혁신라이프코칭연수원 ICC

http://club.koreadaily.com/icclifecoach
전체글보기 클럽방명록  공동체 영상 정보   ICC 안내자료   도시와 자연의 영상 
 
  클럽정보
운영자 simonshin
비공개 개설 2016.07.20
인기도 607838
회원 80명
공동체 영상 정보 (84)
ICC 안내자료 (98)
ICP 안내자료 (75)
도시와 자연의 영상 (90)
신현근 박사 영상 강의 
정신분석의핵심개념 (18)
애도와 상실 (10)
Karen Horney의 정신분석 (74)
대인관계 정신분석 2 (35)
자아심리학 2 (34)
고전적 정신분석 (Freud) (168)
병리적 자기애와 공격성 (Kernberg) (60)
자기 심리학 (Kohut) (81)
임상 기법과 임상감독 (13)
인간성장이론 (12)
전이와 저항 (60)
클라인(Klein) 학파의 대상관계 이론과 그 역사 (58)
정신분열증 (10)
상호주관적 관계적 정신분석 (43)
비온의 대상관계 이론 (59)
융의 정신분석 이론 (10)
강의안과 발제문 
현대정신분석의핵심개념 (5)
라이프코치양성 (23)
진단과평가 (17)
현대갈등이론 (13)
전인격적라이프코칭 (8)
회원자료 (5)
무의식적환상 (22)
현대정신분석의개입기법 (35)
정서적의사소통 (15)
정신분석기법과정신적 갈등 (23)
정신분석적사례이해 (26)
방어기제 (24)
정신분석의역사 (47)
고전적 정신분석 기법 (19)
신경증이론 (23)
대상관계이론의역사 (14)
자아심리학 (23)
현대정신분석 이론 (25)
페어베언의 성격 이론 (24)
성년기 발달 이론 (13)
위니코트의 대상관계 이론 (19)
ICC의 목표
추천링크
ICC YouTube
ICC 웹사이트
ICP, Seoul Korea
ICC 대표 신현근 박사
ICC의 네이버 블로그
ICC의 Moment 블로그
혁신라이프코칭학회 ICS
ICC의 Facebook Page
ICS의 Facebook Page
HeyKorean ICC
한국일보 블로그
ICP YouTube
 
TODAY : 955명
TOTAL : 1207135명
진단과평가
작성자  simonshin 작성일  2016.11.18 19:47 조회수 1294 추천 0
제목
 신현근 박사 강의안 - 정신병리의 이해와 치료에 관한 일반적 문제들  
첨부파일 : f1_20161118194736.pdf
 

과목:  진단과 평가

주제General issues in understanding and treating psychopathology

강사: 신현근 박사

내용: 진단과 평가 정신병리의 이해와 치료에 관한 일반적 문제들

교재: Castonguay, L. G., & Oltmanns, T. F. (2013), General issues in understanding and treating psychopathology In L. G. Castonguay, & T. F. Oltmanns, Psychopathology: From science to clinical practice, pp.1-16, New York: Guilford Press.

 

 

1.         Introduction

1.1          The practice of any mental health profession (clinical and counseling psychology, psychiatry, social work) depends heavily on the ability to recognize and conceptualize various forms of mental disorder.

1.2          Therapists, irrespective of their professional background and theoretical orientation, must be aware of the varied manifestations of psychopathology.

1.3          They also have to understand many forms of vulnerability that set the stage for the development and maintenance of commonly occurring mental disorders, which eventually touch all of our lives, either directly or indirectly.

1.4          Clinical experience raises important research questions, and evidence from scientific studies leads to the development and evaluation of improved treatment procedures.

2.         Defining mental disorders

2.1          Arguably, one of the most influential and widely invoked definitions of “mental disorder” was proposed by Wakefield (1992, 2010). According to his argument, a behavioral condition should be considered a mental disorder if, and only if, it meets two criteria:

2.1.1    The condition results from the inability of some internal mechanism (mental or physical) to perform its natural function. In other words, something inside the person is not working properly. Examples of such mechanisms include those that regulate levels of emotion, and those that distinguish between real auditory sensations and imagined ones.

2.1.2    The condition causes some harm to the person as judged by the standards of the person’s culture. These negative consequences are measured in terms of the person’s own subjective distress or difficulty performing expected social or occupational roles.

2.2          Using Wakefield’s terms, mental disorders are defined as “harmful dysfunctions.”

2.2.1    One element (“ dysfunction”) of this definition is an attempt to incorporate (as much as it is possible) an objective evaluation of behavior.

