The classification of Mental Health Flashcards
What is a psychiatric diagnosis?
The act of classifying an ‘illness’ or ‘disorder’
How do we classify an ‘illness’ or ‘disorder’? List 3 requirements
1) Each disorder category is divided into types and subtypes and should be distinct from other disorders (i.e. a categorical system)
2) A set of rules or criteria which defines each diagnosis
3) A minimum threshold must be met for someone’s experiences to fit the criteria for a diagnosis
What are the examples of minimum thresholds that must be met for someone’s experiences to fit the criteria for a diagnosis?
- A minimum number of symptoms
- Experience occurs within a certain timeframe
- Symptoms typically require a change from usual functioning / an impact on daily life
The most commonly used classification systems in psychiatry are…? List 2
1) Diagnostic and Statistical Manual of Mental Disorder, 5th edition (DSM-5)
2) International Classification of Diseases 11th Revision (ICD-11)
Who published the DSM-5?
American Psychiatric Association (APA)
Who published the ICD-11?
World Health Organization (WHO)
Who uses the DSM-5?
Professionals who diagnose people with disorders (psychiatrists especially)
Used internationally
Who uses the ICD-11?
Used by the NHS mostly and in effect from Jan 2022
When was the first version of the DSM published?
1952
When was the latest version of the DSM published?
2013
How many diseases are listed in the DSM-5?
293
The DSM-5-TR contains revised criteria for more than ….. disorders and includes a new one (prolonged grief disorder)
70
Which of these currently lists all of the recognised mental disorders and all characteristic features/symptoms that are required for an individual to be diagnosed with a specific disorder?
a) DSM-5
b) ICD-11
a) DSM-5
What is inside the DSM-5?
A lists all of the recognised mental disorders and all characteristic features/symptoms that are required for an individual to be diagnosed with a specific disorder
Which of these is the standard manual used for the classification of mental disorders by mental health professionals in the United States
a) DSM-5
b) ICD-11
a) DSM-5
What is the DSM-5 used for?
Used for classification of mental disorders by mental health professionals in the United States
Which of these is free to use?
a) DSM-5
b) ICD-11
b) ICD-11
Which of these only mentions mental disorders and how to classify them?
a) DSM-5
b) ICD-11
a) DSM-5
Which of these contains codes for all physical diseases, illnesses, and mental health problems, but also some descriptive ones too?
a) DSM-5
b) ICD-11
b) ICD-11
What does the ICD-11 contain?
Codes for all physical diseases, illnesses, and mental health problems, but also some descriptive ones too
e.g. acute intoxication from alcohol – F10.0; bitten by a crocodile/alligator – W58
Which of these mentions every single disorder, disease, illness and mental health problem that you can think of?
a) DSM-5
b) ICD-11
b) ICD-11
Can psychiatric diagnoses be useful? List the 5 reasons why it CAN be useful for HEALTH SERVICES AND CLINICIANS
1) To facilitate clinical assessment (mainly psychiatrists; less so for clinical psychologists)
2) To aid communication (common language for all professionals)
3) To guide treatment decisions
4) To help organise mental health services
5) To facilitate research (in order to research something, we need to agree on how to define it)
Can psychiatric diagnoses be useful? List the 6 reasons why it CAN be useful for INDIVIDUALS WHO RECIEVE A DIAGNOSIS.
1) Gives a name to difficulties
2) Allows individuals to look it up online
3) Offers meaning, understanding, relief and explanation
4) Facilitates communication with and understanding from others
5) Provides access to care and support (e.g. benefits)
6) Facilitates the process of finding and forming peer/carer support groups
Who conducted the Rosenhan experiment?
David Rosenhan
Who conducted the Rosenhan experiment?
David Rosenhan
What did David Rosenhan do in his study?
Being sane in insane places
Describe the Rosenhan Experiment
- 8 pseudo-patients (including Rosenhan himself) faked one symptom in order to gain access to 12 different psychiatric hospitals in the US between 1969-1972
- These 8 people claimed to hear a voice that said “empty”, “dull”, “thud” in their head
- They all received severe psychiatric diagnoses (mostly schizophrenia) despite faking their symptoms
What was the purpose of Rosenhan’s experiment?
