Clinical approach

01. Introduction Abnormal psychology is a branch of psychology that deals with psychopathology and abnormal behavior. The term covers a broad range of disorders, from depression to obsession-compulsion to sexual deviation and many more. Counselors, clinical psychologists and psychotherapists often work directly in this field. likewise, Abnormal psychology is the branch of psychology that studies unusual patterns of behavior, emotion and thought, which may or may not be understood as precipitating a mental disorder. Therefore, to study the abnormality of human, abnormal psychology develops its own approaches which involve of wide range of subject matter; and there is diversity of approaches as follows: Approaches • Somatogenic - abnormality is seen as a result of biological disorders in the brain. However, this approach has led to the development of radical biological treatments e.g. lobotomy. • Psychogenic - abnormality is caused by psychological problems. Psychoanalytic (Freud), cathartic, hypnotic and humanistic psychology (Carl Rogers, Abraham Maslow) treatments were all derived from this paradigm. This approach has, as well, led to some esoteric treatments: Franz Mesmer used to place his patients in a darkened room with music playing, then enter it wearing a flamboyant outfit and poke the 'infected' body areas with a stick. But, in some books it signifies other approaches: the biomedical approach, psychodynamic approach, behavioral model, the cognitive model, humanistic approach (Rosenhan & Seligman, 1984).instead there are other approaches thus: Naturalistic approach, Humanistic approach, environmental approach (class note by Dr.sulie). The biomedical as well as somatogenic, two of the pre-mentioned approaches are referring to clinical perspective; the approach tends to provide the treatment. So, it is bond to understand the particular approach. 02. Clinical approach Clinical approach, even the technical term differs, hold the real context similarly to clinical psychology which seeks to assess, understand and treat psychological conditions in clinical practice. So, from now I would like to use word “clinical psychology” for purpose of avoiding confusion on the subject. So, The theoretical field known as "abnormal psychology" may form a backdrop to such work, but clinical psychologists are nowadays unlikely to use the term "abnormal" in reference to their practice. Psychopathology is a similar term to abnormal psychology but has more of an implication of an underlying pathology (disease process), and as such is a term more commonly used in the medical specialty known as psychiatry. Looking at the definition of the term, it would make more understandable of the concept; that is, what clinical approach focuses to? “Clinical, Having to do with the examination and treatment of patients. 2. Applicable to patients. A laboratory test may be of clinical value (of use to patients). The term comes through the French "clinique" from the Greek "kline" (a couch or bed). Clinical medicine was (and is) practiced at the bedside.” Clinical Psychology, branch of psychology devoted to the study, diagnosis, and treatment of people with mental illnesses and other psychological disorders. In addition, many clinical psychologists or clinicians study the normal human personality and the ways in which individuals differ from one another in their patterns of thinking, feeling, behaving, and relating to others. Still other clinical psychologists administer and interpret various kinds of psychological tests. These include personality tests, intelligence tests, and aptitude tests. These tests are routinely given in schools and businesses to assess an individual’s skills, interests, and emotional functioning. Clinical psychologists also use psychological tests to diagnose possible mental disorders. By identifying early signs of distress or mental disturbance, clinical psychologists work to promote mental health and to prevent mental disorders. Clinical psychologists work in a wide variety of settings. These include hospitals, mental health clinics, schools, universities, governmental agencies, prisons, and military bases. Many clinical psychologists also work in private practice. Clinical psychology overlaps with other fields that deal with mental health and mental illness. Counseling psychology focuses primarily on treating people with less severe adjustment problems and everyday difficulties related to work, family, school, or marriage. Psychiatry is the branch of medicine concerned with mental disorders. The work of psychiatrists and clinical psychologists is very similar, except that psychiatrists are physicians who can prescribe medication. The work of clinical psychologists falls into three main categories: (1) testing and diagnosis, (2) treatment of psychological disorders, and (3) research. Many clinical psychologists combine several of these activities. For example, those who work in academic settings often combine teaching, research, and counseling. Likewise, to diagnosis the mental illness or disorders according to clinical approach it has to follow the main steps of it. This following figure may make you to understand the main steps of clinical approach to diagnose and provide treatment to mental disorders. As it has been mentioned before, the main purpose of clinical psychology is to study, diagnose and provide treatment to mental illness. Who diagnoses? Is the question to be raised, the answer is the clinician works in fields of clinical psychology. The following illustrates obviously how clinical approach goes through its main steps in order to treat the patients. Therefore, in simple sense to do clinical work in accordance with above circumstance, the clinical psychologists have to know triple knowledge: I. Psychopathological knowledge II. Clinical knowledge III. Therapeutical knowledge So, the main steps of clinical approach include: diagnosis, clinical investigation, clinical interview, semiology, etiology, psychopathology, nosology, and therapy. 03. FIELD OF SINGULARITY 3.1.Clinical investigation Clinical Investigation A systematic study designed to evaluate a product (drug, device, or biologic) using human subjects, in the treatment, prevention, or diagnosis of a disease or condition, as determined by the product's benefits relative to its risks. Clinical investigation or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient. Together with the medical history, the physical examination aids in determining the correct diagnosis and devising the treatment plan. This data then becomes part of the medical record. With the clues obtained during the history and physical examination the healthcare provider can now formulate a differential diagnosis, a list of potential causes of the symptoms. Specific diagnostic tests (or occasionally empirical therapy) generally confirm the cause, or shed light on other, previously overlooked causes. A complete medical examination includes evaluation of general patient appearance and specific organ systems. It is recorded in the medical record in a standard layout which facilitates others later reading the notes. In practice the vital signs of temperature examination, pulse and blood pressure are usually measured first. So, to do real clinical investigation, form standpoint of clinical approach it is needed a specific clinical Interview to diagnose the diseases. 