2.2.2    Wakefield argues that internal processes (e.g., cognition and perception) have a natural function, and that this function is to allow an individual to perceive the world in ways that are shared with other people and to engage in rational thought, problem solving, and adaptive behavior.

2.2.3    The dysfunctions in mental disorders are assumed to be the product of disruptions of thought, feeling, communication, perception, and motivation.

2.3          By definition, mental disorders are harmful to the person’s adjustment.

2.3.1    They typically affect family relationships, as well as success in educational and occupational activities.

2.4          There are, of course, other types of harm associated with mental disorders. These include subjective distress, such as high levels of anxiety or depression, as well as more tangible outcomes, such as suicide.

2.5          The definition of abnormal behavior presented in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013), which in the United States is considered a standard diagnostic system, incorporates many of the factors we have already discussed.

2.5.1    According to this definition, a “mental disorder” is “a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning” (p. 20).

2.5.2    The manual also notes that mental disorders are associated with subjective distress or impairment in social functioning.

2.5.3    DSM-5 also excludes several conditions from consideration as mental disorders. These include (1) an expectable or culturally sanctioned response to a particular event (e.g., death of a loved one); (2) socially deviant behavior (e.g., the actions of political, religious, or sexual minorities); and (3) conflicts that are between the individual and society (e.g., voluntary efforts to express individuality).

2.6          The DSM definition places primary emphasis on the consequences of certain behavioral syndromes.

2.6.1    Accordingly, mental disorders are defined by clusters of persistent, maladaptive behaviors that are associated with personal distress, such as anxiety or depression, or with impairment in social functioning, such as job performance or personal relationships.

2.6.2    This definition, therefore, recognizes the concept of dysfunction, and it spells out ways in which the harmful consequences of a disorder might be identified.

2.7          The practical boundaries of abnormal behavior are defined by the list of disorders included in DSM.

2.7.1    Therefore, the manual provides a simplistic, though practical, explanation of how someone’s behavior might be considered pathological: It would be considered abnormal if the person’s experiences fit the description of one of the forms of mental disorder listed in the diagnostic manual.

2.7.2     Conceptually, however, it could be argued that a valid and adequate description of a mental disorder, such as major depression, cannot be restricted to its symptomatic picture.

2.7.3    In order to define and understand major depression, it is necessary to consider a description of other clinical features (e.g., marital and health problems with which it is frequently associated), as well as a number of additional issues, such as its typical course (onset, duration, recurrence, relapse), prevalence (across gender and culture), patterns of comorbidity, and vulnerability factors.

2.8          Mental disorders are actually best conceived as “hypothetical constructs” (Morey, 1991; Neale & Oltmanns, 1980), which simply are abstract, explanatory devices.

2.8.1    The construct itself cannot be directly observed, but it is tied to overt referents that can be observed.

2.8.2    For example, we cannot measure major depression directly, but we can see that the person no longer enjoys formerly pleasurable activities, has withdrawn from social contacts, is sleeping more than usual, has lost his or her appetite, and frequently talks about feeling worthless.

2.8.3    Beyond these specific symptoms, the utility of a hypothetical construct ultimately depends on the extent to which it enters into relationships with other constructs and observable events (interrelated dimensions of human functioning).

2.8.4    With this approach, a mental disorder is therefore defined by more than simply the diagnostic criteria identified in a diagnostic manual.

2.9          Clinically, this approach to defining a disorder (e.g., major depression) does not imply that clinicians should disregard ”official” diagnostic criteria.

2.9.1    Rather, it suggests that in order to conduct more comprehensive assessments and case formulations of their clients, as well as to identify a more complete list of potential targets for intervention, therapists should complement their diagnostic (DSM-based) evaluation with a careful consideration of nonsymptomatic factors that have been empirically associated with this disorder.

3.         Epidemiology

3.1          Basic understanding of mental disorders requires data about the frequency with which these disorders occur.

3.1.1    Moreover, important clinical, organizational, and social decisions can be based on epidemiological information, such as whether the frequency of a disorder has increased or decreased during a particular period, whether it is more common in one geographic area than in another, and whether certain types of people— based on factors such as gender, race, and socioeconomic status— are at greater risk than other types for the development of the disorder.

3.1.2    Health administrators often use such information to make decisions about the allocation of resources for professional training programs, treatment facilities, and research projects.

