Week 3-Classification, Diagnosis and Formulation

Question 1

What are the purpose and functions of Classification Systems?

Answer 1

-Research basis

-To suggest “correct” treatment

-To predict clinical outcomes

-To indicate probable cause of condition using research

-To enable clinical communications for referrals, recommendations and treatment

-Understanding of experiences

-Access to support

Question 2

Name the 2 main Diagnostic manuals

Answer 2

1.World Health Organisation’s International Classification of Disease (ICD) (popular in European countries, Basis of NHS diagnosis, Latest is ICD-11 (WHO, 2022))

2.American Psychiatric Association’s Diagnostic and Statistics Manual (DSM) (popular in the US, recommended for research classification - standard in Europe, Latest is DSM-5-TR (APA, 2022))

Question 3

True or false: Autism and ADHD are mental disorders

Answer 3

False! they last a lifetime yet are treated like mental disorders

Question 4

Define Autism

Answer 4

A developmental neurocognitive difference resulting in divergent perception of the world, particularly in relation to sensory and social experiences.

Question 5

Define ADHD

Answer 5

A developmental neurocognitive difference. Associated with interest-driven rather than importance-driven attention, executive functioning difficulties and differences in memory.

Question 6

Define Pathological Demand Avoidance (PDA)

Answer 6

Often a co-morbid diagnosis is given to people diagnosed as autistic who experience anxiety in response to demands. People with PDA report that demands create anxiety and result in avoidance even if they are essential to participating in a desired activity.

Question 7

Why is recognition via classification essential for many neurodivergent people?

Answer 7

Because late diagnosis can result in:
-Lack of access to essential support
-Increased masking (Bargiela et al., 2016)
-Delayed self-acceptance and increased self-criticism (Leedham et al., 2019)
-Mental health and wellbeing consequences

-However, diagnosis too early in life can lead to enrollment in ‘curative’ interventions that can cause trauma

Question 8

Give a brief history of classification

Answer 8

1896:Kraepelin attempted to classify conditions of mental health into 2 broad categories 1.Dementia precox (now schizophrenia) 2.Manic Depression

1908:Bleuler extended Kraepelin to include the group of schizophrenias which encompassed dementia precox and included “autism” as a symptom

1943:Kanner publishes a paper on “autism” as it is known today. Followed shortly in 1944 by Asperger. Kanner’s “classic autism” and “Asperger’s syndrome” were both added as subtypes of a new syndrome later on

Present:Categories and subcategories change with each new edition of the classification systems

Question 9

How were categories constructed?

Answer 9

-DSM-5 included over 500 clinicians, 13 work groups and 13 major conferences and hundreds of peer-reviewed papers from over the last decade

-Social influence is possible (as removal of homosexuality)

-DSM-5 workgroup negotiation with ASAN

-Culture and political movements both influence categories which change over time (meaning future disorders or disabilities could be removed in the future)

Question 10

What was the DSM-5 workgroup negotiation with ASAN?

Answer 10

-ASAN lobbied with the relevant workgroup to try and overturn a decision to include an autism severity scale in DSM-5 (Kapp & Ne’eman, 2020)
-The potential was to overcome the problematic severity assumptions which creates stigma (i.e., how do we know what’s severe?)

-DSM-5 employed a criteria that dichotomised autism into types 1-3 (APA, 2013-based off support needs) due to a DSM-wide decision from APA that all conditions now have severity scales

Question 11

What are causal models?

Answer 11

-Classification takes a BMM position towards mental health conditions

-Mirrors physical healthcare, applying diagnoses based on symptoms (Kinderman, 2014) but is less objective (Johnstone, 2013)

-Psychiatry is treated as a branch of medicine using medical language

-Without biological markers, we can only rely on behaviour as an indicator of cognitive differences or ‘deficits’ (Waltz, 2013)

-Mental health is dynamic and changes over time so hard to diagnose objectively

Question 12

What is the impact of causal models on research and practise?

Answer 12

-Research and practise are predominantly influenced by the BMM and the diagnostic classification systems in place (Johnstone, 2013)

-Like physical health, categories are used to develop interventions

-A cure and prevention model results, which treats human differences as a deficit to be corrected. This is particularly problematic for neurodivergent categories (Waltz, 2013)

Question 13

What are the classification issues in the BMM?