3.2 Clinical interview Diagnostic Classification Diagnostic Criteria • Diagnostic and Statistical Manual of Mental Disorders (DSM) • ICD-10 Chapter V: Mental and behavioural disorders • Chinese Classification of Mental Disorders • Research Diagnostic Criteria (RDC) • Feighner Criteria Interview instruments using the above criteria • Structured Clinical Interview for DSM-IV (SCID) • Schedule for Affective Disorders and Schizophrenia (SADS) • Mini-international neuropsychiatric interview (MINI) • World Health Organisation Composite International Diagnostic Interview (CIDI) • Schedules for Clinical Assessment in Neuropsychiatry (SCAN) The clinical interview, the core of most clinical work, is used by psychologist, psychiatrists, and other mental health professionals. The interview gathers information on current and past behavior, attitudes, and emotions as well as a detailed history of the individual’s life in general and of the presenting problem. Clinicians determine when the specific problem first started and identify other events (e.g. life stress, trauma, physical illness) that might have occurred about the same time. In addition, most clinicians gather at least some information on the patient’s current and past interpersonal and social history, including family make up (e.g. marital status, number of children, college student currently living with parents), and on the individual’s upbringing. Information on sexual development, religious attitudes (currently and past), relevant cultural concerns, and educational history are also routinely collected. In short senses the interview supposed to gather the life chart of patient. To organize the information obtained during an interview, many clinicians use a mental status exam. (Barlon & Durand, 2005) 3.2.1. Mental status examination The mental status examination is a core skill of psychiatrists, psychologists, physician assistants, nurse practitioners and other qualified mental health personnel. It is a key part of the initial psychiatric assessment in an out-patient or psychiatric hospital setting. It is a systematic collection of data based on observation of the patient's behavior while the patient is in the clinician's view during the interview. The purpose is to obtain evidence of symptoms and signs of mental disorders, including danger to self and others, that are present at the time of the interview. Further, information on the patient's insight, judgment, and capacity for abstract reasoning is used to inform decisions about treatment strategy and the choice of an appropriate treatment setting. It is carried out in the manner of an informal enquiry, using a combination of open and closed questions, supplemented by structured tests to assess cognition. The MSE can also be considered part of the comprehensive physical examination performed by physicians and nurses although it may be performed in a cursory and abbreviated way in non-mental-health settings. Information is usually recorded as free-form text using the standard headings, but brief MSE checklists are available for use in emergency situations, for example by paramedics or emergency department staff. The information obtained in the MSE is used, together with the biographical and social information of the psychiatric history, to generate a diagnosis, a psychiatric formulation and a treatment plan. 3.2.2. Domains of MSE Appearance: Clinicians assess the physical aspects such as the appearance of a patient, including apparent age, height, weight, and manner of dress and grooming. Colorful or bizarre clothing might suggest mania, while unkempt, dirty clothes might suggest schizophrenia or depression. If the patient appears much older than his or her chronological age this can suggest chronic poor self-care or ill-health. Clothing and accessories of a particular subculture, body modifications, or clothing not typical of the patient's gender, might give clues to personality. Observations of physical appearance might include the physical features of alcoholism or drug abuse, such as signs of malnutrition, nicotine stains, dental erosion, a rash around the mouth from inhalant abuse, or needle track marks from intravenous drug abuse. Observations can also include any odor which might suggest poor personal hygiene due to extreme self-neglect, or alcohol intoxication. Attitude: Attitude, also known as rapport, refers to the patient's approach to the interview process and the interaction with the examiner. The patient's attitude may be described for example as cooperative, uncooperative, hostile, guarded, suspicious or regressed. The most subjective element of the mental status examination, attitude depends on the interview situation, the skill and behaviour of the clinician, and the pre-existing relationship between the clinician and the patient. However, attitude is important for the clinician's evaluation of the quality of information obtained during the assessment. Behavior: Abnormalities of behavior, also called abnormalities of activity, include observations of specific abnormal movements, as well as more general observations of the patient's level of activity and arousal, and observations of the patient's eye contact and gait. Abnormal movements, for example choreiform, athetoid or choreoathetoid movements may indicate a neurological disorder. A tremor or dystonia may indicate a neurological condition or the side effects of antipsychotic medication. The patient may have tics (involuntary but quasi-purposeful movements or vocalizations) which may be a symptom of Tourette's syndrome. There are a range of abnormalities of movement which are typical of catatonia, such as echopraxia, catalepsy, waxy flexibility and paratonia (or gegenhalten). Stereotypies (repetitive purposeless movements such a rocking or head banging) or mannerisms (repetitive quasi-purposeful abnormal movements such as a gesture or abnormal gait) may be a feature of chronic schizophrenia or autism. More global behavioural abnormalities may be noted, such as an increase in arousal and movement (described as psychomotor agitation or hyperactivity) which might reflect mania or delirium. An inability to sit still might represent akathisia, a side effect of antipsychotic medication. Similarly a global decrease in