Learning outcomes:

1. Learning outcomes: • Consider problems with definingabnormal behaviour • to be able to describe and evaluate the reliability of the diagnosis of mental disorders • To be able to describe and evaluate the validity of the diagnosis of mental disorders • Describe the Rosenhan study in relation to the above issues

2. How do we diagnose? Using the DSM- IV • The Diagnostic and Statistical Manual of Mental Disorder (Edition 5), was last published in 2013. • The DSM is produced by the American Psychiatric Association. • It is the most widely used diagnostic tool in psychiatric institutions around the world

3. ICD - 10 • There is also the International Statistical Classification of Diseases (known as ICD). • It is produced by the World Health Organisation (WHO) and is currently in it’s 10th edition.

4. Reliability and the diagnosis of mental disorders The DSM’s reliability rests on the question of whether one person’s set of symptoms would lead to a common diagnosis by different physicians If different doctors give different diagnosis for the same set of symptoms (e.g. for the same person), then the diagnosis are not reliable and the treatment may not work

5. Identification Prognosis Investigate causes Treatment

6. We are now on DSM V but the exam will allow you to discuss / use / refer to DSM IV – see Blog

7. 4 types of assessment • Observation • Interview • Psych tests • Physio tests

8. This handout will be on the Blog

9. Problems with defining abnormal behaviour Ultimately we view MH as a medical issue…. • What problems do you think we might come across when trying to define abnormal behaviour? • Labelling: still a slight stigma attached to being labelled as mental ill. Do we think everyone in society understands? Is argued that it is easier to get a job after coming out of jail than out of a psychiatric hospital with a label of “mad”” • Cultural differences: hearing voices in the west is seen as abnormal but in certain tribes, it is seen as a valuable and desirable as it is a link to the spirit world • Is it a moral decision rather than medical? Behaviours seen as morally unacceptable and therefore deemed “abnormal” – could be argued this is based on largely middle class, white educated section of society…e.g. homosexuality

10. Signs and symptoms: medical = signs such as cough, pain etc can be explored and symptoms such as high temp, blood pressure can be found. Signs confirm diagnosis. Mental health only usually symptoms and no signs • How can your mind me ill?!! Is there such a thing as mental illness? Or is it organic (physical only) • Where does the responsibility lie? If someone is mentally ill, are they therefore not responsible for their actions? E.g., people pled insanity to crimes so a lenient sentence is given. • What about murderers? Serial killers? Are they mentally ill? Should we label them ill as we find their behaviour difficult to comprehend? • However! Medical model does allow for treatment • Thomas Szasz: Interesting viewpoint…. No such thing as mental illness. Psychiatric hospitals act as “agents of social control” – on the surface try to help but unofficially trying to destroy them – One flew over the Cuckoos Nest

11. D L Rosenhan (1973) On being sane in insane places!

12. The Question……. If sanity and insanity exist How shall we recognise them?

13. Specifically……. 1. Do the characteristics of abnormality reside in the patients or 2. In the environments in which they are observed? Does madness lie in the eye of the observer?

14. Some definitions of abnormality Abnormality IS • Behaviour which deviates from the norm • most people don’t behave that way • Behaviour which does not conform to social demands • most people don’t like that behaviour • Failure to Function Adequately • Deviation from Ideal Mental Health • Behaviour which is maladaptive or painful to the individual • its not normal to harm yourself • Statistical Infrequency

15. What was Rosenhan’s interest? How reliable are diagnoses of abnormality? The astonishing study………..On being sane in insane places…...D L Rosenhan (1973) What did he do? Who were involved?

16. The brave volunteers……the pseudo patients • EIGHT sane people! • one graduate student • three psychologists • a paediatrician • a painter • Housewife • Psychiatrist

17. What did they DO?The procedure…………………….. • telephoned 12 psychiatric hospitals for urgent appointment (in five USA states) • arrived at admissions • gave false name and address • gave other ‘life’ details correctly

18. What else did they do? • complained of hearing unclear voices … saying “empty, hollow, thud” • Said the voice was unfamiliar, but was same sex as themselves • Simulated ‘existential crisis’ • “Who am I, what’s it all for?”

19. What happened? ……….. • Allwere admitted to hospital • All but one were diagnosed as suffering from schizophrenia • Once admitted the ‘pseudo-patients’ stopped simulating ANY symptoms • Took part in ward activities

20. What happened on the wards? • The pseudo-patients were never detected • All pseudo-patients wished to be discharged immediately • BUT - they waited until they were diagnosed as ‘fit to be discharged’

21. How did the ward staff see them? • Normal behaviour was misinterpreted • Writing notes was described as - • “The patient engaged in writing behaviour” • Arriving early for lunch described as • “oral acquisitive syndrome” • Behaviour distorted to ‘fit in’ with theory

22. The pseudo-patient’s observations… If they approached staff with simple request (NURSES & ATTENDANTS) • 88% ignored them ~ (walked away with head averted) • 10% made eye contact • 2% stopped for a chat (Total of 1283 attempts) • (PSYCHIATRISTS) • 71% ignored them ~ (walked away with head averted) • 23% made eye contact • 2% stopped for a chat • (Total of 185 attempts)

23. How long did they stay in hospital? • The shortest stay was 7 days • The longest stay was 52 days • The average stay was 19 days • They had agreed to stay until they convinced the staff they were sane!!

