clinical psychology - diagnosis of mental disorders

Question 1

AO1 Points on diagnosing mental disorders (Introduction)

Answer 1

• Diagnosis is proposing a cause for a medical problem (such as an infection or an injury). It is followed by prognosis, which is a prediction about how the problem will develop with or without treatment.
• Diagnosing medical disorders takes place as part of a clinical interview, in which the therapist asks open-ended questions and the client describes their symptoms.
• The therapist will also make some observations (noticing you have a rash or that you have lost weight) and might use of biometric tools (like taking your temperature or giving you an X-ray).
• With mental disorders, diagnosis becomes more complicated. Often, the client cannot describe their symptoms very well and the therapist cannot make simple observations.
• There are no biometric tools for mental disorders.
• Assessments of abnormality are not based on any one criterion. Several different factors are considered. The main method of assessment used by clinical psychologists is the four Ds.
• The four Ds are used as an assessment tool to decide whether behaviour is abnormal.
• Abnormality may require investigation and diagnosis.
• There is no clear difference between normal and abnormal, its a spectrum. This means that identifying a mental disorder using the four Ds is based on the therapist’s judgement.
• When using the four Ds, a person’s context and situation must be taken into account. Just because the four Ds are present, it doesn’t automatically mean that person must be given a psychiatric diagnosis.

Question 2

AO1 Points on diagnosing mental disorders (Deviance)

Answer 2

• These are behaviours and emotions that are viewed as unacceptable.
• This leads to a question of whether deviance should be measured statistically (in terms of its rareness) or socially/culturally (in terms of social norms).
  Statistical deviance:-
• One way of deciding whether behaviour is deviant is to consider how unusual it is. Behaviour is seen as normal if it occurs frequently but behaviour that occurs relatively rarely in the population is abnormal.
• Extremely rare people can be considered deviant.
• Some behaviours can be measured on a quantitative scale; for example how extraversion levels can be measured by psychometric tests.
• At one end of the scale, there are the extreme extraverts who crave thrills and attention; at the other end of the scale are the introverts who are painfully shy.
• On a normal distribution curve, the majority of scores for a population will cluster around the mean. Any behaviour within the middle 68% of the population is seen as normal.
• This uses the idea of statistical deviation (SD). Normal people are within 1SD of the mean, falling within the 34.1% on either side in terms of their IQ, income, height, weight, age, level of extraversion, etc.
• “Odd” people are further from the mean - 2SD means in the 13.6% on either side of the normal people, so unusually clever or stupid, rich or poor, big or small, outgoing or shy.
• Truly abnormal people are in the 2.1% at the top or bottom of the scale: geniuses or dimwits, billionaires or beggars, giants or dwarfs, party animals or super-nerds.
• This has the great advantage of defining abnormality (and therefore deviance) in objective, mathematical terms.
• The problem is, it ignores how we feel about abnormality. Some things are very rare, but quite harmless and even rather precious. Other things are quite common but we still disapprove of them.
• Moreover, some mental disorders are actually quite common and getting more frequent.
• According to Wittchen et al. (2011), every year 165 million Europeans i.e. 38.2% of Europe’s population, suffer some form of mental illness, with the top 3 being anxiety, insomnia and depression.
  Social Norms:-
• A social norm is an unwritten rule about acceptable behaviour. Norms are therefore the behaviours and attitudes that most people stick to in society. Norms can differ from culture to culture, and from time period to time period.
• When people violate social norms, this is seen as abnormal. Most abnormal behaviour is harmless and abnormal people are treated as eccentric, or rebellious, rather than deviant.
• However, extremely abnormal behaviour conflicts with the values shared by the whole of society; people feel anxious or threatened by the person who is deviant.
• There are a number of factors to take into account when assessing deviance based on social norms:
• Different cultures and subcultures have different social norms. Hearing voices might be seen as normal in a culture that believes in spirits but it is abnormal in another culture that sees it as a mental disorder.
• What is abnormal at one time might become normal later, even in the same culture. Homosexuality used to be viewed as a mental illness (it was in DSM-1), but it is now accepted by most people in western culture.
• Behaviour that is normal in one place or context might be abnormal in a different situation. Nudity is normal in the bath and changing rooms, but not in the supermarket or other public places.
• We have different expectations of men and women and of young people and old people. Cross dressing is viewed by many people as abnormal and adults who “don’t grow out of” behaviour associated with children (like thumb sucking or bed wetting) are seen as abnormal.
• This has the great advantage of defining abnormality (and therefore deviance) in terms of popular feelings and moral values - it is behaviour that frightens or outrages other people.
• However, it’s a rather subjective assessment. There’s a risk that the therapist will be influenced by whether they personally find behaviour shocking or upsetting, rather than be what society-at-large feels.
• It can be difficult to find out what social norms in general are. On many topics, society is quite divided about what should be viewed as normal.

