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Science and Pseudoscience in Clinical Psychology Part I PSYC 4500

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Science and Pseudoscience in Clinical Psychology Part I PSYC 4500 Powered By Docstoc
					     Psychological Models II

PSYC 4500: Introduction to Clinical Psychology
            Brett Deacon, Ph.D.
            September 13, 2012
              Announcements

•   Sona mass testing continues this week
•   Guest today – prepare questions
•   Exam #1 is this Thursday
              From Last Class

•   Operant conditioning
•   Cognitive model
•   Exam review
                  For Today

•   Cognitive model
•   Diagnosis and the DSM
•   Biological models
        The Basic Cognitive Principle

•   People are upset not because of events or
    situations, but by the meaning that people give
    to events or situations

•   When the meaning is negative, negative
    emotions result
Cognitive Models – Clinical Applications

Alex is extremely anxious in the presence of
people he believes are immoral or mentally
deficient. He is concerned that he will literally
take on these characteristics via physical
proximity to such individuals. Alex takes
special care to not inhale, or swallow, in unison
with perceived immoral or mentally deficient
persons in order to prevent himself from
becoming like them.
    Cognitive Models – Clinical Applications

•    Can classical and/or operant conditioning explain
     the development of this problem?
•    From a cognitive perspective, why does Alex have
     this problem?
•    How might Alex’s avoidance and safety-seeking
     behavior actually be maintaining this problem?
•    How would you use cognitive principles to help
     Alex overcome this problem?
    Chapter 5: Diagnosing Mental Disorders

•    Note: pp. 128-133 only for exam 1
•    Primary role of clinical psychologists
•    Diagnosing mental disorders: scientifically
     questionable but practically indispensable
•    Diagnostic and Statistical Manual of Mental
     Disorders (currently DSM-IV)
       Diagnosing Mental Disorders

•   Multiaxial system
•   Axis I: Clinical syndromes
•   Axis II: Personality disorders and characteristics and
    mental retardation
•   Axis III: Medical conditions
•   Axis IV: Psychosocial and environmental stressors
•   Axis V: Global assessment of functioning
                Case Example

Amy is a 21-year-old nurse. She has been
experiencing unexpected panic attacks on a daily
basis for two months. She avoids situations that
might trigger a panic attack, particularly those in
which she would not be able to get help or escape
would be difficult. Amy has asthma and fears that a
panic attack will escalate into a fatal asthma attack.
She has left work, or avoided coming to work, on
numerous occasions in the past two months and is
in danger of losing her job if her absenteeism
continues.
      Diagnosing Mental Disorders

•   Amy’s Diagnosis
•   Axis I: Panic Disorder with Agoraphobia
•   Axis II: No Diagnosis
•   Axis III: Asthma
•   Axis IV: Occupational problems
•   Axis V: GAF = 55 (Current)
          Atheoretical Diagnosis

• Diagnostic criteria focus on symptoms, not on
  their presumed underlying causes
• Improves diagnostic reliability
• Encourages checklist approach to diagnosis
• Discourages attempts to understand the factors
  that are contributing to symptoms
    • Example: major depressive disorder
           Evolution of the DSM

•   History of the DSM
•   5 editions, I in 1952 through IV in 1994
•   Massive changes in length and content
         Number of Diagnoses in the DSMs
           Across Editions (1952-1994)
# Diagnoses




                      # Diagnoses
        Diagnosing Mental Disorders

•   Advantages of diagnosing:
•   Enhanced communication between
    professionals
•   Facilitates study of causes and treatments of
    specific disorders
•   Helps in treatment planning
•   Necessary for insurance reimbursement
         Diagnosing Mental Disorders

•   Disadvantages of diagnosing:
•   Add little to our understanding of a problem;
    describe symptoms but do not explain them
•   Suggests the presence of a disease state
•   May stigmatize patients and invite
    discrimination
•   Many diagnoses have poor reliability
    Reliability of Mental Disorder Diagnoses
•   Inter-rater reliability (kappa) of proposed DSM-5 diagnoses
•   Autism = .69
•   PTSD = .67
•   Bipolar disorder = .54
•   Schizophrenia = .46
•   Oppositional defiant disorder = .41
•   Major depressive disorder = .32
•   Obsessive-compulsive disorder = .31
•   Antisocial personality disorder = .22
•   Generalized anxiety disorder = .20
•   Mixed anxiety/depressive disorder = .06
                 http://1boringoldman.com/index.php/2012/06/09/not-a-toy/
        The Problem of Reification
• “The tendency has always been strong to believe that
  whatever received a name must be an entity or being,
  having an independent existence of its own.”
  -John Stuart Mill
• Reification: treating as real something which is merely an
  idea
• What’s the difference between “feeling depressed” vs.
  having “major depressive disorder,” of being “anxious in
  social situations” vs. having “social anxiety disorder?”
• “You’re feeling depressed because you’re suffering from
  major depressive disorder”
             The Problem of Reification
• Former NIMH Director Steven Hyman (2012), in ”The
  Diagnosis of Mental Disorders: The Problem of
  Reification” http://www.annualreviews.org/doi/pdf/10.1146/annurev.clinpsy.3.022806.091532
• “The disorders contained therein are heuristics that have
  proven extremely useful in clinical practice and research,
  especially by creating a common language that can be
  applied with reasonably good interrater reliability.
  Unfortunately, the disorders within these classifications are not
  generally treated as heuristic, but to a great degree have
  become reified. Disorders within the DSM-IV or ICD-10 are
  often treated as if they were natural kinds, real entities that
  exist independently of any particular rater (Kendell &
  Jablensky 2003).”
            Biological Models