Answer 13

-It pathologises human experience, following the idea that our mental health struggles and/or neurodivergent differences indicate something is ‘wrong’ with us

-For neurodivergent conditions such as ADHD or autism, your experiences have to have a negative impact on your life to justify diagnosis (Pearson and Rose, 2021)

-Overlooks meaning behind behaviour, traits or symptoms e.g., PTSD and PDA

-“Instead of seeing people’s difficulties as understandable and natural responses to the terrible things that have happened to them, the person is seen as having something wrong with them – an ‘illness’.” (Kinderman, 2014) (more an example summarising what was said above)

Question 14

What is meant by construct validity?

Answer 14

-Validity in this context means to be scientifically meaningful and represent ‘real’ things

-Mental health struggles have been recorded throughout human history: Socrates (469-399 BC) - auditory hallucinations and catatonia (awake but not responsive to people and environment)

-“another deceased twentieth-century female writer, whose family had been greatly upset by suggestions that she might have been autistic.’” (Example by Limburg, 2021).

Question 15

How does psychology pathologise experiences?

Answer 15

-Psychology typically views mental illness as experiences and related struggles which are understandable within the context of a person’s life (Johnstone, 2013)

-Singer 1998:Neurodiversity from biodiversity - all human brains differ, divergent groups represent natural species variation

-Classification and pathologisation reduce human experiences and differences to deficits (Kinderman et al., 2013)

-We try to look at what’s happened to people and lead it back to certain traits

Question 16

What is meant by predictive validity?

Answer 16

If a mental health condition were a valid medical category, we should be able to reliably predict outcomes and effective treatments (Johnstone, 2013)

-Diagnosis does not predict outcomes or the course of a condition. It also does not predict medication response (Kendell, 1988)

-This is not to say that medication is not useful or that is should not be offered. But it does suggest that positive effects are non-specific and unpredictable.

Question 17

What is meant by Inter-rater reliability?

Answer 17

-Diagnosis is seen as reliable if 2 people agree on which category best applies and if the same decision would be reached if the person was reassessed (Johnstone, 2013).

-Early research showed clinician disagreement about psychiatric diagnosis and that diagnostic practises differ between countries (Beck et al., 1962; Blashfield 1973)

-Misdiagnosis is still common and people often acquire multiple diagnoses: 50% of people with 1 diagnosis in the USA national co-morbidity study had at least one more, 25% had more than 3 (Kessler et al., 2005).

-Lots of overlap between psychosis and personality disorder approach (so clinicians could give different diagnosis)
-The assumption that diagnosis is objective which isn’t true
-Autism and ADHD was avoided diagnosing because they thought it would make it unreliable

Question 18

What are the 5 sources of error which can cause unreliable diagnoses according to Kreitman (1961)?

Answer 18

1. Raters might differ e.g., psychiatrists
2. Examination might differ each time
3. Patients might differ e.g., mention different things
4. The method of analysis might differ (e.g., different ways of combining symptoms)
5. Could be different systems of names and styles of reporting

Question 19

What’s subjectivity in relation to classification?

Answer 19

-Criteria are based on subjective norms, which leads to low reliability. There is nothing inherently wrong with subjectivity in clinical judgement, the issue is with presenting it as objectivity asif we could obtain everything a person has gone through (Johnstone, 2013).

-Prolonged grief disorder: How much grief is too much grief?
-“I sought your warm ankle between the cold sheets,
Daring to stretch to the foot of the bed. You were nowhere you should be, it filled me with dread.”
Harrison, 2022 (Just an example)

Question 20

What is the impact of racial and cultural bias in classification?

Answer 20

-Black people in the UK are more likely to be diagnosed as having mental illnesses and to be detained in secure hospitals (Commander et al., 1997) than Asian and White people.

-People from ethnic minority groups tend to receive more medical and physical treatments, and are under-represented in less medical forms of treatment, such as counselling and psychotherapy services (Ahmed, 1995; Littlewood and Lipsedge, 1997)

Question 21

How does Diversity impact Classification?

Answer 21

-People who see their experiences as spiritual (e.g., auditory hallucinations or visions) are overlooked and pathologised (Jackson & Fulford, 1997)

-Diagnostic systems risk pathologising behaviours that aren’t considered normal in white, western, male, middle-class culture (Cochrane & Sashidharan, 1995)

-Autistic people make up a large portion of in-patients detained under the mental health act and have an average stay of 5 years (NAS, 2023)

Question 22

How does Heterogeneity impact Classification?

Answer 22

-People with the same diagnosis lack the same experience (Johnstone, 2013)

-Heterogeneity does not challenge that a phenomena exists, but calls for an acknowledgement of cultural influence and to move away from assumptions that clinical conditions are objective and waiting to be discovered (Botha, 2021)

“I wouldn’t want to mislead you into thinking that there is any general agreement as to what autism is – there really, really isn’t.” (Limburg, 2021) (example)

-Understandings need to move away from an assumption of a set group of traits.

