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Basics of Clinical Psychology

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The incidence of psychological disorders is relatively high. This handout introduces clinical psychology — the application of scientific psychology to the understanding and resolution of human psychological problems. We’ll look at ways in which mental disorders can be classified and the issues that are raised by classifying people. Finally we’ll overview the major historical approaches to psychopathology.
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C8005 (Clinical Psychology): Basics of Clinical Psychology
Basics of Clinical Psychology
Aims and Objectives
• What is Clinical Psychology?
• Classification
o Why do we classify mental disorders?
o How do we classify mental disorders?
o Issues of classification
• Approaches to clinical psychology
o Psychodynamic
o Medical
o Behavioural
o Cognitive
Introduction
Within this lecture theatre (containing about 100 people), there are approximately:
• 1-3 people who suffer persistent panic attacks.
• 3-4 people who have/will have GAD in a given 6-month period.
• 2-3 people who have/will have OCD (Robins et al., 1984)
• 12% of males and 20% of females with a lifetime risk of depression (which may be
short-lived or develop to chronic levels).
• 30-40% of males and 15% of females who will suffer from some kind of orgasmic
disorder.
The incidence of psychological disorders is relatively high. This handout introduces clinical
psychology — the application of scientific psychology to the understanding and resolution of
human psychological problems. We’ll look at ways in which mental disorders can be classified
and the issues that are raised by classifying people. Finally we’ll overview the major historical
approaches to psychopathology.
Classifying Psychological Disorders
Classification is a system by which entities are divided into subclasses. So, one example of this
is dividing humans into males and females. We’re taking a set of entities (humans) and
dividing into two subclasses (males and females). If we were a group of aliens who had just
landed on planet earth and we wanted to classify the genders, what would we need to know?
There are two things:
• Attributes of a given entity (what characteristics do males and females posses?)
• Defining characteristics of each subclass (what characteristics define a male and a
female).
The problem is, how do we decide what characteristics define a male or female. If we took a
biological approach then we could look at sex chromosomes and we could define genders in
Dr. Andy Field
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C8005 (Clinical Psychology): Basics of Clinical Psychology
this way (e.g. males have an XY sex chromosome pair but female have an XX sex
chromosome pair). There is a problem with using this characteristic as a defining feature: this
condition is neither necessary nor sufficient because there are chromosome disorders (XO,
XXX, YYY etc.). So, on what attributes should we base classification? Should we base it on
physical attributes (men have beer bellies, Women have larger hips); behavioural attributes
(men drink beer and beat each other up, women don’t), or cognitive (women are capable of
expressing emotion, men are not)? Even something as seemingly black-and-white as gender
is hard to classify (e.g. Imperato-McGuinley et al. 1979, studied males with a deficiency of the
enzyme 5?-reductase which meant they were born with ambiguous genitalia and raised as
females, but at puberty had a normal increase in testosterone and developed male genitalia,
these children were raised and classified as girls for 12 years before ‘becoming’ male at
puberty). If we have these problems classifying something as fundamental as gender, imagine
how difficult it is to find the defining attributes for a complex psychological disorder.
Even assuming we can decide on the necessary and sufficient conditions for a subclass we
have to be able to measure these attributes. With something physical we can measure it (we
can, for example, measure hip size) but with psychological constructs we’re reliant on less
objective and reliable measures (so, can we really reliably measure if a person has persistent
and distressing intrusive thoughts?). These most basic issues are hugely problematic. So, why
do we bother classifying disorders if it is so problematic?
Why Classify Disorders?
“What’s the use of their having names” the Gnat said “If they won’t answer to them?”
“No use to them” said Alice, “but it’s useful to the people that name them, I suppose”
[Lewis Carroll, Through the Looking Glass]
The quote from ‘Through the Looking glass’ asks the question of whether it useful to name
things. Alice has just told the gnat that where she comes from insects do not answer to their
names and the gnat’s response is to question the purpose of them having names to which they
do not answer. Alice responds that it is useful to the namer even if not to the insects
themselves. In clinical psychology we classify disorders in the hope that it allows us a basis
upon which to understand and treat disorders.
