Abnormal Psychology: Session 3: Diagnosis of Mental Disorders

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Abnormal Psychology

Session 3: Diagnosis of mental disorders


Today’s Learning Outcome

Discuss reliability and validity of diagnosis

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What is diagnosis?

 Diagnosis within psychology means


identifying and classifying abnormal
behaviour on the basis of symptoms, the
patient’s self reports, observations, clinical
tests or other factors such as information
from relatives
The purpose of diagnosis

 To identify groups of similar sufferers so that


psychiatrists and psychologists may develop
explanations and treatment methods to help
those groups

 Billing purposes. The government and many


insurance companies require a diagnosis for
payment
Diagnosis

 Diagnosis of Mental Disorders is difficult

 Issue of drawing the line between what is seen as normal behavio


and what is seen as or ‘abnormal’ behavior.

 Because it is difficult to define it is also difficult to diagnose.


What do we mean by reliability and validity
of diagnosis?
 Reliability of diagnosis: Will different diagnosticians
using the same classification system arrive at the same
diagnosis?

 Validity of diagnosis: Does the person diagnosed have


real symptoms with a real underlying cause? (the illness
is not socially constructed, the person is not faking)
What five ways of defining what is abnormal has been studied?

1. Deviation from social norms


2. Deviation from ideal mental health
3. Statistical infrequency
4. Failure to function adequately
5. Mental illness criteria

 Those making diagnoses use a combination of


these factors when making their diagnosis of
mental disorders. They use standardized systems
which aim to increase validity and reliability of
diagnosis.
How are mental disorders diagnosed?

 While a doctor looks for signs of disease using X-


rays, scanners, or blood tests, as well as
observable symptoms, the psychiatrist will often
have to rely primarily on the patient’s subjective
description of the problem.

 This reduces validity and reliability.


How are mental disorders diagnosed?
 Clinical interview is most commonly used means of assessment
 Interview usually involves face to face contact with clinician
 Although format may vary, most interviews cover these topics:
 Identifying data: contact details, marital status, age, gender, employment,
religion, employment
 Description of presenting problems: What are troubling
behaviours/feelings/thoughts? How do they affect functioning? When did they
begin?
 Psychosocial history: Information describing client’s history: educational, social,
early family relationships etc
 Psychiatric history: History of psychiatric illness/past treatment
 Medical problems/medication: Description of medical problems/medication. May
link to psychological problems

 Today the clinician—often a psychiatrist—uses a standardised


diagnostic system e.g. DSM-IV, ICD
Issues with clinical interviews
 Kleinmutz (1967) has noted that there are limitations to
this interview process that can affect reliability/validity of
diagnosis:

◦ Information exchange may be blocked if either the patient or the


clinician fails to respect the other, or if the other is not feeling well.
(e.g. what if the patient is mute?)
◦ Intense anxiety or preoccupation on the part of the patient may affect
the process.
◦ A clinician’s unique style, degree of experience, and the theoretical
orientation (e.g. Cognitive or biological psych) will definitely affect the
interview.
How are mental disorders diagnosed?
In addition to interviews, other methods can be used to assist with
diagnosis.

These include:
 direct observation of the individual’s behaviour

 brain-scanning techniques such as fMRI and PET (especially in cases

such as schizophrenia or Alzheimer’s disease)


 psychological testing, including personality tests (e.g. MMPI-2) and

IQ tests (e.g. WAIS-R).


The Two Major Classification Systems

DSM ICD
Diagnostic and Statistical Manual of Mental Disorders International Classification of Diseases

These classification systems are constantly being revised,


mental disorders are added, deleted and reorganized in
the light of new research evidence
Classification Systems
 Thetwo major classification systems used by western psychiatrists today, the DSM
DSM-IV –TR Diagnostic and Statistical Manual of Mental Disorders, (American
Psychiatric Association, 1994) and the lCD-10 International Classification of
Diseases, (WHO, 1992)

 Based
largely on abnormal experiences and beliefs reported by patients, as well as
agreement among a number of professionals as to what criteria should be used.

 This
can explain why the criteria change in revisions of the diagnostic manuals, for
example homosexuality was included in earlier versions of the DSM.

 Some argue that the difficulties met in trying to identify haracteristics of


“abnormality” reflect the fact that abnormal psychology is a social construction that
has evolved over time without prescriptive and regulating definitions. It is also
argued by some that the DSM-IV is gender and culturally biased. This effects the
reliability of diagnosis
The DSM
 While the main purpose of the ICD is the classification of
disorders, the DSM classification system has the additional
purpose of assisting clinicians to diagnose a persons problem
as a particular disorder.

