5.1.2 - Classification systems (DSM IVR or DSM V, and ICD) for mental health, including reliability and validity of diagnoses. Flashcards
Classification Sysytems (AO1)
x5
- The WHO (World Health Organisation) compiled a list of mental disorders in the ICD in 1948 which was followed by the DSM in 1952 - both have been revised over the years (currently on: DSM 5 and ICD 11)
- once defined as abnormal, they need to know their disorder which can lead to appropriate treatment - DSM was developed as a response to the need for a census of mental health disorders
- Reliable and valid diagnosis is essential in treatment recommendation to ensure correct treatment for condition and accurate prognosis
- BUT many mental disorders don’t have obvious measurable physiological signs = diagnosis is based on interpretation of behavioural symptoms = issues with R+V
- CS - describe clusters of symptoms that define disorders that have been derived from clinical practice, field trials and pooled expertise = if applied well = quality diagnosis (CS not universally accepted)
The ICD
Features of the ICD (x4)
- Its European and was produced in conjunction with WHO for use eg compiling morbidity and mortality stats
- It was not for profit
- Translated into lots of languages
- Is regularly updated - ICD 11 came out in 2019 and lists all known mental and physical health conditions
Detailed AO1 on the ICD
x5
- Unlike DSM, ICD 10 is not just concerned with mental health disorders but with all diseases, looking at general health of population and is used to monitor incidence and prevalence
- ICD provides mortality and morbidity for the WHO - addressing all diseases
- Section F - specific for mental disorders where it groups disorders eg mood (affective) disorders incl. depression, bipolar exc. These are coded F and then given a number for category of illness (3 for mood disorder) then second number for specific disorder = eg F32 is depression
- Further categorization can be done by adding further digits and decimal points to show type of disorder/symptoms for specific categorization which allows clinicians to go from the general to the specific and to convey their diagnosis to others in an easy and systematic way (eg F32.0.01 is mild depression with somatic symptoms eg pain)
- the system allows clinicians to guide their diagnosis through clinical interview with the patient which provides a basis on which to make a judgement, giving details of likely symptoms for each disorder, their severity and duration, allowing diagnosis to be made.
The DSM
Features of the DSM (x4)
- It is American
- Was produced by the APA for profit
- It is regularly updated and the the DSM IV was replaced by DSM 5 that came out in may 2013 where disorders such as mobile phone addiction were added
- The DSM IV had a multi-axial system where it could consider a number of factors in making a diagnosis (eg health and social)
Detailed AO1 on the DSM
x5
- DSM V has similar system of grouping disorders to enable clinicians to go from very general diagnosis to specific ones which guidance provided about the likely combination of symptoms and their severity - would use DSM in combination with info gained from clinical interviews and medical records
- Clinical syndromes include SZ and other psychotic disorders, mood disorders, anxiety disorders, eating disorders, sleep disorders
DSM IV based on 5 axis:
- 1 & 2 = diagnosis of mental disorders
- 1 looks at all disorders apart from personality disorders and mental retardation = 2
- 3-5 = factors which affect mental disorder or its treatment eg 3 - general medical conditions, 5 - global assessment of functioning scale
- Changes in the DSM - in response to critisisms from Rosenhans study, changes in cultural attitudes eg DSM II no longer listed homosexuality as a disorder, DSM V included mobile phone addiction = shows lifestyle change, DSM 5 no longer uses multiaxial system and instead has 3 sections (I, II and III)
State the first 2 sentences you put when asked a question on the reliability of classification system when diagnosing mental disorders
A diagnosis is conciered reliable if more than one psychologist gives the same diagnosis to the same individual. Clinicians diagnosis of disorders must be consistant with each other or issues of reliability will arise when clinicians disagree over a diagnosis and treatment may not work.
Evaluation: Classification systems are reliable when diagnosing mental disorders (AO3 x4/5)
use research evidence
- Brown et al (2001) looked at disorders that were difficult to diagnose consistently because of the overlapping symptoms in mood and anxiety disorders and both being found in the same person. Results found that the interrater reliability was judged to be good-excellent using DSM-IV-TR. Therefore the classification system was reliable as it allowed different clinicians to go through the symptom criteria in the classification system to come to the same diagnosis
- Goldstein (1988) tested DSM-III for reliability and found that it was reliable. She looked at the effects of gender on the experience of SZ and she rediagnosed 169/199 patients after their original diagnosis using DSM-II. Therefore despite the changes in the DSM models, the diagnosis of SZ using the DSM classification system remained reliable
- Rosenhan’s (1972) study had 8 psuedopatients presenting with the same single symptoms of SZ and all but 1 (diagnosed as bipolar) were diagnosed with SZ. Therefore classification systems such as the DSM are reliable as the 8 patients went to all different mental institutions and 7 al got the same diagnosis from the same set of symptoms
- ADD ONCE EDWARDS RESPONDS
Evaluation: Classification systems are not reliable when diagnosing mental disorders (AO3 x4)
- Beck et al (1961) found that agreement among diagnosticians was at about the same level as chance. They gave 2 psychiatrists 153 patients to diagnose, but the two only agreed 54% of the time. Therefore this suggests diagnosis using the DSM is highly unreliable and the reliability of these classification systems makes the diagnosis of mental illness uncertain
- Cooper et al (1972) showed UK and US psychiatrists the same videotaped interview and asked them to make a diagnosis. NY psychiatrists said SZ twice as often whilst LN psychiatrists said depression twice as often. Therefore a cultural bias may affect how reliable the DSM’s classification system is at diagnosing mental illness if the criteria is too vague leading to different cultural interpretations of the DSM
- Nicholls et al (2000) found that in the case of the DSM, over 50% of the sample of 81 children did not fit into the criteria for ED despite having eating problems and reliability was only 64% and similarly the ICD 10 only had 36% agreement between raters. Therefore neither classification system was reliable suggesting that the criteria for diagnosing ED needs to be more detailed for reliable diagnosis of mental disorders using classification systems.
