Clinical Psychology - Diagnosis and tools
What are the two defintions of abnormality?
-Deviation from social norms meaning that people are labelled abnormal if behaviour is different from what we accept as the norms of society.
-A range of characteristics that suggests a person is failing to function adequately in everyday life
Who and when was the first psychiatric handbook?
Kraeplin in 1883
Name 5 factors that affect defining abnormality
Religion, culture, time, race, experience
What might be an issue psychiartrists face when trying to diagnose patients?
If the patient was homophobic it would affect a homosexual psychiatrist
AO1: interview method in clinical psychology (4)
- Psychiatrists can use a structured interview using set questions to collect information on client's symptoms.
- Clinical interviews are often semistructured in that therapist will have a set list of questions they want to talk to the patient about but will also add more questions based on answers the patient gives about their symptoms.
- Open questions used to find cause of diagnosis.
- Closed questions to measure consistency.
AO3: Interview method in clinical psychology - ethics
High ethics. Maintains ethical guidelines when treating patients as they need to consent to take part in the interview so protecting them from being mistreated by a psychiatrist.
AO3: Interview method in clinical psychology - reliability
Standardised questions, high R
AO3: Interview method in clinical psychology - Bias validity
Psychiatrist bias like cultural differences, low V
AO3: Interview method in clinical psychology: SD validity
Social desirability and demand characteristics so low V
AO1: Goldstein study (1988) - Aim
- To see if females experience less severe symptoms of SZ than males
- Check reliability of DSM3
AO1: Goldstein study (1988) - Sample
- Data collected over 10 year period
- 199 SZ patients used to check reliability
- 90 of those patients with hospital stay of less than 6 months from NY psychiatric hospital were checked for gender differences
AO1: Goldstein study (1988) - Method
Self report
AO1: Goldstein study (1988) - Procedure
Hospital gave detailed history of 199 patients and DSM3 used to rediagnose patients by 2 experts who were blind to hypothesis
AO1: Goldstein study (1988) - Primary data
- Trained interviewers asking specific set of questions to retrieve information on characteristics of SZ and other mental health disorders.
- Questionnaires to retrieve information of social isolation, relationships and interest from ages 6-20 to measure premorbid functioning.
AO1: Goldstein study (1988) - Secondary data
Finding out how many times patients were re-hospitalised and for how long which was collected at 5 year and 10 year periods.
AO1: Goldstein study (1988) - Results
- 0.80 (positive correlation) between experts.
- 169 out of 199 patients re-diagnosed with SZ.
- Women experience less severe form of SZ than men and were re-hospitalised less than men and stayed for less time.
- Premorbid factors affected re-hospitalisations and social functioning affected length of stay
AO1: Goldstein study (1988) - Conclusion
- SZ more severe in males who stayed in hospital longer than females
- DSM3 was reliable for mental disorders with premorbid factors and social functioning levels are very important aspects of mental disorders
AO3: Goldstein study (1988) - Generalisability
Low G, restricted sample of NY and short stay patients
AO3: Goldstein study (1988) - Reliability
High R, Quant data, consistent results
AO3: Goldstein study (1988) - Validity SD
Low V, SD want to appear normal or abnormal to psychiatrist
AO3: Goldstein study (1988) - Validity procedure
High V, double blind procedure, psychiatrists unaware of original diagnosis
HCPC guideline 5
Use of counsellors from similar background/ language use can be used or need of translator
HCPC guideline 7
Give patient code name, ensure all files are lock or password protecte and not discussing patients notes with anyone without patient consent
HCPC guideline 13
Ensure up to date training, attend regular refresher courses and examine different ways to explain patient behaviour
HCPC guideline 14
Develop psychological formulation using theory, research outcomes of assessment, using knowledge from a range of sources such as developmental, social, neurological, etc. and appropriate plan of treatment.
HCPC: Character standards
References of character need to be made by individuals that have known psychologist for over 3 years. Cautions and criminal convictions are also taken into account.
HCPC: Health standards
Regular updates (usually every 2 years when registered) and need to stop working as soon as possible if a condition affects clients.
HCPC: Ethics standards
Conform to 10 ethical guidelines like confidentiality, competence, collegiality
Factors affecting assessing HCPC guidelines: Consent
Consent = high DC, low V, not true measure
Factors affecting assessing HCPC guidelines: Confidentiality
Hard to measure effectiveness of HCPC due to confidentiality, difficult to say if guidelines protect patients
Factors affecting assessing HCPC guidelines: Useful
Helps improve patient's general functioning
Factors affecting assessing HCPC guidelines: Protection from harm
SC involving restrictive treatments could be caused by talking about sensitive topics of the patient
Factors affecting assessing HCPC guidelines: Effective
Effective treatment as less likely to misdiagnose
Factors affecting assessing HCPC guidelines: Misdiagnosis
Protect society from people who could misdiagnose mental health disorders
AO1: 4D's - deviance
Behaviour, thoughts and emotions that significantly differ from societal norms. It can also mean if individuals differ from the statistical norm (outside the normal distribution) then an individual is abnormal
AO1: 4D's - distress
Unpleasant and upsetting behaviour causing emotional pain. Distress is viewed separately from the criteria as it's subjective in terms of what is distressing, this may not affect their everyday functioning.
