20.3 Psychology
Key Takeaways
- Major depressive disorder requires depressed mood or anhedonia plus at least four additional symptoms for two weeks, including sleep/appetite change, fatigue, guilt, poor concentration, and suicidal ideation — medical causes must be excluded first
- Generalized anxiety disorder involves excessive worry on most days for six months with restlessness, fatigue, concentration difficulty, irritability, muscle tension, and sleep disturbance
- Cognitive behavioral therapy (CBT) is evidence-based for depression and anxiety; the cognitive triad in Beck's model is negative views of self, world, and future
- Schizophrenia requires two or more characteristic symptoms for one month (delusions, hallucinations, disorganized speech, grossly disorganized behavior, negative symptoms) with functional decline — antipsychotics are first-line, not benzodiazepines alone
- Suicidal ideation with plan or intent is a psychiatric emergency requiring immediate risk assessment, removal of means, and referral — do not promise confidentiality when life is at risk
Why Psychology Matters on Part II
Psychology and mental health items appear throughout Associated Clinical Sciences and overlap with General Diagnosis and Chiropractic Practice. Patients with depression, anxiety, somatization, and chronic pain occupy chiropractic offices daily. Part II tests whether you can recognize DSM-level patterns, apply basic theoretical frameworks, communicate safely, and refer when disorder exceeds your scope — not whether you can provide psychotherapy.
The clinical framework: Is this normal stress or a disorder? Is there a medical mimic (hypothyroidism, B12 deficiency, substance use, medication effect)? Is the patient safe (suicide, homicide, psychosis)? What is the appropriate role of the chiropractor (support, co-manage, refer)?
Major Theories and Concepts
| Theory | Key Figure | Core Idea | Clinical Application |
|---|---|---|---|
| Psychoanalytic | Freud | Unconscious conflict, defense mechanisms, psychosexual stages | Transference, resistance — mainly historical context on boards |
| Behaviorism | Skinner, Watson | Learning through conditioning (classical and operant) | Exposure therapy, reinforcement schedules for habit change |
| Cognitive | Beck, Ellis | Thoughts drive emotions and behavior; maladaptive cognitions are targetable | CBT — most tested modern therapy |
| Humanistic | Rogers | Unconditional positive regard, self-actualization | Patient-centered communication, empathy in informed consent |
| Biopsychosocial | Engel | Biology, psychology, and social context interact in illness | Chronic pain model — fits chiropractic whole-person care |
Beck's Cognitive Triad (High-Yield)
In depression, patients hold negative views of:
- Themselves ("I am worthless")
- The world ("Nothing ever works out")
- The future ("It will never get better")
Cognitive distortions include all-or-nothing thinking, catastrophizing, and personalization. CBT identifies and challenges these automatic thoughts.
Defense Mechanisms (Board Favorites)
- Denial: refusing to accept reality (ignoring a serious diagnosis)
- Projection: attributing one's own unacceptable feelings to others
- Displacement: shifting emotion from the true target to a safer one (yelling at staff after bad news from doctor)
- Rationalization: creating logical excuses for unacceptable behavior
- Sublimation: channeling impulses into socially acceptable activity (aggressive athlete)
- Reaction formation: behaving opposite to true feelings
Mood Disorders
Major depressive disorder (MDD) requires five or more symptoms for at least two weeks, with at least one being depressed mood or anhedonia (loss of interest/pleasure):
- Depressed mood most of the day
- Markedly diminished interest or pleasure
- Significant weight change or appetite disturbance
- Insomnia or hypersomnia
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feelings of worthlessness or excessive guilt
- Diminished concentration
- Recurrent thoughts of death or suicidal ideation
Persistent depressive disorder (dysthymia) is chronic low mood for two or more years with fewer acute symptoms. Bipolar I requires at least one manic episode (elevated/irritable mood plus increased energy for ≥1 week, with distractibility, decreased need for sleep, grandiosity, risky behavior, flight of ideas — often requiring hospitalization). Bipolar II has hypomania plus major depression without full mania. Antidepressant monotherapy without a mood stabilizer can trigger mania in bipolar disorder — a classic safety question.
Seasonal affective disorder is recurrent depression linked to seasons, often treated with light therapy.
Anxiety, Trauma, and Psychotic Disorders
Generalized anxiety disorder (GAD): excessive anxiety and worry about multiple events, more days than not for at least six months, plus three or more of: restlessness, fatigue, concentration difficulty, irritability, muscle tension, sleep disturbance.
Panic disorder: recurrent unexpected panic attacks (surge of fear with palpitations, sweating, trembling, shortness of breath, chest pain, dizziness, fear of dying) plus persistent concern about future attacks or maladaptive avoidance.
