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CLASSIFICATION AND DIAGNOSIS CHRISTMAS CAROLS Do you hear what I hear? (schizophrenia)

CLASSIFICATION AND DIAGNOSIS CHRISTMAS CAROLS Do you hear what I hear? (schizophrenia) Hark! The herald angels sing about me! (narcissism) Jingle bells, jingle bells, jingle bells, jingle bells, jingle bells, jingle bells, jingle bells, jingle bells (obsessive-compulsive disorder)

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CLASSIFICATION AND DIAGNOSIS CHRISTMAS CAROLS Do you hear what I hear? (schizophrenia)

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  1. CLASSIFICATION AND DIAGNOSIS CHRISTMAS CAROLS • Do you hear what I hear? (schizophrenia) • Hark! The herald angels sing about me! (narcissism) • Jingle bells, jingle bells, jingle bells, jingle bells, jingle bells, jingle bells, jingle bells, jingle bells (obsessive-compulsive disorder) • Deck the halls and walls and house and street and stores and . . . (mania) • Santa Claus is coming to get me (paranoia)

  2. CLASSIFICATION AND DIAGNOSIS • LECTURE OUTLINE • Background on classification • DSM-IV • Reliability and validity • Problems and objections to classification • Epidemiological findings re: the different disorders

  3. CLASSIFICATION AND DIAGNOSIS • Background – Some key terms • Classification • Diagnosis and diagnostic system • Assessment • Sign vs. symptom • Comorbidity

  4. CLASSIFICATION AND DIAGNOSIS • Background – Functions of a good classification system • Organization of clinical information • Prognosis/prediction • Treatment possibilities/recommendations • Heuristic • Guidelines for financial support

  5. CLASSIFICATION AND DIAGNOSIS • Background – History • Greeks – melancholia, senility, alcoholism • Kraeplin (1896) – first psychiatric classification system • DSM I (1952) & DSM II (1968) – very brief manuals, guided by psychoanalysis, gross categories (e.g., neurosis, psychosis), lack of reliability, no research base

  6. CLASSIFICATION AND DIAGNOSIS • Background – History • DSM III (1980), DSM IV (1994), DSM IV TR (2000) – field trials to improve reliability, better research base, multiaxial classification

  7. CLASSIFICATION AND DIAGNOSIS • Background – The perfect system would: • classify disorder by presenting signs and symptoms, etiology or history, prognosis, response to treatment • identify different symptom clusters that accurately signal different disorders with no overlap between symptoms or signs between disorders • identity precise effective treatments

  8. CLASSIFICATION AND DIAGNOSIS – DSM IV

  9. CLASSIFICATION AND DIAGNOSIS – DSM IV

  10. CLASSIFICATION AND DIAGNOSIS • Reliability and validity • reliability – consistency or repeatability of diagnoses • inter-rater reliability – extent to which 2 clinicians agree on the diagnosis of a client • study by Beck et al. (1962) – reliability for DSM I categories ranged from 38% to 63%

  11. CLASSIFICATION AND DIAGNOSIS • Reliability and validity • study by Ward et al. (1962) of the same data – found that most of the error in diagnosis had to do with inconsistencies on part of clinicians (33%) or inadequacies of the diagnostic categories (63%), little error attributed to inconsistencies in info presented by clients

  12. CLASSIFICATION AND DIAGNOSIS • Reliability and validity • Spitzer & Fleiss (1974) – review of the literature of reliability of DSM II – only 3 categories (mental retardation, alcoholism, organic brain syndrome) had adequate reliability

  13. CLASSIFICATION AND DIAGNOSIS • Reliability and validity • Research undertaken to improve reliability of subsequent DSM versions • Main finding is that reliabilities for broad categories of Axis I is adequate, but poor for sub-categories

  14. CLASSIFICATION AND DIAGNOSIS • Reliability and validity • Validity – reliability is a prerequisite for validity • Concurrent validity – extent to which diagnostic category is related to non-symptom attributes (e.g., delusions should be related to poor occupational functioning)

  15. CLASSIFICATION AND DIAGNOSIS • Reliability and validity • Predictive validity – extent to which diagnostic category can predict future functioning (e.g., does conduct disorder in childhood predict antisocial behavior in adult life)

  16. CLASSIFICATION AND DIAGNOSIS • Problems of DSM • Discrete categories vs. continuum – where to do draw the line • Gender bias – Phyllis Chesler (1972) – women are diagnosed for overconforming to and underconforming to sex role stereotypes

  17. CLASSIFICATION AND DIAGNOSIS • Problems of DSM • Gender bias – Broverman (1970) – study of therapists’ criteria for healthiness in women and men – healthy woman or unhealthy person, unhealthy woman or healthy woman • Gender bias – Paula Caplan (1991) – SDPD and LLPDD

  18. CLASSIFICATION AND DIAGNOSIS • Problems of DSM • Cultural bias – DSM constructed predominantly by white, US men • Heterosexist bias – “homosexuality” was considered a DSM disorder until 1974; it was de-listed by a referendum of psychiatrists!

  19. CLASSIFICATION AND DIAGNOSIS • Broader objections to classification • Adherence to medical model – do psychologists want to buy into that? • Labeling • Stigma and discrimination • Abuse and iatrogenic illness

  20. CLASSIFICATION AND DIAGNOSIS • Epidemiological findings • incidence • prevalence • Midtown Manhattan study (Srole et al., 1962) – in 1954 study, 23% of adults (20-59) had marked or severe mental illness • 1974 follow-up of original sample, now aged 40-79, 18% marked or severe

  21. CLASSIFICATION AND DIAGNOSIS • Epidemiological findings • Stirling County Nova Scotia study (Leighton et al., 1963) – 37% of sample of 273 people judged to have symptoms indicating mental disorder • NIMH study in 3 US cities in early 1980s – 6-month prevalence rates of 12-13%

  22. CLASSIFICATION AND DIAGNOSIS • Epidemiological findings – Ontario Health Supplement study (1990s) • 1-year prevalence rate for any disorder - 30% • lifetime prevalence rate – 48% • most common disorders – substance abuse, anxiety, mood disorders

  23. CLASSIFICATION AND DIAGNOSIS • Epidemiological findings – Ontario Health Supplement study (1990s) • substance abuse more common among men; anxiety, mood disorders more common among women • of those judged as having a disorder – 75% percent reported that they had NOT sought help for their problems – Why?

  24. CLASSIFICATION AND DIAGNOSIS • Epidemiological findings – Ontario Health Supplement study (1990s) • 81% don’t believe they have a problem • 57% embarrassed to ask for help • 42% uncomfortable asking for help

  25. CLASSIFICATION AND DIAGNOSIS • Epidemiological findings – Ontario Health Supplement study (1990s) • 42% of those who did seek help were judged not to have a mental health problem! • What does this say about the way mental health services are organized?

  26. SUMMARY OF CLASSIFICATION AND DIAGNOSIS • DSM-IV is current diagnostic system; uses multi-axial classification and has improved reliability over previous versions • a number of problems and objections to use of diagnostic systems remain • epidemiological studies of disorders show that these problems are widespread; a major public health problem

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