Question 23

How does Reliability impact Classification?

Answer 23

-Increasing the amount of diagnostic labels and subtypes is seen as a method to improve diagnostic precision and increase reliability (Johnstone, 2013)

-Ignores that new criteria remains subjective and culturally influenced.

-Calls for more homogenous subgroups of autism in light of high heterogeneity (Happé et al., 2006; Frith, 2021)

-Beyond specifying whether intellectual disability and language impairments are present, subtypes have historically been unsuccessful (Fletcher-Watson & Happé, 2019).

Question 24

Why is Stigma an issue around Diagnosis?

Answer 24

-Stigma arises from categorising people based on what is ordinary or typical within a social context (Goffman, 1963).

-This leads to ‘us and them’ thinking, creating stigma which can be felt and internalised by the person being ‘othered’ (Pearson & Rose, 2021)

-Link & Phelan (2001) said there are 3 main types of stigma:
1. Structural
2. Interactional
3. Personal Response

Question 25

What is Structural Stigma?

Answer 25

-A biomedical model of mental health and diversity can create structural stigma by reducing experiences down into deficits, shaping how society thinks about difference towards negative stereotypes (Dinishak & Akhtar, 2013).

-Unemployment & social disadvantage - Less likely to get jobs (Farina & Felner, 1983). Excluded from some professions & life insurance etc.

-Loss of rights - Forced treatment. Exclusion from driving / jury service.

-Problematic interventions – people become seen as commodities, targeted by time-intensive, costly ‘interventions’ that claim to reduce disability (Grinker, 2020).

-Mass media – Negative portrays filter into societal stereotypes (Nordhal-Hansen et al., 2018).

-Creates stereotype as the DSM creates expectation of what a person with that disorder “should” be like

Question 26

What’s interpersonal stigma?

Answer 26

Avoidance:
-People want to create social distance (Gillespie-Lynch et al., 2021; Mehta & farina, 1997; Shtayermman, 2009). For autism this occurs regardless of diagnosis (Grossman, 2015)
-Professionals also have internalised stereotyped conceptualisations (Raskin & Lewandowski, 2000).

Dehumanisation:
-Framing stigmatised people as subhuman protects the fragile idea of normality (Goffman, 1963)
-Even when non-autistic people were knowledgable about autism, they did not attribute human uniqueness traits to autistic people (Cage et al., 2018)
-A psychiatrist or clinician may be less prone to internalised stereotyped conceptualisations but a GP might (as vague knowledge of conditions)

Question 27

What’s personal response stigma?

Answer 27

Internalisation-Prolonged exposure to stigma can experience shame, self-hate and self-degradation

Minority stress-Prolonged internalisation leads to increased stress and lower levels of wellbeing (Botha & Frost, 2020; Meyer, 2003). This can result in physical health consequences as well as further mental health consequences

Concealment and camouflaging-Stignatised individuals often begin to self-monitor and conceal external behaviours that differ from social norms which may proliferate stereotyping and stigma (Goffman, 1963; Pearson & Rose, 2021).

Question 28

What are the effects on services and professionals with stigmatisation?

Answer 28

-Promotes ‘us’ and ‘them’ thinking

-Narrow understanding of people’s problems

-Does not see people as able to change

-Places problem within individual rather than environment

-Narrows the focus of research (it is about diagnosis rather than need, vulnerability and risk)

-Can affect physical healthcare decisions

Question 29

What are dimensional models?

Answer 29

-Argument that DSM and ICD should be based on a dimensional model instead. Categorical models assume a definitive cut-off point (Johnstone, 2013)

-Would assume everyone varies across different dimensions (e.g., anxiety and depression) But doesn’t necessarily address the issues with the disease model of mental health

-Johnstone (2013): DSM-5 considered how dimensional assessments might assist categorical judgement.
-Kapp & Ne’eman (2020): Resulted in severity scales which made categorised more medicalised

-This model makes it worse because it’s essentially made it a severity scale and acts as if people can’t move back and forth very quickly also ignoring factors such as social factors

Question 30

Give an examples of the autism spectrum based on the DSM-4?

Answer 30

-The typical population, some shared traits, diverse but not ‘divergent’

-Pervasive Development Disorder, too ‘mild’ to call autism, some argue other divergent conditions should come in here

-Atypical, autism but features hard to detect or diagnostic criteria not fully met

-‘Asperger syndrome’ or ‘High Functioning Autism’

-‘Classic Autism’ or ‘Low Functioning Autism’

Question 31

What are the severity issues in classification?

