Clinical Psychology

Question 1

Aim of Classical Study

Answer 1

1. To investigate the reliability of mental health diagnoses by seeing whether 8 pseudo-patients would be detected as really being ‘sane’
2. To investigate the experience of ‘being insane’ in a mental institution

Question 2

Research methodology of Classic Study

Answer 2

Field study and naturalistic covert (secret) unstructured observation

Question 3

Describe the observers of Rosenhan’s experiment

Answer 3

• 3 older established psychlogists (including Rosenhan)
• 1 housewife
• 1 painter
• 1 psychiatrist
• 1 pediatrician
• 1 20-year old psychology graduate

Question 4

Describe the location of the Classic study

Answer 4

12 psychiatric hospitals in 5 East & West Coast states in the US which varied in terms of staff:patient ratio and whether they were well-resourced or less well-resourced.

Question 5

Describe the procedure for study 1 of the Classical study

Answer 5

1. 8 pseudo-patients gained admission to the hospital by saying they heard an unfamiliar, same-sex voice saying ‘empty, thud, hollow’.
2. After admission, they acted ‘normally’ towards the staff and the other patients at the hospital, e.g., engaging in conversation in the corridors
3. Pseudo-patients were responsbile for discharge from the hospital by convincing the doctors that they were ‘sane’ in order to get released.

Question 6

Describe the results for Study 1 of the Classic study

Answer 6

• None of the pseudo-patients were detected
• 11/12 hospitals admitted patients with a diagnosis of schizophrenia
• 71% of staff in the hospitals ignored the pseudo-patients
• 7 patients were labelled with a diagnosis of ‘Schizophrenia in remission’, 1 with ‘manic depressive disorder’
• Length of hospital admission was 7-52 days with an average of 19 days

Question 7

Describe the conclusions for Study 1 of the Classic study

Answer 7

The sane cannot be distinguised from the insane.

3 reasons for depersonalisation are:
1. A lack of eye contact and avoidance of patients
2. A hierarchal structure so doctors in senior positions have little contact with patients
3. Medication of patients means contact is not always necessary

Question 8

What was the procedure for study 2 of the Classical study?

Answer 8

3 months later in a follow-up study Rosenhan sent NO pseudo-patients for admission to a hospital.

All 193 patients were real mental health patients.

Each staff member had to ‘rate’ patients one a scale of 1-10 to reflect the likelihood of them being pseudo-patient.

Question 9

What were the results of study 2 of the Classical study?

Answer 9

41 were judged with high confidence as pseudo-patients by at least one staff member.

‘Diagnostic labelling’ of Sz is difficult for a pseudo-patient to overcome.

(Low validity of study 2 as staff were told pseudo-patients would try to gain admission).

Question 10

Evaluate the generalisability of the Classical study

Answer 10

+ Rosenhan included both genders from a range of backgrounds
- The sample is imbalanced (5 males, 3 females) so the findings are arguably still androcentric
- Findings may not be representative for individuals experiencing mental health conditions in other parts of the USA like Central America
- Findings cannot be generalised to collectivist cultures, because America is an individualistic society that values autonomy and freedom

Question 11

Evaluate the reliability of the Classical study

Answer 11

+ Highly reliable due to standardised procedures used by all psueod-patients
+ All patients gained admission by claiming to hear the same thing (unfamiliar same-sex voice saying ‘empty, thud, hollow’).
+ Easy to replicate
+ High inter-rater reliability because several doctors at different hospitals repeatedly gave the same misdiagnosis

Question 12

Evaluate the applications of the Classical study

Answer 12

+ Strong applications to training healthcare professionals
+ The conclusion that ‘the sane cannot be distinguished from the insane’ has been applied to clinical diagnosis to improve type 1 (false positive) errors, by reducing the labelling of patients
+ The study contributed to reforms of the DSM-4 where the diagnosis for ‘hearing voice’ in schizophrenia was changed from a minimum duration of 1 month to 1-6 months repeatedly

Question 13

Evaluate the ecological validity of the Classical study

Answer 13

+ Field experiment, naturalistic observation
+ The range of hospitals in the study means that the results can be directly applied to the real-life healthcare systems
+ The REAL participants (doctors and nurses) were observed in their real-life working environment, which increases mundane realism

Question 14

Evaluate the internal validity of the Classical study

Answer 14

• Seymour Ketty (1974) criticised Rosenhan, claiming the pesudo-patients were faking an unreal mental condition, so the study does not tell us anything about how people with genuine mental health conditions are diagnosed or treated
• Rosenhan’s study is not an entirely valid measure of clinical diagnosis because the findings were based on the experience of pseudo-patients rather than real mental health patients

