Discuss a culture-specific syndrome/culture-bound syndrome. After you have selected the culture, you would like to explore further.
Please include (if applicable):
Name of your selected culture.
Name of the culture-specific syndrome
what symptoms to look for
duration of symptoms and syndrome
https://www.mayoclinic.org/diseases-conditions/mental-illness/symptoms-causes/syc-20374968
Chapter3.pdf
Chapter41.pdf
Classification.pptx
ChangesinDSM.pdf
Chapter 4: Classification, Diagnosis, and Assessment
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Abnormal Psychology, 5th Edition
Charles A. Lyons & Barclay Martin ©2014
1
Learning Objectives
What are the problems in classifying behavior disorders?
Is a categorical approach the best one for diagnosing mental disorders?
How well can different clinicians independently arrive at the same diagnosis?
What are some common diagnostic procedures and tests?
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Classification
Part of a process that leads to a fundamental understanding of basic principles, rather than just a labeling process
The classification system for abnormal behavior has been based in large part in the manner of the classification for physical disease.
A major aim of in the development of a classificatory system is to discover to what extent there are distinctive patterns of abnormal behaviors with their own causative histories.
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Development of a System of Classification for Abnormal Behavior
The American Psychiatric Association (APA) set up a model called the Diagnostic and Statistical Manual of Mental Disorders (DSM-I), first published in 1952.
The manual was revised in 1968 into the DSM-II. In the process, the number of mental disorders listed was increased by 50%.
Both the DSM-I and the DSM-II diagnoses were strongly influenced by Freudian theories.
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A Critical Challenge to the DSM-II: Validity and Reliability of Diagnoses
There were concerns about the accuracy and consistency with which the DSM-II labels could be given.
Agreement among clinicians on the use of a label often was no better than chance.
Unlike medical diagnoses, psychiatric labels were maintained by consensus alone.
For example, homosexuality was listed as a mental disorder under the DSM-II, but it was subsequently removed from the list of disorders as a result of a vote by members of the APA.
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David Rosenhan’s 1973 Studies
David Rosenhan and seven colleagues made appointments at mental hospitals.
Each said they heard voices saying “empty,” “hollow,” or “thud”; other than this and lying about their occupations, they answered all other questions honestly and behaved as usual.
All were admitted, with seven of eight labeled with a diagnosis of schizophrenia.
Once admitted, they never reported hearing the voice again and behaved “normally.”
Length of hospital stay ranged from 7 to 52 days.
Several patients recognized the eight as being sane, but not one of the hospital staff or doctors did.
All seven individuals diagnosed with schizophrenia were released under the label of “schizophrenia, in remission.”
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A Critical Challenge to the DSM-II: David Rosenhan’s 1973 Studies
An area teaching hospital felt their staff would have recognized the “pseudopatients.”
Rosenhan said that over the next three months, he would have several pseudopatients show up at that particular hospital.
Over this time span, 19 individuals were identified as pseudopatients by both staff and psychiatrists at the hospital.
In reality, Rosenhan sent no pseudopatients.
Rosenhan’s conclusion was that “sane” could not be differentiated from “insane” under the prevailing diagnostic model.
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The DSM-III: A Major Overhaul
The DSM-III, published in 1980, represented a marked improvement from the two earlier systems.
Criteria became more objective and behavioral
The largest structural change involved the introduction of five separate dimensions (or axes) on which individuals could be evaluated, in order to give a more complete clinical picture of a person – referred to as multi-axial diagnosis.
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The DSM Multi-Axial Diagnostic Framework (Slide 1 of 3)
Axis I: Clinical disorders and/or other conditions that may be a focus of clinical attention
Axis II: Personality disorders and mental retardation
Axis III: General medical conditions potentially relevant to Axis I and II listings
Axis IV: Psychosocial and environmental problems
Axis V: Global assessment of functioning
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The DSM Multi-Axial Diagnostic Framework (Slide 2 of 3)
Each axis of the DSM system was intended to capture a different component or “layer” of the total picture of disturbance.
Axes I and II represented the basic classificatory system of mental disorders.
Axis I disorders were more florid, and generally had points of onset and offset.
Axis II disorders were characteristic of the long-standing functioning of the person.
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The DSM Multi-Axial Diagnostic Framework (Slide 3 of 3)
This multi-axial approach continued through the next three revisions of the DSM.
The DSM-III-R (revised) was released in 1987.
The DSM-IV was released in 1994.
The DSM-IV-TR (text revision) was released in 2000.
