Behavioural Science Blog

The Science of Human Behaviour

Posts Tagged ‘mental health

Research on classification and case formulation

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It has been postulated (for example see Persons & Miakami) that psycho diagnostic evaluation is an important phase in the treatment of psychopathology. However there is a fierce battle going on between those that argue for a stepped-care model in mental health care and those that argue that we should rather look at the specific needs of an individual (matched care – could not find a suitable link -why?).

Connected to that is the question of how much information about the client you need in order to start treatment and if there is an amount of client information that is enough (that does not enhance the quality of the treatment plan any more).

If you can suffice with the DSM or ICD classification for treatment planning – why should you waste time on making an elaborate functional analysis of the client’s problems? However research (Persons & Miakami) has shown that treatment is not successful in about 40% of the cases and can be improved if diagnosticians make a functional analysis. This can sometimes help to focus treatment on the most important factor that keeps the client from getting healthy.

On the other hand Garb (1998 – it’s a book – for an overview read his 2004 paper: Clinical Judgment and Decision Making) has reported that lively details can influence clinicians to the degree that they make a wrong judgment about treatment decisions.

Thus we would like to know how much information should a therapist have in order to make a good treatment planning? Below I give you are plan for study 1 (total of 5 studies) with which we would like to start-up this line of research. It’s still in the planning phase and things have been changed around a lot, but we have found the direction I guess. I would like to ask you some feedback on this research.

Do you think this study answers the research question?

What do you think is the minimum amount of information that still feels “natural”?

What kind of disorders and empirically supported treatments (EST) would you chose?

What do we need to take care of when writing the vignettes?

Thanks a lot for your feedback. This is an experiment in itself: Can the global community of researchers and therapist help on improving this research idea? Can we work together – even though we will never meet? Or will someone steal this idea and conduct the research themselves? I am very thankful for your critical comments!


Research Proposal Study 1

Study 1 addresses the question whether increasing amounts of diagnostic information, from classification only to classification plus extensive case formulation, changes clinicians’ treatment plans. On the basis of the literature and in line with national and international treatment guidelines, three frequently occurring DSM-IV Axis-I (clinical syndromes) disorders are selected for which familiar first-choice psychological ESTs are available. Using real patient files as a starting point, clinical vignettes are constructed, each one presenting a patient suffering from one of the selected DSM-IV disorders. These three vignettes are rewritten in such a way as to generate three Diagnostic Classification (DC) versions: DC, DC+, and DC++. Starting with the most complete DC++ versions, increasingly information is deleted to come to the DC+ and the DC versions. DC vignettes comprise 5-8 lines. From the DC++ versions information is removed, save: 1. demographic information (e.g., sex, age, marital status, children, current job), 2. treatment history (in all vignettes: ‘moderately successful pharmacological treatment only’), 3. current complete DSM-IV diagnosis, and 4. a recommended EST. DC+ vignettes are twice as long as DC vignettes and comprise 10-16 lines. They contain all the information that is available in DC vignettes, plus further anamnestic and psychodiagnostic information (e.g., family background, life history, personality). On the other hand, all lively details in the DC++ versions have been removed, in line with findings of Garb (1998) that clinicians are biased towards lively details in patients’ life histories. DC++ vignettes comprise 20-32 lines. They contain lively details originating from the patient files of real patients that are used as a starting point. The vignettes are piloted and tested for their ecological validity (cf. De Kwaadsteniet, Krol, & Witteman, 2008; Hutschemaekers, Tiemens, & Kaasenbrood, 2005; Witteman & Koele, 1999).

By contacting mental health institutes, 90 psychologists or psychiatrists are sought who have been involved in the intake and diagnosis of outpatients at least once a week for at least five years, and who are willing to participate in a study on diagnostic decision-making carried out by email. Each participant receives 3 vignettes. The participants are told that these three diagnostic reports were made by experienced clinicians of a large mental health institute. The participants are asked per vignette to address the following three issues: 1. What do you think of the recommended psychological treatment?, 2. Do you have recommendations for additional treatment or interventions?, and 3. Do you want to add contra-indications for certain interventions? Using a Latin Square Design for the selection of vignettes, it is ensured that for each participant all three patients and each of the three versions (DC, DC+ or DC++) are represented, and that all combinations (patients x versions) occur equally as often. For each of the three patient vignettes 30 DC, 30 DC+, and 30 DC++ versions are available. Power tables show that with alphas set at .05 and n = 30 in each cell, moderate to large effects can be identified with a power of .80 (Garssen & Hornsveld, 1992). When comparing the vignette versions without further regard to the patients, there are 90 versions in each cell, enough power to detect small effects.

We expect that the more diagnostic information is left out of the vignettes, the lower the variability in treatment suggestions of the participants. The hypotheses are that the evaluations of DC++ versions compared to evaluations of DC+ and DC versions, and evaluations of DC+ versions compared to DC versions show: 1. more deviations from recommended, first choice EST, and 2. larger numbers of indicated and contra-indicated treatment suggestions.


Please give us some feedback – we are also thankful for questions and remarks about what is clear/not clear and about what you like/dislike! Also you might want to suggest a flash title for our research!

How do biases affect decision making in mental health?