Specific phobia is marked fear of a specific object or situation; social anxiety disorder is fear of scrutiny in social settings. Agoraphobia is fear of situations where escape might be difficult.
Obsessive-compulsive disorder (OCD): obsessions (intrusive thoughts) and compulsions (repetitive behaviors performed to reduce anxiety). Insight is often preserved — distinguish from psychosis.
Post-traumatic stress disorder (PTSD): exposure to actual or threatened death, serious injury, or sexual violence, then intrusion symptoms (flashbacks, nightmares), avoidance, negative mood/cognition changes, and hyperarousal (startle, hypervigilance) lasting more than one month. Acute stress disorder is similar but lasts 3 days to 1 month after trauma.
Schizophrenia requires two or more for one month (at least one must be delusions, hallucinations, or disorganized speech): delusions, hallucinations (often auditory), disorganized speech, grossly disorganized or catatonic behavior, negative symptoms (flat affect, avolition). Continuous signs for six months with functional decline. Positive symptoms respond better to antipsychotics than negative symptoms. Schizoaffective disorder combines schizophrenia with a major mood episode.
Personality Disorders, Somatoform Patterns, and Substance Use
Personality disorders are enduring maladaptive patterns inflexible across contexts, onset by early adulthood:
- Borderline: instability in relationships, self-image, and affect; fear of abandonment; impulsivity; self-harm
- Antisocial: disregard for others' rights, deceitfulness, lack of remorse (must be age 18+ with conduct disorder history)
- Narcissistic: grandiosity, need for admiration, lack of empathy
Somatic symptom disorder involves distressing somatic symptoms plus excessive thoughts, feelings, or behaviors related to those symptoms — common in chiropractic populations. Distinguish from factitious disorder (intentional production for sick role) and malingering (intentional production for external gain such as litigation).
Substance use disorder criteria include impaired control, social impairment, risky use, tolerance, and withdrawal. Alcohol withdrawal can progress to delirium tremens (tremor, autonomic hyperactivity, hallucinations) — a medical emergency, not an adjusting opportunity.
Assessment and Case Management
Mental status examination (MSE) components: appearance, behavior, speech, mood (patient's report) versus affect (observer's impression), thought process and content, perceptions (hallucinations), cognition (orientation, memory, attention), insight, and judgment.
Suicide risk assessment — ask directly about ideation, plan, means, intent, and protective factors. High risk (plan, intent, access to means, prior attempt, psychosis, substance intoxication) requires immediate emergency referral and do not leave the patient alone. Tarasoff-type duties may apply when there is identifiable threat to others (varies by jurisdiction — Part II tests general duty to act).
Chiropractic case management principles:
- Establish rapport and informed consent; document mood and behavior affecting compliance
- Use biopsychosocial framing for chronic pain — catastrophizing and fear-avoidance worsen outcomes
- Co-manage with mental health providers for moderate-to-severe disorder; continue musculoskeletal care when appropriate
- Refer urgently for psychosis, mania, active suicidality, severe substance withdrawal, and eating disorders with medical instability
- Maintain professional boundaries; dual relationships and inappropriate self-disclosure undermine care
Chiropractic Relevance
Depression and anxiety amplify pain perception and disability. Patients with somatization may seek repeated adjustment for undiagnosed medical or psychiatric illness. Flat affect, disorganized speech, or command hallucinations are referral flags before any cervical manipulation. Always screen medical mimics (thyroid disease, anemia, B12 deficiency, medication side effects) when mood symptoms are new.
Takeaways: MDD needs five symptoms for two weeks; GAD needs six months of worry; bipolar needs mood stabilizers before antidepressants alone; PTSD needs trauma exposure plus one month of symptoms; schizophrenia needs antipsychotics; and suicidal plan plus intent equals emergency — not confidentiality.
A 41-year-old woman reports low mood, loss of interest in hobbies, insomnia, fatigue, poor concentration, and feelings of worthlessness daily for the past three weeks. Medical workup is unrevealing. How many total symptoms are required to meet criteria for major depressive disorder?
According to Aaron Beck's cognitive model of depression, which triad best describes the patient's core distorted beliefs?
A 26-year-old man describes one week of elevated mood, decreased need for sleep, pressured speech, and reckless spending. He has no history of similar episodes. Before starting a selective serotonin reuptake inhibitor for presumed depression, what must be ruled out?
During a new-patient interview, a man states he has been hearing a voice telling him to harm his neighbor and says he has a loaded firearm at home. What is the most appropriate immediate action?