 Diagnosis is important because it determines treatment.

 The DSM-I was published in 1952. The DSM-II and DSM-III


caused a lot of debate amongst clinicians because there was a
lack of consensus of the precise listing of disorders (Davison et
al. 2004).

 The DSM-IV was published in 1994 and the DSM-IV-TR (text


revision) was published in June 2000, and the long awaited
DSM-V is coming out this year (2013).
DSM-IV-TR
 The classification system used in the United
States
 Lists more than 250 mental disorders
 The diagnosis of one individual is based on
five dimensions
The five dimensions of DSM-IV-TR
 Axis I: The major diagnostic classification, e.g. major
depressive disorder, anorexia
 Axis II: Related to developmental and personality
disorders (e.g. autism, anti-social personality)
 Axis III: Physical and medical conditions that may
worsen the disorder (e.g. brain injury, drug abuse,
viruses)
 Axis IV: Psychosocial stressors, all stressful events
that may be relevant to the disorder (e.g. poverty,
divorce, loss of job)
 Axis V: Global assessment of functioning. Rates the
highest level of social, occupational and
psychological functioning on a scale of 1 (persistent
danger) and 90 (good in all areas) currently and
during the last year
Have a go!

 Read through the descriptions of each party


guest
 Using some of the descriptors from Axis II

(personality disorders) try to identify which


personality disorder each guest has
 Work individually
 We will compare answers when you have

finished
Task
 Watch the video critique of the DSM
 What are the issues with validity and

reliability?
 Remember you also need to think critically

about the source itself as well!


The ICD: International Classification of
Diseases
 The current edition – the ICD-10 was published in 1992 by
the WHO – the ICD-11 is expected to be published in 2015

 Mental disorders where included in the ICD in 1952 (ICD-6)


 Main purpose of ICD is to make it easier to report health
statistics.
 Enables universal agreement on the definitions of specific
disorders or sets of syndromes – without these it would be
very difficult for clinicians and researchers in different
countries to communicate with each other.
 The ICD identifies 11 general categories of mental
disorders.
ICD 11
Mental
Disorder
Categories
Reliability & Validity of Diagnosis
 Use of the DSM and the ICD increase the validity
& reliability of diagnosis

 Diagnostic systems provide a template which the


clinician can use to compare information about
disorders to the condition of a particular client.

 In this way, clinicians can use the same models


for diagnosis.
Reliability of Diagnosis

 The difficulty arises over whether classification can indeed


be made effectively using classification systems.

 For a classification system to be reliable, it should be


possible for different clinicians, using the same system, to
arrive at the same diagnosis for the same individual. (this is
known as inter rater reliability)

 Although diagnostic systems now use more standardised


assessment techniques and more specific diagnostic
criteria, the classification systems are far from perfect.
Reliability of Diagnosis

Mitchel et al. (2009)


 Carried out a meta-analysis of 41 clinical trials with
(50,000 patients) that had used semi- structured
interviews to assess depression

 General Practitioners (GPs) had an 80% reliability in


identifying healthy individuals and 50% reliability in the
diagnosis of depression.

 GPs had problems making an accurate diagnosis of


depression.
Reliability of diagnosis
Cooper et. al. (1972)
 When shown the same video clips, New York
psychiatrists were twice as likely to
diagnose schizophrenia than London
psychiatrists.
 London psychiatrists were twice as likely to
diagnose mania or depression than New
York psychiatrists
Reliability of Diagnosis

Spitzer and Williams (1985)


 Showed that psychiatrists only agree in diagnoses

about 50% of the time.


Issues surrounding the validity of diagnosis

 The labelling of patients with certain disorders may affect the

practitioners perceptions of them (compare with researcher bias),

patients may act the label that has been given to them (self fulfilling

prophecy). The label itself may simplify a problem that is highly


complex

 People may fake mental illness in order to avoid punishment (The

insanity defense)

 There are significant individual differences for mental disorders. An

individual may have multiple mental disorders


Validity of diagnosis

Temerline (1970)
 Clinically trained psychiatrists were influenced in

their diagnosis by hearing the opinion of a


respected authority (expert influence)
 Participants watched a video-taped interview of a

healthy individual.
 The authority claimed, even though the person only

seemed to be neurotic (distress where behaviour is


not outside social norms, patient has not lost touch
with reality) he was actually psychotic (behaviour is
outside social norms, loss of touch with reality)
Validity of diagnosis

Comer (2004)
•Over inclusion and ‘patholologizing’ problems
•The DSM keeps expanding
•According to Comer 48% of Americans might qualify for
a diagnosis on the DSM.
•E.g. mood changes with the menstrual cycle should that
really be seen as ‘Pre Menstrual Dysphoric Disorder’?
This could be seen as ‘pathologizing’ what is normal
behavior for women (gender bias).
Key Study: Rosenhan (1973) Covert Observation: On being Sane
in Insane Places (pg 142)
The impact of Rosenhan’s (1973) classic study: on being
sane in insane places
 In the 1960s and 70s there was some concern among
psychiatrists that they gave diagnosis of schizophrenia too
readily.