Answer 31

-Oversimplifies complex human experiences and underestimates situational influence

-‘Support needs’ assessments are better assessed in a given situation and not generalised across time frames or people

-Does not overlook that some people have more disability than others, but enables a more complex, individualised view. E.g., people with ‘HFA’ might appear to have low support needs in work but can present as having high support needs in medical situations or become non-verbal during meltdowns

Question 32

What’s neurodivergent constellations?

Answer 32

-For neurodivergent conditions, it might be more advantageous to think of commonalities that encompass groups of diverse individuals, similar to gender (Fletcher-Watson & Happé, 2019).

-“it’s more like a constellation than a spectrum. It does not move along one line going from low to high, it circles in many spheres” (Hearst, 2015)

Question 33

What is formulation?

Answer 33

-It is an individual summary of difficulties based on psychological theory done by clinical psychologists. It involves the co-creation of a narrative that tries to link individual difficulties to life events, social experiences and how a person makes sense of their experiences (Johnstone, 2013)

-Can be used as an alternative to psychiatric diagnosis or in conjunction with it.

-Still enables professionals to see service users as being in urgent need of support for serious distress but relies on more non-medical terms and approaches.

Question 34

What did Kinderman (2022) say about understanding psychosis and schizophrenia?

Answer 34

-“Hearing voices or feeling paranoid are common experiences which can often be a reaction to trauma, abuse or deprivation. Calling them symptoms of mental illness, psychosis or schizophrenia is only one way of thinking about them, with advantages and disadvantages.”

-Essentially the way we think about them isn’t necessarily the only way

Question 35

What did Kinderman (2022) say about understanding depression?

Answer 35

“The experience we call depression is a form of distress. The depth of stress itself, as well as the contributing events and circumstances, can be life-changing. And even life-threatening. However, calling it an illness is only one way to think about it, with advantages and disadvantages.”

Question 36

What are the 4 steps of psychological assessment?

Answer 36

1. Collect information that will help understand the client’s difficulties and highlight areas in which change may be possible (develop a hypothesis).
2. Individual summary co-created with the person.
3. Look at what interventions might help, which results in hypothesis testing and adaptation. Formulation is a work in progress.
4. Can help to predict future outcomes and focus on a person’s strengths. Service users have agency, and are not reliant on expert opinion alone.

-They can also acknowledge things they can’t change e.g., trauma to offer more empathy.

Question 37

What are the axes’ in the DSM-IV diagnostic criteria?

Answer 37

-Since DSM-IV, diagnoses can be supplemented by axes, 2 of which refer to non-medical information.

-Axis 4 = psychological struggles such as employment loss, poverty and social isolation.

-Axis 5 = life functioning in work, relationships and leisure to give a bigger picture.

-Underutilised in DSM and ICD.

-We don’t have to say person has PTSD we can look at individual traumas and piece them together

-Possible to do formulation without diagnostic disorders and categorisation to create a better picture

Question 38

What are the criticisms of the axes diagnostic criteria?

Answer 38

-Subjective by nature and open to bias. This is not necessarily bad if implemented properly and not treated as an objective, scientific process.

-If used improperly might not include co-creation and could overlook social and cultural influence.

-Newer=lack of research to support use and indicate whether service users find it helpful. Impact on therapy outcomes also largely under-researched.

-Not helpful for all conditions (e.g., neurodivergent conditions).

-Clinicians might treat it as objective and as a scientific discipline

-Clinician might create on their own

Question 39

How may formulation help neurodivergent conditions?

Answer 39

-Formulation holds the potential to create accessible mental health care for neurodivergent people.

-Neurodivergent conditions are important socio-political identities (Botha, 2021).

-Concerns of overlooking disability and interactions with physical health e.g., sleep or digestion issues (Grant & Kara, 2021; Lenroot & Yeung, 2013).

-At present, diagnosis remains important for accessing support and overcoming stigma in these groups (Leedham et al., 2019)

Question 40

What are the key differences between diagnosis & formulation? (Adapted from Johnstone, 2013)

Answer 40

Diagnosis:
-Obscures social context, an individual approach overlooking relational influences, not culturally sensitive, expert-driven and removes agency, stigmatising, medical consequences and access to medical adaptations, removes personal meaning

Formulation:
-Can include social context if used well, can include relationships, can be culturally sensitive if used properly, usually driven by collaboration and promotes agency, non-stigmatising, no medical consequences and may be harder to access medical adaptations, centres around personal meaning