner’s observations & impressions of patient at time of interview
Description of patient’s appearance, speech, actions, & thoughts during interview GUIDELINES in CONDUCTING the MMSE & MSE
Inform patient that you will ask questions about his/her mental state
Obtain patient’s consent
Ensure that visual or hearing aids are in place, if needed
Ensure that seating arrangement is comfortable
Ensure that environment is conducive
Ensure that all testing materials are ready
OUTLINE for the MENTAL STATUS EXAMINATION
- Appearance
- Overt behavior
- Attitude
- Speech
- Mood & affect
- Thinking
- Perceptions
- Sensorium
- Judgment
- Insight
####### APPEARANCE
- Overall physical impression: body type, posture, poise, clothing, grooming
- Healthy, sickly, ill at ease, poised, old looking, disheveled, childlike, bizarre, moist hands, perspiring forehead, tense posture, wide-eyed
####### OVERT BEHAVIOR
- Quantitative & qualitative aspects of motor behavior
- Mannerisms, tics, gestures, twitches, echopraxia, hyperactivity, agitation, combativeness, flexibility, rigidity, gait, agility
- Restlessness, wringing of hands, pacing, slowing of body movements, aimless & purposeless activity
####### ATTITUDE
Cooperative, Friendly, Attentive, Interested, Frank, Seductive, Defensive, Contemptuous, Perplexed, Apathetic, Hostile, Playful, Ingratiating, Evasive, Guarded
####### SPEECH
- Quantity, rate of production, quality
- Talkative, garrulous, voluble, taciturn, spontaneous, unspontaneous, normally responsive to cues
- Rapid, slow, pressured, hesitant, emotional, dramatic, monotonous, loud, whispered, slurred, staccato, mumbled
- Stuttering, unusual accents
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####### ORIENTATION
- Allow no more than 10 secs. per reply
- What year is this? (Exact year only)
- What month? (On 1st day of new month or last day of previous, accept either)
- Today’s date? (Day before or day after is acceptable)
- What day of the week? (Exact day only )
- What season is this? (Exact season only)
- What province?
- What city/town?
- What county are we in?
- What is the name of the place? (Exact name only) ⁃ If in clinic – What floor are we on? ⁃ If at home – What room are we in?
####### REGISTRATION
- I am going to name 3 objects.
- Remember them because I am going to ask you to name them again in a few minutes.
- Say objects slowly (1 sec interval)
- Please repeat the objects for me.
- Score 1 point for each reply on the 1st attempt
- Allow 20 seconds for the reply
- If patient cannot repeat all 3 items initially, repeat until they are learned but no more than 5x
####### ATTENTION & CONCENTRATION
- Please subtract 7 from 100 & keep subtracting 7 from what’s left until I tell you to stop
- May repeat 3x if the patient pauses – allow 1 min. for an answer
- Once the patient starts, do not interrupt until 5 subtractions have been done
- If patient stops, repeat “keep subtracting 7 from what’s left” for a maximum of 3x
SCORING of SERIAL 7s
93, 86, 79, 72, 65 - 5 pts
93, 88, 81, 74, 67 - 4 pts
92, 85, 78, 71, 65 - 3 pts
93, 87, 81, 73, 69 - 1 pt
If patient cannot do serial subtractions, ask him/her to spell WORLD or KOPRA
Ask patient to spell backwards
Score is number of letters in correct position
E., "DLROW" = 5 "DLORW" = 3
####### "LROWD" = 0
####### RECALL
- “Now what were the 3 objects that I asked you to remember?”
- Score 1 point each regardless of order
- Allow 10 sec
####### LANGUAGE
Point to a pencil/pen & watch; ask patient to name them as you point
Wristwatch: Accept wristwatch or watch but not ‘clock’ or ‘time’ REPEATING WORDS
No if’s, and’s, or but’s: Exact reply only. Allow only 1 trial.
####### READING
- “Read the words on the page and do what it says.”
- CLOSE YOUR EYES
- Instructions may be repeated 3x (since it is not a memory test) but patient must close eyes for to score
####### 3-STAGE COMMAND
- Ask patient if L- or R-handed
- Paper held in front of patient (or placed in front of patient) & should be taken by the non-dominant hand)
- “Take this paper with your R/L hand, fold it in half, and place it on the floor.”
- 1 point for each correctly action
####### WRITING
- Writing of a complete sentence
- The sentence should make sense (containing a subject and a verb)
- Allow no more than 30 sec
- Ignore minor spelling or grammatical errors
####### VISUOSPATIAL FUNCTION COPYING OVERLAPPING
####### PENTAGONS
- Allow multiple attempts up to 1 minute
- Correct if copy shows a 4-sided drawing within two 5-sided figures
- OR all 10 angles & 2 must intersect to score
- Ignore rotation & distortions & tremors
INTERPRETING the SCORES in the MMSE
- 24 – 30 = normal (depending on age, education, & complaints)
- 20 – 23 = mild cognitive impairment
- 10 – 19 = moderate cognitive impairment
- 1 – 9 = severe cognitive impairment
- 0 = profound cognitive impairment
LIMITATIONS of the MMSE
- Cut-off points between normal & abnormal not absolute & should take into account age, educational level & population
- Using an arbitrary cut-off point may lead to false-positives in older people with lower educational levels & false-negatives in younger ones with higher educational levels
- For severely impaired, MMSE may not be sensitive enough
- E., when there is impairment of expressive & receptive language
- If so, Severe Impairment Battery may be used (Saxton & Swihart; Parisset et al 1992)
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Handouts Abnormal Psychology Day 1 Jason Go
Course: Industrial Psychology
University: University of San Carlos
- Discover more from:Industrial PsychologyUniversity of San Carlos35 Documents
- More from:Industrial PsychologyUniversity of San Carlos35 Documents
