Summaries per article with Clinical Psychology at Leiden University 21/22

What is the Mental status exam (MSE)? 

The Mental status exam (MSE) is used for symptom recognition of various mental illnesses during a psychiatric interview with a patient. The MSE utilizes the ABC-STAMPS approach, which stands for: Appearance, Behavior, Cooperation, Speech, Thought (this includes both thought process and thought content), Affect, Mood, Perceptions, and Suicidality. These nine facets of the patient are all assessed by the psychiatrist during the MSE. 

What were the methods used in the MSE study by Martin et al. (2019)?

Martin et al. investigated the effects of showing several video clips, which featured actors playing psychiatric patients, to both medical and nursing students. Multiple approaches have been used in the past in regards to teaching the MSE, including psychiatric interviews with actual patients, psychiatric interviews with simulated psychiatric patients (SPPs), documentaries and movies about mental illnesses, and online videos from university-level sources. The study by Martin et al. opted for showing clips of psychiatric interviews with SPPs as they found it to be the most accessible and ethically sound option. 

The researchers compiled 16 clips consisting of actors simulating 10 different common mental illnesses: depression, bipolar disorder, generalized and social anxiety, obsessive-compulsive disorder, borderline personality disorder, anorexia nervosa, schizophrenia, dementia, delirium, and opiate dependence/withdrawal. The 16 clips were shown during an hour-long lecture which also included information about the ABC-STAMPS approach. Afterward, students in the intervention group completed an online MSE assessment tool to evaluate their abilities to identify psychiatric symptoms seen in clinical interviews. Students in the control group completed the online MSE assessment without having previously attended the lecture containing the video clips. Additionally, all students were asked to answer questions about their knowledge of the MSE, ranking their perceived skills on a scale of 1-5. 

Martin et al. used the students’ scores on the MSE assessment tool as a dependent variable and didactic (whether students are in the intervention vs. control group) and discipline (medical degree vs. nursing degree) as two independent variables. They carried out a multiple linear regression, and using analysis of variance (ANOVA) they compared the MSE assessment scores between the intervention and control groups. 

What were the findings of the MSE study? 

The researchers found that the intervention group attained significantly higher scores on the MSE assessment than the control group. The effect of discipline on assessment score was not significant. Further, students’ subjective measurements of their MSE knowledge was not shown to be correlated with their score on the objective MSE assessment tool. 

The video clips showing psychiatric interviews featuring SPPs were therefore found to be an effective way to improve students’ knowledge of the MSE and their abilities to recognize psychopathological symptoms. One limitation of the study is that the students researched were all in preclinical university programs, so it is not possible to infer what the effects of the educational clips would be in the rest of the population.

What are some common stress responses to the COVID-19 pandemic?

The immense amounts of psychosocial stress that have arisen in the population due to the current COVID-19 pandemic have largely been due to uncertainty regarding the future. Stress is a reasonable, normal, and adaptive response to the pandemic, especially considering that most people have never dealt with anything like it before. Some of the most common stress and stress-related patterns that have been observed in response to the COVID-19 pandemic are irritability, anxiety, reduced productivity and concentration, interpersonal conflicts, and insomnia.

What role does resilience play in coping with COVID-19? 

Many factors affect how well an individual can cope with major stressors, including the COVID-19 pandemic. One’s living conditions, access to healthcare, literacy, socio-economic status, and level of uncertainty about the future all contribute to the level of adaptation to the pandemic. Resilience, considered to be the opposite of vulnerability, can be used to cope with stress and stay balanced. The concept of resilience exists not only at the individual level but also at the community level.

How do the stress effects of the virus affect at-risk populations? 

Certain populations are at a higher risk to be affected by the negative results of COVID-19 related restrictions. The virus itself, fears surrounding becoming infected, and virus-related restrictions all can exacerbate mental illness or even trigger it. Those with psychiatric disorders who are already more prone to maladaptive stress responses now have less access to mental health care than usual. Healthcare workers must deal with the fear of getting the virus due to their proximity to COVID-19 patients. Feelings of failure have also been rising among healthcare workers who often face ethical issues surrounding COVID-19 patients and their families. Additionally, elderly people are particularly vulnerable to loneliness due to COVID-19 restrictions, especially because they are more often unable to communicate with smartphones and computers.