The experiment was during a time when psychology and psychiatry were at odds
The experiment was an attempt to discredit psychiatry and provide evidence that psychiatric diagnoses are inaccurate and unreliable
What happened in the Rosenhan experiment once the pseudo-patients acted normal again and claimed their symptoms were gone?
- The patients were not allowed to leave (kept in for 8-52 days)
- Anything they did was taken as evidence of psychiatric disorder
- They were discharged with “remitted paranoid schizophrenia” - showing how diagnostic labels ‘stick’
- Treatment? Psychiatric staff were just ignoring patients
Why did Rosenhan perform a follow-up study of his original experiment?
Because hospitals challenged Rosenhan to send more pseudo-patients, claiming that they would identify them
In Rosenhan’s follow-up experiment, what did the results show?
The hospital claimed to have identified 41/193 patients as pseudo-patients (fake patients)
But actually, Rosenhan never actually sent anyone
What did Rosenhan’s experiment conclude overall?
We cannot reliably distinguish the sane from the insane
Because:
- People feigning mental illness all gained admission to psychiatric units
- After they stopped faking symptoms, remained there for long periods without any treatment (being ignored)
How can we evaluate diagnostic systems? List 3 ways
1) Are they reliable?
2) Are they valid?
3) Are they accurate?
What does a reliable diagnostic system imply?
To what extent experts can agree about who has what diagnosis?
What does a valid diagnostic system imply?
To what extent the diagnostic system is useful for the purpose intended?
What does an accurate diagnostic system imply?
Can the diagnosis predict the course and outcome of illness and response to treatment?
You have depression and are given a treatment of social therapy.
The diagnosis of your disorder can predict the course and outcome of the disorder as well as your response to the treatment.
This is known as…?
a. Reliability
b. Validity
c. Accuracy
c. Accuracy
How do we test whether the DSM is reliable for psychiatric diagnosis?
Inter-rater reliability
Can two clinicians assess the same person and assign the same diagnostic category?
In DSM field trials, diagnoses are made under (…….) circumstances (trained raters using a standardised interview schedule)
Ideal
Inter-rater reliability of the DSM is determined by (……….) statistic
Kappa
What is kappa statistic?
Kappa statistic is a measure of agreement ranging from -1(complete disagreement) to 1 (perfect agreement)
What is the range of possible values of the kappa statistic?
The range of possible values usually falls between 0 (agreement no better than expected by chance) and 1
What kappa value is commonly accepted as substantial/excellent agreement during the DSM-5 field trials?
0.75
What kappa value is ideal during the DSM-5 field trials?
- 0.75 excellent agreement
- 0.6 acceptable agreement
After testing the inter-rater reliability of diagnoses from the DSM-5 during the DSM-5 field trials, were the kappa values acceptable or not acceptable?
Many of the diagnoses had kappa values that would be normally regarded as unacceptable/unreliable
Many of the diagnoses had kappa values that would be normally regarded as unacceptable/unreliable during the DSM-5 field trials
What does this say about reliability?
Many of the professionally trained individuals in the inter-rater reliability test could not agree on a diagnosis
Suggests that people do well in creating the criteria of disorders that one must meet to be diagnosed and categorising patients
However, professionals are still unable to agree on the same diagnosis (unable to apply to categorise patients in the same, consistent way)
What kappa value is commonly accepted as excellent agreement after the DSM-5 field trials?
0.6-0.8 excellent
What kappa value is ideal/ a realistic goal after the DSM-5 field trials?
0.4-0.6 realistic goal
What kappa value is commonly accepted as perfect/miraculous agreement after the DSM-5 field trials?
above 0.8 perfect/miraculous
What kappa value is commonly accepted as an acceptable agreement after the DSM-5 field trials?
0.2-0.4 acceptable
Why do highly trained professionals often fail to agree on a diagnosis?
Because the diagnostic criteria is narrow
If the diagnostic criteria is wider, there would be more unique diagnoses that have less overlap with other disorders/diagnoses
The extent to which the diagnostic - system is useful for the intended purpose
This is known as…?
Validity
True or False?
Reliably identifying a category automatically indicate usefulness
False
Reliably identifying a category does not automatically indicate usefulness
What does it mean for the classification system of diagnosis to be valid?
To be valid, the classification system should be useful in predicting the course and outcome of a particular condition
What did Hanlon do in his data analyses on the validity of diagnostic systems?
