Diagnosis of mental disorders including the 4 D’s

What is deviance?

This means that behaviours and emotions are viewed as unacceptable as they deviate from the norm. One way of deciding whether behaviour is deviant is the concise how unusual it is statistically. Behaviours that occur relatively rarely within the population are abnormal and therefore people who exhibit these behaviours can be considered deviant. If a behaviour is not within two standard deviations from the mean for the population it can be considered statistically abnormal and may be used to diagnose a mental disorder.

Another way to assess deviance is to look at social norms. If violated, this can be seen as abnormal and an individual can be labelled deviant.

What is dysfunction?

When abnormal behaviour significantly interfered with someone’s ability to carry out their usual roles and responsibilities. A person is considered abnormal if they cannot cope with the demands of everyday life - looking after themselves, holding down a job, maintaining relationships, etc.

There are various objective measures that can be used to assess dysfunction, such as WHODAS II which assesses 6 areas of functioning including self care and participation in society.

What is distress?

When negative feelings occur inappropriately or persist longer than they should this is considered abnormal. A clinician can collect quantitative data using scales such as the Kessler Psychological Distress Scale (K!)), a 10 items self report questionnaire which focuses on experiences in the past 4 weeks.

What is danger?

Careless, hostile or hazardous behaviour which may affect the safety of the individual or others. Predicting violent behaviour is difficult, but a history of aggression makes another incident more likely. In the UK, if a person is considered to be an immediate danger to themselves they may be detained under the Mental Health Act and sectioned.

Strength?

The 4 D’s are useful as considering these dimensions can help prevent incorrect diagnosis. For example, if we only used deviance then many behaviours that are eccentric though harmless to the individual and others may be falsely diagnosed. On the other hand, symptoms of depression may be missed as they affect a large minority of society. Therefore, using the 4 D’s in combination is useful as it allows clinicians to determine if the patients behaviour requires further investigation using classification systems.

Two weaknesses?

Labelling, risk of subjectivity

Explain labelling in relation to the 4 D’s

A problem with using the 4 D’s as a method of diagnosis is that it can lead to stigmatisation of people with mental health issues. For example, using danger as a criteria leads to the perception that people with mental health issues are dangerous. When in reality, this is not always the case, for example people with diagnosed schizophrenia are considered less dangerous than people with undiagnosed schizophrenia (Fazel et al 2009). This can then lead to people not seeking treatment for fear of being unfairly labelled or even cause self-fulfilling prophecies where the stereotypes cause people to act within the stereotypes of their diagnosis.

Explain risk of subjectivity in relation to the 4 D’s

A problem with using the 4 D’s is that there may be subjectivity in utilising this as a method of diagnosis. Definitions of behaviour are not a standardised way of measuring health. What is considered ‘dysfunctional’ or ‘dangerous’ may differ for each clinician. This lack of objective measurement could lead to different professionals making different diagnoses of the same patient, potentially leading to incorrect diagnoses and subsequent treatments.

One improvement that could be made to the 4 D’s?

A fifth dimension could be added which may make the 4 D’s a more useful method of considering diagnosis. David (2009) suggests that it is also important to consider duration of symptoms when making a diagnosis as this can affect disorders. For example, some psychotic disorders are characterised by the different duration of symptoms. Therefore, not considering duration may lead to the wrong disorder being diagnosed, and incorrect subsequent treatment being given.