arousal and movement (described as psychomotor retardation, akinesia or stupor) might indicate depression or a medical condition such as Parkinson's disease, dementia or delirium. The examiner would also comment on eye movements (repeatedly glancing to one side can suggest that the patient is experiencing hallucinations), and the quality of eye contact (which can provide clues to the patient's emotional state). Lack of eye contact may suggest autism. Mood and affect: The distinction between mood and affect in the MSE is subject to some disagreement, for example Trzepacz and Baker describe affect as "the external and dynamic manifestations of a person's internal emotional state" and mood as "a person's predominant internal state at any one time", whereas Sims refers to affect as "differentiated specific feelings" and mood as "a more prolonged state or disposition". This article will use the Trzepacz and Baker definitions, with mood regarded as a current subjective state as described by the patient, and affect as the examiner's inferences of the quality of the patient's emotional state based on objective observation. Mood is described using the patient's own words, and can also be described in summary terms such as neutral, euthymic, dysphoric, euphoric, angry, anxious or apathetic. Alexithymic individuals may be unable to describe their subjective mood state. An individual who is unable to experience any pleasure may be suffering from anhedonia. Affect is described by labelling the apparent emotion conveyed by the person's nonverbal behavior (anxious, sad etc.), and also by using the parameters of appropriateness, intensity, range, reactivity and mobility. Affect may be described as appropriate or inappropriate to the current situation, and as congruent or incongruent with their thought content. For example, someone who shows a bland affect when describing a very distressing experience would be described as showing incongruent affect, which might suggest schizophrenia. The intensity of the affect may be described as normal, blunted, exaggerated, flat, heightened or overly dramatic. A flat or blunted affect is associated with schizophrenia, depression or post-traumatic stress disorder; heightened affect might suggest mania, and an overly dramatic or exaggerated affect might suggest certain personality disorders. Mobility refers to the extent to which affect changes during the interview: the affect may be described as mobile, constricted, fixed, immobile or labile. The person may show a full range of affect, in other words a wide range of emotional expression during the assessment, or may be described as having restricted affect. The affect may also be described as reactive, in other words changing flexibly and appropriately with the flow of conversation, or as unreactive. A bland lack of concern for one's disability may be described as showing belle indifférence, a feature of hysteria in older texts. Speech: The patient's speech is assessed by observing the patient's spontaneous speech, and also by using structured tests of specific language functions. This heading is concerned with the production of speech rather than the content of speech, which is addressed under thought form and thought content (see below). When observing the patient's spontaneous speech, the interviewer will note and comment on paralinguistic features such as the loudness, rhythm, prosody, intonation, pitch, phonation, articulation, quantity, rate, spontaneity and latency of speech. A structured assessment of speech includes an assessment of expressive language by asking the patient to name objects, repeat short sentences, or produce as many words as possible from a certain category in a set time. Simple language tests form part of the mini-mental state examination. In practice, the structured assessment of receptive and expressive language is often reported under Cognition. Language assessment will allow the recognition of medical conditions presenting with aphonia or dysarthria, neurological conditions such as stroke or dementia presenting with aphasia, and specific language disorders such as stuttering, cluttering or mutism. People with autism or Asperger syndrome may have abnormalities in paralinguistic and pragmatic aspects of their speech. Echolalia (repetition of another person's words) and palilalia (repetition of the subject's own words) can be heard with patients with autism, schizophrenia or Alzheimer's disease. A person with schizophrenia might use neologisms, which are made-up words which have a specific meaning to the person using them. Speech assessment also contributes to assessment of mood, for example people with mania or anxiety may have rapid, loud and pressured speech; on the other hand depressed patients will typically have a prolonged speech latency and speak in a slow, quiet and hesitant manner. Thought process: Thought process in the MSE refers to the quantity, tempo (rate of flow) and form (or logical coherence) of thought. Thought process cannot be directly observed but can only be described by the patient, or inferred from a patient's speech. Regarding the tempo of thought, some people may experience flight of ideas, when their thoughts are so rapid that their speech seems incoherent, although a careful observer can discern a chain of poetic associations in the patient's speech. Alternatively an individual may be described as having retarded or inhibited thinking, in which thoughts seem to progress slowly with few associations. Poverty of thought is a global reduction in the quantity of thought and thought perseveration refers to a pattern where a person keeps returning to the same limited set of ideas. A pattern of interruption or disorganization of thought processes is broadly referred to as formal thought disorder, and might be described more specifically as thought blocking, fusion, loosening of associations, tangential thinking, derailment of thought, or knight's move thinking. Thought may be described as circumstantial when a patient includes a great deal of irrelevant detail and makes frequent diversions, but remains focused on the broad topic. Flight of ideas is typical of mania. Conversely, patients with depression may have retarded or inhibited thinking. Poverty of thought is one of the negative symptoms of schizophrenia, and might also be a feature of severe depression or dementia. A patient with dementia might also experience thought perseveration. Formal thought disorder is a common feature of schizophrenia. Circumstantial thinking might be observed in anxiety disorders or certain kinds of personality disorders. Thought content: A description of thought content would describe a patient's delusions, overvalued ideas, obsessions, phobias and preoccupations. Abnormalities of thought content are established by exploring individual's thoughts