Question 3

AO1 Points on diagnosing mental disorders (Dysfunction)

Answer 3

• This is when the abnormal behaviour is significantly interfering with everyday tasks and living your life.
• Under this definition, a person is considered abnormal if they are unable to cope with the demands of everyday life i.e. looking after yourself, holding down a job, maintaining relationships with friends and family, making yourself understood etc.
• Rosenhan & Seligman (1989) suggest the characteristics that define failure to function adequately:-
• Unpredictably & loss of control (no one knows what you’ll do next, not even you)
• Irrationality/incomprehensibility (no one understands you, you don’t even understand yourself)
• Cause discomfort to observers (you upset, frighten or annoy everyone with your behaviour)
• Suffering (the same as distress, below)
• Maladaptiveness (you are a risk to yourself and others; see danger below)
• Vividness & unconventionality (you stand out; see deviance above)
• Violate moral standards (similar to deviance)
• Dysfunction gets across the idea of a behaviour getting in the way of living a healthy life (which the statistical definition of deviance ignores) but it’s a bit more objective than appealing to social norms.
• For example, even if a person’s sexuality is unusual or shocking to other people, if they can still lead a healthy life then they’re not abnormal.
• A problem with this is that abnormal behavior may actually be helpful for the individual. For example, taking drugs might help people with stressful jobs or help artists unlock their creativity.
• In fact, there might be some social groups where not taking drugs is dysfunctional behaviour.
• Also, many people engage in behavior that is unhealthy, but we don’t class them as abnormal: adrenaline sports, smoking, drinking alcohol and driving too fast.

Question 4

AO1 Points on diagnosing mental disorders (Distress)

Answer 4

• This is the simple view that abnormality involves being unhappy: experiencing negative feelings like anxiety, isolation, confusion and fear.
• Obviously, everyone experiences negative feelings from time to time (exam stress, bereavement, relationship breakup, victims of crime or disasters).
• However, abnormality is when these negative feelings occur inappropriately or persist longer than they should.
• This has the advantage of connecting abnormality to quality of life, the same as dysfunction. You may have odd behaviours like keeping 100 cats in your house, but if it makes you happy, who cares?
• On the other hand, a phobia of cats is a trivial thing - unless it prevents you from going outside for fear that you will meet one, in which case it is clearly distressing you and must be treated.
• A problem with this is that judging distress is quite subjective. It is perfectly normal to be distressed in some situations. After all, who’s to say how long you should grieve for after the death of a loved one or the breakup of a relationship? Some people get very distressed about global warming or animal welfare: is that abnormal?
• Then there are people who don’t feel distress when other people think that they should. If a person stops washing, wearing clean clothes or going outside, most of us would regard that as abnormal and cause for concern.

Question 5

AO1 Points on diagnosing mental disorders (Danger)

Answer 5

• This is when the behaviour harms, or put at risk, the individual or others around them.
• This is based on the harm principle, which states that you have a right to behave in any way you like so long as you don’t cause harm.
• Obviously, there are some things everybody does that can be harmful (like driving a car), but abnormal behaviour puts yourself or other people at excessive risk (like driving a car while drunk).
• This is similar to the principle of distress, because it takes a liberal view that people should be left to their own devices if their behaviour is harmless - as opposed to the deviance and dysfunction principles.

