Lecture 2 - Classification and Diagnosis

Question 1

What 2 components does today’s definition of mental disorder involve?

Answer 1

1. Seen as socially unaccepted/harmful (does not exist independent of social ‘norms’)
2. Caused by a dysfunction internal to the individual

Question 2

FIX CARD

What is a limitation of the DSM and the

Answer 2

DSM fails to apply its own general definition of mental illness to specific diagnostic categories

Question 3

Is the prevalence of mental disorder in the community likely to be over or under estimated?
Why?

Answer 3

Overestimated, because diagnosis is based on symptoms only, ignoring the question of internal dysfunction.

Question 4

What are the 2 current classification systems we have to mental disorders?

When were these established, by whom and what edition are we currently on?

Answer 4

1. International Classification of Diseases and Related Health Problems (ICD).
   ◦ World Health Organisation
   ◦ Mental disorders first added in 1948.
   ◦ Currently in its 10th edition
2. DSM
   ◦ American Psychiatric Association
   ◦ 1st Edition published in 1952
   ◦ Currently in its 5th edition (2013)

Question 5

What ‘model’ do the ICD and DSM reflect?

Answer 5

The medical model

used to be psychoanalytic

Question 6

In the medical model, what 5 assumptions does the classification and diagnosis of illnesses base itself on?

Answer 6

1 Illness is qualitatively different from health

2 different illnesses are clearly distinguishable from each other –

3 occur independently from each other –

4 have specific, identifiable causal agents

5 respond to specific treatment

Question 7

What is the ultimate goal of the medical (psychiatric) classification?

Answer 7

Diagnosis based on known causation
◦ i.e., aim is to identify diagnostic categories (syndromes) that have their own specific causes, lead to specific treatments
aka◦ Aim: identify independent groups of symptoms (syndromes), each reflecting a specific cause

A ‘syndrome’ is only a ‘disease’ once we know its cause (e.g., AIDS)

Question 8

FIX CARD

Answer 8

Early attempts for aetiologically based classification of various types of ‘insanity’ were based on hypothesised causes

Question 9

FIX CARD

Answer 9

Hippocrates (c. 460-377 BCE) – Hysteria (“hustera” = uterus)
◦ Paracelsus (16th Century) – Vesania, Lunacy, Insanity
◦ Henry Maudsley (1867) – Masturbatory insanity
– “extreme perversion of feeling and derangement of thought, failure of intelligence, nocturnal hallucinations, and suicidal and homicidal propensities.”

Question 10

FIX CARD

When are who germ theory

Answer 10

1850s: Louis Pasteur and the germ theory of disease

Question 11

FIX CARD

Answer 11

P. Broca (1824-1880), C. Wernicke (1848-1905)

– Identified associations between specific syndromes (expressive vs receptive aphasia) and localised damage to the brain

Question 12

FIX CARD

Answer 12

Eventually, all mental illnesses will be identified and categorised according to their underlying biological causes:
◦ Bacterial or viral infections, 
◦ Localised brain damage,
◦ Toxins,
◦ Heredity

These would lead to effective treatment or prevention

Question 13

Which decades were the psychoanalytic model very influential in psychiatry during?

Answer 13

1940-70s

Question 14

What three ways did the psychoanalytic model revolutionalise the concept of mental illness?

Answer 14

– 1/ No clear dividing line between normal and abnormal – ‘Pathological’ is extreme manifestation of ‘normal’.
–
2/ Include conditions other than psychotic states – ‘neuroses’: anxiety, depression, various phobias
–
3/ No clear dividing line between different categories of mental disorder (neuroses and psychoses).

Question 15

FIX CARD

Answer 15

Extended client base to those with milder conditions
◦ Proliferation of mental health professions
– Move from insane asylums to outpatient private practices

Question 16

What were some problems with the DSM I and II?

Answer 16

Problematic reliability
◦ Inter-rater reliability:
◦ Can we agree on the diagnosis?
– How much depression/ self deprecation is needed? How often? What if guilt is not present? What qualifies as a ‘loss’? etc
—
Problematic validity
◦ Is this really what “depression” is?
– Based on unproven theories about etiology:
– Depression as a defense from unacceptable unconscious ambivalent feelings

Question 17

Who was the father of modern psychiatric classification?

Answer 17

Emil Kraepelin - (1856-1926)

Question 18

Which DSM stopped reflecting the psychoanalytic model and started reflecting the medical model?

Answer 18

DSM III, 1980

Question 19

What are the pros about the medical model being used in the DSM-III (1980) and beyond?

(DSM-III-R (1987), DSM-IV (1994), DSM-IV-TR (2000), DSM-5 (2013))

Answer 19

◦ No theoretical assumptions about causation
- If causation is not known: Description of symptoms –
- based on measurement, direct observation, patient
report
- – Clear, explicit criteria and decision rules for
diagnosis
◦ Improvement in reliability
◦ Validity? (but we can all be wrong!)

Question 20

What are the cons about the medical model being used in the DSM-III (1980) and beyond?

(DSM-III-R (1987), DSM-IV (1994), DSM-IV-TR (2000), DSM-5 (2013))

Answer 20

◦ Validity? (but we can all be wrong!)
◦ –Comorbidity is very common
–◦ Diagnostic instability is high (diagnosing u with many things- changing between)
––◦ Lack of treatment specificity (e.g., antidepressants)
- Borders between diagnostic categories are
“beginning to collapse under the weight of evidence”

Question 21

True or False?

Some DSM mental disorders qualify as a‘disease’ – a syndrome with known causation

Answer 21

False, none qualify

Question 22

FIX

Answer 22

Applied to all the ‘new’ disorders introduced by

psychoanalysis (not only ‘insanity’)