Clinical Psychology: A Brief Tour of the Field

1. Clinical Psychology: A Brief Tour of the Field A Workshop for Members of the OSU Social Psychology Program Michael Vasey Ohio State University September 20, 2005

2. Overview • What is Clinical Psychology? • Setting the Context: Video examples • Major Domains of Clinical Psychology • Psychopathology • Classification • Assessment • Diagnosis and clinical decision-making • Intervention • Treatment and prevention

3. What is Clinical Psychology? • APA Division 12 definition (1991): • “…Clinical Psychology involves research, teaching, and services relevant to the application of principles, methods, and procedures for understanding, predicting, and alleviating intellectual, emotional, biological, psychological, social and behavioral maladjustment, disability and discomfort, applied to a wide range of client populations.”

4. Branches of Clinical Psychology: Trend Toward Increasing Specialization • The generalist training model is no longer predominant • Specialized graduate training programs are becoming the norm: • Examples: • Clinical Child and Adolescent Psychology • Clinical Geropsychology • Clinical Neuropsychology • Clinical Health Psychology • Pediatric Psychology

5. Board Certification Specialties • American Board of Professional Psychology (ABPP) now lists 8 specialties relevant to clinical psychology: • Child & Adolescent • Clinical Health • Clinical Neuropsychology • Cognitive & Behavioral • Family • Forensic • Group • Psychoanalysis • More are undoubtedly on the way

6. Getting a Feel For the Territory: Some Case Examples • Purpose: To illustrate the great diversity of “problems of living” dealt with in clinical psychology. • Examples (based on DSM-IV categories): • Anxiety Disorders • Affective Disorders • Schizophrenia • Borderline Personality Disorder • Bulimia Nervosa

7. Anxiety Disorders • Most common mental disorders in the U.S. • In any given year, they affect ≈19% of the adult population in the U.S. • Most common to meet criteria for more than one at a time • Anxiety disorders cost about $42 billion each year in health care, lost wages, and lost productivity

8. Anxiety Disorders • Six major categories: • Obsessive-compulsive disorder (OCD) • Generalized anxiety disorder (GAD) • Panic disorder and Agoraphobia • Specific phobias • Social anxiety disorder • Post-traumatic stress disorder (PTSD)

9. Social Anxiety Disorder • Severe, persistent, and unreasonable fears of social or performance situations in which embarrassment may occur • May be narrow–talking, performing, eating, or writing in public • May be generalized–general fear of functioning inadequately in front of others

10. Social Anxiety Disorder • Affects ≈8% of U.S. population in any given year • Women outnumber men 3:2 • Often begins in youth and persists for many years • Can greatly interfere with functioning • Often kept a secret • Fewer than 20% of sufferers seek treatment

11. Posttraumatic Stress Disorder (PTSD) • Symptoms of PTSD: • Reexperiencing the traumatic event • Flashbacks, nightmares • Avoidance • Reduced responsiveness • Increased arousal, anxiety, and guilt

12. Posttraumatic Stress Disorder (PTSD) • Can occur at any age and affect all aspects of life • ≈4% of U.S. population affected each year • ≈8% of U.S. population affected sometime during life • Ratio of women to men is ≈ 2:1 • Some events are more likely to cause disorders than others • Examples: • combat, disasters, abuse, and victimization

13. Dysthymic Disorder • Depressed mood for most of the day, for more days than not, for at least 2 years. • Presence of at least 2 of the following: • Poor appetite or overeating • Insomnia or hypersomnia • Low energy or fatigue • Low self-esteem • Poor concentration or diff. making decisions • Feelings of hopelessness • Often punctuated by major depressive episodes • Called “Double Depression”

14. Borderline Personality Disorder • People with this disorder display great instability, including major shifts in mood, an unstable self-image, and impulsivity • Interpersonal relationships are also unstable • People with borderline personality disorder are prone to bouts of anger, which sometimes result in physical aggression and violence • Just as often, however, they direct their impulsive anger inward and harm themselves

15. Borderline Personality Disorder • Many of the patients who come to mental health emergency rooms are individuals with borderline personality disorder who have intentionally hurt themselves • Their impulsive, self-destructive behavior can include: • Alcohol and substance abuse • Reckless behavior, including driving and unsafe sex • Cutting themselves • Suicidal actions and threats

16. Bulimia Nervosa • Bulimia nervosa, also known as “binge-purge syndrome,” is characterized by binges: • Bouts of uncontrolled overeating during a limited period of time • Often objectively more than most people would/could eat in a similar period

17. Bulimia Nervosa: Binges • For people with bulimia nervosa, the number of binges per week can range from 2 to 40 • Average: 10 per week • Binges are often carried out in secret • Binges involve eating massive amounts of food rapidly with little chewing • Usually sweet foods with soft texture • Binge-eaters commonly consume more than 1500 calories (often more than 3000 calories) per binge episode

18. Bulimia Nervosa: Binges • Binges are usually preceded by feelings of tension or negative affect • Although the binge itself may be pleasurable, it is usually followed by feelings of extreme self-blame, guilt, depression, and fears of weight gain and “discovery”

