Chapter 7: Diagnosis and Classification Issues PDF

CHAPTER 7: DIAGNOSIS AND CLASSIFICATION ISSUES Josée L Jarry, Ph.D., C.Psych. Introduction to Clinical Psychology (PSYC 3330-01) University of Windsor October 1, 2024  DEFINING NORMALITY AND ABNORMALITY What defines abnormality? Pers...

CHAPTER 7: DIAGNOSIS AND CLASSIFICATION ISSUES Josée L Jarry, Ph.D., C.Psych. Introduction to Clinical Psychology (PSYC 3330-01) University of Windsor October 1, 2024  DEFINING NORMALITY AND ABNORMALITY What defines abnormality? Personal distress to the individual Deviance from cultural norms Statistical infrequency Impaired social functioning Wakefield’s Harmful Dysfunction Theory Disorder a harmful dysfunction Harmful: value term based on social norms Dysfunction: failure of mental mechanism to perform a natural function designed by evolution Concept combines value and scientific components  SOCIAL NORMS & NATURAL FUNCTION Is a socially condoned behaviour always “normal?” Consider Nazi Germany Hatred of Jews was normative and encouraged Non-hatred of Jews was a character flaw Hatred now is part of what constitutes some disorders, ex: paranoid personality disorder (bears grudges…) Natural function Hallucinations are a clear cut failure of perception function Obvious distortion of visual/auditory/somatoform stimuli Fear vs panic, is that so clear cut?  WHO DEFINES ABNORMALITY? Diagnostic and Statistical Manual of Mental Disorders (DSM) Defines mental disorder as a clinically significant disturbance in cognition, emotion regulation and behaviour Indicates a dysfunction in mental functioning Usually associated with significant distress or disability Expectable reactions to common stressors are not mental disorders Reflects a medical model of psychopathology Each disorder categorically listed and defined with a list of specific symptoms Culture and values of those defining disorders play influential role in the definitions produced The DSM has been criticized for its: Lack of input from other nonmedical health professionals who use the DSM (e.g., social workers, counselors, etc.) Emphasis on a medical model of psychopathology: categorial definitions Lack of culturally diverse representation among authors (though this has improved over more recent editions)  WHY IS THE DEFINITION OF ABNORMALITY IMPORTANT? For professionals For clients Consideration by clinicians Access to treatment Research Demystifying the conditions Treatment protocols Frequent relief with ADHD Communicating with other diagnosis professionals Stigma I have BPD… Attenuated psychosis syndrome Overall reality testing intact Light hallucination, delusion, or disorganized speech Different from OCD with poor or absent insight? Delusional disorder, Grandiose type, religious content  A BRIEF HISTORY OF DIAGNOSIS AND CLASSIFICATION: BEFORE DSM Discussions of abnormal behavior appear in ancient Chinese, Hebrew, Egyptian, Greek, and Roman texts Hippocrates’ theories of abnormality emphasized natural causes Emphasized bodily fluids: blood, phlegm, black bile, yellow bile) Was a significant early step to current definitions 19th century establishment of asylums Philippe Pinel proposed specific categories: melancholia, mania, dementia, etc. Around 1900, Emil Kraepelin put forth some of the first specific categories of mental illness Manic-depressive psychosis Dementia praecox Primary purpose of diagnostic categories as the collection of statistical/census data EARLY EDITIONS OF THE DSM DSM-I (1952) and DSM-II (1968) Similar to each other, but different from later editions Not scientifically or empirically based Based on “clinical wisdom” of leading psychiatrists Psychoanalytic/Freudian influence Contained three broad categories of disorders Psychoses: schizophrenia Neuroses: depression, bipolar disorder, anxiety Character disorders: personality disorders No specific criteria; just paragraphs with somewhat vague descriptions DSM-II ANXIETY NEUROSIS (GAD) DSM-III TO DSM-IV-TR DSM-III (1980) More reliant on empirical data; less reliant on clinical consensus Attempt at validity Specific criteria defined disorders Attempt at reliability Psychoanalytic language replaced by atheoretical language Multiaxial assessment (5 axes) Axis 1: mental disorders, e.g. depression Axis 2: personality disorders Axis 3: medical conditions Axis 4: psychosocial problems Axis V: Global Assessment of Functioning (GAF) Longer and more expansive than previous versions Included many new disorders DSM-III-R (1987), DSM-IV (1994), and DSM-IV-TR (2000) retained the major quantitative and qualitative changes instituted by DSM-III  DSM-5 Published in 2013 First substantial revision after 20 years Led by David Kupfer and Darrel Regier, with involvement from hundreds of experts from dozens of countries Researched over 12 years Coordinated efforts with World Health Organization, who publishes the International Classification of Diseases (ICD-11), used in countries outside the US  GENERAL POINTS ABOUT CLASSIFICATION All systems of classification represent a “best effort”, and are always inadequate and flawed in some manner. A “perfect” nosology* does not exist.  *(classification of diseases) “Chicken and egg” relationship between categories and those placed in the categories.  Do you build the category from observed behaviour?  Do you start seeing the category after it has been developed? DECISIONS AND ERRORS OF CLASSIFICATION Disorder Disorder not actually actually present present Say present Correct False positive diagnosis (type 1 error) Say not False negative Correct present (type 2 error) non-diagnosis DIAGNOSIS Error is inherent in putting someone in a category, or stating they are not in a category. Inverse relationship between Type 1 and Type 2 error…  To decrease 1, the other must increase Example: Consider your job as an expert witness on violent offenders or suicide (type 1 better?) vs. you job assessing learning disability or a stigmatized disorder (type 2 better?) UTILITY OF CATEGORICAL SYSTEMS Caution: Categories most likely DO NOT EXIST in reality. (think about it…) UTILITY OF CATEGORICAL SYSTEMS So why categorize? 