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Patterns of Mental Health Group 4

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Jami Akins

on 28 February 2013

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Transcript of Patterns of Mental Health Group 4

Depression in the Twentieth Century Group 4 Kraepelin and Normal Sadness The Post-Kraepelins The DSM-III’s Approach to
Depressive Disorder Emergence of the Research Diagnostic Criteria (RDC) The DSM-III as a Response to
the Challenges Confronting Psychiatry Robert Leopold Spitzer:
Born in White Plains, New York in May 22, 1932. He received his bachelor’s degree in Psychology at Cornwell University, and his M.D. from New York University School of medicine. http://www.colbertnation.com/the-colbert-report-videos/181464/january-24-2006/most-depressing-day-of-the-year Significant contribution:
-Developed the biopsychosocial approach which looked at:
- One's predispositions
- Environmental circumstances
- Specific experiences The DSM-III was published in 1980 and provided a completely new standpoint in the history of psychiatric diagnosis. At the forefront of this change, Spitzer took on the role of politician, as he found compromise with other clinical constituencies that felt the new symptom based diagnosis was a threat to their traditional ways. Initial Psychiatric Classifications Major Changes to the way Depression was Defined -The DSM-III separated bi-polar and major depressive disorder.

-DSM-III also had to include a category for “simple depression” -A break from Kraepelin’s ideas

-Previous versions focused solely on psychotic depression
-Simple depression became the more commonly diagnosed form of depression What was Excluded? -DSM-III did not specify what is considered an excessive or normal reaction to an event -Only distinguishes depressive disorders based on symptoms

-Does not define symptoms based on their relation to an event

-Chose to exclude those definitions because they were simply normal responses to loss and were not related to any medical cause What are some of your thoughts? Should depression be defined as a medical illness or as a mental illness? Reasons for Omitting Definition of Normal Sadness -Believed that it would lessen their reliability

-Desire to keep it from favoring any particular theory

-Felt that is did not matter if the disorder was ‘with’ or ‘without’ a normal cause.

-Concerned about labeling those who where truly disordered as normal -Wanted to keep the DSM-III strictly medical

-Although, every theory had the same definition of normal; so this cause is irrelevant

-Treatment would be the same for hospitalized patients no matter what the reason
-It would be important to know the distinction between normal and disordered behavior to be sure that the proper treatment is given

-Though, they were not interested in mislabeling normal individuals as disordered First Half of 20th Century focused on institutionalized patients
Administrative need drove the development of statistical manuals
Did not focus on less severe "outpatient" conditions wdwdw Statistical Manual for the Use of Hospitals of Mental Diseases First standardized classification system
Divided Mentall Illness into 22 groups
2 Groups that covered Depression
Distinguishes depressive disorder from normal sadness
Recognizes wide range of causes for intense normal sadness DSM I By the 1950s psychiatry was moving towards outpatient practice
Statistical Manual was no longer relavent to most patients
DSM I was developed in 1952
Did not distinguish disordered depression and normal sadness DSM II Provided a definition of depression that differentiates between "proportionate" and "excessive" reactions
Return to classic thought
2,500 years of psychiatry Paving the Road to the DSM-III: The Feighner Criteria A group of research psychiatrists from Washington University in St. Louis led by Eli Robins and Samuel Guze
They felt that with the current system there was no hope for psychiatry as a scientific discipline What is the Feighner Criteria? It was created in 1972 by John Feighner when he codified and published a diagnostic criteria for 15 mental disorders
It was an attempt to relieve researchers of the problem of imprecise definitions that were in use, and make research easier and more accurate
It divides primary affective disorders into 2 categories: depression and mania How Depression is Diagnosed Must have three of the criteria:
Dysphoric mood
At least 5 other symptoms must be present
Must have lasted at least 1 month and not be due to another preexisting mental disorder
The only people who were excluded from this diagnosis were those who had life-threatening or incapacitating medical illness Issues with the Feighner Criteria All depressive conditions were grouped into a single category
There was no exception at all for depressive reactions of more than one month that stemmed from normal loss responses
It did not allow for the possibility that some depressive symptoms were proportionate to their causes Why did it Ignore Normal Sadness? They wanted more researchers to use their criteria.
The samples they based their research on consisted of disordered individuals
They recognized the distinction but assumed that more than 1 month is "prolonged" and is disproportionate to the stressor Why use the Feighner Criteria? They claimed it's groundings were in empirical research rather than just theoretical speculation like other diagnostic models
It served a need in the research community Psychiatric Diagnosis The first symptom based psychiatric textbook
Diagnosing affective disorders emphasizes the importance of observation and measuring symptoms without any inferences because of the poor knowledge about the causes of depression Who created the DSM-III criteria? Feighner Criteria vs. Research Diagnostic Criteria Feighner Criteria:
15 symptom based diagnoses
Require symptom to persist for 1 month.
Reliability of .90