in an open-ended conversational manner with regard to their intensity, salience, the emotions associated with the thoughts, the extent to which the thoughts are experienced as one's own and under one's control, and the degree of belief or conviction associated with the thoughts. A delusion can be defined as "a false, unshakeable idea or belief which is out of keeping with the patient's educational, cultural and social background ... held with extraordinary conviction and subjective certainty", and is a core feature of psychotic disorders. The patient's delusions may be described as persecutory or paranoid delusions, delusions of reference, grandiose delusions, erotomanic delusions, delusional jealousy or delusional misidentification. Delusions may be described as mood-congruent (the delusional content in keeping with the mood), typical of manic or depressive psychoses, or mood-incongruent (delusional content not in keeping with the mood) which are more typical of schizophrenia. Delusions of control, or passivity experiences (in which the individual has the experience of the mind or body being under the influence or control of some kind of external force or agency), are typical of schizophrenia. Examples of this include experiences of thought withdrawal, thought insertion, thought broadcasting, and somatic passivity. Schneiderian first rank symptoms are a set of delusions and hallucinations which have been said to be highly suggestive of a diagnosis of schizophrenia. Delusions of guilt, delusions of poverty, and nihilistic delusions (belief that one has no mind or is already dead) are typical of depressive psychoses. An overvalued idea is a false belief that is held with conviction but not with delusional intensity. Hypochondriasis is an overvalued idea that one is suffering from an illness, dysmorphophobia is an overvalued idea that a part of one's body is abnormal, and people with anorexia nervosa may have an overvalued idea of being overweight. An obsession is an "undesired, unpleasant, intrusive thought that cannot be suppressed through the patient's volition", but unlike passivity experiences described above, they are not experienced as imposed from outside the patient's mind. Obsessions are typically intrusive thoughts of violence, injury, dirt or sex, or obsessive ruminations on intellectual themes. A person can also describe obsessional doubt, with intrusive worries about whether they have made the wrong decision, or forgotten to do something, for example turn off the gas or lock the house. In obsessive-compulsive disorder, the individual experiences obsessions with or without compulsions (a sense of having to carry out certain ritualized and senseless actions against their wishes). A phobia is "a dread of an object or situation that does not in reality pose any threat",and is distinct from a delusion in that the patient is aware that the fear is irrational. A phobia is usually highly specific to certain situations and will usually be reported by the patient rather than being observed by the clinician in the assessment interview. Preoccupations are thoughts which are not fixed, false or intrusive, but have an undue prominence in the person's mind. Clinically significant preoccupations would include thoughts of suicide, homicidal thoughts, suspicious or fearful beliefs associated with certain personality disorders, depressive beliefs (for example that one is unloved or a failure), or the cognitive distortions of anxiety and depression. The MSE contributes to clinical risk assessment by including a thorough exploration of any suicidal or hostile thought content. Assessment of suicide risk includes detailed questioning about the nature of the person's suicidal thoughts, belief about death, reasons for living, and whether the person has made any specific plans to end his or her life. Perceptions: A perception in this context is any sensory experience, and the three broad types of perceptual disturbance are hallucinations, pseudohallucinations and illusions. A hallucination is defined as a sensory perception in the absence of any external stimulus, and is experienced in external or objective space (i.e. experienced by the subject as real). An illusion is defined as a false sensory perception in the presence of an external stimulus, in other words a distortion of a sensory experience, and may be recognized as such by the subject. A pseudohallucination is experienced in internal or subjective space (for example as "voices in my head") and is regarded as akin to fantasy. Other sensory abnormalities include a distortion of the patient's sense of time, for example déjà vu, or a distortion of the sense of self (depersonalization) or sense of reality (derealization). Hallucinations can occur in any of the five senses, although auditory and visual hallucinations are encountered more frequently than tactile (touch), olfactory (smell) or gustatory (taste) hallucinations. Auditory hallucinations are typical of psychoses: third-person hallucinations (i.e. voices talking about the patient) and hearing one's thoughts spoken aloud (gedankenlautwerden or écho de la pensée) are among the Schneiderian first rank symptoms indicative of schizophrenia, whereas second-person hallucinations (voices talking to the patient) threatening or insulting or telling them to commit suicide, may be a feature of psychotic depression or schizophrenia. Visual hallucinations are generally suggestive of organic conditions such as epilepsy, drug intoxication or drug withdrawal. Many of the visual effects of hallucinogenic drugs are more correctly described as visual illusions or visual pseudohallucinations, as they are distortions of sensory experiences, and are not experienced as existing in objective reality. Auditory pseudohallucinations are suggestive of dissociative disorders. Deja vu, derealization and depersonalization are associated with temporal lobe epilepsy and dissociative disorders. Cognition: This section of the MSE covers the patient's level of alertness, orientation, attention, memory, visuospatial functioning, language functions and executive functions. Unlike other sections of the MSE, use is made of structured tests in addition to unstructured observation. Alertness is a global observation of level of consciousness i.e. awareness of, and responsiveness to the environment, and this might be described as alert, clouded, drowsy, or stuporose. Orientation is assessed by asking the patient where he or she is (for example what building, town and state) and what time it is (time, day, date). Attention and concentration are assessed by the serial sevens test (or alternatively by spelling a five-letter word backwards), and by testing digit span. Memory is assessed in terms of immediate registration (repeating a set of words), short-term memory (recalling the set of words