Diagnosing abnormal behaviour
This document contains:
 DSM and ICD – basics.
 Diagnosis
o Assessment
o Issues in classification and diagnosis
 Validity
 Reliability
 Cultural issues
 Ethical issues
DSM IV – classification system – classroom notes (based on Course
Companion)
 Kraepelin developed the first comprehensive classification system for
mental disorders, believing that they could be diagnosed from
observable symptoms, just like physical illness.
 DSM IV (Diagnostic and Statistical Manual of Mental Disorder” +
ICD 10 (Internatioanl Classification of Diseases)
Differences; different headings, different names at times. ICD – more
likely to indicate causes rather than purely sumptoms.
 Revised many times
DSM – composed of several axis:
Axis 1 – Clinical symptoms (eg. Catatonic schizophrenia)
Axis 2 – Developmental and personality disorders (additional diagnostic
classifications that may contribute to an understanding of the Axis 1
syndrome)
Axis 3 – Medical conditions (physical problems relevant to the mental
disorder)
Axis 4 – All potentially stressful events (loss of job, divorce), enduring
circumstances (poverty) that might be relevant to the disorders are rated on
a scale ranging from 1 (none) to 6 (catastrophic) for the past year.
Axis 5 Global assessment of functioning 1-9 social, occupational and
psychological functioning is rated (during last year).
So, a person might be suffering from depression (Axis 1) but on top of that
he has occasional panic attacks (Axis 2) and is shy, verging on social phobia
(Axis 2). He has no contributing medical conditions (Axis 3), but has
recently lost his sister in a terrible accident (Axis 4) and his parents are
divorced and not talking since the accident (Axis 4). He goes to school on
regular basis but has no friends (Axis 5).
Look at Mini DSM (Swedish copy)
Diagnosis
1. Therapists tries to collect as much information as possible about a person.
This is called Assessment. The goal is to compile idiographic information
(individual) about the person (idiographic vs. nomothetic-general info). This
would include causes and probable course of her present dysfunction and
suggest what kind of strategies would help her.
“To help a particular person the practitioner must have the fullest possible
understanding of that person” (Tucker, 1998).
What kind of assessment is used depends on the theoretical background of the
practitioner.
2. Diagnosis, very often using a classification system like DSM IV
3. Treatment, drug-treatment, CBT, Psychoanalysis, group therapy… also
depends on the practitioner’s theoretical background.
CLINICAL ASSESSMENT
Each practitioner has their way of doing this, but most assessments can be
divided into the following categories:
- Clinical interviews
- Tests
- Observations
Each of these needs to be standardized (common steps exist), reliability (refers
to the consistency of the test, we have test-retest reliability and inter-rater
reliability), validity (it must accurately measure what it is supposed to measure.
Here we have face validity – how valid it is by first sight. Eg. If a depression test
contain a question about how often a person cry, this might seem like a valid
question, but it really doesn’t give an accurate picture of depression. We also
have predictive validity).
Clinical interviews
Very widely used by must practitioners.
Problems:
- Validity and reliability issues
- The client gives false reports/are unable to give accurate reports
- Interviewer bias (race, sex, age).
Tests
Eg. Projective tests (like Rorschack, TAT, intelligence tests, neurophysical tests)
+ can reveal subtle information
- difficult to get standardized, reliable, valid measures
Personal inventories (problems with culture and validity problems)
Issues in Diagnosis and Classification:
Problems with assessment interviews (CC p. 140)
But also(collected by Kleinmutz (1967) that there are limitations to the
interview process:
 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.
 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 will definitely affect the interview.
Reliability= this is high when different psychiatrists agree on a patient’s
diagnosis when using the same diagnostic system. This is also known as
inter-rate reliability.