In simple terms clinical psychology is the application of scientific methods to understand and
resolve human problems. Classification helps us to do this. First, imagine trying to develop a
theory of why people are suicidal without having first decided what it is to be suicidal.
Classification enforces some homogeneity upon the groups we study. This allows us to develop
theories of how disorders develop, which in turn informs us about how these disorders might
be treated. Without some agreement about what constitutes a particular disorder, we would be
unlikely to unearth common underlying processes (because we’d be studying a heterogeneous
group of people), and we’d be unable to communicate with other scientists about the theories
we develop (because our understanding of a disorder would differ from someone else’s).
How should we classify?
A good classification system needs to do a number of things (as we’ve seen):
Divide into mutually exclusive and collectively exhaustive subclasses: disorders should
be distinct (I.e. if something belongs to one subclass it cannot belong to another: so, in
the case of gender you are either male or female not both). Collectively exhaustive
means that all entities can be classified (I.e. all people who are in reality male, should
be categorised as male by our definitions). In psychological terms it is important that
our system classifies people with the correct disorder, and that all people with a
disorder can be classified as having a disorder based on the system we use.
Necessary & Sufficient Conditions: There must be characteristics that are necessary for
classification into a subclass (I.e. to define someone as having OCD it may be
necessary that they have intrusive thoughts). There must also be a set of sufficient
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C8005 (Clinical Psychology): Basics of Clinical Psychology
conditions to belong to a subclass (for example, there may be many people without
OCD who have intrusive thoughts, so this condition alone is not sufficient to have OCD,
you may perhaps need to have intrusive thoughts AND a heightened belief that you'll
act upon these thoughts).
Concept: Once the conditions of membership have been defined, the subclass must be
described by some kind of concept that reflects the nature of the conditions. For
example, OCD as a concept reflects the persistent and uncontrollable nature of the
thoughts and actions associated with the conditions that define the disorder).
Extend the Concept: Once we have a concept, it must be possible to generalise this
concept and extend it to new exemplars. So, if a new entity is encountered that has not
previously been classified, it must be possible to classify this new exemplar based on
our concept.
Are disorders discrete or continuous?
The next problem is whether mental disorders are discrete of continuous. We can loosely think
of this distinction in terms of whether people with disorders can be neatly placed within a
diagnostic ‘box’ or not. So, does someone with a mental disorder have attributes not
experienced at all by ‘normal’ people, or does having a mental disorder mean that some of
your ‘normal’ attributes are experienced in some qualitatively distinct way?
Think about something like OCD, if we’re to define it in terms of having intrusive thoughts
(such as ‘I want to kill my father’). Is it the case that people with OCD experience intrusive
thoughts and ‘normal’ people do not? Or is it the case that intrusive thoughts are part of
normal life (e.g. how many people have been at a train station and had the thought they
should jump in front of a train?) but that people with OCD experience these thoughts in a
qualitatively distinct way (I.e. with an exaggerated sense that they might act upon the
thought, or they experience these thoughts more frequently)? Is there a continuum underlying
disorders?
You cry when you watch
You cry at nothing,
Casablanca
sometimes for ages and
afterwards you don’t feel
You go to bed for an
afterwards you don’t feel
afternoon mope
any better
You’re too lethargic to go
You go to bed for a week at
a time
clubbing
a tim
You feel useless, helpless
You phone round your
You feel useless, helple
friends asking for 3 of your
and hopeless
good points
You find it hard to make
It takes a good episode of
decisions
the Simpsons to make you
You wake up earlier than
smile
usual
You eat a box of
You have difficulty sleeping
peppermint Matchsticks for
You lose appetite or weight
comfort and enjoy them
(or the reverse)
You go off sex, but only
You go off sex
because you think no-one
You go off se
wants to do it with a
You avoid other people
misery guts
You think of suicide

The boxes above are examples from the Guardian Newspaper highlighting the difference
between sadness (red) and depression (blue). Now in some sense they’ve trivialised sadness
and used slightly fatuous examples. However, it illustrates the issue nicely. For example, if we
use ‘inability to get up in the morning’ as a defining attribute of depression we’re talking about
something that everyone experiences. At what point does it become part of depression. Is it
when we can’t get out of bed for 2 hours, 3 hours, or a week? There are other examples that
hint towards a discrete classification system (thoughts of suicide): This ‘symptom’ is a biggie
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C8005 (Clinical Psychology): Basics of Clinical Psychology
diagnostically, if you go to a GP and say you’ve thought about suicide you’ll be on Prozac
before you can say ‘antidepressant’, do non depressed people never think about suicide?
