Presentation on theme: "Science and Pseudoscience in Abnormal Psychology, Part III; Diagnosis & the DSM February 10, 2014 PSYC 2340: Abnormal Psychology Brett Deacon, Ph.D."— Presentation transcript:
1Science and Pseudoscience in Abnormal Psychology, Part III; Diagnosis & the DSM February 10, 2014 PSYC 2340: Abnormal Psychology Brett Deacon, Ph.D.
2Announcements This week: Today: Diagnosing mental disorders and the DSMWednesday: Rosenhan articleFriday: Exam #1
3On Being Sane in Insane Places (Rosenhan, 1973) http://www. youtube
4“It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals.” -D.L. Rosenhan
5Diagnosis and Stigma On being sane in insane places (Rosenhan, 1973) Issues to consider in the article(1) how diagnoses were made(2) the effects of being labeled with a diagnosis(3) the effects of being a patient in a mental institution(4) your personal reaction to the study
6From Last ClassNaïve realism and the accuracy of subjective impressions (intuition)My debate with EPA president about antidepressant efficacySecond half of Scott Lilienfeld’s presentation
7Important Points Pseudoscientific therapies are popular In part, their popularity is due to the romantic “way of knowing” (as opposed to empiricism)Romantics endorse naïve realism and fall prey to confirmation biasScientific thinking is unnaturalScientists should be humbleScientific training – thinking like a scientist vs. learning scientific technologiesLast few slides
8Causes of Spurious Therapy Effectiveness Name reasons why a client might appear to improve during therapy – other than the direct effects of the therapy itself.
9Causes of Spurious Therapy Effectiveness Placebo (expectancy) effectsSpontaneous remissionRegression to the meanDemand characteristicsMaturationAbsence of knowledge of the hypothetical counterfactual
10Ethics, Science, and Pseudoscience APA ethics code (http://www.apa.org/ethics/code2002.html#general)Principle A: Beneficence and Nonmaleficence“Psychologists strive to benefit those with whom they work and take care to do no harm. In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons.”
11Exam Review Chapter 1 (Intro and Historical Context) Defining abnormality, mental disorder, insanity, and diseaseDSM-IV and diagnosing mental disordersDifferences between mental health professionsScientist-practitioner modelHistorical conceptions of psychopathology (supernatural, biological, psychological)
12Exam Review Chapter 1 (Intro and Historical Context) Assumptions of the modern biological approach, classifying psychotropic medications and understanding drug action, chemical imbalance theory
13Exam Review Chapter 1 (Intro and Historical Context) Psychoanalytic theoryHumanistic theoryAssumptions of scientific approach to psychotherapy research vs. humanistic philosophyBehavioral and cognitive theory (classical and operant conditioning, cognition)
14Exam Review Costs of pseudoscientific therapies Lilienfeld talk Romantic vs. empiricismReasons why what we think is so might not beImportance of science in abnormal psychology
15Exam Review Rosenhan article Arguments, and responses from critics The anti-psychiatry movement
16Exam Review Chapter 3 (Diagnosis; pp. 85-96 only) Categorical, dimensional, and prototypical approaches to classificationAdvantages and disadvantages of diagnosingReliability and validity in diagnosisCharacteristics of previous and current versions of the DSM
18Diagnosing Mental Disorders Diagnostic classificationClassification is central to all sciencesDevelop categories based on shared attributesControversial when applied to abnormal psychology
19ClassificationScientific classification strives to “carve nature at its joints”Seeks to identify “natural categories”Examples of natural categories of medical diseases: tuberculosis, hepatitis, influenza, HIV/AIDSNot all medical problems are natural categoriesHypertension, obesity, etc.
21Issues in Diagnosing Mental Disorders Natural vs. artificial categoriesAre mental disorders distinct entities that can be meaningfully (validly) classified into different categories?Does nature have “joints” that represent different mental disorders?Do mental disorders represent natural categories?
22Issues in Diagnosing Mental Disorders Mental disorders are not valid, in the sense that there is no objective test for themMental disorders are “fictive categories” or “heuristics” not to be misconstrued as “natural kinds” or “real entities” (former NIMH Director Steven Hyman)
23Issues in Diagnosing Mental Disorders Does this mean that psychological problems do not exist?Is schizophrenia a “myth” (Szasz, 1961)?Validity issues aside, are there advantages to classifying mental disorders?
24Classification and Natural Categories: Analogy to Mental Disorders
25Classifying Psychopathology Categorical (classical) approachA person either has a disorder or does notAssumes each disorder has a clear underlying cause (most likely biological)Assumes each disorder is fundamentally uniqueEverybody with the disorder should meet all diagnostic criteria
26Classifying Psychopathology Dimensional approachPeople have varying degrees of psychopathologyDimensions can overlap with each otherDoes not assume the presence of pathology
27Classifying Psychopathology Dimensional approachAdvantages: it is accurateResearch shows that many mental disorder symptoms (e.g., depressed mood, obsessions and compulsions) are continuous, not categoricalNo need to assume people with problems are abnormal, defective, or fundamentally different from others
28Classifying Psychopathology Dimensional approachDisadvantages:What are the dimensions? How many are there? How to rate them? What to do with these ratings? What would third-party payers do with these ratings?Nobody has ever generated a clinically useful dimensional system of classification
29Classifying Psychopathology Prototypical approach1. Identifies essential characteristics of a disorder2. Allows for variations within the diagnosisDiagnostic criteria include a number of symptoms, only some of which need to be metCombines elements of categorical and dimensional approach, but in the end a person either has or does not have a disorderExemplified in the DSM
30Issues in Diagnosing Mental Disorders 1. Problems are diagnosed based on symptoms without regard to their cause
31Issues in Diagnosing Mental Disorders Do all people who meet DSM diagnostic criteria for major depressive disorder have the same problem?Person A: homesick college studentPerson B: terminally ill cancer patientDoes the cause of a problem matter if we wish to understand and treat it?