Hanlon et al (2018) analysed data collected from people diagnosed with schizophrenia, bipolar disorder, or schizoaffective disorder (all diagnoses with overlapping features) and a control group with no diagnoses
What did Hanlon find in his data analyses on the validity of diagnostic systems?
Receiving a specific diagnosis had little impact on the “real-life functioning” of participants (i.e. managing daily tasks, engaging in education/employment)
However, the presence and severity of the symptoms were more important/relevant to the participants
Why do generalised anxiety disorder and major depressive disorder have low inter-rater reliability/kappa value?
Because they are mainly diagnosed by GPs who didn’t train as much as psychiatrists, thus, the diagnoses tend to be inaccurate
True or False?
Specific diagnoses are the best predictor of outcomes under many circumstances
False
specific diagnoses are not the best predictor of outcomes under many circumstances
What does construct validity mean in diagnostic systems?
Do the symptoms of specific psychiatric diagnoses correlate with each other?
Do the symptoms of specific psychiatric diagnoses correlate with each other?
Most likely not
- Different clusters within the same diagnosis
- e.g. studies have shown that there are at least 3 clusters of symptoms of schizophrenia/psychotic symptoms (first demonstrated by Liddle in 1987 and much replicated since)
- Individuals diagnosed with schizophrenia/psychotic symptoms could come under any of those clusters
- But their presenting problems could be very different
What are the implications of the validity of diagnostic systems?
People who receive the same diagnosis have very different problems and need different treatments
Hallucinations and delusions are known as…?
a. Positive symptoms
b. Cognitive Disorganisation
c. Negative symptoms
a. Positive symptoms
Flat affect and lack of motivation are known as…?
a. Positive symptoms
b. Cognitive Disorganisation
c. Negative symptoms
c. Negative symptoms
Cognitive and attentional deficits are known as…?
a. Positive symptoms
b. Cognitive Disorganisation
c. Negative symptoms
c. Negative symptoms
What are positive symptoms?
Any change in behaviour or thoughts
What is cognitive disorganisation?
Reflects a disorganization of thought and is defined by the presence of bizarre behaviour, alogia, and impaired attention.
What are negative symptoms?
Where people appear to withdraw from the world around then, take no interest in everyday social interactions, and often appear emotionless and flat
What makes diagnosing a patient difficult?
Patients may have the same disorder but may show different symptoms
Also the symptom of a particular disorder could overlap with the symptom of another similar disorder
What is comorbidity?
Meeting the criteria for more than one
diagnosis
Meeting the criteria for more than one
diagnosis
This is known as…?
Comorbidity
True or False?
The norm rather than the exception- more than 50% of people diagnosed with a mental disorder in a given year, meet the criteria for multiple disorders
True
How many people with disorders carry only a single diagnosis?
55%
How many people with disorders carry 2 diagnoses?
22%
How many people with disorders carry 3 or more diagnoses?
23%
Are diagnoses distinct, separate entities or are they interrelated?
They are interrelated
The problem of comorbidity raises significant questions about ….?
The underlying structure & assumptions of classification
In order for the classification system to be valid, it must…?
Be able to predict response to treatment
True or False?
Different illnesses should respond to different treatments
True
What is supposedly the treatment for Schizophrenia?
Neuroleptics
What is supposedly the treatment for Manic depression?
Lithium carbonate
Lithium carbonate is supposedly the treatment for what disorder?
Manic depression
Neuroleptics are supposedly the treatment for what disorder?
Schizophrenia
What did Johnstone et al. discover about treatments and drugs?
The drug response was symptom-specific but not diagnosis-specific
e.g. Delusions and hallucinations were successfully treated using neuroleptics
Mood difficulties were successfully treated using lithium carbonate
The drug response was symptom-specific but not diagnosis-specific
Who proposed this?
Johnstone et al.
What did Johnstone et al. do in their study investigating whether different illnesses should respond to different treatments?
Randomly assigned patients to pimozide (a neuroleptic), lithium carbonate, both or neither.
Do diagnoses predict treatment response?
Not really. The drug response was symptom-specific but not diagnosis-specific.
True or False?
Most NHS services use diagnoses as inclusion criteria.
False
However, most NHS services do not use diagnoses as inclusion criteria.