after an interval, or recalling a short paragraph), and long-term memory (recollection of well known historical or geographical facts). Visuospatial functioning can be assessed by the ability to copy a diagram, draw a clock face, or draw a map of the consulting room. Language is assessed through the ability to name objects, repeat phrases, and by observing the individual's spontaneous speech and response to instructions. Executive functioning can be screened for by asking the "similarities" questions ("what do x and y have in common?") and by means of a verbal fluency task (e.g. "list as many words as you can starting with the letter F, in one minute"). The mini-mental state examination is a simple structured cognitive assessment which is in widespread use as a component of the MSE. Mild impairment of attention and concentration may occur in any mental illness where people are anxious and distractible (including psychotic states), but more extensive cognitive abnormalities are likely to indicate a gross disturbance of brain functioning such as delirium, dementia or intoxication. Specific language abnormalities may be associated with pathology in Wernicke's area or Broca's area of the brain. In Korsakoff's syndrome there is dramatic memory impairment with relative preservation of other cognitive functions. Visuospatial or constructional abnormalities here may be associated with parietal lobe pathology, and abnormalities in executive functioning tests may indicate frontal lobe pathology. This kind of brief cognitive testing is regarded as a screening process only, and any abnormalities are more carefully assessed using formal neuropsychological testing. The MSE may include a brief neuropsychiatric examination in some situations. Frontal lobe pathology is suggested if the person cannot repetitively execute a motor sequence (e.g. "paper-scissors-stone"). The posterior columns are assessed by the person's ability to feel the vibrations of a tuning fork on the wrists and ankles. The parietal lobe can be assessed by the person's ability to identify objects by touch alone and with eyes closed. A cerebellar disorder may be present if the person cannot stand with arms extended, feet touching and eyes closed without swaying (Romberg's sign); if there is a tremor when the person reaches for an object; or if he or she is unable to touch a fixed point, close the eyes and touch the same point again. Pathology in the basal ganglia may be indicated by rigidity and resistance to movement of the limbs, and by the presence of characteristic involuntary movements. A lesion in the posterior fossa can be detected by asking the patient to roll his or her eyes upwards (Perinaud's sign). Focal neurological signs such as these might reflect the effects of some prescribed psychiatric medications, chronic drug or alcohol use, head injuries, tumors or other brain disorders. Insight: The person's understanding of his or her mental illness is evaluated by exploring his or her explanatory account of the problem, and understanding of the treatment options. In this context, insight can be said to have three components: recognition that one has a mental illness, compliance with treatment, and the ability to re-label unusual mental events (such as delusions and hallucinations) as pathological. As insight is on a continuum, the clinician should not describe it as simply present or absent, but should report the patient's explanatory account descriptively. Impaired insight is characteristic of psychosis and dementia, and is an important consideration in treatment planning and in assessing the capacity to consent to treatment. Judgment: Judgment refers to the patient's capacity to make sound, reasoned and responsible decisions. Traditionally, the MSE included the use of standard hypothetical questions such as "what would you do if you found a stamped, addressed envelope lying in the street?"; however contemporary practice is to inquire about how the patient has responded or would respond to real-life challenges and contingencies. Assessment would take into account the individual's executive system capacity in terms of impulsiveness, social cognition, self-awareness and planning ability. Impaired judgment is not specific to any diagnosis but may be a prominent feature of disorders affecting the frontal lobe of the brain. If a person's judgment is impaired due to mental illness, there might be implications for the person's safety or the safety of others. 3.2.3. Cultural considerations There are potential problems when the MSE is applied in a cross-cultural context, when the clinician and patient are from different cultural backgrounds. For example, the patient's culture might have different norms for appearance, behavior and display of emotions. Culturally normative spiritual and religious beliefs need to be distinguished from delusions and hallucinations - without understanding may seem similar though they have different roots. Cognitive assessment must also take the patient's language and educational background into account. Clinician's racial bias is another potential confounder. 3.3.Semiology Furthermore, we need semiology, the study of syndrome of illness, to diagnose syndromes: group of signs, of mental illnesses. The clinician uses three approaches to detect the syndromes of illness. I. Macroscopic II. Microscopic III. Dynamic(class note by Dr.sulie) Signs of mental illness in psychology are arranged into six categories: thinking, feeling, socializing, functioning, problems at home and poor self-care. These are symptoms of psychological disorders - and none by themselves are necessarily indicative of a mental illness, such as bipolar disorder or depression. However, two or three of these signs of mental illness may indicate some sort of psychological disorder. These signs of mental illness don't cover all the possible symptoms of psychological disorders. These signs are just the more common symptoms of depression, bipolar, schizophrenia or anxiety disorders. Problems Thinking and Cognition is a Sign of Mental Illness • Has trouble concentrating, is easily distracted. • Can't remember information. • Processes information slowly, is confused. • Has to work hard to solve problems. • Can't think abstractedly. False or odd perceptions: • Has a perceptual distortion: unusually bright colors or loud sounds. • Hears voices. • Feels old situations are strangely new. • Believes hidden messages are on TV, the radio, or public transportation. Problems with Feelings is a Sign of Mental Illness Depression symptoms: • Decreased appetite, weight loss. • Difficulty sleeping, interrupted sleep, sleeping too much. • Intrusive thoughts of death or suicide. • Unable to make decisions, concentrate, or follow through. • Feels worthless, hopeless, and helpless. • Guilty feelings over minor things. • Loss