clinical psychology

1. The Process of DiagnosisThe Process of Diagnosis
Lecture 14Lecture 14

2. The Importance of DiagnosisThe Importance of Diagnosis
 Expert level of categorization used byExpert level of categorization used by
mental health professionals that enablesmental health professionals that enables
us to make important distinctions.us to make important distinctions.
 Helps us to make important distinctionsHelps us to make important distinctions
(for example, a mild cold versus viral(for example, a mild cold versus viral
pneumonia.pneumonia.

3. Advantages of diagnosisAdvantages of diagnosis
 Four major advantages of diagnosis:Four major advantages of diagnosis:
1. Communication1. Communication
For example, if a patient with a diagnosis of paranoidFor example, if a patient with a diagnosis of paranoid
schizophrenia is referred to a psychologist.schizophrenia is referred to a psychologist.
A symptom pattern will come to mind.A symptom pattern will come to mind.
Diagnosis as "verbal shorthand"Diagnosis as "verbal shorthand"

4. 2. use of diagnoses enables and promotes2. use of diagnoses enables and promotes
empirical research in psychopathologyempirical research in psychopathology

5. 3. research into the etiology, or causes, of3. research into the etiology, or causes, of
abnormal behavior would be almost impossibleabnormal behavior would be almost impossible
to conduct without a standardized diagnosticto conduct without a standardized diagnostic
systemsystem
Experience of childhood sexual abuse mayExperience of childhood sexual abuse may
predispose individuals to develop features ofpredispose individuals to develop features of
border­line personality disorder (BPD).border­line personality disorder (BPD).

6. 4. diagnosis may suggest which mode of treatment is4. diagnosis may suggest which mode of treatment is
most likely to be effectivemost likely to be effective
 For example, a diagnosis of schizophrenia suggests toFor example, a diagnosis of schizophrenia suggests to
us that the administration of an antipsychoticus that the administration of an antipsychotic
medication is more likely to be effective than is amedication is more likely to be effective than is a
course of psychoanalytic psychotherapy.course of psychoanalytic psychotherapy.
 In summary, diagnosis and classification ofIn summary, diagnosis and classification of
psychopathology serves many useful functions.psychopathology serves many useful functions.
Whether they are researchers or practitioners,Whether they are researchers or practitioners,
contemporary clinical psychologists use some form ofcontemporary clinical psychologists use some form of
diagnostic scheme in their work.diagnostic scheme in their work.

7. Early Classification SystemsEarly Classification Systems
 the earliest reference to a depressive syndromethe earliest reference to a depressive syndrome
appeared as far back as 2600 B.C.appeared as far back as 2600 B.C.
 Congress of Mental Science adopted a singleCongress of Mental Science adopted a single
classification system in 1889 in Parisclassification system in 1889 in Paris
 More recent attempts : World Health Organization andMore recent attempts : World Health Organization and
its 1948 International Statistical Classification ofits 1948 International Statistical Classification of
Diseases, Injuries, and Causes of Death, whichDiseases, Injuries, and Causes of Death, which
included a classification of abnormal behavior.included a classification of abnormal behavior.

8.  American Psychiatric Association published Diagnostic andAmerican Psychiatric Association published Diagnostic and
Statistical Manual in 1952Statistical Manual in 1952
 revisions in 1968 (DSM­II), 1980 (DSM­III), and 1987 (DSM­III­revisions in 1968 (DSM­II), 1980 (DSM­III), and 1987 (DSM­III­
R).R).
 (DSM­IV) : 1994 (most widely used classification system)(DSM­IV) : 1994 (most widely used classification system)
 The most revolutionary changes in the diagnostic system wereThe most revolutionary changes in the diagnostic system were
introduced in DSM­III (1980).introduced in DSM­III (1980).
 These changes included the use of explicit diagnostic criteriaThese changes included the use of explicit diagnostic criteria
for mental disorders, a multiaxial system of diagnosis, afor mental disorders, a multiaxial system of diagnosis, a
descriptive approach, and a greater emphasis on the clinicaldescriptive approach, and a greater emphasis on the clinical
utility of the diagnostic system.utility of the diagnostic system.