Instead of using diagnoses as inclusion criteria, what do most mental health services (in the UK; NHS) use to accept or decline clients?
Most services accept referrals on the basis of need, severity/complexity of distress, and the specialist skills of their staff
What did Allsopp & Kinderman do in their study?
They did a freedom of information request to services in the North of England to find out to what extent psychiatric diagnoses were used to offer clients services
Who did a freedom of information request for services in the North of England to find out to what extent psychiatric diagnoses were used to offer clients services?
Allsopp & Kinderman
In Allsopp & Kinderman’s study, what were the 4 types of services used to offer clients services?
1) Services that used diagnosis
2) Services that responded to specific needs/severity (largest category)
3) Services that worked with specific problems but were non-diagnostic
4) Services that supported specific life circumstances
Which health service helped individuals with eating disorders and learning difficulties?
Services that used diagnosis
Which health service involves ‘Improving Access to Psychological Therapies’ (IAPT) services (for mild to moderate mental health problems), secure services, crisis teams?
Services that responded to specific needs/severity (largest category)
Which health service helped individuals with traumatic stress, alcohol and drug misuse, and early intervention in ‘psychosis’?
Services that worked with specific problems but were non-diagnostic
Which health service helped individuals with military veterans, homeless & traveller teams and perinatal mental health?
Services that supported specific life circumstances
What is the main implication for the individual following a diagnostic system?
Language, labelling & stigma
Simply = Language from the biomedical model (disorder, symptoms) means difficulties are seen as problems belonging within the individual
Labelling mental health problems as illness & using biomedical causal theories (Read et al., 2006) is associated with….? List 2 things
1) perceptions of dangerousness & unpredictability
2) fear and desire for social distance
True or False?
Diagnoses contribute to power imbalance between clients & clinicians (clinicians giving diagnoses)
True
True or False?
Diagnoses can pathologise/regard “normal” behaviour to a particular event as a mental disorder
e.g. You might be diagnosed with BPD but actually, you react this way because of your past abuse trauma. There is no disorder; it is a trauma response.
True
Do diagnoses relate to racism, sexism and minority discrimination? If so, how?
Yes
Psychiatry is ethnocentric and is related to the ideologies of Western culture, including racism
The practice of psychiatry, including its ways of diagnosing, is influenced by the social ethos and the political system
True or False?
African American and Hispanic patients are less likely to receive a diagnosis of schizophrenia than white patients
False
African American and Hispanic patients are more likely to receive a diagnosis of schizophrenia than white patients
True or False?
White psychiatric inpatients were more likely than African Americans to be diagnosed with bipolar disorder, and less likely to be diagnosed with schizophrenia
True
White psychiatric inpatients were more likely than African Americans to be diagnosed with bipolar disorder, and less likely to be diagnosed with schizophrenia
Why is this?
Racism
Bipolar disorder is less severe compared to schizophrenia. Because western society is biased towards white people over other ethnic minorities, their disorders are perceived as less extreme because they are “less problematic”
In England (from 2017-2018) amongst the five broad ethnic groups, Black or Black British were over (….) times more likely to be detained in hospital under the Mental Health Act than those who identified as white
4 times
Around (….)% of those given the diagnosis of ‘borderline personality disorder’ are female
Despite clear evidence of a causal relationship between childhood trauma and later diagnosis of borderline personality disorder, particularly for sexual trauma
75%
Some researchers have argued that instead of seeing women’s distress as symptoms of a ‘borderline personality disorder’ we should …?
Understand their difficulties as a response to societal sexual violence and oppression
True or False?
Psychiatric diagnoses take into consideration the context of a person’s life experiences
False
Psychiatric diagnoses do not take into consideration the context of a person’s life experiences
True or False?
A person’s background, history and context are needed to meaningfully understand a person’s distress
True
Adverse or traumatic life experiences include a wide spectrum of experiences
List at least 5 examples
- Childhood sexual or physical abuse
- Neglect
- Losing a parent
- Bullying
- Job loss
- Poverty
- Homelessness
- Healthcare workers during COVID-19
- Systemic oppression (e.g. racism; misogyny; homophobia; islamophobia)
- Trauma resulting from mental health services and the criminal justice system
Other than adverse/traumatic life experiences, what other factor is linked to post-traumatic stress disorder (PTSD)?