AO1: 4D's - dysfunction
Individual inability to functioning independently in everyday life.
AO1: 4D's - danger
Hazardous behaviour posing threat to individual safety or other people's safety.
4D's: dysfunction SE
Remick found threefold increase in number of sick days in months preceding illness for workers with or without depression showing mental health disorders cause disruption to everyday life
4D's: danger SE
Davis showed people with mental health disorders have 25% higher chance of dying from unnatural causes meaning danger is an accurate aspect if mental health diagnosis
4D's: deviance CE
Limited as what is considerd deviance changes over time like homosexuality laws changing in 1967 meaning less consistent
4D's: distress CE
Subjective as one may define distress differently to others therefore limits how distress defines mental health
AO3: 4D's - High R
Quant data, objective
AO3: 4D's - High V
holistic, shows how mental health affects aspects of life therefore diagnosis is a true and accurate disorder
AO3: 4D's - Low R
Clinician factors could affect reliability as not consistent across all clinicians.
AO3: 4D's - Low V
SD may note report danger due to stigma or consequences, not accurate measure
AO3: 4D's - Useful
- Get appropriate treatment and get relief from understanding symptoms
AO3: 4D's - Not useful
Leads to labelling in media which could add scientific weight to prejudice
AO1: ICD-10 - Specifying disorders
Number after decimal point to specify disorders
AO1: ICD-10 - Section F
Listed in section F, following digit represents family of disorders, another number to tell what the disorder is
AO1: ICD-10 - Annex 1
Includes disorders that haven't been classed as a real disorder yet
AO1: ICD-10 - Annex 2
Looks at disorders that are classed in certain cultures
AO3: ICD-10 - high R
Ponizosky (2006), increase 26% in rediagnosis of SZ so not affected
AO3: ICD-10 - high V
Mason (1997), diagnosis good predictor for 13 years later for SZ
AO3: ICD-10 - low R
Cheniaux (2009), not consistent across ICD-10 and DSM5
AO3: ICD-10 - low V
Jansson (2002), different focus of symptoms therefore can't measure SZ
AO3: ICD-10 - Useful
If diagnosed, appropriate treatment
AO3: ICD-10 - Not useful
Could be misdiagnosed due to overlapping symptoms in similar classifications
AO1: DSM5 - Section 1
Introduces DSM5 and how to use it
AO1: DSM5 - Section 2
List of codes for disorder and criteria of symptoms and how long they last
AO1: DSM5 - Section 3
Provides cultural information to help psychiatrists understand social factors that could impact diagnosis
AO1: DSM5 - Emerging disorders
Psychiatrists can refer to emerging disorders if a patient does not precisely fit into any other disorders
AO3 - DSM5 - high R
Watson (2015), self reporting symptoms consistent across both DSM4 and DSM5
AO3 - DSM5 - high V
Andrews (99), DSM4 and ICD have 68% concurrent validity
AO3 - DSM5 - low R
Cheniaux (2009), ICD10 SZ more likely to be diagnosed than DSM4, not consistent
AO3 - DSM5 - low V
Schwartz (2014), Afro-Americans 3-4 times more likely to be diagnosed than Euro-Americans, still affected by other factors
AO3 - DSM5 - Useful
Diagnostic tools can measure disorders consistently
AO3 - DSM5 - Not useful
Social factors can affect diagnosis
Define external validity
Disorder in classification system can be generalised to patients with same symptoms and causes
Define concurrent validity
Researcher gains similar results as other research that has been carried out at the same time
Define predictive validity
Researcher gains similar results to other research that has been carried out at a different time to look at if the results can be used to back each other up and predict future outcomes
Define aetiological validity
Sufferers of disorder have same causal factors so to be diagnosed with a disorder, it must match to other people's symptoms to have the same disorder.
Define internal validity
Whether diagnosis given is due to symptoms listed in classification systems and not social factors.
In order to be valid, a classification system must accurately diagnose a mental health disorder, and lead to the right treatment for the diagnosed mental health disorder.