3.2          One important dataset regarding this question comes from a large-scale study known as the National Comorbidity Survey Replication (NCS-R) conducted between 2001 and 2003 (Kessler et al., 2005; Kessler, Merikangas, & Wang, 2007).

3.2.1    Members of this research team interviewed a nationally representative sample of approximately 9,000 people living in the continental United States.

3.2.2    Questions were asked pertaining to several (but not all) of the major disorders listed in DSM-IV (American Psychiatric Association, 1994).

3.2.3    The NCS-R found that 46% of the people they interviewed received at least one lifetime diagnosis (meaning that they met the criteria for one of the disorders assessed at some point during their lives), with first onset of symptoms usually occurring during childhood or adolescence.

3.3          The most prevalent specific types of disorder were major depression (17%) and alcohol abuse (13%). Various kinds of anxiety disorders were also relatively common. Substantially lower lifetime prevalence rates were found for obsessive– compulsive disorder and bipolar disorder, which each affect approximately 2% of the population.

3.4          Epidemiological studies such as the NCS-R have consistently found gender differences for many types of mental disorder: Major depression, anxiety disorders, and eating disorders are more common among women; alcoholism and antisocial personality disorders are more common among men.

3.5          Epidemiologists also measure the extent of mental disorders’ impact on people’s lives. In a study sponsored by the World Health Organization (WHO), López et al. (2006) compared the impact of more than 100 forms of disease and injury throughout the world.

3.5.1    Although mental disorders are responsible for only 1% of all deaths, they produce 47% of all disability in economically developed countries, such as the United States, and 28% of all disability worldwide.

3.5.2    When their impact is measured by combining indices of mortality and disability, mental disorders are the second leading When their impact is measured by combining indices of mortality and disability, mental disorders are the second leading source of disease burden in developed countries.

3.5.3    Investigators in the WHO study predict that relative to other types of health problems, the burden of mental disorders will increase by the year 2020.

3.5.4    These surprising results indicate strongly that mental disorders are one of the world’s greatest health challenges.

4.         Culture and Psychopathology

4.1          Epidemiological studies comparing the frequency of mental disorders in different cultures suggest that some disorders, such as schizophrenia, show important consistencies in cross-cultural comparisons. They are found in virtually every culture that social scientists have studied.

4.2          Other disorders, such as bulimia nervosa, are more specifically associated with cultural factors, as revealed by comparisons of prevalence in different parts of the world and changes in prevalence over generations.

4.2.1    Almost 90% of patients with bulimia are women. Within the United States, the incidence of bulimia is much higher among university women than among working women, and it is more common among younger women than among older women.

4.2.2    The prevalence of bulimia is much higher in Western nations than in other parts of the world. Furthermore, the number of cases increased dramatically during the latter part of the 20th century (Keel & Klump, 2003).

4.3          Several general conclusions can be drawn from cross-cultural studies of psychopathology (Draguns & Tanaka-Matsumi, 2003), including the following points: All mental disorders are shaped, to some extent, by cultural factors.

4.3.1    No mental disorders are entirely due to cultural or social factors.

4.3.2    Psychotic disorders are less influenced by culture than are nonpsychotic disorders.

4.3.3    The symptoms of certain disorders are more likely to vary across cultures than are the disorders themselves.

4.4          The accuracy and utility of a clinical diagnosis depend on more than a simple count of the symptoms that appear to be present.

4.4.1    They also hinge on the clinician’s ability to consider the cultural context in which the problem appeared.

4.4.2    This is a particularly challenging task when the clinician and the person with the problem do not share the same cultural background.

4.5          Clinicians can also become sensitized to the importance of cultural issues by considering cultural concepts of distress, patterns of erratic or unusual thinking and behavior that have been identified in diverse societies around the world and do not fit easily into the other diagnostic categories.

4.5.1    A list of these syndromes is included in the appendix of DSM-5.

4.5.2    They have also been called “culture-bound syndromes” because they are considered to be unique to particular societies, particularly in non-Western or developing countries.

4.6          The DSM’s glossary on cultural concepts of distress has been praised as a significant advance toward integrating cultural considerations into the classification system (López & Guarnaccia, 2000).

4.6.1    It has also been criticized for its ambiguity.

4.6.2    The most difficult conceptual issue involves the boundary between culture-bound syndromes and categories found elsewhere in the diagnostic manual.

4.6.3    Some critics have argued that they should be fully integrated, without trying to establish a distinction (Hughes, 1998).