9. DSM-IVDSM-IV
 DSM-IV (1994) revisions guided by a three-stageDSM-IV (1994) revisions guided by a three-stage
empirical process.empirical process.
 First, 150 comprehensive reviews of the literatureFirst, 150 comprehensive reviews of the literature
 Second, 40 major re-analyses of existing dataSecond, 40 major re-analyses of existing data
 Third, 12 DSM-IV field trials were conductedThird, 12 DSM-IV field trials were conducted
 In summary, the changes made in DSM-IV wereIn summary, the changes made in DSM-IV were
based on empirical data to a much greater extent thanbased on empirical data to a much greater extent than
was true in previous editions of the DSM.was true in previous editions of the DSM.

10. Multi-axial assessmentMulti-axial assessment
 Axis l = clinical disorders or other relevant conditionsAxis l = clinical disorders or other relevant conditions
 Axis ll = personality disorders and mental retardationAxis ll = personality disorders and mental retardation
 Axis lll = General medical conditionsAxis lll = General medical conditions
 Axis lV = Psychosocial and environmental problemsAxis lV = Psychosocial and environmental problems
 Axis V = Global Assessment of Functioning (GAF) aAxis V = Global Assessment of Functioning (GAF) a
quantitative estimate (1 to 100) scalequantitative estimate (1 to 100) scale

11. The Case of Michelle M.The Case of Michelle M.
1.1. 23-year-old woman23-year-old woman
2.2. Sixth suicide attempt in two yearsSixth suicide attempt in two years
3.3. Had a five-year history of multiple depressive symptomsHad a five-year history of multiple depressive symptoms
4.4. They included dysphoric mood, poor appetite, low self-They included dysphoric mood, poor appetite, low self-
esteem, poor concentration, and feelings of hopelessness.esteem, poor concentration, and feelings of hopelessness.
5.5. Had great difficulty controlling her emotionsHad great difficulty controlling her emotions
 Polysubstance abuse, impulsive behaviors, and binge eating.Polysubstance abuse, impulsive behaviors, and binge eating.

12. 5.5. intense and unstable relationships, often be angryintense and unstable relationships, often be angry
and devalue them.and devalue them.
6.6. constantly reported an intense fear that others mightconstantly reported an intense fear that others might
abandon her (including her parents)abandon her (including her parents)
7.7. attempted to leave home and attend college inattempted to leave home and attend college in
nearby cities on four occasions, Each time, shenearby cities on four occasions, Each time, she
returned home within a few weeks.returned home within a few weeks.
8.8. Prior to her hospital admission, her words to her ex-Prior to her hospital admission, her words to her ex-
boyfriend over the telephone were, "I want to end itboyfriend over the telephone were, "I want to end it
all. No one loves me."all. No one loves me."

13. DSM-IV diagnostic evaluation forDSM-IV diagnostic evaluation for
Michelle M.Michelle M.
 Axis I:Axis I: 300.4300.4 Dysthymic Disorder early onsetDysthymic Disorder early onset
305.00305.00 Alcohol AbuseAlcohol Abuse
305.20305.20 Cannabis AbuseCannabis Abuse
305.60305.60 Cocaine AbuseCocaine Abuse
305.30305.30 Hallucinogen AbuseHallucinogen Abuse
 Axis II:Axis II: 301.83301.83 Borderline Personality DisorderBorderline Personality Disorder
 (PRINCIPAL DIAGNOSIS)(PRINCIPAL DIAGNOSIS)
 Axis III:Axis III: nonenone
 Axis IV:Axis IV: Problems with primay support groupProblems with primay support group
Educational problemsEducational problems
 Axis V:Axis V: GAF = 20 (Current)GAF = 20 (Current)