24. Were they treated in the same way as normal patients... • Given total of 2100 medication tablets • they flushed them down the loos Noted that other patients did the same and that this was ignored as long as patients behaved themselves!!

25. What sorts of records did they keep …….? • Nurses stayed in ward offices 90% of time • Each ‘real patient’ spent less than 7 minutes per day with psychiatric staff

26. Perhaps they behaved ‘abnormally’ • Pseudo-patient’s visitors detected “No serious behavioural consequences” DID ANYONE SUSPECT? 35 out of 118 real patients voiced their suspicions

27. On release ………………... The pseudo-patients were diagnosed as Schizophrenia “IN REMISSION”

28. RosenhanThe follow up study…………….. A teaching & research hospital were told of the first study and warned that … Over the next three months ONE OR MORE pseudo-patient would attempt to be admitted

29. What happened……….? Staff members rated ‘new patients’ on scale 1 - 10 as ‘how likely to be a fraud’ • 193 patients ‘assessed’ • 41 rated as a pseudo-patient (by staff) • 23 rated as pseudo-patient (by psychiatrist) • 19 rated as pseudo-patient (by both)

30. How many of these SUSPECTS were pseudo-patients?……... NONE No pseudo-patients were sent Staff were rating their regular intake

31. What did Rosenhan conclude? Remember .. His question was … Do the characteristics of abnormality reside in the patients? or In the environments in which they are observed? Does madness lie in the eye of the observer

32. Rosenhan’s conclusion….. “It is clear that we are unable to distinguish the sane from the insane in psychiatric hospitals” In the first study - We are unable to detect ‘sanity’ In the follow up study - We are unableto detect ‘insanity’

33. Rosenhan’s study highlighted ... • The depersonalisation and powerlessness of patients in psychiatric hospitals • That behaviour is interpreted according to expectations of staff and that these expectations are created by the labels SANITY & INSANITY The pseudo-patients described their stay in the hospitals as a negative experience This is not to say that REAL patients have similar experiences Real patients do not know the diagnosis is false & are NOTpretending (Remember Zimbardo)

34. Questions YOU should be able to answer... Methodology of Rosenhan…. • This was a participant observation, why? • Who were the OTHER participants? • Was this study ethical? If not why not? • Why might the reports of the pseudo-patients have been unreliable?

35. * The DSM and diagnosis underpin the evaluation of explanations and therapies that we are going to look at. So, you will not be asked questions on the DSM specifically but it is expected that you refer to todays lesson when evaluating the disorders (OCD, Phobias and Depression) Overview of DSM Thought shower in your groups, strengths and weaknesses of the DSM

36. Evaluation of the DSM Strengths 1. Allows for common diagnosis (although many revisions) because it has stood the test of time When 2 or more doctors use the DSM, they should come close to the same diagnosis. 2. Evidence suggests that it is reliable ~Goldstein looked at the reliability between DSM-II and DSM-III is (1988) She found there was evidence of reliability within the DSM-III (but less so between DSM-II and DSM-III)

37. Evaluation of the DSM Weaknesses • The DSM is seen as a confirmation of the medical state of mental disorder, as suffers are ‘patients’ and ‘treatment’ is suggested. Mental health issues are ‘disorders’ and ‘illnesses’ so ‘cures’ are looked for. However, it might be said that some mental disorders are simply ways of living …. who is to say whether it is ‘illness’ or not. (e.g. schizophrenics may be trying to get back to their normal self)

38. ‘One Flew Over The Cuckoo’s Nest’ is the story of a criminal, Randle. P. McMurphy, who transfers himself into a psychiatric hospital from a hard labour camp in order to get what he thinks will be an easy ride. He rebels against the Nurse overlooking the hospital who has taken away any confidence the inmates had by being loud, destructive and by attempting to ruin any routine she has built. As time goes on the inmates all grow fond of him while the staff do just the opposite. However, the only way he can get out is for the Nurse to decide he is ready to go, but by now they think he may well be crazy.

39. HOMEWORK I want to ensure that we are revising… so please can you revise for a short test Lesson 3 of next week on the approaches and Biopsychology Watch the Broadmoor documentary. Think about what it means to be sane / insane. https://www.youtube.com/watch?v=X1QQD7MVehY