How we diagnose and classify mental illness

• What is the DSM?

  • Most commonly used classification and diagnostic system although the World Health Organisation has also published the ICD​
  • First published 1952 (DSM I); five revisions now DSM IV TR, (2000), DSM V (2013)​
  • Groups symptoms together into syndromes which relate to specific mental health conditions​
  • Published by the American Psychological Association (APA)​
  • Criteria to help psychiatrists around the world to make diagnoses; contains roughly 400 disorders ​
  • DSM evolved from a classification system developed by US army based on simple categories neuroses and psychoses.
• DSM – IV-TR & DSM-V

  • DSM stand for the Diagnostic and statistical manual of mental disorders​
  • DSM-IV-TR is the 4th edition which has had a text review​
  • DSM-V is the 5th edition published in 2013​
  • The DSM is published by the APA (American psychiatric association).​
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  • There is also the ICD which is currently on it’s 10th edition.​
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  • The DSM was developed for a census of mental health disorders and was based around something created by the US army to diagnose mental disorders.
• DSM-IV-TR – a multi-axial system

  • The DSM is a ‘multi axial’ system; In DSM III, multi-axial classification was introduced; the individual is rated on 5 axes or dimensions to help with the process of diagnosis​
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  • Axis I Disorders, clinical and mental eg schizophrenia​
  • Axis II Personality (underlying) including mental retardation​
  • Axis III Medical and Physical conditions​
  • Axis IV Environmental factors​
  • Axis V Global functioning
• Development of the DSM over time

  • The understanding of mental illness has developed over time. A good example of this is homosexuality.​
  • Has evolved in response to research (such as ‘the Kinsey report’) and changing social norms, e.g. in DSM II the 1974 revision, homosexuality was removed as a form of mental disorder and replaced with ‘sexual orientation disturbance.’ DSM III ‘ego-dystonic homosexuality’ and has since been removed.​
  • DSM-IV-TR has a category ‘ sexual disorder not otherwise specified’ but this is to do with ‘persistent and marked distress about ones sexual orientation’.
• DSM-V

  • Wants to harmonise with the ICD system.​
  • No longer uses the old axis system.​
  • Lists all disorders in section II. Axis IV has become psychosocial issues and the context of presenting an issue.​
  • Axis V, the global assessment of functioning has been dropped. ​
  • There are 3 sections​
  • Use page 12 to outline the DSM-V
• What does the DSM suggest about individuals once diagnosed?

  It suggests that the individual has an illness and a cure or treatment is looked for.
• How did RD Laing view conditions like schizophrenia?

  He suggested that conditions like schizophrenia are just another way of living.
• What was argued about the development of DSM-V?

  It was suggested to be guarded, meaning it was not transparent and therefore not credible.
• Who was allowed to comment on DSM-V?

  Members of the public were allowed to comment on DSM-V.
• What are some criticisms of the DSM regarding disorders?

  Criticisms include no links of disorders to biological underpinnings and the use of stigmatizing names for disorders.
• What is an example of a stigmatizing disorder name mentioned in the study material?

  Borderline personality disorder.
• What concerns does the BPS express regarding social norms in diagnosis?

  The BPS expresses concerns that the use of social norms can vary between clinicians and become biased.
• Goldstein (1988)

  • she re-diagnosed 199 patients using DSMIII, originally diagnosed using DSM–II; some differences....... But 85% consistent = Test-retest reliability ​
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  • she asked two other experts to re-diagnose a random sample of 8 of the patients using the case histories with all indication of previous diagnoses removed – she found a high level of agreement/consistency of diagnosis = Inter rater reliability
• How do deviance and dysfunction relate to culture and social norms?

  Deviance and dysfunction are linked to culture and social norms, which can vary widely.
• How can the DSM be viewed in terms of labeling individuals?

  It can be considered a way of labeling people whose behavior is seen as “different.”
• What argument is made regarding psychiatrists and mental illnesses in the US?

  Some argue that by inventing mental illnesses, psychiatrists can make more money.
• Brown (2001)

  • Diagnosis of 362 out patients in Boston (USA) with anxiety and mood disorders.​
  • Independent interviews using DSM-IV.​
  • Excellent reliability with inter-rater reliability.​
  • Only issue was inconsistency in understanding of how severe and often symptoms must be for it to be a serious issue.
• What is the likelihood that if someone is diagnosed with schizophrenia by one clinician, another clinician would reach the same diagnosis according to Cooper (2014)?

