Diagnosis

1. Diagnosis Diagnosis, Explanation and the Psychotherapy Relationship

2. Gallup Poll (2005) How many Americans believe … • ESP 41 • That houses can be haunted 37 • Ghosts 32 • Mental Telepathy 31 • Clairvoyance (predict the future) 26 • Astrology 25 • Witches 21

3. How to define abnormality? • Maladaptiveness: The 3 D’s • Dysfunction • Distress • Deviance • All mediated by culture, gender, etc. • (Nolen-Hoeksema text) • 7 Dimensions to Consider: • Maladaptiveness • Suffering • Irrationality • Unpredictability and loss of control • Rareness or Unconventionality • Observer discomfort • Violation of standards • (Seligman text)

4. “A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.. …Socially deviant behavior…and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.” • Criterion for clinical significance -- The disorder must cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning.” DSM - 5

5. Diagnosis Diagnosis, Explanation and the Psychotherapy Relationship

6. Goals of Diagnosis • Guide understanding • Course, prognosis, comorbidity • Etiology • Attend to meanings of ‘illness’ • Build relationship • Guide treatment • Evidence informed • Increase research-based knowledge

7. ImportantTerms: Nosology: a classification and naming system for medical and psychological phenomena. A basic goal of a nosology is to identify clusters of symptoms that reliably co-occur and facilitate the identification of patients whose problems are homogeneous in terms of etiology and treatment. A valid syndrome (cluster of symptoms) will explain why certain symptoms co-occur in different patterns and why certain treatments work, while others do not. Etiology: the cause or source of a disorder

8. Pre-DSMIII DSM III, IV, and V • Theory-driven • Focused on etiology • Problems with inter-rater reliability • No empirical basis for categories, poor validity • Symptom based • Descriptive • Improved reliability (over time) • Goal of developing improved validity • No etiological foundation ‘Field Guide’

9. Dangers of Descriptive Diagnosis(Pennington, 2002) • What counts as a symptom or problem? • Need to know what is normal • Need population vs. clinic samples • Developmental differences important • May be continuous rather than categorical difference • Where do you draw the line? • Polythetic vs. monothetic diagnoses • Few features necessary, none sufficient • Individuals with same diagnosis can look totally different with non-overlapping symptoms • Need cultural validity • Danger of “Nominal fallacy” • Diagnostic label may interfere with knowledge building and understanding at individual and societal level • Stigma

10. Rosenhan’s Question:

11. Where do we go from here?

12. Pre-DSMIII DSM III, IV, and V • Theory-driven • Focused on etiology • Problems with inter-rater reliability • No empirical basis for categories, poor validity • Symptom based • Descriptive • Improved reliability (over time) • Goal of developing improved validity • No etiological foundation ‘Field Guide’ (Post DSM?): RDoC (Research Domain Criteria Project, 2013)

13. RDoC: Addressing 3 key problems RDoC: 3 Assumptions • Descriptive (consensus based) diagnoses not matching emerging neuroscientific findings • DSM categories not helping sufficiently in prediction of prognosis, course, or treatment response • Diagnoses don’t inform us about pathophysiology • Psychological disorders are brain disorders • They will be diagnosable using tools of neuroscience (functional MRI, genetic analyses, electrophysiology, etc. • This approach will improve clinical care “RDoC are intended to ultimately provide a classification based on empirical data from genetics and neuroscience.”Insel, 2010

14. “Risk factors will be found at different levels of analysis for different developmental psychopathologies: the molecular level for some and the attachment system for others. But all risk factors act on the same complex developmental system that cannot be eliminated from an explanation. Pennington, (2002) The Development of Psychopathology

15. “Literally, every time we think, feel, or do something, the brain and the rest of the body are hard at work. Perhaps not as obvious, however, is that our thoughts, feelings, and actions inevitablyinfluence the function and even the structure of the brain, sometimes permanently. In other words, our behavior, both normal and abnormal is the product of a continual interaction of psychological, biological, and social influences….[T]he only currently valid model of psychopathology is multidimensional and integrative.” Barlow and Durand, 2013

16. Integrating levels of analysis: Ex: Schwartz, Stoessel, Baxter, Martin, & Phelps (1996)

17. Unidirectional causation Etiology Brain Neuro-psychology Behavior Bidirectional causation Etiology Brain Neuro-psychology Behavior Pennington, 2002

18. “Disease is …what the practitioner creates in the recasting of illness in terms of theories of disorder….Disease is the problem from the practitioner’s perspective.. …In the practitioner’s act of recasting illness as disease something essential to the experience of chronic illness is lost; it is not legitimated as a subject for clinical concern, nor does it receive intervention.” Kleinman, “The Meanings of Illness”