What interventions are most effective at increasing resilience? 

People have been shown to be more negatively impacted by stressors that they deem uncontrollable. It is up to the governments of nations to emphasize that COVID-19 is not an uncontrollable threat, but one that can be reduced through specific individual and community actions. The more that people acknowledge that the situation is controllable, the better they will be able to cope with its ensuing stress. Governments should also be clear about the pandemic-related information that they have and communicate it in a way that the general public, not just experts, can understand. Conversely, nationalism and unilateralism in decision-making will most likely only increase the stress-related impact of the pandemic on a given society. 

To promote resilience to the pandemic, governments, organizations, families, and workplaces should encourage social connectedness, self-care, planning everyday activities, exercise, good nutrition, and taking media breaks. Stress monitoring and team support can also help to lower the burden of the pandemic on healthcare workers. Resilience enhancing interventions for low socio-economic status individuals include assuring access to health and economic infrastructures and providing funds for those who are left without work due to the pandemic. Telemedicine approaches are helpful for those in need of regular mental health care. Finally, acquiring data on the psychosocial impact of the virus and the restrictions on COVID-19 patients and their families will provide a way to create interventions on the individual and community level that will increase resilience in the population.

In what ways are the depictions of mental illness in Joker problematic? 

In recent years, awareness about more common mental illnesses like anxiety and depression has grown exponentially. Unfortunately, more severe disorders have seen no such growth in recognition. The portrayal of severe mental illnesses in popular media is still inaccurate and stereotypical. The 2019 movie Joker is one of the culprits of spreading this type of misinformation. A common stereotype about individuals with severe mental illnesses is that they are violent. Joker perpetuates this myth, as Arthur, the titular “joker”, grows more violent after stopping his medication. In actuality, people with severe mental illnesses are more susceptible to experiencing violence coming from others than are people in the general population, but they are not averagely more violent themselves. 

Joker is misinformative about the details of mental illnesses in more ways than one. Instead of selecting one psychopathology for the main character to suffer from, the writers of Joker seemed to pick and choose from symptoms that they found interesting and attribute them all to Arthur. Instead of representing symptoms that were plausible to occur together and that would perhaps portray one or two distinct mental illnesses, the movie used various and (seemingly) unrelated symptoms as plot devices.

What implications does Joker have for the real world? 

The effect of misinformation in popular media regarding mental illness has been seen before. One Flew Over the Cuckoo’s Nest, a 1975 film depicting the unethical use of electro-convulsive therapy, has been said to have created undue levels of mistrust around electro-convulsive therapy, which can be very effective as a treatment. Movies, (especially extremely popular and widely viewed ones like Joker) have to be held accountable for their representations of the severely mentally ill if the stigmatization around these disorders is ever to drastically improve. The misrepresentation of mental illness in Joker is misinformative at best and dangerous at worst. 

What does the levels problem refer to? 

The levels problem in psychopathology refers to the fact that psychopathological disorders are investigated in different ways (or at different levels). Most frequently, these include the psychological level and the biological level. The boundary between these two levels is blurry, and it may be difficult at times to differentiate between them. For example, autism is not only a psychological disorder but also a biological one, so from what level should it be analyzed? As will be explained in the next section, there are also multiple different ways of categorizing levels. Since these categorizations have much overlap, levels should not be taken too literally, and should instead be used for heuristic purposes. The level problem makes it more difficult for researchers and clinicians to decide the best framework for advancing psychopathology research.

What are three ways of thinking about levels? 

