Abnormal Psych Chapter 4

Chapter 4: Classification, Diagnosis, and Assessment

Overview

• Classification

• Problems associated with classification systems

• Diagnostic Process

Classification

• Classification is the beginning of a process leading to a deeper understanding of basic principles, rather than merely labeling.

• Developed with strong influence from the classification of physical diseases.

Understanding Syndromes

• Individuals showing a consistent pattern of symptoms without treatment are categorized under the same syndrome (e.g., malaria).

• Syndrome: A collection of symptoms occurring together in a particular condition.

Main Goals of Psychopathology Classification

• Identify distinct patterns of abnormal behavior.

• Understand the causes and influences of such behaviors.

• Formulate rational treatment plans.

• Detect early signs of disorders.

Development of Classification Systems

• ICD-6 (1949): World Health Organization included a section for psychiatric disorders.

• DSM-I (1952): Created by the American Psychiatric Association to replace the ICD-6.

• Heavily influenced by Freud’s psychodynamic theories.

• DSM-I focused on reactions of personality to psychological or biological events.

Evolution to DSM-II

• Revised in 1968 leading to DSM-II with a 50% increase in listed disorders.

• Removed “reaction” terminology but remained influenced by Freudian concepts (e.g., depressive neurosis).

Issues with DSM-II

• Concerns regarding accuracy and consistency.

• David Rosenhan's research highlighted the subjective nature of psychiatric diagnoses.

• Demonstrated poor interrater reliability among clinicians.

DSM-III Improvements

• Criteria in DSM-III were more objective—focused on observable behaviors rather than intrapsychic causes.

• Introduced a multiaxial approach to diagnosis.

Revisions to DSM

• DSM-III-R (1987): Addressed inconsistencies, modified categories based on DSM-III learnings.

• DSM-IV (1994) aimed for consistency with ICD-9.

• DSM-IV-TR (2000): Minor updates without changing criteria.

Multiaxial Diagnostic Framework

• Axis I: Clinical disorders.

• Axis II: Personality disorders and mental retardation.

• Axis III: General medical conditions relevant to Axis I and II.

• Axis IV: Psychosocial and environmental issues.

• Axis V: Global assessment of functioning.

Transition to DSM-5

• Shifted focus away from multiaxial systems to a single list of disorders.

• Coordinated with ICD-10 and future ICD-11 guidelines.

• Categories reorganized; introduced a spectrum approach for related disorders.

DSM-5-TR (2022)

• Introduced new diagnostic categories and modifications for clarity.

• Updated terminology and ensured non-stigmatizing language was adopted.

Problems with Classification Systems

• Questions of reliability and validity.

• Diagnostic Reliability: Consistency of diagnosis among different clinicians.

• Diagnostic Validity: Accuracy in assessing what diagnosis claims to measure.

Reliability Statistics

• Varying reliability among categories; some show strong consistency while others, like bipolar disorder, remain unreliable.

• Spectrum diagnoses generally reflect better reliability.

Validity in DSM-5

• Continuous evaluation ensures the categorized diagnoses are meaningful and distinct.

• Movement of certain diagnoses (e.g., autism) reflects evolving understanding.

Medical Model of DSM-5

• Emphasizes classification similar to physical diseases despite lack of biological tests for many psychiatric conditions.

• The ongoing dominance of disease perspectives despite limitations.

The Diagnostic Process

• Essential to carry out a diagnosis to inform treatment;

• Involves answering specific clinical questions about the patient's condition.

  • Evaluating organic issues, drug reactions, and the severity of symptoms.

Components of Diagnosis

• Interviews, observations, and psychological tests form the core methods of assessment.

Interviews

• Key assessment tool based on self-reports of symptoms.

• Initial diagnostic interviews help formulate a preliminary diagnosis.

• Understanding of the presenting problem involves multiple factors: severity, duration, impact on functioning, and history of episodes.

Structured Clinical Interviews

• Standardized interviews lead to specific questions aligned with diagnostic categories (e.g., SCID).

Observations

• Provide insights into behavior versus self-reported symptoms.

• Include aspects evaluated during Mental Status Examination (MSE) to assess functioning levels.

Psychological Testing

• Standardized procedures help quantify behavior and psychological functioning.

• Tests assist in reducing uncontrolled influences from interviews.

Types of Psychological Tests

1. Intelligence Tests: Assess intellectual capacity and identify disabilities; examples include WAIS.

2. Personality Tests: Measure traits and internal processes, including projective tests and inventories.

Projective Tests

• Include Rorschach and Thematic Apperception Tests; useful for exploring psychodynamic aspects but are less reliable than objective tests.

Personality Inventories

• Minnesota Multiphasic Personality Inventory (MMPI): A widely used self-report measure assessing various psychological aspects through 550 items and multiple subscales for validity.

Neuropsych Assessment

• Encompasses brain imaging and assessments of cognitive functions, important in diagnosing conditions like TBI, dementia, and strokes.

• Techniques include CAT scans, MRI, PET scans, and fMRI for a detailed view of neurological health.

Conclusion

• This chapter encompasses the evolution and importance of classification systems within psychological diagnoses, alongside methods of diagnostic processes to establish reliable and valid assessments.

Chapter 4: Classification, Diagnosis, and Assessment

Overview

This chapter discusses the importance and evolution of classification systems in psychopathology, alongside the diagnostic processes essential for effective treatment.

Classification

Purpose of Classification

Classification serves as a foundational step towards a more profound comprehension of psychopathology, moving beyond mere labeling of individuals. It aims to categorize behaviors and experiences systematically, thus leading to better understanding and treatment options.