19. Bulimia Nervosa • The disorder is also characterized by compensatory behaviors, which mark the subtype of the condition: • Purging-type bulimia nervosa • Vomiting • Misusing laxatives, diuretics, or enemas • Nonpurging-type bulimia nervosa • Fasting • Exercising excessively

20. Bulimia Nervosa: Compensatory Behaviors • After a binge, people with bulimia nervosa try to compensate for and “undo” the caloric effects • The most common compensatory behaviors: • Vomiting • Affects ability to feel satiated  greater hunger and bingeing • Laxatives and diuretics • Almost completely fail to reduce the number of calories consumed

21. Major Aspects of Clinical Psychology • Psychopathology • Classification • Research on etiology, course, etc. • Assessment and Clinical Decision-Making • Diagnosis • Case conceptualization and treatment planning • Outcome evaluation • Intervention • Treatment and prevention

22. Psychopathology • The study of the origins, course, and manifestations of mental or behavioral “disorders.” • Classification: • The lynchpin of a scientific approach to psychopathology.

23. The Problem of Classification

24. Goals of Classification • Definition of disorder constructs is meant to describe and distinguish between problems in ways that permit or lead to understanding of their: • Behavioral, psychological, social, and biological correlates • Etiological and maintaining factors • Course • Prognosis • Treatment response

25. Characteristics of A Useful Diagnostic System • Facilitates Communication • Possesses Etiological Validity • Provides Reliable Information on Disabilities, Abilities, Functional Impairments, etc. • Guides Research (homogeneous groups) • Informs Treatment Decisions • Predicts Clinical Course

26. What Is Psychological Abnormality? • Many definitions have been proposed, yet none are universally accepted • Most definitions, however, share some common features… • “The Four Ds” • Deviance – Different, extreme, unusual • Distress – Unpleasant & upsetting • Disability – Causes interference with life • Danger – Poses risk of harm

27. Definitions Typically Involve Social Judgment

28. Wakefield’s Concept of Disorder as Harmful Dysfunction • Meant to reduce extent of social value judgment in definitions of mental disorders. • Harmful: • Reflects a subjective value judgment that a problem is unpleasant or undesirable. • This means that some things that are disorders in one culture, may not be in another if the dysfunction does not cause harm in that culture. • Dysfunction: • A supposedly objective feature. Dysfunction exists with a physiological or psychological system fails to perform one of its natural functions. • Natural function: the function that it was evolutionarily selected to perform.

29. But Even Dysfunction Has Subjective Component • Wakefield’s attempt to make definition of dysfunction objective fails • Examples of Specific Reading Disorder • Reading cannot be the natural function of whatever systems support it. • Wakefield responds by saying the HD analysis permits the harm to be an indirect consequence of the failure. • But this leads to serious problems for the HD analysis because, when H and D are dissociated, all sorts of things end up qualifying as disorders that are difficult to justify.

30. Lilienfeld & Marino’s Example of “Driving Disorder” • Lilienfeld & Marino (1999) use Wakefield’s indirect harm rationale to support “Driving Disorder”: • The attribution of disorder to the inability to drive is based on a line of reasoning roughly as follows: • 1) inability to drive is a significant harm, • 2) the brain was not designed specifically to enable people to learn to drive; • 3) however, when all of a person’s brain and motor systems are functioning as they were designed to function, a side effect is that the person can learn to drive; • 4) therefore, the inability to learn to drive (despite conducive environmental and motivational circumstances) is caused by some underlying dysfunction of brain or motoric system and is thus a disorder.

31. DSM-IV • Published in 1994, revised slightly in 2000 (DSM-IV Text Revision) • Lists approximately 400 disorders • Describes criteria for diagnoses, key clinical features, and related features which are often but not always present • People can be diagnosed with multiple disorders…

32. Understanding DSM-IV: Some Definitions • Sign/Symptom: • single behavior (sign) or subjective report of single characteristic (symptom). • By itself, a sign/symptom has multiple possible meanings • Syndrome: • A group of signs and symptoms which covary systematically • Disorder: • Syndrome with specified duration, and (hopefully) course, prognosis, treatment response and etiology.

33. Assumptions of DSM-IV • Neo-Kraepelinian Approach: • Assumes mental disorders are discrete entities separated from one another, and from normality, either by: • Recognizably distinct combinations of symptoms and signs, and/or • Demonstrably distinct etiologies • Assumes meaningful syndromes can be identified based on clusters created based on similarity of symptom/sign topography. • Ultimately, each syndrome will be refined until it is homogeneous in terms of: • Etiology, course, treatment response, etc.

34. DSM-IV Definition of Disorder • Each disorder is conceptualized as: • A clinically significant behavioral or psychological syndrome or pattern • Occurring in an individual • That is associated with: • Distress OR • Disability in one or more areas of functioning OR • A significant increase in risk of death, pain, disability, or important loss of freedom • Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. • BUTdysfunction is not defined • Not merely an expectable and culturally sanctioned response to a specific event.