- Di Nardo et al (1993) studied reliability for anxiety disorders. They found very low reliability for assessing generalised anxiety disorder (.57) due to problems with interpretation of how excessive a persons worries were. Therefore due to the subjective nature of diagnosing mental illness, this affects how reliable the classification system is if criteria for mental diagnosis lacks objectivity.
Write a concluding paragraph on the reliability of classification systems eg DSM
point and however
In conclusion, the DSM is reliable as more recent versions have added detailed lists of symptoms, which used alongside the 4D’s, means different clinicians can can use the classification system to diagnose a patient with the same disorder. Howeve,r cultural issues mean that there are still variations due to clinician and patient factors.
State the first 2 sentences you put when asked a question on the validity of classification system when diagnosing mental disorders
A diagnosis is concidered valid if the diagnosis is correct and a patient’s symptoms match those listed in the DSM. Predictive validity is present if a diagnosis can lead to an accurate prediction of the patient’s outcome and the treatment is effective.
Evaluation: Classification systems are valid when diagnosing mental disorders (strengths - AO3 x4)
- Kim-Cohen et al (2005) studied the validity of the DSM IV with regard to conduct disorder in 5 yr old children and using research methods eg interviews with mothers, a questionnaire and comparisons with other children’s behaviour. Therefore from using this detailed data they could conclude that the diagnoses were accurate and valid.
- The DSM IV and 5 take account of cultural issues in acknowledging culture-bound syndromes by adding them into the appendix. Therefore this improves the validity of diagnosis using classification systems by attempting to remove factors such as ethnocentrism which affect the accuracy of diagnosis
- Hoffman studied different diagnoses of alcohol abuse, alcohol dependence and cocaine dependence using prison inmates and found that the symptoms matched the DSM criteria. Therefore, this shows that the DSM is valid for patients who are suffering from addictive disorders, although perhaps this is because the disorders are more obvious when they are in sever cases like this.
- Kupfer (2013) suggests that the DSM 5 is the strongest system available for classifying disorders. There is a revised chapter to show how disorders can relate to one another or be on a spectrum as well as how disorders are linked to age, gender and cultural expectations. Therefore the DSM 5’s classification system is valid as there is now a more detailed criteria to improve accuracy of diagnosing disorders eg comorbid conditions, autism or disorders influenced by culture eg depression.
Evaluation: Classification systems are not valid when diagnosing mental disorders (weaknesses - AO3 x4/5)
- Rosenhan (1973) concluded the DSM-III wasn’t valid as it couldn’t tell the sane from the insane. Results found that 8 ‘normal’ people were diagnosed with SZ. Therefore the diagnosis was invalid and the use of the classification system couldn’t produce an accurate diagnosis from the criteria
- Moreover, Rosenhan’s 8 patients all presented with the same symptoms saying they heard voices - hollow, empty and thud, but 7 got diagnosed with SZ and one with bipolar. Therefore the DSM lacks validity as the classification system is not detailed enough on the symptoms and criteria specific to each disorder a they all had the same symptoms but not the same or accurate diagnosis
- Banister et al (1964) studied 1000 cases and found no clear cut relationship between diagnosis and treatment. Therefore this suggests that predictive validity in the sample was low and the DSM can help diagnose a disorder but individual practitioners have their own way of treating different conditions and the validity can easily be affected by factors eg gender and race
- Cochrane (1977) reported the incidence of SZ in the West Indies and Britain to be similar (1%) but those of African Caribbean origin are 7x more likely to be diagnosed with SZ living in Britain. Therefore this suggests that either they have more stressors leading to SZ or that diagnoses lack validity due to cultural bias in classification systems such as the DSM
Write a concluding paragraph on the validity of classification systems eg DSM
In conclusion, studies have shown that more recent editions of the DSM are valid and criteria is seen to match symptoms across many different disorders. However, cultural issues are still problematic as the DSM remains ethnocentric meaning that there are cultural differences in diagnosis dispite more recent attemps to acknowledge CBS’s
Cultural issues lead to misdiagnosis of mental health disorders
issues vs how they are reduced
CBS - Asia vs Appendix
- Culture bound syndromes can affect diagnosis, eg it is relatively rare for Asian patients to report psychological symptoms of depression due to Asian community preferring to sort such problems with family. Instead they may report physiological symptoms of depression eg lack of sleep. Therefore clinicians may diagnose patients with sleep disorders due to cultural bias rather than diagnosing and treating the underlying cause i.e. depression.
- However DSM-IV and five attempts to take account of cultural issues and acknowledging culture bound syndromes by adding them into the appendix. Therefore this reduces cultural issues by attempting to remove factors such as ethnocentrism which affect the accuracy of diagnosis
Cultural issues lead to misdiagnosis of mental health disorders
issues vs how they are reduced
Malgady vs SZ interpretation
- Malgady et al (1987) found that Puerto Ricans believe that people can become possessed by evil spirits. This is a very common belief for people in this culture, making them not SZ. Therefore cultural issues could lead to the misdiagnosis of mental disorders e.g. schizophrenia if psychiatrists were not culturally aware of this Puerto Rican belief.
- However there has been an attempt to remove focus from bizarre symptoms such as the belief of possession by evil spirits, in schizophrenia as it was acknowledged that such symptoms are open to interpretation. Therefore this reduces cultural issues leading to misdiagnosis as risk of wrong interpretations of symptoms are removed
