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UNIT 1
PSYCHOPATHOLOGY
UNIT ONE
CLINICAL CHARACTERISTICS OF DEPRESSION
ISSUES SURROUNDING THE CLASSIFICATION AND DIAGNOSIS OF DEPRESSION
Specification requirements
LEARNING OBJECTIVES: You will be able to:
Outline the clinical characteristics of depression
Apply knowledge and understanding of the classification and diagnosis of
depression.
INTRODUCTION
Psychopathology is the scientific study of abnormal behaviour.
There is no single explanatory approach in psychology. This is also true in the field of
psychopathology where several different models are used to explain the origins of mental
disorders and to suggest methods of treatment. These models can be split into two major
categories:
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The medical (biological) model views mental disorder as an illness caused by
underlying biological factors.
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Psychological models view mental disorder as the result of psychological
dysfunction.
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A GENERAL OVERVIEW
Classification and diagnosis
Key considerations:
1. The necessity to diagnose and classify mental disorders.
2. The advantages and disadvantages of diagnosing and classifying mental disorders
in this way.
3. The way in which diagnosis and classification is attempted.
4. The problems of validity and reliability when attempting to diagnose and classify
mental disorders?
5. The effect of cultural differences on validity and reliability of diagnosis and
classification of mental disorders.
The need to diagnose and classify mental disorders
1.
The dominant approach to psychopathology is the biological model. This uses the model of
physical illness and applies it to psychological disorders. It assumes:
 There is a physical cause for mental disorders
 Mental disorders have signs and symptoms which are particular to a type of disorder
 Signs and symptoms regularly occur together in clusters called ‘syndromes.
 Syndromes represent distinctive disorders
 These disorders can be explained and treated
Advantages
2.
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It makes it easier for health professionals to communicate with each other about a patient if there is a
label that can be placed on a number of symptoms
Some disorders are reliably associated with particular aetiologies (causes). This can help researchers
to investigate these further.
An appropriate treatment is more likely to be selected if a disorder can be correctly diagnosed.
It will be easier to predict the course of a disorder which will help the planning and treatment of the
disorder if it is diagnosed correctly.
Disadvantages
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Misdiagnosis is often a problem as mental disorders can be tricky. This will result in inappropriate
therapy.
People experience the same disorder in varying degrees, e.g. mild depression / severe depression so it
is not always clear cut – there are grey areas.
Diagnosis leads to labelling and, while this can be helpful, it can have negative effects as there is still a
stigma attached to mental illness. It can also cause the individual to feel helpless and give in to the
symptoms
Disorders included in the diagnostic manuals sometimes reflect social/political attitudes at the time.
There is a need to be aware of historical and cultural context. Sometimes there are cultural nuances
which a clinician may be unaware of and this may lead to an incorrect judgement about an individual.
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The attempt to diagnose and classify mental disorders
There are two widely used systems in psychiatry for defining and classifying mental disorders:
i.
The International Classification System for Diseases (ICD) was developed by the World Health
Organisation (WHO).
ii.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) was developed by the American
Psychiatric Associaiton (APA).
Both systems categorise disorders on the basis of signs and symptoms
They do not contain causal explanations.
The manuals are frequently revised to keep up with changing views on mental disorders.
The ICD is a collection of general health statistics. Mental disorders form only a small part of the
manual and were first included in 1952.
The ICD is currently being revised to its 11th edition. The APA and WHO are working together for
greater agreement and consistency. It identifies 11 general categories of mental disorder.
The DSM is currently being revised to its 5th edition. It is used by health professionals and also for
research purposes. The DSM uses categories consisting of groups of symptoms. For nearly half of the
disorders, symptoms must be sufficient to cause ‘clinically significant distress or impairment in social,
occupational, or other important areas of functioning’. In contrast, OCD-10 criteria do not include the
social consequences of the disorder.
The DSM organises each psychiatric diagnosis into five levels (axes) relating to different
aspects of the disorder.
Axis I:
clinical disorders, including major mental disorders, as well as developmental and learning disorders
(these include depression, anxiety disorders and schizophrenia)
Axis II: underlying pervasive or personality conditions, as well as mental retardation (e.g. antisocial
personality disorder and problems of intellectual development).
Axis III: Acute medical conditions and physical disorders. (This includes medical problems that could lead to or
exacerbate mental disorders, e.g. brain injuries).
