Clinical Psychology

Question 1

What are the 4Ds of diagnosis

Answer 1

Deviance, dysfunction, distress, danger

Question 2

Deviance

Answer 2

Unusual, undesirable or bizarre behaviour (deviant from the statistical or social norms)
Depend on historical context, culture, age and gender of individual
Failure to conform to social norms may lead to negative attention from others and social exclusion from others, norm-breaking seen as indicator of psychological abnormality

Question 3

Dysfunction

Answer 3

Symptoms that distract, confuse or interfere with a person’s ability to carry out their usual roles and responsibilities.
WHODAS II (objective measure to assess dysfunction) a questionnaire which looks at factors such as a person’s understanding of what goes on around them
Can also manifest as trouble getting up in the morning, completing tasks at work or college and problems participating in work or routine activities

Question 4

Distress

Answer 4

When symptoms cause emotional pain or anxiety, a sign that a diagnosis may be beneficial to the person
Can be manifested as physical symptoms: aches, pains, fatigue, etc.
Can be considered normal depending on the situation: e.g. if a person had just lost their job or been bereaved
Consideration of intensity and duration of distress needed
Quantitative data collected through scales e.g. K10 (Kessler Psychological distress scale)

Question 5

Danger

Answer 5

Careless, hostile or hazardous behaviour which jeopardises the safety of the individual and/or others may be considered grounds for diagnosis.
In the UK if a person is perceived to be a danger to themselves or others, they may be detained under the Mental Health Act, client can be taken to a mental hospital for treatment

Question 6

How is the 4Ds of diagnosis helpful

Answer 6

Can determine the point at which a mental health ‘issue’ might be more helpfully considered as a mental heath ‘disorder’

Question 7

Strength of using 4Ds approach

Answer 7

Help avoid errors in diagnosis
E.g. if deviance from social norms is the only consideration, then those who deviate, yet are harmless may be seen as abnormal while those with common but misleading symptoms of depression may be missed
Valid system should neither over- nor under-inclusive

Question 8

Competing argument - strength of the 4Ds approach

Answer 8

No hard and fast rules about how the Ds should be combined
E.g. if a person is struggling to cope and showing signs of distress and dysfunction but no signs of danger or deviance, the person may not require a diagnosis, possibly the system which is causing the problem, not a problem that could be resolved by treatment

Question 9

Weakness with using the 4Ds - subjective

Answer 9

No objective measurement
Various methods aimed to be objective (e.g. WHODAS II and K10)
But these ratings are being made of feelings, this affects reliability
Since 4Ds involved making comparisons between the individual and others in society, it would tend to be made based on the subjective view of the clinician
Shows that if 4Ds are to be applied meaningfully, a clinician requires detailed information of the person and their community

Question 10

4D Weakness - labelling

Answer 10

We end up with labels for people with mental health issues
E.g. using ‘danger’ as a criterion for mental disorder leads people to equate mental illnesses with being dangerous, distorted in media - most people with schizophrenia aren’t actually dangerous
May also lead to ‘self-fulfilling prophecies’ - stereotypes lead people to act in the way predicted by the stereotype

Question 11

Application of 4D to diagnosis

Answer 11

Used by mental health clinicians in conjunction with classification manuals such as DSM-5 and ICD-10 to help decide whether making a diagnosis is appropriate and if so which one
Different disorders have a different combinations of 4Ds

Question 12

4D - potential of social control

Answer 12

Those who breach social norms or challenge government policies can be quieted by being labelled as mentally disturbed
E.g. KGB in USSR pressured psychiatrists in 1960s to diagnose and incarcerate political dissidents
Demonstrates how the misuse of psychiatric diagnosis can be used to ‘legitimise’ punitive treatments and social exclusion

Question 13

What is the DSM

Answer 13

The Diagnostic and Statistical Manual (DSM)
Describes symptoms, features and associated risk factors of over 300 mental and behavioural disorders
Used throughout the US and nations around the world
Provides appropriate support, however, erroneous diagnosis can lead to labelling, stigmatisation and ineffective treatment

Question 14

DSM-5 (and the 3 sections)

Answer 14

Published in 2013, manual divided into sections

• section 1: guidance on using new system
• section 2: details the disorders, categorising them to our current understanding of causes and symptoms. Allows for independent measurement of the level, number and duration of the symptoms
• section 3: suggestions for new disorders, also includes information about the impact of culture on the presentation of symptoms and how they are communicated

Question 15

Making a diagnosis using the DSM

Answer 15

May gather information through observation. Most diagnosis based on unstructured (clinical) interviews
Also structured interview schedules available on symptom lists, such as Beck Depression Inventory
Diagnostic process involves ruling out disorders that do not match the person’s symptoms sufficiently before deciding on the ‘best fit’
Difficult cases may take weeks or months in order to understand the consistency of symptoms over time

Question 16

Assessing the DSM’s reliability

Answer 16

Spritzer introduced Cohen’s kappa to improve the reliability of the DSM-III
Statistic written as a decimal, refers to those who receive the same diagnosis when assessed then re-assessed at a later time by a later time (test-retest reliability) or by another practitioner (inter-rather reliability)
0.7 would indicate a ‘good agreement’

Question 17

Assessing the DSM’s validity

Answer 17

Disorders have been removed or added to different versions of the DSM leading it to be criticised