Three common ways of conceptualizing different levels are the following: part-whole related levels, levels based on the scale of what is being measured, and levels based on the time range of what is being measured. Although these are not the only ways to think about levels, they are the most relevant in terms of psychopathology. To begin, part-whole levels refer to hierarchies, for example, within an organism. An organism can be broken down into tissues, cells, cell parts, molecules, and eventually atoms. The whole of an organism is at a higher level than that of its parts — thus, it is a hierarchical structure. This hierarchical system of levels, however, can vary even within the same organism, as what is considered a higher or lower level is determined by what is being measured. Additionally, the concept of part-whole levels is not always clear-cut. Ideally, there would be no overlap between levels in the hierarchy and no components that would fall between levels, but this is seldom the case in practice. There is also no agreed-upon way to decide with consistency which component belongs to which level in the part-whole system. 

Levels can also be thought of in terms of scales. Essentially, this means that the size of the thing being studied is what determines its level. The example of analyzing the activity of neurons is given in the article. In functional neuroimaging, each data point consists of millions of neurons, whereas cellular neuroscience analyzes neurons individually. In this case, the scale of functional imaging is much broader. Finally, there is the temporal scale, in which the length of the process being studied determined its level. For example, the interactions between brain areas take much longer than the interactions between neurotransmitters and receptors. Importantly, the temporal scale can be applied quite easily to the concept of psychopathology, because the time that it takes for symptoms and mental states to appear, progress, and fade can be measured and compared to the time it takes for neurobiological states to change.

What are explanatory reductionism and explanatory pluralism? 

People that take an extreme explanatory reductionist view believe that the neurobiological mechanisms of the brain make explanations at the psychological level useless. They think that the only reason psychological-level explanations are accepted as explanations at all is because we do not know the neurobiology behind those explanations yet. Those who subscribe to a more lenient version of explanatory reductionism believe that psychological explanations are real, but will never be as important or powerful as explanations on the neurobiological level. All explanatory reductionists think that biological explanations, which are on a lower level, are more useful than psychological explanations, which are on a higher level. This is partially due to explanatory reductionists’ reasoning that all behavior is merely an outward expression of biological activity, which in “mind-body debate” terms is a monism view. In past scientific research, it has often been very helpful to study the lowest biological levels. DNA, for instance, was discovered this way. However, it is not always sensible to ignore higher levels. In physics, for example, investigating only very low levels like molecules is not sufficient for actually explaining and predicting physical laws and behavior on a higher level. 

In the context of psychopathology, explanatory pluralism is more useful than explanatory reductionism. Explanatory pluralism advocates not just for exploring higher levels, but for investigating multiple levels (both higher and lower) in the context of one concept. Explanatory pluralism is most useful when the information received from each level is integrated into a more comprehensive system. Integrating all this information may mean that professionals from many fields have to compile and align concepts related to a specific psychological problem.

Why is examining psychopathology from a higher-level useful?

The field of clinical psychology relies on higher-level explanations of psychopathologies because it is exceedingly difficult to discover genes or other biological anomalies that wholly or substantially explain a specific psychiatric disorder. It is very unlikely that something as low level as a strand of DNA can ever explain something as high level and abstract as a mood disorder, for instance. On the other hand, researchers have made much progress in understanding the causes and subtypes of obsessive-compulsive disorder through analyzing the disorder's typical cognitive processes. Considering this, it would be prudent for psychopathological research to be done at multiple levels which differ in time, scale, and part-whole hierarchies. 

What symptoms comprise Alice in Wonderland syndrome? 

Alice in Wonderland syndrome (AIWS) was first described in 1955 by the psychiatrist John Todd, and its symptoms include various distortions of sensory perception, including visual distortions, and distortions of time and self. These distortions differ from hallucinations and illusions in the sense that they are based in the real world but involve very specific alterations to sensory input. AIWS currently comprises 42 visual symptoms (called metamorphopsias) and 16 non-visual symptoms. The two most common symptoms are micropsia; seeing things as smaller than they really are, and macropsia; seeing things as larger than they really are. 58.6% of AIWS patients suffer from micropsia while 45% suffer from macropsia. A few other visual symptoms include kinetopsia, in which people see stationary objects as moving, and prosopometamorphopsia, in which eyes are seen as much larger than they are. Symptoms sometimes include feelings of levitation and alterations in the passage of time, among others. It is most common for people with AIWS to only experience one symptom, although many people experience up to four. Generally, AIWS symptoms tend to be short-lived, lasting a few minutes to a few days. Years-long or lifelong symptoms occur rarely.