Pihlajamma (2008), found that ICD-10 was valid as it produced a diagnosis of SZ that maatched diagnosis of other classification systems
Predictive validity is when upon diagnosing a mental health disorder accurate prediction can be made about how the disorder will progress, and how it will respond to treatment
Mason (1997) found that diagnosis when assessing ICD10 for 99 SZ patients was a good predictor of future behaviour 13 years later meaning accurate measure of predicting course of SZ over time
If a classification system has concurrent validity then it should come up with the same diagnosis for same symptoms at same time as other classification systems.
Andrews et al (99) assessed 1500 people using DSM4 and ICD have 68% concurrent validity
Symptoms must be operationalised and measureable like social withdrawal for SZ
Overlapping symptoms therefore hard to operationalise symptoms of one disorder, less valid
Open to bias, psychiatrists have different values, misinterpretation can lead to wrong diagnosis
Applying a western interpretation of symptoms like hearing voices which affects final diagnosis
Can't be influenced by social factors such as culture
Schwartz (2014), Afro-Americans 3-4 times more likely to be diagnosed as psychotic than Euro-Americans so DSM5 less accurate as still affected by ethnicity
Impact of classification systems being high in validity
Treatment given to patient should help reduce symptoms and improve quality of life
Impact of classification systems being low in validity
Wrong treatment may be given which could worsen symptoms and create further problems for patient
Define external reliability
How much diagnosis varies everytime it is tested using a classification system
Define Test-retest reliability
Assessed using Cohen's Kappa referring to proportion who receive same diagnosis when re-assessed at later date
Define Inter-rater reliability
Same diagnosis given by different psychiatrists for same patient
Define Internal reliability
how consistent a classification system is compared to itself over time
Classification systems uses structured format psychiatrists follow in standardised way so more reliable when diagnosing patients with similar disorders.
ICD10 and DSM5 use set lists of symptoms to diagnose disorders in similar patients
Good agreement would be a Kappa score of 0.7
Tarriha et al (2014), inter-rater reliability for ICD-10 was 0.95 when assessing opioid user is Iran showing ICD-10 gives consistent outcome when diagnosing drug dependency
Consistency changes with each new version that is published as symptoms and disorders are added or removed.
Ponizosky (2006), increase 26% in rediagnosis of SZ so not affected consistency of diagnosis
Less reliable as psychiatrists may intepret symptoms differently leading to different diagnosis given by different psychiatrists
Culture that the psychiatrist is from will affect how they view symptoms like hearing voices which using DSM5 is seen as a major symptom of SZ in the USA yet may not be viewed as a problem in more spiritual based cultures leading to less consistent diagnosis of SZ
Reliability of classification systems is affected due to them being more consistent for some disorders and less consistent for others.
Cooper (2014), 15% of disorders in DSM5 scored 0.6 compared to DSM3 scored 0.7 meaning DSM5 is less consistent with disorders like major depression in earlier versions
Different psychiatrists need to give same diagnosis to same patients
Cheniaux et al (2009) had 2 psychiatrists assess 100 in-patients and found more likely to diagnose SZ with ICD-10 than DSM-IV therefore not consistent
Impact of classification systems being high in reliability
Means that similar patients will be given similar treatments as they can consistently predict how symptoms will be affected
Impact of classification systems being low in reliability
If diagnosis not consistent, difficult to consistently explain how symptoms will respond to treatment methods and each patient will need to be treated on a trial and error basis
AO1: Classic study Rosenhan (1973) - Aim
Investigate psychiatric life such as psychiatrists see behaviour as symptomatic of an underlying disorder affecting validity of diagnosis
AO1: Classic study Rosenhan (1973) - Sample
- Doctors and nurses who worked in 12 hopsitals across 5 states
- Old, new, good and bad (in terms of patient to staff ratio) hospitals used
AO1: Classic study Rosenhan (1973) - Method
Covert participant observation in natural environment (field experiment)
AO1: Classic study Rosenhan (1973) - Procedure
- 8 pseudo patients (3 female, 5 male) with no history of mental health problems
- Pseudo patients telephoned one of 12 for an appointment and arrived at the admission office complaining that they have been hearing voices "empty", "hollow", "thud"
- Pseudo patients given false jobs and names but all other details were true including relationships, ups and downs in life
- When admitted, pseudo patients stopped producing symptoms and took part in activities and answered questions honestly except that they were part of a study.
- Pseudo patients spent time making notes about hospital life, trying to convince that they were sane so they could secure release
- Pseudo patients had daily visitors who said the patients were behaving normally.