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Current Classification System: The DSM-5 (Slide 1 of 2)
Much was altered with the DSM-5 (2013).
The multi-axial structure was eliminated by compressing disorders formerly distinguished as Axis I, II, or III into a single list
The notion of a spectrum of disorders is now applied to some categories that had similar “relatives.”
Autistic disorder and Asperger’s disorder (DSM-IV-TR) are autism spectrum disorders in the DSM-5.
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Current Classification System: The DSM-5 (Slide 2 of 2)
The DSM-5 remains a categorical diagnostic system.
However, it includes specific dimensional assessments to quantify degree of symptom severity or to measure personality traits.
A Level 1 assessment involves a brief survey of 12 or 13 symptom domains rated on a 5-point severity scale.
A more in-depth Level 2 assessment involves additional checklists and rating scales that are more specific to the issue.
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Table 4-1 Categorical Organization of the DSM-5
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Table 4-2 Some Conditions Listed for Further Study in the DSM-5
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Problems Associated with Classification Systems
Two important questions should be asked of any classification system
How reliably can the categories be judged?
How valid are the categories in the sense of discriminating among disorders that have distinctive etiologies and possibly require different treatments?
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The Reliability of Categories
In order for a diagnosis to be reliable, different clinicians should come to the same diagnostic conclusion after independently examining the same patient (diagnostic reliability).
Their agreement on a diagnosis suggests that the label can be applied in a consistent way.
Diagnostic reliability can be measured through the kappa statistic.
As in correlations, kappa values of 1.0 indicate perfect agreement.
In the DSM-III, a reliability estimate of 0.70 or higher was considered to indicate good agreement in the use of the diagnosis.
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The Reliability of Categories of the DSM-III
An important component of the development of the DSM-III was the use of extensive field trials to evaluate reliability by having pairs of clinicians make independent diagnoses on several hundred patients.
The most reliable diagnostic categories included mental retardation, mood disorders, substance use disorders, and schizophrenia.
Less reliable diagnoses included somatoform disorders, factitious disorders, and personality disorders.
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Table 4-4 Summary of Diagnostic Reliabilities for Selected DSM-III Adult Disorders
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The Reliability of Categories of the DSM-IV
The results of reliability trials were not included with the publication of either the DSM-IV or DSM-IV-TR, nor have they been widely disseminated in the professional literature.
In an independent study of DSM-IV criteria for anxiety and mood disorders (Brown et al., 2001), reliabilities above .70 were found for all principle anxiety and mood diagnoses except for major depression (.68) and dysthymia (.22).
Generally, reliability studies suggested that DSM-IV diagnoses were at least as reliable as their DSM-III counterparts.
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Table 4-5 Diagnostic Reliabilities for Selected DSM-5 Disorders
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The Validity of Categories
A reliable classification is not necessarily a valid one.
Diagnostic validity concerns whether the diagnosis measures what it claims to measure.
If diagnoses show construct validity, then the separations between different categories should be discernible.
Evidence should be available to support what belongs inside the category (convergent validity), as well as what does not (divergent validity).
If a diagnosis has predictive validity, we should be able to say something about what to expect in terms of outcome or course.
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Validity of Categories of the DSM-5 (Slide 1 of 2)
There is general agreement that DSM-5 criteria, though far from perfect, makes valid distinctions between different symptom presentations. Those distinctions can also be meaningful in selecting treatment and projecting the course of many disorders.
However, validity presupposes reliability.
The validity of any DSM-5 diagnostic category is limited by the reliability of that diagnosis.
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Validity of Categories of the DSM-5 (Slide 2 of 2)
The DSM series is a product of the medical profession, and consequently reflects the perspective that psychological disorders should be considered in the same way as physical diseases.
However, diagnoses are not diseases.
At present, there are no medical or biological tests that can confirm or verify the vast proportion of specific DSM-5 diagnoses.
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The Diagnostic Process: Providing a DSM-5 Diagnosis
The interview
Observation
Psychological tests
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The Interview
The basic, often the only, instrument of assessment, because the diagnostic criteria of the DSM-5 are based largely on a person’s self-report
The general goals include establishing rapport with the client, decreasing the client’s anxiety about the process, and collecting some basic details
Formal structured clinical interviews: standardized interviews in which the diagnostician asks specific questions tied to DSM categorization
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The Interview: Potential Problems (Slide 1 of 2)
The interviewer relies heavily on the accuracy of the person's self-report.
Various circumstances can affect what a patient tells an interviewer.