What are the causes of AIWS? 

There are many possible causes of AIWS, and more will likely be added as more cases are identified. The causes differ between young people and adults. For youths, the most common cause of AIWS is encephalitis (inflammation of brain tissues). Encephalitis can be caused by various infections, but the Epstein-Barr virus is the one most frequently cited in cases of encephalitis-induced AIWS. In adults, neurological disorders were cited most often as the medical cause for AIWS, with migraines being the most common among them. However, symptoms of AIWS are sometimes unassociated with any type of medical disorder or pathology. Symptoms of this syndrome are caused by functional and/or structural abnormalities in the perceptual system.

What are the prevalences of AIWS in the population? 

Although AIWS is thought of as a rare syndrome, some of its symptoms are seen quite regularly in the general population. In fact, singular symptoms of AIWS unrelated to another disorder or medical condition have been experienced by around 30% of all adolescents. When considering specific symptoms, it was found that 5.6% of male adolescents and 6.2% of female adolescents have experienced micropsia and/or macropsia. It was also found that 15% of patients with migraines suffer from AIWS.

What are the treatment methods and prognoses for AIWS? 

Patients with AIWS often suffer from underlying medical conditions like encephalitis, migraines, or epilepsy. When this is the case, pharmacological treatment is used in an attempt to diminish or eliminate the underlying cause. Typically, medication is only necessary in medically-induced cases, and this treatment must target the medical condition rather than the symptoms themselves. Generally, these treatments include antiepileptic medication, antibiotics, antiviral medication, or migraine medication. Oftentimes in medical cases of AIWS, symptoms disappear and return in coordination with the severity of the disease at the time. In most cases of non-medically-induced AIWS, a helpful treatment can consist merely of reassurance from a clinician that the symptoms they are experiencing are benign. Chronic cases may warrant functional neuroimaging to better understand specific symptoms. Almost all cases of AIWS are considered benign and treatable, as full remission of symptoms is often achieved both in medically-induced and non-medically induced cases. This can occur either spontaneously or after treatment. However, the prognosis for patients with epilepsy or migraine-induced AIWS is poorer — these patients rarely achieve full remission due to the difficulty of treating their underlying conditions.

Why is AIWS so regularly discounted in scientific literature and clinical practice? 

It is estimated that AIWS is severely underdiagnosed. This is partially due to its apparent similarities to schizophrenia spectrum disorders, as patients’ perceptual distortions may be attributed to hallucinations. The diagnosis of AIWS is also made more difficult because it is not featured in either the DSM-5 or the ICD-10. In practice, symptoms of AIWS may not be recognized because of this factor. It is suggested that AIWS should be included in the next versions of the DSM and ICD under the categorization of nervous system disorders or perceptual disorders. An international database that documents cases of AIWS and their treatments would also be extremely helpful for clinicians trying to learn about and diagnose this syndrome.

How does Pavlovian conditioning work in the context of addiction? 

It has been known for decades that addicts experience symptoms of drug withdrawal when they encounter situations or environments that they associate with their drug use. Just the sight of drug paraphernalia or speaking about drugs to other people can elucidate these symptoms. This is due to Pavlovian (or classical) conditioning. In Pavlovian conditioning, there are unconditional and conditional stimuli, as well as unconditional and conditional responses. In the context of drug use, the unconditional stimulus is the pharmacological effect of the drug. The drug induces a compensatory response in the body. For example, alcohol has a temperature-lowering effect, so after ingestion, the body raises its temperature to compensate. The cues or environment accompanying the administration of the drug are the conditional stimuli, which need to be associated with the effects of the drug multiple times before being effective in elucidating withdrawal symptoms. Eventually, these cues (the conditional stimuli) will bring about conditional compensatory responses. These conditional compensatory responses also counteract the drug effect, even when no drug was administered.