  60%
• What does a 60% chance of agreement between clinicians in diagnosing schizophrenia indicate about the reliability of the diagnosis?

  It indicates that the reliability is not very good.
• What was the reliability score of DSM-III?

  0.81
• What was the reliability score of the trial of DSM-V?

  0.46
• How does the reliability of earlier DSMs compare to that of the current DSM according to Cooper (2014)?

  The reliability of earlier DSMs was higher than that of the current DSM.
• Which disorders have high reliability according to the study material?

  ADHD and PTSD
• Which disorder is mentioned as having low reliability?

  Major depressive disorders
• What is a notable feature of the current DSM compared to previous models?

  The current DSM has more specific descriptions for the diagnosis of disorders.
• Why might the old research into the old DSMs be considered less reliable and inaccurate?

  Because new research into reliability is more scientific than old research.
• According to Cooper (2014), why is the low percentage of agreement between clinicians not considered very important?

  Because the diagnosis is used to look for the most effective treatment tailored to the individual.
• What is construct validity in the context of mental disorders?

  It refers to the need for mental disorders to be measurable through listed symptoms and behaviors.
• Why is it important to operationalize a mental disorder?

  Operationalizing a disorder helps in measuring symptoms and behaviors for diagnosis.
• What is a potential drawback of operationalizing a mental disorder?

  It can lead to a loss of understanding of the sufferer's experiences, making the diagnosis less valid.
• What does a lack of construct validity indicate?


  It indicates that the lists and criteria do not accurately represent the disorder or illness.
• What did the previous version of the DSM consider when diagnosing a person?


  It took into consideration a person's personal and social functioning in relation to their disorder.
• Why might personal and social functioning issues not be connected to a person's illness?

  Because factors like being anti-social may arise from circumstances such as financial difficulties rather than the illness itself.
• concurrent validity- When 2 studies or diagnosis taken at the same time give the same diagnosis
• Predictive validity

  • Same as concurrent validity, except the diagnosis take place at different points.​
  • The DSM could be used to diagnose, then later a doctors view or information from families could support this diagnosis.​
  • If the diagnosis are consistent the model is said to have predictive validity
• Kim-Cohen et al (2005)

  • Longitudinal study looking at conduct disorder in over two thousand 5 year olds​
  • Children’s mothers were interviewed and the teachers were asked to complete postal questionnaires about conduct disorder symptoms (from DSM IV) observed in last 6 months​
  • The children who received the diagnosis were also more likely to display behavioural and educational difficulties at age 7 = Predictive validity
• Lee (2006) Aimed to reveal whether the DSM criteria for diagnosing ADHD would be useful for Korean children​

  • Assessed 18 ADHD criteria in DSM IV​
  • Questionnaire given to 48 primary school teachers. ​
  • 1663 children were rated – large sample​
  • There was a match between the features of ADHD outlined in the DSM and the responses to the questionnaires, an ADHD test and teacher assessments ​
  • …but the match was not as good for girls as it was for boys .... Maybe a validity problem
• Stinchfield (2003)

  • Diagnosis of pathological gambling (severe enough habit to inhibit and interfere with daily functioning)​
  • 803 men and women from general population of Minnesota and 259 men and women on gambling treatment programme​
  • Questionnaire using 19 items from DSM IV criteria for pathological gambling​
  • Questionnaire results were able to help researches to correctly sort the gamblers from the non-gamblers.- so the DSM is doing what it should .... It’s VALID and RELIABLE!
• Evaluation of validity issues STRENGTHS​

  • The DSM has been shown to be valid across a variety of studies covering a range of different conditions​
  • Because it is reliable it is likely to be valid too​
  • Much work has been done to increase its validity as it has been rewritten
• Rosenhan (1973)​use for reliability and validity

  • Because the diagnosis was the same across all 12 of the hospitals presumably using the current DSM at the time, we could say this shows the DSM to be reliable​
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  • Because the diagnosis of healthy people was schizophrenia, if they were using the DSM this means it lacks any validity