Question 6

AO2 Application Points on diagnosing mental disorders

Answer 6

Cultural problems in diagnosis:-
- Psychology is a very Western discipline and psychiatry (the medical study of mental disorders) is very Western in outlook, based on the experiences of doctors and patients in Europe and North America. The DSM is an American diagnositic manual and its influence is huge.
- Increasingly, psychiatrists have to diagnose mental disorders in patients from non-Western backgrounds.
- This might be because Western healthcare is being introduced to non-Western countries (Asia, Africa, South America) or because ethnic minorities in Western countries need mental healthcare.
- Disorders, classifications and symptoms that are recognised by Western psychiatry become “official” mental disorders and attract research which develops treatments; “unofficial” mental disorders are considered to be folk illnesses and are not taken seriously. This can lead to false negative diagnosis.
- People from other cultures presenting their symptoms to a Western doctor may express themselves in unfamiliar ways.
- For example, among African-Caribbeans it is not abnormal to talk to dead relatives while grieving. This can lead to them being diagnosed with a much more severe disorder than they really have (such as schizophrenia rather than mild depression) - a false positive diagnosis.
Medicalising normal experiences:
- Related to False Positives is the concern that clinical psychologists are ‘medicalising’ normal experiences like sadness, anger, laziness and bad habits.
- This means that feelings that used to be seen as normal parts of life and behaviours that used to be viewed as down to willpower and conscience are now seen as medical problems instead.
- Lisa Appignanesi (2008) argues there are a number of reasons for this:
- We trust doctors and accept a medical diagnosis more than people in the past did.
- Doctors want to help and believe that, if our problems are medical in nature, then they can be treated.
- We are lazy and believe that, if our problems are medical in nature, it’s up to doctors to fix them, not us to change or improve.
- Companies that make medicines (‘Big Pharma’) want to sell us their cures. even if the medical problem doesn’t really exist.
- The latest edition of DSM has been criticised for this, because it contains a lot of “new” mental disorders that include shyness and loneliness as well as unhappiness over bereavement.
- Critics like psychiatrist Nick Craddock argue that if people believe they have a mental illness when in fact they are going through a normal experience, this does more harm than good.
- Some clinical psychologists defend this trend. They argue that, by medicalising problems, we focus on treatment rather than blame.
- Medicalising problems also removes a lot of stigma from behaviours that people used to be ashamed of and keep secret, making it more likely they will come forward and seek help.

Question 7

AO3 Evaluation points on diagnosing mental disorders (Credibility)

Answer 7

• Is diagnosis valid and reliable?
• The reliability of diagnosis can be significantly improved when clinicians communicate with other clinicians when making diagnosis, as this increases inter-rater reliability.
• The use of diagnostic systems means more communication between clinicians, which increases reliability (Spitzer & Fleiss, 1974).
• The DSM and ICD are always being reviewed. Updates ensure that it is possible to make more valid diagnoses based on up-to-date evidence.
• The DSM focuses on the Four Ds, showing each has validity. For example, in the DSM, it’s not enough for schizophrenia to include deviant behaviour; distress must also be present as well as dysfunction.
• Factitious disorders (like Munchausen Syndrome) exist where people fake illness or psychological disorder to get medical attention. - This indicates deviance from the norm, as well as distress felt by the individual through faking illness; there may be danger, as they may harm themselves to back up their claims; dysfunction may incur as faking the illness involves losing jobs, withdrawing from social life, etc.