The vast majority of diagnostic criteria reflect everyday experiences to which we can all relate.
In fact, throughout this course, as you listen to the diagnostic criteria for the various disorders,
most of you will at some point convince yourself that you’re phobic, depressed, social phobic,
have panic disorder or some kind of sexual dysfunction. The chances are you haven’t got any
of these disorders, so, at what point do any one of these attributes become severe enough to
indicate a mental disorder?
How do we classify: DSM–IV?
Kraeplin was one of the first to distinguish distinct syndromes. He made the distinction
between dementia praecox and manic-depressive psychosis. Much of the modern classification
systems owe their origin to Kraeplin who defined two discrete disorders both having necessary
and sufficient attributes for classification. The World Health Organisation (WHO) publish
diagnostic manuals for medicine, and the American Psychiatric Association (APA) developed a
similar set of diagnostic manuals based on the WHO’s system of classification, which again
depends on defining necessary and sufficient criteria for diagnosis. This manual is known as
the Diagnostic and Statistical Manual (DSM) and has been revised over the years: DSM (1952),
DSM II (1969), DSM III (1980), DSM III-R (1987), DSM IV (1994). DSM IV is probably the
most widely used diagnostic manual for psychiatric problems and is based on a multiaxial
Classification:
• Axis I: Diagnostic Categories (except II)
• Axis II: Personality disorders/mental retardation
• Axis III: General medical conditions
• Axis IV: Psychosocial & environmental problems
• Axis V: Level of adaptive functioning (GAFS)
All of the disorders we cover on this course are found on Axis I, with the remaining axes used
to identify other contributing factors (medical conditions, environmental factors etc.). Axis I
contains the following disorders:
• Disorders usually first diagnosed in infancy, childhood or adolescence
• Delirium, dementia, amnestic & other cognitive disorders
• Substance related disorders
• Schizophrenia and other psychotic disorders
• Mood disorders
• Anxiety disorders
• Somatoform disorders
• Factitious disorders
• Dissociative disorders
• Sexual and gender identity disorders
• Eating disorders
• Sleeping disorders
• Impulse control disorders not elsewhere classified
• Adjustment disorders
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C8005 (Clinical Psychology): Basics of Clinical Psychology
Assessing a classification system
A good classification system needs to be both reliable and valid.
Reliability: A classification must be reliable in that if different clinicians diagnosed the
same person, that person should always be classified in the same way (I.e. a system is
not reliable if one clinician classifies someone as obsessive-compulsive whereas another
classifies the same person as schizophrenic). Reliability is necessary for validity, but it
is not sufficient. The use of standardized interview techniques and more explicit criteria
has improved the reliability of DSM classification.
Validity: First and foremost a valid system must be reliable. Validity comes also from
many sources. Can we isolate causal factors for a given disorder (etiological validity),
can we predict future outcomes based on what we know about the disorder (predictive
validity), does the classification correlate with other measures (e.g. questionnaires that
measure OCD), and does the construct itself have an intuitive validity?
Criticisms of DSM
A number of criticisms have been levelled at DSM. Historically, it has been a very unreliable
measure with the original manual leading to only 54% agreement between therapists in
diagnosis (Beck et al., 1962) and recent manuals (DSM III and III-R) improving this value to
only 70% (Kirk & Kutchins, 1992).
Specificity: There is considerable overlap between disorders (e.g. 30-50% of people
with agoraphobia are diagnosed as having panic disorder). Also, looking at the
symptoms of Borderline Personality Disorder (out-of-control emotions that cannot be
smoothed, hypersensitivity to abandonment, self-harm, emptiness) are also
benchmarks of depression and the vast majority of sufferers are also diagnosed as
being depressed, having GAD, PTSD, Panic or some other anxiety disorder.
