Clinical psychology

The 4d of diagnosis: deviance

Deviance from social norms:

• Based around the idea of social norms (agreed ways of acting/normal behaviours within a society).

• Those who break them are abnormal (abnormal in society), e.g., hearing voices

• Affected by:

  • Culture (different cultures have different social norms)

  • Context (e.g., the clothes you wear in certain situations)

  • Age (certain behaviours expected by different age groups)

  • Gender (certain behaviours expected in males vs females)

  • Historical context (e.g., behaviours that used to be considered abnormal, such as homosexuality, are not abnormal now).

Statistical deviations:

• Those in society who have a characteristic which is infrequent are ‘abnormal’ e.g.,

• If you’re more than 2Sd away from the mean then you might be abnormal

• Illnesses examples - schizophrenia, OCD

The 4d of diagnosis: dysfunction

• If behaviours interfere with a person’s everyday life, it can be used as a way to diagnose mental disorders.

• Dysfunction can affect their working life, for example, not being able to go to work everyday, or complete work that is required if you are there.

• Inability to function normally, live life effectively etc is abnormal. For example, not going out with friends, not going food shopping etc.

• Illnesses examples: schizophrenia, OCD

The 4d of diagnosis: distress

• An abnormal behaviour is abnormal because it causes upset to the individual. E.g., they are unhappy with the symptoms they experience e.g., the symptoms that relate to OCD, Phobias, Depression, Schizophrenia

• Can be thought of on a continuum. Everyone can feel distress at times but persistent and serious distress is a concern and should be considered abnormal.

• Deals with subjective experience – each individual feels their distress uniquely.

• Illnesses examples - schizophrenia, depression, OCD

The 4d of diagnosis - danger

• This relates to people who are a danger to themselves or others (usually because of faulty thinking/behaviour).

• Examples include self-harm, suicide and violence towards themselves, or towards other individuals.

• Can be thought of on a continuum (varying degrees of danger to themselves or others).

• Illnesses examples - schizophrenia, depression

Strengths of deviance

• Deviance takes into account so many factors which make something a social norm e.g. gender, age, historical context etc → it makes this a little more holistic as a definition as it doesn't just say there is only one social norm. One clear example is the inclusion of 'context' as a factor which takes into account the fact that different behaviours may be allowable in different situations.

• Deviance (statistical) makes it more objective as there is a statistical cut off

Weaknesses of deviance

• Some behaviours may be considered deviant by some doctors but not by others, e.g., talking to yourself → using deviance may be subjective because it depends on the psychiatrist's perception of why the person is taking part in something that is deviating from social norms.

• Thomas Szasz suggests that Deviance has an issue with Social Control. In his work 'the myth of mental illness' we take behaviours we view as negative and use our power to diagnose them as a mental health issue.

• It is a reductionist way to decide on abnormality because it does not consider anything about the patient other than whether they fit within norms → means it fails to take into account other factors (like the other Ds) which might be important to make that decision.

• Deviance doesn't take into account the patient's wellbeing like D's such as Distress do. It only considers whether they fit into a social norm or not rather than how their behaviour impacts on them → making it a less complete/useful definition

• One issue is that this can be impacted by cultural factors because hearing voices is seen as normal in some cultures → this makes it a less valid/credible definition of abnormality because it isn't objective if it can change between cultures.

• Some behaviours may be considered deviant but not a symptom of a mental disorder → this makes the definition less valid/credible because if a behaviour breaks a social norm but isn't linked to a mental disorder then we can question how good a definition it is.

Strengths of dysfunction, distress and danger

• This definition is better than deviance as it considers the life quality of the patient as a factor because it talks about dysfunction/ life quality/ distress in their lives (which will damage life quality) → This means it takes into account factors about the wellbeing of the patient themselves rather than just social norms.

• We try to create objective measures of this D which doctors can use to test various illnesses, for example the 5th axis of DSM IV measured 'global functioning' which measures this.

Weaknesses of dysfunction, distress and danger

• Some behaviours may be considered dysfunctional by some doctors but not by others, such as gambling/drinking → using dysfunction may be subjective because it depends on the psychiatrist's perception of why the person is taking part in something that is 'dysfunctional'.

• This definition runs into problems because many behaviours are dysfunctional/ cause distress/ may be dangerous without being classed as an abnormality/ mental health problem e.g., repeated drunkenness → therefore questioning the validity of this definition.