 Reliability can be questioned. Despite using the same diagnostic manual
psychiatrists end up with different diagnosis. Famous studies:
o Rosenhan (1973). A teaching hospital was told to expect pseudopatients – not a single one ventured near the hospital but 41 genuine
patients were suspected to be fake. Conclusion: it was not possible
to distinguish between sane and insane in psychiatric hospital.
o Beck (1962) Agreement on diagnosis for 153 patients between two
psychiatrists was only 54%
o Cooper (1972) New York psychiatrist were twice as likely to
diagnose schizophrenia than London psychiatrists.
Result of this: new versions of DSM IV, local variants (eg. The Great Ormond
Street Children’s Hospital in London 0.88 reliability (should be compared with
64% agreement between raters)
Validity: this is the extent to which the diagnosis is accurate. This is much
more difficult to assess in psychological disorders, for example because
some symptoms may appear in different disorders.
Lack of validity is most often due to bias in diagnosis.
Bias in diagnosis – how the diagnosis might be influenced by the attitude and
prejudices of the psychiatrist or the diagnostic test itself:
o Racial
o Gender bias
o Misconception of the nature of mental states.
o Expectation of clinicians.
o Over pathologization
Ethics
 Labelling – ethics. What do different classifications lead to:
o Sheff – summarized labelling effects (1966)
 Self-fulfilling prophecy – start behaving the disorder – as
they believe they are expected to leading to an increase in
symptoms.
 Distortion of behaviour/confirmation bias (clinicians
tendency to have expectations about the person who consults
them) – misinterpreting the patient’s behaviour to support
assessment. Rosenhan’s (1973) famous study showed that it
was difficult to convince staff that the admitted really was
just faking their disorder. All behaviour was perceived as
being a symptom. Langer and Abelson (1974) – social
perception (p. 143 in CC – same man filmed but one
condition was that he was a patient – the other that he was a
work applicant. Judged completely differently (attractive,
conventional looking vs. tight, defensive, dependent) Farina
1980 – natural experiment. One member of a pair of male
college students was falsely led to believe the other had been
a mental patient – was perceived to be inadequate,
incompetent and not likeable
 Racial/Prejudice (eg.). Gender in the study by Jenkins-Hall
and Sacco involving European American therapists
evaluating female patients, their rated the African American
woman more negatively than the European white one.
 Institutionalisation:
 Lack of normal interaction
 Powerlessness and depersonalisation
 Dependency
Szasz “Idiology and Insanity” (1974 – argued that the use of labels such as
mentally ill, criminal or foreigner excluded people. People who are different
are stigmatized. Schizophrenic vs. an individual with schizophrenia.
Cultural considerations in diagnosis:
 Culture bound syndromes: though many disorders appear to be universal –
that is, present in all cultures – some abnormalities, or disorders are
thought to be culturally specific.
Eg. Shenjing shuairuo – a disorder only listed in the Chines Classification of
Mental Disorders but not included in DSM IV even though it accounts for over
half of psychiatric outpatients in China (combination of mood and anxiety).
Discussion about this? Should this be listed in DSM IV as well? Do patient start
acting the additional symptoms just because it is listed (labelling?). What does it
say about our classification system that these are not listed?
 Some common disorders are not seen in other cultures. Depression in Asia
for example – why? Proposed that social support + doctors take care of
physical problems. = reporting bias.
Eg. India – mentally ill people are cursed and looked down on. China – the same
(but the greatest problems are labelled – the rest are ignored).
Real cultural differences? Marsella (2003) – differences between symptoms in
collectivistic and individualistic countries. Individualistic societies take more
affective (emotional) forms (loneliness and isolation), while collectivistic
societies take a more somatic (physiological ) form (headaches). Marsella means
that it is impossible to compare depression cross-culturally – because it is
experienced so differently.
Culture blindness – the problem of identifying symptoms of a psychological
disorder if theya re not the norm in the clinician’s own culture i.e. seeing the
white population as the norm. Eg. In some cultures hearing and seeing a
diseased is seen as normal when mourning.
How to avoid it (cultural bias)=
 Learn about the culture of the person being assessed.
 Evaluation of belingual patients should be undertaken in both languages.
 Diagnostic procedures should be modified to ensure that the person
understands the requirements of the task.