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Psychiatric diagnoses and therapies (2.14, 2.1.19-20, 2.3.8)

Updated: Mar 7, 2022



Describe the current DSM and ICD frameworks for classification of psychiatric disorders with particular focus on mood disorders and anxiety


The DSM 5 is an authoritative volume that defines and classifies mental disorders to improve diagnosis, treatment and research


Both DSM 5 and ICD take an a nosological (method or procedure that focuses on the naming and classifying of disorders) approach and base the classification of mental disorders on psychopathology.


The major difference is the role of functional impairments that are a requirement in DSM-5 but not in ICD -11. They have some time course differences and handling of brief psychotic disorders. Both struggle with defining where normal ends and pathology begins.

 

Critically discuss the role of:

  • CBT

A form of talking therapy that emphasises the importance of both behaviour and conscious thoughts in shaping our emotional experiences.

It includes thoretical behavioural learning principles (e.g. operant conditioning) and incorporates cognitive factors (e.g. beliefs and attributions) - to recognise the role of these cognitions on how they influence our behaviour, effect how we feel, and shape physiological responses.


CBT is a heterogenous term involving many different types of therapies and their delivery in an array of different formats.

For example, ACT, behaviour therapy, can all be given in individual, group, face to face, teleemedicine and in different doses





Evidence for CBT in chronic pain (not headache):

Cochrane review in 2009 and again in 2012 - 24 meta-analyses with 40 RCTs with 5000 participants.

CBT was shown to have a small effect on reduction in pain and a small effect on mood. There may have been small benefit for disability.


CBT for low back pain Systematic review and meta analysis in 2015 showed majority of studies with small to moderate and not statistically significant outcomes.


Pros:

- Can be as effective as medication for some mood disorders

- Can be completed in a relatively short time

- Fosues on re-training and provides a self-managed skill

- Can work in multiple formats e.g. online, self-guided

- Skills can be used in other aspects of life


Cons:

- Person has to commit to the process

- Attending regular CBT sessions is required and completion of homework

- Structured nature can be limiting for those with disabilities or mental health concerns

- Can confront emotions and at times worsen symptoms/pain

- Does not always explore other psychological aspects such as attachment and childhood

- Can not have a bearing on a persons environment


Reference:


Richmond, H., Hall, A. M., Copsey, B., Hansen, Z., Williamson, E., Hoxey-Thomas, N., ... & Lamb, S. E. (2015). The effectiveness of cognitive behavioural treatment for non-specific low back pain: a systematic review and meta-analysis. PloS one, 10(8), e0134192.


  • Mindfulness therapies with ACT

Mindfulness for chronic pain systematic review involving 38 RCTs in 2017 showed low-quality evidence that mindfulness meditation was associated with a small decrease in pain compared to controls. Statistically significant benefits were found for depression symptoms and quality of life.


ACT is about accepting your distressing symptoms or situation and not trying to suppress them.


Systematic review in 2017 looking at ACT - Significant small to medium effects were found for measures of functioning, anxiety and depression. Pain intensity and QOL were not significantly different. Effect sizes reduced further at follow up.


Reference:

Hilton, L., Hempel, S., Ewing, B. A., Apaydin, E., Xenakis, L., Newberry, S., Colaiaco, B., Maher, A. R., Shanman, R. M., Sorbero, M. E., & Maglione, M. A. (2017). Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine, 51(2), 199–213. https://doi.org/10.1007/s12160-016-9844-2


  • Motivational interviewing

Systematic review in 2016 looking at motivational interviewing for chronic pain looked at 7 studies of 1000 participants. Small to moderate increased adherence to treatment from baseline to after intervention but not at follow up. Short term studies had significant bias and statements of reduced pain are questioned. Uncertain if this better adherence actually led to better functional outcomes.


Reference:

Alperstein, D., & Sharpe, L. (2016). The Efficacy of Motivational Interviewing in Adults With Chronic Pain: A Meta-Analysis and Systematic Review. The journal of pain, 17(4), 393–403. https://doi.org/10.1016/j.jpain.2015.10.021

 

Recognise the role of other therapies including:

  • Narrative therapy

Narrative therapy is a therapeutic tradition of 'reauthorising' stories of suffering into stories of resilience and efficacy. It has been utilised for over 30 years. The basis is that we have stories about our lives that we have accrued over time and these are linked together to gain a sense of who we are. When problems affect our lives, narrative therapy tries to work out what is going on based upon our history.


It has not been fully explored regarding chronic pain efficacy.

  • Psychodynamic therapy

The aim of psychodynamic therapies is to enable the patient to develop insight into their unconscious processes (one's motivations, to resolve conflicts, overcome earlier traumas, and experience catharsis by expressing emotions).

Evidence for this type of therapy in chronic pain is lacking. There is some expert suggestion that it may play a higher role in somatoform pain disorders and psychic comorbidity.


Reference:

Csaszar, N., Bagdi, P., Stoll, D. P., & Szoke, H. (2014). Pain and psychotherapy, in the light of evidence of psychological treatment methods of chronic pain based on evidence. Journal of Psychology & Psychotherapy, 4(3), 1.

  • Problem-solving therapy

RCT in 2018 did not show benefit of pharmacology + PST vs pharmacology + general therapies.

It is a structured facilitated problem-solving approach. It has three key steps: Discovery (finding a solution), performance (implementing the solution) and verification (assessing the outcome).

  • Family therapy

Clearly the family plays a role in initiation, maintenance, and management of a variety of health-related behaviours and medical conditions.

There are few structured models for family therapy which makes completing studies difficult.

Some small RCTs have shown no statistically significant outcomes.

 

Demonstrate an understanding of research methodology including:

  • Principles of clinical epidemiology


  • Principles of biostatistics

  • Concepts of reliability, validity, sensitivity, specificity, bias, false positivity and false negativity

Bias - Systematic error that distorts the relationship between exposure and outcome

- Selection bias - Criteria used to select or exclud has a bearing on results

- Information bias - Means of measurement has introduced bias


Confounding - There is a relationship of cause and effect which is distorted by a third factor


Validity - Accuracy of a study

- Internal validity - If measurements made on the study population are free of confounding and bias

- External validity - If its results can be applied to other cohorts or populations


Systematic review - Searches for all relevant published studies using a comprehensive protocol and assesses their methods against set criteria


Meta-analysis - Uses statistical techniques to combine the results of multiple studies and thereby obtain a more accurate estimate, or alternatively, to investigate the causes of differences between studies


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