Interventions and treatment in clinical psychology semester 2
Lecture 1: psychiatric classification
Conventional approaches to psychosis
- At both a clinical and populational level this approach has had almost no impact on
mental health
- Long term outcomes for patients with psychosis have not improved since the end of
WW2
- Developing countries with poorly resourced mental health services have better
outcomes
The role of psychiatric diagnoses
- Facilitate communication between clinicians
- Determining access to services
- Public health surveillance
- Selection of participants for research into mechanisms and aetiology
- Prediction of clinical outcome
- Prediction of treatment response
Psychiatry in Germany
- Teaching in psychiatry first began in Leipzig in 1811
- In 1865 wilhelm griesinger established the first modern academic psychiatry
department in berlin and two years later he founded the archives for psychiatry and
nervous disease
- Was the first to say that mental illness is disease of nerves and brain
Emil Kraepelin
- Wrote the compendium of psychiatry 1883
- Used wide ranging research methods including clinical observation, psychological
tests, psychopharmacology and cross cultural studies
- Saw course of illness as clue to classification
- He collected detailed case studies
- Believed that diagnosis by symptoms would be a rosseta stone that would lead to an
understanding of aetiology
- First described schizophrenia and differentiated it from manic depression, he later
saw paranois as a separate illness
- Assumed schizophrenia was a product of gross deficits in cognitive processes cause
by underlying neuropathology
,Two systems of classification
- The American psychiatric association in 1948 formed a task force to create a new
standardized system (DSM)
- In 1948 WHO assumed responsibility for an international list of causes of death.
When creating ICD-6 in 1961 WHO added nonfatal diseases including psychiatric
disorders.
Problems of diagnosis and the neokraepelinians
- Early concerns: US-UK diagnostic project
- Early concerns; problem of reliability = relaibilty refers to the consistency of
diagnosis; validity to its usefulness.
- Neokraepelinian movement = in the US in 1970s tried to return psychiatry to its
karepelinian roots
Projects for a new approach to classification
- Hierarchical models = research is converging on hierarchical models where at the top
there is a small number of disorders that are then subdivided
- The symptom approach = alternative approach has been to carry out research
focusing on specific symptoms. Clinicians should simply write down a list of
symptoms.
, Lecture 2: environmental determinants of psychosis
Psychosis is not primarily genetic
- Data from quantitative genetic studies have been used to calculate high heritability
estimates for schizophrenia which has led to the assumption that environmental
factors play little role
- Heritability is defined as the proportion of the shared phenotypic variation
attributable to genes. It can be calculated in various ways by looking at the
concordance in a trait in groups of people who vary in their relatedness to each
other.
- It is often wrongly assumed that high levels of heritability preclude environmental
influences. But if variance in the environment is low then heritability will always be
high. Turkeimer et al found that 60% of variance in IQ in impoverished environment
is attributable to shared environmental effects with close to zero genetic effects. The
reverse was true in middle class families.
Genome wide association studies
- International schizophrenia consortium 2009 relaxed statistical rules to identify
genes with very modest associations with schizophrenia and created scores for
polygenic association.
There are no ‘genes’ for schizophrenia
- Genetic risk seems to be diagnostically non specific. There is a genetic risk for
psychiatric disorder not for schizophrenia. There are no schizophrenia genes of
major effect. Hundreds or thousands of genetic variations contribute to the risk of
psychosis.
A wide range of social and environmental risk factors are associated with psychosis
- Urban environments = faris & dunham first showed that psychosis is most common
in inner city areas and this is often attributed to the downward social drift of the
mentally ill. The effect is strongest for exposure to cities during childhood.
- Poverty
- Inequality = countries with the highest social inequality have the highest rates of
almost all forms of negative outcomes including crime, teenage pregnancies and
common psychiatric disorders. Neighbourhoods with the highest inequality have the
highest rates of first episode psychosis.
- Migration = it has long been known that afro carribeans in the UK have the highest
rates of psychosis. The effect is greatest for child migrants and when people
experience forced migration.