14. General Issues inGeneral Issues in
ClassificationClassification
Eight major issues :

15. 1. Categories versus Dimensions1. Categories versus Dimensions
 The patient is placed in a category based upon his symptoms.The patient is placed in a category based upon his symptoms.
 A circular form of description : "This patient is experiencingA circular form of description : "This patient is experiencing
obsessions because she has obsessive-compulsive disorder"obsessions because she has obsessive-compulsive disorder"
or "This person is acting psychotic because he hasor "This person is acting psychotic because he has
schizophrenia.schizophrenia.
 Abnormal behavior is not qualitatively different from so-calledAbnormal behavior is not qualitatively different from so-called
normal behavior. Rather, these are endpoints of a continuousnormal behavior. Rather, these are endpoints of a continuous
dimension.dimension.
 There may be relatively few diagnostic constructs that are trulyThere may be relatively few diagnostic constructs that are truly
categorical in nature.categorical in nature.

16. 2. Bases of Categorization2. Bases of Categorization
 There are multiple bases for a diagnosis.There are multiple bases for a diagnosis.
 E.g., case history, behavioral observation,E.g., case history, behavioral observation,
self reports, physiological examination etc.self reports, physiological examination etc.

17. 3. Pragmatics of Classification3. Pragmatics of Classification
 Psychiatric classification has always beenPsychiatric classification has always been
accompanied by a certain degree of appeal to medicalaccompanied by a certain degree of appeal to medical
authority.authority.
 For example, psychiatry for many years regardedFor example, psychiatry for many years regarded
homosexuality as a disease to be cured throughhomosexuality as a disease to be cured through
psychiatric intervention.psychiatric intervention.
 Classification systems such as the DSM are crafted byClassification systems such as the DSM are crafted by
committees and may represent political compromises.committees and may represent political compromises.

18. 4. Description4. Description
 DSM-IV provides thorough descriptions ofDSM-IV provides thorough descriptions of
the diagnostic categories.the diagnostic categories.
 Also provides additional informationAlso provides additional information
e.g., age of onset, course, prevalence,e.g., age of onset, course, prevalence,
complications, family patterns, culturalcomplications, family patterns, cultural
considerationsconsiderations

19. 5. Reliability5. Reliability
 A scheme that cannot establish its reliability hasA scheme that cannot establish its reliability has
serious problems.serious problems.
 Study illustrating the unreliability of previousStudy illustrating the unreliability of previous
diagnostic systems by Beck, Ward and associates.diagnostic systems by Beck, Ward and associates.
 Two different psychiatrists each interviewed the sameTwo different psychiatrists each interviewed the same
153 newly admitted psychiatric patients. Overall153 newly admitted psychiatric patients. Overall
agreement among these psychiatrists was only 54%.agreement among these psychiatrists was only 54%.
 Unreliability problem seemed to lie with theUnreliability problem seemed to lie with the
diagnosticians and/or the diagnostic system itself.diagnosticians and/or the diagnostic system itself.

20.  Certain pragmatic factors such as the "humanitarian"Certain pragmatic factors such as the "humanitarian"
choice often seems to be to alter a diagnosis.choice often seems to be to alter a diagnosis.
 Sometimes it happens that a given institution will notSometimes it happens that a given institution will not
admit patients who carry a certain diagnosis.admit patients who carry a certain diagnosis.
 A diagnosis may be intentionally or unintentionallyA diagnosis may be intentionally or unintentionally
manipulated.manipulated.
 Or perhaps one diagnosis permits six therapy visitsOr perhaps one diagnosis permits six therapy visits
but another allows as many as 15 sessions.but another allows as many as 15 sessions.
 Meehl (1977), feels that psychiatric diagnosis is notMeehl (1977), feels that psychiatric diagnosis is not
nearly as unreliable as it is made out to be.nearly as unreliable as it is made out to be.