The skill of the interviewer
Personal characteristics of the patient
The immediate circumstances and purposes of the interview
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The Interview: Potential Problems (Slide 2 of 2)
Cultural factors can influence the interview process.
When the interviewer and the client are of different ages, genders, and/or ethnic origins, bias and misinterpretation of self report are common outcomes.
There is considerable variation between cultures in how psychological distress is described.
There are forms of psychological problems that are highly specific to certain cultural groups (culture-bound syndromes).
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Observation
Concerned with what persons do rather than what they say they do
Observations made during the interview, together with a person’s responses to certain types of questions, comprise a mental status examination, which provides a current picture of the person’s level of function.
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Psychological Tests
A highly standardized procedure for obtaining a sample of behavior from which inferences can be made about the person's general psychological functioning
Usually constructed so that a person's responses can be quantified and compared with norms obtained on a large sample of other individuals
Common psychological tests used for classification include intelligence tests, personality tests, and neuropsychological testing.
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Intelligence Tests
Intelligence tests, such as the Stanford-Binet and Wechsler's intelligence scales for adults and children, are especially useful when there is a question of intellectual disability or when, for some other reason, an estimate of the person's general level of intellectual ability is required.
An individual’s pattern of strengths and weaknesses across various parts of the tests can provide evidence of specific types of learning disorders, developmental disabilities, neurological impairments, and memory problems.
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Personality Tests
These tests are used primarily by clinicians to assess various aspects of personality, such as characteristic motives, defenses, conflicts, self-image, and thought processes.
The two most common types of personality tests are:
Projective tests (or techniques)
Personality inventories
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Projective Personality Tests (Slide 1 of 2)
The basic assumption in all projective techniques, which are derived from the psychodynamic perspective, is that people project their own internal dispositions into their responses to ambiguous stimulus materials.
Projective techniques are used mainly in an intuitive and clinical fashion by more psychodynamically-oriented therapists.
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Projective Personality Tests (Slide 2 of 2)
Once the most common form of psychological assessment, projective techniques are now employed less often than other forms of personality tests. The reliability, validity, and usefulness of projective tests continue to be topics of disagreement.
A major problem with the psychometric quality of the projective techniques involves the open-ended, unstructured responses that the tests evoke.
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Personality Inventories
Consist of a large number of statements to which the person is asked to respond in terms of fixed categories, such as “yes,” “no,” or “cannot say”
Usually divided into various subscales to measure different aspects of the personality
The Minnesota Multiphasic Personality Inventory (MMPI) is perhaps the most widely used personality inventory in the field of abnormal psychology.
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Personality Inventories: The MMPI & the MMPI-2
The MMPI, developed by Hathaway and McKinley (1943) and revised as the MMPI-2 in 1989, consists of over 550 items covering a wide range of topics, including physical health, religious attitudes, moods, beliefs, fears, and social interests.
When the test was developed, the items were administered to eight groups of psychiatric patients with known diagnoses—such as hysteria, depression, and schizophrenia—and a control group of normals.
Subscales were then constructed from clusters of test items that distinguished each group, so that a person scoring high on a scale is essentially answering certain groups of questions in the same way as people with certain diagnoses.
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Personality Inventories: The MMPI-2
The MMPI-2 has become a standard component of personality assessment and psychological evaluations relating to such legal issues as child custody, likelihood to re-offend, competency to stand trial, and insanity.
The interpretation of the MMPI-2 is more structured than the interpretation of projective techniques, but it remains a complex activity with room for disagreement.
Many clinicians tend to use the MMPI in a rather loose fashion, drawing upon their past experience and clinical intuition to make inferences about personality dynamics and psychopathology from a particular profile.
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Neuropsychological Assessment
Techniques designed to provide information about brain functioning can offer valuable information to the diagnostic process.
Some of these assess behavioral abilities to infer neurological integrity, while others involve imaging of the physical brain and its metabolic functioning.
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Neuropsychological Testing
These types of tests measure a person’s capacities in memory, attention, expressive and receptive language, and eye-hand coordination to indicate whether neurological difficulties should be suspected
The Halstead-Reitan Neurological Battery consists of a variety of tasks involving verbal, auditory, and tactile assessments that gives an impairment index score and allows for comparison of an individual’s test results to that of normal, unimpaired people.
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Brain Imaging (Slide 1 of 2)
Rapidly advancing technology in brain imaging techniques is providing vast improvement in our abilities to observe the structures of the living brain and its function.
Computerized axial tomography (CAT scans) involve a series of X-rays of the brain, organized by computers as slices or layers that allow progressive scanning for tumors or other structural abnormalities.