Understanding Syndromes

Individuals exhibiting a consistent pattern of symptoms, regardless of treatments, are grouped under the same syndrome. For example, patients with malaria present similar symptoms, which aids in the identification of this syndrome.

• Syndrome Definition: A syndrome is defined as a collection of symptoms that appear together, indicative of a specific condition.

Main Goals of Psychopathology Classification

• Identifying Distinct Patterns: Recognizing various types of abnormal behavior.

• Understanding Causes: Exploring underlying influences and causes of these behaviors.

• Formulating Treatment Plans: Creating rational and effective treatment strategies to address identified disorders.

• Detecting Early Signs: Facilitating the early identification of emerging disorders to allow for timely intervention.

Development of Classification Systems

Historical Milestones

• ICD-6 (1949): The World Health Organization included a dedicated section for psychiatric disorders.

• DSM-I (1952): Developed by the American Psychiatric Association, it sought to replace the ICD-6, influenced heavily by Freudian psychodynamic theories and focusing on the reactions of personality to psychological or biological events.

• Evolution to DSM-II: In 1968, DSM-I was revised to produce DSM-II, which saw a 50% increase in the number of listed disorders. The term "reaction" was removed, though Freudian concepts, such as depressive neurosis, persisted.

Issues with DSM-II

Concerns arose regarding its accuracy, consistency, and the subjective nature of psychiatric diagnoses. David Rosenhan's studies pointed out the variabilities in interrater reliability among clinicians, questioning DSM-II's diagnostic utility.

DSM-III Improvements

The DSM-III introduced significant advancements by establishing more objective diagnostic criteria focused on observable behaviors rather than intrapsychic causes. This edition introduced a multiaxial approach, aiding the diagnostic process considerably.

Revisions to DSM

• DSM-III-R (1987): This revision tackled inconsistencies noted in DSM-III and made modifications to categories based on accumulated knowledge.

• DSM-IV (1994): Aimed for consistency with the ICD-9 classifications.

• DSM-IV-TR (2000): Provided minor updates while retaining existing criteria.

Multiaxial Diagnostic Framework

The multiaxial system comprised five axes assessing different dimensions of diagnosis:

1. Axis I: Clinical disorders.

2. Axis II: Personality disorders and mental retardation.

3. Axis III: General medical conditions relevant to Axis I and II.

4. Axis IV: Psychosocial and environmental issues that may affect the individual.

5. Axis V: A global assessment of functioning to provide an overall picture of the patient’s mental health.

Transition to DSM-5

The DSM-5 marked a significant transition by replacing the multiaxial approach with a single list of disorders. This edition was coordinated with ICD-10 guidelines, and future updates aimed to reflect the evolving understanding of mental health, reorganizing categories and introducing a spectrum for related disorders.

DSM-5-TR (2022)

This latest update introduced new diagnostic categories with modifications for enhanced clarity, adopting more respectful and non-stigmatizing language throughout the manual.

Problems with Classification Systems

• Reliability Issues: Questions regarding diagnostic reliability (consistency among clinicians) and validity (accuracy in diagnostic assessment).

• Reliability Statistics: Noteworthy variability across diagnostic categories; for instance, some categories maintain strong consistency, while others like bipolar disorder are known for fluctuating reliability.

• Validity in DSM-5: Continuous evaluations of the diagnostic categories ensure they maintain their relevance and meaningfulness.

• Medical Model of DSM-5: Emphasizes the classification similar to physical diseases, despite the absence of biological tests for numerous psychiatric conditions, underscoring a persistent focus on disease perspectives.

The Diagnostic Process

A structured process essential to diagnosis involves answering specific clinical questions relevant to the patient's condition. This encompasses evaluations of organic issues, potential drug reactions, and the severity of symptoms.

Components of Diagnosis

• Interviews: A key assessment tool based on self-reports that help develop a preliminary diagnosis. Understanding the presenting problem requires consideration of severity, duration, functional impact, and historical context of symptoms.

  • Structured Clinical Interviews: Standardized formats provide specific inquiries aligning with diagnostic categories, such as the Structured Clinical Interview for DSM Disorders (SCID).

• Observations: Essential for gaining insights into behavior that may differ from self-reported symptoms, typically assessed during a Mental Status Examination (MSE) to evaluate functioning.

• Psychological Testing: Standardized procedures assist in quantifying behaviors and psychological functioning, mitigating the uncontrolled influences inherent in interviews.

Types of Psychological Tests

• Intelligence Tests: Measure intellectual capacity and identify cognitive disabilities; examples include the Wechsler Adult Intelligence Scale (WAIS).

• Personality Tests: Evaluate traits and internal processes using both projective tests and inventories.

  • Projective Tests: Rorschach and Thematic Apperception Tests explore psychodynamic aspects but offer lower reliability than objective tests.

  • Personality Inventories: E.g., Minnesota Multiphasic Personality Inventory (MMPI), assessing various psychological dimensions through extensive questions and validity scales.

• Neuropsych Assessment: Encompasses brain imaging and evaluations of cognitive functions critical in diagnosing conditions like traumatic brain injuries, dementia, and stroke. This may involve techniques like CAT scans, MRIs, PET scans, and fMRIs, providing comprehensive insights into neurological health.

Conclusion

This chapter extensively details the evolution and critical role of classification systems within psychological diagnoses, alongside the methods employed in diagnostic processes to create reliable and valid assessments for effective psychological treatment.