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1. A2 Clinical Psychology – Categories, Definitions and Biases in the Diagnosis of Dysfunctional Behaviour DSM IV The International Classification of Diseases (ICD) is…
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  • 1. A2 Clinical Psychology – Categories, Definitions and Biases in the Diagnosis of Dysfunctional Behaviour DSM IV The International Classification of Diseases (ICD) is a largely bio-medical classification of all medical diseases world wide. It was developed by the World Health Organisation and is now in its 10th Edition. Part of the manual is devoted to mental disorders and there are similarities between it and the DSM first established in America by the American Psychiatric Association in 1952. The manual is for use by doctors and describes hundreds of disorders based on published studies and research. However the reasons for the discussion and debate which takes place in mental health and its categorisation by doctors is ‘do objective measures which may be used in some illnesses such as AIDs, tuberculoisis or cancer apply to mental health?’ The relationship between physical, psychologial and social influences is complex and is the area you will be expected to debate in your examination answer. You will need to understand what factors might affect the construction of such classification systems, and how a doctors diagnosis of mental ill health and the system of classicification itself may be affected by social or psychological rather than medical factors alone. The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, is the handbook used most often in diagnosing mental disorders in the United States. The International Statistical Classification of Diseases and Related Health Problems (ICD) is a commonly-used alternative internationally. The DSM tends to be the more specific of the two. Both assume medical concepts and terms, and state that there are categorical disorders that can be diagnosed by set lists of criteria. It is controversial and some mental health professionals and others question the usefulness of this classification system. There are five axis (categories) used: 1. Major clinical syndromes (schizophrenia, mood disorders, anxiety etc) 2. Personality disorders and mental retardation 3. General medical conditions (liver damage, immunity etc) 4. Psychosocial and envionrmental problems (divorce, poverty, which may impact on symptoms) 1
  • 2. 5. Global assessment of functioning scale (rated 1 – 100 on their ability to function effectivley in their social world – a person who scores less than 10 would be possibly unable to wash themselves or may self harm or harm others etc) The DSM has gone through five revisions (II, III, III-R, IV, IV-TR) since it was first published. The next version will be the DSM V, due for publication in approximately 2011. The Diagnostic and Statistical Manual of Mental Disorders (DSM) was initially developed to give more objective terms for psychiatric research. Before the DSM, communication between psychiatrists and diagnosis of mental health problems, was not uniform, especially in different countries. The establishment of specific criteria was also an attempt to facilitate mental health research and make diagnosis more reliable. The range and breadth of the DSM represents an extensive scope of psychiatric and psychological issues, and it is not exclusive to what one may consider "illnesses." Impotence, premature ejaculation, jet lag, and caffeine intoxication are examples of inclusions that you might find surprising, and are only some of several that are not normally considered to be mental illnesses. The criteria and classification system of the DSM are based on a process of consultation and committee meetings involving primarily psychiatrists. Therefore, the content of the DSM does not reflect all opinions on the subject of psychopathology, emotional distress and social functioning. Nor are there any objective, biological verifiable standards to which it adheres. The criteria, and the way they are applied by individual clinicians are at least to some extent influenced by cultural variables and are periodically altered to reflect contemporary social issues. For example, what is and what is not considered a mental disorder changes over time. In 1973, homosexuality was listed in the DSM as a diagnosable mental illness. It is also known that the diagnosis of some mental disorders is influenced by gender role expectations. That is, while diagnostic criteria do not mention gender, clinicians may diagnose women's and men's behaviour in different ways (evidenced by more women than men being diagnosed with anxiety or depression). We also know that in some countries people from different ethicnic backgrounds or cultures are more likely to be diagnosied with mental health problems than the indigenous population. Some critics go as far as to suggest that DSM invents illnesses and behaviours (iatrogenisis). Some doctors argue that dissasociative identity disorder or MPD is an iatrogenic disorder and not a valid medical diagnosis! Some say that patients frequently fail to fit into any particular category or fall into several (may be schizophrenic with learning difficulties or with personality disorder), that clinical characteristics required for a categorisation are arbitrary and that medical attention would be better spent discussing possible life-history events that precipitated a mental disturbance or just in monitoring treatment. However you cannot deny that there are useful applications for the system of categorisation. The contents of the DSM are determined by experts whose are trying to make diagnoses replicable and meaningful (reliable). The classification system has provided a forum for discussion into research in both diagnosis and treatment and helped the sharing of that information world wide. It is also widely used by both clinicians and insurance companies and helps those with mental health problems have access to both treatment and the social and financial benefits required to manage their ill health. 2