Research Diagnostic Criteria:
25 symptom based diagnoses + 11 subtypes of MDD (major depression disorder)
Require symptom to persist for 2 weeks
Differentiate symptom of those with schizophrenia from a depression diagnosis.
Reliability of .97 Emil Kraepelin Attempted to place psychiatry within a strictly biomedical framework
Began his classification system at a Munich asylum
His efforts at categorization based on symptoms is now seen as the forerunner of the DSM-III Emil Kraepelin (1856-1926) A Biological Approach Attempted to place psychiatry within a strictly biomedical framework
Worked as a physician in a Munich asylum, and began classifying patients by description of symptoms
Seen as the forerunner of the DSM-III and the recent DSMs are referred to as "neo-Kraepelinian" Kraeplin Continued Kraeplin was greatly influenced by the realization that the greatest mental disorder of his time, general paresis was caused from the syphilitic infection

This discovery imparted two lessons: 1. mental disorders could be due to underlying physical pathology

2. Symptoms can change markedly over time, yet the same disorder is present A Division of Thought Frued vs Kraeplin -In the late 1800s, mental disorders were divided into two distinct ways of thought: First - Freud's followers sought to understand mental illness through suppressed unconscious desires Second - Kraeplin's followers sought to understand mental illness through a classical medical model -Many psychiatrists viewed the publication of the DSM-III in the 1980 as finally resolving the struggle between the Freudian & Kraeplischns school of thought. Favoring Kraeplins approach Sigmund Freud (1856-1939) The heart of his approach was to understand pathological symptoms in terms unconscious mental process
Coined the term "Psychoanalysis"
Paid little attention to treating symptoms
For psychoanalysts, depression was one major mechanism underlying symptom formation that, to some degree, was present in nearly every neurosis Different Movements the DSM-III Combated -Behaviorists movement: Believed that all behavior (including that of the psycho-pathologically “disordered”, is the result of social learning and henceforth that no medical disorder truly existed.

-“Antipsychiarty” movement: Suggested that this type of psychiatric diagnosis was being used to apply social control to behavior that was against the norm, but not truly medically disordered.

-In spite of the different theories these movements and schools were based on, Spitzer culminated a manual by which the use of would allow “diagnosticians to arrive at the same diagnosis based on the same clinical information” Rosenhan's Study: "On Being Sane in Insane Places" - 1973 David Rosenhan published a study

- 8 "Normal people"
- They hear “thud”, “dull”, and “empty” in their heads
- All of the patients were admitted and classifed with psychiatic disorders (7 out of 8 with schizophrenia) On Being Sane in Insane Places Cont. - Attitudes of the elite: “..the morning attendants would often wake patients with, “Come on, you m_ _ _ __ f _ _ _ _ _ s, out of bed!” (Rosenhan, 1973)

-Powerlessness: (Personal space rule?)“ Personal privacy is minimal. His personal history and anguish is available to any staff member who chooses to read his folder, regardless of their therapeutic relationship to him. His personal hygiene and waste evacuation are often monitored.” (Rosenhan, 1973) The Realization - The DSM-III as a revolution, had to address all of these types of controversies.