DSM - diagnostic statistical manual

• Created in USA by APA in the 1950s to diagnose mental health conditions to improve the reliability of diagnosis (standardised criteria)

• Illnesses are grouped by family e.g., psychotic illness, affective disorders

• Contains diagnostic criteria for all the different mental health illnesses e.g., Depression must show 5 of 9 items from the list of symptoms for a two week period

The diagnostic interview process

• Clinician interviews the patient finding out about their symptoms and what is going on, eg hearing voices or unable to sleep

• Note key words describing symptoms

• Matches symptoms to ICD symptoms

DSM-V

• Diagnostic criteria - groups illnesses into categories and criteria

• Emerging models/ cultural formations

• Each diagnosis might contain: diagnostic criteria, diagnostic features, associated features, development and course, risk factors, culture and gender related issues, differential diagnosis, comorbidity

• Changes included removing the 5 types of Schizophrenia

• Removing the axis system

• Removing the clause for bereavement in Depression

• Combining Aspergers with Autism to become ASD

• Culturally bound syndromes included

DSM-V changes

• DSM-V is attempting to harmonise with ICD-10 a little more

• It has done away with the axis system

• Now has 3 sections:

  • Organisational and changes

  • Diagnostic criteria Emerging models - all of the illnesses

  • Emerging measures and models

• Reducing ‘over diagnosed’ criteria eg Asperger’s was merged with autism spectrum

• The 5 types of schizophrenia were removed

ICD

• Published by the World Health Organisation (WHO)

• Creates a universal language for healthcare professionals worldwide

• Example: Depression diagnosed in Japan = Depression diagnosed in UK = Depression diagnosed in Brazil

• Translated into 43 different languages--Not just translation- it uses cultural adaptation (Different cultures express mental health differently for example some asian cultures describe anxiety as "heart discomfort" rather than "worry" and other cultures emphasise physical symptoms (tiredness, aches) over emotional ones (sadness)

The dimensional approach

• Old way (Categorical): You either have depression or you don’t

• New way (Dimensional): Mental health exists on a spectrum

• Tracks severity: Mild → Moderate → Severe

• Monitors changes over time e.g.

  • Month 1: Severe symptoms - can't get out of bed

  • Month 2: Moderate symptoms - functioning but struggling with low mood

  • Month 3: Mild symptoms - occasional low days but mostly managing

ICD changes

• ICD-11 removed Asperger's as a possible diagnosis and again incorporated it within the 'Autism Spectrum disorder'

• ICD 11 includes training material to help clinicians use it as well as a table to compare it with ICD 10 to help clinicians use it to diagnose patients with mental disorders.

Aim of Rosenhan study 1

To investigate if sane people who present themselves to a psychiatric hospital would be diagnosed as being insane.

Sample of rosenhan study 1

• 12 different hospitals from across 5 states and included a range of different psychiatric institutions (modern and old, well-staffed and poorly staffed, one was private).

• The pseudopatients in the experiment included 5 men and 3 women.

Procedure of rosenhan study 1

• Pseudo-patients call psychiatric hospitals claiming to be hearing a muffled voice, but they could make out the words 'thud' 'hollow' and 'empty'.

• Once admitted, all participants gave honest life stories.

• As soon as they had been admitted, they claimed the 'voice' had stopped.

• The pseudopatients were observed in a natural, participant, 'covert' observation.

Results of rosenhan study 1

• 100% of pseudo-patients were admitted for treatment for diagnosed mental illnesses - 11/12 hospitals admitted them with Schizophrenia, 1 diagnosed with manic depression

• They remained in hospital for between 7-52 days, with a mean stay of 19 days.

• They were then released with a diagnosis of Schizophrenia "IN REMISSION".

• When in hospital, normal behaviours were viewed as symptoms of the illness by medical staff, e.g., waiting outside the cafe for lunch = ORAL ACQUISITIVE SYNDROME & writing in diaries = PATIENT ENGAGES IN PATHOLOGICAL WRITING BEHAVIOUR.

• A total of 2100 pills were handed to the pseudo-patients (only 2 were actually swallowed).

• Each 'real patient' spent less than 7 minutes per day with psychiatric staff.

• 35 out of 118 patients voiced their suspicions about the pseudopatient not being a 'real' patient.

• Treated inhumanely - ignored

Aim of rosenhan study 2

To see if the tendency toward diagnosing the sane as insane could be reversed

Procedure of rosenhan study 2

A teaching & research hospital was told of the first study and warned that over the next three months one or more pseudo-patients will attempt to be admitted. In reality, no pseudopatients were admitted into any hospital. Staff members rated 'new patients' on scale 1 - 10 as 'how likely to be a fraud'. 193 patients were 'assessed'.