• descriptive validity: when 2 people with the same diagnosis exhibit similar symptoms
• aetiological validity: when they share similar casual factors
• concurrent validity: when a clinician uses more than one method or technique to reach the same diagnosis
• predictive validity: when the clinician was able to accurately predict outcomes for an individual from their diagnosis

Question 18

DSM-5 strength - good level of agreement for some disorders

Answer 18

Field trials demonstrated impressive levels of agreement between clinicians on a variety of disorders
Regire and colleagues (2013) reported that 3 disorders (including PTSD) had kappa values ranging from 0.60-0.79 (very good), seven more diagnoses had kappa values ranging form 0.40-0.59 (good)
Important as criteria for PTSD had changed in terms of numbers and symptoms required to make a diagnosis, this shows that clinicians had adapted to these changes

Question 19

Weakness - falling standards

Answer 19

What was considered as an acceptable level of agreement had plummeted over the last 35 years
Cooper (2014) explains that DSM-5 task force classified levels as low as 0.2-0.4 as ‘acceptable’
Suggests DSM may be less reliable than previous versions

Question 20

DSM-5 competing argument - falling standards

Answer 20

Kupfer and Kramer (2012)
Clinicians in DSM-5 trial were asked to ‘work as they normally would’, to mirror normal practice
While DSM-III used carefully screened ‘test’ clients and clinicians were given detailed training.
Therefore unsurprising that DSM-5 trials had lower levels of reliability (but higher levels of ecological validity)

Question 21

DSM-5 strength - support for validity of conduct disorder (CD)

Answer 21

Supports the validity of certain disorders
Kim-Cohen et al. (2005) demonstrated…
Concurrent validity of CD through interviewing children and mothers, observing behaviour and using questionnaires done by the student’s teachers
Aetiological validity of CD through risk factors, e.g. male, low income, etc. were common in many children with CD
Predictive validity of CD through 5-year olds being significantly more likely to display behavioural and educational difficulties aged 7
Accurate diagnosis could reduce mental health problems which are preceded by symptoms of CD

Question 22

DSM-5 weakness - labels tell us nothing about causes

Answer 22

DSM-5 lacks validity
Publication of DSM-5 let to a storm of criticism from psychiatrist and psychologists that psychiatric diagnosis tells us nothing about a disorder - tells us nothing about the causes
Arguments are circular: why is a person hearing voices? Because they have schizophrenia. How do we know they have schizophrenia? Because they are hearing voices.

Question 23

What is the ICD

Answer 23

International List of Causes and Death - includes both physical and mental disorders
Had many revisions over the years, current version is ICD-11
Multilingual, freely available resource used by clinicians and researchers
Provides a ‘common language’ so data collected in different countries can be usefully compared

Question 24

ICD - mental disorders and ICD codes

Answer 24

Chapter 5 of the ICD-10 is called Mental and Behavioural disorders
Each disorders have a code, starting with F, listed consecutively and there are 11 sections
Each section have a few ‘leftover codes’, allowing for new disorders to be added
Codes are used for indexing medical records, making it easy when conducting research to find examples of people with specific conditions

Question 25

Making a diagnosis with ICD-10

Answer 25

Contains both physical and psychological disorders, coded in the same way
Clinician selects key words from an interview that relates to their symptoms
They can look it up in an alphabetic index or go to an obvious section
Then uses other symptoms to locate subcategory

Question 26

Improvements made to the ICD-10

Answer 26

Language and culture may influence the interpretation and communication of symptoms (also a problem for DSM)
‘Culture bias’ - clients in one culture could be given a different diagnosis from clients in another culture
Posed problems for international research community, led to research programmes to review differences in diagnostic practice and differing use of diagnostic terminology across the world

Question 27

ICD reliability strength - improvements in reliability

Answer 27

Ponizovsky et al. (2006) compared reliability of ICD-9 and ICD-10, 3000 patients assessed
Stability (reliability) of diagnosis measured using positive predictive value (proportion of people who get the same diagnosis when they are reassessed
For schizophrenia, PPV increased from 68% in 1989 to 94.2% in 2003
Higher figures for 2003 show improved reliability and suggest that the increased number of disorders from ICD-9 to ICD-10 did not detract reliability

Question 28

ICD reliability competing argument - improvements in reliability

Answer 28

High reliability is meaningless without validity

Just because the system is reliable, it doesn’t mean it is valid, no true meaning of the diagnosis

Question 29

ICD strength - Inter-rater reliability

Answer 29

Good consistency when two clinicians assess the same clients using the ICD-10
Galeazzi et al. (2004) arranged for two researchers to conduct a joint interview to assess 100 consecutive clients for psychosomatic symptoms - kappa values ranged from 0.69 to 0.97 showing very high agreement

Question 30

ICD strength - predictive validity

Answer 30

Good predictive validity for schizophrenia
Mason et al. (1997) showed that diagnosis of schizophrenia using ICD-10 has good predictive validity
Compared different ways of making a diagnosis - ICD-9 and ICD-10 were ‘reasonably good at predicting’ schizophrenia in 99 people 13 years later, measured by global assessment of functioning questionnaire
Shows that initial diagnosis was useful and meaningful in terms of its ability to accurately predict future outcomes

Question 31

ICD application to diagnosis

Answer 31

aim to improve the ‘clinical utility’ of the ICD-11
WHO conducted a huge international survey of clinicians and found a preference for simplicity and flexibility, suggesting the ICD-11 task force would be cautious about adding new disorders and merging disorders
System would become more ‘user-friendly’ - may improve validity of diagnosis