Question 15

Evaluate the ethics of the Classical study

Answer 15

+ Confidentiality: all patients were given ‘pseudonyms’ and allocated pretend occupations and places of employment
+ Protection from harm: pseudo-patients were trained on how to avoid taking medication by pocketing or depositing drugs in the toilet.
+ Informed consent was given to take part in the study by pseudo-patients
- No right to withdraw because they were responsible for their own discharge from the hospital
- The longest stay was 52 days, which could have caused long-term psychological harm
- Deception: The real participants of the study (staff) did not give informed consent

Question 16

Describe the 4 D’s used for diagnosis of mental health conditions

Answer 16

1. Deviance
2. Dysfunction
3. Distress
4. Danger

Question 17

Describe ‘deviance’

Answer 17

Refers to statistically rare behaviours and emotions that are not the norm (disapproved of) in a society.

Question 18

Describe ‘dysfunction’

Answer 18

Behaviour that interferes with a person’s everyday life, causing a person to not live a normal life, e.g., insomnia, unable to work, relationship breakdown.

Question 19

Describe ‘distress’

Answer 19

The extent to which a person perceives their own negative behaviours/emotions as upsetting

Question 20

Describe ‘danger’

Answer 20

Refers to danger to others or the individual themselves, e.g., violence towards others, suicidal thoughts or self-harm.

Question 21

Evaluate ‘deviance’ in the context of a clinical diagnosis

Answer 21

+ Practical applications in helping professionals decide whether a patient’s symptoms warrant a clinical diagnosis
- Perceptions of deviance may change over time depending on societal norms (e.g., homosexuality used to be on the DSM but is considered normal today)

Question 22

Evaluate ‘dysfunction’ in the context of a clinical diagnosis

Answer 22

+ Using dysfunction to diagnose a mental health condition provides a holistic way to assess someone’s mental health, as the 4 D’s cover a wide range of symptoms.
- Dysfunction is difficult to measure which reduces the internal validity. There is likely to be subjectivity in the applications of the 4 Ds. No universal consensus about what constitutes dysfunctional behaviour

Question 23

Evaluate ‘distress’ in the context of a clinical diagnosis

Answer 23

+ Distress can be measured objectively using quantitative scales, like the Beck Depression INventory which indicates self-report scales of emotion and harm. Easily repeated, therefore reliable.
- Interpretations of distress are subjective based on clinicians’ biases.
- Cooper et al (1972) have demonstrated that New York and British psychiatrists shown the same videotaped interview came to different clinical diagnosis, NY psychiatrists diagnosed schizophrenia twice as often, whereas British psychiatrists diagnosed depression twice as often

Question 24

Evaluate ‘danger’ in the context of a clinical diagnosis

Answer 24

+ Dangerous behaviours are easier to identify as they’re likely to be overt, which increases practical applications
- Davis (2009) argues that the model is incomplete, and a 5th D ‘Duration’ should be added. Duration defined as the length of time the person has experienced symptoms, in the case of schizophrenia according to the DSM-5, 2 or more symptoms should last at least 1 month.

Question 25

Define cross-cultural research

Answer 25

The study of human behaviour between different cultures to identify similarities and differences across cultures.

Question 25

Why is cross-cultural research carried out?

Answer 25

Cross-cultural research enables universal behaviours (nomothetic laws of universality) which are common to many cultures to be identified, as well as, culturally specific behaviours.

Question 25

Define the emic perspective

Answer 25

The Emic insider perspective ‘cultural relativism’ is based on how the local culture and native people understand a behaviour by ‘looking within’.

Question 26

Define the etic perspective

Answer 26

The Etic outsider perspective does not adapt to local cultural beliefs and understands a behaviour by ‘looking from the outside.’
If psychologists adopt the ‘Etic standpoint’ when conducting cross-cultural research this lends itself to subjective cultural bias as Western cultures tend to see the mind and body as separate entities.

Question 26

Define ethnocentrism

Answer 26

Research that is centred around one culture only

Question 27

Define Eurocentrism

Answer 27

Where the Western World’s societal or cultural perspective is deemed as superior to all and the ‘gold standard’ for clinical diagnosis.

Question 28

What issues to do language and translation pose to clinical diagnoses?

Answer 28

Patients and psychologists may find themselves ‘lost in translation’ if a psychiatrist speaks a different language or if particular words cannot be directly translated from the English language to another language.

