临床与咨询心理学导论 10 - Issues in Diagnosis

L10 Issues in Diagnosis 

参考文献/图片来源：Pomerantz, A. (2013). Clinical psychology: science, practice, and culture (3rd ed.). Thousand Oaks, CA: SAGE Publications.

10.1 Defining Abnormality

What is Abnormality?

• In clinical and counseling psychology:

- Focus of work is often on psychopathology

- Rely on DSM-based diagnoses as the indicators of mental disorders

• The quality of our research, diagnostic system, and treatments hinges on a solid definition of what constitutes abnormal behavior

What is Abnormality? Hard to define, examples:

To Engage in “Self Harm:” Tattoos? But what about body modification and non-suicidal self-injury?

To “Hear Voices:” from dead People? God? Persecutory voices?

Definitions of Abnormality (4 D’s)

• Abnormality characterized by: (Subjective) Distress / Deviance from Cultural Norms / Statistical Infrequency (Deviance) / Impaired Social Function (Dysfunction)

• Jerome Wakefield (1992)

Propose: A disorder is a harmful dysfunction

• Harmful (a value term): Based on social norms

• Dysfunction (a scientific term): The failure of a mental mechaniSM to perform the function for which it was designed via evolution

• His theory has become increasingly popular in recent years for incorporating both social context and scientific data

• DSM-5 (2013) - most wildly used definition of Abnormality

Mental disorders - not expected reactions or simply any behavior

• Clinically significant disturbances in cognition, emotion regulation, or behavior

• Indicate a problem (dysfunction) in mental functioning

• Produce significant distress or disability in work, relationships, and/or other areas of functioning

• Impact of Definitions:

For professionals: clinically, research, organizations’ focus (eg workshops)

For individuals: own experiences, find resources, stigma, discrimination

Rosenhan: Being Sane in Insane Places

• Study published in 1973

• General Study Procedures:

- 8 people without mental health problems tried to get admitted psychiatric hospitals (“pseudopatients”)

[Reported hearing voices that were often unclear. They seemed to say, “empty,” “hollow,” and “thud.”]

- All other information provided was accurate

- Typical behavior after admission; denied to have symptoms anymore

• Primary Findings

- All participants were hospitalized (between 1969-1972)

- Stays ranged from 7-52 days (M = 19)

- No “pseudopatients” were discovered by staff

- Some other patients suspected the “pseudopatients”

• Follow-up study

- Skeptical hospital informed that one or more pseudopatients would attempt to gain admission

- Staff asked to identify (rate likelihood) which patients were pseudopatients

• 41/193 admitted were thought to be pseudopatients by ≥1 staff

- In reality, none were pseudopatients!

10.2 DSM-5

10.2.1 Current edition: DSM-5 (2013)

• Process of revision was a major undertaking

Work groups created for each disorder - review last edition, consider changes

Scientific Review Committee assembled - data support for work group changes

Field trials for proposed changes to the DSM - reliability & clinical utility

• Updates for the public starting in 2010 at DSM5.org, thousands of comments

Change in Name: from IV to 5

• From Roman numerals to Arabic numerals

• Done to make naming the DSM easier following revisions, more frequently SMall revisions: DSM 5.1, DSM5.2, etc. DSM - a living document

New Diagnoses in DSM-5

• Several new disorders added

- Binge Eating Disorder

- Disruptive Mood Dysregulation Disorder

- Hoarding Disorder

- Mild Neurocognitive Disorder

- Premenstrual Dysphoric Disorder

- Somatic Disorder

• Several existing disorders revised

- New names, different diagnostic criteria, changes in category

10.2.2 Controversy & CriticiSMs

Controversy around DSM-5

• Transparency in the revision process

- Only vague information was provided on the website

- Many many decisions were made behind closed doors

• Membership of work groups

- Most of the people involved were researchers (not clinicians, lack practices)

• Field trial problems

- Poor reliability in new diagnoses (eg consistence, second-stage)

• Cost of the manual

- Jumped from $65 (DSM-IV) to $199 (DSM-5)

CriticiSMs of DSM-5

• Categorical approach with arbitrary cut-offs

• Too many disorders, including some disorders that may be medical conditions; eg sexual disorders, substance-use disorders, sleep disorders, etc.

• Historical lack of diversity (many white male) among members of work groups

• Lack of diversity in (US participants) empirical studies used to make decisions

• Gender differences in diagnoses for some disorders may reflect biases

• Diagnostic Validity: Do diagnoses accurately reflect phenomenon of interest?

- Heterogeneity of symptom profiles within the single diagnosis

- Comorbidity (overlap, co-occur) of diagnoses and symptoms substantial

10.2.3 Alternative to the DSM-5 Approach

• DSM-5 is a primarily categorical approach - decision is yes or no

- An individual either does or does not meet criteria for each disorder

• Some psychologists have argued for a dimensional approach

- Presence or absence of a disorder is not determined

- Continuum of symptoms are considered

Dimensional Model Example

• Personality disorders (10 disorders in DSM-5)

• A dimensional model for personality disorders (right)

• Five factor model of personality (Big Five)

• Maybe change for next revision