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Published byPriscilla Osborne Modified over 9 years ago
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Chapter 1: Issues in Diagnosis: Conceptual Issues and Controversies
Scott O. Lilienfeld Sarah Francis Smith Ashley L. Watts
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General Terminological Issues
Classification Versus Diagnosis Classification: Overarching taxonomy Diagnosis: Act of placing an individual into a category within a taxonomy Signs Versus Symptoms Signs: Observable indicators (e.g., crying) Symptoms: Subjective indicators (e.g., feelings of guilt in depressed patient) Syndrome Versus Disorder Versus Disease Syndrome: Constellations of signs and symptoms that co-occur across individuals Disorder: Syndromes that cannot be readily explained by other conditions Disease: Disorders in which pathology and etiology are reasonably well understood
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Functions of Psychiatric Diagnosis
Diagnosis as communication Distills information in a shorthand form that aids in other professionals’ understanding of a case Establishing linkages to other diagnoses Locates a patient’s problems within the context of more and less related diagnostic categories Provision of surplus information Generates predictions about case trajectory, response to treatment, family history, laboratory research and so on.
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Misconceptions Regarding Psychiatric Diagnosis
Mental illness is a myth Mental illness as “acute problems in living” (Szasz, 1960) Mental disorders cannot be clearly recognized by corresponding lesions in the anatomical structure of the body Rebuttal: Many medical disorders cannot be traced to lesions and many lesions do not give rise to medical disorders
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Misconceptions Regarding Psychiatric Diagnosis
2. Psychiatric diagnosis is merely pigeonholing Diagnosing people with mental disorders deprives them of uniqueness. Rebuttal: Diagnosis merely indicates one way in which people are alike.
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Misconceptions Regarding Psychiatric Diagnosis
3. Psychiatric diagnoses are unreliable Rebuttal: There are many kinds of reliability, which are frequently discrepant with each other Evaluation of reliability hinges on the conceptualization of a disorder (e.g., high test-retest reliability may be expected for chronic disorders) Interrater reliability for most psychiatric diagnoses is as high as that of other major medical disorders (Lobbestael, Leurgans, & Arntz, 2011; Matarazzzo, 1983)
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Misconceptions Regarding Psychiatric Diagnosis
4. Psychiatric diagnoses are invalid Simply descriptive labels for behavior we do not like Rebuttal: Many psychiatric diagnoses provide surplus information (e.g., schizophrenia)
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Misconceptions Regarding Psychiatric Diagnosis
5. Psychiatric diagnoses stigmatize people, and often result in self-fulfilling prophecies Lead to the interpretation of ambiguous behaviors as consistent with the psychiatric diagnosis (e.g., Rosenhan, 1973) Rebuttal: Incorrect diagnoses may lead to stigma, but correct diagnoses may actually lead to reduced stigma by providing an explanation for otherwise unexplainable behavior (Ruscio, 2004)
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What Is Mental Disorder?
Statistical Model Disorder = Statistical Rarity No guidelines for cutoff between abnormality and normality Assumes all common conditions are normal (Wakefield, 1992) Subjective Distress Model Core feature of mental disorders is psychological pain In some ego-syntonic conditions, individuals do not see their behavior as problematic (e.g., narcissistic personality disorder). Biological Model Disorder defined in terms of biological (or evolutionary) disadvantage to an individual (e.g., increased risk for suicide in depressed patients) (Joiner, 2006). Some behaviors incur such disadvantage but are not disorders (e.g., military combat). Some disorders do not incur long-term decrease in evolutionary fitness but are disorders (e.g., phobias)
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What Is Mental Disorder?