• Deacon article
• Chapter 4
• Read about:
   • Brain imaging (scanning) techniques
   • Logical issues in interpreting biological
     findings
   • Behavioral genetic research methods
     (twin, family, and adoption studies) and
     findings
Heritability of Psychological Traits
• “Genetic influence on human psychological
  traits” (Bouchard, 2004)
    http://www18.homepage.villanova.edu/diego.fernandezduque/Teaching/PhysiologicalPsychology/zCurrDir4200/CurrDirGeneticsTraits.pdf



• Heritability estimates for psychological phenomena:
•   Autism = .90
•   Schizophrenia = .80
•   Intelligence (in adults) = .80
•   ADHD = .75 - .80
•   Extraversion = .54
•   Right-wing authoritarianism (in adults) = .50 to .64
•   Positive emotionality = .50
•   Major depressive disorder = .37
         Biomedical Model Critique
•   Deacon, B. J. (in press). The biomedical model of mental
    disorder: A critical analysis of its assumptions, consequences,
    and effects on psychotherapy research. Clinical Psychology
    Review.

• What is the biomedical model?
      • Key assumptions

• Historical context
      • Important events
     Biomedical Model Critique
• Promotion of the biomedical model
   • NIMH
   • Chemical imbalance story
   • DTC drug advertisements
   • Disease-centered language of drug action
   • Use of psychotropic medications
   • Health websites
   • Anti-stigma campaigns
      Biomedical Model Critique
• NIMH Director Thomas Insel vs. Thomas
  Insel
• “Many illnesses previously defined as ‘mental’
  are now recognized to have a biological
  cause.”
                        vs.
• “What we are missing is an understanding of
  the biology of the disorders and what is really
  going wrong.”
        Biomedical Model Critique
• NIMH Director Thomas Insel vs. Thomas
  Insel
• “…mental disorders appear to be disorders of
  brain circuits.”
                                  vs.
• “In truth, we still do not know how to define a [brain] circuit.
  Where does a circuit begin or end? How do the patterns of
  “activity” on imaging scans actually translate to what is
  happening in the brain? What is the direction of information flow?
  In fact, the metaphor of a circuit in the sense of flow of electricity
  may be woefully inadequate for describing how mental activity
  emerges from neuronal activity in the brain.”
        Biomedical Model Critique
• NIMH Director Thomas Insel vs. Allen Frances
• Insel: “…there is an increasing recognition in the decade
  following the Decade of the Brain that these are brain disorders,
  that mental disorders are brain disorders, a simple and
  profound truth that has completely altered the way that we
  approach diagnosis and ultimately will alter the way we treat
  them.”
                                 vs.
• Frances: “The incredible recent advances in neuroscience,
  molecular biology, and brain imaging . . . are still not relevant to
  the clinical practicalities of everyday psychiatric diagnosis. The
  clearest evidence supporting this disappointing fact is that not
  even one biological test is ready for inclusion in the criteria sets
  for DSM‐V.”
         Biomedical Model Critique
• Former NIMH Director Steven Hyman vs.
  Steven Hyman
•   “[Mental disorders] are real illnesses of a real organ, the brain,
    just like coronary artery disease is a disease of a real organ, the
    heart.”
                                     vs.
•   “The disorders contained [in the DSM] are heuristics that have proven
    extremely useful in clinical practice and research, especially by creating
    a common language that can be applied with reasonably good
    interrater reliability. Unfortunately, the disorders within these
    classifications are not generally treated as heuristic, but to a great
    degree have become reified. Disorders within the DSM-IV or ICD-10
    are often treated as if they were natural kinds, real entities that exist
    independently of any particular rater.”
       Biomedical Model Critique
• American Psychiatric Association vs.
  American Psychiatric Association
• “Research has shown that serious neurobiological
  disorders such as schizophrenia reveal reproducible
  abnormalities of brain structure (such as ventricular
  enlargement) and function.”
                             vs.
• “…brain science has not advanced to the point where
  scientists or clinicians can point to readily discernible
  pathologic lesions or genetic abnormalities that in and of
  themselves serve as reliable or predictive biomarkers of a
  given mental disorder or mental disorders as a group.”
      Biomedical Model Critique
• Are mental disorders biologically-based brain
  diseases? Chemical imbalances?
• Has biomedical research developed
  diagnostically useful biological tests?
• Has biomedical research developed
  diagnostically more effective medications?
• Are mental health outcomes improving?
• Has the biomedical approach been a
  success? For whom?
     Biomedical Model Critique
• Fruits of the biomedical revolution
   • Knowledge of the biological basis of
      mental disorder
   • Chemical imbalance story
   • Stigma
   • Lack of clinical innovation
   • Poor long-term outcomes of medications
   • Increased chronicity and severity of
      mental disorders, especially in children
    Response Paper Questions for Today

• Deacon, B. J. (in press). The biomedical model of mental disorder:
  A critical analysis of its assumptions, consequences, and effects
  on psychotherapy research. Clinical Psychology Review.
• 1. Describe the extent to which the evidence reviewed in the “Fruits of the
  Biomedical Revolution” section is consistent with your pre-existing
  beliefs/assumptions about the biomedical model. (e.g., Were you aware of this
  evidence? Is it consistent or inconsistent with what you had heard or assumed to
  be true about the validity of biomedical theories and treatments?)
• 2. Is it scientifically and/or ethically justifiable for treatment providers, mental
  health organizations, patient advocacy groups, and other entities to promote the
  “chemical imbalance” and/or “brain disease” stories of mental disorder? Why or
  why not?
• 3. Is it scientifically and/or ethically justifiable for the mental health field to persist
  in the dominant biomedical approach based on faith that it will eventually
  revolutionize clinical practice? Why or why not?

				
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