1. Format for organizing observations 2. To help professionals communicate, study, and plan. 3. Specific problems may indicate specific treatments ….Categories, like any good hypothetical construct, should be modified.  CREATION OF DSM-5 Steps: Creation of Task Force Work groups Each focused on a specific area of mental disorders Scientific Review Committee Oversee scientific evidence to support/reject changes proposed by work groups Field trials Ask practicing clinicians to try the new criteria Website dsm5.org To communicate progress to public Receive feedback from public, over 13,000 comments + 12,000 e-mails & letters  CHANGES CONSIDERED BUT NOT MADE Emphasis on neuropsychology Shift from description to biological evidence Dimensional definition of mental disorders View disorders along a continuum: “depression 1 to 10” Most support for dimensional approach for personality disorders Removing 5 of the 10 personality disorders Paranoid, schizoid, histrionic, dependent, narcissistic Disorders in Conditions for Further Study Attenuated psychosis syndrome, Internet gaming disorder, Non-suicidal self-injury disorder Proposed as new disorders, but rejected (for now) CHANGES WITH DSM-5 Title change Roman to Arabic numeral Allows to naming of minor changes: 5.1, etc Reflects the evolving nature of the DSM Dropped the multiaxial assessment system May introduce a new way of thinking about former Axis II disorders: always enduring? New disorders: Premenstrual dysphoric disorder Disruptive mood dysregulation disorder Binge eating disorder Mild neurocognitive disorder (mild NCD) Somatic symptom disorder (SSD) Hoarding disorder Prolonged grief disorder (DSM-5-TR)  REVISIONS IN DSM-5 Bereavement exclusion for diagnosis of depression dropped Asperger’s syndrome absorbed in Autism spectrum disorder Attention-deficit/hyperactivity disorder Age move from 7 to 12 years old Bulimia nervosa 2 to 1 binge per week Anorexia nervosa Amenorrhea & 85% of expected weight Substance use disorder Tolerance & withdrawal no longer just for Substance dependence vs Substance abuse “Mental retardation” renamed “intellectual disability” or “intellectual development disorder” Learning disabilities in math, reading, and writing combined as specific learning disorder Obsessive Compulsion Disorder removed from Anxiety Disorders to new category Obsessive-Compulsive & Related Disorders: trichotillomania, Body Dysmorphic Disorder Mood Disorders split into two: Depressive Disorder & Bipolar Related Disorder VALIDITY OF DSM-5 For example: OCD now a category of its own instead of part of anxiety disorders Anxiety disorders feature: Fear: emotional response to real or perceived imminent threat Anxiety: anticipation of future threat Obsessive Compulsion feature: Obsessions: recurrent and persistent thoughts experienced as unwanted & intrusive Compulsions: repetitive mental or behavioural acts in response to the obsession according to rigid rules Are anxiety and OCD that separate? Some OCDs involve intense fear Some do not, just strong urges, such as trichotillomania  VALIDITY OF DSM-5, FOR EXAMPLE… Eating disorders People “travel” from one diagnostic category to the other Often starts with AN, or highly restrictive eating combined with excessive compensatory behaviours such as fasting & excessive exercise As restricting becomes more difficult, people move on to binging & additional compensatory behaviours: vomiting, laxative use, etc. Now diagnosed with: BN if not significantly underweight AN if significantly underweight AN and BN can look exactly the same behaviourally except AN specifies underweight Are AN and BN different disorders? The same disorder with a typical course? Eating disorders now part of “Eating & Feeding Disorders” Some have Body Image preoccupation as a core diagnostic criterion Some have “0” BI preoccupation: ARFID Completely different subjective experience CRITICAL EVALUATION OF DSM Recent editions of DSM widely used by all mental health professions Strengths Emphasis on empirical research Use of explicit diagnostic criteria Interclinician reliability Atheoretical language Facilitates communication between researchers and clinicians DSM: VALIDITY VS RELIABILITY The DSM has tremendously improved reliability Common language among clinicians and researchers But is this language valid? Does the language designate a true entity? Are AN, BN, and BED feeding disorders? Does a BI preoccupation distinguish the disorders in which it is present from those in which it is absent? CRITICISMS OF THE DSM Breadth of coverage Some disorders with physical factors are considered mental disorders: sleep disorder, somatic symptom disorder with predominant pain (pain disorder) IBS used to be considered “somatization” Breast tenderness part of criteria for Premenstrual Dysphoric Disorder (PMDD) Common problems of living, such as grieving, now pathologized as depression Controversial cutoffs Many cutoffs seem arbitrary 5 symptoms for MDD: what if you have only one but it’s ruining your life? Cultural issues The empirical data on which criteria are developed for disorders mainly comes from research on white people  ALTERNATIVE DIRECTIONS IN DIAGNOSIS AND CLASSIFICATION Categorical Approach Dimensional Approach New approach Current approach of DSM Place clients’ symptoms on a continuum rather An individual falls in the “yes” or than into discrete diagnostic categories “no” category for having a Assumes that all of us share the same particular disorder fundamental characteristics, but we differ in how much of these characteristics we possess “Black and white” approach—no “shades of gray” More difficult to efficiently communicate, but more thorough description of clients? May correspond well with human Five-factor model of personality could provide the tendency to think categorically dimensions Facilitates communication May be better suited for some disorders (e.g., personality disorders) ALTERNATIVE DIRECTIONS IN DIAGNOSIS AND CLASSIFICATION Five-factor model of personality is a leading contender We all are on a continuum for these characteristics: Neuroticism Extraversion Openness to experience Agreeableness Conscientiousness