of interest and pleasure in most things. Bipolar mania symptoms: • Overly confident and grandiose about abilities, talents, wealth, appearance. • Excessive energy, needs little sleep. • Irritable much of the time. • Extreme mood swings with no provocation. • Speaks very fast, difficult to interrupt. • Is easily angered. • Excited, euphoric, overly confident, disruptive to others. Anxiety symptoms: • Overalert and on guard most of the time. • Feels anxious, afraid, and worried about everyday events. • Avoids normal activities (taking the bus, grocery shopping). • Uncomfortable around people. • Compelled to do ritualistic or repeated behaviors. • Has upsetting, intrusive memories or nightmares of past events. Problems with Socializing is a Sign of Mental Illness • Has few close friends. • Anxious and afraid around others. • Verbally or physically aggressive. • Has tumultuous relationships, from overly critical to worshipful. • Hard to get along with. • Can't read other people. Problems with Functioning is a Sign of Mental Illness • Gets fired or quits frequently. • Is easily angered or irritated by normal stresses and expectations. • Can't get along with others at work, school, or home. • Can't concentrate or work effectively. Problems at Home is a Sign of Mental Illness • Can't attend to others' needs. • Overwhelmed by chores or household expectations. • Can't keep up with housework. • Instigates arguments and fights with family, passively or actively. Poor Self-Care is a Sign of Mental Illness • Does not take care of appearance or cleanliness. • Doesn't eat enough, or overeats. • Doesn’t take care of yard or home. • Doesn't attend to finances, insurance bills, vehicle, etc. • Pays little or no attention to physical health. Specific mental illnesses such as depression, bipolar, schizophrenia and anxiety disorders don't necessarily have symptoms that fall into one category. In other words, someone struggling with bipolar disorder could have signs of mental illness from each category (though there are indications that are strictly bipolar, such as excessive energy and extreme mood swings). 3.4.Etiology Through understanding the semilogy, it leads us to know about the causes of mental illness, which is called Etiology. Etiology (alternatively aetiology, aitiology) is the study of causation, or origination. The word is derived from the Greek αἰτιολογία, aitiologia, "giving a reason for" (αἰτία, aitia, "cause"; and -λογία, -logia).The word is most commonly used in medical and philosophical theories, where it is used to refer to the study of why things occur, or even the reasons behind the way that things act, and is used in philosophy, physics, psychology, government, medicine, theology and biology in reference to the causes of various phenomena. But proof of causation in infectious diseases is limited to individual cases that provide experimental evidence of etiology. The following are globally accepted criteria on cause of mental illness. Genetics • Investigated through family studies, mainly of monozygotic (identical) and dizygotic (fraternal) twins, often in the context of adoption. • These studies allow calculation of a heritability coefficient. Biological causal factors Neurotransmitter [Imbalances of Neurotransmitters like (1) Norepinephrine (2) Dopamine (3) Serotonin and (4) GABA (Gamma aminobutryic acid)] and Hormonal imbalances in the brain • Genetic vulnerabilities • Constitutional liabilities [Physical Handicaps and temperament] • Brain dysfunction and neural plasticity • Physical deprivation or disruption [Deprivation of basic physiological needs] Socio-cultural factors • Effects of urban/rural dwelling, gender and minority status on state of mind. Systemic factors • Family systems • Negatively Expressed Emotion playing a part in schizophrenic relapse and anorexia nervosa. Biopsychosocial factors • Holistic causal model • Illness dependent on stress 'triggers'. 04. FIELDS OF GLOBALITY 4.1.Psychopathology Keep in mind along the diagnostic processes, the field of singularity is not enough, but it is needed the global knowledge to diagnose the mental illness which are to be treated through therapy. Many different professions may be involved in studying mental illness or distress. Most notably, psychiatrists and clinical psychologists are particularly interested in this area and may either be involved in clinical treatment of mental illness, or research into the origin, development and manifestations of such states, or often, both. More widely, many different specialties may be involved in the study of psychopathology. For example, a neuroscientist may focus on brain changes related to mental illness. Therefore, someone who is referred to as a psychopathologist, may be one of any number of professions who have specialized in studying this area. Psychiatrists in particular are interested in descriptive psychopathology, which has the aim of describing the symptoms and syndromes of mental illness. This is both for the diagnosis of individual patients (to see whether the patient's experience fits any pre-existing classification), or for the creation of diagnostic systems (such as the Diagnostic and Statistical Manual of Mental Disorders or International Statistical Classification of Diseases and Related Health Problems) which define exactly which signs and symptoms should make up a diagnosis, and how experiences and behaviours should be grouped in particular diagnoses (e.g. clinical depression, paraphrenia, paranoia, schizophrenia). Psychopathology should not be confused with psychopathy, which is a type of personality disorder. Before diagnosing a psychological disorder, Clinicans must study the themes, also known as abnormalities, within psychological disorders. The most prominent themes consist of: deviance, distress, dysfunction and danger. These themes are known as the 4 D's, which define abnormality. Psychopathology should not be confused with psychopathy, which is a type of personality disorder. Description of the 4 D's when defining abnormality: Deviance: this term describes the idea that specific thoughts, behaviours and emotions are considered deviate when they are unacceptable or not common in society. Clinicians must, however, remember that minority groups are not always deemed deviate just because they may not have anything in common with other groups. Therefore, we define an individual’s actions as deviate or abnormal when his or her behaviour is deemed unacceptable by the culture he or she belongs to. Distress: this term accounts for negative feelings by the individual with the disorder. He or she may feel deeply troubled and affected by their illness. Dysfunction: this term involves maladaptive behaviour that impairs the individuals ability to perform normal daily functions such as getting ready for work in the morning, or