Question 29

Describe Luhrmann et al’s (2015) support for cultural differences:

Answer 29

• Compared 20 people from different cultural backgrounds with serious psychotic disorder who meet the inclusion criteria for schizophrenia and hear voices.
• California sample: people were more likely to describe their voices as ‘intrusive unreal thoughts’.
• South Indian sample: people were more likely to describe voices as providing ‘useful guidance’.
• West African sample: people were more likely to describe voices as ‘morally good and causally powerful.’
• Hearing voices was seen as a negative experience in ‘Westernised’ society like America but a positive one in more Eastern societies like India and Western Africa
• This could change the way psychologists treat patients who are saying they can hear voices.

Question 30

Describe Tortelli et al’s (2015) support for cultural differences

Answer 30

• A systematic review of black Caribbean-born migrants in the UK since the 1960’s.
• Results showed that 16 out of 18 studies demonstrated statistically significant elevated incidence rates in the black Caribbean group, for major psychotic disorders, including schizophrenia and bipolar disorder. 
• This shows higher incidence rates of psychotic disorders diagnosed in ethnic minority populations in England for over 60 years.

Question 31

Describe Andrade et al’s (2012) support for cultural differences

Answer 31

• São Paulo Metropolitan Area (SPMA) a mega city within an urban setting using 5037 participants who were interviewed face to face.
• Explored aspects of urban living such as, internal migration, exposure to violence, and neighbourhood-level social deprivation.
• Results showed high social deprivation was associated with substance disorders in Sao Paulo, demonstrating that socioeconomic background can affect individual mental health disorders.
• Gender differences were also found, with 29.6%  women more likely to have mood, anxiety and severe/moderate disorders than men.

Question 32

Describe Philips (2001) support for cultural difference

Answer 32

• In China, higher level of schizophrenia were found in urban areas than in rural areas and a higher prevalence was also diagnosed in woman than in men.
• In China suffering from a mental health disorder is often seen as ‘failure in society’ as the person is not following the social norms.
• With this research, Western classification systems could become more accessible as we can translate the new findings into better outcomes for the untreated or poorly treated patients suffering from schizophrenia. 

Question 33

Describe Lin (1996) refuting cultural differences

Answer 33

• Lin (1996) argues when studying the symptoms of schizophrenia, there were more similarities across different cultures than differences.
• This suggests cultural differences would NOT lead to a difference in diagnosis. Therefore, for the clinical condition schizophrenia, cross cultural perspectives may be inefficient or even redundant. 

Question 34

Describe the overcompensation argument, refuting cultural differences

Answer 34

Psychiatrists can over compensate for cultural differences (by considering the local cultural beliefs ‘too much’ when using an ‘emic’ standpoint).
This can lead to clinicians NOT diagnosing a mental disorder when in fact there was one, so cultural differences may not have caused any difference in the disorders but have impacted the diagnosis.

Question 35

DSM

Answer 35

The Diagnostic and Statistical Manual of Mental Disorders.

Question 36

ICD-11

Answer 36

International classification of diseases version 11

Question 37

Describe the DSM-IV

Answer 37

• DSM 4th edition revised
• Multi-axial system
• Each diagnosis of a disorder is split into 5 levels called axes.
• A patient is assigned a category based on their symptoms which informs the diagnosis.

Question 38

Describe the DSM-V

Answer 38

• Aims to coincide with the ICD to avoid confusion with having more than one universal classification system.
• No longer a multi-axial system instead there are 3 sections:
  1 = Introduction and explanation of changes.
  2 = Diagnostic codes taken from ICD-9 in an attempt to ‘harmonise’ the two systems. For example, schizophrenia, depressive disorders, OCD, anxiety, trauma and stress.
  3 = Emerging measures and models, self-assessment by patient, cultural issues.

Question 39

Describe ICD-11

Answer 39

Used to monitor: incidence, prevalence, morbidity
WHO (World Health Organisation) use ICD figures.
ICD is for all illnesses not just mental health issues.

Question 40

Define reliability of clinical diagnosis

Answer 40

Refers to the consistency of a clinical diagnosis when using a classification system

Question 41

Define inter-rater reliability of clinical diagnosis

Answer 41

The extent to which two or more different clinicians are in agreement and arrive to the same clinical diagnosis when diagnosing the same patient

Question 42

Define intra-rater reliability of clinical diagnosis

Answer 42

When the same clinician diagnoses the same patient with the same symptoms as having the same disorder at two different points in time.