Strong associations with many other forms of distress
e.g. Depression and Anxiety
What are the 3 limitations of focusing only on diagnostic symptoms?
1) Does not consider trauma as much as it should. Trauma is only mentioned in one specific chapter of diagnostic (DSM) manuals
e.g. post-traumatic stress disorder (PTSD)
2) Focuses on symptoms, not context. Therefore, for people with diagnoses that don’t come under this chapter, wider factors about their life may be missed
3) People do not always receive support and treatment that address underlying issues
Instead of using the DSM to diagnose people, what other health manuals can we use?
Clinicians could use ICD psychosocial codes to record adversity
e.g. neglect and abandonment (Y06 and Y07); homelessness, poverty, discrimination, and negative life events in childhood, including trauma (Z55-Z65)
Current classification systems for mental health problems…
a) Are still unreliable in diagnosing patients
b) Do not inform patterns of symptoms
c) Do not predict the outcome
d) Do not predict treatment response
i.e. do not demonstrate reliability or validity
The Division of Clinical Psychology (DCP) of the British Psychological Society (BPS) (2013) has criticised the value of diagnostic classification systems and called for a …?
“Paradigm shift” towards new conceptual systems that are no longer based on diagnoses or disease/medical models
What are the 6 limitations of Clinical Psychology?
1) Limited clinical and research utility (due to poor reliability and validity)
2) Limited cross-cultural applicability
3) Encourages labelling
4) Excessive biological emphasis
5) Little consideration of the context of people’s life stories and social circumstances
6) Exclude the possibility of finding meaning in people’s experiences, disempowering people, and preventing them from understanding how they might use their own resources to address their difficulties
What is the Power Threat Meaning Framework?
They represent a shift from diagnostic to narrative-based understandings
The Framework sees people as actively making choices and creating meaning in their lives
It recognises that emotional distress and troubled or troubling behaviour are intelligible responses to a person’s history and circumstances that can only be understood with reference to the cultures in which they occur
A new perspective on why people sometimes experience a whole range of forms of distress, confusion, fear, despair, and troubled or troubling behaviour.
This is known as…?
The Power Threat Meaning Framework
The main aspects of the Power Threat Meaning Framework have been summarised into 4 questions, which can apply to individuals, families or social groups.
What are the questions?
- What has happened to you?
- How did it affect you?
- What sense did you make of it?
- What did you have to do to survive? (understand coping mechanisms to deal with difficulties)
What are 4 other possible solutions to the problems of diagnoses and clinical psychology?
1) Develop more reliable categorical classification systems
2) Develop ‘dimensional systems’
3) Trans-diagnostic approaches
4) Psychological interventions
Clinical psychology encourages labelling. Why is this bad?
Naming someone by their illness can lead to stigma, passivity and hopelessness in people with mental health difficulties (the “sick role”)
Clinical psychology excessively emphasises biology. Why is this bad?
Diagnoses convey the idea that people’s difficulties can be understood in the same way as bodily diseases
People will over-rely on medication as the ‘answer’ to their diseases
Clinical psychology considers very little of the context of people’s life stories. Why is this bad?
We need to understand illness in the context of the patient’s life story and social circumstances
e.g. child sexual abuse/adversities can be a strong feature of schizophrenia
Clinical psychology has limited clinical and research utility. Why is this?
Due to poor reliability and validity
One alternative solution to diagnoses and clinical psychology is to develop ‘dimensional systems’. What does this mean?
Where people are seen as varying in the severity of mental health difficulties, rather than either having one or not having one.
One alternative solution to diagnoses and clinical psychology is to develop more reliable categorical classification systems. What is the limitation of this approach?
It is unlikely to improve the validity
The diagnosis systems do not distinguish symptom patterns or predict outcomes or responses to treatment.
Does this mean the systems have…?
a. Insufficient accuracy
b. Insufficient reliability
c. Insufficient validity
c. Insufficient validity
True or False?
Although diagnoses present some strengths, there are many limitations that undermine their clinical utility
True
True or False?
The diagnosis systems distinguish symptom patterns or predict outcomes or responses to treatment.
False
The diagnosis systems do not distinguish symptom patterns or predict outcomes or responses to treatment
True or False?
Considerable work is being done to develop other ways of thinking about mental distress
True