35. DSM-IV Multiaxial System Axis I Clinical disorders Personality disorders Mental retardation Axis II General medical conditions Axis III Psychosocial and environmental problems Axis IV Axis V Global assessment of functioning

36. Major Axis I Diagnostic Categories

37. Axis II Disorders • Mental Retardation • Personality Disorders • 10 categories • Generally having poor reliability and validity • Cluster A: • Marked by odd, eccentric behavior, including paranoid, schizoid and schizotypal personality disorders. • Cluster B: • Marked by dramatic, emotional behavior, including histrionic, narcissistic, antisocial and borderline personality disorders. • Cluster C: • Marked by anxious, fearful behavior and include obsessive-compulsive, avoidant and dependent personality disorders.

38. Lifetime Prevalence of DSM Diagnoses (Axes I & II)

39. Are DSM-IV Classifications Reliable? • DSM-IV has greater reliability than any previous editions • Used field trials to increase reliability • But reliabilityis still a concern • Especially for Axis II Personality Disorders and Childhood Disorders

40. Are DSM-IV Classifications Valid? • DSM-IV has greater validity than any previous editions • Disorder-specific subcommittees conducted extensive literature reviews and studies - But only for a subset of categories • But validity of many categories remains a serious concern • Validity of many categories inadequately studied. • Especially Axis II Personality Disorders

41. Problems With DSM Approach • Individuals who share few signs/symptoms receive the same diagnosis • Example: Major Depressive Disorder • Of 9 criteria only 5 must be met. • Must have either depressed mood or loss of pleasure • Plus 4 of remaining 8 features • But many of these specify several possibilities • Examples: Insomnia or hypersomnia; weight loss or weight gain; agitation or psychomotor retardation; feelings of worthlessness or excessive guilt • Thus, any 2 MDD patients may be more different than similar

42. Problems With the DSM Approach • Within syndrome heterogeneity presents a potential problem • Even those people sharing the same symptoms may vary in important ways: • Example: Variable treatment response • Only about 50% of depressed patients respond to treatments (both biological and psychosocial) • DSM-approach responds by dividing syndromes further or narrowing the diagnostic criteria. • But this can lead to excessively complex taxonomy • We are at nearly 400 disorders and counting

43. Problems With the DSM Approach • Original DSM-III disorders and their lists of criteria were not founded on research • Validity was largely unknown • Revisions have tended to preserve these questionable disorders and criteria • Improvements were begun in producing DSM-IV • Revisions based on: • Comprehensive literature reviews • Analyses of existing databases • Some new research (field trials) • But only for a subset of categories • Further, the process was rushed

44. Problems With the DSM Approach • Comorbidity • Comorbidity is the rule – single disorders are the exception • Raises questions about the distinctions between many categories • Leads to problems interpreting results because we are typically dealing with combinations of disorders rather than one disorder at a time. • Sub-clinical cases • DSM-IV is a dichotomous system • Leaves unclear the status of those who nearly meet criteria • Also means diagnostic status can be a poor outcome measure

45. Toward DSM-V • Preliminary work has begun on DSM-V • Series of planning conferences have produced a monograph comprising 6 “white papers” detailing a research agenda for DSM-V (Kupfer et al., 2002). • Produced under a partnership between the American Psychiatric Association and NIMH • Explicit goal: To provide direction and potential incentives for research. • Target date for DSM-V: 2010 • Many changes recommended in Kupfer et al. (2002) are unlikely to occur until DSM-VI or even DSM-VII

46. Highlights of Kupfer et al. (2002) • Enhanced reliability has been obtained at the expense of validity. • Exclusive reliance on discrete categories has not produced a satisfactory system. • No biological markers distinguishing disorders have been found. • High degree of short-term diagnostic instability

47. Questioning the Categorical Approach • Many have begun to argue for a dimensional approach • Especially in the case of PDs (Frist et al., 2002). • Cloninger (1999): “There is no empirical evidence” for “natural boundaries between major syndromes” and that “the categorical approach is fundamentally flawed (pp. 174-175).

48. Questioning the Categorical Approach • Examples: • Research shows anxiety and depression share much in common and may be better conceptualized as points on a continuum of negative affect (Barlow, 2002) • Even for severe disorders with high genetic loading like schizophrenia, a dimensional approach may prove superior (e.g., Widiger & Sankis, 2000). • Carson (1996) reviewed the lack of progress in understanding schizophrenia and attributed it to use of the DSM approach.

49. Reasons for Questioning the Categorical Approach • Only a few mental disorders have been shown to have distinct etiologies: • Examples: • Down Syndrome • Fragile X Syndrome • PKU • Alzheimer’s Disease • Most mental disorders appear to merge imperceptably into one another and into normality (Kendler & Gardner, 1998) • Examples: • Major Depressive Disorder • Anxiety Disorders • Schizophrenia • Bipolar Disorder

50. Reasons for Questioning the Categorical Approach • Specific underlying causes for each disorder category have not emerged. • The genetic and environmental factors underlying syndromes are typically non-specific. • Example: • Genetic factors associated with depression and anxiety overlap completely (Eley & Stevenson, 1999; Kendler et al., 1992)