  • 3. However, a Columbia University team headed by Robert Spitzer, one of the creators of the DSM, acknowledges a concern about the DSM in their annual report of 2001, “Problems with the current DSM-IV categorical (present vs. absent) approach to the classification of personality disorders have long been recognized by clinicians and researchers.” Among the problems, they list “arbitrary distinction between normal personality, personality traits and personality disorder” and point out the fact that the most commonly diagnosed personality disorder is 301.9, Personality Disorder not Otherwise Specified. Another problem with categorisation of mental health is that it is often influenced by the prevailing perspective of the day. For example when the DSM was first published it was havily influenced by psychotherapy and the theories of Freud. Recently it has been more influcned by the medical model of health. However any view about the causes of mental ill health will have its flaws as at present there is very little evidence and much controversy about the actual causes of many mental health diseases. There have also been questions of potential bias of DSM authors who define psychiatric disorders. According to The Washington Post, an analysis published in Psychotherapy and Psychosomatics pointed out that "every psychiatric expert involved in writing the standard diagnostic criteria for disorders such as depression and schizophrenia has had financial ties to drug companies that sell medications for those illnesses." However, an important limitation of this study was that the analysis did not reveal the extent of their relationships with industry or whether those ties preceded or followed their work on the manual. In the United States, health insurance typically will not pay for psychological or psychiatric services unless a DSM-IV mental disease diagnosis accompanies the insurance claim. Critics claim that this may have exacerbated the ever-expanding number of disease categories. It may also cause people to be labeled with "illness" for the purpose of re-imbursement. All physician services in the United States require an ICD code for health insurance payment, regardless if the patient has a definable illness or not. This is equally true of mental or physical complaints. We also have to consider how culture, time and place in history influences the content of this manual. Can the manual be used world wide? Are we imposing one cultural or ethnocentric bias on others - the imposed etic!? However before the publication of the DSM there were a wide range of methods of categorisation of mental health all of which were equally fraught with problems: Statistical Infrequency: In this definition of abnormality, behaviors which are seen as statistically rare, are said to be abnormal. For instance one may say that an individual who has an IQ below or above the average level of IQ in society, is abnormal. However this definition obviously has limitations, it fails to recognize the desirability of the particular behavior. Going back to the example, someone who has an IQ level above the normal average wouldn't necessarily be seen as abnormal, rather on the contrary they would be highly regarded for their intelligence. This definition also implies that the presence of abnormal behavior in people should be rare or statistically unusual, which is not the case. Instead, any specific abnormal behavior may be unusual, but it is not unusual for people to exhibit some form of prolonged abnormal behavior at some point in their lives. 3
  • 4. Deviation from Social Norms: Defines the departure or deviation of an individual, from society's unwritten rules (norms). For example if one was to witness a man jumping around, nude, on the streets, the man would be perceived as abnormal, as he has broken society's norms about wearing clothing, not to mention ones self dignity. There are also a number of criteria for one to examine before reaching a judgment as to whether someone has deviated from society's norms. The first of these criterion being culture; what may be seen as normal in one culture, may be seen as abnormal in another. The second criterion being the situation & context one is placed in; for example going to the toilet is a normal human act, but going in the middle of a supermarket would be seen as highly abnormal. The third criterion is age; a child at the age of three could get away with taking off its clothing in public, but not a man at the age of twenty. The fourth criterion is gender. The fifth criterion is historical context; standards of normal behavior change in some societies, sometimes very rapidly. The Failure to Function Adequately: This definition of abnormality defines whether or not a behavior is abnormal if it is counter-productive to the individual. The main problem with this definition however is that psychologists cannot agree on the boundaries that define what is 'functioning' and what is 'adequately', as some behaviors that can cause 'failure to function' are not seen as bad i.e. firemen risking their lives to save people in a blazing fire. Deviation from Ideal Mental Health: This model defines abnormality by determining if the behavior the individual is displaying is affecting their mental well-being. As with the Failure to Function definition, the boundaries that stipulate what 'ideal mental health' is are not properly defined, and the bigger problem with the definition is that all individuals will at some point in their life deviate from ideal mental health, but it does not mean they are abnormal; i.e., someone who has lost a relative will be distressed, but would not be defined as abnormal for showing that particular behavior. On the contrary, there are some indications that some people require assistance to grieve properly. Definitions of mental health without the use of categories: Rosenhan and Seligman (1989) propose seven major features of abnormality that appear in abnormal behaviour as opposed to normal behaviour. The more of these features that are possessed by the individual, the more likely they are to be considered abnormal.  Suffering: Most abnormal individuals (such as those suffering with anxiety disorders) report that they are suffering. However normal people can suffer at times in their lives and some abnormal individuals, such as those with personality disorders, treat others badly but do not appear to suffer themselves  Maladaptiveness: Maladaptive behaviour is behaviour that prevents an individual from achieving major life goals, from having fulfilling relationships with others or 4