Biases: Szasz (1961) argues that abnormality does not exist and that DSM reflects a
societal desire to suppress individuals whose behaviour does not conform to our socially
constructed norms. For example, anthropologists have noted culturally endorsed
behaviours (e.g. the wild man of Borneo) that would be deemed antisocial or abnormal
in the Western world. DSM has also been criticised for adopting a male-dominated
perspective on disorders. For example, ‘Dependent Personality Disorder’ (characterised
by fear of abandonment and indecisiveness) is said to pathologize normal female
behaviour because it doesn’t conform to male perceptions of normality (Caplan & Gans,
1991).
Stigma: diagnostic labels change perceptions of the person. Rosenhan (1973) reports a
study in which 8 ‘normal’ people reported to 12 psychiatric hospitals (over a period of
time) reporting hearing voices saying ‘empty’, ‘hollow’ and ‘thud’. All were diagnosed as
Schizophrenic. Rosenhan reported that doctors and staff treated these pseudopatients
differently from the minute this label was attached (for example, staff would ignore the
pseudopatients’ attempts at conversation, their normal histories were distorted into
tales of ambivalent relationships and outbursts were attributed to the pathology and not
the behaviour of staff etc.).
Political influence: Some of the disorders included (and excluded) in DSM are the result
of political agendas. For example, PTSD was included after Vietnam soldiers protested
for its inclusion so that they could receive sickness benefit. Homosexuality was dropped
as a disorder in 1973 due to pressure from Gay rights groups (which demonstrates how
cultural and historical perceptions of ‘abnormality’ influence what we consider to be
abnormal. There are far fewer of our generation who would consider homosexuality a
mental disorder, but two generations ago in Victorian Britain it would have been
considered just that. Masochistic Personality Disorder was a recent controversial
example (it was going to be included and then was dropped because of pressure from
psychologists who felt it would serve to pathologize women in abusive relationships
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C8005 (Clinical Psychology): Basics of Clinical Psychology
(and the solution to have an equivalent Sadistic Personality Disorder was dropped
because it would allow abusers legal protection through diminished responsibility.
Homogeneity of sufferers: classification imposes homogeneity within disorders and
encourages therapists to ignore the individual characteristics of a particular patient.
Approaches to Clinical Psychology
There are a number of different approaches to theory and therapeutic practice in clinical
psychology. This course is based heavily on medical, behavioural and cognitive models (usually
in combination). This course has very little to say about psychodynamic theories and therapies.
I admit that this is largely because as an empirical researcher studying experimental
psychopathology, the non-scientific nature of psychodynamic therapies sits uncomfortably with
me. I’ll get this personal bias out into the open now, but you should feel free to ignore it.
Psychodynamic
Freud’s basic premise was that there was a conflict between unconscious desires/drives and
conscious behaviours and actions. In essence he conceptualised these in a number of ways.
Freud’s Thanatos and Eros were basic drives towards death and life. These are in conflict.
There was the Id (unconscious primitive desires – eat, drink, procreate, please), Super-ego
(conscience and morality) and the ego (reality principle). Characterized as “A sex crazed
monkey (id) locked in mortal combat with a puritanical matron aunt (super-ego) refereed by a
timid nervous clerk (ego)”.
Freud also proposed the psychosexual stages: Oral (0-1 years), Anal (1-2 years), and Phallic
(3-6) years. Failure to resolve any one of these stages would lead to trauma. I.e. Anal fixation
(obsession), oral fixation (eating disorders), and the Oedipal complex (phobias: male is
attracted to mother and fears castration from a jealous father, anxiety is transferred to a more
socially appropriate target, in females penis envy).
Therapeutically, Freud looked to hypnosis (regression to an early state), dream analysis and
the talking cure to unearth the cause of trauma. However, all of this was incredibly subjective
and led to an amazing array of ridiculous case studies (I.e. little Hans). The theory is
unfalsifiable because it offers no predictions about behaviour, is based on single case studies
(non-scientific) and reflects Freud’s own ambivalent parental relationships (which, ironically,
he projected (to use his terminology) onto any poor sod who entered his office!).
Medical (Biological)
The medical model is basically what is applied in medicine: all disorders can be attributed to
some biological cause. This cause can take many forms:
Structural abnormalities. The brain consists of a huge array of complex matter and
liquid-filled ventricles. Psychopathology could be attributed to unusually large or small
ventricles, or structural abnormalities of key areas such as the hypothalamus or
amygdala.