AO1: Classic study Rosenhan (1973) - Results
- 11/12 hospitals admitted one pseudo patient
- All but one were diagnosed with SZ, exception was manic depression with psychosis using DSM2
- None detected, discharged with diagnosis being in remission
- In hospital with average 19 days (shortest 7, longest 52)
AO1: Classic study Rosenhan (1973) - Follow up study
- One leading institution agreed to do similar study to test if they could be fooled as they felt it was unlikely
- Staff were asked to rate on ten point scale each patient they dealt with on the probability they could be a pseudo patient
- Over a three month period 193 patients were assessed and 41 were judged to be false by at least 1 member of staff and 19 were judged to be false by at least 2 members of staff
- No pseudo patients were sent to hospital
AO1: Classic study Rosenhan (1973) - Conclusion
- Using diagnostic processes like DSM lead to inaccurate outcomes, less valid, demonstrates failure to detect insanity in patients
- Rosenhan suggests that labelling a patient with a mental health disorder could lead to self-fulfilling prophecy in that people respond to how they're treated
- Likely to make type 2 error saying no disorder when they believe they're being watched so more cautious with diagnosis but create more type 1 errors in normal everyday diagnoses as it's easier to admit a patient than to send them away
AO3: Classic study Rosenhan (1973) - Generalisability
Strength - Represents a variety of hospitals (new,old, staffed and understaffed.) This makes the sample more representative of all hospital types and their quality of diagnosis.
AO3: Classic study Rosenhan (1973) - Reliability
Weakness - The study's method is a covert observation, there is no informed consent meaning the study cannot be replicated safely to check for consistency of results of diagnosis by doctors and nurses.
AO3: Classic study Rosenhan (1973) - Validity
Strength - Psychiatrists were observed in their natural environment and deceived. This means the study is higher in validity as there will be no demand characteristics meaning there is an accurate measure on diagnosis of disorders
AO3: Classic study Rosenhan (1973) - Ethics
Weakness - Gathered data using covert observation so doctors and nurses weren't able to give informed consent to be observed, therefore the experiment gives clinical psychology a bad reputation and doesn't allow the experiment to be repeated in the future as it's unethical
Where does ICD-10 accommodate cultural differences?
Annex 2
Where does DSM5 accommodate cultural differences?
Section 3 by interview method
ID: SE - Luhrmann et al (2015)
Hearing voices seen as negative in USA but more positive in India therefore what is seen as abnormal will be different across cultures so may not be reported by patient.
ID: SE - Kim (2001)
SZ in Japan translates to "disease of disorganised mind" suggesting social stigma so very few people diagnosed with disorder compared to other countries
ID: CE - DSM5
Includes cultural information to help reduce bias, it assesses cultural values to prevent affecting diagnosis
ID: CE - ICD-10
Accounts for culture information in annex 2 which also helps to reduce impact of cultural variations on diagnosis of psychiatric disroders
Luhrmann et al (2015) - Hearing voices seen as negative in USA but more positive in India therefore what is seen as abnormal will be different across cultures so may not be reported by patient. (Validity)
ID affects diagnosis as culture specific syndromes are only accurate for that culture, so lower in validity as not measuring symptoms in all cultures
Luhrmann et al (2015) - Hearing voices seen as negative in USA but more positive in India therefore what is seen as abnormal will be different across cultures so may not be reported by patient. (Reliability)
Evidence shows that if cultural variations are not accounted for them reliability will be low as diagnosis of disorders will not be consistent across different cultures leading to some patients being misdiagnosed
Boogra (96) - Afro-Carribean's were twice more likely to be diagnosed with SZ that white or Asian males based on the same symptoms (validity)
Both ICD-10 and DSM5 now take culture into account with annex 2 or cultural formulation so higher validity as diagnosis using classification system is not fooled by cultural factors
Boogra (96) - Afro-Carribean's were twice more likely to be diagnosed with SZ that white or Asian males based on the same symptoms (reliability)
ID such as impact of social norms as they will remain the same over time will be consistent within one culture so should lead to more reliable diagnosis of a disorder within that culture
Kim (2001) - SZ in Japan translates to "disease of disorganised mind" suggesting social stigma so very few people diagnosed with disorder compared to other countries (validity)
Racial discrimination is less likely to occur with modern classification systems due to them collecting information on cultural variations so more valid as less likely to see Afro-Carribean's being over diagnosed with SZ
Kim (2001) - SZ in Japan translates to "disease of disorganised mind" suggesting social stigma so very few people diagnosed with disorder compared to other countries (reliability)
Due to use of new classification systems it means that diagnosis of disorders will not be consistent over time so leading to low reliability as diagnosis is not consistent regardless of culture
Lin (1996) - Looking at symptoms of SZ, more similarities across different cultures than differences suggesting cultural differences would not lead to different diagnosis (validity)
Limited evidence as only representative of how disorders are diagnosed in one culture so low in validity as assumptions about diagnosis not accurate for other cultures
Lin (1996) - Looking at symptoms of SZ, more similarities across different cultures than differences suggesting cultural differences would not lead to different diagnosis (reliability)
Using cultural variations in beliefs about what causes disorders will lead to the same diagnosis as the new classification systems now account for culture so diagnosis should be consistent