Axis IV: psychosocial and environmental factors contributing to the disorder.
Axis V: Global Assessment of Functioning or Children’s Global Assessment Scale for children under the age of
18 (on a scale from 100 – 0). This scale is used to rate the ability to function socially, psychologically
and at work. A score above 90 indicates superior functioning, while a score below 30 indicates serious
impairment.
Each patient has to be assessed by the clinician in the light of all five axes in an attempt to
improve the accuracy and reliability of the diagnosis.
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Reliability and validity of the classification system
There has to be agreement about a particular diagnosis if a classification system is to be useful. In
physical medicine, a diagnosis can usually be verified by some sort of laboratory test, e.g. blood test,
X-rays, but for abnormal behaviour, there is no objective test and the only means of assessing
reliability is to see whether diagnosticians agree with one another. There is more agreement about
some disorders than others. Where there is low descriptive validity, it means that syndromes are not
described accurately and may be mistaken for something else. Predictive validity refers to the ability
of the systems to predict the course of the disorder and the outcome of any treatment.
Earlier versions of the manuals were not very reliable. This means that the likelihood of two clinicians
coming to the same conclusions about a patient would be low. This was because key terms were not
clearly defined and that clinicians used different techniques when interviewing and assessing
patients. These two problems have now been addressed – more operational definitions have been
included in later versions of the manuals and psychiatrists now use standardised interview schedules
when assessing patients and taking clinical history (e.g. the Present State Examination – PSE – was
developed by Wing et al. 1974. Wing and colleagues also produced computer programs which
generate a diagnosis based on a rating of symptoms.
5.
Cultural issues of diagnosis and classification of mental disorders
The widespread international acceptance of the ICD and DSM has meant that other diagnostic
systems are no longer in frequent use. However, psychiatrists in some countries such as Pakistan,
India and China think that the classifications developed in the west place too much emphasis on the
separation of mind and body. The Chinese classification of mental disorders, second edition (CCMD-2R), although largely based on ICD-10, excludes certain categories and includes a category called
neurasthenia. This is defined as a ‘weakness of the nerves’ and is one of the most frequent diagnoses
made in China and in other far-eastern countries. It is listed in ICD-10 but only because this is an
international classification system. The term has been dropped from the DSM, but it is listed in an
appendix of culture-bound syndromes. It is noted here because the diagnosis is sometimes made in
far-eastern countries as a cover for the more serious disorders of schizophrenia and depression as a
way of avoiding the stigma associated with those disorders. This is a problem because of the
implications for treatment.
Key points
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Psychology is a broad-ranging discipline that encompasses many different theoretical perspectives (or
paradigms). In the felid of psychopathology, several different models are used to explain the origins of
mental disorders and to suggest methods of treatment. These models can be split into two major
categories: biological and psychological.
While all of the models offer explanations for mental disorder and suggest treatment methods, some of
these are more appropriate to certain disorders than others.
Therapies have been suggested by all of the models. It is important to make sure that the most
appropriate an defective therapy is chosen for each individual patient. The effectiveness of therapy is
assessed by research studies. It is important to be aware of some of the methodological and ethical
issues that surround such research because these issues can affect the accuracy of conclusions.
Classification systems have been developed to make the process of research and diagnosis simpler. The
major systems in use across the world today are DSM-IV-TR and ICD-10. They have been revised many
times and are now very similar to each other.
There are several issues surrounding the classification and diagnosis of mental disorders which need to
be considered. One major issue concerns and reliability and validity of diagnostic categories.
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UNIT 1
CLASSIFICTION AND DIAGNOSIS OF MAJOR DEPRESSIVE DISORDER
(UNIPOLAR DEPRESSION)
CLINICAL CHARACTERISTICS
The term ‘depression’ is used in everyday speech to cover a range of experiences. We sometimes use the term
to convey a mood state in which we feel upset over the bread-up of a relationships or the loss of a job. This is a
normal reaction to a distressing event and is usually temporary. Clinical depression, on the other hand, is a
collection of physical, mental, emotional and behavioural experiences that are more prolonged, severe and
damaging. Depression is one of several disorders generically called mood (or affective) disorders.
The two major mood disorders in the DSM-IV are Major Depressive Disorder (MDD) (unipolar) and bipolar 1
disorder.
You are studying Major Depressive Disorder
The diagnostic criteria for MDD are very similar in the DSM-IV and the ICD-10. The symptoms have to be
present for at least two weeks but may often have been present for considerably longer before the patient
consults a doctor.
DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSIVE DISORDER
according to the DSM-IV.
Five (or more) of the following symptoms have been present for the same two-week period and represent a
change from previous functioning; at least one of the first two symptoms (depressed mood or loss of interest
or pleasure) is included in these:
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Depressed mood most of the day, nearly every day (as indicated by either subjective report or
observation by others). In children and adolescents, this can be irritable mood.
Markedly diminished interest or pleasure in all (or almost all) activities most of the day, nearly every
day (as indicated by either subjective report of observation by others).
Significant weight loss when not dieting, or weight gain (e.g. a change of more than 5 per cent of body
weight in a month), or decrease or increase in appetite nearly every day. In children, consider failure
to make expected weight gains.
Insomnia (not being able to sleep) or hypersomnia (sleeping too much) nearly every day.
Psychomotor agitation or retardation nearly every day (observable by others not merely subjective
feelings of restlessness or being slowed down).
Fatigue or loss of energy every day
Feelings of worthlessness or excessiveness or inappropriate guilt (which may be delusional) near;u
every day (not merely self-reproach or guilt about being sick).
Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective
account or as observed by others)
Recurrent thoughts of death (not just fear of dying) recurrent suicidal ideation without a specific plan
or a suicide attempt or a specific plan committing suicide.
In addition, the symptoms:
Cause clinically significant distress or impairment in social, occupational, or other important areas
of functioning
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Are not due to the direct physiological effects of a substance or a general medical condition
Are not better accounted for by bereavement.
ACTIVITY
The symptoms can be divided into different categories. Put them into the correct box.
LOW SELF-ESTEEM
LOSS OF APPETITE
IRRITABILITY
SLEEP DISTURBANCE
POOR MEMORY
SUICDAL THOUGHTS
LACK OF ENERGY
APATHY
LOSS OF CONCENTRATION
LACK OF SEXUAL DRIVE
NEGATIVE THOUGHTS
CRYING
POOR CARE OF SELF OR OTHERS
SADNESS
GUILT
ACHES AND PAINS
LACK OF INTEREST
FOR WOMEN, CHANGES IN MENSTRUAL CYCLE
SUICIDE ATTEMPTS
Cognitive (THE WAY PEOPLE THINK)
Behavioural (THE THINGS PEOPLE DO)
Physical (EFFECTS ON THE BODY)
Emotional (THE WAY PEOPLE FEEL)
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Different types of depression
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Postnatal depression – where a woman develops depression after having a baby
Bipolar disorder –also known as manic depression where there are periods of depression and also
periods of excessively high mood (mania). The depression symptoms are similar to clinical depression,
but the periods of mania can include harmful behaviour there are few or no inhibitions such as
gambling to a harmful extent, going on spending sprees, having unsafe sex etc.
Seasonal affective disorder – also known as ‘winter depression’, SAD is a type of depression that has
seasonal pattern usually related to winter.
Interesting information
The DSM-1V includes a category of mood disorder called dysthymic disorder (dysthymia in the ICD-10) where
fewer and, usually, milder depressive symptoms are present for over two years. As well as the symptoms of
major depression, there are symptoms of pessimism, low self-esteem, low energy, irritability and decreased
productivity. There is also a category of ‘depressive disorder not otherwise specified’, which includes:
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Premenstrual dysphoric disorder – depressive symptoms occur regularly towards the end of the
menstrual cycle – symptoms are enough to interfere with work, school or other usual activities.
Minor depressive disorder – episodes of at least tow weeks of depressive symptoms, but with
fewer than five of the items required for MDD.
Recurrent brief depressive disorder- episodes lasting from two days to two weeks and occurring
at least once a month for a year (but not associated with the menstrual cycle).
COURSE OF THE DISORDER
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MDD is a universal disorder and is found with similar frequency in all of the countries sampled in
a review by Smith and Weissman (1992). It is the most common mental disorder.
The most common age of onset is in late adolescence or early adulthood. Depression is on the
increase in young people, although it is not clear why this should be so.
Depression is more common in women than men at a ratio of about 2:1
There is considerable variation in the length of depressive episodes
Most major depressions disappear eventually whether treated or not (various longitudinal
studies e.g. Coaryell et al., 1994)
Most individuals recover within a period of 4-6 months
Relapse and recurrence are fairly common
Ongoing behavioural problems arising from the disorder may be fairly substantial often affecting
functioning
The three main areas affected are work, parent/child relationship and marital relationship
Even relatively mild depression can interfere with normal functioning.