4.6.4    Others have noted that if culturally unique disorders must be listed separately from other, “mainstream” conditions, then certain disorders now listed in the main body of the manual— especially eating disorders, such as bulimia— should actually be listed as culture-bound syndromes.

4.7          Though it is imperfect, the DSM-5’ s list of cultural concepts of distress raises important conceptual and clinical implications.

4.7.1    The fact that some diagnostic categories that are familiar to most mental health professionals working in Western or developed countries are unique to their cultural environment helps to challenge the frequently held assumption that culture shapes only conditions that appear to be exotic in faraway lands.

4.7.2    At a more direct, clinical level the glossary serves to make clinicians more aware of the extent to which their own views of what is normal and abnormal have been shaped by the values and experiences of their own culture (Mezzich, Berganza, & Ruiperez, 2001).

5.         Classification of Psychopathology

5.1          Despite many tribulations and debates associated with the classification of psychopathology, this process has served several purposes.

5.1.1    A classification system helps clinicians to (1) identify (as accurately and comprehensively as possible) their clients’ problems, and (2) formulate a plan of intervention that is most likely to be effective for these difficulties.

5.1.2    A classification system also serves an important role in the search for new knowledge. The classification of a specific set of symptoms has often laid the foundation for research that eventually identified a cure or a way of preventing the disorder.

5.2          Currently, two diagnostic systems for mental disorders are widely recognized.

5.2.1    We have already mentioned DSM-5, which is published by the American Psychiatric Association.

5.2.2    The other— the ICD— is published by the World Health Organization.

5.2.3    Both systems were first developed shortly after World War II and have been revised several times. The World Health Organization’s manual is in its 10th edition and is therefore known as ICD-10.

5.2.4    Deliberate attempts are made to coordinate the production of the DSM and ICD manuals. Most of the categories listed in the manuals are identical, and the criteria for specific disorders are usually similar.

5.2.5    More than 200 specific diagnostic categories are described in the current edition of DSM.

5.2.6    Interestingly, under both systems (DSM and ICD), a person can be assigned more than one diagnosis if he or she meets criteria for more than one disorder.

5.3          Most of the available data regarding the etiology and treatment of mental disorders are based on criteria set forth in DSM-IV.

5.3.1    Changes in DSM-5 are intended to address perceived shortcomings in these diagnostic criteria. Nevertheless, until empirical studies have been done using the DSM-5 criterion sets, we will not have a solid evidence base from which to draw conclusions about presenting problems, possible etiological mechanisms underlying them, or treatments designed to target them.

5.3.2    Until that dataset is established, our work as researchers and clinicians will have to continue to refer to DSM-IV. Thus, in the chapters to come, you will see authors referring to both editions of the DSM.

6.         Evaluation of psychiatric classification

6.1          The most important issue in the evaluation of a diagnostic category is whether it is useful (Kendell & Jablensky, 2003).

6.1.1    By knowing that a person fits into a particular group or class, do we learn anything meaningful about that person?

6.1.2    For example, is the person who fits the diagnostic criteria for schizophrenia likely to improve when he or she is given antipsychotic medication?

6.1.3    Or is that person likely to have a less satisfactory level of social adjustment in 5 years than a person who meets diagnostic criteria for bipolar mood disorder?

6.1.4    Does the diagnosis tell us anything about the factors or circumstances that might have contributed to the onset of this problem?

6.1.5    These questions are concerned with the validity of the diagnostic category.

6.2          Etiological validity” is concerned with factors that contribute to the onset of the disorder.

6.2.1    These are things that have happened in the past.

6.2.2    Was the disorder regularly triggered by a specific set of events or circumstances?

6.2.3    Did it run in families?

6.2.4    The ultimate question with regard to etiological validity is whether there are any specific causal factors that are regularly, and perhaps uniquely, associated with this disorder.

6.2.5    If we know that a person exhibits the symptoms of the disorder, do we in turn learn anything about the circumstances that originally led to the onset of the problem?

6.3          “Concurrent validity” is concerned with the present time and with correlations between the disorder and other symptoms, circumstances, and test procedures.

6.3.1    Is the disorder currently associated with any other types of behavior, such as performance on psychological tests?

6.3.2    Do precise measures of biological variables, such as brain structure and function, distinguish reliably between people who have the disorder and those who do not?

6.3.3    Clinical studies aimed at developing a more precise description of a disorder also fall into this type of validity.