Hormones: Disorders could be due to abnormal levels of certain hormones (for example
the secretion of cortisol during stress).
Neurology: neurons communicate by releasing neurotransmitters into the gap between
them (the synaptic gap). Reuptake (when the ‘sending’ neuron releases a
neurotransmitter into the synaptic gap and then re-absorbs some of that
neurotransmitter reducing the amount left in the synaptic gap) and degradation (when
the ‘receiving’ neuron releases an enzyme to break down the neurotransmitter. Too
much or too little reuptake and degradation can lead to high or low levels of
neurotransmitters in the synaptic gap.
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C8005 (Clinical Psychology): Basics of Clinical Psychology
Genetics: Any of the above may result from genetic factors (inherited structural
abnormalities, hormone imbalances or neurological factors).
For therapy, the solution is drugs to act on the biological problems (I.e. increase production of
a neurotransmitter, prevent reuptake or a neurotransmitter, encourage production of a
neurotransmitter, redress hormonal imbalances etc.)
Behavioural
The behavioural model basically suggests that mental illness results from maladaptive learning
processes (emphasis is on environment and not behaviour). These responses are not
cognitively mediated (I.e. out of conscious control). The model simply assumes that by
treating the learnt behaviour, you treat the underlying cause (I.e. by re-learning about the
environment you over-write the maladaptive learning).
In its radical form, behaviourists believed that we have no free will; we are simply a product of
a set of learnt responses over which we have no conscious control.
Therapy hinges on re-learning: for example exposure to a threat (so you can re-learn that it is
not actually threatening) and counter-conditioning (where a new and non anxious response is
learnt to a threatening situation (e.g. relaxation while encountering a threatening situation).
Unlike the medical model it emphasises social/environmental aspects.
Cognitive
The cognitive model is in a sense the complete opposite to the behavioural one in that it
emphasises the role of consciously controlled processes. The basic premise is that biased
thought processes lead to maladaptive behaviour (for example someone is spider phobic
because they perceive spiders as being huge – for whatever reason).
Little is hypothesised about how this maladaptive thinking is caused – however it seems likely
that biology and learning have a role to play (and hence these three models are by no means
mutually exclusive).
Therapy hinges on challenging thought biases (I.e. get rid of the maladaptive thoughts and the
maladaptive behaviours will go).
When we study simple phobias we’ll look in more detail at the behavioural and cognitive
models and how they differ.
Key References
Approaches to Psychopathology:
Gelder, M. (1997). The scientific foundations of cognitive behaviour therapy. In D. M. Clark
and C. G. Fairburn (Eds.), Science and practice of cognitive behaviour therapy. Oxford:
Oxford University Press (pp 3–26). (Main/Short RC489.C63 Sci)*
Ledwidge, B. (1978). Cognitive behaviour modification: a step in the wrong direction?
Psychological Bulletin, 85, 353–375. (QZ10 Psy)**
Rachman, S. J. (1997). The evolution of cognitive behaviour therapy. In D. M. Clark and C. G.
Fairburn (Eds.), Science and practice of cognitive behaviour therapy. Oxford: Oxford
University Press (pp 3–26). (Main/Short RC489.C63 Sci)**
Salkovskis, P. M. (1986). The cognitive revolution: new way forward, backward somersault or
full circle? Behavioural Psychotherapy, 14, 278–282.** [in reserve]
Classification and Diagnosis:
Rosenhan, D. L. (1973). On being sane in insane places. Science, 179, 250–258. (Q 1 Sci)**
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C8005 (Clinical Psychology): Basics of Clinical Psychology
Spitzer, R. L. (1975). On pseudoscience in science, logic in remission and psychiatric
diagnosis: a critique of ‘on being sane in insane places’. Journal of Abnormal Psychology,
84, 442–452. (QZ10 Jou)**
The two articles above are an informative debate of the issue of whether diagnostic labels
hinder treatment.
American Psychiatric Association (1994). DSM-IV. Washington D.C.: APA (Main RC 454.4 Dia)
(Not really for reading; but skimming will give you some sense of how classification really
‘works')




Dr. Andy Field
Page 8
10-Oct-2000

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