• What is psychopathology
• Its significance in different settings
• How to elicit specific symptoms & other important information

Pathology arising from the psychological state of the Pt

• Eg. When mind affects body: anxiety -> weakens immune system (reduced T cells), activates SNS
• Eg. When body affects mind: chronic illness can cause depression/ anxiety
• Eg. Boy with leukaemia become very naughty and hyperactive
• To make Dx, look at temporal sequence
• If boy usually hyperactive: cold Dx
• If boy only hyperactive after Dx of leukaemia: psycho-pathology secondary to biological illness

• Look at level of impairment
• Eg. Summer holidays, no classes to attend, stay in room and cry about relationship problems for weeks -> doesn't affect social/ school/ ADL - therefore normal
• But if occurs during school time (less study, don't see school-mates, don't participate in sports anymore) -> more pathological
• Eg. Difference between grief and pathological grief: normal grief - symptoms should decrease with time; if grief and symptoms persist over 3m -> pathological grief

The boundaries are unclear

• A clinically significant behavioural, or psychological syndrome or pattern that occurs in an individual
• And that is associated with

1. Present distress (e.g. a painful symptom) or
2. Disability (i.e. impairment in one or more important areas of functioning) or
3. With a significantly increased risk of suffering death, pain, disability (eg. Suicide, self-mutilation), or
4. Important loss of freedom (eg. Obsessive-compulsive disorder, Pt not distressed but frequency of washing hands interferes with ADL; checking door locks so much that they can't leave the house)

• Must not be merely an expectable and culturally sanctioned response (eg. Upset after relationship break-up; grief after loved-one's death)
• It must be currently considered a manifestation of a behavioural, psychological, or biological dysfunction in the individual (ie. Currently believed to be 'strange')
• Neither deviant behaviour (e.g. political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual

• An official nomenclature - a need for explicit definitions as a means of promoting reliable clinical diagnosis
• Used by clinicians and researchers of different disciplines and orientations
• Based on a formal evidence-based process

Not classifying people, but the disorders people have

1. Disorders usually first diagnosed in infancy, childhood, or adolescence
2. Cognitive disorders
3. Mental disorders due to a general medical condition not elsewhere classified
4. Substance-related disorders
5. Schizophrenia and other psychotic disorders
6. Mood disorders: common
7. Anxiety disorders: common
8. Somatoform disorders
9. Factitious disorders: invent disorder even though they know they are not sick (cf. hypochondriasis, who really believe they are sick)
10. Dissociative disorders
11. Sexual and gender identity disorders
12. Eating disorders: cultural, in affluent countries, on the increase
13. Sleeping disorders
14. Impulse-control disorders not elsewhere classified
15. Adjustment disorders
16. Personality disorders
17. Other conditions that may be a focus of clinical attention

• Each category is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder [F]
• Individuals described as having the same mental disorder are alike in all important ways [F]
• Individuals sharing a diagnosis are likely to be heterogeneous even in regard to the defining features of the diagnosis [T]
• Additional clinical information that goes beyond classification and diagnosis are important [T]
• Clinical judgement is important. DSM was not meant to be used in a cookbook fashion [T]. Symptoms often not clear cut; accurate Dx may be difficult (eg. Early schizophrenia/ prodromal phase)

1. Medical
2. Psychological
3. Social

• Different levels of understanding:

1. GP - know basic treatment and when to refer
2. Medical specialist - medication and basic counselling
3. Psychotherapist - systematic psychological treatment of the pathology

1. Nature: what is the problem?
2. Associated signs & symptoms?
3. How intense or severe?
4. Cause & course: how did it start and develop?
5. Variability: over time and situations?
6. What is the impact?
7. Distress and suffering
8. Role impairment: eg. Vocational, social, mother, leisure, ADL

1. Build a therapeutic alliance
2. Obtain the psychiatric database/ history
3. Interview for diagnosis
4. Negotiate a treatment plan

• Be warm, courteous, and emotionally sensitive
• Actively defuse the strangeness of the clinical situation

1. Greet Pt naturally
2. Get to know the Pt as a person first (but not close friends - reduced objectivity)
3. Explain the nature of the interview
4. Address Pt's concerns

• Let Pt express (& finish expressing) their concerns
• Gain Pt's trust by projecting competence

An art of hypothesis-testing

• Difficulties

1. Translating terminology into meaningful language
2. Distinguishing false positives

• Tips

1. Establish that the symptom is truly a change from baseline
2. Establish that the frequency and duration of the symptoms are in accordance with the criteria
3. Try not to ask leading questions
4. Establish level of functional impairment

1. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusion or hallucinations.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by other (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
3. Significant weight loss when not dieting, or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
4. Insomnia or hypersomnia nearly every day (sleep problem)
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

1. The symptoms do not meet criteria for a Mixed Episode (see P. 335).
2. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
3. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
4. The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterised by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

A1 In the past month

… has there been a period of time when you were feeling depressed or down most of the day, nearly every day? (What was that like?)

If YES, how long did it last? (As long as 2 weeks?)

A2 … what about losing interest or pleasure in things you usually enjoyed?

If YES, was it nearly every day? How long did it last (As long as 2 weeks?)

FOR THE FOLLOWING QUESTIONS, FOCUS ON THE WORST 2 WEEK PERIOD:

During [2-WEEK PERIOD]

A3 … did you lose or gain any weight? (How much? Were you trying to lose weight?)