Question 43

Define test-retest reliability of clinical diagnosis

Answer 43

The same patients are observed separately by two or more clinicians within a period of time where the clinical conditions of the patients are unlikely to have changed. It is test-retest reliability that reflects the effect of the diagnosis on clinical decision making and that is the focus of the DSM-5 field trials.

Question 44

Outline the DSM field trials

Answer 44

• The DSM-5 field trials were designed to evaluate the test-retest reliability.
• 2246 patients and 279 clinicians were involved in 11 centres in the US and Canada
• The criteria for 23 diagnosis were tested: 15 adults and 8 children
• Each patient was interviewed twice by 2 different clinicians using the DSM-5 criteria.

Question 45

What was the measurement used to assess diagnosis in the DSM field trials?

Answer 45

Kappa score

Question 46

Describe the adult schizophrenia score for the DSM field trials

Answer 46

0.46 = ‘good’ level of reliability and agreement

Question 47

Describe the adult PTSD score for the DSM field trials

Answer 47

0.67 = ‘very good’ level of reliability and agreement

Question 48

Describe the adult MDD score for the DSM field trials

Answer 48

0.28 = ‘questionable level of reliability and agreement

Question 49

Describe Regier et al (2013) supporting reliability of the DSM

Answer 49

The DSM-5 field trials show reliability of the DSM-5 is very good for disorders like PTSD which have some of the highest levels of agreement and reliability between clinicians resulting in scores of 0.67.

Question 50

Describe Brown et al (2001) supporting reliability of the DSM

Answer 50

Brown et al (2001) found good reliability in clinical diagnosis when using DSM-4 in 1,127 outpatients. There was good to excellent consistency for most of the DSM categories for generalised anxiety disorders and mood disorders.

Question 51

Describe the concept of time supporting reliability of the DSM

Answer 51

The DSM has stood the test of time; despite the revisions it is still one of the most widely used classification systems in mental health. The DSM-5 has fine-tuned previous diagnoses, for example ‘eating disorder’ has becoming ‘binge eating disorder’, which is more specific and reliable, enabling clinicians to come to a common diagnosis.

Question 52

Describe Jakobsen et al (2005) supporting reliability of the DSM

Answer 52

Jakbosen et al (2005) tested the reliability of the ICD-10 classification system in diagnosing schizophrenia. 100 danish patients with a history of psychosis were assessed, a concordance rate of 98% was obtained. This demonstrates the high reliability of the clinical diagnosis of schizophrenia using up-to-date classification.

Question 53

Describe culture supporting reliability of the DSM

Answer 53

DSM-5 gets rid of the list of ‘culture-bound syndromes and replaces it with advice on ‘cultural concepts of distress’, which has increased multi-cultural perspectives. This has resulted in positive contributions to cross-cultural diagnosis by making new conditions known outside of the USA. For example, ADHD and Borderline Personality Disorder are now recognised in the UK.

Question 54

Describe the Kappa score refuting the reliability of the DSM

Answer 54

The DSM-5 field trials show only 5 out of 23 diagnoses were found to be ‘very good’. This raises questions about the reliability of conditions like schizophrenia where the kappa score was still quite low (0.46). This suggests that there are many clinical diagnoses which remain unreliable amongst different clinicians.
Spitzer & Colleagues (2012) argue that a kappa score below 0.60 would be concerning, even considering the DSM-5’s test-retest methodology.

Question 55

Describe Cooper et al (1972) refuting the reliability of the DSM

Answer 55

Cooper et al (1972) showed American and British psychiatrists the same videotaped interview and asked them to make a diagnosis. New York psychiatrists said it was schizophrenia twice as often, whereas the London psychiatrists said it was depression twice as often.

Question 56

Describe Buckley et al (2009) refuting the reliability of the DSM

Answer 56

Comorbidity describes people who suffer from two or more mental disorders, For example, schizophrenia and depression are often found together, This makes it more difficult to confidently diagnose schizophrenia. Comorbidity occurs because the symptoms of different disorders overlap. For example, major depressive disorder and schizophrenia both involve very low levels of motivation. This creates problems of reliability. Buckley et al (2009) found that 50% of schizophrenia patients also had a diagnosis of depression, 29% had a post-traumatic stress disorder diagnosis, and 23% had an OCD diagnosis.

Question 57

Describe Loring and Powell (1988) refuting the reliability of the DSM

Answer 57

Loring and Powell (1988) found that some behaviour which was regarded as psychotic in males was not regarded as psychotic in females. There Is gender and cultural bias present in the diagnosis of schizophrenia.
Men are far more likely to be diagnosed, potentially because women experience the symptoms differently to men and much of the clinical research remains androcentric.