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Bias in treatment recommendations is a problem health care in general. The focus on my research looks specifically at the biases in mental health care. In this field we find literature that suggests certain disorders are viewed as more “psychological” in nature and others are viewed as more “biological” in nature, and to some degree, there is evidence for this distinction (for example, see Ahn et al., 2009). However, this thinking can be problematic for two reasons: (1) mental health clients with a disorder that is viewed as more psychological in nature than biological in nature are seen to be more at fault for having their illness (Miresco & Kirmayer, 2006); and (2) holding someone accountable for his or her illness is associated with recommending psychotherapy for treatment rather than medication (Miresco & Kirmayer, 2006; Ahn et al., 2009). Perhaps this seems logical, if the cause is psychological then psychotherapy should be the best treatment choice, and when the cause is biological then medication should be the best treatment. However, this implies dualistic thinking. That is, when considering that psychological symptoms are best treated by medication it implies that there is a separation between the psychological and the biological self. Dualism assumes that our mind is non-material and therefore separate from our physical beings. The current paradigm in psychology rejects this notion and teaches materialism. According to the materialist paradigm our mind and body are both made of matter and therefore are not to be treated as separate parts of the person that need to be treated different. This is confirmed from our knowledge that changing our cognition can change the physical aspects of our brains, and also that medication can change our cognition. Additionally, we know that psychotherapy and medication both affect the brain (Kandel, 1998). Therefore, the bias that distinguishes psychological and biological causes of disorders can negatively affect the way we view individuals with mental illness and the treatment that is recommended for them.

In the current literature we see that when people are held responsible for the cause of their illness, whether it is a physical or mental illness, they are stigmatized (i.e. Crisafulli, von Holle, & Bulik, 2008). My current research seeks to understand whether the treatment choice of clinicians (and opinions of laypeople) differs when the client is clearly to blame for the causes of his/her mental disorder compared to when the client is not at blame for the causes of his/her mental disorder. One prediction of my research is that explicitly ascribing blame to the client will influence treatment choices such that those at blame are more likely be prescribed psychotherapy over medication for treatment.

To fully understand the influences of attitudes and biases in clinical decision making it is imperative to examine the biases themselves, the nature of the biases, and how they affect decision making and client care. Researching what biases exist in mental health care is important to further understand how these biases develop and the impact they might have in the mental health field. It is also imperative to look for ways to reduce biases in practice, either by awareness, training, or use of decision making aids.


Ahn, W., Proctor, C., & Flanagan, E.H. (2009). Mental Health Clinicians’ Beliefs About the Biological, Psychological and Environmental Bases of Mental Disorders. Cognitive Science (33), 147-182.

Crisafulli, M. A., Von Holle, A., & Bulik, C. M. (2008). Attitudes toward anorexia nervosa: The impact of framing on blame and stigma. International Journal of Eating Disorders 41(4), 333-339.

Kandel, E. R. (1998). A new intellectual framework for psychiatry. American Journal of Psychiatry (155), 457-469.

Miresco, M. J. & Kirmayer, L. J. (2006). The persistence of mind-brain dualism in psychiatric reasoning about clinical scenarios. American Journal of Psychiatry (163), 913-918.

Written by Christina S

October 26, 2009 at 3:34 pm

Developmental Psychopathology

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The study of developmental psychopathology is a multidisciplinary approach for studying factors that contribute or impede mental health. These factors can be internal (for example genes) or external (environment) and are conceptualized not as directly influencing mental health, but as building vulnerabilities or enhance adaptation. It is assumed these factors differ in their mechanics according to age. Data about the risk factors and protective factors is recorded by the means of longitudinal studies and then analyzed with their regard to adaptive versus maladaptive developmental outcome. Psychopathology is expected to be found in individuals that are exposed to many risk factors during their development, without access to protective factors that can counteract maladaptive development.

Most studies conducted within the field of psychopathology employ a framework of several factors that spread through multiple levels (macro, exo, micro, intogenetic) from society to the individual. Normal development is studied next to pathological development in order to better understand the processes at hand and their interaction with each other.

Research so far has stressed the influence of the microsystem (family, school and work) for the development of the child. Especially factors related to the quality of parenting have shown to exert much influence on the individual development as either source of or buffer against stress. A well functioning microsystem might be the cause why some children who grow up under bad conditions never develop psychopathology and why children who seem to have perfect premises for a good development do develop psychopathology.

Early inadequate treatment in parent-child interactions might play an important role in maladaptive developmental path, as maltreated children show difficulties in dealing with emotional stimuli. Research supports a sensitization model that leads to stronger emotional reactions with repeated exposure. Biological effects of this developmental path might be connected to altered activity of the hypothalamic-pituitary-adrenocortical-system.

As the toddler grows affect regulation is transferred from the parents to the child. If the emotional system is not able to handle the stress of this transition the child will regard internal affective information as a threat and start to avoid this information. This will impair further development as affect regulation is regarded to be a central process in successfully achieve later developmental stages.

This is especially evident when in kindergarten or primary school peers start to become more important as social interaction partners. Maladaptive development in earlier stages often leads to aggression and/or social withdrawal. Maladaptive social interaction not only keep others from becoming important protective factors, it can also be a source of tremendous stress.

Studying extreme maladaptive development might enable us to understand developmental processes that usually are too subtle and gradual to be observed by the current methodology.

While most social sciences try to reduce reality to a few variables for any given hypothesis, developmental psychopathology often deals with massive amount of data to get as close to reality as possible. New methodological analysis such as structural equation modeling are often used to identify effects that go beyond simple cause and effect relations between to factors, as bidirectional influences between the child and his environment are considered to be an important process.

Written by Martin Metzmacher

April 1, 2008 at 1:02 am