6.4          “Predictive validity” is concerned with the future and with the stability of the problem over time.

6.4.1    Will it be persistent?

6.4.2    If it is short lived, how long will an episode last?

6.4.3    Will the disorder have a predictable outcome?

6.4.4    Do people with this problem typically improve if they are given a specific type of medication or a particular form of psychotherapy?

6.5          The overall utility of a diagnostic category depends on the body of evidence that accumulates as scientists seek answers to questions raised by these multiple forms of validity (“ reliability,” or consistency of the diagnostic decisions, is also crucial, as it precedes validity).

6.5.1    More research needs to confirm and enhance the validity (thus, the utility) of our current diagnostic categories.

6.5.2    Such research should be conducted in parallel with other efforts (conceptual and empirical) to address serious criticism directed toward the diagnostic manual.

7.         Limitations and possible improvement to DSM

7.1          One fundamental question that applies to every disorder involves the boundary between normal and abnormal behavior.

7.1.1    The definitions included in the DSM-5 are often vague with regard to this threshold (Widiger & Clark, 2000).

7.1.2    The manual is based on a categorical approach to classification, but most of the symptoms that define the disorders are actually dimensional in nature.

7.1.3    Depressed mood, for example, can vary continuously, from the complete absence of depression to moderate levels of depression, on up to severe levels of depression.

7.1.4    The same issue applies to symptoms of anxiety disorders, eating disorders, and substance use disorders. These are all continuously distributed phenomena, and there is not a bright line that divides people with problems from those who do not have problems.

7.2          The absence of a specific definition of social impairment is another conceptual and clinical issue that has plagued the current diagnostic manual.

7.2.1    Most disorders in DSM include the requirement that a particular set of symptoms causes “clinically significant distress or impairment in social or occupational functioning.”

7.2.2    However, no specific measurement procedures are provided to make this determination.

7.2.3    There is an important need for more specific definitions of these concepts, and better measurement tools are needed for their assessment.

7.3          In addition, criticisms of the current classification system have emphasized broad conceptual issues.

7.3.1    Some clinicians and investigators have argued that the syndromes defined in the DSM do not represent the most useful ways to think about psychological problems, in terms of either planning current treatments or designing programs of research.

7.3.2    For example, it might be better to focus on more homogeneous dimensions of dysfunction, such as anxiety or angry hostility, rather than on syndromes (groups of symptoms) (Smith & Combs, 2010).

7.3.3    In our current state of uncertainty, diversity of opinion should be encouraged, particularly if it is grounded in cautious skepticism and supported by rigorous scientific inquiry.

7.4          From an empirical and clinical point of view, the DSM is hampered by a number of problems that suggest it does not classify clinical problems into syndromes in the simplest and most beneficial way (Helzer, Kraemer, & Krueger, 2006).

7.4.1    One of the thorniest issues involves “comorbidity,” which is defined as the simultaneous appearance of two or more disorders in the same person.

7.4.2    Comorbidity rates are very high for mental disorders as defined in the DSM system (Eaton, South, & Krueger, 2010).

7.4.3    For example, in the National Comorbidity Survey, among those people who qualified for at least one diagnosis at some point during their lifetime, 56% met the criteria for two or more disorders.

7.5          Major clinical problems associated with comorbidity can arise when a person with a mixed pattern of symptoms, usually of a severe nature, simultaneously meets the criteria for more than one disorder.

7.6          The comorbidity issue is related to another limitation of the DSM: the failure to make better use of information regarding the course of mental disorders over time.

7.6.1    Our knowledge of mental disorders would be greatly enriched if greater emphasis were placed on questions regarding lifespan development (Buka & Gilman, 2002; Oltmanns & Balsis, 2011).

7.7          These issues are being considered by the experts who develop each new edition of the DSM and ICD.

7.7.1    Of course, all of them will not be solved immediately.

7.7.2    Attempts to provide solutions to these problems and limitations will ensure that the classification system will continue to be revised.

7.7.3    As before, these changes will be driven by the interaction of clinical experience and empirical evidence.

7.7.4    Students, clinicians, and research investigators should all remain skeptical when using this classification system and its successors.

7.7.5    At the same time, the complexity of psychopathology and its treatment should encourage all scholars and providers in the field of mental health to pay close attention to our current knowledge, and to derive from it new and creative ways to think about and intervene with mental disorders.


 
 
 
 
이전글   다음글이 없습니다.
다음글   이전글이 없습니다.