driving a car. Such maladaptive behaviours prevent the individual from living a normal, healthy lifestyle. However, we must remember that a person's behaviour, who is acting dysfunctional, is not always caused by a disorder. Dysfunctional behaviour may be voluntary, such as engaging in a hunger strike. Danger: this term involves dangerous or violent behaviour directed at the individual, or others in the environment. An example of dangerous behaviour that may suggest a psychological disorder is engaging in suicidal activity. In order for a clinician to determine whether someone has a psychological disorder or illness, all four D's must be present in combination with other factors 4.2.Nosology Nosology (from the Greek νόσος, nosos, "disease" + λόγος "logos") is a branch of medicine that deals with classification of diseases. A nosologist understands how the classification is underpinned. Nosologists consult nationally and internationally to resolve issues in the classification and are viewed as experts who can not only code, but design and deliver education, assist in the development of the classification and the rules for using it. Nosologists are usually expert in more than one classification, including morbidity, mortality and casemix. In some countries the term "nosologist" is used as a catch-all term for all levels. 4.2.1.Types of Classification Diseases may be classified by etiology (cause), pathogenesis (mechanism by which the disease is caused), or by symptom(s). Alternatively, diseases may be classified according to the organ system involved, though this is often complicated since many diseases affect more than one organ.A chief difficulty in nosology is that diseases often cannot be defined and classified clearly, especially when etiology or pathogenesis are unknown. Thus diagnostic terms often only reflect a symptom or set of symptoms (syndrome).The early nosological efforts grouped diseases by their symptoms, whereas modern systems (e.g. SNOMED) focus on grouping diseases by the anatomy and etiology involved. The classification of mental disorders, also known as psychiatric nosology or taxonomy, is a key aspect of psychiatry and other mental health professions and an important issue for consumers and providers of mental health services. There are currently two widely established systems for classifying mental disorders—Chapter V of the International Classification of Diseases (ICD-10) produced by the World Health Organization (WHO) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) produced by the American Psychiatric Association (APA). Both list categories of disorders thought to be distinct types, and have deliberately converged their codes in recent revisions so that the manuals are often broadly comparable, although significant differences remain. Other classification schemes may be in use more locally, for example the Chinese Classification of Mental Disorders. Other manuals have some limited use by those of alternative theoretical persuasions, such as the Psychodynamic Diagnostic Manual. The widely used DSM and ICD classifications employ operational definitions. There is a significant scientific debate about the relative validity of a "categorical" versus a "dimensional" system of classification, as well as significant controversy about the role of science and values in classification schemes and the professional, legal and social uses to which they are put. ICD-10 The International Classification of Diseases (ICD) is an international standard diagnostic classification for a wide variety of health conditions. Chapter V focuses on "mental and behavioural disorders" and consists of 10 main groups: • F0: Organic, including symptomatic, mental disorders • F1: Mental and behavioural disorders due to use of psychoactive substances • F2: Schizophrenia, schizotypal and delusional disorders • F3: Mood [affective] disorders • F4: Neurotic, stress-related and somatoform disorders • F5: Behavioural syndromes associated with physiological disturbances and physical factors • F6: Disorders of personality and behaviour in adult persons • F7: Mental retardation • F8: Disorders of psychological development • F9: Behavioural and emotional disorders with onset usually occurring in childhood and adolescence • In addition, a group of "unspecified mental disorders". Within each group there are more specific subcategories. The ICD includes personality disorders on the same domain as other mental disorders, unlike the DSM. The ICD-10 states that mental disorder is "not an exact term", although is generally used "...to imply the existence of a clinically recognisable set of symptoms or behaviours associated in most cases with distress and with interference with personal functions." DSM-IV The DSM-IV, produced by the American Psychiatric Association, characterizes mental disorder as "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual,...is associated with present distress...or disability...or with a significant increased risk of suffering" but that "...no definition adequately specifies precise boundaries for the concept of 'mental disorder'...different situations call for different definitions" (APA, 1994 and 2000). The DSM also states that "there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder." The DSM-IV-TR (Text Revision, 2000) consists of five axes (domains) on which disorder can be assessed. The five axes are: Axis I: Clinical Disorders (all mental disorders except Personality Disorders and Mental Retardation) Axis II: Personality Disorders and Mental Retardation Axis III: General Medical Conditions (must be connected to a Mental Disorder) Axis IV: Psychosocial and Environmental Problems (for example limited social support network) Axis V: Global Assessment of Functioning (Psychological, social and job-related functions are evaluated on a continuum between mental health and extreme mental disorder) The main categories of disorder in the DSM are: DSM GroupExamplesDisorders usually first diagnosed in infancy, childhood or adolescence. *Disorders such as ADHD and epilepsy have also been referred to as developmental disorders and developmental disabilities. Mental retardation, ADHD Delirium, dementia, and amnesia and other cognitive disorders Alzheimer's disease Mental disorders due to a general medical conditionAIDS-related psychosis Substance-related disorders Alcohol abuse Schizophrenia and other psychotic disorders Delusional disorder Mood disorders Major depressive disorder, Bipolar disorder Anxiety disorders General anxiety disorder Somatoform disorders Somatization disorder Factitious disorders Münchausen syndrome Dissociative disorders Dissociative identity disorder Sexual and gender identity disorders Dyspareunia, Gender identity disorder Eating disorders Anorexia nervosa, Bulimia nervosa Sleep disorders Insomnia Impulse control