 There was an even greater concern that many people where


admitted to mental hospitals when they were not mentally ill, and
once admitted they were detained and given treatment without
their informed consent.

 Rosenhan’s key study supports this and led to the revision of


the DSM.

 Rosenhan's study raises questions about the content validity of


the DSM.

 Content validity being whether the DSM actually measures what it


sets out to measure.
The impact of Rosenhan’s (1973) classic study: on being sane
in insane places
 Validity is always going to be a problem for mental health workers –
because unlike physical illnesses – the symptoms are not clear cut

 E.g. a person suffering from schizophrenia may or may not exhibit


paranoia, they may or may not hear voices.

 Rosenhan’s research showed the low level of validity in the diagnosis of


mental illness

 However – the diagnosis was high in inter rater reliability – since nearly
all the ‘pseudo patients’ where given the diagnosis of schizophrenia –
but this was not a valid diagnosis.

 This shows that a diagnosis may be high in reliability and low in validity
at the same time.

 Each edition of the DSM attempts to improve both the reliability and
validity of diagnostic criteria.
Task
 Look at page 142 in your textbook
 Answer the questions about Rosenhan’s

study in the ‘Be a critical thinker’ box


A method to improve reliability and
validity: The Composite International
Diagnostic Interview
 Andrews & Peters (1997) developed the CIDI to improve
the reliability and validity of the DSM.

 This involves the client working through a structured


interview either using a computer program or with an
assistant.

 They answer a range of questions on psychological


disorders and their responses are used to determine
which questions from the pool are asked or omitted.

 If enough symptoms occur in patterns or clusters, then a


diagnosis is made. All this is done by a computer
program.
The Composite International
Diagnostic Interview
A more acceptable method
 Patients feel more comfortable answering

questions on a computer
 It gave them the opportunity to reveal symptoms

they had never been asked before


 Less subjective

High reliability and validity


 Research suggests that the CIDI is high in validity

and reliability
Evaluation: limitations
 There is a large amount of research supporting
the view that the reliability and validity of
diagnosis are poor. This is due to many reasons,
e.g. a possible social construction of mental
illness, poor diagnostic tools, the possibility of
faking, social influence, errors in attribution by
practitioners and labeling
 There are significant individual and cultural
differences for the symptoms of mental
disorders.
 An individual may have multiple mental disorders
 A wrong diagnosis may lead to a social stigma
(an ethical issue)
Counter argument
 There are methodological problems with the studies on
validity and reliability (researcher bias, generalisability,
ecological validity)
 Revised diagnostic tools are higher in reliability than
earlier versions, e.g. DSM-IV-TR
 Many people do seek help voluntarily for disorders (which
may mean that the disorder is valid)
 The reliability of diagnosis is high for some disorders,
e.g. obsessive compulsive disorder
 There are many similarities of disorders across cultures
 Diagnostic systems do not classify people, but the
disorders that they have
 Alternative methods for diagnosis are being developed all
the time
Key Terms Test

Have a go at defining the following terms


Validity

Reliability

ICD

DSM

Diagnosis

Classification
Key Terms Reminder

Validity: this is the extent to which the diagnosis is accurate.

Reliability:
this is how effective the use of a particular method of diagnosis (for example the DSM) is at
identifying a disorder.

ICD:(International Classification of Diseases and Related Health Problems): The classification system
for medical and mental health problems used by the World Health Organization (WHO).

DSM: (The Diagnostic and Statistical Manual of Mental Disorders): The classification and diagnosis
system developed by the American Psychiatric Association (APA).

Diagnosis: is the process of identifying a medical condition or disease by its signs (what the physician
sees), symptoms (what the patient says), and from the results of various diagnostic procedures.The
conclusion reached through this process is called a diagnosis. Diagnosis is a clinical judgment on the
part of the psychiatrist.

Classification:
A list of disorders along with descriptions of symptoms and guidelines for making
appropriate diagnosis (Comer, 2004). For example, deciding what schizophrenia is as apposed to
depression.

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