What factors influence the strength of an addict’s tolerance? 

An addict’s tolerance to a certain drug increases when, due to repeated use, the drug’s effect on their body decreases. The more that the conditional compensatory response strengthens, and thus the drug’s effects are more highly counteracted, the higher someone’s tolerance will be. Situational specificity of tolerance is a concept that illustrates the effects of the specific environment (conditional stimuli) on drug tolerance levels. In experiments designed to demonstrate situational specificity of tolerance, people are administered drugs in the exact same environment multiple times in the tolerance-development phase. After, in a tolerance-test session, the participants are split up into two groups. One group is administered drugs in the same environment as before, and one group’s drug administration environment changes. Those in the unchanged environment will show heightened tolerance to the drug due to the conditional stimuli (the environmental cues). However, those in the changed environment will show lowered tolerance, and the effect of the drug on them is stronger than it was at the end of the tolerance-development phase. For example, college students have been shown to display less alcohol tolerance when they consume a familiar alcoholic beverage than when they consume an unfamiliar, peppermint-flavored blue beverage with the same alcohol content. This situational specificity of tolerance has also been shown to apply to potentially lethal doses of drugs.

What causes symptoms of withdrawal? 

Withdrawal symptoms are caused by conditional compensatory responses when there is no drug provided after the conditional stimuli. In other words, if a drug is not administered after the typical stimuli that precede drug use, withdrawal symptoms begin. The feeling of withdrawal is simply the compensatory response reaching its full expression because there is no drug effect to counteract it. It is important to note that the anticipation of drug use is what causes withdrawal, not the drug itself. In addition to drug compensatory responses, these withdrawal symptoms can also manifest as neurochemical responses which are felt as cravings. 

What are the different types of drug-related cues? 

There are two broad categories of cues when it comes to the Pavlovian conditioning of drugs: exteroceptive and interoceptive cues. Exteroceptive cues, which are more commonly used in experiments, are those that can be seen, heard, or smelled by both the experimenter and the subject. Interoceptive clues are those that only the subject is aware of which become associated with the administration of a drug. Within interoceptive cues, there are self-administration cues and drug-onset cues. Self-administration cues refer to the ritual that one participates in while administering themselves the drug, such as injecting themselves with a drug intravenously. This kind of cue will also function as a conditional stimulus, bringing about a conditional compensatory response. It has been shown that tolerance is higher after one goes through their typical self-administration procedure than when they are administered the same amount of the drug by an experimenter. Drug-onset cues describe the immediate effect of a drug before its full effect comes through. Drug-onset cues, such as the warm feeling that alcohol tends to immediately elicit, consistently precede the stronger effects of the drug. In rats, it has been shown that administering a small dose of a drug elicits symptoms of withdrawal when the full and expected dose is not then provided. The rats had associated the drug-onset cues with the eventual full drug effect. 

What are the implications of these findings for addiction treatment? 

Behavioral therapies for drug addiction can utilize Pavlovian conditioning. In these therapies, predrug conditional cues can be extinguished by presenting the addict with the conditional cue and denying them access to the drug. It would be helpful to incorporate interoceptive drug cues, including memories, emotions, and cognitions into the pool of conditional predrug cues. Accurate insight into the possible predrug cues for the addict, both exteroceptive and interoceptive, will allow for the most effective drug addiction treatment.

What are the prevalences and causes of anxiety disorders? 

As a group, anxiety disorders are the most common mental health disorders, and they often greatly diminish quality of life. In the DSM-5, the following disorders are listed under anxiety disorders: panic disorder (PDA), agoraphobia, generalized anxiety disorder (GAD), social anxiety disorder (SAD), specific phobias, separation anxiety disorder, and selective mutism. Specific phobias are the most common anxiety disorder, displaying a 12-month prevalence of 10.3% in the general population. PDA is the second most common, with a 12-month prevalence of 6%. SAD and GAD are the third and fourth most common anxiety disorders, with 2.7% and 2.2% 12-month prevalence rates, respectively. Generally, anxiety disorders are chronic, and symptoms fluctuate back and forth over time. However, the only anxiety disorder that still shows up frequently in adults over the age of 50 is GAD. Women are diagnosed 1.5 to 2 times more often with an anxiety disorder than men are. Anxiety disorders are frequently comorbid with depression, personality disorders, and other anxiety disorders. 