21.  Reliability by developing structured diagnosticReliability by developing structured diagnostic
interviews that essentially "force" diagnosticiansinterviews that essentially "force" diagnosticians
 For example, there are now several structuredFor example, there are now several structured
interviews that assess features of Axis I disorders, andinterviews that assess features of Axis I disorders, and
a number of structured interviews for Axis II disordersa number of structured interviews for Axis II disorders
exist as well.exist as well.
 The presence versus absence of some disorders mayThe presence versus absence of some disorders may
be particularly difficult to judge.be particularly difficult to judge.
 Busy clinicians will devote the time and effort,Busy clinicians will devote the time and effort,
necessary to systematically evaluate the relevantnecessary to systematically evaluate the relevant
diagnostic criteria.diagnostic criteria.

22. 6. Validity6. Validity
 Reliability will directly affect the validity ofReliability will directly affect the validity of
a diagnostic system.a diagnostic system.
 Important correlates include prognosis,Important correlates include prognosis,
treatment outcome, ward management,treatment outcome, ward management,
etiology, and so on.etiology, and so on.

23.  The predominant method for establishing theThe predominant method for establishing the
validity of a diagnostic constructvalidity of a diagnostic construct
By Robins and Guze (1970):By Robins and Guze (1970):
Establishing the diagnostic validity = five-stage process:Establishing the diagnostic validity = five-stage process:
(1)(1) clinical description (such as demographic features);clinical description (such as demographic features);
(2)(2) laboratory studies (including psychological tests)laboratory studies (including psychological tests)
(3)(3) delimitation from other disorders (to ensure somedelimitation from other disorders (to ensure some
homogeneity among diagnostic members)homogeneity among diagnostic members)
(4)(4) follow-up studies (to assess the test-retest reliabilityfollow-up studies (to assess the test-retest reliability
of a diagnosis)of a diagnosis)
(5)(5) family studies (suggesting a hereditary componentfamily studies (suggesting a hereditary component
to the disorder)to the disorder)

24. 7. Bias7. Bias
 The two areas of potential bias that haveThe two areas of potential bias that have
received the most attention :received the most attention :
 Sex bias and Racial bias.Sex bias and Racial bias.
 DSM system attacked as a male-centeredDSM system attacked as a male-centered
device that overestimates pathology in womendevice that overestimates pathology in women

25.  Widiger and Spitzer : clinicians may beWidiger and Spitzer : clinicians may be
biased in the way they apply diagnoses tobiased in the way they apply diagnoses to
men versus women (same symptoms)men versus women (same symptoms)
 For example, antisocial personalityFor example, antisocial personality
disorder is diagnosed much moredisorder is diagnosed much more
frequently in men than in womenfrequently in men than in women
 Clinicians may exhibit sex biasClinicians may exhibit sex bias

26. 8. Coverage8. Coverage
 Scope of DSM-IV is too broadScope of DSM-IV is too broad
 Many question the appropriateness or benefitMany question the appropriateness or benefit
of labeling childhood developmental disordersof labeling childhood developmental disorders
as mental disorders.as mental disorders.
 Dyslexia, stutteringDyslexia, stuttering

27. Additional ConcernsAdditional Concerns
 Learned reactions about mental disorders &Learned reactions about mental disorders &
disease processdisease process
 Classifying people is more satisfying than tryingClassifying people is more satisfying than trying
to relieve their problemsto relieve their problems

28.  Public's desire to regard problems in livingPublic's desire to regard problems in living
as medical problemsas medical problems
 Diagnosis can be harmful or evenDiagnosis can be harmful or even
stigmatizing to the person who is labeledstigmatizing to the person who is labeled

29. Other Classification SystemsOther Classification Systems
 The Five-Factor Model of personality (FFM)The Five-Factor Model of personality (FFM)
 Neuroticism,Neuroticism,
 Extraversion,Extraversion,
 Openness to Experience,Openness to Experience,
 Agreeableness, andAgreeableness, and
 ConscientiousnessConscientiousness
 Relationship between the FFM and Axis IIRelationship between the FFM and Axis II
disorders is positivedisorders is positive