-Before publication, the reliability and validity of the system was tested by hundreds of psychiatrists in order to conclude that not only would they all arrive at the same diagnosis, but the same CORRECT diagnosis. Why Was This Important ? -By the 1970s, the psychiatric profession had been divided into a variety of different sub groups and theoretical schools. The DSM-III had to provide an unbiased, neutral way of distinguishing disorder without stating cause as any one particular theory
-Unfortunately this meant that relation to life events was not included On Being Sane in Insane Places Cont. Rosenhan WELCOME TO
WARD 4 Adolf Meyer Focused more on life circumstances and personalities than distinct disease conditions Kraepelin's View -Did not diagnose by symptoms, but rather by external cause
-His views differ from the DSM
People show normal/healthy sadness
Not just focused on duration or severity
Rather for no reason to be depressed Morbid Emotions vs. Normal Sadness Morbid sadness- lack of suffiecient cause as well as intensity and persistence

Normal sadness- A healthy response. Moods can be controlled

Morbid sadness can attach to external occassions but don't vanish. These moods cannot be controlled

Normal can evolve into morbid Examples Farmer, 59, admitted to hospital
-Illness began 7-8 months before admission
-Began with loss of appetite and indigestion
-Apprehension depression came later
due to sin

Widow, 54 tried to commit suicide
-Married at age 30, four kids
No history of insanity
-Began with insomnia and loss of appetite
-Apprehensive depression came later Major Contribution Issues with his Concept Why is He Important? He was the major translator of the Feighner research criteria into what were to become the clinical diagnostic criteria of the DSM-III.
Published the Research Diagnostic Criteria (RDC) with Eli Robbins in 1978
Spitzer also developed one of the first structure interviews to measure depression Born in November 8, 1990 at Adelaide, Australia. First Professor of Psychiatry at the Institute of Psychiatry.

• In 1934 Aubrey Lewis conducted a study of 61 patients treated at the Maudsley Hospital in London.

• Lewis confirmed Kraepelin’s claim that almost all depression is
one disorder, varying along a continuum of severity from mild to
severe but not differing by endogenous or reactive causes. Aubrey Lewis: The Breakdown of the “With” and “Without” Cause Tradition

• Argued how the endogenous “without cause” usually had external factors
that lead to the depression, and does have a cause.

• Explained how Labeling a form of depression to “with cause” or “without
cause” had dire consequences for misdiagnosis.

• His studies from Kraepelin did help pave way for a succeeding revolution
in psychiatric diagnoses because of the approach he took in identifying
depressive disorder.

• His study helped bring about a definitive set of symptomatic criteria for
depression that remained stable until the present. • His concept does not distinctively differentiate the depression cause from biological factor. (Hallucinations and delusion)

• Most researchers rejected this notion and believed that endogenous depression was a distinct type of depression.

• Because of the scarce amount non-triggered depressions that were truly “without cause”, the term endogenous came to refer to a pattern of symptoms; not a cause of symptoms. • His concept does not distinctively differentiate the depression cause from biological factor. (Hallucinations and delusion)

• Most researchers rejected this notion and believed that endogenous depression was a distinct type of depression.

• Because of the scarce amount non-triggered depressions that were truly “without cause”, the term endogenous came to refer to a pattern of symptoms; not a cause of symptoms. • Lewis' concept does not distinctively differentiate the depression
cause from biological factor (hallucinations and delusions)

• Most researchers rejected this notion and believed that
endogenous depression was a distinct type of depression

• Because of the scarce amount non-triggered depressions that
were truly “without cause”, the term endogenous came to refer to
a pattern of symptoms; not a cause of symptoms
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