Question 8

AO3 Evaluation points on diagnosing mental disorders (Objections)

Answer 8

• Is diagnosis invalid and unreliable?
• There are two diagnostic systems used worldwide: ICD and DSM. There are distinct differences in how they classify mental disorders and some disorders are included in one but not in the other.
• Since the diagnosis depends on which system is used, the validity of diagnosis is in doubt of diagnosis. There has been found to be only a 68% agreement (Andrews et al, 1999) between the ICD and DSM.
• Rosenhan (1973) provides evidence that diagnoses are flawed, as staff were unable to tell mentally disordered patients apart from those who were healthy.
• Since there are no objective measures of each of the four Ds, the therapist has to use their professional judgement. What one views as dysfunctional (such as not going to work) might not be considered dysfunctional by the client or by a different therapist.
• This can lead to people “shopping around” for a psychiatrist who will support their beliefs about their disorder.
• The lack of objectivity of the four Ds raise issues about reliability of diagnosis. If the four Ds are used by two different therapists, they may not reach the same diagnoses.
• For example, Dissociative Identity Disorder (multiple personality) is a recognised disorder in the USA but not in Britain.
• Spitzer & Fleiss (1974) carried out a meta-analysis of 6 studies and found some similarities in how disorders were diagnosed by psychiatrists but many differences.
• They claim that reliability is not high for the diagnosis of any mental disorder and that reliability for schizophrenia is just ‘fair’ rather than ‘good’.
• However, this study is from before DSM-III (1980) and it may be that diagnosis is more valid and reliable today. Mitchell Wilson (1993) suggests that DSM-III was developed precisely to tackle the unreliability of the previous systems.

Question 9

AO3 Evaluation points on diagnosing mental disorders (Differences)

Answer 9

• Timothy Davies proposes that a 5th D - Duration - needs to be included.
• Grief is a good example, because a period of grief is normal after the death of a loved one (in fact, not grieving would be abnormal) but if the grief goes on too long (like Queen Victoria) then that becomes abnormal instead.
• Another example is the different types of schizophrenia. Schizophrenia Undifferentiated requires symptoms to have lasted for more than a few hours, whereas Schizophrenia Disorder is a possible diagnosis if symptoms have lasted for a month but not longer than six months.
• One radical new approach is the recovery model. This is a holistic approach that rejects focusing on symptoms and fitting patients into categories.
• It grew out of a movement in the 1980s and ’90s that rejected institutionalization and drug therapy and focused on the testimonies of people who “beat their illness” by changing their lives.
• For example, with schizophrenia the recovery model advocates treatments like counseling (such as CBT), diet, exercise and meditation and not just drug therapy.
• Bradshaw’s case study of Carol shows that CBT can be effective for schizophrenia - but Carol was also being treated with drugs.
• Jessica Arenella (2015) argues that the recovery model is gaining ground over the medical model because drugs and psychiatrists are expensive but social workers are much cheaper.
• More extreme advocates of the recovery model reject the idea that their conditions are “illnesses” at all - just unusual variations on the human condition that they need to find ways of coping with.
• Their argument is that society should change to accommodate them, rather than silencing them with drugs and medical labels.
• Even if we don’t agree with the recovery model, it still makes some good points. People with mental disorders are more than just broken machines that need to be “fixed” by a wonder-drug.
• Medical diagnoses can become part of the problem, taking away people’s sense of control over themselves, making them see themselves as a damaged human beings; they become dependent on drugs and psychiatrists to make their life bearable rather than trying to change their life.

Question 10

AO3 Evaluation points on diagnosing mental disorders (Applications)

Answer 10

• Timothy Davis (2009) argues that diagnosing mental disorders involves deciding when a characteristic is problematic enough to become a clinical diagnosis.
• The four Ds can assist in making a decision by matching behaviour and beliefs to the DSM. This helps therapists to know when a condition might need a DSM diagnosis,
• Diagnoses are conducted through clinical interviews. These are semi-structured interviews which gather information on the client’s behaviour to make a clinical assessment.
• This could lead to problems because semi-structured interviews can be unreliable, subjective and biased. For example, African-Caribbean people in the UK are 3-5 times more likely to be diagnosed with schizophrenia and hospitalised than other groups.
• You are also more likely to be diagnosed with serious mental disorders if you are poor. Women are more likely to be diagnosed than men.