Results of rosenhan study 2

• 41 rated as a pseudo-patient (by staff)

• 23 rated as pseudo-patient (by psychiatrist)

• 19 rated as pseudo-patient (by both)

Conclusion of rosenhan study 1 and 2

We are unable to detect sanity vs insanity

Strengths of rosenhan

• Various style of hospitals over 5 states (and a large number of their staff) which makes the results more generalisable → This means the results about diagnosis could be applied to a wider population of medical staff.

• Standardised procedure e.g., the words (thud, hollow, empty) used when going for diagnosis → This makes the study more replicable as you could repeat it with the same words like thud to see if you get a reliable result about diagnosis.

• The study is high in ecological validity because it was carried out in the staff’s natural environment of hospitals → This means the results about diagnosis could be applied to a wider population of medical staff.

• The study is low in demand characteristics because doctors and nurses didn’t know they were being observed or that the patients being admitted was actually a pseudopatient → This means they wouldn’t have changed their behaviour relating to how they treated the pseudopatients making the results more internally valid.

• The fact that the pseudopatients began acting totally normally when they were admitted means that their misdiagnosis and treatment is a valid representation of real diagnosis and treatment (rather than being influenced by their acting up) → This makes the results about diagnosis and treatment more valid.

• Quantitative and qualitative data were gathered by the pseudopatients → This means the quantitative data about diagnosis can be compared effectively whilst the qualitative data e.g., how they were treated by staff, give more depth and detail so a better understanding of mental health facilities and diagnosis.

• All of the pseudo patients were trained by Rosenhan in their observations meaning there is a high possibility of interrater reliability.

Weaknesses of rosenhan

• Validity issues- As the pseudo patients were admitted, the staff had no reason to think they were faking it, as healthy people do not say they hear voices that are not there. They lied, can’t blame the doctors for getting it wrong (essentially they showed demand characteristics).

• USA hospitas only so the results about validity of diagnosis are ethnocentric and not generalisable → The results about validity of diagnosis might not apply in other cultures like the UK or collectivist cultures.

• Only 12 hospitals were used in this sample so it is small and not generalisable → This means the results about diagnosis might not be representative of diagnosis and treatment in the whole population

• The situations which the pseudopatients found themselves in each hospital couldn’t be standardised and so it might be difficult to replicate → This means the results about diagnosis from the study might not be reliable.

• Since this is a naturalistic observation there will be extraneous variables which impact on the behaviour/treatment of the staff/pseudopatients in each hospital → This might make the results about diagnosis and treatment less valid as the EVs could have an impact.

• There could be bias in the reporting of the pseudo-patients (as this is essentially a participant observation) because they were being held there for so long when not ill → They might have some interpretation in their analysis of the results which makes their reports of treatment etc less valid.

• No inter rater reliability as there was only one pseudopatient per hospital

• Cahalan - suggests rosenhan removed data from a pseudopatient who gave positive feedback about hospitals

Validity in diagnosis

Have we given the correct diagnosis/has the correct illness been diagnosed, and lead to the right treatment for the diagnosed mental health disorder

Predictive validity

• We can suggest how your illness will progress (and we’re right) and/or I can give you medication for your illness and your symptoms should go away

• Eg if I say in 6 months you’ll be having hallucinations, do you?

Aetiological validity

• People suffering from the same disorder should have the same causes for that illnesses

• Eg if depression is genetic then everyone with depression should be carrying that gene

Concurrent validity

• Two separate test/measures give the same diagnosis

• Eg you are diagnosed by both the ICD and DSM and you get the same illness

Construct validity

• Are we measuring the thing we say we are

• Eg are the symptoms for schizophrenia in the DSM the symptoms people get with schizophrenia

Retest (intra-rater) reliability

You get the same diagnosis again when rediagnosed

Inter-rater reliability

Two different doctors give the same diagnosis

Things which affect the validity and reliability of diagnosis

• Standardised symptoms in diagnostic manuals e.g. in depression, should improve validity and reliability

• Updates will increase construct validity - up to date with knowledge and understanding

• DSM 5 includes section 3 which advises cultural issues should be taken into account so these should have less of an effect on the reliability of diagnosis.

• If a classification system is not reliable then it cannot be a valid measurement of mental disorders.

• DSM and ICD differences in criteria might lead to different diagnoses, reducing the validity and reliability of diagnosis

• Co-morbidity – some illnesses overlap and could be diagnosed as one by one doctor and a different, overlapping illness by another doctor.

• Updates can reduce the reliability as the changes in criteria changes the diagnosis

• Patients may lie/omit information due to embarrassment, or not realising something is a symptom.

• Bias e.g. gender or racial bias – misdiagnosing based on race or gender

• Culturally bound syndromes – mental illnesses specific to one culture that may not be diagnosed if the patient is in a different culture when seeing a doctor.