10-15 per cent of individuals with a diagnosis of major depressive disorder kill themselves
eventually (Clark and Fawcett, 1992)
It is also associated with increased mortality because of accidents and other medical problems.
This could be because depressed individuals are likely to seek treatment or because depressive
symptoms make them more accident prone.
Depression might affect the body’s immune system (Evans et al, 1992)
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Issues surrounding classification and diagnosis of
depression
 Not everyone agrees that depression should be medicalised. All humans
have moods so it is wrong to call it a pathology. However, supporters of
the medical model say that mood can show extreme manifestations, like
other natural biological phenomena such as blood pressure or blood
sugar, and can cause illness in some people. We all experience sadness at
times but in some cases a depressed mood causes serious impairment of
functioning.
 The symptoms of depression as outlined in teh DSM criteria could be
experienced by a range of people in unhappy situations or with abnormal
personalities. A minimum of five symptoms form the DSM are required
for diagnosis. One problem is that two individuals could score their five
symptoms from a completely different set of alternatives. This means
that their depression could look quite different.
 It can sometimes be difficult for clinicians to make the distinction
between one type of depression and another. One clear distinction would
seem to be between unipolar and bipolar disorder, but even this is not
straightforward. About 10 per cent of people diagnosed with major
depressive disorder go on to develop bipolar episodes (Coryell et al.,
1995). Similarly, someone with dysthymic disorder can have a major
depressive episode as well. This is called ‘double depression’ and was
observed in about 25 per cent of depressed patients in a large study
conducted by the National Institute of Mental health (NIMH) (Keller et
al., 1983)
 The diagnostic manuals do not distinguish between endogenous
depression and reactive depression. There is little conclusive evidence to
support this distinction in terms of the causes of depression (Hammen,
1995) but there do seem to be two fairly reliable different symptom
clusters with the so-called melancholic (endogenous) depression
characterised by more severe symptoms and a greater likelihood of
suicide. Endogenous means that it arises from internal, biological factors
rather than as a reaction to something in the person’s life circumstances
as in reactive depression). It might simply be that the two types exist
along a continuum and that melancholic depression is simply at the most
severe end. However, it does seem to have implications for therapy, with
melancholic depression responding more positively to ECT and to certain
antidepressant medication.
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 It can be difficult to determine whether mood disorder symptoms in a
patient who has another medical condition (e.g. dementia, cancer,
thyroid disorders) are:
 secondary to the effects on the brain of the medical condition
(classified as a mood disorder caused by general medical condition)
 secondary to the effects on the brain of drugs used to treat the
medical condition (classified as substance-induced mood disorder
 reflective of a primary mood disorder unrelated to the medical
condition (e.g. MDD)
 Co-morbidity is often a problem. Depression frequently occurs alongside
other disorders such as substance abuse, alcoholism, eating disorders and
schizophrenia, and it can be difficult for clinicians to decide which is the
primary disorder. Anxiety so frequently coexists with depression that a
new category has appeared in the DSM of ‘anxiety not otherwise
specified’ that is a mixture of anxiety/depression symptoms.
 While psychiatrists are doctors who specialise in mental disorders, the GP
is usually the first point of reference for someone suffering the symptoms
of depression. It is estimated that about 3 per cent of the general
population in the UK are treated by their GP for depression. However, it
has also been suggested that approximately half of the people who go to
their GP with depressive symptoms are not recognised as having
depression (Goldberg and Huxley, 1992)
 Cultural background should also be taken into account when making a diagnosis.
While depression is a universal disorder and symptoms are similar around the
world, there are some cultural differences, the most pronounced being between
Western and non-Western cultures. As American and western cultural ideals
have shaped the construction of both the diagnostic manuals, they are emic
constructs. To impose these on other cultures is to assume that here is no
difference between cultures. This is referred to as imposing an etic. This
assumption that there is no difference or that Western ideals are the correct
ones is culturally biased (ethnocentrism). Therefore, when the DSM and ICD are
used to classify and diagnose depression in non-western cultures they are an
imposed etic and may not be measuring what they claim to be measuring which
means they may not be a valid classification tool. If they lack consistency across
cultures, they also lack reliability.
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