- Parental communication deviance
- Separation from parents at an early age
- Childhood sexual and physical abuse
- Bullying by peers
Lecture 1: psychiatric classification
Conventional approaches to psychosis
- At both a clinical and populational level this approach has had almost no impact on
mental health
- Long term outcomes for patients with psychosis have not improved since the end of
WW2
- Developing countries with poorly resourced mental health services have better
outcomes
The role of psychiatric diagnoses
- Facilitate communication between clinicians
- Determining access to services
- Public health surveillance
- Selection of participants for research into mechanisms and aetiology
- Prediction of clinical outcome
- Prediction of treatment response
Psychiatry in Germany
- Teaching in psychiatry first began in Leipzig in 1811
- In 1865 wilhelm griesinger established the first modern academic psychiatry
department in berlin and two years later he founded the archives for psychiatry and
nervous disease
- Was the first to say that mental illness is disease of nerves and brain
Emil Kraepelin
- Wrote the compendium of psychiatry 1883
- Used wide ranging research methods including clinical observation, psychological
tests, psychopharmacology and cross cultural studies
- Saw course of illness as clue to classification
- He collected detailed case studies
- Believed that diagnosis by symptoms would be a rosseta stone that would lead to an
understanding of aetiology
- First described schizophrenia and differentiated it from manic depression, he later
saw paranois as a separate illness
- Assumed schizophrenia was a product of gross deficits in cognitive processes cause
by underlying neuropathology
,Two systems of classification
- The American psychiatric association in 1948 formed a task force to create a new
standardized system (DSM)
- In 1948 WHO assumed responsibility for an international list of causes of death.
When creating ICD-6 in 1961 WHO added nonfatal diseases including psychiatric
disorders.
Problems of diagnosis and the neokraepelinians
- Early concerns: US-UK diagnostic project
- Early concerns; problem of reliability = relaibilty refers to the consistency of
diagnosis; validity to its usefulness.
- Neokraepelinian movement = in the US in 1970s tried to return psychiatry to its
karepelinian roots
Projects for a new approach to classification
- Hierarchical models = research is converging on hierarchical models where at the top
there is a small number of disorders that are then subdivided
- The symptom approach = alternative approach has been to carry out research
focusing on specific symptoms. Clinicians should simply write down a list of
symptoms.
, Lecture 2: environmental determinants of psychosis
Psychosis is not primarily genetic
- Data from quantitative genetic studies have been used to calculate high heritability
estimates for schizophrenia which has led to the assumption that environmental
factors play little role
- Heritability is defined as the proportion of the shared phenotypic variation
attributable to genes. It can be calculated in various ways by looking at the
concordance in a trait in groups of people who vary in their relatedness to each
other.
- It is often wrongly assumed that high levels of heritability preclude environmental
influences. But if variance in the environment is low then heritability will always be
high. Turkeimer et al found that 60% of variance in IQ in impoverished environment
is attributable to shared environmental effects with close to zero genetic effects. The
reverse was true in middle class families.
Genome wide association studies
- International schizophrenia consortium 2009 relaxed statistical rules to identify
genes with very modest associations with schizophrenia and created scores for
polygenic association.
There are no ‘genes’ for schizophrenia
- Genetic risk seems to be diagnostically non specific. There is a genetic risk for
psychiatric disorder not for schizophrenia. There are no schizophrenia genes of
major effect. Hundreds or thousands of genetic variations contribute to the risk of
psychosis.
A wide range of social and environmental risk factors are associated with psychosis
- Urban environments = faris & dunham first showed that psychosis is most common
in inner city areas and this is often attributed to the downward social drift of the
mentally ill. The effect is strongest for exposure to cities during childhood.
- Poverty
- Inequality = countries with the highest social inequality have the highest rates of
almost all forms of negative outcomes including crime, teenage pregnancies and
common psychiatric disorders. Neighbourhoods with the highest inequality have the
highest rates of first episode psychosis.
- Migration = it has long been known that afro carribeans in the UK have the highest
rates of psychosis. The effect is greatest for child migrants and when people
experience forced migration.
- Parental communication deviance
- Separation from parents at an early age
- Childhood sexual and physical abuse
- Bullying by peers