32Issues in Diagnosing Mental Disorders 2. Excessive variation within the same diagnosis
33Diagnosing Obsessive-Compulsive Disorder The following people all have the same diagnosis:Patient #1: hoarding worthless objectsPatient #2: contamination fear and washing ritualsPatient #3: fear of stabbing others with knifePatient #4: fear of hitting pedestrians with carPatient #5: symmetry and arranging compulsionsPatient #6: blasphemous obsessions and compulsive religious rituals
34Issues in Diagnosing Mental Disorders 3. Excessive overlap between different diagnoses
35Comorbidity Exemplar: Major Depressive Disorder and Generalized Anxiety Disorder Common symptoms:Physical agitation/restlessnessFatigue/loss of energyDifficulty concentratingIrritabilitySleep disturbanceExtremely high comorbidity“All depressed patients are anxious, but not all anxious patients are depressed” (your text)
36Purposes and Evolution of the DSM Diagnostic and Statistical Manual of Mental Disorders (DSM); published by American Psychiatric AssociationDSM-I (1952) and DSM-II (1968)Both relied on unproven theories and were unreliable
37Diagnostic Criteria for “Phobic Reaction” in DSM-I (1952)
38Evolution of the DSM History of the DSM 5 editions, I in 1952 through IV in 1994DSM-I (1952)DSM-II (1968)DSM-III (1980)DSM-III-R (1987)DSM-IV (1994; “Text revision” in 2000)
39Number of Diagnoses in the DSMs Across Editions (1952-1994)
40The Modern DSM DSM-III (1980), DSM-III-R (1987), DSM-IV (1994) Atheoretical, emphasizing clinical descriptionDetailed diagnostic criteria for each disorderChecklist approach to diagnosisImproved reliability for most disordersProblems include low reliability for some disorders and reliance on committee consensusWhich disorder has low reliability? Depression, BPDExamples of reliance on committee consensus?
41The Modern DSM Paradigm shift from DSM-II to DSM-III (1980) From vague, psychoanalytic model to atheoretical, symptom checklistThis shift was not precipitated by advances in scientific understanding of mental disordersWhy did it occur?
42Atheoretical Diagnosis Diagnostic criteria focus on symptoms, not on their presumed underlying causesImproves diagnostic reliabilityFosters checklist approach to diagnosisDiscourages attempts to understand the factors that are contributing to symptoms
43The DSM-IV (1994) Basic characteristics Multiaxial approach to diagnosisFive axes describing full clinical presentation
44The DSM-IV Axis I – Most major disorders Axis II – Stable, enduring problems (e.g., personality disorders, mental retardation)Axis III – Medical conditions related to abnormal behaviorAxis IV – Psychosocial problemsAxis V – Global clinician rating of adaptive functioning (Global Assessment of Functioning, or GAF)
45The Case of JennyJenny, a 21-year-old nurse, has mild asthma. She worries that shortness of breath signifies an impending episode of suffocation and death. When she has difficulty breathing, she often experiences severe panic attacks during which she is convinced she is dying. She was referred to a psychologist after numerous ER visits, unsuccessful medication trials, and relaxation training. She frequently misses work because of her panic symptoms and is in danger of being fired if she takes any more sick days.
46Jenny’s DSM-IV Diagnosis Axis I: Panic Disorder with AgoraphobiaAxis II: No diagnosisAxis III: AsthmaAxis IV: Occupational problemsAxis V: GAF = 55 (Current)
47Diagnosing Mental Disorders Primary role of mental health professionalsScientifically questionable but practically indispensable in our current healthcare system
48Reliability and Diagnosis Reliability (interrater agreement). Affected by:Subjectivity of diagnostic criteriaPatient report (accuracy, self-disclosure)Types of questions being asked by assessorUnstructured vs. structured interviewsAnd test-retest reliability.
49Reliability and Diagnosis Diagnosing ADHDAPA President Jeffrey Lieberman: ““…clinicians must resist marketing pressures, as well as parental pressures, to ensure that diagnoses are made in a rigorous way and that treatments are prescribed judiciously.”So, diagnoses are to be made in a rigorous way. Could anyone explain to me how the criterion item “Often runs or climbs about in situations where it is inappropriate (Note: in adolescents or adults may be limited to feeling restless)” can be applied in a rigorous way? How often is “often”? How would one even begin to assess the frequency with which a child runs or climbs about? How do we define appropriate? A strict, uptight nanny might say that running and climbing about is never appropriate. A parent or teacher might feel that running and climbing about were OK for boys but not for girls, etc… And apparently adolescents and adults score yes on this item if they often feel restless! I would guess that during the winter, half the adult population of the northern United States feel restless. We call it cabin fever! And aren’t adolescents supposed to feel restless? Isn’t it the time of the great awakening – when young people look to the horizon and dream their dreams?
50Validity and Mental Disorders Mental disorders overlap a great deal and are not separated by “natural boundaries”We have no objective tests to detect themMental disorders are not categorically distinct from normality (i.e., mental health problems exist on a continuum)Thus, mental disorders are not valid in the traditional senseThey are, however, useful by virtue of conveying information about cause, outcome, and treatment (Kendell & Jablensky, 2003)
51Advantages of Diagnosing Enhances communication between professionalsFacilitates study of causes and treatments of specific disordersHelps in treatment planningNecessary for insurance reimbursement
52Disadvantages of Diagnosing Adds little to our understanding of a problemMany diagnoses have poor reliabilityStigmatizes patients and invites discriminationSuggests the presence of a disease state