If NO, how was your appetite? (What about compared with your usual appetite? Did you have to force yourself to eat? Eat [less/more] than usual? Was that nearly every day?

A4 … how were you sleeping? (Trouble falling asleep, waking too frequently, trouble staying asleep, waking too early, OR sleeping too much? How many hours a night compared with usual? Was that nearly every night?)

A5 … were you so fidgety or restless that you were unable to sit still? (Was it so bad that other people noticed it? What did they notice? Was that nearly every day?)

If NO, what about the opposite - talking or moving more slowly than is normal for you? (Was it so bad that other people noticed it? What did they notice? Was that nearly every day?)

A6 … what was your energy like? (Tired all the time? Nearly every day?)

A7 … how did you feel about yourself? (Worthless? Nearly every day?)

If NO, what about feeling guilty about things you have done or not done? (Nearly every day?)

A8 … did you have trouble thinking or concentrating? (What kinds of things did it interfere with?) Nearly every day?)

If NO, was it hard to make decisions about everyday things?

A9 … were things so bad that you were thinking a lot about death or that you would be better off dead? What about thinking of hurting yourself?

If YES, did you do anything to hurt yourself?

A10 Make calculations for answers thus far

A11 IF UNCLEAR, has [the depression/OWN WORDS] make it hard for you to do your work, take care of things at home, or get along with other people?

A12 Just before this began, were you physically ill? Just before this began, were you taking any medications?

If YES, any change in the amount you were taking?

Just before this began, were you drinking or using any street drugs?

MAIS PECGS

• Mood
• Appetite
• Interest
• Sleep
• Psychomotor
• Energy
• Concentration
• Guilt
• Suicidal ideas

Note: A Panic Attack is not a codable disorder. Code the specific diagnosis in which the Panic Attack occurs (e.g., 300.21 Panic Disorder With Agoraphobia).

A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, light-headed, or faint
9. Derealisation (feelings of unreality) or depersonalisation (being detached from oneself)
10. Fear of losing control or going crazy
11. Fear of dying
12. Paraesthesias (numbness or tingling sensations)
13. Chills or hot flushes

F1 Have you ever had a panic attack when you suddenly felt frightened or suddenly developed a lot of physical symptoms?

If YES, have these attacks ever come on completely out of the blue - in situations where you did not expect to be nervous or uncomfortable?

If UNCLEAR, how many of these kinds of attacks have you had? (At least two?)

F2 After any of these attacks…

Did you worry that there might be something terribly wrong with you, like you were having a heart attack or were going crazy? (How long did you worry? At least a month?)

If NO, did you worry a lot about having another one? (How long did you worry? At least a month?)

If NO, did you do anything differently because of the attacks, like avoiding certain places or not going out along? (What about avoiding certain activities such as exercise? What about things like always making sure you're near a bathroom or an exit?)

When was the last bad on? What was the first thing you noticed? Then what?

F3 If UNKNOWN, did the symptoms come on all of a sudden?

If YES, how long did it take from when it began to when it got really bad? (Less than 10 minutes?)

During that attack…

F4 … did your heart race, pound or skip?

F5 … did you sweat?

F6 …did you tremble or shake?

F7 … were you short of breath? (Have trouble catching your breath?)

F8 … did you feel as if you were choking?

F9 … did you have chest pain or pressure?

F10 … did you have nausea or an upset stomach or the feeling you were going to have diarrhoea?

F11 … did you feel dizzy, unsteady, or like you might faint?

F12 … did things around you seem unreal or did you feel detached from things around you or detached from parts of your body?

F13 … were you afraid you were going crazy or might lose control?

F14 … were you afraid you might die?

F15 … did you have tingling or numbness in parts of your body?

F16 … did you have flushes (hot flashes) or chills?

F17 Score for questions thus far

F18 Just before this began, were you physically ill?

Just before this began, were you taking any medications?

If YES, any change in the amount you were taking?

Just before this began, were you drinking or using any street drugs?

1. Long-term causes/ predisposing factors
2. Short-term causes/ triggering factors
3. Maintaining factors

• Eg. Anxious about car crashed: less medication and more psych counselling
• Eg. More medication when psych manifestations are secondary to something physical

• Independence, appropriateness, effectiveness, and sustainability
• The kinds and number of activities restricted
• Overall degree of restriction

• History of conflict, fear of strangers, avoidance of interpersonal relationships, social isolation
• Ability to initiate social contacts, communicate clearly, interact and actively participate in group activities
• Co-operative behaviours, consideration for others, awareness of others' sensitivities, and social maturity

• Problems in attendance, making decisions, scheduling, completing tasks
• Interaction with superiors and peers
• Stress tolerance & coping strategies

• No impairment
• Absent or minimal symptoms, generally good functioning
• Transient symptoms, slight impairment in day-to-day functioning (self-care, social, occup, etc.)
• Impairment significantly impedes normal functioning
• Impairment precludes normal functioning

"If you really want to help somebody, first of all you must find him where he is and start there. This is the secret of caring. If you cannot do that, it is only an illusion, if you think you can help another human being. Helping somebody implies your understanding more than he does, but first of all you must understand what he understands. If you cannot do that, your understanding, will be of no avail. All true caring starts with humiliation. The helper must be humble in his attitude towards the person he wants to help. He must understand that helping is not dominating, but serving. Caring implies patience as well as acceptance of not being right and of not understanding what the other person understands"