disorders not elsewhere classified Kleptomania Adjustment disorders Adjustment disorder Personality disorders Narcissistic personality disorder Other conditions that may be a focus of clinical attentionTardive dyskinesia, Child abuse 5. PSYCHOTHERAPHY The field of psychotherapy is very broad, therefore here it is hoped to mention that the psychotherapy is for treatments of mental illness. Psychotherapy may be performed by practitioners with a number of different qualifications, including psychiatry, clinical psychology, clinical social work, counseling psychology, mental health counseling, clinical or psychiatric social work, marriage and family therapy, rehabilitation counseling, music therapy, occupational therapy, psychiatric nursing, psychoanalysis and others. There are several main broad systems of psychotherapy: • Psychoanalytic - it was the first practice to be called psychotherapy. It encourages the verbalization of all the patient's thoughts, including free associations, fantasies, and dreams, from which the analyst formulates the nature of the unconscious conflicts which are causing the patient's symptoms and character problems. • Behavior Therapy/applied behavior analysis focuses on changing maladaptive patterns of behavior to improve emotional responses, cognitions, and interactions with others. • Cognitive behavioral - generally seeks to identify maladaptive cognition, appraisal, beliefs and reactions with the aim of influencing destructive negative emotions and problematic dysfunctional behaviors. • Psychodynamic - is a form of depth psychology, whose primary focus is to reveal the unconscious content of a client's psyche in an effort to alleviate psychic tension. Although its roots are in psychoanalysis, psychodynamic therapy tends to be briefer and less intensive than traditional psychoanalysis. • Existential - is based on the existential belief that human beings are alone in the world. This isolation leads to feelings of meaninglessness, which can be overcome only by creating one's own values and meanings. Existential therapy is philosophically associated with phenomenology. • Humanistic - emerged in reaction to both behaviorism and psychoanalysis and is therefore known as the Third Force in the development of psychology. It is explicitly concerned with the human context of the development of the individual with an emphasis on subjective meaning, a rejection of determinism, and a concern for positive growth rather than pathology. It posits an inherent human capacity to maximize potential, 'the self-actualizing tendency'. The task of Humanistic therapy is to create a relational environment where this tendency might flourish. Humanistic psychology is philosophically rooted in existentialism. • Brief - "Brief therapy" is an umbrella term for a variety of approaches to psychotherapy. It differs from other schools of therapy in that it emphasizes (1) a focus on a specific problem and (2) direct intervention. It is solution-based rather than problem-oriented. It is less concerned with how a problem arose than with the current factors sustaining it and preventing change. • Systemic - seeks to address people not at an individual level, as is often the focus of other forms of therapy, but as people in relationship, dealing with the interactions of groups, their patterns and dynamics (includes family therapy & marriage counseling). Community psychology is a type of systemic psychology. • Transpersonal - Addresses the client in the context of a spiritual understanding of consciousness. • Body Psychotherapy - Addresses problems of the mind as being closely correlated with bodily phenomena, including a person's sexuality, musculature, breathing habits, physiology etc. This therapy may involve massage and other body exercises as well as talking. Psychotherapy can be seen as an interpersonal invitation offered by (often trained and regulated) psychotherapists to aid patient in reaching their full potential or to cope better with problems of life. Psychotherapists usually receive remuneration in some form in return for their time and skills. This is one way in which the relationship can be distinguished from an altruistic offer of assistance. Psychotherapists and counselors often require creating a therapeutic environment referred to as the frame, which is characterized by a free yet secure climate that enables the patient to open up. The degree to which patient feels related to the therapist may well depend on the methods and approaches used by the therapist or counselor. Psychotherapists use a range of techniques to influence or persuade the patients to adapt or change in the direction the client has chosen. These can be based on clear thinking about their options; experiential relationship building; dialogue, communication and adoption of behavior change strategies. Each is designed to improve the mental health of a client or patient, or to improve group relationships (as in a family). Most forms of psychotherapy use only spoken conversation, though some also use other forms of communication such as the written word, artwork, drama, narrative story, or therapeutic touch. Psychotherapy occurs within a structured encounter between a trained therapist and patient(s). Because sensitive topics are often discussed during psychotherapy, therapists are expected, and usually legally bound, to respect client or patient confidentiality. References Print sources 1. Barlow H.D & Durand V.M. (2005). Abnormal psychology: an integrative Approach (4th edt). Belmont: Thomson wadsworth. 2. Rosenhan D.V & Seligman M.E. (1984). Abnormal psychology. New York: w. w. Norton and company. 3. Class note by Dr.sulie. Electronic sources 1. Abnormal Psychology (no date). Retrieved December 15, 2010 from http://en.wikipedia.org/wiki/Abnormal psychology. 2. Herry, kendra. (2005). what Is Abnormal psychology? About.com Guide. Retrieved November 15, 2010 from http://psychology.about.com/od/abnormalpsychology/f/abnormal-psychology.htmAbnormal psychology (no date.) Retrieved November 15, 2010 from http://en.wikipedia.org/wiki/Abnormal_psychology 3. Arnold A. Lazarus and Andrew M. Colman (1995). Abnormal Psychology. London and New York: Longman. Retrieved November 15, 2010 from http://www.le.ac.uk/psychology/amc/lepsabno.html 4. Nosology (no date). Retrieved December 15, 2010 from http://en.wikipedia.org/wiki/Nosology 5. Mental illness (no date). Retrieved December 15, 2010 from http://en.wikipedia.org/wiki/ Mental illness. 6. Psychopathology (no date). Retrieved December 15, 2010 from http://en.wikipedia.org/wiki/ Psychopathology. 7. Psychotherapy (no date). Retrieved December 15, 2010 from http://en.wikipedia.org/wiki/Psychotherapy. 8. Classification of mental disorders (no date). Retrieved December 15, 2010 from http://en.wikipedia.org/wiki/classificationofmentaldisoders