Anxiety disorders are thought to be caused by an interaction between a genetic predisposition to the disorder and environmental factors, such as stress, trauma, or adversity during childhood. Although much research has been done, no genetic biomarkers specific to anxiety disorders have been found. 

How are anxiety disorders treated?

Anxiety disorders are commonly treated with psychotherapy, pharmacologically, or a mixture of both. The patients with anxiety disorders who seek help most often suffer from GAD, PDA, and/or SAD. Treatment is not always needed in mild cases, but daily impairment due to the disorder indicates a need for intervention. In rarer cases, patients may need to be hospitalized due to suicidal tendencies, comorbidities, or extreme unresponsiveness to treatment. Patients suffering from certain anxiety disorders (specifically, PDA) are much more likely to seek treatment than those suffering from specific phobias. This may have to do with the perceived severity and imminency of the consequences of a panic attack. Conversely, those with specific phobias might not realize they have a treatable disorder. It had been found that as a group, anxiety disorders go untreated very frequently, with only about 20% of those with an anxiety disorder ever seeking treatment. 

What drugs are used to treat anxiety disorders? 

There are many drugs available to treat anxiety disorders. Selective serotonin reuptake inhibitors (SSRIs) and selective serotonin norepinephrine reuptake inhibitors (SNRIs) are both antidepressants usually prescribed as the first line of defense against anxiety disorders. These drugs are very effective, yet their tendency to increase anxiety symptoms within the first few weeks of treatment may hinder treatment compliance. Because of this, patients are often started at a lower dose of the drug, and work their way up to a higher dose. Many studies show that SSRIs are better tolerated than SNRIs. Withdrawal reactions to SSRIs are possible but unlikely. 

Pregabalin, a calcium modulator, has a sedative effect which is helpful for those with anxiety disorders and a comorbid sleep disorder. This drug works more quickly than antidepressant anxiety drugs but withdrawal is more of an issue. Tricyclic antidepressants are as effective as SSRIs and SNRIs but are associated with more frequent adverse effects. Tricyclic antidepressants should not be used as a first-line defense against anxiety disorders. 

Benzodiazepines are also not recommended for first-line treatment, although they are effective drugs in combatting anxiety disorders. The effects of benzodiazepines are more immediate than the anxiety-soothing effects that come from antidepressants, but they are associated with central nervous system depression, which can cause many adverse effects. Benzodiazepines can be used in coordination with other anxiety-reducing drugs in severe cases, or during the weeks after starting an SSRI or SNRI before it kicks in. 

Drug treatment for anxiety disorders should be continued for at least 12 months after the apparent remission of symptoms in a patient. When the patient does terminate the drug plan, their dose should be tapered off over 2 weeks so as to not cause withdrawal symptoms or other unwanted effects. 

How effective is therapy in psychotherapy in treating anxiety disorders? 

In contrast to drug treatment of anxiety disorders, everyone who suffers from anxiety could benefit from psychotherapy. Cognitive-behavioral therapy (CBT) is especially effective. For those with phobias, exposure therapy techniques are often effective and should be included in treatment. Only 1 to 5 therapy sessions using exposure techniques have been shown to effectively treat phobias. While psychotherapy can be extremely effective in treating anxiety disorders, medication has a stronger pre-post treatment effect size. The effect of therapy on reducing the symptoms of anxiety disorders is similar to that of taking a placebo drug said to treat anxiety. This points not to the relative weakness of psychotherapy but rather the relative strength of a medication-based placebo effect. Both drug treatment and psychotherapy can have a major impact on those suffering from anxiety disorders.