Need for Treatment Disorder is any condition characterized by a need for medical intervention by a health professional (Kraupl Taylor, 1971) Some conditions require medical intervention but are not disorders (e.g., pregnancy) Harmful Dysfunction Disorders are socially devalued (harmful) breakdowns of evolutionarily selected systems (Wakefield, 1992) Many medical conditions are adaptive defenses (e.g., vomiting in the flu); many psychological conditions are adaptive reactions to threat Roschian Analysis Concept of mental disorder is inherently fuzzy Mental disorders lack defining features and boundaries Controversies over concept of mental disorder are inevitable and unresolvable
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Psychiatric Classification From DSM-I to the Present
DSM-I and DSM-II DSM-I (APA, 1952): First clear attempt at describing major psychiatric diagnoses in one manual DSM-II (APA, 1968): Similar in scope to DSM-I; greater detail concerning signs and symptoms of disorders Major criticisms: Low interrater reliability for many disorders Influenced heavily by psychoanalytic concepts of disorders Neglected consideration of contextual factors (e.g., co-occurring medical disorders)
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Psychiatric Classification From DSM-I to the Present
DSM-III (APA, 1980) and Beyond Dramatic increase in coverage of disorders and detailed guidelines for making diagnoses Standardized Diagnostic Criteria Signs and symptoms of each disorder explicitly delineated Algorithms and Decision Rules for Diagnoses Highly structured guidelines for number of symptoms and combinations of symptoms that must be met for a diagnosis Hierarchical Exclusions Rules Rules to prevent diagnoses from being made if other diagnoses better account for the clinical picture
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Psychiatric Classification From DSM-I to the Present
DSM-III (APA, 1980) and Beyond Multiaxial Approach Evaluations along series of axes (e.g., Axis I – Major mental disorders, Axis II – Personality disorders) Forced a holistic approach to diagnoses Dropped in DSM-5 Theoretical Agnosticism Agnostic with respect to etiology of disorders Permits use of the manual by practitioners of many different theoretical backgrounds
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Psychiatric Classification From DSM-I to the Present
DSM-III-R and DSM-IV Retained major features/innovations of DSM-III Gradual move to a polythetic approach to diagnosis Led to increased heterogeneity of diagnoses Relaxation of many hierarchical exclusion rules (Pincus, Tew, & First, 2004) DSM-IV added appendix for culture-bound syndromes (e.g., koro)
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Psychiatric Classification From DSM-I to the Present
Published May 2013 (APA, 2013) Retained most of major categories of DSM-IV Dropped multiaxial system Attempted to decrease proliferation of new diagnoses by necessitating rigorous validity data for new diagnoses Criticized for lowering diagnostic threshold for several diagnostic categories (Batstra & Frances, 2012) Criticized for inadequate field trials focusing on clinical feasibility rather than validity of new diagnostic categories (Frances & Widiger, 2012)
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Criticisms of Current Classification System
Comorbidity High levels of co-occurrence and covariation among many diagnostic categories One disorder may lead to others; two disorders may mutually influence each other or be different expressions of the same underlying liability May result from overlapping diagnostic criteria or clinical selection bias (du Fort, Newman, & Bland, 1993) Especially problematic for personality disorders (Widiger & Rogers, 1989) Often underestimated in clinical practice May be attaching multiple labels to different manifestations of the same condition
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Criticisms of Current Classification System
Medicalization of Normality 1. Increased number of diagnoses in DSMs 2. Lowered threshold for diagnoses in DSM-V (e.g., age of onset in ADHD) May reflect splitting of broad diagnoses into narrower subtypes (Wakefield, 2001) rather than increased coverage DSM-V also practiced lumping of narrower diagnostic categories into broader ones (e.g., autism spectrum disorder) Neglect of the Attenuation Paradox (Loevinger, 1957) Efforts to achieve high reliability (especially internal consistency) may decrease validity of psychiatric diagnoses Occurs when a narrow pool of items is used to describe a broad, multifaceted construct
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Criticisms of Current Classification System
Unsupported Retention of a Categorical Model DSM is exclusively categorical at measurement level- individuals either meet a diagnostic criteria for a disorder or not Growing evidence that many DSM diagnoses are underpinned by dimensions rather than taxa (Kendell & Jablensky, 2003) Measuring most disorders dimensionally almost always results in higher correlations with external validating variables (Craighead, Sheets, Craighead, & Madsen, 2011)
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The DSM : Quo Vadis? Dimensional Approach
Growing evidence for dimensionality of many psychiatric conditions Many suggest using sets of dimensions from personality science to aid in psychiatric diagnosis (Krueger et al., 2011; Widiger & Clark, 2000) Five-Factor Model (FFM; Goldberg, 1993) Disagreement about nature and number of personality dimensions to be used Distinction between basic tendencies and characteristic adaptations is often neglected (Harkness & Lilienfeld, 1997) Personality dimensions may not be sufficient by themselves to capture full variance in psychopathology
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The DSM : Quo Vadis? Endophenotypic Markers
Accumulating research on biochemistry, brain imaging, performance on laboratory tasks and psychopathology Widespread assumption that endophenotypic markers are more closely related to etiology than exophenotypic markers (Kihlstrom, 2002) No endophenotypic markers of psychiatric diagnoses to date come close to serving as inclusion criteria for respective disorders May better serve as exclusion criteria Research Domain Criteria (RDoC): Proposed alternative to DSM; goal is to identify psychobiological systems that underlie psychopathology (Morris & Cuthbert, 2012) and markers of those systems
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