  • 5. working effectively (for instance an agrophobic will not venture out of the house due to fear).  Vividness and unconventionality: Vivid and unconventional behaviour is relatively unusual. It is behaviour that differs substantially from the way in which you would expect normal people to behave in similar situations. However there are many people who behave in this way that are not deemed to be abnormal.  Unpredictability and loss of control: With most people, you normally predict what they will do in known situations. In contrast, abnormal behaviour is often highly unpredictable and uncontrolled and inappropriate for the situation.  Irrationality and incomprehensibility: One of the characteristics of abnormal behaviour is that there appears to be no good reason why the person should choose to behave in that way.  Observer discomfort: Our social behaviour is governed by a number of unspoken rules about behaviour, such as the way we maintain eye contact or personal space. When others break these rules we experience discomfort. But this does not necessarily indicate abnormal behaviour, for instance different cultures may well have different social rules about behaviour.  Violation of moral and ideal standards: When moral standards are violated, this behaviour may be judged to be abnormal. However different cultures and different times in history have different standards? Whatever the system of diagnosis (using categories or definitions) there are still problems with biases in diagnosis. The DSM is controversial in that it has shown bias in its classification systems with cultural norms (homosexuality), bias in approach (the psychodynamic approach predominated in the middle of the 20thcentury and the medical model more recently) and bias toward different types of illnesses in different cultures. There are also other social biases and gender biases found in mental health diagnosis: Biases in diagnosis of mental health: ON BEING SANE IN INSANE PLACES : social / environmental bias D.L.ROSENHAN (1973) Pseudo-patient's sanity went undetected. They spent an average of 19 days (range of 7 to 52 days) on the ward, before being released. When released, they were diagnosed as being `schizophrenic in remission' not as being sane. The social environment led to the behaviour being interpreted in a certain way. The evidence suggested that we are not sure as to what a mental illness really is, and the categorisation of an illness is not easy as a result. It would seem that labelling plays a part in how `patients' are treated. A broader concern is if we are so uncertain as to what constitutes a mental illness, this could lead to miscarriages of justice and the abuse of human rights. A plea of insanity might help a criminal escape a harsher punishment than treatment in a psychiatric hospital would afford. Labelling a political opponent as insane, might be a convenient way of suppressing him or her. Abelson’s Study – the effect of expectation on diagnosis (1974) Professionals watched a video of a young man being interviewed. One group were told that he was a job applicant; the other group were told he was a patient in a psychiatric clinic. 5
  • 6. The group who had been told he was a job applicant assessed him as being attractive, conventional and innovative. A panel of independent judges who looked at the group’s description said they were describing a well adjusted person. The second group who thought he was a patient, described him as uptight, defensive, passive and aggressive. The independent panel of judges said that members of this group have described a disturbed person. Gender Bias Kaplan (1983),argued that "diagnostic systems, are male centered" . The authors of every edition of the DSM have been predominately male, including the membership on the more recent personality disorder work groups: 89% for DSM-III, with only one of the 9 members female . It might not be surprising to find that male members of these DSM committees have pathologized stereotypic feminine traits rather than, or more so than, stereotypic masculine traits, reflecting "masculine-biased assumptions about what behaviours are healthy and what behaviours are crazy" (Kaplan, 1983,). Kaplan suggested that the inclusion of gender-normative behaviours within the histrionic and dependent diagnostic criteria (e.g., emotionality and submissive compliance, respectively) leads to an over diagnosis of these disorders in women. Women who display behaviour normative for their gender would then be diagnosed more frequently with these personality disorders. Kaplan (1983) even went so far as to assert that "via assumptions about sex roles made by clinicians, a healthy women automatically earns the diagnosis of histrionic personality disorder" . When provided with the same symptoms via case histories, clinicians are more likely to provide a diagnosis of histrionic personality disorder if the patient is female than if the patient is male. In a complementary fashion, clinicians are somewhat more likely to diagnose a male patient with antisocial personality disorder than a female patient They aimed to find out f clinicians apply the criteria differentially to men and women, then whatever biases occur must be within the clinicians rather than the criteria sets. Method self report – health practitioners given scenarios and asked to make a diagnosis. The IV was gender and the DV was the type of diagnosis. Sample of 354 clinical psychologists with a mean of 15.6 years clinical experience selected randomly from the national register. Participants were randomly provided with one of nine case histories. Case studies of patients with antisocial personality disorder or histrionic personality disorder or an equal balance of both were given to the clinicians. They had to make a diagnosis and rate it on a 7 point scale the extent to which the patient displayed the symptoms of the disorders. Results showed that sex unspecified case histories were most often diagnosed with borderline personality disorder. Antisocial personality disorder was diagnosed correctly 52% of the time in males but only 15% of time in females. Females were misdiagnosed with histrionic personality disorder 46% of the time but males on 15% of the time. Conclusions were that practitioners are clearly biased by stereotypical views of gender. Histrionic personality disorder (a pattern of excessive emotional behaviour and attention seeking with a need to have approval and inappropriate seductiveness) lead more readily to a female typical disorder diagnosis. 6
  • 7. The ICD was set up to accumulate data about the spread of disease and is now managed by the World Health Organisation. It is useful as it collates information from around the world and helps pinpoint areas in need of extra vaccination or medical support etc. The ICD has descriptions of the main features associated with each mental disorder. The ICD 100 has categories for psychological abnormalities including schizophrenia, mental disorder due to substance abuse, neurotic and stress related illnesses etc. The DSM 1V on the other hand, was developed in the U.S by psychiatrists to standardise the categorisation of mental health and consists of not only categories
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